Profile and Prognostic Impact of Multimorbidity in Elderly Patients with Heart Failure: Are there Differences between Men and Women?

PURPOSE OF REVIEW: Heart failure (HF) represents a pathology in constant growth, but, despite the fact that a significant proportion of its population is comprised of elderly patients, they are not adequately represented in clinical trials or registries. They constitute a heterogeneous population with their particularities and interaction of the multiple comorbidities that characterize this age group, which makes the clinical course, prognosis and outcomes of the disease different. RECENT FINDINGS: Compared to men, women with HF tend to be older, with a greater burden of non-cardiovascular comorbidities, less ischemic heart disease and preserved ventricular function in most cases. This fact translates into worse self-perceived quality of life, with lower hospitalization and mortality rates. Moreover, paradoxically, women are less likely to receive treatment recommended by clinical practice guidelines, including revascularization and device placement. As there are not enough representative studies of this population, the reasons for these results with better prognosis and relatively benign impact in the elderly female population are unknown, which is why it is necessary to continue with research in order to obtain greater evidence of the exposed gaps.

Left Atrial Peak Systolic Strain as an Indicator Pathway of Diastolic Dysfunction of the Left Ventricle.

BACKGROUND: Left atrial peak systolic strain (LA-PSS) imaging is an emerging index of left atrial function, and it was shown to be decreased in heart failure with preserved ejection fraction (EF). We aimed to determine whether LA-PSS could be used as an additional diagnostic parameter to current existing guidelines for the presence of left ventricle diastolic dysfunction (LVDD). MATERIALS AND METHODS: A total of 190 consecutive adult patients with cardiovascular risk factors and normal left ventricle EF with no prior history of heart failure were included in the study. Speckle tracking software was used to study ventricular parietal deformity, left ventricle global longitudinal systolic strain, and LA-PSS. RESULTS: The median left ventricle global longitudinal systolic strain was -19%, with a significant difference ( P < 0.001) between patients with normal diastolic function versus those with LVDD. The median LA-PSS was 33% (30% to 38%) ( P < 0.001). Most patients (61%) had grade 1 atrial dysfunction based on PSS (range 24%-35%). The analysis of the area under the receiver operating characteristic curve of the LA-PSS as a potential indicator pathway of LVDD was 67% [95% confidence interval (CI), 62-72], and 75% (95% CI, 70-80), when the indeterminate pattern was included. The decreased LA-PSS made it possible to reclassify patients with an indeterminate pattern of diastolic function in 96% of cases. CONCLUSIONS: These results support the potential role of LA-PSS as an additional parameter for the diagnosis of LVDD in patients with normal EF, and may be integrated into the guidelines for routine evaluation of patients.

Identificación de Factores Clínicos Relacionados a una Mayor Mortalidad Asociada a Insuficiencia Renal Aguda en pacientes de Terapia Intensiva

La insuficiencia renal aguda (IRA) es una de las complicaciones más frecuentes en los pacientes hospitalizados, siendo un factor de riesgo de mortalidad. Es de suma importancia identificar la asociación de factores clínicos que empeoran la mortalidad en pacientes con IRA internados en una unidad de terapia intensiva (UTI). Se incluyeron 218 pacientes, de los cuales el 63,7% (n=139) correspondieron a hombres con un promedio de edad de 43±19 años. El análisis de correlación de variables de control, dependiente e independiente fue a través del coeficiente de Spearman y el OR fue analizado mediante regresión logística. De los 218 pacientes, falleció el 33% (n=72) de los pacientes internados en UTI. La IRA ocurrió en 28,4% (n=62) del total de pacientes y de estos, el 61,3% (n=38) fallecieron, con un OR de 4,94 (p 0,0001). La mayor proporción de fallecidos perteneció a la categoría AKIN 3. Las variables clínicas de ventilación mecánica (PR 3,57, IC 95%, 0,34-37,93), uso de drogas vasoactivas (PR 8,32, IC 95%, 3,20-21,64), puntuación APACHE III (PR 1,12, IC 95%, 1,03-1,23), edad (PR 1,01, IC 95%, 0,99-1,04) y los sometidos a cirugía (PR 0,28, IC 95%, 0,10-0,80) tuvieron asociación positiva y aumentaron la mortalidad. La presencia de variables clínicas de ventilación mecánica, la utilización de drogas vasoactivas, sepsis, el estudio APACHE III, la edad, la categoría AKIN 3, y el antecedente de cirugía previo al ingreso a UTI aumentan significativamente la mortalidad en pacientes con IRA en UTI.

Acute renal failure (ARF) is one of the most frequent complications in hospitalized patients and is a risk factor for mortality. It is extremely important to identify the association of clinical factors that worsen mortality in patients with ARF admitted to an intensive care unit (ICU). A total of 218 patients were included, of which 63.7% (n=139) were men with a mean age of 43±19 years. The correlation analysis of control, dependent, and independent variables was done through Spearman's coefficient and the OR was analyzed through logistic regression. Of the 218 patients, 33% (n=72) died in the ICU. ARF occurred in 28.4% (n=62) of all patients and of these, 61.3% (n=38) died, with an OR of 4.94 (p 0.0001). The highest proportion of deceased patients were in the AKIN 3 category. The clinical variables of mechanical ventilation (PR 3.57, 95% CI, 0.34-37.93), use of vasoactive drugs (PR 8.32, 95% CI, 3.20-21.64), APACHE III score (PR 1.12, 95% CI, 1.03-1.23), age (PR 1.01, 95% CI, 0.99-1.04) and those who underwent surgery (PR 0.28, 95% CI, 0.10-0.80) had a positive association and increased mortality. The presence of clinical variables of mechanical ventilation, the use of vasoactive drugs, sepsis, APACHE III stage, age, AKIN 3 category, and a history of surgery before admission to the ICU significantly increase mortality in patients with ARF in ICU.

ST-Segment Elevation Acute Myocardial Infarction Associated to Covid-19 Vaccination in A Healthy Young Adult with Normal Coronary Arteries.

Despite the beneficial effects of anti-COVID-19 vaccination, monitoring its safety has identified potential cardiac adverse events, mainly myocarditis and pericarditis. The case of a healthy 32-year-old male patient who developed acute myocardial infarction (AMI) 48 hours after the second dose of anti-COVID-19 mRNA vaccine (BNT162b2) is reported. This is the first reported case in the literature of an AMI associated to post-COVID-19 vaccination with mRNA vaccine (BNT162b2) in a healthy young adult without coronary risk factors and normal coronary arteries. Despite this adverse event, the continuation of the anti-COVID-19 vaccination campaign is encouraged due to the benefits it brings.

Role of the Electrocardiographic MVP Risk Score (Morphology-Voltage-P Wave Duration) in Predicting the Development of Atrial Fibrillation in Patients With Systemic Arterial Hypertension.

BACKGROUND: There is a global tendency to emphasize the prevention and early diagnosis of diseases that have a great impact on public health. Atrial fibrillation (AF) has a prevalence affecting 1.5-2% of the general population. Certain variables of the P wave allow us to identify and stratify patients at risk of developing AF. MATERIALS AND METHODS: This is an observational, descriptive, and longitudinal study to determine the applicability of the electrocardiographic (ECG) morphology, voltage, and P wave duration (MVP) risk score to predict the development of AF in consecutive patients with systemic hypertension (SH) in an initial follow-up of 12 months. RESULTS: Initially, 104 patients were included, of whom 12 died during follow-up and 17 did not attend subsequent checkups during the COVID-19 pandemic; therefore, they were excluded. The study patients were 75, of whom AF was detected in 25 patients (33%). The average duration of the P wave was 120 ± 26 ms, the average voltage was 0.1 ± 0.5 Mv. The high-risk MVP ECG score had an [area under the curve, 0.69; 95% confidence intervals (CI), 0.59-0.79] and demonstrated a specificity and a positive predictive value of 100%, a negative predictive value of 76%, and a sensitivity of 40% for predicting the development of AF. CONCLUSIONS: The present study establishes for the first time that SH patients who possess a high-risk MVP ECG score have a significantly higher incidence of developing AF. The high-risk MVP Score has a specificity and a positive predictive value of 100% and a high negative predictive value with a moderate sensitivity for the prediction of the development of AF in SH patients.

Fisiopatología del bloqueo interauricular y su rol como predictor de arritmias supraventriculares

El Bloqueo Interauricular (BIA) puede servir como un valioso marcador electrocardiográfico para evaluar el riesgo del desarrollo de arritmias auriculares, y nueva aparición de fibrilación auricular (FA). El BIA se produce por un deterioro en la conducción auricular que implica un retraso en la conducción del estímulo eléctrico desde la aurícula derecha a la aurícula izquierda. Las causas probables de interrupción del haz de Bachmann incluyen isquemia, enfermedad degenerativa del envejecimiento, enfermedades infiltrativas, enfermedad coronaria difusa y afecciones inflamatorias. Los factores de riesgo para el BIA avanzado, la fibrilación auricular (FA) y el accidente cerebrovascular (ACV) parecen ser muy similares, y la patogénesis subyacente probablemente se deba a fibrosis miocárdica y remodelación auricular. El bloqueo interauricular se relaciona clínicamente a la aparición de taquiarritmias supraventriculares y está relacionado al remodelamiento auricular. Aunque el agrandamiento auricular y el BIA comparten un patrón electrocardiográfico similar, son dos entidades separadas. Sin embargo, muchos autores aún asocian una duración de la onda P mayor a 120 ms con agrandamiento de la aurícula izquierda. El remodelamiento auricular modifica la velocidad de conducción, la arquitectura cardiaca, los canales iónicos dependientes de voltaje, y los componentes de resistencia y capacitancia, como son el espacio extracelular y las uniones celulares. La alteración de estas propiedades afecta las propiedades electrofisiológicas de la conducción auricular y favorece el BIA, los trastornos auriculares y la génesis de FA.

Interatrial block (IAB) can serve as a valuable electrocardiographic marker to assess the risk of developing atrial arrhythmias, and new onset of atrial fibrillation (AF). The IAB is produced by a deterioration in atrial conduction that implies a delay in the conduction of the electrical stimulus from the right atrium to the left atrium. Probable causes of Bachmann bundle interruption include ischemia, degenerative disease of aging, infiltrative diseases, diffuse coronary disease, and inflammatory conditions. The risk factors for advanced IAB, atrial fibrillation (AF), and cerebrovascular accident (CVA) appear to be very similar, and the underlying pathogenesis is probably due to myocardial fibrosis, and atrial remodeling. The interatrial block is clinically related to the appearance of supraventricular tachyarrhythmias and is related to atrial remodeling. Although atrial enlargement and IAB share a similar electrocardiographic pattern, they are separate entities. However, many authors still associate P wave duration greater than 120 ms with left atrial enlargement. Atrial remodeling modifies conduction velocity, cardiac architecture, voltage-gated ion channels, and resistance and capacitance components, such as the extracellular space and cell junctions. The alteration of these properties affects the electrophysiological properties of atrial conduction and favors IAB, atrial disorders, and the genesis of AF.

Disfunción del nódulo sinusal asociado a estenosis severa proximal de la arteria coronaria derecha y vasoespasmo coronario

RESUMEN La disfunción del nódulo sinusal (DNS) es generalmente secundaria a la senescencia del nodo sinusal y del miocardio auricular circundante. Estamos presentando un paciente de 59 años de edad, hipertenso sin tratamiento y con antecedente de síncope en dos oportunidades en los últimos 4 meses. Ingresa debido a un flutter auricular con conducción auriculoventricular 1:1 con una frecuencia cardiaca de 280 lat/min que cede con goteo de amiodarona. Un Holter de 24 horas demostró un ritmo sinusal predominante, episodios paroxísticos de fibrilación auricular con respuesta ventricular alta, bradicardia sinusal de 47 lat/min. Se realizó el diagnóstico de disfunción del nódulo sinusal, Rubenstein tipo III (Síndrome Bradicardia-Taquicardia). Una coronariografía constató una estenosis del 80% en segmento proximal de la arteria coronaria derecha con componente espástico. La arteria del nódulo sinusal emerge del segmento proximal de la coronaria derecha. Se realizó una angioplastia exitosa con stent medicado. Otro estudio Holter de 24 horas de control pos-angioplastia registró nuevamente episodios paroxísticos de fibrilación auricular con respuesta ventricular alta y episodios de pausas de hasta 3.100 milisegundos por lo que se implantó un marcapasos bicameral. A pesar del restablecimiento de un flujo sanguíneo adecuado a la arteria del nódulo sinusal con la angioplastia de la coronaria derecha no se obtuvo una mejoría de la disfunción del nódulo sinusal.

ABSTRACT Sinus node dysfunction (SND) is generally secondary to senescence of the sinus node and the surrounding atrial myocardium. We are presenting a 59-year-old patient, hypertensive without treatment and with a history of syncope on two occasions in the last 4 months. He was admitted due to a 1: 1 atrioventricular conduction atrial flutter with a heart rate of 280 beats/min that subsides with an amiodarone drip. A 24-hour Holter monitor showed predominant sinus rhythm, paroxysmal episodes of atrial fibrillation with high ventricular response, sinus bradycardia of 47 beats/min. The diagnosis of sinus node dysfunction, Rubenstein type III (Bradycardia-Tachycardia Syndrome) was made. A coronary angiography confirmed an 80% stenosis in the proximal segment of the right coronary artery with a spastic component. The sinus node artery emerges from the proximal segment of the right coronary artery. A successful angioplasty was performed with a medicated stent. Another 24-hour Holter study of post-angioplasty control again recorded paroxysmal atrial fibrillation with high ventricular response episodes and pause episodes of up to 3,100 milliseconds, for which a dual-chamber pacemaker was implanted. Despite the restoration of adequate blood flow to the sinus node artery with right coronary angioplasty, no improvement in sinus node dysfunction was obtained.

Rol del bloqueo interauricular avanzado en la predicción de accidentes cerebrovasculares isquémicos

RESUMEN El bloqueo interauricular (BIA) es un marcador significativo en la predicción del desarrollo de Fibrilación Auricular (FA). El sustrato histopatológico que se observa en el proceso de remodelación auricular es la fibrosis del miocardio auricular induciendo disincronía interauricular. La disfunción electromecánica de la aurícula izquierda (AI) produce una activación anormal de sus paredes, el aumento de la presión, la dilatación, la disfunción endotelial, y la fibrosis de la AI. Estas alteraciones favorecen la conducción lenta, el bloqueo unidireccional y el desarrollo de mecanismos de reentrada con la aparición de la FA con sus nefastas complicaciones, entre ellas el accidente cerebrovascular (ACV). El BIA está presente hasta en un 59% de los pacientes mayores de la población general y se asoció con un aumento del riesgo de unas 3 veces más de FA de nueva aparición y ACV isquémico. Es evidente el interés académico, clínico, y terapéutico en el diagnóstico electrocardiográfico certero del BIA avanzado, ya que el mismo se asocia con arritmias supraventriculares, fibrilación auricular, ACV embólicos y mortalidad. La detección de BIA avanzado en pacientes con ACV isquémico previo permite identificar a pacientes de alto riesgo de recurrencia en los que algunas terapias farmacológicas podrían ser beneficiosas. Los pacientes con BIA avanzado sin episodios previos de FA documentada también presentan un riesgo aumentado de ACV embólico. Por lo tanto, es necesario realizar ensayos clínicos randomizados cuyos resultados podrían avalar el uso de anticoagulantes en ausencia de FA documentada en pacientes con BIA avanzado.

ABSTRACT Interatrial block (IAB) is a significant marker in the prediction of the development of Atrial Fibrillation (AF). The histopathological substrate observed in the atrial remodeling process is fibrosis of the atrial myocardium, inducing interatrial desynchrony. Electromechanical dysfunction of the left atrium (LA) produces abnormal activation of its walls, increased pressure, dilation, endothelial dysfunction, and fibrosis of the LA. These alterations favor slow conduction, unidirectional block and the development of reentry mechanisms with the appearance of AF with its disastrous complications, including cerebrovascular accident (CVA). IAB is present in up to 59% of older patients in the general population and was associated with a 3-fold increased risk of new-onset AF and ischemic stroke. The academic, clinical, and therapeutic interest in the accurate electrocardiographic diagnosis of advanced IAB is evident, since it is associated with supraventricular arrhythmias, atrial fibrillation, embolic stroke and mortality. The detection of advanced IAB in patients with previous ischemic stroke allows the identification of patients at high risk of recurrence in which some pharmacological therapies could be beneficial. Patients with advanced IAB with no prior documented AF episodes are also at increased risk of embolic stroke. Therefore, it is necessary to conduct randomized clinical trials whose results might be available in the use of anticoagulants in the absence of documented AF in patients with advanced IAB.

Rol de la morfología y dispersión de la onda P en la predicción de fibrilación auricular

RESUMEN Las características anisotrópicas ocasionadas por un miocardio auricular patológico pueden jugar un papel importante en la creación de circuitos de reentrada al causar propagación no homogénea y discontinua del impulso en el miocardio auricular. Este miocardio auricular alterado puede generar bloqueo unidireccional, retraso de la conducción y ritmos auriculares reentrantes. En estas condiciones la onda P del electrocardiograma (ECG) puede mostrar alteraciones que pueden asociarse con arritmias auriculares y fibrilación auricular (FA). La dispersión de la onda P (DP) se considera un marcador no invasivo del ECG para el remodelado auricular y es predictor sensible y específico del desarrollo de FA. Se ha demostrado que el aumento de la duración de la onda P y la DP reflejan la prolongación del tiempo de conducción auricular dentro de la aurícula derecha y entre ambas aurículas, y una propagación auricular no homogénea y discontinua de los impulsos sinusales. Un valor de corte de 40 ms de la DP demostró tener una sensibilidad del 83%, una especificidad del 85% y un valor predictivo positivo del 89% para la identificación de pacientes con antecedentes de FA paroxística aislada. Los pacientes con alteración de la morfología de la onda P y dispersión de la onda P en el ECG tienen una gran susceptibilidad a desarrollar FA porque poseen electrogramas endocárdicos auriculares anormalmente prolongados y fraccionados, una duración de onda P significativamente mayor, un tiempo de conducción intraauricular e interauricular significativamente más largo, y una mayor incidencia de inducción de fibrilación auricular sostenida.

ABSTRACT The anisotropic characteristics caused by a pathological atrial myocardium can play an important role in the creation of reentry circuits by causing discontinuous and inhomogeneous impulse propagation in the atrial myocardium. This altered atrial myocardium can lead to unidirectional block, conduction delay, and reentrant atrial rhythms. Under these conditions, the P wave of the electrocardiogram (ECG) can demonstrate alterations that can be associated with atrial arrhythmias and atrial fibrillation (AF). The P-wave dispersion (PD) is considered a non-invasive ECG marker for atrial remodeling and is a sensitive and specific predictor of the development of AF. Increased P wave duration and PD have been shown to reflect prolonged atrial conduction time within the right atrium and between both atria, and discontinuous, inhomogeneous atrial propagation of sinus impulses. A cutoff value of 40 ms for PD was shown to have a sensitivity of 83%, a specificity of 85%, and a positive predictive value of 89% for the identification of patients with a history of isolated paroxysmal AF. Patients with abnormal P wave morphology and P wave dispersion on the ECG are highly susceptible to developing AF because they have abnormally prolonged and fractionated atrial endocardial electrograms, significantly longer P wave duration, and significantly longer intra-atrial and inter-atrial conduction time, and a higher incidence of sustained atrial fibrillation induction.

The relation between QRS complex fragmentation and segmental abnormalities of the myocardial contractility in patients with coronary artery disease.

BACKGROUND: Fragmented QRS (fQRS) is defined as any QRS complex with duration of less than 120 ms (ms) and at least one notch in the R or S wave in two or more leads belonging to the same coronary territory. The fQRS represents a delay in ventricular conduction caused by a myocardial scar associated to arrhythmic events. METHODS: This is a descriptive, retrospective, cross-sectional study of a total of 123 patientsadmitted with ischemic heart disease. The aim was to correlate the presence of fQRS in a conventional 12-leads electrocardiogram (ECG) with myocardial regional motility disorders. RESULTS: A total of 62% of the patients were male, the mean age was 63 ± 12 SD. fQRS was observed in 44% (64% men and 36% women), the most frequent location being the inferior wall (61%), followed by the anteroseptal and lateral walls (14% for both). Of the 36 patients with fQRS, 30 had segmental disorders, while 6 did not. Of the 45 patients without fQRS, 28 had segmental disorders, but 17 did not, which gives us a sensitivity of 52% (moderate SnNout) and specificity of 74% (high SpPin), with a positive predictive value of 83%, a negative predictive value of 38% and a prevalence of 72%. CONCLUSION: The presence of fQRS in the ECG has high specificity and a high positive predictive value of the existence of segmental myocardial motility disorders in patients with documented coronary artery disease.

Manejo terapéutico farmacológico actual en la hipertensión arterial sistémica del adulto

RESUMEN El tratamiento con agentes farmacológicos de la hipertensión arterial sistémica (HTA) produce una disminución significativa de las complicaciones cardiovasculares. La terapia antihipertensiva farmacológica produce una reducción del riesgo relativo de casi 50% en la incidencia de insuficiencia cardíaca, una reducción del riesgo relativo de ictus de hasta 40%, y de hasta 25% de reducción del riesgo relativo en el infarto de miocardio. El grado de reducción de la presión arterial, no la elección de la medicación antihipertensiva, es el principal determinante de la reducción del riesgo cardiovascular en pacientes con HTA. La terapia de combinación con fármacos de diferentes clases tiene un efecto de reducción de la presión arterial sustancialmente mayor que la duplicación de la dosis de un solo agente. Sin embargo, el riesgo de efectos adversos, costos e inconvenientes para el paciente aumentan a medida que se agregan más medicamentos antihipertensivos. El objetivo es realizar una revisión narrativa sobre el manejo terapéutico farmacológico actual de la HTA del adulto.

ABSTRACT Treatment with pharmacological agents for systemic arterial hypertension (HT) produces a significant decrease in cardiovascular complications. Pharmacologic antihypertensive therapy produces a relative risk reduction of nearly 50% in the incidence of heart failure, a relative risk reduction of stroke of up to 40%, and a relative risk reduction of up to 25% in myocardial infarction. The degree of reduction in blood pressure, not the choice of antihypertensive medication, is the main determinant of cardiovascular risk reduction in patients with HT. Combination therapy with drugs of different classes has a blood pressure lowering effect substantially greater than doubling the dose of a single agent. However, the risk of adverse effects, costs, and inconvenience to the patient increase as more antihypertensive medications are added. The objective is to carry out a narrative review on the current pharmacological therapeutic management of hypertension in adults.

Potential Mechanisms of Cardiac Injury and Common Pathways of Inflammation in Patients With COVID-19.

Due to the lack of prospective, randomized, controlled clinical studies on inflammation and cardiovascular involvement, the exact mechanism of cardiac injury among patients with Coronavirus Disease 2019 (COVID-19) still remains uncertain. It was demonstrated that there is a high and significantly positive linear correlation between troponin T and plasma high-sensitivity C-reactive protein levels, biomarkers of cardiac injury and systemic inflammation, respectively. Cardiac injury and inflammation is a relatively common association among patients hospitalized with COVID-19, and it is related to higher risk of in-hospital mortality. In our literature search, we identified several potential mechanisms of myocardial tissue damage, namely, coronavirus-associated acute myocarditis, angiotensin-converting enzyme 2 receptor binding affinity to the virus Spike protein, increased cytokine secretion, and hypoxia-induced cardiac myocyte apoptosis. Elucidation of the disease pathogenesis and prospective histopathological studies are crucial for future proper treatment in case of renewed outbreaks. Of interest is that with hundred of thousands of bodies available for autopsy studies, no prospective investigation has been reported so far. Strong efforts and continued research of the cardiovascular complications and identification of risk factors for poor prognosis in COVID-19 are steadily needed. The high morbidity and mortality of COVID-19, its monumental economic burden and social impact, the despair of a new pandemic outbreak, and the thread of potential utilization of novel severe acute respiratory syndrome coronavirus 2 as biologic weapons make it a preponderant necessity to better comprehend the therapeutic management of this lethal disease. Emerging as an acute infectious disease, COVID-19 may become a chronic epidemic because of genetic recombination. Therefore, we should be ready for the reemergence of COVID-19 or other coronaviruses.

Medidas preventivas y manejo diagnóstico y terapéutico de la hipertensión arterial y las crisis hipertensivas / Preventive measures and diagnostic and therapeutic management of arterial hypertension and hypertensive crises

Introducción: La hipertensión arterial (HTA) es definida por algunos como una enfermedad, aunque también se la considera como factor de riesgo cardiovascular. Hoy conocemos como las enfermedades cardiovasculares dependen más de la influencia simultánea de varios factores de riesgo que de la acción aislada de uno de ellos. Por ello, toda actividad preventiva en este campo, debe ser multifactorial y dirigida en diversos sentidos. Desarrollo: Cuando la HTA no es controlada se triplica la probabilidad de accidente cerebrovascular e insuficiencia cardiaca, con menor incidencia de enfermedad coronaria y arterial periférica. El propio aumento de la masa del ventrículo izquierdo, así como los cambios estructurales que tienen lugar a nivel del miocardio y de los vasos coronarios pueden desencadenar episodios de cardiopatía isquémica. El remodelado intersticial y el aumento de la masa del ventrículo izquierdo son factores predisponentes a la aparición de arritmias ventriculares y muerte súbita. Es importante evaluar y tratar a los pacientes recién diagnosticados con HTA con medicamentos adecuados y seguimiento para prevenir la progresión de la hipertensión no controlada a crisis hipertensivas, es decir, urgencia o emergencia hipertensiva. Conclusiones: El reconocimiento inmediato de una emergencia hipertensiva con las pruebas de diagnóstico apropiadas conducirá a una reducción adecuada de la presión arterial, aliviando la incidencia de consecuencias negativas a los órganos diana. El tratamiento adecuado ayudará a aliviar la progresión de la enfermedad y mejorar los resultados a largo plazo.

Introduction: Hypertension (HT) is defined by some as a disease, although it is also considered a cardiovascular risk factor. Today we know cardiovascular diseases depend more on the simultaneous influence of several risk factors than on the isolated action of one of them. Therefore, all preventive activity in this field must be multifactorial and directed in various ways. Developing: When HT is not controlled, the probability of stroke and heart failure, with a lower incidence of coronary and peripheral arterial disease triples. The increase in left ventricular mass itself, as well as, the structural changes that occur at the level of myocardium and coronary vessels, can trigger episodes of ischemic heart diseases. Interstitial remodeling and increased left ventricular mass are predisposing factors to the appearance of ventricular arrhythmias and sudden death. It is important to evaluate and treat newly diagnosed patients with HT with recommended medications and follow-up to prevent the progression of uncontrolled HT to hypertensive crises, that is, urgency or emergency hypertension. Conclusion: The immediate recognition of a hypertensive emergency with the affected diagnostic tests will lead to an adequate reduction of blood pressure, alleviating the incidence of negative consequences to the target organs. Proper treatment helps to decrease the progression of the disease and improves long-term outcomes.

Bloqueo interauricular avanzado en pacientes con hipertensión arterial sistémica y fibrilación auricular / Advanced interatrial block in patients with systemic arterial hypertension and atrial fibrillation

La hipertensión arterial sistémica (HTA) continúa siendo un factor de riesgo de indudable importancia en el proceso del desarrollo de la enfermedad cardiovascular y la fibrilación auricular (FA). La FA constituye la arritmia sostenida más frecuentemente detectada. Es primordial dar el énfasis necesario a la prevención y al diagnóstico precoz de enfermedades con gran impacto social, médico y económico a la salud pública. En este contexto, es importante detectar la enfermedad en estadio subclínico e identificar factores que determinen con gran confiabilidad la aparición y desarrollo de una enfermedad. El electrocardiograma (ECG) es un método auxiliar de diagnóstico seguro, económico, de fácil manejo y accesible en prácticamente todos los centros médicos, y que nos sirve para detectar diversas entidades nosológicas. El bloqueo interauricular (BIA) diagnosticado por el ECG ocurre debido a un enlentecimiento de conducción entre las aurículas derecha e izquierda a causa de un retardo en la conducción de impulsos a través del haz de Bachmann. El sustrato anatómico para BIA está producido por la remodelación auricular debido a fibrosis, induciendo disincronía interauricular. El BIA está presente hasta en un 59% de los pacientes mayores de la población general y estuvo directamente asociado a la HTA y la FA. Además, el BIA avanzado se asoció con un aumento del riesgo de unas 3 veces más de FA de nueva aparición y accidente cerebrovascular isquémico. Por lo tanto, es imprescindible realizar una investigación prospectiva adicional para determinar las estrategias óptimas en el adecuado manejo terapéutico de estos pacientes

Systemic arterial hypertension (AHT) continues to be a risk factor of undoubted importance in the process of development of cardiovascular disease and atrial fibrillation (AF). AF is the most frequently detected sustained arrhythmia. For this reason, it is essential to give the necessary emphasis to the prevention and early diagnosis of diseases with great social, medical and economic impact on public health. In this context, it is important to detect the subclinical stage disease and identify factors that determine with great reliability the appearance and development of a disease. The electrocardiogram (ECG) is a safe, inexpensive auxiliary diagnostic method, easy to use and accessible in practically all medical centers, and which serves to detect various nosological entities. The interatrial block (IAB) diagnosed by the ECG occurs due to a slowing down of conduction between the right and left atria due to a delay in the conduction of impulses through the Bachmann pathway. The anatomical substrate for IAB is produced by atrial remodeling due to fibrosis, inducing interatrial dyssynchrony. IAB is present in up to 59% of older patients in the general population and was directly associated with AHT and AF. In addition, advanced IAB was associated with a 3-fold increased risk of new-onset AF and ischemic stroke. Therefore, it is essential to carry out additional prospective research to determine the optimal strategies in the adequate therapeutic management of these patients

Fisiopatología, perfil epidemiológico y manejo terapéutico en el síndrome coronario agudo / Pathophysiology, epidemiological profile and therapeutic management in acute coronary syndrome

Las enfermedades cardiovasculares siguen siendo ampliamente la primera causa de muerte en el mundo actual. La cardiopatía isquémica conlleva a una importante carga de gastos de Salud Pública, por lo cual es importante conocer la prevalencia, epidemiología, fisiopatología y el manejo diagnóstico y terapéutico adecuado del síndrome coronario agudo (SCA). Los hallazgos recientes indican que los primeros pasos en la aterosclerosis son esencialmente inflamatorios. Una respuesta inflamatoria sistémica a menudo acompaña al SCA, y la documentación de su presencia ha sido ampliamente reconocida como un indicador de eventos coronarios a repetición. La medicina basada en la evidencia sugiere fuertemente la importancia de la etiología inflamatoria en el SCA. Los factores tradicionales de riesgo coronario terminan en un pasaje final común que desarrolla un proceso inflamatorio en la pared arterial. El entendimiento mejorado y la comprensión adecuada de la influencia de los procesos inflamatorios en el SCA pueden llevar no solo a una mejor utilización de la terapéutica actualmente disponible sino también al desarrollo de nuevas herramientas terapéuticas. Sin duda alguna los refinamientos constantes en las diferentes estrategias terapéuticas del SCA, sumados a la combinación del entendimiento científico en el uso adecuado de los marcadores inflamatorios, los nuevos agentes farmacológicos y las nuevas técnicas de intervención coronaria percutánea con los nuevos stents y otros dispositivos intracoronarios van a aclarar nuestras dudas y mejorar nuestro manejo diagnóstico y terapéutico del síndrome coronario agudo basado en la evidencia científica

Cardiovascular diseases are still widely the leading cause of death in the world today. Ischemic heart disease leads to a significant burden of public health expenses, which is why it is important to know the prevalence, epidemiology, pathophysiology and the adequate diagnostic and therapeutic management of acute coronary syndrome (ACS). Recent findings indicate that the first steps in atherosclerosis are essentially inflammatory. A systemic inflammatory response often accompanies ACS, and the documentation of its presence has been widely recognized as an indicator of recurrent coronary events. Evidence based medicine strongly suggests the importance of the inflammatory etiology in ACS. The traditional coronary risk factors end in a common final passage that develops an inflammatory process in the arterial wall. Improved and adequate understanding of the influence of inflammatory processes in ACS can lead not only to a better use of currently available therapeutics but also to the development of new therapeutic tools. Undoubtedly the constant refinements in the different therapeutic strategies of the ACS, combined with the addition of scientific understanding in the proper use of inflammatory markers, new pharmacological agents and new techniques of percutaneous coronary intervention with newer stents and other intracoronary devices will clarify our doubts and improve our diagnostic and therapeutic management of acute coronary syndrome based on scientific evidence

Biogénesis y mecanismo de acción de los MicroARN como biomarcadores séricos en las enfermedades cardiovasculares / Biogenesis and mechanism of action of MicroRNAs as serum biomarkers in cardiovascular diseases

Las enfermedades cardiovasculares constituyen la principal causa de mortalidad y morbilidad en el mundo actualmente, lo que obliga a la realización de los continuos avances en las estrategias diagnóstico precoz y tratamiento con el fin de mejorar el pronóstico y disminuir la mortalidad. Sin duda esto abre las puertas al campo de la investigación y en los últimos años aparecen los llamados biomarcadores séricos y entre ellos los microARN (miARN) que juegan un papel fundamental tanto en el desarrollo y como en la regulación del sistema cardiovascular. Los microARN tienen un tamaño de 19-25 nucleótidos, son el grupo de ARN de pequeño tamaño que ha atraído mayor atención durante los últimos años. Hasta la fecha, se han identificado aproximadamente unos 2500 miARN en el genoma humano. Los miARN desempeñan un papel en la regulación de diversos procesos biológicos, como la embriogénesis, la proliferación y diferenciación celular, la apoptosis o la tumorogénesis. En el sistema cardiovascular, los miARN controlan el crecimiento y la contractilidad de los cardiomiocitos, el desarrollo y mantenimiento del ritmo cardíaco, la formación de la placa arterioesclerótica, el metabolismo de los lípidos y la angiogénesis. Además están vinculados en la fisiopatología de varias enfermedades cardiovasculares, fundamentalmente la insuficiencia cardiaca, el infarto de miocardio, la enfermedad coronaria, la ateroesclerosis, y las cardiomiopatías de diversas etiologías, de allí que su determinación en la circulación podría ser de utilidad en la práctica clínica como potencial biomarcador diagnóstico y pronóstico de las enfermedades cardiovasculares. Palabras clave: Micro RNA; Enfermedades cardiovasculares; Biomarcadores séricos.

Cardiovascular diseases are the main cause of mortality and morbidity in the world today, which forces the continuous progress in early diagnosis and treatment strategies in order to improve the prognosis and decrease mortality. Undoubtedly this opens the doors to the field of research and in recent years there are the so-called serum biomarkers and among them microRNAs (miRNAs) that play a fundamental role both in the development and in the regulation of the cardiovascular system. The microRNAs are 19 to 25 nucleotides in size, they are the small group of RNA that has attracted the most attention in recent years. To date, approximately 2,500 miRNAs have been identified in the human genome. The miRNAs play a role in the regulation of various biological processes, such as embryogenesis, cell proliferation and differentiation, apoptosis or oncogenesis. In the cardiovascular system, miRNAs control the growth and contractility of cardiomyocytes, the development and maintenance of heart rhythm, the formation of atherosclerotic plaque, lipid metabolism and angiogenesis. They are also linked in the pathophysiology of several cardiovascular diseases, mainly heart failure, myocardial infarction, coronary heart disease, atherosclerosis, and cardiomyopathies of various etiologies, hence their determination in circulation could be useful in clinical practice as a potential biomarker in the diagnosis and prognosis of cardiovascular diseases. Keywords: Micro RNA; Cardiovascular diseases; Serum biomarkers.

Frecuencia de factores de riesgo para el desarrollo de prediabetes en el personal sanitario

RESUMEN Introducción: los factores de riesgo importantes para el desarrollo de y diabetes tipo 2 son la obesidad, la dislipidemia y la hiperglucemia. El incremento de la frecuencia las enfermedades crónicas no transmisibles es un fenómeno mundial y Paraguay no es la excepción. Objetivos: determinar la frecuencia de desarrollar prediabetes con respecto a patrones alimentarios, identificando trastornos en el metabolismo de los hidratos de carbono en el personal de blanco, teniendo en cuenta el horario laboral y actitudes alimentarias. Metodología: estudio analítico, prospectivo, observacional, de corte trasversal. Estudio enfocado en el personal de blanco del Hospital San Pablo (Asunción, Paraguay), de ambos sexos, quienes aceptaron voluntariamente participar de una encuesta de factores de riesgo para el desarrollo de durante el período de julio a diciembre de 2017. Resultados: se encontró una elevada frecuencia de factores de riesgo para en una población joven y dedicada al cuidado de la comunidad. En cuanto a la evaluación de conocimientos de los encuestados, todos describían la influencia negativa de los factores de riesgo, desconociendo ciertas peculiaridades sobre aspectos relacionados con el consumo de hidratos de carbono simples o complejos o el valor de sus niveles de lípidos. En cuanto a la percepción sobre el peso y la actividad física, manifestaron su preocupación. Conclusiones: se halló una elevada frecuencia de factores de riesgo para desarrollar prediabetes. En cuanto a la evaluación de conocimientos de los encuestados, todos describían la influencia negativa de los factores de riesgo, desconociendo ciertas peculiaridades sobre aspectos relacionados con el consumo de hidratos de carbono simples o complejos o el valor de sus niveles de lípidos

ABSTRACT Introduction: The important risk factors for the development of type 2 diabetes are obesity, dyslipidemia and hyperglycemia. The increase in the frequency of chronic noncommunicable diseases is a worldwide phenomenon and Paraguay is no exception. Objectives: To determine the frequency of developing prediabetes with respect to dietary patterns, identifying disorders in the metabolism of carbohydrates in health personnel, taking into account working hours and eating attitudes. Methodology: Analytical, prospective, observational and cross-sectional study. Study focused on the health staff of the San Pablo Hospital (Asunción, Paraguay), males and females, who voluntarily agreed to participate in a survey of risk factors for development during the period from July to December 2017. Results: A high frequency of risk factors was found in a young population dedicated to community care. In relation to the evaluation of the knowledge of respondents, all described the negative influence of the risk factors, ignoring certain peculiarities about aspects related to the consumption of simple or complex carbohydrates or the value of their lipid levels. Regarding the perception of weight and physical activity, they expressed concern. Conclusions: A high frequency of risk factors was found to develop prediabetes. Regarding the evaluation of the knowledge of respondents, all described the negative influence of risk factors, ignoring certain peculiarities about aspects related to the consumption of simple or complex carbohydrates or the value of their lipid levels.