[Acute ischemic stroke in cancer patients. A case-control study]. / Accidente cerebrovascular isquémico en pacientes con cáncer. Un estudio caso-control.

One in 10 patients with ischemic stroke has comorbid cancer. Our goal was to compare stroke patients with cancer against those without cancer in terms of clinical and radiological features, and the underlying mechanism. We conducted a retrospective case-control study in patients admitted with ischemic stroke between July 2013 and September 2018. Cases had a concomitant diagnosis of cancer and acute ischemic stroke, controls only of ischemic stroke. Age, gender, vascular risk factors (VRF), pattern of ischemic lesion in neuroimaging, etiology and clinical outcome were compared between groups. Fifty-seven cases were identified, 61% were male (n = 35), and mean age was 75 ± 11. Fiftytwo had known oncologic disease at the onset of stroke. Most of them had solid tumors (91%, n = 52), and 54% (n = 31) had a non-metastatic tumor at the time of stroke. Prevalence of common VRF between groups was not significantly different. Previous deep venous thrombosis and pulmonary thromboembolism were more frequent in the cancer cohort (8% vs. 1%, p = 0.01). The average NIHSS was 3.8 ± 4 in the cancer group and 9 ± 7 in the control group (p = 0.01). Small artery disease as the etiology of stroke was significantly less common in the cancer group (2% vs. 26%, p = 0.001). Regarding neuroimaging, the embolic pattern was more frequent in patients with cancer (82% vs. 35%, p = 0.001). In these patients recurrence and mortality at 90 days was three and six times higher (10% vs. 3%, and 18% vs. 3%. p = 0.08 and 0.001, respectively).

Aproximadamente uno de cada 10 pacientes que sufre un accidente cerebrovascular isquémico (ACVi) padece cáncer concomitantemente. Nuestro objetivo fue evaluar características clínicoradiológicas del ACVi en pacientes con cáncer y compararlas con otros sin cáncer. Fue un estudio caso-control retrospectivo que incluyó pacientes con ACVi entre julio 2013 y septiembre 2018. Los casos tenían diagnóstico de cáncer y ACVi, y los controles solamente ACVi. Se comparó edad, sexo, factores de riesgo vascular, patrones radiológicos de lesiones, etiología y evolución clínica entre ambos grupos. Hubo 57 casos, 61% (n = 35) eran varones. La edad media fue 75 ± 11 años, sin diferencias en prevalencia de factores de riesgo vascular. En los casos hubo más pacientes con antecedentes de trombosis venosa profunda y/o tromboembolismo pulmonar (8% vs. 1%, p = 0.01). En 52 se conocía la presencia del cáncer antes del ACVi. El 91% se trató de tumores sólidos (n = 52) y en 54% el tumor no presentaba metástasis. El puntaje NIHSS promedio fue 3.8 ± 4 en los casos, y 9 ± 7 en los controles (p = 0.01). Las lesiones de pequeña arteria fueron menos frecuentes en los casos (2% vs. 26%, p = 0.001). Las lesiones de aspecto embólico fueron más comunes entre los casos (82% vs. 35%, p = 0.001). Aquellos con cáncer tuvieron menor NIHSS, menor frecuencia de lesiones de pequeña arteria, y mayor frecuencia de lesiones de aspecto embólico. La recurrencia a 90 días fue 3 veces mayor y la mortalidad 6 veces mayor en pacientes con cáncer (10% vs. 3%, y 18% vs. 3%. p = 0.08 y 0.001 respectivamente).

Accidente cerebrovascular isquémico en pacientes con cáncer. Un estudio caso-control / Acute ischemic stroke in cancer patients. A case-control study

Resumen Aproximadamente uno de cada 10 pacientes que sufre un accidente cerebrovascular isquémico (ACVi) padece cáncer concomitantemente. Nuestro objetivo fue evaluar características clínicoradiológicas del ACVi en pacientes con cáncer y compararlas con otros sin cáncer. Fue un estudio caso-control retrospectivo que incluyó pacientes con ACVi entre julio 2013 y septiembre 2018. Los casos tenían diagnóstico de cáncer y ACVi, y los controles solamente ACVi. Se comparó edad, sexo, factores de riesgo vascular, patrones radiológicos de lesiones, etiología y evolución clínica entre ambos grupos. Hubo 57 casos, 61% (n = 35) eran varones. La edad media fue 75 ± 11 años, sin diferencias en prevalencia de factores de riesgo vascular. En los casos hubo más pacientes con antecedentes de trombosis venosa profunda y/o tromboembolismo pulmonar (8% vs. 1%, p = 0.01). En 52 se conocía la presencia del cáncer antes del ACVi. El 91% se trató de tumores sólidos (n = 52) y en 54% el tumor no presentaba metástasis. El puntaje NIHSS promedio fue 3.8 ± 4 en los casos, y 9 ± 7 en los controles (p = 0.01). Las lesiones de pequeña arteria fueron menos frecuentes en los casos (2% vs. 26%, p = 0.001). Las lesiones de aspecto embólico fueron más comunes entre los casos (82% vs. 35%, p = 0.001). Aquellos con cáncer tuvieron menor NIHSS, menor frecuencia de lesiones de pequeña arteria, y mayor frecuencia de lesiones de aspecto embólico. La recurrencia a 90 días fue 3 veces mayor y la mortalidad 6 veces mayor en pacientes con cáncer (10% vs. 3%, y 18% vs. 3%. p = 0.08 y 0.001 respectivamente).

Abstract One in 10 patients with ischemic stroke has comorbid cancer. Our goal was to compare stroke patients with cancer against those without cancer in terms of clinical and radiological features, and the underlying mechanism. We conducted a retrospective case-control study in patients admitted with ischemic stroke between July 2013 and September 2018. Cases had a concomitant diagnosis of cancer and acute ischemic stroke, controls only of ischemic stroke. Age, gender, vascular risk factors (VRF), pattern of ischemic lesion in neuroimaging, etiology and clinical outcome were compared between groups. Fifty-seven cases were identified, 61% were male (n = 35), and mean age was 75 ± 11. Fiftytwo had known oncologic disease at the onset of stroke. Most of them had solid tumors (91%, n = 52), and 54% (n = 31) had a non-metastatic tumor at the time of stroke. Prevalence of common VRF between groups was not significantly different. Previous deep venous thrombosis and pulmonary thromboembolism were more frequent in the cancer cohort (8% vs. 1%, p = 0.01). The average NIHSS was 3.8 ± 4 in the cancer group and 9±7 in the control group (p = 0.01). Small artery disease as the etiology of stroke was significantly less common in the cancer group (2% vs. 26%, p = 0.001). Regarding neuroimaging, the embolic pattern was more frequent in patients with cancer (82% vs. 35%, p = 0.001). In these patients recurrence and mortality at 90 days was three and six times higher (10% vs. 3%, and 18% vs. 3%. p = 0.08 and 0.001, respectively).

[Consensus on acute ischemic stroke]. / Consenso sobre accidente cerebrovascular isquémico agudo.

Stroke is the third cause of death and the first cause of disability in Argentina. Ischemic events constitute 80% of cases. It requires the implementation of systematized protocols that allow reducing the time of care, morbidity and mortality. Specialists from nine medical societies related to the care of patients with cerebrovascular disease participated in the consensus. A separate agenda was agreed upon in chapters and for the writing of them, work groups were formed with members of different medical specialties. The level of recommendation was discussed and agreed upon for each topic based on the best clinical evidence available for each of them. An adaptation to the local scope of the recommendations was made when it was considered necessary.The American Heart Association system was used to draft the recommendations and their level of evidence. The correction and editing were done by five external reviewers, who did not participate in the writing and with extensive experience in vascular pathology. Once the preliminary document was finalized, a general meeting was held with all the members of the working groups and the reviewers to reach final recommendations. The consensus covers the management of ischemic stroke in the pre-hospital phase, initial evaluation in the emergency center, recanalization therapies (thrombolysis and/ or mechanical thrombectomy), decompressive craniectomy, neuroimaging and clinical care in the hospital.

El accidente cerebrovascular es la tercera causa de muerte y la primera de discapacidad en la Argentina. Los eventos isquémicos constituyen el 80% de los casos. Los accidentes vasculares cerebrales requieren la implementación de protocolos sistematizados que permitan reducir los tiempos en la atención, la morbilidad y mortalidad. En el consenso participaron especialistas de nueve sociedades médicas relacionadas con la atención de pacientes con enfermedad cerebrovascular. Se consensuó un temario separado en capítulos y para la redacción de los mismos se conformaron grupos de trabajo con miembros de diferentes especialidades médicas. Se discutió y acordó para cada tema el nivel de recomendación en base a la mejor evidencia clínica disponible para cada tópico. Se realizó una adaptación al ámbito local de las recomendaciones cuando se consideró necesario. El sistema de la American Heart Association se utilizó para redactar las recomendaciones y su grado de evidencia. La corrección y edición fue realizada por cinco revisores externos, que no participaron en la redacción y con amplia experiencia en enfermedad vascular. Finalizado el documento preliminar, se organizó una reunión general con todos los integrantes de los grupos de trabajo y los revisores para redactar las recomendaciones definitivas. El consenso abarca la atención del paciente con accidente cerebrovascular isquémico en la fase pre-hospitalaria, evaluación inicial en la central de emergencias, terapias de recanalización (trombolisis y/o trombectomía mecánica), craniectomía descompresiva, neuroimágenes y cuidados clínicos en la internación.

Consenso sobre accidente cerebrovascular isquémico agudo / Consensus on acute ischemic stroke

El accidente cerebrovascular es la tercera causa de muerte y la primera de discapacidad en la Argentina. Los eventos isquémicos constituyen el 80% de los casos. Los accidentes vasculares cerebrales requieren la implementación de protocolos sistematizados que permitan reducir los tiempos en la atención, la morbilidad y mortalidad. En el consenso participaron especialistas de nueve sociedades médicas relacionadas con la atención de pacientes con enfermedad cerebrovascular. Se consensuó un temario separado en capítulos y para la redacción de los mismos se conformaron grupos de trabajo con miembros de diferentes especialidades médicas. Se discutió y acordó para cada tema el nivel de recomendación en base a la mejor evidencia clínica disponible para cada tópico. Se realizó una adaptación al ámbito local de las recomendaciones cuando se consideró necesario. El sistema de la American Heart Association se utilizó para redactar las recomendaciones y su grado de evidencia. La corrección y edición fue realizada por cinco revisores externos, que no participaron en la redacción y con amplia experiencia en enfermedad vascular. Finalizado el documento preliminar, se organizó una reunión general con todos los integrantes de los grupos de trabajo y los revisores para redactar las recomendaciones definitivas. El consenso abarca la atención del paciente con accidente cerebrovascular isquémico en la fase pre-hospitalaria, evaluación inicial en la central de emergencias, terapias de recanalización (trombolisis y/o trombectomía mecánica), craniectomía descompresiva, neuroimágenes y cuidados clínicos en la internación.

Stroke is the third cause of death and the first cause of disability in Argentina. Ischemic events constitute 80% of cases. It requires the implementation of systematized protocols that allow reducing the time of care, morbidity and mortality. Specialists from nine medical societies related to the care of patients with cerebrovascular disease participated in the consensus. A separate agenda was agreed upon in chapters and for the writing of them, work groups were formed with members of different medical specialties. The level of recommendation was discussed and agreed upon for each topic based on the best clinical evidence available for each of them. An adaptation to the local scope of the recommendations was made when it was considered necessary.The American Heart Association system was used to draft the recommendations and their level of evidence. The correction and editing were done by five external reviewers, who did not participate in the writing and with extensive experience in vascular pathology. Once the preliminary document was finalized, a general meeting was held with all the members of the working groups and the reviewers to reach final recommendations. The consensus covers the management of ischemic stroke in the pre-hospital phase, initial evaluation in the emergency center, recanalization therapies (thrombolysis and/ or mechanical thrombectomy), decompressive craniectomy, neuroimaging and clinical care in the hospital.

[Clinical predictors of hemorrhagic transformation in non lacunar ischemic stroke]. / Predictores clínicos de transformación hemorrágica en accidente cerebrovascular isquémico no lacunar.

Hemorrhagic transformation is a complex phenomenon where brain tissue bleeds, which could be associated or not to an increase in the neurological deficit after the acute ischemic stroke. The aim of our study was to evaluate clinical predictors of hemorrhagic transformation in patients with non-lacunar ischemic stroke. We performed a prospective analysis of the clinical records and images of patients with non-lacunar ischemic stroke. Demographics, vascular risk factors, previous medications and the information of the event in patients with and without hemorrhagic transformation were here compared. We included in this study 747 patients with non-lacunar stroke, the mean age was 77 ± 11 years and 61% were females. In the univariate analysis, the age, a history of hypertension, atrial fibrillation, chronic kidney disease and the previous use of oral anticoagulation resulted statistically significant. In the multivariate analysis of logistic regression adjusted by age and vascular risk factors: the age > 80 years (OR 3.6, CI 95% 1.8-7.6), the pulse pressure > 60 mmHg at admission (OR 5.3, CI 95% 3.2-9.1), the chronic kidney disease (OR 3, CI 95% 2.5-3.8) and the presence of previous atrial fibrillation (OR 3.5, CI 95% 2.1-6.1) were associated with and increased risk of hemorrhagic transformation. The predictors of hemorrhagic transformation in our cohort showed a relationship with severe vascular illness. The identification of these patients could influence therapeutic decisions that could increase the risk of hemorrhagic transformation.

Predictores clínicos de transformación hemorrágica en accidente cerebrovascular isquémico no lacunar / Clinical predictors of hemorrhagic transformation in non lacunar ischemic stroke

La transformación hemorrágica es un fenómeno complejo en el que el tejido cerebral isquémico sangra; este proceso puede asociarse o no a un deterioro del estado neurológico inicial. El objetivo de nuestro estudio fue evaluar los predictores clínicos de trasformación hemorrágica en los pacientes con accidente cerebrovascular isquémico no lacunar. Se analizaron las historias clínicas y las imágenes de pacientes con infarto cerebral no lacunar incluidos prospectivamente en un programa de prevención secundaria. Se compararon datos demográficos, factores de riesgo vascular, medicación previa y datos del evento de los pacientes con transformación hemorrágica y sin ella. Se incluyeron 747 pacientes, la edad promedio fue de 77 ± 11 años, 61% mujeres. En el análisis univariado, la edad, el antecedente de hipertensión arterial, la fibrilación auricular, la insuficiencia renal crónica y la anticoagulación oral previa se relacionaron significativamente con la presencia de transformación hemorrágica. En el análisis multivariado de regresión logística ajustado por edad y factores de riesgo vascular, resultaron predictores de transformación hemorrágica: la edad > 80 años (OR 3.6; IC 95% 1.8-7.6), la presión de pulso > 60 mmHg al ingreso (OR 5.3; IC 95% 3.2-9.1), la insuficiencia renal crónica (OR 3; IC 95% 2.5-3.8) y el antecedente de fibrilación auricular (OR 3.5; IC 95% 2.1-6.1). En nuestra cohorte los predictores clínicos de conversión hemorrágica del infarto cerebral muestran una relación con la gravedad de la enfermedad vascular. La identificación de estos pacientes influenciaría en la toma de decisiones terapéuticas que pudieran incrementar el riesgo de transformación hemorrágica.

Hemorrhagic transformation is a complex phenomenon where brain tissue bleeds, which could be associated or not to an increase in the neurological deficit after the acute ischemic stroke. The aim of our study was to evaluate clinical predictors of hemorrhagic transformation in patients with non-lacunar ischemic stroke. We performed a prospective analysis of the clinical records and images of patients with non-lacunar ischemic stroke. Demographics, vascular risk factors, previous medications and the information of the event in patients with and without hemorrhagic transformation were here compared. We included in this study 747 patients with non-lacunar stroke, the mean age was 77 ± 11 years and 61% were females. In the univariate analysis, the age, a history of hypertension, atrial fibrillation, chronic kidney disease and the previous use of oral anticoagulation resulted statistically significant. In the multivariate analysis of logistic regression adjusted by age and vascular risk factors: the age > 80 years (OR 3.6, CI 95% 1.8-7.6), the pulse pressure > 60 mmHg at admission (OR 5.3, CI 95% 3.2-9.1), the chronic kidney disease (OR 3, CI 95% 2.5-3.8) and the presence of previous atrial fibrillation (OR 3.5, CI 95% 2.1-6.1) were associated with and increased risk of hemorrhagic transformation. The predictors of hemorrhagic transformation in our cohort showed a relationship with severe vascular illness. The identification of these patients could influence therapeutic decisions that could increase the risk of hemorrhagic transformation.

[Medication adherence to secondary prevention for coronary artery disease]. / Adherencia a la prevención secundaria de la enfermedad coronaria.

We compared the use of evidence-based secondary prevention drugs for coronary artery disease at hospital discharge and 3 years of follow-up in a group of patients associated to an integrated network of health services. We conducted a retrospective group study that included 125 patients under 80 years of age who were hospitalized for acute coronary syndrome. McNemar's test was used to compare values at baseline and 3 years. The mean age of of participants was 63.7 years (SD ± 10.08) and 65.6% (95% CI 56.6-73.9) of male sex. The average follow-up time was 2.94 years (SD ± 0.25). The use of secondary prevention drugs for coronary heart disease decreased at 3 years of follow-up: anti-platelet 97.6 to 88.0% (p = 0.012), beta-blockers 94.4 to 84.8% (p = 0.021) and statins 83.7 to 91.2% (p = 0.035). Patients medicated with a combination of anti-platelet, beta blockers and statins showed a decrease from 86.4 to 66.3% (p < 0.0001). It is necessary to study the causes for the decreased adherence to long-term cardio-protective drugs.

Adherencia a la prevención secundaria de la enfermedad coronaria / Medication adherence to secondary prevention for coronary artery disease

Se comparó la adherencia a la prevención secundaria de enfermedad coronaria mediante el uso indicado de fármacos de probada eficacia, al momento del egreso hospitalario y a 3 años de seguimiento, en una cohorte de pacientes afiliados al Plan de Salud del Hospital Italiano. Se realizó un estudio de cohorte retrospectivo que incluyo 125 pacientes menores de 80 años de edad, afiliados a una red integrada de salud, con internación por síndrome coronario agudo. En el análisis se utilizó el test de McNemar. La edad media de los participantes fue 63.7 años (DS 10.08) y el 65.6% (IC95% 56.6-73.9) fue de sexo masculino. El 76.8% (IC95% 68.4-83.9) presentó como evento calificante un síndrome coronario agudo sin elevación del segmento ST. El tiempo de seguimiento promedio fue 2.94 años (DS 0.25). Se observó que el uso de drogas de probada eficacia en la prevención secundaria de enfermedad coronaria descendió entre el momento del egreso hospitalario y los 3 años de seguimiento: antiagregantes de 97.6 a 88.0% (p = 0.012); beta-bloqueantes de 94.4 a 84.8% (p = 0.021); estatinas 91.2 a 83.7% (p = 0.035). Uso combinado de antiagregantes, betabloqueantes y estatinas de 86.4 a 66.3% (p < 0.0001). Es necesario estudiar las causas de la disminución de la adherencia a drogas cardioprotectoras a largo plazo.

We compared the use of evidence-based secondary prevention drugs for coronary artery disease at hospital discharge and 3 years of follow-up in a group of patients associated to an integrated network of health services. We conducted a retrospective group study that included 125 patients under 80 years of age who were hospitalized for acute coronary syndrome. McNemar´s test was used to compare values at baseline and 3 years. The mean age of of participants was 63.7 years (SD ± 10.08) and 65.6% (95% CI 56.6-73.9) of male sex. The average follow-up time was 2.94 years (SD ± 0.25). The use of secondary prevention drugs for coronary heart disease decreased at 3 years of follow-up: anti-platelet 97.6 to 88.0% (p = 0.012), beta-blockers 94.4 to 84.8% (p = 0.021) and statins 83.7 to 91.2% (p = 0.035). Patients medicated with a combination of anti-platelet, beta blockers and statins showed a decrease from 86.4 to 66.3% (p < 0.0001). It is necessary to study the causes for the decreased adherence to long-term cardio-protective drugs.

Adherencia a la prevención secundaria de la enfermedad coronaria / Medication adherence to secondary prevention for coronary artery disease

Se comparó la adherencia a la prevención secundaria de enfermedad coronaria mediante el uso indicado de fármacos de probada eficacia, al momento del egreso hospitalario y a 3 años de seguimiento, en una cohorte de pacientes afiliados al Plan de Salud del Hospital Italiano. Se realizó un estudio de cohorte retrospectivo que incluyo 125 pacientes menores de 80 años de edad, afiliados a una red integrada de salud, con internación por síndrome coronario agudo. En el análisis se utilizó el test de McNemar. La edad media de los participantes fue 63.7 años (DS 10.08) y el 65.6% (IC95% 56.6-73.9) fue de sexo masculino. El 76.8% (IC95% 68.4-83.9) presentó como evento calificante un síndrome coronario agudo sin elevación del segmento ST. El tiempo de seguimiento promedio fue 2.94 años (DS 0.25). Se observó que el uso de drogas de probada eficacia en la prevención secundaria de enfermedad coronaria descendió entre el momento del egreso hospitalario y los 3 años de seguimiento: antiagregantes de 97.6 a 88.0% (p = 0.012); beta-bloqueantes de 94.4 a 84.8% (p = 0.021); estatinas 91.2 a 83.7% (p = 0.035). Uso combinado de antiagregantes, betabloqueantes y estatinas de 86.4 a 66.3% (p < 0.0001). Es necesario estudiar las causas de la disminución de la adherencia a drogas cardioprotectoras a largo plazo.(AU)

We compared the use of evidence-based secondary prevention drugs for coronary artery disease at hospital discharge and 3 years of follow-up in a group of patients associated to an integrated network of health services. We conducted a retrospective group study that included 125 patients under 80 years of age who were hospitalized for acute coronary syndrome. McNemar´s test was used to compare values at baseline and 3 years. The mean age of of participants was 63.7 years (SD ± 10.08) and 65.6% (95% CI 56.6-73.9) of male sex. The average follow-up time was 2.94 years (SD ± 0.25). The use of secondary prevention drugs for coronary heart disease decreased at 3 years of follow-up: anti-platelet 97.6 to 88.0% (p = 0.012), beta-blockers 94.4 to 84.8% (p = 0.021) and statins 83.7 to 91.2% (p = 0.035). Patients medicated with a combination of anti-platelet, beta blockers and statins showed a decrease from 86.4 to 66.3% (p < 0.0001). It is necessary to study the causes for the decreased adherence to long-term cardio-protective drugs.(AU)

Adherencia a la prevención secundaria de la enfermedad coronaria. / [Medication adherence to secondary prevention for coronary artery disease].

We compared the use of evidence-based secondary prevention drugs for coronary artery disease at hospital discharge and 3 years of follow-up in a group of patients associated to an integrated network of health services. We conducted a retrospective group study that included 125 patients under 80 years of age who were hospitalized for acute coronary syndrome. McNemars test was used to compare values at baseline and 3 years. The mean age of of participants was 63.7 years (SD ± 10.08) and 65.6

(95

CI 56.6-73.9) of male sex. The average follow-up time was 2.94 years (SD ± 0.25). The use of secondary prevention drugs for coronary heart disease decreased at 3 years of follow-up: anti-platelet 97.6 to 88.0

(p = 0.012), beta-blockers 94.4 to 84.8

(p = 0.021) and statins 83.7 to 91.2

(p = 0.035). Patients medicated with a combination of anti-platelet, beta blockers and statins showed a decrease from 86.4 to 66.3

(p < 0.0001). It is necessary to study the causes for the decreased adherence to long-term cardio-protective drugs.

Myths and facts concerning the use of statins in very old patients.

As population grows old, the number of persons at risk of cardiovascular events also grows. Though octogenarians form a small percentage of the general population their absolute risk of coronary and cerebrovascular disease is high, but there is still some doubt as to whether high plasma cholesterol levels increase vascular risk in this age group, as published data are conflicting. There is evidence that elevated plasma cholesterol increases the risk of coronary artery disease in older adults, and an inverse linear relationship was found between HDL cholesterol levels and the risk of mortality from ischemic heart disease in all age groups. The relationship between total plasma cholesterol and the risk of death from ischemic stroke is weak in younger populations and is even lower in people between 70 and 89 years, and is inverse for hemorrhagic stroke. However, studies showed that statin treatment lowers the risk of ischemic stroke, independently of age. Statins are underused in the elderly, perhaps because of lack of perception of the real vascular risk of older adults, concerns about statin efficacy or safety in this population, or the increase of comorbidities and polypharmacy which could affect adherence to drug-treatment. Trials designed to address this issues are urgently needed, in order to be able to make evidence-guided decisions on lipid management of the elderly.

Protocolo de efectividad de un programa de prevención secundaria de eventos coronarios / Effectiveness assessment of a program for secondary prevention of coronary events

A pesar de los avances farmacológicos en el tratamiento de la cardiopatía isquémica se observan dificultades para alcanzar los objetivos terapéuticos en la práctica clínica. Con el propósito de superarlas se ha propuesto implementar en el Hospital Italiano de Buenos aires (HIBA) un programa de prevención secundaria. El objetivo de este artículo es describir cómo será la implementación del programa y su protocolo de evaluación. Material y Métodos: estudio cuasiexperimental con control histórico: cohorte prospectiva intervenida comparada con una cohorte retrospectiva control. El período de seguimiento será de 3 años. Serán elegibles pacientes de 18 a 79 años,afiliados al Plan de Salud, que hayan ingresado en unidad coronaria del HIBa por síndrome coronario agudo con elevación del segmento ST o sin ella.Durante el programa, el equipo de salud trabajará con los pacientes aplicando técnicas cognitivo-conductuales para lograr cambios en el estilo de vida, estimulará el autocuidado por parte de los pacientes y coordinará su atención para favorecer la continuidad del cuidado. Se implementarán intervenciones según el caso clínico: terapia antitabáquica, ejercicio, educación nutricional, tratamiento de obesidad/sobrepeso, monitoreo del control de factores de riesgo cardiovascular modificables y de la adherencia a tratamientos farmacológicos. La efectividad del Programa se evaluará mediante un indicador compuesto de calidad de atención. Conclusiones: considerando que un gran número de pacientes con enfermedad coronaria no logra alcanzar las metas terapéuticas, es necesario desarrollar un programa basado en un equipo multidisciplinario y centrado en las necesidades del paciente. La efectividad a largo plazo de este programa en nuestro centro debe ser evaluada.

Recent respiratory infection predicts atherothrombotic stroke: case-control study in a Buenos Aires healthcare system.

BACKGROUND AND PURPOSE: Increasing evidence links infections to atherosclerosis. Case-control and cohort studies have found that infections, especially respiratory and dental, are associated with coronary heart disease. However, data on the association of infections with cerebrovascular disease are limited, especially beyond Europe and the United States. We assessed the relationship between recent infections and atherothrombotic disease in a South American cohort. METHODS: We conducted a case-control study of 105 cases and 354 control subjects in a Buenos Aires healthcare system matched by age (mean age, 73.2+/-12.3 and 72.9+/-12.8 years), sex, and major cardiovascular risk factors. Cases were patients hospitalized with atherothrombotic ischemic stroke from December 2006 to October 2007. Control subjects were randomly assigned from an electronic outpatient database. Data from the preceding year on inpatient and ambulatory respiratory, urinary and abdominal infections as well as peripheral white blood cell count were collected. RESULTS: Infections were more frequent in cases than control subjects (29% versus 13%; OR, 2.6; 95% CI, 1.4 to 4.5; P=0.0004); however, this was driven by community-acquired respiratory tract infections (19% versus 6%; OR, 3.9; 95% CI, 1.9 to 8; P<0.001) because there were no differences between cases and control subjects for other types of infection. Respiratory tract infections were the most prevalent type of infection during the 3 months before an atherothrombotic ischemic event, occurring more in cases compared with control subjects (17% versus 4%; OR, 5; 95% CI, 2.2 to 11.3; P<0.001). In multivariable analysis adjusting for major vascular risk factors, history of respiratory infection in the prior year was associated more with cases than control subjects (OR, 4.9; 95% CI, 2.3 to 10.2;P<0.001). White blood cell count was slightly higher in cases versus control subjects (7602+/-2058 versus 7121.6+/-1947, P=0.01). CONCLUSIONS: In this South American cohort, recent respiratory tract infections were significantly associated with atherothrombotic stroke, suggesting that prompt identification and treatment of individuals with or at risk for these infections may mitigate the burden from this type of stroke.