The weight-adjusted-waist index predicts all-cause and cardiovascular mortality in general US adults.

BACKGROUND: The authors examined the relationship between Weight-adjusted Waist Index (WWI) and all-cause and cardiovascular mortality among adults in the US. METHODS: This prospective cohort study included 26,882 individuals who participated in the National Health and Nutrition Examination Survey (NHANES) from 2005 through 2014. WWI was calculated as waist circumference divided by the square root of weight. The main outcomes of this study were all-cause mortality and cardiovascular mortality. Mortality status and cause of death were determined by NHANES-linked National Death Index records through December 31, 2015. Cox proportional hazard models and Kaplan-Meier analysis were used to estimate Hazard Ratios (HR) and 95% CIs for mortality for all causes and cardiovascular diseases. RESULTS: A total of 26,882 participants with a mean WWI of 10.89 ± 0.01, of whom 49.23% were male. The average follow-up time was 68.95 ± 1.07 months, and 1870 participants were determined as deceased (4.99%), including 349 cardiovascular death (0.88%). The Kaplan-Meier analysis demonstrated a significant difference in all-cause and cardiovascular mortality between patients with WWI <11.33 and ≥11.33 (both log-rank test p < 0.0001). The fully adjusted Cox proportional hazard model indicated that a higher WWI level (≥ 11.33) was associated with an increased 95% risk for cardiovascular mortality (HR = 1.95, 95% CI 1.30‒2.93) and 68% risk for all-cause death (HR = 1.68, 95% CI 1.41‒2.00) compared with the counterparts. CONCLUSIONS: Elevated WWI levels were associated with a higher risk of cardiovascular mortality and all-cause mortality independently.

The weight-adjusted-waist index predicts all-cause and cardiovascular mortality in general US adults

Abstract Background The authors examined the relationship between Weight-adjusted Waist Index (WWI) and all-cause and cardiovascular mortality among adults in the US. Methods This prospective cohort study included 26,882 individuals who participated in the National Health and Nutrition Examination Survey (NHANES) from 2005 through 2014. WWI was calculated as waist circumference divided by the square root of weight. The main outcomes of this study were all-cause mortality and cardiovascular mortality. Mortality status and cause of death were determined by NHANES-linked National Death Index records through December 31, 2015. Cox proportional hazard models and Kaplan-Meier analysis were used to estimate Hazard Ratios (HR) and 95% CIs for mortality for all causes and cardiovascular diseases. Results A total of 26,882 participants with a mean WWI of 10.89 ± 0.01, of whom 49.23% were male. The average follow-up time was 68.95 ± 1.07 months, and 1870 participants were determined as deceased (4.99%), including 349 cardiovascular death (0.88%). The Kaplan-Meier analysis demonstrated a significant difference in all-cause and cardiovascular mortality between patients with WWI <11.33 and ≥11.33 (both log-rank testp < 0.0001). The fully adjusted Cox proportional hazard model indicated that a higher WWI level (≥ 11.33) was associated with an increased 95% risk for cardiovascular mortality (HR = 1.95, 95% CI 1.30‒2.93) and 68% risk for all-cause death (HR = 1.68, 95% CI 1.41‒2.00) compared with the counterparts. Conclusions Elevated WWI levels were associated with a higher risk of cardiovascular mortality and all-cause mortality independently.

Vericiguat in patients with coronary artery disease and heart failure with reduced ejection fraction.

AIMS: Coronary artery disease (CAD) portends worse outcomes in heart failure (HF). We aimed to characterize patients with CAD and worsening HF with reduced ejection fraction (HFrEF) and evaluate post hoc whether vericiguat treatment effect varied according to CAD. METHODS AND RESULTS: Cox proportional hazards were generated for the primary endpoint of cardiovascular death or HF hospitalization (CVD/HFH). CAD was defined as previous myocardial infarction, percutaneous coronary intervention, or coronary artery bypass grafting. Of 5048 patients in VICTORIA with available data on CAD status, 2704 had CAD and were older, were more frequently male, diabetic, and had a lower glomerular filtration rate than those without CAD (all p <0.0001). Use of implantable cardioverter defibrillators and cardiac resynchronization therapy (CRT) was higher in patients with versus without CAD (33.5% vs. 21.1%; p <0.0001 and 16.3% vs. 12.8%; p = 0.0006). The primary endpoint of CVD/HFH was higher in those with versus without CAD (40.6 vs. 30.1/100 patient-years; adjusted hazard ratio [HR] 1.23; p <0.001) as was all-cause mortality (17.9% vs. 12.7%; adjusted HR 1.32; p <0.001). The primary outcome of CVD/HFH associated with vericiguat in patients with or without CAD was 38.8 versus 27.6 per 100 patient-years and for placebo was 42.6 versus 32.7 per 100 patient-years (interaction p = 0.78). CONCLUSION: In this post hoc study, CAD was associated with more CVD and HFH in patients with HFrEF and worsening HF. Vericiguat was beneficial and safe regardless of concomitant CAD.

Instrumentos para la investigación de la muerte súbita cardiovascular / Tools for the study of sudden cardiovascular death

Introducción: La mitad de las muertes cardiovasculares son debidas a una de las manifestaciones de mayor impacto y significación dentro de la enfermedad isquémica del corazón: la muerte súbita cardiovascular. Objetivo: Describir el Algoritmo Diagnóstico y el Modelo de Recolección del Dato Primario utilizados como instrumentos para la investigación de la muerte súbita cardiovascular en Cuba. Métodos: Se presenta un Algoritmo Diagnóstico con la metodología para el estudio de los casos de muerte súbita cardiovascular y un Modelo de Recolección del Dato Primario con las principales variables sociodemográficas, clínicas y anatomo-patológicas. Resultados: El Grupo de Investigación en Muerte Súbita ha desarrollado, en un periodo de 25 años (1995-2020), investigaciones científicas con la aplicación del Algoritmo Diagnóstico y el empleo del Modelo de Recolección del Dato Primario. De las 33 718 muertes naturales estudiadas mediante estos instrumentos, se han documentado 2252 decesos súbitos, lo que representa el 6,6 por ciento de la mortalidad global registrada. Conclusiones: Se hace necesario por los colectivos de investigación disponer de instrumentos que permitan ejecutar estudios poblacionales sobre la muerte súbita cardiovascular, considerando que el 90 por ciento de los eventos anualmente sobreviene en este grupo(AU)

Introduction: Half of all cardiovascular deaths are due to sudden cardiovascular death, one of the manifestations with the greatest impact and significance in the realm of ischemic heart disease. Objective: Describe the Diagnostic Algorithm and the Primary Data Collection Model used as tools to study sudden cardiovascular death in Cuba. Methods: A presentation is made of a Diagnostic Algorithm for the study of sudden cardiovascular death cases accompanied by the corresponding methodology, and a Primary Data Collection Model with the main sociodemographic, clinical and anatomopathological variables. Results: The Sudden Death Research Team has used the Diagnostic Algorithm and Primary Data Collection Model herein presented as a scientific research tool for a period of 25 years (1995-2020). Of the 33 718 deaths by natural causes studied with these tools, 2 252 have been sudden, representing 6.6 percent of the overall mortality recorded. Conclusions: Research teams should have access to tools for the conduct of population studies about sudden cardiovascular death, considering that 90 percent of the events recorded annually occur in this risk group(AU)

Occupational mortality in the New Mexico oil and gas industry.

New Mexico's oil and natural gas industry has the second highest occupational fatality rate among oil and gas workers in the nation. There is currently limited data available regarding the top contributing factors to occupational mortality specific to the state's oil and gas industry. This study seeks to understand causes of mortality among oil and gas workers in New Mexico between 2008 and 2018. To facilitate this study, case reports were obtained from the New Mexico Office of the Medical Investigator, and population data was acquired from the US Department of Labor. In this 11-year span, there were 73 cases, with an average annual mortality rate of 37 deaths per 100,000 oil and gas workers. Leading causes of death were vehicle accidents (36%), cardiovascular incidents (22%), and crush injuries (19%). The majority of vehicle accidents involved single vehicle accidents, and correct seat belt use was only documented 23% of the time. The majority of cardiovascular deaths were due to arteriosclerotic and atherosclerotic cardiovascular disease. Alcohol was present in 18% of cases, and drugs were present in 19% of cases with methamphetamine present in 10% of investigated deaths. This is the first study to directly include cardiovascular incidents in the leading causes of death; otherwise, this study reflects national data reporting vehicle accidents and crush injuries as the leading causes of death. Going forward, prevention measures should effectively target safe driving practices focusing on seatbelt use, and mitigation of workplace drug and alcohol consumption.

Estudio de género en la muerte súbita cardiovascular / Study of Gender in Sudden Cardiovascular Death

RESUMEN Fundamento las enfermedades cardiovasculares representan la principal causa de muerte en el mundo, específicamente, la muerte súbita cardiovascular ocasiona el 50 % de todas las muertes por esta causa. Sin embargo, existen diferencias de género entre los determinantes que las producen. Objetivo describir el comportamiento de la muerte súbita cardiovascular según sexo en el municipio Arroyo Naranjo, en la Habana, Cuba, entre los años 2007 y 2014. Métodos se realizó un estudio descriptivo, correlacional y transversal, en el municipio habanero de Arroyo Naranjo, entre los años 2007 y 2014. Fueron incluidos todos los casos de muerte súbita cardiovascular, atendidos en el Hospital Clínico Quirúrgico Julio Trigo López (N=605). Se estudió la correlación de sexo y otros factores sociodemográficos (edad, nivel de escolaridad, ocupación, situación conyugal) y entre la variable sexo y factores de riesgo (diabetes mellitus, consumo de alcohol, tabaquismo, hábitos dietéticos, inactividad física, valor del hematocrito y dislipidemia). Se aplicaron a partir de variables los diferenciales determinantes entre hombres y mujeres. Se utilizó la prueba estadística Chi Cuadrado y el modelo de los Residuos Corregidos de Haberman. Resultados en los hombres los factores de riesgo más frecuentes fueron: el tabaquismo, el consumo de alcohol y la hipertensión arterial. Las mujeres se caracterizaron por más inactividad física y estuvieron más afectadas por diabetes mellitus, dislipidemia y valores elevados de hematocrito. Conclusión la muerte súbita cardiovascular en el municipio de Arroyo Naranjo de La Habana en el período analizado afectó a hombres fumadores y consumidores de alcohol siendo más hipertensos que las mujeres. Las mujeres con mayor inactividad física resultaron ser más diabéticas, dislipidémicas y presentaron un mayor valor referencial del hematocrito que los hombres.

ABSTRACT Background: cardiovascular diseases represent the main cause of death in the world, specifically, sudden cardiovascular death causes the 50 % of all deaths from this cause. However, there are gender differences between the determinants that produce them. Objective: to describe the gender differences in sudden cardiovascular death according to sex in the municipality of Arroyo Naranjo, in Havana, Cuba, between 2007 and 2014. Methods a descriptive, correlational and cross-sectional study was carried out in the Arroyo Naranjo municipality Havana, between 2007 and 2014. All cases of sudden cardiovascular death treated at the Julio Trigo López Clinical Surgical Hospital were included (N = 605). The correlation between sex and other sociodemographic factors (age, education, occupation, marital status), and between the variable sex and risk factors (diabetes mellitus, alcohol consumption, smoking, dietary habits, physical inactivity, hematocrit value and dyslipidemia). The determining differentials between men and women were applied from variables. The Chi Square statistical test and the Haberman Corrected Residuals model were used. Results: in men, the most frequent risk factors were: smoking, alcohol consumption and arterial hypertension. Women were characterized by more physical inactivity and were more affected by diabetes mellitus, dyslipidemia, and elevated hematocrit values. Conclusion sudden cardiovascular death in the municipality of Arroyo Naranjo, Havana, in the period analyzed affected men who smoked and consumed alcohol, being more hypertensive than women. Women with greater physical inactivity were found to be more diabetic, dyslipidemic, and presented a higher reference value of hematocrit than men.

Preoperative soluble VCAM-1 contributes to predict late mortality after coronary artery surgery.

BACKGROUND: Soluble vascular cell adhesion molecule-1 has been associated with long-term cardiovascular mortality in patients with stable coronary artery disease and to the development of new atrial fibrillation in subjects with cardiovascular risk factors but no evidence of cardiac disease. HYPOTHESIS: Preoperative soluble vascular cell adhesion molecule-1 predicts the risk of future all-cause death and cardiovascular death among patients submitted to elective coronary artery bypass surgery. METHODS: From a cohort of 312 patients who underwent elective coronary artery bypass surgery prospectively followed for a median of 6.7 years, we evaluated the prognostic role of preoperative soluble vascular cell adhesion molecule-1, inflammatory markers, CHA2DS2-VASc score and development of postoperative atrial fibrillation (POAF). Univariable and multivariable Cox regression analyses were performed to establish an association of these parameters with long term all-cause death and cardiovascular death. RESULTS: During 2112 person-years of follow-up, we observed 41 deaths, 10 were cardiovascular deaths. Independently increased levels of preoperative soluble vascular cell adhesion molecule-1, POAF, and CHA2DS2-VASc score were associated with all-cause mortality. After multivariate adjustment, elevated preoperative soluble vascular cell adhesion molecule-1 and POAF were the only independent predictors of all-cause death. Also, preoperative soluble vascular cell adhesion molecule-1, POAF, and CHA2DS2-VASc score resulted in being independent predictors of cardiovascular mortality. CONCLUSIONS: Increased circulating levels of preoperative soluble vascular cell adhesion molecule-1, together with POAF and CHA2DS2-VASc score, were significantly associated with future all-cause death and cardiovascular death among patients submitted to coronary artery bypass surgery.

Association of endothelial dysfunction with cardiovascular risk factors and new-onset diabetes mellitus in patients with hypertension.

Asymmetric dimethylarginine (ADMA), which is the main endogenous inhibitor of nitric oxide synthase, plays a critical role in the process of endothelial dysfunction. The authors evaluated the association between high plasma ADMA levels in patients with hypertension and the presence of cardiovascular risk factors and the development of type 2 diabetes mellitus (DM) and cardiovascular outcomes, including death. The authors evaluated 191 patients with hypertension who were stratified into two groups according to the median value of basal ADMA: those with high levels of plasma ADMA (>0.55 µmol/L) and low levels of plasma ADMA (≤0.55 µmol/L) who were prospectively evaluated over 5.8 years. High ADMA levels were seen in patients with higher weight, body mass index, waist circumference, triglycerides, uric acid, and high-sensitivity C-reactive protein, and lower levels of high-density lipoprotein cholesterol and in patients with type 2 DM. There was an association between high plasma ADMA levels and the occurrence of cardiovascular death. In a subgroup of patients with hypertension free from metabolic syndrome and DM at baseline, there was an association between high ADMA levels and the development of type 2 DM. This study confirms the association of high plasma ADMA levels and the presence of cardiovascular risk factors in patients with hypertension and suggests a positive predictive value of high plasma ADMA levels for cardiovascular death in patients with hypertension and also for the development of type 2 DM in a subgroup of patients with hypertension free from metabolic abnormalities.

Disrupted day-night pattern of cardiovascular death in obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea (OSA) patients who suffer sudden cardiac death die predominantly during the night. We aimed to investigate whether all cardiovascular-related deaths display the same night-time peak as sudden cardiac death. METHODS: Data from a large cohort of adults who underwent full-night polysomnography between 1985 and 2015 in a university-affiliated sleep clinic were analyzed. Time and cause of death of these patients and of persons from the general population were identified in death certificates from the State Health Secretariat. The day-night pattern of cardiovascular death was compared among groups of non-OSA, OSA (apnea-hypopnea index, AHI ≥5), CPAP users, and persons from the general population. RESULTS: Among 619 certificates, 160 cardiovascular-related deaths were identified. The time of death of the 142 persons with OSA was uniformly distributed over 24 h, with neither an identifiable peak nor a circadian pattern (Rayleigh test; P = 0.8); the same flat distribution was seen in those with purported CPAP use (n = 49). Non-OSA individuals presented a morning peak and a night nadir of deaths, clearer when analyzed in eight-hour intervals. The same pattern was observed in 92 836 certificates from the State general population, with cardiovascular deaths showing the expected morning peak, night nadir, and a significant circadian pattern (Rayleigh test; P < 0.001). CONCLUSIONS: In OSA patients, the distribution of cardiovascular-related deaths throughout the 24-h period is virtually flat, in contrast with the described nighttime peak of sudden cardiac death. OSA-related phenomena during nighttime might be blunting the mechanisms, arrhythmic or not, behind the morning peak of cardiovascular-related deaths.

Net atrioventricular compliance is an independent predictor of cardiovascular death in mitral stenosis.

OBJECTIVES: Rheumatic mitral stenosis (MS) is a progressive disease, and risk of death may persist despite relief of the obstruction. Net atrioventricular compliance (Cn) modulates the overall haemodynamic burden of the MS and may be useful in predicting cardiovascular death after percutaneous mitral valvuloplasty (PMV). METHODS: A total of 427 patients (mean age 50±16 years, 84% female) with severe MS undergoing PMV were enrolled. Doppler-derived Cn was estimated at baseline using a previously validated equation. The primary endpoint was late cardiovascular death, and the secondary endpoint was a composite of all-cause mortality, mitral valve (MV) replacement or repeat PMV over a median follow-up of 31 months (IQR: 7.8-49.2 months). RESULTS: At baseline, 209 patients (49%) were in New York Heart Association (NYHA) functional class III or IV. During follow-up, 49 patients died (41 cardiovascular deaths), 50 underwent MV replacement and 12 required repeat PMV, with an overall incidence of cardiac mortality and adverse events of 4.1 deaths and 11.1 events per 100 patient-years, respectively. Low baseline Cn was a strong predictor of both cardiac death (adjusted HR 0.70, 95% CI 0.49 to 0.86) and composite endpoint (adjusted HR 0.81, 95% CI 0.67 to 0.91) after adjusting for clinical factors, baseline pulmonary artery pressure, tricuspid regurgitation severity, right ventricular function and immediate procedural haemodynamic data. The inclusion of Cn in a model with conventional parameters resulted in improvement in 5-year cardiovascular mortality risk prediction. CONCLUSIONS: Baseline Cn is a strong predictor of cardiovascular death in patients with MS undergoing PMV, independent of other prognostic markers of decreased survival in MS, including baseline patient characteristics and postprocedural data. Cn assessment therefore has potential value in evaluation of cardiovascular mortality risk in the setting of MS.

Prognostic effect of high-flux hemodialysis in patients with chronic kidney disease

We investigated the prognostic effects of high-flux hemodialysis (HFHD) and low-flux hemodialysis (LFHD) in patients with chronic kidney disease (CKD). Both an electronic and a manual search were performed based on our rigorous inclusion and exclusion criteria to retrieve high-quality, relevant clinical studies from various scientific literature databases. Comprehensive meta-analysis 2.0 (CMA 2.0) was used for the quantitative analysis. We initially retrieved 227 studies from the database search. Following a multi-step screening process, eight high-quality studies were selected for our meta-analysis. These eight studies included 4967 patients with CKD (2416 patients in the HFHD group, 2551 patients in the LFHD group). The results of our meta-analysis showed that the all-cause death rate in the HFHD group was significantly lower than that in the LFHD group (OR=0.704, 95%CI=0.533-0.929, P=0.013). Additionally, the cardiovascular death rate in the HFHD group was significantly lower than that in the LFHD group (OR=0.731, 95%CI=0.616-0.866, P<0.001). The results of this meta-analysis clearly showed that HFHD decreases all-cause death and cardiovascular death rates in patients with CKD and that HFHD can therefore be implemented as one of the first therapy choices for CKD.

Infarto miocárdico crónico como factor de riesgo de muerte súbita cardíaca / Chronic myocardial infarction as a risk factor for sudden cardiac death

INTRODUCCIÓN: el infarto miocárdico crónico constituye un factor de riesgo independiente para la muerte súbita cardiovascular. OBJETIVO: identificar la presencia de infarto miocárdico crónico en fallecidos de muerte súbita cardiovascular en un estudio poblacional. MÉTODO: se diseñó un estudio observacional, descriptivo y de corte transversal de los casos diagnosticados de forma consecutiva en 11 años, en el hospital "Julio Trigo López" en La Habana, Cuba. RESULTADOS: el infarto miocárdico crónico estuvo presente en el 24,7 % del universo analizado, con predominio en hombres (64,7 %), en edades de 60-74 años (41,3 %). La asistolia fue la arritmia documentada con mayor frecuencia en el medio extra hospitalario (51,6 %). El diagnóstico de un trombo coronario fresco y/o infarto agudo del miocardio representó la principal causa de muerte (63,5 %). CONCLUSIONES: en los pacientes con infarto miocárdico crónico, la muerte súbita constituye la causa más frecuente de muerte. Este factor de riesgo incrementa, por sí sólo, la probabilidad de ocurrencia del evento en los primeros 18 meses de ocurrida la necrosis miocárdica aguda. En la estratificación de riesgo del paciente post-infarto se hace necesaria la búsqueda de inestabilidad eléctrica, isquemia residual y disfunción ventricular izquierda como predictores para este tipo de evento.

INTRODUCTION: chronic myocardial infarction is an independent risk factor for sudden cardiovascular death. OBJECTIVE: identify the presence of chronic myocardial infarction in sudden cardiovascular death victims included in a population study. METHOD: a cross-sectional observational descriptive study was conducted of cases diagnosed consecutively in a period of 11 years at Julio Trigo López hospital in Havana, Cuba. RESULTS: chronic myocardial infarction was present in 24.7% of the study universe, with a predominance of men (64.7%) and the 60-74 age group (41.3%). Asystole was documented as the most common arrhythmia occurring in out-of-hospital conditions (51.6%). The main causes of death (63.5%) were a freshly diagnosed coronary thrombus and/or acute myocardial infarction. CONCLUSIONS: sudden death is the most common cause of death among patients with chronic myocardial infarction. This risk factor of itself increases the probability of occurrence of the event during the 18 months following the appearance of acute myocardial necrosis. Stratification of risk in post-infarction patients should include the search for electrical instability, residual ischemia and ventricular dysfunction as predictors of this type of event.

Resultados del Grupo de Investigación en Muerte Súbita, 20 años después de su creación / The Research Group on Sudden Death and its results after 20 years

La muerte súbita representa en la actualidad uno de los principales desafíos para los sistemas sanitarios a nivel mundial dada su elevada incidencia, dramatismo en su presentación y años de vida que se pierden prematuramente como consecuencia de esta entidad. OBJETIVO: describir los antecedentes de la creación hace 20 años del Grupo de Investigación en Muerte Súbita en Cuba y mostrar sus resultados más significativos. MÉTODO: se realizó una revisión documental de los primeros 20 años de trabajo de investigación científica del Grupo de Investigación en Muerte Súbita en Cuba (1995-2014). RESULTADOS: se estudiaron 24 758 muertes naturales a las cuales se les aplicó un algoritmo diagnóstico para documentar 1 953 eventos de muerte súbita cardiovascular, que representaron el 7,8 por ciento de la mortalidad global registrada. El 98,1 por ciento de la casuística investigada correspondió a 14 municipios de la provincia La Habana. El 2 por ciento restante incluyó 26 municipios de 11 provincias del país. Los estudios han demostrado un incremento en la probabilidad para este evento en pacientes con hipertensión arterial, obesidad, diabetes mellitus, cardiopatía isquémica, necrosis miocárdica previa, tabaquismo, engrosamiento ventricular izquierdo y alteración del perfil lipídico. CONCLUSIONES: la creación del Grupo de Investigación en Muerte Súbita ha permitido, en los últimos 20 años, el diseño y ejecución de investigaciones científicas encaminadas a la caracterización epidemiológica de este problema de salud en Cuba, elementos útiles para trazar estrategias de intervención que permitan lograr una disminución sensible en la incidencia e impacto económico, familiar y social de esta entidad(AU)

Sudden death presently represents one of the main challenges for the health care systems worldwide due to high incidence, dramatic presentation and life years prematurely lost as a result of this event. OBJECTIVE: to describe the background of the creation of the research group on sudden death in Cuba twenty years ago, and to show its most significant results. METHODs: a documentary review of the first 20 years of scientific research work performed by the Research Group on Sudden Death in Cuba (1995-2014). RESULTS: twenty four thousand eight hundred and seventy six deaths of natural causes were studied and applied a diagnostic algorithm to document 1 953 events of sudden cardiovascular death accounting for 7.8 percent of recorded global mortality. In the studied casuistry, 98.1 percent went to 14 municipalities from 11 provinces. The studies showed increased probabilities for this event in patients suffering blood hypertension, obesity, diabetes mellitus, ischemia, previous myocardial necrosis, smoking, left ventricle thickening, and lipid profile impairment. CONCLUSIONS: the creation of the Research Group on Sudden Death allowed in the last twenty years designing and performing scientific research studies aimed at the epidemiological characterization of this health problem in Cuba and those are useful elements to draw up intervention strategies to significantly reduce the incidence and the economic, family and social impact of this event(AU)