Real-world outcomes of ponatinib treatment in 724 patients with CML and Ph+ ALL: a post-marketing surveillance study with a special interest in arterial occlusive events in Japan.

BACKGROUND: In September 2016, ponatinib was approved in Japan for the treatment of patients with chronic myeloid leukemia with resistance/intolerance to prior tyrosine kinase inhibitors and patients with relapsed or refractory Philadelphia chromosome-positive acute lymphoblastic leukemia. METHODS: We conducted a post-marketing all-case surveillance to study the safety and efficacy of ponatinib in clinical practice, focusing on arterial occlusive events. RESULTS: Data from 724 patients were collected for 2 years from the initiation of ponatinib. The arterial occlusive events were reported in 6.49% (47/724) with an exposure-adjusted incidence rate of 6.8/100 person-years. The risks associated with arterial occlusive events were age and comorbidities including hypertension and diabetes. At 104 weeks, the cumulative major molecular response rate in patients with chronic-phase chronic myeloid leukemia was 67.2% and the complete cytogenetic response in patients with Philadelphia chromosome-positive acute lymphoblastic leukemia was 80.0%. Furthermore, the estimated 1-year overall survival rate was 98.5% for chronic-phase chronic myeloid leukemia and 68.6% for Philadelphia chromosome-positive acute lymphoblastic leukemia. CONCLUSIONS: This surveillance demonstrated that ponatinib has a favorable safety and efficacy profile in Japanese patients and also showed the necessity of closely monitoring arterial occlusive events in older adults and patients with predisposing factors for atherosclerosis.

Distal Versus Proximal Radial Arterial Access for Percutaneous Coronary Angiography and Intervention: Updated Meta-Analysis of Randomized Controlled Trials.

Radial artery occlusion (RAO) is a major impediment to reintervention in patients who underwent proximal transradial access (p-TRA) for coronary catheterization. Distal transradial access (d-TRA) at the level of snuffbox distal to the radial artery bifurcation is a novel alternative to p-TRA. We conducted an updated meta-analysis of all available randomized controlled trials (RCTs) to compare the incidence of RAO between p-TRA and d-TRA, along with access site-related complications. PubMed, Web of Science, and Google Scholar were searched for RCTs published since 2017 to October 2023 comparing d-TRA and p-TRA for coronary angiography and/or intervention. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals were calculated using the random-effects model for procedural and clinical outcomes for the 2 approaches. A total of 18 RCTs with 8,205 patients (d-TRA n = 4,096, p-TRA n = 4,109) were included. The risk of RAO (RR 0.31, 0.21 to 0.46, p ≤0.001) and time to hemostasis (minutes) (MD -51.18, -70.62 to -31.73, p <0.001) was significantly lower in the d-TRA group. Crossover rates (RR 2.39, 1.71 to 3.32, p <0.001), access time (minutes) (MD 0.93, 0.50 to 1.37, p <0.001), procedural pain (MD 0.46, 0.13 to 0.79, p = 0.006), and multiple puncture attempts (RR 2.13, 1.10 to 4.11, p = 0.03) were significantly higher in the d-TRA group. The use of d-TRA for coronary angiography and/or intervention is associated with a lower risk of RAO at the forearm and may preserve p-TRA site for reintervention in selective patients by reducing the incidence of RAO.

Comparison of long-term radial artery occlusion via distal vs. conventional transradial access (CONDITION): a randomized controlled trial.

BACKGROUND: The distal transradial access (dTRA) has become an attractive and alternative access to the conventional transradial access (TRA) for cardiovascular interventional diagnosis and/or treatment. There was a lack of randomized clinical trials to evaluate the effect of the dTRA on the long-term radial artery occlusion (RAO). METHODS: This was a prospective, randomized controlled study. The primary endpoint was the incidence of long-term RAO at 3 months after discharge. The secondary endpoints included the successful puncture rate, puncture time, and other access-related complications. RESULTS: The incidence of long-term RAO was 0.8% (3/361) for dTRA and 3.3% (12/365) for TRA (risk ratio = 0.25, 95% confidence interval = 0.07-0.88, P = 0.02). The incidence of RAO at 24 h was significantly lower in the dTRA group than in the TRA group (2.5% vs. 6.7%, P < 0.01). The puncture success rate (96.0% vs. 98.5%, P = 0.03) and single puncture attempt (70.9% vs. 83.9%, P < 0.01) were significantly lower in the dTRA group than in the TRA group. However, the number of puncture attempts and puncture time were higher in the dTRA group. The dTRA group had a lower incidence of bleeding than the TRA group (1.5% vs. 6.0%, P < 0.01). There was no difference in the success rate of the procedure, total fluoroscopy time, or incidence of other access-related complications between the two groups. In the per-protocol analysis, the incidence of mEASY type ≥ II haematoma was significantly lower in the dTRA group, which was consistent with that in the as-treated analysis. CONCLUSIONS: The dTRA significantly reduced the incidence of long-term RAO, bleeding or haematoma. TRIAL REGISTRATION: ClinicalTrials.gov identifer: NCT05253820.

In young patients with stroke of undetermined etiology, large vessel occlusions are less frequent in the group with high-risk patent foramen ovale.

INTRODUCTION: Patent foramen ovale (PFO) is present in a significant proportion of young patients with stroke of undetermined etiology, but is not always causal. Therefore, classifications (RoPE, PASCAL) have been developed to determine the probability that PFO is the stroke cause. However, the presence of an initial arterial occlusion as a prediction factor was not studied when these classifications were built. Our aim was to evaluate the presence of arterial occlusion in young patients with stroke of undetermined etiology with/without high-risk PFO. METHODS: From a prospectively-built monocentric database, we identified patients aged≥18 to<60-years with strokes of undetermined etiology and complete etiological work-up, including transesophageal echocardiography. We divided patients in two groups: (i) with high-risk PFO [i.e. PFO with large interatrial shunt (>30 microbubbles) or associated with atrial septal aneurysm] and (ii) with low-risk/without PFO. We recorded the presence of arterial occlusion and large vessel occlusion (LVO) in the acute phase. RESULTS: We included 96 patients; 55 (57%) had high-risk PFO. Their median age was 48 (40-52) years, and 28 (29%) were women. The percentages of patients with arterial occlusion and with LVO were lower in the high-risk PFO group than in the low-risk/without PFO group: 11 (20%) versus 19 (46%) (P=0.008), and 5 (9%) versus 15 (37%) (P=0.002), respectively. There was no difference in the median RoPE score between groups (P=0.30). CONCLUSION: The presence of LVO could represent a "red flag" of PFO causality in stroke of undetermined etiology, and could be implemented in future PFO-related stroke classifications.

Incidence and Outcomes of Visceral Ischemia in Acute Aortic Occlusion.

BACKGROUND: Acute aortic occlusion (AAO) is a morbid diagnosis in which mortality correlates with severity of ischemia on presentation. Visceral ischemia (VI) is challenging to diagnose and its presentation as a consequence of AAO is not well-studied. We aim to identify characteristics associated with VI in AAO to facilitate diagnosis. METHODS: Patients diagnosed with AAO who underwent revascularization were identified retrospectively from institutional records (2006-2020). The primary outcome was the development of VI (intra-abdominal ischemia). Univariate analysis was used to compare demographic, exam, imaging, and intraoperative variables between patients with and without VI in the setting of AAO. RESULTS: Ninety-one patients were included. The prevalence of VI was 20.9%. Preoperative comorbidities, time to revascularization, and operative approach did not differ between patients with and without VI. Patients with VI more frequently were transferred from outside institutions (100% vs. 53%, P = 0.02), presented with advanced acute limb ischemia (Rutherford III 36.9% vs. 7.5%, P < 0.01), and had elevated preoperative serum lactate (4.31 vs. 2.41 mmol/L, P < 0.01). VI patients had an increased occurrence of bilateral internal iliac artery (IIA) occlusion (47.4% vs. 18.1%, P = 0.01). Unilateral IIA occlusion, level of aortic occlusion, and patency of inferior mesenteric arteries were not associated with VI. Patients with VI had worse postoperative outcomes. In particular, VI conferred significant risk of mortality (odds ratio 5.45, P < 0.01). CONCLUSIONS: Visceral ischemia is a common consequence of AAO. Elevated lactate, bilateral IIA occlusion, and advanced acute limb ischemia (ALI) should increase clinical suspicion for concomitant VI with AAO and may facilitate earlier diagnosis to improve outcomes.

Evaluation of the distal radial approach in percutaneous coronary interventions. A controlled, randomized non-inferiority trial.

INTRODUCTION: The conventional radial approach (CRA), the gold standard approach for percutaneous coronary interventions (PCI), is associated with the risk of radial artery occlusion (RAO). The distal radial approach (DRA) is an effective alternative with fewer complications. AIM: To evaluate the efficacy in terms of puncture success and safety by RAO rate of the DRA in elective PCI in Tunisian patients. METHODS: It was a randomized controlled non-inferiority trial including patients hospitalized for elective PCI. The protocol was previously published (Tunis Med 2022; 100(3): 192-202). The primary endpoints were puncture success and RAO rate at 30 days. RESULTS: Overall, 250 patients were included and the groups were comparable. The preprocedural examination of the radial pulse and the Barbeau test were similar. The majority of PCIs were coronary angiography (82%). In ITT, respectively in CRA versus DRA, puncture success rates were similar (97.6% versus 96.8%; p≤0.500). RAO rates were similar (2.4% versus 3.2%; p≤0.500). Crossovers were similar. PCI through DRA lasted longer but was not more irradiating, however it required more contrast. Overall bleeding and vascular complications were similar. CONCLUSION: This study demonstrated the non-inferiority of DRA compared to CRA for elective PCIs in a Tunisian population regarding puncture success and RAO rate at 30 days. Multicenter trials including urgent PCI with systematic ultrasound screening for RAO are needed.

Impact of hepatitis virus infection on arterial calcification among incident hemodialysis patients / Impacto de la infección por el virus de la hepatitis en la calcificación arterial en nuevos pacientes en hemodiálisis

BACKGROUND: The impact of hepatitis virus infection on arterial calcification (AC) was not studied. OBJECTIVE: To study the prevalence, severity and distribution of AC in incident hemodialysis patients with hepatitis B and C viral infection. Cases and methods: 172 stage 5 CKD adults (98 male and 74 female) were included; 58 of them were seronegative for both hepatitis B and C (SN group), 48 were positive for hepatitis B virus infection (HBV group) and 66 were hepatitis C virus positive (HCV group). Beside histopathology of the obtained arterial samples, all these cases were examined for body mass index (BMI), serum calcium (Ca), phosphorus (P), alkaline phosphatase (AP), serum albumin, uric acid (UA), alanine transaminase (ALT), parathormone (PTH), fibroblast growth factor 23(FGF23), interleukin 6 (IL6), and 25 hydroxy vitamin D (25 (OH) vit D), hemoglobin concentration, and serum ferritin. RESULTS: 86 (50%) of the cases had AC; 11 of them were in SN group (19%), 9 in HBV group (18.8%) and all the 66 CV group (100%). In SN group, 4 had intimal calcification, 5 had medial calcification, and 2 had both intimal and medial calcification. In HBV group, 9 had intimal calcification, while no cases were encountered with either medial or both site calcifications. In HCV group, 16 had intimal calcification, 31 had medial calcification, and 19 had both intimal and medial calcification. Calcification was in the form of spots in one case in SN group, and 6 cases in HBV group, a single plaque of calcification in 5 cases of SN group, 3 cases of HBV group, and 16 cases of HCV group, multiple plaques were detected in 4 cases in SN group, and 31 cases in HCV group, and diffuse calcification in one case in SN group, and 19 cases in HCV group. In HBV group, calcification was only detected in patients with high viremia, while all patients with low or moderate viremia were devoid of calcification. In HCV group, all patients with low viremia had intimal solitary plaque of calcification, all patients with moderate viremia had multiple plaques of medial calcification, while all patients with high viremia had diffuse intimal and medial calcification. Both groups of viral hepatitis were significantly different in comparison to SN group in either distribution or calcification score (P < 0.001 in all). HBV group had significantly lower serum P, CaxP and PTH in comparison to SN group (4.6±0.66 vs. 5.45±0.77mg/dL, 36.4±7.2 vs. 44.1±8.69, and 348±65.4 vs. 405.9±83.2pg/mL, P<0.001, <0.001, and 0.035 respectively). On the other hand, HCV group did not show any significant difference in any of the studied parameters compared to SN group. CONCLUSION: HCV positive patients are more prone to develop AC that is more extensive. HBV positive patients were less likely to have arterial medial calcification, probably related to lower serum phosphorus, CaxP product and PTH. HCV infection should be added as risk factor for AC among CKD patients. Further studies are needed to confirm these findings

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Asociaciones entre la estructura microvascular de la retina y la gravedad y extensión de la enfermedad arterial coronaria / Associations between retinal microvascular structure and the severity and extent of coronary artery disease

Introducción: Las implicaciones de las alteraciones microvasculares con los procesos fisiopatológicos relacionados con la cardiopatía isquémica son cada vez más reconocidas, aunque no se pueda precisar su contribución exacta. El objetivo de este estudio es definir la asociación entre los signos microvasculares de la retiniana y la extensión y severidad de la enfermedad coronaria. Métodos: Se incluyeron a 1.120 pacientes del Australian Heart Eye Study. El calibre de los vasos de la retiniana se midió a partir de imágenes digitales. La enfermedad coronaria en la angiografía se cuantificó con 3 métodos: una escala basada en el número de arterias y segmentos afectados, la escala Gensini score y la escala Extent. Resultados: Tras un análisis multivariante ajustado por los factores cardiovasculares clásicos; las mujeres con arteriolas retinianas estrechas (en el cuartil más bajo del calibre frente al cuartil más alto) y los varones con venas de la retina amplias (cuartil más alto frente al más bajo) tenían un riesgo 2 veces y 54% mayor, respectivamente de tener estenosis coronarias ≥50%. Las mujeres en el tercer frente al primer tercil del calibre de las venas de la retina tenían una probabilidad 92% y 2 veces mayor de tener puntuaciones más altas en las escalas Gensini y Extent. Las mujeres con menor frente al mayor tercil del calibre de las venas retinianas tenían mayor riesgo de presentar mayor puntuación en la escala Extent(odds ratio: 2,99, intervalo de confianza al 95%: 1,45-6,16). En los varones se observaron tendencias no significativas entre el calibre microvascular de la retina y las puntuaciones de las escalas Gensini y Extent. Conclusiones: La presencia de ciertas alteraciones microvasculares retinianas (estrechamiento del calibre de las arteriolas y la dilatación del calibre de las venas) se asoció en las mujeres con enfermedad coronaria más difusa y severa (AU)

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Prevalencia de enfermedad arterial periférica y factores asociados en pacientes mayores de 65 años mediante dispositivo automático oscilométrico / Prevalence of peripheral arterial disease and associated factors in elderly patients using an automated oscillometric device

El objetivo del trabajo es determinar la presencia de enfermedad arterial periférica (EAP) y los factores a los que se asocia en pacientes mayores de 65 años, analizando distintas variables como el sexo, la edad, el tabaquismo, la diabetes, la hipertensión, la dislipemia y la historia de problemas cardiovasculares. La investigación se realizó en 257 pacientes, mediante la valoración del índice tobillo-brazo (ITB). Para ello se utilizó el WatchBP® Office, un tensiómetro automático específico para valoración del ITB, capaz de determinar el índice tobillo-brazo y la diferencia de presión entre ambos brazos de forma simultánea y automática, lo que minimiza el sesgo de medición. Como resultados importantes, hemos observado mayor presencia de oclusión arterial (ITB < 0.90) en el sexo masculino, y un mayor predomino de calcificación (ITB > 1.3) en el sexo femenino. Debe destacarse que existe una relación significativa entre la presencia de oclusión arterial y la mayor edad del paciente (p = 0.00), la diabetes (p = 0.04), la hipertensión (p = 0.02), problemas cardiacos (p = 0.004) y el hábito tabáquico (p = 0.01). No se encontró una relación significativa entre la presencia de oclusión y dislipemia (p = 0.92). En el análisis multivariante, la edad (OR = 1.082; p = 0.02), los antecedentes de problemas cardiacos (OR = 2.76; p = 0.03) y la presión arterial sistólica (OR = 1.03; p = 0.04) mostraron asociación con la oclusión (AU)

The objective is to determine the presence of peripheral arterial disease (PAD) and the factors associated in elderly patients, analyzing variables such as sex, age, smoking, diabetes, hypertension, dyslipidemia, and cardiovascular problems. The investigation was conducted in 257 patients by assessing their ankle-brachial index (ABI). To do this, WatchBP® Office, a specific automatic blood pressure measurement device for assessing ABI, was used. A greater presence of arterial occlusion (ABI < 0.90) was observed in males, and a greater predominance of calcification (ABI > 1.3) occurred in females. Also standing out was the significant relationship between the presence of arterial occlusion and the advanced age of the patient (p = 0.00), diabetes (p = 0.04), hypertension (p = 0.02), heart problems (p = 0.004), and smoking (p = 0.01). No significant relationship was found between the presence of occlusion and dyslipidemia (p = 0.92). In multivariate analysis, age (OR = 1.082; p = 0.02), cardiovascular problems (OR = 2.76; p = 0.03) and systolic blood pressure (OR = 1.03; p = 0.04) showed an association with the occlusion (AU)

Valor pronóstico de marcadores inflamatorios y perfil lipídico en pacientes con claudicación intermitente. Estudio piloto / Prognostic value of inflammatory markers and lipid profile in patients suffering from intermittent claudication – a pilot study

Fundamento y objetivo: Analizar variables clínicas y serológicas (perfil lipídico, marcadores inflamatorios) como potenciales factores de riesgo para el desarrollo de eventos cardiovasculares y mortalidad a corto plazo en pacientes con claudicación intermitente. Pacientes y método: Incluimos todos los pacientes con diagnóstico inicial de claudicación intermitente vascular en nuestro centro durante 2005-2006. Analizamos datos clínicos, parámetros serológicos (creatinina, colesterol total, colesterol unido a lipoproteínas de baja densidad [colesterol LDL], colesterol unido a lipoproteínas de alta densidad [colesterol HDL], apolipoproteína A1, apolipoproteína B100, lipoproteína(a), homocisteína, proteína C reactiva, velocidad de sedimentación globular [VSG], fibrinógeno), eventos cardiovasculares y mortalidad durante el seguimiento a 1-3 años. Resultados:Incluimos 162 pacientes, de los que 143 (88,3%) eran varones. La edad media (DE) fue de 66 (10,4) años (extremos 41-86), 76 (46,9%) eran fumadores activos, 96 (59,3%) hipertensos, 56 (34,6%) diabéticos y 129 (79,6%) hipercolesterolémicos. Registramos 16 (9,9%) eventos coronarios/cerebrovasculares, 18 (11,1%) eventos vasculares en extremidades inferiores y 9 (5,9%) muertes tardías durante el seguimiento (media de 18,2 [8] meses). La hipertensión arterial fue el único predictor de eventos coronarios o cerebrovasculares (p=0,013); la cardiopatía y el colesterol HDL<45mg/dL se asociaron de forma independiente a eventos vasculares de extremidades inferiores (p=0,021 y 0,049), y la VSG>20mm/h a mortalidad (p=0,008). Conclusiones: Las cifras reducidas de colesterol HDL y elevadas de VSG han resultado factores de riesgo independientes para eventos vasculares periféricos y mortalidad a corto plazo (AU)

Background and objective: To analyse clinical and serological variables (lipid profile, inflammatory biomarkers) as potential risk factors for the development of short-term cardiovascular events and mortality in patients suffering from intermittent claudication. Patients and methods: We included all patients with a first-time diagnosis of vascular intermittent claudication in our center during 2005-2006. We analysed clinical data, serological parameters (creatinine, total cholesterol, LDL-cholesterol, HDL-cholesterol, ApolipoproteinA1, ApolipoproteinB100, lipoprotein(a), homocysteine, C-reactive protein, erythrocyte sedimentation rate [ESR], fibrinogen), cardiovascular events and mortality during 1-3 year follow-up.Results: We included 162 patients: 143 (88.3%) men, mean (SD) age 66 (10.4) (41-86) years, 76 (46.9%) active smokers, 96 (59.3%) hypertensive, 56 (34.6%) diabetic, 129 (79.6%) hypercholesterolemic. We registered 16 (9.9%) coronary/cerebrovascular events, 18 (11.1%) lower limb vascular events and 9 (5.9%) late deaths during follow-up (mean [SD] 18.2 [8] months). Hypertension was the only predictor of coronary or cerebrovascular events (p=0.013); heart disease and HDL-cholesterol<45mg/dL were independent risk factors for lower limb vascular events (p=0.021 and 0.049), and ESR>20mm/h was associated with all-cause death (p=0.008). Conclusions: Reduced HDL-cholesterol and elevated ESR have emerged as independent risk factors for short-term lower limb vascular events and death

Características clínicas y evolución intrahospitalaria de los pacientes con isquemia crítica de miembros inferiores: estudio ICEBERG / Clinical characteristics and in-hospital outcomes of patients with critical leg ischemia: ICEBERG Study

Fundamento y objetivos: La isquemia crítica de miembros inferiores (ICMI) es una urgencia médico-quirúrgica con una elevada morbimortalidad. Si bien su pronóstico ha mejorado durante los últimos años, no se dispone de datos en nuestro país sobre sus características clínicas, su tratamiento y su pronóstico intrahospitalario. Pacientes y método: Fueron incluidos 671 pacientes (81% varones, edad media 71,2 años) con ICMI de etiología aterosclerótica atendidos en 46 servicios de Cirugía Vascular.Resultados: La población incluida tenía una elevada prevalencia de factores de riesgo (72% hipertensos, 27% fumadores activos, 59% diabéticos) y de comorbilidad (25% enfermedad coronaria, 18% enfermedad cerebrovascular). Un 71% tenía un diagnóstico previo de enfermedad arterial periférica. Al ingreso, en un 71% se realizó algún tipo de revascularización, en un 5% amputación directa y en un 24% tratamiento conservador. Hubo 22 muertes y 49 pacientes fueron dados de alta con una amputación mayor. La presencia de gangrena fue el único factor asociado con la amputación durante el ingreso (odds ratio [OR] 2,45; intervalo de confianza del 95% [IC 95%] 1,22-4,92). La insuficiencia renal (OR 3,38; IC 95% 1,36-8,39) y la ICMI previa (OR 0,20; IC 95% 0,05-0,89) se asociaron con la mortalidad. Al alta hospitalaria, la prescripción de hipolipidemiantes fue del 59%, la de antihipertensivos del 70% y la de antiagregantes del 85%.Conclusiones: Los pacientes con ICMI atendidos en servicios de Cirugía Vascular españoles tienen una baja tasa inicial de amputaciones y de mortalidad. Sin embargo, y dado el alto riesgo cardiovascular de estos sujetos a medio plazo, se precisa mejorar la prescripción de los fármacos preventivos que reciben al alta (AU)

Background and objectives: Critical leg ischemia (CLI) is a medical emergency with a high morbidity and mortality. Although its prognosis has improved during the last years, there are no data on its clinical characteristics, treatment and in-hospital prognosis in our country.Patients and method: 671 patients (81% males, mean age 71.2 years) with atherosclerotic CLI, attended in 46 departments of vascular surgery were included in the study.Results: Participants had a high prevalence of cardiovascular risk factors (72% hypertensive, 27% current smokers, 59% diabetics) and comorbidity (25% coronary heart disease, 18% cerebrovascular disease). 71% had a previous diagnosis of peripheral arterial disease. Upon admission, 71% were referred for revascularization, 5% for direct amputation and 24% for conservative treatment. During hospitalization 22 patients died and 49 were discharged with a major amputation. On multivariate analysis, the only factor associated with the risk of amputation was gangrenous lesions (OR 2.45; IC95% 1.22-4.92). Factors associated with mortality were the presence of chronic renal failure (OR 3.38; IC95% 1.36-8.39) and previous CLI (OR 0.20; IC95% 0.05-0.89). At discharge, 59% received lipid lowering drugs, 70% blood-pressure lowering medications and 85% antiplatelet drugs. Conclusion: CLI patients attended in Spanish vascular surgery departments have a low amputation rate and a low hospital mortality. However, and due to their high cardiovascular risk, it is necessary to improve the prescription rate of evidence-based cardiovascular prevention therapies at discharge (AU)

Isquemia crítica de miembros inferiores: una enfermedad cada vez más prevalente / Critical lower limb ischemia: an increasingly prevalent disease

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Beneficios de la determinación del índice tobillo brazo en la consulta de atención primaria / Benefits of determination of the ankle-brachal index in primary health car

Las escalas de riesgo cardiovascular, como el índice de Framingham o el Score, estiman globalmente el riesgo vascular y facilitan una adecuada intervención terapéutica para reducir la morbimortalidad de las enfermedades cardiovasculares; pero en determinadas poblaciones esta estimación puede no ser la adecuada, lo que ha llevado a utilizar pruebas diagnósticas de evaluación directa, capaces de detectar la presencia de lesiones ateroescleróticas en fase asintomática. Una de estas técnicas es la prueba del índice tobillo-brazo (ITB): método diagnóstico fácil, objetivo y no invasivo de la enfermedad arterial periférica (EAP), y probablemente el procedimiento más sencillo de evaluación directa de la lesión arteriosclerótica. Es una prueba barata, precisa y reproducible que no requiere personal especializado, con gran precisión diagnóstica. La diabetes, el tabaco y la edad son los factores que más estrechamente se asocian con un ITB disminuido. La mayor utilidad del ITB reside en su valor como marcador predictor independiente de mortalidad cardiovascular, posibilitando la identificación de pacientes de alto riesgo en prevención primaria. Esta sencilla exploración debe formar parte de la evaluación sistemática del riesgo cardiovascular en las consultas de atención primaria, especialmente en pacientes con diabetes, y así identificar, a los sujetos con mayor riesgo cardiovascular (AU)

Cardiovascular risk scales, such as the Framingham index or Score, estimated overall vascular risk and facilitate appropriate therapeutic intervention for reducing morbidity and mortality of cardiovascular disease in certain populations but this estimate may not be adequate, which has diagnostic tests led to the use of direct assessment, which can detect the presence of atherosclerotic lesions in asymptomatic phase. One such technique is the test of ankle-brachial index (ABI): easy diagnostic method, objective and noninvasive peripheral arterial disease (PAD), and probably the easiest direct assessment of the atherosclerotic lesion. It is an inexpensive, accurate and reproducible that does not require specialized personnel with high diagnostic accuracy. Diabetes, snuff and age are the factors most closely associated with low ABI. The relevance of the ITB lies in its value as a marker independent predictor of cardiovascular mortality, allowing the identification of high risk patients in primary prevention. This simple examination should be part of the systematic evaluation of cardiovascular risk in primary care, especially in patients with diabetes, and identify, subjects with increased cardiovascular risk (AU)

Infradiagnóstico de la arteriopatía periférica en la población española. Estudio ARTPER / Underdiagnosis of peripheral arterial disease in the spanish population. ARTPER study

Fundamento y objetivo: Aunque la arteriopatía periférica (AP) es un importante marcador de morbimortalidad cardiovascular, desconocemos cuántos pacientes están infradiagnosticados. El objetivo es conocer el infradiagnóstico de la AP y estudiar los factores asociados.Pacientes y método: Se estudió a 3.786 pacientes mayores de 49 años, seleccionados aleatorizadamente. Se definió AP si el índice tobillo-brazo (ITB) era inferior a 0,9. Se consideró infradiagnóstico si era inferior a 0,9 y no estaban diagnosticados de AP en la historia clínica, se determinó también la presencia de claudicación intermitente (CI) mediante el cuestionario de Edinburgh. Resultados: El 7,6% tenía un ITB inferior a 0,9 (intervalo de confianza [IC] del 95% de 6,7–8,4). De estos pacientes, estaba infradiagnosticado el 80,7%, a pesar de que el 29,3% presentaba clínica de CI. El infradiagnóstico fue inferior en fumadores o ex fumadores (odds ratio [OR] de 0,20; IC del 95% de 0,07–0,59), si existía CI (OR de 0,40; IC del 95% de 0,18–0,89), si el ITB estaba entre menos de 0,7 y 0,5 o más (OR de 0,36; IC del 95% de 0,16–0,81) o si era inferior a 0,5 (OR de 0,04; IC del 95% de 0,01–0,20); fue superior en los pacientes de 70 años de edad o más (OR de 3,12; IC del 95% de 1,12–8,67). Conclusiones: El infradiagnóstico de AP es elevado, especialmente en los pacientes de edad avanzada. Es necesario consensuar criterios para la práctica del ITB en la población general (AU)

Background and objectives: Although peripheral arterial disease (PA) is an important clinical marker of cardiovascular morbimortality, the rate of under-diagnosis is unknown. Our aimed to know the proportion of patients underdiagnosed of PA and the associated factors. Patients and methods: 3786 patients >49 years old, randomly selected, were studied. PA was diagnosed by means of the ankle-brachial index (ABI<0, 9). Underdiagnosed was considered when ABI<0,9 and when they were not diagnosed of PA in the clinical record. We also determined the presence of intermittent claudication (IC) defined by Edinburgh's questionnaire.Results: 7,6% had an ABI <0, 9 (IC95% 6,7–8, 4). Of these patients 80.7%, were underdiagnosed, although the 29,3% had IC. PA underdiagnosis was low in current smokers or former smokers (OR 0.20; IC95% 0,07–0,59), if IC (OR 0.40; IC95% 0,18–0,89), if ABI between <0.7 and 0.5 (OR 0.36; IC95% 0,16–0,81) or <0,5 (OR 0,04; IC95 % 0,01–0,20), being higher in >70 years (OR 3,12; IC95% 1,12–8,67). Conclusions: PA underdiagnosis is high, especially in old patients. It is necessary to reach consensus criteria for the practice of the ABI in the general population (AU)

Tratamiento agresivo de las complicaciones arteriales del trasplante hepático. Impacto sobre la supervivencia y las complicaciones biliares / Aggressive management of the arterial complications of liver transplantation. Impact upon survival and biliary complications

Se estudian las complicaciones arteriales (CA) ocurridas en 400 trasplantes realizados entre 1997 y 2006. Se dividen en 2 grupos según el tipo de tratamiento realizado: grupo i: tratamiento invasivo (tratamiento sobre la arteria o retrasplante), y grupo ii: tratamiento conservador o sintomático. Se analizan el impacto del tratamiento sobre la supervivencia y las complicaciones biliares (CB).Resultados Se han presentado 18 CA (4,5%), 10 complicaciones precoces (7 trombosis y 3 estenosis) y 8 complicaciones tardías (5 trombosis y 3 estenosis). El 90% de las complicaciones precoces se trató de forma invasiva (4 trombectomías urgentes, un retrasplante, 3 angioplastias y una ligadura de arteria hepática), y el 25% de las complicaciones tardías se trató con retrasplante (3); el 75% restante recibió tratamiento sintomático. Resultados La supervivencia a 12 y 60 meses fue inferior en el grupo ii (el 57 y el 42%) que en el grupo i (el 90 y el 68%), aunque sin alcanzar significación estadística. La tasa global de CB de enfermos con trombosis arterial fue del 50%. En el grupo i del %, significativamente menor que el grupo ii con el 71% (p<0,04).Conclusiones El tratamiento invasivo de las CA en el trasplante hepático se asocia a una mayor supervivencia a corto plazo y reduce de forma significativa la aparición de CB. En nuestra experiencia, los pacientes se benefician de un diagnóstico precoz y un tratamiento intensivo en este tipo de complicaciones (AU)

Abstract A study was made of the arterial complications documented in 400 transplants performed between 1997 and 2006. The patients were divided into two groups according to the type of treatment provided. Group I: invasive management (arterial treatment or re-transplant), and Group II: conservative or symptomatic management. The impact of management upon survival and biliary complications was analysed. Results There were 18 arterial complications (4.5%): 10 early (7 thromboses and 3 stenoses) and 8 late (5 thromboses and 3 stenoses). Ninety percent of the early complications were subjected to invasive management (4 emergency thrombectomies, 1 re-transplant and 3 angioplasties), while 25% of the late complications were treated in the form of re-transplant and the remaining 75% were subjected to symptomatic treatment. Survival after 12 and 60 months was lower in Group II (57% and 42%) than in Group I (90% and 68%), although without reaching statistical significance. The overall biliary complications rate among the patients with arterial thrombosis was 50%. The rate was significantly lower in Group I than in Group II (10% versus 71%) (P<04).Conclusions Invasive management of the arterial complications of liver transplantation is associated with longer short-term survival and significantly fewer biliary complications. In our experience, patients benefit from an early diagnosis and aggressive management of complications of this kind (AU)

Análisis de variables clínicas en pacientes con obstrucción arterial aguda en Hospital Gustavo Fricke / Clinical variables analysis in patients with acute arterial obstruction in Gustavo Fricke’s Hospital

INTRODUCCIÓN: La obstrucción arterial aguda (OAA) de extremidades es un cuadro grave, con una mortalidad cercana al 20 por ciento, por lo que requiere un diagnostico etiológico y manejo oportuno. El objetivo del presente estudio fue analizar sobrevida y variables clínicas según etiología. MATERIAL Y MÉTODO: Estudio observacional analítico de casos de OAA no traumáticos atendidos entre años 2003 y 2007 en el Hospital Dr. Gustavo Fricke, con seguimiento vía registro civil y telefónico para obtener datos actualizados. RESULTADOS: Hubo 65 episodios de OAA en 60 pacientes durante el período. Se registraron 42 embolías (64,6 por ciento), 17 trombosis (26,1 por ciento), y 6 trombosis de by pass (9,2 por ciento). Se apreciaron diferencias significativas en edad (p=0,031) y género (p=0,033). El tabaquismo presentó un LR(+) de 2,61 y claudicación intermitente LR(+) 6,67para predecir etiología trombótica. El antecedente de accidente cerebrovascular presentó un LR(+) 4,65, el de arritmia LR(+) 12,05 y el de insuficiencia cardíaca LR(+) 8,76 para predecir etiología embólica. La sobrevida libre de amputación a 6 meses fue 90 por ciento. La sobrevida a 5 años fue 54,2 por ciento, siendo 37,8 por ciento en el grupo con embolía y 81,8 por ciento en el con trombosis (p<0,001). Pacientes con OAAde etiología embólica tenían un OR de 5,42 (IC95 por ciento 1,53-19,12) de fallecer comparados con pacientes con etiología trombótica. DISCUSIÓN: Las variables clínicas analizadas se comportarían como factores predictores de la etiologia de OAA, y por tanto del pronóstico y sobrevida de los pacientes. La mayor mortalidad del grupo de embolías se puede explicar por mayor edad, comorbilidades cardiovasculares, y embolías fatales a otros territorios.

INTRODUCTION: The acute arterial obstruction (AAO) of a limb is a severe condition, with almost 20 percent mortality, and therefore requires an appropriate diagnosis and treatment. The objective of this study was to analyze survival rates according to etiology and clinical variables. MATERIAL AND METHODS: Analytic observational study of non-traumatic AAO cases treated between 2003 and 2007 at Hospital Dr. Gustavo Fricke, confirming survival through the Office of Civil Registration and telephonic follow up. RESULTS: There were 65 episodes of AAO in 60 patients during this period; 42 of these were embolism episodes (64.6 percent), 17 thrombosis episodes (26.1 percent) and 6 by-pass thrombosis (9.2 percent). There was significant difference in age (p=0.031) and gender (p=0.033). Smoking had a LR (+) of 2.61 for predicting thrombotic etiology whereas intermitent claudication had a LR (+) of 6.67. History of stroke, arrhythmia, and heart failure showed LR (+) for predicting embolic etiology of 4.65, 12.05, and 8.76 respectively. The amputation-free survival at 6 months was 90 percent. The 5 years survival was 54.2 percent 37.8 percent in the group with embolic etiology and 81.8 percent for thrombosis etiology (p <0.001). Patients with AAO with embolic etiology had an OR of 5.42 (IC95 percent 1,53-19,12) for decease compared with patients with thrombotic etiology. DISCUSSION: The clinical variables analyzed were proven to be good predictors for AAO etiology, hence for patients´ prognosis and survival. Higher mortality in the embolic etiology group could be explained by older age, cardiovascular comorbidities, and fatal stroke in other territories.

El cribaje de arteriopatía periférica en Atención Primaria mediante doppler / Doppler screening of peripheral arteriopathy in Primary Care

La arteriopatía periférica es causa de numerosas complicaciones responsables de una morbi-mortalidad elevada. El cribaje de esta enfermedad mediante técnica doppler está siendo realizado por enfermeras en centros de Atención Primaria.Objetivos: conocer la relación entre los factores de riesgo cardiovascular y el resultado de la prueba de cribaje de arteriopatía periférica realizada con doppler e identificar la relevancia de la prueba.Método: estudio observacional descriptivo. Sujetos del estudio (n = 119): pacientes con diabetes mellitus II remitidos al programa de cribaje de arteriopatía periférica, mediante doppler, del Centro de Atención Primaria Florida Sur durante el año 2007, seleccionados por muestreo de conveniencia.Resultados: no se observan asociaciones estadísticamentesignificativas entre el resultado obtenido con doppler y los diferentes factores de riesgo cardiovascular que presentan los sujetos. Sólo se observan diferencias estadísticamente significativas con la varia-ble “revisión de pulsos previa”. No se registró ninguna actuación tras obtener un resultado patológicoen el 66,67% de la muestra.Conclusión: aunque no hay asociación entre el resultado positivo del ITB y la presencia de factores de riesgo cardiovascular, la técnica de cribaje con doppler es útil para la detección de arteriopatía periférica. Hay que mejorar la relevancia de su utilización en lo referente a las actuaciones posteriores al resultado positivo, especialmente, la educación sanitaria

Peripheral arteriopathy causes numerous complicationsthat lead to a high morbidity and mortality. Doppler screening of this disease is performed by nurses in Primary Care centres.Objectives: to learn about the relationship between cardiovascular risk factors and the peripheral arteriopathy screening test results performed with doppler and identify the relevance of this test.Method: descriptive observational study. Study subjects(n=119): patients with diabetes mellitus II, selected by convenience sampling referred to the peripheral arteriopathy doppler screening program in the Florida Sur Primary Care Centre during 2007.Results: no statistically significant associations were found between the results obtained by doppler and the subjects’ different cardiovascular risk factors. There were only statistically significant differences in the variable “previous pulse examination”. No measures were taken after obtaining a pathological result in 66,67% of the sample.Conclusion: even though there is no association betweenthe positive result of AAI and the presence of cardiovascular risk factors, the Doppler screening technique is useful for the detection of peripheral arteriopathy. The relevance of its use must be improved in regards to subsequent measures to be taken based on positive results, especially in healthcare education (AU)

Comparación de estudios de prevalencia de arteriopatía periférica en población general o seleccionada / Comparative study of prevalence of peripheral arterial disease in general population or selected

INTRODUCCIÓN. La apertura del Servicio de Angiología y Cirugía Vascular del Hospital de Cabueñes impulsó la necesidad deconocer la prevalencia de la de la Isquemia Crónica (IC) en los pacientes mayores de 65 años que residían en el AreaSanitaria de Gijón, con el fin de concretar los recursos necesarios y planear la organización del trabajo, y comparar los resultadoscon los obtenidos en los trabajos ya realizados con los usuarios que acudían por cualquier motivo a un Centro de Salud.MATERIAL Y MÉTODOS. Se diseña un estudio descriptivo transversal, incluyendo finalmente 232 sujetos, 114 hombres y 118mujeres, seleccionados aleatoriamente a partir de los datos de la tarjeta sanitaria. Se les historia, explora, y se calcula elíndice tobillo-brazo. Se procede a la búsqueda bibliográfica, centrada en estudios sobre prevalencia de EAP en usuarios deCentros de Salud. RESULTADOS. La prevalencia global de la IC es del 9,9%, está 6 puntos por encima en el grupo de los mayoresde 75 años y 8 puntos por encima en los hombres, y estas diferencias son estadísticamente significativas. En los estudioscon que se compara este trabajo las cifras de prevalencia de un índice tobillo/brazo disminuido oscilan entre el 23 y el 27.4%CONCLUSIÓN. Los estudios basados exclusivamente en el ITB, y los realizados en aquellas personas que acuden a un Centrode Salud por uno u otro motivo, parecen sobrevalorar la prevalencia de la EAP. La incorporación de la anamnesis y la exploraciónal ITB eleva la certeza diagnóstica (AU)

INTRODUCTION. The opening of the Service of Angiology and Vascular Surgery of the Cabueñes Hospital impelled the necessityto know the prevalence the one of Chronic Ischaemia (CI) in the greater patients of 65 years than they resided in the SanitaryArea of Gijón, with the purpose of making specific the resources necessary and to plan the organization of the work, and tocompare the results with the obtained ones in the works already made with the users who went for whatever reason to aCenter of Health. MATERIAL AND METHODS. A cross-sectional descriptive study is designed randomly, including 232 subjects,114 men and 118 women, finally selected from the data of the sanitary card. Them history, explores, and the index calculatesankle-arm. It is come to the bibliographical search, centered in studies on prevalence of EAP in users of Centers ofHealth. RESULTS. the global prevalence of the IC is of 9.9%, it is 6 points superficially in the group of greater of 75 years and8 points superficially in the men, and these differences are statistically significant. In the studies whereupon east work is comparedthe numbers of prevalence of an index ankle/diminished arm oscillate between the 23 and the 27,4% CONCLUSION. Thestudies based exclusively on the ITB, and the made ones in those people who go to a Center of Health by one or another reason,seem to overvalue the prevalence of the EAP. The incorporation of the anamnesis and the exploration to the ITB elevatethe certainty diagnoses (AU)

Prevalence of peripheral arterial occlusive disease in patients referred to a tertiary care hospital in Salvador, Bahia, Brazil, for coronary angiography

The presence of peripheral arterial occlusive disease increases the morbidity and mortality of patients with coronary artery disease. The objective of the present study was to calculate the prevalence of peripheral arterial occlusive disease in patients referred for coronary angiography. This prevalence study was carried out at the Hemodynamics Unit of Hospital Santa Isabel, Salvador, Brazil, from December 2004 to April 2005. After approval by the Ethics Committee of the hospital, 397 patients with angiographic signs of coronary artery disease were enrolled. Diagnosis of peripheral arterial occlusive disease was made using the ankle-brachial blood pressure index (£0.90). Statistical analyses were performed using the z test and a level of significance of a = 5 percent, 95 percentCI, the chi-square test and t-test, and multiple logistic regression analysis. The prevalence of peripheral arterial occlusive disease was 34.3 percent (95 percentCI: 29.4-38.9). Mean age was 65.7 ± 9.4 years for patients with peripheral arterial occlusive disease, and 60.3 ± 9.8 years for patients without peripheral arterial occlusive disease (P = 0.0000003). The prevalence of peripheral arterial occlusive disease was 1.57 times greater in patients with hypertension (P = 0.007) and 2.91 times greater in patients with coronary stenosis ³50 percent (P = 0.002). Illiterate patients and those with little education had a 44 percent higher chance of presenting peripheral arterial occlusive disease probably as a result of public health prevention policies of limited effectiveness. The prevalence of peripheral arterial occlusive disease in patients referred to a tertiary care hospital in Salvador, Bahia, for coronary angiography, was 34.3 percent.

Bloqueo epidural con ropivacaína en la insuficiencia arterial crónica de miembros inferiores: ensayo clínico / Epidural blockade with ropivacaine for chronic arteriopathies of the lower limbs: a clinical trial

Objetivo:Evaluar los efectos terapéuticos del bloqueo epiduralcon ropivacaína en pacientes con insuficiencia arterial crónicade miembros inferiores.Material y método:Estudio descriptivo, prospectivo y longitudinal en 58 pacientesa los que se les realizó bloqueo epidural con ropivacaína.Determinamos grado de bloqueo motor según la escalade Bromage, nivel de bloqueo sensitivo por métododel pinchazo, grado de analgesia por medio de la escala visualanalógica (EVA), aparición o cambios en la intensidad de los pulsos y las modificaciones en la temperatura cutáneade los miembros afectados, así como la mejoría de laslesiones tróficas de la piel. Estas evaluaciones se hicieron alos 15 y 30 minutos siguientes al bloqueo, luego cada cuatrohoras en las primeras 24 horas y posteriormente cadadía hasta el alta, luego a los 15 y 30 días.Resultados:Después del bloqueo se observó mejoría inmediata deldolor en 56 pacientes y todos recuperaron la intensidad delos pulsos explorados. Al mes persistía el dolor en 6 pacientes.Las alteraciones tróficas mejoraron en el 82,8%,las lesiones cutáneas en el 86,3% y los pulsos en el 91,4%.En más de la mitad de los pacientes la temperatura cutánease elevó de 3 a 3,9 °C y en algunos en más de 5 °C.Conclusiones:El resultado fue bueno en el 89,6% de los casos, por loque consideramos que este método de tratamiento es útilsobre todo para el alivio del dolor en reposo y la mejoríaen la circulación del miembro afectado

Objective:To determine therapeutic effects of epidural blockadewith ropivacaine in patients with chronic arteriopathies ofthe lower limbs.Material and method:Descriptive, prospective and longitudinal study in 58 patientsundergoing epidural blockade with ropivacaine. Wedetermined the degree of motor blockade according toBromage´s scale, the level of sensitive blockade using thepricking method, the degree of analgesia according to thevisual analogical scale (VAS), appearance or changes inpulse rate and changes in skin temperature at the limbs involved,as well as improvement of skin trophic lesions.These determinations were performed 15 and 30 minutesafter the blockade, then at 4-hours intervals during the first 24 hours and subsequently once daily until hospital dischargeand 15 and 30 days afterwards.Results:After the blockade, an immediate relief of pain was observedin 56 patients and all of them recovered the pulserates measured. One month later, pain persisted in 6 patients.Trophic disorders improved in 82.8%, skin lesionsin 86.3% and pulse rate in 91.4%. In more than half of thepatients, skin temperature increased from 3 to 3.9 °C andin some patients it increased in more than 5 °C.Conclusions:The results were satisfactory in 89.6% of patients, sowe conclude that this therapeutic method is effective particularlyfor the management of pain at rest and for the improvementof blood circulation in the limb involved