Post-cardioversion time Course of Atrial Remodeling Markers and their Association with Recurrence in Subjects with Long-standing, Persistent Atrial Fibrillation.

BACKGROUND: Activation of the renin-angiotensin-aldosterone axis with elevation of inflammatory markers and the resulting fibrosis play a very important role in atrial remodeling in patients with atrial fibrillation (AF), which is associated with post-cardioversion recurrence. AIM OF THE STUDY: The purpose of the study was to describe the time course of angiotensin II (AngII), aldosterone, and of the amino terminal pro-peptide of type III pro-collagen (PIIINP) following cardioversion, and their association with arrhythmia recurrence. METHODS: Ninety-nine subjects with long-standing, persistent, non-valvular atrial fibrillation who underwent successful electrical cardioversion were included, with a 6 month follow up. Angiotensin II (AngII), aldosterone and PIIINP concentrations were measured at 0, 1, 7, 30, and 180 d. Two groups were formed for the analysis: continuing sinus rhythm and recurrence of AF. RESULTS: 53% of the subjects experienced recurrence of AF. Subjects with recurrence had larger left atrial diameters and lower global peak atrial longitudinal strain (8.7 vs. 19.7%; p <0.001), higher levels of AngII (431.85 vs. 257.97 pg/mL; p = 0.003) at 180 d, higher pre-cardioversion levels of aldosterone, (11.42 vs. 5.46 pg/mL; p = 0.048) at 1 d (12.01 vs. 5.05 pg/mL; p = 0.004) and at 180 d (12.66 vs. 7.51 pg/mL; p = 0.011). There were no differences in PIIINP levels between both groups. CONCLUSIONS: Electrical post-cardioversion recurrence in subjects with long-standing, persistent AF is associated with elevated levels of AngII and aldosterone.

Effect of Interleukin-17 in the Activation of Monocyte Subsets in Patients with ST-Segment Elevation Myocardial Infarction.

Interleukin- (IL-) 17 is increased in acute myocardial infarction (AMI) and plays a key role in inflammatory diseases through its involvement in the activation of leukocytes. Here, we describe for the first time the effect of IL-17 in the migration and activation of monocyte subsets in patients during ST-segment elevation myocardial infarction (STEMI) and post-STEMI. We analyzed the circulating levels of IL-17 in patient plasma. A gradual increase in IL-17 was found in STEMI and post-STEMI patients. Additionally, IL-17 had a powerful effect on the recruitment of CD14++CD16+/CD14+CD16++ monocytes derived from patients post-STEMI compared with the monocytes from patients with STEMI, suggesting that IL-17 recruits monocytes with inflammatory activity post-STEMI. Furthermore, IL-17 increased the expression of TLR4 on CD14 + CD16 - and CD14++CD16+/CD14+CD16++ monocytes post-STEMI and might enhance the response to danger-associated molecular patterns post-STEMI. Moreover, IL-17 induced secretion of IL-6 from CD14++CD16- and CD14++CD16+/CD14+CD16++ monocytes both in STEMI and in post-STEMI, which indicates that IL-17 has an effect on the secretion of proinflammatory cytokines from monocytes during STEMI and post-STEMI. Overall, we demonstrate that in STEMI and post-STEMI, IL-17 is increased and induces the migration and activation of monocyte subsets, possibly contributing to the inflammatory response through TLR4 and IL-6 secretion.

Excerpts from the documents of Mexican positions and recommendations in cardiovascular diseases and COVID-19.

The recommendations in which the Mexican Society of Cardiology (SMC) in conjunction with the National Association of Cardiologists of Mexico (ANCAM) as well as different Mexican medical associations linked to cardiology are presented, after a comprehensive and consensual review and analysis of the topics related to cardiovascular diseases in the COVID-19 pandemic. Scientific positions are analyzed and responsible recommendations on general measures are given to patients, with personal care, healthy eating, regular physical activity, actions in case of cardio-respiratory arrest, protection of the patient and health personnel as well as precise indications in the use of non-invasive cardiovascular imaging, prescription of medications, care in specific topics such as systemic arterial hypertension, heart failure, arrhythmias and acute coronary syndromes, in addition to emphasizing electrophysiology, interventionism, cardiac surgery and in cardiac rehabilitation. The main interest is to provide the medical community with a general orientation on what to do in daily practice and patients with cardiovascular diseases in the setting of this unprecedented epidemiological crisis of COVID-19.

Se presentan las recomendaciones en las cuales la Sociedad Mexicana de Cardiología (SMC) en conjunto con la Asociación Nacional de Cardiólogos de México (ANCAM), así como diferentes asociaciones médicas mexicanas vinculadas con la cardiología, después de una revisión y análisis exhaustivo y consensuado sobre los tópicos relacionados con las enfermedades cardiovasculares en la pandemia de COVID-19, se analizan posturas científicas y se dan recomendaciones responsables sobre medidas generales a los pacientes, con cuidados personales, alimentación saludable, actividad física regular, acciones en caso de paro cardiorrespiratorio, la protección del paciente y del personal de salud así como las indicaciones precisas en el uso de la imagen cardiovascular no invasiva, la prescripción de medicamentos, cuidados en tópicos específicos como en la hipertensión arterial sistémica, insuficiencia cardiaca, arritmias y síndromes coronarios agudos, además de hacer énfasis en los procedimientos de electrofisiología, intervencionismo, cirugía cardiaca y en la rehabilitación cardiaca. El interés principal es brindar a la comunidad médica una orientación general sobre el quehacer en la práctica cotidiana y pacientes con enfermedades cardiovasculares en el escenario esta crisis epidemiológica sin precedentes de COVID-19.

Extractos de los documentos de posicionamientos y recomendaciones mexicanas en enfermedades cardiovasculares y COVID-19 / Excerpts from the documents of Mexican positions and recommendations in cardiovascular diseases and COVID-19

Resumen Se presentan las recomendaciones en las cuales la Sociedad Mexicana de Cardiología (SMC) en conjunto con la Asociación Nacional de Cardiólogos de México (ANCAM), así como diferentes asociaciones médicas mexicanas vinculadas con la cardiología, después de una revisión y análisis exhaustivo y consensuado sobre los tópicos relacionados con las enfermedades cardiovasculares en la pandemia de COVID-19, se analizan posturas científicas y se dan recomendaciones responsables sobre medidas generales a los pacientes, con cuidados personales, alimentación saludable, actividad física regular, acciones en caso de paro cardiorrespiratorio, la protección del paciente y del personal de salud así como las indicaciones precisas en el uso de la imagen cardiovascular no invasiva, la prescripción de medicamentos, cuidados en tópicos específicos como en la hipertensión arterial sistémica, insuficiencia cardiaca, arritmias y síndromes coronarios agudos, además de hacer énfasis en los procedimientos de electrofisiología, intervencionismo, cirugía cardiaca y en la rehabilitación cardiaca. El interés principal es brindar a la comunidad médica una orientación general sobre el quehacer en la práctica cotidiana y pacientes con enfermedades cardiovasculares en el escenario esta crisis epidemiológica sin precedentes de COVID-19.

Abstract The recommendations in which the Mexican Society of Cardiology (SMC) in conjunction with the National Association of Cardiologists of Mexico (ANCAM) as well as different Mexican medical associations linked to cardiology are presented, after a comprehensive and consensual review and analysis of the topics related to cardiovascular diseases in the COVID-19 pandemic. Scientific positions are analyzed and responsible recommendations on general measures are given to patients, with personal care, healthy eating, regular physical activity, actions in case of cardio-respiratory arrest, protection of the patient and health personnel as well as precise indications in the use of non-invasive cardiovascular imaging, prescription of medications, care in specific topics such as systemic arterial hypertension, heart failure, arrhythmias and acute coronary syndromes, in addition to emphasizing electrophysiology, interventionism, cardiac surgery and in cardiac rehabilitation. The main interest is to provide the medical community with a general orientation on what to do in daily practice and patients with cardiovascular diseases in the setting of this unprecedented epidemiological crisis of COVID-19.

Left atrial longitudinal strain by speckle tracking as independent predictor of recurrence after electrical cardioversion in persistent and long standing persistent non-valvular atrial fibrillation.

Atrial fibrillation (AF) is the most common arrhythmia in humans. After successful cardioversion, there is a recurrence of 60% due to atrial remodeling, and it has been shown that the global peak atrial longitudinal strain (GPALS) is decreased in these subjects. The aim of this study was to evaluate the predictive value of GPALS for AF recurrence. A prospective cohort of patients with persistent (PnVAF) and long standing persistent non-valvular AF (LSPnVAF) which underwent electrical cardioversion was evaluated with standard echocardiographic variables and GPALS quantification. The primary endpoint was AF recurrence at 6 months. We included PnVAF (n = 50, aged 68.4 ± 10.2 years, female 46%, lasted AF 6 months) and LSPnVAF (n = 81, aged 66.5 ± 13.1 years, female 36%, lasted AF 18 months). At 6 months there were a 68% of recurrence of AF in PnVAF and 53% in LSPnVAF group. GPALS was lower in recurrence 7.8 ± 2.0% versus 21.2 ± 8.9% (p < 0.001) for PnVAF and 7.3 ± 2.7% versus 20.7 ± 7.6% (p < 0.001) in LSPnVAF. GPALS ≤ 10.75% discriminates recurrence at 6 months with a sensitivity of 85%, specificity 99%, PPV 85%, NPV 90%, LR + 8.5 and LR- 0.17. The independent predictors of recurrence in PnVAF were GPALS ≤ 10.75% HR 8.89 [(2.2-35.7), p < 0.01] meanwhile in LSPnVAF were age HR 1.039 [(1.007-1.071), p = 0.01], and GPALS ≤ 10.75% HR 28.1 [(7.2-109.1), p < 0.001]. In subjects with PnVAF and LSPnVAF with successful electrical cardioversion, GPALS ≤ 10.75% predicts arrhythmia recurrence at 6-month follow-up.

Effect of Native and Minimally Modified Low-density Lipoprotein on the Activation of Monocyte Subsets.

BACKGROUND: In atherosclerosis, monocytes are essential and secrete pro-inflammatory cytokines in response to modified low-density lipoprotein (LDL). Human CD14++CD16-, CD14++CD16+ and CD14+CD16++ monocytes produce different cytokines. The objective of this research was to determine the number of monocyte subsets positives to cytokines in response to native (nLDL) and minimally modified LDL (mmLDL). METHODS: Human monocytes from healthy individuals were purified by negative selection and were stimulated with nLDL, mmLDL or LPS. Subsequently, human total monocytes were incubated with monoclonal antibodies specific for CD14 or both CD14 and CD16 to characterize total monocytes and monocyte subsets and with antibodies specific to anti-tumor necrosis factor (TNF)-α, anti-interleukin (IL)-6 and anti-IL-10. The number of cells positive for cytokines was determined and cells cultured with nLDL, mmLDL and LPS were compared with cells cultured only with culture medium. RESULTS: We found that nLDL does not induce in the total monocyte population or in the three monocyte subsets positives to cytokines. MmLDL induced in total monocytes positives to TNF-α and IL-6 as well as in both CD14++CD16+ and CD14+CD16++ and in CD14++CD16+ monocytes, respectively. Moreover, total monocytes and the three monocyte subsets expressed few amounts of cells positives to IL-10 in response to mmLDL. CONCLUSION: Our study demonstrated that nLDL did not induce cells positives to cytokines and that the CD14++CD16+ and CD14+CD16++ monocyte subsets could be the main sources of TNF-α and IL-6, respectively, in response to mmLDL, which promotes the development and progression of atherosclerotic plaque.

Dysfunctional immunometabolic effects of vitamin D deficiency, increased cardiometabolic risk. Potential epidemiological alert in America? / Efectos inmunometabólicos disfuncionales de la deficiencia de vitamina D y aumento de riesgo cardiometabólico. ¿Potencial alerta epidemiológica en América?

Vitamin D deficiency is a serious public health problem worldwide that affects not only skeletal health, but also a wide range of acute and chronic diseases. However, there is still skepticism because of the lack of randomized, controlled trials to support association studies on the benefits of vitamin D for non-skeletal health. This review was based on articles published during the 1980-2015 obtained from the Cochrane Central Register of controlled trials, MEDLINE and PubMed, and focuses on recent challenges with regard to the definition of vitamin D deficiency and how to achieve optimal serum 25-hydroxyvitamin D levels from dietary sources, supplements, and sun exposure. The effect of vitamin D on epigenetic fetal programming and regulation of genes that may potentially explain why vitamin D could have such lifelong comprehensive health benefits is reviewed. Optimization of vitamin D levels in children and adults around the world has potential benefits to improve skeletal health and to reduce the risk of chronic diseases, including some types of cancer, autoimmune diseases, infectious diseases, type 2 diabetes mellitus, and severe cardiovascular disorders such as atherothrombosis, neurocognitive disorders, and mortality.

Efectos inmunometabólicos disfuncionales de la deficiencia de vitamina D y aumento de riesgo cardiometabólico. ¿Potencial alerta epidemiológica en América? / Dysfunctional immunometabolic effects of vitamin D deficiency, increased cardiometabolic risk. Potential epidemiological alert in America?

La deficiencia de vitamina D es un problema grave de salud pública en todo el mundo y que afecta no solo la salud músculo-esquelética sino también una amplia gama de enfermedades agudas y crónicas, incluyendo las no trasmisibles de riesgo cardiovascular, algunas enfermedades autoinmunes, metabólicas y mecanismos fisiopatológicos en obesidad. Sin embargo, subsiste el escepticismo de la falta de ensayos controlados aleatorizados para apoyar los estudios de asociación sobre los beneficios de salud no esqueléticos de vitamina D. Los artículos en los que se basó esta revisión fueron obtenidos de las bases de datos de MEDLINE, PubMed de 1980-2015 con respecto a la definición de deficiencia de vitamina D y su participación en trastornos proinflamatorios, inmunometabólicos y factores de riesgo cardiovascular. Se revisan las acciones de la vitamina D sobre la programación epigenética fetal y regulación de los genes que potencialmente podrían explicar por qué la vitamina D podría tener tales beneficios para la salud a lo largo de la vida en el humano. Hay potencialmente una ventaja en optimizar los niveles de la vitamina D de niños y adultos mayores en todo el mundo para mejorar no solo la salud músculo-esquelética, sino también para reducir el riesgo de enfermedades crónicas, incluyendo algunos factores de riesgo cardiovascular, así como ciertos tipos de cáncer, enfermedades autoinmunes, enfermedades infecciosas, diabetes mellitus tipo 2, trastornos cardiovasculares, incluyendo aterotrombosis, alteraciones neurocognitivas y, como consecuencia sobre la morbimortalidad global (AU)

Vitamin D deficiency is a serious public health problem worldwide that affects not only skeletal health, but also a wide range of acute and chronic diseases. However, there is still skepticism because of the lack of randomized, controlled trials to support association studies on the benefits of vitamin D for non-skeletal health. This review was based on articles published during the 1980-2015 obtained from the Cochrane Central Register of controlled trials, MEDLINE and PubMed, and focuses on recent challenges with regard to the definition of vitamin D deficiency and how to achieve optimal serum 25-hydroxyvitamin D levels from dietary sources, supplements, and sun exposure. The effect of vitamin D on epigenetic fetal programming and regulation of genes that may potentially explain why vitamin D could have such lifelong comprehensive health benefits is reviewed. Optimization of vitamin D levels in children and adults around the world has potential benefits to improve skeletal health and to reduce the risk of chronic diseases, including some types of cancer, autoimmune diseases, infectious diseases, type 2 diabetes mellitus, and severe cardiovascular disorders such as atherothrombosis, neurocognitive disorders, and mortality (AU)

[Treatment of hypertension in patients with coronary arterial disease]. / El tratamiento de la hipertensión arterial sistémica en pacientes con enfermedad arterial coronaria.

Reports of randomized controlled trials and prospective observational studies provide the most reliable data on the association between blood pressure and coronary heart disease (CHD). The totality of the evidence indicate a strong association between blood pressure and coronary heart disease, which is continuous at levels of less than 115 mm Hg of systolic. In general, 60 to 69 years of age, 10 lower mm Hg systolic blood pressure is associated with lower risk of one-fifth of a coronary heart disease event. The size and shape of this Association are consistent in all regions, for men and women and life-threatening events such as stroke and myocardial infarction. Trials that compared active treatment with placebo or no treatment have shown that the benefits of reducing blood pressure with different classes of drugs (e.g., diuretics, beta-blockers, ACE inhibitors, calcium antagonists) are quite similar, with about a fifth of reduction in coronary heart disease. The important points in this review are: First, that the relative benefit to the decline in blood pressure for the prevention of coronary heart disease appears to be constant in a range of different populations. Second, it is likely that considerable benefit with blood pressure low below thresholds of "traditional" blood pressure (140/90 mm Hg), especially in those with high absolute risk. Third, start, reduce with caution -especially in adult- and keep the maximum tolerance of blood pressure reduction is an issue more important than the choice of the initial agent.

Los ensayos controlados aleatorios y los estudios observacionales prospectivos ofrecen los datos más confiables sobre la asociación entre la presión arterial y la cardiopatía coronaria (CC). Toda la evidencia indica que hay una fuerte asociación entre la presión arterial y la CC, que es continua a niveles menores a 115 mm Hg de presión sistólica. En general, de los 60 a los 69 años de edad, la presión arterial sistólica más baja en 10 mm Hg se asocia con riesgo menor de tener un evento de enfermedad coronaria. El tamaño y la forma de esta asociación son constantes en todas las regiones, para hombres y mujeres, y para eventos mortales como el infarto de miocardio y el accidente vascular cerebral. Los ensayos han demostrado que los beneficios de la reducción de la presión arterial con diferentes clases de fármacos (diuréticos, betabloqueantes, inhibidores de la ECA, antagonistas del calcio) son bastante similares, con una quinta parte de reducción en enfermedad coronaria. Los puntos importantes de esta revisión son: a) que los beneficios relativos a la baja de la presión arterial para la prevención de enfermedad coronaria parecen ser constantes en una gama de diferentes poblaciones; b) que es probable que se obtenga un beneficio considerable con la presión arterial baja, por debajo de umbrales de hipertensión «tradicional¼ (140/90 mm Hg), especialmente en aquellos con alto riesgo absoluto, y c) que iniciar, reducir con precaución (sobre todo en el adulto mayor) y mantener la reducción de la tolerancia máxima de la presión arterial es un problema más importante que la elección del agente inicial.

[Systemic arterial hypertension in child and adolescent]. / Hipertensión arterial sistémica en el niño y adolescente.

The epidemic of childhood obesity, the risk of developing left ventricular hypertrophy, and evidence of the early development of atherosclerosis in children would make the detection of and intervention in childhood hypertension important to reduce long-term health risks; however, supporting data are lacking. Secondary hypertension is more common in preadolescent children, with most cases caused by renal disease. Primary or essential hypertension is more common in adolescents and has multiple risk factors, including obesity and a family history of hypertension. Evaluation involves a through history and physical examination, laboratory tests, and specialized studies. Management is multifaceted. Nonpharmacologic treatments include weight reduction, exercise, and dietary modifications. Although the evidence of first line therapy for hypertension is still controversial, the recommendations for pharmacologic treatment are based on symptomatic hypertension, evidence of end-organ damage, stage 2 of hypertension, or stage 1 of hypertension unresponsive to lifestyle modifications, and hypertension with diabetes mellitus where is the search for microalbuminuria justified.

La pandemia de la obesidad en el niño y adolescente, el riesgo de desarrollar hipertrofia ventricular y la evidencia del desarrollo temprano de la aterosclerosis hacen necesaria una detección temprana y una intervención oportuna en la hipertensión de la niñez para reducir riesgos de salud a largo plazo; sin embargo, los datos epidemiológicos de apoyo a las cifras de referencia son escasos. La hipertensión secundaria es más común en niños preadolescentes y una buena proporción está en relación a enfermedad renal. La hipertensión arterial sistémica esencial es más común en adolescentes y tiene múltiples factores de riesgo asociados, incluyendo obesidad y antecedentes familiares. La evaluación clínica integral implica una historia cuidadosa y un examen físico completo, pruebas de laboratorio y estudios especiales. Los tratamientos no farmacológicos incluyen la reducción del peso, ejercicio y modificaciones dietéticas. Las recomendaciones para el tratamiento farmacológico se basan sobre todo en la hipertensión sintomática, la evidencia de daño a órganos blanco y la hipertensión arterial que no se reduce con las modificaciones de la forma de vida, o bien, la hipertensión arterial asociada con diabetes mellitus, en la que la búsqueda de microalbuminuria está justificada.

[Consensus on Systemic Arterial Hypertension In México]. / Consenso de Hipertensión Arterial Sistémica en México.

This Consenso Nacional de Hipertensión Arterial Sistémica (National Consensus on Systemic Arterial Hypertension) brings together experiences and joint work of 79 specialists who have been in contact with the patient affected by systemic arterial hypertension. All concepts here presented were outlined on the basis of the real world practice of Mexican hypertensive population. The consensus was developed under strict methodological guidelines. The Delphi technique was applied in two rounds for the development of an appropriate statistical analysis of the concepts exposed by all the specialists, who posed key questions, later developed by the panel of experts of the Hospital de Cardiología, and specialists from the Centro Médico Nacional. Several angles of this illness are shown: detection, diagnosis, pathophysiology, classification, treatment and prevention. The evidence analysis was carried out using PRISMA method. More than 600 articles were reviewed, leaving only the most representative in the references. This document concludes with practical and useful recommendations for the three levels of health care of our country.

Este Consenso Nacional de Hipertensión Arterial Sistémica reúne las experiencias y el trabajo conjunto de 79 especialistas que han estado en contacto con el paciente que padece hipertensión arterial sistémica. Todos los conceptos aquí presentados se plantearon con base en la práctica del mundo real de la población hipertensa de México. El consenso se desarrolló bajo lineamientos metodológicos estrictos. La técnica de Delphi se aplicó en dos vueltas para el desarrollo de un análisis estadístico apropiado de los conceptos vertidos por todos los especialistas con preguntas clave que desarrolló el panel de expertos del Hospital de Cardiología y especialistas del Centro Médico Nacional. Se presentan los aspectos de detección, diagnóstico, fisiopatología, clasificación, tratamiento y prevención. El análisis de la evidencia en la literatura se hizo utilizando el método de PRISMA para análisis de evidencia. Se revisaron más de 600 artículos y se dejaron en la bibliografía solo los más representativos. Este documento concluye con recomendaciones prácticas y de utilidad para los tres niveles de atención en salud de nuestro país.

[Cardiovascular complications of hypertensive crisis]. / Complicaciones cardiovasculares de la crisis hipertensiva.

It is inexorable that a proportion of patients with systemic arterial hypertension will develop a hypertensive crisis at some point in their lives. The hypertensive crises can be divided in hypertensive patients with emergency or hypertensive emergency, according to the presence or absence of acute end-organ damage. In this review, we discuss the cardiovascular hypertensive emergencies, including acute coronary syndrome, congestive heart failure, aortic dissection and sympathomimetic hypertensive crises (those caused by cocaine use included). Each is presented in a unique way, although some patients with hypertensive emergency report non-specific symptoms. Treatment includes multiple medications for quick and effective action with security to reduce blood pressure, protect the function of organs remaining, relieve symptoms, minimize the risk of complications and improve patient outcomes.

Inevitablemente, una proporción de pacientes con hipertensión arterial sistémica desarrollará crisis hipertensiva en algún momento de su vida. Las crisis hipertensivas pueden dividirse en hipertensos con emergencia o urgencia hipertensiva, según la presencia o ausencia de daño agudo en órganos blanco. En esta revisión discutimos la emergencia cardiovascular hipertensiva, la cual incluye el síndrome coronario agudo, la disección aórtica, la insuficiencia cardiaca congestiva y las crisis hipertensivas simpaticomiméticas (de estas, también mencionaremos aquellas causadas por el consumo de cocaína). Cada una de estas crisis se presenta de una manera única, aunque algunos pacientes con emergencia hipertensiva reportan síntomas inespecíficos. El tratamiento incluye varios medicamentos de acción rápida y eficaces con seguridad para reducir la presión arterial, proteger la función de órganos restantes, aliviar los síntomas, minimizar el riesgo de complicaciones y mejorar los resultados del paciente.

[Systemic arterial hypertension in the elderly. Recommendations for clinical practice]. / Hipertensión arterial sistémica en el adulto mayor. Recomendaciones para la práctica clínica.

Hypertension is common in people aged 65 and older. In those aged 70 and older, hypertension is more poorly controlled than in those whose age is between 60 and 69 years. The number of trials available concerning the elderly population is limited; therefore, strong recommendations on blood pressure (BP) goals are limited. The American College of Cardiology has recently published a consensus report of management of hypertension in the elderly population. This review presents an overview of that consensus report and reviews specific studies that provide some novel findings regarding BP goals and the progression of nephropathy. In general, the evidence strongly supports a BP goal < 150/80 mm Hg for the elderly with scant data in those aged 80 and older. However, it was decided to set the goal < 140/90 mm Hg, unless the patient cannot tolerate it, and then try to achieve 140-145 mm Hg. Diuretics and calcium antagonists are the most efficient treatment; however, most patients will require two or more drugs to achieve such goals.

La hipertensión es común en personas mayores de 65 años de edad. En los mayores de 70 años, se lleva un peor control que entre los adultos de 60 a 69 años. El número de ensayos disponibles acerca de la población de edad avanzada es limitado; por lo tanto, las recomendaciones robustas de metas de presión arterial (PA) para este grupo etario son pocas. El Colegio Americano de Cardiología ha publicado recientemente un consenso de manejo de la hipertensión en la población anciana. Esta revisión presenta una visión general de ese informe de consenso y comentarios sobre estudios específicos que proporcionan algunos resultados nuevos con respecto a la meta de PA y la progresión de la nefropatía. En general, la revisión de la evidencia para el informe de consenso apoya una meta < 150/80 mm Hg para la tercera edad con escasos datos en los mayores de 80. Sin embargo, se decidió establecer una meta <140/90 mm Hg, a menos que el paciente no pueda tolerarlo y luego trate de llegar a 140-145 mm Hg. Los diuréticos y los antagonistas del calcio son los agentes individuales más eficaces para el tratamiento; sin embargo, la mayoría de los pacientes requerirá dos o más fármacos para alcanzar sus metas.

[Hypertension during pregnancy: the challenge continues]. / Hipertensión durante el embarazo: el reto continúa.

Hypertensive disorders of pregnancy affect approximately from 5 to 10 % of all pregnant women, and are the main contributors of maternal and neonatal morbidity and mortality worldwide. This group of disorders includes chronic hypertension, as well as the conditions that arise de novo in pregnancy: gestational hypertension and preeclampsia. This last group is believed to be part of the same continuum, but with arbitrary division. Research on the etiology of hypertension in pregnancy largely have focused on preeclampsia, with a majority of studies that explore any factor associated with pregnancy, e.g., the answers derived from the placenta or immunological reactions to tissue from the pregnancy or maternal constitutional factors, such as cardiovascular health and endothelial dysfunction. The basic foundations for the pathophysiology and progression of hypertensive pregnancy disorders, particularly preeclampsia, are reviewed in this paper. Therapeutic options for the treatment of preeclampsia are also explored.

Los trastornos hipertensivos del embarazo afectan aproximadamente entre 5 y 10 % de todas las embarazadas y son los principales factores que contribuyen a la morbilidad materna y neonatal, y a la mortalidad en todo el mundo. Este grupo de trastornos incluye la hipertensión crónica, así como las condiciones que surgen de novo en el embarazo: hipertensión gestacional y preeclampsia. Se cree que este último grupo es parte de un mismo continuo pero con división arbitraria. La investigación sobre la etiología de la hipertensión en el embarazo en gran parte se ha centrado en la preeclampsia, con una mayoría de estudios que exploran cualquier factor asociado con el embarazo, como las respuestas derivadas de la placenta, o las reacciones inmunológicas al tejido del embarazo, o factores constitucionales maternos, como la salud cardiovascular y la disfunción endotelial. Se revisan en este trabajo los fundamentos básicos para la fisiopatología y la progresión de los trastornos hipertensivos en el embarazo, en especial de la preeclampsia. También se revisan las opciones terapéuticas para el tratamiento de este estado patológico.

Valor pronóstico de la microalbuminuria en el paciente con infarto agudo del miocardio con elevación del ST / Prognostic value of microalbuminuria in ST-elevation myocardial infarction

Introducción: La microalbuminuria (MA) es un marcador de disfunción endotelial, y se ha asociado con mayor morbimortalidad en la enfermedad cardiovascular. En México, las enfermedades isquémicas del corazón ocupan los primeros lugares de mortalidad, por lo que resulta necesario estudiar marcadores que puedan proporcionar pronóstico en los sujetos con síndrome coronario agudo. Objetivo: Determinar el valor pronóstico de la microalbuminuria sobre la evolución de los pacientes con infarto agudo del miocardio con elevación del segmento ST (IAMST). Material y métodos: Estudio de cohorte, observacional, longitudinal, prospectivo y analítico. Se incluyeron pacientes consecutivos con diagnóstico de IAM en las primaras 24 horas de evolución, de cualquier género, mayores de 18 años, que ingresaron a la Unidad de Cuidados Cardiovasculares de un Hospital de Tercer Nivel. Se definió la cohorte expuesta a microalbuminuria en orina de 24 horas (albúmina > 20 µg/min) dentro de las primeras 72 horas de su ingreso, y se dio seguimiento a 30 días registrando la presentación de eventos cardiovasculares. Resultados: Se estudiaron a 99 pacientes, 51 (51.5%) sujetos presentaron MA. Las características basales no presentaron diferencias significativas. Los pacientes con MA tuvo mayor puntuación de las escalas APACHE II, TIMI, GRACE y EUROSCORE (todos p < 0.05). La presentación de Killip-Kimball ≥ III, arritmias, bloqueo atrioventricular avanzado, choque cardiogénico, reinfarto y muerte, se asociaron significativamente con la presencia de MA (todos p < 0.05), y esta asociación es independiente para la presencia de muerte ajustado para las puntuaciones de TIMI, GRACE y la presencia de infarto ventricular derecho. De la misma manera, los sujetos con IAM portadores de MA tienen una supervivencia significativamente menor que aquellos sin MA, p = 0.002. Conclusiones: La microalbuminuria se asocia de manera independiente con muerte a 30 días, y puede ser un biomarcador a medirse rutinariamente en los pacientes con síndrome coronario agudo con elevación del ST.

Introduction: Microalbuminuria (MA) is an endothelial dysfunction biomarker, and has been associated to higher morbidity and mortality in cardiovascular disease. The ischemic heart disease is among the leading causes of death, and it's necessary to study new risk and prognostic biomarkers in patients with ST-elevation acute myocardial infarction (ST-AMI). Objective: To determine the predict value of microalbuminuria in patients with ST-AMI. Material and methods: We developed an observational, longitudinal, prospective and analytical cohort study, patients older than 18 years old, any sex, within 24 hours evolution ST-AMI were included. Exposed cohort was defined as MA > 20 µg/min in a 24-hour urine sample within 72 hour of myocardial infarction, and were followed for 30 days and cardiovascular events were recorded. Results: We studied 99 patients; 51 (51.5%) presented MA. Basal clinical features were not significantly different. MA subjects had higher APACHE II, TIMI, EUROSCORE and GRACE scores (p < 0.05 for all). Killip-Kimball ≥ III, arrhythmia, advanced atrioventricular block, cardiogenic shock, re-infarction and death were significantly associated to MA (p < 0.05 for all), and this association remains as an independent death predictor adjusted to TIMI and GRACE scores and right ventricle infarction. In the same way, MA is associated with lower survival rate at 30 day, p = 0.002. Conclusions: Microalbuminuria is an independent risk factor for death at 30 days, and should be included as part of biochemical markers in patients with ST elevation acute myocardial infarction.

Clinical outcome in patients with acute coronary syndrome and outward remodeling is associated with a predominant inflammatory response.

BACKGROUND: Pro-inflammatory molecules and low-density lipoproteins play essential roles in the atherosclerosis. The aim of our study was to establish an association among the cytokines secreted by peripheral blood mononuclear cells and the serum concentration in patients with unstable angina and coronary outward remodeling before and after percutaneous coronary intervention. The clinical and coronary responses were evaluated 6 months after the procedure. FINDINGS: Twenty-two patients with unstable angina were evaluated prior to after percutaneous coronary intervention and 6 months after procedure by coronary intravascular ultrasound. Eleven of the patients had recurrent angina, while 9 presented restenosis and an increase in the percentage of total plaque area. These 11 patients displayed higher levels of C-reactive protein than those without coronary events (1.27 vs. 0.43 mg/dl, respectively; p = 0.029) and a tendency to increase levels of interleukin (IL)-8 and transforming growth factor-ß1, but lower levels of IL-10 (52.09 vs. 141.5 pg/ml, respectively; p = 0.035). Activated peripheral blood mononuclear cells from patients with restenosis presented higher levels of proliferation, CD86 expression and higher IL-1, and increased IL-10 compared to those in patients without restenosis. CONCLUSIONS: Patients with unstable angina and coronary outward remodeling who displayed a pro-inflammatory response experienced recurrent coronary events and an increased percentage of total plaque area. In contrast, better outcomes were observed in patients with anti-inflammatory responses. This response could be secondary to low-density lipoproteins.

[Left main coronary artery aneurysm thrombosis in a young patient with acute myocardial infarction]. / Trombosis de aneurisma del tronco coronario izquierdo en paciente joven con infarto agudo de miocardio.

INTRODUCTION: The left main coronary artery aneurysm is rare, with an incidence of 0.1%, being the atherosclerosis its main etiology. Angiography is the gold standard for diagnosis and treatment. Depending on the severity of coexisting coronary stenosis, patients with left main coronary artery aneurysms can be effectively managed either surgical or pharmacologically. CLINICAL CASE: We present a case of a 44 year-old male with a history of obesity, smoking and dyslipidemia, complaining of oppressive chest pain, dyspnea and diaphoresis. An electrocardiogram showed an ST-segment elevation on the anterior and lateral wall and positive enzymatic curve for infarction. He was initially treated with streptokinase with no reperfusion evidence after 3 hours of the onset of symptoms, so he underwent to rescue angioplasty. Angiography reported left main coronary artery aneurysm thrombosis. Afterwards, he presented cardiogenic shock and was revascularized with a coronary artery bypass graft of the mammary artery to the left anterior descending artery and the saphenous vein to the obtuse marginal, however he did not survive. Determination for 4G/5G PAI-1 polymorphism, glycoprotein IIIa PLA1/A2 gene and Glu298Asp polymorphism of the endothelial nitric oxide synthase gene was performed. CONCLUSIONS: Left main coronary artery aneurysms are rare, finding ONE in an acute myocardial infarction is a serious situation because of the challenging reperfusion techniques that are implied, such as in this case. The search for genetic factors related with hypofibrinolysis could guide stratification and therapy towards medical surgical or interventional management.

The activation of CD14, TLR4, and TLR2 by mmLDL induces IL-1ß, IL-6, and IL-10 secretion in human monocytes and macrophages.

UNLABELLED: Atherosclerosis is considered a chronic inflammatory disease in which monocytes and macrophages are critical. These cells express CD14, toll-like receptor (TLR) 2, and TLR4 on their surfaces, are activated by minimally modified low-density lipoprotein (mmLDL) and are capable of secreting pro-inflammatory cytokines. The aim of this research was thus to demonstrate that the activation of CD14, TLR2, and TLR4 by mmLDL induces the secretion of cytokines. METHODS: Human monocytes and macrophages were incubated with monoclonal antibodies specific for CD14, TLR4, and TLR2 prior to stimulation with mmLDL. Cytokine secretion was then compared to that observed upon mmLDL stimulation in untreated cells. RESULTS: Stimulation with mmLDL induced the secretion of pro-inflammatory cytokines. Blocking CD14 in monocytes inhibited secretion of interleukin (IL)-1ß (72%), IL-6 (58%) and IL-10 (63%), and blocking TLR4 inhibited secretion of IL-1ß by 67%, IL-6 by 63% and IL-10 by 60%. Blocking both receptors inhibited secretion of IL-1ß by 73%, IL-6 by 69% and IL-10 by 63%. Furthermore, blocking TLR2 inhibited secretion of IL-1ß by 65%, IL-6 by 62% and IL-10 by 75%. In macrophages, we found similar results: blocking CD14 inhibited secretion of IL-1ß by 59%, IL-6 by 52% and IL-10 by 65%; blocking TLR4 inhibited secretion of IL-1ß by 53%, IL-6 by 63% and IL-10 by 61%; and blocking both receptors inhibited secretion of IL-1ß by 69%, IL-6 by 67% and IL-10 by 65%. Blocking TLR2 in macrophages inhibited secretion of IL-1ß by 57%, IL-6 by 40% and IL-10 by 72%. CONCLUSION: Our study demonstrates that CD14, TLR4, and TLR2 participate in the immune response against mmLDL by inducing the production of pro-inflammatory cytokines in both monocytes and macrophages. These findings suggest that the activation of these receptors by mmLDL contributes to the inflammatory process of atherosclerosis.

Ipact of bezafibrate treatment in patients with hyperfibrinogenemia and ST-elevation acute myocardial infarction: a randomized clinical trial.

BACKGROUND: Hyperfibrinogenemia is a predictor of cardiovascular events in healthy subjects and in patients with chronic ischemic heart disease. Bezafibrate decreases fibrinogen levels and also the incidence of major cardiovascular events in primary prevention, but its effects in acute coronary syndrome are unknown. METHODS: This is a randomized, controlled clinical trial with conventional therapy. We included patients with Acute ST Elevation Myocardial Infarction (STEAMI) and fibrinogen concentration >500 mg/dl at 72 h of evolution. We randomized subjects into two groups: bezafibrate 400 mg (group I) and conventional therapy (group II). Primary end point was decrease of fibrinogen concentrations. Secondary end points were recurrence of angina or infarction, left ventricular failure and combined end points during hospitalization. RESULTS: We included 25 patients in each group. Fibrinogen concentrations were lower at hospital discharge in Group I than in Group II (532.42 +/- 129.6 vs. 889 +/- 127.32 mg/dl in group II, p <0.0001). Secondary end points were more frequent in Group II than in Group I: angina (56% vs. 4%, RR 0.071 [0.010-0.503], p <0.0001), left ventricular failure (24% vs. 4%, RR 0.167 [0.022-1.286], p = 0.049) and combined end points (76% vs. 8%, RR 0.105 [0.027-0.405], p <0.001). CONCLUSIONS: Bezafibrate treatment was a safe treatment and reduced fibrinogen levels in patients with STEAMI and hyperfibrinogenemia. In the short term, this reduction was associated with a lower incidence of major cardiovascular events.

Impacto del tratamiento con bezafibrato en pacientes con hiperfibrinogenemia e infarto agudo del miocardio con elevación del ST / Impact of bezafibrate treatment in patients with hyperfibrinogenemia and ST-elevation acute myocardial infarction: a randomized clinical trial

Introducción: La hiperfibrinogenemia se considera predictora de eventos cardiovasculares en sujetos sanos y pacientes con cardiopatía isquémica. Como medida de prevención primaria, el bezafibrato disminuye el fibrinógeno sanguíneo y los eventos cardiovasculares, pero su efecto en el síndrome coronario agudo aún no se conoce. Material y métodos: Ensayo clínico, aleatorizado, controlado con tratamiento convencional. Se incluyeron pacientes con infarto agudo del miocardio con elevación del segmento ST y concentraciones de fibrinógeno > 500 mg/dl a las 72 horas de evolución. Se asignaron a recibir 400 mg de bezafibrato (grupo I) o tratamiento convencional (grupo II). Punto primario de evaluación: concentraciones de fibrinógeno; puntos secundarios: recurrencia de angina o infarto, falla ventricular izquierda y puntos finales combinados durante la estancia hospitalaria. Resultados: Se incluyeron 25 pacientes por grupo. Las concentraciones de fibrinógeno al egreso hospitalario fueron significativamente menores en el grupo I (532.42 ± 129.6 versus 889 ± 127.32 mg/dl del grupo II, p < 0.0001). Los puntos secundarios se presentaron con mayor frecuencia en el grupo II que en el grupo I: angina (56 versus 4%, riesgo relativo 0.071 [0.010-0.503], p < 0.0001), falla ventricular (24 versus 4%, riesgo relativo 0.167 [0.022-1.286], p = 0.049) y puntos finales combinados (76 versus 8%, riesgo relativo 0.105 [0.027- 0.405], p < 0.001). Conclusiones: El tratamiento con bezafibrato fue seguro y logró reducir el fibrinógeno en pacientes con infarto agudo. Esta reducción se asoció con menor frecuencia de eventos cardiovasculares a corto plazo.

BACKGROUND: Hyperfibrinogenemia is a predictor of cardiovascular events in healthy subjects and in patients with chronic ischemic heart disease. Bezafibrate decreases fibrinogen levels and also the incidence of major cardiovascular events in primary prevention, but its effects in acute coronary syndrome are unknown. METHODS: This is a randomized, controlled clinical trial with conventional therapy. We included patients with Acute ST Elevation Myocardial Infarction (STEAMI) and fibrinogen concentration >500 mg/dl at 72 h of evolution. We randomized subjects into two groups: bezafibrate 400 mg (group I) and conventional therapy (group II). Primary end point was decrease of fibrinogen concentrations. Secondary end points were recurrence of angina or infarction, left ventricular failure and combined end points during hospitalization. RESULTS: We included 25 patients in each group. Fibrinogen concentrations were lower at hospital discharge in Group I than in Group II (532.42 +/- 129.6 vs. 889 +/- 127.32 mg/dl in group II, p <0.0001). Secondary end points were more frequent in Group II than in Group I: angina (56% vs. 4%, RR 0.071 [0.010-0.503], p <0.0001), left ventricular failure (24% vs. 4%, RR 0.167 [0.022-1.286], p = 0.049) and combined end points (76% vs. 8%, RR 0.105 [0.027-0.405], p <0.001). CONCLUSIONS: Bezafibrate treatment was a safe treatment and reduced fibrinogen levels in patients with STEAMI and hyperfibrinogenemia. In the short term, this reduction was associated with a lower incidence of major cardiovascular events.