ARGEN SHOCK: Mortality related to the use of Swan Ganz and to the hemodynamic pattern found in patients with AMICS.

The Swan Ganz Catheter (SGC) allows us to diagnose different types of cardiogenic shock (CS). OBJECTIVES: 1) Determine the frequency of use of SGC, 2) Analyze the clinical characteristics and mortality according to its use and 3) Analyze the prevalence, clinical characteristics and mortality according to the type of Shock. METHODS: The 114 patients (p) from the ARGEN SHOCK registry were analyzed. A "classic" pattern was defined as PCP > 15 mm Hg, CI < 2.2 L/min/ m2, SVR > 1,200 dynes × sec × cm-5. A "vasoplegic/mixed" pattern was defined when p did not meet the classic definition. CS due to right ventricle (RV) was excluded. RESULTS: SGC was used in 35 % (n:37). There were no differences in clinical characteristics according to SGC use, but those with SGC were more likely to receive dobutamine, levosimendan, and intra aortic balloon pump (IABP). Mortality was similar (59.4 % vs 61.3 %). The pattern was "classic" in 70.2 %. There were no differences in clinical characteristics according to the type of pattern or the drugs used. Mortality was 54 % in patients with the classic pattern and 73 % with the mixed/vasoplegic pattern, but the difference did not reach statistical significance (p:0.23). CONCLUSIONS: SGC is used in one third of patients with CS. Its use does not imply differences in the drugs used or in mortality. Most patients have a classic hemodynamic pattern. There are no differences in mortality or in the type of vasoactive agents used according to the CS pattern found.

Heart Failure at Admission Complicating ST-Elevation Myocardial Infarction in a Middle-Income Country. Experience of the ARGEN-IAM-ST Registry.

Despite advances in the management of ST-elevation myocardial infarction (STEMI), when associated with heart failure (HF) its prognosis remains ominous. This study assessed the differences in admission and mortality of HF complicating STEMI at admission (HFad) in a middle-income country. Data from the National Registry of STEMI of Argentina (ARGEN-IAM-ST) from January 1, 2016, to September 30, 2020, were analyzed. HFad was defined by the identification of Killip/Kimball ≥2 at admission. About 3174 patients were analyzed (22.3% had HFad). Patients with HFad were older, more often women, hypertensive, and diabetic. Received less reperfusion (87.6% vs 92.6%, P < 0.001) and had increased in-hospital mortality (28.4% vs 3.0%, P < 0.001). In multivariate analysis HFad was an independent predictor of death (OR: 4.88 [95%CI: 3.33-7.18], P < 0.001) and reperfusion adjusted to HFad was associated with lower mortality (OR: 0.57 [95%CI: 0.34-0.95], P = 0.03). HFad in STEMI is associated with a worse clinical profile, receives fewer reperfusion strategies, and carries a higher risk of in-hospital mortality while reperfusion reduces mortality.

Registro ARGEN-IAM-ST: infarto de miocardio con elevación del segmento ST en el "nuevo" adulto mayor / ARGEN-IAM-ST Registry: ST-elevation myocardial infarction in "new" older adults

RESUMEN Introducción: La Organización Mundial de la Salud (OMS) considera adulto mayor (AM) a las personas que tienen 60 años o más. Es sabido que la mortalidad por infarto agudo de miocardio (IAM) aumenta a edades más avanzadas, pero siempre se han utilizado umbrales de edad mayores que el propuesto por la OMS, por lo cual describir las características y evolución intrahospitalaria de este subgrupo (de acuerdo con la definición de la OMS) se torna relevante. Objetivos: 1) conocer la prevalencia de los AM según la OMS, con IAM con elevación del segmento ST en Argentina y 2) com- parar sus características, tratamientos de reperfusión y mortalidad con los adultos jóvenes. Material y métodos: Se analizaron los pacientes ingresados en el Registro Nacional de Infarto (ARGEN-IAM-ST). Se compara- ron las características clínicas, tratamientos y evolución de los AM y los adultos jóvenes. Resultados: Se incluyeron 6676 pacientes, de los cuales 3626 (54,3%) eran AM. Los AM fueron más frecuentemente mujeres (37,6% vs. 31,4%, p <0,001), hipertensos (67,8% vs. 47%, p <0,001), diabéticos (26,1% vs. 19,9%, p <0,001), dislipidémicos (45,4% vs. 37%, p <0,001), y tuvieron más antecedentes coronarios (16% vs. 10,3%, p <0,001). El tiempo a la consulta de los AM fue mayor (120 min vs. 105 min, p <0,001) con similar tiempo total de isquemia (314 min vs. 310 min, p = 0,33). Recibi- eron menos tratamiento de reperfusión (89,9% vs. 88,6%, p = 0,04) y más angioplastia primaria (91 % vs. 87,4%, p <0,001). Tuvieron más insuficiencia cardíaca (27,3% vs. 18,5%, p <0,001), similar incidencia de sangrado (3,7 vs. 3,1%, p = 0,33) y una mortalidad significativamente mayor (11,4% vs. 5,5%, p <0,001). Ser AM fue predictor independiente de mortalidad. Conclusiones: Más de la mitad de los IAM en nuestro país ocurren en AM. Los pacientes mayores tienen menor probabilidad de recibir reperfusión, más insuficiencia cardíaca y el doble de la mortalidad que los pacientes menores de 60 años.

ABSTRACT Background: The World Health Organization (WHO) defines an Older Adult (OA) as any individual aged 60 or older. It is known that mortality due to acute myocardial infarction (AMI) increases with age, but age thresholds higher than those proposed by the WHO have been consistently used; therefore, describing the characteristics and in-hospital progress of this subgroup of patients, in accordance with the WHO definition, becomes relevant. Objectives: 1) To know the prevalence of OA with acute ST-elevation myocardial infarction (STEMI) in Argentina according to the WHO, and 2) to compare their characteristics, reperfusion treatments, and mortality against those in young adults. Methods: Patients included in the National Registry of ST- Elevation Myocardial Infarction (Registro Nacional de Infarto con Elevación del ST, ARGEN-IAM-ST) were analyzed. Clinical features, therapies, and progress were compared in OA versus young adults. Results: A total of 6676 patients were enrolled, 3626 of which (54.3%) were OA. OA were mostly female (37.6% vs 31.4%, p <0.001), had hypertension (67.8% vs 47%, p <0.001), diabetes (26.1% vs 19.9%, p <0.001), dyslipidemia (45.4% vs 37%, p <0.001), and a longer coronary artery disease history (16% vs 10.3%, p < 0.001). The time to consultation in OA was longer (120 min vs 105 min, p <0.001), with a similar total ischemic time (314 min vs 310 min, p = 0.33). They received less reperfu- sion treatment (89.9% vs 88.6%, p = 0.04) and more primary angioplasty (91% vs 87.4%, p <0.001). Heart failure was more common in OAs (27.3% vs 18.5%, p <0.001), with a similar bleeding incidence (3.7% vs 3.1%, p = 0.33), and significantly higher mortality (11.4% vs 5.5%, p<0.001). Being an OA was an independent mortality predictor. Conclusions: More than half the cases of AMI in our country occur in OA. Older patients are less likely to receive reperfusion, more likely to have heart failure, and show twice the rate of mortality as compared to patients under 60.

Utilización de la estrategia farmacoinvasiva en Argentina. Análisis del registro ARGEN-IAM ST / Use of the Pharmacoinvasive Strategy in Argentina. ARGEN-IAM ST Registry Analysis

RESUMEN Introducción : La angioplastia primaria (ATCp) es el tratamiento de elección para el infarto agudo de miocardio con elevación del segmento ST (IAMCEST). En nuestro país, de tanta extensión territorial y con tiempos a la reperfusión subóptimos, la estrategia farmacoinvasiva (Finv) podría considerarse. Material y métodos : El ARGEN-IAM-ST es un registro prospectivo, multicéntrico, nacional y observacional. Se incluyen pacien tes con IAMCEST dentro de las 36 horas de evolución. Se definió en el mismo la utilización de Finv y las variables asociadas. Resultados : Se analizaron 4788 pacientes de los cuales en el 88,56 % se realizó ATCp, en el 8,46 % trombolíticos con reperfusión positiva (TL+), y solo en un 2,98% Finv. La mediana y rango intercuartílico (RIC) del tiempo total de isquemia fueron menores en aquellos que recibieron TL+ (165 min, RIC 100-269) y los que fueron a Finv (191 min, RIC 100-330) que en aquellos que fueron a ATCp (280 min, RIC 179- 520), p <0,001. No existieron diferencias en mortalidad intrahospitalaria, en el grupo Finv 4,9%, 5,2% en el grupo TL + y en el grupo ATCp 7,8% (p = 0,081). No hubo diferencias en término de sangrados mayores. Se observó que un 57% de los pacientes con TL+ reunían características de alto riesgo, y no recibieron Finv acorde a lo recomendado Conclusiones : Solo 3 de cada 100 pacientes con IAMCEST que se reperfunden reciben Finv. Su implementación no está ligada en forma sistemática al alto riesgo de eventos. Pese a esta subutilización, por presentar un menor tiempo total de isquemia que la ATCp, sin aumento en los sangrados clínicamente relevantes persiste como una opción a considerar en nuestra realidad.

ABSTRACT Background : Primary percutaneous coronary intervention (PPCI) is the treatment of choice for acute ST-elevation myocardial infarction (STEMI). In Argentina, a country with a large area and suboptimal reperfusion times, the pharmacoinvasive (PI) strategy might be considered. Methods : ARGEN-IAM-ST is a national prospective, multicenter, and observational registry that includes STEMI patients with less than 36 hours of progression. The PI strategy usage and its associated variables were defined. Results : In this registry, 4788 patients were analyzed, of which 88.56% underwent PPCI, 8.46% received thrombolytics with positive reperfusion (TL+), and only 2.98% received PI strategy. Median and interquartile range (IQR) of total ischemia time were lower in patients receiving TL+ (165 min, IQR 100-269) and PI (191 min, IQR 100-330) than in patients undergoing PPCI (280 min, IQR 179-520), p <0.001. No differences in intra-hospital mortality were observed: 4.9% in the PI strategy group, 5.2% in the TL+ group and 7.8% in the PPCI group (p = 0.081). No differences in major bleeding events were observed. It was observed that 57% of the TL+ patients met the criteria for high cardiovascular risk, but they did not receive PI strategy, as recommended. Conclusions : Only 3 out of 100 reperfused STEMI patients received PI strategy. Its administration is not systematically associated to high cardiovascular risk. Despite the under-usage, it remains an option to be considered due to its total ischemia time lower than in the PPCI, with no increase in clinically significant bleedings.

Prognostic Value of Insulin Resistance Assessed by HOMA-IR in Non-Diabetic Patients with Decompensated Heart Failure.

The predictive value of insulin resistance in patients hospitalized with heart failure is unknown. To evaluate prognostic value of insulin resistance (defined by a HOMA IR ≥ 2.5) for the combined event of death and readmission at 90 and 365 days post discharge and to determine if there are differences according to ejection fraction. Prospective study of 156 p hospitalized for acute heart failure without diabetes. A total of 83 years, 48% female, EF ≤ 45% 48%. Of 28% presented HOMA ≥2.5. HOMA IR ≥2.5 was associated with combined event (OR 2.4; 95% CI 1.9-5.1; P: 0.02) at 90 days. A multivariate analysis demonstrated its independent predictive value (OR 2.5, 95% CI 1.1-5.8; P: 0.03). At 1 year follow-up HOMA IR did not predict events. The predictive value of HOMA-IR was not associated with ventricular function. HOMA IR index was a predictor of a combined event at 90 days in our population. It is a simple determination that could contribute to identify higher risk patients during this vulnerable post-discharge phase. These data must be validated in larger studies.

Clinical characteristics and evolution of patients with cardiogenic shock in Argentina in the context of an acute myocardial infarction with ST segment elevation. Data from the nationwide ARGEN-IAM-ST Registry.

Cardiogenic Shock is one of the main causes of death in ST segment Elevation Myocardial Infarction. To know the clinical characteristics, in-hospital evolution and mortality of patients with Cardiogenic Shock. Patients enrolled in the ARGEN-IAM-ST Registry were analyzed. Predictors of Cardiogenic Shock and death during hospital stay were established. A total of 6122 patients were admitted between 2015 and 2022. Cardiogenic Shock was present in 10.75% of cases. Patients with CS were older (64.5 vs 60 years), more females (41% vs 36%), with more antecedents of infarction and a higher prevalence of anterior location of infarction and multivessel disease. They were also less revascularized (88.5% vs 91.5%) and had a higher incidence of failed angioplasty (15.7% vs 2.7%). They also evidenced a higher occurrence of mechanical complications (6.8% vs 0.4%), ischemic recurrence (7.4% vs 3.4%) and cardiac arrest on admission (44.8% vs 2.6%). All the differences described showed statistical significance with P < 0.05. Overall mortality was 58% in contrast to 2.77% in patients without Cardiogenic Shock (P < 0.001). Only age, DBT, and early cardiac arrest were independent predictors of shock on admission whereas age, female gender, cardiac arrest on admission and failed angioplasty were independent predictors of death. One out of 10 patients with ST Elevation Myocardial Infarction presented cardiogenic shock. Its clinical characteristics were similar to those described more than 20 years ago. Despite a high use of reperfusion strategy cardiogenic shock continues to have a very high mortality Argentina.

[Incidence and clinical characteristics of patients with ST-elevation acute myocardial infarction without obstructive coronary disease (MINOCA)]. / Incidencia y características clínicas de los pacientes con infarto agudo de miocardio con elevación del ST sin enfermedad coronaria obstructiva (MINOCA).

INTRODUCTION: MINOCA is an acute myocardial infarction without obstructive coronary disease, this definition was recently incorporated into the 4th universal definition of myocardial infarction. However, since it is an unconventional ischemic coronary syndrome in clinical practice, its etiology is very complex to elucidate and requires a differential diagnosis process to rule out other causes of cardiac injury. The objective of this study is to characterize patients with acute myocardial infarction without significant obstructive lesions included in the Argentine Registry of STsegment Elevation Myocardial Infarction (ARGEN-IAM-ST). METHODS: Prospective, multicenter national study including patients with STEMI within 36 hours of symptom onset. All patients studied with coronary angiography at admission were analyzed and those without significant obstructive lesions of the culprit artery were considered MINOCA. This MINOCA patients were compared with patients with significant atherosclerotic coronary lesions. RESULTS: 30 patients with MINOCA out of 2894 patients entered in the registry (incidence: 1%). MINOCA patients were younger, had a similar proportion for gender, had fewer diabetics patients, and had a greater history of heart failure. They were admitted without heart failure and preserved ejection fraction. In-hospital mortality was 7%, with no significant difference compared to classic AMI. At discharge, they received P2Y12 inhibitors, statins, and beta-blockers in fewer proportion. DISCUSSION: There was no predominance of the female gender as in other series. In-hospital mortality is high despite not having significant coronary disease. It is worth mentioning the low use of dual antiaggregating and statins.

Introducción: MINOCA es un infarto agudo de miocardio sin enfermedad coronaria obstructiva, esta definición se ha incorporado recientemente a la 4° definición universal del infarto. Sin embargo, por tratarse de un síndrome coronario isquémico no convencional en la práctica clínica, su etiología es muy compleja de dilucidar y demanda un proceso de diagnósticos diferenciales para descartar otras causas de lesión cardíaca. El objetivo del presente trabajo fue caracterizar a los pacientes con infarto agudo de miocardio sin lesiones obstructivas significativas incluidos en el Registro Argentino de Infarto con Elevación del segmento ST (ARGEN-IAM-ST). Métodos: estudio prospectivo, multicéntrico de carácter nacional con inclusión de pacientes con IAMCEST dentro de las 36 horas comenzado los síntomas. Se analizaron todos los pacientes estudiados con cinecoronariografía al ingreso y se consideró MINOCA a aquellos sin lesiones obstructivas significativas de la arteria responsable y se los comparó con los pacientes con lesiones coronarias ateroscleróticas significativas. Resultados: 30 pacientes con MINOCA sobre 2894 pacientes ingresados al registro (incidencia: 1%). Los pacientes con MINOCA fueron más jóvenes, proporción similar en cuanto al género, menos diabéticos y con más antecedentes de insuficiencia cardíaca. Ingresan sin falla cardíaca y fracción de eyección preservada. Mortalidad intrahospitalaria 7%, sin diferencia significativa comparado con IAM clásico. Al alta recibieron en menor proporción inhibidores P2Y12, estatinas y betabloqueantes. Discusión: No se encontró predominancia de género femenino como otras series. La mortalidad intrahospitalaria es elevada a pesar de no tener enfermedad coronaria significativa. Se destaca la baja utilización de doble antiagregación y estatinas.

Incidencia y características clínicas de los pacientes con infarto agudo de miocardio con elevación del ST sin enfermedad coronaria obstructiva (MINOCA) / Incidence and clinical characteristics of patients with ST-elevation acute myocardial infarction without obstructive coronary disease (MINOCA)

Resumen Introducción: MINOCA es un infarto agudo de miocardio sin enfermedad coronaria obstructiva, esta definición se ha incorporado recientemente a la 4° definición universal del infarto. Sin embargo, por tratarse de un síndrome coronario isquémico no convencional en la práctica clínica, su etiología es muy compleja de dilucidar y demanda un proceso de diagnósticos diferenciales para descartar otras causas de lesión cardíaca. El objetivo del presente trabajo fue caracterizar a los pacientes con infarto agudo de miocardio sin lesiones obstructivas significativas incluidos en el Registro Argentino de Infarto con Elevación del segmento ST (ARGEN-IAM-ST). Métodos: estudio prospectivo, multicéntrico de carácter nacional con inclusión de pacientes con IAMCEST dentro de las 36 horas comenzado los síntomas. Se analizaron todos los pacientes estudiados con cinecoronariografía al ingreso y se consideró MINOCA a aquellos sin lesiones obstructivas significativas de la arteria responsable y se los comparó con los pacientes con lesiones coronarias ateroscleróticas signifi cativas. Resultados: 30 pacientes con MINOCA sobre 2894 pacientes ingresados al registro (incidencia: 1%). Los pacientes con MINOCA fueron más jóvenes, proporción similar en cuanto al género, menos diabéticos y con más antecedentes de insuficiencia cardíaca. Ingresan sin falla cardíaca y fracción de eyección preservada. Mortalidad intrahospitalaria 7%, sin diferencia significativa comparado con IAM clásico. Al alta recibieron en me nor proporción inhibidores P2Y12, estatinas y betabloqueantes. Discusión: No se encontró predominancia de género femenino como otras series. La mortalidad intrahospitalaria es elevada a pesar de no tener enfermedad coronaria significativa. Se destaca la baja utilización de doble antiagregación y estatinas.

Abstract Introduction: MINOCA is an acute myocardial infarction without obstructive coronary disease, this definition was recently incorporated into the 4th universal definition of myocardial infarction. However, since it is an unconventional ischemic coronary syndrome in clinical practice, its etiology is very complex to elucidate and requires a differential diagnosis process to rule out other causes of cardiac injury. The objective of this study is to characterize patients with acute myocardial infarction without significant obstructive lesions included in the Argentine Registry of ST-segment Elevation Myocardial Infarction (ARGEN-IAM-ST). Methods: Prospective, multicenter national study including patients with STEMI within 36 hours of symptom onset. All patients studied with coronary angiography at admission were analyzed and those without significant obstructive lesions of the culprit artery were considered MINOCA. This MINOCA patients were compared with patients with significant atherosclerotic coronary lesions. Results: 30 patients with MINOCA out of 2894 patients entered in the registry (incidence: 1%). MINOCA patients were younger, had a similar proportion for gender, had fewer diabetics patients, and had a greater history of heart failure. They were admitted without heart failure and preserved ejection fraction. In-hospital mortality was 7%, with no significant difference compared to classic AMI. At discharge, they received P2Y12 inhibitors, statins, and beta-blockers in fewer proportion. Discussion: There was no predominance of the female gender as in other series. In-hospital mortality is high despite not having significant coronary disease. It is worth mentioning the low use of dual antiaggregating and statins.

Recomendaciones de manejo de los anticoagulantes orales directos (DOACs) anti Xa y anti IIa / Recommendations for the practical management of the direct oral anticoagulants anti Xa and anti IIa

Resumen Los anticoagulantes orales directos han surgido como una de las herramientas que ha cambiado el manejo de la enfermedad trombótica en los últimos 15 años. Sus ventajas, desde el punto de vista de la facilidad de uso y menor riesgo de sangrado, especialmente de sangrado cerebral, han posicionado a estos nuevos anticoagulantes como la primera alternativa de tratamiento en las dos indicaciones más frecuentes en que necesitamos estas drogas, la fibrilación auricular y la enfermedad tromboembólica venosa. Sin embargo, no todos los pacientes pueden recibir estos agentes, no todos los anticoagulantes directos tienen las mismas pro piedades y fundamentalmente, no todas las enfermedades con indicación de un anticoagulante pueden tratarse con ellos;con lo cual es necesario que todos los profesionales que están involucrados en el manejo de estos medicamentos estén obligados a conocerlos en profundidad, para poder decidir el mejor tratamiento en cada caso particular. Este documento de posición de expertos de diferentes especialidades de Argentina, presenta lineamientos para el uso correcto de los anticoagulantes directos en base a nueva evidencia y a la experiencia de uso de un amplio grupo de profesionales. La forma de relacionarnos con el tratamiento anticoagulante ha cambiado. Los médicos que trabajamos con ellos también debemos hacerlo.

Abstract Direct oral anticoagulants have emerged as the drugs that have changed the man agement of the antithrombotic treatment in the last 15 years. Their advantages, like a more friendly way of anticoagulation and their lower risk of bleeding, especially in the brain, have positioned these new anticoagu lants as the first drug of choice in the two most frequent indications of anticoagulation, atrial fibrillation, and the venous thromboembolic disease. However, not all the patients can receive these agents, not all the direct oral anticoagulants have the same characteristics, and most importantly, not all the diseases with an indication of an anticoagulant drug can be treated with them. Therefore, it is mandatory that all the faculties involved in the management of these drugs must know them in depth, to decide the best treatment for the patient. This position paper, from a group of experts in anticoagulation in Argentina, can help the general practitioner in the daily use of direct oral anticoagulants based on the new evidence and the experience of a wide group of professionals. The way we relate to the anticoagulant treatment has changed in the last years. The doctors who work with them must also do so.

Características generales y evolución según el índice de masa corporal en pacientes con Infarto Agudo de Miocardio en Argentina. (Registro ARGEN-IAM-ST) / General Characteristics and Outcome of Patients with Acute Myocardial Infarction in Argentina According to Body Mass Index. (ARGEN-IAM-ST Registry)

RESUMEN Introducción: El índice de masa corporal (IMC) en rangos de sobrepeso y obesidad es un factor de riesgo cardiovascular cada vez más frecuente. Su valor pronóstico es discutido en el contexto del infarto agudo de miocardio (IAM). Objetivos: Conocer características basales, estrategias de reperfusión y evolución de los casos incluidos del registro ARGENIAM ST según el IMC. Material y Métodos: Estudio prospectivo de los casos incluidos en el registro. Se excluyeron los que no presentaban datos antropométricos completos. Se definieron 3 grupos; IMC saludable: < 25 kg/m2 (G1), sobrepeso: IMC entre 25 y 29,9 kg/m2 (G2) y obesidad: IMC mayor o igual a 30 kg/m2 (G3). Resultados: Se incluyeron 2925 casos. Los pacientes del G3 tenían menor edad (G1: 63 ± 12, G2: 61 ± 11, G3: 60 ± 11 años, p = 0,0001), más frecuentemente diabetes (G1: 11%, G2: 22%, G3: 28%; p = 0,0001) y dislipidemia (G1: 35%, G2: 40%, G3: 43%; p = 0,01). No encontramos diferencias en el tiempo puerta balón, (medianas de 104 minutos en G1, 110 en G2 y 110 en G3, p = 0,27), la enfermedad de dos o más vasos (G1 38%, G2 34,5% y G3 37%; p = 0,26) y la mortalidad intrahospitalaria (G1 9,7%, G2 7,5% y G3 8,4%; p = 0,22). En el análisis multivariado el Killip y Kimball no A (OR: 20,1; IC95% 13,1-30,8; p < 0,0001), la edad (OR: 1,7; IC95 1,2-2,5; p <0,0001) y la enfermedad de dos o más vasos (OR: 1.5; IC95% 1,03-2,1; p < 0,0001) fueron predictores independientes de mortalidad en la internación. Conclusiones: Los pacientes con sobrepeso y obesidad eran más jóvenes, con más antecedentes de diabetes y dislipidemia. No hubo diferencias significativas en la forma de presentación, tratamiento y complicaciones. En el análisis multivariado el sobrepeso y la obesidad no fueron predictores de mortalidad.

ABSTRACT Background: Body mass index (BMI) in overweight and obesity ranges is an increasingly frequent cardiovascular risk factor. Its prognostic value is debatable in the setting of acute myocardial infarction (AMI). Objectives: The aim of this study is to acknowledge the clinical characteristics, reperfusion strategies outcome of the cases included in the ARGEN-IAM ST according to BMI. Methods: We conducted a prospective study of the cases included in the registry. Patients with incomplete anthropometric data were excluded. Three groups were defined: healthy BMI < 25 kg/m2 (G1), overweight: BMI between 25 and 29.9 kg/m2 (G2) and obesity: BMI ≥30 kg/m2 (G3). Results: 2925 cases were included. Patients in G3 were younger (G1: 63±12, G2: 61±11, G3: 60±11 years, p=0.0001), and had higher incidence of diabetes (G1: 11%, G2: 22%, G3: 28%; p=0.0001) and dyslipidemia (G1: 35%, G2: 40%, G3: 43%; p=0.01). There were no differences in door-to-balloon time (median 104 minutes in G1, 110 in G2 and 110 in G3, p=0.27), two-vessel disease or greater (G1 38%, G2 34.5% and G3 37%; p=0.26) and in-hospital mortality (G1 9.7%, G2 7.5% and G3 8.4%; p=0.22). In multivariate analysis Killip class other than A (OR: 20.1; 95% CI 13.1-30.8; p<0.0001), age (OR: 1.7; 95% CI 1.2-2.5; p<0.0001) and two-vessel disease or greater (OR: 1.5; 95% CI 1.03-2.1; p<0.0001) were independent predictors of in-hospital mortality. Conclusions: Overweight and obese patients were younger, with higher incidence of diabetes and dyslipidemia. There were no significant differences in the type of presentation, treatment and complications. In multivariate analysis, overweight and obesity were not predictors of mortality.

[MANAGEMENT RECOMMENDATIONS FOR DIRECT ORAL ANTICOAGULANTS (DOACs) ANTI Xa AND ANTI IIa]. / RECOMENDACIONES DE MANEJO DE LOS ANTICOAGULANTES ORALES DIRECTOS (DOACS) ANTI Xa Y ANTI IIa.

Direct oral anticoagulants have emerged as the drugs that have changed the management of the antithrombotic treatment in the last 15 years. Their advantages, like a more friendly way of anticoagulation and their lower risk of bleeding, especially in the brain, have positioned these new anticoagulants as the first drug of choice in the two most frequent indications of anticoagulation, atrial fibrillation, and the venous thromboembolic disease. However, not all the patients can receive these agents, not all the direct oral anticoagulants have the same characteristics, and most importantly, not all the diseases with an indication of an anticoagulant drug can be treated with them. Therefore, it is mandatory that all the faculties involved in the management of these drugs must know them in depth, to decide the best treatment for the patient. This position paper, from a group of experts in anticoagulation in Argentina, can help the general practitioner in the daily use of direct oral anticoagulants based on the new evidence and the experience of a wide group of professionals. The way we relate to the anticoagulant treatment has changed in the last years. The doctors who work with them must also do so.

Los anticoagulantes orales directos han surgido como una de las herramientas que ha cambiado el manejo de la enfermedad trombótica en los últimos 15 años. Sus ventajas, desde el punto de vista de la facilidad de uso y menor riesgo de sangrado, especialmente de sangrado cerebral, han posicionado a estos nuevos anticoagulantes como la primera alternativa de tratamiento en las dos indicaciones más frecuentes en que necesitamos estas drogas, la fibrilación auricular y la enfermedad tromboembólica venosa. Sin embargo, no todos los pacientes pueden recibir estos agentes, no todos los anticoagulantes directos tienen las mismas propiedades y fundamentalmente, no todas las enfermedades con indicación de un anticoagulante pueden tratarse con ellos;con lo cual es necesario que todos los profesionales que están involucrados en el manejo de estos medicamentos estén obligados a conocerlos en profundidad, para poder decidir el mejor tratamiento en cada caso particular. Este documento de posición de expertos de diferentes especialidades de Argentina, presenta lineamientos para el uso correcto de los anticoagulantes directos en base a nueva evidencia y a la experiencia de uso de un amplio grupo de profesionales. La forma de relacionarnos con el tratamiento anticoagulante ha cambiado. Los médicos que trabajamos con ellos también debemos hacerlo.

Valor pronóstico del índice de shock en el infarto de miocardio. Datos del Registro Argentino de infarto con elevación del segmento ST (ARGEN IAM-ST) / Prognostic value of the shock index in myocardial infarction. Data from Argentine Registry of ST-segment elevation infarct (ARGEN IAM-ST)

Resumen El índice de shock (IS) se obtiene mediante un cálculo simple del cociente entre la frecuencia cardíaca (FC) y la tensión arterial sistólica (PAS) (IS: FC/TAS) y el índice de shock ajustado por edad (ISA) multiplicando el IS x edad. Evaluamos su valor predictivo para el evento combinado intrahospitalario (EC) muerte y/o shock cardiogénico (SC) y de los eventos individuales en los pacientes incluidos en el registro argentino de infarto con elevación del segmento ST (ARGEN-IAM-ST). Se excluyeron 248 con SC de ingreso. Se realizaron curvas ROC para ambos índices utilizando el mejor punto de corte para dicotomizar la población. Se incluyeron 2928 pacientes. Edad (mediana) 60 años (RIC 25-75% 53-68), varones 80%, EC: 6.4%. Un 30.5% tuvo IS ≥ 0.67 y éstos presentaron mayor incidencia de EC: 11% vs. 4% (p < 0.001), shock cardiogénico (8% vs. 2.6%, p <0.0001) y muerte (7.3% vs. 3%, p < 0.0001) que los pacientes con IS < 0.67. Un 28% tuvo ISA ≥ 41.5. Estos presentaron más EC: 14% vs. 3%, p < 0.001, SC: 10% vs. 2%, (p < 0.001) y muerte: 9.5% vs. 2.3%, (p < 0.001) comparados con los pacientes con valores ISA < 41.5. El área bajo la curva ROC del ISA para EC fue significativamente mejor que la del IS (0.72 vs. 0.62, p < 0.001).En los modelos de análisis multivariados reali zados, el IS tuvo un OR de 2.56 (IC95% 1.56-4.02; p < 0.001) y el ISA de 3.43 (IC95% 2.08-5.65; p<0.001) para EC. El IS y el ISA predicen muerte y/o el desarrollo de shock cardiogénico intrahospitalario en una población no seleccionada de infartos con elevación del ST.

Abstract The shock index (IS) is the quotient between the heart rate (HR) and the systolic blood pressure (SBP) (IS: HR / SBT), and the age-adjusted shock index (ISA) multiplying the IS by age. We evaluated its predictive value for the combined in-hospital event (EC), death and / or cardiogenic shock (CS) and for individual events in the patients included in the Argentine registry of ST-segment elevation infarction (ARGEN-ST-AMI); 248 with CS on admission were excluded. ROC curves were made for both indices using the best cut-off point to dichotomize the population. The analysis included 2928 subjects. Age (median) 60 years (IQR 25-75% 53-68), men 80%, EC: 6.4%; 30.5% had IS ≥ 0.67, and they had a higher incidence of EC: 11% vs. 4% (p < 0.001), cardiogenic shock (8% vs. 2.6%, p <0.0001) and death (7.3% vs. 3%), p <0.0001) than patients with IS < 0.67. A 28% had ISA ≥ 41.5. These presented plus EC: 14% vs. 3%, p < 0.001, SC: 10% vs. 2%, (p < 0.001) and death: 9.5% vs. 2.3%, (p < 0.001) compared with patients with values < 41.5. The area under the ROC curve of the ISA for EC was significantly better than that of the IS (0.72 vs. 0.62, p < 0.001). In the multivariate analysis models performed, the IS had an OR: 2.56 (95% CI 1.56-4.02; p < 0.001) and the ISA: 3.43 (95% CI 2.08-5.65; p < 0.001) for EC. The IS and ISA predict death and / or the development of in-hospital cardiogenic shock in an unselected population of ST elevation infarcts.

[Prognostic value of the shock index in myocardial infarction. Data from Argentine Registry of ST-segment elevation infarct (ARGEN IAM-ST)]. / Valor pronóstico del índice de shock en el infarto de miocardio. Datos del Registro Argentino de infarto con elevación del segmento ST (ARGEN IAM-ST).

The shock index (IS) is the quotient between the heart rate (HR) and the systolic blood pressure (SBP) (IS: HR / SBT), and the age-adjusted shock index (ISA) multiplying the IS by age. We evaluated its predictive value for the combined in-hospital event (EC), death and / or cardiogenic shock (CS) and for individual events in the patients included in the Argentine registry of ST-segment elevation infarction (ARGEN-ST-AMI); 248 with CS on admission were excluded. ROC curves were made for both indices using the best cut-off point to dichotomize the population. The analysis included 2928 subjects. Age (median) 60 years (IQR 25-75% 53-68), men 80%, EC: 6.4%; 30.5% had IS = 0.67, and they had a higher incidence of EC: 11% vs. 4% (p < 0.001), cardiogenic shock (8% vs. 2.6%, p <0.0001) and death (7.3% vs. 3%), p <0.0001) than patients with IS < 0.67. A 28% had ISA = 41.5. These presented plus EC: 14% vs. 3%, p < 0.001, SC: 10% vs. 2%, (p < 0.001) and death: 9.5% vs. 2.3%, (p < 0.001) compared with patients with values < 41.5. The area under the ROC curve of the ISA for EC was significantly better than that of the IS (0.72 vs. 0.62, p < 0.001). In the multivariate analysis models performed, the IS had an OR: 2.56 (95% CI 1.56-4.02; p < 0.001) and the ISA: 3.43 (95% CI 2.08-5.65; p < 0.001) for EC. The IS and ISA predict death and / or the development of in-hospital cardiogenic shock in an unselected population of ST elevation infarcts.

El índice de shock (IS) se obtiene mediante un cálculo simple del cociente entre la frecuencia cardíaca (FC) y la tensión arterial sistólica (PAS) (IS: FC/TAS) y el índice de shock ajustado por edad (ISA) multiplicando el IS x edad. Evaluamos su valor predictivo para el evento combinado intrahospitalario (EC) muerte y/o shock cardiogénico (SC) y de los eventos individuales en los pacientes incluidos en el registro argentino de infarto con elevación del segmento ST (ARGEN-IAM-ST). Se excluyeron 248 con SC de ingreso. Se realizaron curvas ROC para ambos índices utilizando el mejor punto de corte para dicotomizar la población. Se incluyeron 2928 pacientes. Edad (mediana) 60 años (RIC 25-75% 53-68), varones 80%, EC: 6.4%. Un 30.5% tuvo IS = 0.67 y éstos presentaron mayor incidencia de EC: 11% vs. 4% (p < 0.001), shock cardiogénico (8% vs. 2.6%, p <0.0001) y muerte (7.3% vs. 3%, p < 0.0001) que los pacientes con IS < 0.67. Un 28% tuvo ISA = 41.5. Estos presentaron más EC: 14% vs. 3%, p < 0.001, SC: 10% vs. 2%, (p < 0.001) y muerte: 9.5% vs. 2.3%, (p < 0.001) comparados con los pacientes con valores ISA < 41.5. El área bajo la curva ROC del ISA para EC fue significativamente mejor que la del IS (0.72 vs. 0.62, p < 0.001).En los modelos de análisis multivariados realizados, el IS tuvo un OR de 2.56 (IC95% 1.56-4.02; p < 0.001) y el ISA de 3.43 (IC95% 2.08-5.65; p <0.001) para EC. El IS y el ISA predicen muerte y/o el desarrollo de shock cardiogénico intrahospitalario en una población no seleccionada de infartos con elevación del ST.

El índice de shock e índice de shock ajustado por edad como predictores de muerte en la insuficiencia cardíaca descompensada / Shock Index and Age-Adjusted Shock Index as Predictors of Mortality in Decompensated Heart Failure

RESUMEN Introducción: El índice de shock (IShock), calculado a partir de los valores al ingreso de la frecuencia cardíaca (FC) y tensión arterial sistólica (TAS) y el IShock ajustado por edad, son herramientas que han demostrado utilidad pronóstica en algunos contextos clínicos; sin embargo, su valor pronóstico en la insuficiencia cardíaca descompensada (ICD) es desconocido. Objetivo: evaluar la capacidad pronóstica para mortalidad total intrahospitalaria de ambos índices en pacientes ingresados a unidad coronaria por ICD. Material y métodos: Estudio retrospectivo de pacientes consecutivos ingresados en 2 unidades coronarias durante el periodo enero 2010/agosto 2020. Se calcularon ambos índices, se determinó su valor predictivo y mediante curva ROC se definieron los valores de corte con mejor combinación de sensibilidad y especificidad. Se efectuó análisis multivariado para encontrar los predictores independientes de mortalidad intrahospitalaria. Resultados: Población: 1472 pacientes. Edad (mediana) 81 años, 50% con fracción de eyección ventricular izquierda <40%, y 50% con antecedentes de ICD previa. Mortalidad intrahospitalaria 6,2%. Un IShock ≥0,58 e IShock ajustado por edad ≥45,6 (hallados por índice de Youden) fueron predictores de mortalidad. En el análisis multivariado que incluyó edad, tensión arterial sistólica (TAS) <115 mmHg, nitrógeno ureico en sangre (BUN) >43 mg/dL, creatinina >2,75 mg/dL, hemoglobina <10 g/dL y el ISHock ≥0,58, solo mantuvieron su valor predictivo la edad, el BUN >43 mg/dL y la anemia. En un modelo multivariado donde se evaluó al IShock ajustado por edad ≥45,6 junto a las otras variables (excepto edad), éste fue predictor independiente (OR 2,41 IC95% 1,37-4,2 p <0,01) al igual que el BUN >43 mg/dL y la anemia. Conclusión: Un cálculo sencillo como el IShock ajustado por edad es de gran utilidad en la predicción de la mortalidad hospitalaria de los pacientes internados con ICD y agrega información adicional a las variables pronósticas clásicas.

ABSTRACT Background: Shock index (SI), calculated as the ratio of heart rate (HR) to systolic blood pressure (SBP) obtained on admission, and age-adjusted SI are tools that have already demonstrated prognostic value in some clinical contexts, but their prognostic value in decompensated heart failure (DHF) is unknown. Objective: The aim of this study was to evaluate the prognostic ability of both indices for total in-hospital mortality in patients admitted to the coronary unit for DHF. Methods: We conducted a retrospective study of consecutive patients admitted to 2 coronary care units between January 2010 and August 2020. Both indices and their respective predictive values were calculated. The cutoff point values with the best combination of sensitivity and specificity were defined using the ROC curve. Multivariate analysis was performed to identify independent predictors of in-hospital mortality. Results: Population: 1472 patients. Median age was 81 years, 50 had left ventricular ejection fraction <40% and 50% had a history of DHF. In-hospital mortality 6.2%. Youden's index identified SI ≥0.58 and age-adjusted SI ≥45.6 as predictors of mortality. On multivariate analysis including age, systolic blood pressure (SBP) <115 mmHg, blood urea nytrogen (BUN) >43 mg/ dL, creatinine level >2.75 mg/dL, hemoglobin (Hb) <10 g/dL and SI ≥0.58, only age, BUN >43 mg/dL and anemia remained as independent predictors of in-hospital mortality. On multivariate analysis, when age-adjusted SI ≥45.6 was analyzed with the other variables (but not with age), the independent predictors were age-adjusted SI ≥45.6 (OR 2.41; 95% CI, 1.37-4.2; p <0.01), BUN >43 mg/dL and anemia. Conclusion: A simple calculation as age-adjusted SI is highly useful to predict in-hospital mortality in patients hospitalized with DHF and provides additional information to the classic prognostic variables.

Mortalidad por infarto agudo de miocardio en el registro continuo ARGEN-IAM-ST. Su relación con las diferentes terapias de reperfusión / Mortality of Acute Myocardial Infarction in the Continuous Registry ARGEN-AMI-ST and its Relationship with the Different Reperfusion Therapies

RESUMEN Introducción: El tratamiento de reperfusión es la terapéutica de mayor eficacia para reducir la mortalidad del infarto agudo de miocardio con elevación del segmento ST (IAMCEST) , y su efectividad es inversamente proporcional al tiempo total de isquemia. El mayor desafío es instrumentar su aplicación en la vida real y corregir en forma continua los desvíos o las barreras que se presentan en la práctica cotidiana. Objetivos: Evaluar la mortalidad con las diferentes modalidades de reperfusión, su relación con el tiempo de tratamiento y su efectividad en un registro prospectivo multicéntrico del mundo real de Argentina. Material y Métodos: estudio prospectivo, multicéntrico de carácter nacional, incluidos los pacientes con IAMCEST hasta las 36 h del comienzo de los síntomas (ARGEN-IAM-ST registro continuo). Resultados: participaron 2464 pacientes de 78 centros entre 2015 y 2019. El 88,5% recibió tratamiento de reperfusión. La mortalidad fue de 8,68%. Los pacientes tratados con reperfusión tuvieron una mortalidad de 7,81% versus 15,38% sin tratamiento (p <0,001). La mortalidad con angioplastia primaria fue 7,51%, con trombolíticos 9,03%, con estrategia farmacoinvasiva 2,99% y con angioplastia de rescate 9,40%, sin diferencia estadísticamente significativa entre angioplastia primaria y trombolíticos (OR 0,81 IC 95% 0,56-1,18, p = ns). Los pacientes fallecidos fueron de mayor edad, con mayor proporción de mujeres e insuficiencia cardíaca. El tratamiento de reperfusión e ingreso a la institución dentro de 3 horas del comienzo de los síntomas se asoció a menor mortalidad. Los pacientes fallecidos con angioplastia primaria tuvieron mayor tiempo total de isquemia (378 minutos versus 285 minutos, p < 0,001). Conclusiones: La mortalidad por IAMCEST se relacionó con el acceso a la reperfusión y su precocidad. Fue mucho mayor en los pacientes no reperfundidos, y menor cuando la reperfusión se efectuó en forma precoz dentro de las primeras tres horas del comienzo de los síntomas. En los pacientes tratados con angioplastia primaria la mortalidad se incrementó con mayor tiempo total de isquemia. Este registro de la práctica real del tratamiento del IAMCEST refuerza la necesidad de una mejor articulación del sistema de atención para bajar los tiempos y utilizar la estrategia mejor y más oportuna.

ABSTRACT Background: reperfusion treatment is the most effective therapy in reducing mortality from acute ST elevation myocardial infarction and its effectiveness is inversely proportional to the total time of ischemia. The greatest challenge is to implement its application in real life and continuously correct the deviations or barriers that arise in daily practice. Objectives: to evaluate mortality with the different reperfusion modalities, its relationship with treatment time and to evaluate its effectiveness. Methods: a prospective, multicenter national study, including patients with STEMI up to 36 h after symptoms began (ARGENAMI-ST continuous registry). Results: 2464 patients were included from 2015 to 2019 in 78 centers. 88.5% received reperfusion treatment. Mortality was 8.68%. The patients treated with reperfusion had a mortality of 7.81% versus 15.38% without treatment (p <0.001). Mortality with primary angioplasty was 7.51%, thrombolytics 9.03%, pharmacoinvasive strategy 2.99%, and rescue angioplasty 9.40%, with no statistically significant difference between primary angioplasty and thrombolytics (OR 0.81; 95% CI 0.56-1.18, p = ns). The deceased patients were older, a higher proportion of women, and heart failure. Reperfusion treatment and admission to the institution within 3 hours of starting symptoms were associated with lower mortality. Patients who died with primary angioplasty had a longer total ischemia time (378 minutes versus 285 minutes, p <0.001). Conclusions: mortality from STEMI was related to access to reperfusion and its earliness. It was much higher in non-reperfused patients, and lower when reperfusion was carried out early within the first three hours of the onset of symptoms. In patients treated with primary angioplasty, mortality increased with a longer total ischemia time. This record of the actual practice of the treatment of infarction reinforces the need for a better articulation of the care system to reduce times and use the best timely strategy.

Diabetes as a Predictor of In-Hospital and One-Year Outcomes After Decompensated Heart Failure.

Diabetes and heart failure are closely interdependent, but its significance in decompensated heart failure (DHF) is not uniformly accepted. OBJECTIVE: To compare mortality between diabetics and nondiabetics with DHF. METHODS AND RESULTS: In-hospital and 1-year mortality of 1004 consecutive patients with DHF: 25.6% diabetics; median age was 81, 53% male. Diabetics were younger, more often male, with higher prevalence of ischemic etiology and reduced ejection fraction. Congestion was the most prevalent finding in both groups. In hospital mortality was 6.3% vs 6.6 % in nondiabetics and diabetics respectively and 1-year mortality was 35.77% in nondiabetics and 29.3% in diabetics. There were no significant differences in mortality at univariate and multivariate analyses. We applied a propensity score restricted to 378 patients, 189 (50%) diabetics and 189 (50%) and no significant differences were found. CONCLUSION: Diabetes had no impact on prognosis in DHF. Advanced age may played a major role in outcomes i thus making less relevant the presence of diabetes.

SCA con elevación del ST: impacto del tiempo al diagnóstico en el tiempo puerta-balón en el mundo real. Datos del registro ARGEN-IAM-ST / ST-Segment Elevation ACS: Impact of Time to Diagnosis on Door-To-Balloon Time in the Real World. Data from the ARGEN-IAM-ST Registry

RESUMEN • Introducción: El tiempo trascurrido desde el inicio de los síntomas de infarto hasta el diagnóstico (TAD) puede influir en lograr un tiempo puerta-balón (TPB) <90 min. Material y métodos: Análisis retrospectivo que incluyó 1518 pacientes ingresados en forma prospectiva y consecutiva al registro ARGEN-IAM-ST. El 37,8% de ellos fue tratado con un TPB <90 min y el TAD (mediana) fue de 120 min (RIC 60-266). Se dividió a la población de acuerdo al TAD en dos grupos: menor de 120 min y mayor o igual que 120 min. Un TPB <90 min se logró más frecuentemente en el primer grupo (TAD <120 min): 44%, vs. 32,2% en el segundo grupo (p <0,001). Resutados: En el 56% de los pacientes con ATC in situ y TAD <120 min se logró un TPB <90 min, vs. en el 37,1% de quienes tuvieron un TAD >120 min (p <0,001). En pacientes derivados, no hubo diferencias en TPB <90 min de acuerdo al TAD: 27,5% vs. 25,7 (p: 0,3). En pacientes ingresados en horario laborable, el TPB <90 min se logró con TAD <120 min en un 49,8% vs. 36,3% con TAD >120 min (p: 0,003); la frecuencia siguió un patrón similar en los pacientes ingresados en horarios no laborables: 41,9% vs. 30,4%, respectivamente (p <0,001). Los predictores independientes de lograr un TPB <90 min en el análisis multivariado fueron la edad <75 años: OR 1,57 (1,1-2,25; p: 0,01), ATC en horario laborable: OR 1,32 (1,04-1,67; p: 0,002), ATC in situ: OR 2,4 (1,9-3,0; p <0,001), tener un ECG prehospitalario: OR 2,22 (1,73-2,86; p <0,001) y un TAD <120 min: OR 1,53 (1,23-1,9; p <0,001). Conclusiones: En los pacientes con un TAD <120 minutos se logra más frecuentemente un TPB <90 min, especialmente en los tratados in situ y en horario laborable. En los pacientes derivados, solo 1 de cada 3 logra un TPB <90 min y no hay relación con el TAD.

ABSTRACT • Background: Time elapsed from the onset of symptoms to diagnosis (TTD) can influence in achieving a door-to-balloon time <90 min (DBT <90 min). Methods: A retrospective analysis was performed on 1,518 patients prospectively and consecutively included in the ARGEN-AMI-ST registry. In 37.8% of cases. patients were treated with DBT <90 min and a median TTD of 120 min (IQR 60-266). The population was divided according to TTD above or below 120 min. A DBT <90 min was achieved more frequently in those with TTD <120 min: 44% vs. 32.2% (p <0.001) respectively. Results: In patients with in situ percutaneous coronary intervention (PCI) and TTD <120 min, DBT <90 min was achieved in 56% vs. 37.1% of cases with TTD >120 min (p <0.001). In referred patients, there were no differences in DBT <90 min according to TTD: 27.5% vs. 25.7% (p: 0.3). In patients admitted during working hours, DBT <90 min was achieved with TTD <120 min in 49.8% vs. 36.3% with TTD >120 min (p: 0.003), as well as in patients admitted during non-working hours: 41.9% vs. 30.4% (p <0.001). The independent predictors of achieving a DBT <90 min in the multivariate analysis were age <75 years: OR 1.57 (1.1-2.25; p: 0.01), PCI during working hours: OR 1.32 (1.04-1.67; p: 0.002), PCI in situ: OR 2.4 (1.9-3.0; p <0.001), having a pre-hospital ECG: OR 2.22 (1.73-2.86; p <0.001) and a TTD <120 min: OR 1.53 (1.23-1.9; p <0.001). Conclusions: In patients with TTD <120 minutes, a DBT <90 minutes is more frequently achieved, especially in those treated in situ and during working hours. In referred patients, only 1 in 3 achieves a DBT<90 min and there is no relationship with TTD.

[Cardiovascular admissions in Intensive Care Units during COVID-19 pandemic]. / Internaciones cardiovasculares en Unidades de Cuidados Intensivos durante la pandemia por COVID-19.

The COVID-19 pandemic has led to measures of social isolation, labor restrictions, a strong information campaign and the suspension of scheduled medical activities. The aim of this study was to describe the impact of these measures on the number of hospitalizations in Cardiovascular Intensive Care Units, with the hypothesis that the social behavior generated by this emergency promotes a decreased demand for medical care, even when severe cardiovascular disease is involved. We compared the number of admissions in March-April 2010-2019 versus March-April 2020, based on a prospective study including six institutions (three public and three private) that use Epi-Cardio® as a multicenter registry of cardiovascular care unit discharge. Altogether, we included 6839 patients discharged during the 11-year study period (2010-2020). The average number of patient admissions on March-April 2010-19 was 595 (CI 95%: 507-683) and decreased to 348 in 2020 (fall of 46.8%, p < 0.001). The reasons for hospitalization were classified into 11 groups and a statistically significant reduction was seen in 10 of these groups: cardiovascular surgery 72.3%, electrophysiological interventions 67.8%, non-ST acute coronary syndromes 52.6%, angioplasties 47.6%, arrhythmias 48.7%, heart failure 46%, atrial fibrillation 35.7%, ST elevation myocardial infarction 34.7%, non cardiac chest pain 31.8%, others 51.6%. Although with low prevalence, hypertensive crisis increased in 89%. The abrupt decrease observed in the number of admissions due to critical pathologies may be considered an "adverse effect" related to the measures adopted, with potentially severe consequences. This trend could be reversed by improving public communication and policy adjustment.

La pandemia de COVID-19 ha llevado a medidas de aislamiento social, restricciones laborales, fuerte campaña mediática y suspensión de las actividades médicas programadas. El objetivo de nuestro estudio fue relevar el impacto de estas medidas sobre las internaciones en Unidades de Cuidados Intensivos Cardiovasculares, con la hipótesis de que se ha generado un comportamiento social que puede disminuir la demanda de consultas, aun las de enfermedades graves. Comparamos las internaciones de marzo-abril de 2010-2019 con las del mismo bimestre de 2020 sobre la base del registro prospectivo multicéntrico Epi-Cardio® en seis instituciones, tres públicas y tres privadas, que utilizan la epicrisis computarizada para las altas. Fueron incluidos 6839 egresos de ese bimestre en los 11 años. El promedio del número de internaciones en ese bimestre del decenio 2010-19 fue 595 (intervalo de confianza 95%: 507-683) y se redujo a 348 en 2020 (caída del 46.8%, p < 0.001). En la agrupación por 11 causas de internación, la reducción observada fue: cirugía cardiovascular 72.3%, intervenciones electrofisiológicas 67.8%, síndrome coronario agudo sin elevación del ST 52.6%, angioplastias 47.6%, arritmias 48.7%, insuficiencia cardíaca 46%, fibrilación auricular 35.7%, infarto con elevación del ST 34.7%, dolor no coronario 31.8% y otros 51.6%. Solo se incrementaron las consultas por crisis hipertensivas (89%), aunque la prevalencia fue baja. La caída observada en la internación de entidades clínicas críticas ha sido un "efecto adverso" de las medidas adoptadas ante la pandemia, con consecuencias potencialmente graves, que podrían revertirse con un ajuste de las políticas y la comunicación pública.