Chronic hyperkalemia, diagnosis and management. Colombian consensus.

OBJECTIVE: Generate recommendations for the diagnosis, management, and follow-up of chronic hyperkalemia. METHOD: This consensus was made by nephrologists and cardiologists following the GRADE methodology. RESULTS: Chronic hyperkalemia can be defined as a biochemical condition with or without clinical manifestations characterized by a recurrent elevation of serum potassium levels that may require pharmacological and or non-pharmacological intervention. It can be classified as mild (K+ 5.0 to < 5.5 mEq/L), moderate (K+ 5.5 to 6.0 mEq/L) or severe (K+ > 6.0 mEq/L). Its incidence and prevalence have yet to be determined. Risk factors: chronic kidney disease, chronic heart failure, diabetes mellitus, age ≥ 65 years, hypertension, and drugs that inhibit the renin angiotensin aldosterone system (RAASi), among others. There is no consensus for the management of chronic hyperkalemia. The suggested pattern for patients is to identify and eliminate or control risk factors, provide advice on potassium intake and, for whom it is indicated, optimize RAASi therapy, administer oral potassium binders and correct metabolic acidosis. CONCLUSIONS: The recommendation is to pay attention to the diagnosis, management, and follow-up of chronic hyperkalemia, especially in patients with risk factors.

OBJETIVO: Generar recomendaciones para el diagnóstico, el manejo y el seguimiento de la hiperkalemia crónica. MÉTODO: Este consenso fue realizado por nefrólogos y cardiólogos siguiendo la metodología GRADE. RESULTADOS: La hiperkalemia crónica puede definirse como una condición bioquímica, con o sin manifestaciones clínicas, caracterizada por una elevación recurrente de las concentraciones séricas de potasio que puede requerir una intervención farmacológica, no farmacológica o ambas. Puede clasificarse en leve (K+ 5,0 a < 5,5 mEq/l), moderada (K+ 5,5 a 6,0 mEq/l) o grave (K+ > 6,0 mEq/l). Su incidencia y prevalencia no han sido claramente determinadas. Se consideran factores de riesgo la enfermedad renal crónica, la insuficiencia cardiaca crónica, la diabetes mellitus, la edad ≥ 65 años, la hipertensión arterial y el tratamiento con inhibidores del sistema renina-angiotensina-aldosterona (iSRAA), entre otros. No hay consenso sobre el manejo de la hiperkalemia crónica. Se sugiere identificar y eliminar o controlar los factores de riesgo, brindar asesoramiento sobre la ingesta de potasio y, para quien esté indicado, optimizar la terapia con iSRAA, administrar aglutinantes orales del potasio y corregir la acidosis metabólica. CONCLUSIONES: Se recomienda prestar atención al diagnóstico, el manejo y el seguimiento de la hiperkalemia crónica, en especial en los pacientes con factores de riesgo.

Hiperkalemia crónica, diagnóstico y manejo. Consenso colombiano / Chronic hyperkalemia, diagnosis and management. Colombian consensus

Resumen Objetivo: Generar recomendaciones para el diagnóstico, el manejo y el seguimiento de la hiperkalemia crónica. Método: Este consenso fue realizado por nefrólogos y cardiólogos siguiendo la metodología GRADE. Resultados: La hiperkalemia crónica puede definirse como una condición bioquímica, con o sin manifestaciones clínicas, caracterizada por una elevación recurrente de las concentraciones séricas de potasio que puede requerir una intervención farmacológica, no farmacológica o ambas. Puede clasificarse en leve (K+ 5,0 a < 5,5 mEq/l), moderada (K+ 5,5 a 6,0 mEq/l) o grave (K+ > 6,0 mEq/l). Su incidencia y prevalencia no han sido claramente determinadas. Se consideran factores de riesgo la enfermedad renal crónica, la insuficiencia cardiaca crónica, la diabetes mellitus, la edad ≥ 65 años, la hipertensión arterial y el tratamiento con inhibidores del sistema renina-angiotensina-aldosterona (iSRAA), entre otros. No hay consenso sobre el manejo de la hiperkalemia crónica. Se sugiere identificar y eliminar o controlar los factores de riesgo, brindar asesoramiento sobre la ingesta de potasio y, para quien esté indicado, optimizar la terapia con iSRAA, administrar aglutinantes orales del potasio y corregir la acidosis metabólica. Conclusiones: Se recomienda prestar atención al diagnóstico, el manejo y el seguimiento de la hiperkalemia crónica, en especial en los pacientes con factores de riesgo.

Abstract Objective: Generate recommendations for the diagnosis, management, and follow-up of chronic hyperkalemia. Method: This consensus was made by nephrologists and cardiologists following the GRADE methodology. Results: Chronic hyperkalemia can be defined as a biochemical condition with or without clinical manifestations characterized by a recurrent elevation of serum potassium levels that may require pharmacological and or non-pharmacological intervention. It can be classified as mild (K+ 5.0 to < 5.5 mEq/L), moderate (K+ 5.5 to 6.0 mEq/L) or severe (K+ > 6.0 mEq/L). Its incidence and prevalence have yet to be determined. Risk factors: chronic kidney disease, chronic heart failure, diabetes mellitus, age ≥ 65 years, hypertension, and drugs that inhibit the renin angiotensin aldosterone system (RAASi), among others. There is no consensus for the management of chronic hyperkalemia. The suggested pattern for patients is to identify and eliminate or control risk factors, provide advice on potassium intake and, for whom it is indicated, optimize RAASi therapy, administer oral potassium binders and correct metabolic acidosis. Conclusions: The recommendation is to pay attention to the diagnosis, management, and follow-up of chronic hyperkalemia, especially in patients with risk factors.

Laparoscopy has better performance than laparotomy in the treatment of stable penetrating abdominal trauma: A retrospective cross-sectional study in a trauma referral hospital in Colombia.

Background: Abdominal trauma is one of the leading causes of death. In Colombia, few studies have evaluated the results on related factors and outcomes when comparing laparotomy versus laparoscopy in the management of penetrating abdominal trauma. Therefore, the aim of this study was to investigate the feasibility and safety of laparoscopy in the treatment of stable penetrating abdominal trauma in a limited resources environment in a middle-income country. Methods: Retrospective cross-sectional study was conducted in Bogota, Colombia from January 2018 to October 2020. Patients over 18 years old, hemodynamically stable with penetrating abdominal trauma without other body parts injuries, that underwent laparoscopy and/or laparotomy surgical exploration and treatment were included. Frequencies, percentages, correlations, and odds ratio were calculated. Results: A total of 52 patients were analyzed (26 laparoscopy vs. 26 laparotomy). Stabbing injuries were more frequent in both groups (76.9%), as well as involvement of the anterior abdomen. None missed enterotomies were reported in the laparoscopy group. Surgical time and bleeding were significantly lower in the laparoscopic approach group (63 vs. 115 min and 65 vs. 992 cc, respectively). The time to oral intake and length of stay in the intensive care unit was significantly shorter in the laparoscopic management group (2 vs. 3 days and 1 vs. 4 days, respectively). Conclusions: Surgical results found a safe scenario in a limited resources environment for the application of the laparoscopic technique to approach penetrating abdominal trauma in stable patients without missed injuries, low threshold of conversion to open approach, and additionally not presenting a higher percentage of complications compared with the laparotomy group in Colombia. Operative time, oral intake, and length of hospital stay were lower in the fully therapeutic laparoscopy group.

Hernia de Garengeot y revisión de las variantes de hernias encarceladas / Garengeot's hernia and review of variants of incarcerated hernias

Introducción. La hernia de Garengeot se caracteriza por contener el apéndice cecal dentro del saco femoral, y forma parte de una variedad de hernias que reciben el epónimo de acuerdo con su localización anatómica. Entre ellas se encuentra la hernia de Richter, la hernia de Amyand, la hernia de Littré y la hernia de Spiegel. Se presenta una revisión de los abordajes laparoscópicos para estas diversas variantes. Caso clínico. Paciente femenina de 82 años de edad quien consultó al servicio de urgencias por dolor inguinal derecho de ocho días de evolución, asociado a clínica de obstrucción intestinal. Se hizo diagnóstico de hernia inguinal encarcelada y se llevó a cirugía encontrando una hernia de Garengeot. Discusión. Además de los tipos de hernia tradicionalmente conocidos, existen variantes inusuales de hernias de la pared abdominal, que deben ser sospechadas y tenidas en cuenta como diagnóstico diferencial, lo que permitirá realizar su tratamiento de forma oportuna disminuyendo el riesgo de que ocurra una perforación intestinal. Conclusiones. Las variantes de hernia inguinal o de localización inusual, son susceptibles de tratamiento quirúrgico mediante abordajes laparoscópicos con adecuados resultados.

Introduction. Garengeot's hernia is characterized by containing the cecal appendix within the femoral sac, and is part of a variety of hernias that receive their eponymous according to their anatomical location. These include Richter's hernia, Amyand's hernia, Littré's hernia, and Spiegel's hernia. We present a review of the laparoscopic approaches for these variants. Clinical case. An 82-year-old female patient consulted to the emergency department for right groin pain of eight days of evolution, associated with symptoms of intestinal obstruction. With a diagnosis of incarcerated inguinal hernia, she underwent surgery finding a Garengeot ́s hernia. Discussion. In addition to the traditionally known types of hernia, there are unusual variants of hernias of the abdominal wall, which must be suspected and taken into account as a differential diagnosis, which will allow treatment to be carried out in a timely manner, reducing the risk of intestinal perforation. Conclusions. Variants of inguinal hernia or unusual location are susceptible to surgical treatment by laparoscopic approaches with adequate results.

Serum levels of neutrophil Gelatinase associated Lipocalin (NGAL) predicts hemodialysis after coronary angiography in high risk patients with acute coronary syndrome.

BACKGROUND: Contrast-induced nephropathy (CIN) following a percutaneous coronary intervention (PCI) is the third most common cause of acute kidney injury (AKI) worldwide. Patients who require hemodialysis secondary to CIN have an elevated mortality rate as high as 55%. The current definition of CIN is based on an elevation of creatinine and decrease in urinary output. Creatinine typically increases 48 h after the contrast exposure, which delays the diagnosis and treatment of CIN. The neutrophil gelatinase associated lipocalin (NGAL) has emerged as a sensitive and specific biomarker of renal injury. Limited data exists about the effectiveness of NGAL to predict CIN in high-risk patients with acute coronary syndrome (ACS) that underwent PCI. The primary aim of this study was to determine the association of serum NGAL levels and the need for hemodialysis after PCI. METHODS: This is a prospective, observational study. NGAL levels were measured using ELISA. Blood samples were obtained within the first 6 h of hospital admission, and 12 and 24 h after contrast exposure from angiography. The primary outcome was the requirement of hemodialysis. The non-parametric Mann-Whitney U test was used to test for differences in median serum levels of NGAL. A receiver operating characteristic (ROC) curve was developed to assess the accuracy of NGAL to predict the need for hemodialysis after PCI. RESULTS: A total of 2875 were screened; however, 45 patients with ACS that underwent PCI were included. All patients were at high risk of developing CIN defined by Mehran score > 11 points. The median (IQR) serum concentration of NGAL was significantly higher in patients that required versus did not require hemodialysis (340 [83-384] vs. 169 [100-210], p = 0.01). Elevated serum levels of NGAL with a cut-off at 6 h post PCI of 281 mg/dL predicted the need for hemodialysis with an area under the curve of 0.86 (95% CI, 0.66-1.00). CONCLUSIONS: In patients with ACS undergoing PCI; and high risk of developing CIN, an elevated serum level of NGAL 6 h after contrast exposure predicts the development of acute kidney injury requiring hemodialysis.

Contemporary Characteristics and Outcomes in Chagasic Heart Failure Compared With Other Nonischemic and Ischemic Cardiomyopathy.

BACKGROUND: Chagas' disease is an important cause of cardiomyopathy in Latin America. We aimed to compare clinical characteristics and outcomes in patients with heart failure (HF) with reduced ejection fraction caused by Chagas' disease, with other etiologies, in the era of modern HF therapies. METHODS AND RESULTS: This study included 2552 Latin American patients randomized in the PARADIGM-HF (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) and ATMOSPHERE (Aliskiren Trial to Minimize Outcomes in Patients With Heart Failure) trials. The investigator-reported etiology was categorized as Chagasic, other nonischemic, or ischemic cardiomyopathy. The outcomes of interest included the composite of cardiovascular death or HF hospitalization and its components and death from any cause. Unadjusted and adjusted Cox proportional hazards models were performed to compare outcomes by pathogenesis. There were 195 patients with Chagasic HF with reduced ejection fraction, 1300 with other nonischemic cardiomyopathy, and 1057 with ischemic cardiomyopathy. Compared with other etiologies, Chagasic patients were more often female, younger, and had lower prevalence of hypertension, diabetes mellitus, and renal impairment (but had higher prevalence of stroke and pacemaker implantation) and had worse health-related quality of life. The rates of the composite outcome were 17.2, 12.5, and 11.4 per 100 person-years for Chagasic, other nonischemic, and ischemic patients, respectively-adjusted hazard ratio for Chagasic versus other nonischemic: 1.49 (95% confidence interval, 1.15-1.94; P=0.003) and Chagasic versus ischemic: 1.55 (1.18-2.04; P=0.002). The rates of all-cause mortality were also higher. CONCLUSIONS: Despite younger age, less comorbidity, and comprehensive use of conventional HF therapies, patients with Chagasic HF with reduced ejection fraction continue to have worse quality of life and higher hospitalization and mortality rates compared with other etiologies. CLINICAL TRIAL REGISTRATION: PARADIGM-HF: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01035255; ATMOSPHERE: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00853658.

Contrapulsación externa aumentada, un tratamiento no invasivo recomendado para la angina refractaria, valoración de la clase funcional y la calidad de vida / Enhanced external counterpulsation, a non-invasive therapy recommended for refractory angina. Functional class and quality of life

Resumen Introducción: La enfermedad coronaria es una causa importante de la morbilidad y la mortalidad en el mundo. Dentro de este grupo, se encuentran los pacientes con angina refractaria. Objetivo: El objetivo de la investigación fue evaluar la eficacia y seguridad de la contrapulsación externa aumentada con 35 sesiones de una hora, en una población atendida desde diciembre de 2013 hasta noviembre de 2015. Materiales y métodos: Se realizó un estudio observacional analítico de cohorte concurrente. Se seleccionaron los pacientes que fueron remitidos para contrapulsación. A todos se les realizó una evaluación incial y a los seis meses de la clase funcional de angina según la Canadian Cardiovascular Society y disnea de la New York Heart Association, se valoraron los medicamentos recibidos y procedimientos realizados. Se aplicó el cuestionario de calidad de vida EQ - 5 D antes y a los seis meses. Para establecer la presencia de diferencias en el seguimiento en la clase funcional, la calidad de vida al inicio y a los seis meses, se utilizó la prueba no paramétrica de Wilcoxon para datos pareados, con un nivel de significación menor de 0,05. Las estadísticas fueron analizadas con el programa SPSS versión 20,0. Resultados: El análisis inicial de 74 pacientes, 50 hombres (67,6%), el promedio de edad 65,5 años. Al inicio de la terapia el 74,4% de los pacientes, se encontraban con disnea clase II - III de la New York Heart Association y el 77% con angina II - III de la Canadian Cardiovascular Society. La mediana de la fracción de eyección fue 50,5% (35,0 - 60,0). Los antecedentes más importantes fueron: la hipertensión arterial 62 (83,8%) y la diabetes mellitus 28 (37,8%). Medicamentos recibidos para la angina y procedimientos realizados: betabloqueadores 74 (100%), estatinas 71 (95,9%), aspirina 67 (90,5%), inhibidores de la enzima convertidora de angiotensina/bloqueadores de los receptores de angiotensina 64 (86,5%), trimetazidina 56 (75,7%), nitratos 37 (50%), calcioantagonistas 20 (27%), ivabradina 15 (20,3%), revascularización quirúrgica 41 (55,4%), revascularización percutánea 51 (68,9%), rehabilitación cardiovascular 45 (60,8%) y uso de dispositivos como el marcapasos, el cardiodesfibrilador o el Cardiodesfibrilador con resincronizador 19 (25,6%). A los seis meses se analizaron 45 pacientes que habían terminado el tratamiento, encontrando que el 91,1% estaba en clase I - II de disnea de la New York Heart Association y el 93,2% clase I - II de angina de la Canadian Cardiovascular Society (p < 0,01 para ambos). En la evaluación de la calidad de vida se revisaron 36 pacientes que llenaron el instrumento EQ - 5 D, encontrando una mejoría significativa en la variable de movilidad (p = 0,021) y en la escala visual análoga de salud, con una mediana inicial de 70,0 (RIQ: 50,0 - 80,0), que mejoró a los 6 meses a 80 (RIQ: 70,0 - 90,0), p = 0,003. No se encontraron complicaciones con la contrapulsación. Conclusiones: La terapia de contrapulsación externa aumentada, mejora la calidad de vida y la clase funcional de angina y disnea en pacientes con angina refractaria y se convierte en un procedimiento no invasivo seguro y eficaz.

Abstract Introduction: Coronary disease is an important cause for morbidity and mortality worldwide. Within this group there are patients with refractory angina. Objective: The goal of this investigation was to assess efficiency and security of enhanced external counterpulsation (EECP) with 35 one-hour sessions, in a population assisted between December 2013 and November 2015. Material and methods: Analytical observational recurrent cohort study. Patients who were referred for counterpulsation were selected. All of them were assessed in the beginning and after six months of the functional class of angina according to the Canadian Cardiovascular Society (CCS) and dyspnoea to the New York Heart Association (NYHA). Medication received and the procedures carried out were evaluated. The EQ-5D quality of life questionnaire was applied before and after six months. In order to establish the presence of differences in the follow-up of the functional class, the quality of life in the beginning and after six months, the Wilcoxon nonparametric test for paired data was used, with a significance level below 0.05. Data were analysed using SPSS version 20.0. Results: Initial analysis of 74 patients, 50 men (67.6%), with an average age of 65.5 years. In the beginning of the therapy 74.4% of patients had class II - III dyspnoea (NYHA) and 77% class II - III angina (CCS). The median ejection fraction was 50.5% (35.0 - 60.0). The most important previous conditions were arterial hypertension 62 (83.8%) and diabetes mellitus 28 (37.8%). Medication received for angina and conducted procedures: betablockers 74 (100%), statins 71 (95.9%), aspirin 67 (90.5%), angiotensin-converting-enzyme inhibitors/angiotensin receptor antagonists 64 (86.5%), trimetazidine 56 (75.7%), nitrates 37 (50%), calcium antagonists 20 (27%), ivabradine 15 (20.3%), surgical revascularisation 41 (55.4%), percutaneous revascularisation 51 (68.9%), cardiovascular rehabilitation 45 (60.8%) and use of devices such as pacemakers, implantable cardioverter-defibrillators (CDI) or ICDs with synchronizers 19 (25.6%). After six months 45 patients who had finished the treatment were analysed, revealing that 91.1% was in class I - II dyspnoea (NYHA) and 93.2% were class I - II angina (CCS) (p < 0.01 for both). For the quality of life assessment 36 patients who has filled out the EQ-5D were reviewed, thus finding a significant improvement in the mobility variable (p = 0.021) and the visual analogue scale, with an initial median of 70.0 (RIQ: 50.0 - 80.0), that improved after six months to 80 (RIQ: 70.0 - 90.0), p = 0.003. No complications for counterpulsation were found. Conclusions: Enhanced external counterpulsation therapy improves quality of life and functional class of angina and dyspnoea in patients with refractory angina and becomes a non-invasive, safe and efficient procedure.

Geographic variations in the PARADIGM-HF heart failure trial.

AIMS: The globalization of clinical trials has highlighted geographic variations in patient characteristics, event rates, and treatment effects. We investigated these further in PARADIGM-HF, the largest and most globally representative trial in heart failure (HF) to date. METHODS AND RESULTS: We looked at five regions: North America (NA) 602 (8%), Western Europe (WE) 1680 (20%), Central/Eastern Europe/Russia (CEER) 2762 (33%), Latin America (LA) 1433 (17%), and Asia-Pacific (AP) 1487 (18%). Notable differences included: WE patients (mean age 68 years) and NA (65 years) were older than AP (58 years) and LA (63 years) and had more coronary disease; NA and CEER patients had the worst signs, symptoms, and functional status. North American patients were the most likely to have a defibrillating-device (54 vs. 2% AP) and least likely prescribed a mineralocorticoid receptor antagonist (36 vs. 65% LA). Other evidence-based therapies were used most frequently in NA and WE. Rates of the primary composite outcome of cardiovascular (CV) death or HF hospitalization (per 100 patient-years) varied among regions: NA 13.6 (95% CI 11.7-15.7) WE 9.6 (8.6-10.6), CEER 12.3 (11.4-13.2), LA 11.2 (10.0-12.5), and AP 12.5 (11.3-13.8). After adjustment for prognostic variables, relative to NA, the risk of CV death was higher in LA and AP and the risk of HF hospitalization lower in WE. The benefit of sacubitril/valsartan was consistent across regions. CONCLUSION: There were many regional differences in PARADIGM-HF, including in age, symptoms, comorbidity, background therapy, and event-rates, although these did not modify the benefit of sacubitril/valsartan. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01035255.

A putative placebo analysis of the effects of LCZ696 on clinical outcomes in heart failure.

AIMS: Although active-controlled trials with renin­angiotensin inhibitors are ethically mandated in heart failure with reduced ejection fraction, clinicians and regulators often want to know how the experimental therapy would perform compared with placebo. The angiotensin receptor-neprilysin inhibitor LCZ696 was compared with enalapril in PARADIGM-HF. We made indirect comparisons of the effects of LCZ696 with putative placebos. METHODS AND RESULTS: We used the treatment-arm of the Studies Of Left Ventricular Dysfunction (SOLVD-T) as the reference trial for comparison of an ACE inhibitor to placebo and the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity-Alternative trial (CHARM-Alternative) as the reference trial for comparison of an ARB to placebo. The hazard ratio of LCZ696 vs. a putative placebo was estimated through the product of the hazard ratio of LCZ696 vs. enalapril (active-control) and that of the historical active-control (enalapril or candesartan) vs. placebo. For the primary composite outcome of cardiovascular death or heart failure hospitalization in PARADIGM-HF, the relative risk reduction with LCZ696 vs. a putative placebo from SOLVD-T was 43% (95%CI 34­50%; P < 0.0001) with similarly large effects on cardiovascular death (34%, 21­44%; P < 0.0001) and heart failure hospitalization (49%, 39­58%; P < 0.0001). For all-cause mortality, the reduction compared with a putative placebo was 28% (95%CI 15­39%; P < 0.0001). Putative placebo analyses based on CHARM-Alternative gave relative risk reductions of 39% (95%CI 27­48%; P < 0.0001) for the composite outcome of cardiovascular death or heart failure hospitalization, 32% (95%CI 16­45%; P < 0.0001) for cardiovascular death, 46% (33­56%; P < 0.0001) for heart failure hospitalization, and 26% (95%CI 11­39%; P < 0.0001) for all-cause mortality. CONCLUSION: These indirect comparisons of LCZ696 with a putative placebo show that the strategy of combined angiotensin receptor blockade and neprilysin inhibition led to striking reductions in cardiovascular and all-cause mortality, as well as heart failure hospitalization. These benefits were obtained even though LCZ696 was added to comprehensive background beta-blocker and mineralocorticoid receptor antagonist therapy.

Angiotensin receptor neprilysin inhibition compared with enalapril on the risk of clinical progression in surviving patients with heart failure.

BACKGROUND: Clinical trials in heart failure have focused on the improvement in symptoms or decreases in the risk of death and other cardiovascular events. Little is known about the effect of drugs on the risk of clinical deterioration in surviving patients. METHODS AND RESULTS: We compared the angiotensin-neprilysin inhibitor LCZ696 (400 mg daily) with the angiotensin-converting enzyme inhibitor enalapril (20 mg daily) in 8399 patients with heart failure and reduced ejection fraction in a double-blind trial. The analyses focused on prespecified measures of nonfatal clinical deterioration. In comparison with the enalapril group, fewer LCZ696-treated patients required intensification of medical treatment for heart failure (520 versus 604; hazard ratio, 0.84; 95% confidence interval, 0.74-0.94; P=0.003) or an emergency department visit for worsening heart failure (hazard ratio, 0.66; 95% confidence interval, 0.52-0.85; P=0.001). The patients in the LCZ696 group had 23% fewer hospitalizations for worsening heart failure (851 versus 1079; P<0.001) and were less likely to require intensive care (768 versus 879; 18% rate reduction, P=0.005), to receive intravenous positive inotropic agents (31% risk reduction, P<0.001), and to have implantation of a heart failure device or cardiac transplantation (22% risk reduction, P=0.07). The reduction in heart failure hospitalization with LCZ696 was evident within the first 30 days after randomization. Worsening of symptom scores in surviving patients was consistently more common in the enalapril group. LCZ696 led to an early and sustained reduction in biomarkers of myocardial wall stress and injury (N-terminal pro-B-type natriuretic peptide and troponin) versus enalapril. CONCLUSIONS: Angiotensin-neprilysin inhibition prevents the clinical progression of surviving patients with heart failure more effectively than angiotensin-converting enzyme inhibition. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01035255.

The reality of heart failure in Latin America.

Heart failure (HF) data in Latin America (LA) were reviewed to guide health service planning in the prevention and treatment of HF. The HF epidemiology and the adequacy of relevant health service provision related to HF in LA are not well delineated. A systematic search of the electronic databases and the World Health Organization website was undertaken for HF in LA. LA countries have reduced gross income and lower total expenditure on health per capita. LA is a heterogeneous region with HF risk factors of developed and nondeveloped countries, including lower risk of raised blood glucose levels, obesity, tobacco, and aging, whereas systemic hypertension (SH), rheumatic fever, and Chagas' disease (C'D) are higher in LA. Main etiologies of HF in LA are idiopathic dilated cardiomyopathy (from 1.3% to 37%), C'D (from 1.3% to 21%), ischemic (from 68% to 17%), SH (from 14% to 76%), valvular (from 3% to 22%), and alcohol related (from 1.1% to 8%). The prognosis of C'D HF is worse than for other etiologies. Chronic HF is the cause of death in 6.3% of cases. Decompensated HF is the main cause of cardiovascular hospitalization. The prevalence of systolic HF varies from 64% to 69%. LA is under the awful paradox of having the HF risk factors and HF epidemiology of developed countries with the added factors of SH, C'D, and rheumatic fever. Overall, in the scenario of lower total expenditure on health per capita and lower gross national income per capita, new strategies are essential for prevention and treatment of HF in LA.

Identificación de pacientes con falla cardiaca y función sistólica preservada: un estudio epidemiológico regional (I-PREFER Study) - Colombia / Identification of patients with heart failure and preserved systolic function: a regional epidemiological study (I-PREFER Study)-Colombia

El objetivo principal del estudio I-PREFER, fue determinar la prevalencia de falla cardiaca con función sistólica preservada y comparar las características clínicas de estos pacientes con las de aquellos con función sistólica reducida en los países en vía de desarrollo. Se definió función sistólica preservada como una fracción de eyección del ventrículo izquierdo (FEVI), medida en el ano previo a la visita, mayor o igual a 45%. Aquí se presentan los resultados para Colombia de un estudio observacional, multirregional (países en vía de desarrollo), de corte trasversal, donde se reclutaron pacientes ambulatorios de manera consecutiva durante tres meses, mayores de 21 anos, con diagnóstico reciente o previo de falla cardiaca. Para cada paciente se registraron: historia médica, factores de riesgo cardiovascular, función ventricular, medicamentos, co-morbilidades asociadas y exámenes complementarios de manera estandarizada. De 211 pacientes incluidos en el registro, sólo 151 (71,6%) tenían información disponible acerca de su función ventricular. Entre éstos, 102 (67,5%) tenían falla cardiaca con función sistólica preservada y 49 (32,5%) falla cardiaca sin ésta. En comparación con los pacientes del grupo de falla cardiaca sin función sistólica preservada, los del grupo de falla cardiaca con función sistólica preservada fueron más frecuentemente mujeres (57,8% vs. 40,8%, p=0,04), tenían índices de masa corporal más elevados (26,83 + 4,27kg/m² vs. 24,60 ± 3,53 kg/m², p=0,002) y cifras de presión arterial sistólica (129,17 + 19,93 mm Hg vs. 117,05 + 22,53 mm Hg, p<0,001) y diastólica (76,25 + 10,87 mm Hg vs. 71,29 + 12,71 mm Hg, p=0,014) más altas, así como más antecedentes de revascularización (34,7% vs. 17,6%, p=0,20). 71,6% de los pacientes con función sistólica preservada presentaban hipertensión y sólo 47,9% de éstos tenían la presión arterial controlada. Los resultados del estudio I-PREFER para Colombia demuestran que la falla cardiaca con función sistólica preservada representa 67,5% de los casos atendidos de manera ambulatoria por esta condición y que este valor es similar al encontrado para Latinoamérica en el estudio global (69%; 65-72%). Estos pacientes fueron, en su mayoría, mujeres; tenían índices de masa corporal más elevados, cifras de presión arterial sistólica y diastólica más altas y más antecedentes de revascularización, similar a lo reportado en el estudio I-PREFER global donde estos pacientes también fueron más frecuentemente mujeres, mayores de edad, hipertensos y obesos. Más de dos tercios de los pacientes con función sistólica preservada presentaban hipertensión y menos de la mitad de éstos tenían la presión arterial controlada.

The main objective of the I-PREFER study was to determine the prevalence of heart failure with preserved systolic function and compare the clinical characteristics of these patients with those with reduced systolic function in the developing countries. Preserved systolic function was defined as an ejection fraction of the left ventricle (LVEF) ?45%, measured in the year prior to the visit. We present the Colombian results of an observational, multi-regional (developing countries), cross-sectional study, where outpatients over 21 years with recent or previous diagnosis of heart failure were recruited consecutively for three months. For each patient we recorded medical history, cardiovascular risk factors, ventricular function, medications, co-morbidities and complementary tests in a standardized manner. Of 211 patients included in the registry, only 151 (71.6%) had available information respect their ventricular function. Among these, 102 (67.5%) had heart failure with preserved systolic function and 49 (32.5%) heart failure without it. Compared with patients in the heart failure group without preserved systolic function, those in the group of heart failure with preserved systolic function were more often women (57.8% vs. 40.8%, p = 0.04), had higher body mass index (26.83 + 4.27 kg/m2 vs. 24.60 + 3.53 kg/m2, p = 0.002), higher systolic (129.17 + 19.93 mm Hg vs . 117.05 ± 22.53 mm Hg, p <0.001) and diastolic blood pressure (76.25 + 10.87 mm Hg vs. 71.29 + 12.71 mm Hg, p = 0.014), and higher medical history of revascularization (34.7% vs. 17.6%, p = 0.20). 71.6% of patients with preserved systolic function had hypertension and only 47.9% of them had controlled blood pressure. The results of the I-PREFER study for Colombia show that heart failure with preserved systolic function represents 67.5% of the cases treated on an outpatient basis for this condition and that this value is similar to that found for Latin America in the global study (69% , 65-72%). These patients were mostly women, had higher body mass indexes, higher systolic and diastolic blood pressure, and history of revascularization, similar to that reported in the I-PREFER global study where these patients were also more often women, elderly, hypertensive and obese. More than two thirds of patients with preserved systolic blood pressure had hypertension and less than half of them had controlled blood pressure.

Neuropatía autonómica diabética cardiovascular / Diabetic autonomic cardiovascular neuropathy

La neuropatía autonómica diabética cardiovascular es un trastorno en el cual una alteración en la regulación del sistema nervioso cardiovascular, por parte del sistema nervioso autónomo, desemboca en una constelación de síntomas, que pueden ir desde intolerancia al ejercicio hasta muerte súbita. Si bien no se conoce su prevalencia exacta, se estima que es alta en pacientes diabéticos, particularmente en aquellos con diabetes de larga data y con presencia de otras comorbilidades. Su reconocimiento temprano puede facilitar el manejo de estos pacientes y a su vez disminuir los costos asociados a pruebas e intervenciones innecesarias con el objetivo de evitar complicaciones asociadas con la enfermedad.

Cardiac autonomic diabetic neuropathy is a condition in which impairment of the autonomic control of the cardiovascular system leads to a myriad of symptoms, ranging from mild exercise intolerance to sudden cardiac death. Even though its exact prevalence is unknown, it is believed that it is highly prevalent in patients with long-standing diabetes, particularly those who have other pathologic conditions. Early detection is expected to have a positive impact in patient treatment, lowering costs associated with unnecessary tests and treatments, while at the same time avoiding disease-related complications.

Falla cardiaca e hiperaldosteronismo primario: presentación de un caso / Heart failure and primary hyperaldosteronism: case report

La insuficiencia cardiaca es un síndrome asociado con alta morbilidad y mortalidad, principalmente debido a episodios de agudización o descompensación. La cardiopatía hipertensiva es una etiología de la insuficiencia cardiaca con alta prevalencia en el mundo. El hiperaldosteronismo primario es una causa de hipertensión con incidencia creciente, que, independiente de la hipertensión, puede desencadenar miocardiopatía con todas sus consecuencias. En este artículo se presenta el caso de un paciente de cincuenta años con insuficiencia cardiaca agudizada con disfunción sistólica, asociada a hipertensión resistente y como patología de base un estado con hipersecreción de aldosterona (hiperaldosteronismo primario).

Heart failure is a syndrome associated with high morbidity and mortality, mainly due to episodes of exacerbation or decompensation. Hypertensive heart disease is a cause of heart failure with a high prevalence in the world. Primary hyperaldosteronism is a cause of hypertension with increasing incidence, which, independent of hypertension, can lead to cardiomyopathy with all its consequences. This article presents the case of a fifty years old male patient with acute heart failure exacerbated with systolic dysfunction, associated with resistant hypertension and having as underlying pathology a condition of aldosterone hypersecretion (primary hyperaldosteronism).

Prevalence of heart failure with preserved ejection fraction in Latin American, Middle Eastern, and North African Regions in the I PREFER study (Identification of Patients With Heart Failure and PREserved Systolic Function: an epidemiological regional study).

The aims of the present study were to estimate the prevalence of heart failure (HF) with preserved ejection fraction (HF-PEF) in patients with HF and to compare their clinical characteristics with those with reduced ejection fraction in non-Western countries. The left ventricular ejection fraction ≥ 45% if measured < 1 year before the visit was used to qualify the patients as having HF-PEF. Of the 2,536 consecutive outpatients with HF, 1990 (79%) had the EF values recorded. Of these patients, 1291 had HF-PEF, leading to an overall prevalence of 65% (95% confidence interval 63% to 67%). Compared to the patients with HF and a reduced ejection fraction, those with HF-PEF were more likely to be older (65 vs 62 years, p < 0.001), female (50% vs 28%, p < 0.001), and obese (39% vs 27%, p < 0.001). They more frequently had a history of hypertension (78% vs 53%, p < 0.001) and atrial fibrillation (29% vs 24%, p = 0.03) and less frequently had a history of myocardial infarction (21% vs 44%, p < 0.001). Only 29% of patients with HF-PEF and hypertension had optimal blood pressure control. Left ventricular hypertrophy was less frequent in those with HF-PEF (58% vs 69%, p < 0.001). The prevalence of HF-PEF was lower in the Middle East (41%), where coronary artery disease was more often found than in Latin America (69%) and North Africa (75%), where the rate of hypertension was greater. In conclusion, in the present diverse non-Western study, HF-PEF represented almost 2/3 of all HF cases in outpatients. HF-PEF mostly affects older patients, women, and the obese. Hypertension was the most frequently associated risk factor, highlighting the need for optimal blood pressure control.

Prevalencia de insuficiencia renal en pacientes que asisten a la clínica de falla cardiaca / Prevalence of heart failure in patients attending to a heart failure clinic

Antecedentes: los pacientes con falla cardiaca tienen incremento de la morbimortalidad en la medida en que se presenta deterioro de la función renal, considerando como predictor de eventos adversos la elevación de la depuración de creatinina. Métodos: se realizó un análisis descriptivo de los pacientes que asistieron a la clínica de falla cardiaca de la Clínica Shaio desde enero de 1997 hasta octubre de 2009, con el objetivo de conocer su función renal por medio de la depuración de creatinina mediante la fórmula de Cockcroft. Como factores de riesgo se tuvo en cuenta la presencia de hipertensión arterial, diabetes mellitus, tabaquismo y dislipidemia, y además se valoraron algunos medicamentos que pueden alterar la función renal, tales como: espironolactona, digital, inhibidores de la enzima convertidora de angiotensina y antagonistas de los receptores de angiotensina II, así como la etiología correlacionada con la depuración de creatinina. Resultados: en la base de datos se registraron 1.123 pacientes, de los cuales 557 (49,6%) cumplieron los criterios de inclusión, y de éstos 461 (82,8%) presentaron alteración en la función renal, 301 (65%) correspondían al género masculino y 160 (35%) al femenino. Con base en la depuración de creatinina los hallazgos fueron: entre 60-89 mL/min 172 (37,6%) pacientes, entre 30-59 mL/min 240 (51,8%), entre 15-29 mL/min 42 (9,1%), menor de 15 mL/min 7 (1,5%) pacientes. Entre los factores de riesgo se encontró hipertensión arterial en 59,2% de los pacientes, dislipidemia en 49,6%, tabaquismo en 23,9% y diabetes en 18,5%. El medicamento más utilizado fue la espironolactona en 70,2% de los pacientes, seguida por los inhibidores de la enzima convertidora de angiotensina en 52,1%, los diuréticos en 52%, la digital con 45,4% y por último los antagonistas de los receptores de angiotensina II en 36,1%. La etiología más común fue la cardiopatía isquémica seguida por la hipertensión arterial. Conclusiones: la prevalencia de insuficiencia renal determinada por la depuración de creatinina, es alta tanto en hombres como en mujeres evaluados en la clínica de falla cardiaca, lo cual conduce a replantear los esquemas de manejo dependiendo de la función renal ya que algunos de los medicamentos utilizados son nefrotóxicos o incrementan los niveles de potasio. Por lo tanto, la valoración de la función renal mediante la utilización de la depuración de creatinina por medio de la fórmula de Cockcroft, puede ser más conveniente que sólo basarse en la creatinina, por lo cual se recomienda realizarla en todos los pacientes que se estén siguiendo en las clínicas de falla cardiaca al igual que al considerar cambios en el esquema de manejo médico.

Background: patients with heart failure have an increased morbidity to the extend that they present impaired renal function, taking as a predictor of adverse events the elevation of creatinine clearance. Methods: a descriptive analysis of patients attending the heart failure clinic of the Shaio Clinic from January 1997 until October 2009 was realized, in order to know their renal function through creatinine clearance using the Cockcroft formula. Risk factors taken into account were the presence of hypertension, diabetes mellitus, smoking and dyslipidemia, and some drugs that can affect renal function, such as spironolactone, digitalis, angiotensin-converting enzyme and antagonists of angiotensin II receptors were also assessed, as well as the etiology correlated with creatinine clearance. Results: 1,123 patients were registered in the data base, of whom 557 (49.6%) meet the inclusion criteria, and of these 461 (82.8%) present impaired renal function. 301 (65%) are males and 160 (35%) female. Based on the creatinine clearance, the finding were: between 60-89 mL/min 172 patients (37.6%); between 30-59 mL/min 240 patients(51.8%); between 15-29 mL/min 42 patients (9.1%); less than 15 mL/min 7 patients(1.5%). Among the risk factors we found for arterial hypertension in 59.2% of patients, dyslipidemia in 49.6%, smoking in 23.9% and diabetes in 18.5%. The most commonly used drug was spironolactone in 70.2% of patients, followed by inhibitors of angiotensin converting enzyme in 52.1%, diuretics in 52%, digitalis in 45.4% and finally angiotensin receptor II antagonists in 36.1%. The most common etiology was ischemic heart disease followed by hypertension. Conclusions: the prevalence of renal failure determined by creatinine clearance is high for both men and women evaluated in the clinic for heart failure, which leads to rethinking management schemes depending on renal function, given that some of the drugs used are nephrotoxic or increase potassium levels. Therefore, assessment of renal function using creatinine clearance using the Cockcroft formula may be more convenient than being based only in creatinine; therefore, its performance is recommended in all patients who are being followed in the heart failure clinics as well as when considering changes in the pattern of medical management.

Comportamiento de la TSH y la T4 en una cohorte de pacientes con arritmia cardiaca tratados con amiodarona u otros antiarrítmicos / Behavior of TSH and T4 in a cohort of patients with cardiac arrhythmia treated with amiodarone or other antiarrhythmics

La amiodarona es uno de los antiarrítmicos de uso más extendido, pero de la misma forma es un medicamento con efectos adversos bien conocidos y a múltiples niveles; uno de los más importantes es el que se describe para el tejido tiroideo. Cerca de 80 porciento de los pacientes que la toman de forma indefinida, presentarán algún efecto adverso; sin embargo, menos de 15 porciento la suspenderán. En la glándula tiroides, los mecanismos de lesión se relacionan, por su semejanza estructural, con la levotiroxina, la liberación de altas concentraciones de yodo y la inducción de reactividad inmune, entre otras. No obstante, la mayoría de los pacientes permanece eutiroideos.Este estudio describe la variación de la función tiroidea a corto plazo, en 77 pacientes que recibieron diferentes tipos de antiarrítmicos, que no tenían factores de riesgo asociados a disfunción tiroidea, y que se reclutaron en el servicio de hospitalización. Se tomaron muestras de TSH al inicio y al cabo de tres meses de seguimiento. Se observaron niveles de TSH normales en 26 porciento (43 pacientes) y tendencia a valores más altos en el control al tercer mes en el grupo medicado con amiodarona. De manera adicional, se describió una proporción mayor de trastornos de la función de la glándula tiroides en la población masculina.

El afecto olvidado / The forgoten affect

Dentro del marco de la teoría de los afectos de Tomkins, tratamos de sintetizar varias psicologías, con el objeto de presentar una vista multidimensional y panorámica de un afecto importante pero olvidado: la vergüenza.

Historia del movimiento psiconalítico: Nueva York / History of the psychoanalytical movement: New York

Desde que empezó el movimiento psicoanalítico internacional en Viena, mucho de su historia se ha repetido no solamente en Nueva York, sinó en otras ciudades del mundo. Por eso primero es necesario separar su hisotria de su leyenda. Segundo, reexaminar algunos hechos que se ocultan en versiones oficiales del Psicoanálisis.