Angioplastía con balón para el tratamiento de la hipertensión arterial pulmonar por enfermedad tromboembólica crónica. Resultados hemodinámicos y clínicos inmediatos / Balloon pulmonary angioplasty for the treatment of chronic thromboembolic pulmonary hypertension

Background: Balloon pulmonary angioplasty (BPA) is a therapeutic alternative for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Aim: To report the initial experience with the "refined BPA technique" with the use of intravascular images. Patients and Methods: Between June 2015 and June 2016 we selected fourteen patients with CTEPH who were considered candidates for BPA. Lesions targeted for treatment were further analyzed using intravascular imaging with optical frequency domain imaging (OFDI). We report the immediate hemodynamic results and four weeks of follow-up of the first eight patients of this series. Results: We performed 16 BPA in eight patients aged 61 ± 14 years (88% women). Mean pulmonary artery pressure (PAPm) was 48.6 ± 5.8 mmHg. Success was achieved in seven patients (88%). A mean of 2.3 segments per patient were intervened in 11 sessions (1.6 sessions/ patient). Only one patient developed lung reperfusion injury. No mortality was associated with the procedure. After the last BPA session, PAPm decreased to 37.4 ± 8.6 mmHg (p=0.02). Pulmonary vascular resistance (RVP) decreased from 858,6 ± 377,0 at baseline to 516,6 ± 323,3 Dynes/sec/cm−5 (p<0.01) and the cardiac index increased from 2.4±0.6 at baseline to 2.8±0.3 L/min/m2 (p=0.01). At 4 weeks after the last BPA, WHO functional class improved from 3.3±0.5 to 2.5±0.5 (p<0,01) and six minutes walking distance from 331±92 to 451±149 m (p=0.01). Conclusions: BPA guided by OFDI for the treatment of inoperable CTEPH patients is a safe alternative with excellent immediate hemodynamic and clinical results.

Prevención secundaria post infarto agudo de miocardio en hospitales públicos: implementación y resultados de las garantías GES / Universal health coverage and accomplishment of secondary prevention goals among patients with acute myocardial infarction

Background: In 2005, acute myocardial infarction (AMI) was included in a universal health plan (GES) to reduce inequity in care and optimize its diagnosis and treatment. Aim: To evaluate the effect of GES in risk factor control and therapeutic management among patients with AMI. Material and Methods: A survey was conducted in 2008-2009 in six public hospitals. Patients were identified from a hospital based registry of AMI and evaluated one year later with laboratory tests and an interview. Results: The registry enrolled 534 patients with ST and non ST segment elevation myocardial infarction. Of these, 416 patients aged 63 ± 12 years (25% women) were evaluated one year later. Eighty three percent were evaluated by a cardiologist and 37% by a general practitioner. Twenty two percent were evaluated by a nurse and 22% by a nutritionist. At the moment of the interview, 9% smoked, 78% were overweight or obese, 24% performed moderate or vigorous physical activity ≥ 150 min/week, 60% had systolic pressure > 130 mmHg and 63% a diastolic pressure > 80 mmHg. In 30%, LDL cholesterol was > 100 mg/dl and in 43%, triglycerides were > 150 mm/dl. Twenty two percent were diabetic and among them, 52% had a glycosilated hemoglobin > 7%. Forty five percent of non-diabetic patients had a fasting glucose > 100 mg/dl. Ninety three percent were in treatment with aspirin, 86% with statins, 66% with b-blockers, and 73% with angiotensin converting enzyme inhibitors or angiotensin receptor blockers and 20% with clopidogrel. Conclusions: Despite the high proportion of patients in treatment with evidence-based therapy, many do not achieve the targets for risk factor control with the new health care model.

Incidencia y letalidad por infarto agudo del miocardio en Chile: 2001-2007 / Incidence and case fatality due to acute myocardial infarction in Chile in the period 2001-2007

Background: Acute myocardial infarction (AMI) causes 73.6 percent of coronary heart disease (CHD) deaths in Chile. Aim: To estimate the incidence and case fatality of AMI and analyze their trends between 2001-2007. Material and Methods: A time-series study analyzing all cases of AMI (according to the International Classification of Diseases (ICD)-10, I21 code), registered in the National Hospitalizations and Death databases. Annual incidence rates and case fatality by sex and age groups were calculated. The direct method was used to standardize rates by age, using the World Health Organization 2000 Population. Prais-Winsten regression models were used to evaluate trends, expressed as relative change. Results: Between 2001 and 2007, we estimated that 83,754 cases of AMI occurred. Standardized annual incidence rate was 74.4 per 100,000 inhabitants (98.0 in men and 51.0 in women). Incidence rates increased by 34 percent in individuals < 45 years of age and 9.2 percent in the group 55-64 years (p < 0.001, both). Total case fatality was 49.5 percent (45.4 percent in men and 57.2 percent in women; p < 0.001), and its trend analysis showed a significant annual reduction of 1.2 percent in men and 0.81 percent in women. In-hospital case fatality was 14.2 percent (11.3 and 20.4 percent in men and women, respectively; p < 0.001). There was a significant annual reduction of mortality (0.57 and 1.01 percent in men and women, respectively (p < 0.05). Conclusions: The incidence of AMI was stable in the whole population, but increased in younger age groups. Total and in-hospital case-fatality decreased. Despite the greater reduction of case fatality in women, they still have a higher risk of dying while in hospital.

Implicancias de la glicemia de ingreso en la mortalidad intrahospitalaria y alejada según el método de reperfusión en pacientes con infarto agudo del miocardio y supradesnivel del segmento ST / Admission hyperglycemia and mortality of ST segment elevation myocardial infarction

Background: Hyperglycemia at admission has been associated to an adverse prognosis in patients with ST-segment elevation acute myocardial infarction (STE-MI). However, its impact over the results of reperfusion therapies in patients with STEMI is still a matter of controversy. Aim: To determine the impact of admission hyperglycemia on hospital and long term mortality, according to the method of reper-fusion utilized in patients with STEMI. Material and Methods: Prospective registry of 1,634 consecutive patients aged 60 ± 12 years (77 percent male), from 3 participating hospitals in the Chilean Registry of Myocardial Infarction (GEMI). We evaluated demographic, clinical and laboratory variables, reperfusion method used, hospital and long term mortality. The impact of hyperglycemia on hospital and long term mortality was evaluated by a logistic regression analysis and Cox risk, respectively, adjusted by Thrombolysis in Myocardial Infarction (TIMI) risk score. Results: Twenty four percent of patients were diabetics and in 45 percent, the infarct was located on the anterior wall. The mean TIMI risk score was 3.2 ± 2.4. Hyperglycemia at entry was associated to a greater hospital and long term mortality, independently of the reperfusion strategy utilized. Primary angioplasty was associated to a greater benefit, compared to thrombolysis among hyperglycemic patients with an odds ratio: 2.9, 95 percent confi dence intervals: 1.0-8.0 and a hazard ratio of 2.9, 95 percent confi dence intervals: 1.44-5.88, independently of a previous history of diabetes mellitus and TIMI risk score. Conclusions: In patients with STEMI, admission hyperglycemia is associated with a worse prognosis which was significantly improved with primary angioplasty compared to thrombolysis, independently of the admission TIMI risk score.

Mortalidad intrahospitalaria en hombres y mujeres según terapias de reperfusión en infarto agudo del miocardio con supradesnivel del ST / ln-hospital mortality after ST-segment elevation myocardial infarction according to reperiusion therapy

Primary angioplasty is considered the best reperiusion therapy in the treatment of ST-segment elevation myocardial infarction (STEMI). However, thrombolysis is the reperiusion method most commonly used, due to its wide availability, reduced costs and ease of administration. Aim: To compare inhospital mortality in STEMI patients according to reperiusion therapy. Material and Methods: Patients admitted to Chilean hospitals participating in the GEMI network, from 2001 to 2005, with STEMI were included. They were divided in three groups: a) treated with thrombolytics, b) treated with primary angioplasty, c) without reperiusion procedure. Inhospital mortality according to gender, was analized in each group, using a logistic regression method, to assess risk factors associated with mortality. Results: We included 3,255 patients. Global mortality was 9.9 percent (7.5 percent in men and 16.7 percent in women, p <0.001). Mortality in patients treated with thrombolytics, was 10.2 percent (7.6 percent in men and 18.7 percent in women, p <0.01). The figure for patients treated with primary angioplasty, was 4.7 percent (2.5 percent in men and 13 percent in women, p <0.01), and in patients without reperiusion, was 11.6 percent (9.8 percent in men and in 15.4 percent women, p <0.01). In each group women were older, had a higher prevalence of hypertension and a higher percentage of Killip 3-4 infarctions. Logistic regression showed that angioplasty, compared with no reperiusion, was associated with a reduced mortality only in men. The use oí thrombolytics in women was associated with a higher mortality. Conclusions: Primary angioplasty was the reperiusion therapy associated to the lower mortality in STEMI. Use of thrombolytics in women was associated with a higher mortality rate than in non reperfused women.

Resultados alejados de la angioplastía coronaria en Chile en elRegistro Nacional de Angioplastía Coronaria (RENAC) 2001-2002 / Long-term results of coronary angioplasty in Chile according to the National Registry of Angioplasty (RENAC)

Introducción: En el año 2004 publicamos los resultados intrahospitalarios del primer registro chileno de angioplastía coronaria (AC), RENAC. Sin embargo, la información nacional sobre los resultados alejados de la AC en Chile hasta la fecha ha sido escasa y parcelar. Objetivo: Evaluar los resultados alejados de la angioplastía coronaria en pacientes sin infarto agudo de miocardio (IAM) en el país. Pacientes y métodos: Seis de los 10 centros participantes en el RENAC entre junio de 2001 y octubre de 2002 efectúan seguimiento clínico alejado de sus pacientes. Resultados: De un total de 892 pacientes sin IAM sometidos a AC y dados de alta vivos, se obtuvo seguimiento clínico en 744 (83,3 por ciento) y en 772 (86,5 por ciento) sólo de su estado vital. La mayoría había presentado un síndrome coronario agudo y en el 88,7 por ciento fueron sometidos a angioplastía de un vaso. El 84,8 por ciento de las 936 lesiones fueron tratadas con stents. Se obtuvo éxito angiográfico en el 97,2 por ciento de las lesiones y clínico en un 97,6 por ciento de los pacientes. Al cabo de un seguimiento promedio de 21 meses, la mortalidad cardíaca fue de 0,9 por ciento y la total de 1,7 por ciento. Se efectuó una nueva revascularización del vaso tratado en el 5,5 por ciento de los pacientes. La sobrevida libre de eventos isquémicos mayores fue de 90,0 por ciento. Conclusiones: Los resultados extrahospitalarios de pacientes sin IAM y sometidos a AC en Chile muestran una baja mortalidad cardíaca, una baja frecuencia de revascularización del vaso tratado y una alta sobrevida libre de eventos isquémicos.

Background: In 2004 we published the in-hospital results of the first Chilean coronary angioplasty registry (RENAC). To date the long-term results of coronary angioplasty in Chile is scant. Aim: To assess the long-term results of coronary angioplasty in patients without acute myocardial infarction in Chile. Patients and Methods: Six out of 10 participating centers in RENAC between June 2001 and October 2002, providedclinical follow-up of their patients. Results: A total of 892 patients without acute myocardial infarction underwent angioplasty and were discharged alive. In 744 (83,3 percent) patients clinical follow-up was obtained and in 772 (86,5 percent) only vital status could be ascertained. Most patients underwent one vessel angioplasty (88,7 percent) for an acute coronary syndrome. Stent implantation was performed in 84,8 percent of the 936 treated coronary lesions. Angiographic success was obtained in 97,2 percent of lesions and clinical success in 97,6 percent of patients. After an average follow-up of 21 months, cardiac and all cause mortality were 0,9 and 1,7 percent. Target vessel revascularization was performed in 5,5 percent and survival free of cardiac ischemic events was 90,0 percent Conclusions: Long-term results of coronary angioplasty in patients without an acute myocardial infarction shows low rates of cardiac death, target vessel revascularization and a high survival free of cardiac ischemic events.