Comparison of the ACC/AHA and Framingham algorithms to assess cardiovascular risk in HIV-infected patients

ABSTRACT The aim of this study was to compare the predictions of Framingham cardiovascular (CV) risk score (FRS) and the American College of Cardiology/American Heart Association (ACC/AHA) risk score in an HIV outpatient clinic in the city of Vitoria, Espirito Santo, Brazil. In a cross-sectional study 341 HIV infected patients over 40 years old consecutively recruited were interviewed. Cohen's kappa coefficient was used to assess agreement between the two algorithms. 61.3% were stratified as low risk by Framingham score, compared with 54% by ACC/AHA score (Spearman correlation 0.845; p < 0.000). Only 26.1% were classified as cardiovascular high risk by Framingham compared to 46% by ACC/AHA score (Kappa = 0.745; p < 0.039). Only one out of eight patients had cardiovascular high risk by Framingham at the time of a myocardial infarction event registered up to five years before the study period. Both cardiovascular risk scores but especially Framingham underestimated high-risk patients in this HIV-infected population.

Importancia de las co-morbilidades en la insuficiencia cardiaca / Importance of the co morbidities in the heart failure

La insuficiencia cardíaca afecta aproximadamente a 5.1 millones de adultos en los Estados Unidos de América, con expectativas de alcanzar a casi 8 millones de adultos para 2030. Los pacientes portadores de insuficiencia cardiaca están en mayor riesgo de sufrir una mayor morbilidad y mortalidad que la población en general; además, existen co-morbilidades que pueden complicar el cuidado de estos pacientes. La diabetes mellitus, el dolor crónico y la depresión son diagnósticos que muy a menudo coexisten con la insuficiencia cardiaca. Los medicamentos con que normalmente se tratan estas co-morbilidades pueden inducir o empeorar los síntomas de la insuficiencia cardiaca, así que determinar la terapia apropiada es de vital importancia. Los médicos deben entender la relación que existe entre estas medicaciones y la insuficiencia cardiaca para mejorar la asistencia, aumentar la seguridad del paciente y reducir la morbilidad y mortalidad. Este trabajo analiza la asociación entre ciertos medicamentos usados para el tratamiento de estas co-morbilidades y su relación con la insuficiencia cardiaca. El propósito de este artículo es proporcionar una orientación farmacológica donde las opciones de tratamiento tengan especial consideración con un aumento de la supervisión médica, para evitar la descompensación o aparición de la insuficiencia cardiaca en los pacientes portadores de diabetes mellitus, dolor crónico y depresión (AU).

Heart failure affects approximately 5.1 million adults in the USA, with expectations of a rise to nearly 8 million adults by 2030. Patients with heart failure are at increased risk for morbidity/mortality, and co-morbidities can further complicate care for these patients. Diabetes mellitus, chronic pain, and depression are diagnoses that often coexist with heart failure. Medications commonly used to treat these co-morbidities may induce or worsen heart failure symptoms, so determining appropriate drug therapy is important. Healthcare providers must understand the relationship between these medications and heart failure in order to improve prescribing practices to increase patient safety and reduce morbidity and mortality. This manuscript discusses the association between certain medications used to treat the aforementioned diagnoses and their relationship to heart failure. The purpose of this article is to provide guidance on which pharmacologic options require special consideration, increased monitoring, or complete avoidance in heart failure patients with diabetes mellitus, chronic pain, and/or depression (AU).

Allogeneic hematopoietic stem cell transplantation in the elderly: Predicting the risk for non relapse mortality

We have retrospectively reviewed 137 medical records of patients older than 50 years receiving an allogeneic hematopoietic stem cell transplantation (HSCT) between January 1997 and July 2013. Median follow up was 1.3 years. Sex, age, diagnosis, disease stage, comorbidities (according to HCT-CI score), type of donor, histocompatibility, conditioning regimen and graft-versus-host disease (GVHD) prophylaxis were evaluated. The incidence and severity of acute and chronic GVHD, overall survival (OS), disease free survival (DFS), non-relapse mortality (NRM) and relapse were investigated according those variables. Acute GVHD incidence was 41% (7.3% GIII-IV). Patients with acute myeloid leukemia had lesser aGVH GII-IV (14% vs. 35%, p < 0.01) comparing to the entire population. Extensive cGVHD incidence was 9.4%. Global OS 1-3 years was 44-20%, DFS 33-20%, relapse 35-41% and NRM 36-43% respectively. The presence of comorbidities showed a significant increase in NRM (CT-CI 0 vs. 1 vs ≥ 2: 1-3 years 17-24% vs. 40-46% vs. 45-67%, p = 0.001, MA HR 2.03, CI 95% 1.02-5.29), as well as cyclosporine vs. tacrolimus (1-3 years 47-53% vs. 25-36%, p = 0.01). Tacrolimus patients had higher 1-3 years OS (49-25% vs. 31-13%, p = 0.01) and DFS (41-26% vs. 20-11%, p < 0.01). Age, type of donor and myeloablative conditioning showed no significant differences in any outcome. Allogeneic HSCT is a valid therapeutic option for older patients in Argentina. The main risk factor for a significantly increased NRM and a trend to inferior OS was the number of comorbidities. Age was not a factor for a worse result. The other factor having a significant effect in better outcome was tacrolimus administration.

Se efectuó un análisis retrospectivo de 137 historias clínicas de pacientes mayores de 50 años que recibieron un trasplante alogénico de precursores hematopoyéticos (TAPH). Se evaluaron las siguientes características: sexo, edad, enfermedad, estadio, comorbilidades (según el HCT-CI), donante, acondicionamiento e inmunosupresión. Se analizó la incidencia de enfermedad injerto vs. huésped aguda (aEICH) y crónica (cEICH), supervivencia global (SG), supervivencia libre de enfermedad (SLE), recaída y mortalidad libre de enfermedad (MLE). Los trasplantes fueron realizados entre 1997-2013, mediana de seguimiento 1.3 años. La incidencia de aEICH fue de 41% (7.3% GIII-IV). Los pacientes con leucemia mieloide aguda presentaron menor incidencia de EICHa GII-IV (14% vs. 34%, p < 0.01). La incidencia de EICHc extenso fue de 9.4%. La SG a 1-3 años fue 44-20%, SLE 33-20%, recaída 35-41% y la MLE 36-43%. Los pacientes con comorbilidades tuvieron un aumento significativo de la MLE (HCT-CI 0 vs. 1 vs. ≥2: 1-3 años 17-24% vs. 40-46% vs. 45-67%, p = 0.001, AMV HR 2.03, IC 95% 1.02-5.29), al igual que el uso de ciclosporina vs. tacrolimus (1-3 años 47-53% vs. 25-36%, p = 0.01). Los pacientes que recibieron tacrolimus tuvieron una mayor SG (1-3 años 49-25% vs. 31-13%, p = 0.01) y SLE (1-3 años 41-26% vs. 20-11%, p < 0.01). La edad, tipo de donante y acondicionamiento no resultaron significativos para ningún evento. El TAPH es una herramienta terapéutica válida en pacientes mayores. Los factores pronósticos que inciden mayormente en el trasplante son las comorbilidades y no la edad. El otro factor que demostró un efecto significativo fue el uso de tacrolimus.

A influência da Síndrome Metabólica sobre a qualidade de vida de pacientes em São Caetano do Sul / The influence of the Metabolic Syndrome on the life quality of patientsin São Caetano do Sul

The Metabolic Syndrome (MS) is characterized by disorders including glucose intolerance, insulin resistance, abdominal obesity, dyslipidemiaand hypertension. The objective of this study was to verify the perceptionof quality of life by individuals with MS in comparison to individualswithout MS. From February 2006 through April 2007, 127 individuals,both male and female, were studied: 76 individuals forwarded by the UBS(Health Basic Units) of the city of São Caetano do Sul were considered as "cases" and 51 employees of a city University were considered as "controls". The "case" patients featured at least one of the three criteria proposed by the National Cholesterol Education Program?s Adult Treatment Panel III (NCEP-ATP III) for the MS diagnosis. The "control" subjects had no chronic diseases. In order to evaluate the perception of life quality, the World Health Organization Quality of Life Questionnaire (WHOQOL-bref), involving the physical, psychological, social and environmental domains, was used. The SPSS software with a 5% level of signifi cance was also used. Among the subjects forwarded by the UBS, 38 individuals were diagnosed with MS and 38 were not diagnosed with MS, which represented 50,0% of the studied "cases" (N=76). All the scores of the domains for subjects, whether diagnosed with MS or not, as well as for the subjects without chronic diseases, were compared. The MS subjects presented reduced psychological, social, and physical domain scores compared to the subjects without MS. The presence of co-morbidities together with MS determines signifi cant reduction in the subject's perception of life quality, mainly in the psychological and physical domains compared to individuals with chronic diseases, although without MS; and an even more pronounced reduction in relation to the subjects without non-chronic diseases.

El síndrome metabólico (SM) se caracteriza por alteraciones que incluyen intolerancia a la glucosa, resistencia a la insulina, obesidad abdominal, dislipidemia e hipertensión arterial. El objetivo del estudio fue evaluar la percepción de la calidad de vida de las personas con SM en relación a los no portadores. Se estudiaron 127 individuos de ambos sexos, 76 enviados por una UBS (unidad básica de salud) del municipio de São Caetano do Sul, São Paulo, Brasil, considerados "casos" y 51 funcionarios de una universidad del mismo municipio, considerados "control", durante el período de Febrero/2006 a Abril/2007. Los pacientes "casos" presentaban al menos un de los tres criterios propuestos por el "National Cholesterol Education Program del Adult Treatment Panel III" (NCEP-ATP III) parael diagnóstico de SM, los pacientes "control" no tenían enfermedades crónicas. Para evaluar la percepción de la calidad de vida se utilizó el Cuestionario de Calidad de Vida de la Organización Mundial de la Salud (WHOQOLbref ), que contiene los dominios físicos, psicológicos, sociales y ambientales. Utilizamos el programa SPSS y el nivel de signifi cancia de5%. Del total de pacientes remitidos por la UBS, 38 fueron diagnosticados positivos y 38 negativos para SM, lo que representa el 50% de los casos.Se compararon las puntuaciones de todos los dominios entre los pacientes positivos y negativos para SM. Los pacientes con SM presentaran los dominios psicológico, físico y social reducidos en relación a los individuos con diagnóstico negativo. La presencia de comorbilidades en el SM determina una reducción signifi cativa en la percepción de la calidad de vida principalmente en los dominios psicológico y físico en relación a personas con enfermedades crónicas, pero negativos para SM y una reducción aún mayor en relación a individuos sin enfermedadescrónicas.

A Síndrome Metabólica caracteriza-se por alterações que incluem intolerância à glicose, resistência à insulina, obesidade abdominal,dislipidemias e hipertensão. O objetivo deste estudo foi verifi car a percepção da qualidade de vida de portadores de SM em comparação anão portadores. Foram estudados 127 indivíduos de ambos os sexos, sendo 76 encaminhados pelas UBS do Município de São Caetano,considerados "casos" e 51 funcionários de uma Universidade do município de São Caetano do Sul, considerados "controle", no período de fev/2006 a abr/2007. Os pacientes "casos" possuíam pelo menos um dos três critériospropostos pelo National Cholesterol Education Program?s Adult Treatment Panel III (NCEP-ATP III) para diagnóstico de SM, os indivíduos "controles" não possuíam doenças crônicas. Para avaliar a percepção da qualidade de vida utilizou-se o World Health Organization Quality of Life Questionnaire (WHOQOL-bref) contendo os domínios físico, psicológico, social e ambiental. Utilizou-se o programa SPSS e o nível de significância de 5%. Do total de pacientes encaminhados pelas UBS, 38 tiveram diagnóstico positivo e 38 negativo para SM, o que representou 50,0% do total de "casos". Foram comparados todos os escores dos domínios entre os pacientes positivos e negativos para SM (casos), e para os que não apresentaram doenças crônicas (controles). Os pacientes com SM apresentaram os domínios psicológico, físico e social reduzidos em relação aos indivíduos com diagnóstico negativo. A presença de comorbidades na SM determina signifi cativa redução na percepçãoda qualidade de vida particularmente nos domínios psicológico e físico em relação a indivíduos portadores de doenças crônicas, porém, negativos para SM e uma redução ainda maior em relação a indivíduos sem doençascrônicas.