Seguimiento a un año de la revascularización percutánea de oclusiones coronarias crónicas en el Hospital México / One-year follow-up of percutaneous revascularization of chronic coronary occlusions at Hospital México

Resumen La prevalencia de la enfermedad arterial coronaria compleja en la población mundial es alta. Las oclusiones coronarias crónicas totales (OCT) generan gran morbilidad en la población y significan un reto terapéutico por su alta complejidad. En años recientes con el desarrollo de nuevas tecnologías se ha visto a nivel mundial un beneficio en la calidad de vida, síntomas y función sistólica del ventrículo izquierdo al realizar intervención coronaria percutánea (ICP) de las OCT con una alta tasa de éxito y pocas complicaciones. En este trabajo se describen los resultados clínicos cardiovasculares a un año de realizar ICP en pacientes con OCT intervenidos en el Hospital México en Costa Rica durante 2016-2017. Se registraron 54 pacientes con seguimiento de 1 año posterior a ICP de OCT. Se analizaron variables sociodemográficas y clínicas, cuantificando síntomas según la escala funcional de la Asociación de Corazón de Nueva York (NYHA) y la Sociedad Canadiense de Cardiología (CCS) de angina, así como valoración de la fracción de eyección (FE) por ecocardiografía en forma basal y posterior a la ICP, y las complicaciones asociadas De los 54 pacientes sometidos a ICP de OCT, la mayoría fueron hombres con edad promedio de 64 años y nivel académico básico. No hubo diferencia significativa en la FE previo y posterior al procedimiento (p=0.68), con una tendencia a la mejoría en los pacientes con disfunción sistólica severa con tejido viable. Sí hubo diferencias significativas en mejoría de síntomas basados en la escala funcional NYHA (p<0,01) y la escala de angina CCS (p<0,01). Se alcanzó un éxito en el procedimiento en el 96.3% de los casos sin diferencia significativa según el acceso vascular ni la escala J-CTO con una tasa de complicaciones baja. Concluimos que hay un beneficio clínico significativo en cuanto a los síntomas, al revascularizar a pacientes con oclusiones coronarias crónicas totales, con una alta tasa de éxito en el procedimiento y pocas complicaciones.

Abstract There is a high prevalence of complex coronary artery disease worldwide, in this group chronic total occlusions (CTO) generate a great burden of disease in the population and are a difficult therapeutic challenge. In recent years and with the development of new technologies, the world have seen a benefit in quality of life, symptoms and systolic function of the left ventricle when performing a percutaneous coronary intervention (PCI) of CTO with high success rate and low rate of complications. In this study we describe the cardiovascular clinical results one year after performing PCI in patients with CTOs in Hospital Mexico in Costa Rica during 2016-2017. Methods: We registry 54 patients completing one year follow up after PCI of CTO. We measure sociodemographic and clinical variables quantifying symptoms using NYHA and CCS scales, ejection fraction (EF) using echocardiography previous and after PCI, and the complications developed. We identified 54 patients who underwent PCI of CTO, most were men with an average age of 64 years and a basic academic level. There was no significant difference in the pre-and-post-procedure EF (p=0.68), with a trend to improvement in patients with severe left ventricle systolic dysfunction and viable myocardium. There were significant differences in symp- tom improvement based on the NYHA functional status score (p<0.01) and the CCS angina score (p<0.01). A successful procedure was achieved in 96.3% of cases with no significant difference depending on vascular access or the J-CTO scale with low complication rate. Conclusions: There is a significant clinical benefit based on symptoms of performing PCI in patients with CTO with a high success rate in the procedure and a few associated complications.

Caracterización de los factores de riesgo en pacientes con cardiopatía isquémica Hospital "Mártires del 9 de Abril", período 2016-2017 / Characterization of risk factors in patients with ischemic heart disease. Hospital "Martires del 9 de abril", period 2016-2017

RESUMEN Introducción: las enfermedades cardiovasculares constituyen la principal causa de muerte en la mayoría de los países. Se describen los factores de riesgo para enfermedad coronaria como no modificables: edad, sexo y antecedentes familiares; y modificables relacionados al estilo de vida: tabaquismo, dislipidemia, obesidad, sedentarismo, diabetes, uso abusivo de alcohol y la enfermedad hipertensiva. Objetivo: caracterizar los factores de riesgo asociados a la cardiopatía isquémica en Atención Secundaria de Salud. Materiales y métodos: estudio observacional, descriptivo transversal en pacientes ingresados en el Hospital "Mártires del 9 de Abril" de Sagua la Grande, en el periodo comprendido entre los años 2016 y 2017. Integraron la muestra 96 pacientes que ingresaron con diagnóstico de cardiopatía isquémica. Se describieron las características demográficas de los mismos; fueron identificados los factores de riesgo y se determinó la frecuencia de asociación de otras formas clínicas de ateromatosis. Resultados: los pacientes fueron mayores de 60 años de edad; la mayoría tenían color de la piel blanca; presentaban antecedentes patológicos familiares de cardiopatía isquémica; las principales formas de cardiopatía isquémica fueron: angina e insuficiencia cardiaca; todos los pacientes presentaron uno o más factores de riesgo cardiovascular, los más significativos fueron, hipertensión arterial, tabaquismo aumento de la circunferencia abdominal y personalidad tipo "A". Conclusiones: la mayoría de los pacientes exhibieron alteraciones en el electrocardiograma: descenso del segmento ST, bloqueo de rama izquierda del haz de His y fibrilación auricular; se observó hipertrigliceridemia y se apreció asociación entre enfermedad renal crónica y angina.

ABSTRACT Introduction: cardiovascular diseases are the main cause of death in most of the countries. The risk factors for coronary disease are described as unmodifiable: age, sex and family history; and modifiable related to lifestyle: smoking, dyslipidemia, obesity, sedentary lifestyle, diabetes, abusive use of alcohol and hypertensive disease. Objective: to characterize the risk factors associated to ischemic heart disease in secondary health care. Material and methods: observational, cross-sectional, descriptive study in patients admitted in "Mártires del 9 de Abril" Hospital, Sagua la Grande, between 2016 and 2017. The sample consisted of 96 patients admitted with a diagnosis of ischemic heart disease. Their demographic characteristics were described; the risk factors were identified and the frequency of association of other clinical forms of atheromatosis was determined. Results: the patients were aged more than 60 years; most of them were white people and had family pathological antecedents of ischemic heart disease; the main forms of ischemic heart disease were angina and heart failure; all patients showed one or more cardiovascular risk factors being arterial hypertension, smoking, increase of abdominal circumference and type A personality the most significant ones. Conclusions: the majority of patients showed alterations in the electrocardiogram: ST segment decrease, His bundle left branch blockage and atrial fibrillation; hypertriglyceridemia was observed and there was an association between chronic kidney disease and angina.

Trend of mortality from ischemic heart disease and influenza vaccination in older adults in São Paulo / Tendência da mortalidade por doenças isquêmicas do coração e a vacinação contra influenza em idosos em São Paulo

Abstract The aim of the present study was to analyze the mortality trend due to ischemic heart disease (IHD) among older adults, identify changes in the trend and determine the correlation with influenza vaccine coverage (2000 to 2012) in the state of São Paulo between 1980 and 2012. An ecological time series study was conducted involving secondary data from Brazilian information systems. Linear and polynomial regression models as well as joinpoint regression were used to estimate the trends. Pearson's correlation coefficient was used to evaluate the correlation between age-standardized mortality coefficients and vaccine coverage. A decreasing tendency in mortality due to IHD occurred in both sexes, higher mortality rates were found for males and greater reductions were found in the period after the vaccination campaigns. However, no statistically significant changes occurred in the year coinciding with or near the onset of the campaigns. In the overall sample, no evidence of a linear correlation was found between the mortality coefficients and vaccination coverage. Other factors directly associated with morbidity and mortality due to ischemic heart disease may have influenced the trend.

Resumo O objetivo deste artigo é analisar a tendência dos coeficientes de mortalidade por doenças isquêmicas do coração (DIC) nos idosos no estado de São Paulo, entre 1980 e 2012, identificar mudanças na tendência e verificar a relação entre as coberturas da vacinação contra influenza e os referidos coeficientes de mortalidade. Trata-se de um estudo ecológico de série temporal, realizado com dados secundários do Sistema de Informação sobre Mortalidade (SIM), do Instituto Brasileiro de Geografia e Estatística (IBGE) e do Sistema de Informações do Programa Nacional de Imunização. Para análise dos dados, utilizaram-se técnicas de correlação, modelos de regressão linear, polinomial e joinpoint regression. Observou-se tendência de queda dos coeficientes de mortalidade por DIC em ambos os sexos, sobremortalidade masculina e redução mais expressiva dos coeficientes no período após a intervenção vacinal. As mudanças estatisticamente significativas encontradas nas tendências não ocorreram em ano coincidente ou próximo do início das campanhas. Para o total de idosos, não foi constatada correlação linear entre os coeficientes de mortalidade e as coberturas vacinais. Outros fatores associados à morbimortalidade dos idosos por DIC podem ter influenciado na tendência.

Fine particulate matter and ischemic heart diseases inrelation to sex. An ecological time series study

ABSTRACT BACKGROUND: Exposure to some air pollutants is associated with cardiovascular diseases. The objective of this study was to quantify the effect of exposure to fine particulate matter in hospitalizations due to ischemic heart disease and the costs to the healthcare system. DESIGN AND SETTING: Time-series ecological study conducted in Taubaté, Brazil. METHODS: Data on hospitalizations due to ischemic heart diseases (ICD I-20 to I-24) in the municipality of Taubaté (SP), Brazil, among adults of both sexes aged 40 years and over, from August 2011 to July 2012, were obtained from DATASUS. Fine particulate matter (PM2.5) concentrations were estimated from a mathematical model. Poisson regression was used in statistical analyses to estimate the relative risks of exposure to PM2.5 for both sexes and after stratification according to sex. The excess of hospitalizations and consequent excess expenditure for the healthcare system were calculated. RESULTS: There were 1040 admissions, among which 382 had ischemic heart diseases (257 males). Themean PM2.5 concentration was 13.2 µg/m3 (SD = 5.6). Significant effects from exposure were noted 4and 5 days after exposure (lag 4 and lag 5) for both sexes and for male sex; for female sex, the effect was 2 days after exposure (lag 2). There were 59 excess hospitalizations for an increase in PM2.5 concentration of 5 µg/m3 and excess expenditure of US$ 150,000 for the National Health System. CONCLUSIONS: An excess of hospital admissions due to ischemic heart disease, with excess expenditure, was identified consequent to PM2.5 exposure.

Factores de riesgo de cardiopatía isquémica en área intensiva municipal. Pedro Betancourt. 2013- 2014 / Risk factors of ischemic cardiopathy in the municipal intensive care area. Pedro Betancourt. 2013-2014

Introducción: la cardiopatía isquémica es un problema de salud que cobra un gran número de vidas y es causa de invalidez en la población mundial. Constituyó en el 2013, la primera causa de muerte en el mundo, en Cuba y en la provincia de Matanzas. Objetivo: cuantificar la presencia de factores de riesgo de cardiopatía isquémica en el AIM del Policlínico Docente Cesáreo Sánchez, en Pedro Betancourt entre los meses de diciembre 2013 a Mayo del 2014. Materiales y Métodos: se realizó un estudio observacional, descriptivo, transversal de 59 pacientes que ingresaron con este diagnóstico entre los meses de diciembre 2013 a Mayo 2014. Se recogieron variables como la edad, sexo, factores de riesgo, formas clínicas de presentación, complicaciones presentadas durante el ingreso y presencia del síndrome metabólico. Resultado: hubo un predominio del sexo masculino y del grupo de edad de 65 y más. La hipertensión arterial y el sedentarismo fueron los factores de riesgo más sobresalientes, así como la angina estable y las arritmias cardíacas como la forma clínica y complicación más frecuente respectivamente. La presencia del síndrome metabólico caracterizó a los pacientes estudiados. Conclusiones: la detección y control oportuno de los factores de riesgo de la cardiopatía isquémica continuara siendo la piedra angular de cualquier estrategia preventiva esencial (AU).

Introduction: the ischemic cardiopathy or ischemic cardiovascular disease is a health problem claiming a great number of lives, being a cause of disability in the world population. In 2013 it was the first cause of death worldwide, in Cuba and in the province of Matanzas. Objective: to quantify the presence of the ischemic cardiopathy risk factors in the municipal intensive area (AIM as abbreviation in Spanish) of the Teaching Policlinic Cesareo Sanchez, in Pedro Betancourt, from December 2013 to May 2014. Materials and methods: a cross-sectional, descriptive, observational study was carried out in 59 patients who entered the area with this diagnosis from December 2013 to May 2014. The collected variables were age, sex, risk factors, clinical forms of presentation, complications during staying, and presence of the metabolic syndrome. Results: the results showed the predominance of the male sex and the age group of 65 years and more. Arterial hypertension and sedentary lifestyle were the most outstanding risk factors, and the stable angina and heart arrhythmias were the most frequent clinical form and complication, respectively. The presence of metabolic syndrome characterized the studied patients. Conclusions: the timely detection and control of the ischemic cardiopathy risk factors is still going to be the cornerstone of any essential preventive strategy (AU).

Factors associated with subendocardial ischemia risk in patients on hemodialysis / Fatores associados ao risco de isquemia subendocárdica em pacientes em hemodiálise

Abstract Introduction: Bone metabolism disorder (BMD) and vascular dysfunction contribute to excess cardiovascular mortality observed in hemodialysis patients. Vascular dysfunction, a new marker of atherosclerosis, can play a role in this risk. Even though associated with higher mortality in the general population, such vascular evaluation in patients on hemodialysis has not been extensively studied. Methods: In this cross-sectional study, hemodialysis patients were submitted to flow-mediated dilation, subendocardial viability ratio (SEVR) and ejection duration index assessment, in order to estimate the impact of BMD markers on vascular dysfunction. Results: A matched cohort of patients with (n = 16) and without (n = 11) severe secondary hyperparathyroidism (SHPT) was studied. Additionally, time spent under severe SHPT was also evaluated. Patients with severe SHPT had lower SEVR and higher ejection duration index, indicating higher cardiovascular risk. Lower SEVR was also associated to diastolic blood pressure (r = 0.435, p = 0.049), serum 25-Vitamin-D levels (r = 0.479, p = 0.028) and to more time spent under severe secondary hyperparathyroidism (SHPT), defined as time from PTH > 500pg/ml until parathyroidectomy surgery or end of the study (r = -0.642, p = 0.027). In stepwise multiple regression analysis between SEVR and independent variables, lower SEVR was independently associated to lower serum 25-Vitamin-D levels (p = 0.005), female sex (p = 0.012) and more time spent under severe SHPT (p = 0.001) in a model adjusted for age, serum cholesterol, and blood pressure (adjusted r² = 0.545, p = 0.001). Conclusion: Subendocardial perfusion was lower in patients with BMD, reflecting higher cardiovascular risk in this population. Whether early parathyroidectomy in the course of kidney disease could modify such results still deserves further investigation.

Resumo Introdução: Distúrbios do metabolismo ósseo (DMO) e alterações da função vascular contribuem para a elevada mortalidade de pacientes em hemodiálise. A disfunção vascular, um novo marcador de aterosclerose, pode contribuir para este risco. Apesar de associada a aumento de mortalidade na população geral, a avaliação de tal disfunção ainda não foi realizada de modo amplo em pacientes em hemodiálise. Métodos: Neste estudo transversal, pacientes em hemodiálise foram submetidos à avaliação da vasodilatação mediada por fluxo, razão de viabilidade subendocárdica (RVSE) e índice de duração de ejeção, como estimativas de avaliação dos marcadores de DMO sobre disfunção vascular. Resultados: Uma coorte pareada com (n = 16) e sem (n = 11) hiperparatireoidismo secundário (HPTS) grave foi estudada. Adicionalmente, o tempo transcorrido do diagnóstico de HPTS grave também foi avaliado. Pacientes com HPTS grave apresentaram menores valores de RVSE e maiores valores de índice de duração de ejeção, apontando maior risco cardiovascular. Baixa RVSE também foi associada à pressão arterial diastólica (r = 0,435, p = 0,049), níveis séricos de 25-Vitamina D (r = 0,479, p = 0,028) e maior tempo transcorrido desde diagnóstico de HPTS grave, definido como tempo em que o paciente permaneceu com valores de paratormônio superiores a 500 pg/ml até realização de cirurgia de paratireoidectomia ou término do estudo (r = -0,642, p = 0,027). Em regressão logística stepwise entre RVSE e variáveis independentes, menor RVSE foi independentemente associado a menores valores de 25-Vitamina D (p = 0,005), sexo feminino (p = 0,012) e maior tempo transcorrido desde diagnóstico de HPTS grave (p = 0,001) em um modelo ajustado para idade, colesterol sérico e pressão arterial (r2 ajustado = 0,545, p = 0,001). Conclusão: A perfusão subendocárdica foi menor em pacientes com DMO, refletindo o maior risco cardiovascular nesta população. Investigações adicionais são necessárias para definir se a paratireoidectomia precoce no curso da doença renal crônica poderia interferir neste risco.

Factores de riesgo coronarios asociados al infarto agudo del miocardio en el adulto mayor / Coronary risk factors associated with the acute myocardial infarction in the elderly

Se realizó un estudio observacional, analítico y retrospectivo, de tipo caso-control, de los adultos mayores con infarto agudo del miocardio, pertenecientes al área de salud Municipal de Santiago de Cuba, desde enero de 2006 hasta diciembre de 2011, a fin de identificar los factores de riesgo coronarios asociados al mismo. Se seleccionaron 33 casos y 2 controles por cada uno de ellos. Se calcularon el riesgo relativo a través de la razón de productos cruzados y el riesgo atribuible en expuestos porcentual como medida de impacto. El sedentarismo y la hipertensión arterial tuvieron una acentuada relación significativa de causalidad con el infarto agudo del miocardio y de forma moderada con el tabaquismo, no así los antecedentes familiares ni personales de cardiopatía isquémica, sexo, obesidad y diabetes mellitus

An observational, analytic and retrospective study of case-control type, of aged patients with acute myocardial infarction, belonging to the health Municipal area of Santiago de Cuba was carried out from January, 2006 to December, 2011, in order to identify the coronary risk factors associated with it. Thirty three cases and two controls for each were selected. The relative risk through the odds ratio and the attributable risk in percentage exposed as impact measure were calculated. Sedentarism and hypertension had a considerable significant causative relationship with acute myocardial infarction and in a moderate way with smoking habit. Family or personal history of ischemic cardiopathy, sex, obesity or diabetes mellitus had no relation with it

Doença isquêmica do coração e fatores associados em adultos de Ribeirão Preto, SP / Ischemic heart disease and correlates in adults from Ribeirão Preto, Brazil

OBJETIVO: Identificar a prevalência da doença isquêmica do coração em adultos e fatores associados. MÉTODOS: Estudo epidemiológico transversal de base populacional, conduzido em amostra ponderada de 2.471 adultos de ambos os sexos e com 30 anos ou mais residentes em Ribeirão Preto, SP, em 2007. A prevalência da doença foi estimada por pontos e por intervalos com 95% de confiança (IC95%), após a aplicação do Questionário Rose. Para a identificação de fatores associados (fatores sociodemográficos, de riscos cardiovasculares e relacionados ao acesso a serviços e ao padrão de atividade física), razões de prevalências brutas e ajustadas foram estimadas por meio da regressão de Poisson. RESULTADOS: A prevalência de doença isquêmica do coração foi maior no sexo feminino que no masculino, em todas as faixas etárias. No modelo final permaneceram independentemente associadas ao desfecho as seguintes variáveis: ter trabalho (RP = 0,54 [0,37;0,78]); antecedentes familiares de doença isquêmica do coração (RP = 1,55 [1,12;2,13]); hipertensão arterial (RP = 1,70 [1,18;2,46]); saúde autorreferida (RP = 2,15 [1,40;3,31]); duração do hábito de fumar (3° terço) (RP = 1,73 [1,08;2,76]); circunferência da cintura alterada (RP = 1,79 [1,21;2,65]) e hipertrigliceridemia (RP = 1,48 [1,05;2,10]). Teste de tendência linear para as RP nas categorias da variável saúde autorreferida apresentou significância estatística (p < 0,05). CONCLUSÕES: Além da elevada prevalência de doença isquêmica do coração, os fatores associados ao desfecho são quase todos modificáveis e passíveis de intervenção por meio de políticas públicas.

OBJECTIVE: To identify the prevalence of ischemic heart disease (IHD) and correlates in an adult population. METHODS: Cross-sectional population-based epidemiological study including a weighted sample of 2,471 adults of both sexes and with age 30 years or older residing in Ribeirão Preto, Southeastern Brazil, in 2007. The Rose Questionnaire was administered, and IHD prevalence was calculated with point estimates and 95% confidence intervals. To identify correlates (sociodemographic, cardiovascular risk factors, and those related to access to health services and to physical activity level), crude and adjusted prevalence ratios were estimated using Poisson regression. RESULTS: IHD prevalence was higher in females than males at all age strata. In the final model, the following variables were independently associated with IHD: work status (PR= 0.54 [0.37;0.78]); family history of IHD (PR=1.55 [1.12;2.13]); hypertension (PR= 1.70 [1.18;2.46]); self-reported health status (PR=2.15 [1.40;3.31]); smoking duration (third tertile) (PR= 1.73 [1.08;2.76]); adjusted waist circumference (PR=1.79 [1.21;2.65]) and hypertriglyceridemia (PR=1.48 [1.05;2.10]). Linear trend test of PR across self-reported health status categories was statistically significant (p<0.05). CONCLUSIONS: A high prevalence of IHD was found, and the factors associated with the outcome are almost all modifiable and potentially influenced by public policy interventions.

OBJETIVO: Identificar la prevalencia de la enfermedad isquémica del corazón en adultos y factores asociados. MÉTODOS: Estudio epidemiológico transversal de base poblacional, conducido en muestra ponderada de 2471 adultos de ambos sexos y con 30 años o más residentes en Ribeirao Preto, SP, en 2007. La prevalencia de la enfermedad fue estimada por puntos y por intervalos con 95% de confianza (IC95%), posterior a aplicación del Cuestionario Rose. Para la identificación de factores asociados (factores sociodemográficos, de riesgos cardiovasculares y relacionados al acceso a servicios y al patrón de actividad física), tasas de prevalencias brutas y ajustadas se estimaron por medio de la regresión de Poisson. RESULTADOS: La prevalencia de enfermedad isquémica del corazón fue mayor en el sexo femenino que en el masculino, en todos los grupos etarios. En el modelo final permanecieron independientemente asociadas al resultado las siguientes variables: tener trabajo (RP=0,54 [0,37;0,78]); antecedentes familiares de enfermedad isquémica del corazón (RP=1,55 [1,12;2,13]); hipertensión arterial (RP= 1,70 [1,18;2,46]); salud auto-referida (RP=2,15 [1,40;3,31]), duración del hábito de fumar (3° tercio) (RP=1,73 [1,08;2,76]); circunferencia de la cintura alterada (RP=1,79 [1,21;2,65]) e hipertrigliceridemia (RP=1,48 [1,05;2,10]). Prueba de tendencia linear para las RP en las categorías de la variable salud auto-referida presentó significancia estadística (p<0,05). CONCLUSIONES: Aunado a la elevada prevalencia de enfermedad isquémica del corazón, los factores asociados al resultado son casi todos modificables y propensos a intervención por medio de políticas públicas.

Diabetes mellitus, obesidad y función renal en el riesgo coronario de mayores de 15 años en el Consejo Popular La Demajagua, 2008 / Diabetes mellitus, obesity and renal function as coronary risk factors in adults aged over 15 from

Se realizó un estudio de casos y controles durante el año 2008 para identificar la relación causal de algunas variables de riesgo de cardiopatía isquémica en la población mayor de 15 años del Consejo Popular La Demajagua-Isla de la Juventud, Cuba. La muestra estuvo compuesta por 80 pacientes; de ellos, 40 casos con un equiparamiento por edad y sexo de 1:1. Se determinó que el sexo femenino, la edad de 51-59 años y el antecedente de diabetes mellitus y obesidad constituyeron factores de riesgo significativos en nuestra muestra de estudio, con un comportamiento diferente para la disminución del filtrado renal en la cual no se demostró una relación causal. La obesidad resultó ser el factor de riesgo de mayor significación en la aparición de la isquemia coronaria en la presente muestra, pues si pudiera ser eliminada o controlada se podría disminuir la incidencia de la enfermedad en alrededor del 35 porciento

A case-control study was conducted throughout the year 2008 to identify the causal role of some ischemic heart disease risk factors in adults aged over 15 from La Demajagua People's Council on the Isle of Youth, Cuba. The sample was composed of 80 patients, of whom 40 were 1:1 paired for age and sex. Female sex, the 51-59 age range and a history of diabetes mellitus and obesity were found to be significant risk factors in the study sample, unlike reduced renal filtration, for which a causal relationship was not found. Obesity was the most significant coronary ischemia risk factor in the study group. The incidence of the disease would be reduced in about 35 percent if this risk factor could be either eliminated or controlled

Control ambulatorio de la presión arterial en hipertensos sistólicos con cardiopatía isquémica asociada / Ambulatory control of arterial systolic pressure in hypertensive patients presenting with associated ischemic heart disease

Cuando la cardiopatía isquémica coexiste con la hipertensión arterial, el tratamiento de esta se torna una tarea compleja. El objetivo de este trabajo fue evaluar el efecto sobre el control ambulatorio de la presión arterial (en una cohorte de hipertensos sistólicos mayores de 50 años con cardiopatía isquémica asociada) de una estrategia de tratamiento antihipertensivo basada en un betabloqueador (atenolol), un diurético y un inhibidor de la enzima convertidora de angiotensina. Se incluyeron 126 pacientes (hipertensos no controlados mayores de 50 años con cardiopatía isquémica estable crónica que fueron evaluados al inicio y a las 6, 24 y 52 sem. A las 6 sem estaban controlados el 52,38 por ciento de los pacientes, a los 6 meses 54,76 por ciento y al año el 71,42 por ciento. Los resultados indican que el tratamiento fue efectivo para controlar la presión arterial y reducir las crisis de angina de pecho en hipertensos sistólicos. Para lograr esto, la mayoría de los pacientes necesitó 2 ó 3 medicamentos, lo que indica que esta cohorte de pacientes hipertensos sistólicos, en su mayoría de la tercera edad y con una cardiopatía isquémica estable crónica asociada, necesitan una terapéutica adecuada, con un seguimiento frecuente

When ischemic heart disease is associated with arterial hypertension, treatment becomes a complex task. A group of 126 non-controlled patients with isolated systolic hypertension aged over 50 with associated ischemic heart disease was studied to assess the effect of an antihypertensive treatment strategy based on the combination of a b-blocker (Atenolol), a diuretic, and an angiotensin-converting enzyme inhibitor (ACEI) on the ambulatory control of arterial pressure. All patients were assessed at onset and 6, 24 and 52 weeks later. The percentage of patients achieving blood pressure control was 52.38 percent; 54.76 percent and 71.42 percent at 6, 24 and 52 weeks respectively. The results showed that treatment was effective to control the arterial pressure and to reduce the angina episodes in the systolic hypertensive ones. To achieve it, most of patients needed two or three drugs indicating that this group of hypertensive and systolic patients in the main of third age and with an associated chronic stable ischemic heart disease needs an appropriate therapy with a frequent follow-up

Análise espacial das internações por doenças do coração no Vale do Paraíba / Spatial analysis of hospitalization for heart diseases in Vale do Paraíba

FUNDAMENTO: As doenças isquêmicas do coração (DIC) são causa importante de internação no Vale do Paraíba paulista. OBJETIVO: Identificar padrões de distribuição espacial para internações por infarto agudo do miocárdio (IAM) e DIC no Vale do Paraíba paulista. MÉTODOS: Realizou-se um estudo ecológico e exploratório utilizando técnicas de análise espacial dos dados de internação por infarto agudo do miocárdio e doença isquêmica do coração no Vale do Paraíba paulista entre 2004 e 2005. A análise estatística espacial utilizou uma base de dados georreferenciados de 35 municípios e rotinas de estatística espacial. Os dados de internações foram obtidos no Portal Datasus do Ministério da Saúde. As variáveis estudadas foram o número de internações por sexo masculino e feminino, na faixa etária acima dos 30 anos. Para avaliação da dependência espacial foram utilizados os coeficientes de autocorrelação global de Moran e o índice local de Moran. Também foram analisadas as correlações entre as variáveis pelo programa TerraView. O nível de significância foi de 5 por cento. RESULTADOS: Foram identificadas 6.287 internações. As taxas foram de 161,66/100 mil. Do total dos 35 municípios, 31,4 por cento possuem taxas acima da média. Os coeficientes de Moran (global) mostraram significância estatística. Os índices locais mostraram agrupamentos, apontando um aglomerado com 9 municípios onde ocorre dependência espacial com dinâmicas próprias. CONCLUSÃO: A análise espacial permitiu identificar aglomerado espacial no médio Vale do Paraíba paulista para as internações por infarto agudo do miocárdio e doença isquêmica do coração, permitindo intervenção para redução das taxas. (Arq Bras Cardiol 2007;88(6):624-628)

BACKGROUND: Ischemic heart diseases (IHD) are important causes of death in the Vale do Paraíba paulista. OBJECTIVE: To identify patterns of spatial distribution of hospitalizations for acute myocardial infarction (AMI) and IHD in the Vale do Paraíba paulista. METHODS: This was an ecological study using exploratory spatial analysis of hospitalization data for acute myocardial infarction and ischemic heart disease in the Vale do Paraíba between 2004 and 2005. The statistical analysis used spatial georeferenced databases of 35 municipalities and spatial statistics routines. The admission data were obtained from the Portal Datasus of the Ministry of Health. The variables were the number of admissions for males and females aged over 30 years. To evaluate the spatial dependence we used the autocorrelation coefficients of Global Moran and Local Moran's index. We also analyzed the correlations between variables, using the TerraView program. The level of significance was 5 percent. RESULTS: Among 6,287 admissions, the rates were 161.66/100 thousand. Of the total of 35 municipalities, 31.4 percent had rates above average. The coefficient of Moran (global) showed a statistical significance. Local indexes showed clusters, indicating a cluster of 9 municipalities in which there was spatial dependence with their own dynamics. CONCLUSION: In the mid Vale do Paraíba paulista, the spatial analysis identified spatial clusters of hospitalizations due to acute myocardial infarction and ischemic heart disease, allowing intervention to reduce rates. (Arq Bras Cardiol 2007;88(6):624-628)

Prevalência de isquemia induzida por estresse mental / Prevalence of induced ischemia by mental distress

FUNDAMENTOS: A cintilografia miocárdica com estresse mental parece induzir isquemia através de uma fisiopatologia particular quando comparada com a cintilografia, utilizando o estresse físico ou farmacológico. OBJETIVO: Avaliar a prevalência de isquemia miocárdica induzida por estresse mental, em pacientes com dor torácica e cintilografia com estresse convencional normal, utilizando 99mTc-Sestamibi. MÉTODOS: 22 PAcientes foram admitidos com dor torácica na emergência, ou foram encaminhados ambulatorialmente ao serviço de medicina nuclear da nossa instituição, onde realizaram cintilografia miocárdica de estresse e repouso sem alterações isquêmicas. Então, foram convidados a realizar uma fase adicional com indução de estresse mental através do conflito de cores (Stroop Color Test) com o objetivo de detectar isquemia miocárdica. Dois cardiologistas e médicos nucleares realizaram a análise cega dos dados perfusionais e consequente quantificação através do SDS (Summed Diference Score), pontuando os segmentos com alteração perfusional após o estresse mental e comparando com a imagem de repouso. A presença de isquemia miocárdica foi considerada com SDS > 3. RESULTADOS: A prevalência de isquemia miocárdica induzida por estresse mental foi de 40 por cento (9 pacientes positivos). Nos 22 pacientes estudados não houve diferença estatística quanto ao número de fatores de risco, alterações hemodinâmicas induzidas pelo estresse mental, uso de medicações, sintomas apresentados, presença ou ausência de doença coronariana e variações da fração de ejeção e volume sistólico final do Gated SPECT. CONCLUSÃO: EM Uma amostra selecionada de pacientes com dor torácica e cintilografia miocárdica convencional normal, a pesquisa de isquemia miocárdica induzida pelo estresse mental através de cintilografia pode ser positiva em até 40 por cento dos casos.

BACKGROUND: The myocardial radionuclide imaging with mental distress seems to induce ischemia through a particular physiopathology when compared to radionuclide imaging with physical or pharmacological distress. OBJECTIVE: To assess the prevalence of induced myocardial ischemia by mental distress in patients with thoracic pain and radionuclide imaging with normal conventional distress, with 99mTc-Sestamibi. METHODS: Twenty-two patients were admitted with thoracic pain at emergency or were referred to the nuclear medicine service of our institution, where myocardial radionuclide imaging of distress or rest without ischemic alterations was carried out. The patients were, then, invited to go through an additional phase with mental distress induced by color conflict (Strop Color Test) with the objective of detecting myocardial ischemia. Two cardiologists and nuclear physicians performed the blind analysis of perfusional data and consequent quantification through Summed Difference Score (SDS), punctuating the segments that were altered after mental distress and comparing it to the rest period image. The presence of myocardial ischemia was considered if SDS > 3. RESULTS: The prevalence of mental distress-induced myocardial ischemia was 40 percent (9 positive patients). Among the 22 studied patients, there were no statistical differences with regard to the number of risk factors, mental distress-induced hemodynamic alterations, usage of medications, presented symptoms, presence or absence of coronary disease and variations of ejection fraction and final systolic volume of Gated SPECT. CONCLUSION: In a selected sample of patients with thoracic pain and normal myocardial radionuclide imaging, the research of myocardial ischemia induced by mental distress through radionuclide imaging may be positive in up to 40 percent of cases.

Perfil sociodemográfico de pacientes atendidos em ambulatório de isquemia cardíaca / Perfil sociodemográfico de pacientes atendidos en ambulatorio de isquemia cardiaca / Socio-demographic profile of patients assisted in myocardial ischemia ambulatory

As doenças cardiovasculares estão associadas a fatores de risco, comorbidades, hábitos de vida inadequados e condições socioeconômicas desfavoráveis. Estudo de corte transversal e descritivo, cujo objetivo foi caracterizar o perfil dos indivíduos revascularizados do miocárdio atendidos no ambulatório de um hospital filantrópico da cidade de Salvador, BA. Foram realizadas entrevistas com 61 usuários, entre abril e agosto de 2007. Os dados registrados e codificados nos formulários constituíram um banco de dados no programa estatístico SPSS 13.0 for Windows. Entre os sujeitos, 55,7% eram do sexo masculino, 52,5% com idade inferior a 60 anos, provedores da família, com tempo de cirurgia entre 45 dias a 17 anos, renda de até três salários mínimos, baixa escolaridade e reduzida atividade social. O perfil sociodemográfico dos sujeitos pode estar contribuindo para a não adesão ao tratamento implementado. Conhecer essas características possibilita propor práticas de cuidar individualizado para a melhoria da qualidade do cuidado de enfermagem.

Cardiovascular diseases are associated to risk factors, co-morbidity, inadequate living habits, and unfavorable socio-economic conditions. A cross sectional and descriptive study, whose objective was to characterize the profile of the individuals with myocardial revascularization assisted in the ambulatory of a philanthropic hospital in the city of Salvador-Bahia, Brazil. Interviews were carried out with 61 users, from April to August, 2007. The information recorded and codified fed the data base for the statistics program SPSS 13.0 for Windows. 55.7% of the interviewees were male; 52.5% were under the age of 60, family providers, with surgeries performed within the time span of 45 days and 17 years, income of up to three minimum wages, low schooling, and reduced social activities. The socio-demographic profile of the subjects can be favoring the non-adhesion to the treatment implemented. Identifying those characteristics can make it possible to consider practices for individualized care aiming at the improvement in the quality of nurse care.

Las enfermedades cardiovasculares están asociadas a factores de riesgo, co-morbidades, hábitos de vida inadecuados y condiciones socioeconómicas desfavorables. Estudio transversal y descriptivo, cuyo objetivo fue caracterizar el perfil de los individuos revascularizados del miocardio atendidos en el ambulatorio de un hospital filantrópico de la ciudad de Salvador-Bahia-Brasil. Fueron realizadas entrevistas con 61 usuarios, entre abril y agosto de 2007. Los datos registrados y codificados en los formularios constituyeron un banco de datos en el programa estadístico SPSS 13.0 for Windows. Entre los sujetos, 55,7% eran del sexo masculino, 52,5% con edad inferior a 60 anos, proveedores de la familia, con tiempo de cirugía entre 45 días a 17 años, renta de hasta tres sueldos mínimos, baja escolaridad y reducida actividad social. El perfil sociodemográfico de los sujetos puede estar contribuyendo para la no adhesión al tratamiento implementado. Conocer esas características permite proponer prácticas de atención individualizada, posibilitando una mejoría en la calidad do los cuidados de la enfermería.

Influencia de factores socioculturales en la evolución alejada de pacientes con insuficiencia cardíaca / Influence of social and cultural factors in the late course of patients with congestive heart failure

Objetivo: Evaluar el impacto de los factores socioculturales (SC) en Las características del cuidado de la insuficiencia cardiaca (IC) y la evolución post alta en pacientes admitidos con diagnostico de IC descompensada a hospitales del registro ICARO en el periodo 2006-2008.Método: Registro prospectivo de 14 hospitales. Se incorporaron en forma consecutiva pacientes admitidos con el diagnostico de IC descompensada entre enero 2006 y mayo 2008. La mortalidad al fin del seguimiento se determino por la base de datos del Servicio Nacional del Registro Civil e Identificación. Se definió como terapia optima la combinación de en betabloqueador con cualquiera de los siguientes: inhibidores de la enzima convertidora de angiotensina (IECA), antagonistas del receptor de angiotensina Il (ARAlI), hidralazina/isosorbide o espironolactona. Las características de los pacientes se compararon mediante t de Student o chi cuadrado según correspondía. La sobrevida se evaluó mediante Kaplan-Meier.Resultados: Los pacientes de bajo nivel SC son do mayor edad (71 +/- 11 v/s 66 +/-15 años respectivamente, p<0.01). predomina el género femenino (52.2 por ciento v/s 26.1 por ciento, p<0,01), y su previsión fue mayoritariamente FONASA (90 por ciento). La etiología isquémica fue más frecuente en el estrato SC alto (34,5 vs. 16,6 por ciento) y la hipertensiva en el nivel SC bajo (30,3 v/s 16,6 por ciento). La utilización de ARA II fue más frecuente en el nivel SC alto con una tendencia a menor utilización de IECA, el uso de betabloqueadores espironolactona hidralazina e isosorbide amiodarona y anticoagulante fue menor en el estrato SC bajo.

Aim: to evaluate de impact of social and cultural (S-C) factors in the care and course of patients with congestive heart failure (CHF) enrolled in the ICARO study (national registry for patients with head failure). Methods: Patients were enrolled from 2006 through 2008. They were discharged from 14 hospitals participating in the prospectively designed ICARO study. Late mortality was obtained from the national Identification registry. Optimal medical therapy was defined as the use of a betablocker in addition to any of the following ACE inhibitors, ARA II. combination of hydralazine and nitrates, or spironolactone. Statistical analysis included Students t tesl. chi square and Kaplan Meir and Log-rank testing, as appropriate. Results: Patients with a low S-C level were older (71 +/- 11 vs 66 +/- IS years. p<0.01). more frequently females (52.2 percent vs 26.1 percent, p<0.01) and most of them belonged in the FONASA health insurance system (90 percent). Ischemic heart disease was more prevalent in the high S-C level (34.5 vs 16.6 percent) and hypertension in the low S-C level (30.3 vs 16.6 percent). ARA II rather than ACE inhibitors were more commonly used in the high S-C level: A CE inhibitors, betablockers, spironolactone, hydralazine-nitrates, amiodarone and anticoagulatioo were less frequently used in the low S-C level. After discharge a more intensive treatment of heart failure was observed; however, this was less seen in the low S-C level. Patients with decreased left ventricular ejection fraction were similarly treated in both groups. An optimal therapy for CHF was used in 43.7 percent, 43.3 percent and 51.1 percent in S-C levels low, intermediate and high, respectively (NS). Independent predictors for late mortality were age>70 years (HR 2.71 (CI 1.55-3.03), low S-C level (HR 1.57, CII. 17- 2.09), EF<50 percent (HR 1.49, CI 1.04-2.14) and absence of optimal medical therapy at discharge (HR 0.52, CI 0.41-0.66).

Estudio piloto: costos directos atribuibles al tabaquismo en dos hospitales de Santiago / Pilot study: tobacco-attributable direct costs in two hospitais in Santiago, Chile

Background: Tobaceo is the fourth cause of the global burden of disease, accounting for 79.9 million loss of disability-adjusted Ufe years (DALYs) in 2001. In 2002, tobacco-attributable mortality in Chile represented 17 percent of total mortality. Aim: To estimate the direct cost of tobaceo in Ischemic Heart Disease, Chronic Obstructive Pulmonary Disease and Lung Cáncer, explore patients' disposition to answer a health related expenses questionnaire, valídate the instruments used and determine an adequate sample size for an upcoming study. Material and methods: Socio-demographic and health care related variables were investigated among patients attending two publie hospitais for ischemic heart disease, chronic obstructive pulmonary disease and lung cancer, in a cross-sectional study. Costs were estimated using the national publie health insurance price list and market pnces. Tobacco-attributable fraction was then applied to calcúlate the tobacco-attributable cost ofeach disease. Results: The instruments used were validated. The group of lung cáncer patients was smaller due to increased mortality prior to interview. Lung cancer generated the largest total and attríbutable direct costs. The costs in patients with ischemic heart disease were significantly lower Conclusions: There were some difficulties in the application of the questionnaire to register medication use. The sample size needed in a larger study was calculated for each of the three diseases. We recommend that a definitive study addresses tobacco-attributable direct costs related to chronic obstructive pulmonary disease.

Las enfermedades crónicas no transmisibles en México: sinopsis epidemiológica y prevención integral / Chronic non-communicable diseases in Mexico: epidemiologic synopsis and integral prevention

El gobierno federal desarrolla acciones para reducir la mortalidad por las "enfermedades crónicas no transmisibles" (ECNT). Una de ellas es la creación de unidades médicas de especialidad (Uneme) diseñadas para el tratamiento especializado de las ECNT (sobrepeso, obesidad, riesgo cardiovascular y diabetes). La intervención se basa en la participación de un grupo multidisciplinario entrenado ex profeso, la educación del paciente sobre su salud, la incorporación de la familia al tratamiento y la resolución de las condiciones que limitan la observancia de las recomendaciones. El tratamiento está indicado con base en protocolos estandarizados. La eficacia de la intervención se evalúa en forma sistemática mediante indicadores cuantitativos predefinidos. Se espera que las Uneme resulten en ahorros para el sistema de salud. En suma, este último desarrolla mejores medidas de control para las ECNT. La evaluación del desempeño de las Uneme generará información para planear acciones preventivas futuras.

The federal government has implemented several strategies to reduce mortality caused by chronic non-communicable diseases (CNTD). One example is the development of medical units specialized in the care of CNTD (i.e. overweight, obesity, cardiovascular risk and diabetes), named UNEMES (from its Spanish initials). These units -consisting of an ad-hoc, trained, multi-disciplinary team- will provide patient education, help in the resolution of obstacles limiting treatment adherence, and involve the family in patient care. Treatment will be provided using standardized protocols. The efficacy of the intervention will be regularly measured using pre-specified outcomes. We expect that these UNEMES will result in significant savings. In summary, our health care system is developing better treatment strategies for CNTD. Evaluating the performance of the UNEMES will generate valuable information for the design of future preventive actions.

O perfil de saúde cardiovascular dos idosos brasileiros precisa melhorar: estudo de base populacional / The profile of cardiovascular health of elderly brazilian people needs to improve: a population-based study

FUNDAMENTO: No Brasil, existe pouca informação de base populacional sobre a aglomeração de fatores de risco e sua relação com doenças cardiovasculares em idosos. OBJETIVO: Estimar prevalência e aglomeração de fatores de risco e investigar associação com doença isquêmica do coração (DIC) em idosos. MÉTODOS: Foram incluídos todos os participantes > 60 anos do "Inquérito domiciliar sobre comportamentos de risco e morbidade referida de doenças e agravos não-transmissíveis", realizado pelo Ministério da Saúde em 2002/2003, em quinze capitais e no Distrito Federal. Investigou-se a prevalência de fatores de risco (tabagismo, consumo de álcool, inatividade física, dieta inadequada e obesidade) e de morbidade referida (hipertensão, hipercolesterolemia e diabete), além da associação entre DIC e aglomeração desses fatores pela regressão de Poisson. RESULTADOS: Os idosos representaram 13,4 por cento (3.142/23.457), 59,4 por cento mulheres e 40,6 por cento homens. A idade média foi de 69,5 anos. Prevalências de dieta inadequada, inatividade física, obesidade, tabagismo e consumo de risco de álcool foram 94,4 por cento, 40 por cento, 17 por cento, 12,7 por centoe 3,2 por cento, respectivamente. Cerca de 50 por cento referiram hipertensão; 33 por cento hipercolesterolemia e 18 por cento, diabete. Tabagismo e hipercolesterolemia reduziram significativamente com a idade. Hipertensão, inatividade física, obesidade e hipercolesterolemia foram mais prevalentes em mulheres. Aglomeração de dois ou mais fatores foi observada em 71,3 por cento dos idosos e reduziu com o avançar da idade. Idosos com DIC apresentaram uma prevalência quatro vezes maior de aglomeração de quatro ou mais fatores (RP = 4,1; IC_95 por cento: 2,6-6,4). CONCLUSÃO: A associação entre DIC e maior aglomeração de fatores de risco expressa, provavelmente, maior risco acumulado ao longo da vida, mas indica também a necessidade de melhorar o perfil de risco desses idosos.

BACKGROUND: In Brazil, population-based information on risk factors and their relationship with cardiovascular diseases in the elderly is scarce. OBJECTIVE: To estimate the prevalence and clustering of risk factors and investigate their association with ischemic heart disease (IHD) in elderly people. METHODS: All subjects >60 years of age participating in the "Inquérito domiciliar sobre comportamentos de risco e morbidade referida de doenças e agravos não transmissíveis" (Household Survey on Risk Behaviors and Reported Morbidity of Non Transmissible Diseases and Health Conditions) carried out by the Ministry of Health, in 2002/2003 in 15 capitals and the Federal District were included. The prevalence of risk factors (smoking, alcohol consumption, lack of physical activity, inappropriate diet, and obesity) and reported morbidity (hypertension, hypercholesterolemia, and diabetes) was assessed, as well as the association between IHD and clustering of these factors using the Poisson regression model. RESULTS: Elderly individuals represented 13.4 percent (3,142/23,457), 59.4 percent women and 40.6 percent men. The mean age of the participants was 69.5 years. Approximately 50 percent of participants reported having hypertension, 33 percent hypercholesterolemia, and 18 percent diabetes. Smoking and hypercholesterolemia dropped significantly with age. Hypertension, physical inactivity, obesity, and hypercholesterolemia were more prevalent among women. Clustering of two or more factors was observed in 71.3 percent of the elderly, and diminished with age. Elderly subjects with IHD had a four-fold higher prevalence of clusters with four or more factors (PR=4.1; 95 percent CI: 2.6-6.4). CONCLUSION: The relationship between IHD and a larger clustering of risk factors probably represents a greater accumulated risk throughout life, but it also indicates the need to improve the risk profile of these elderly people.

Diferencias geográficas de las hospitalizaciones por enfermedades cardiovasculares: algunos factores posibles: Chile 2003-2005 / Geographical differences of hospital admission rates for cardiovascular conditions: some possible factors: Chile 2003-2005

Las tasas de hospitalización por enfermedad isquémica del corazón son diferentes entre los 28 Servicios de Salud de Chile, y presentan, en general, una tendencia ascendente en los últimos años. Se asocian con las tasas de egresos por todas las causas y con el índice de envejecimiento de las poblaciones de los Servicios. Hubo una correlación baja con la ausencia de pobreza. No apareció correlación con mortalidad por enfermedades circulatorias (20-64 años) ni con ruralidad. Las tasas de egresos por enfermedad cerebrovascular son ligeramente inferiores a las tasas de egresos por enfermedad isquémica (EIC) y difieren algo menos entre los Servicios de Salud. Presentan una tendencia descendente, en general. Se asocian en mayor grado que los egresos por EIC con los egresos totales y con el envejecimiento poblacional. Hubo una correlación baja con la pobreza y no la hubo con ruralidad. La asociación con mortalidad por enfermedades circulatorias fue importante. Se discuten las implicaciones de los resultados locales para la epidemiología, y para la administración de los Servicios y hospitales; y se señalan aspectos dignos de investigar ulteriormente.

Hospital admission rates for ischemic heart disease differ among the 28 Health Areas of Chile and the recent short term trend shows an increase. They are associated with the total admissions rate and with the proportion of old age persons in the population of the areas. There is a low correlation with non-poverty. No association was seen with cardiovascular diseases mortality (20-64 years) or with the percentage of rural population. Admission rates for cerebrovascular disease are slightly lower than those due to ischemic heart disease and the dispersion among health areas is also slightly lower. In general, the short term recent trend is a declining one. They are more strongly associated with the rate of all admissions and with the proportion of elderly persons. There was a low correlation with poverty and none with the percentage of rural population. There was a clear association with mortality from circulatory diseases. The implications of the area specific results for epidemiology and for the administration of the Health Services and Hospitals are discussed. Challenges for further research are indicated.