Vitamin D deficiency among patients with pulmonary hypertension.

BACKGROUND: There is little information about vitamin D (Vit D) deficiency in patients with pulmonary hypertension (PH). The objective of this study was: 1) compare Vit D levels between patients with PH, left ventricular failure (LVF) and healthy subjects (HS); 2) correlate, in patients with PH, Vit D levels with prognosis-related variables, such as the 6-min walk test (6MWT). METHODS: Vitamin D levels were measured in a cross-sectional study in 126 patients from one of three groups: patients with PH (n = 53), patients with LVF (n = 42) and healthy subjects (n = 31). In all groups, 8-h fasting blood samples were obtained in the morning. In the PH and the LVF group, functional class (WHO criteria), metres covered in the 6MWT and echocardiographic parameters were analysed. In the PH group, plasma N terminal pro B type natriuretic peptide (NT-proBNP) level was analysed and a complete haemodynamic evaluation by right heart catheterisation was made. RESULTS: Mean Vit D levels were lower in PH than in both other groups (ng/ml, mean ± SD): PH 19.25 ± 10, LVF 25.68 ± 12, HS 28.8 ± 12 (PH vs LVF p = 0.017, PH vs HS p = 0.001 and HS vs LVF p = 0.46). Vit D deficiency prevalence was higher in PH as compared to the other groups (PH 53.8%, LVF 45.2%, HS 25%, p = 0.01). Patients with PH in functional class (FC; WHO criteria) III-IV had higher Vit D deficiency prevalence than those in FC I-II (86.7% vs 40.5%, p = 0.003). There was a significant linear correlation between the 6MWT and Vit D levels in PH (p < 0.01), but not in LVF (p = 0.69). CONCLUSIONS: Vit D levels were lower in patients with PH as compared to patients with LVF and HS and correlated directly with 6-min walk distance.

Loss of dystrophin is associated with increased myocardial stiffness in a model of left ventricular hypertrophy.

Transition from compensated to decompensated left ventricular hypertrophy (LVH) is accompanied by functional and structural changes. Here, the aim was to evaluate dystrophin expression in murine models and human subjects with LVH by transverse aortic constriction (TAC) and aortic stenosis (AS), respectively. We determined whether doxycycline (Doxy) prevented dystrophin expression and myocardial stiffness in mice. Additionally, ventricular function recovery was evaluated in patients 1 year after surgery. Mice were subjected to TAC and monitored for 3 weeks. A second group received Doxy treatment after TAC. Patients with AS were stratified by normal left ventricular end-diastolic wall stress (LVEDWS) and high LVEDWS, and groups were compared. In mice, LVH decreased inotropism and increased myocardial stiffness associated with a dystrophin breakdown and a decreased mitochondrial O2 uptake (MitoMVO2). These alterations were attenuated by Doxy. Patients with high LVEDWS showed similar results to those observed in mice. A correlation between dystrophin and myocardial stiffness was observed in both mice and humans. Systolic function at 1 year post-surgery was only recovered in the normal-LVEDWS group. In summary, mice and humans present diastolic dysfunction associated with dystrophin degradation. The recovery of ventricular function was observed only in patients with normal LVEDWS and without dystrophin degradation. In mice, Doxy improved MitoMVO2. Based on our results it is concluded that the LVH with high LVEDWS is associated to a degradation of dystrophin and increase of myocardial stiffness. At least in a murine model these alterations were attenuated after the administration of a matrix metalloprotease inhibitor.

Isolated Intrapulmonary Vascular Dilatations and the Risk of Developing Hepatopulmonary Syndrome in Liver Transplant Candidates.

BACKGROUND: The natural history of intrapulmonary vascular dilations (IPVD) and their impact on patient outcomes in the setting of portal hypertension has only been described in small series. AIMS: To assess the development of hepatopulmonary síndrome (HPS) in patients with isolated IPVD and to evaluate outcomes of IPVD and HPS among patients evaluated for liver transplantation (LT). MATERIAL AND METHODS: Data from a prospective cohort of patients evaluated for LT with standardized screening for HPS were analyzed. IPVDs were defined as the presence of microbubbles in the left atrium > 3 cycles following right atrial opacification. HPS was defined as the presence of IPVD and hypoxemia (Alveolar-arterial gradient ≥ 15 mmHg) in the absence of concomitant cardiopulmonary disease. RESULTS: A total of 104 patients with negative contrast-enhanced echocardiogram (CE) were compared to 63 patients with IPVD and 63 patients with HPS. Only four patients were categorized as 'severe' HPS based on degree of hipoxemia (defined as PaO2 < 60 mmHg). Twenty IPVD patients were followed with ABG over a mean duration of 21 months (range 9-43), of whom 7 (35%) subsequently met HPS criteria. Overall unadjusted survival from the time of LT evaluation using multi-state survival models that accounted for pre- and post-LT time was not statistically different among the three groups (negative CE, IPVD, and HPS; p > 0.5). CONCLUSIONS: Patients with IPVD appear to have a substantial risk of developing oxygenation impairment over time and progress to HPS. In our cohort, survival in patients with HPS and isolated IPVD is not different when compared to those without IPVDs.

Obstructive membrane at the base of the left atrial appendage, a multi-imaging approach.

The left atrial appendage (LAA) is a small muscular extension that grows from the anterolateral wall of the left atrium, in the proximity of the left pulmonary veins. The presence of a membrane in the LAA is a rare clinical entity whose origin is not known. Its clinical implication in the genesis of atrial arrhythmias and thromboembolic risk remains unknown. We report a case of an obstructive membrane located at the base of the LAA, found incidentally in a young patient who was initially undergoing a transesophageal echocardiogram prior to an invasive treatment for atrial fibrillation.

Prevalence and Burden of Carotid and Femoral Atherosclerosis in Subjects Without Known Cardiovascular Disease in a Large Community Hospital in South-America.

INTRODUCTION: Clinical guidelines recommend measurement of arterial (carotid and femoral) plaque burden by vascular ultrasound (VUS) as a risk modifier in individuals at low or moderate risk without known atherosclerotic cardiovascular disease (ASCVD). AIM: To evaluate the prevalence of carotid and femoral plaques by age and sex, the burden of subclinical atherosclerosis (SA), and its association with classic CVRF in subjects over 30 years of age without ASCVD. METHODS: We prospectively enrolled 5775 consecutive subjects referred for cardiovascular evaluation and determined the prevalence and burden of SA using 2D-VUS in carotid and femoral arteries. RESULTS: Sixty-one percent were men with a mean age of 51.3 (SD 10.6) years. Overall, plaque prevalence was 51% in carotid arteries, 39.3% in femoral arteries, 62.4% in carotid or femoral arteries, and 37.6% in neither. The prevalence of plaques and SA burden showed an increasing trend with age, being higher in men than in women and starting before the age of 40, both in the carotid and femoral sites. There was also an increasing prevalence of plaques according to the number of CVRF, and interestingly we found a high prevalence of plaques in subjects with 0 or 1 classic CVRF. CONCLUSIONS: We observed an increased prevalence and burden of carotid or femoral SA, higher in men, beginning before the fourth decade of life and increasing with age. Despite a significant association with classic CVRF, a significant number of subjects with low CVRF were diagnosed with SA.

Looking for a definition of aortic dilatation in overweight and obese individuals: body surface area-indexed values versus height-indexed diameters.

INTRODUCTION: Patient's body size is a significant determinant of aortic dimensions. Overweight and obesity underestimate aortic dilatation when indexing diameters by body surface area (BSA). We compared the indexation of aortic dimensions by height and BSA in subjects with and without overweight to determine the upper normal limit (UNL). METHODS: The MATEAR study was a prospective, observational, and multicenter study (53 echocardiography laboratories in Argentina). We included 879 healthy adult individuals (mean age: 39.7 ± 11.4 years, 399 men) without hypertension, bicuspid aortic valve, aortic aneurysm, or genetic aortopathies. Echocardiograms were acquired and proximal aorta measured at the sinus of Valsalva (SV), sinotubular junction (STJ), and ascending aorta (AA) levels (EACVI/ASE guidelines). We compared absolute and indexed aortic diameters by height and BSA between groups (men with body mass index [BMI] < 25 and BMI ≥ 25, women with BMI < 25 and BMI ≥ 25). RESULTS: Indexing of aortic diameters by BSA showed significantly lower values in overweight and obese subjects compared to normal weight in their respective gender (for women: SV 1.75 cm/m2 in BMI < 25 vs. 1.52 cm/m2 in BMI between 25 and 29.9 vs. 1.41 cm/m2 in BMI ≥ 30; at the STJ: 1.53 cm/m2 vs. 1.37 cm/m2 vs. 1.25 cm/m2; and at the AA: 1.63 cm/m2 vs. 1.50 cm/m2 vs. 1.37 cm/m2; all p < 0.0001 and for men, all p < 0.0001). These differences disappeared when indexing by height in both gender groups (all p = NS). CONCLUSION: While indexing aortic diameters by BSA in obese and overweight subjects underestimate aortic dilation, the use of aortic height index (AHI) yields a similar UNL for individuals with normal weight, overweight, and obesity. Therefore, AHI could be used regardless of their weight.

INTRODUCCIÓN: El tamaño corporal es un determinante significativo de las dimensiones aórticas. El sobrepeso lleva a subestimar la dilatación aórtica. La altura (A) permanece estable durante la adultez, por lo que sería útil para indexar diámetros aórticos en pacientes obesos, aunque desconocemos los valores normales. Comparamos la indexación de diámetros aórticos por (IA) y superficie corporal (SC) en sujetos con y sin sobrepeso para determinar el límite superior normal (LSN, P97.5). MÉTODO: Se realizó un registro nacional, prospectivo, en 53 centros de Argentina. Se realizaron ecocardiogramas a 528 sujetos con índice de masa corporal (IMC) > 25 y 351 sujetos con IMC ≤ 25 seleccionados al azar. La población se subdividió en cuatro grupos según sexo e IMC y se compararon diámetros aórticos absolutos e indexados. RESULTADOS: Se incluyeron 879 individuos (39.7 ± 11.4 años, 399 hombres). La indexación de los diámetros aórticos por SC mostró valores significativamente más bajos en sujetos con sobrepeso y obesidad en comparación con los de peso normal en cada sexo. Estas diferencias desaparecieron al indexar por altura en ambos géneros (todos p = NS). El LSN de los diámetros IA fue de 2.20 cm/m para senos, 1.99 cm/m para unión sino-tubular (UST) y 2.09 cm/m para aorta ascendente. CONCLUSIONES: La indexación de los diámetros aórticos por SC en individuos con sobrepeso y obesidad subestima la dilatación aórtica. El IA permite establecer un LSN sin tener en cuenta el aumento espurio de la SC determinado por la grasa corporal. Podría ser utilizado en ambos sexos y de manera independiente del peso.

[Bruton tyrosine kinase inhibitors. What does the oncohematologist and the cardiologist need to know?] / Inhibidores de Bruton tirosina quinasa ¿qué necesita saber el oncohematólogo y el cardiólogo?

Advances in knowledge incorporated in the last decade have modified the treatment paradigm in most of the malignant hematological diseases. In particular, the introduction of Bruton tyrosine kinase inhibitors (BTKi) and other target drugs together with new monoclonal antibodies have become agents of choice for both chronic lymphocytic leukemia (CLL) and other peripheral "B" lymphomas such as mantle cell lymphoma (MCL). The results of efficacy against genotoxic therapy are so successful that the end of chemoimmunotherapy, especially for CLL, is already a postulate recognized by the main research groups. On the other hand, the new drugs modified the profile of adverse events, which forced the development of new subspecialties such as cardio-oncology, which currently constitutes a bastion for the rational management of these patients. This review aims to highlight the current state of knowledge on these pathologies, pharmacological principles together with new adverse events of iBTK and the invaluable contribution of cardiology for correct management of these patients.

Los avances en el conocimiento incorporados en la última década han modificado en gran parte el paradigma del tratamiento de las enfermedades hematológicas malignas. Particularmente la introducción de los inhibidores de la Bruton tirosina quinasa (iBTK) y otras drogas blanco junto a nuevos anticuerpos monoclonales se han transformado en los agentes de elección, tanto para la leucemia linfática crónica (LLC) como para otros linfomas "B" periféricos como el linfoma de células del manto (LCM). Los resultados de eficacia frente a la terapia genotóxica son tan exitosos que el fin de la quimio inmunoterapia, sobre todo para la LLC, es ya un postulado reconocido por los principales grupos de investigación. Por otra parte, los nuevos fármacos modificaron el perfil de eventos adversos lo que obligó al desarrollo de nuevas subespecialidades como la cardiooncología, la cual constituye actualmente un baluarte para el manejo racional de estos pacientes. La presente revisión tiene como objetivo destacar el estado actual del conocimiento sobre estas enfermedades, los principios farmacológicos junto a los nuevos eventos adversos de los iBTK y el invalorable aporte de la cardiología para un correcto tratamiento y control de estos pacientes.

International consensus statement on the management of cardiovascular risk of Bruton's tyrosine kinase inhibitors in CLL.

Bruton's tyrosine kinase inhibitors (BTKis) have altered the treatment landscape for chronic lymphocytic leukemia (CLL) by offering effective and well-tolerated therapeutic options. However, since the approval of ibrutinib, concern has risen regarding the risk of cardiovascular (CV) adverse events, including atrial fibrillation (AF), hypertension, and heart failure. Newer BTKis appear to have lower CV risks, but data are limited. It is important to understand the risks posed by BTKis and how those risks interact with individual patients, and we convened a panel of physicians with expertise in CLL and CV toxicities in oncology to develop evidence-based consensus recommendations for community hematologists and oncologists. Care providers should thoroughly assess a patient's CV risk level before treatment initiation, including established CV diseases and risk factors, and perform investigations dependent on preexisting diseases and risk factors, including an electrocardiogram (ECG). For patients with high CV risk, BTKi treatment is often appropriate in consultation with a multidisciplinary team (MDT), and more selective BTKis, including acalabrutinib and zanubrutinib, are preferred. BTKi treatment should generally be avoided in patients with a history of heart failure. Ibrutinib should be avoided in patients with a history of ventricular arrhythmias, but the risk of newer drugs is not yet known. Finally, an MDT is crucial to help manage emerging toxicities with the goal of maintaining BTKi therapy, if possible. Optimizing heart failure, arrhythmia, and hypertension control will likely improve tolerance and maintenance of BTKi therapy. However, additional studies are needed to identify the most optimal strategy for these drugs.

[Specific pharmacological treatment guide for transthyretin amyloid cardiomyopathy, 2021]. / Guía de tratamiento farmacológico específico de la cardiomiopatía amiloidótica por transtiretina, 2021.

This clinical practice guideline for treating transthyretin amyloid (ATTR) cardiomyopathy is based on the best available evidence of clinical effectiveness. The PICO format was used to generate a list of questions focused on the effectiveness and safety of the specific treatment of patients with ATTR cardiomyopathy. The search was conducted in PubMed, Cochrane and Epistemokus, between July-August 2020, and selected articles between 2000-2020, in English and Spanish. The level of evidence and recommendations were analyzed and classified by the GRADE system. The following drugs were included in the analysis: tafamidis, diflunisal, inotersen, patisiran y doxycycline and ursodeoxycholic acid. The expert panel had an agreement that tafamidis 80mg/daily is the only available drug with moderate evidence and weak recommendation for the reduction of total mortality, cardiovascular morbidity, heart failure hospitalization and progression of the disease in patients with ATTR cardiomyopathy and NYHA class = 3. In contrast, tafamidis 20 mg/daily had low-quality evidence in this group of patients. The expert panel did not recommend inotersen, patisiran and diflunisal in patients with ATTR cardiomyopathy due to the lack of supporting evidence, local drug availability, and the potential risk of toxicity. When patients did not have access to tafamidis, the expert panel stated a weak recommendation to use doxycycline and ursodeoxycholic acid in patients with ATTR cardiomyopathy.

Con el propósito de confeccionar una guía con la mejor evidencia disponible en el tratamiento de la amiloidosis por depósito de transtiretina (ATTR), se generó un listado de preguntas en formato PICO centradas en la efectividad y seguridad y se realizó una búsqueda en PubMed, Cochrane y Epistemokus de los artículos publicados entre 2000-2020 y se incluyeron dos estudios de extensión en relación al tafamidis. Los niveles de evidencia y los grados de recomendación se basaron en el sistema GRADE, emitiéndose 11 recomendaciones para ATTRv y ATTwt. Se consideraron los siguientes fármacos: tafamidis, diflunisal, inotersen, patisiran y doxiciclina más ácido ursodesoxicolico. El grupo de expertos consensuó que el único tratamiento que demostró reducir de la mortalidad global, mortalidad cardiovascular, internaciones cardiovasculares y la progresión de la cardiopatía con un nivel moderado de evidencia fue el tafamidis 80 mg, mientras que para la formulación tafamidis 20 mg la calidad de evidencia es baja. Para inotersen y diflunisal, se formuló una recomendación en contra del tratamiento dada la falta de evidencia de calidad respecto a su efectividad, el perfil de toxicidad y la falta de disponibilidad en el ámbito local. Con respecto al patisirán, la recomendación se focalizó en la población ATTRv. El panel de expertos consensuó que el tratamiento con doxiciclina más ácido ursodeoxicólico podría ser utilizado ante la imposibilidad de iniciar tratamiento con tafamidis, recomendación débil y calidad de evidencia muy baja.

Clinical value of the tissue Doppler s wave to characterize left ventricular hypertrophy as defined by echocardiography.

UNLABELLED: Left ventricular hypertrophy (LVH) may be a physiological finding and may also be associated with different disease entities and hence, with different outcomes. Regional myocardial function can be assessed with color Doppler tissue imaging, specifically by the waveform of the isovolumic contraction (IC) period and the regional systolic wave ("s"). METHODS AND RESULTS: We studied five groups (G): healthy, sedentary young volunteers (G1, n:10); healthy sedentary adult volunteers (G2, n:8); and subjects with LVH (left ventricular mass index >125 g/m(2)) including: high performance athletes (G3, n:21), subjects with hypertension (G4, n:21), subjects with hypertrophic cardiomyopathy (HCM) (G5, n:18). We measured peak "s" wave velocity (cm/sec) at the basal and mid septum, the IC/s ratio, and basal to mid-septal velocity difference (BMVD) of the "s" wave. Regional "s" wave values (cm/sec) were G1 = 5.6 +/- 1; G2 = 5.4 +/- 0.8; G3 = 5.7 +/- 0.6; G4 = 5.3 +/- 1.1; G5 = 4.2 +/- 1.1 (P < 0.0001). The IC/s ratio was G1 = 0.28 +/- 0.18; G2 = 0.39 +/- 0.21; G3 = 0.23 +/- 0.10; G4 = 0.42 +/- 0.15; G5 = 0.64 +/- 0.15 (P < 0.0001). The BMVD (cm/sec) was G1 = 2 +/- 0.51; G2 = 1.71 +/- 0.29; G3 = 1.78 +/- 0.44; G4 = 1.26 +/- 0.96; G5 = 0.45 +/- 0.4 (P < 0.0001). IC/s < 0.38 discriminated physiological from pathological forms of hypertrophy (sensitivity 90%; specificity 88%). Peak "s" wave velocity discriminated HCM from other causes of hypertrophy, with a cutoff value of 4.46 cm/sec (sensitivity 72%; specificity 90%). BMVD <0.98 cm/sec detected HCM with 89% sensitivity and 86% specificity. CONCLUSIONS: Peak "s" wave velocity and two indices: IC/s and BMDV are novel parameters that may allow to discriminate physiological from pathological forms of hypertrophy as well as different subtypes of hypertrophy.

Septal myectomy and mitral plication through a transaortic approach.

Currently, the gold standard treatment for hypertrophic cardiomyopathy in its obstructive variant is a wide septal myectomy through a transaortic approach. In some cases, where mitral regurgitation is added to septal hypertrophy due to systolic anterior movement of the anterior leaflet, concomitant procedures are proposed for the resolution of both. In this tutorial, we present a case of hypertrophic cardiomyopathy with associated systolic anterior movement that was resolved with septal resection and plication of the anterior leaflet of the mitral valve via a transaortic approach.

¿Tienen los pacientes con tromboembolismo pulmonar agudo y un puntaje PESI (Índice de Severidad del Embolismo Pulmonar) intermedio o alto, asociado a cáncer activo, un mayor riesgo de presentar una evolución desfavorable respecto de aquellos sin cáncer? / Do Patients with Acute Pulmonary Embolism and an Intermediate or High PESI (Pulmonary Embolism Severity Index) Score Associated with Active Cancer Have Higher Risk of an Unfavorable Progression Versus Those Without Cancer?

RESUMEN Introducción: El Índice de Severidad del Embolismo Pulmonar (PESI) se utiliza para categorizar el riesgo de mortalidad en el tromboembolismo pulmonar agudo (TEP). Por definición, los pacientes con cáncer siempre presentarán un puntaje PESI simplificado alto y serán considerados de mayor riesgo. Existe información limitada respecto de si los pacientes con PESI intermedio o alto (≥86 puntos) y cáncer activo, tienen mayor riesgo de presentar una evolución desfavorable respecto de aquellos sin cáncer. Objetivos: Determinar si, en pacientes con TEP y un puntaje PESI ≥86 puntos, la presencia de cáncer activo se asocia a una evolución desfavorable respecto de aquellos sin cáncer. Material y métodos: Análisis retrospectivo en pacientes con TEP y un puntaje PESI ≥86, entre los años 2008 y 2022. Se evaluó la ocurrencia de muerte intrahospitalaria (MIH), uso de drogas vasopresoras (DV) y necesidad de asistencia respiratoria mecánica (ARM) en los pacientes con vs. sin cáncer. Resultados: Se analizaron 209 pacientes. La población con cáncer, respecto de aquella sin cáncer, resultó ser más joven (65 vs. 70 años; p=0,006), presentó valores de PESI simplificado altos con mayor frecuencia (100 % vs. 84 %; p<0,001), tuvo menor requerimiento de ARM (9 % vs. 34 %; p=0,005) y menor uso de DV (11 % vs. 23 %; p=0,019), aunque no se observaron dife rencias en las tasas de MIH (12,7 % vs. 8 %; p=NS). Conclusiones: Los pacientes con TEP y un puntaje PESI ≥86 con cáncer no presentaron mayor MIH e incluso tuvieron menor requerimiento de ARM y DV. En la población estudiada, los pacientes con TEP y cáncer no tuvieron mayor riesgo de presentar una evolución desfavorable.

ABSTRACT Background: The Pulmonary Embolism Severity Index (PESI) is used to categorize the risk of death in acute pulmonary em bolism (PE). By definition, cancer patients will always have a high simplified PESI score and will be considered at high risk. There is limited information regarding whether patients with an intermediate or high PESI score (≥86 points) and cancer are at greater risk of an unfavorable progression versus those without cancer. Objectives: To determine whether the presence of active cancer in patients with a PESI score ≥86 points is associated with an unfavorable progression versus those without cancer. Methods: A retrospective analysis in patients with PE and a PESI score ≥86, between 2008 and 2022. The occurrence of in-hospital mortality (IHM) the use of vasopressor drugs (VDs), and the need for mechanical ventilatory support (MVS) were evaluated in patients with vs. without cancer. Results: 209 patients were analyzed. The population with cancer was younger than patients without cancer (65 vs 70 years; p=0.006), showed high simplified PESI values more frequently (100% vs 84%; p<0.001), had lower MVS requirement (9% vs 34%; p=0.005), and used fewer VDs (11% vs 23%; p=0.019). However, no difference was observed in IHM rates (12.7% vs 8%; p=NS). Conclusions: Patients with PE and a PESI score ≥86 who have cancer did not show higher IHM and also had lower MVS and VDs requirement. Therefore, in the studied population, patients with PE and cancer had no greater risk of having an unfavorable progression.

Alta temprana en infarto agudo de miocardio con elevación del segmento ST tratado con angioplastia primaria: estudio de intervención no controlado en Argentina / Early Discharge in Acute ST-segment Elevation Myocardial Infarction Treated with Primary Angioplasty: Uncontrolled Intervention Study in Argentina

RESUMEN Introducción y objetivos: El alta hospitalaria temprana (dentro de las primeras 48 horas) en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) tratados con angioplastia coronaria primaria con stent (ATCp) ha sido adoptada en países desarrollados. Sin embargo, su implementación en Sudamérica ha sido dispar. Material y métodos: Estudio piloto de intervención no controlado, argentino, de pacientes con IAMCEST de bajo riesgo tratados con ATCp, para evaluar tasa de alta temprana y comparar la incidencia de eventos cardiovasculares adversos mayores (MACE) con la que ocurre en pacientes externados en forma no temprana. Resultados: Desde 2013 hasta 2021 se trataron con ATCp 320 pacientes con IAMCEST, de los que 158 fueron de bajo riesgo. Alta temprana en 63,9% (IC 95% 55,9-71,4%). La diabetes (OR 0,31; IC 95% 0,12-0,83) y el IAMCEST anterior (OR 0,34; IC 95% 0,16-0,69) se asociaron en forma independiente con menor probabilidad de alta temprana. Durante una mediana de seguimiento de 27,2 meses, la razón de tasas de incidencia de MACE entre los grupos de alta temprana y no temprana fue de 0,77 (IC 95 % 0,25-2,58; p = 0,61). Las variables asociadas de forma independiente con MACE fueron la revascularización completa (HR 0,18; IC 95% 0,03-0,95) y el tiempo de fluoroscopía (HR 1,02; IC 95% 1,01-1,05). No hubo diferencias significativas en las complicaciones del acceso vascular, las tasas de reingreso a 30 días y sobrevida global entre los grupos. Conclusiones: El alta temprana en pacientes con IAMCEST de bajo riesgo tratados con ATCp puede ser factible incluso en países en desarrollo, sin aumento significativo de la morbimortalidad.

ABSTRACT Background and objectives: Early discharge (within the first 48 hours) in patients with ST-segment elevation myocardial infarction (STEMI) managed with primary percutaneous coronary intervention (PCI) with stenting is a strategy that has been adopted in developed countries. However, its implementation in South America has been uneven. Methods: We conducted an uncontrolled intervention pilot study on low-risk STEMI patients managed with primary PCI to evaluate the early discharge rate and compare the incidence of major adverse cardiovascular events (MACE) with those occurring in patients discharged later. Results: Of 320 STEMI patients managed with primary PCI from 2013 to 2021, 158 were low-risk patients and 63.9% (95% CI 55.9-71,4%) of them were discharged early. Diabetes (OR 0.31, 95% CI 0.12-0.83), and anterior wall STEMI (OR 0.34, 95% CI 0.16-0.69) were independently associated with lower probability of early discharge. During a median follow-up period of 27.2 months, the incidence rate ratio of MACE between the early discharge and non-early discharge groups was 0.77 (95% CI 0.25-2.58; p = 0.61). The variables independently associated with MACE were complete revascularization (HR 0.18, 95% CI 0.03-0.95) and fluoroscopy time (HR 1.02, 95% CI 1.01-1.05). There were no significant differences in vascular access complications, 30-day readmission rate and overall survival between groups. Conclusions: Early discharge in low-risk STEMI patients managed with primary PCI may be feasible even in developing countries, without significantly increasing morbidity and mortality.

Looking for a definition of aortic dilatation in overweight and obese individuals: body surface area-indexed values versus height-indexed diameters / En búsqueda de la definición de dilatación aórtica en individuos con sobrepeso y obesidad: rol de la indexación por altura. Análisis del Registro MATEAR

Abstract Introduction: Patient's body size is a significant determinant of aortic dimensions. Overweight and obesity underestimate aortic dilatation when indexing diameters by body surface area (BSA). We compared the indexation of aortic dimensions by height and BSA in subjects with and without overweight to determine the upper normal limit (UNL). Methods: The MATEAR study was a prospective, observational, and multicenter study (53 echocardiography laboratories in Argentina). We included 879 healthy adult individuals (mean age: 39.7 ± 11.4 years, 399 men) without hypertension, bicuspid aortic valve, aortic aneurysm, or genetic aortopathies. Echocardiograms were acquired and proximal aorta measured at the sinus of Valsalva (SV), sinotubular junction (STJ), and ascending aorta (AA) levels (EACVI/ASE guidelines). We compared absolute and indexed aortic diameters by height and BSA between groups (men with body mass index [BMI] < 25 and BMI ≥ 25, women with BMI < 25 and BMI ≥ 25). Results: Indexing of aortic diameters by BSA showed significantly lower values in overweight and obese subjects compared to normal weight in their respective gender (for women: SV 1.75 cm/m2 in BMI < 25 vs. 1.52 cm/m2 in BMI between 25 and 29.9 vs. 1.41 cm/m2 in BMI ≥ 30; at the STJ: 1.53 cm/m2 vs. 1.37 cm/m2 vs. 1.25 cm/m2; and at the AA: 1.63 cm/m2 vs. 1.50 cm/m2 vs. 1.37 cm/m2; all p < 0.0001 and for men, all p < 0.0001). These differences disappeared when indexing by height in both gender groups (all p = NS). Conclusion: While indexing aortic diameters by BSA in obese and overweight subjects underestimate aortic dilation, the use of aortic height index (AHI) yields a similar UNL for individuals with normal weight, overweight, and obesity. Therefore, AHI could be used regardless of their weight.

Resumen Introducción: El tamaño corporal es un determinante significativo de las dimensiones aórticas. El sobrepeso lleva a subestimar la dilatación aórtica. La altura (A) permanece estable durante la adultez, por lo que sería útil para indexar diámetros aórticos en pacientes obesos, aunque desconocemos los valores normales. Comparamos la indexación de diámetros aórticos por (IA) y superficie corporal (SC) en sujetos con y sin sobrepeso para determinar el límite superior normal (LSN, P97.5). Método: Se realizó un registro nacional, prospectivo, en 53 centros de Argentina. Se realizaron ecocardiogramas a 528 sujetos con índice de masa corporal (IMC) > 25 y 351 sujetos con IMC ≤ 25 seleccionados al azar. La población se subdividió en cuatro grupos según sexo e IMC y se compararon diámetros aórticos absolutos e indexados. Resultados: Se incluyeron 879 individuos (39.7 ± 11.4 años, 399 hombres). La indexación de los diámetros aórticos por SC mostró valores significativamente más bajos en sujetos con sobrepeso y obesidad en comparación con los de peso normal en cada sexo. Estas diferencias desaparecieron al indexar por altura en ambos géneros (todos p = NS). El LSN de los diámetros IA fue de 2.20 cm/m para senos, 1.99 cm/m para unión sino-tubular (UST) y 2.09 cm/m para aorta ascendente. Conclusiones: La indexación de los diámetros aórticos por SC en individuos con sobrepeso y obesidad subestima la dilatación aórtica. El IA permite establecer un LSN sin tener en cuenta el aumento espurio de la SC determinado por la grasa corporal. Podría ser utilizado en ambos sexos y de manera independiente del peso.

Validity, reliability, feasibility and satisfaction of the Mini-Clinical Evaluation Exercise (Mini-CEX) for cardiology residency training.

AIMS: The purpose of the study was to determine the validity, reliability, feasibility and satisfaction of the Mini-CEX. METHODS AND RESULTS: From May 2003 to December 2004, 108 residents from 17 cardiology residency programs in Buenos Aires were monitored by the educational board of the Argentine Society of Cardiology. Validity was evaluated by the instrument's capability to discriminate between pre-existing levels of clinical seniority. For reliability, generalisability theory was used. Feasibility was defined by a minimum number of completed observations: 50% of the residents obtaining at least four Mini-CEX's. Satisfaction was evaluated through a one to nine rating scale from the evaluators, and residents' perspectives. The total number of encounters was 253. Regarding validity, Mini-CEX was able to discriminate significantly between residents of different seniority. Reliability analysis indicated that a minimum of ten evaluations are necessary to produce a minimally reliable inference, but more are preferable. Feasibility was poor: 15% of the residents were evaluated four or more times during the study period. High satisfaction ratings from evaluators' and residents' were achieved. CONCLUSION: Mini-CEX discriminates between pre-existing levels of seniority, requires considerable sampling to achieve sufficient reliability, and was not feasible within the current circumstances, but it was considered a valuable assessment tool as indicated by the evaluators' and residents' satisfaction ratings.

Inhibidores de bruton tirosina quinasa. ¿Qué necesita saber el oncohematólogo y el cardiólogo? / Bruton tyrosine kinase inhibitors. What does the oncohematologist and the cardiologist need to know?

Resumen Los avances en el conocimiento incorporados en la última década han modificado en gran parte el paradigma del tratamiento de las enfermedades hematológicas malignas. Particularmente la intro ducción de los inhibidores de la Bruton tirosina quinasa (iBTK) y otras drogas blanco junto a nuevos anticuerpos monoclonales se han transformado en los agentes de elección, tanto para la leucemia linfática crónica (LLC) como para otros linfomas "B" periféricos como el linfoma de células del manto (LCM). Los resultados de eficacia frente a la terapia genotóxica son tan exitosos que el fin de la quimio inmunoterapia, sobre todo para la LLC, es ya un postulado reconocido por los principales grupos de investigación. Por otra parte, los nuevos fármacos modificaron el perfil de eventos adversos lo que obligó al desarrollo de nuevas subespecialidades como la cardio-oncología, la cual constituye actualmente un baluarte para el manejo racional de estos pacientes. La presente revisión tiene como objetivo destacar el estado actual del conocimiento sobre estas enfermedades, los principios farmacológicos junto a los nuevos eventos adversos de los iBTK y el invalorable aporte de la cardiología para un correcto tratamiento y control de estos pacientes.

Abstract Advances in knowledge incorporated in the last decade have modified the treatment paradigm in most of the malignant hematological diseases. In particular, the introduction of Bruton tyrosine kinase inhibitors (BTKi) and other target drugs together with new monoclonal antibodies have become agents of choice for both chronic lym phocytic leukemia (CLL) and other peripheral "B" lymphomas such as mantle cell lymphoma (MCL). The results of efficacy against genotoxic therapy are so successful that the end of chemoimmunotherapy, especially for CLL, is already a postulate recognized by the main research groups. On the other hand, the new drugs modified the profile of adverse events, which forced the development of new subspecialties such as cardio-oncology, which currently constitutes a bastion for the rational management of these patients. This review aims to highlight the current state of knowledge on these pathologies, pharmacological principles together with new adverse events of iBTK and the invaluable contribution of cardiology for correct management of these patients.

Resultados a largo plazo de la cirugía de revascularización coronaria según la presencia o no de enfermedad del tronco de la arteria coronaria izquierda / Long-term Outcomes of Coronary Artery Bypass Surgery According to the Presence or Absence of Left Main Coronary Artery Disease

RESUMEN Introducción: La cirugía de revascularización miocárdica (CRM) ha modificado la evolución natural de los pacientes con enfermedad de tronco de la arteria coronaria izquierda (TCI). En nuestro medio es escasa la información relacionada con el seguimiento a mediano y largo plazo de los pacientes intervenidos. Objetivo: Evaluar la implicancia de la enfermedad del TCI en la evolución alejada de los pacientes intervenidos con CRM, y conocer la mortalidad e incidencia de infarto de miocardio (IAM) y/o accidente cerebrovascular (ACV). Resultados: El seguimiento se completó en 438 pacientes (95,6%) con una mediana de 58 meses [Rango intercuartilo (RIC) 35-88 meses]. La sobrevida actuarial fue a 10 años del 91,8% para toda la población, sin diferencias significativas entre el grupo TCI (91,57%) vs. el grupo no TCI (91,86%), HR 1,008, IC95% 0,38-2,65, p=0,98. En el análisis multivariado se encontraron como predictores de mortalidad alejada la fracción de eyección ventricular izquierda preoperatoria (HR 0,95, IC 95% 0,93-0,97, p<0,001), la edad (HR 1,1, IC 95% 1,04-1,13, p< 0,001) y la prioridad no electiva de la cirugía (HR = 3,71; IC 95%: 1,3-10,35; p = 0,01). La sobrevida libre de IAM fue del 96,8% (TCI 94% vs. no TCI 97,4%, p= 0,8) y la libertad de ACV fue del 98% (TCI 97,8% vs. no TCI 98,1%, p= 0,8). Conclusión: En los pacientes sometidos a CRM, la presencia de enfermedad del TCI no incrementó la tasa de eventos duros (muerte, IAM y ACV) en el seguimiento alejado. Los resultados obtenidos en esta serie de pacientes son similares a los publicados en la bibliografía internacional utilizada para desarrollar las guías de revascularización miocárdica.

ABSTRACT Background: Coronary artery bypass grafting (CABG) has modified the natural evolution of patients with left main coronary artery (LMCA) disease. There is little information in our setting regarding the mid- and long-term follow-up of operated patients. Objective: The aim of this study was to evaluate the implication of LMCA disease in the long-term evolution of patients operated on with CABG, and to assess the mortality and incidence of myocardial infarction (AMI) and/or stroke. Results: Follow-up was completed in 438 patients (95.6%) with a median of 58 months [interquartile range (IQR) 35-88 months]. Actuarial survival at 10 years was 91.8% for the entire population, with no significant differences between the LMCA group (91.57%) vs. the non-LMCA group (91.86%), HR 1,008 95% CI 0.38-2.65, p=0.98. In multivariate analysis, preoperative left ventricular ejection fraction (HR = 0.95; 95% CI 0.93-0.97; p < 0.001), age (HR 1.1, 95% CI 1.04-1.13, p<0.001) and non-elective priority of surgery (HR=3.71; 95% CI 1.3-10.35; p=0.01) were independent predictors of long-term mortality. AMI-free survival was 96.8% (LMCA 94% vs. non-LMCA 97.4%, p=0.8) and freedom from stroke was 98% (LMCA 97.8% vs. non-LMCA 98.1 %, p=0.8). Conclusion: In patients undergoing CABG, the presence of LMCA disease did not increase the rate of hard events (death, AMI, and stroke) at the long-term follow-up. The results obtained in this series of patients are similar to those published in the international literature used to develop myocardial revascularization guidelines.

Guía de tratamiento farmacológico específico de la cardiomiopatía amiloidótica por transtiretina, 2021 / Specific pharmacological treatment guide for transthyretin amyloid cardiomyopathy, 2021

Resumen Con el propósito de confeccionar una guía con la mejor evidencia disponible en el tratamiento de la amiloidosis por depósito de transtiretina (ATTR), se generó un listado de preguntas en formato PICO centradas en la efectividad y seguridad y se realizó una búsqueda en PubMed, Cochrane y Epistemokus de los artículos publicados entre 2000-2020 y se incluyeron dos estudios de extensión en relación al tafamidis. Los niveles de evidencia y los grados de recomendación se basaron en el sistema GRADE, emitiéndose 11 recomendaciones para ATTRv y ATTwt. Se consideraron los siguientes fármacos: tafamidis, diflunisal, inotersen, patisiran y doxiciclina más ácido ursodesoxicolico. El grupo de expertos consensuó que el único tratamiento que demostró reducir de la mortalidad global, mortalidad cardiovascular, internaciones cardiovasculares y la progresión de la cardiopatía con un nivel moderado de evidencia fue el tafamidis 80 mg, mientras que para la formulación tafamidis 20 mg la calidad de evidencia es baja. Para inotersen y diflunisal, se formuló una recomendación en contra del tratamiento dada la falta de evidencia de calidad respecto a su efectividad, el perfil de toxicidad y la falta de disponibilidad en el ámbito local. Con respecto al patisirán, la recomendación se focalizó en la población ATTRv. El panel de expertos consensuó que el tratamiento con doxiciclina más ácido ursodeoxicólico podría ser utilizado ante la imposibilidad de iniciar tratamiento con tafamidis, recomendación débil y calidad de evidencia muy baja.

Abstract This clinical practice guideline for treating transthyretin amyloid (ATTR) cardiomyopathy is based on the best available evidence of clinical effectiveness. The PICO format was used to generate a list of ques tions focused on the effectiveness and safety of the specific treatment of patients with ATTR cardiomyopathy. The search was conducted in PubMed, Cochrane and Epistemokus, between July-August 2020, and selected articles between 2000-2020, in English and Spanish. The level of evidence and recommendations were analyzed and classified by the GRADE system. The following drugs were included in the analysis: tafamidis, diflunisal, inotersen, patisiran y doxycycline and ursodeoxycholic acid. The expert panel had an agreement that tafamidis 80mg/daily is the only available drug with moderate evidence and weak recommendation for the reduction of total mortality, cardiovascular morbidity, heart failure hospitalization and progression of the disease in patients with ATTR cardiomyopathy and NYHA class ≤ 3. In contrast, tafamidis 20 mg/daily had low-quality evidence in this group of patients. The expert panel did not recommend inotersen, patisiran and diflunisal in patients with ATTR cardiomyopathy due to the lack of supporting evidence, local drug availability, and the potential risk of toxicity. When patients did not have access to tafamidis, the expert panel stated a weak recommendation to use doxycycline and ursodeoxycholic acid in patients with ATTR cardiomyopathy.

Rol de los péptidos natriuréticos en insuficiencia cardíaca: El fino equilibrio entre la medicina de precisión y la optimización de los recursos

La insuficiencia cardíaca constituye la fase final de la mayoría de las patologías cardiovasculares. Si bien el interrogatorio, el conocimiento de los antecedentes personales y familiares del paciente, sumados al examen físico detallado, contribuyen en sobremanera al diagnóstico; muchas veces el diagnóstico diferencial del síndrome de insuficiencia cardíaca no nos permite diferenciar entre los cuadros compensados de aquellos portadores de insuficiencia cardíaca en las primeras fases de la descompensación o nos llevan a la duda entre diagnósticos diferenciales. La falta de disponibilidad de camas de hospitalización, problemas de cobertura médica o incluso problemas sociales o psicológicos, obligan muchas veces a la determinación de altas precoces con el riesgo presente de descompensaciones e internaciones reiteradas. Evitar descompensaciones frecuentes es el trabajo silencioso que debe realizar el médico para tratar de detectar precozmente con la finalidad de enlentecer o detener el progreso de la enfermedad cardiovascular, evitando estudios e internaciones costosas. Entre el armamento necesario para cumplir con esta finalidad se encuentra el dosaje de péptidos natriuréticos. La presente revisión trata de resumir los datos disponibles que valoran el control de los niveles de péptidos natriuréticos en nuestra asistencia de los pacientes con insuficiencia cardíaca.

Heart failure constitutes the final stage of most cardiovascular diseases. Although the questioning, the knowledge of the patient s personal and family history, added to the detailed physical examination, greatly contribute to the diagnosis; Many times the differential diagnosis of heart failure syndrome does not allow us to differentiate between the compensated conditions of those with heart failure in the early stages of decompensation or leads us to doubt between differential diagnoses. The lack of availability of hospital beds, problems of medical coverage or even social or psychological problems, often force the determination of early discharges with the present risk of decompensation and repeated hospitalizations. Avoiding frequent decompensations is the silent work that the physician must do to try to detect it early in order to slow down or stop the progress of cardiovascular disease, avoiding expensive studies and hospitalizations. Among the weapons necessary to fulfill this purpose is the dosage of natriuretic peptides. This review attempts to summarize the available data that assess the control of natriuretic peptide levels in our care of patients with heart failure.

A insuficiência cardíaca constitui o estágio final da maioria das doenças cardiovasculares. Apesar do questionamento, o conhecimento da história pessoal e familiar do paciente, somado ao exame físico detalhado, contribuem muito para o diagnóstico; Muitas vezes, o diagnóstico diferencial da síndrome da insuficiência cardíaca não nos permite diferenciar as condições compensadas dos portadores de insuficiência cardíaca nos estágios iniciais de descompensação ou nos leva à dúvida entre os diagnósticos diferenciais. A falta de disponibilidade de leitos hospitalares, problemas de cobertura médica ou mesmo problemas sociais ou psicológicos, muitas vezes obrigam à determinação de altas precoces com o risco atual de descompensação e hospitalizações repetidas. Evitar descompensações frequentes é o trabalho silencioso que o médico deve fazer para tentar detectá-la precocemente, a fim de retardar ou interromper o progresso das doenças cardiovasculares, evitando estudos e internações dispendiosas. Entre as armas necessárias para cumprir esse propósito está a dosagem de peptídeos natriuréticos. Esta revisão tenta resumir os dados disponíveis que avaliam o controle dos níveis de peptídeo natriurético em nosso tratamento de pacientes com insuficiência cardíaca.