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RESUMEN Los pacientes que presentan síndrome coronario agudo se benefician de la utilización de antiagregantes plaquetarios para reducir la recurrencia de eventos isquémicos. Durante mucho tiempo estuvimos acostumbrados a indicar una combinación fija de aspirina más un inhibidor del receptor P2Y12 por un tiempo estricto. Sin embargo, la complejidad de los pacientes y de los procedimientos que en ellos se realizan nos obligan, como médicos, a buscar las mejores combinaciones posibles, tanto en lo referido al tipo de fármacos utilizados como a la duración del tratamiento, con el fin de lograr el mejor equilibrio entre protección isquémica y riesgo hemorrágico. En los últimos años, múltiples estudios llevados a cabo en esta línea han mostrado que diferentes estrategias pueden beneficiar a nuestros pacientes en distintos escenarios. En la siguiente revisión brindamos una descripción general de los conocimientos actuales sobre el tratamiento con antiagregantes plaquetarios, junto con algunas sugerencias sobre su manejo. ABSTRACT Patients with acute coronary syndrome benefit from the use of antiplatelet agents to reduce the recurrence of ischemic events. For a long time, we have been used to indicating a fixed combination of aspirin plus a P2Y12 receptor inhibitor during a strict period of time. However, the complexity of patients and procedures force us, as physicians, to seek the best possible combinations, both of the type of drugs used as treatment duration, in order to achieve the best balance between ischemic protection and bleeding risk. In recent years, numerous studies carried out in this regard have shown that different strategies may benefit our patients in different settings. In the following review we provide an overview of the current knowledge about antiplatelet therapies, along with some suggestions on their management.

espanolIntroduccion: La insuficiencia cardiaca aguda es una problematica epidemiologica actual, en correlacion con el incremento dela edad poblacional y la mayor sobrevida de los pacientes con enfermedades cardiovasculares.Objetivos: Evaluar el perfil clinico, las estrategias diagnosticas y terapeuticas y las complicaciones durante la internacion yel seguimiento a 30 dias del registro ARGEN-IC.Materiales y Metodos: Se efectuo un estudio prospectivo multicentrico nacional, basado en los datos suministrados por 50instituciones de salud (periodo: agosto 2018 a marzo 2019) referidos a pacientes con diagnostico primario de insuficienciacardiaca aguda, con un seguimiento de 12 meses.Resultados: Se incluyeron los datos de 909 pacientes aportados por 74 investigadores de 18 provincias. La media y el desvioestandar de la edad de los pacientes fue 72,2 (+-14) anos y el 60,5% era de sexo masculino. Entre las caracteristicas basales deesta cohorte, se destacaron las siguientes (prevalencia): diabetes (33%); IAM previo (17%); fibrilacion auricular (31%); coberturamedica de prepagas (38%). Entre los factores desencadenantes, predominaron las causas desconocidas (28.5%), seguidas de lasinfecciosas (15,7%) y de transgresion alimentaria (13,5%). Se destaca la etiologia isquemico-necrotica (26%), la presentacioncomo congestion mixta (48%) y el grupo con fraccion de eyeccion (Fey) deteriorada EnglishIntroduction: Acute Heart Failure is currently an epidemiological problem, with a close correlation with the increase in thepopulation age and the greater survival of patients with cardiovascular diseases.Objectives: Evaluate the clinical profile, the diagnostic and therapeutic strategies and the complications during hospitalizationand the 12-month follow up of the ARGEN IC Registry.Materials and Methods: It’s a prospective, multicenter, national Registry which included 50 health centers (August 2018-March 2019) and included patients with a confirmed diagnosis of acute heart failure with a 12-month follow-up.Results: A total of 909 patients were included, corresponding to 18 provinces and 73 active researchers. The mean age was 72.2(SD 14) years, 60.5% of the patients were males. Baseline characteristics include a prevalence of diabetes of 33%, previousAMI 17%, and Atrial Fibrillation 31% and a predominant private security medical coverage (38%) Among the trigger factorsof decompensation, 28.5% were associated with unknown causes, 15.7% infectious causes, and 13.5% with food transgression.The ischemic-necrotic etiology (26%), the presentation as mixed congestion (48%) and the impaired ejection fraction (EF)group stand out. 77.6% of the patients were admitted to the critical care unit, with a median overall hospital stay of 8 daysand overall mortality of 7.9%. The pharmacological treatment at discharge, including the group with reduced EF: Beta Blockers(BB) 78.7%, ACEI, ARA II or ARNI 70.9% and anti aldosteronic 56.3% and the referral to cardiovascular rehabilitationin 17%. The 30-day follow-up showed a rehopitalization rate of 16.7%, mortality of 5.5% and combined events of 18%. Only47% accessed the medical consultation.Conclusions: The ARGEN-IC Registry represents a heterogeneous population, with high middle ages and comorbidities. Thediagnostic and therapeutic strategies are underutilized during hospitalization and in the first 30 days, with poor access tothe health system. The overall combined rate of in-hospital events and at 30 days remains high.

Background : The aim of the clinical practice guidelines (CPGs) in the management of difficult airway is to provide optimal responses to a potentially life-threatening clinical problem.Objective : to summarize and compare relevant recommendations and algorithms from evidence-based CPGs (EB-CPGs).Methods : We conducted a systematic review (overview) of CPGs, following Cochrane methods. We summarized recommendations, its supporting evidence and strength of recommendations according to the GRADE methodology. In July 2018, we searched CPGs that were published in the last 10 years, without language restrictions, in electronic databases, and searched specific CPG sources, reference lists and consulted experts. We searched PubMed, EMBASE, Cochrane Library, LILACS, Tripdatabase and additional sources. Pairs of independent reviewers selected EB-CPGs and rated their methodological quality using the AGREE-II instrument. We included those EB-CPGs reporting standard methods for identification, data collection, study risk of bias assessment and recommendations’ level of evidence. Discrepancies were solved by consensus.Results: We included 11 EB-CPGs out of 2505 references identified in literature searches within the last ten years. Only three of them used the GRADE system. The domains with better performance in the AGREE-II assessment, were ‘adequate description of scoping’ and ‘objectives’ while those with worst performance were ‘‘Guidelines’ applicability’ and ‘monitoring’. As a result, only three EB-CPGs were classified as ‘Highly recommended, two as ‘Recommended’ and six as ‘Not recommended. We summarized 22 diagnostic recommendations, 22% of which were supported by high/moderate quality of evidence (41% of them were considered by developers as strong recommendations), and 16 therapeutic/preventive recommendations, 59% of which were supported by high/moderate quality of evidence (76% strong). Only half of the EB-CPGs were updated in the past five years.Conclusions : The main EB-CPGs in the management of difficult airway in anesthesia presented significant heterogeneity in terms of their quality and system of grading the evidence and strength of recommendation used, and most used their own systems. We present many strong recommendations that are ready to be considered for implementation, and we reveal opportunities to improve guidelines’ quality.

To evaluate the predictive value of a bedside index in hospitalized patients with acute coronary syndromes (ACS).We studied the association of leuko-platelet index (LPI: platelet count * leukocyte count/10In the derivation cohort we included 1100 patients with non STEM-ACS, GRACE score of 133 ± 52, Crusade score 24,3 ± 14, 66% male, 65 + 11 years. LPI was 17 (12-24). LPI was higher (19 (13-25)) in patients with MI than in patients with unstable angina (16 (12-22) in (p 0.001)). A total of 115 patients (10.5%) had the CEP. CEP was associated to LPI (OR 1.04 (1.002-1.08), p = 0.03), age (OR 1.01 (0.97-1.05), p = 0.62) and GRACE140 (OR 8.1 (2.2-29), p = 0.02). LPI (OR 1.04 (1.004-1.07) p = 0.03) and GRACE score (OR 1.02 (1.01-1.03) p 0.01) were associated to cardiovascular mortality. We confirmed these results in the validation cohort #1 (686 patients, 61 + 11 years old, 47% nonST-ACS, 53% ST-ACS, 21% had CEP) and in validation cohort #2 (218 patients, 56.8% males, 73 + 7 years old, 79% nonST-ACS, GRACE score 136 + 30) and 8.3% with CEP. We used the cutoff points of LPI obtained in the derivation cohort (24).LPI 24 was associated to CEP (OR (1.7-5.2), p 0.01), independently of age (OR 1 (0.98-1.02), p = 0.8), and GRACE score (OR 1.01 (0.99-1.01), p 0.69), and It was associated to antiplatelet resistance (OR 1.03 (95% CI 1.00-1.06) p = 0.05).

One in every four coronarographies performed to study myocardial ischemia shows coronary angiographic stenosis less than 50%. This data triggered an increasing interest in the medical community. The American Society of Cardiology recently published a position paper about the pathophysiology, diagnosis and treatment of this entity. Our group performed a narrative review reflecting the opinion of cardiology experts from different centers in Argentina. It aims physiopatologic and diagnostic aspect to understand the current approach in patients with MINOCA (myocardial infarction with non-obstructive coronary arteries) e INOCA (demonstrated angina and ischemia but without coronary lesions that justify this syndrome).Una de cada 4 coronariografías realizadas por isquemia miocárdica presenta lesiones menores al 50% Este dato desencadenó un creciente interés en la comunidad médica. La Sociedad Americana de Cardiología publicó recientemente un artículo que describe la posición consensuada de un grupo de expertos sobre la fisiopatología, el diagnóstico y el tratamiento de esta entidad. Nuestro trabajo refleja una revisión narrativa y la posición de un grupo de expertos pertenecientes a diferentes instituciones con servicios de Cardiología jerarquizados. Aborda aspectos fisiopatológicos y diagnósticos para comprender el enfoque actual del tratamiento, tanto en pacientes que ingresan con diagnóstico de MINOCA (infa rto de miocardio con lesiones angiográficas no graves) o de INOCA (angina e isquemia demostradas, pero sin lesiones coronarias que justifiquen este síndrome).

Our objective was to evaluate clinical characteristics, results and morbi-mortality in primary angioplasty (PA), of patients treated with PA within 36 hours of a myocardial infarction (MI), included in a prospective, transversal, multicenter and national survey (ARGEN-IAM-ST). A total of 1142 patients treated with PA were registered, 61.2 ± 12 years old, 88% male, 20% diabetics and 58% with hypertension; 77.6% in Killip Kimball I and 6.2% in cardiogenic shock. The time from the onset of pain until admission was 153 (75-316) minutes, and door-balloon of 91 (60-150) minutes. The transferred patients (17%) showed longer delay to admission, 200 minutes (195-420; p = 0.0001) and door-to-balloon 113.5 minutes (55-207); p = 0.099. In 47.6% of the cases, the PA was made in the anterior descending artery, in 36.4% in the right coronary artery, in 14.8% in the circumflex artery and in 1.2% in the left coronary artery; in 95% with stent (29% pharmacological); 95% was successful, 1.3% presented post-infarct angina (APIAM), 1.3% re-infarct, 8.8% shock and 3.2% bleeding. Age64 years (OR 6.2 (95% CI: 3.2-12), p0.001), diabetes (OR 2.5, 95% CI 1.6-3.9, p0.001), re-infarction or APIAM (OR 3.3, 95% CI 1.3-8.3, p = 0.011) and shock (OR 29.2 (15.6-54.8), p0.001) were independently associated with higher mortality. In-hospital mortality of acute myocardial infarction with ST-segment elevation treated with PA was 7.6%. Transference from other center was associated with delay in the admission and treatment. Cardiogenic shock and post-infarct ischemia were associated with high mortality. There were no procedural variables associated with mortality.Se evaluaron las características clínicas, demoras, resultados y morbimortalidad de 1142 pacientes tratados con angioplastia primaria (AP) dentro de las 36 horas del infarto, incluidos en el registro ARGEN-IAM-ST, de carácter prospectivo, transversal, multicéntrico y de alcance nacional. Edades: 61.2 ± 12 años, 88% varones, 20% diabéticos y 58% hipertensos; 77.6% en Killip y Kimball I y 6.2% en shock cardiogénico. El tiempo desde el inicio del dolor hasta el ingreso fue de 153 (75-316) minutos, y puerta-balón de 91 (60-150) minutos. Los casos derivados (17%) tuvieron mayor demora de ingreso, 200 minutos (195-420; p = 0.0001) y mayor tiempo puerta-balón, 113 minutos (55-207); p = 0.099. En 47.6% de los casos la AP se hizo en arteria descendente anterior, en 36.4% a coronaria derecha, en 14.8% a circunfleja y en 1.2% al tronco de coronaria izquierda; en 95% con stent (29% farmacológico). El 95% fue exitoso. El 1.3% presentó angina post-infarto (APIAM), 1.3% re-infarto, 8.8% shock y 3.2% sangrado. Se asociaron a mayor mortalidad edad64 años (OR 6.2 (IC 95%: 3.2-12), p0.001), diabetes (OR 2.5, IC 95% 1.6-3.9, p0.001), re-infarto o APIAM (OR 3.3, IC 95% 1.3-8.3, p = 0.011) y shock (OR 29.2 (15.6-54.8), p0.001). La mortalidad hospitalaria del infarto agudo de miocardio con elevación del segmento ST tratado con AP fue de 7.6%. La derivación se asoció a demora de tratamiento. El shock cardiogénico y la isquemia post-infarto se asociaron a alta mortalidad. No hubo variables del procedimiento asociadas a mortalidad.

espanolAntecedentes y objetivo: la incidencia de la endofuga tipo I proximal (Ia) en pacientes con aneurismas de aorta abdominal (AAA) que fueron tratados por via endovascular todavia es objeto de controversia. Los datos disponibles en la literatura se basan en estudios iniciales con dispositivos que fueron retirados del mercado, aplicando tacticas operatorias y de seguimiento obsoletas, o, por otro lado, en publicaciones actuales con nuevas tecnologias, pero que presentan solo seguimientos a corto y medio plazo. Para tal fi n, el objetivo del estudio fue evaluar en una seleccion de pacientes las caracteristicas anatomicas del cuello proximal y relacionarlas con la aparicion de una endofuga tipo Ia. Material y metodo: analizamos retrospectivamente los datos clinicos y morfologicos de pacientes sometidos a tratamiento endovascular del AAA que completaron al menos 24 meses de seguimiento sin complicaciones. Las variables clinicas a largo plazo a estudiar fueron la endofuga tipo Ia y su consecuente ausencia de reintervencion (AR), la supervivencia, la mortalidad relacionada con el aneurisma (ruptura, conversion, nueva operacion) y la progresion del diametro aortico suprarrenal e infrarrenal. Los diametros aorticos (D) se midieron a nivel del tronco celiaco (D1), en la arteria mesenterica superior (D2), a nivel de las arterias renales (D3 mas proximal y D4 mas dista) y 1 cm por debajo de la arteria renal mas baja (D5). Se compararon los diametros aorticos preoperatorios (T0) y en seguimiento (T1) mediante la prueba t-apareada. La supervivencia y la AR se evaluaron mediante analisis de Kaplan-Meier. Resultados: se evaluaron 76 pacientes con una edad media de 72 anos (rango de 60 a 84 anos) y un diametro medio del aneurisma de 56 mm (rango de 48 a 100 mm). El seguimiento promedio fue de 61 meses (de 24 a 106 meses). Se detectaron 8 endofugas tipo Ia, de las que se trataron 6. La supervivencia y la tasa de AR a los 3, 5 y 8 anos fue del 100%, 80,1% y 51,8%, y del 98,6%, 96,8% y 84,6%, respectivamente. Todos los diametros aorticos suprarrenales e infrarrenales aumentaron signifi cativamente durante el seguimiento. El porcentaje de crecimiento de los segmentos aorticos estudiados, comparando el estudio preoperatorio (T0) con el ultimo durante el seguimiento (T1), fue del 4,7% para D1 (T0, 27,2 ± 3,6 mm a T1, 28,5 ± 3,85 mm, p En el analisis univariado, la endofuga tipo Ia se asocio al valor de D5, a un cuello proximal menor a 10 mm de longitud y a la trombosis de mas del 50% de la circunferencia del cuello proximal. En el estudio multivariado, un valor creciente de D5 y la trombosis signifi cativa en el cuello proximal fueron predictores de endofuga tipo Ia a largo plazo. Conclusion: el estudio nos permitio detectar a una subpoblacion de pacientes con mayor incidencia de endofuga tipo Ia: aquellos que en el momento de la cirugia tuvieron trombos en mas del 50% de la circunferencia del cuello proximal y un diametro aortico a nivel de D5 mayor o igual a 30 mm. Por otro lado, si bien el agrandamiento del cuello proximal despues del tratamiento endovascular fue universal, vimos que tiene importancia clinico-quirurgica, especialmente en los pacientes con un diametro de cuello inicial de 30 mm o mas. Esta caracteristica, asociada a su evolucion, deberia justifi car la realizacion de algun tratamiento alternativo que impida la produccion de endofugas proximales a largo plazo. EnglishBackground and objective: the incidence of proximal type I endoleak (Ia) in patients with abdominal aortic aneurysms (AAA) who were treated by the endovascular repair (EVAR) is still controversial. The data available in the literature are based on studies with devices withdrawn from the market, under obsolete technical, technological and follow-up protocols, or, otherwise, on current publications with new technologies but with only short and medium follow up. The aim of this study was to evaluate anatomical characteristics of the proximal neck and the relationships with the developed of a late type Ia endoleak. Material and method: we retrospectively analyzed the clinical and morphological data of patients, and who received an EVAR and completed at least 24 months of follow-up without complications. The long-term end points were type Ia endoleak, freedom from reintervention (FFR), survival, AAA-related mortality, and infrarenal and suprarenal aortic diameter progression. The aortic diameters (D) were measured on three-dimensional workstation center lumen line reconstructions, at the level of the celiac trunk (D1), in the superior mesenteric artery (D2), at the level of the renal arteries (D3 and D4) and 1 cm below the lowest renal artery (D5). Preoperative (T0) and follow-up (T1) aortic diameters were compared using the t-paired test. Survival and FFR were assessed by Kaplan-Meier analysis. Results: 76 patients with a mean age of 72 years (range 60 to 84 years) and an average aneurysm diameter of 56 mm (range 48 to 100 mm) were evaluated. The average follow-up was 61 months (24 to 106 months). Eight type Ia endoleaks were detected (6 were treated, all endoluminally). The survival and FFR rate at 3, 5 and 8 years was 100%, 80.1% and 51.8%, and 98.6%, 96.8% and 84.6% respectively. All suprarenal and infrarenal aortic diameters expanded during follow-up. The mean increased was 4.7% for D1 (T0, 27.2 ± 3.6 mm at T1, 28.5 ± 3, 85 mm, p In the univariate analysis, type Ia endoleak was associated with the value of D5, a proximal neck less than 10 mm in length, thrombosis of more than 50% of the proximal neck circumference. In the multivariate study, the latter two, the thrombus and the neck greater than 30 mm, were predictors of long-term type Ia endoleak. Conclusion: the study allowed us to detect a subpopulation of patients with a higher incidence of type endoleak than, at the time of surgery, thrombi in more than 50% of the circumference of the proximal neck and an aortic diameter at the level of D5 greater than or equal to 30 mm. On the other hand, if the enlargement of the proximal neck after endovascular treatment is universal, it has clinical-surgical importance, especially in patients with an initial diameter of 30 mm or more. This characteristic, associated with its evolution, should justify the performance of an alternative treatment that prevents the production of long-term proximal endoleaks.

Este Consenso sale a la luz en medio de una de las peores crisis sanitarias globales de los últimos 100 años. El SARS-CoV-2 y su manifestación clínica, COVID-19, han provocado una disrupción en cómo médicos y pacientes nos relacionamos. Si bien se trata de una enfermedad infecciosa, una de las características más notables es que su mortalidad se acrecienta en pacientes con enfermedades crónicas no transmisibles y, en particular, con antecedentes de diabetes y enfermedad cardiovascular.En tal contexto, entonces, creemos que cobran más relevancia las recomendaciones vertidas en este documento, que apuntan a identificar y proteger a estos pacientes, al tiempo que se vuelve prioritaria la implementación, más allá de los enunciados, de políticas concretas de prevención cardiometabólica.

Resumen es: Introduccion: Se conoce que la leucocitosis y la hiperglucemia se correlacionan a corto plazo con peor pronostico en pacientes con sindrome coronario agu...

Actualmente existen dudas sobre la seguridad del uso del catéter de Swan Ganz (CSG). Para definir la opinión de los cardiólogos de nuestro país, el Consejo de Emergencias Cardiovasculares de la Sociedad Argentina de Cardiología (SAC) realizó una reunión para evaluar la opinión de expertos en diferentes escenarios (cirugía no cardíaca, cardíaca, síndromes coronarios e insuficiencia cardíaca), usando el método RAND-UCLA appropiateness. Se envió la evidencia bibliográfica previa a la reunión en la SAC y en la misma los panelistas seleccionaron las variables para conformar las situaciones clínicas que luego fueron enviadas para que individualmente, en una segunda etapa, determinaran si consideraban beneficioso o perjudicial la utilización del catéter con una escala de 1 a 9 (1 significaba que los potenciales perjuicios superaban a los beneficios, 9 que los beneficios eran mayores y 5 que podía considerarse indistintamente beneficioso o perjudicial). Dos expertos analizaron los resultados, describiendo la tasa de acuerdo/desacuerdo. Finalmente, cada indicación se clasificó como “apropiada”, “dudosa” o inapropiada de acuerdo a la mediana definida por los panelistas: 1-3 se clasificó como inapropiado, 4-6 dudoso y 7-9 como indicación apropiada. Observamos gran discrepancia en la opinión sobre la indicación de CSG entre los expertos. Sin embargo, los panelistas estuvieron a favor de su utilización en situaciones que incluían shock y disfunción miocárdica, especialmente cuando se asoció disfunción orgánica. Hubo situaciones en las que los panelistas consideraron inapropiada la indicación del CSG, en pacientes sin disfunción orgánica.

Introduction: obesity is frequent in argentinian children and arterial hypertension affects 2.4% of scholars. Objective: the objectivesof the present study are to evaluate the prevalence of obesity and hypertension and their association, and to analyze the ability ofelectrocardiograms to detect conditions in healthy children and adolescents who attended to request a medical certificate of fitness.Methods: 1030 children (47.9% females and 52.1% males) ranging from 1 to 18 years old who concurred for a check up between Janury andMarch 2012, were consecutively included. Their body mass index, blood pressure, weight, height, and electrocardiogram findings werecalculated and evaluated by a pediatrician and a cardiologist. Results: obesity was detected in 12.1% of males and 9.9% of females, andmalnutrition was found in 1.9% and 1.4, respectively. Overweight was more frequent in males, consistent across all age groups. Systolichypertension (adjusted to the 95th height percentile) was observed in 8.8% males and 8.6% females, more prevalent in children rangingfrom 4 to 11 years old. A significant association between hypertension and high body mass index was observed. The ECG assessmentsresulted in six patients with pauses, one patient with asymptomatic Wenchebach AV block, three patients with asymptomatic sinus arrest,and one patient with ventricular bigeminy. Five cases of Wolf-Parkinson-White syndrome were diagnosed, and 2.7% children had long QTcsegments. Conclusions: a high prevalence of hypertension was found, which was more frequent in obese children. The electrocardiogramanalysis resulted in patients with potentially high risk conditions. MED.UIS. 2016;29(3):49-53.Keywords: Risk. Cardiovascular System. Hypertension. Obesity. Body Mass Index. Electrocardiography.

La hiperglucemia con o sin diabetes preexistente es un hallazgo frecuente en pacientes que cursan un síndrome coronario agudo. Estudios previos han demostrado que la hiperglucemia es altamente prevalente y se asocia a un mayor riesgo de muerte y complicaciones hospitalarias. Los mecanismos fisiopatológicos mediante los cuales la hiperglucemia provoca resultados adversos no son claros, y se desconoce si es un marcador de eventos o su causa. Los efectos perjudiciales de la hiperglucemia en el sistema cardiovascular son múltiples, y el control de los niveles de glucosa con insulina parece mejorar el pronóstico en estos pacientes. Se han desarrollado numerosos protocolos para el control de glucemia que demostraron ser seguros y efectivos. En una iniciativa originada en el Consejo de Emergencias de la Sociedad Argentina de Cardiología, se convocó a expertos de nuestro medio con el propósito de debatir estrategias para el control de la glucemia en pacientes que cursan un síndrome coronario agudo. Este documento refleja lo discutido en este evento académico con la intención de resumir los principales aspectos del control de la glucemia y ofrecer recomendaciones generales de tratamiento en la Unidad Coronaria.

La hiperglucemia en el postoperatorio de cirugía cardÍaca es un hallazgo frecuente asociado a peor evolución, que afecta tanto a diabéticos como no diabéticos. A pesar de las múltiples publicaciones disponibles, aún no existe un abordaje universalmente aceptado a este problema. En una iniciativa originada en el Consejo de Emergencias de la Sociedad Argentina de Cardiología, se convocó a expertos de nuestro medio con el propósito de debatir cómo debe ser el manejo de la glucemia en el paciente crítico cardiovascular. Este documento refleja lo discutido en este evento académico con la intención de resumir los principales aspectos del control de la glucemia en el postoperatorio de cirugía cardíaca.

La nefropatía inducida por contraste (NIC) es una de las causas más frecuentes de insuficiencia renal en pacientes internados. En el síndrome coronario agudo (SCA), la presencia de NIC aumenta la morbimortalidad. Las medidas de profilaxis y los factores de riesgo intervinientes de NIC en SCA no han sido determinados con exactitud. El objetivo de este estudio fue evaluar la incidencia de NIC y los factores asociados a su desarrollo en pacientes ingresados en unidad coronaria con requerimiento de cinecoronariografía (CCG). Se realizó un estudio de cohorte retrospectivo. Se incluyeron pacientes consecutivos cursando SCA estudiados con CCG dentro de las 72 horas de su admisión. Se definió NIC al aumento del 25% del valor de creatinina a las 48 h sobre el nivel basal de ingreso. El período de inclusión fue entre el 1° de enero de 2004 hasta el 30 de junio de 2010. Se analizaron 125 casos. La incidencia de NIC fue del 10.4% (n = 13). En el análisis multivariado, los factores asociados independientemente a su desarrollo fueron la edad [OR 1.05 (IC 95% 1.004 - 1.11) p = 0.034], la angioplastia a múltiple vaso [OR 2.2 (IC 95% 1.07 - 4.8), p = 0.03] y el volumen de contraste utilizado [OR 1.007 (IC 95% 1.001 - 1.01), p = 0.014].

The use of genomics to predict adverse drug reactions (ADRs) has been the subject of much research over the last decade. Concerns about the muscular safety of statins, a highly prescribed group of drugs, are partially related to their high exposure. Many studies have identified a variety of genetic markers related to statin-induced myopathy. However, only polymorphisms in the SLCO1B1 gene (which encodes the carrier responsible for the hepatic uptake of statins, which, in turn, contributes to the regulation of plasma levels of SLCO1B1) were strongly associated with statin-induced muscular adverse effects. These was found to be most prominent for simvastatin. The strength of these findings relies on the use of modern genetic approaches, such as well-designed, case-controlled and genome-wide association studies. Nevertheless, the clinical use of this information is far from known at present and needs to be evaluated.The links between genetic polymorphisms (i.e., SLCO1B1 gene) and statin-induced muscle ADRs and the methodological issues involved in the establishment of such an association are explored.Despite there being a statin-gene association for myopathy, in the case of some statins the usefulness of this information still needs to be proven.

Se realizó una reunión de expertos para establecer normas para el abordaje de pacientes con dispositivos cardiovasculares cuando requieran la realización de una resonancia magnética (RM) en los escenarios clínicos más frecuentes, definiendo si la realización de la RM es segura, insegura o condicional.We conducted a meeting of experts to establish rules for the management of patients with cardiovascular devices when they require a magnetic resonance imaging (MRI) study in the most common clinical scenarios, defining whether the study is safe, unsafe or conditional.

Clinical nonresponse to clopidogrel has been associated with variability in response. This has led to the development of other P2Y12 receptor inhibitors, such as prasugrel and ticagrelor, with different pharmacokinetic characteristics that influence their pharmacodynamics.Clopidogrel response variability is attributable to its complex pharmacokinetics and is vulnerable to genetic polymorphisms in genes involved in absorption, metabolism and drug-drug interactions (i.e., proton pump inhibitors). Prasugrel which has a simpler metabolism, leading to greater bioavailability, seems to be less affected by genetic or drug-drug interactions and achieves a greater antiplatelet effect. Ticagrelor is the most novel compound approved with a simpler metabolism. Both prasugrel and ticagrelor reached their antiplatelet effect faster and to a much greater extent than clopidogrel. All these differences observed in kinetics explain, to some degree, the efficacy and safety profile observed in clinical trials for these molecules associated with other antiplatelet agents (aspirin, gpIIb/IIIa inhibitors) and anticoagulants.Clopidogrel is still the best standard of care. However, the pharmacokinetic advantages of both prasugrel and ticagrelor allow clinicians to center patient management by selecting the best drug for the appropriate subject.

Vitamin K antagonists (VKAs) are the main therapeutic agents used to prevent embolic events in patients with atrial fibrillation (AF). Despite their proven efficacy, VKAs are underused and have several limitations. In recent years, there has been great interest in the development of new oral anticoagulants with a more efficient pharmacological profile, first tested in venous thromboembolism prevention and later in AF.The authors review the pharmacological differences between dabigatran, rivaroxaban and apixaban, and potential subgroups of patients in whom these new drugs would constitute a possible alternative to VKA therapy. Pharmacodynamic and pharmacokinetic data from each compound are analyzed in respect to their potential use in AF. This article provides an exhaustive review of the current status of this topic and the controversies still regarding each drug.Apixaban and rivaroxaban are under evaluation for thromboembolic prevention in AF; dabigatran was recently approved for this indication. Therefore, it is important to know the characteristics of these drugs as a potential alternative to VKAs.

Objetivo Comparar el perfil y la evolución de la endocarditis infecciosa (EI) en nuestro país a lo largo de 10 años, a través de los registros EIRA-1 y EIRA-2. Determinar las características clínicas y epidemiológicas y la evolución hospitalaria de la EI por Staphylococcus aureus (EISA) en la Argentina. Métodos El estudio EIRA-2 fue un registro prospectivo multicéntrico conducido en 82 hospitales de 16 provincias de la Argentina. En el presente análisis se incluyeron pacientes con EI definidas (clasificación de Duke) relevados en un período de 18 meses. Resultados Se registraron 390 episodios de EI definidas (108 EISA y 282 no EISA); edad media 58,5 ± 17,3 años, sexo masculino 70%. No existieron diferencias estadísticamente significativas entre las 108 EISA y las 282 no EISA con respecto a edad, sexo, endocarditis de válvula protésica, enfermedad valvular degenerativa, presencia de insuficiencia cardíaca y frecuencia de tratamiento quirúrgico. La comparación de los registros EIRA-2 y EIRA-1 demostró cambios importantes en el perfil de la enfermedad en la última década, actualmente caracterizada por pacientes de mayor edad (58 versus 51 años), mayor prevalencia de cardiopatía subyacente 67% versus 55% (en particular prótesis valvulares 19,2% versus 8,5%, enfermedades valvulares degenerativas 12,4% versus 4,8% y cardiopatías congénitas 9,5% versus 4,2%), mayor frecuencia de infección causada por S. aureus (30% versus 26%) y menor por Streptococcus viridans (30,8% versus 26,8%), con una reducción del tiempo hasta el diagnóstico definitivo (21,5 versus 33 días). No se encontraron modificaciones en la tasa de mortalidad de la enfermedad. Se observó una diferencia estadísticamente significativa (p < 0,01) de las EISA con respecto a las no EISA en la prevalencia de cardiopatía subyacente [58,3% versus 67,4% (OR 0,7 IC 95% 0,4-0,99)]; la EISA presentó una prevalencia menor de enfermedad valvular reumática [0,9% versus 7,1% (OR 0,1 IC 95% 0,01-0,9)] y de cardiopatías congénitas [3,7% versus 11,7% (OR 0,29 IC 95% 0,08-0,9)]. Los antecedentes de procedimientos invasivos previos [33,3% versus 22% (OR 1,8 IC 95% 1,1-3,0)] y hemodiálisis [21,3% versus 10,6% (OR 2,2 IC 95% 1,2-4,3)] fueron más frecuentes en los pacientes con EISA, al igual que la incidencia de accidente cerebrovascular [17,6% versus 11,3% (OR 1,7 IC 95% 1,0-3,2)], embolia [8,3% versus 2,8% (OR 3,1 IC 95% 1,06-9,2) y mortalidad hospitalaria [34,3% versus 20,9% (OR 2,0 IC 95% 1,2-3,3)]. Conclusiones Los pacientes con EISA tienen un perfil de alto riesgo clínico, un peor pronóstico y una incidencia mayor de ACV, embolia y mortalidad hospitalaria. La comparación de los resultados generales de los registros EIRA-1 y EIRA-2 demuestra que el perfil de la EI en la Argentina ha cambiado en el transcurso de la última década. El cambio del perfil de riesgo posiblemente sea el principal responsable de que la mortalidad por EI no se haya reducido. Estos resultados sugieren que se necesitan medidas de diagnóstico y tratamiento más agresivas para mejorar el pronóstico de la EI.

Investigators have raised doubts as to the safety of the Swan Ganz catheter (SGC). In order to define the point of view of cardiologists in our country, the Argentine Society of Cardiology's Emergency Council organized a meeting to analyze their views in different settings (non-cardiac surgery, cardiac surgery, acute coronary syndromes and heart failure) using the RAND-UCLA appropriateness method. A detailed review with the scientific evidence was sent to the experts in cardiology prior to the meeting in the SAC auditorium where the panellists selected the clinical variables create the specific situations. These hypothetic situations were resent to the panellists at a second stage for their individual evaluation, rating the benefit-to-harm ratio of the procedure on a scale of 1 to 9 (1 meant that the expected harms greatly outweighed the expected benefits, and 9 that the expected benefits greatly outweighed the expected harms, 5 could mean either that the harms and benefits were roughly equal). Two experts analyzed the results, describing the agreement/disagreement ratio. Finally, each indication was classified as "appropriate" "uncertain" or "inappropriate" ,for the procedure in accordance with the panelists' median score: median scores in the 1-3 range were classified as inappropriate, those in the 4-6 range as uncertain, and those in the 7-9 range as appropriate. We observed high disagreement rates in SGC indications between cardiologists. However, the panelists were in favor of SGC use when situations included shock and myocardial dysfunction, especially in the presence of organic dysfunction. There were some situations when panelists considered SGC not useful, in patients without organ failure.

Vitamin D (VitD) deficiency is associated with increased morbidity and mortality. We evaluated the association of VitD deficiency (50 mmol/l) and cardiovascular risk factors in a healthy population, from July-November 2012, in a private center at Buenos Aires province. 333 people were included, aged 41.6±12.4 years (58.6% men), 49.2% practiced no physical activity, 56.8% were overweight (70.3% man vs 37.7% women, p0.001), 12.5% with systolic blood pressure (SBP)140 mmHg and 6% diastolic blood pressure (DBP)90 mmHg. VitD deficiency was observed in 29.1% (31.3% man vs 26.1% women, p=0.3), more frequent with obesity (OR 1.85, IC95:1.05-3.25, p=0.02), HDL-cholesterol (HDL-C)50 mg/dl (OR 1.71, IC95:1.06-2.76, p=0.02) and triglycerides150 mg/dl (OR 1.77, IC95:1.02-3.06, p=0.03). A trend towards VitD deficiency and SBP140 mmHg (OR 1.88, IC95:0.93-3.77, p=0.07) or DBP90 mmHg (OR 1.39, IC95:0.5-3.65, p=0.5) was observed. Lineal correlation between VitD and HDL-C (p0.001) or triglycerides (p0.001) was observed. Multiple logistic regression showed that VitD deficiency association with low HDL-C was independent of age, female sex, obesity and physical activity. Association of VitD deficiency with hypetriglyceridemia was independent of age, female sex and obesity. This study shows an association between VitD deficiency and cardiovascular risk factors like obesity, low HDL50 mg/dl and hypertriglyceridemia. A trend toward higher SBP was also observed. Experimental studies are granted in order to establish a cause-effect relationship.El déficit de vitamina D (VitD) se asocia con mayor morbimortalidad. Se evaluó la relación entre el déficit de VitD (20 mg/dl) y los factores de riesgo cardiovascular (FRCV) en pacientes sin antecedentes, de Julio a Noviembre 2012, en un centro privado de la Provincia de Buenos Aires. Se incluyeron 333 pacientes de 41.6±12.4 años (58.6% hombres), el 49.2% no realizaba actividad física, 56.8% con sobrepeso (hombres 70.3% vs 37.7% mujeres, p0.001), 12.5% con PAS140 mmHg y 6% PAD90 mmHg. El déficit de VitD se observó en el 29.1% (31.3% hombres y 26.1% mujeres, p=0.3), más frecuente en obesos (OR 1.85, IC95:1.05-3.25, p=0.02), en HDL50 mg/dl (OR 1.71, IC95:1.06-2.76, p=0.02) y triglicéridos(TG)150 mg/dl (OR 1.77, IC95:1.02-3.06, p=0.03). Se observó tendencia a mayor déficit de VitD en TAS140 mmHg (OR 1.88, IC95:0.93-3.77, p=0.07) y TAD90 mmHg (OR 1.39, IC95:0.5-3.65, p=0.5). Se observó correlación lineal entre VitD con HDL (p0.001) y triglicéridos (p0.001). Por regresión logística múltiple, el déficit de VitD se asoció con HDL bajo independientemente de edad, sexo femenino, obesidad y actividad física, mientras que la asociación con hipertrigliceridemia fue independiente de edad, obesidad y sexo femenino, que fueron las otras variables asociadas con diferencia estadísticamente significativa en el univariable. Este estudio muestra una asociación entre el déficit de VitD y FRCV como la obesidad, el HDL50 mg/dl y la hipertrigliceridemia. Se observó también una tendencia a mayor PA en pacientes con déficit de VitD. Se necesitan estudios experimentales para evaluar si la asociación es causal.

Hyperglycemia with or without pre-existing diabetes mellitus, occurs frequently in the setting of acute coronary syndrome. Previous studies have demonstrated that hyperglycemia is highly prevalent and is associated with an increased risk of hospital complications and death. The underlying pathophysiology related an adverse clinical outcome to hyperglycemia is unclear, and it is uncertain whether increased serum glucose is simply a marker of adverse outcomes or their cause. Detrimental effects of hyperglycemia on the cardiovascular system are multiple. Glycemia control with insulin would prevent adverse outcomes. Numerous glucose-control protocols have been developed and tested proving to be safe and effective. In an initiative from the Emergency Council of the Argentine Society of Cardiology, local experts analyzed the management of hyperglycemia in acute coronary syndrome. The main objective of the prevent statement is to summarize the current state of knowledge on glycemic control, and to offer general recommendations regarding glucose management in the coronary care unit.

Contrast induced nephropathy (CIN) is one of the most frequent causes of acute renal failure in hospitalized patients. It is associated with an increase in morbidity and mortality in patients hospitalized for acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Risk factors and prevention strategies are not well defined. The aim of this study was to assess the incidence and clinical risk factors associated to the development of contrast induced nephropathy in patients hospitalized for ACS. In a retrospective cohort we analyzed consecutive patients hospitalized for ACS undergoing urgent PCI within 72 hours from the admission. CIN was defined as a 25% increase of creatinine levels from baseline at 48 hours from the PCI. The inclusion period was from January 1, 2004 to June 30, 2010. A total of 125 patients were analyzed, and CIN occurred in 13 (10.4%) patients. An independent association was found between age (OR 1.05; 95% CI 1.004 to 1.11; p = 0.034), multiple vessel angioplasty (OR 2.2; 95% IC 1.07 to 4.8; p = 0.03) and the volume of contrast infused (OR 1.007; 95% CI 1.001 to 1.01; p = 0.014) with the development of CIN.

Background Peak V o 2 has traditionally been used for prognostic evaluation in systolic heart failure. However, in the past years, VE/V co 2 slope has been shown to be similar or even superior in many studies. We performed a systematic review and a meta-analysis of diagnostic studies of VE/V co 2 slope to assess its ability to predict cardiovascular events in systolic heart failure. Methods We searched the published literature in PubMed and ISI Web of Science for VE/V co 2 slope in heart failure, and performed a systematic review and a meta-analysis of diagnostic studies in articles fulfilling previously established selection criteria. End points were serious cardiovascular events defined as death or the combined end point of death, ventricular assist device implantation, or heart transplant. A sub-analysis was also performed with those articles providing enough data to compare VE/V co 2 slope prognostic ability to that of peak V o 2. Results Four hundred ninety-one articles that are potentially relevant were identified, and 12 studies were selected based on our predefined criteria. No heterogeneity or evidence of publication bias was found. The 12 studies included a total of 2,628 patients with a mean follow-up of 31 months (95% CI 16-46 months). The combined event rate at 1 year was 11.2% (95% CI 7.8%-14.6%). Diagnostic odds ratio and area under the curve for serious cardiovascular events were 5.02 (95% CI 4.06-6.21) and 0.75 (95% CI 0.72-0.78), respectively. Six studies provided sufficient data for VE/V co 2 slope and peak V o 2 comparison. Both variables showed similar performance, although VE/V co 2 did present a trend to superiority. Conclusions In this meta-analysis, VE/V co 2 slope represents a reasonable ability to predict serious cardiovascular events in systolic heart failure, and is at least as effective as peak V o 2.

ObjectivesThe present analysis included patients with myocardial infarction from the SCAR registry in Argentina. It reports how health insurance coverage influenced the outcomes.MethodsEighty-seven centers participated in a cross-sectional nation-wide multicenter survey.ResultsSeven hundred and fifty-eight patients were included, 476 (60.55%) with STEMI and 281(39.45%) non-STEMI (NSTEMI).In-hospital mortality was 7.35%. Mortality was independently associated with age (OR 1.06, CI95 1.02–1.1, p=0.001), left ventricular dysfunction (OR 7.12, CI95 2.5–20, p