La ivabradina, de hecho, está contraindicada en pacientes con fibrilación auricular. Inicialmente (aunque recientemente han aparecido evidencias que matizan esa información) se dijo que la ivabradina era selectora sobre la corriente de sodio If en el nodo sinusal. Si el paciente está en FA, no tiene ningún sentido actuar sobre el nodo sinusal.

Hombre de 84 de edad, con insuficiencia cardiaca crónica en grado funcional II secundario a cardiopatia isquémica con dlsfunción sistólica grave no revascularizable, enfermedad renal crónica estadio 3 (filtrado glomerular 45-50 mL/min) y fibrilación auricular permanente con frecuencia cardiaca >80 latidos por minuto. ¿Cuál de los siguientes farmacos NO aporta beneficio al paciente según la evidencia disponible en la actualidad?

Inhibidores de la enzima convertidora de angiotensina.

Correlación del volumen de entrenamiento en MET-min/semana con el porcentaje de ganancia de VO2p-carga en pacientes con insuficiencia cardiaca con fracción de expulsión reducida, sometidos a un programa de rehabilitación cardiaca.

Objetivo: La insuficiencia cardiaca (IC) es un síndrome clínico caracterizado por disminución en la capacidad funcional. Los programas de rehabilitación cardiaca y prevención secundaria (PRHCyPS) han mostrado mejorar la calidad de vida y tolerancia al esfuerzo en este grupo de pacientes, pero sus efectos son dependientes del volumen. Nuestro objetivo es evaluar el grado de correlación del volumen de entrenamiento medido en equivalentes metabólicos (MET)-min/semana con el porcentaje de ganancia de consumo pico de oxígeno (VO2p) (MET-carga) posterior a un PRHCyPS en pacientes con IC. Método: Estudio cuasiexperimental que evaluó la ganancia de VO2p (MET-carga) en 31 pacientes posterior a un PRHCyPS, antes y después de una prueba de ejercicio convencional, que consistió en 30 min de entrenamiento dinámico al 70% frecuencia cardíaca de reserva (FCR) durante seis semanas, así como entrenamiento de kinesioterapia e intervención interdisciplinaria. Se calculó el volumen de entrenamiento de cada paciente en MET-min/semana (método de Kaminsky). Se midió el índice de correlación con Rho de Spearman y se consideró significancia estocástica con valor de p < 0.05. Resultados: El 70.6% fueron de sexo masculino, promedio de edad 61.5 ± 8.9 años, con fracción de expulsión del ventrículo izquierdo promedio de 38 ± 4.6%; el 96.8% de la IC fue de origen isquémico; un 55.9, un 29.4 y un 5.9% en clase funcional según la New York Heart Association I, II y III, respectivamente. Con un volumen de entrenamiento promedio de 504.34 ± 164 MET-min/semana. La mayor correlación se obtuvo en las poblaciones de alto riesgo, con una Rho: 0.486 (p = 0.008) por VO2p-carga. Conclusiones: Si bien existe una ganancia sustancial en tolerancia al esfuerzo medido por VO2p-carga, no obtuvimos suficiente grado de correlación entre el volumen de entrenamiento aplicado y la ganancia obtenida.

[Mineralcorticoid receptor blockers in chronic kidney disease].

There are many experimental data supporting the involvement of aldosterone and mineralcorticoid receptor (MR) activation in the genesis and progression of chronic kidney disease (CKD) and cardiovascular damage. Many studies have shown that in diabetic and non-diabetic CKD, blocking the renin- angiotensin-aldosterone (RAAS) system with conversion enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) decreases proteinuria, progression of CKD and mortality, but there is still a significant residual risk of developing these events. In subjects treated with ACEi or ARBs there may be an aldosterone breakthrough whose prevalence in subjects with CKD can reach 50%. Several studies have shown that in CKD, the aldosterone antagonists (spironolactone, eplerenone) added to ACEi or ARBs, reduce proteinuria, but increase the risk of hyperkalemia. Other studies in subjects treated with dialysis suggest a possible beneficial effect of antialdosteronic drugs on CV events and mortality. Newer potassium binders drugs can prevent / decrease hyperkalemia induced by RAAS blockade, and may reduce the high discontinuation rates or dose reduction of RAAS-blockers. The nonsteroidal MR blockers, with more potency and selectivity than the classic ones, reduce proteinuria and have a lower risk of hyperkalemia. Several clinical trials, currently underway, will determine the effect of classic MR blockers on CV events and mortality in subjects with stage 3b CKD and in dialysis patients, and whether in patients with type 2 diabetes mellitus and CKD, optimally treated and with high risk of CV and kidney events, the addition of finerenone to their treatment produces cardiorenal benefits. Large randomized trials have shown that sodium glucose type 2 cotransporter inhibitors (SGLT2i) reduce mortality and the development and progression of diabetic and nondiabetic CKD. There are pathophysiological arguments, which raise the possibility that the triple combination ACEi or ARBs, SGLT2i and aldosterone antagonist provide additional renal and cardiovascular protection.

[Not Available].

Introducción: la rehabilitación de la alimentación por vía oral (RVO) es compleja en pacientes que han recibido nutrición enteral (NE) prolongada. Objetivo: describir este proceso en niños con enfermedades respiratorias crónicas y sonda nasoenteral (SNE) o gastrostomía (GT).Pacientes y métodos: estudio retrospectivo con revisión de registros clínicos de niños con NE mayor a dos meses, ingresados entre 2005 y 2014 al Hospital Josefina Martínez.Resultados: Se incluyeron 116 pacientes, con mediana de edad 10 meses (Rango: 3 a 101), 56% hombres. Diagnóstico: 34,5% Daño pulmonar crónico postinfeccioso (DPC), 29,3% Insuficiencia respiratoria por enfermedad neuromuscular, 19% Displasia broncopulmonar y 17,2% enfermedad de la vía aérea. Con traqueostomía: 82,8%. Eran usuarios de GT 89,7% y de SNG 10,3%, instaladas con mediana de edad 6 meses (0 a 74), por ingesta insuficiente (6,6%) o trastorno de deglución (92,4%). Del grupo total, 36,2% (42/116) tenía indicación de RVO, los cuales habían recibido NE durante 12,2 meses (2 a 41); de estos 50% (21/42) logró alimentarse exclusivamente por vía oral (91% SNG y 35,4% GT, Chi2 p = 0,023), 14% parcialmente y 36% no lo logró. El tiempo para lograr la vía oral exclusiva fue de 9,75 meses (0,5 a 47), sin diferencia por edad, sexo, vía de acceso, duración NE ni presencia de enfermedad neurológica.Conclusión: en pacientes con enfermedades respiratorias crónicas graves y NE prolongada, la RVO es un proceso lento pero posible: 64% lo logra de modo completo o parcial.

[Chronic heart failure treatment in uremic patients with beta-blockers].

The interpretation of congestive heart failure (CHF) in '80 was exclusively in haemodynamic terms. In accordance with such a pathophysiologic hypothesis, cardiovascular drugs, mainly positive inotropics and/or vasodilators were experimented with not significative results. From the second half of the 80's the attention starts focusing on the neurohumoral asset, strongly activated in patients suffering from CHF and that was it selves cause of worsening of CHF and responsible for the poor prognosis of these patients, so as to become therapeutic targets and to represent the rationale for using ace-inhibitors (ACE-I), betablockers and angiotensin II receptor blockers (ARBs). Evidence has been provided that these drugs can reduce morbidity and mortality. However, this evidence derives only from studies on general population. In uraemic patients there are no controlled trials dedicated and the nephrological guidelines recommends the use of ACE-I on the hypothesis that they may have similar efficacy than non uremic patients. Among all the medications used to treat CHF in the general population, only betablockers has been shown to be effective in a randomized trial in the dialysis population. Carvedilol was found to improve left ventricular function and decrease hospitalization, cardiovascular deaths and total mortality, remarking that pathophysiology, rationale for using and results may be similar in uremic and non uremic patients suffering from CHF.

The Impact of Chronic Kidney Disease in Patients With Locally Advanced Rectal Cancer Treated With Neoadjuvant Chemoradiation.

Patients with chronic kidney disease are commonly excluded from clinical trials. The impact of chronic kidney disease on outcomes in patients with locally advanced rectal cancer has not been previously studied. This study aimed to investigate the impact of chronic kidney disease on outcomes in patients with locally advanced rectal cancer. This is a multi-institutional, retrospective cohort study. This study was conducted at academic and community cancer centers participating in the Canadian Health Outcomes Research Database Consortium Rectal Cancer Database. Consecutive patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiation before curative-intent surgery from 2005 to 2013 were selected. Disease-free survival, overall survival, pathologic complete response, and neoadjuvant chemotherapy/radiotherapy completion rate were the primary outcomes measured. A total of 1254 patients were included. Median age was 62, and 29%/69% had clinical stage II and III disease. Median estimated creatinine clearance was 93 mL/min, with 11% <60 mL/min (n = 136). There was no significant difference in the completion rate of neoadjuvant chemotherapy (82% vs 85%, p = 0.36) or radiotherapy (93% vs 95%, p = 0.45) between patients with and without chronic kidney disease. Patients with chronic kidney disease were less likely to receive adjuvant chemotherapy (63% vs 77%, p < 0.01). On multivariate analysis, patients with chronic kidney disease had decreased disease-free survival (HR, 1.37; 95% CI, 1.03-1.82; p = 0.03) but not overall survival (HR, 1.23; 95% CI, 0.88-1.75; p = 0.23) or pathologic complete response (OR, 0.83; 95% CI, 0.50-1.39; p = 0.71). This study was limited by its retrospective design and by limited events for overall survival analysis. In patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiation, baseline chronic kidney disease was associated with less use of adjuvant chemotherapy and decreased disease-free survival. Chronic kidney disease was not independently associated with neoadjuvant chemotherapy/radiotherapy completion rate, pathologic complete response, or overall survival. These data suggest that patients with locally advanced rectal cancer with chronic kidney disease may have distinct outcomes and, accordingly, the results of landmark clinical trials may not be generalizable to this population. See Video Abstract at http://links.lww.com/DCR/B694. ANTECEDENTES:Los pacientes con enfermedad renal crónica generalmente se excluyen de los ensayos clínicos. La repercusión de la enfermedad renal crónica en el desenlace en pacientes con cáncer de recto localmente avanzado no se ha estudiado previamente.OBJETIVO:Investigar la repercusión de la enfermedad renal crónica en los desenlaces en pacientes con cáncer de recto localmente avanzado.DISEÑO:Estudio de cohorte retrospectivo multiinstitucional.ESCENARIO:Centros oncológicos académicos y comunitarios que participan en la base de datos de cáncer rectal del consorcio CHORD.PACIENTES:Pacientes consecutivos con cáncer de recto localmente avanzado, tratados con quimiorradioterapia neoadyuvante, previa a la cirugía con intención curativa del 2005 al 2013.PRINCIPALES VARIABLES EVALUADAS:Sobrevida libre de enfermedad, sobrevida global, respuesta patológica completa, tasa de conclusión de quimioterapia / radioterapia neoadyuvante.RESULTADOS:Se incluyeron 1254 pacientes. El promedio de edad fue de 62, y el 29% / 69% tenían enfermedad en estadio clínico II y III, respectivamente. El promedio de la depuración de creatinina estimada fue de 93 mililitros / minuto, con un 11% <60 mililitros / minuto (n = 136). No hubo diferencias significativas en la tasa de conclusión de la quimioterapia neoadyuvante (82% vs 85%, p = 0,36) o radioterapia (93% vs 95%, p = 0,45) entre pacientes con y sin enfermedad renal crónica. Los pacientes con enfermedad renal crónica tenían menos probabilidades de recibir quimioterapia adyuvante (63% contra el 77%, p <0,01). En el análisis multivariado, los pacientes con enfermedad renal crónica tenían una sobrevida libre de enfermedad menor (HR 1,37, IC 95% 1,03-1,82, p = 0,03) pero no en la sobrevida global (HR 1,23, IC 95% 0,88-1,75, p = 0,23) o respuesta patológica completa (OR 0,83, IC 95% 0,50-1,39, p = 0,71).LIMITACIONES:Diseño retrospectivo y acontecimientos limitados para el análisis de sobrevida global.CONCLUSIONES:En pacientes con cáncer de recto localmente avanzado tratados con quimiorradioterapia neoadyuvante, la enfermedad renal crónica de base se asoció con un menor uso de quimioterapia adyuvante y una menor sobrevida libre de enfermedad. La enfermedad renal crónica no se asoció de forma independiente con la tasa de conclusión de la quimioterapia / radioterapia neoadyuvante, la respuesta patológica completa o la sobrevida global. Estos datos sugieren que los pacientes con cáncer de recto localmente avanzado con enfermedad renal crónica pueden tener resultados distintos y, en consecuencia, los resultados de los ensayos clínicos de referencia pueden no ser generalizables a esta población. Consulte Video Resumen en http://links.lww.com/DCR/B694.

[Prescription of renin-angiotensin-aldosterone system blockers in patients with stage 3 chronic kidney disease].

To reduce the progression of chronic kidney disease (CKD) and cardiovascular risk, the guidelines recommend the blockade of the renin-angiotensin-aldosterone system (RAAS) in patients with proteinuria. To assess the frequency of enalapril or losartan use in diabetics or hypertensive patients with stage 3 CKD. Review of clinical records of patients with CKD in an urban primary care clinic. We identified 408 subjects aged 40 to 98 years (66% women) with stage 3 CKD. Sixty six percent had only hypertension and 34% were diabetic with or without hypertension. Seventy four percent received RAAS blockers (52% used enalapril, 45% losartan and 2% both medications). RAAS blockers were used in 70% of hypertensive and 78% of diabetic patients. The prescription in hypertensive diabetics with microalbuminuria was lower than in those without microalbuminuria (72% vs 87%, p < 0.05), but the opposite occurred in pure hypertensive patients with and without microalbuminuria (88% vs 69%, p < 0.05). There were no significant differences in blood pressure levels, microalbuminuria or serum potassium levels between RAAS blocker users and non-users. No differences were observed either between enalapril and losartan users. The adherence to clinical guidelines is insufficient and users of the recommended drugs did not achieve the expected goals.

Cardiorenal syndrome: Clinical and echocardiographic aspects.

El síndrome cardiorrenal (SCR) es un trastorno en el que intervienen el corazón y los riñones, interactuando y produciendo una disfunción entre ellos en forma aguda o crónica. Existen diferentes fenotipos clínicos bien identificados como «desórdenes del corazón y riñón en los que la disfunción aguda o crónica en un órgano induce la disfunción aguda o crónica del otro». La alta incidencia de morbimortalidad cardiovascular presente en los pacientes con enfermedad renal crónica terminal (ERCT), en especial la insuficiencia cardiaca (IC), origina inicialmente una lesión miocárdica que conlleva remodelamiento ventricular, lo cual induce a la activación de mecanismos compensadores, entre los cuales el riñón es pieza fundamental, ya que regula la homeostasis hidroelectrolítica y así el volumen circulante, siendo esto en la etapa dialítica más evidente. Los cambios funcionales y anatómicos cardiovasculares que se producen en estos pacientes son muy prevalentes e incluyen las interacciones hemodinámicas del corazón y los riñones en la insuficiencia cardiaca, y el impacto de la enfermedad aterosclerótica en ambos sistemas de órganos. También describimos estrategias diagnósticas y terapéuticas aplicables al síndrome cardiorrenal, que determinan la importancia de la ecocardiografía como modelo de diagnóstico útil. Finalmente, se analizan las posibilidades de tratamiento y la remisión de las alteraciones funcionales cardiacas con el trasplante renal en los pacientes con ERCT. Cardiorenal syndrome (CRS) is a disorder in which the heart and kidneys are involved, interacting and producing a dysfunction between them in an acute or chronic way. There are different clinical phenotypes well identified as “heart and kidney disorders in which acute or chronic dysfunction in one organ induces acute or chronic dysfunction in the other”. The high incidence of cardiovascular morbimortality in patients with chronic terminal kidney disease (CKD), especially heart failure (HF), initially causes a myocardial lesion that leads to ventricular remodeling, which induces the activation of compensatory mechanisms, among which the kidney is a fundamental part since it regulates the hydroelectrolytic homeostasis and thus the circulating volume, being this in the dialytic stage more evident. The functional and anatomical changes at cardiovascular level that occur in these patients are very prevalent, and include hemodynamic interactions of the heart and kidneys in heart failure and the impact of atherosclerotic disease in both organ systems. We also describe diagnostic and therapeutic strategies applicable to cardiorenal syndrome, which determine the importance of echocardiography as a useful diagnostic model. Finally, we analyze the possibilities of treatment and remission of cardiac functional alterations with renal transplantation in patients with T-CKD.

[Antihypertensive drugs in diabetic's hypertension].

Hypertension is defined by the Joint National Committee (JNC 7) as blood pressure (BP) > or =Y130/80 mmHg. It affects up to 70% of patients with type 2 diabetes and is twice as prevalent in diabetics as in non-diabetics. Due to its contribution to renal and cardiovascular disease, hypertension increases diabetic mortality four to five-fold. Therefore, a BP goal of 130/80 mmHg or less (125/75 mmHg in patients with proteinuria >1 g/die and increased creatinemia), is recommended. For isolated systolic hypertension, defined as a systolic BP > or =Y180 mmHg with normal diastolic BP, the treatment goal is to reduce systolic BP to <160 mmHg. The evidence from most trials suggests that there are only minimal differences between the various antihypertensive drugs, and that almost all agents are capable of successfully reducing adverse clinical events. Nevertheless, there is evidence that certain drugs are more useful in preventing damage to a specific organ system; and therefore, the selection of the therapy should be guided by the presence of concomitant disease and the protection of the organ system that is most at risk. Beta-blockers and calcium channel blockers are effective antianginals; diuretics, angiotensin-converting enzyme (ACE) inhibitors and beta-blockers are useful for heart failure; ACE inhibitors and angiotensin receptor blockers are especially effective in preserving renal function. Adequate BP control, irrespective of the type of antihypertensive drugs used, should replace the academic debate on what is the best antihypertensive agent.

Cardiac sympathetic denervation for conventional treatment refractory arrhythmias.

La denervación simpática cardiaca izquierda (DSCI) por toracoscopia se ha convertido en una alternativa terapéutica para el manejo de arritmias cardíacas refractarias al tratamiento convencional en pacientes con cardiopatía estructural, principalmente isquémicos, y enfermedades hereditarias asociadas con muerte súbita como el síndrome de QT largo. Generalmente se realiza en quienes manifiestan episodios recurrentes de arritmias ventriculares o incluso tormenta eléctrica a pesar del tratamiento convencional. El objetivo de este estudio es mostrar la experiencia de esta institución con la DSCI en pacientes refractarios al manejo convencional y los resultados derivados de su aplicación. Se revisaron los registros de 6 pacientes con antecedente de arritmias ventriculares tratados previamente con medicamentos y en algunos casos con ablación con catéter y la mayoría con desfibrilador automático implantable, que fueron llevados DSCI por toracoscopia video-asistida (VATS). La principal enfermedad de base fue la cardiopatía estructural, la indicación más prevalente fue tormenta arrítmica incontrolable, la edad promedio fue de 56 ± 16 años, el 67% de los individuos fueron hombres. Este procedimiento no mostró complicaciones en ninguno de los pacientes y se encontró mejoría sintomática en todos los casos. Se realizó seguimiento por 24 meses; dos pacientes tuvieron recurrencias por taquicardia ventricular lenta sin síntomas severos y uno por fibrilación ventricular. La DSCI por VATS debe considerarse como opción terapéutica para pacientes con arritmias de difícil manejo.

[Angiotensin II receptor blocker add-on therapy for low cardiac output in decompensated heart failure].

During heart failure (HF) decompensation, an intense activation of the renin-angiotensin-aldosterone system occurs; however, the use of angiotensin-converting enzyme inhibitor (ACEI) cannot block it completely. Otherwise, the addition of angiotensin II receptor blocker (ARB) can be useful when the inotropic dependence occurs. We evaluated the efficacy of the ARB-ACEI association on dobutamine withdrawal in advanced decompensated HF. To assess the efficacy of association angiotensin receptor blocker--angiotensin converting enzyme inhibitor to withdraw the intravenous inotropic support in decompensated severe heart failure. In a case-control study (N = 24), we selected patients admitted at the hospital due to HF that had been using dobutamine for more than 15 days, with one or more unsuccessful drug withdrawal attempts; optimized dose of ACEI and ejection fraction (EF) < 0.45. Then, the patients additionally received ARB (n=12) or not (control, n=12). The outcome was the successful dobutamine withdrawal, evaluated by logistic regression, with a p < 0.05. The EF was 0.25 and the age was 53 years, with a dobutamine dose of 10.7 microg/kg x min. The successful drug withdrawal was observed in 8 patients from the ARB group (67.7%) and in 2 patients from the control group (16.7%). The odds ratio (OR) was 10.0 (95%CI: 1.4 to 69.3; p = 0.02). The worsening in renal function was similar (ARB group: 42% vs. control group: 67%; p=0.129). In this pilot study, the ARB-ACEI association was associated with successful dobutamine withdrawal in advanced decompensated heart failure. The worsening in renal function was similar in both groups. Further studies are necessary to clarify the issue.

Evaluación de la dinámica cardiaca con la aplicación de metodologías basadas en entropía proporcional y la ley Zipf-Mandelbrot.

Las metodologías fisicomatemáticas son de utilidad para el diagnóstico de la dinámica cardiaca. Comparar la aplicación de dos métodos matemáticos de evaluación de la dinámica cardiaca. Una basada en proporciones de la entropía y otra en la ley de Zipf-Mandelbrot. Se tomaron 10 registros Holter, cinco de pacientes con enfermedad aguda y cinco normales. Se construyó un atractor numérico, se evaluó la probabilidad, entropía y proporciones de entropía. Para aplicar la segunda metodología se agruparon los valores de frecuencia cardiaca en rangos de 15 latidos/minuto y se aplicó la ley de Zipf-Mandelbrot para obtener la dimensión fractal estadística. Finalmente se comparó la evaluación matemática obtenida por ambas metodologías. La metodología basada en las proporciones de la entropía diferenció normalidad, enfermedad y estados intermedios. La segunda metodología diferenció normalıdad de enfermedad aguda mediante el grado de complejidad. Ambas metodologías establecen evaluaciones de ayuda diagnóstica de la dinámica cardiaca de forma objetiva y reproducible. La entropía proporcional permite cuantificar normalidad, enfermedad y evolución entre estados con carácter predictivo y mayor precisión. Physical-mathematical methodologies have been useful for the diagnosis of cardiac dynamics. To compare the application of two mathematical methodologies for cardiac dynamics evaluation, one of them based on entropy proportions and the other based on of Zipf-Mandelbrot law. 10 Holter, 5 acute disease dynamics and 5 normal records were taken. A numerical attractor was constructed; probability, entropy and entropy proportions were evaluated. To apply the second methodology, heart rate values were grouped in 15-beat/min ranges, and Zipf-Mandelbrot’s law was applied in order for the statistical fractal dimension to be obtained. Finally, the mathematical evaluation obtained by both methodologies was compared. The methodology based on entropy proportions differentiated normality, disease and intermediate states. The second methodology differentiated normality from acute disease through the degree of complexity. Both methodologies establish diagnostically helpful evaluations of cardiac dynamics in an objective and reproducible way. Proportional entropy allows normality, disease and evolution between states to be quantified in a predictive manner and with higher accuracy.

[Management of the treatment with converting enzyme inhibitors in chronic heart failure].

Treatment with angiotensin-converting enzyme (ACE) inhibitors can begin at any time when a left ventricular dysfunction has been diagnosed. In the absence of rare contra-indications (renal artery stenosis, connective tissue disease, severe renal failure), all patients with asymptomatic or, a fortiori, symptomatic chronic heart failure can benefit from ACE inhibitors, whatever the origin of the heart failure. Among the ACE inhibitors now available, the benefits of captopril (3 daily doses) and of enalapril (2 daily doses) on all the targets of cardiac failure treatment are now well established. The effects of lisinopril on mortality are not yet known, but the haemodynamic and symptomatic benefits of this drug are also well established (with the advantage of once daily administration). Other ACE inhibitors with less numerous and less convincing trial reports can be used or rejected depending on the physician's faith in the effects of this pharmaceutical class. With all ACE inhibitors the initial dose must be very low, to be gradually increased over several days or even weeks until the highest dose tolerated is reached. ACE inhibitors can be associated with the classical treatment of cardiac failure. A previous diuretic treatment with sodium depletion may increase the risks of first dose effect and renal intolerance due to the introduction of the ACE inhibitors. Theoretically, the combination of ACE inhibitors and spironolactone is to be avoided for fear of hyperkalaemia and renal deterioration. Yet, provided some precautions are taken this combination may improve the benefits of ACE inhibition when the renin-angiotensin-aldosterone system inhibition is not optimal. However, this has yet to be demonstrated by prospective clinical trials.

Differential characteristics of the typical and atypical advanced interatrial block.

Se denomina bloqueo interauricular avanzado (BIA) a la existencia de una onda P ≥ 120 ms y bifásica +/- en las derivaciones inferiores (II-III-VF) del electrocardiograma (ECG) de superficie, el cual constituye un factor predictivo significativo del desarrollo de fibrilación auricular. En fecha reciente se han descrito cuatro patrones de BIA atípicos (BIA-At) con base en la morfología y la duración de la onda P, sin conocer si comparten patogenia y características clínicas similares. Estudio observacional, descriptivo y retrospectivo de pacientes, visitados en el Servicio de Cardiología, en ritmo sinusal y con BIA. Las variables analizadas se obtuvieron de la historia clínica informatizada. El análisis de la onda P se efectuó al aumentar el tamaño del electrocardiograma y mediante calipers electrónicos. El análisis estadístico se realizó con SPSS 19.0, con nivel de significación de p < 0.05. Se incluyó a 75 pacientes con media de edad de 74.4 ± 11.7 años, con 62.7% de varones. Se compararon los grupos de pacientes con BIA típico (BIA-T) y BIA-At. El primero se relacionó con la existencia de diabetes mellitus (p = 0.001), enfermedad renal crónica estadio ≥ 3 (p = 0.036), bloqueo auriculoventricular (p = 0.006) y una menor fracción de expulsión ventricular media (p = 0.025); no hubo diferencias respecto de la prevalencia de fibrilación auricular/flúter o accidente cerebrovascular. Sólo la diabetes se acompañó de riesgo de ser un BIA-T (OR: 6.4; p = 0.002; IC 95%: 2.0-21.1). La diabetes mellitus constituye el único factor de riesgo de que un BIA sea típico. Los pacientes con BIA-T y BIA-At presentan similar prevalencia de fibrilación auricular y accidente cerebrovascular, por lo que son objeto de un mismo tratamiento clínico. It is called advanced interatrial block (IAB) to the existence of a P wave ≥ 120 ms and biphasic ± in the lower leads II-III-VF of the surface electrocardiogram (ECG), which constitutes a significant predictive factor for the development of atrial fibrillation. Recently, four patterns of atypical aIAB (At-IAB) have been described based on the morphology and duration of the P wave, but it’s unknown if they share the same pathogenesis and clinical characteristics. An observational, descriptive and retrospective study was performed with patients, visited in cardiology, who have a sinus rhythm and with aIAB. The analyzed variables were obtained from the computerized clinical history. The analysis of the P wave was made by increasing the size of the ECG and by electronic calipers. Statistical analysis was performed with SPSS 19.0; level of significance: p < 0.05. A total of 75 patients with an average age of 74.4 ± 11.7 years and with a 62.7% males, were included. It was compared the group of patients with typical aIAB (T-aIAB) and with At-aIAB. The first one was associated with the existence of diabetes mellitus (p = 0.001), chronic kidney disease stage ≥ 3 (p = 0.036), atrioventricular block (p = 0.006) and a lower mean ventricular ejection fraction (p = 0.025); there were no differences regarding the prevalence of atrial fibrillation/flutter or stroke. Only diabetes was associated with the risk of T-aIAB (odds ratio: 6.4; p = 0.002; 95% confidence interval: 2.0-21.1). Diabetes mellitus is the only risk factor for an aIAB to be typical. Patients with T-aIAB and At-aIAB have a similar prevalence of atrial fibrillation and stroke, so they must follow the same clinical management.

[Is there an indication for the association of betablockers and angiotensin II receptor antagonists in cardiac failure?].

ACE inhibitors initially developed as vasodilators are effective by their anti-hormonal action. Antagonists of the receptors of angiotensin II (ARA II) should provide an equivalent or better blockade of the rennin-angiotensin system (absence of tolerance). Clinical trials have shown equivalent haemodynamic effects of the two classes, equal functional tolerance but mortality studies have shown more variable results. None have shown the superiority of ARA II over ACE inhibitors and the demonstration of their equivalence has just been reported with high doses in the post-infarction period. A deleterious effect of ARA II in association with betablockers was reported in two mortality studies but has not been confirmed in the most recent trials. The difficulty is to determine the roles of the association of ARA II-ACE inhibitors, ARA II-antialdosterones or of the association of all three classes of molecules.

Effect of statins on development of post thrombotic syndrome: cohort study.

Explorar la asociación entre consumo de estatinas (CE) y desarrollo de síndrome postrombótico (SPT). Cohorte retrospectiva con pacientes con primer episodio de trombosis venosa profunda (TVP) entre el 06/2006 y el 12/2017, incluidos en el Registro Institucional de Enfermedad TromboEmbólica (RIET) del Hospital Italiano de Buenos Aires. Se consideró exposición al CE entre los 30 días previos y hasta 180 días posterior al diagnóstico de TVP. Se definió SPT según constaba este dato en la base de seguimiento del RIET. Se evaluó el desarrollo de SPT con un modelo de riesgos proporcionales de Cox, reportando hazard ratios (HR) crudas y ajustadas. Se consideró la confusión por indicación del CE y se utilizó un propensity score (PS) para el ajuste del riesgo estimado, reportando los HR con sus intervalos de confianza del 95% (IC 95%). Se incluyeron 905 pacientes, de los cuales 273 fueron CE y 632 no consumidor de estatinas (NCE). Al seguimiento, la incidencia de SPT fue: 6.59% (18) en el grupo CE y 8.07% (51) en el grupo NCE, con p = 0.412. La razón de riesgo para el desarrollo de SPT de CE resultó no significativa (HR cruda: 0.78; IC 95%: 0.43-1.41; p = 0.414). La HR de CE ajustada por edad, sexo, antiinflamatorios no esteroideos, corticosteroides, inmovilidad, anticoagulante, hipertensión arterial, diabetes, dislipidemia, insuficiencia renal crónica, enfermedad coronaria, accidente cerebrovascular, insuficiencia cardiaca y enfermedad oncológica fue 0.45 (IC 95%: 0.13-1.5; p = 0.196). La HR del CE ajustado por edad, sexo, antiinflamatorios no esteroideos, corticosteroides, inmovilidad, tratamiento anticoagulante, enfermedad oncológica y PS fue de 0.52 (IC 95%: 0.17-1.66; p = 0.272). El CE no se asoció con menor SPT, aunque hubo escaso número de eventos detectados. To evaluate the association between statin consumption and development of post-thrombotic syndrome (PTS). Retrospective cohort study which included patients with a first episode of deep vein thrombosis (DVT) between 06/2006 and 12/2017, included in the Institutional Registry of ThromboEmbolic Disease of the Italian Hospital of Buenos Aires, Argentina. Exposure to statin use (SU) was considered between the 30 days before and up to 180 days after the diagnosis of DVT. PTS was defined as recorded dataset on registry. The development of PTS was evaluated with Cox proportional hazards model, raw and adjusted hazard ratios (HR) were reported. Confusion was considered by indication of SU and a propensity score (PS) was used for adjustment. We reported HR with their 95% confidence interval (CI); p value < 0.05 was considered statistically significant. Of 1393 patients, 905 were included for the analysis, of which 273 were SU and 632 non-statin users (NSU). At follow-up, incidence of PTS was: 6.59% (18) in the SU group and 8.07% (51) in the NSU group, with p = 0.412. Crude HR for PTS for SU was not significant (0.78; 95% CI: 0.43-1.41; p = 0.414). Adjusted HR of SU by age, sex, non-steroidal anti-inflammatory drugs, corticosteroids, immobility, anticoagulant, high blood pressure, diabetes, dyslipidemia, chronic renal failure, coronary heart disease, stroke, heart failure and cancer disease was 0.45 (95% CI: 0.13-1.5; p = 0.196) for PTS. While HR for the development of PTS adjusted by age, sex, non-steroidal anti-inflammatory drugs, corticosteroids, immobility, anticoagulant treatment, cancer disease and PS of the SU was 0.52 (95% CI: 0.17-1.66; p = 0.272). No statistically significant association was found between CE and the development of SPT, although there were a small number of events detected in both groups.

[Influence of recent trials on essential arterial hypertension management].

Following recent trials, U.S (JNC7), European (ESH/ESC) and world (WHO) guidelines concerning the management of arterial essential hypertension have recently been updated. They indicate that hypertension treatment may succeed in preventing complications such as stroke or myocardial infarction. The therapeutic target is less than 140/90 mmHg (130/80 mmHg for diabetics). To reach this objective, a combination using a diuretic is required in almost all cases. Trials comparing the efficiency of "old drugs" such as diuretics or beta-blockers with "new drugs" such as ACEI or ARAII, or CCB observed minor differences in terms of cardiovascular outcomes. However, ACEI and ARAII appeared to be of particular efficiency in preventing heart and kidney failures.

Vitamin D (25(OH)D) in patients with chronic kidney disease stages 2-5.

To establish the impact the chronic kidney disease stage has in the native vitamin D levels in patients not undergoing dialysis treatment. A study performed in Manizales, Colombia, a city located 2,200 meters above sea level, without important stational variations. Patients with 18 years of age or more, with chronic kidney disease stages 2 to 5 and not undergoing dialysis treatment were recruited for this study. Demographic and anthropometric variations were evaluated as well as solar exposure, CKD etiology and laboratory variables related to bone and mineral diseases. For each CKD clinical stage, correlations were evaluated for vitamin D levels, laboratory results for bone and mineral diseases, solar exposure and ethnicity. Three hundred thirty-three patients were evaluated with a median age of 71 years, most of them mestizo (71%), 173 were women. The main CKD etiology was hypertensive nephropathy (32.2%). 21.1% of patients had normal vitamin D levels, 70.1% were within insufficient range and 8.8% were in deficit. A negative correlation was found between the levels of vitamin 25 (OH) D and the values for: creatinine, phosphorous, calcium x phosphorous product, PTH, 24 hours urine protein and BMI. A positive relationship was found for calcium and albumin. Positive significant statistical correlation was found for vitamin 25(OH) D levels and solar exposure for stages 3b and 4 of CKD. It is common to find low levels of vitamin 25(OH) D in patients with CKD; these can contribute to the appearance of secondary hyperparathyroidism. Establecer el impacto del estadio clínico en los niveles de vitamina D nativa en pacientes con enfermedad renal crónica (ERC) sin diálisis. Estudio realizado en Manizales, Colombia, una ciudad tropical ubicada a 2,200 metros de altura sobre el nivel del mar, sin variaciones estacionales importantes a lo largo del año. Se incluyeron pacientes mayores de 18 años, con enfermedad renal crónica estadio 2 a 5 sin tratamiento dialítico. En ellos se evaluaron variables demográficas, antropométricas, grado de exposición solar, etiología de la enfermedad, y variables de laboratorio relacionadas con desórdenes óseos y minerales. Para cada estadío clínico se evaluó la correlación entre los niveles de vitamina D y los resultados de las pruebas de laboratorio relacionadas con desordenes óseos y minerales, exposición solar y etnia. Se evaluaron 331 pacientes, con una edad media de 71 años, la mayoría mestizos (71%), 173 mujeres. La principal etiología de ERC fue nefropatía hipertensiva (33.2%). El 21.1% de los pacientes tenían niveles normales de vitamina D, fueron insuficientes en 70.1% y 8.8% en déficit. Se detectó correlación negativa, entre los niveles de vitamina 25(OH)D y los valores de creatinina, fósforo, producto calcio x fósforo, PTH, proteínas en orina de 24 horas e IMC. Correlación positiva para el calcio y la albumina. Se encontró significancia estadística positiva entre los niveles de vitamina 25(OH)D y la exposición solar para los estadios 3b y 4. En pacientes con ERC es comun detectar bajos niveles de 25(OH)D, los cuales pueden contribuir a la generación de hiperparatiroidismo secundario.

[Underestimated frequency of resistant hypertension in predialysis nondiabetic patients].

The real prevalence of resistant hypertension (RH) is unknown. Studies suggest that it affects 10%-15% of patients treated for hypertension by primary care physicians. RH is defined as blood pressure (BP) remaining above the goal despite the use of optimal doses of 3 or more medicines of different classes (including a diuretic). It means BP >140/90 mm Hg for the general population and >130/80 mm Hg for patients with diabetes or kidney disease. Prior to diagnosing a patient as having RH, it is important to document medication compliance and exclude white-coat hypertension, inaccurate BP measurement, and secondary causes. The role of aldosterone in RH has gained increasing recognition. There is strong evidence for the use of spironolactone as a highly effective antihypertensive agent. Aldosterone plays a significant role in RH pathogenesis, primarily due to its vasoconstrictive effects and the possibility of altering vascular compliance. In RH, there is a high prevalence of cardiac and extra-cardiac target organ damage. It is known that BP control in chronic kidney disease is the key factor for reducing cardiovascular risk and renal disease progression. The objective of the study was to evaluate the prevalence of RH in predialysis nondiabetic (CKD stage I-IV) patients.

[Aortitis sifilítica: a propósito de un caso del sur colombiano].

Se expone el caso de una paciente de 73 años procedente y residente de Florencia, Caquetá (Colombia), con antecedentes de hipertensión arterial, que ingresa a un hospital de alta complejidad por un cuadro clínico de 3 meses de evolución consistente en dolor torácico tipo opresivo en la región anterior izquierda del tórax, no irradiado, de intensidad 8/10. En el ecocardiograma se evidencia enfermedad calcificada de la válvula aórtica con estenosis aortica grave, insuficiencia aórtica, hipertrofia del ventrículo izquierdo e insuficiencia mitral leve. Dentro de los estudios prequirúrgicos presentó VDRL con 1:4 diluciones, se confirmó el diagnóstico con el resultado de la prueba treponémica y se descartaron otras enfermedades infecciosas. Se realizó remplazo valvular con bioprótesis y tubo valvular supracoronario. En la biopsia se confirmó la valvulitis crónica cicatricial con extensas calcificaciones. Posterior a la intervención quirúrgica se dio egreso por adecuada evolución clínica.

[How I treat... by optimizing the blockade of the renin-angiotensin-aldosterone system].

The blockade of the renin-angiotensin-aldosterone system (RAAS) has been shown to be useful, or even mandatory, in the management of arterial hypertension, congestive heart failure, post-myocardial infarction and nephropathy with albuminuria, due to diabetes or not. Such blockade can be obtained with an angiotensin converting enzyme inhibitor, a specific antagonist of angiotensin II AT1 receptors and/or recently a direct inhibitor of renin such as aliskiren. Various studies have demonstrated the advantage of optimising RAAS blockade in order to benefit of the best cardiorenal protection. The present article describes the various modalities to optimize the RAAS blockade, either by using a maximal dosage of a monotherapy, or by choosing a double inhibition of RAAS. New prospects for the RAAS blockade will be also briefly considered.

Documento de consenso sobre el uso de iSGLT2 en pacientes con enfermedad renal crónica y diabetes.

La enfermedad renal crónica (ERC) del paciente diabético es frecuentemente una consecuencia directa de la diabetes mellitus (DM) de larga evolución y se la conoce como nefropatía diabética. En México cerca del 50% de los pacientes en terapia sustitutiva de la función renal tienen ERC por DM, y este porcentaje podría aumentar en los próximos años. Nuevas opciones terapéuticas, combinadas con cambios en el estilo de vida, han mejorado el control de la glucemia y pueden contribuir sustancialmente a retrasar la aparición o la progresión a estadios avanzados de la ERC. Las sociedades científicas internacionales han elaborado guías clínicas para el diagnóstico y manejo de la nefropatía diabética, sin embargo, en algunos puntos estas recomendaciones no se adaptan a la realidad mexicana. Se presentan las conclusiones de un consenso realizado por especialistas mexicanos sobre diabetes y ERC, con especial énfasis en el uso de los inhibidores del cotransportador de sodio-glucosa. Chronic kidney disease (CKD) in the diabetic patient is mainly a consequence of long-term diabetes mellitus itself. In Mexico approximately 50% of patients on dialysis are diabetics and this will could increase in the coming years. New therapeutic options available, combined with lifestyle changes, have improved glycemic control and may contribute to delay the onset as well as the progression of CKD. International scientific societies have developed clinical guidelines for the diagnosis and management of CKD in diabetics, although in some points, these recommendations are not adapted to the Mexican reality. We hereby present the conclusions of the consensus reached by Mexican specialists on diabetic nephropathy.

[Aliskiren (Rasilez), direct renin inhibitor].

Aliskiren (Rasilez) is the first oral renin inhibitor. Its present indication is essential hypertension, as monotherapy or in combination with other antihypertensive agents (diuretic, calcium antagonist, ...). It may also be associated with an angiotensin converting enzyme inhibitor (or an AT1 angiotensin receptor antagonist) in order to benefit of a dual blockade of the renin-angiotensin-aldosterone system. The usual daily dose is 150 mg, to be increased up to 300 mg if necessary. New clinical trials are ongoing to validate this novel therapeutic approach in other indications such as congestive heart failure and diabetic nephropathy.

Objetivo. Resumir la evidencia científica sobre las altera-ciones renales asociadas con la infección por SARS-CoV-2. Material y métodos. Se realizó una revisión rápida con la metodología Cochrane. Resultados. La enfermedad renal crónica (ERC) preexistente en pacientes con SARS-CoV-2 varió de 1 a 38% y la lesión renal aguda (LRA), de 2.9 a 86.4%. El pronóstico de la infección fue peor en pacientes con ERC y en aquellos con reserva renal remanente (RRR) intacta que desarrollaron LRA. El riesgo de muerte fue mayor (riesgo relativo combinado = 1.49; IC95%: 1.09-2.04) en pacientes infectados por SARS-CoV-2 con ERC preexistente. Los mar-cadores de RRR mostraron alteraciones en pacientes con SARS-CoV-2 graves y fatales; el marcador más utilizado fue la creatinina sérica. Conclusiones. La evidencia científica muestra la relevancia de la evaluación y monitoreo perma-nente de la RRR en pacientes hospitalizados por SARS-CoV-2 para mejorar el pronóstico de aquellos con ERC preexistente, así como de aquellos sin ERC que desarrollan LRA.

[Is there still a place for a dual blockade of the renin-angiotensin system in 2012?].

The blockade of the renin-angiotensin system (RAS) improves the prognosis of patients with complications related to diabetes, hypertension or, in general, atherosclerosis. Several observational studies have suggested the use of a dual blockade of the RAS to benefit from a better cardiorenal protection. However, recent randomized controlled studies failed to demonstrate that a dual blockade exert a better protection than single blockade, but showed a higher risk for renal complications and hyperkalemia. To decrease the residual risk, other opportunities may be recommended such as reinforcement of low salt diet, use of supraphysiological dose of a monotherapy inhibiting the RAS (perhaps prescribed at the evening) or addition of an aldosterone antagonist. However, all these approaches, as dual therapy, may also increase the risk of hypotension and renal insufficiency and thus require to be used under strict medical supervision.

Vitamin D in systemic lupus erythematosus with and without lupus nephritis.

Las concentraciones séricas subóptimas de vitamina D se presentan en múltiples enfermedades crónicas, como las enfermedades autoinmunitarias. Los objetivos del estudio fueron: 1) comparar las concentraciones séricas de 25-hidroxivitamina D (25OHD3) en pacientes con lupus eritematoso sistémico (LES) con y sin nefritis lúpica (NL), y 2) evaluar la asociación de las concentraciones séricas de 25OHD3 con la actividad de la enfermedad. Estudio comparativo, transversal, que incluyó 48 mujeres con LES, con y sin NL. Se excluyeron aquellas con enfermedad renal crónica en estadio IV, cáncer, hiperparatiroidismo, embarazo o lactancia. La actividad fue evaluada con el instrumento SLEDAI-2K. La concentración sérica de 25OHD3 se determinó mediante inmunoanálisis quimioluminiscente. La media de edad de las pacientes con y sin NL fue de 36.3 ± 8.6 años y 42.7 ± 7.6 años, respectivamente. Se observó una elevada prevalencia de valores subóptimos de 25OHD3 en todas las pacientes (93%). Las concentraciones séricas de 25OHD3 fueron diferentes entre pacientes con y sin NL: 21.5 ± 6.8 ng/ml frente a 19.2 ± 7.1 ng/ml (p = 0.362). No se encontró correlación entre la concentración sérica de 25OHD3 y la actividad de la enfermedad (r = -045, p = 0.761). En pacientes con LES, las concentraciones séricas de 25OHD3 fueran diferentes entre pacientes con y sin NL; sin embargo, esta diferencia no fue significativa. Además, no se encontró correlación entre las concentraciones séricas de 25OHD3 y la actividad de la enfermedad evaluada por SLEDAI-2K. Sub-optimal serum vitamin D levels occur in multiple chronic diseases such as autoimmune diseases. The objectives of this study were: 1) compare the serum concentration of 25-hidroxivitamin D (25OHD3) in patients with systemic lupus erythematosus (SLE) with and without lupus nephritis (LN), and 2) evaluate the association of serum concentration of 25OHD3 with the activity of the disease. A comparative, cross-sectional study was conducted, including 48 women with SLE, with and without clinical diagnosis of LN, according to the score of renal activity evaluated by SLEDAI-2K. Patients with stage IV chronic kidney disease, cancer, hyperparathyroidism, pregnancy and lactation were excluded. The activity was evaluated by the SLEDAI-2K instrument. The serum concentration of 25OHD3 was assessed by chemiluminescent immunoassay. The mean age of patients with and without LN was 36.3 ± 8.6 and 42.7 ± 7.6 years, respectively. High prevalence of suboptimal 25OHD3 levels was observed (93%). 25OHD3 concentrations were different between patients with and without LN, 21.5 ± 6.8 ng/mL vs. 19.2 ± 7.1 ng/mL (p = 0.362). No correlation was found between serum 25OHD3 concentration (r = −045, p = 0.761). There were no differences found in serum concentrations of 25OHD3 in patients with or without NL. Moreover, no correlation was found between serum 25OHD3 levels and the activity of the disease evaluated by SLEDAI-2K.

[Which optimal antihypertensive bitherapy for kidney patients?].

In this editorial review on the optimal antihypertensive treatment for chronic kidney disease (CKD) patients, we start with the controversy triggered by Casas et al., for proposing a bitherapy optimal not only for nephroprotection, but also for global cardiovascular protection. The incidence of cardiovascular complications are indeed much greater than the occurrence of end stage renal disease (ESRD) in these patients, so that their prevention has at least the same priority. We explain the huge amount of discordant papers, on the basis of methodology deficiencies in the studies aiming at evidencing the truth of 2 antinomic concepts underlying this controversy: 1) "The correction by antihypertensive drugs of the cardiovascular risk excess in hypertensive patients is exclusively related to their blood pressure lowering effect, the optimal blood pressure (BP) level being defined by epidemiologists at 115/75 mmHg"; 2) "Independently of BP lowering effect, antihypertensive drugs may have intrinsic, protective or deleterious, renal and cardiovascular effects which may be variable according to the target organ". We think that truth is conciliating and that both mechanisms should not be exclusive. However more rigorous studies are still needed to evidence it. Meanwhile we propose the optimal therapy by hypokaliemic diuretics (thiazides+/-loop diuretics according to glomerular filtration decline)+inhibitors of the angiotensin AT1-receptor (ACE inhibitors or AT1RB), in preference to the association of dihydropyridines with diuretics. This recommendation is strong however, only for CKD patients with macroproteinuria. The priority that we give to diuretic therapy is based on the evidence that this class confers good prevention against both heart failure and strokes, which is not the case for all AT1-inhibitors and dihydropyridines. Furthermore the diuretics are the drugs with the longest antihypertensive effect (many weeks) and their efficiency in CKD patients is proportional to the sodium depletion they initially induce and therefore to the dose (specially of the loop diuretics). Indeed volemia control is an incontrovertible factor for optimal BP control in renal insufficiency. As regards the use of betablockers, they should no more be considered as first drug for hypertension because they have the strongest diabetogenic effect. They should be used selectively for their specific cardiologic indications such as angina, heart failure, arythmia and as substitute for ACEI or AT1RB when general anesthesia is considered. Regarding the choice between ACEI and AT(1)RB, on the basis of indirect comparisons, we think that the latter may grant a comparable cardiac protection while giving a better cerebral protection. We shall have to wait the results of ONTARGET study to have or not the evidence for this preference. Finally, we want to stress the necessity to individualize the treatment by taking into account coexistence of cardiovascular complications and of other diseases, as well as the tolerance of the treatment (which may be influenced by seasons, in particular the canicula one), and the cost of the drugs.

Cardiac rehabilitation in the COVID-19 time. Programs. Results.

La pandemia de enfermedad por coronavirus 2019 (COVID-19) ha incidido de forma negativa en los programas de rehabilitación cardiaca (PRC) españoles. Este trabajo tiene como objetivo fundamental el analizar la posibilidad de mantenerlos abiertos y como secundario valorar si se mantienen los beneficios demostrados a nivel físico y psicológico. Analizamos los resultados de nuestro PRC en el año 2020 (119 pacientes) y los comparamos con los del año 2019 (121 pacientes), libre de COVID-19. Se comparan distintas variables generales, y los resultados obtenidos en capacidad física, a nivel psicológico, así como las complicaciones y abandonos. No existen diferencias significativas entre ambos grupos en la edad (61.6 vs. 61.5), sexo (mujeres: 12.6 vs. 14.8%), diagnóstico de cardiopatía isquémica (106 vs. 99) y fracción de eyección de ventrículo izquierdo (55.9 vs. 55.8%). La ansiedad media-alta fue superior al inicio (p = 0.02) y final (p = 0.002) del programa en el año 2019, así como las puntuaciones del patrón de conducta tipo A (p = 0.041 vs. 0.034). El porcentaje de depresión fue similar. Más del 95% de los pacientes del año 2020 referían miedo al contagio. La capacidad funcional aumentó, pero menos en el año 2020 (p = 0.001). La duración del programa fue superior en el año 2020 (p = 0.001). Los abandonos (15 vs. 11 pacientes) no mostraron diferencias significativas. Los PRC en época COVID-19 son posibles y siguen mostrando beneficios. La duración del programa fue mayor por periodos de falta de asistencia. La menor capacidad física puede estar relacionada con el uso de la mascarilla. COVID-19 pandemic has had a negative impact on Spanish Cardiac Rehabilitation Programmes (CRP). The main objective of this study is to analyze the possibility of keeping these units open and, secondly, to assess whether demonstrated physical and psychological benefits are preserved. We analyzed results of our CRP in 2020 (119 patients) and compared them with those of 2019 (121 patients), year free of Covid. We compare different general variables, and results obtained in physical capacity, psychological level, as well as complications and dropouts. There were no significant differences between two groups in age (61.6 vs. 61.5), sex (women: 12.6% vs. 14.8%), diagnosis of ischemic heart disease (106 vs. 99) and left ventricular ejection fraction (55.9% vs. 55.8%). Mean-high anxiety was higher at baseline (p = 0.02) and endline (p = 0.002) of program in 2019, as well as type A behavior pattern scores (p=0.041 and 0.034). Percentage of depression was similar. More than 95% of patients in 2020 reported fear of infection. Functional capacity increased, but less in 2020 (p = 0.001). Programme duration was longer in 2020 (p=0.001). Dropouts (15 vs. 11 patients) showed no significant differences. CR programmes in COVID-19 era are possible and continue to show benefits. The duration of programme was longer due to periods of non-attendance. Lower physical capacity may be related to mask use.

[Which is the role of the angiotensin II receptor blockers (ARBs) for the treatment of heart failure? Do we work based on evidence/recommendations or pharmaceutical industry pressure?].

Chronic heart failure (CHF) represents the first cause of hospitalization in persons older than 6o years in our environment. Beside its incidence and prevalence is increasing although new therapeutic treatments. We think the recommendations of the guidelines of clinical practise are an important instrument to make decisions, although sometimes it is used a numeric language little clear. We do not have either to forget that sometimes patients selected for the clinical trials aren t really representative. Finally to add that pharmaceutical industry spends a lot of money on investigating active basics, but as company itself is needs to obtain benefits. With all of this, in this article we try to study the role of angiotensin II receptor blockers (ARBs) occupy in the medic strategy for the planification of a patient s treatment with chronic heart failure.

Study of longitudinal myocardial deformation in patients with ischemic cardiopathy.

Las enfermedades cardiovasculares constituyen la primera causa de muerte en Cuba y la mayoría de los países desarrollados. La ecocardiografía con speckle tracking bidimensional (ST 2D) es una técnica reciente en la evaluación de la función cardíaca. Determinar la relación entre la deformación miocárdica medida por ST 2D y el estado de la circulación coronaria en pacientes con cardiopatía isquémica, en el CIMEQ, durante un año. Se realizó un estudio analítico y transversal con 55 pacientes con indicación de coronariografía sometidos a ecocardiograma bidimensional y estudio de ST 2D con medición de la deformación longitudinal (DLG). Se crearon dos grupos: enfermedad coronaria significativa (ECS = 32) y no significativa (ECNS = 23). Se utilizó SSPS para análisis de los resultados. La edad promedio fue mayor en la ECS (55.6 ± 9.3 vs. 61.8 ± 8.8; p = 0.014). Predominaron los hombres con ECS (47.3%), los hipertensos (ECS = 90.6% y ENCS = 65.2%; p = 0.02) y los fumadores (ECS = 59.4% y ENCS = 17.4%; p = 0.002). El diagnóstico más frecuente fue la angina crónica estable (87%). En la ECS predominó la enfermedad de tres vasos (75%). La DLG fue menor en la ECS [(-20.0 ± 3.2 vs. -22.1 ± 3.6; p = 0.035); AUC = 0.458]. No hubo diferencias en la DLG según el número de vasos significativamente afectados. Los resultados encontrados no justifican el empleo del ST 2D para diferenciar la ECS. Cardiovascular diseases are the leading cause of death in Cuba and most of the developed countries. Two-dimensional speckle tracking echocardiography (2D ST) is a recent technique in the evaluation of cardiac function. To determine the relationship between myocardial deformation measured by 2D ST and coronary circulation in patients with ischemic heart disease, in the CIMEQ, for 1 year. An analytical, cross-sectional study was carried out with 55 patients with an indication for coronary angiography who underwent 2D echocardiography and 2D ST study with longitudinal strain measurement (LSM). Two groups significant coronary disease (SCD = 32) and not significant (NSCD = 23) were created. SSPS was used to analyze the results. The average age was higher in SCD (55.6 ± 9.3 vs. 61.8 ± 8.8, p = 0.014). Men with SCD (47.3%), hypertensive (SCD = 90.6% and NSCD = 65.2%, p = 0.02) and smokers (SCD = 59.4% and NSCD = 17.4%, p = 0.002) predominated. The most frequent diagnosis was chronic stable angina (87%). Three-vessel disease (75%) prevailed in SCD. The LMS was lower in SCD ([−20.0 ± 3.2 vs. −22.1 ± 3.6, p = 0.035]; AUC = 0.458). There were no differences in LSM according to the number of significantly diseased vessels. The results found do not justify the use of 2D ST to discriminate SCD.

[Effect of the optimal neurohormonal blockade on long-term survival in patients with chronic heart failure].

In recent years large scale clinical trials have cleary shown that a number of pharmacological treatments can improve the outcomes of patients (pts) with chronic heart failure (CHF). The aim of this study was to assess the effect of optimal neurohormal blockade in pts with chronic heart failure on survival during 12 month follow-up. We analyzed data on 489 pts in NYHA II-IV class of HF, referred to our Dept. (mean age was 69 +/- 12). We define doptimal neurohormonal therapy as beta-blocker and ACE-inhibitor in pts with NYHA II, and beta-blocker, ACE-Inhibitor and spironolactone in patients with NYHA III-IV class. Pts were divided into groups: group 1--optimal neurohormonal blockade (n = 232, mean age, 67 +/- 11), group 2--non-optimal neurohormonal blockade (n = 257, mean age, 70 +/- 13). Pts were followed for 12 month. Group with optimal therapy were frequent male gender, of ischemic aetiology, and NYHA class II (p < 0.05). Diabetes mellitus, hypertension, left ventricular ejection fraction did not differ the groups (p = NS). Pts with non-optimal therapy were more frequent with prior history of renal dysfunction and anemia at admission (p < 0.05). During 12 month follow-up 12% in optimal vs 40% in non-optimal therapy died (p < 0.005). The rehospitalisation rate during one-year was also significantly higher in pts receiving non-optimal therapy (69% vs 48%, p < 0.005). Cox multivariate analysis showed after adjusting for age, gender, etiology of HF, NYHA functional class, renal dysfunction, EF, had significantly 62% reduction in mortality and 41% reduction in cardiovascular rehospitalisation in pts receiving optimal therapy. The optimal neurohormonal therapy have favorable effects on outcomes in pts with CHF. This data strongly support that optimalization of care and evidence-based treatment of CHF pts can improve poor prognosis in this group.

[Experiencia en el tratamiento de la hemorragia uterina anormal en adolescentes con enfermedad renal crónica].

La enfermedad renal crónica (ERC) se asocia con alteraciones menstruales, y el manejo del sangrado uterino suele ser complejo por las condiciones de este grupo de pacientes. El objetivo de este trabajo fue describir la respuesta clínica al tratamiento hormonal de las alteraciones menstruales de adolescentes con ERC. Se presentan los datos de una serie de casos de pacientes adolescentes con ERC que cursaron con alteraciones menstruales y que recibieron tratamiento desde el año 2008 al 2012. Se identificaron las características del trastorno menstrual, del tratamiento hormonal recibido y de la respuesta al mismo. El análisis estadístico fue descriptivo. Se estudiaron 11 pacientes de sexo femenino con edad promedio de 14.5 años, que se encontraban en prediálisis (n = 1), diálisis peritoneal (n = 7) y hemodiálisis (n = 3). Las pacientes presentaron hiperpolimenorrea asociada a la opsomenorrea (n = 3), en su mayoría clasificadas como hemorragia uterina anormal secundaria. El tratamiento, en general, fue con progestágenos de manera inicial (clormadinona con o sin medroxiprogesterona) o bien con anticonceptivos combinados. En la mayoría de las pacientes se obtuvo una respuesta favorable; sin embargo, hubo casos en los que fue necesario modificar la dosis y el tiempo de tratamiento. La mayor parte de las adolescentes con ERC que han sido tratadas por hemorragia uterina anormal en nuestro estudio tuvieron una respuesta favorable al tratamiento hormonal. Chronic kidney disease (CKD) is associated with menstrual abnormalities and management of uterine bleeding is often complex because of the conditions in this group of patients. The aim of this study was to describe the clinical response to hormonal treatment of menstrual alterations in adolescents with CKD. We present data of cases of adolescent patients with CKD who had undergone menstrual changes and received treatment during the period 2008 to 2012. The characteristics of the menstrual disorder, hormone treatment received, and response to treatment were evaluated. The statistical analysis aplicated to analyze the results was descriptive. We studied 11 patients with a mean age of 14.5 years, who were in predialysis (n = 1), peritoneal dialysis (n = 7), hemodialysis (n = 3). Patients had hyperpolymenorrhea associated with opsomenorrhea (n = 3), mostly classified as secondary abnormal uterine bleeding. Treatment, in general, was with progestins initially (chlormadinone with or without medroxyprogesterone) or combined contraceptives. In the majority of the patients, a favorable response was obtained; however, there were cases where it was necessary to modify the dose and time of treatment. The majority of adolescents with CKD who have been treated for abnormal uterine bleeding in our study had a favorable response to hormonal treatment.

[Lights and shadows on single and dual RAAS blockade].

Angiotensin-converting enzyme inhibitors (ACE-i) and angiotensin II receptor blockers (ARBs) are of paramount importance in everyday clinical practice. Developed as antihypertensive drugs, they soon acquired another important indication as a result of their antiproteinuric activity and capacity to delay the progression of chronic kidney disease. ACE-i and ARBs started out being used as single drugs and were subsequently combined to obtain more complete blocking of the renin-angiotensin-aldosterone system (RAAS). The most evident advantages derived from the administration of these drugs - alone or in combination - have been obtained in proteinuric nephropathies, such as chronic glomerulonephritis and diabetic nephropathy, where they have become the treatment choice. Dual RAAS blockade has been recently evaluated in a large trial of high-risk cardiovascular patients, in whom no related benefits were shown. To the contrary, a higher risk of worsening renal function emerged. It is now quite clear that patients with high proteinuria levels are the ones that benefit most from RAAS inhibition, also with combined ACE-i and ARB. It is very important to pay the utmost attention when these drugs are used in patients in whom no benefit is obtained by RAAS inhibition, such as patients with chronic kidney disease and atherosclerosis, elderly patients, and those without any significant proteinuria.