Nelson Murillo

Importance: Most epidemiological studies of heart failure (HF) have been conducted in high-income countries with limited comparable data from middle- or low-income countries. Objective: To examine differences in HF etiology, treatment, and outcomes between groups of countries at different levels of economic development. Design, Setting, and Participants: Multinational HF registry of 23 341 participants in 40 high-income, upper-middle-income, lower-middle-income, and low-income countries, followed up for a median period of 2.0 years. Main Outcomes and Measures: HF cause, HF medication use, hospitalization, and death. Results: Mean (SD) age of participants was 63.1 (14.9) years, and 9119 (39.1%) were female. The most common cause of HF was ischemic heart disease (38.1%) followed by hypertension (20.2%). The proportion of participants with HF with reduced ejection fraction taking the combination of a β-blocker, renin-angiotensin system inhibitor, and mineralocorticoid receptor antagonist was highest in upper-middle-income (61.9%) and high-income countries (51.1%), and it was lowest in low-income (45.7%) and lower-middle-income countries (39.5%) (P < .001). The age- and sex- standardized mortality rate per 100 person-years was lowest in high-income countries (7.8 [95% CI, 7.5-8.2]), 9.3 (95% CI, 8.8-9.9) in upper-middle-income countries, 15.7 (95% CI, 15.0-16.4) in lower-middle-income countries, and it was highest in low-income countries (19.1 [95% CI, 17.6-20.7]). Hospitalization rates were more frequent than death rates in high-income countries (ratio = 3.8) and in upper-middle-income countries (ratio = 2.4), similar in lower-middle-income countries (ratio = 1.1), and less frequent in low-income countries (ratio = 0.6). The 30-day case-fatality rate after first hospital admission was lowest in high-income countries (6.7%), followed by upper-middle-income countries (9.7%), then lower-middle-income countries (21.1%), and highest in low-income countries (31.6%). The proportional risk of death within 30 days of a first hospital admission was 3- to 5-fold higher in lower-middle-income countries and low-income countries compared with high-income countries after adjusting for patient characteristics and use of long-term HF therapies. Conclusions and Relevance: This study of HF patients from 40 different countries and derived from 4 different economic levels demonstrated differences in HF etiologies, management, and outcomes. These data may be useful in planning approaches to improve HF prevention and treatment globally.

Background: Fabry disease (FD) is an X-linked lysosomal sphingolipidosis. It is caused by pathogenic variants in the GLA gene with a consequent deficiency of the enzyme α-galactosidase A, resulting in the pathological accumulation of glycolipids - mainly globotriosyl ceramide (GL-3, GB3) and its deacylated product, globotriaosylsphingosine (Lyso-Gb-3) - in plasma and in a wide variety of cell types throughout the human body; it is characterized as a chronic, multisystemic disease with progressive evolution, which causes deterioration of the patient's quality of life and decreases survival and life expectancy.In Latin America there are different limitations to the management of patients with Fabry disease, in most countries, access to diagnostic tools and treatment on time is complex and can sometimes suffer delays in its implementation. This situation is due to the high costs to health systems of follow-up and pharmacological therapy for Fabry patients, creating barriers to timely access. Conclusions: Although medical criteria are fundamental in the choice of pharmacological therapy, the final decision should also rely on the patient's choice according to their expectations and the adherence and compliance with the treatment that they are willing to follow. As it has been described, there are currently three therapeutic options, for which the appropriate profile must be defined to achieve the best clinical outcomes, considering that it is a permanent treatment; experts consider that Fabry patients need comprehensive and interdisciplinary management to stop the progression and functional deterioration of the affected organs by its multiple systemic manifestations. In Latin-American countries, it is difficult to guarantee this comprehensive and coordinated management, due to limited public policies related to orphan diseases diagnosis, treatment and follow up.It is considered crucial to structure support networks specialized in Fabry disease and generate partnerships with health institutions and other health system stakeholders, that would articulate and coordinate patients and relatives counseling and management, establish the specific pharmacological treatment to reduce the progression of the disease and the systemic involvement, deciding between the administration of enzyme replacement therapy or the most recent option of oral management with pharmacological chaperone both with proven effectiveness. This will be the decision of the attending physician, who will propose and advise the therapeutic choice that best suits the patient's needs.

Los puentes miocárdicos son una condición congénita, con una frecuencia variable. Han sido considerados como variante anatómica, hasta causantes de isquemia, infarto agudo del miocardio y muerte súbita. Los mecanismos involucrados guardan relación con la compresión sistólica de la arteria, el retardo en la recuperación de su diámetro en diástole y la alteración en el perfil de las velocidades y el flujo coronario. El abordaje diagnóstico aún considera la angiografía coronaria, pero cada vez se acepta un rol mayor del ultrasonido intravascular y el doppler intracoronario. El tratamiento farmacológico es la primera opción, aunque en pacientes seleccionados con angina refractaria o falla a la terapia médica se podría considerar la revascularización percutánea y/o quirúrgica. A continuación se presenta una serie de once pacientes en quienes se documentaron puentes miocárdicos como parte del estudio diagnóstico en el contexto de un síndrome coronario agudo (infarto agudo del miocardio sin elevación del ST), y se discute su relación como agente causal y las opciones terapéuticas disponibles. The myocardial bridges are a congenital condition, with a variable frequency. These have been considered from an anatomical variant up to the cause of ischemia, acute myocardial infarction and sudden death. The mechanisms involved are related to the systolic compression of the coronary artery, the delay in recovering its diameter during diastole and the alteration in the speed profile and the coronary flow. The diagnostic approach still considers coronary angiography, but a greater role of intravascular ultrasound and intracoronary Doppler is increasingly accepted. Drug therapy is the first choice, but in selected patients with refractory angina or medical therapy failure, percutaneous and / or surgical revascularization could be considered. We report a series of eleven patients with documented myocardial bridges as part of the diagnostic study in the context of an acute coronary syndrome (acute myocardial infarction without ST elevation), and discuss their relationship as causal agent and the available therapeutic options.

Colombia, conocedor de la importancia de la Antartida, es adherente del Tratado Antartico desde el ano 1989 y desde esa fecha se han efectuado algunas actividades que han permitido preparar la Primer Expedicion Cientifica de Colombia en la Antartida, como punto de partida para cambiar el status del pais, de estado de adherente a consultivo del Tratado. El 16 de diciembre del 2014 el buque de la Armada Nacional de Colombia, ARC “20 DE JULIO, zarpo de la Base Naval ARC “BOLIVAR” ubicada en la ciudad de Cartagena, para dar inicio a la Primera Expedicion Cientifica de Colombia en la Antartida. La expedicion llevo abordo 57 tripulantes del buque ARC “20 DE JULIO”, 13 personas de apoyo (medico, tripulacion helicoptero, medios de comunicacion), 3 asesores operacionales de la Armada de Chile y 19 cientificos de 9 instituciones nacionales y una internacional (Chile). El buque ARC “20 DE JULIO” atraco en la ciudad de Cartagena por termino de la expedicion antartica el 24 de marzo del 2015, logrando resultados mas alla de lo planeado y despues de superar retos tecnicos, operativos y logisticos, con lo que se marca un hito en el camino de Colombia como miembro consultivo del Tratado Antartico.