The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase 1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age  6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score  652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc = 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N = 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in Asia and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701

El rescate de la docencia dañada por la pandemia COVID-19

Antecedentes y Objetivo: Los estragos causados por la pandemia COVID-19 alcanzaron también la educación médica perdiéndose la enseñanza tutorial que ejercíamos en nuestro Instituto. Método: Se implementaron estrategias a través de las tecnologías de la información y de la comunicación que se describen en este artículo. Resultados: Con las estrategias llevadas a cabo se pudo continuar con toda la educación teórica de manera virtual a distancia, incluyendo el pase cotidiano de visita a los enfermos, la presentación de casos clínicos, el análisis a distancia de los métodos de laboratorio y gabinete, así como la enseñanza de la exploración física y la adquisición de los métodos de ayuda diagnóstica de los gabinetes. El número de asistentes a la sesión general semanaria del Instituto incremento de 100 asistentes presenciales a 500 virtuales (promedio) con reproducciones de las mismas en un promedio de 5,000. Se discuten las ventajas e inconvenientes de estas nuevas técnicas y cuáles son los desafíos para el futuro. Conclusiones: Sin duda alguna, la pandemia ha causado daño a la enseñanza de dos generaciones de estudiantes de la medicina en los años 2020 y 2021 y aún seguimos temerosos de que en el 2022 persista. A nuestro juicio la educación médica implementada por nosotros no es lo ideal, pero por lo menos constituye un buen paliativo del daño que la pandemia produjo en la educación médica

Características clínicas, modalidades de tratamiento y mortalidad en la ruptura del septum interventricular posinfarto

Objetivo: Conocer las características, estrategia de tratamiento y mortalidad en pacientes con infarto agudo al miocardio y ruptura del septum interventricular posinfarto. Métodos: Se incluyeron 40 pacientes atendidos en un periodo de ocho años por infarto agudo al miocardio complicado con ruptura del septum interventricular posinfarto. Se utilizó ecocardiograma para confirmar la ruptura del septum interventricular posinfarto. Se evaluaron las características clínicas, el tipo de tratamiento y la mortalidad hospitalaria. Las variables se compararon con prueba U de Mann-Withney o prueba exacta de Fisher. Resultados: Edad 64 años (56 a 73), 67% hombres, 53% diabetes, 43% hipertensión, 40% tabaquismo. Los tratamientos fueron: conservador 45%, quirúrgico 38% o dispositivo Amplatzer 17%. La mortalidad general fue de 65%, con manejo conservador 54%, con cirugía 35% y con Amplatzer 12% (p = 0.02), y estuvo asociada a menor tiempo entre infarto agudo al miocardio y ruptura del septum interventricular posinfarto (p <0.001) y menor tiempo entre ruptura del septum interventricular posinfarto y tratamiento de cierre (p <0.001). Todos los pacientes con Killip Kimbal III o IV murieron. Conclusiones: Hasta el momento no existe una estrategia de manejo en la ruptura del septum interventricular posinfarto que demuestre ventajas sobre las demás. El único marcador de buen pronóstico podría ser el mayor tiempo entre la ruptura y el tratamiento de cierre. Es probable que la indicación de manejo de las guías internacionales no aplique para todos los pacientes y estos deban estratificarse de acuerdo a su estado hemodinámico

The TIMI risk score for STEMI predicts in-hospital mortality and adverse events in patients without cardiogenic shock undergoing primary angioplasty

Introduction: Patients with ST elevation acute myocardial infarction (STEMI) comprise a heterogeneous population with respect to the risk for adverse events. Primary percutaneous coronary intervention (PCI) has shown to be better, mainly in high-risk patients. Objective: The purpose of this study was to determine if the Thrombolysis in Myocardial Infarction (TIMI) risk score for STEMI applied to patients undergo primary PCI identifies a group of patients at high risk for adverse events. Methods: We identifed patients with STEMI without cardiogenic shock on admission, who were treated with primary PCI. The TIMI and CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) risk scores were calculated to determine their predictive value for in hospital mortality. Patients were divided into two groups according to their TIMI risk score, low risk being 0-4 points and high risk &#8805;5 points, and the frequency of adverse events was analyzed. Results: We analyzed 572 patients with STEMI. The c-statistics predictive value of the TIMI risk score for mortality was 0.80 (p=0.0001) and the CADILLAC risk score was 0.83, (p=0.0001). Thirty-two percent of patients classifed as high risk (TIMI &#8805;5) had a higher incidence of adverse events than the low-risk group: mortality 14.8% vs. 2.1%, (p=0.0001); heart failure 15.3% vs. 4.1%, (p=0.0001); development of cardiogenic shock 10.9% vs. 1.5%, (p=0.0001); ventricular arrhythmias 14.8% vs. 5.9%, (p=0.001); and no-refow phenomenon 22.4% vs. 13.6%, (p=0.01). Conclusions: The TIMI risk score for STEMI prior to primary PCI can predict in hospital mortality and identifes a group of high-risk patients who might develop adverse events