Alejandro Macchia

CARMELA: assessment of cardiovascular risk in seven Latin American cities.

OBJECTIVE This cross-sectional, population-based observational study using stratified multistage sampling assessed the prevalence of cardiovascular risk factors and carotid plaques and measured carotid intima-media thickness in individuals living in major cities in 7 Latin American countries. PATIENTS AND METHODS The study comprised individuals (n=11,550) aged 25 to 64 years, living in Barquisimeto, Bogota, Buenos Aires, Lima, Mexico City, Quito, and Santiago. Data on anthropometric parameters, blood pressure, fasting glucose, total and high-density lipoprotein cholesterol, triglycerides, carotid intima-media thickness, carotid plaque, and smoking status were collected through household interviews and clinical, biochemical, and sonographic measurements. RESULTS The overall prevalence rates (ranges across cities) were as follows: hypertension (> or = 140/90 mm Hg or pharmacologic treatment), 18% (9%-29%); hypercholesterolemia (total cholesterol > or = 240 mg/dL), 14% (6%-20%); diabetes (glycemia > or = 126 mg/dL or self-reported diabetes), 7% (4%-9%); metabolic syndrome, 20% (14%-27%); obesity (body mass index > or = 30 kg/m2), 23% (18%-27%); smoking, 30% (22%-45%); and plaque, 8% (5%-14%). The mean intima-media thickness was 0.65 mm (0.60-0.74 mm). CONCLUSION The prevalence of hypertension mirrored the world average in 3 cities but was lower in the rest. Hypercholesterolemia was highly prevalent even in countries of different socioeconomic levels. The prevalence of diabetes was similar to that in the developed countries. Tobacco use in women living in Santiago and Buenos Aires was among the worlds highest. Intima-media thickness and carotid plaque prevalences varied widely.

Left ventricular systolic dysfunction, total mortality, and sudden death in patients with myocardial infarction treated with n-3 polyunsaturated fatty acids

Sudden death (SD) has a major impact on mortality (M) in patients with left ventricular systolic dysfunction (SyD). In GISSI‐Prevenzione, treatment with n‐3 polyunsaturated fatty acids (PUFA) reduced M and SD in post‐MI patients, but their effect in patients with SyD is unknown.

Systematic review of trials using vasodilators in pulmonary arterial hypertension: why a new approach is needed.

BACKGROUND In a previous meta-analysis on the approved treatments for pulmonary hypertension, we reported that all therapies caused small changes in 6-minute walk distance over a short period, with minimal effects on hemodynamics and no effect on survival. Since that last review, 10 new clinical trials with about 1,500 patients have been published, which has increased the statistical power of our observations. METHODS A systematic review of all clinical trials in pulmonary arterial hypertension was done. RESULTS The pooled effect of all treatments strategies (relative risk [95% CI], P) now shows a significant reduction of 39% (2%-62%, P = .041) in all-cause mortality. The benefits were confined only to patients with advanced disease for 16 weeks, regardless of which class of drug is used. When considering the effects within each drug family, no class of drug produced a statistically significant reduction in all-cause mortality. The improved survival bore no relationship with the change in 6-minute walk, the primary end point in most of the trials. CONCLUSIONS The impact of vasodilators on long-term survival in pulmonary arterial hypertension remains uncertain. Future trials need to (a) adopt new trial designs that can better address clinical benefits, (b) use new end points that incorporate our best understanding of the disease rather than the ones that are easy to administer, and (c) include longer durations of study and other strategies to clarify if survival is affected.

The prognostic influence of chronic obstructive pulmonary disease in patients hospitalised for chronic heart failure

To investigate the prevalence and the prognostic impact of chronic obstructive pulmonary disease (COPD), in patients hospitalised with chronic heart failure (CHF).

Total myocardial revascularization with arterial conduits: Radial artery combined with internal thoracic arteries

OBJECTIVE We prospectively tested the feasibility of achieving total arterial revascularization with the use of the radial artery to revascularize the circumflex, diagonal, and right coronary arteries combined with a left internal thoracic artery graft to the left anterior descending artery and, in some cases, a right internal thoracic artery graft to the right coronary artery. METHODS In 164 patients, the radial artery was used as a free Y or T graft from the left internal thoracic artery. Of 568 grafts (3.5 +/- 1 [standard deviation] per patient), 296 (1.8 +/- 0.8 per patient) were constructed with the radial artery as single grafts or as double, triple, or quadruple sequential anastomoses to the circumflex, diagonal, and posterior descending arteries. Diltiazem was administered to prevent spasm. Forty-six patients underwent coronary angiography before discharge from the hospital. Follow-up time was 1 to 19 (9.5 +/- 6.1) months. RESULTS Total arterial revascularization was achieved in 137 patients (83.5%). Three (1.8%) died postoperatively of sepsis, ventricular fibrillation, and heart failure, respectively. Three (1.8%) had postoperative myocardial infarction. No hand ischemia occurred. Angiography showed patency of all arterial conduits. Radial artery spasm appeared in 3 (6.5%) of 46 angiograms. Two patients (1.2%) died during the follow-up period of pneumonia and gastrointestinal tract bleeding, respectively. No other events or reoperations occurred, and 95.1% of the patients are free of symptoms. CONCLUSIONS The radial artery, as a free Y or T graft from the left internal thoracic artery to the circumflex, diagonal, and right coronary arteries, permits total arterial revascularization with excellent patency rates, minimal morbidity and mortality, and no need for reoperation. Longer follow-up times are necessary to draw definitive conclusions.

Vitamin E increases the risk of developing heart failure after myocardial infarction: results from the Gissi-prevenzione trial

Objective Although results from basic science suggested a protective role of vitamin E treatment in the prevention of cardiovascular disease, recent evidence indicates increased cardiovascular mortality due to vitamin E treatment. Recently, the HOPE trial showed an increment of the incidence of congestive heart failure (CHF) in patients treated with vitamin E. Methods We explored the effect of vitamin E on development of CHF in 8415 postinfarction patients without CHF at baseline, with an echocardiographic measure of left ventricular ejection fraction, who have been followed up for 3.5 years in the GISSI-Prevenzione trial. CHF during follow-up was defined as hospitalization or death for CHF. Cox regression models adjusted for relevant prognostic indicators were fitted. Results Main clinical characteristics were balanced in the 4202 and 4213 patients allocated vitamin E and control group, respectively. During follow-up, 220 patients (2.6%) developed CHF. Patients allocated vitamin E had a nonsignificant 20% (95% confidence intervals 0.92–1.56, P = 0.18) increased risk of developing CHF. Vitamin E treatment, however, was associated with a significant 50% increase (95% confidence intervals 1.03–2.20, P = 0.034) of CHF in patients with left ventricular dysfunction (ejection fraction < 50%). Conclusions Our results confirm and extend previous evidence on the possible harmful effect of vitamin E on ventricular function in patients with cardiovascular disease. Available evidence should discourage the use of vitamin E in patients with left ventricular dysfunction.

Hypertension in seven Latin American cities: the Cardiovascular Risk Factor Multiple Evaluation in Latin America (CARMELA) study.

Background Little information is available regarding hypertension, treatment, and control in urban population of Latin America. Objective We aimed to compare blood pressure (BP) distribution, hypertension prevalence, treatment, and control in seven Latin American cities following standard methodology. Methods The Cardiovascular Risk Factor Multiple Evaluation in Latin America (CARMELA) study was a cross-sectional, epidemiologic study assessing cardiovascular risk factors using stratified multistage sampling of adult populations (aged 25–64 years) in seven cities: Barquisimeto (Venezuela; n = 1848); Bogotá (n = 1553); Buenos Aires (n = 1482); Lima (n = 1652); Mexico City (n = 1720); Quito (n = 1638); and Santiago (n = 1655). The prevalence of hypertension and high normal BP were determined based on 2007 European Society of Hypertension and European Society of Cardiology definitions. Results BP increased with age in men and women; pulse pressure increased mainly in the upper age group. The hypertension prevalence ranged from 9% in Quito to 29% in Buenos Aires. One-quarter to one-half of the hypertension cases were previously undiagnosed (24% in Mexico City to 47% in Lima); uncontrolled hypertension ranged from 12% (Lima) to 41% (Mexico City). High normal BP was also evident in a substantial number of each city participants (≈5–15%). Majority of population has other cardiovascular risk factors despite hypertension; only 9.19% of participants have no risk factors apart from hypertension. Conclusion From 13.4 to 44.2% of the populations of seven major Latin American cities were hypertensive or had high normal BP values. Most hypertensive patients have additional risk factors. Public health programs need to target prevention, detection, treatment, and control of total cardiovascular risk in Latin America.

Clinical ResearchHeart Rhythm Disorders in Heart FailureOmega-3 Fatty Acids for the Prevention of Recurrent Symptomatic Atrial Fibrillation: Results of the FORWARD (Randomized Trial to Assess Efficacy of PUFA for the Maintenance of Sinus Rhythm in Persistent Atrial Fibrillation) Trial

OBJECTIVES The aim of this study was to evaluate the efficacy of polyunsaturated fatty acids (n-3 PUFA) for the prevention of recurrent atrial fibrillation (AF) in patients with normal sinus rhythm. BACKGROUND Current pharmacological treatments to limit recurrent AF in patients with previous AF have limited efficacy and high rates of adverse events. Results of trials that tested the efficacy of n-3 PUFA provided heterogeneous results. METHODS This was a prospective, randomized, double-blind, placebo-controlled, multicenter trial involving 586 outpatient participants with confirmed symptomatic paroxysmal AF that required cardioversion (n = 428), at least 2 episodes of AF in the 6 months before randomization (n = 55), or both (103). Patients were randomly allocated to n-3 PUFA (1 g/day) or placebo for 12 months. The primary endpoint was symptomatic recurrence of AF. RESULTS There were no significant differences between patients allocated to placebo and those who received n-3 PUFA for the main outcome. At 12 months, 56 of 297 participants (18.9%) in the placebo group and 69 of 289 participants (24.0%) in the n-3 PUFA group had a recurrent symptomatic AF (hazard ratio: 1.28, 95% confidence interval: 0.90 to 1.83, p = 0.17). There was no difference between treatment with placebo and n-3 PUFA for any of the other pre-specified endpoints, including the composite of all-cause mortality, nonfatal stroke, nonfatal acute myocardial infarction, systemic embolism, heart failure development, or severe bleeding that occurred in 20 (6.7%) and 16 (5.5%) of patients randomized to placebo or n-3 PUFA, respectively (hazard ratio: 0.86, 95% confidence interval: 0.44 to 1.66, p = 0.65). CONCLUSIONS Pharmacological supplementation with 1 g of n-3 PUFA for 1 year did not reduce recurrent AF. (Randomized Trial to Assess Efficacy of PUFA for the Maintenance of Sinus Rhythm in Persistent Atrial Fibrillation [FORWARD]; NCT00597220).

Previous prescription of β-blockers is associated with reduced mortality among patients hospitalized in intensive care units for sepsis*

Objectives: Results from basic science and narrative reviews suggest a potential role of &bgr;-blockers in patients with sepsis. Although the hypothesis is physiologically appealing, it could be seen as clinically counterintuitive. We sought to assess whether patients previously prescribed chronic &bgr;-blocker therapy had a different mortality rate than those who did not receive treatment. Setting: Record linkage of administrative databases of Italian patients hospitalized for sepsis during years 2003–2008 were identified and followed up for all-cause mortality at 28 days. Interventions: None. Measurements and Main Results: We identified 9,465 patients aged ≥40 yrs who were hospitalized in critical care units for sepsis. Of these, 1,061 patients were on chronic prescription with &bgr;-blockers and 8404 were not previously treated. Despite a higher risk profile, patients previously prescribed with &bgr;-blockers had lower mortality at 28 days (188/1061 [17.7%]) than those previously untreated (1857/8404 [22.1%]) (odds ratio 0.78; 95% confidence interval 0.66–0.93; p = .005 for unadjusted analysis, and odds ratio 0.81; 95% confidence interval 0.68–0.97; p = .025 for adjusted analyses). Sensitivity and pair-matched results confirm the primary findings. Conclusions: As far as we are aware, this pharmacoepidemiologic assessment is the largest to examine the potential association of previous &bgr;-blocker prescription and mortality in patients with sepsis. Chronic prescription of &bgr;-blockers may confer a survival advantage to patients who subsequently develop sepsis with organ dysfunction and who are admitted to an intensive care unit. Prospective randomized clinical trials should formally test this hypothesis.

Depression worsens outcomes in elderly patients with heart failure: An analysis of 48,117 patients in a community setting

To assess the relationship between depression and clinical outcomes among elderly patients with heart failure (HF) in a community setting.