S1409-414220010002 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000200001 Speranza Sánchez Mario , 08 2001 2001 3 03 03
S1409-414220010002 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000200002 Tratamiento de la trombosis venosa profunda con heparina de bajo peso molecular: impacto económico, seguridad y eficacia Pucci Juan J ,CCSS Hospital México Servicio de Cirugía de Tórax y Cardiovascular San José Costa Rica 08 2001 2001 3 04 05
S1409-414220010002 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000200003 De lo que no se habla: ¿por qué se puede dormir a los animales y no a los hombres? Ansin Juan Carlos ,Consultorios Médicos Paitilla Ciudad de Panamá Panamá 08 2001 2001 3 06 07
S1409-414220010002 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000200004 Uso de heparinas de bajo peso molecular en el manejo ambulatorio de pacientes con trombosis venosa profunda. Estudio comparativo: heparina no fraccionada vs heparina de bajo peso molecular Quirós M Gerardo Zamora Morera Marco V ,CCSS Hospital Calderón Guardia Servicio de Cirugía Vascular San José Costa Rica 08 2001 2001 3 08 13

Justificación y Objetivos: El presente estudio establece un análisis comparativo del uso de las heparinas no fraccionadas (convencionales) aplicadas en infusión continua endovenosa y las heparinas de bajo peso molecular (HBPM) administradas en forma subcutánea. Se compara la evolución de pacientes con trombosis venosa profunda, ofreciendo a la vez una perspectiva económica que señala una diferencia significativa y que, a la larga, podría marcar la pauta para la incorporación en nuestro medio de nuevas variantes terapéuticas en el tratamiento de nuestros pacientes. Material y Métodos: En forma prospectiva fueron evaluados un total de 40 pacientes con trombosis venosa profunda diagnosticada por primera vez mediante los hallazgos clínico y corroborados por ultrasonografía doppler. El primer grupo de 20 pacientes, elegido en forma aleatoria, fue tratado con hepa-rina de bajo peso molecular (nadroparina) a dosis de 0,6 cc. Sc cada 12 horas, por tres días e iniciando en forma concomitante warfarina a dosis estándar de carga de 15 mg vía oral, el primer día, 10 mg el segundo día y 5 mg días restantes con monitorización del tiempo de tromboplastina ( TPT ), tiempo de protrombina ( TP ) y del cociente internacional normalizado ( INR ) al cuarto día valorados en consulta externa. El segundo grupo control de 20 pacientes fueron hospitalizados requiriendo la infusión continua endovenosa de heparina no fraccionada con el respectivo monitoreo seriado de los tiempos de coagulación hasta lograr los niveles óptimos. Resultados: Se identificaron tres casos de retrombosis en el grupo tratado con heparina no fraccionada (15%). Así mismo se registró un cuadro de tromboembolismo pulmonar ( TEP ) ( 5% ) y dos sangrados menores (10%). En los 20 pacientes manejados con HBPM no se reportaron complicaciones. Los controles de laboratorio mostraron una tendencia a la sobreanticoagulación en el 25% de los pacientes que recibieron infusión endovenosa contínua de heparina no fraccionada con TPT en intervalos de 57- 120 segundos e INR de 1,9- 5,4. El TPT de los pacientes ambulatorios no sobrepasó los 62 segundos y el INR osciló en un rango de 2,0- 4,2 durante los los primeros controles. En cuanto a la estancia hospitalaria y costos en el grupo de pacientes ambulatorios se registraron un total de días promedio por individuo de 0,16 días para un total de 79,2 horas ( 3,3 días) de estancia para todos los 20 pacientes. En el grupo de control se obtuvo un promedio de 5,4 días por paciente, para un total de 2592 horas (108 días), cifra que refleja la estancia global de este grupo. Los costos individuales por estancia fueron de 486 mil colones por paciente hospitalizado contra 12.800 colones por paciente ambulatorio. A la vez tomados en cuenta los costos del tratamiento en ambos grupos y sumando a esto las horas de estancia, el costo global de cada grupo fueron de 8.880.000 millones de colones (aproximado), para el grupo hospitalizado contra 1.464.000 millones de colones para el que fue manejado en forma ambulatoria con HBPM. Conclusiones: Las heparinas de bajo peso molecular aplicadas en forma subcutánea, son una alternativa eficaz, segura y de menor costo en el manejo de pacientes con trombosis venosa profunda, si se le compara al manejo hospitalario que requiere el uso de heparina no fraccionada endovenosa y monitoreo inicial frecuente de los tiempos de coagulación.

Background: a comparative study was carried out on the use of intravenous Unfractionated heparin, administered inside the hospital in continuos infusion versus the subcutaneous low -molecular - weight heparin. Clinical and economical aspects are analyzed in both groups of patients. Methods: Prospective study of two groups of 20 patients each randomly chosen during 1 year. The diagnosis was made by duplex ultasound. The first group was treated whit low molecular weight heparin. (Nadroparin ) in subcutaneous doses of 0.6 cc (5700 UI Axa )of the standard doses every 12 hours during tree days. 15 mg of oral warfarin was also initiated the first day followed by 10 mg the second day and 5mg the following days. Prothrombin time (PT), thromboplastin time (TPT)and international normalized ratio (INR)were monitored on the fourth day during the external medical check/up. The second group was hospitalized with intravenous administration of non-fractioned heparin and received adequate control of their PT, TPT and INR until reaching optimal levels. Results: Patients who received low molecular heparin did not require formal hospitalization due to the absence of complications and the economical cost of treatment was only 20% of the total cost reported in the group that did require hospitalization. The group treated whit non-fractioned heparin presented rethrombosis (15%), pulmonary embolism (5%) and minor bleedings (10%), which did not alter the hemodinamical state.

 Trombosis venosa profunda Heparina de bajo peso molecular Heparina no fraccionada tratamiento ambulatorio Deep venous thrombosis low molecular weight heparin home treatment economical cost unfractionated Russell D Hull MBBS Gary Treatment of proximal vein Thrombosis with subcutaneous low-molecular weight heparin. US intravenous heparin. An economic perspective Hull RD Ach. Intern. Med 1997 157 ^s3 Russell D Hull, E Raskob Graham Subcutaneous low molecular weight heparin Vs warfarin for prophylaxis of deep vein trombosis Arch. Intern Med 1997 F eb 157 ^s3 Levine Mark Gert Michel Hirrsh Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular- weight heparin administered at home N. Engl. J. Med 1996 m ar 334 ^s11 Michel Gert Hirrsh Leclerc MD Comparison of low- molecular weight heparin administered primarly at home with unfractionated heparin administered in the hospital for proximal deep vein thrombosis N. Engl. J. Med 1996 m ar 334 ^s11 Russell D Hull MBBS Gary Low- molecular weight heparin an opportunity for home treatment of deep venous thrombosis N. Engl. J. Med 1996 m ar 334 ^s11 Kovacs Michael Anderson Davis Low-molecular-weight-heparine. Reduction of trombotic and haemorragic complications Am Heart Journal 1996 D ec 132 ^s6 Büller H. R Gent M Gallus AS Low- molecular weight heparin in the treatment of patients with venous thromboembolism N. Engl. J. Med 1997 s ep 337 ^s10 Simonnean Gerald Sois Herve Comparison of low- molecular weight heparin with unfractionated heparin for acute pulmonary embolism N. Engl. J. Med 1997 s ep 337 ^s10 Villan Andrew Powers Peter Haby Susa Heparin associated trombocytopenia and Thrombosis Heparin associated trombocytopenia and Thrombosis Ginsberg Jeffrey Brien William Low- molecular weight heparin- biochemistry pharmacology- perioperative prophylaxis Anesthesiology 1997 85 ^s4 Koch A Bouges S Zielgler S Low- molecular weight heparin and unfractionated heparin in thrombosis prophylaxis after major surgical intervention Br. Journal Surgery 1997 j un 84 ^s6 Raskob E Pireo G.F Hull R. D Heparin and antithrombotic efficacy Plast Reconstructive surgery 1997 , ju 100 ^s1 Jack Hirsh Mark Levine Treatment of patients with an undefined hypercoagulable state with long term low- molecular weight heparin West J. Med 1996 164 ^s4 Hull R.D Koopman M Pradani Severe proximal proximal deep vein thrombosis treated with low- molecular weight heparin." Glanzmann Thromobostenia Blood 1997 j ul 90 ^s2 John IVP John EP MD G. A Silver Donald Diagnóstico y tratamiento en cirugía Vascular 1995 33 Faivre R Newhart E Kieffu Y Subcutaneous administration of low- molecular heparin ( CY 222), compared with subcutaneous administration of standard heparin Thromb Heamost 1987 58 Hull R.D Raskob G.E Subcutaneous low- molecular heparin compared with continuos intravenous heparin in the treatment of proximal thrombosis N. England J. Med 1992 326 Prandoni P Lensing AWA Bulle "Comparison of subcutaneous low- molecular heparin "with intravenous standard heparin in proximal deep thrombosis Lancet 1992 339 Hyers TM Hull RD Weg JG Thrombotic therapy for venous thromboembolic disease Chest 1995 108 Hirsh J Levine MN Low molecular weight heparin Blood 1992 79 Koopman MMW Prardoni P Piovella F Treatment of venous thrombosis with intravenous unfractionated heparin administrated in the hospital as compared with subcutaneous low- molecular weight heparin administrated at home N. Engl. J. Med 1996 Planes A Vochelle N Once daily dosing of Enoxaparin ( a low molecular weight heparine) in prevention of deep vein thrombosis Acta Chirugica Scadinaavica 1990 556 Anthonieu W Lensing A Martin Tratamiento de Trombosis venosa profunda con heparinas de bajo peso molecular Arch. Intern. Med 1995 155 Bratt G Johnson Abery, W "Two daily subcutaneous injections of Fragmin as compared with intravenous standard heparin in treatment of deep venous thrombosis 1990 64 Leizorovicz A Simonneau g Comparison of efficacy and safety of low molecular weight heparins and unfractionated heparin in initial treatment of deep venous thrombosis BMJ 1994 309
S1409-414220010002 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000200005 Efecto de un programa de rehabilitación cardíaca en la alimentación, peso corporal, perfil lipídico y ejercicio físico de pacientes con enfermedad coronaria Roselló Araya Marlene Guzmán Padilla Sonia Bolaños Arrieta Mario ,Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud Cartago Costa Rica ,Centro Nacional de Rehabilitación 08 2001 2001 3 15 20

Efecto de un programa de rehabilitación cardíaca en la alimentación, peso corporal, perfil lipídico y ejercicio físico de pacientes con enfermedad coronaria. Justificación y objetivo: Los programas de rehabilitación cardíaca (PRC), constituyen el mejor tratamiento para el control de los factores de riesgo cardiovascular en pacientes con enfermedad coronaria. El objetivo del presente estudio fue determinar los efectos de un PRC en el perfil lipídico, índice de masa corporal (IMC) y alimentación de éstos pacientes. Métodos: El estudio fue prospectivo. Al inicio y final del programa se realizaron evaluaciones antropométricas, bioquímicas, dietéticas y de la capacidad funcional. El programa consistió de intervenciones educativas al paciente y su familia, la práctica de ejercicio físico (tres veces / semana, durante doce semanas), sesiones de psicología (una vez / semana) y sesiones nutricionales (una vez al mes por siete meses). Resultados: Participaron 61 pacientes, 76% masculino, la edad promedio de la población fue 53±12 años. Al momento de sufrir el evento coronario, 60% suspendió el fumado, 19% era diabético, 59% hipertenso, 80% dislipidémico y 61% sedentario. Al finalizar se observaron mejoras en el IMC (-1,47%), relación cintura / cadera (-1,14%), HDL-C (+3,76%), TG (-2,2%), LDL-C (-7,0%), Colesterol total (-4,9%) y en la capacidad aeróbica (+193%). Se encontró un patrón alimentario que reflejó la orientación nutricional recibida, aumento en la ingesta de frutas y vegetales, modificaciones en el consumo de grasa saturada por insaturada y consumo de leche descremada. Se presentó una mejoría de la capacidad funcional, aumentaron el umbral de la angina y se negativizaron el 10,7% de las pruebas de esfuerzo. Conclusión: Los datos evidencian que los PRC constituyen una alternativa viable para mejorar la calidad de vida de los pacientes después de sufrir un infarto.

Effect the Cardiac Rehabilitation Program on food patterns, body mass index, lipid profile and cardiovascular fitness in patients with coronary artery disease. Background: The Cardiac Rehabilitation Program, (CRP) has been proposed as the bast treatment for controlling the cardiovascular risk factors in patients with the coronary artery disease. The purpuse of this study was to determine the effect of CRP on lipid profile, body mass index and food intake patterns in a group of individuals with coronary artery disease. Methods: Heigth, weigth, and body mass index, waist/hip ratio, fasting plasma lipids, food intake and estimated METS were assesed at baseline and after the completion of the CRD. This program consisted of exercise (three times a week), psychological(once a week) and nutrition seccions(once a month for a total of seven months)for patients and their families. Each session lasted aproximately 2 hours. A total of 61 individuals with recent history of myocardial infarction participated in the study. Results: After the CRP there were redutions of BMI (-1.47%), waist/hip ratio (-1.14%) triglyceride levels (-2.2%), LDL-cholesterol levels (-7.0%), total cholesterol levels (+3.73) and the aerobic capacity (+193). The food intake pattern reflected an increase in fruits and vegetables and reduction in the consumption of meat and high fat-diary products. Conclusions: Our results suggest that the CPR represents an excellent alternative for reductingthe cardiovascular risk factors in post- myocardical event patients.

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S1409-414220010002 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422001000200010 Infusión intermitente de inotrópicos en la insuficiencia cardíaca avanzada Ventura Héctor O Salazar Holger P ,Tulane University Hospital and Clinic New Orleans LA 08 2001 2001 3 65 68

Es conveniente seleccionar adecuadamente a los pacientes en los que se administrará terapia con agentes inotrópicos. Se deben descartar potenciales causas reversibles de insuficiencia cardíaca y evaluar factores que puedan precipitar una descompensación. Los pacientes deben estar tratados con dosis máximas de medicamentos convencionales. Los niveles electrolíticos, especialmente potasio y magnesio deben ser controlados periódicamente con el fin de evitar arritmias, manteniendo el potasio por encima de 4mEq/L y el magnesio por encima de 2mEq/L, y evitar que los niveles de digoxina sean mayores de 2ng/dl. Deben seguir adecuadamente las instrucciones médicas y ser dotados de una educación adecuada acerca de su enfermedad junto con sus familiares cercanos. En conclusión, las indicaciones para el uso de agentes inotrópicos en el tratamiento de insuficiencia cardíaca avanzada deberían estar limitadas a: 1. Pacientes que estén en espera de trasplante cardíaco en los que se pueda utilizarlos como un puente hasta que sean trasplantados. 2. Se puede utilizarlos a corto plazo después de cirugía cardíaca para dar un soporte adecuado, hasta que el corazón del paciente comience a funcionar adecuadamente. 3. Como ya hemos discutido extensamente, se pueden utilizar en pacientes con insuficiencia cardíaca inestable y refractaria, como un puente hacia el uso de beta bloqueantes. 4. En pacientes con descompensación aguda. 5. Finalmente se deberían utilizar en pacientes con insuficiencia cardíaca avanzada y que no son candidatos a trasplante cardíaco, en los cuales es indispensable brindarles una calidad de vida mas digna. Idealmente, deben ser los pacientes los que escojan entre un tipo de medicamento que puede mejorar sus síntomas, pero a expensas de una disminución de su sobrevida. Es decir, poder escoger entre calidad versus cantidad.

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