S1409-414220030003 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000300001 Speranza S. Mario , 12 2003 2003 5 3 3
S1409-414220030003 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000300002 Estudio retrospectivo del diagnóstico de cardiopatías congénitas en el período prenatal en el Hospital Nacional de Niños Junio 2001 - Mayo 2002 Acón Fabiola Mas Romero Carlos ,CCSS Hospital Nacional de Niños San José Costa Rica ,CCSS Hospital Nacional de Niños Servicio de Cardiología San José Costa Rica 12 2003 2003 5 5 10

Objetivo: Evaluar la eficacia del diagnóstico prenatal de cardiopatías congénitas en la Clínica de Cardiología Fetal del Hospital Nacional de Niños, así como establecer principales centros de referencia, motivos de referencia, factores de riesgo asociados a cardiopatía congénita y cardiopatías más frecuentemente diagnosticadas y no diagnosticadas. Métodos: Se les realizó ecocardiogarfía prenatal y postnatal a todos los fetos y posteriormente neonatos de mujeres embarazadas que fueron referidas al Centro de Cardiología Fetal en un plazo de un año. Se compararon los resultados de los diagnósticos pre y postnatal para establecer sensibilidad y especificidad de dicha técnica diagnóstica y se realizaron estudios estadísticos para determinar asociación con algunos factores de riesgo y porcentajes descriptivos de la muestra. Resultados: De las 208 mujeres embarazadas incluidas en el estudio, 20 (9.6%) fetos presentaron alguna anomalía estructural y 19 (9.13%) algún trastorno del ritmo. Los principales centros referidores fueron el Hospital San Juan de Dios (57.3%) y el Hospital Calderón Guardia (23.8%). El principal motivo de referencia fue el tener algún factor de riesgo para cardiopatía congénita (75.7%) y dentro de estos los más frecuentes fueron: gestante tardía (25.5%), diabetes mellitus materna (18.8%) y antecedente de aborto u óbito (17.8%). Sólo 12.3% fueron referidos por ultrasonido obstétrico anormal y de estos el 52% presentaron alguna anomalía estructural. La sensibilidad de la ecocardiografía fetal en el Centro de Cardiología fetal del Hospital Nacional de Niños se estimó en 94.11% (IC 95% 82.93-100) y la especificidad de 99.36% (IC 98.16- 100). Conclusión: La Clínica de Cardiología Fetal de Hospital Nacional de Niños cuenta con el equipo técnico y humano necesario para realizar estudios ecocardiográficos fetales con alta sensibilidad y especificidad.

Objective: Evaluate the efficiency of prenatal diagnosis of congenital cardiopathy at the Fetal Cardiology Clinic of The Children’s National Hospital as well as to establish the main reference centers, motives for the reference, risk factors associated to the congenital cardiopathy and the most frequently diagnosed and not diagnosed cardiopathies. Methods: Prenatal and postnatal echocardiography was done to all fetus and later newborns of pregnant women that were referred to the Center of Fetal Cardiology within a one year period. The results of the pre and postnatal diagnosis were compared so as to establish the sensibility and specificity of this diagnostic technique and statistical studies were carried out to determine the association with some of the risk factors and descriptive percentages of the sample. Results: Of the 208 pregnant women included in the study, 20(9.6%) of the fetus presented a structural anomaly and 19 (9.13%) presented some kind of rhythm disorder. The main reference centers were The San Juan Hospital (57.3%), and the Calderon Guardia Hospital (23.8%). The main motive of reference was to have a risk factor for congenital cardiopathy (75.7%) of which the most frequent were: late pregnancy (25.5%), maternal diabetes mellitus (18.8%) and prehistory of abortions or obitus (17.8%). Only 12.3% were referred by abnormal obstetric ultrasound and of these, 52% presented structural anomaly. The sensibility of the fetal echocardiography in the Center of Fetal Cardiology of the Children’s National Hospital was estimated in 94.11% (IC 95% 82.93-100) and the specificity in 99.36% (IC 98.16-100).

 Cardiopatías congénitas período prenatal Allan LD A practical approach to fetal heart scanning Semin Perinatol 2000 24 ^s5 Comstock CH What to expect from routine midtrimester screening for congenital heart disease Semin Perinatol 2000 24 ^s5 Hoffman JI Firpo C Silverman NH Evaluation of fetal heart dimensions from 12 weeks to term Am J Cardiol 2001 87 ^s5 Bonnet D Detection of transposition of the great arteries in fetuses reduces neonatal morbidity and mortality Circulation 1999 99 Allan LD The outcome of fetal congenital heart disease Semin Perinatol 2000 24 ^s5 Verheijen PM Lisowski LA Stoutenbeek P Prenatal diagnosis of congenital heart disease affects preoperative acidosis in the newborn patient J Thorac Cardiovasc Surg 2001 121 ^s4 Simpsom JM Jones A Accuracy and limitations of transabdominal fetal echocardiography at 12-15 weeks of gestation in a population at high risk for congenital heart disease BJOG 2000 107 ^s12 Rona RJ Smeeton NC Beech R Anxiety and depression in mothers related to severe malformation of the heart of the child and foetus Acta Paediatrica 1998 87 Welch KK Brown SA The role of genetic counseling in the management of prenatally detected congenital heart defects Semin Perinatol 2000 24 ^s5 Devine PC Simpson LL Nuchal translucency and its relationship to congenital heart disease Semin Perinatol 2000 24 ^s5 Budorick NE Millman SL New modalities for imaging the fetal heart Semin Perinatol 2000 24 ^s5 Tripodi E Fetal echocardiography: a comparison of different techniques Clin Exp Obstet Gynecol 2000 27 ^s3-4 Levine D Mehta TS Technical factors influencing sonographic visualization of fetal echogenic intracardiac foci J Clin Ultrasoud 2000 28 ^s9 Oberhansli Fetal echocardiography in pregnancies of women with congenital Heart disease- clinical utility and limitations J Thorac Cardiovasc Surg 2000 48 ^s6 Srinivasan S Fetal echocardiography Indian J Pediatr Mar 2000 67 ^s3 Mahle WT Impact of prenatal diagnosis on survival and early neurologic morbidity in neonates with the hypoplasic left heart syndrome Pediatrics 2001 107 ^s6 Tworetzky W Improved outcome after fetal diagnosis of hypoplastic left heart syndrome Circulation 2001 103 ^s9
S1409-414220030003 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000300003 Efectividad de la valvuloplastia pulmonar percutánea en el tratamiento de la estenosis pulmonar valvular moderada y severa en el Hospital Nacional de Niños, a los 10 años de practicar el procedimiento Castro B. Abdón Yong P. Bernal Yong R. Adrián Zúñiga V. Marcela ,CCSS Hospital Nacional de Niños Sección de Medicina ,CCSS Hospital Nacional de Niños Asistente de Cardiología 12 2003 2003 5 11 14

La valvuloplastía pulmonar es, actualmente, el tratamiento de elección para la estenosis pulmonar valvular de moderada a severa. Introducida como técnica por Kan, hoy día constituye un procedimiento de fácil aplicación, barato y con resultados excelentes. Con el fin de conocer la situación en el Hospital Nacional de Niños de San José, Costa Rica, se planeó este estudio retrospectivo. Se encontraron un total de 98 casos a los que se les realizó valvuloplastía pulmonar con edades que variaron de 4 días a 24 años. No hubo predominancia de sexo alguno. Los menores de un año fueron 41 niños y los mayores de un año fueron 56. La edad mas frecuente a la que se realizó el procedimiento fue a los tres años de edad. Los gradientes pre-dilatación variaron de 31 a 170 mmHg y post dilatación de 0 a 96 mmHg. No hubo ninguna defunción y las complicaciones más observadas fueron asistolia, flutter y taquicardia supraventricular cada uno con un caso. En conclusión la valvuloplastía pulmonar es un procedimiento de bajo riesgo y con resultados satisfactorios.

Pulmonary valvuloplasty is nowadays the treatment of choice for moderate to severe valvular pulmonary stenosis. In 1992, Kan introduced the technic and today it is a procedure easy to perform, cheap and with excellent results. A retrospective study was carried out in the Hospital Nacional de Niños in San José, Costa Rica in order to analyze their situation. A total of 98 cases with pulmonary valvuloplasty were found with ages from 4 days to 24 years.. There was no sex predominance. Forty one children were under one year of age and 56 were older than one year. The most frequent age when the procedure was done was at three years. The transvalvular gradients varied from 31 to 170 mmHg in pre-dilation and 0 to 96 mmHg in post dilation of the pulmonary valve. No deaths were reported and the most common complications were one case of asystole, one case of atrial flutter and one case of supraventricular tachycardia. In conclusion, pulmonary valvuloplasty is a low risk procedure with satisfactory results.

 Estenosis pulmonar Valvuloplastías Hernández MA Bermúdez R Fernandez L Quero C Díaz P Valvuloplastía pulmonar percutánea con balón: Resultados a mediano plazo de una serie de 100 pacientes pediátricos consecutivos Ann Españoles de Pediatría 1998 49 Alcibar J García E Gutiérrez F Moreno F Alvares MP Santos J Guías de actualización clínica de la Sociedad Española de Cardiología. Requerimientos y equipamientos de las técnicas invasivas en cardiología pediátrica: aplicación clínica Rev Esp Cardiol 1999 52 Cheatham JP McMillan J De Angelis J Feigin R Warshaw J Pulmonary Stenosis Oski¨s Principles of Pediatrics Oski¨s Principles of Pediatrics 1998 New York Lipincott Williams and Wlkins Echigo S Balloon valvuloplasty for congenital heart disease: immediate and long-term results of multi-institutional study Pediatr Int 2001 43 Lissauer T Clayden G Texto Ilustrado de Pediatría Texto Ilustrado de Pediatría 1998 Harcourt Brace Berhman RE Kliegman RM Jenson HB Estenosis de la válvula pulmonar con tabique interventricular intacto Tratado de Pediatría Tratado de Pediatría 1991 Mac Graw Hill Kan JS White RJ Mitchell SE Gardner TJ Percutaneous balloon valvuloplasty: a new method for treating congenital pulmonary valve stenosis N Eng J Med 1982 397 McCrindle WB Indepnedent predictors of long term results after balloon pulmonary valvuloplasty Circulation 1994 89 Santos de Soto J Grueso J Parreño A García J Castillo J Descalzo A Valvuloplastía transluminal percutánea pulmonar. Resultados en 34 pacientes Ann Esp Pediatr 1991 34
S1409-414220030003 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000300004 Experiencia preliminar en el tratamiento de la vasoplejia post-circulación extracorpórea con azul de metileno Sánchez Suen Kwok Ho Salazar Vargas Carlos Dobles Ramírez Carlos ,CCSS Hospital Calderón Guardia Medicina Crítica y Terapia Intensiva ,CCSS Hospital Calderón Guardia Cirugía Cardíaca ,CCSS Hospital Calderón Guardia Medicina Crítica y Terapia Intensiva San José 12 2003 2003 5 15 18

Justificación: La enfermedad coronaria, las valvulopatías y las cardiopatías congénitas constituyen un grave problema de la salud pública a nivel mundial. Muchas veces requieren de tratamiento quirúrgico. El éxito de este tipo de cirugía no fue posible hasta el desarrollo de la circulación extracorpórea (CEC), que sin embargo; puede generar un síndrome de reacción inflamatoria sistémica severa (SRIS) con vasoplejia. Cuando se presenta esta condición, se asocia con una alta morbimortalidad. Hasta donde sabemos, no hay ningún estudio publicado en la literatura nacional acerca del uso del azul de metileno para el manejo de la vasoplejia post-CEC. Objetivo: Reportar una serie consecutiva de los primeros cinco casos de vasoplejia post-CEC del Servicio de Cirugía Cardíaca del Hospital Dr. R.A. Calderón Guardia, manejados con azul de metileno. Materiales y métodos: Los pacientes con vasoplejia refractaria a epinefrina post-CEC fueron tratados con azul de metileno (2 mg/kg IV administrados en 20 minutos). Se evaluaron los efectos hemodinámicos y los resultados clínicos. Resultados: Entre marzo y agosto del 2003 se realizaron 52 cirugías cardíacas con CEC. Cinco pacientes desarrollaron el SRIS severo con vasoplejia refractaria a altas dosis de epinefrina. Un incremento clínicamente relevante en la resistencia vascular sistémica fue observado en 4 de los 5 pacientes a los 30 min y 120 min después de la infusión del azul de metileno (incremento del 4,6% y 40% respectivamente con respecto a las cifras basales). No se observaron efectos adversos relacionados con la infusión del medicamento. Dos de los 5 pacientes fallecieron (uno de ellos no tuvo respuesta al azul de metileno). Conclusiones: Coincidiendo con la literatura, la administración de azul de metileno puede ser una alternativa útil, segura y económica en el manejo de la vasoplejia refractaria a epinefrina post-CEC. Los inhibidores de la guanilato ciclasa como el azul de metileno representan una nueva clase de fármacos para el tratamiento de la vasoplejia. Se requieren estudios en el futuro que incluyan un número mayor de pacientes para poder hacer una recomendación definitiva al respecto.

Background: Coronary disease, valvulopathys and congenital cardiopathys constitute a major problem in public health worldwide. Many times, surgical procedures are required. The success of this type of procedures was obtained until the development of extracorporeal circulation (ECC), even though it could produce a severe systemic inflammatory reaction syndrome (SIRS) with vasoplegia. When this condition appears, it is associated with a high morbi-mortality. As far as it is known there are no studies published in Costa Rican literature related to the use of blue methylene for the management of post-ECC vasoplegia. Objective: Report a consecutive series of the first five cases of post- ECC vasoplegia in the Cardiac Surgery Service of the Hospital Calderon Guardia managed with blue methylene. Materials and methods: Patients with post ECC vasoplegia refractory to epinephrine were treated with blue methylene (2mg/kg IV administered in 20 minutes). Hemodynamic effects and clinical results were evaluated. Results: Between March and august 2003, 52 cardiac surgeries with ECC were completed. 5 patients developed severe SIRS with vasoplegia refractory to high doses of epinephrine. A clinically relevant increase in the systemic vascular resistance was observed in 4 out of 5 patients within 30 and 120 minutes after the infusion with blue methylene (increase of 4.6% and 40% respectively compared to basal digits). No adverse effects related to the infusion of the drug were observed. Two of the five patients died (one of them had no response to the blue methylene). Conclusions: In accordance to the literature, the administration of blue methylene could provide a useful, safe and economic alternative in the management of post ECC vasoplegia refractory to epinephrine. The inhibitors of the guanilate cyclasa such as blue methylene represent a new kind of drug for the treatment of vasoplegia. Future studies are required where more patients can participate in order to make a definite recommendation regarding this subject.

 Cirugía cardíaca circulación extracorpórea vasoplejia azul de metileno hemodinamia Paparella D Yau TM Young E Cardiopulmonary bypass induced inflammation: pathophysiology and treatment: an update Eur J Cardiothorac Surg 2002 21 Carrel T Englberger L Mohacsi P Neidhart P Schimidli J Low systemic vascular resistance after cardiopulmonary bypass : incidence, etiology, and clinical importance J Cardiovasc Surg 2000 15 Boyle EMJ Morgan EN Kovacich JC Canty TGJ Verrier ED Microvascular responses to cardiopulmonary bypass J Cardiothorac Vasc Anesth 1999 13 Grossi EA Kallenbach K Chau S Derivaux CC Aguinaga MG Steinberg BM Impact of heparin bonding on pediatric cardiopulmonary bypass: A prospective randomized study Ann Thorac Surg 2000 70 Hingorani AD Cross J Kharbanda RK Mullen MJ Bhagat K Taylor M Acute systemic inflammation impairs endothelium-dependent dilatation in humans Circulation 2000 102 Hauser GJ Ben-Ari J Colvin MP Dalton HJ Hertzog JH Bearb M Interleukin-6 levels in serum and lung lavage fluid of children undergoing open heart surgery correlate with postoperative morbidity Intensive Care Med 1998 24 Laffey JG Boylan JF Cheng DCC The systemic inflammatory response to cardiac surgery: implications for the anesthesiologist Anesthesiology 2002 97 Tof ukuji M Stahl GL Metais C Tomita M Agah A Bianchi C Fink MP Sellke FW Mesenteric dysfunction after cardiopulmonary bypass: role of complement C5a Ann Thorac Surg 2000 69 Brett S Quinlan GJ Mitchell J Pepper JR Evans TW Production of nitric oxide during surgery using cardiopulmonary bypass Crit Care Med 1998 26 Mekontso-Dessap A Houel R Soustelle C Kirsch M Thebert D Loisance DY Risk factors for post-cardiopulmonary bypass vasoplegia in patients with preserved left ventricular function Ann Thorac Surg 2001 71 Tassani P Richter JA Barankay A Braun SL Haehnel C Spaeth P Does high-dose methylprednisolone in aprotinin-treated patients attenuate the systemic inflammatory response during coronary artery bypass grafting procedures? J Cardiothorac Vasc Anesth 1999 13 Mollhoff T Loick HM Van Aken H Schmidt C Rolf N Tjan TD Asfour B Berendes E Milrinone modulates endotoxemia, systemic inflammation, and subsequent acute phase response after cardiopulmonary bypass (CPB) Anesthesiology 1999 90 Viaro F Dalio MB Evora PR Catastrophic cardiovascular adverse reactions to protamine are nitric oxide/cyclic guanosine monophosphate dependent and endothelium mediated: should methylene blue be the treatment of choice? Chest 2002 122 Yiu P Robin J Pattison C Reversal of refractory hypotension with single-dose methylene blue after coronary artery bypass surgery Thorac Cardiovasc Surg 1999 118 Evora PR Ribeiro PJF Andrade JCS Methylene blue administration in SIRS after cardiac operations Ann Thorac Surg 1997 63 Evora PR Should methylene blue be the drug of choice to treat vasoplegias caused by cardiopulmonary bypass and anaphylactic shock? Thorac Cardiovasc Surg 2000 119 Evora PR Roselino CH Schiavetto PM Methylene blue in anaphylactic shock Ann Emerg Med 1997 30 Leyh RG Kofidis T Strüber M Fischer S Knobloch K Wachsmann B Methylene blue: the drug of choice for catecholamine-refractory vasoplegia afte cardiopulmonary bypass? J Thorac Cardiovasc Surg 2003 125 Pagni S Austin EH Use of intravenous methylene blue for the treatment of refractory hypotension after cardiopulmonary bypass J Thorac Cardiovasc Surg 2001 122
S1409-414220030003 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000300005 Disfunción Endotelial en el paciente diabético Tipo 2 Poveda Jonathan Nuñez Sonia Arauz Gloria ,C.C.S.S. Hospital Calderón Guardia Departamento de Cardiología San José Costa Rica ,C.C.S.S. Hospital México Departamento de Imágenes Médicas San José Costa Rica 12 2003 2003 5 19 23

Introducción: La disfunción endotelial es un marcador temprano de la enfermedad arterioesclerótica, y su detección nos permite determinar cuáles pacientes son potenciales sujetos de tratamiento para revertir la progresión del padecimiento vascular. Dado que el paciente diabético es un paciente con alta prevalencia de complicaciones arterioscleróticas, la detección de éste fenómeno en el mismo, es de capital importancia. Métodos y Resultados: Mediante Doppler braquial en estado basal, isquemia y post-itroglicerina, se determinó la capacidad vascular de aumentar el flujo sanguíneo en 10 pacientes sanos y 20 pacientes diabéticos, con el objetivo de correlacionarlos con su HbA1c y perfil lipídico. La vasodilatación mediada por endotelio (VMF) y la vasodilatación mediada por nitroglicerina (VMN) expresadas en porcentaje de cambio del diámetro vascular, se encontraron reducidas en forma estadísticamente significativa en el grupo de diabéticos, (5.57% vs. 9.97% para el grupo control p= 0.04, y 21.49% vs. 12.64% para el grupo control p = 0.04 respectivamente) éstas alteraciones correlacionaron con los años de evolución de la enfermedad y los niveles de colesterol total, LDL y triglicéridos en éstos pacientes. Conclusión: El estudio doppler braquial es un instrumento útil para determinar mediante la disfunción endotelial, las fases tempranas de la arterioesclerosis en pacientes de alto riesgo para ésta, y los factores potencialmente reversibles que alteran este fenómeno podrían ser intervenidos en aras de mejorar el pronóstico de estos pacientes.

Introduction: Endothelial dysfunction is a common accepted surrogate marker of atherosclerotic disease. It’s early detection allows us to determine which patients need attention in order to stop the progression of the vascular disease. Since diabetic patients have a high prevalence of cardiovascular complications, the early detection of this phenomenon is of capital importance for their prognosis. Methods: Using brachial Doppler during rest, ischemia and post- nitroglycerin ischemia, the vascular reactivity of the vessel was obtained in 10 healthy patients and 20 type 2 diabetic patients. This data was correlated with their glycosilated hemoglobin levels and lipid profiles. Their endothelium derived vasodilatation and their nitroglycerin derived vasodilatation were expressed as the percentage of change in the luminal diameter of the vessel and both of them were reduced in the diabetic patients with a statistical significance (5.57% vs. 9.97% for the control patients p =0.04, y 21.49% vs. 12.64%, p= 0.04 for the diabetic patients). These alterations correlated with the years of evolution of the disease and the total colesterol levels as well as the LDL and tryglicerides levels. Conclusion: The Brachial Doppler study is a useful tool to detect endothelial dysfunction as an early stage of atherosclerosis in high risk patients and allows the treatment of the factors that might influence this phenomenon in order to improve their prognosis.

 Disfunción Endotelial Diabetes Mellitus Fein F Scheir J Rifkin H Porte J Heart Disease in Diabetes Mellitus: Theory and practice Heart Disease in Diabetes Mellitus: Theory and practice 1990 New York Elsevier Sementovich CF Heinecke JW The mystery of diabetes and atherosclerosis Diabetes 1997 46 Cohen RA Disfunction of vascular endothelium in Diabetes Mellitus Circulation 1993 87 ^sV Winocour PP Platelet anormalities in diabetes mellitus Diabetes 1992 41 ^s2 Reaven GM Role of insulin resistance in human disease Diabetes 1988 37 Godsland IK Stevenson JC Insulin Resistance: Syndrome or tendency? Lancet 1995 346 Ross R Atherosclerosis and inflammatory disease N. Eng. J. Med 312 Hasdai D Holmes DR Garret KN Mechanical pressure and stress release endothelin -1 from human atherosclerotic coronary arteries in vivo Circulation 1997 95 Celermajer DS Sorensen KE Goock WM Non invasive detection of endothelial disfunction in children and adults at risk of atherosclerosis Lancet 1992 340 Celermajer D Sorensen K Bull C Endothelium dependent vasodilatation in the systemic arteries of asymptomatic subjects relates to coronary risk factor and their interaction J. American Coll. Cardiol 1994 24 McLenachan SM Vita J Fish RD Early evidence of endothelial vasodilator disfunction at coronary branch points Circulation 1990 82 Osborne A Lento PH Sigfried MR Cardiovascular effects of acute hypercolesterolemia in rabbits, reversal with lovastatin treatment J. Clin. Invest 1989 83 Ross R The pathogenesis of atherosclerosis a perspective for the 1990’s Nature 1993 44 Jensen-Ustar KJ Reichard DE Rosfors JJ Early atherosclerosis is retarded by improved blood glucose control in patients with IDDM Diabetes 1996 45 Lanbert S Aarsen M Denker AJM Endothelium dependent and independent vasodilatation of large arteries in normoalbuminuric IDDM Artheriosescler. Thromb. Vasc. Biol 1996 16 Goodfellow J Ramsey MW Luddintong LA Endothelium and inelastic arteries: and early marker of vascular disfunction in non insulin dependent diabetes mellitus BMJ 312 Kawano H Motoyama T Hiroshima O Hyperglicemia rapidly suppresses FMD dependent vasodilatation of brachial artery J. Am. Coll. Cardiol 1999 39 Balletshofer BM Rittig K Enderle MD Endothelial dysfunction is detectable in young normotensive first degree relatives of subjects with type 2 diabetes in association with insulin resistance Circulation 2000 101 Wilmink HW Banga JP Hijmering MD Effect of ACE inhibition and AT-II type 1 receptor antagonism on postprandial endothelial function J. Am. Coll. Cardiol 1999 39 Kavin M Barnes PJ Mechanisms of Disease : Nuclear transcription factor (Kappa) b a pivotal transcription factor in chronic inflammatory diseases N. Eng. J. Med 1997 336 Zeiher AM Fisstthaler B Scrhay- Utz B NO modulates the expression of monocite chemoattractant protein 1 in cultured human endothelial cells Circ. Res 115 ^s76 Zeiher AM Endothelial vasodilation dysfunction pathogenetic link to myocardial ischemia or epiphenomenona? Lancet 1996 348 ^s1 Cannon RO Cardiovascular benefit of cholesterol lowering therapy does improved endothelial vasodilator function matter Circulation 2000 102 Hamnoud T Tanguay JF Bourassa MG Management of coronary artery disease: Therapeutic options in patients with diabetes J. American Coll. Cardiol 2000 36 Mancini GBJ Henry GC Macaya C ACE inhibition with quinapril improves endothelial vasomotor dysfunction in patients with coronary artherioesclerotic disease Circulation 1996 54 O’ Driscoll G Green D Maiorana A Improvement in endothelialfunction by angiotensin convertoing enzyme inhibition in NIDDM J. Am. Coll. Cardiol 1999 33 Effects of an angiotensin converting enzyme inhibition, ramipril, on cardiovascular events in high risk patients N Engl J Med 2000 342 Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and micro-HOPE substudy Lancet 355
S1409-414220030003 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000300006 Mortalidad por infarto agudo de miocardio: distribución geográfica y lugar de ocurrencia. Costa Rica, 1970 - 2002 Roselló Araya Marlene Guzmán Padilla Sonia ,Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud (INCIENSA) Cartago Costa Rica 12 2003 2003 5 25 29

Introducción: En Costa Rica, desde 1970 la mortalidad por las enfermedades cardiovasculares ha constituido la principal causa de muerte tanto en hombres como en mujeres. El 48% correspondió a la enfermedad isquémica del corazón y de ésta, dos terceras partes al infarto agudo de miocardio (IAM). Objetivo: Describir la evolución de la mortalidad por IAM, según distribución geográfica y lugar de ocurrencia en Costa Rica durante el período 1970 al 2002. Metodología: Se utilizó la base de datos del Programa Centroamericano de Población del Instituto Nacional de Estadística y Censos, con información de las defunciones de todas las edades durante el período de estudio. Se realizaron estadísticas descriptivas con Excel. Resultados: La tasa de mortalidad estandarizada (TME) por IAM en los hombres aumentó 12,5% y en las mujeres descendió 7,7% de 1970 al 2002. Para el 2000-2002, la TME de San José fue mayor que la de Alajuela, Guanacaste, Puntarenas y Limón (p<0,001), la TME de Guanacaste fue menor que la Alajuela, Cartago y Heredia. A partir de los 25 años de edad las TME de los hombres, fueron superiores que las femeninas. En el quinquenio 1970-1974, 53,1% de las personas murieron en el hogar; 37,7% en el hospital y 9,5% en otro establecimiento de salud, para 2000-2002, 47,6% de las muertes ocurrieron en el hogar y 43,9% en el hospital. No se hallaron diferencias por sexo y edad. Conclusión: Las diferencias encontradas sugieren la necesidad de investigar la presencia de factores de riesgo asociados al lugar de ocurrencia y áreas geográficas de nuestro país.

Introduction: Since 1970, in Costa Rica the mortality by cardiovascular disease, has been the main cause of death, for women and men. 48% of these deaths are due to isquemic heart disease and, out of this, two thirds to acute myocardial infarction (AMI). Objective: To describe the evolution of the acute myocardial infarction mortality rate, by geographic distribution and place of occurrence in Costa Rica, from 1970 to 2002. Methodology: For the present study, data of the Central American Population Program of the National Statistics and Census Institute was used, information on decease costarrican residents of all ages was obtained. Descriptive statistics were elaborated using Excel program. Results: Standardized Mortality Rate (SMR) by AMI rose 12,5% in men and, decreased 7,7% women, from 1970 to 2002. For the period 2000-2002, the SMR of San Jose was higher than in Alajuela, Guanacaste, Puntarenas and Limón (p<0,001); the SMR from Guanacaste was lower than Alajuela´s, Cartago´s and Heredia´s. From 25 years up, the SMR of men were higher than women’s. In the five-year term of 1970-1074, 53,1% of people died in their homes; 37,7% at the hospital and, 9,5% in other health establishments. In 2000-2002, 47,6% of people died at home and 43,9% at the hospital. No differences of age and sex were found. Conclusion: The differences found in this study, suggests the need to investigate the presence of AMI risk factors, associated to the place of occurrence and geographic areas of our country.

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