Background: Premature death is a challenge from the social, medical, sanitary and economic point of view. Many of these deaths are avoidable with the impleme...

Background Economic crises have heterogeneous effects on population-level mortality between high- and low- or middle-income countries. Argentina - a middle income country- has suffered economic crises repeatedly over the past 30 years and is a model case study for the effects of economic crises on mortality. Methods Over 28 years (1990-2017), all death records in Argentina were analysed at the most disaggregated level possible (departments, that is, second-level administrative divisions). Age-and-sex-standardized all-cause mortality, premature death (<75 years) and the probability of death at different ages for both the entire population and each socio-economic quintile were calculated by level of unsatisfied basic needs (UBNs). Standardized rates are reported as biannual average and 95% confidence interval. Results Considered globally since the beginning of the series and using the 1990-1 biennium as a reference category, the standardized death rate was significantly reduced from biennium 2 (1992-3) to biennium 14 (2016-7), interrupted by two statistically significant increases in mortality, in years 2002-3 and 2016-7. In 2002-3, women had greater increase in mortality than men, and in 2016-7, even more so. The probability of dying before 75 years of age increased significantly in the last biennium, mostly among people between 50 and 74 years in the most deprived quintiles. Conclusions Despite significant overall improvement over time, economic crises impose severe increases in mortality, especially among vulnerable groups such as the poor, the elderly, and women.

espanolIntroduccion: Aunque recientemente se reporto la relacion entre la muerte prematura y la condicion socioeconomica en laArgentina, no existen analisis sobre el impacto que dicha condicion tiene en distintas regiones del pais.Objetivo: Describir el impacto que la condicion socioeconomica presento sobre la incidencia de muerte prematura en las distintasprovincias de la Argentina durante el periodo 2000-2010.Material y metodos: Se utilizo un modelo ecologico, que evaluo las tasas estandarizadas de muerte prematura (≤ 74 anos)durante el periodo 2000-2010. Asimismo, se examino la relacion entre la condicion socioeconomica medida en deciles denecesidades basicas insatisfechas por departamento geografico y la muerte prematura. La unidad de analisis fueron los 512departamentos de la Argentina y las 15 comunas de la ciudad de Buenos Aires.Resultados: La condicion socioeconomica estuvo significativamente asociada con la muerte prematura en la Argentina durante el periodo analizado. En todas las provincias y regiones se observo un gradiente lineal entre la muerte precoz y la condicion socioeconomica. Sin embargo, la pendiente de desigualdad entre los componentes de la condicion socioeconomica vario significativamente entre los distintos departamentos. Mientras que en toda la Argentina la diferencia absoluta en la tasa estandarizada de muerte prematura entre los componentes extremos de condicion socioeconomica fue de 10 muertes (rango:7,81-12,36) por cada 10.000 personas por ano, en la ciudad de Buenos Aires esa diferencia fue de 61 muertes (rango: 53-69).Las comunas del sur de la ciudad de Buenos Aires fueron las zonas con mayor desigualdad social y sanitaria de la Argentina.Conclusiones: Aunque la inequidad social tuvo un impacto significativo en la muerte prematura en todo el periodo en toda laArgentina, la ciudad de Buenos Aires se mostro como la region mas desigual. EnglishBackground: Although the relationship between premature death and socioeconomic status has been recently reported in Argentina,there are no analyses on the impact of this condition in different regions of the country.Objective: The aim of this study was to describe the influence of socioeconomic status on the incidence of premature death rate indifferent provinces of Argentina, from 2000 to 2010.Methods: An ecological model was used to evaluate standardized premature death rates (≤74 years) during the period between 2000 and 2010. In addition, the relationship between socioeconomic status, measured in deciles of unmet basic needs at geographic departmental level, and premature death was examined. The units of analysis were the 512 Argentine departments and the 15 communesof the city of Buenos Aires.Results: Socioeconomic status was significantly associated with premature death rate in Argentina during the study period. A lineargradient was observed between premature death and socioeconomic status in all provinces and regions. However, the slope index ofinequality varied significantly between departments. While the absolute difference in standardized premature death rate betweenthe extreme components of socioeconomic status was 10 deaths (range: 7.81-12.36) per 10,000 persons per year in all Argentina, inthe city of Buenos Aires this difference was 61 deaths (range: 53-69). The Southern communes of Buenos Aires were the areas withthe highest social and health inequalities of Argentina.Conclusions: Although social inequity had a significant impact on premature death rate throughout Argentina during the studyperiod, the city of Buenos Aires was the most unequal region.

Introduccion: Aunque recientemente se reporto la relacion entre la muerte prematura y la condicion socioeconomica en laArgentina, no existen analisis sobre el impacto que dicha condicion tiene en distintas regiones del pais.Objetivo: Describir el impacto que la condicion socioeconomica presento sobre la incidencia de muerte prematura en las distintasprovincias de la Argentina durante el periodo 2000-2010. Material y metodos: Se utilizo un modelo ecologico, que evaluo las tasas estandarizadas de muerte prematura (≤ 74 anos)durante el periodo 2000-2010. Asimismo, se examino la relacion entre la condicion socioeconomica medida en deciles denecesidades basicas insatisfechas por departamento geografico y la muerte prematura. La unidad de analisis fueron los 512departamentos de la Argentina y las 15 comunas de la ciudad de Buenos Aires. Resultados: La condicion socioeconomica estuvo significativamente asociada con la muerte prematura en la Argentina durante el periodo analizado. En todas las provincias y regiones se observo un gradiente lineal entre la muerte precoz y la condicion socioeconomica. Sin embargo, la pendiente de desigualdad entre los componentes de la condicion socioeconomica vario significativamente entre los distintos departamentos. Mientras que en toda la Argentina la diferencia absoluta en la tasa estandarizada de muerte prematura entre los componentes extremos de condicion socioeconomica fue de 10 muertes (rango:7,81-12,36) por cada 10.000 personas por ano, en la ciudad de Buenos Aires esa diferencia fue de 61 muertes (rango: 53-69).Las comunas del sur de la ciudad de Buenos Aires fueron las zonas con mayor desigualdad social y sanitaria de la Argentina. Conclusiones: Aunque la inequidad social tuvo un impacto significativo en la muerte prematura en todo el periodo en toda laArgentina, la ciudad de Buenos Aires se mostro como la region mas desigual.

Background The EXAMINE trial showed non-inferiority of the DPP-4 inhibitor alogliptin to placebo on major adverse cardiac event (MACE) rates in patients with type 2 diabetes and recent acute coronary syndromes. Concerns about excessive rates of in-hospital heart failure in another DPP-4 inhibitor trial have been reported. We therefore assessed hospital admission for heart failure in the EXAMINE trial.Methods Patients with type 2 diabetes and an acute coronary syndrome event in the previous 15-90 days were randomly assigned alogliptin or placebo plus standard treatment for diabetes and cardiovascular disease prevention. The prespecified exploratory extended MACE endpoint was all-cause mortality, non-fatal myocardial infarction, non-fatal stroke, urgent revascularisation due to unstable angina, and hospital admission for heart failure. The post-hoc analyses were of cardiovascular death and hospital admission for heart failure, assessed by history of heart failure and brain natriuretic peptide (BNP) concentration at baseline. We also assessed changes in N-terminal pro-BNP (NT-pro-BNP) from baseline to 6 months. This study is registered with ClinicalTrials.gov,number NCT00968708.Findings 5380 patients were assigned to alogliptin (n=2701) or placebo (n=2679) and followed up for a median of 533 days (IQR 280-751). The exploratory extended MACE endpoint was seen in 433 (16.0%) patients assigned to alogliptin and in 441 (16.5%) assigned to placebo (hazard ratio [HR] 0.98, 95% CI 0.86-1.12). Hospital admission for heart failure was the first event in 85 (3.1%) patients taking alogliptin compared with 79 (2.9%) taking placebo (HR 1.07, 95% CI 0.79-1.46). Alogliptin had no effect on composite events of cardiovascular death and hospital admission for heart failure in the post hoc analysis (HR 1.00, 95% CI 0.82-1.21) and results did not differ by baseline BNP concentration. NT-pro-BNP concentrations decreased significantly and similarly in the two groups.Interpretation In patients with type 2 diabetes and recent acute coronary syndromes, alogliptin did not increase the risk of heart failure outcomes.

La muerte prematura constituye un desafio desde el punto de vista social, medico, sanitario y economico. Muchas son evitables con la implementacion de politicas de estado. Las sociedades cientificas pueden y deben participar en el asesoramiento de politicas publicas. Sin embargo, para esto son necesarios datos precisos y una mirada inclusiva. El objetivo de este trabajo es describir la tendencia temporal de muertes prematuras por todas las causas y cardiovasculares en la Argentina en el periodo 2000-2011. Se utilizo un modelo ecologico, que evaluo la evolucion de las tasas especificas y estandarizadas de muerte prematura (≤74 anos). Asimismo, se examino la relacion entre la condicion socioeconomica (CSE) y la muerte prematura. La unidad de analisis fueron los 513 departamentos de Argentina. La muerte prematura (mediana cada 10.000 personas / ano; p) por todas las causas se redujo significativamente desde el ano 2000 (42,65 hasta el 2011 (38,7); p<0.001). Lo propio sucedio con la muerte cardiovascular (12,75 en el ano 2000 a 10,09 en el ano 2011;p<0.001). La muerte prematura tuvo una asociacion significativa con la CSE, existiendo un gradiente lineal, sin umbrales en todos los anos entre CSE y muerte prematura. La velocidad y la reduccion relativa fueron significativamente distintas entre los diversos estratos de CSE. Aunque la tasa de mortalidad se redujo, la brecha entre la CSE y la muerte prematura se incremento, lo que obliga a reflexionar sobre en quienes y como debemos depositar la mirada.

BACKGROUND To assess potentially elevated cardiovascular risk related to new antihyperglycemic drugs in patients with type 2 diabetes, regulatory agencies require a comprehensive evaluation of the cardiovascular safety profile of new antidiabetic therapies. We assessed cardiovascular outcomes with alogliptin, a new inhibitor of dipeptidyl peptidase 4 (DPP-4), as compared with placebo in patients with type 2 diabetes who had had a recent acute coronary syndrome. METHODS We randomly assigned patients with type 2 diabetes and either an acute myocardial infarction or unstable angina requiring hospitalization within the previous 15 to 90 days to receive alogliptin or placebo in addition to existing antihyperglycemic and cardiovascular drug therapy. The study design was a double-blind, noninferiority trial with a prespecified noninferiority margin of 1.3 for the hazard ratio for the primary end point of a composite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. RESULTS A total of 5380 patients underwent randomization and were followed for up to 40 months (median, 18 months). A primary end-point event occurred in 305 patients assigned to alogliptin (11.3%) and in 316 patients assigned to placebo (11.8%) (hazard ratio, 0.96; upper boundary of the one-sided repeated confidence interval, 1.16; P<0.001 for noninferiority). Glycated hemoglobin levels were significantly lower with alogliptin than with placebo (mean difference, -0.36 percentage points; P<0.001). Incidences of hypoglycemia, cancer, pancreatitis, and initiation of dialysis were similar with alogliptin and placebo. CONCLUSIONS Among patients with type 2 diabetes who had had a recent acute coronary syndrome, the rates of major adverse cardiovascular events were not increased with the DPP-4 inhibitor alogliptin as compared with placebo. (Funded by Takeda Development Center Americas; EXAMINE ClinicalTrials.gov number, NCT00968708.).

Background Previous studies have suggested that n‐3 polyunsaturated fatty acids (n‐3 PUFA s) have antiarrhythmic effects on atrial fibrillation ( AF ). We aimed to assess the effects of therapy with n‐3 PUFA s on the incidence of recurrent AF and on postoperative AF . Methods and Results Electronic searches were conducted in Web of Science, Medline, Biological Abstracts, Journal Citation Reports, and the Cochrane Central Register of Controlled Trials databases. In addition, data from the recently completed FOR ω ARD and OPERA trials were included. We included randomized controlled trials comparing treatment with n‐3 PUFA s versus control to (1) prevent recurrent AF in patients who underwent reversion of AF or (2) prevent incident postoperative AF after cardiac surgery. Of identified studies, 12.9% (16 of 124) were included, providing data on 4677 patients. Eight studies (1990 patients) evaluated n‐3 PUFA effects on AF recurrence among patients with reverted AF and 8 trials (2687 patients) on postoperative AF . Pooled risk ratios through random‐effects models showed no significant effects on AF recurrence ( RR , 0.95; 95% CI , 0.79 to 1.13; I 2 , 72%) or on postoperative AF (0.86; 95% CI , 0.71 to 1.04; I 2 , 53.1%). A funnel plot suggested publication bias among postoperative trials but not among persistent AF trials. Meta‐regression analysis did not find any relationship between doses and effects ( P =0.887 and 0.833 for recurrent and postoperative AF , respectively). Conclusions Published clinical trials do not support n‐3 PUFA s as agents aimed at preventing either postoperative or recurrent AF . Clinical Trial Registration URL: http://www.crd.york.ac.uk/PROSPERO . Unique Identifier: CRD42012002199.

Blocking the adverse effects of the renin-angiotensin-aldosterone system has been a major focus in the development of drugs for the treatment of cardiovascular disease in the last 30 years. Plasma aldosterone levels transiently decrease after initiation of treatment with inhibitors of angiotensin converting enzyme. In two consecutive meetings, 50 opinion leaders met to discuss critically the current evidence. The present document reflects the consensus of the subject: "Monitoring of aldosterone blockade." In the last decade, it has been shown that aldosterone have detrimental effects on the cardiovascular system, endothelial dysfunction, hypertrophy, fibrosis and cardiovascular inflammation, the effects are independent of angiotensin II. To monitor the different effects of aldosterone drugs, we must consider an algorithm, stating: pretreatment baseline assessment, intra-treatment assessment, contraindications and adverse effects. The search for clinical response and drug monitoring using biomarkers will allow us to assess the evolution of the patient and the desired effect of the drug.

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) (J Am Coll Cardiol 2013;61:463-8) (C) 2013 by the American College of Cardiology Foundation

Recently, Clark et al. ([1][1]) reviewed what they considered all available evidence on the effectiveness of disease management trials in heart failure, concluding that the evidence thus far lacks methodological quality. They particularly emphasized the poor quality of reports and design methods

Objectives The purpose of this study was to assess the rate of death and hospitalization for heart failure (HF) 1 and 3 years after a randomized trial of telephone intervention aimed to improve education and compliance in stable patients with HF ended.Background The long-term effects of HF programs are not well known.Methods In all, 1,518 patients with HF were randomized into the DIAL (Randomized Trial of Phone Intervention in Chronic Heart Failure). After completion of the trial, patients were followed up to 3 years to assess major outcomes. Compliance with diet, weight control, and treatment was evaluated. The effect of the intervention on mortality and HF hospitalizations was assessed using relative risk (RR), relative risk reduction, and Cox proportional hazards model for adjusting by potential confounders.Results The rate of death or hospitalization for HF was lower in the intervention group (37.2% vs. 42.6%, RR: 0.81, 95% confidence interval [CI]: 0.69 to 0.96; p = 0.013) 1 and 3 years (55.7% vs. 57.5%, RR: 0.88, 95% CI: 0.77 to 1.00; p = 0.05) after the intervention ended. This benefit was mainly caused by a reduction in admission for HF (28.5% vs. 35.1% after 3 years, RR: 0.72, 95% CI: 0.60 to 0.87; p = 0.0004). Patients who showed improvement in 1 or more of 3 key compliance indicators (diet, weight control, and medication) had lower risks of events.Conclusions The benefit observed during the intervention period persisted and was sustained 1 and 3 years after the intervention ended. This effect may be explained by the impact of the educational intervention on patients' behavior and habits. (J Am Coll Cardiol 2010;56:372-8) (c) 2010 by the American College of Cardiology Foundation

Background Atrial fibrillation (AF) is associated with increased risk of death, thromboembolic complications, and a lowered quality of life. Despite this burden, pharmacologic agents for prevention of AF in patients who achieved normal sinus rhythm are of limited utility, mostly because of serious and frequent side effects, Thus, the availability of safer and more effective drugs may reduce the burden of disease.Trial Design Patients aged >= 21 years with previous symptomatic AF and who have recovered normal sinus rhythm will be randomized to I g daily of omega-3-acid ethyl esters or identical placebo. To be included in the trial, patients must have either (a) at least 2 symptomatic episodes of documented AF in the 6 months before randomization, with the last episode occurring in the 14 to 90 days before randomization (paroxysmal AF), or (b) successful electrical or pharmacalogic cardioversion for persistent AF, Ethical committees of 71 cardiology centers in 16 provinces of Argentina have qualified and approved the protocol and are expected to enroll 1,400 patients to test the primary end point of efficacy, which is survival free of AF during follow-up.Conclusion The Fish Oil Reserach with omega-3 for Atrial fibrillation Recurrence Delay (FORwARD) trial will determine whether pharmacologic supplementation with 1 g of omega-3-acid ethyl esters can reduce AF recurrence in patients with previous AF who have recovered normal sinus rhythm. (Am Heart J 2009; 157:423-7.)

Circannual variation in cardiovascular events is well-known. Seasonal variation (SV) in heart failure (HF) has been described in the Northern Hemisphere, but there is scarcity of data in South America. The goals of the present study were to (1) describe the SV of admissions and deaths for HF, and (2) describe trends in HF morbidity and mortality in a community hospital in Argentina from 1992 to 1999. The study sample included 6369 admissions. During this period, the number of HF admissions rose by 188% and the rate HF admissions/all admissions increased from 3.28% to 7.84%. In-hospital mortality decreased from 21% to 13%. HF admissions followed a seasonal pattern with a winter-spring predominance. Male and very old patients were the subgroups with the highest SV. The authors identified clear SV in HF deaths and admissions, which raises a different hypothesis about the rationale of HF admissions and provides information for the organization of care and resource allocation.

Resumen es: Objetivos Comparar las caracteristicas clinicas en pacientes con insuficiencia cardiaca (IC) de acuerdo con el IMC, evaluar si el IMC tiene valor pronost...