To identify and quantify potentially inappropriate prescribing , based on Beers, STOPP, Prescrire and BSP listings using AM (older adults) prescription indicators, one for each listing. Most older adults (67%) were prescribed at least one medication, with a mean of 2.7 medications per prescription. The PPI prevalence was 74% according to the BSP criteria, 67% according to the STOPP listing, 59% with the Beer criteria, and 20% with Prescrire. The most frequent PPI prescriptions were NSAIDs, vasodilators and sulfonylureas. The use of PPIs in AM is high in Mexico. The higher prevalence found in this study may reflect the use of a source with population representativeness. The partial use and adaptations of the criteria make difficult comparing the studies; however, the STOPP criteria are the ones with the highest prevalence, as they cover a greater number of drugs and their use is more common in the first level of care. Some of the factors that contribute to this situation are the physiological changes associated with age, since they affect the pharmacodynamics and pharmacokinetics of some drugs, as well as the multiple morbidity that leads to varied pharmacological regimens. In addition, the aging of the population and health system factors also influence, as well as the limited accessibility and updating of guidelines for pharmacological consultation in AM; care with multiple specialists and frequently at different levels of complexity. This population group is very vulnerable to high-risk prescribing, including potentially inappropriate prescribing (PPI)2.Medication misuse in older adults  due to drug-drug interactions, which leads to clinical and economic impacts8.PPI detection methods began in the 1990s. Beers was who firstly designed and published a detection tool, which consisted of an explicit list of drugs whose prescription, as identified by a group of experts, would be inappropriate. It was designed for AM residents of nursing homes specialized in older people’s care in the United States of America (USA). In 2012, an updated version was launched for use in outpatient care of the population ≥ 65 years. The update has a list of 53 groups of potentially inappropriate medications divided into three categories for AM: those to be avoided; to be avoided for given pathologies; and those to be used with caution9.Some countries have gradually created or adapted the Beers list. A specific case is the STOPP criteria, developed in Europe by experts in geriatric pharmacotherapy for AM living in the community. It includes greater number of groups of potentially inappropriate drugs (65), divided by devices and systems. In addition, they consider other criteria such as comorbidity, severity of the pathology for which the drug is indicated and duration of treatment10.France developed its own criteria, called “Prescrire”. It is a list of 74 groups of drugs that are more harmful than beneficial in all indications, i.e., for all age groups and general population. These criteria were established by systematic literature search rather than using a panel of experts6.In developed countries, 20% of the population is ≥ 60 years old, and it is estimated to be 32% by 2050. In developing countries, the ratio of the population aged 60 years or older is expected to increase from 8% in 2005 to 20% by 205011.In a middle-income country such as Mexico, the population aged ≥ 65 years in 2019 was estimated to be 9.5 million, accounting for 7.5% of the total population. In 2030, AMs will be 14 million 12.The main causes of death among AMs in Mexico during 2017 were cardiovascular diseases (27.1%); diabetes mellitus (16.6%); chronic degenerative diseases, such as malignant tumors (11.6%), and cerebrovascular diseases (6.7%)8. Similar figures were reported in Ireland in 2008, 25% using the Beers criteria and 35% using the STOPP criteria9. Few studies have been conducted in Mexico. In 2014 a study of prevalence of PPI among AM of ≥ 70 using the Beers criteria found prevalence levels of 49% in a public hospital. However, each prevalence reported should carefully considered, due to the high variability of the samples selected, as well as the partial use of the components of each criterion for measuring13.Using the Beers criteria in the USA, a prevalence of PPI in outpatient AM was found to be 25–30%, and 40% in homes for older people (2009 and 2012)6. PPI has important impacts on several healthcare areas. Studies have been carried out to investigate how the identification of PPI among AM can reduce the burden of AE, hospitalization and drug-related mortality5. In addition, it has been estimated that PPI-related annual health expenditure is 7.2 billion dollars in the USA8.The use of inappropriate medication is a major concern in patient safety, especially for the AM population, due to its characteristics, as previously mentioned14 that serves as a guide for all public healthcare institutions, based on the concept of rational drug use proposed by the World Health Organization (WHO): efficacy, safety and cost. However, there are few studies on drug prescription patterns and errors among AM in Mexico, and even fewer in public primary healthcare or outpatient care institutions6. In the last five years, two studies were conducted in primary healthcare units of the Mexican Social Security Institute, which is one of the main healthcare institutions in Mexico that serves the social security-dependent population. In both studies, the populations reported were small16. Some of the findings of these studies are as follows: the use of non-steroidal anti-inflammatory drugs in hypertensive patients, with peptic acid disease or for a period longer than three months; use of glibenclamide that increases the risk of hypoglycemia; use of benzodiazepines with risk of balance disorders; use of calcium-antagonists in patients with constipation; use of diuretics in patients without congestive heart failure; β-blockers combined with verapamil or in the presence of chronic obstructive disease, where β-blockers can alter the ventilatory dynamics.Mexico has an Essential Drug List (EDL)It is necessary to dimension at population level the issue of inappropriate drugs prescription, review its prevalence, and the drugs that are most frequently prescribed in an inadequate way. In this way, it would be possible to reduce the risk of events associated with inappropriate prescribing, reduce costs and provide safer and more effective care. The objective of this study is to identify and quantify PPI and other issues related to the prescription of medications in public healthcare services in a population-based study at the three levels of complexity existing in Mexico.A descriptive cross-sectional study was performed on the Study of Satisfaction of Users of the Social Protection System in Health (ESASPSS) applied in 2014, 2015 and 2016. The general objective of the ESASPSS was to document the perception of satisfaction of SPSS users with the health services they received and, in due course, make recommendations to increase user’s satisfaction, and influence the effective access to healthcare services.17.The survey was probabilistic, stratified and two-stage, with national, state and regional representativeness. The medical units attended by the users were defined as primary sample units, the approximate number of units per state was 26 totaling approximately 832 units in the country, distributed among the three levels of care: 80% first level, 16% second level and 4% third level. For each unit selected, 31 questionnaires were applied, estimating an effective sample of around 26,000 interviews nationwide per year. The detailed description of the sampling procedure, and the survey methodology are described in a previous publicationThis study used the section of drugs prescription and supply of the ESASPSS for the three years. The section contains information on the drugs recorded in users’ prescriptions. The survey sampling comprised AMs aged ≥ 65 years who attended the healthcare facilities and were prescribed at least one medication on the day of the survey. The AMs who attended for reasons other than medical consultation were excluded; a final subsample of 6,071 AMs accrued over the three years was obtained.8, STOPP9 and Prescrire10 lists were used to identify the PPI. The 2012 update of the Beers criteria was used; none of the 53 groups of drugs included in this criterion were excluded. For the STOPP criteria, the 2008 list was used. For Prescrire, the 2016 version of 74 drugs was used. From the three criteria, a criterion called “BSP” was created. In it the PPI is considered in cases where at least one contraindicated drug was found in any of the lists. Some contraindicated drugs appear in two or more lists of the above mentioned criteria.The BeersFor the four criteria, all listed drugs were considered regardless of the diagnosis or condition of each individual in the database.Four indicators were constructed for the analysis: two general indicators of prescribing among AM, one on the percentage of PPI according to each criterion used and, finally, one that evaluates the most frequent groups of contraindicated drugs .To apply the PPI indicator by criterion, the drugs prescribed for each user were scored and coded, generating binomial variables by criterion, with a value of 1 = contraindicated and 0 = not contraindicated. The procedure and formulas used for each indicator are detailed in the To compare percentages between the survey years, Pearson’s chi-squared test was used, taking a value of p ≤ 0.05 as significant. Additionally, the indicator was analyzed by geographic area, creating four maps of the Mexican Republic (one for each criterion), where the prevalence of PPI was ranked. To assign the tonality in all the maps, these were categorized into 20% quintiles according to the range (maximum minus minimum) of each criterion.18. For the distribution of groups of drugs, they were recorded according to the active substance contained, and divided by the group of drugs prescribed among AM, with their respective 95% confidence interval (95%CI).Finally, to determine the main groups of PPIs, these were grouped according to the active substance listed on the US Food and Drug Administration websiteAll statistical calculations were adjusted for survey design, considering weightings to obtain population estimators.Of the total AMs in the three years of study , on average, 67% of AMs were prescribed at least one medication. The year 2014 showed the highest prescription prevalence, 71%, with a decrease of 13 percentage points in 2016. The mean number of medications per prescription was 2.7 , the difference by year was only significant in 2016 with the lowest mean of 2.4 medications per prescription .The prevalence of PPI does not disclose significant differences between years of measurement and criteria used, but an increase in prevalence is observed as the number of drugs prescribed increases . In the The NSAIDs are the group of PPIs most prescribed in the three-year sample . Ranked in second there is a group of oral hypoglycemic agents (sulfonylureas), followed by drugs for cardiovascular pathologies such as: vasodilators, beta-blockers, diuretics and calcium blockers .The results of this study show relevant aspects regarding the quality of healthcare services provided to the population aged ≥ 65 years, particularly in relation to drugs prescribing. Considered by type of criteria used, there are differences by region, type of drug and number of drugs prescribed. Because the largest proportion of the sample is represented by first-level care medical units, results show mainly the behavior of these units.19. Despite the lower number of drugs, the prevalence of PPI found in the study is similar to that reported by community studies under the STOPP criteria conducted in Canada, Europe, Australia and Asia (from 21% to 69%)20. The very wide range between prevalence levels may be due to the indiscriminate use of multiple criteria, adaptations, and the source of information used for their application, especially information on dosage and the study population’s history of pathologies. This hinders comparability between studies.The number of drugs per prescription is below that found by the WHO (3.5) in the same age group of the population21. The prevalence levels of previous studies are twice lower than those found in this study. This difference may be a result of the use of comorbidity for the identification of PPIs. Simplifying criteria disregarding this variable allows a greater number of drugs to be considered PPIs, increasing prevalence levels. In a study carried out in a primary healthcare unit in Mexico, in which morbidity was considered, a prevalence of 67% was found15, the same as that found in this study. Therefore, it could be inferred that the prevalence of PPI in Mexico is high.In 2014, population-based studies conducted in Ireland comprising AM aged ≥ 65 years found prevalence levels of 15%, taking into account the morbidity and dosage of the drugs, and 36% taking only the presence of the contraindicated drug. The STOPP criteria were used for both studies, and the sample was similar to the current study22. No comparative studies were found using the Prescrire criteria. It may be due to the specialized nature of the drugs comprised by this criterion, and the fact that it is not designed for a specific age group.In Latin America, specifically Colombia and Argentina, lower prevalence levels have been found  using the Beers criteria. These studies only considered outpatient care at the first level of care in AM. Our results are more representative of the first level of care, so similar behavior could be expected23. However, identification is enhanced by combining criteria, as proposed in this study (BSP). This suggests that combined criteria may be a potentially better option for the identification of PPI.Of the three international criteria used, the STOPP criterion identified significantly higher number of PPI than the Beers, similarly to those identified in other studies25.A steady increase in prevalence was observed as the number of medications increased, with a maximum at 7 medications, similar to other studies in which an increased risk of PPI is related to each additional medication prescribed, with possibilities ranging from 2 to 6 times more with the intake of 6 or more medicationsThis study found differences in the prevalence of PPI by region, higher in the north of the country, and we could not attribute it to any study variable. To explain this, a comparison was made by proportion of AM in each state, as well as by the total number of chronic patients (diabetic and hypertensive), and no difference was found to explain this behavior. Another possible cause could be access to medications (availability or supply in the basic pharmacopoeia). This situation is not documented in this or other studies.26. Despite the consensus that they should not be used in AM for the management of chronic pain, as they are associated with an increased risk of gastric ulcer and bleeding, worsening of cardiovascular pathologies and drug-drug interactions. On the other hand, not using these drugs represents a challenge for health personnel, since chronic pain in AM affects ambulation, with an increased risk of falls, complications associated with depression, cognitive deterioration and increased drug consumption25.The NSAIDs were the most prescribed group of drugs among AM, as in other studies27. However, in Mexico, meloxicam is not included in the basic drug list28. So, the use of adjuvants is important when availability of drugs is limited. For example, it has been shown that physical therapy can be beneficial in some AM27.According to studies carried out among AM on chronic pain management, paracetamol continues to be the first choice for the management of mild to moderate pain, especially musculoskeletal pain, followed by meloxicam. Both medications should be used respecting the maximum recommended dose and taking into account its contraindication in users with hepatic dysfunction and severe renal insufficiency6. Among other factors, the decrease in hepatic parenchyma, as well as of blood flow in AM, decreases the bioavailability of certain drugs, including some antihypertensive medications, which could lead the physician to prescribe higher doses, increasing the risk of adverse reactions29. On the other hand, the decrease in the glomerular filtration rate, and consequently the decrease in drug excretion, may cause frequent adverse events if the necessary dosage adjustments are not made.Finding five groups of drugs for chronic pathologies among the ten most frequent PPIs is a consequence of their high prevalence in Mexico, where cardiovascular disease is the main cause of death in the population of AM, followed by diabetes mellitus19, in addition to ensuring adequate follow-up of non-pharmacological treatment30.Special care should be taken with the use of sulfonylureas for the treatment of diabetes mellitus. The risk of severe hypoglycemia is high, which can lead to more serious events such as myocardial infarction and cerebral vascular accidents. All oral hypoglycemic agents in AM should be indicated at the lowest effective dose to minimize these adverse events29. As these are medications that are not regularly chronically used, the search for alternatives is a feasible possibility for the service provider.As in other studies, antihistamines are an important group of PPIs, despite their association with increased morbidity, hospitalizations, cognitive impairment and mortalityThis population-based study showed that the use of PPIs in AM, in users of public health services, is high in Mexico, implying that the quality of prescriptions is low. Although the prevalence of PPI is not attributable exclusively to health personnel, they are the ones who have the necessary knowledge to seek the best therapeutic alternative to limit the possibility of AE.The AM presents comorbidities that often require management by different levels of care, as well as a greater number of medications, thus increasing the risk of PPI and, therefore, the risk of AE. This makes the management of these patients complex, increases costs for the health system and further fragments the possibility of comprehensive care due to the lack of coordination between physicians, and between levels of care.31. This increases the risk of PPI derived from the sum of drugs for a particular condition, which may be ideal if considered individually, but dangerous if patient is not assessed integrally, exposing them to pharmacological interactions and side effects that reduce their quality of life.Despite the growing number of AM worldwide and the correlation with multimorbidity, the multiple medical care guidelines and protocols are usually directed at a single condition, and frequently conflict with treatments for other diseasesIn the light of quality, it is necessary to develop studies with better and deeper analysis of the PPI tools, combining and adapting them to the country’s context, to be used as a guide. In addition, there is a need to improve regulation on the provision and prescription of medicines in synergy with the PPI tools, and favorable to the proper prescription of medicines.The source of information used derives from a national survey, whose main objective was not aimed at screening for PPI. Therefore, there were limitations regarding the clinical information (morbidity and comorbidities) required to apply all the criteria of the PPI screening tools.Dosage, frequency, and timing of prescribed medications were not considered as part of compliance with criteria.Comparison of prevalence levels with other studies is difficult because each study has considered different populations and made adjustments based on the information available. 2.La medicación en adultos mayores (AM) se reconoce como un problema de alta complejidad en la práctica clínica. Algunos de los factores que contribuyen a esta situación son los cambios fisiológicos asociados a la edad, dado que afectan la farmacodinamia y farmacocinética de algunos fármacos, así como la morbilidad múltiple que conlleva a variados regímenes farmacológicos. Además, influyen el envejecimiento poblacional y factores del sistema de salud como la limitada accesibilidad y actualización de lineamientos de consulta sobre farmacología en AM; atención con múltiples especialistas y frecuentemente en diferentes niveles de complejidad. Este grupo poblacional es muy vulnerable a la prescripción de alto riesgo, dentro de la que se encuentra la prescripción potencialmente inapropiada (PPI)3.En los AM, la prescripción de alto riesgo se define como aquella que puede conducir a resultados clínicos adversos o que no se ajusta al uso correcto de medicamentos. Se han propuesto una variedad de indicadores para cuantificar la prescripción de alto riesgo en AM, entre otros: polifarmacia, prescripción potencialmente inapropiada y exposición a medicamentos de alto riesgo5.La PPI en el contexto de las personas mayores se puede definir como la prescripción de “medicamentos o clases de medicamentos que generalmente deben evitarse en personas de ≥ 65 años porque son ineficaces o representan un riesgo innecesariamente alto para las personas mayores y una alternativa más segura está disponible”7.La prescripción en AM es un componente esencial en la atención médica y su correcta aplicación es un problema de salud pública en todo el mundo debido a que es el grupo poblacional que presenta mayor consumo, con el consecuente incremento de eventos adversos (EA) por interacciones medicamentosas, que conlleva a impactos clínico y económico8.Los métodos de detección de PPI iniciaron en los 90´s, el primero en diseñar y publicar una herramienta de detección fue Beers, esta consistía en una lista explícita de medicamentos identificados por un grupo de expertos cuya prescripción sería inapropiada. Se diseñó para AM residentes de hogares especializados para su cuidado en los Estados Unidos de América (EUA); hay una actualización de 2012 para uso en la atención ambulatoria de la población ≥ 65 años. La actualización cuenta con un listado de 53 grupos de medicamentos potencialmente inapropiados divididos en tres categorías para AM: los que se deben evitar; a evitar con ciertas patologías y los que deben ser usados con precaución9.Algunos países fueron creando o adaptando la lista Beers. Un caso concreto son los criterios STOPP, desarrollados en Europa por expertos en farmacoterapia geriátrica para AM que viven en la comunidad, que incluyen un mayor número de grupos de medicamentos potencialmente inapropiados (65), divididos por aparatos y sistemas. Además, consideran otros criterios como comorbilidad, severidad de la patología por el que se indica el medicamento y duración de tratamiento10.Francia desarrolló sus propios criterios, llamados “Prescrire”. Es un listado de 74 grupos de medicamentos que son más dañinos que beneficiosos en todas las indicaciones, es decir, para todos los grupos de edad y población general; estos criterios fueron creados mediante la búsqueda bibliográfica sistemática en lugar de usar un panel de expertos6.En los países desarrollados, un 20% de la población tiene ≥ 60 años y se estima que será un 32% para 2050. En los países en desarrollo, se espera que la proporción de la población de 60 años o más aumente del 8% en 2005 al 20% para 205011.En un país de ingresos medios como México, se estimó en 2019 que la población de ≥ 65 años era de 9.5 millones, lo que representa 7.5% de la población total. En 2030, los AM serán 14 millones 12.Las principales causas de muerte en AM en México durante el 2017 fueron enfermedades cardiovasculares (27.1%); diabetes mellitus (16.6%); enfermedades crónicas degenerativas, como los tumores malignos (11.6%), y enfermedades cerebrovasculares (6.7%)8. Cifras similares se han presentado en Irlanda en 2008, el 25% usando los criterios Beers y el 35% con los criterios STOPP9. En México se han realizado pocos estudios, en 2014 en un hospital público se realizó un estudio de prevalencia de PPI en AM de ≥ 70 utilizando los criterios Beers encontrando prevalencias del 49%. Sin embargo, cada prevalencia reportada se debe tomar con reserva, por la alta variabilidad de las muestras seleccionadas, así como del uso parcial de los componentes de cada criterio para la medición13.En EUA, utilizando los criterios de Beers, se encontró una prevalencia de PPI en AM atendidos ambulatoriamente del 25 al 30% y del 40% en estancias de atención al AM (2009 y 2012)6. La PPI tiene importantes impactos en varias áreas de la atención a la salud. Se ha estudiado como la identificación de PPI en AM puede reducir la carga de EA, hospitalización y mortalidad por medicamentos5. Además se estimó un gasto anual en salud relacionado con PPI de 7.2 mil millones de dólares en EUA8.El uso inapropiado de medicamentos es una preocupación importante en la seguridad del paciente, especialmente para la población de AM, por sus características, como ya se mencionó previamente14 que sirve de guía para todas las instituciones públicas de salud, se basa en el concepto de uso racional de medicamentos propuesto por la Organización Mundial de la Salud (OMS): eficacia, seguridad y costo. Sin embargo, existen pocos estudios sobre patrones y errores de prescripción de medicamentos en AM en México y aún menos en instituciones públicas de atención primaria a la salud o atención ambulatoria6. En los últimos cinco años, se cuenta con dos estudios realizados en unidades de primer nivel de atención del Instituto Mexicano del Seguro Social, que es una de las principales instituciones de salud de México que atiende a la población con seguridad social, en ambos estudios, las poblaciones reportadas fueron pequeñas16. Dentro de los hallazgos en estos estudios está: el uso de antiinflamatorios no esteroideos en pacientes hipertensos, con enfermedad ácido péptica o por un periodo mayor a tres meses; uso de glibenclamida que aumenta el riesgo de hipoglucemias; uso de benzodiacepinas con riesgo de trastornos del equilibrio; uso de calcio-antagonistas en pacientes con estreñimiento; uso de diuréticos en pacientes sin insuficiencia cardiaca congestiva; β-bloqueadores combinado con verapamilo o en presencia de enfermedad obstructiva crónica a los cuales puede alterar la dinámica ventilatoria.México cuenta con una Lista de Medicamentos Esenciales (EDL)Es necesario dimensionar el problema de prescripción inapropiada de medicamentos a nivel poblacional, analizar su prevalencia y los medicamentos que con mayor frecuencia se prescriben de forma inapropiada. Así, podría plantearse la disminución del riesgo de eventos asociados a una mala prescripción, reducir costos y brindar una atención más segura y efectiva. El objetivo de este estudio es identificar y cuantificar la PPI y otros problemas en la prescripción de medicamentos en los servicios públicos de atención médica en un estudio poblacional en los tres niveles de complejidad existentes en México.Se realizó un estudio descriptivo de corte transversal del Estudio de Satisfacción de Usuarios del Sistema de Protección Social en Salud (ESASPSS) aplicado en 2014, 2015 y 2016. El objetivo general del ESASPSS fue documentar la percepción de satisfacción de las(los) usuarias(os) del SPSS respecto de los servicios de salud que recibían y, en su momento, realizar recomendaciones para incrementar la satisfacción de las(los) usuarias(os) e incidir en el acceso efectivo a los servicios de salud.17.La encuesta fue probabilística, estratificada y bietápica con representatividad nacional, estatal y regional. Las unidades médicas a las que acudieron los usuarios fueron definidas como unidades primarias de muestra, el número aproximado de unidades por estado fue de 26, un total de 832 unidades aproximadamente en el país, distribuidas en los tres niveles de atención: el 80% primer nivel, el 16% segundo nivel y el 4% tercer nivel. Por cada unidad seleccionada se aplicaron 31 cuestionarios, estimando una muestra efectiva de alrededor de 26,000 entrevistas en todo el país por año. La descripción detallada del procedimiento de muestreo y metodología de la encuesta se encuentra descrita en una publicación previaPara este estudio se utilizó la sección de prescripción y surtimiento de medicamentos de la ESASPSS de los tres años, que contiene información de los medicamentos registrados en las recetas de los usuarios. Se incluyó en el análisis a AM de ≥ 65 años de edad, que acudieron a los establecimientos de salud y se les prescribió al menos un medicamento el día de la encuesta. Se excluyeron los AM que acudieron por otros motivos que no fuera consulta médica, se obtuvo una submuestra final de 6,071 AM acumulada en los tres años.8, STOPP9 y Prescrire10. Para los criterios Beers se tomó la actualización de 2012, no se excluyó ninguno de los 53 grupos de medicamentos que integran este criterio. En los criterios STOPP se usó el listado de 2008. Para Prescrire, se tomó la versión 2016 de 74 medicamentos. A partir de los tres criterios, se creó un criterio llamado “BSP”, en el cual se considera PPI en los casos en que se encontraba al menos un medicamento contraindicado en cualquiera de las listas. Algunos medicamentos contraindicados aparecen en dos o más listados de los criterios anteriores.Para la identificación de la PPI se usaron los listados BeersPara los cuatro criterios, se consideraron la totalidad de los medicamentos enlistados con independencia del diagnóstico o condición de cada individuo en la base de datos.Para el análisis se construyeron cuatro indicadores, dos indicadores generales de prescripción en AM, uno sobre el porcentaje de PPI de acuerdo a cada criterio utilizado y, por último, uno que valora los grupos de medicamentos contraindicados más frecuentes .Para la aplicación del indicador de PPI por criterio, se calificaron y codificaron los medicamentos prescritos de cada usuario, generando variables binomiales por criterio, se otorgó el valor de 1 = contraindicado y 0 = no contraindicado. El procedimiento y fórmulas utilizadas para cada indicador se detallan en el Para comparar porcentajes entre años de la encuesta se utilizó la prueba de ji2 de Pearson, tomando como significativo un valor de p ≤ 0.05. Adicionalmente, el indicador se analizó por área geográfica, creando cuatro mapas de la República Mexicana (uno por cada criterio), donde se clasificó la prevalencia de PPI. Para asignar la tonalidad en todos los mapas, se categorizaron en quintiles del 20% según el rango (el máximo menos el mínimo) de cada criterio.18. Para la distribución de los grupos de medicamentos, se contabilizaron según la sustancia activa que contienen y se dividieron entre el grupo de medicamentos prescritos en AM, con su respectivo intervalo de confianza al 95%.Por último, para determinar los principales grupos de PPI, se agruparon de acuerdo a la sustancia activa señalada en la página de la Food and Drug Administration de Estados Unidos (Administración de Medicamentos y Alimentos)Todos los cálculos estadísticos se ajustaron por el diseño de la encuesta, considerando los ponderadores para obtener estimadores poblacionales.Del total de AM en los tres años de estudio , en promedio, el 67% de los AM recibieron prescripción de al menos un medicamento. En 2014 se presentó la prevalencia más alta de prescripción con el 71%, con un descenso de 13 puntos porcentuales en 2016. La media de medicamentos por receta fue de 2.7 , la diferencia por año solo fue significativa en 2016 donde se presentó la media más baja con 2.4 medicamentos por receta .En la La prevalencia de PPI no presenta diferencias significativas entre años de medición y criterio utilizado, pero se observa un incremento de la prevalencia conforme aumenta el número de medicamentos prescritos . En los En la Los AINES son el grupo de PPI que más se prescribieron en la muestra de los tres años , en segundo lugar, se encuentra un grupo de hipoglucemiantes orales (sulfonilureas), seguido de medicamentos para patologías cardiovasculares como son: vasodilatadores, beta-bloqueadores, diuréticos y bloqueadores de calcio .Los resultados de este estudio muestran aspectos relevantes en la calidad de la prestación de servicios de salud a la población de ≥ 65 años, en particular con relación a la prescripción de medicamentos. Por tipo de criterios utilizados existen diferencias por región, tipo de medicamento y número de medicamentos recetados. Debido a que la mayor proporción de la muestra se encuentra representada por unidades médicas de primer nivel de atención, los resultados muestran principalmente el comportamiento de estas unidades.19. A pesar de que el número de medicamentos es menor, la prevalencia de PPI encontrada en el estudio es similar a la reportada por estudios comunitarios bajo los criterios STOPP, realizados en Canadá, Europa, Australia y Asia 20. El intervalo entre las prevalencias, muy amplio, puede derivar del uso indistinto de múltiples criterios, adaptaciones, y de la fuente de información utilizada para la aplicación de los mismos, en especial información sobre dosificación y el historial de patologías de la población en estudio. Lo anterior dificulta la comparabilidad entre estudios.El número de medicamentos por receta está por debajo de lo encontrado por la OMS (3.5) en el mismo grupo de edad de la población21. Las prevalencias de los estudios anteriores son dos veces menores que lo encontrado en este estudio, esta diferencia puede ser resultado del uso de la comorbilidad para la identificación de los PPI; simplificar el criterio sin considerar esta variable permite que mayor número de medicamentos se consideren PPI, elevando las prevalencias. En un estudio realizado en una unidad de primer nivel de atención en México, en el cual se consideró la morbilidad, se encontró una prevalencia del 67%15, igual a la encontrada en este estudio, por lo que se podría inferir que, la prevalencia de PPI en México es alta.En 2014, estudios poblacionales realizados en Irlanda, en AM de ≥ 65 años, encontraron prevalencias del 15% tomando en cuenta la morbilidad y dosificación de los medicamentos y del 36% tomando solo la presencia del medicamento contraindicado. Para ambos estudios se utilizaron los criterios STOPP y la muestra fue similar al presente estudio22. No se encontraron estudios comparativos en los que se usaran los criterios Prescrire, esto puede ser por lo especializado de los medicamentos que contiene este criterio y que no está diseñado para un grupo de edad específico.En Latinoamérica, Colombia y Argentina específicamente, se han encontrado prevalencias más bajas (el 21% y el 20% respectivamente) usando los criterios Beers. En estos estudios solo consideraron la atención ambulatoria de primer nivel de atención en AM; nuestros resultados tienen una mayor representatividad del primer nivel de atención por lo que se podría esperar un comportamiento similar23. Sin embargo, la identificación se potencia al realizar una combinación de criterios como es el propuesto en este estudio (BSP), lo que indica el potencial para que los criterios combinados sean usados como una mejor opción para la identificación de PPI.De los tres criterios internacionales usados, el criterio STOPP identificó significativamente mayor número de PPI que Beers, similar a los identificados en otros estudios25.Se observó un incremento constante de la prevalencia conforme se incrementó el número de medicamentos, con un máximo a los 7 medicamentos, similar a otros estudios en los que se relaciona un mayor riesgo de PPI con cada medicamento adicional recetado, con posibilidades que van desde 2 a 6 veces más con la toma de 6 o más medicamentosEn este estudio se observaron diferencias en la prevalencia de PPI por región, más alta en el norte del país, sin poder atribuirlo a alguna variable del estudio. Para explicarlo se realizó la comparación por proporción de AM en cada estado, así como, por el total de pacientes crónicos (diabéticos e hipertensos), sin encontrar diferencias que pudieran explicar este comportamiento. Otra posible causa sería el acceso a los medicamentos  necesarias para aplicar todos los criterios de las herramientas de detección de PPI.No se consideró la dosificación, la frecuencia y el tiempo de los medicamentos prescritos como parte del cumplimiento de los criterios.Es difícil la comparación de prevalencias con otros estudios, debido a que cada estudio ha considerado poblaciones distintas y ha realizado ajustes con base en la disponibilidad de la información.


Free-floating thrombus in the deep venous system has a high potential to cause pulmonary embolization. It can also be found in patients with superficial venous thrombosis (SVT) that extends to a deep vein. There are still no defined criteria for treatments described in the literature, which range from anticoagulation and fibrinolytic treatments with vena cava filter implants, through open or endovascular thrombectomies, to more invasive procedures such as surgical interruption with ligation of the venous system. We present the case of a patient with extensive deep venous thrombosis affecting the iliofemoral-popliteal territory with a floating thrombus extending from the left common iliac vein to the inferior vena cava. Treatment was performed with fibrinolytic therapy delivered with a multiperforated catheter, supplemented with anticoagulation with heparin and daily control angiography. At the end of the treatment, a significant stenosis was identified in the left common iliac vein, and angioplasty was performed with stenting. Voet and Afschrift4,With regard to treatment, a number of different approaches are described in the literature. Some studies suggest only anticoagulation, because of autolysis of floating thrombi, combined with rest.9The patient was a 47-year-old female who had been admitted with intense pain and edema in the left lower limb (LLL) the day before. Physical examination revealed edema of the limb starting at the thigh, clubbing, venous flushing, and the Homans and Bancroft signs. DUS showed enlarged calibers of the left common and external iliac veins, with no blood flow, and hypoechoic intraluminal material, indicating acute DVT. The femoral, popliteal, tibial, and fibular veins were compressible and had normal flow, with no evidence of thrombi .Anticoagulation was initiated with full dosage low molecular weight heparin (LMWH). After 2 days of treatment, the patient’s edema worsened, and the decision was taken to perform thrombolysis.Phlebography was conducted via left popliteal vein DUS-guided puncture, using a 6Fr Bernstein catheter , showing progression of the thrombosis to the femoral and popliteal veins, which had not been present when the DUS examination had been conducted on the day of admission, as can be observed in After the procedure, the patient was transferred to the intensive care unit (ICU), serial laboratory tests were conducted and she was monitored for bleeding. Control phlebography was conducted every 24 hours. 72 hours after fibrinolysis, symptoms had improved and control phlebography showed venous recanalization of the iliac-femoropopliteal segment and stenosis of the LCIV characteristic of May-Thurner Syndrome . In respPatients with FFVT in the lower limbs are at increased risk of PTE because of instability of the thrombus. Norris et al.There are not yet any guidelines in the literature specifically for FFVT, and different approaches diverge greatly in terms of treatment, ranging from full anticoagulation,Anticoagulation is the standard treatment for DVT in lower limbs, but in FFVT cases, medication alone may be insufficient to prevent displacement of the thrombus and, consequently, pulmonary thromboembolism (PTE).Surgical procedures are one option, but the high mortality rate associated with ligature of the IVC prompted development of techniques for partial occlusion of larger veins or use of clips.13Casian et al.Thrombectomy with removal of the thrombotic mass via a Fogarty catheter is another option since, in addition to preventing severe postthrombotic syndrome, it reduces the risk of PTE. Fibrinolytic treatment also reduces postthrombotic syndrome with dissolution of the thrombus, but it is associated with hemorrhagic complications.15Xue et al.16Endovascular treatment motivated by worsening of the patient’s symptoms after conservative management was effective in the case described, carefully following our institution’s protocol for catheter-directed thrombolysis. Good results were achieved with the treatment chosen, considering the improved clinical status confirmed by phlebography showing venous recanalization.The posterior discovery of May-Thurner Syndrome confirms the importance of this disease in thrombotic events associated with compressive syndromes involving the iliocaval segment. Definitive treatment with angioplasty and a self-expanding stent has proven effective and with low rates of relapse and new thrombotic events over the short and medium term.Although several treatment options for cases of FFVT in lower limb deep veins are described in the literature, there are not yet any specific guidelines. We believe that the choice of fibrinolysis, following the institutional protocol, is one option for extensive DVT in lower limbs, including in the present case with free-floating thrombus. This approach has a role to play in patients with severe symptomology and long life expectancy. -Há mais de três décadas, o tromboembolismo venoso (TEV) foi estimado como o terceiro evento cardiovascular agudo mais comum no mundo com incidência anual global nos Estados Unidos entre 1 e 2 por 1.000 pessoas1,laser endovenoso para tratamento de veias safenas insuficientesO trombo venoso flutuante (TVF) consiste em uma forma particular de trombose venosa profunda (TVP) com alto potencial de embolização pulmonar5-Estudos sobre TVF são escassos e divergem em aspectos como mortalidade, prevalência e localização predominante dos trombos. Na pesquisa desenvolvida por Voet e Afschrift4,No que se refere à abordagem terapêutica, existem divergências na literatura. Alguns estudos sugerem apenas anticoagulação devido à autólise dos trombos flutuantes e repouso9Paciente de 47 anos, sexo feminino, admitida com dor intensa e edema em membro inferior esquerdo (MIE) há um dia. Ao exame físico, detectou-se edema nesse membro desde a coxa, empastamento, pletora venosa e sinais de Homans e Bancroft. O USD evidenciou veias ilíacas comum e externa esquerda com calibres aumentados, fluxo ausente e material hipoecoico intraluminal indicando TVP aguda. As veias femorais, poplítea, tibiais e fibulares eram compressíveis e com fluxo normal, não evidenciando presença de trombos .Iniciou-se anticoagulação com heparina de baixo peso molecular (HBPM) em dose plena. Após dois dias do tratamento, a paciente manifestou piora do edema, e optou-se por tratamento trombolítico.bolus do fibrinolítico Alteplase. O cateter foi mantido no local para a infusão contínua do fibrinolítico na dose de 0,01 mg/kg/hora. Acrescentou-se heparina endovenosa, em infusão contínua, simultaneamente ao uso do fibrinolítico.A flebografia realizada por meio de punção da veia poplítea esquerda guiada por USD com a utilização de cateter 6Fr Bernstein  possibilitou visualizar a progressão da trombose para as veias femorais e poplítea, que não existia quando realizado USD no dia da internação, como pode ser observado na Na sequência do procedimento, a paciente foi encaminhada à unidade de terapia intensiva (UTI), com exames laboratoriais seriados e monitorização de sangramentos. O controle flebográfico foi realizado a cada 24 horas. Após 72 horas de fibrinólise, verificou-se melhora dos sintomas, e a flebografia de controle revelou recanalização venosa no segmento ilíaco-fêmoro-poplíteo e presença de estenose em VICE, característica da síndrome de May-Thurner . Diante Os pacientes com TVF de MMII exibem um risco maior de TEP por causa da instabilidade do trombo. Norris et al.Ainda não existe na literatura uma diretriz específica para TVF, e as condutas são bastante divergentes quanto à terapêutica: desde anticoagulação plenaA anticoagulação é o tratamento padrão em TVP de membros inferiores, entretanto, nos casos de TVF, apenas a medicação pode não ser suficiente para prevenir o deslocamento do trombo e, como consequência, o tremboembolismo pulmonar (TEP).Procedimentos cirúrgicos consistem em uma alternativa, mas a taxa de mortalidade alta associada com a ligadura de VCI resultou em técnicas para oclusão parcial das veias maiores ou aplicação de clipesCasian et al.A trombectomia com remoção da massa trombótica com cateter de Fogarty constitui uma alternativa, pois, além de prevenir uma síndrome pós-trombótica severa, diminui o risco de TEP. O tratamento fibrinolítico também reduz a síndrome pós-trombótica com a dissolução do trombo; todavia, está associado a complicações hemorrágicasXue et al.O tratamento endovascular motivado pela piora dos sintomas da paciente após a abordagem conservadora foi eficaz no caso descrito, seguindo-se de forma criteriosa o protocolo de trombólise cateter-dirigido da nossa instituição. Chegou-se a bons resultados com a terapêutica utilizada, haja vista a melhora do quadro clínico comprovada na flebografia evidenciando recanalização venosa.A posterior descoberta da síndrome de May-Thurner corrobora a importância da doença em eventos trombóticos associados às síndromes compressivas em segmento cavo-ilíaco. O tratamento definitivo com angioplastia e stent autoexpansível revelou-se eficiente e com baixa recidiva de novo evento trombótico a curto e médio prazos.Embora várias opções de tratamento nos casos de TVF em veias profundas dos MMII sejam descritas na literatura, ainda não existe uma diretriz específica. Acreditamos que a opção pela fibrinólise, seguindo o protocolo institucional, possa ser uma alternativa para TVP extensa de MMII, incluindo o presente caso com trombo flutuante associado. Ressalta-se, por fim, o papel da conduta em questão em pacientes com sintomatologia exuberante e elevada expectativa de vida.


O entusiasmo por uma terapia menos invasiva do que a cirurgia de revascularização do miocárdio (CABG) para pacientes com doença da artéria coronária principal esquerda desprotegida (ULMCA) remonta aos anos 90. versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL)” 2 , quando se trata de desfechos duros, como morte e acidente vascular cerebral, nos últimos anos vários ensaios randomizados e não-randomizados demonstraram não-inferioridade ou mesmo superioridade da ICP em comparação à CABG. 6 Recentemente, esses dados foram compilados em duas meta-análises nas quais o seguimento de longo prazo não mostrou diferença significativa na mortalidade e na taxa de AVC entre ICP e CABG. 8 Além disso, dois desses ensaios randomizados com seguimento prolongado de longo prazo, de até 10 anos, demonstraram bons resultados sustentados da ICP, com taxas de mortalidade semelhantes às da CABG, respectivamente, 14,5% x 13,8% e 27 % x 28%. 5Apesar das controvérsias a respeito da publicação de 5 anos do estudo “XIENCE 9 apresentam sua experiência com ICP para doença de ULMCA em uma série consecutiva de 107 pacientes. 9 Esses dados são muito importantes para toda a comunidade médica envolvida no tratamento da doença arterial coronariana, à luz da escassez de dados sobre CABG ou ICP para doença de ULMCA em nossa região. Do ponto de vista da medicina baseada em evidências, os ensaios clínicos randomizados (ECR) são o “padrão ouro” para avaliar a segurança e eficácia dos agentes terapêuticos, ainda mais no complexo cenário de comparação de dois métodos de tratamento invasivos, tão distintos como a CABG e a ICP. Entretanto, registros e experiências locais, como o de Grion et al. 9 são importantes para fornecer todo o espectro de pacientes tratados no ambiente do mundo real e a possibilidade de avaliar se os tratamentos e resultados dos ECRs são realmente aplicados diariamente. Os rígidos critérios de inclusão e exclusão necessários implicam que as populações do estudo muitas vezes não são representativas dos pacientes encontrados na prática clínica. Por exemplo, nos estudos EXCEL e NOBLE, mais de um terço dos pacientes elegíveis foram na verdade excluídos e quase metade deles devido a condições clínicas que levam o cirurgião cardíaco ou cardiologista intervencionista participante a acreditar que o equilíbrio clínico não estava presente.Nesta edição dos Arquivos Brasileiros de Cardiologia, Grion et al., 2 NOBLE 3 e PRECOMBAT. 4 Apesar desses perfis de risco altamente clínicos e de lesão, eles alcançaram resultados muito bons em curto prazo com alto sucesso do procedimento (99%) e baixa taxa de mortalidade intra-hospitalar . Taxas semelhantes foram observadas em nosso país por Constantini et al., 10 em 2011 , bem como nos principais registros internacionais do tipo “ all-comers ” 11 como DELTA 1, DELTA 2 12 e MAIN-COMPARE, 14 onde o a mortalidade hospitalar foi de 2,0% e 1,1% e 0,8%, respectivamente. Apesar da relevância dos resultados intra-hospitalares, obviamente, os resultados do seguimento de longo prazo ainda são necessários para confirmar esses bons achados intra-hospitalares. Posto isto, devemos ter em mente que para alcançar bons resultados em longo prazo em qualquer tipo de intervenção para pacientes com doença arterial coronariana multiarterial estável ou ULMCA, é essencial ter uma mortalidade hospitalar abaixo de 2%.O presente estudo incluiu uma população do mundo real, geralmente excluída de ensaios clínicos randomizados com complexidade aumentada. Diabetes estava presente em mais da metade dos pacientes (57%) e a média de idade foi de até 69 anos. A fração de ejeção média de 53% é menor do que a dos ECRs e um maior número de stents foram implantados por paciente . Finalmente, o escore SYNTAX médio foi 46 ± 23, substancialmente mais alto do que os dos estudos EXCEL, 15Por outro lado, tem sido amplamente demonstrado que mesmo a ICP contemporânea, comparada à CABG, apresenta maior risco de revascularização repetida no seguimento em longo prazo. Nesse contexto, vale ressaltar a excelência do atual grupo, que utiliza o ultrassom intracoronário (USIC) para guiar a ICP em 100% dos pacientes com doença de ULMCA. Mesmo nos ECRs, a ICP guiada por USIC não excede 70% do uso. Além disso, há muita experiência e uma riqueza de evidências que apoiam o uso rotineiro de USIC na ICP da ULMCA. O uso de USIC durante a ICP da ULMCA é seguro e está associado a reduções substanciais em ECAM no seguimento de longo prazo, incluindo revascularização repetida e até morte. 9 demonstraram resultados hospitalares muito bons com a ICP da ULMCA complexa guiada por USIC em nosso ambiente. Conhecer e divulgar nossos resultados intra-hospitalares é o primeiro passo para podermos incorporar os resultados dos ECRs em nossa prática diária.Em conclusão, Grion et al.  1 Although the contribution of CABG in the survival of patients with ULMCA disease is undeniable, in the last few years, several authors have demonstrated the safety and efficacy of percutaneous coronary intervention (PCI).The estimated prevalence of left main artery disease found during diagnostic angiography is 6% in published series. The enthusiasm for a less invasive therapy than coronary artery bypass grafting (CABG) for patients with unprotected left main coronary artery (ULMCA) disease dates back to the 90s.2 trial, when it comes to hard outcomes, as death and stroke, in the last years several randomized and non-randomized trials have demonstrated non-inferiority or even superiority of PCI against CABG.6 Recently, these data were compiled in two meta-analysis where long term follow-up has shown no significant difference in mortality and stroke rate between PCI and CABG.8 In addition, two of these randomized trials with extended long-term follow-up, up to 10 years, have demonstrated sustained good results after PCI, with death rates similar to CABG, respectively, 14.5% x 13.8% and 27% x 28%.5Despite the controversies regarding the 5-year publication of the Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL)Arquivos Brasileiros de Cardiologia , Grion et al.9 present their experience with PCI for ULMCA disease in a consecutive series of 107 patients.9 These data are very important for the entire medical community involved in the treatment of coronary artery disease, in light of the scarcity of data regarding CABG or PCI for ULMCA disease in our region. From the point of view of evidence-based medicine, randomized control trials (RCT) are the “gold standard” for evaluating the safety and efficacy of therapeutic agents, even more in the complex scenario of comparing two invasive treatment methods as distinct as CABG and PCI. However, registries and local experience, such as that of Grion et al.9 are important for providing the full spectrum of patients treated in the real world setting and the possibility of assessing whether the treatments and results of the RCTs are actually applied on a daily basis. The necessary strict inclusion and exclusion criteria implies that trial populations are often not representative of the patients encountered in clinical practice. For example, in the EXCEL and NOBLE trials, more than one-third of the eligible patients were actually excluded and almost half of them were so due to clinical conditions, which leads the participating cardiac surgeon or interventional cardiologist to believe that clinical equipoise were not present.In this issue of 2 NOBLE3 and PRECOMBAT4 trials. Notwithstanding these hugely clinical and lesion risk profiles, they have achieved very good short-term results with high procedural success (99%) and low rate of in-hospital mortality (1.86%). Similar rates were observed in our country by Constantini et al.10 in 2011 , as well as in the major all-comers11 international registries like DELTA 1, DELTA 212 and MAIN-COMPARE,14 where the hospital mortality was respectively 2.0% and 1.1% and 0.8%. Despite the relevance of in-hospital results, obviously long-term follow-up outcomes are still needed to confirm these good in-hospital findings. Having said that, we must bear in mind that in order to accomplish good long-term results in any kind of intervention for patients with stable multivessel coronary artery disease or ULMCA, it is essential to have in-hospital mortality below 2%.The present study included a real-world population, usually excluded from randomized clinical trials with increased complexity. Diabetes was present in more than half of the patients (57%) and the mean age was as high as 69 years old. The mean ejection fraction of 53% is lower than those from RCTs and a higher number of stents were implanted per patient (3.9). Finally, the mean SYNTAX score was 46 ± 23, substantially higher than those from the EXCEL,15On the other hand, it has been widely demonstrated that even the contemporary PCI, compared to CABG, has a greater risk of repeated revascularization in the long-term follow-up. In this context, it is worth mentioning the excellence of the current group, using intracoronary ultrasound (IVUS) to guide PCI in 100% of the ULMCA disease patients. Even in the RCTs, IVUS-guided PCI does not exceed 70% of use. Moreover, there is plenty of experience and a wealth of evidence supporting routine use of IVUS in ULMCA PCI. IVUS during ULMCA PCI is safe and associates with substantial reductions in MACE in the long-term follow up, including repeated revascularization and even death.9 demonstrated very good in-hospital results of IVUS-guided complex ULMCA PCI in our environment. Knowing and publicizing our in-hospital results isIn conclusion, Grion et al.


A Organização Mundial da Saúde estima que as doenças cardiovasculares (DCVs) sejam a principal causa de morte no mundo, sendo responsáveis por 17,5 milhões de mortes por ano, número que deve ultrapassar 23,6 milhões até 2030.A hipertensão é quantitativamente o fator de risco mais importante para DCVs, como acidente vascular cerebral, infarto do miocárdio e insuficiência cardíaca.–D. lanata, usada no tratamento da insuficiência cardíaca congestiva por muitas décadas, e a reserpina, derivada da R. serpentina, que foi um dos primeiros medicamentos utilizados no tratamento da hipertensão.É importante ressaltar que mesmo com a grande diversidade de medicamentos disponíveis atualmente, ainda existe um aumento na prevalência das DCVs. Isso enfatiza a importância de estudos com o objetivo de descobrir novas substâncias com efeitos anti-hipertensivos ou cardioprotetores, de baixo custo e poucos efeitos adversos. Nesse sentido, o potencial terapêutico de produtos derivados de plantas para DCVs foi documentado em estudos anteriores.Monteiro et al.,Salvia officinalis.O manool pertence à classe dos compostos diterpênicos e é encontrado em maiores concentrações na espécie Esses estudos apontaram os diterpenóides como um alvo potencial para o desenvolvimento de novos agentes terapêuticos cardiovasculares. Corroborando com estes estudos, Monteiro et al., The World Health Organization estimates that cardiovascular diseases (CVD) are the leading cause of death globally, accounting for 17.5 million deaths per year, a number that is expected to grow to more than 23.6 million by 2030.Hypertension is quantitatively the most important risk factor for CVD, such as stroke, myocardial infarction, and cardiac failure.–D lanata, used in the treatment of congestive heart failure for many decades, and the reserpine, derived from R serpentine, which was one of the first drugs used on the treatment of hypertension.It is important to note that even with the great diversity of drugs currently available, there is still an increase in the prevalence of CVD. This emphasizes the importance of studies with purposes of discovering new substances with antihypertensive or cardioprotective effects, low cost, and few adverse effects. In this sense, the therapeutic potential of plant-derived products for treatment of CVD has been documented in previous studies.Monteiro et al.Salvia officinalis.Manool belongs to the class of diterpene compounds and is found in higher concentrations in the species These studies pointed out the diterpenoids as a potential target for the development of novel cardiovascular therapeutic agents. In this sense, Monteiro et al.


The nutcracker syndrome is caused by compression of the left renal vein by thesuperior mesenteric artery and aorta and is associated with characteristic symptoms,such as lower abdominal pain, varicocele, and hematuria. Diagnosis is often difficultand, therefore, is often delayed. Invasive treatment is controversial, particularlyin pediatric patients. However, it is indicated in cases of gross hematuriaassociated with anemia, renal function impairment, severe pelvic pain, or ineffectiveconservative treatment. We report the case of a 12-year-old boy presenting withsevere hematuria for 12 hours, with no abnormal findings at a first evaluation, whoprogressed with severe anemia and urinary retention. Further investigation providedimages suggestive of nutcracker syndrome, and endovascular stenting (smart controlstent) followed by balloon dilatation was the treatment of choice. Hematuria ceasedafter the procedure, and the patient is still asymptomatic at 5-year follow-up. The nutcracker syndrome is a difficult-to-diagnose condition that is often identifiedlate3The syndrome is most common among women aged from 20 to 40 years. The most frequentsymptom is hematuria, followed by abdominal and flank pains, which can spread to thighsand buttocks. Pain may worsen in sitting and standing positions.1Imaging exams are essential for diagnosis, and the most widely-used methods for thispurpose are renal Doppler ultrasonography and computed tomography angiography.2This report presents the case of a 12-year-old patient with a diagnosis of nutcrackersyndrome who was treated successfully with stenting of the LRV.A 12-year-old male patient was admitted via the urology service after presenting withgross hematuria lasting 12 hours. He had no other complaints and mentioned nothing ofnote in relation to personal or family history. Computed tomography was ordered, butshowed nothing, according to the report. A blood test conducted at admission showedserum hemoglobin (Hb) of 11.7 mg/dL.Over 24 hours, the patient developed intense anemia, reaching Hb of 7.4 mg/dL, andurinary retention. Urethral catheterization was performed to relieve the bladder,eliminating countless clots, and ultrasonography revealed a large clot in the bladderinterior.A transfusion was then performed with two packed red blood cell units, and cystoscopywas conducted with bladder lavage and removal of clots. Active blood flow was observedfrom the left ureter into the interior of the bladder and so the urology team inserted aJJ catheter.Arteriography was ordered and ruled out arteriovenous malformations and renalarteriovenous fistulas . HoweverRepair was attempted by angioplasty with a 10 × 40 mm balloon, but there wasconsiderable recoil, and stenosis remained . The casThe patient’s hematuria ceased completely in 6 hours, even though he was onacetylsalicylic acid (ASA) and clopidogrel. The patient has been asymptomatic for 5years, with control angiotomography showing the stent patent and no compressions .,2,Initially described in 1950, the nutcracker syndrome typically consists of compressionof the LRV between the aorta and the SMA.2nd to3rd decades of life.3Compression of the LRV can also be caused by pancreatic cancer, periaorticlymphadenopathy, retroperitoneal cancer, or presence of localized fibrotic tissuebetween the aorta and the SMA. Prevalence is higher among females and it can have onsetin childhood or adulthood, but frequency is highest in from the 2,Symptoms can be aggravated by physical activity and other clinical conditions arecommon, primarily kidney stones. Nutcracker syndrome is difficult to diagnose, and it isnecessary to first investigate and rule out other more common and/or serious causes ofthe symptoms, particularly of hematuria.2Arteriography was ordered to test for arteriovenous malformations or renal arteriovenousfistula, which could have been the cause of gross hematuria, and ruled out theseconditions. Clinical and biochemical characteristics may not be evident and detection ofhypertension in the left renal vein by radiological procedures is subject to operatorerror, to the extent that the syndrome may be more common than is described in theliterature.8Prognosis is variable with nutcracker syndrome and is dictated by the magnitude ofcompression of the renal vein. In some cases, development of collateral venouscirculation can trigger regression of the symptomatology.7Since hematuria will resolve in 75% of cases, treatment should be conservative for atleast 2 years in patients under the age of 18 years. However, in cases with severesymptoms, interventional treatment should be provided and this encompasses a range ofsurgical options, including nephropexy and renal vein bypass, transposition of the leftrenal vein, with or without dacron reinforcement, transposition of the superiormesenteric artery, kidney autotransplantation and renal vein bypass to the vena cava,through gonadocaval bypass, or even nephrectomy.3,12Placement of external or intravascular stents has been described with good results. Thecurrent tendency to favor minimally invasive surgery suggests that intravascularstenting could be beneficial for patients, but care should be taken to avoid intimalhyperplasia and later occlusion of the stent. Therefore, it is recommended that plateletantiaggregants or anticoagulants should be used for at least 2 to 3 months, whilewaiting for full neoendothelialization of the site. There are few publicationsdescribing implantation of venous stents in young patients and there is no consensus onthis application. While there are reports of promising results so far, there is littleevidence on the long-term patency of these stents in these patients.9The results in the case presented here were satisfactory. After deployment of a 12 × 40mm smart control stent, followed by 10 × 40 mm balloon angioplasty, the patient’shematuria ceased completely in 6 hours, even though he was on platelet antiaggregantsand anticoagulants. The patient has remained asymptomatic for 5 years. nutcracker, é uma condição de diagnóstico difícil e frequentementetardioA síndrome do quebra-nozes, também conhecida como Essa síndrome é mais comum em mulheres entre 20 e 40 anos. O sintoma mais frequente éa hematúria, seguido de dor abdominal e nos flancos, com possível irradiação paracoxas e nádegas. A dor pode apresentar piora nas posições sentada e ortostáticaExames de imagem são essenciais no diagnóstico, e os mais utilizados são aultrassonografia com Doppler renal e a angiotomografia computadorizadaEste relato tem como objetivo apresentar o caso de um paciente de 12 anos comdiagnóstico de síndrome do quebra-nozes, tratado com sucesso por implante de stent naVRE.Paciente do sexo masculino, 12 anos, deu entrada pelo serviço de urologia com quadrode hematúria maciça havia 12 horas. Negava outros tipos de queixas e não relatavanada digno de nota em antecedentes pessoais e familiares. Foi solicitada tomografiacomputadorizada, que não evidenciou alterações segundo laudo, e também um hemogramacom nível sérico de hemoglobina (Hb) de entrada de 11,7 mg/dL.Em 24 horas, o paciente evoluiu com anemia intensa, apresentando Hb de 7,4 mg/dL equadro de retenção urinária. Assim, foi realizada sondagem uretral de alívio comeliminação de inúmeros coágulos, além de uma ultrassonografia que evidenciou umgrande coágulo no interior da bexiga.Em seguida, realizou-se transfusão com dois concentrados de hemácias e cistoscopiacom lavagem vesical e retirada de coágulos. Evidenciou-se saída ativa de sangue peloureter esquerdo no interior da bexiga e, então, foi passado cateter duplo J pelaequipe de urologia.nutcracker  e clopidogrel. Há 5 anos, o paciente permanece assintomático ecom angiotomografia de controle evidenciando perviedade do stent e ausência decompressões .nutcracker) consiste na típica compressão da VRE pela AA e pela AMS2,2,Inicialmente descrita em 1950, a síndrome do quebra-nozes 2Para descartar malformações arteriovenosas ou fístula arteriovenosa renal, quepoderiam justificar a hematúria maciça, foi solicitada uma arteriografia, quedescartou as lesões. As características clínicas e bioquímicas podem não serevidentes, além de a detecção da hipertensão da veia renal esquerda por procedimentosradiológicos estar sujeita à falha do operador, de forma que a síndrome possa sermais comum do que se encontra na literaturaO prognóstico da Síndrome de Nutcracker é variável e ditado pela magnitude dacompressão da veia renal. Em alguns casos, o desenvolvimento de circulação venosacolateral desencadeia uma regressão da sintomatologiabypass da veia renal, passando por transposição daveia renal esquerda com ou sem reforço de dacron, transposição da artéria mesentéricasuperior, autotransplante renal e derivação da veia renal para a veia cava, atébypass gonadocaval ou mesmo nefrectomiaUma vez que em 75% dos casos a hematúria se resolve, o tratamento deve serconservador durante pelo menos 2 anos em pacientes com idade abaixo de 18 anos. Noentanto, em casos com sintomas graves, o tratamento intervencionista deve serrealizado e compreende várias opções de cirurgias, incluindo desde nefropexia estent intravascular pode ser benéfico para o paciente, masdeve-se tomar cuidado com hiperplasia intimal e posterior oclusão do stent. Para tanto, aconselha-se o uso de antiagregantesplaquetários ou anticoagulantes por pelo menos 2 a 3 meses, a fim de aguardar aefetiva neoendotelização local. Há poucas publicações em relação ao implante destents venosos em pacientes jovens, e falta de consenso nessa indicação. Mas atéentão, há relatos de resultados promissores. Porém não há muitas evidências sobre aperviedade destes stents a longo prazo nestesindivíduos9,stents foram descritosFoi descrita, com bom resultado, a colocação de stent externo ou intravascular.Atualmente, a tendência de cirurgia minimamente invasiva sugere que o stent smart control 12 × 40 mm, seguido de angioplastia combalão 10 × 40 mm, a hematúria do paciente cessou completamente em 6 horas, mesmo comuso de antiagregantes plaquetários e anticoagulantes. Há 5 anos, o paciente permaneceassintomático.No presente caso apresentado, o resultado foi satisfatório. Após implante de


O RNSCA é um registo observacional prospetivo e contínuo. Foram convidados a participar voluntariamente todos os serviços e departamentos de Cardiologia dos hospitais portugueses. A inclusão de doentes teve início em 1 de janeiro de 2002 e mantém-se sem interrupções até o presente momento. Brevemente, foi solicitado a cada centro que incluísse de forma consecutiva doentes internados com o diagnóstico de SCA , com base na clínica, no eletrocardiograma e nos biomarcadores de necrose miocárdica. Os dados recolhidos incluem dados demográficos, características basais, evolução laboratorial, evolução clínica, terapêutica efetuada, dados da intervenção percutânea, dados da alta e do seguimento aos seis meses (na primeira fase do registo) ou ao primeiro ano (na segunda fase do registo). Inicialmente, os dados eram preenchidos em papel, posteriormente transferidos para uma base eletrônica e desde 2004 são submetidos diretamente por via eletrônica. Em consulta ao Uma pergunta está presente na abordagem da revascularização da síndrome coronariana aguda que evolui com choque cardiogênico: devemos abordar apenas o vaso culpado ou todas as lesões coronarianas significativas? O estudo das estratégias de revascularização em doentes com infarte agudo do miocárdio em choque cardiogênico, proveniente dos resultados do Registro Português de Síndromes Coronárias Agudas, traz esclarecimentos e ajuda na tomada de decisão.Um estudo multicêntrico brasileiro mostrou que a estratégia de revascularização completa esteve associada à redução significativa dos desfechos primários  e secundários  no seguimento de um ano quando comparada à estratégia de revascularização incompleta.versus um grupo composto pela revascularização completa diferida ou incompleta, quando relacionados ao desfecho primário composto por morte intra-hospitalar ou reinfarto.–,–O estudo baseado no RNSCA português envolve pacientes com marcadores prognósticos sabidamente ruins, anatomicamente multiarteriaisUma grande vantagem demonstrada no estudo3 é a disponibilidade de um registro nacional contínuo, de longa duração, com grande abrangência e múltiplas variáveis que possibilite a realização de diferentes estudos, seguimento temporal de eventos, recomendações ou intervenções e tendência nos números e desfechos das síndromes coronarianas agudas em Portugal. No Brasil, não dispomos de registro semelhante; ele não é impossível de ser feito, mas um país continental, com dois sistemas de saúde distintos, se torna, no mínimo, difícil. ,The Portuguese Registry on Acute Coronary Syndromes was drafted in 2002 by the Portuguese Cardiology Society due to the need for a broader knowledge concerning the national approach to Acute Coronary Syndromes (ACS) and created the National Cardiology Data Collection Center (NCDCC) to centralize all of the information and support its analysis, culminating in the creation of its first records: The National Registry of Acute Coronary Syndromes (NRACS) was created simultaneously with the National Register of Interventional Cardiology. The NRACS is a prospective and continuous observational registry. All Portuguese hospital cardiology services and departments were invited to participate voluntarily in this study. The inclusion of patients began on January 1, 2002, and has been maintained to the present day without interruption. Briefly, each center received a request to consecutively include all patients hospitalized with a diagnosis of ACS , without unstable ST-elevation or angina), based on clinical evaluation, on the electrocardiogram, and on the biomarkers of myocardial necrosis. The collected data include demographic data, baseline characteristics, laboratory evolution, clinical evolution, executed therapy, data on percutaneous intervention, as well as data on hospital discharge and follow-up for six months (in the first stage of the registry) or for one year (in the second stage of the registry). Initially, the data were collected on paper and then transferred to an electronic data base, but since 2004, they are being submitted directly in electronic form. Upon consulting the NRACS e-mail address in February 2021, 62,029 records were found.One question arises in the ACS revascularization approach, which evolves with cardiogenic shock: Treat only the culprit blood vessel or treat all of the significant coronary lesions? The study of revascularization strategies in patients with acute myocardial infarction in cardiogenic shock stemming from the results of the Portuguese Registry of Acute Coronary Syndromes sheds light on the issue and aids professionals in decision-making.One Brazilian multicenter study demonstrated that the complete revascularization strategy was associated with a significant reduction in the primary  and secondary  outcomes in the one-year follow-up when compared to the incomplete revascularization strategy.–,–The study based on the Portuguese NRACS involves patients with knowingly poor prognostic markers, as they are anatomically multiarterialOne major advantage illustrated in this study3 is the availability of a continuous, long-standing, national Registry, with a broad coverage and multiple variables that make it possible to conduct different studies; the temporary follow-up of events, recommendations, or interventions; and the tendency in the numbers and outcomes of ACS throughout Portugal. Brazil lacks a similar registry. It is not impossible to create, but, as a continental country with two different health systems, it is, to say the least, quite difficult.


A fragilidade é reconhecida como uma síndrome geriátrica caracterizada por um excesso de vulnerabilidade a estressores, com baixa capacidade de manter ou recuperar a homeostase após um evento desestabilizador.,Apesar da descrição original restringir o termo a pacientes com mais de 65 anos,,,,O diagnóstico e a terapia da síndrome têm sido quase exclusivamente limitados aos pacientes com mais de 65 anos de idade.–A fragilidade está associada ao aumento da mortalidade geral e também prediz piores desfechos em receptores de transplante renal, cirurgia geral e cirurgia cardíaca.Quando um procedimento cirúrgico precisa ser indicado, instantaneamente uma série de fatores vêm à mente. O momento certo, o risco cirúrgico e o prognóstico do paciente com e sem o procedimento. Os escores de risco analisam a parte orgânica através de dados objetivos, associados ao tipo de cirurgia proposta. No entanto, muitas vezes nos deparamos com valores extremamente baixos, que, subjetivamente, sabemos não serem confiáveis.Em pacientes idosos com estenose valvar aórtica, os escores de fragilidade já são rotineiramente incorporados à avaliação do risco cardiovascular, auxiliando na indicação ou não da troca transcateter.O presente estudoO estudo engloba uma série de características que o tornam relevante. Primeiramente, trata-se de um tema comum e ainda pouco explorado. Em segundo lugar, permite-nos estimar objetivamente o quanto a fragilidade contribui para o desfecho de pacientes não idosos frágeis submetidos à cirurgia cardíaca, independentemente do tipo. Por fim, chama a atenção dos médicos para a necessidade de incorporar os escores de fragilidade à sua rotina para melhor estratificar e até mesmo definir quando um procedimento deve ou não ser indicado, dando ao médico, paciente e familiares ferramentas que auxiliam na tomada de decisão. TAVI ou cirurgia convencional? CRM ou ACTP? Espero que tenhamos a força de evidência apropriada para indicar aos nossos pacientes o procedimento com a melhor relação risco-benefício. Frailty is recognized as a geriatric syndrome characterized by an excess of vulnerability to stressors, with a low ability to maintain or recover homeostasis after a destabilizing event.,Despite the original description restricting the term to patients older than 65 years,,,,The diagnosis and therapy of the syndrome has been almost exclusively limited to patients over 65 years of age.–Frailty is associated with an increase in overall mortality and also predicts worse outcomes in kidney transplant recipients, general surgery and cardiac surgery.When a surgical procedure has to be indicated, instantly a series of factors comes to mind: the right moment, the surgical risk and the patient's prognosis, with and without the procedure. The risk scores analyze the organic part through objective data, associated with the type of surgery proposed. However, we are often faced with extremely low values, which, subjectively, we know are not reliable.In elderly patients with aortic valve stenosis, frailty scores are already routinely incorporated into the assessment of cardiovascular risk, helping in the indication or not of transcatheter exchange.The present studyThe study encompasses a series of characteristics that make it relevant. First, it deals with a common and still little explored topic. Second, it allows us to objectively estimate how much frailty contributes to the outcome of fragile, non-elderly patients undergoing cardiac surgery, regardless of the type. Finally, it draws the attention of physicians to the need to incorporate frailty scores into their daily routines in order to better stratify and even define when a procedure should or should not be indicated, providing the doctor, patient and family with tools that assist in the decision-making. TAVI or conventional surgery? CABG or PTCA? I hope that we have the appropriate strength of evidence to indicate to our patients the procedure with the best risk-benefit ratio.