Resumo: Introdução: A hipertensão arterial (HA) é a principal causa de morte por doenças cardiovasculares. Apesar dos avanços, o percentual de hipertensos não diagnosticados e não tratados é de 58,4%. A avaliação do dano cognitivo na hipertensão concentra-se na prevenção do acidente vascular cerebral, enquanto o dano funcional é ignorado. Esse manejo inadequado pode ser multifatorial. É objetivo fue analisar a opinião dos médicos sobre a relação entre hipertensão arterial e danos cognitivos. Metodologia: Estudo observacional, descritivo, transversal desenvolvido no período entre agosto de 2020 e agosto de 2023. Análise de dados obtidos a partir de questionário autoaplicável, anônimo e voluntário. Revelar informações sobre o perfil profissional, conhecimento sobre a HA, sua ligação com o comprometimento cognitivo (DC), diagnóstico e tratamento. Resultados: Foram incluídos 222 profissionais, 215 (96,8%) concordam com a existência de ligação entre hipertensão e outros fatores de risco cardiovascular na DC e 218 (98,1%) reconhecem ajudar pacientes com risco de sofrer de D.C. A avaliação da DC é realizada em casos selecionados por 132 (59,4%) participantes e 59 (26,7%) a fazem sempre. Dos que realizam avaliação, 103 (54%) utilizam o Mini Exame do Estado Mental (MEEM), 10 (5,2%) utilizam a Avaliação Cognitiva de Montreal (MoCA) e 9 (4,7%) utilizam o Clock Drawing Test. Em relação à diminuição da pressão arterial em pacientes idosos e a ligação com o risco de DC: 54 (24,3%) não reconhecem risco e 65 (29,2%) reconhecem risco moderado-alto. Em referência à implicação do tratamento de doenças cardiovasculares e DC: 217 (97,7%) reconheceram o efeito benéfico. Discussão: Dado o reconhecimento da ligação entre hipertensão e DC, seria de esperar que a DC fosse investigada na grande maioria, no entanto apenas 26,7% sempre a avaliam. Não há consenso sobre o método, sendo o MEEM o mais utilizado, com baixa aplicação do teste MoCA e/ou Clock Drawing Test, sendo estes últimos os que avaliam a função executiva, majoritariamente alterada nos DC vinculados à HA. Embora o tratamento das doenças cardiovasculares seja reconhecido como benéfico em relação à DC, o controle da HA em idosos é considerado arriscado. É feito um diagnóstico de uma situação em que é evidente uma disparidade entre o que se reconhece como saber e o que se afirma fazer. Conclusões: O papel da doença vascular no dano cerebral funcional é reconhecido, considerando-se necessário conhecer o estado cognitivo dos pacientes, porém há baixa aplicação de testes de triagem que avaliam a função executiva. Nesse contexto, evidencia-se uma lacuna entre o conhecimento e a prática médica.

Abstract: Introduction: High blood pressure (HBP) is the leading cause of death from cardiovascular disease. Despite the advances, the percentage of undiagnosed and untreated hypertensive patients is 58.4%. The evaluation of cognitive damage in HBP focuses on preventing stroke, while functional damage is ignored. This inadequate management may be multifactorial. The objective was to analyze the opinions that doctors have about the relationship between high blood pressure and cognitive damage. Methodology: Observational, descriptive, cross-sectional study developed in the period between August 2020 and August 2023. Analysis of data obtained from a self-administered, anonymous and voluntary questionnaire. Revealing information on the professional profile, knowledge of HBP, its link with cognitive impairment (CD), diagnosis and treatment. Results: 222 professionals were included, 215 (96.8%) agree with the existence of a link between HBP and other cardiovascular risk factors in CD, and 218 (98.1%) acknowledge assisting patients at risk of suffering from CD. The CD evaluation is carried out in selected cases by 132 (59.4%) participants and 59 (26.7%) always do it. Of those who perform evaluation, 103 (54%) use the Mini Mental State Examination (MMSE), 10 (5.2%) use the Montreal Cognitive Assessment (MoCA) and 9 (4.7%) use the Clock Drawing Test. Regarding the decrease in blood pressure in elderly patients and the link with risk of CD: 54 (24.3%) do not recognize risk and 65 (29.2%) recognize a moderate-high risk. In reference to the implication of the treatment of cardiovascular disease and CD: 217 (97.7%) recognized a beneficial effect. Discussion: Given the recognition of the link between HBP and CD, it would be expected that CD would be investigated in the vast majority, however only 26.7% always evaluate it. There is no consensus on the method, the MMSE being the most used, with a low application of the MoCA test and/or Clock Drawing Test, the latter being the ones that evaluate executive function, mostly altered in CD linked to HBP. Although the treatment of cardiovascular disease is recognized as beneficial with respect to CD, the control of HBP in older adults is considered risky. A diagnosis is made of a situation where a disparity is evident between what one recognizes as knowing and what one claims to do. Conclusions: The role of vascular disease in functional brain damage is recognized, considering it necessary to know the cognitive status of patients, however there is a low application of screening tests that evaluate executive function. In this context, a gap between medical knowledge and practice is shown.

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Introdução: As doenças cardiovasculares (DCV) continuam a ser a principal causa de mortalidade em todo o mundo. A adesão ao tratamento medicamentoso é uma questão importante no manejo das DCV crônicas, influenciando diretamente os resultados e os custos com saúde. Objetivos: Esta revisão sistemática, apoiada pela Sociedade Brasileira de Cardiologia, avalia o impacto da baixa adesão aos medicamentos cardiovasculares em desfechos clínicos críticos, como morte e eventos cardiovasculares. Métodos: Foi realizada uma busca abrangente em quatro bases de dados, incluindo Medline, Embase, Lilacs e Cochrane Library. A revisão incluiu revisões sistemáticas com meta-análises que relataram estimativas de risco para a adesão aos medicamentos cardiovasculares. Foram selecionadas quatro revisões sistemáticas, cada uma incorporando estudos observacionais. Resultados: Os principais achados indicam que um aumento na adesão aos medicamentos reduz significativamente o risco de eventos cardiovasculares, acidente vascular cerebral (AVC) e morte por todas as causas. Especificamente, uma melhoria de 20% na adesão a medicamentos antihipertensivos, hipolipemiantes e outros medicamentos cardiovasculares correlacionou-se com reduções nos eventos cardiovasculares de 7%, 10% e 9%, respectivamente; AVC de 17%, 13% e 18%; e morte de 12%, 9% e 10%. A certeza das evidências foi moderada, sugerindo que esses efeitos provavelmente estão presentes. Esses achados enfatizam a importância de melhorar a adesão ao tratamento medicamentoso para aprimorar os resultados clínicos no manejo das DCV. Conclusões: As evidências demonstraram reduções em desfechos duros tanto na prevenção primária quanto secundária através do controle de condições como hipertensão e concentrações elevadas de colesterol LDL, bem como os benefícios da terapia antiplaquetária em doenças ateroscleróticas. No entanto, são necessários estudos adicionais para elucidar melhor a relação entre a adesão aos medicamentos cardiovasculares e a melhoria dos desfechos clínicos críticos.

Background: Cardiovascular diseases (CVD) remain the leading cause of mortality worldwide. Medication adherence is an important issue in managing chronic CVD, directly influencing outcomes and healthcare costs. Objectives: This systematic review, supported by the Brazilian Society of Cardiology, evaluates the impact of poor adherence to cardiovascular medications on critical clinical outcomes such as death and cardiovascular events. Methods: A comprehensive search was conducted across four databases, including Medline, Embase, Lilacs, and the Cochrane Library. The review included systematic reviews with meta-analyses that reported risk estimates for adherence to cardiovascular medications. Four systematic reviews, each incorporating observational studies, were selected. Results: The principal findings indicate that an increase in adherence to medications significantly reduces the risk of cardiovascular events, stroke, and all-cause death. Specifically, a 20% improvement in adherence to antihypertensive, lipid-lowering, and other cardiovascular medications correlated with reductions in cardiovascular events by 7%, 10%, and 9%, respectively; stroke by 17%, 13%, and 18%; and death by 12%, 9%, and 10%. The certainty of the evidence was moderate, suggesting that these effects are likely present. These findings emphasize the importance of enhancing medication adherence to improve clinical outcomes in CVD management. Conclusions: Evidence has demonstrated reductions in hard endpoints in both primary and secondary prevention through the control of conditions such as hypertension and elevated LDL cholesterol concentrations, as well as the benefits of antiplatelet therapy in atherosclerotic disease. However, additional studies are needed to better elucidate the relationship between adherence to cardiovascular medications and the improvement of critical clinical outcomes.

ABSTRACT Purpose The clinical outcomes of kidney transplantation from deceased donors have seen significant improvements with the use of machine perfusion (MP), now a standard practice in transplant centers. However, the use of perfusate biomarkers for assessing organ quality remains a subject of debate. Despite this, some centers incorporate them into their decision-making process for donor kidney acceptance. Recent studies have indicated that lactate dehydrogenase (LDH), glutathione S-transferase, interleukin-18, and neutrophil gelatinase-associated lipocalin (NGAL) could predict post-transplant outcomes. Materials and Methods Between August 2016 and June 2017, 31 deceased-donor after brain death were included and stroke was the main cause of death. Pediatric patients, hypersensitized recipients were excluded. 43 kidneys were subjected to machine perfusion. Perfusate samples were collected just before the transplantation and stored at -80ºC. Kidney transplant recipients have an average age of 52 years, 34,9% female, with a BMI 24,6±3,7. We employed receiver operating characteristic analysis to investigate associations between these perfusate biomarkers and two key clinical outcomes: delayed graft function and primary non-function. Results The incidence of delayed graft function was 23.3% and primary non-function was 14%. A strong association was found between NGAL concentration and DGF (AUC=0.766, 95% CI, P=0.012), and between LDH concentration and PNF (AUC=0.84, 95% CI, P=0.027). Other perfusate biomarkers did not show significant correlations with these clinical outcomes. Conclusion The concentrations of NGAL and LDH during machine perfusion could assist transplant physicians in improving the allocation of donated organs and making challenging decisions regarding organ discarding. Further, larger-scale studies are required. MP, MP , (MP) However debate this decisionmaking decision acceptance LDH, (LDH) Stransferase, Stransferase S transferase, transferase S-transferase interleukin18, interleukin18 interleukin 18, 18 interleukin-18 gelatinaseassociated gelatinase associated (NGAL posttransplant post 201 2017 3 deceaseddonor patients excluded 4 80ºC. 80ºC ºC -80ºC 5 years 349 34 9 34,9 female 24637 24 6 7 24,6±3,7 nonfunction. nonfunction non function. 233 23 23.3 14 14% AUC=0.766, AUC0766 AUC 0 766 (AUC=0.766 95 CI P=0.012, P0012 P P=0.012 012 P=0.012) AUC=0.84, AUC084 84 (AUC=0.84 P=0.027. P0027 P=0.027 . 027 P=0.027) discarding Further largerscale larger scale required (MP (LDH interleukin1 1 interleukin-1 20 34, 2463 2 24,6±3, 23. AUC=0.766 AUC076 76 (AUC=0.76 P001 P=0.01 01 AUC=0.84 AUC08 8 (AUC=0.8 P002 P=0.02 02 interleukin- 246 24,6±3 AUC=0.76 AUC07 (AUC=0.7 P00 P=0.0 AUC=0.8 AUC0 (AUC=0. 24,6± AUC=0.7 P0 P=0. AUC=0. (AUC=0 24,6 P=0 AUC=0 (AUC= 24, P= AUC= (AUC

RESUMEN Introducción. La miocardiopatía hipertrófica (MCH), es la enfermedad genética cardiovascular más común, causada por mutaciones en proteínas del sarcómero cardíaco, con una prevalencia considerable y clínica variable, desde asintomática hasta insuficiencia cardíaca y muerte súbita. Existen pacientes seguidos en centros no especializados, y es necesario conocer datos que puedan mostrar la realidad de su diagnóstico, tratamiento y pronóstico. Objetivo. Conocer las características clínicas, estrategias diagnósticas y terapéuticas al abordar la MCH en centros no especializados en la patología. Material y métodos. Estudio de corte transversal, multicéntrico, de alcance nacional, con análisis cuantitativo, de pacientes con MCH confirmada o altamente probable. Resultados. Se registraron 95 pacientes, mayormente hombres con hipertensión arterial (40 %) y dislipidemia (22 %) como principales factores de riesgo. Se observó baja proporción de comorbilidades: enfermedad pulmonar obstructiva crónica (6 %), infarto de miocardio previo (5 %), accidente cerebro vascular previo (1 %) e insuficiencia renal crónica (1 %). Los síntomas principales fueron la disnea (47 %) y el ángor (27 %), y los métodos diagnósticos más usados fueron el ecocardiograma (97 %) y la resonancia cardíaca (71 %). La localización más frecuente fue septal, con 37 % de tipo obstructivo. El test genético, realizado en un 33 %, fue positivo en más de la mitad de los pacientes. No se realizó en dos tercios de los casos principalmente por falta de cobertura. Conclusiones. Los hallazgos son concordantes con los de registros internacionales. Con base a nuestros hallazgos, se resalta la necesidad de mejorar el acceso a estudios diagnósticos más complejos y optimizar recursos en un sistema de salud fragmentado.

ABSTRACT Background . Hypertrophic cardiomyopathy (HCM) is the most common genetic disease caused by cardiac sarcomere protein mutations, with considerable prevalence and different clinical presentation, varying from asymptomatic to heart failure and sudden death. Some patients are followed-up in nonspecialized centers, and it is necessary to know data that show the reality of their diagnosis, treatment, and prognosis. Objective. The aim of this study was to know the clinical characteristics, and diagnostic and therapeutic strategies when HCM is managed in centers not specialized in this disease. Methods. This was a national, cross-sectional, multicenter study, with quantitative analysis of patients with confirmed or highly probable HCM. Results. A total of 95 patients were recruited, mostly men, with hypertension (40%) and dyslipidemia (22%) as main risk factors. A low proportion of comorbidities was observed: chronic obstructive pulmonary disease (6%), prior myocardial infarction (5%), prior stroke (1%) and chronic kidney failure (1%). The main symptoms were dyspnea (47% and angina (27%), and the most used diagnostic methods were echocardiogram (97%) and cardiac magnetic resonance imaging (71%)). The most frequent localization was septal, with 37% of hypertrophic obstructive cardiomyopathy. The genetic test, performed in 33% of patients, was positive in more than half of cases. It was not performed in the rest of the patients, mainly due to lack of health coverage. Conclusions. These findings are in agreement with international registries. Based on our findings, emphasis should be placed in improving the access to more complex diagnostic studies and optimizing the resources in a fragmented health system.

INTRODUCTION: The rising prevalence of stroke in sub-Saharan Africa necessitates the exploration of the role of occupational therapy in rehabilitation of stroke. In the southern African country of South Africa, occupational therapy aligns with healthcare policies and laws, and this article presents a review of synthesized evidence of occupational therapy intervention in stroke care and rehabilitation. METHOD: Rapid review methodology was used to develop a research question about cerebrovascular accident - intervention by occupational therapists., The Cochrane Library and MEDLINE databases were searched for relevant articles published between 2018 and 2023. Twenty four articles met the inclusion criteria and were analysed according to quantitative and qualitative parameters. RESULTS: Evidence of occupational therapy intervention with post-stroke upper limb impairment was found in 37,5% of articles. Occupational therapy for global improvement in function, cognitive rehabilitation, balance, social participation, work, and leisure comprised 45,8% of articles, and one article each reported evidence for occupational therapy addressing ADL and caregiver interventions. CONCLUSION: Evidence from the past five years reflect diverse occupational therapy interventions with clients with stroke. Gaps in recent evidence remain in relation to context-specific interventions, especially from low- and middle-income countries. IMPLICATIONS FOR PRACTICE Occupational therapists adopt a holistic approach to stroke rehabilitation, tailoring interventions to address the multifaceted needs and goals of individual stroke survivors. The effectiveness of individualised, occupation-based approaches across various domains are highlighted. • Therapists stay informed and up to date about emerging technologies and evidence-based practice to enhance their effectiveness in stroke rehabilitation. • This review provides evidence of the prevalence of upper limb impairments post-stroke, which will enable therapists to be well-versed in the diverse intervention approaches for upper limb rehabilitation as outlined in the literature reviewed, including technologies like Brain Computer Interface, Mental Practice, Mirror Therapy, and Action Observation Therapy. • Occupational therapy is vital in addressing cognitive impairments in stroke survivors, and practitioners can apply the evidence provided on interventions such as Virtual Reality and computer-assisted cognitive rehabilitation that have shown promise in improving cognition and ADL.

BACKGROUND: Despite inpatient rehabilitation many stroke survivors struggle with community reintegration on returning home. The environment to which the stroke survivor returns affects and may limit participation in home and community-based activities. AIM: To describe stroke survivors' lived experiences of the environmental barriers and facilitators to community reintegration in an under resourced urban metropolitan sub-district in the Western Cape, South Africa. METHODS: A descriptive, qualitative study design with a phenomenological emphasis used semi-structured interviews to collect the data from purposefully selected stroke survivors who had been discharged for more than one year following inpatient rehabilitation. Supporting data were collected from interviews with two occupational therapists providing rehabilitation services to the stroke survivors. Deductive priori coding of semi-structured interviews with 11 stroke survivors, based on the environment subsystems described in the Person-Environment-Occupation-Performance (PEOP) model explored the barriers and facilitators to their community reintegration. FINDINGS: Of the six environmental sub systems in the PEOP model the systems and policy, access to information and health education, social determinants of health in the form of poor rehabilitation planning and loss of income as well as the built and natural environment presented the greatest barriers to the stroke survivor participants' community reintegration. However, reintegration was facilitated by social support and social capital, social determinants of health in the form of support groups as well as assistive technologies. CONCLUSION: Community reintegration continues to be a challenge for stroke survivors in an under-resourced urban sub-district due to environmental barriers associated with factors such as poor social support, inadequate implementation of policies and systems, poor compliance with home programmes, low socioeconomic status, poor access within the built and natural environment and inappropriate assistive devices. Several facilitators that occupational therapists can focus on to enable community reintegration included ensuring effective social support, access to community-based organisations, the introduction of home visits and provision of appropriate assistive devices. IMPLICATIONS FOR PRACTICE All stroke survivors must receive a comprehensive discharge plan to facilitate adequate access to continued rehabilitation and support for successful community reintegration. • There must be a specific referral to primary health care rehabilitation services on discharge from hospital. • Occupational therapists at community level have the responsibility to: o advocate for, or assist stroke survivors to self-advocate, the removal of inter-sectoral environmental barriers that limit their community reintegration and community participation, o where possible provide services in the home and involve midlevel workers when conducting home visits to enable successful reintegration into the home and resumption of occupational roles where possible, o look to other resources in their community that can assist in facilitating the community reintegration of stroke survivors to enable access to health, education, productive activities, and social and leisure participation opportunities, o improve their collaboration with the communities that they service.

RESUMEN Introducción: El infarto de miocardio sin obstrucciones coronarias significativas (MINOCA) es una conocida entidad que se ha redefinido recientemente al excluir la injuria miocárdica no isquémica. ReSCAR fue un registro prospectivo, multicéntrico de pacientes hospitalizados por síndrome coronario agudo (SCA) desde enero hasta agosto de 2022. Objetivo: Un objetivo principal del registro fue definir la prevalencia de pacientes con MINOCA, sus características basales clínicas y paraclínicas y evolución intrahospitalaria. Los resultados del análisis respectivo son la base de esta publicación. Material y métodos: Registro nacional prospectivo y multicéntrico de SCA. Diagnóstico de MINOCA de acuerdo con la Cuarta Definición Universal de Infarto de Miocardio. Análisis de las características basales, evolución y diferencias significativas respecto de los pacientes con coronariopatía obstructiva. Los centros participantes debían contar con determinación de troponina de alta sensibilidad y la posibilidad de realizar cinecoronariografía. Resultados: Se incluyeron 984 pacientes de 15 centros. Ochenta y cinco pacientes (8,6 %) tuvieron diagnóstico final de MINOCA al alta. Cuarenta y cuatro pacientes (51,8 %) eran mujeres, la mediana de edad fue de 65 años (53-63), 55 (64,7 %) pacientes eran hipertensos, 44 (51,8 %) dislipidémicos, 9 (10,6 %) diabéticos y 23 (27,1 %) fumadores. La mediana de troponina al ingreso (expresada como múltiplo del percentilo 99) fue de 2,42 (0,85-10,21) y el 71,8 % se presentó con un ECG sin cambios isquémicos. La angiografía coronaria fue normal en el 72,9 % de los pacientes y con lesiones menores de 50 % en el resto. Se realizó resonancia cardíaca a 16 pacientes. La mediana del score GRACE fue de 115 puntos (98-139), lo cual perfila un riesgo intermedio; con una tasa de eventos combinados de accidente cerebrovascular/infarto o muerte de 1,2 %, sin haberse registrado sangrados BARC 2 o más. La prescripción al alta de aspirina fue del 72,9 %, clopidogrel 27,1 %, estatinas 88,2 %, beta bloqueantes 67,1 % y antagonistas cálcicos 22,4 %. Conclusión: En este registro, los pacientes con MINOCA representan una proporción significativa de aquellos con SCA. La tasa de complicaciones intrahospitalarias, incluida la mortalidad, fue baja. Impresiona existir una fuerte oportunidad para profundizar los estudios para confirmar este diagnóstico, sus mecanismos fisiopatológicos y su tratamiento.

ABSTRACT Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a well-known condition that has been recently redefined after excluding non-ischemic myocardial injury. ReSCAR was a prospective, multicenter registry of patients hospitalized for acute coronary syndrome (ACS) from January to August 2022. Objective: One of the main objectives of the registry was to define the prevalence of patients with MINOCA, their baseline clinical and paraclinical characteristics, and in-hospital outcome. This publication focuses on the results of the respective analysis. Methods: We conducted a nationwide, multicenter, prospective study of patients with ACS. The diagnosis of MINOCA was made following the Fourth Universal Definition of Myocardial Infarction. The baseline characteristics of the patients wereanalyzed, as well as their outcome and significant differences with patients with obstructive coronary artery disease. The participating centers should have the availability to measure high-sensitivity cardiac troponin and perform coronary angiography. Results: A total of 984 patients from 15 centers were included. Eighty-five patients (8.6%) had a final diagnosis of MINOCA at discharge. Median age was 65 years (53-63), 48 (51.8%) were women, 55 (64.7%) had hypertension, 44 (51.8%) had dyslipidemia, 9 (10.6%) were diabetics and 23 (27.1%) were smokers. Median high-sensitivity cardiac troponins on admission (expressed as multiples of the 99th percentile) were 2.42 times higher (0.85-10.21) and the ECG had no ischemic changes in 71.8% of the patients. Coronary angiography was normal in 72.9% of the patients and the rest of the cases had coronary artery stenoses < 50%. Sixteen patients underwent cardiac magnetic resonance imaging. The median GRACE score was 115 (98-139), which corresponds to intermediate risk. The event rate for the composite outcome of stroke/myocardial infarction or death was1.2%, and there were no bleeding events BARC ≥type 2. The discharge prescription rate was 72.9% for aspirin, 27.1% for clopidogrel, 88.2% for statins, 67.1% for beta-blockers, and 22.4% for calcium channel blockers. In this registry, patients with MINOCA represent a significant proportion of those with ACS. Conclusion: The rate of in-hospital complications, including mortality, was low. There seems to be a strong opportunity for further investigations to confirm the diagnosis, pathophysiological mechanisms, and treatment of MINOCA.

Abstract Introduction: Carotid endarterectomy is used for treating patients with severe stenosis (>70%) or cerebrovascular symptoms secondary to internal carotid disease. Eagle score has been used as a predictor of cardiovascular events after major surgery. This study aims to assess the use of Eagle Score as a predictor of major cardiovascular events after carotid endarterectomy. Materials and methods: A retrospective observational cross-sectional study was conducted. Medical records of patients who underwent carotid endarterectomy between 2017 and 2021 were reviewed. The EAGLE scale was performed pre-surgically to assess the risk of the risk of major complications after carotid endarterectomy from surgery to the last day of hospitalization. Discussion: A total of 19 patients were assessed pre-surgically using the Eagle scale score and subsequently underwent carotid endarterectomy (Mean age of 77 years-old). The surgical procedure was predominantly performed on symptomatic patients (89.4%), including 10 patients (59%) with a history of transient ischemic attack (TIA) and 7 patients (41%) with a cerebrovascular attack. Previous diagnostic imaging indicated severe carotid artery stenosis in 18 patients (94.7%). According to the EAGLE Scale, the majority presented a moderate risk (68.42%), among whom 5 patients experienced minor complications, and none experienced major complications. Conclusions: Patients with minor cardiovascular complications after carotid endarterectomy were most commonly adjudicated as moderate risk according to the Eagle score. Further studies with large sample sizes are required to elucidate the role of Eagle Score as predictor of major cardiovascular events after carotid endarterectomy.

Resumen Introducción: La endarterectomía carotídea se emplea para el tratamiento de pacientes con estenosis severa (> 70 %) o síntomas cerebrovasculares por enfermedad de la carótida interna. La escala Eagle ha sido usada como predictor de eventos cardiacos luego de una cirugía mayor. Este estudio busca determinar el uso de la escala Eagle como predictor de eventos mayores luego de endarterectomía carotídea. Materiales y métodos: En este estudio observacional retrospectivo de corte transversal, se revisaron historias clínicas de pacientes sometidos a endarterectomía carótida entre los años 2017 y 2021, donde la escala Eagle se realizó durante la visita prequirúrgica, para evaluar el riesgo de complicaciones mayores luego de una endarterectomía carotídea hasta finalizar la hospitalización. Discusión: Un total de 19 pacientes fueron evaluados prequirúrgicamente con el puntaje de la escala de Eagle y fueron tratados con endarterectomía carotídea, con un promedio de edad de 77 años. El procedimiento quirúrgico se realizó con mayor frecuencia en pacientes sintomáticos (89,40 %), incluyendo 10 (59 %) con antecedentes de ataque isquémico transitorio (AIT) y 7 (41 %) con ataque cerebrovascular. Las imágenes diagnósticas indicaron estenosis severa de la arteria carótida en 18 pacientes (94,7 %) y la mayoría de los pacientes presentaron riesgo moderado (68,42 %) según la escala Eagle, además, 5 presentaron complicaciones menores y ninguno presentó complicaciones mayores. Conclusiones: Un puntaje moderado en la escala de Eagle indica riesgo de desarrollar complicaciones cardiovasculares menores luego de endarterectomía carotídea, pero se requieren estudios con mayor tamaño de muestra para dilucidar el papel del puntaje Eagle como predictor de complicaciones cardiovasculares mayores luego de una endarterectomía carotídea.

Abstract Introduction: Stroke in young patients is associated with unconventional risk factors. The active search for these risk factors can reduce the recurrence of such events. Case presentation: We present two cases of young patients with human immunodeficiency virus (HIV) infection presenting neurological symptoms, with evidence of a subacute ischemic event in the magnetic resonance, and high homocysteine levels who underwent a search for the methylenetetrahydrofolate reductase (MTHFR) mutation, which was positive for the homozygous mutation. Discussion: HIV infection increases the risk of stroke in the young population; however, its effect in patients with controlled viremia is unclear. The presence of protein S deficiency and hyperhomocysteinemia are the most frequent procoagulant states in patients with HIV. The role of genetic mutations and hyperhomocysteinemia in patients with HIV is yet to be established. Conclusion: The active search for rare risk factors in young stroke patients plays an important role in preventing future events and modifying the course of the disease. Genetic tests open up new possibilities to understand the pathophysiology of the disease and find new relationships between risk factors.

Resumen Introducción: El ataque cerebrovascular (ACV) en pacientes jóvenes está asociado a factores de riesgo no convencionales y su búsqueda activa puede disminuir la recurrencia de estos eventos. Presentación del caso: Se presentaron dos casos de pacientes jóvenes con infección por virus de inmuno-deficiencia humana (VIH) que mostraron síntomas neurológicos, con evidencia en resonancia magnética (RM) de un evento isquémico de evolución subaguda y niveles de homocisteína elevados, a quienes se les realizó una búsqueda de mutación de metilenotetrahidrofolato reductasa (MTHFR), la cual fue positiva para mutación homocigota. Discusión: La infección por VIH aumenta el riesgo de ACV en la población joven, sin embargo, su efecto en pacientes con viremia controlada está poco claro (1). La presencia de déficit de proteína S y la hiperhomocisteinemia son los estados procoagulantes más frecuentes en pacientes con VIH (2). El papel que juegan la presencia de mutaciones genéticas en relación con la hiperhomocisteinemia en pacientes con VIH aún está por establecerse. Conclusiones: La búsqueda activa de factores de riesgo no frecuentes en pacientes jóvenes con ACV juega un rol importante en la prevención de futuros eventos y modificación de la enfermedad. Así, las pruebas genéticas abren nuevas posibilidades para entender la fisiopatología de la enfermedad y encontrar nuevas relaciones entre factores de riesgo.

ABSTRACT Foundation: cerebrovascular disease is any alteration of one or more brain areas, whether temporary or permanent, secondary to a cerebral circulation disorder of ischemic or hemorrhagic origin. For many years it has been considered one of the main causes of death worldwide. It is among the main causes of death in Ecuador. Objective: to describe the risk factors for cerebrovascular diseases in adult patients diagnosed with cerebrovascular diseases at the Tulcán Sur Health Center over a period of 1 year. Methods: a descriptive and cross-sectional study was carried out at the Tulcán Sur Health Center, over a period of 1 year, from September 2022 to September 2023. The universe consisted of 130 patients. The sociodemographic variables were analyzed: age and sex; clinical: presence or absence of high blood pressure, smoking, alcoholism, diabetes mellitus, dyslipidemia, atrial fibrillation and sedentary lifestyle. The normality of the data distribution was analyzed using the Kolmogorov-Smirnov test. Categorical variables were expressed in absolute and relative frequencies. Quantitative variables were described using the mean and standard deviation. Results: the mean age of the population was 61.0 ± 16.5. The male sex predominated with 70 patients (53.8 %). High blood pressure, smoking and obesity were the most common cardiovascular risk factors with 73 (56.5 %), 79 (60.7 %), 64 (49.2 %) patients respectively. Conclusions: high blood pressure, smoking and obesity were the most prevalent risk factors.

RESUMEN Fundamento: la enfermedad cerebrovascular es toda alteración de una o varias áreas encefálicas, ya sea de forma transitoria o permanente, secundaria a un trastorno de la circulación cerebral de origen isquémico o hemorrágico. Por muchos años ha sido considerada una de las principales causas de muerte a nivel mundial. Está entre las principales causas de muerte en Ecuador. Objetivo: describir los factores de riesgo de enfermedades cerebrovasculares en pacientes adultos diagnosticados con enfermedades cerebrovasculares en el Centro de Salud Tulcán Sur en un periodo de 1 año. Métodos: se realizó un estudio descriptivo y transversal, en el Centro de Salud Tulcán Sur, en un periodo de 1 año, desde septiembre del 2022 a septiembre del 2023. El universo lo constituyeron 130 pacientes. Se analizaron las variables sociodemográficas: edad y sexo; clínicas: presencia o no de hipertensión arterial, tabaquismo, alcoholismo, diabetes mellitus, dislipidemia, fibrilación auricular y sedentarismo. La normalidad de la distribución de los datos fue analizada utilizando la prueba de Kolmogorov-Smirnov. Las variables categóricas fueron expresadas en frecuencias absoluta y relativa. Las variables cuantitativas se describieron utilizando la media y la desviación típica. Resultados: la media de edad de la población fue de 61,0 ± 16,5. El sexo masculino predominó con 70 pacientes (53,8 %). La hipertensión arterial, el tabaquismo y la obesidad fueron los factores de riesgo cardiovascular más frecuentes con 73 (56,5 %), 79 (60,7 %), 64 (49,2 %) pacientes respectivamente. Conclusiones: la hipertensión arterial, el tabaquismo y la obesidad fueron los factores de riesgo con más prevalencia.

Abstract Inflammation is an important pathogenic factor for the development of atherosclerotic cardiovascular disease. Currently, the most frequently used biomarker reflecting systemic inflammation is C-reactive protein (CRP), an acute-phase protein produced primarily by hepatocytes under the influence of interleukin-6, interleukin-1 beta, and tumor necrosis factor. Growing evidence from epidemiological studies has shown a robust association between elevated serum or plasma CRP concentrations and the incidence of a first cardiovascular adverse event (including acute myocardial infarction, ischemic stroke, and sudden cardiac death) in the general population, as well as recurrence of major adverse cardiovascular events among patients with established disease. The additive value that CRP measurement gives to traditional risk factors is reflected in novel cardiovascular risk calculators and in current intervention regimens, which already consider CRP as a target therapeutic. However, the variations in CRP levels, that depend on sex, ethnicity, hormonal status, and some peculiarities of the measurement assays, must be taken into consideration when deciding to implement CRP as a useful biomarker in the study and treatment of atherosclerotic cardiovascular disease. This review aims to offer an updated vision of the importance of measuring CRP levels as a biomarker of cardiovascular risk beyond the traditional factors that estimate the risk of atherosclerotic disease.

Resumen La inflamación es un factor patogénico importante para el desarrollo de la enfermedad cardiovascular aterosclerótica. Actualmente, el biomarcador utilizado con mayor frecuencia que refleja la inflamación sistémica es la proteína C reactiva (PCR), una proteína de fase aguda producida principalmente por los hepatocitos bajo la influencia de la interleucina 6, la interleucina 1 beta y el factor de necrosis tumoral. La evidencia proveniente de estudios epidemiológicos ha demostrado una fuerte asociación entre las concentraciones elevadas de PCR en suero o plasma y la incidencia de un primer evento cardiovascular (incluido infarto agudo de miocardio, accidente vascular cerebral isquémico y muerte cardíaca súbita) en la población general, así como la recurrencia de eventos cardiovasculares adversos en los pacientes con enfermedad establecida. El valor aditivo que la medición de la PCR otorga a los factores de riesgo tradicionales se refleja en novedosas calculadoras de riesgo cardiovascular y en los actuales regímenes de intervención, que ya consideran a la PCR como objetivo terapéutico. Sin embargo, las variaciones en los niveles de PCR, que dependen del sexo, la etnia, el estado hormonal y algunas peculiaridades de los ensayos de medición, deben tenerse en cuenta al decidir implementar la PCR como un biomarcador útil en el estudio y el tratamiento de la enfermedad cardiovascular aterosclerótica. Esta revisión pretende ofrecer una visión actualizada de la importancia de medir la PCR como biomarcador de riesgo cardiovascular más allá de los factores tradicionales que estiman el riesgo de enfermedad aterosclerótica.

Abstract Paradoxical embolism due to an isolated pulmonary arteriovenous malformation (PAVM) is a rare cause of ischemic stroke. PAVMs are abnormal high-flow connec tions between pulmonary arteries and veins, diverting deoxygenated blood into the systemic circulation and they represent a less common source of paradoxical embolisms, especially in young individuals. Endovascular embolization is the preferred treatment for clinically significant PAVMs. We present the case of a 34-year-old woman with a left thalamic ischemic stroke. Severe contrast passage was detected in cerebral arteries through transcranial Doppler. Intracardiac ultrasound did not reveal a patent foramen ovale, prompting further investigation with pulmonary CT angiography, confirming the presence of PAVM. The patient underwent successful endovascular treatment. It is essential to consider PAVM in the etiological di agnosis of ischemic stroke, especially in young patients with signs of abnormal right-to-left communication. Periodic follow-up imaging is recommended to assess potential recurrence or changes in PAVM, emphasizing the importance of appropriate management of these malformations.

Resumen La embolia paradojal debido a una malformación arteriovenosa pulmonar (MAVP) aislada es una causa in frecuente de accidente cerebrovascular (ACV) isquémico. Las MAVP son conductos anómalos de alta circulación entre arterias y venas pulmonares, desviando sangre desoxigenada hacia la circulación sistémica y represen tan una fuente menos común de embolias paradojales, especialmente en personas jóvenes. La embolización endovascular es el tratamiento preferido para MAVP clínicamente significativas. Presentamos el caso de una mujer de 34 años con ACV isquémico talámico izquierdo. Se detectó pasaje de burbujas “en cortina” en arterias cerebrales mediante Doppler transcraneal. En ecografía intracardíaca no se encontró foramen oval permeable, motivo por el cual se avanzó con realización de angiotomografía pulmonar, la cual confirmó la presencia de MAVP. La paciente recibió tratamiento endovascular exitoso. Es esencial considerar la MAVP en el diagnóstico etio lógico del ACV isquémico, especialmente en pacientes jóvenes con signos de comunicación anormal de derecha a izquierda. Se recomienda un seguimiento periódico mediante imágenes para evaluar la posible recurrencia o cambios en la MAVP, resaltando la importancia del manejo adecuado de estas malformaciones.

Objective: To analyze the risk factors and short-term results of the carotid endarterectomy in our hospital. Materials and method: The present is an observational, retrospective and descriptive study, where 89 carotid endarterectomies are analyzed in a period of 8 years (January 2015 to January 2023) performed in 85 patients, the patients were divided in to two groups, symptomatic and asymptomatics, as for the complications there were divided in minor and mayor. Results: 89 carotid endarterectomies where perform between January 2015 to January 2023. In the symptomatic group are 78 (87.64%) patients, in the asymptomatic group there are 11 patients (12.35%). 62 where male (69.66%) and 27 where women (30.33%). Only 1 (1.12%) patient died, this one from the symptomatic group. Perioperatory stroke in 3 (3.37%) patients, all of them with neurologic secuela at 30 days of post operatory. 5 (5.61%) cases of post operatory hematomas 4 of them requiring reintervention. There was 1 (1.12%) patient with neurologic affection. 1 (1.12%) case of superficial wound infection. Conclusion: The carotid endarterectomy remains as the gold standard to prevent strokes in symptomatic patients. Performed in high volume centers it has excellent results as for the prevention of new strokes.

Resumen Objetivo: Analizar los factores de riesgo y resultados de la endarterectomía carotídea (EC) en el hospital Metropolitano de la Florida Dra. Eloísa Díaz Insunza. Materiales y métodos: Se trata de un estudio observacional, retrospectivo y descriptivo, donde se analizan 89 endarterectomías carotídea, en un período de 8 años (enero del 2015 a enero de 2023) realizadas en 85 pacientes, los pacientes fueron divididos en 2 grupos, sintomáticos y asintomáticos, con respecto a las complicaciones fueron clasificadas en mayores y menores. Resultados: Se realizaron 89 endarterectomías carotídeas desde enero del 2015 hasta enero del 2023. El grupo sintomático corresponde a 78 (87,64%) pacientes, el grupo asintomático 11 (12,35%). 62 en hombres (69,66%) y 27 en mujeres (30,33%). Hubo muerte en 1 (1,12%) solo paciente, perteneciendo éste al grupo sintomático. Accidentes vasculares perioperatorios en 3 (3,37%) pacientes, todos con secuelas neurológicas presentes a 30 días post-operatorios (uno de estos fallecido en post-operatorio inmediato). Hematomas en 5 (5,61%) casos, 4 (3,56%) que requirieron intervención quirúrgica para drenaje del mismo. Lesión neurológica periférica en 1 (1,12%) solo paciente que corresponde a lesión del laríngeo recurrente. 1 (1,12%) caso de infección superficial de herida operatoria. 1 (1,12%) caso de síndrome de reperfusión cerebral Discusión: Todas las grandes series y guías internacionales demuestran el amplio beneficio de la endarterectomía carotídea en la prevención de eventos neurológicos. Conclusión: La endarterectomía carotídea sigue siendo el tratamiento de elección en la estenosis carotídea sintomática, realizada en centros con experiencia presenta resultados excelentes en cuanto a la prevención de nuevos eventos neurológicos.

Abstract A continuous increase in levels of atmospheric pollution and emission restrictions has forced scientists and engineers to adopt new strategies to improve and develop internal combustion engines. One strategy is based on the development of new simulation methodologies using computational fluid dynamic (CFD) techniques, proposed in the present article. In this study,the dynamic loop methodology with ANSYS Fluent code is proposed to perform the numerical simulation ofa four-stroke spark ignition engine. The complexity of the real case was first simplified with three-dimensional CAD geometry, which was then discretized in ANSYS Meshing, whereby a hybrid mesh was created using prismatic and tetrahedral elements. Simulations for in-cylinder analyses were performed in cold flow and employing common flow parameters, such as swirl and tumble. The mesh quality results were classified as good or excellent, being higher than 0.79 for orthogonal quality criteria and lower than 0.36 for skewness criteria. Turbulent effects were introduced concerning the opening and closing of the valves. It was found that the turbulence increases during the intake stroke up to 90°, and during the power stroke, wherein the of the piston bowl, had a great contributionthat can be seen from the swirl and tumble profile for the engine cycle. In the case of the turbulence intensity, a sharp increase was registered during the admission step up to 90°, at which point the turbulence intensity was 4.0. It canbe concluded that this is an innovative approach, capable of simulating the engine motion profile in cold flow. engines CFD (CFD techniques article studythe study fourstroke four threedimensional three dimensional geometry Meshing elements incylinder cylinder parameters excellent 079 0 79 0.7 036 36 0.3 valves 90 90° bowl cycle 40 4 4.0 approach 07 7 0. 03 3 9 4.

RESUMEN Introducción: La enfermedad descompresiva es un síndrome clínico complejo causado por la sobresaturación de gases respiratorios en la sangre y los tejidos, después de una reducción abrupta de la presión ambiental, que puede presentarse como parte de los accidentes de buceo. Dada su baja prevalencia se da a conocer una de sus formas de presentación en los servicios de urgencias, que requiere rapidez en el diagnóstico y conducta terapéutica inmediata. Objetivo: Presentar un caso grave de enfermedad descompresiva del oído interno. Caso clínico: Paciente masculino de 71 años de edad, buzo aficionado y antecedente de un accidente vascular encefálico isquémico hace aproximadamente 1 año. Realizó inmersiones, luego de las cuales comenzó a presentar síntomas como mareos, náuseas, vómitos copiosos, inestabilidad para la marcha y manifestaciones sensitivas en la cara. Horas después de ser evaluado en centro médico de urgencia, sin diagnóstico específico, se trasladó al cuerpo de guardia del hospital, para su valoración por el especialista en medicina subacuática. Conclusiones: La orientación diagnóstica de un paciente con enfermedad descompresiva requiere derivación urgente a un centro de tratamiento de enfermedades disbáricas.

ABSTRACT Introduction: Decompression illness is a complex clinical syndrome caused by supersaturation of respiratory gases in the blood and tissues, after an abrupt reduction in environmental pressure, which can occur as part of diving accidents. Given its low prevalence, one of its forms of presentation is revealed in emergency services, which requires speed in diagnosis and immediate therapeutic conduct. Objective: To present a severe case of decompressive disease of the inner ear. Clinical case: 71-year-old male patient, amateur diver, with a history of an ischemic stroke approximately 1 year ago. He performed dives, after which he began to present symptoms such as dizziness, nausea, copious vomiting, unsteadiness in walking, and sensitive manifestations on the face. Hours after being evaluated at the emergency medical center, without a specific diagnosis, he was transferred to the hospital's emergency room, for evaluation by the underwater medicine specialist. Conclusions: The diagnostic orientation of a patient with decompression illness requires urgent referral to a center for the treatment of dysbaric diseases.