Sociedad Venezolana de Medicina Interna

16/06/2019

La Sociedad Venezolana de Medicina Interna y el Comité Científico del XXV Congreso Venezolano de Medicina Interna, se complacen en anunciar la nueva fecha y sede de nuestro magno evento. Los esperamos con los brazos abiertos del 9 al 11 de octubre en los espacios de la Universidad Metropolitana en la ciudad de Caracas. Están todos invitados a compartir esta gran fiesta de ciencia y academia, donde además daremos respuestas para un país que no puede esperar.

23/08/2016

A los que puedan ir...

COUNTDOWN TO WCIM2018 and have the opportunity to meet Frank Bosch, The Netherlands; Roger Chen, Australia; Paul Dorian, Canada; E. Wesley Ely, USA; Charles Feldman, South Africa; Martin Green, Canada and many more

www.wcim2018.com

20/01/2016

En relación con algunos personajes que hacen "preguntas" en los congresos médicos y estando próximo nuestro congreso de Medicina Interna me permito compartir un algoritmo que conseguí en twitter: Publicado por Pascal Meier, MD,BMJ
Brilliant guide to asking questions at medical conferences, via MT

16/01/2016

Satisfechos por la concurrencia y la calidad de los expositores en el primer club de Medicina Interna del 2016 efectuado el día de hoy en la sede de la Sociedad. El próximo está planteado para el día sábado 20 de febrero, aunque será confirmado próximamente.

En la cuenta twitter de la SVMI hay un grupo de preguntas a modo de encuesta para los miembros de la Sociedad, a los que se pide gentilmente nos la contesten, está en twitter.com/SVMI_Nacional

Muchas gracias

The latest Tweets from Soc. Vzlana Med. Int (). Guiando la salud de la población adulta de Venezuela en el siglo XXI. Venezuela

12/01/2016

Estimados colegas miembros del club de Medicina interna, reciban mis mejores deseos para este 2016. Están invitados al primer club de medicina interna del 2016 que se realizará el sábado 16 de enero 9 am en la sede de la sociedad. Anexo les envío el programa y 2 de los 3 casos a ser presentados. Le agradezco a la Sra Elena pasar la información a los interesados.
Hasta pronto
Dr. Enrique Vera
Coordinador
Nota: 2 de los casos están publicados y pueden descargarse del twitter de la SVMI en forma de pdf

10/01/2016

Por cada 10 puntos que se reduce la presión sistólica se disminuye significativamente la mortalidad | Por:

Reducir la presión arterias SISTÓLICA (la máxima) en 10 milímetros de mercurio significa, de manera general, redujo la mortalidad un 13%. Otras conclusiones son que se redujo un 20% el riesgo de eventos cardiovasculares mayores, un 17% las enfermedades coronarias, un 27% el riesgo de ictus (anteriormente llamados ACV) y un 28% el de insuficiencia cardíaca.

En el trabajo dirigido por Kazem Rahimi, del Instituto George para la Salud Global de la Universidad de Oxford, publicado en la revista The Lancet se han revisado 123 trabajos publicados entre 1966 y noviembre de 2015 y se reclutaron 613.815 participantespara el meta-análisis tabular. Los análisis de meta-regresión mostraron reducciones del riesgo relativo proporcionales a la magnitud de las reducciones de la presión arterial obtenidas.

Para esta revisión sistemática y meta-análisis, se realizaron búsquedas en MEDLINE de ensayos clínicos a gran escala de disminución de la presión arterial, publicados entre el 1 de enero 1966, y 7 de julio de 2015, y se realizaron búsquedas en la literatura médica para identificar los trabajos hasta el 09 de noviembre 2015. Todos los ensayos controlados aleatorios de tratamiento para bajar la presión arterial fueron elegibles para su inclusión si incluían un mínimo de 1.000 pacientes-año de seguimiento en cada brazo del estudio.

Ningún ensayo fue excluido debido a la presencia de comorbilidades de base, y también fueron elegibles los ensayos de fármacos antihipertensivos para indicaciones distintas de la hipertensión arterial. Se extrajeron los datos a nivel de resumen sobre las características de los estudios y los resultados de los eventos mayores de enfermedad cardiovasculares, de cardiopatía isquémica, ictus, insuficiencia cardíaca, insuficiencia renal y mortalidad por cualquier causa. Se utilizó varianza inversa ponderada de efectos fijos inversas de meta-análisis para poner en común las estimaciones.

El trabajo es importante porque cuestiona las recomendaciones asumidas por muchos médicos y pacientes de que hay que bajar la tensión hasta 140/90, considerado el límite máximo saludable. Hay excepciones, como en personas con insuficiencia renal o insuficiencia cardiaca.

Los beneficios del tratamiento para disminuir la presión arterial para la prevención de la enfermedad cardiovascular están bien establecidos. Sin embargo, el grado en que estos efectos se difieren de acuerdo a la presión arterial basal, la presencia de comorbilidades o la clase de medicación es menos claro. Para ello se realizó una revisión sistemática y meta-análisis para aclarar estas diferencias.

Cada 10 mm Hg en la reducción de la presión arterial sistólica redujo 20% (significativamente) el riesgo de eventos mayores de enfermedad cardiovascular (riesgo relativo [RR] 0,8), 17% la enfermedad coronaria (0·83), 27% los ictus (0·73), y 28% la insuficiencia cardiaca (0·72), lo cual, en las poblaciones estudiadas, condujo a una significativa reducción del 13% en la mortalidad por cualquier causa (0·87). Sin embargo, la disminución de 5% de la insuficiencia renal no fue significativa (0·95). Reducciones similares de riesgo proporcional (por 10 mm Hg de presión arterial sistólica) se observaron en los ensayos con mayor presión arterial sistólica media basal así como en los ensayos con menor presión arterial sistólica media basal (Tendencia de p general > 0,05).

No hubo evidencia clara de que las reducciones de riesgo proporcional en la enfermedad cardiovascular mayor difirieran por la historia de la enfermedad de base, a excepción de la diabetes y la enfermedad renal crónica, para los que se detectaron, reducciones de riesgo más pequeñas, pero significativas.
Diferencias en la prevención farmacológica

Los β bloqueadores fueron inferiores a otros fármacos para la prevención de eventos mayores de enfermedad cardiovasculares, ictus e insuficiencia renal. Los bloqueadores de los canales de calcio fueron superiores a otros fármacos para la prevención del ictus.

Para la prevención de la insuficiencia cardíaca, los bloqueadores de los canales de calcio fueron inferiores y los diuréticos fueron superiores a otras clases de fármacos. El riesgo de sesgo se consideró bajo en 113 ensayos y poco claro para 10 ensayos. La heterogeneidad de los resultados fue baja a moderada; la estadística I2 (un nuevo índice denominado I2, que comienza a aparecer ya en las revisiones sistemáticas: El parámetro I2 indica la proporción de la variación entre estudios respecto de la variación total, es decir la proporción de la variación total que es atribuible a la heterogeneidad) para la heterogeneidad de los eventos mayores de enfermedad cardiovascular fue de 41%, para la cardiopatía isquémica 25%, para el ictus 26%, para la insuficiencia cardíaca 37%, para la insuficiencia renal 28%, y para la mortalidad por todas las causas 35%.
Nuevas tendencias acerca de la meta del tratamiento

Esta metaanálisis llega poco después de que se hayan publicado resultados del estudio Sprint, indica Almudena Castro, presidenta de la Sección de Riesgo Cardiovascular de la Sociedad Española de Cardiología, quien recalca que siempre tiene más fuerza científica un estudio que un metaanálisis. Este trabajo siguió a 9.000 personas durante cuatro años asignadas a dos grupos: uno perseguía la reducción de la tensión máxima a menos de 14 (140 milímetros de mercurio); el otro, a 12. Los beneficios fueron tan claros para los que recibían un tratamiento para bajar la tensión más agresivo que a los 3,26 años se suspendió el estudio, y se pasó a todos los pacientes al grupo que perseguía el objetivo más estricto. “Con 120/80 hay una mejor supervivencia”.

Estas dos características (problemas renales o insuficiencia cardiaca) son parte de los matices que se aplican a las conclusiones del estudio. Plantea la oportunidad de dar medicación antihipertensiva a personas con unos valores de partida de este indicador considerados seguros, si su perfil general de riesgo cardiovascular (que incluye factores como la edad, tabaquismo, peso, niveles de actividad física, colesterol o si tienen diabetes) lo recomiendan, señala Liam Smeeth, de la London School of Hygiene & Tropical Medicine.

Fuentes:

DOI: http://dx.doi.org/10.1016/S0140-6736(15)01225-8

Dr. Rigoberto J. Marcano Pasquier
Medicina Interna

13/11/2015

Algunos datos acerca de la diabetes a propósito del día mundial de la diabetes

13/11/2015

DPP-4 inhibitors associated with lower mortality and cardiac risk than sulfonylureas as add-on therapy, study finds

Dipeptidyl peptidase-4 (DPP-4) inhibitors as add-on therapy to metformin were associated with better outcomes than sulfonylureas, according to a recent study.

Researchers in Taiwan used a national health insurance database to compare clinical outcomes when DPP-4 inhibitors or sulfonylureas were added to metformin in patients with type 2 diabetes. Patients who were at least 20 years of age between 2009 and 2012 were included, and those taking metformin who hadn't previously taken another oral hypoglycemic agent were considered enrolled in the study cohort when they filled a DPP-4 inhibitor or sulfonylurea prescription. The index date was defined as the first day on which a DPP-4 inhibitor or sulfonylurea was used. Patients using other hypoglycemic agents for diabetes control between the first day of metformin prescription and the index date were excluded from the study. The study outcomes were all-cause mortality; major adverse cardiovascular events (MACEs), including myocardial infarction and ischemic stroke; heart failure hospitalization; and hypoglycemia. Patients were followed until death or until Dec. 31, 2013. Results were published online Oct. 13 by Annals of Internal Medicine.

Overall, 10,089 propensity score-matched pairs of DPP-4 inhibitor users and sulfonylurea users were examined. Mean age was approximately 58 years, and mean follow-up was 2.8 years. DPP-4 inhibitors as an add-on to metformin appeared to be associated with lower risks for all-cause death (hazard ratio [HR], 0.63; 95% CI, 0.55 to 0.72), MACEs (HR, 0.68; 95% CI, 0.55 to 0.83), ischemic stroke (HR, 0.64; 95% CI, 0.51 to 0.81), and hypoglycemia (HR, 0.43; 95% CI, 0.33 to 0.56) versus sulfonylureas. No effect was seen, however, on risks for myocardial infarction and hospitalization for heart failure.

The authors noted that the study was limited by its observational cohort design, the lack of information on diabetes control, and its relatively short follow-up, especially considering that DPP-4 inhibitors are fairly new drugs. "With respect to the clinical outcome of MACEs, we found that DPP-4 inhibitors reduced the risks for all-cause death and stroke but did not alter the risks for myocardial infarction and hospitalization for heart failure relative to sulfonylureas," the authors wrote. "This study adds to the clinical evidence for the evaluation of cardiovascular risk in patients with [type 2 diabetes mellitus] treated with sulfonylureas versus DPP-4 inhibitors after metformin."

The author of an accompanying editorial pointed out the increasing difficulty for physicians of keeping up with newly available classes of diabetes drugs and determining which therapy is best for each patient. He noted that while the study was able to relieve some of the concern that DPP-4 inhibitors might increase cardiac events versus sulfonylureas, it also "raises questions it cannot answer," such as the effect of add-on therapy on glucose control. "How the observed rates of adverse outcomes might be weighed in clinical decision making would depend on whether the addition of a sulfonylurea resulted in lower hemoglobin A1c levels than the addition of a DPP-4 inhibitor. Is this greater efficacy worth the risk?" he continued.

"Good diabetes care requires the clinician and patient to set defined, individualized goals. Only with such targets in mind can the clinician balance concerns of adequate glycemic control and possible adverse events," the editorialist wrote. "For each patient, the clinician must not only set goals for glucose control but also weigh patient concerns—hypoglycemia, weight gain, affordability, or cardiac risk—that might modify these goals."

13/11/2015

Mortality in diabetes may vary greatly by age, glycemic control, renal complications

Mortality risk among people with type 2 diabetes varied greatly, including substantially increased risks with worse glycemic control, impaired renal function, and younger age, a study found.

Researchers in Sweden assessed risks among people with type 2 diabetes who were in the Swedish National Diabetes Register by Jan. 1, 1998. For each patient, 5 controls were randomly selected from the general population and matched by age, s*x, and county. All the participants were followed until Dec. 31, 2011, in the Swedish Registry for Cause-Specific Mortality. The mean follow-up was 4.6 years in the diabetes group and 4.8 years in the control group.

Overall, 77,117 of 435,369 patients with diabetes (17.7%) died, compared to 306,097 of 2,117,483 controls (14.5%) (adjusted hazard ratio [HR], 1.15; 95% CI, 1.14 to 1.16). The rate of cardiovascular death was 7.9% among diabetic patients versus 6.1% among controls (adjusted HR, 1.14; 95% CI, 1.13 to 1.15). Results appeared in the Oct. 29 New England Journal of Medicine.

The increase in mortality seen with diabetes increased with HbA1c. Among patients with HbA1c ≥9.7% who were younger than 55 years old, the HR for death from any cause compared to controls was 4.23 (95% CI, 3.56 to 5.02) and the HR for cardiovascular death was 5.38 (95% CI, 3.89 to 7.43). Among patients 75 years of age or older in this HbA1c category, the corresponding HR for death from any cause was 1.55 (95% CI, 1.47 to 1.63) and the HR for cardiovascular death was 1.42 (95% CI, 1.32 to 1.53).

The decrease in risk difference with older age was a continuing pattern. In diabetes patients under age 55 years with an HbA1c of 6.9% or less and normoalbuminuria, the HR for death compared with controls was 1.60 (95% CI, 1.40 to 1.82); the corresponding HR among patients 75 years of age or older was 0.76 (95% CI, 0.75 to 0.78), and diabetic patients 65 to 74 years of age also had a significantly lower risk of death (HR, 0.87; 95% CI, 0.84 to 0.91).

Renal function was also associated with mortality risk. Across the different age categories (younger to older), the HRs for death from any cause associated with diabetes ranged from 2.61 to 1.04 among patients with microalbuminuria, from 3.78 to 1.40 among those with macroalbuminuria, and from 14.63 to 3.31 among those with stage 5 chronic kidney disease.

No interaction was seen between diabetes and s*x for all-cause mortality (P=0.21) or cardiovascular mortality (P=0.67). There was a time interaction, in which the risk of death from any cause among patients with diabetes as compared with controls was significantly lower during the last 7 years of follow-up (2005 or later) than during the first 7 years of follow-up (before 2005). Similar results were found for cardiovascular mortality.

The authors wrote, "… [I]n younger patients with type 2 diabetes, strict control of blood pressure, prescription of statins, targeting of good glycemic control, and avoidance of microalbuminuria are probably not enough to reduce excess mortality to the rate in the general population. Smoking cessation, increased physical activity, and the development of new cardiovascular-protective drugs, such as alternative lipid-lowering medications for persons who cannot take statins, may further improve outcomes in younger patients. Reducing the risk of renal complications in all age groups is highly important; the excess mortality among younger patients with advanced chronic kidney disease was approximately 15 times as high as that among controls."

13/11/2015

New algorithm may help physicians set glycemic targets for patients with diabetes

Researchers have created a new algorithm for physicians that may help when developing individual glycemic targets for patients with diabetes.

They constructed the algorithm using survey input from 151 international diabetologists and validated it by surveying additional diabetologists. Results were published online on Oct. 30 in Diabetes Care.

Surveyed physicians ranked 11 factors they take into consideration when setting a patient's glycemic target in terms of relative importance. "Risk of hypoglycemia from treatment" ranked the highest, with more than 50% of those surveyed ranking it in the top 3. "Life expectancy" was ranked among the top 3 by 48% of survey responders. "Disease duration" and "resources and support system" were both ranked the lowest. The physicians then suggested appropriate glycemic targets for 6 clinical vignettes, which represented a wide range of patients.

The study's authors used this information to create the algorithm, which computes an individualized HbA1c target according to the severity score of 8 clinical parameters (they excluded 3 parameters for redundancy). The researchers restricted target HbA1c numbers calculated by the algorithm to between 6.5% and 8.5% because this range encompassed 95.1% of the recommended values proposed by survey respondents.

The algorithm was validated by presenting 3 new cases to 57 diabetes experts that did not participate in the original survey, who suggested glycemic targets that were very similar to those calculated by the algorithm.

Three of the 8 parameters used in the algorithm could be considered subjective: "cognitive function," "adherence to therapy," and "resources and support system," the authors noted. The combined weight of these parameters is nearly 25%, and they could shift target HbA1c by up to 0.5%. The authors also proposed an alternative, more minimalistic model using only the 5 objective parameters, which are easily extrapolated from electronic medical records: "risk of hypoglycemia from treatment," "life expectancy," "important comorbidities," "macrovascular and advanced microvascular complications," and "disease duration." (See study for full algorithm.)

The authors noted several limitations of their work, such as that the selection of surveyed physicians was not based on a systematic scoring system and that it's probable that many experts around the world were not included. They also did not collect data regarding the physicians' age or years in practice, although they did aim to include those nationally and internationally recognized for their contributions in the field.

This algorithm is an attempt at standardizing individualized care, and it needs further study and validation, the authors acknowledged. "The aid of a validated algorithm would have great clinical importance and would enhance our ability to deliver better diabetes care for our patients while avoiding the hazards associated with both over- and undertreatment," they wrote.

10/11/2015

Study finds masked and white coat hypertension prevalent and associated with higher risk of adverse cardiovascular events

Masked hypertension and white coat hypertension were independently associated with cardiovascular events, according to a recent study.

Researchers looked at markers for organ damage and adverse cardiovascular outcomes associated with white coat hypertension (clinic BP ≥140/90 mm Hg, home BP

31/10/2015

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