Papers by Enrique Melgarejo
The COVID-19 pandemic surprised humanity through an unknown virus and its "strange" behavior, for... more The COVID-19 pandemic surprised humanity through an unknown virus and its "strange" behavior, for which we were obviously not prepared and which, due to its characteristics, became an epidemic after two months and only one month later a pandemic, and may ultimately mutate to an endemic. To date (August 13), it has caused 758,761 deaths with an average mortality rate of 3.6% and a total of 21,079,074 confirmed cases. In Colombia, 433,805 confirmed cases and 14,451 deaths have been reported, to date, with a mortality of 3.26%. It began, apparently, on December 31, 2019, when a cluster of cases of pneumonia of unknown etiology was reported in Wuhan, Hubei Province, China. On January 9, 2020, the Chinese Center for the Control and Prevention of Diseases reported that the etiological agent was a new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease caused by SARS-CoV-2 was subsequently named COVID-19 by WHO (2, 3). As is known, this virus uses angiotensin-converting enzyme 2 (ACE2) from the reninangiotensin system as the entry receptor, initially in type II pulmonary alveolar epithelial cells (including cilia) (4, 5). It may manifest as a simple "cold" or flu without major consequences, but some cases may present deregulation of the immune system associated with endothelial alteration -endotheliitis, really, and even a viral sepsis -with an exaggerated inflammatory, immunological and prothrombotic response and systemic manifestations, which may ultimately lead to multi-organ failure and death. This has been called a "cytokine storm" due to the overexpression of these polymorphic and complex molecules, triggering an unusual systemic increase of (IL)-2, IL-6, IL-7, granulocyte colony-stimulating factor, C-X-C motif chemokine 10e (CXCL10), chemokine (C-C motif) ligand 2 (CCL2), tumor necrosis factor alpha (TNFα), and interferon C, in addition to ferritin, with the latter leading to early worsening of tissue and cellular oxygenation (6-8). Some of these cytokines are also involved in hypertensive disease; thus, uncontrolled arterial hypertension (HTN) or HTN which is not treated as a comorbidity is a marker for greater mortality in COVID-19 patients (9). Lymphopenia is a common and early finding, and a degree of correlation has recently been found between the severity or chronicity of HTN and lymphocytes (9-11), with a greater elevation of proinflammatory cytokines in uncontrolled hypertensive patients, especially if they are lymphopenic. That is, there is a coincidence correlation between the COVID-19 inflammatory response and hypertension (which ultimately has a vascular inflammatory effect, including arterial stiffness and biomechanical alterations) . This said, it is not surprising that type 2 diabetes mellitus (T2DM) has also proven to be a high impact comorbidity, considering that it is a disease associated with an inflammatoryoxidative state with early and accelerated endothelial dysfunction. The same occurs with heart failure (vascular inflammation, arterial stiffness and oxidation) and obesity, in which the adipocyte is an AgII augmenter with its consequent propensity towards, and facilitation of, inflammation and oxidation (14-16). Initially, there was controversy due to confusion regarding the blocking of the reninangiotensin system by ACE inhibitors or ARBs possibly magnifying the damage from or risk for COVID-19 through overexpression of the ACE-2 receptor by these medications.
Revista Colombiana de Cardiología (English Edition)
Revista Colombiana de Cardiología
Existen ciertas reglas de oro que facilitan la evaluacion de un pacientecon arritmia y encausan h... more Existen ciertas reglas de oro que facilitan la evaluacion de un pacientecon arritmia y encausan hacia el adecuado manejo de estos pacientes segun el tipo de arritmia que padezcan ya sea ventricuar o supraventricular y si se trata de una emergencia o no. Este ultimo criterrio se evalua con base en el estado hemodinamico del paciente; es por esto que una arritmia supraventricular catalogada como emergencia se trata con cardioversion electrica, si no lo es se debe determinar el ritmo, evaluar los sintomas del paciente manejar la respuesta ventricular, intervalo R-R, restaurar el ritmo sinusal, prevenir la recurrencia y curar la arritmia en los casos en que sea posible. Si se esta frente a una arritmia ventricular y es una emergencia la conducta a seguir es cardioversion electrica; si no es emergencia pero es maligna se debe optar por un manejo agresivo y si no es maligna se debe estudiar al paciente de manera integra
Revista Colombiana de Cardiología, 2017
International Journal of Clinical Practice, 2009
To the Editor: It is well known that diabetes increases the risk of developing heart failure (HF)... more To the Editor: It is well known that diabetes increases the risk of developing heart failure (HF) (1). However, it was not clear whether this increased risk also occurred in patients with new-onset diabetes. A manuscript has recently been published that analysed the risk of HF in patients with recent-onset type 2 diabetes (2). Interestingly, authors found that type 2 diabetes was a major risk factor for the development of HF, and also that HF developed soon after diagnosis. Thus, the risk of new HF in individuals with diabetes was approximately threefold greater than for ageand sex-standardised controls. This is in accordance with the data reported in the VALIANT trial (3), in which diabetes mellitus, whether newly diagnosed or previously known, was associated with poorer long-term outcomes after myocardial infarction in highrisk patients. On the other hand, it has been suggested that there are associations between patient and physician characteristics with the prescription of the recommended drugs that should be taken into account to translate guideline recommendations for application in general practice (4). In this context, although thiazolidinediones precipitate fluid retention in clinical trials, current guidelines advocate their use for patients with diabetes who are felt to be at low risk for HF (5). However, thiazolidinediones (pioglitazone and rosiglitazone) seem to increase the risk of HF (6,7). This has been related to the activation of the peroxisome proliferator-activated receptorgamma (PPAR-c) that modifies the metabolism of fat acids, which are crucial in the heart metabolism, and secondarily might facilitate the development of HF (8). This is very relevant, not only in daily clinical practice but also in the outcomes of clinical trials. For example, despite diabetes is associated with an increased risk of hospitalisations for HF and that available data suggest that inhibition of renin angiotensin system may prevent the development of HF (9), the results of the TRANSCEND trial are at least surprising (10). In this study, telmisartan was compared with placebo in patients with cardiovascular disease or diabetes with endorgan damage intolerant to angiotensin-converting enzyme inhibitors. Although the drug had no significant effect on the primary outcome, which included hospitalisations for HF, when this condition was excluded, it modestly reduced the risk of the composite outcome of cardiovascular death, myocardial infarction or stroke. Interestingly also in ONTARGET study (11), hospitalisation for HF was less frequently reported in the ramipril group than in the telmisartan arm. This is even more unexpected as telmisartan reduced the incidence of left ventricular hypertrophy, an independent predictor of new-onset HF, especially in diabetics (10). How is it possible that the addition of telmisartan to the standard treatment of patients with cardiovascular disease did not prevent admission due to HF? In these studies, although the proportion of patients with diabetes was given as well as the oral antidiabetics, however, unfortunately the percentage of patients taking thiazolidinediones was not provided (10,11). Did the use of this drug influence the final results of these trials? Even more, as telmisartan modulates the PPAR-c (12), unlike the other renin angiotensin system inhibitors, did the possible interaction between rosiglitazone and telmisartan has any importance in the results obtained in the diabetic population? However, it should be noted that thiazolidinediones differ with respect to activity on PPAR receptors a and c. They are selective but not specific for a and c binding. Therefore, drug interactions may be complex with agents that have partial PPAR activity such as telmisartan (13). Anyway, further investigations are needed to assess a potential deleterious interaction of thiazolidinediones, particularly, rosiglitazone and telmisartan in the development of HF.
Revista Colombiana de Cardiología; Vol. 21 Supl. 1 (2014), Feb 1, 2014
Revista Colombiana de Cardiología
Patients with type 2 diabetes mellitus have a higher risk of developing cardiovascular and renal ... more Patients with type 2 diabetes mellitus have a higher risk of developing cardiovascular and renal problems. The scientific evidence as regards how this must be approached in the diabetic patient in an integrated manner in order to prevent complications continues changing rapidly. In cardiovascular safety studies, the new anti-diabetic drugs have demonstrated that they reduce the combined cardiovascular outcome and deterioration of kidney function. Other anti-diabetic drugs also the risk of hospital admission due to heart failure. This document sets out the position of four scientific societies through their expert committees, who were also responsible for replying to fifteen questions related to cardiovascular and kidney risk in patients with type 2 diabetes mellitus.
Horizonte Médico (Lima), 2021
This article briefly reviews the pandemics suffered by humankind throughout its history. Addition... more This article briefly reviews the pandemics suffered by humankind throughout its history. Additionally, it analyzes the current pandemic caused by a "strange” virus that has generated a new and complex disease. A description of its "new" vascular wall-centered physiopathology (and more specifically from the endothelium) is given. Moreover, the possibility to detect a subclinical endothelial dysfunction in young patients who have shown different susceptibility and lethality indices is considered. Finally, the question “will this pandemic change us or will it help us change?” is attempted to be answered.
Revista Colombiana de Cardiología, 2016
Journal of Electrocardiology, 1984
The ectopic cycle length of a ventricular parasystole was influenced in a predictable fashion (mo... more The ectopic cycle length of a ventricular parasystole was influenced in a predictable fashion (modulated) by nonparasystolic beats. Although the interectopic intervals were not multiples of the ectopic cycle length (as in "classical" parasystole), the diagnosis could be established because: a) nonparasystolic beats falling during the first half of the cycle produced an 8-12% shortening of the ectopic cycle length; and b) nonparasystolic beats occurring during the second half of the cycle decreased the ectopic cycle length by 9-14%. The events occurring in this case are further proof that the classical criteria for the diagnosis of parasystole have to be reevaluated.
Archives of Disease in Childhood, 2013
Objectives: This study aimed to determine the relationship between glycaemic control and carotid ... more Objectives: This study aimed to determine the relationship between glycaemic control and carotid atherosclerotic disease among patients with acute ischaemic stroke (AIS). Methods: This retrospective crosssectional study took place in the
Anales de la Facultad de Medicina, 2014
Resumen Existen diferencias intrasexo en lo referente a función y disfunción endotelial. Aunque a... more Resumen Existen diferencias intrasexo en lo referente a función y disfunción endotelial. Aunque ambos sexos comparten los mismos receptores hormonales (estrogénicos y de testosterona), varían en su expresión. Los receptores estrogénicos en la mujer ejercen acción protectora vascular por vía genómica y no genómica, mediadas a través del óxido nítrico. La mujer está 'protegida' para la aterotrombosis hasta la menopausia. La pérdida abrupta de la protección vascular conlleva a magnificación del daño vascular posmenopausia, más si ya tiene disfunción endotelial. La mujer hasta la menopausia tiene un ambiente vascular menos oxidativo con relación al hombre. Las mujeres tienen más angina microvascular y menos infarto con elevación del segmento ST, debido a que hacen más disfunción endotelial ante los factores de riesgo. Las mujeres posmenopáusicas hacen más hipertensión sistólica y por consiguiente tienen mayor presión de pulso y rigidez arterial, esto último mediado por el óxido nítrico. Palabras clave: Endotelio, endotelio y mujer, estrógenos y endotelio.
Revista Colombiana de Cardiología, 2013
La neuropatía autonómica diabética cardiovascular es un trastorno en el cual una alteración en la... more La neuropatía autonómica diabética cardiovascular es un trastorno en el cual una alteración en la regulación del sistema nervioso cardiovascular, por parte del sistema nervioso autónomo, desemboca en una constelación de síntomas, que pueden ir desde intolerancia al ejercicio hasta muerte súbita. Si bien no se conoce su prevalencia exacta, se estima que es alta en pacientes diabéticos, particularmente en aquellos con diabetes de larga data y con presencia de otras comorbilidades. Su reconocimiento temprano puede facilitar el manejo de estos pacientes y a su vez disminuir los costos asociados a pruebas e intervenciones innecesarias con el objetivo de evitar complicaciones asociadas con la enfermedad.
Revista Colombiana de Cardiología, 2009
Desde hace mucho tiempo se sabe que en las diferentes escalas zoológicas la frecuencia cardiaca e... more Desde hace mucho tiempo se sabe que en las diferentes escalas zoológicas la frecuencia cardiaca es un factor que determina la esperanza de vida en años. En la especie humana parece suceder algo similar. En un reciente estudio (BEAUTIFUL), en enfermos con falla cardiaca y enfermedad coronaria, los pacientes con una frecuencia cardiaca > 70 lpm obtuvieron un beneficio significativo en eventos coronarios, hospitalización por infarto del miocardio y revascularización coronaria, al reducirla con un nuevo medicamento que actúa exclusivamente en la corriente If del nodo sinusal, reduciéndola sin componente hemodinámico asociado (esto es, no efecto inotrópico negativo). La enfermedad isquémica cardiaca se ha visto como un disbalance entre la oferta y la demanda de oxígeno en el miocardio. Por tal motivo, los medicamentos que disminuyen su consumo (betabloqueadores y algunos calcioantagonistas), a través del efecto inotrópico negativo, se han convertido en el pilar fundamental para el man...
Revista Colombiana de Cardiología
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Papers by Enrique Melgarejo