Clopidogrel versus prasugrel en síndrome coronario agudo tratado con angioplastia / Clopidogrel versus prasugrel in acute coronary syndrome treated with coronary angioplasty

Al uso del clopidogrel se han agregado nuevos antiagregantes como prasugrel y ticagrelor. El objetivo de este estudio fue comparar la incidencia de eventos isquémicos y hemorrágicos en pacientes que han recibido clopidogrel o prasugrel.Se incluyeron de manera consecutiva todos los pacientes con angioplastia durante la internación por síndrome coronario agudo entre diciembre 2011 y diciembre 2012.Fueron incluidos 398 pacientes. No se observaron diferencias en la mortalidad de causa cardiovascular (clopidogrel 2.5% vs. prasugrel 2.9%, p = 0.48). El grupo prasugrel presentó una reducción en la tasa de infarto (1.9% vs. 6.8%, p = 0.01) con sangrado totales (18.5% vs. 8.5%, p = 0.001) a expensas de sangrados menores (12.4% vs. 3.4%, p < 0.001), sin diferencia en sangrados mayores (p = 0.27) y sangrados con peligro de vida (p =.0.20). Por análisis multivariado los predictores independientes de mortalidad cardiovascular fueron edad (odds ratio 1.08, intervalo de confianza, IC, 95% 1.02-1.16, p = 0.02) insuficiencia renal (odds ratio 6.98, IC 95% 1.23-39.71, p < 0.0001). En cuanto al sangrado total se identificaron la edad (odds ratio 1.06, IC 95% 1.02-1.09, p = 0.002), elevación del segmento ST (odds ratio 1.99, IC 95% 1.05-3.79, p = 0.02), insuficiencia renal (odds ratio 3.32, IC 95% 1.62-6.78, p = 0.002) y utilización de prasugrel (odds ratio 3.97, IC 95% 1.87-8.41, p < 0.0001). La utilización de prasugrel se asocia a una menor tasa de infarto agudo de miocardio al año de seguimiento, con incremento de hemorragias menores. No se observaron diferencias significativas en la mortalidad cardiovascular entre ambos grupos.

Greater antithrombotic potency new antiplatelet agents have been added such as prasugrel (PR) and ticagrelor to the traditional use of clopidogrel (CL) in the treatment of acute coronary syndrome (ACS). This study was aimed at comparing the incidence of long term ischemic and hemorrhagic events in patients treated with CL or PR during hospitalization. Retrospective ACS data base analysis performed by our cardiology service was completed prospectively. There were consecutively included all patients with percutaneous coronary intervention (PCI) during hospitalization due to ACS from December 2011 thru December 2012. A total of 398 ACS patients who underwent PCI with stent implantation were recruited. No differences in cardiovascular related deaths were observed in both groups (PR 2.9% vs. CL 2.5%, p = 0.48). PR group showed less re-infraction (1.9% vs. 6.8%, p = 0.01) with more total bleedings (18.5% vs. 8.5%, p = 0.001) and minor bleedings (12.4% vs. 3.4%, p < 0.001) with no differences in major and life threatening bleedings (p = ns). Multivariate analysis showed that independent predictors of cardiovascular mortality were age (OR 1.08, CI 95% 1.02-1.16) and renal failure (OR 6.98, CI 95% 1.23-39.71). Independent predictors for total bleeding were age (OR 1.06, CI 95% 1.02-1.09),ST segment elevation myocardial infarction (OR 1.99, CI 95% 1.05-3.79), renal failure (OR 3.32, CI 95% 1.62-6.78) and prasugrel use (OR 3.97, CI 95% 1.87-8.41). Use of prasugrel, in the ACS that requires PCI with stent, is associated with a lower myocardial infarction a year after follow-up, and it also leads to an increase of milder hemorrhage. No significant differences were observed in the cardiovascular mortality of both groups.

Intervalo QTc prolongado y taquicardia ventricular polimórfica ligada a hemorragia subaracnoidea / QTc interval prolongation and polymorphic ventricular tachycardia related to subarachnoid hemorrhage

Mujer de 55 años trasladada al hospital luego de recuperarse de un episodio presincopal. El electrocardiograma mostró bradicardia sinusal con intervalo QT corregido de 840 mseg. Pocos minutos después la paciente presenta episodio de taquicardia ventricular polimórfica y posterior paro cardiorrespiratorio que requirió maniobras de reanimación cardiopulmonar avanzada que fueron efectivas. A la semana presentó cefalea intensa y convulsiones con movimientos de descerebración. La tomografía axial computarizada de cerebro mostró hemorragia subaracnoidea con hipertensión intracraneal que requirió craniectomía descompresiva. Durante la internación todos los electrocardiogramas evidenciaron el QT corregido prolongado, pero la paciente no presentó un nuevo evento arrítmico. La paciente evolucionó desfavorablemente requiriendo fármacos vasoactivos en dosis máximas. Falleció a los 13 días de su admisión.

A 55-yr-old woman was taken to the hospital after recovering from a presyncopal episode. The electrocardiogram showed sinus bradycardia with QTc interval of 840 msec. Few minutes later, the patient developed a polymorphic ventricular tachycardia and subsequent cardiac arrest requiring cardiopulmonary resuscitation. A week later she presented with severe headache, seizures and decerebrate movements. Cranial computed tomography scan showed subarachnoid hemorrhage with intracranial hypertension requiring decompressive craniectomy. On the follow- up the electrocardiograms always showed prolonged QTc interval, without any new arrhythmic event. The patient's clinical course was unfavorable and required maximum dose of vasoactive drugs. She died 13 days after admission.