Caracterización clínica y angiográfica según sexo de pacientes con síndrome coronario agudo sin supradesnivel del segmento ST / Clinical and angiographic characterization according to sex of patients with acute coronary syndrome without ST segment elevation

Ischemic Heart Disease is the leading cause of death and of potential years of life lost in Chile. The most frequent acute presentation of this group of pathologies is the Acute Coronary Syndrome (ACS) without ST segment elevation. According to the literature, there is a proportion of patients with non-ST elevated ACS in which coronary angiography reveals a mild coronary lesion or even shows no detectable lesion at all. This scenario is more common in women than in men. Compared with men, women with non-ST elevated ACS are older than men and more frequently have hypertension. Furthermore, women are less likely to have previous cardiac diseases, and are less common to present serum troponin rise at admission. In Chile, there are no previous studies about the differences between sexes in this disease. The objective of this study is to determine if there are major differences between sexes in aspects like clinical and angiographic findings in patients with non-ST elevated ACS. The study used a database of 1900 consecutive patients who were submitted for coronary angiography and had been previously diagnosticated with non-ST elevated ACS, between the years 2001-2017. Clinical assessment, laboratory and angiographic results were collected and analyzed to establish major differences considering p<0,05. 69% of patients were men. When comparing, the proportion of smokers was greater in men, who also more frequently had progressive worsening of angina or treatment-resistant chest pain as clinical presentations. Furthermore, previous coronary bypass surgery, previous percutaneous coronary intervention and previous myocardial infarction were more common in men. As to women, they were older and more frequently had hypertension and/or hypothyroidism. Unstable angina as a clinical presentation was more usual than in men and electrocardiographic findings as a negative T-wave in the anterior wall, evolutive segment changes and left branch bundle block were also more common. In addition, serum troponin rise was more frequent than in men. There was no difference in risk stratification with TIMI score. When comparing angiographic findings, women had more frequently mild lesions or no lesions at all (44% in women versus 27% in men). In conclusion, clinical aspects are different in between sexes as to presence of comorbidities, cardiovascular risk factors and previous cardiovascular disease. Clinical presentation is also different, as to symptoms and as to electrocardiographic findings and laboratory exams. At last, and as evidence suggests, there is a greater proportion of women with mild coronary lesions or without lesions than in men when comparing angiographic findings. (AU)

Factores pronósticos de morbimortalidad cardiovascular en pacientes egresados con infarto agudo al miocardio seguidos por un año / Prognostic factors of cardiovascular morbidity and mortality in patients with acute myocardial infarction followed for one year

Acute myocardial infarction is one of the main causes of death in the world, this occurs in the in-hospital period as well as in the follow-up. It has been much studied what occurs in the in-hospital period, but much less what occurs in the follow-up of patients with this pathology. The objective of this study was to follow patients discharged after myocardial infarction for 1 year and analyze predictors of cardiovascular events. 1174 patients were followed for 1 year, of which 17% presented some serious cardiovascular event, associated with the presence of male sex, older age, arterial hypertension, previous history of angina, hospital treatment only pharmacological, inclusion of positive inotropes in the initial treatment and use of calcium channel blockers, factors already shown by international literature but less analyzed in our country, and furthermore, the demonstration that invasive management with coronary angioplasty or bypass surgery are protective factors of the occurrence of events in this period, which reinforces the idea of a more intensive and invasive management in patients with this pathology. (AU)

Síndrome coronario agudo sin supradesnivel ST. Diagnóstico y tratamiento inicial / Acute coronary syndrome without ST segment elevation. Diagnosis and initial treatmen

Coronary heart disease can manifest as stable or unstable forms, being these variations differentiated mainly by the underlying pathophysiological cause, their clinical presentation and the risk associated to each of these clinical presentations. In the unstable form, nowadays known as acute coronary syndrome, recommendations over its characterization and particularly its management are periodically updated in published international guidelines about this topic. Their epidemiological relevance makes important that these aspects should be known by anyone that sees patients in their practices, motivating this review in which we will summarize aspects of the clinical presentation, initial studies and management of the acute coronary syndrome without ST segment elevation emphasizing novelties from the last few years. (AU)

Síndrome de ALCAPA en adulto: caso clínico / Anomalous left coronary artery origin from the pulmonary artery causing angina: report of one case

Anomalies of the origin of coronary arteries are detected in 0.5-1.5% of all angiographies. Anomalous origin of the left main trunk is the most uncommon and its origin from pulmonary artery in adults is exceptional, usually because it is associated with a short survival. We report a 49-year-old female, presenting with a two months history of angina. The exercise electrocardiogram suggested ischemia. A coronary angiography was performed, showing the absence of the left main trunk in the left coronary sinus, a dilated right coronary artery, with no lesions and extensive collateral circulation to the anterior descending and circumflex arteries, with inverted flow and the left main trunk draining to the pulmonary artery. The left ventricle was mildly dilated with middle and apical anterior hypokinesia. Global systolic function was conserved. A surgical correction was decided, occluding the left main anomalous origin and performing a coronary artery bypass grafting from the left internal thoracic artery. The patient was discharged with no complications. At two years of follow-up she is symptom free and has a normal physical capacity.

Infarto agudo al miocardio en octogenarios, caracterización y comparación con pacientes menores en 20 años de registro / Acute myocardial infarction in octogenarians, characterization and comparison with younger patients in 20 years of registry

Cardiovascular diseases are the main cause of death in Chile, being acute myocardial infarction (AMI) the most frequent. Its incidence increases with age, so, as the population gets older; a higher number of cases is expected. Despite this, AMI within octogenarian patients (OP) has been understudied in our country and worldwide; there are no specific guidelines for their management, only a few isolated studies that reveal the poor applicability of the standard treatments indicated in AMI clinical guidelines. Objective: To describe the clinical features, initial treatment, in-hospital evolution and five-year outcome of OP with AMI, and compare them to patients under 80 years of age. Method: Consecutive registration of all patients diagnosed with AMI that were hospitalized in our coronary unit between 1988 and 2007. Description of clinical features, in-hospital and 5-year evolution of all OP cases. Comparison to the younger group of patients through chi-square or t-student tests, considering p-value...

Daño hepático crónico como manifestación de pericarditis constrictiva: reporte de un caso / Chronic liver failure as a manifestation of constrictive pericarditis: report of a case

Constrictive pericarditis (CP) is an uncommon condition which clinical presentation becomes very unspecific, making its diagnosis a hard challenge. It has multiple and varied causes, all of them determine pericardium inflammation and progressive fibrosis that restricts heart filling and develops diastolic dysfunction, expressing mainly as right heart failure. Symptoms of this last condition allow posing different diagnosis as they can appear in many other diseases, including chronic liver disease as happens in the following clinical case. A 27 year-old male patient with a history of progressive edema on his extremities, increased abdominal volume, a 3-month body weight loss, and dyspnea; is firstly diagnosed as CLD after medical Evaluation. However, etiological studies for CLD appear negative and the patient does not respond to general approaches, motivating his hospitalization for further studies. Cardiologic tests reveal pulmonary hypertension, which is studied by MRI showing a thickened pericardium suggesting constriction that is confirmed by cardiac catheterization. The patient undergoes surgery without incidents and a favorable post-operatory period, being completely asymptomatic 3 months later. This clinical case reflects how difficult can become diagnosing CP; as well as presenting the right way to study these patients in order to confirm this alternative diagnosis, the treatment of choice, and the excellent results that surgery can achieve. Finally, CP is a rare condition that must be included within differential diagnosis of patients with clinical manifestations of RHF.

Disección coronaria espontánea posterior a ejercicio: presentación de un caso y revisión bibliográfica / Spontaneous Coronary Artery Dissection after to exercise: a case report and literature review

Spontaneous coronary dissection (SCD) is a rare cause of acute coronary syndrome (ACS) in patients with no risk factors, usually described in young women within delivery period. The test of choice to approach diagnosis is coronary angiography, which could result therapeutic as it achieves myocardial revascularization though angioplasty. Occasionally, complementary radiologic techniques are required for diagnosis, as well as other treatments such as coronary bypass surgery (CBS). The prognosis of successfully revascularized patients is favorable, generally with no recurrence. We report the case of a 25 year-old woman, with no medical records, who experienced two episodes of ACS; first after exercise and two days later while she was at rest,revascularized in our hospital due to a double SCD that required CBS with a propitious evolution and remaining asymptomatic trough a six-year follow up...

Disección coronaria espontánea posterior a ejercicio: presentación de un caso y revisión bibliográfica / Spontaneous coronary artery dissection posterior to exercise: presentation of a case and bibliographic review

Spontaneous coronary dissection (SCD) is a rare cause of acute coronary syndrome (ACS) in patients with no risk factors, usually described in young women within delivery period. The test of choice to approach diagnosis is coronary angiography, which could result therapeutic as it achieves myocardial revascularization though angioplasty. Occasionally, complementary radiologic techniques are required for diagnosis, as well as other treatments such as coronary bypass surgery (CBS). The prognosis of successfully revascularized patients is favorable, generally with no recurrence. We report the case of a 25 year-old woman, with no medical records, who experienced two episodes of ACS; first after exercise and two days later while she was at rest,revascularized in our hospital due to a double SCD that required CBS with a propitious evolution and remaining asymptomatic trough a six-year follow up. (AU)

Infarto agudo al miocardio: cómo diagnosticarlo en forma precoz / Acute myocardial infarction: how to diagnose at an early stage

Acute Myocardial infarction is the first cause of death in our country, to reduce its mortality early hospitalization is critical, so adequate treatments that have demonstrated to improve survival can be applied, particularly reperfusion therapy, that requires a diagnosis before 12 hours of evolution of symptoms to be effectively used, to do this early diagnosis two key elements are basic: clinical history and electrocardiography. This two elements are reviewed as their correct application and possible related mistake.

Síndrome de Tako-tsubo: presentación y revisión actualizada del tema / Tako-Tsubo syndrome: typical clinical case and review

An acute left ventricular disfunction, induced by physical or emotional stress, has been described, known as Tako-tsubo syndrome. Acute coronary disease has shown to be its most important differential diagnosis, based on the similar clinical findings described in this group of patients. It usually presents with chest pain, reversible ST segment elevation in the electrocardiogram, discrete myocardial enzyme elevation and transient left ventricular wall motion abnormality, with no significant coronary arteries disease demonstrated. In this article we present the case of a46 year old woman with a typical Tako-tsubo’s syndrome medical profile who was hospitalized in our Hospital, with an initial diagnosis of an acute ST elevation myocardial infarction. We describe the general study and management of this syndrome and make a discussion about the subject.

Infarto agudo al miocardio secundario al uso de cocaina. Caso clínico y revisión del tema / Acute myocardial infarction secondary to use of cocaine. Case report and subject revision

There is same evidence to suggest that the use of cocaine has increased in our country in recent years. The negative actions of the drug can be observed in different organs; the cardiovascular system is particularly vulnerable. We present the clinical case of a young man who, as a consequence of occasional inhalation of cocaine presents an acute myocardial infarction. The reperfusion of the coronary artery was obtained with a Coronary angioplasty very close to the beginning of the occlusion. We discuss the pathophysiology of this particular form of myocardial infarction and emphasis the different therapeutic options in this arena and in particular, our preferred way of treatment.

Resultados clínicos inmediatos y alejados del implante de stents metálicos no recubiertos: ¿Se justifica un reemplazo total por los stents liberadores de drogas? / Acute and long-term clinical results of bare metal coronary stenting

Background: Since the introduction of stents in 1994, improved clinical results have boosted the development of coronary angioplasty in Chile. Drug eluting stents, that have a reduced rate of restenosis, are being increasingly used. Aim: To assess the acute and long-term results of bare metal stent implantation. Patients and Methods: Acute and long-term clinical, procedural and angiographic results were assessed in non acute myocardial infarction patients undergoing coronary stent implantation between August 1996 and December 2003. Results: During the study period, 932 patients aged 30 to 87 years (194 women) had at íeast one stent implanted. Twenty two percent were diabetic, 33 percent had recent myocardial infarction, 53 percent unstable angina and 22 percent stable angina. Angiographic and clinical success were 99.6 percent and 98.2 percent, respectively. In hospital death was 0.5 percent. During a mean follow-up of 19.1 months, all cause mortality was 3.9 percent, cardiac death 1.9 percent and survival free of major cardiac ischemic events was 85.3 percent. Only 6.4 percent of lesions underwent target vessel revascularization (TVR). Independent predictors of TVR were previous surgery, íeft anterior descending artery, small post stent minimum luminal diameter. Ostial location, in-stent restenosis, and younger age were non significant predictors. Conclusions: Acute and long-term results of bare metal stents in this population were excellent. An intriguingly low rate of TVR was seen. Selective bare metal stenting should continue in lesions and patients with a low risk of clinical restenosis.

Angioplastía coronaria en pacientes octogenarios / Coronary angioplasty in octogenarians patients

Introduction: According to international literature, the percutaneus coronary angioplasty (PTCA) can be performed in octogenarian with a high rate of success and favorable long term prognosis. There are no Chilean publications about PTCA in octogenarian patients. Objective: To show our experience in octogenarian patients who underwent PTCA. Material and method: From a serial prospective registration of patients who underwent coronary angiography studies between 1992and 2005, all the octogenarian patients subjected to PTCA were evaluated, being described their pre and in-hospital variables, with emphasis in the results of the PTCA Results: Of a total of 7262 patients, 77 octogenarian patients underwent PTCA (1percent). The average age was 83.2 +/- 3.4 years, 54.5 percent male. They were studied mainly by myocardial infraction (MI) (55.8 percent) and unstable angina (29.8 percent). 59.7 percent were hypertensive and 19.4 percent had diabetes. The angiographic study showed mainly single vessel (37.6 percent) and two vessel disease in 32.4 percent. The PTCA was elective in 57.1 percent, the rest were emergency procedures. The PTCA was successful in 88.3 percent. There were no intra procedure complications, and 7 patients presented smaller post procedure complications. 11 patients (14.3 percent) died; 10 because of MI. 66 were discharged without complications. Conclusion: The PTCA is a feasible procedure to perform in octogenarian patients, with good immediate results.

Infarto agudo del miocardio del ventrículo derecho: una actualización / Right ventricular myocardium infarction: an update

La oclusión aguda de la arteria coronaria derecha proximal conduce al desarrollo del IAM inferior con compromiso del VD. A diferencia del VI, éste responde a la isquemia aguda con alteración de su motilidad, dilatación y disfunción diastólica aguda, que determinan disminución del débito derecho y mayor dependencia de la contracción septal para mantener el débito, adquiriendo particular importancia la contracción auricular. Si ésta se ve comprometida, mayores serán la caída del gasto cardiaco y el aumento de las presiones en el territorio derecho. El diagnóstico debe sospecharse en todo infarto inferior y se basa en los signos clínicos de aumento de las presiones del lado derecho en ausencia de elementos de hipertensión venocapilar del lado izquierdo. Al ECG, las derivaciones precordiales derechas, especialmente V4R, son de alta especificidad. Un elemento de gran utilidad como apoyo diagnóstico es el Ecocardiograma bidemensional. Este IAM con frecuencia se presenta con compromiso hemodinámico, acentuado por el uso de vasodilatadores venoso. Puede cursar con bradiarritmias, bloqueo AV y se asocia a un mayor incidencia de arritmias ventriculares malignas. Implica mayor mortalidad y complicaciones intrahospitalarias, por lo que su confirmación obliga a actuar en forma agresiva, siendo de especial utilidad el tratamiento de reperfusión preferentemente con angioplastia primaria, o en su defecto, con terapia trombólica. El manejo agresivo de la precarga (volumen), apoyo inotrópico si es necesario e incluso en algunos casos medidas como Balón de Contrapulsación Aórtica y excepcionalmente la asistencia ventricular, pueden permitir esperar la recuperación de la función del VD, la que en general ocurre, tanto más precoz si ha habido reperfusión. Ocasionalmente puede utilizarse la asistencia ventricular como puente al trasplante cardiaco en pacientes muy seleccionados cuando su refractariedad terapéutica haga recomendable esa opción de tratamiento.

Estudio comparativo de la angioplastia coronaria en pacientes con diabetes: resultados clínicos y angiográficos inmediatos y evolución clínica en el primer año / Comparative study of coronary angioplasty in diabetic patients: clinical and angiographic results and clinical evolution at 1 year of follow up

Background: The success of revascularization procedures for coronary artery disease could be lower in diabetic patients. Aim: To report the results of coronary angioplasty in diabetic and non diabetic patients. Patients and methods: All angioplasty procedures performed between 1996 and 1999 were recorded. Demographic data, procedure details, hospital outcome and evolution at one year of follow up were analyzed. Results: During the study period, 358 patients were treated; of these, 79 were diabetics. Despite the greater severity of coronary lesions among diabetic patients the clinical success of the procedure was 92.4 percent in diabetics and 91.8 percent in non diabetics. Hospital mortality was 1.3 pecent in diabetics and 0.7 percent in non diabetics. Major complications occurred in 3.8 percent of diabetics and 3.2 percent in non diabetics. One year survival was 95.9 percent for diabetics and 98 percent in non diabetics. There were five late cardiac deaths among non diabetics and 3 among diabetics during the year of follow up. The frequency of new revascularization procedures was 4.3 percent in diabetics and 8.3 percent in non diabetics. Event-free survival was 95.6 percent in diabetics and 89.2 percent in non diabetics. Conclusions: Results of angioplasty were similar in diabetic and non diabetic patients in terms of hospital outcome and late follow-up

Infarto agudo del miocardio por oclusión total del tronco común de arteria coronaria izquierda tratado con revascularización percutánea endoluminal: caso clínico / Acute myocardial infarction caused by total occlusion of the left main coronary artery treated with percutaneous endoluminal revascularization: report of case

We report a 43 years old female who developed an intense precordial pain and arterial hypotension. The patient was admitted to the emergency room in cardiogenic shock. An emergency angiography revealed a total occlusion of the left main coronary artery. An endoluminal coronary angioplasty with the placement of two stents was performed and coronary reperfusion TIMI III was achieved. The patient had a good evolution and one month later, a surgical revascularization was done, to avoid new occlusions. She was discharged in good conditions and in functional capacity I

La clasificación de lesiones coronarias de la Society for Cardiac Angiography and Interventions, predice mejor el éxito de la angioplastía coronaria que la del American College of Cardiology/American Heart Association / Prediction of coronary angioplasty success using different coronary artery lesion scores

Background. The classification of coronary lesion complexity, using the American College of Cardiology/American Heart Association (ACC/AHA) is a predictor of balloon angioplasty success. Stents have improved results even in complex lesions. Aim. To compare the ACC/ AHA and the new Society for Cardiac Angiography (SCA&I) coronary lesion scores as predictors of angioplasty success. Patients and Methods. Al' consecutive angioplasty procedures (n=346, 456 lesions, 47 per cent stents) were prospectively analized from August 1996 to March 1999. Coronary lesions were classified using the ACC/AHA and SCA&I scores. Angiographic success was assesed and its multivariate predictors determined with logistic regression analysis. Results. According to the ACC/AHA score, angiographic success was 97, 92.7, 93.3, and 82.3 per cent in A, Bl, B2 and C lesions respectively (p=0.013). There only were significant differences in success between C and A, Bl or B2 lesions. According to the SCA&I score success was achieved in 97.3, 97.9, 75.8 and 33.3 per cent in nonCP, CP, nonCO and CO lesions respectively (P<0.001). With the SCA&I score statistically significant differences in angiographic success were found for all lesion score comparisons, except between nonCP and CP lesions. No other variables had predictive value for angiographic success. Conclusions. Coronary angioplasty angiographic success is better predicted by the new SCA&l lesion score than with the ACC/AHA lesion clasification in a group of patiens with frequent use of stents