Variables electrocardiográficas asociadas a la aparición de eventos cardiovasculares adversos en el infarto agudo de miocardio sin elevación del segmento ST / Electrocardiographic variables associated to the occurrence of adverse cardiovascular events in non-ST elevation acute myocardial infarction

Introducción: La frecuencia de infarto agudo de miocardio sin elevación del segmento ST se está incrementando y, con ella, los resultados adversos en pacientes con enfermedad coronaria isquémica aguda. Objetivo: Identificar las variables electrocardiográficas asociadas a la aparición de eventos cardiovasculares adversos en el infarto agudo de miocardio sin elevación del segmento ST. Método: Se realizó un estudio transversal, de tipo correlacional, con 68 pacientes con infarto agudo de miocardio sin elevación del segmento ST atendidos en el Hospital Arnaldo Milián Castro, en la provincia de Villa Clara. Se estudiaron los hallazgos electrocardiográficos y eventos cardiacos adversos durante el ingreso. Se hicieron análisis bivariados para establecer la relación de ambas variables, utilizando el estadígrafo chi cuadrado y el riesgo relativo. Resultados: Los hallazgos electrocardiográficos más frecuentes fueron la inversión de la onda T (#8805; 2mm), depresión del segmento ST y el QT corregido largo mediante la fórmula de Bazzet. El 26,5 por ciento presentaron eventos cardiovasculares adversos. La depresión del segmento ST, el QT largo corregido y la elevación del segmento ST en aVR se asociaron significativamente con eventos adversos intrahospitalarios (p lt; 0,05). Conclusiones: La asociación de la depresión del segmento ST, la elevación del segmento ST en aVR y el QT largo corregido con la ocurrencia de eventos cardiovasculares adversos intrahospitalarios, sugiere que estos hallazgos se pueden tener en cuenta como posibles indicadores de evolución desfavorable en pacientes con infarto agudo de miocardio sin elevación del segmento ST(AU)

Introduction: The frequency of non-ST elevation acute myocardial infarction is on the increase, and so is the number of adverse results in patients with acute ischemic coronary disease. Objective: Identify the electrocardiographic variables associated to the occurrence of adverse cardiovascular events in non-ST elevation acute myocardial infarction. Method: A cross-sectional correlational study was conducted of 68 patients with non-ST elevation acute myocardial infarction cared for at Arnaldo Milián Castro Hospital in the province of Villa Clara. Attention was paid to electrocardiographic findings and adverse cardiac events occurring during the hospital stay. Bivariate analyses were performed to establish the relationship between the two variables, using the chi square statigram and relative risk estimation. Results: The most common electrocardiographic findings were T-wave inversion (#8805; 2 mm), ST depression and long corrected QT by Bazzet's formula. Of the total study subjects 26.5 percent had adverse cardiovascular events. ST depression, long corrected QT and ST elevation in aVR were significantly associated to in-hospital adverse events (p < 0.05). Conclusions: Association of ST depression, ST elevation in aVR and long corrected QT with the occurrence of adverse in-hospital cardiovascular events suggests that these findings may be taken into account as possible indicators of an unfavorable evolution in patients with non-ST elevation acute myocardial infarction(AU)

Hallazgo de fístula coronaria en paciente con infarto agudo del miocardio con elevación del ST / Coronary fistula in patient with ST-elevation acute myocardial infarction

Resumen La fístula coronaria es una anormalidad de la circulación, que consiste en una comunicación, a través de uno o más ramos, a sitios como el tronco de la arteria pulmonar, el seno coronario, la vena cava, las venas pulmonares, o directamente a una cavidad cardiaca. Es una entidad infrecuente, de causa congénita o adquirida. Debido a su baja incidencia es subdiagnosticada, atribuyendo los síntomas a otras causas. El tratamiento cuando es necesario es la resección quirúrgica o la oclusión percutánea. Se describe un caso en el que el hallazgo de la fistula coronaria se realiza en el contexto de un evento coronario agudo con elevación de segmento ST aumentando la complejidad del enfoque y manejo.

Abstract Coronary fistula consists of an abnormal arterial communication, via one or more branches, to places like the trunk of a pulmonary artery, coronary sinus, vena cava, pulmonary veins or directly to a heart chamber. It is a rare condition, of congenital or acquired origin. Due to their low incidence they are underdiagnosed, symptoms are attributed to other causes. When required, treatment is surgical resection or percutaneous closure. A case where the finding of a coronary fistula is carried out in the context of ST-elevation acute myocardial infarction is described, increasing complexity of management and approach.

Pre-hospital delay factor of coronary reperfusion therapy for acute myocardial infarction patients presenting with non-chest pains / 中华危重病急救医学

Objective To explore pre-hospital delay factor of coronary reperfusion therapy for ST-elevation acute myocardial infarction (STEAMI) patients presenting with non-chest pains. Methods A retrospective observation was conducted. The clinical data of STEAMI patients underwent emergency percutaneous coronary intervention (PCI) admitted to Luoyang Central Hospital Affiliated to Zhengzhou University from August 2013 to August 2015 were analyzed. The patients were divided into chest pain group and non-chest pain group according to the presence of chest pain or not. Clinical characteristics were compared between the two groups, and incidence of major adverse cardiac events (MACE), door-to-balloon time, door-to-electrocardiograms (ECG) time and ECG-to-balloon time were evaluated. Influencing factors of pre-hospital delay was analyzed by logistic multiple stepwise regression. Results A total of 259 patients with STEAMI were enrolled, including 154 patients with chest pain and 105 presented with non-chest pains. Compared with chest pain group, the patients in the non-chest pain group were older (years: 68.12±8.93 vs. 62.34±7.12, P < 0.05), less female (26.67% vs. 42.20%, P< 0.05), and had a higher past history of angina, stroke and heart failure (27.61% vs. 13.63%, 31.42% vs. 18.83%, 26.67% vs. 11.68%, respectively, all P < 0.05), and higher percentage of Killip ≥ Ⅲ patients (15.24% vs. 6.49%, P < 0.05), the lower ambulance use (26.67% vs. 44.81%, P < 0.01), longer hospitalization time (days: 12.50±2.89 vs. 9.50±2.67, P < 0.05), higher incidence of MACE (19.05% vs. 9.09%, P < 0.05), longer door-to-balloon time and door-to-ECG time (minutes: 159.01±51.21 vs. 115.31±36.74, 53.06±18.17 vs. 30.35±9.93, both P < 0.01). It was shown by logistic multivariate regression analysis that no-chest pain [odds ratio (OR) = 5.14, 95% confidence interval (95%CI) = 2.34-10.81, P < 0.001], age ≥ 65 years old (OR = 1.43, 95%CI = 0.93-2.99, P = 0.022), diabetes (OR = 1.57, 95%CI = 0.66-2.15, P = 0.015) and no-ambulance transport (OR = 1.55, 95%CI = 0.73-2.75, P < 0.001) were risks factors of coronary reperfusion delay ≥ 2 hours. Conclusions STEAMI patients presenting without chest pain showed higher incidences of MACE, longer time of ECG obtained and initial PCI time delay. Clinicians should try to reduce the delay time of the patients in order to improve patient survival rates.

Valor pronóstico de la microalbuminuria en el paciente con infarto agudo del miocardio con elevación del ST / Prognostic value of microalbuminuria in ST-elevation myocardial infarction

Introducción: La microalbuminuria (MA) es un marcador de disfunción endotelial, y se ha asociado con mayor morbimortalidad en la enfermedad cardiovascular. En México, las enfermedades isquémicas del corazón ocupan los primeros lugares de mortalidad, por lo que resulta necesario estudiar marcadores que puedan proporcionar pronóstico en los sujetos con síndrome coronario agudo. Objetivo: Determinar el valor pronóstico de la microalbuminuria sobre la evolución de los pacientes con infarto agudo del miocardio con elevación del segmento ST (IAMST). Material y métodos: Estudio de cohorte, observacional, longitudinal, prospectivo y analítico. Se incluyeron pacientes consecutivos con diagnóstico de IAM en las primaras 24 horas de evolución, de cualquier género, mayores de 18 años, que ingresaron a la Unidad de Cuidados Cardiovasculares de un Hospital de Tercer Nivel. Se definió la cohorte expuesta a microalbuminuria en orina de 24 horas (albúmina > 20 µg/min) dentro de las primeras 72 horas de su ingreso, y se dio seguimiento a 30 días registrando la presentación de eventos cardiovasculares. Resultados: Se estudiaron a 99 pacientes, 51 (51.5%) sujetos presentaron MA. Las características basales no presentaron diferencias significativas. Los pacientes con MA tuvo mayor puntuación de las escalas APACHE II, TIMI, GRACE y EUROSCORE (todos p < 0.05). La presentación de Killip-Kimball ≥ III, arritmias, bloqueo atrioventricular avanzado, choque cardiogénico, reinfarto y muerte, se asociaron significativamente con la presencia de MA (todos p < 0.05), y esta asociación es independiente para la presencia de muerte ajustado para las puntuaciones de TIMI, GRACE y la presencia de infarto ventricular derecho. De la misma manera, los sujetos con IAM portadores de MA tienen una supervivencia significativamente menor que aquellos sin MA, p = 0.002. Conclusiones: La microalbuminuria se asocia de manera independiente con muerte a 30 días, y puede ser un biomarcador a medirse rutinariamente en los pacientes con síndrome coronario agudo con elevación del ST.

Introduction: Microalbuminuria (MA) is an endothelial dysfunction biomarker, and has been associated to higher morbidity and mortality in cardiovascular disease. The ischemic heart disease is among the leading causes of death, and it's necessary to study new risk and prognostic biomarkers in patients with ST-elevation acute myocardial infarction (ST-AMI). Objective: To determine the predict value of microalbuminuria in patients with ST-AMI. Material and methods: We developed an observational, longitudinal, prospective and analytical cohort study, patients older than 18 years old, any sex, within 24 hours evolution ST-AMI were included. Exposed cohort was defined as MA > 20 µg/min in a 24-hour urine sample within 72 hour of myocardial infarction, and were followed for 30 days and cardiovascular events were recorded. Results: We studied 99 patients; 51 (51.5%) presented MA. Basal clinical features were not significantly different. MA subjects had higher APACHE II, TIMI, EUROSCORE and GRACE scores (p < 0.05 for all). Killip-Kimball ≥ III, arrhythmia, advanced atrioventricular block, cardiogenic shock, re-infarction and death were significantly associated to MA (p < 0.05 for all), and this association remains as an independent death predictor adjusted to TIMI and GRACE scores and right ventricle infarction. In the same way, MA is associated with lower survival rate at 30 day, p = 0.002. Conclusions: Microalbuminuria is an independent risk factor for death at 30 days, and should be included as part of biochemical markers in patients with ST elevation acute myocardial infarction.

Registro de síndromes coronarios agudos sin elevación del segmento ST en un centro hospitalario de tercer nivel de atención (estudio RESCATA-SEST) / Registry of non-ST elevation acute coronary syndromes in a tertiary hospital (RESCATA-SEST registry)

Objetivo: Describir el perfil clinicoepidemiológico y el proceso de atención del síndrome coronario agudo sin elevación del segmento ST en un hospital de tercer nivel. Método: Se analiza la información clínica, la estratificación de riesgo, la terapia de revascularización y los hábitos de prescripción al egreso de los casos con síndrome coronario agudo sin elevación del segmento ST atendidos en un año. Resultados: Se incluyeron 283 pacientes con una edad media de 58 años; el 63%, masculino. La mayoría (88.6%) de los casos ocurrió entre los 50 y 59 años. La hipertensión arterial fue el factor de riesgo predominante. El 82.5% de los sujetos tuvo índice TIMI de riesgo bajo-intermedio. En el 37% de los pacientes hubo isquemia residual y en 80 (70%) se demostraron obstrucciones coronarias. Setenta y dos pacientes (90%) fueron revascularizados con stent, principalmente farmacológico (87.5%). Más del 90% de los casos recibió estatina y antiplaquetarios al egreso; otros medicamentos se indicaron en poco más del 50%. Conclusiones: En la población estudiada, el síndrome coronario agudo sin elevación del ST predomina en hombres relativamente jóvenes e hipertensos. Estratificar el riesgo, buscar isquemia residual y revascularizar con stent farmacológico son prácticas comunes; el cumplimiento de las recomendaciones basadas en la evidencia es subóptimo.

Objective: To describe the clinical-epidemiologic profile and the process of care of the non-ST elevation acute coronary syndromes in a tertiary hospital. Method: We analyzed the clinical information, the risk stratification and diagnostic methods, the revascularization therapy and the prescription trends at discharge, of patients with non-ST elevation acute coronary syndromes cared for in one year. Results: Two hundred and eighty-three patients with mean age of 58 years were included (63% men). The largest number of non-ST elevation acute coronary syndromes (88.6%) was found between 50 to 59 years of age. The most common risk factor was hypertension; 82.5% of the patients had a low-intermediate TIMI score; residual ischemia was demonstrated in 37% and coronary obstructions were seen in 80 patients (70%). In 90%, a percutaneous coronary intervention was performed, mainly with drug-eluting Stents (87.5%). At discharge, even though antiplatelet agents and statins were prescribed in more than 90%, other drugs were indicated in a few more than 50% of patients. Conclusions: In this population, non-ST elevation acute coronary syndromes predominates in relatively young men, often with hypertension. To stratify risk, to look for residual ischemia and to revascularize with drug-eluting stents are common practices, but the evidence-based guidelines compliance is still suboptimal.

A study of the treatment of delayed emergency percutaneous coronary intervention on the prognosis of patients with ST elevation acute myocardial infarction / 重庆医学

Objective To compare the prognosis of ST elevation acute myocardial infarction(STEMI) of delayed emergency per‐cutaneous coronary intervention(PCI) and elective PCI following the thrombolysis with reteplase ,and to investigate the clinic value of the former solution .Methods One hundred and twenty STEMI patients were reviewed retrospectively and were divided into 2 groups according to PCI .Eighty two cases were divided into emergency group :thrombolysis with reteplase offered within 6h was followed by elective PCI;38 cases were divided into delayed group:PCI was done after 12-24 h after ATEMI′occurring .The clini‐cal features and CTG changes were recorded ,TIMI class of IRA was conducted before and after PCI ,and their prognosis were com‐pared .Results There was no statistical differences in the class of thrombolysis of myocardial infarction(Class 0 -1 ,2 -3) of in‐farction relative artery (IRA)(4 .88% ,95 .12% vs .5 .26% ,94 .74% ) after PCI(P>0 .05) .There was no statistical difference in LVEF ,LVEDVI and LVESVI 3 months after attack between two groups(P>0 .05) .There was statistical difference in the severe cardiac failure and malignancy arrhythmia between two groups(P0 .05) .Conclusion Delayed emergency PCI to remove the ob‐struction in the coronary artery has no significant difference with elective PCI following thrombolysis in the incidence of composite end point events in STEMI .

The TIMI risk score for STEMI predicts in-hospital mortality and adverse events in patients without cardiogenic shock undergoing primary angioplasty / La escala de riesgo TIMI para infarto del miocardio con elevación del segmento ST predice mortalidad y eventos adversos intrahospitalarios en pacientes sin choque cardiogénico sometidos a angioplastía coronaria

Introduction: Patients with ST elevation acute myocardial infarction (STEMI) comprise a heterogeneous population with respect to the risk for adverse events. Primary percutaneous coronary intervention (PCI) has shown to be better, mainly in high-risk patients. Objective: The purpose of this study was to determine if the Thrombolysis in Myocardial Infarction (TIMI) risk score for STEMI applied to patients undergo primary PCI identifies a group of patients at high risk for adverse events. Methods: We identifed patients with STEMI without cardiogenic shock on admission, who were treated with primary PCI. The TIMI and CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) risk scores were calculated to determine their predictive value for in hospital mortality. Patients were divided into two groups according to their TIMI risk score, low risk being 0-4 points and high risk ≥5 points, and the frequency of adverse events was analyzed. Results: We analyzed 572 patients with STEMI. The c-statistics predictive value of the TIMI risk score for mortality was 0.80 (p=0.0001) and the CADILLAC risk score was 0.83, (p=0.0001). Thirty-two percent of patients classifed as high risk (TIMI ≥5) had a higher incidence of adverse events than the low-risk group: mortality 14.8% vs. 2.1%, (p=0.0001); heart failure 15.3% vs. 4.1%, (p=0.0001); development of cardiogenic shock 10.9% vs. 1.5%, (p=0.0001); ventricular arrhythmias 14.8% vs. 5.9%, (p=0.001); and no-refow phenomenon 22.4% vs. 13.6%, (p=0.01). Conclusions: The TIMI risk score for STEMI prior to primary PCI can predict in hospital mortality and identifes a group of high-risk patients who might develop adverse events.

Introducción: Los pacientes con infarto agudo del miocardio con elevación del segmento ST (IAM CEST), son una población heterogénea por lo que toca al riesgo de eventos adversos. La intervención coronaria percutánea (ICP) primaria mostró ser mejor, principalmente en los pacientes de riesgo alto. Objetivo: La propuesta de este estudio fue determinar si la escala de riesgo de trombólisis en infarto del miocardio (TIMI) para IAM CEST, aplicado a los pacientes sometidos a ICP primaria, identifica a grupos de pacientes de riesgo alto de eventos adversos. Métodos: Se identificaron a pacientes con IAM CEST sin choque cardiogénico al ingreso, quienes fueron tratados con ICP primaria. Se calcularon las escalas de riesgo TIMI y CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications), para determinar su valor predictivo de mortalidad intrahospitalaria. Los pacientes se dividieron en dos grupos de acuerdo a su escala de riesgo TIMI, riesgo bajo con 0-4 puntos y riesgo alto con ≥5 puntos, se analizó la frecuencia de eventos adversos. Resultados: Se analizaron 572 pacientes con IAM CEST. El valor predictivo del estadístico C de la escala de riesgo TIMI para mortalidad fue de 0.80 (p=0.0001), y la escala de riesgo CADILLAC fue de 0.83, (p=0.0001). El 32% de los pacientes clasificados como riesgo alto (TIMI ≥5), tuvo una alta incidencia de eventos adversos comparada con el grupo de riesgo bajo: la mortalidad 14.8% vs. 2.1%, (p=0.0001); falla cardiaca 15.3% vs. 4.1%, (p=0.0001); desarrollo de choque cardiogénico 10.9% vs. 1.5%, (p=0.0001); arritmias ventriculares 14.8% vs. 5.9%, (p=0.001), y fenómeno de no reflujo 22.4% vs. 13.6%, (p=0.01). Conclusiones: La escala de riesgo TIMI para IAM CEST, previo a ICP primaria puede predecir mortalidad intrahospitalaria e identificar a un grupo de pacientes de riesgo alto, los cuales pueden desarrollar eventos adversos.