Fibrinolíticos en el infarto agudo de miocardio. Análisis de una cohorte uruguaya en un período de cuatro años / Fibrinolytics in acute myocardial infarction. Analysis of an uruguayan cohort in a four years period

Introducción: el tratamiento fibrinolítico (FBL) en el infarto agudo de miocardio con elevación del ST (IAMCEST) se realiza en Uruguay desde hace más de 30 años. Dado que el acceso a angioplastia primaria está restringido a Montevideo, los FBL siguen siendo el método de reperfusión para muchos pacientes. Desde el año 2011 el Fondo Nacional de Recursos (FNR) ofrece la cobertura financiera del tratamiento FBL. Existe escasa información actualizada sobre su empleo en nuestro medio. Objetivo: conocer el estado actual del uso de tratamiento FBL bajo cobertura del FNR, el proceso asistencial y los resultados obtenidos con el mismo. Método: estudio retrospectivo, observacional, que analiza una cohorte de pacientes con IAMCEST a quienes se les adminstró FBL financiados por el FNR entre el 1º de julio de 2011 y el 30 de junio de 2015. Se estudiaron de forma anónima factores demográficos, cobertura asistencial, características clínicas, tiempos asistenciales al tratamiento, signos clínicos de reperfusión, realización de cineangiocoronariografía (CACG), tratamiento coadyuvante, complicaciones intrahospitalarias y mortalidad. Resultados: se incluyeron 841 pacientes con IAMCEST que fueron tratados con FBL. La edad media fue de 62,6 años (rango 23-95 años), 74,2% era de sexo masculino. Cobertura asistencial pública 23,5% y privada 76,5%. Se utilizó estreptoquinasa (SK) en 52,9% y tenecteplase (TNK) en 47,1%. El tiempo medio entre el inicio de síntomas y el primer contacto médico (PCM) fue de 128 minutos. El tiempo medio PCM-ingreso a puerta fue de 78 minutos y el tiempo puerta-aguja de 77 minutos. Montevideo y tres departamentos cercanos presentaron las tasas más bajas de uso de FBL, el 97,2% fue tratado en el interior del país. Tuvo criterio electrocardiográfico de reperfusión a los 90 minutos, el 54,1%. Se presentó sangrado del sistema nervioso central (SNC) en 0,8%, sangrado digestivo en 0,5% y otros sangrados que requirieron transfusión en 0,6%. El primer día se realizó CACG en el 37,8% de los pacientes (32,8% del grupo SK y 43,5% del grupo TNK, p=0,001), y a los 30 días en 65% (60,6% del grupo SK y 69,7% del grupo TNK, p=0,002). La mortalidad en el primer día fue 5,1%, a los 30 días 10,9% y al año 14,3%, sin diferencia significativa entre los tratados con SK o TNK. Conclusiones: la tasa de uso de FBL en el IAMCEST en Uruguay es baja y aproximadamente la mitad se realizan bajo cobertura del FNR. Existen diferencias regionales e inequidad según la cobertura asistencial. Los tiempos al tratamiento son prolongados y están lejos de las pautas internacionales. Se realizó CACG dentro de los 30 días a casi dos tercios de los pacientes, pero solo a 37,8% en las primeras 24 horas. La mortalidad de esta serie es comparable con registros internacionales.

Introduction: fibrinolytic (FBL) treatment in ST-Elevation Myocardial Infarction (STEMI) has been performed in Uruguay for more than 30 years. Considering that access to primary angioplasty is restricted to Montevideo, FBL remain the reperfusion method for many patients. Since 2011, Fondo Nacional de Recursos (FNR) offers the financial coverage of the FBL treatment. There is limited updated information on the use of FBL in our country. Objective: to know the current state of the use of FBL treatment under FNR coverage, the care process and the results obtained with it. Method: retrospective, observational study analyzing a cohort of patients with STEMI who were administered FBL funded by the FNR between 1st July 2011 and 30th June 2015. Demographic factors, health care coverage, clinical features, treatment times, clinical signs of reperfusion, cineangiocoronariography (CACG), adjuvant treatment, intrahospital complications and mortality, were studied anonymously. Results: were included 841 patients with STEMI who were treated with FBL. The mean age was 62,6 years (range 23-95 years), 74,2% were male. Public health care coverage 23.5% and private 76.5%. Streptokinase (SK) was used in 52,9% and tenecteplase (TNK) in 47,1%. The mean time between the onset of symptoms and the first medical contact (FMC) was 128 min. The mean time between FMC and emergency admission was 78 minutes and door to needle time was 77 minutes. Montevideo and three nearby departments presented the lowest rates of FBL use, 97.2% were treated in another city outside the capital. The 54,1% had electrocardiographic reperfusion criteria at 90 minutes. Central nervous system bleeding occurred in 0,8%, digestive bleeding in 0.5% and other bleeds requiring transfusion in 0.6%. On the first day, CACG was performed in 37,8% of the patients (32,8% in the SK group and 43,5% in the TNK group, p = 0,001), and at 30 days in 64,9% (60,6% % Of SK group and 69,7% of TNK group, p = 0,002). Mortality on the first day was 5,1%, at 30 days 10.9% and 14,3% at the year, with no significant difference between those treated with SK or TNK. Conclusions: the FBL use rate at STEMI in Uruguay is low and approximately half is done under FNR coverage. There are regional differences and inequity according to health care coverage. Treatment times are prolonged and far from international guidelines. CACG was performed within 30 days in almost two thirds of patients, but only 37,8% in the first 24 hours. Mortality in this series is comparable with international registries.

Avaliação clínica dos pacientes submetidos à cineangiocoronariografia no Hospital Nossa Senhora da Conceição, da cidade de Tubarão, SC / Clinical evaluation of patients submitted to cineangiocoronariography at Nossa Senhora da Conceição Hospital in Tubarão, SC

Introdução: A doença arterial coronariana é considerada importante causa de aumento da morbimortalidade em países desenvolvidos e em desenvolvimento. A cineangiocoronariografia permite conhecer a anatomia coronariana, delinear prognóstico e traçar a melhor estratégia terapêutica. O objetivo deste estudo foi traçar o perfil e avaliar a evolução clínica dos pacientes submetidos à cineangiocoronariografia em hospital no Sul do Brasil. Métodos: Estudo transversal realizado em dois momentos. Inicialmente foram coletados dados sociodemográficos e clínicos, e posteriormente avaliada a evolução clínica com informações sobre: complicações, retorno ao cardiologista, medicações em uso, óbito, controle de peso, mudança no estilo de vida e novo episódio de infarto agudo do miocárdio. Resultados: A média de idade dos pacientes foi de aproximadamente 60 anos, maioria homens e peso médio de 74,8 quilos. Desse total, 19,3% eram tabagistas, 68,5% eram hipertensos, 39,1% eram cardiopatas, 19,9% tinham diabetes mellitus e 2,9% doença renal. O retorno ao cardiologista foi relatado por 91,8%; houve dois novos episódios de infarto e nenhum óbito. Cerca de 70% afirmaram mudanças positivas nos hábitos e estilo de vida, sendo que 61,8% estão praticando atividades físicas regulares e 51,8% estão fazendo dieta hipossódica e hipocalórica. Conclusão: O perfil dos pacientes submetidos a cineangiocoronariografia são homens, com idade elevada, hipertensos e que iniciaram atividade física após o procedimento. Pacientes com angina estável ou instável e síndrome metabólica apresentaram um risco maior para tratamento clínico, enquanto que pacientes com insuficiência cardíaca congestiva ou infarto agudo do miocárdio apresentaram maior risco de sofrer intervenções como angioplastia e cirurgia cardíaca

Introduction: Coronary artery disease is considered as a major cause of increased morbidity and mortality in developing and developed countries. Cineangiocoronariography allows to know coronary anatomy, outline prognosis, and trace the best therapeutic strategy. The aim of this study was to determine the profile and clinical course of patients undergoing cineangiocoronariography at a hospital in south Brazil. Methods: A survey was performed in two stages. First, socio-demographic and clinical data were collected, and subsequently clinical progress was evaluated with information about complications, return to the cardiologist, medications being used, death, weight control, lifestyle changes, and new episode of acute myocardial infarction. Results: The mean age of patients was about 60 years, mostly males, and the average weight 74.8 kilograms. Of the total, 19.3% were smokers, 68.5% were hypertensive, 39.1% had heart disease, 19.9% had diabetes mellitus, and 2.9% kidney disease. A return to the cardiologist was reported by 91.8%, there were two new episodes of infarction and no deaths. About 70% reported positive changes in habits and lifestyle, 61.8% are practicing regular physical activities, and 51.8% are on low-calorie and low sodium diets. Conclusion: Most patients undergoing cineangiocoronariography are older males with hypertension, who started physical activity after the procedure. Patients with stable or unstable angina and metabolic syndrome had a higher risk for clinical treatment, while patients with congestive heart failure or acute myocardial infarction had a higher risk of interventions such as angioplasty and cardiac surgery

Perfil lipídico e intensidade de doença aterosclerótica na síndrome coronariana aguda / Lipid profile and intensity of atherosclerosis disease in acute coronary syndrome

FUNDAMENTO: A relação entre doença arterial coronariana (DAC) e dislipidemia nas síndromes coronariana agudas tem sido pouco demonstrada por meio de estudos clínico-epidemiológicos. OBJETIVO: Avaliar associação entre perfil lipídico e intensidade de DAC em pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST. MÉTODOS: Neste estudo retrospectivo, foram revisados prontuários de 107 pacientes consecutivos, admitidos no período de um ano com diagnóstico de síndrome coronariana aguda (SCA) sem supradesnivelamento de ST, que realizaram cineangioronariografia durante a internação. A avaliação laboratorial incluiu níveis séricos das frações lipídicas. A intensidade de DAC foi determinada pela avaliação do número, grau e escore das obstruções das artérias coronárias. Análise estatística: Teste t de Student, qui-quadrado e ANOVA com significância estatística definida por p<0,05. Realizou-se análise multivariada. RESULTADOS: Dos 107 pacientes incluídos, 94 (88 por cento) tinham DAC e, destes, 50 (53,2 por cento) eram do sexo masculino e com predominância de lesões multiarteriais. Sobre o perfil lipídico, observou-se que 64 (59,8 por cento) dos pacientes tinham CT<200 mg/dl, 33 (30,8 por cento) tinham HDL< 40mg/dl e 38 (35,5 por cento) com LDL<100 mg/dl. Na análise das cineangiocoronariografias: 94 (88 por cento) pacientes tinham DAC, 84 por cento com estenose >70 por cento. Na associação entre perfil lipídico e DAC, observou-se que a relação CT/HDL foi superior nos grupos multiarterial e biarterial quando comparados ao grupo uniarterial (4,3±2, 4,0±1,7, 2,9±1,6, respectivamente) com p ANOVA igual a 0,049. Na análise multivariada, a relação CT/HDL permaneceu um preditor significativo (p = 0,016). CONCLUSÃO: A relação CT/HDL foi marcador de gravidade de DAC em relação ao número de vasos comprometidos, demonstrando que perfil lipídico pode ser um determinante de gravidade em pacientes com SCA sem sup...

BACKGROUND: The relationship between coronary artery disease (CAD) and dyslipidemia in acute coronary syndromes has been rarely demonstrated in clinical and epidemiological studies. OBJECTIVE: To evaluate the association between lipid profile and severity of CAD in patients with acute coronary syndrome without ST-segment elevation. METHODS: In this retrospective study, the authors reviewed medical records of 107 consecutive patients diagnosed with acute coronary syndrome (ACS) without ST-segment elevation admitted within a one-year period and who had undergone coronary angiography during hospitalization. Laboratory evaluation included serum levels of lipid fractions. Severity of CAD was determined by evaluating the number, degree, and score of coronary artery obstructions. For statistical analysis, the Student’s t test, chi-square test and ANOVA with statistical significance set at p<0.05, as well as multivariate analysis were performed. RESULTS: A total of 107 patients were included; 94(88 percent) had CAD, of which 50 (53.2 percent) were males with predominance of multivessel disease. As regards the lipid profile, 64(59.8 percent) patients were observed to have TC<200mg/dl, 33(30.8 percent) had HDL<40mg/dl, and 38(35.5 percent) had LDL<100mg/dl. The analysis of coronary angiographies showed that 94(88 percent) patients had CAD, and 84 percent had > 70 percent stenosis. In the association between lipid profile and CAD, we observed a higher TC/HDL ratio in the multivessel and two-vessel groups in comparison with the one-vessel group (4.3±2, 4.0±1.7, 2.9±1.6, respectively) with ANOVA p=0.049. In the multivariate analysis, the TC/HDL ratio remained a significant predictor (p = 0.016). CONCLUSION: The TC/HDL ratio was a marker of severity of CAD in relation to the number of vessels affected, thus demonstrating that the lipid profile can be a determinant of severity in patients with ACS without ST-segment elevation.

Relação entre o ECG convencional e a artéria coronária responsável no infarto agudo do miocárdio / The relationship between conventional ECG and the culprit coronary artery in acute myocardial infarct

PURPOSE--To evaluate electrocardiogram (ECG) in detecting acute myocardial infarction (AMI) during the first 12 hours of symptoms and its relationship to the culprit coronary artery. METHODS--We studied 68 patients aged 55.6 (30 to 76) years, 61 males, with AMI confirmed by elevated CKMB isoenzyme and cinecoronariography (CINE). In all of them we obtained two ECG: first (i), with < 12 hours of symptoms and a second, > or = 5 days during evolution. ECG were analyzed in order to disclose up and downward ST-T segments > or = 1 mm, new Q waves > or = 0.04 s and R/S > or = 1 plus downward ST-T segment in leads V1 and V2. Then we have done correlation between these and the culprit coronary lesions at CINE. RESULTS--The culprit coronary lesions were: right coronary artery (RCA) in 16, left circumflex (LC) in 26 and left anterior descending (LAD) in 31 cases. According to the ECG, the RCA determined inferior AMI in all patients and the LC only in 62 por cento of cases. Posterior AMI due to LC was seen in 81 por cento of cases at ECG and, associated with lateral AMI, in 52 por cento . Lone lateral AMI was seen in 5 por cento and true posterior in 14 por cento of cases, all of them due to LC. CONCLUSION--False negative ECG (i) in AMI is in fact due to LC occlusion which, frequently, causes posterior wall more then inferior wall myocardial infarction at ECG