Infarto agudo de miocardio con elevación del segmento ST anterior extenso en joven deportista de alto rendimiento sin factores de riesgo coronario / Extensive anterior acute myocardial infarction in young high-performance athlete without coronary risk factors

RESUMEN El ejercicio físico evita las enfermedades cardiovasculares pero cuando es intenso debe tener planificación y dosificación correctas y, de ser posible, es muy útil contar con una prueba ergométrica previa y un especialista orientador; porque también puede producir accidentes cardiovasculares en deportistas de alto rendimiento, entre otras cosas, por no cumplir con una programación bien definida con un basamento científico. La complicación más temida es la muerte súbita cardíaca, habitualmente por arritmias malignas y enfermedad isquémica. Se presenta el caso de un deportista de alto rendimiento, de 34 años de edad, en fase desentrenamiento y sin factores de riesgo cardiovascular u otros antecedentes de interés, que sufrió un infarto agudo de miocardio anterior extenso, con angina postinfarto, debido a una estenosis suboclusiva de la descendente anterior proximal. Se realizó angioplastia de rescate, con implantación de un stent farmacoactivo y el paciente evolucionó favorablemente.

ABSTRACT Physical exercise avoids cardiovascular diseases but when it is intense, it must have correct planning and dosage and, if possible, a previous ergometric test and a guidance specialist could be very useful; because it can also cause cardiovascular events in high performance athletes, among other things, for not complying with a well-defined schedule with a scientific base. The most feared complication is sudden cardiac death, usually due to malignant arrhythmias and ischemic heart disease. Here is presented the case of a 34-year-old high-performance athlete, in the detraining phase and without cardiovascular risk factors or other history of interest, who suffered an extensive acute myocardial infarction, with post-infarction angina, due to a stricture suboclusive of the proximal left anterior descending artery. A rescue angioplasty was performed, with implantation of a drug-eluting stent and the patient evolved favorably.

Terapia de restauración vascular con plataformas biorreabsorbibles. La cuarta revolución / Vascular restoration therapy using bioresorbable scaffolds. The fourth revolution

Con la aprobación y concesión del Registro Sanitario 201300 4713 del 25 de febrero de 2013, con vigencia hasta el año 2023, por parte del Instituto Nacional de Vigilancia de Medicamentos y Alimentos como órgano oficial del Ministerio de Salud y Protección Social de Colombia, a la plataforma biorreabsorbible Absorb BVS®, con el nombre de stent medicado biorreabsorbible, la introducción de estas plataformas al portafolio terapéutico del cardiólogo intervencionista para el tratamiento de pacientes seleccionados con enfermedad coronaria, ha generado gran expectativa gracias a la seguridad y eficacia que han demostrado en comparación con los stents liberadores de medicamento, con resultados de no inferioridad y con el ofrecimiento de una serie de ventajas por las cuales ha sido considerado la «cuarta revolución¼. En este artículo se hace una revisión acerca de las plataformas existentes, de su mecanismo de acción, así como de sus potenciales ventajas y limitaciones.

The approval and the concession of the Health Registration 201300 4713 dated February 25th 2013, in force until 2013, by the National Institute of Food and Drug Monitoring as a body of the Colombian Ministry of Health and Social Protection, in favor of the Absorb BVS® bioresorbable scaffold, under the name of bioresorbable medicated stent, has created high expectations regarding the introduction of these scaffolds in the therapeutic repertoire of the interventional cardiologist for treatment of selected patients with coronary disease. The security and efficiency that they have shown in comparison to the drug-eluting stents, with results of non-inferiority and offering various advantages, have been the reasons why they have been called the fourth revolution. This article reviews the existing scaffolds and their operating methods, as well as their advantages and limitations.

Angina inestable secundaria a disección coronaria espontánea / Unstable angina secondary to spontaneous coronary dissection

La disección coronaria espontánea es una causa rara de infarto agudo del miocardio y puede debutar además como angina estable o síndrome de falla cardiaca. Se presenta el caso de una mujer de 35 años quien tuvo eventos recurrentes de dolor torácico en el primer mes de posparto y en quien se diagnosticó disección coronaria de la arteria circunfleja, la cual fue intervenida con stents medicados. Veinte meses después permanecía libre de síntomas y sin evidencia de isquemia miocárdica inducible.

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction which may also occur as stable angina or heart failure syndrome. Here reported the case of a 35 years old woman who presented recurrent chest pain events in the first month of postpartum and in whom coronary dissection of the circumflex artery was diagnosed, which was intervened with drug eluting stents. Twenty months later she remained free of symptoms and with no evidence of inducible myocardial ischemia.

Adequação das indicações da intervenção percutânea na doença coronariana estável e preditores do seu emprego inapropriado em um hospital de ensino / Appropriateness of percutaneous intervention indications in stble coronary disease and inappropriate use predictors at a teaching hospital

Fundamentos: A intervenção coronariana percutânea(ICP) promove melhora sintomática e menor necessidade de antianginosos na doença coronariana estável, masnão reduz a incidência de infarto do miocárdio e morte. Objetivo: Avaliar a adequação das indicações de ICPem pacientes com doença coronariana estável em um hospital universitário.Métodos: Foram estudados 102 pacientes com doença coronariana estável submetidos consecutivamentea ICP em um hospital universitário, com média de idade de 65,9±10,7 anos, sendo 67,3 % homens. Coletaram-se informações referentes ao paciente(dados clínico-epidemiológicos, resultados de testes provocativos de isquemia e uso de antianginosos) e aomédico solicitante (tempo de formação e especialidade). Considerou-se adequada a indicação de ICP a pacientes com angina do peito refratária ao tratamento clínico ou a pacientes assintomáticos apresentando grande área de isquemia miocárdica em testes provocativos.Resultados: A indicação de ICP foi considerada adequada em 34 (33,3 %) pacientes, inadequada em 2 e incerta nos 66 restantes. À análise univariada,mostraram-se significativamente associadas à indicação de ICP inadequada/incerta as variáveis: idade mais elevada (p=0,001), aposentadoria (p=0,006) e ausência de tabagismo (p=0,041) e de dislipidemia(p=0,039), observando-se tendência à significância em relação a sedentarismo (p=0,094), renda mais baixa(p=0,013) e tempo de formação do médico solicitante ≥10 anos (p=0,094). Após análise de regressão logística,apenas idade mais elevada (OR=1,10 [1,06-11,1]; p=0,048), renda mais baixa (OR=2,84 [1,5-7,6]; p=0,039)e maior tempo de formação do médico solicitante...

Background: Percutaneous coronary intervention (PCI) results in improved symptoms and less need forantianginal medications for stable coronary artery disease, but does not reduce myocardial infarction and death rates. Objective: To assess the appropriateness of PCIindications in patients with stable coronary artery disease at a university hospital. Methods: The study involved 102 patients with stable coronary artery disease consecutively undergoing PCIat a university hospital, with a mean age of 65.9 ± 10.7 years and 67.3% male. Information was collected on the patient (clinical and epidemiological data,ischemia provocation test results and antianginal drug use) and the requesting physician (time since graduation and speciality). PCI indications wereconsidered appropriate for patients with angina pectoris to clinical treatment, or for asymptomatic patients presenting large areas of myocardial ischemia in provocation tests. Results: PCI indications were consideredappropriate for 34 (33.3%) patients, inappropriate for two others, and uncertain for the remaining 66.In the univariate analysis, the following variables were significantly associated with inappropriate/uncertain ICP indications: older (p=0.001), retired(p=0.006), non-smoker (p=0.041) and dyslipidemia (p=0.039), noting a trend towards sedentary lifestyles (p=0.094), lower income (p=0.013) and≥10 years time since graduation (p=0.094). After the logistic regression analysis, only the older (OR=1.10 [1.06-11.1]; p=0.048), lower income(OR=2.84[1.5-7.6]; p=0.039) and longer time since...

Intervenção coronariana complexa e tardia pós-tratamento quimioterápico / Complex late coronary intervention after chemotherapy

A associação entre o uso de quimioterápicos e a ocorrência de síndromes coronarianas agudas (SCA) ou mesmo infarto agudo do miocárdio (IAM) é rara, todavia constitui complicação por vezes de natureza grave, surpreendendo pacientes em curso de tratamento de uma doença já debilitante. Relata-se um caso dessa ocorrência, representada por um lado pelo uso de paclitaxel (taxol) para o tratamento de câncer de ovário e, do outro, por uma lesão complexa, de bifurcação, tratada percutaneamente.

Although associations between chemotherapy and acutecoronary syndromes or even acute myocardial infarctions are rare, they may result in complications that might even be severe, surprising patients during treatments of diseases that are already debilitating. We present a case study of such an association, represented on the one hand by the use of paclitaxel (Taxol), with a complex coronary lesion (bifurcation) treated percutaneously on the other.

Relación de la fracción de eyección ventricular con la calidad de vida después de cirugía de bypass coronario o angioplastia coronaria en la clínica Guayaquil entre abril 2010 y marzo 2011 / Relationship between ventricular ejection fraction and the quality of life after coronary bypass surgery or coronary angioplasty at the Guayaquil private hospital between april 2010 and march 2011

Objetivo: determinar si los valores de la fracción de eyección ventricular (FEV) pre y post procedimiento se relacionan con una mejoría en la calidad de vida (CdV) de los pacientes que fueron sometidos a cirugía de bypass coronario vs. angioplastia coronaria. Diseño: estudio prospectivo observacional realizado en la clínica Guayaquil con 56 pacientes en quienes se llevó a cabo un procedimiento de revascularización coronaria, entre abril de 2010 y marzo de 2011. La CdV fue evaluada por medio del cuestionario SF-36v2 y la FEV mediante ecocardiografía; se hizo una reevaluación de los pacientes 4 a 8 semanas posteriores a la intervención. Resultados: de la muestra, 27 (48.2%) fueron tratados con angioplastia y 29 (51.8%) con cirugía de bypass. Se observó una mejoría en 7 de las 8 dimensiones de la salud, siendo mayor en el grupo de bypass coronario, aunque la diferencia no fue significativa (p>0.05); en cambio, la dimensión de dolor corporal mostró un incremento similar en ambas técnicas (p>0.05). En cuanto a la FEV, el mayor porcentaje de mejoría se obtuvo en aquellos sometidos a bypass (41.4% vs. 25%, p>0.05). No se encontró relación entre FEV y CdV (R2=0.27 para angioplastia, R2=0.07 para bypass). Conclusiones: ambas estrategias resultaron en una mejoría de la CdV durante las cuatro semanas de seguimiento; no se encontró una relación entre los cambios en la CdV y los valores de FEV en los pacientes.

Objective: to determine if the pre and post-procedure ventricular ejection fraction (VEF) values are associated with improved quality of life (QOL) of the patients who underwent coronary bypass surgery vs. coronary angioplasty. Design: prospective observational study conducted in the Guayaquil clinic with 56 patients who underwent a coronary revascularization procedure between April 2010 and March 2011. QOL was assessed using the SF-36v2 questionnaire and the VEF through echocardiography. Patients were re-assessed 4 to 8 weeks after the operation. Results: of the sample, 27 (48.2%) were treated with angioplasty and 29 (51.8%) with bypass surgery. Improvement was observed in 7 of the 8 health dimensions, being higher in the coronary bypass group, although the difference was not significant (p>0.05). The bodily pain dimension showed a similar increase in both techniques (p> 0.05). In terms of VEF, the highest percentage of improvement was obtained with those undergoing the bypass (41.4% vs. 25%, p> 0.05). No relationship was found between VEF and QOL (R2= 0.27 for angioplasty, R2= 0.07 for bypass). Conclusions: both strategies resulted in an improvement of QOL during the four-week follow up; no relationship was found between changes in QOL and FEV values in the patients.

Tratamento operatório da dissecção iatrogênica do tronco de coronária esquerda / Operative treatment after iatrogenic left main dissection

A dissecção coronária iatrogênica apresenta alta morbidade e mortalidade. Diante da oclusão aguda do fluxo coronariano, é fundamental a restauração imediata da perviabilidade do vaso para limitar a extensão e duração da isquemia. Nesta situação, pode estar indicada a revascularização cirúrgica do miocárdio de emergência. Os autores apresentam caso de um paciente com dissecção iatrogênica do tronco de coronária esquerda durante angioplastia transluminal percutânea, que foi solucionada pela realização de revascularização completa do miocárdio, com resultado satisfatório.

Coronary dissection has a significant morbity and mortality. The ideal management of acute coronary occlusion is the prompt restoration of the vessel patency to limit the extent and duration of ischemia. In the setting of dissection during percutaneous procedure, the usual approach has been emergency aortocoronary bypass surgery. The authors present a case of a patient with left main dissection during percutaneous transluminal coronary angioplasty. This problem was successfully managed with emergent aortocoronary bypass surgery.