Herramientas para la toma de decisiones en pacientes con enfermedad de múltiples vasos / Tools for Decision Making in Patients with Multivessel Disease

RESUMEN La decisión sobre la mejor estrategia de revascularización para los pacientes con enfermedad de múltiples vasos se ha tornado una tarea compleja a medida que la angioplastia coronaria ha mejorado sus resultados. En la siguiente revisión nos propusimos evaluar las variables que en nuestra experiencia definen el beneficio de una técnica sobre la otra, entendiendo que de esta manera la decisión del médico tratante se hace más sencilla y objetiva. Por otro lado, y festejando el saludable protagonismo que se le da al paciente, creemos que esta evaluación permite ofrecer argumentos sólidos para ayudarlo en la toma de la decisión.

ABSTRACT The decision on the best revascularization strategy for patients with multivessel disease has become a complex task as coronary angioplasty has improved its results. In the following review, we set out to evaluate the variables that, in our experience, define the benefit of one technique over the other, understanding that in this way the treating physician's decision will become simpler and more objective. On the other hand, and celebrating the healthy prominence given to patients, we believe that this evaluation allows solid arguments to help them in decision making.

Impacto de la rehabilitación cardiaca de 8 vs 12 semanas sobre la calidad de vida de personas con angioplastia. Ensayo clínico aleatorizado / Impact of an 8 and 12-week Cardiac Rehabilitation Program on the Perception of Quality of Life in Patients with Coronary Angioplasty. A Randomized Controlled Trial

Introducción. La evaluación de la calidad de vida es un resultado de salud que comúnmente se asocia con la eficacia de los tratamientos derivados a los pacientes con enfermedad de las arterias coronarias. Específicamente, la literatura no es clara con respecto al papel de la rehabilitación cardíaca sobre la calidad de vida en población sometida a revascularización coronaria. Objetivo. Determinar si existen diferencias en la percepción de calidad de vida relacionada con la salud, después de asistir a un programa de rehabilitación cardiaca de 8 semanas comparado con uno de 12 semanas en personas post revascularización percutánea. Métodos. Ensayo clínico controlado aleatorizado, conformado por personas que asisten a rehabilitación cardíaca, divididas en dos grupos de estudio (8 y 12 semanas), quienes se evaluaron a través del Cuestionario SF-36.Resultados. La muestra estuvo conformada por 17 personas, con edad promedio de 63.1±6.9 años. Al comparar la evaluación pre y posttratamiento en cada grupo, se encontraron diferencias significativas en los dominios función física y rol físico en el grupo de 8 semanas; al realizar la comparación entre grupos hubo diferencias en el dominio emocional. Conclusión. Los resultados del estudio no evidenciaron diferencias en cuanto a la calidad de vida relacionada con la salud entre los grupos de estudio en el resultado global del cuestionario SF-36. Sin embargo, al comparar las dos intervenciones, el grupo de 8 semanas demostró mejores valores sobre el rol emocional

Introduction. The evaluation of quality of life is a health outcome that is commonly associated with the efficacy of treatments derived from patients with coronary artery disease. The literature is unclear regarding the role of cardiac rehabilitation on quality of life in the population undergoing coronary revascularization.Aim. To determine if there are differences in perception of health-related quality of life after attending an 8-week cardiac rehabilitation program compared to a 12-week program in people after coronary angioplasty. Methods. Randomized controlled clinical trial that included people with coronary angioplasty, who attended a cardiac rehabilitation program, divided in two groups (8 and 12 weeks), who were evaluated through the 8 domains of Short Form-36 Health Survey (SF-36). Results. The sample was made up of 17 people, with an average age of 63.1 ± 6.9 years. When comparing the evaluation before and after treatment in each group, sta-tistical differences were found in the physical-functioning and role-physical in 8 weeks group. Comparation between group show differences in role-emotional. Conclusion. The results of the present study did not show differences between the global score on health-related quality of life. However, when comparing the two in-terventions, the 8-week group showed better values on the role-emotional.

Síndrome de Wellens: o infarto agudo do miocárdio iminente / Wellens Syndrome: impending acute myocardial infarction

A síndrome de Wellens foi descrita em 1982 por Zwaan, Bär e Wellens. No eletrocardiograma, observam-se alterações morfológicas da onda T nas derivações precordiais, sugerindo estenose proximal grave da artéria coronária descendente anterior que representa iminente risco de infarto agudo do miocárdio e/ou morte súbita, com discreta ou nenhuma alteração da troponina sérica. Seu reconhecimento antecipado e a abordagem com reperfusão miocárdica precoce evitam desfechos desfavoráveis. A intervenção coronária percutânea e a revascularização miocárdica cirúrgica são as estratégias mais utilizadas para tratamento. Os autores descrevem dois casos de síndrome de Wellens tipos A e B tratados por diferentes estratégias de reperfusão.

Wellens syndrome was described by Zwaan, Bär and Wellens, in 1982. On the electrocardiogram, T wave morphological alterations are observed in precordial leads, suggesting severe proximal stenosis of the left anterior descending coronary artery and an imminent risk of acute myocardial infarction and/or sudden death, with slight or no alteration in serum troponin. Its early recognition and management with early myocardial reperfusion avoid unfavorable outcomes. Percutaneous coronary intervention and surgical myocardial revascularization are the most used strategies for treatment. The authors describe two cases of types A and B Wellens syndrome treated with different reperfusion strategies.

Mortalidad por infarto agudo de miocardio en el registro continuo ARGEN-IAM-ST. Su relación con las diferentes terapias de reperfusión / Mortality of Acute Myocardial Infarction in the Continuous Registry ARGEN-AMI-ST and its Relationship with the Different Reperfusion Therapies

RESUMEN Introducción: El tratamiento de reperfusión es la terapéutica de mayor eficacia para reducir la mortalidad del infarto agudo de miocardio con elevación del segmento ST (IAMCEST) , y su efectividad es inversamente proporcional al tiempo total de isquemia. El mayor desafío es instrumentar su aplicación en la vida real y corregir en forma continua los desvíos o las barreras que se presentan en la práctica cotidiana. Objetivos: Evaluar la mortalidad con las diferentes modalidades de reperfusión, su relación con el tiempo de tratamiento y su efectividad en un registro prospectivo multicéntrico del mundo real de Argentina. Material y Métodos: estudio prospectivo, multicéntrico de carácter nacional, incluidos los pacientes con IAMCEST hasta las 36 h del comienzo de los síntomas (ARGEN-IAM-ST registro continuo). Resultados: participaron 2464 pacientes de 78 centros entre 2015 y 2019. El 88,5% recibió tratamiento de reperfusión. La mortalidad fue de 8,68%. Los pacientes tratados con reperfusión tuvieron una mortalidad de 7,81% versus 15,38% sin tratamiento (p <0,001). La mortalidad con angioplastia primaria fue 7,51%, con trombolíticos 9,03%, con estrategia farmacoinvasiva 2,99% y con angioplastia de rescate 9,40%, sin diferencia estadísticamente significativa entre angioplastia primaria y trombolíticos (OR 0,81 IC 95% 0,56-1,18, p = ns). Los pacientes fallecidos fueron de mayor edad, con mayor proporción de mujeres e insuficiencia cardíaca. El tratamiento de reperfusión e ingreso a la institución dentro de 3 horas del comienzo de los síntomas se asoció a menor mortalidad. Los pacientes fallecidos con angioplastia primaria tuvieron mayor tiempo total de isquemia (378 minutos versus 285 minutos, p < 0,001). Conclusiones: La mortalidad por IAMCEST se relacionó con el acceso a la reperfusión y su precocidad. Fue mucho mayor en los pacientes no reperfundidos, y menor cuando la reperfusión se efectuó en forma precoz dentro de las primeras tres horas del comienzo de los síntomas. En los pacientes tratados con angioplastia primaria la mortalidad se incrementó con mayor tiempo total de isquemia. Este registro de la práctica real del tratamiento del IAMCEST refuerza la necesidad de una mejor articulación del sistema de atención para bajar los tiempos y utilizar la estrategia mejor y más oportuna.

ABSTRACT Background: reperfusion treatment is the most effective therapy in reducing mortality from acute ST elevation myocardial infarction and its effectiveness is inversely proportional to the total time of ischemia. The greatest challenge is to implement its application in real life and continuously correct the deviations or barriers that arise in daily practice. Objectives: to evaluate mortality with the different reperfusion modalities, its relationship with treatment time and to evaluate its effectiveness. Methods: a prospective, multicenter national study, including patients with STEMI up to 36 h after symptoms began (ARGENAMI-ST continuous registry). Results: 2464 patients were included from 2015 to 2019 in 78 centers. 88.5% received reperfusion treatment. Mortality was 8.68%. The patients treated with reperfusion had a mortality of 7.81% versus 15.38% without treatment (p <0.001). Mortality with primary angioplasty was 7.51%, thrombolytics 9.03%, pharmacoinvasive strategy 2.99%, and rescue angioplasty 9.40%, with no statistically significant difference between primary angioplasty and thrombolytics (OR 0.81; 95% CI 0.56-1.18, p = ns). The deceased patients were older, a higher proportion of women, and heart failure. Reperfusion treatment and admission to the institution within 3 hours of starting symptoms were associated with lower mortality. Patients who died with primary angioplasty had a longer total ischemia time (378 minutes versus 285 minutes, p <0.001). Conclusions: mortality from STEMI was related to access to reperfusion and its earliness. It was much higher in non-reperfused patients, and lower when reperfusion was carried out early within the first three hours of the onset of symptoms. In patients treated with primary angioplasty, mortality increased with a longer total ischemia time. This record of the actual practice of the treatment of infarction reinforces the need for a better articulation of the care system to reduce times and use the best timely strategy.

Perfil clínico y angiográfico de las mujeres con infarto agudo al miocardio en un hospital nacional / Clinical and angiographic profile of women with acute myocardial infarction in a national hospital

Resumen Justificación: La cardiopatía isquémica es la principal causa de muerte de mujeres en Costa Rica, y su incidencia ha aumentado con los años. A pesar de esto, hay pocos estudios clínicos a este respecto en nuestro país. El objetivo del presente trabajo es presentar las principales características clínicas y angiográficas de un grupo de pacientes con infarto agudo del miocardio con la idea de establecer no solo sus particularidades sino permitir comparaciones con otras poblaciones. Métodos: Se trató de un estudio observacional, descriptivo y retrospectivo, de un periodo de cinco años, en el cual se incluyeron a las pacientes ingresadas con infarto del miocardio a la Unidad de Cuidados Intensivos. Se registraron datos demográficos, de evolución clínica, complicaciones, hallazgos angiográficos, tratamiento y desenlace. El análisis estadístico fue cuantitativo descriptivo, realizado con el programa informático SPSS v.21 (IBM Corp., EEUU) y éste consistió en cálculos de frecuencia, tendencia central, medidas de variabilidad de rango, percentiles, y chi-cuadrado. El protocolo de la investigación fue aprobado por el Comité Ético Científico del Hospital Rafael Ángel Calderón Guardia (DG-3380-2020). Resultados: De 190 pacientes se incluyeron un total de 54. La edad promedio fue de 60 años, con una mortalidad del 17,9%, la cual fue 5,4 % más alta que en los hombres. La mayor parte de las pacientes padecía de hipertensión arterial (74%), 24 (44,5%) eran taba- quistas y 23 (42,5%) tenían diabetes mellitus. Los síntomas más frecuentes fueron: dolor torácico, criodiaforesis y disnea. Se consideró que hubo dolor torácico atípico en 8 casos (15%). A 48 pacientes se le llevó a angioplastia coronaria y solo 35% la recibieron en tiempo oportuno. A 17 pacientes se les aplicó trombólisis farmacológica y solo en 3 pacientes fue exitosa. La arteria coronaria derecha y la arteria descendente anterior fueron los vasos responsables en la mayoría de los casos (19 casos (39,5%) cada uno de ellas.) Conclusión: Esta población tuvo síntomas isquémicos claros, con enfermedad coronaria severa y una mortalidad mayor que los hombres. En general la terapia farmacológica, así como la mecánica se aplicaron en forma tardía.

Abstrac Justification: The ischemic heart disease is the main cause of death of women in Costa Rica, and its incidence has increased with the years. In spite of this, there are few clinical studies in this respect in our country. The aim of this paper is to present the main clinical and angiographic characteristics of a group of patients with acute myocardial infarction in order to establish not only their particularities but also to allow comparisons with other populations. Methods: An observational, descriptive and retrospective study was carried out over a period of five years, in which patients admitted with myocardial infarction to the Intensive Care Unit were included. Demographic data, clinical evolution, complications, angiographic findings, treatment, and outcome were recorded. Statistical analysis was quantitative and descriptive, performed with SPSS v.21 software (IBM Corp., USA) and consisted of calculations of frequency, central tendency, measures of variability, percentiles, and chi-square. The Ethical Committee of the Hospital Rafael Angel Calderon Guardia approved the research protocol (DG-3380-2020). Results: A total of 54 out of 190 patients were included. The average age was 60 years, with a mortality rate of 17.9%, which was 5.4% higher than in men. Most of the patients suffered from arterial hypertension (74%), 24 (44.5%) were smokers and 23 (42.5%) had diabetes mellitus. The most frequent symptoms were chest pain, cryodiaphoresis and dyspnea. It was considered that there was atypical chest pain in 8 cases (15%). Forty-eight patients were taken for coronary angioplasty and only 35% received it in time. Pharmacological thrombolysis was applied to 17 patients, and it was successful in only 3 patients. The right coronary artery and the anterior descending artery were the vessels responsible in most cases (19 cases (39.5%) each). Conclusión: This population had clear ischemic symptoms, with severe coronary disease and higher mortality than men. In general, pharmacological as well as mechanical therapy was applied late.

Intervenção Coronariana Percutânea em Lesões não Protegidas de Tronco / Percutaneous Coronary Intervention in Unprotected Left Main Coronary Artery Lesions

Resumo Fundamento O advento dos stents farmacológicos permitiu que a intervenção coronariana percutânea apresentasse resultados seguros nas lesões de tronco da artéria coronária esquerda. Objetivos Analisar os resultados do tratamento percutâneo da lesão não protegida de tronco da artéria coronária com a utilização de ultrassom intravascular. Métodos Estudo de série de casos consecutivos realizado no período de janeiro de 2010 a dezembro de 2018. Coletaram-se dados clínicos dos pacientes, assim como escores prognósticos e dados da lesão coronariana. Considerou-se de sucesso a lesão residual menor que 50% à angiografia e a área mínima da luz maior que 6 mm 2 ao ultrassom intravascular. O nível de significância adotado foi de 5%. Resultados Analisaram-se 107 casos. A lesão multiarterial foi predominante, sendo com maior frequência (39,25%) encontradas lesões em três vasos além do tronco coronariano. O escore SYNTAX apresentou média de 46,80 (DP: 22,95), e 70 (65,42%) pacientes tiveram escore SYNTAX acima de 32 pontos. Considerou-se sucesso angiográfico da intervenção percutânea em 106 (99,06%) pacientes. A taxa geral de evento maior cardíaco e cerebrovascular no desfecho hospitalar foi 6,54%, sendo semelhante nos pacientes com escore SYNTAX ≤ 32 (8,10%) e ≥ 33 (5,71%; p = 0,68) . Conclusões A intervenção percutânea em casos de lesão não protegida de tronco coronariano foi realizada com segurança e apresentou ótimos resultados. Atingiu-se alto sucesso angiográfico de tratamento guiado pelo ultrassom intravascular. A taxa de eventos cardíacos e cerebrovasculares maiores foi semelhante entre os pacientes de menor e de maior risco.

Abstract Background The advent of drug-eluting stents allowed the percutaneous coronary intervention to present safe results in lesions in the left main coronary artery. Objectives To analyze the results of the percutaneous treatment of unprotected left main coronary artery lesion with the use of intravascular ultrasound. Methods Study of consecutive case series carried out from January 2010 to December 2018. Clinical data were collected from patients as well as prognostic scores and data on coronary lesion. Low-grade residual lesion (less than 50%) on angiography and minimum luminal area greater than 6 mm2on intravascular ultrasound were considered successful. The adopted significance level was 5%. Results 107 cases were analyzed. The multivessel lesion was predominant, with most (39.25%) of the lesions being found in three vessels in addition to the left main coronary artery. The SYNTAX score had a mean of 46.80 (SD: 22.95), and 70 (65.42%) patients had a SYNTAX score above 32 points. Angiographic success of percutaneous intervention was considered in 106 (99.06%) patients. The overall rate of major cardiac and cerebrovascular events in the hospital outcome was 6.54%, being similar in patients with SYNTAX score ≤ 32 (8.10%) and ≥ 33 (5.71%; p = 0.68). Conclusions Percutaneous intervention in cases of unprotected left main coronary artery lesion was safely performed and presented excellent results. Considerable angiographic success of treatment guided by intravascular ultrasound was achieved. The rate of major cardiac and cerebrovascular events was similar between patients at low and high risks.

Perfil Aterosclerótico da Artéria Carótida como Preditor de Risco para Reestenose após Implante de Stent Coronário / Carotid Artery Atherosclerotic Profile as Risk Predictor for Restenosis After Coronary Stenting

Resumo Fundamento: A incidência de reestenose da artéria coronária após o implante de um stent não farmacológico é mais baixa que na angioplastia com balão; no entanto, ainda apresenta altas taxas. Objetivo: O objetivo deste estudo foi identificar novos indicadores de risco para reestenose de stent usando ultrassonografia das carótidas que, em conjunto com indicadores já existentes, ajudariam na escolha do stent. Métodos: Realizamos um estudo prospectivo transversal incluindo 121 pacientes consecutivos com doença arterial coronariana que foram submetidos à intervenção coronária percutânea com angiografia nos 12 meses anteriores. Após os casos de reestenose de stent serem identificados, os pacientes foram submetidos à ultrassonografia de carótidas para avaliar a espessura da camada íntima média e placas ateroscleróticas. Os dados foram analisados por regressão múltipla de Cox. O nível de significância foi p<0,05. Resultados: A idade mediana dos pacientes foi de 60 anos (1º quartil = 55, 3º quartil = 68), e 64,5% dos pacientes eram do sexo masculino. A angiografia coronária mostrou que 57 pacientes (47,1%) apresentaram reestenose de stent. Cinquenta e cinco pacientes (45,5%) apresentaram placas ateroscleróticas ecolucentes nas artérias carótidas e 54,5% apresentaram placas ecogênicas ou nenhuma placa. Dos pacientes que apresentaram placas ecolucentes, 90,9% apresentaram reestenose do stent coronário, e daqueles com placas ecogênicas ou nenhuma placa, 10,6% apresentaram reestenose de stent. A presença de placas ecolucentes nas artérias carótidas aumentou o risco de reestenose de stent coronário em 8,21 vezes (RR=8,21;IC95%: 3,58-18,82; p<0,001). Conclusões: A presença de placas ateroscleróticas ecolucentes na artéria carótida constitui um preditor de risco de reestenose de stent coronário e deve ser considerada na escolha do tipo de stenta ser usado na angioplastia coronária.

Abstract Background: The incidence of restenosis of the coronary artery after a bare-metal stent implant has been lower than in simple balloon angioplasty; however, it still shows relatively high rates. Objective: The aim of this study was to find new risk indicators for in-stent restenosis using carotid ultrasonography, that, in addition to the already existing indicators, would help in decision-making for stent selection. Methods: We carried out a cross-sectional prospective study including 121 consecutive patients with chronic coronary artery disease who had undergone percutaneous coronary intervention with repeat angiography in the previous 12 months. After all cases of in-stent restenosis were identified, patients underwent carotid ultrasonography to evaluate carotid intima-media thickness and atherosclerosis plaques. The data were analyzed by Cox multiple regression. The significance level was set a p<0.05. Results: Median age of patients was 60 years (1st quartile = 55, 3rd quartile = 68), and 64.5% of patients were male. Coronary angiography showed that 57 patients (47.1%) presented in-stent restenosis. Fifty-five patients (45.5%) had echolucent atherosclerotic plaques in carotid arteries and 54.5% had echogenic plaques or no plaques. Of patients with who had echolucent plaques, 90.9% presented coronary in-stent restenosis. Of those who had echogenic plaques or no plaques, 10.6% presented in-stent restenosis. The presence of echolucent plaques in carotid arteries increased the risk of coronary in-stent restenosis by 8.21 times (RR=8.21; 95%CI: 3.58-18.82; p<0.001). Conclusions: The presence of echolucent atherosclerotic plaques in carotid artery constitutes a risk predictor of coronary instent restenosis and should be considered in the selection of the type of stent to be used in coronary angioplasty.

SCA con elevación del ST: impacto del tiempo al diagnóstico en el tiempo puerta-balón en el mundo real. Datos del registro ARGEN-IAM-ST / ST-Segment Elevation ACS: Impact of Time to Diagnosis on Door-To-Balloon Time in the Real World. Data from the ARGEN-IAM-ST Registry

RESUMEN • Introducción: El tiempo trascurrido desde el inicio de los síntomas de infarto hasta el diagnóstico (TAD) puede influir en lograr un tiempo puerta-balón (TPB) <90 min. Material y métodos: Análisis retrospectivo que incluyó 1518 pacientes ingresados en forma prospectiva y consecutiva al registro ARGEN-IAM-ST. El 37,8% de ellos fue tratado con un TPB <90 min y el TAD (mediana) fue de 120 min (RIC 60-266). Se dividió a la población de acuerdo al TAD en dos grupos: menor de 120 min y mayor o igual que 120 min. Un TPB <90 min se logró más frecuentemente en el primer grupo (TAD <120 min): 44%, vs. 32,2% en el segundo grupo (p <0,001). Resutados: En el 56% de los pacientes con ATC in situ y TAD <120 min se logró un TPB <90 min, vs. en el 37,1% de quienes tuvieron un TAD >120 min (p <0,001). En pacientes derivados, no hubo diferencias en TPB <90 min de acuerdo al TAD: 27,5% vs. 25,7 (p: 0,3). En pacientes ingresados en horario laborable, el TPB <90 min se logró con TAD <120 min en un 49,8% vs. 36,3% con TAD >120 min (p: 0,003); la frecuencia siguió un patrón similar en los pacientes ingresados en horarios no laborables: 41,9% vs. 30,4%, respectivamente (p <0,001). Los predictores independientes de lograr un TPB <90 min en el análisis multivariado fueron la edad <75 años: OR 1,57 (1,1-2,25; p: 0,01), ATC en horario laborable: OR 1,32 (1,04-1,67; p: 0,002), ATC in situ: OR 2,4 (1,9-3,0; p <0,001), tener un ECG prehospitalario: OR 2,22 (1,73-2,86; p <0,001) y un TAD <120 min: OR 1,53 (1,23-1,9; p <0,001). Conclusiones: En los pacientes con un TAD <120 minutos se logra más frecuentemente un TPB <90 min, especialmente en los tratados in situ y en horario laborable. En los pacientes derivados, solo 1 de cada 3 logra un TPB <90 min y no hay relación con el TAD.

ABSTRACT • Background: Time elapsed from the onset of symptoms to diagnosis (TTD) can influence in achieving a door-to-balloon time <90 min (DBT <90 min). Methods: A retrospective analysis was performed on 1,518 patients prospectively and consecutively included in the ARGEN-AMI-ST registry. In 37.8% of cases. patients were treated with DBT <90 min and a median TTD of 120 min (IQR 60-266). The population was divided according to TTD above or below 120 min. A DBT <90 min was achieved more frequently in those with TTD <120 min: 44% vs. 32.2% (p <0.001) respectively. Results: In patients with in situ percutaneous coronary intervention (PCI) and TTD <120 min, DBT <90 min was achieved in 56% vs. 37.1% of cases with TTD >120 min (p <0.001). In referred patients, there were no differences in DBT <90 min according to TTD: 27.5% vs. 25.7% (p: 0.3). In patients admitted during working hours, DBT <90 min was achieved with TTD <120 min in 49.8% vs. 36.3% with TTD >120 min (p: 0.003), as well as in patients admitted during non-working hours: 41.9% vs. 30.4% (p <0.001). The independent predictors of achieving a DBT <90 min in the multivariate analysis were age <75 years: OR 1.57 (1.1-2.25; p: 0.01), PCI during working hours: OR 1.32 (1.04-1.67; p: 0.002), PCI in situ: OR 2.4 (1.9-3.0; p <0.001), having a pre-hospital ECG: OR 2.22 (1.73-2.86; p <0.001) and a TTD <120 min: OR 1.53 (1.23-1.9; p <0.001). Conclusions: In patients with TTD <120 minutes, a DBT <90 minutes is more frequently achieved, especially in those treated in situ and during working hours. In referred patients, only 1 in 3 achieves a DBT<90 min and there is no relationship with TTD.

Infarto agudo de miocardio con elevación del segmento ST en la Argentina. Datos del registro continuo ARGEN-IAM-ST / Acute ST-segment Elevation Myocardial Infarction in Argentina. Data from the continuous ARGEN-IAM-ST registry

RESUMEN Introducción: A través del Registro Nacional de Infarto Agudo de Miocardio (IAM) con Elevación del ST (ARGEN IAM-ST) realizado en 2015 se conocieron datos de la realidad del IAM en Argentina; en esta ocasión, se presenta un reporte actual. Material y métodos: Estudio prospectivo multicéntrico, con alcance nacional. Luego de la primera fase de la encuesta ARGEN-IAM-ST, se invitó a los centros a continuar con el registro de IAM. Se incluyeron pacientes con IAM con elevación del segmento ST en el electrocardiograma de hasta 36 horas de evolución. Resultados: La población analizada abarcó 2464 pacientes asistidos en 78 centros. La media de edad fue 60 ± 12 años y el 80% fue de sexo masculino. Los factores de riesgo prevenibles se distribuyeron del siguiente modo: tabaquismo 45%, hipertensión arterial 58%, diabetes 24% y dislipidemia 41%. El 11% tuvo antecedente de enfermedad coronaria. El 88% recibió reperfusión; el 21% de estos pacientes recibieron trombolíticos y al 89% se le realizó angioplastia. La demora desde el inicio de los síntomas hasta la admisión fue de 130 minutos (RIC 25-75: 60-305); los médicos reportaron demoras hasta el tratamiento en el 49% de los casos, con impacto en los tiempos totales de isquemia (TTI). La mortalidad intrahospitalaria fue del 8,7%. En el análisis multivariado, ser tratado en un centro con hemodinamia no se asoció de forma independiente con la supervivencia. Conclusiones: Los datos actuales del registro continuo de IAM en la Argentina son similares a los que mostró la encuesta de 2015. Las demoras hasta el tratamiento son importantes, especialmente por el tiempo de demora en la consulta de los pacientes, lo que impacta en gran medida en los TTI.

ABSTRACT Background: The National ST-segment elevation Acute Myocardial Infarction (ARGEN-AMI-ST) registry carried out in 2015 provided data on the reality of AMI in Argentina. Objective: The aim of this study was to present an updated report of the ARGEN-AMI-ST registry. Methods: This was a national, prospective, multicenter study. After the first phase of the ARGEN-AMI-ST survey, centers were invited to continue with the AMI registry including patients with up to 36-hour electrocardiographic STEMI evolution. Results: The analyzed population comprised 2,464 patients assisted in 78 centers. Mean age was 60±12 years and 80% were men. Preventable risk factors were: 45% smoking, 58% hypertension, 24% diabetes, 41% dyslipidemia and 11% history of coronary heart disease. Eighty-eight percent of patients underwent reperfusion, and among them, 21% received thrombolytics and 89% percutaneous coronary intervention. The delay from onset of symptoms to admission was 130 minutes (IQR 25-75: 60-305); physicians reported delays to treatment in 49% of cases, with an impact on total ischemic times (TIT). In-hospital mortality was 8.7%. In the multivariate analysis, being treated in a center with hemodynamic availability was not independently associated with survival. Conclusions: Current data from the continuous AMI registry in Argentina are similar to those shown in the 2015 survey. Delays to treatment are important, especially due to the delay in patient consultation, which greatly impacts on TIT.

Manejo percutáneo de infarto con elevación del ST sin colocación de stent: reporte de un caso / Percutaneous management of ST elevation myocardial infarction without stent placement: a case report

Resumen Reportamos el caso de manejo percutáneo de un infarto agudo al miocardio utilizando una combinación atípica de estrategias cuyo resultado fue seguro y costoefectivo, que consistió en tromboaspiración, angioplastía con balón y utilización de la reserva fraccional de flujo para descartar la necesidad de colocación de stent.

Abstract Percutaneous management of ST elevation myocardial infarction without stent placement : a case report We herein report the case of percutaneous management of an acute myocardial infarction using an atypical combination of strategies whose outcome was safe and costeffective, which consisted of thrombus aspiration, balloon angioplasty and use of fractional flow reserve to rule out the need for stent placement.

Contrast-Induced Nephropathy in patients submitted to percutaneous coronary intervention: an integrative review / Nefropatía Inducida por Contraste en pacientes sujetos al intervención coronaria percutánea: revisión integrativa / Nefropatia induzida por contraste em pacientes submetidos à intervenção coronária percutânea: revisão integrativa

ABSTRACT Objective: to demonstrate scientific evidence on incidence and factors associated with contrast-induced nephropathy in patients undergoing percutaneous coronary intervention. Methods: an integrative review carried out in the VHL, PubMed, VHL Regional Portal and SciELO databases, of articles published between 2014 and 2019. Results: the sample consisted of five original articles, two cohorts, two control cases and a clinical trial. The incidence of contrast-induced nephropathy ranged from 6% to 24%. It stands out among patients with advanced age, male gender, diabetes mellitus, systemic arterial hypertension, volume of contrast infused and osmolarity. Intravenous hydration, sodium bicarbonate, ascorbic acid and statin were important prophylactic agents. Conclusion: this study envisioned the main risk factors for contrast-induced nephropathy in patients undergoing percutaneous coronary intervention and elucidated preventive measures that guide multidisciplinary health care aiming at a quality and safe care.

RESUMEN Objetivo: demostrar evidencia científica sobre la incidencia y factores asociados a la nefropatía inducida por contraste en pacientes sometidos a intervención coronaria percutánea. Métodos: revisión integrativa, realizada en las bases de datos BVS, PubMed, Portal Regional BVS y SciELO, de artículos publicados entre 2014 y 2019. Resultados: la muestra estuvo conformada por cinco artículos originales, dos cohortes, dos casos-controles y un ensayo clínico. La incidencia de nefropatía inducida por contraste osciló entre el 6% y el 24%. Destaca entre los pacientes con edad avanzada, sexo masculino, diabetes mellitus, hipertensión arterial sistémica, volumen de contraste infundido y osmolaridad. La hidratación intravenosa, el bicarbonato de sodio, el ácido ascórbico y las estatinas fueron importantes agentes profilácticos. Conclusión: este estudio visualizó los principales factores de riesgo de nefropatía inducida por contraste en pacientes sometidos a intervención coronaria percutánea, dilucidando las medidas preventivas que orientan la atención de salud multiprofesional con el objetivo de una atención de calidad y segura.

RESUMO Objetivo: demonstrar evidências científicas sobre incidência e fatores associados à nefropatia induzida por contraste em pacientes submetidos à intervenção coronária percutânea. Métodos: revisão integrativa, realizada nas bases de dados BVS, PubMed, Portal Regional da BVS e SciELO, de artigos publicados entre 2014 e 2019. Resultados: a amostra foi composta por cinco artigos originais, duas coortes, dois caso-controle e um ensaio clínico. A incidência da nefropatia induzida por contraste variou de 6% a 24%. Destaca-se entre os pacientes idade avançada, sexo masculino, diabetes mellitus, hipertensão arterial sistêmica, volume do contraste infundido e osmolaridade. Hidratação endovenosa, bicarbonato de sódio, ácido ascórbico e estatina foram importantes agentes profiláticos. Conclusão: este estudo vislumbrou os principais fatores de risco para a nefropatia induzida por contraste em pacientes submetidos à intervenção coronária percutânea, elucidando medidas preventivas que orientam o cuidado multiprofissional em saúde visando uma assistência de qualidade e segura.

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.

Síndrome compartimental posangioplastía coronaria transradial: a propósito de un caso / Post transradial coronary angioplasty compartimental syndrome

Resumen Introducción: El síndrome compartimental se genera por aumento de presión compartimental que sobrepasa a la de perfusión. Es una entidad rara en contexto posangioplastía coronaria. Requiere alta sospecha y medidas rápidas. Caso clínico: Hombre de 41 años con diagnóstico de infarto agudo de miocardio (IAM) con supradesnivel ST (SDST) que fue trombolizado y derivado para angioplastía, que sufre sangrado en antebrazo derecho posprocedimiento y evoluciona con síndrome compartimental que requiere de fasciotomía en volar y medial. Discusión: La entidad clínica es rara en este contexto, por ende, requiere alta sospecha basándose principalmente en dolor de inicio súbito con aumento de volumen. El tratamiento es fasciotomía de urgencias. De no pesquisarse a tiempo puede evolucionar con severas alteraciones neuromusculares llevando a trastornos de la anatomía de la mano.

Introduction: The compartment syndrome is caused by an increase on the compartment pressure that exceed the perfusion pressure. In coronary postangioplasty context it is a rare entity. Requires a high suspicion and to take fast steps. Clinical case: Forty-one years old man with a STEMI thrombolysed and derived to angioplasty suffered a post-procedure bleeding on his right forearm and evolved with a compartment syndrome that required a volar and medial fasciotomy. Discussion: The clinical entity is rare in this context, so require a high suspicion based basically on sudden pain with an increase of volume. The treatment is the urgent fasciotomy. To not diagnose it at time could evolve with severe neuromuscular disorders and hand anatomy disorders.

Comparative Analysis between Transferred and Self-Referred STEMI Patients Undergoing Primary Angioplasty / Análise Comparativa entre Pacientes com IAMCSST Transferidos e Pacientes de Demanda Espontânea Submetidos à Angioplastia Primária

Abstract Background: Studies have shown the benefits of rapid reperfusion therapy in acute myocardial infarction. However, there are still delays during transport of patients to primary angioplasty. Objective: To evaluate whether there is a difference in total ischemic time between patients transferred from other hospitals compared to self-referred patients in our institution. Methods: Historical cohort study including patients with acute myocardial infarction treated between April 2014 and September 2015. Patients were divided into transferred patients (group A) and self-referred patients (group B). Clinical characteristics of the patients were obtained from our electronic database and the transfer time was estimated based on the time the e-mail requesting patient's transference was received by the emergency department. Results: The sample included 621 patients, 215 in group A and 406 in group B. Population characteristics were similar in both groups. Time from symptom onset to arrival at the emergency department was significantly longer in group A (385 minutes vs. 307 minutes for group B, p < 0.001) with a transfer delay of 147 minutes. There was a significant relationship between the travel distance and increased transport time (R = 0.55, p < 0.001). However, no difference in mortality was found between the groups. Conclusion: In patients transferred from other cities for treatment of infarction, transfer time was longer than that recommended, especially in longer travel distances.

Resumo Fundamento: Estudos mostram o benefício da terapia de reperfusão rápida no infarto agudo do miocárdio. No entanto, ainda ocorrem atrasos durante o transporte de pacientes para angioplastia primária. Objetivo: Definir se existe uma diferença no tempo total de isquemia entre pacientes transferidos de outro hospital comparados aos que procuram o serviço espontaneamente. Método: Estudo de coorte histórico, incluindo pacientes atendidos com infarto entre abril de 2014 e setembro de 2015. Os pacientes foram divididos em pacientes transferidos (grupo A) e por demanda espontânea (grupo B). As características clínicas dos pacientes foram retiradas do banco de dados de infarto e o tempo de transferência foi estimado tendo como base o correio eletrônico de acordo com o horário de contato. O nível de significância adotado foi um p < 0,05%. Resultados: A amostra incluiu 621 pacientes, 215 no grupo A e 406 no grupo B. As características populacionais foram semelhantes nos dois grupos. O delta T foi significativamente maior no grupo de pacientes transferidos (385 minutos vs. 307 minutos para o grupo B, p < 0,001) com um atraso decorrente do transporte de 147 minutos. Houve relação significativa da distância de transferência e aumento do tempo de transporte (R = 0,55; p < 0,001). Entretanto, não houve diferença na mortalidade entre os grupos. Conclusão: Pacientes transferidos de outras cidades para tratamento de infarto tem Delta T de transferência acima do recomendado, com tempo ainda mais longo quanto maior a distância a ser percorrida.

Clinical Outcomes and Cost-Effectiveness Analysis of FFR Compared with Angiography in Multivessel Disease Patient / Impacto Clínico e Custo-Efetividade da FFR em Comparação à Angiografia em Pacientes com Doenças Multiarteriais Submetidos à ICP

Abstract Background: In multivessel disease patients with moderate stenosis, fractional flow reserve (FFR) allows the analysis of the lesions and guides treatment, and could contribute to the cost-effectiveness (CE) of non-pharmacological stents (NPS). Objectives: To evaluate CE and clinical impact of FFR-guided versus angiography-guided angioplasty (ANGIO) in multivessel patients using NPS. Methods: Multivessel disease patients were prospectively randomized to FFR or ANGIO groups during a 5 year-period and followed for < 12 months. Outcomes measures were major adverse cardiac events (MACE), restenosis and CE. Results: We studied 69 patients, 47 (68.1%) men, aged 62.0 ± 9.0 years, 34 (49.2%) in FFR group and 53 (50.7%) in ANGIO group, with stable angina or acute coronary syndrome. In FFR, there were 26 patients with biarterial disease (76.5%) and 8 (23.5%) with triarterial disease, and in ANGIO, 24 (68.6%) with biarterial and 11 (31.4%) with triarterial disease. Twelve MACEs were observed - 3 deaths: 2 (5.8%) in FFR and 1 (2.8%) in ANGIO, 9 (13.0%) angina: 4(11.7%) in FFR and 5(14.2%) in ANGIO, 6 restenosis: 2(5.8%) in FFR and 4 (11.4%) in ANGIO. Angiography detected 87(53.0%) lesions in FFR, 39(23.7%) with PCI and 48(29.3%) with medical treatment; and 77 (47.0%) lesions in ANGIO, all treated with angioplasty. Thirty-nine (33.3%) stents were registered in FFR (0.45 ± 0.50 stents/lesion) and 78 (1.05 ± 0.22 stents/lesion) in ANGIO (p = 0.0001), 51.4% greater in ANGIO than FFR. CE analysis revealed a cost of BRL 5,045.97 BRL 5,430.60 in ANGIO and FFR, respectively. The difference of effectiveness was of 1.82%. Conclusion: FFR reduced the number of lesions treated and stents, and the need for target-lesion revascularization, with a CE comparable with that of angiography.

Resumo Fundamentos: Em pacientes multiarteriais e lesões moderadas, a reserva de fluxo fracionada (FFR) avalia cada lesão e direciona o tratamento, podendo ser útil no custo-efetividade (CE) de implante de stents não farmacológicos (SNF). Objetivos: Avaliar CE e impacto clínico da angioplastia + FFR versus angioplastia + angiografia (ANGIO), em multiarteriais, utilizando SNF. Métodos: pacientes com doença multiarteriais foram randomizados prospectivamente durante ±5 anos para FFR ou ANGIO, e acompanhados por até 12 meses. Foram avaliados eventos cardíacos maiores (ECAM), reestenose e CE. Resultados: foram incluídos 69 pacientes, 47(68,1%) homens, 34(49,2%) no FFR e 35(50,7%) no ANGIO, idade 62,0 ± 9,0 anos, com angina estável e Síndrome Coronariana Aguda estabilizada. No FFR, havia 26 com doença (76,5%) biarterial e 8 (23,5%) triarterial, e no grupo ANGIO, 24(68,6%) biarteriais e 11(31,4%) triarteriais. Ocorreram 12(17,3%) ECAM - 3(4,3%) óbitos: 2(5,8%) no FFR e 1(2,8%) no ANGIO, 9(13,0%) anginas, 4(11,7%) no FFR e 5(14,2%) no ANGIO, 6 reestenoses: 2(5,8%) no FFR e 4 (11,4%) no ANGIO. Angiografia detectou 87(53,0%) lesões no FFR, 39(23,7%) com ICP e 48(29,3%) com tratamento clínico; e 77(47,0%) lesões no ANGIO, todas submetidas à angioplastia. Quanto aos stents, registrou-se 39(33,3%) (0,45 ± 0,50 stents/lesão) no FFR e 78(66,6%) (1,05 ± 0,22 stents/lesão) no ANGIO (p = 0,0001); ANGIO utilizou 51,4% a mais que o FFR. Análise de CE revelou um custo de R$5045,97 e R$5.430,60 nos grupos ANGIO e FFR, respectivamente. A diferença de efetividade foi 1,82%. Conclusões: FFR diminuiu o número de lesões tratadas e de stents e necessidade de revascularização do vaso-alvo, com CE comparável ao da angiografia.

Impacto de la angiografía coronaria rotacional en la cantidad total de contraste administrado y la exposición a las radiaciones ionizantes en pacientes en los que se realizan procedimientos coronarios invasivos: revisión sistemática y metaanálisis / Impact of rotational coronary angiography in the amount of iodinated contrast and the exposure to ionising radiations in patients undergoing invasive coronary procedures: A systematic review and meta-analysis

Resumen Antecedentes: Los procedimientos coronarios invasivos conllevan la administración de contraste y la exposición a radiaciones ionizantes, comportando un incremento de la morbimortalidad. La angiografía coronaria rotacional (ACR) permite adquirir múltiples proyecciones con una inyección de contraste. Hasta la fecha, no hay metaanálisis específicos comparando la ACR y la angiografía coronaria convencional (ACC) en pacientes en los que se realizan procedimientos coronarios invasivos, tanto diagnósticos como diagnósticos y terapéuticos. El objetivo de este metaanálisis es evaluar el impacto de la ACR en la cantidad de contraste, y la radiación ionizante en procedimientos coronarios invasivos. Métodos: Se realizó una búsqueda en las bases de datos PubMed y Ovid para identificar estudios tanto diagnósticos como diagnósticos y terapéuticos que comparasen ACR y ACC. Los estudios fueron evaluados sobre la calidad y los sesgos, y fueron incluidos si contemplaban alguna de las siguientes variables de valoración: volumen de contraste, radiación ionizante medida como producto dosis-área, Kerma-aire o tiempo de fluoroscopia. Resultados: Dieciséis estudios, totalizando 2,327 pacientes, fueron incluidos en el análisis final (1,146 pacientes recibieron ACR y 1,181, ACC), objetivándose diferencias significativas en volumen de contraste (diferencia estándar de medias (intervalo de confianza al 95%) −1.887 (−2.472 a −1.302); p < 0.001), producto dosis-área (−0.726 (−1.034 a −0.418); p < 0.001), Kerma-aire (−0.842 (−1.104 a −0.581); p < 0.001) y tiempo de fluoroscopia (0.263 (−0.496 a −0.030); p = 0.027). Conclusiones: La ACR permite reducir el volumen de contraste y la radiación, evaluada como producto dosis-área, Kerma-aire y tiempo de fluoroscopia en pacientes a los que se les realizan procedimientos coronarios invasivos.

Abstract Background: Invasive coronary procedures involve the administration of iodinated contrast and the exposure to ionising radiations, increasing morbidity and mortality. The rotational coronary angiography (RCA) allows acquiring multiple projections with a unique injection of iodinated contrast. To date, there are no meta-analyses specifically comparing RCA and conventional coronary angiography (CCA) in patients undergoing invasive coronary procedures, whether diagnostic or diagnostic and therapeutic. The aim of this meta-analysis is to assess the impact of RCA on the amount of iodinated contrast and the exposure to ionising radiations during invasive coronary procedures. Methods: A search in PubMed and Ovid databases was conducted to identify studies, including diagnostic and diagnostic and therapeutic studies, comparing RCA and CCA. The manuscripts were evaluated on quality and biases, and were included if they analysed any of the following endpoints: volume of contrast and exposure to ionising radiations measured as dose-area product, and Kerma-air or fluoroscopy time. Results: Sixteen studies, with a total of 2,327 patients, were included in the final analysis (1,146 patients underwent RCA and 1,181 patients underwent CCA), with significant differences being detected in volume of contrast (standard difference in means (95% confidence interval) −1.887 (−2.472 to −1.302); P < .001), dose-area product (−0.726 (−1.034 to −0.418); P < .001), Kerma-air (−0.842 (−1.104 to −0.581); P < .001), and fluoroscopy time (0.263 (−0.496 to −0.030); P = .027). Conclusions: RCA reduces the volume of contrast and the exposure to radiation, evaluated as dose-area product, Kerma-air, and fluoroscopy time, in patients undergoing invasive coronary procedures.

Acute coronary syndrome associated with anomalous origin of circumflex artery. Case report and literature review / Síndrome coronario agudo asociado al origen anómalo de la arteria circunfleja. Reporte de caso y revisión de literatura

Abstract: We present a case of an acute coronary ischemic syndrome associated with anomalous origin of the circumflex artery, with a right coronary sinus origin independent of the right coronary artery, which has a prevalence of 0.1 to 8.4%. This type of anomaly is classified according to the international guidelines as low-risk, however, at high risk of presenting atheroma, coronary complications,(1) and acute coronary ischemic syndrome due to its occasionally intraarterial pathway. The treatment depends on the complexity of the coronary anatomy. In this case with the presence of total obstruction the correct therapy was to perform a percutaneous coronary angioplasty with drug-eluting stent (DES) placement, which improves the survival and is therapeutic at the acute phase, as in the case of this patient.

Resumen: Presentamos un caso de síndrome isquémico coronario agudo asociado al origen anómalo de la arteria circunfleja, a partir del seno coronario derecho independiente de la arteria coronaria derecha, que tiene una prevalencia de 0.1 a 8.4%. Este tipo de anomalía se clasifica según las guías internacionales como de bajo riesgo; sin embargo, con alto riesgo de presentar desarrollo de ateroma y complicaciones coronarias, síndrome isquémico coronario agudo debido a su trayecto en ocasiones intraarterial. El tratamiento depende de la complejidad de la anatomía coronaria. En este caso de obstrucción total, la terapéutica correcta fue realizar angioplastia coronaria percutánea con la colocación de stent fármaco activo, lo que mejora la sobrevida y es terapéutico en el momento agudo, como en el caso de este paciente.