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RESUMEN Introducción: La estrategia trombolítica no solo mejora la esperanza de supervivencia del infarto, sino que también reduce la mortalidad general a un mes en los pacientes que reciben este tratamiento. Objetivo: Caracterizar los pacientes con infarto agudo de miocardio con elevación del segmento ST tratados con estreptoquinasa recombinante en el Hospital Clínico Quirúrgico Docente «Celia Sánchez Manduley». Métodos: Se realizó un estudio descriptivo, longitudinal y retrospectivo en 94 pacientes que recibieron tratamiento trombolítico desde diciembre de 2018 a noviembre de 2020. Las variables utilizadas fueron: edad, sexo, comorbilidades, tiempo de ventana terapéutica, causas de suspensión temporal, complicaciones, topografía, criterios de reperfusión clínico, eléctrico y enzimático y mortalidad. Se calculó la frecuencia absoluta y relativa, y la media aritmética con desviación estándar. Resultados: Predominó el sexo masculino y el grupo de edad entre 61 - 70 años. Prevalecieron los pacientes con antecedentes de hipertensión y diabetes. La hipotensión arterial fue la causa de suspensión más frecuente. El 69,1 % fueron trombolizados pasadas las 6 horas. Solo 27 pacientes sufrieron complicaciones, de las cuales, el bloqueo auriculoventricular y Killip - Kimball II fueron las más vistas. Por otra parte, 9 pacientes no presentaron criterios de reperfusión, y solo el 7,4 % fallecieron. Conclusiones: La trombolisis se realiza en una minoría de los pacientes aun en período de ventana terapéutica. La hipotensión fue la causa más frecuente de suspensión temporal de la trombolisis, y la letalidad fue inferior a la letalidad general por infarto agudo de miocardio.
ABSTRACT Introduction: thrombolytic strategy not only improves survival expectancy after infarction, but also reduces overall one-month mortality in patients receiving this treatment. Objective: to characterize patients with ST-segment elevation acute myocardial infarction treated with recombinant streptokinase at "Celia Sánchez Manduley" Clinical and Surgical Teaching Hospital. Methods: a descriptive, longitudinal and retrospective study was conducted in 94 patients who received thrombolytic treatment from December 2018 to November 2020. Age, gender, comorbidities, time-related therapeutic window, causes of temporary suspension, complications, topography, clinical, electrical and enzymatic reperfusion criteria as well as mortality were the variables used in this study. Absolute and relative frequency and arithmetic mean with standard deviation were calculated. Results: male gender and group aged 61-70 years predominated. Patients with a history of hypertension and diabetes predominated. Arterial hypotension was the most frequent cause of thrombolysis discontinuation. The 69.1 % were thrombolyzed after 6 hours. Only 27 patients suffered complications; atrioventricular block and Killip-Kimball II were the most frequently seen complications. On the other hand, 9 patients did not show reperfusion criteria and only 7.4 % died. Conclusions: thrombolysis is performed in a minority of patients even in the therapeutic window period. Hypotension was the most frequent cause of temporary suspension of thrombolysis, and case fatality was lower than the overall case fatality for acute myocardial infarction.
Subject(s)
Thrombolytic Therapy , ST Elevation Myocardial Infarction/therapyABSTRACT
Abstract ST elevation myocardial infarction (STEMI) is a highly prevalent condition worldwide. Reperfusion therapy is strongly associated with the prognosis of STEMI and must be performed with a high standard of quality and without delay. A systematic review of different reperfusion strategies for STEMI was conducted, including randomized controlled trials that included major cardiovascular events (MACE), and systematic reviews in the last 5 years through the PRISMA ( Preferred Reporting Items for Systematic Reviews and Meta-Analysis) methodology. The research was done in the PubMed and Cochrane Central Register of Controlled Trials databases, in addition to a few manual searches. After the exclusion criteria were applied, 90 articles were selected for this review. Despite the reestablishment of IRA patency in PCI for STEMI, microvascular lesions occur in a significant proportion of these patients, which can compromise ventricular function and clinical course. Several therapeutic strategies - intracoronary administration of nicorandil, nitrates, melatonin, antioxidant drugs (quercetin, glutathione), anti-inflammatory substances (tocilizumab [an inhibitor of interleukin 6], inclacumab, P-selectin inhibitor), immunosuppressants (cyclosporine), erythropoietin and ischemic pre- and post-conditioning and stem cell therapy - have been tested to reduce reperfusion injury, ventricular remodeling and serious cardiovascular events, with heterogeneous results: These therapies need confirmation in larger studies to be implemented in clinical practice
Subject(s)
Prognosis , Myocardial Reperfusion/methods , Reperfusion Injury , ST Elevation Myocardial Infarction/therapy , Stents , Thrombolytic Therapy , Health Strategies , Thrombectomy , Hydroxymethylglutaryl-CoA Reductase Inhibitors , Electrocardiography/methods , Purinergic P2Y Receptor Antagonists , Ischemic Postconditioning , Fibrinolytic Agents/therapeutic use , Percutaneous Coronary Intervention , ST Elevation Myocardial Infarction/diagnosis , ST Elevation Myocardial Infarction/rehabilitation , Dual Anti-Platelet Therapy , Myocardial RevascularizationABSTRACT
Introducción: El registro sobre Síndromes Coronarios Agudos en Argentina (SCAR) analizó la evolución intrahospitalaria del infarto de miocardio en nuestro país en pacientes que contaban con diferentes coberturas del sistema de salud, lo cual ha llevado al presente subanálisis derivado del registro SCAR. Objetivo: Determinar la influencia de la cobertura médica en el pronóstico intrahospitalario del infarto de miocardio. Material y métodos: El registro SCAR fue un estudio transversal, prospectivo y multicéntrico, que incluyó 476 pacientes con diagnóstico de infarto agudo de miocardio con supradesnivel del segmento ST (IAMST). La cobertura médica se diferenció en prepaga, obra social, PAMI y sin cobertura (solo estatal). Resultados: El 80% de los IAMST recibieron reperfusión, el 75% por angioplastia transluminal coronaria primaria (ATCP). La ATCP fue más frecuente en quienes tenían prepaga [OR 5,5 (2,5-12,4); p < 0,001] y los pacientes con PAMI [OR 0,47 (0,24-087); p = 0,02] o sin cobertura recibieron menos ATCP [OR 0,34 (0,2-0,6); p < 0,001]. El 13% fueron derivados a otro centro, más frecuentemente si tenían PAMI (p = 0,002). El tiempo hasta la ATCP fue mayor en pacientes con PAMI [240 (88-370) min; p = 0,0005] y menor si tenían prepaga [80 (42-120) min; p < 0,001]. La mortalidad intrahospitalaria del IAMST fue del 8%, 2,8% con prepaga, 4,3% con cobertura estatal, 6,88% con obra social y 25% con PAMI (ANOVA < 0,001). Tener prepaga se asoció con una mortalidad menor [OR 0,27 (0,08-0,91); p = 0,035] y tener PAMI se asoció con una mortalidad mayor, aun ajustado por sexo, edad y comorbilidades [OR 2,40 (1,1-5,8); p = 0,05]. Conclusión: El tratamiento y la mortalidad del IAMST fueron diferentes según la cobertura médica.
Background: The Acute Coronary Syndromes in Argentina (SCAR) registry analyzed in-hospital myocardial infarction out-come in patients with different medical coverage provided by the healthcare system; this has led to the present subanalysis derived from the SCAR registry. Objective: The aim of this study was to determine the influence of medical coverage on myocardial infarction in-hospital prognosis. Methods: The SCAR registry was a cross-sectional, prospective, multicenter study including 476 patients with ST-segment elevation acute myocardial infarction (STEMI). Medical coverage was classified in prepaid health insurance, social security insurance, PAMI and without medical coverage (except public coverage). Results: Eighty percent of STEMI patients received reperfusion therapy, 75% by primary transluminal coronary angioplasty (PTCA). PTCA was more frequent in those with prepaid health insurance [OR 5.5 (2.5-12.4); p<0.001] and less frequent in PAMI patients [OR 0.47 (0.24-0.87), p=0.02] or in those without any medical coverage [OR=0.34 (0.2-0.6), p<0.001]. Thirteen percent of patients were transferred to another hospital, more frequently if they were PAMI patients (p=0.002). Time to PTCA was longer in patients with PAMI [240 (88-370) min, p=0.0005] and shorter in patients with prepaid health insurance [80 (42-120) min, p<0.001]. Overall in-hospital STEMI mortality was 8%, 2.8% in patients with prepaid health insurance, 4.3% in patients with public medical coverage, 6.88% in patients with social security insurance and 25% in patients covered by PAMI (ANOVA <0.001). Mortality was significantly lower in patients with prepaid health insurance [OR=0.27 (0.08-0.91), p=0.035] and higher in patients with PAMI, even after adjusting by sex, age and comorbidities [OR 2.40 (1.1-5.8), p=0.05]. Conclusion: STEMI treatment and mortality were different according to the type of medical coverage.
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Objectives To investigate clinic outcome of ticagrelor in treatment of patients with acute ST-segment elevation my ocardial infarction receiving primary percutaneous coronary intervention.Methods Sixty-two consecutive patients with ST segment elevation myocardial infarction (STEMI) receiving primary percutaneous coronary intervention (PCI) were included in this study.The clinic characteristics,thrombolysis in myocardial infarction (TIMI) refuse after PCI,clinical outcomes after 30 d of patients were compared between patients who were treated with ticagrelor (group A 30 cases) and clopidogrel (group B 32 cases).Results There was no difference in the age,proportion of women,hypertension,and diabetics (P ＞ 0.05).TIMI 3 refuse after PCI were significantly higher in group A than group B (96.7％ vs 87.5％,P ＜ 0.05).The 30 d re-angina pectoris was lower in group A than group B (3.3％ vs 12.5％,P ＜0.05).However,tiny bleeding of group A was higher than group B (13.3％ vs 3.1％,P ＜0.05).Conclusions Ticagrelortreatment can improve the prognosis of STEMI receiving primary PCI,but increase the risk of bleeding.
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Objective To investigate the relationship between the severity of coronary artery disease and malignant arrhythmia in the acute ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), and guide clinical prevention and treatment .Methods By retrospective analysis method , 418 cases of hospitalized patients with a diagno-sis of STEMI undergoing direct PCI were continuously collected in the Department of Cardiology , the First Affiliated Hospital of China Medical University, from 2008 January to 2010 December.Electrocardiography (ECG) was given after admission.Those patients were divided into two groups according to whether the occurrence of malignant ventricular arrhythmias that was defined as sustained ventricu -lar tachycardia (sVT) or ventricular fibrillation (VF)].In sVT/VF patients, the preoperative and postoperative groups were divided according to sVT/VF time.The degree of coronary artery lesions was calculated in patients with STEMI .The incidence of sVT/VF was counted in each group with Gensini scores I, fast heart rate , low blood pressure , and low ejection fraction were risk factors of sVT/VF( P <0.05).The occurrence of sVT/VF among the Gensini groups were significant difference (7.1%vs 10.8%vs 20.5%, P =0.012 ) .⑵The occurrence of sVT/VF was 44.8% ( 22 patients ) with direct PCI before operation; the preoperative sVT/VF rate among the Gensini groups had significant difference (2.1%vs 5.9%vs 9.6%, P =0.045).⑶The occurrence of sVT/VF is 53.3%(25 patients) with direct PCI after operation; the postoperative sVT/VF rate among Gensini groups had no significant difference(5.0%vs 4.9%vs 11.0%, P =0.142);⑷Paired with age ( x±2), gender, hypertension, and diabetes 1, Logistic re-gression analysis showed that the heart rate greater than 80 beats /min ( P =0.04 , OR:2.667 , 95%CI:1.043~6.815 ) was an independent risk factor of preoperative sVT/VF, that Gensini score was not an independent risk factor of preoperative malignant ar -rhythmia.Conclusions For STEMI PCI patients, the more serious the degree of coronary artery is , the higher may be preoperative malignant arrhythmia , while the postoperative malignant arrhythmia rate has no significant difference .
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As síndromes coronarianas agudas sem supradesnivelamento do segmento ST são causadas, na maioria das vezes, por instabilização ou ruptura da placa de ateroma, com consequente formação de trombo não oclusivo. A escolha adequada de antiplaquetários é fundamental no tratamento, com redução dos eventos isquêmicos e da mortalidade. O objetivo deste artigo é a revisão crítica atualizada dos principais agentes antiplaquetários disponíveis para uso no Brasil, os mecanismos de ação de cada droga, bem como suas indicações e contraindicações em pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST. A aspirina, isoladamente, é capaz de reduzir eventos de forma significativa. Sua associação com derivados tienopiridínicos, principalmente com o clopidogrel, acarretou sinergismo de ação com importante redução de eventos adversos. Novas drogas surgiram, gerando redução de recorrência de infarto e aumento nas taxas de sangramento, tornando mais complexa a escolha de antiplaquetários. O prasugrel, na sala de hemodinâmica, é opção basicamente nos pacientes que não receberam clopidogrel e que se submetem à angioplastia precoce, com baixo risco de sangramento avaliado por escores. O ticagrelor é uma opção ao clopidogrel para pacientes submetidos a tratamento invasivo, com possível benefício adicional na mortalidade. A escolha de antiplaquetários deve ser individualizada, conforme as circunstâncias definidas no texto, conforme o perfil de risco hemorrágicoe também conforme o perfil de risco de morte ou infarto do paciente.
Acute coronary syndromes without ST segment elevation are usually caused by destabilization or rupture of the atheroma plaque and the subsequent formation of non-occlusive thrombus. The right choice of antiplatelet drugs is crucial for treatment and to reduce both ischemicevents and mortality. This paper provides an updated critical review of the main antiplatelet drugs available in Brazil, describing the mechanisms of action, indications and contraindications of each drug for patients with acute coronary syndrome without ST segment elevation.Aspirin alone is capable of reducing events significantly. Its association with thienopyridine derivatives, especially with clopidogrel leads to synergisms and meaningful reduction of adverse events. Choosing the most adequate antiplatelet drug has become increasingly difficultas new drugs have been developed, which have reduced infarction recurrence but increased bleeding rates. Prasugrel is basically an option for patients that have not been treated with clopidogrel and undergo angioplasty in early stages, with low risks of bleeding as assessedthrough scores. Ticagrelor is an alternative to clopidogrel for patients that have undergone invasive treatment. The choice of antiplatelet drugs should be individualized for each patient, according to circumstances herein described, and according to patients? death and bleeding risk rankings.
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Humans , Myocardial Infarction/drug therapy , Platelet Aggregation Inhibitors/therapeutic use , Aspirin/therapeutic use , Ticlopidine/therapeutic useABSTRACT
O infarto com supradesnivelamento do segmento ST (IAMCSST) é uma importante causa de morbimortalidade no Brasil. O tratamento ideal para o IAMCSST depende principalmente do diagnóstico precoce e da rápida seleção de estratégia de reperfusão apropriada. A angioplastia coronária percutânea (ICP) primária é a estratégia de escolha em hospitais com serviço de hemodinâmica. Em hospitais sem esse serviço, duas estratégias de reperfusão são possíveis: transferência para ICP primária ou terapia com trombolíticos. A ICP primária apresenta melhores resultados, com redução de eventos cardiovasculares, entretanto, essa vantagem pode ser perdida, dependendo do tempo de atraso para transferência. A criação de rede de cuidado para pacientes com IAMCSST é um desafio para nosso município e pretende possibilitar o acesso à terapia de reperfusão em tempo adequado, levando em consideração as condições clínicas do paciente e do sistema de saúde em que ele é atendido.
Myocardial infarction with ST segment elevation is one of the major causes of morbimortality in Brazil. The ideal treatment for the disease depends mostly on early diagnosis and choice of adequate reperfusion strategy. Primary percutaneous coronary angioplasty (PCI) is a strategywidely adopted in hospitals that provide cardiac services, whereas hospitals without such services usually adopt either transfer for PCI or therapy with thrombolytic drugs. Primary PCI usually provides better results, reducing cardiovascular events, but this may not be effective in the event of significant transference delay. The creation of a health care network for patients with the disease is a challenge in our Municipality that can provide access to reperfusion therapy as soon as possible considering both patients? clinical conditions and health insurance.
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Humans , Patient-Centered Care , Myocardial Infarction/therapy , Critical Pathways , Acute Coronary Syndrome/drug therapy , Angioplasty , Fibrinolytic Agents/therapeutic use , Myocardial Infarction/historyABSTRACT
ObjectiveTo assess the effects and safety of glycoprotein Ⅱ b/Ⅲ a receptor inhibitors tirofiban( intracoronary administration and venous maintenance) combined with DIVERTM CE thrombus-aspiration catheter in the percutaneous coronary intervention (PCI)-treated patients with acute ST-segment elevation myocardial infarction (ST-EMI).Methods Sixty patients with ST-EMI who underwent PCI were randomized into two groups.Thirty-two patients in group A were treated with tirofiban,twenty-eight patients in group B were treated with tirofiban and thrombus-aspiration catheter.Between two groups,the thrombolysis in myocardial infarction (TIMI) risk score,hemorrhagic complications,and incidence of major adverse cardiovascular events (MACE) were compared.ResultsThe TIMI flow was improved in both groups,and it was better in group B than group A ( P ＜ 0.05 ).The incidence of MACE in group B was lower than group A (25.0％ vs 3.6％,P ＜0.05). No fatal hemorrhagic complications were found in both groups.ConclusionsApplication of tirofiban and DIVERTM CE thrombus-aspiration catheter is safe and effective in ST-EMI patients,which can greatly improve myocardial reperfusion and reduce incidence of MACE.
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O infarto do ventrículo direito (VD) não é entidade clínica rara. É observado em 10 a 50% dos pacientes com infarto da parede inferior do ventrículo esquerdo (VE). Estão agrupados nesse amplo espectro diagnóstico os pacientes com disfunção ventricular leve, assintomáticos e aqueles em choque cardiogênico. O reconhecimento do infarto do VD é importante, porque se associa a mais morbi e mortalidade imediatas, além de apresentar prioridade de tratamento específico. O diagnóstico do infarto do VD é baseado em sinais clínicos, eletrocardiográficos, hemodinâmicos e ecográficos. A abordagem adequada do infarto do VD inclui medidas para manter a pré-carga adequada e reduzir a pós-carga do VD, suporte inotrópico, e manutenção do sincronismo átrio-ventricular. A terapia de reperfusão miocárdica com fibrinolítico ou a angioplastia primária deve ser indicada e iniciada precocemente. A maior parte dos pacientes que sobrevivem ao infarto do VD tem resolução completa das alterações hemodinâmicas com o restabelecimento da função do VD no decorrer de semanas a meses, sugerindo que ?atordoamento? do miocárdio direito, em vez de necrose irreversível, ocorre com mais frequência.
Right ventricle infarction (RVI) is not a rare clinical entity. It complicates 10 to 50% of patients with inferior wall myocardial infarctions. Under the term RVI we can find mild, asymptomatic dysfunction of right ventricle and cardiogenic shock as well. Recognition of the syndrome of RVI is important as it is associated with considerable immediate morbidity and mortality and has a well-delineated set of priorities for its management. Diagnosis is based on clinical signs, electrocardiographic findings, hemodynamic measurements and echographic evaluations. The proper management of RVI includes volume loading to maintain adequate right ventricular preload, ionotropic support, reduction of right ventricular afterload and maintenance of atrioventricular synchrony. Early reperfusion with fibrinolytic therapy or direct angioplasty should be initiated at the earliest signs of right ventricular dysfunction. Most patients who survive RVI have complete resolution of hemodynamic abnormalities with restoration of proper right ventricle function over a period of weeks to months, suggesting right ventricular stunning rather than irreversible necrosis has occurred.
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Objective To investigate the effects of rapamycin eluting stent(Cypher~(TM)) and metal bare stent on the prognosis and C-reactive protein(CRP) in elderly patients with acute myocardial infarction(AMI).(Methods The) immediate angiographic and clinic follow-up outcomes of 45 elderly patients with AMI reciving Cypher~(TM) and bare stent were retrospectively analyzed.CRP levels in Cypher~(TM) and bare stent groups were determined before implantation,6 h,1 d,7 d and 30 d after implantation.Clinical follow-up and major coronary events analysis were developed after operation.Results 27 rapamycin eluting stents were implanted in patients of Cypher~(TM) group and(26 bare) stents were implanted in patients of bare stent group.The Cypher~(TM) stents were successfully implanted with 100%.In patients of Cypher~(TM) group,no serious complications were found in the term of operation and in hospital.There was no restenosis,revascularization and events.In patients of bare stent group,except for(1 patients) with sudden death,angina pectoris occurred in 2 patients,repeat angiography showed that there were new lesions in other coronary arteries of these patients.Restenosis attacked in 2 patients.The concentrations of CRP in Cypher~(TM) and bare stent groups 6 h and 7 d after operation were much higher than that of(pre-operation (P
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0.05).Myocardial perfusion defect scores were decreased significantly from 14.8?3.0 to 10.5?1.8(P