A intervenção precoce do paciente com síndrome coronariana aguda e sua implicação na redução da morbimortalidade cardiovascular / The early intervention of acute coronary disease and its implication in the reduction of cardiovascular morbimortality

Introdução. O infarto agudo do miocárdio apresenta significativas taxas de morbimortalidade. A reperfusão precoce por angioplastia primária é a intervenção que reduz a mortalidade e as complicações, e deve ser iniciada em até 12 horas, a fim de impedir a perda muscular irreversível. O tempo entre chegada do paciente ao hospital e a abertura da artéria acometida, tempo porta-balão, determina a morbimortalidade do paciente. Objetivo. Esse estudo busca analisar o potencial benefício do tratamento da reperfusão coronariana precoce, os fatores de risco, as possíveis complicações e o Killip em pacientes que sofreram infarto agudo do miocárdio relacionando-os a sua morbimortalidade. Materiais e métodos. Estudo observacional transversal realizado por meio de coleta de dados dos prontuários dos pacientes submetidos a angioplastia primária de um hospital privado. Resultados. A hipertensão arterial sistêmica foi a variável mais prevalente (75%), e que houve predomínio no sexo masculino (71%) e associação com a progressão da idade. 61% dos pacientes apresentaram um tempo porta balão menor que 90 minutos. Houve significância estatística entre o tempo porta balão e a evolução do Killip, evidenciando um tempo porta-balão maior que 90 minutos na maioria dos pacientes que obtiveram aumento da pontuação do Killip. Conclusão. A precocidade da intervenção no paciente com IAM impacta na morbimortalidade, visto que o tempo porta balão está diretamente associado a evolução da do Killip. Logo, deve-se identificar os fatores que interferem no atendimento, a fim de proporcionar uma intervenção otimizada. (AU)

Introduction. Acute myocardial infarction has significant rates of morbidity and mortality. Early reperfusion by primary angioplasty is the intervention that reduces mortality and complications, and should be started within 12 hours in order to prevent irreversible muscle loss. The time between the patient's arrival at the hospital and the opening of the affected artery, door-to-balloon time, determines the patient's morbidity and mortality. Objective. The proposition of this study is to analyze the potential benefits of early coronary reperfusion, associated with the risk factors, possible complications, and the Killip score in patients whit acute myocardial infarction (AMI) and the relation of those factors with the morbidity and mortality. Materials and methods. This is a transversal observational study and uses data collected of medical records of patients subjected to primary angioplasty in a private hospital. Results. Systemic arterial hypertension was the most prevalent one (75%), it was more common in males (71%) and associated with a higher age. In 61% of the patients port-balloon time was less than 90 minutes. There was statistical significance between port-balloon time and Killip score evaluation, that showed a higher score in patient with a port-balloon time that exceeded 90 minutes. Conclusion. Early intervention in patients with AMI impacts morbimortality, once that the port-balloon time is directly associated with the Killip score results. Therefore, all factors that can lead to a delay in their care of those patients should be identified with the objective of optimize the intervention. (AU)

Pharmacoinvasive strategy versus primary angioplasty in patients with acute ST-segment elevation myocardial infarction / Estrategia farmacoinvasiva versus angioplastia primaria en pacientes con infarto agudo al miocardio con elevación del segmento ST

Abstract: Background: Primary percutaneous coronary intervention (PPCI) is the treatment of choice for acute ST-elevation myocardial infarction (STEMI). The delays associated with PPCI reduce the benefits of this therapy. To minimize these delays, the pharmacoinvasive strategy (PS) was developed, consisting of applying thrombolytic therapy followed by coronary angioplasty 2 to 24 hours after. Objective: To compare the safety and efficiency of PPCI vs PS in STEMI. Methods: We included patients with STEMI who had emergency PCI. The primary endpoint was combined major adverse cardiac events (MACE), death, reinfarction, stroke, target vessel revascularization (TVR) during hospitalization. The secondary endpoints were the individual components of MACE, and major bleeding (Bleeding Academic Research Consortium: BARC ≥ 3). Results: A total of 400 patients, 263 (65.8%) for PPCI group, 114 (28.5%) for PS group and 23 (5.75%) for diagnostic group. The PS group, 79 (69.3%) were then categorized as systematic angioplasty having had a successful thrombolysis, and 35 (30.7%) were rescue angioplasty because they had a failed thrombolysis. There were no differences in MACE: 13 (9.5%) patients in PS and 27 (10.3%) patients in the PPCI (p = 0.806), there were no differences in the individual components of MACE. The rate of major bleeding was the same, 5 (3.6%) and 4 (1.5%) respectively (p = 0.173). The multivariate analysis did not show a relationship between MACE and the reperfusion strategy. Conclusions: The pharmacoinvasive strategy when compared to PPCI has a similar rate of primary and secondary endpoints. There is no increase in major bleeding therefore, it is an important strategy that offers a reperfusion therapy for patients with STEMI in a non-PCI capable hospital.(AU)

Resumen: Antecedentes: La intervención coronaria percutánea primaria (ICPP) es el tratamiento de elección en infarto agudo al miocardio con elevación del ST (IAMCEST). El retraso relacionado con ICPP disminuye el beneficio. Buscando una reperfusión oportuna se implementa la estrategia farmacoinvasiva (EFI), que consiste en realizar trombólisis seguido de ICP entre 2 a 24 horas después. Objetivo: Comparar la seguridad y eficacia en pacientes sometidos a ICPP contra EFI en IAMCEST. Métodos: Se incluyeron pacientes con IAMCEST sometidos a ICP emergente. El punto final primario son eventos cardiacos adversos mayores (ECAM), muerte, reinfarto, evento vascular cerebral y revascularización del vaso tratado, durante la hospitalización. Los puntos finales secundarios son la presencia de los componentes individuales del ECAM, y el sangrado mayor (BARC ≥ 3). Resultados: Se estudiaron 400 pacientes, 263 (65.8%) de ICPP, 114 (28.5%) a EFI y 23 (5.75%) angiografía diagnóstica. Del grupo EFI, 79 (69.3%) fueron angioplastia sistemática por trombólisis exitosa y 35 (30.7%) por angioplastia de rescate por trombólisis fallida. No se observó diferencia en la frecuencia de ECAM: EFI 13 (9.5%) contra ICPP 27 (10.3%) respectivamente (p = 0.806), tampoco hubo diferencia en los componentes individuales. No se observó diferencia en sangrado mayor, 5 (3.6%) vs 4 (1.5%), (p = 0.173). El análisis multivariado no relacionó la estrategia de reperfusión con los ECAM. Conclusiones: La EFI comparada con ICPP demuestra una tasa similar de ECAM, así como de sus componentes individuales. No se asocia con aumento de hemorragia mayor, concluyendo que ofrece el beneficio de una reperfusión oportuna sin aumento del riesgo en los hospitales que no tienen la capacidad para realizar ICPP.(AU)

Immediate multivessel revascularization may increase cardiac death and myocardial infarction in patients with ST-elevation myocardial infarction and multivessel coronary artery disease: data analysis from real world practice

BACKGROUND/AIMS: The best revascularization strategy for patients with both acute ST-elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) is still debatable. We aimed to compare the outcomes of multivessel revascularization (MVR) with those of culprit-only revascularization (COR). METHODS: A cohort of 215 consecutive patients who had received primary angioplasty for STEMI and MVD were divided into two groups according to whether angioplasty had been also performed for a stenotic nonculprit artery. The primary endpoint was one-year major adverse cardiac events defined as a composite of cardiac death, recurrent myocardial infarction, or any repeat revascularization. RESULTS: One-year major adverse cardiac events were not significantly different between MVR (n = 107) and COR (n = 108) groups. However, the one-year composite hard endpoint of cardiac death or recurrent myocardial infarction was notably increased in the MVR group compared to the COR group (20.0% vs. 8.9%, p = 0.024). In subgroup analysis, the hard endpoint was significantly more frequent in the immediate than in the staged MVR subgroup (26.6% vs. 9.8%, p = 0.036). The propensity score-matched cohorts confirmed these findings. CONCLUSIONS: In patients with STEMI and MVD, MVR, especially immediate MVR with primary percutaneous intervention, was not beneficial and led to worse outcomes. Therefore, we conclude that COR or staged MVR would be better strategies for patients with STEMI and MVD.

Adenosina intracoronaria durante la angioplastía primaria para la preservación del flujo coronario / Intracoronary adenosine during primary angioplasty and coronary flow preservation

Introducción: El uso de adenosina intracoronario durante la angioplastía coronaria ha sido controversial en los últimos años. El beneficio teórico en el flujo epi-cárdico y microcirculatorio (MC) no se ha demostrado categóricamente en estudios clínicos. Objetivo: Evaluar el efecto de protección de la MC y del flujo epicárdico al utilizar adenosina intracoronaria durante la AP. Métodos: Estudio clínico randomizado multicéntrico, caso-control con análisis post hoc ciego, en pacientes portadores de SCA con SDST. Un total de 122 pacientes aleatorizados 1:1, se consideró caso (A(+)) aquel que se administró adenosina en dosis de 120 microgramos intracoronario en bolo y luego infusión periférica de 6mg en 33ml de suero fisiológico a pasar en 2-3 minutos Se evaluaron criterios clínicos, angiográficos y electrocar-diográficos de reperfusión epicárdica y microvascular. Observadores ciegos evaluaron el conteo de cuadros TIMI (cTFC) y "blush" miocárdico (BM). Se compararon las características clínicas, angiográficas basales y los resultados angiográficos finales entre ambos grupos, usando t-Student, prueba de Mann-Whitney, Chi cuadrado y test exacto de Fisher según correspondiera. En todos los pacientes se evaluó la resolución del SDST con el score de ST. Además, se evaluó las posibles complicaciones por uso de adenosina intracoronaria. Resultados: Entre 2012-2014 se reclutaron 122 pacientes. Al comparar las características basales entre el grupo A(+) vs los A(-) no hubo diferencias significativas en la edad (59+/-10 años para A(+) vs 58+/-10 años para A(-), p:0,97), ni en las comorbilidades. Al comparar las características angiográficas basales, no se encontró diferencias en los vasos culpables (ADA 44% en A(+) vs 43% en A(-), p:0.57), en las cargas trombóticas (Alta carga: 69% para A(+) vs 74% para A(-), p:0.53), en el flujo TIMI pre (TIMI 0-1 86% para ambos grupos, p:0,69), cTFC pre (87+/-23 cuadros en A(+) vs 88+/-25 cuadros en A(-), p:0.99), Killip de ingreso (Killip I, 86% para A(+) vs 76% para A(-), p:0,11) y fracción de eyección (51+/-8% para A(+) vs 48+/-9% para (-), p:0,61). Al evaluar los resultados angiográficos finales encontramos diferencias significativas en el flujo TIMI (TIMI 3 96% para grupo A(+) vs 74% para grupo A(-), p:0,002). No encontramos diferencias significativas en el BM (Blush 3 73% para ambos grupos, p:0.74), el cTFC final (24+/-11 cuadros en A(+) vs 26+/-12 cuadros en A(-), p:0,85). Si consideramos cTFC <23cuadros como éxito angiográficos, tampoco encontramos diferencias significativas (56% para A(+) vs 53% para A(-), p:0,45). Por último tampoco hubo diferencias significativas con la resolución del segmento ST (44% para A(+) vs 58% para A(-), p:0,126). Conclusión: De acuerdo a los resultados obtenidos podemos inferir que la adenosina intracoronaria cumple un rol en la conservación óptima del flujo epicárdico coronario, pero sin influir en la microcirculación. Mayores estudios se requieren para determinar si se traduce en algún beneficio clínico.

Background: The effect of Intracoronary adenosine for coronary flow preservation during primary PTCA is debatable. Clinical studies have not established a benefit of adenosine administration upon epicar-dic or microcirculatory flows. Aim: to evaluate micro circulatory flow preservation after administration of intracoronary adenosine during primary PTCA. Method: From 2012 to 2014, 122 patients with ST elevation myocardial infarction randomized to either adenosine of control (2:1) were included in a controlled clinical trial. Adenosine was administered in a 120 mg bolus followed by 6mg solution during 2 to 3 min. Epicardic and micro vascular flows were evaluated through clinical, angiographic, electrocardiographic and reperfusion variables. TIMI (cTFC) and myocardial "blush" were measured by blind observers. Results: Basal characteristics, namely age and co-morbidities were similar between groups. Also, the distribution of coronary vessels involved in MI was similar with a preponderance of the LAD artery. There was an high proportion of patients with an elevated thrombus load (Adenosine 69%, controls 74%) ; TIMI flow 0-1 was 86% in both groups and TIMI cTFC was not different (adenosine: 87±23 , controls 88±25 ). Over 75% of patients were Killip I, and the ejection fraction was slightly decreased (adenosine 51±8% , controls 48±9% , NS). In contrast, TIMI flow was significantly greater for adenosine (TIMI 3 96% for adenosine and 74% for controls, p=0.002). No difference was observed in myocardial blush (B 3 73% in both groups) nor cTFC (24±11 vs. 26±12, respectively). Finally, regression of ST elevation was similar in both groups. Conclusion: Intracoronary adenosine during PTCA in ST elevation MI was associated to a better epicardial but not microvascular flow. Further study is needed to evaluate the eventual clinical benefit of these effects.

Angioplastia primaria en el infarto agudo de miocardio: predictores de eventos en el seguimiento a largo plazo / Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction: Long-Term Predictors of Adverse Events

Introducción: El infarto agudo de miocardio (IAM) es una de las principales causas de muerte cardiovascular. Los tratamientos de reperfusión, aplicados dentro de las primeras horas del evento, han contribuido a disminuir significativamente esa mortalidad. No existen en nuestro país registros con seguimiento a largo plazo de pacientes con IAM tratados con angioplastia transluminal coronaria primaria (ATCP). Objetivos: Evaluar los resultados intrahospitalarios y el pronóstico alejado de pacientes sometidos a ATCP por IAM con supra-desnivel del segmento ST (IAMCST) y su relación con las principales variables clínicas y terapéuticas aplicadas en diferentes décadas (1993-2002 vs. 2003-2012). Material y métodos: Estudio observacional y retrospectivo de todos los pacientes con diagnóstico de IAMCST a los que se les realizó una ATCP en dos hospitales de comunidad entre los años 1993 y 2012. Resultados: Se incluyeron 851 pacientes ingresados consecutivamente entre los años 1993 y 2012. La edad promedio fue de 61 ± 12 años y la mediana de seguimiento fue de 7,8 años en el 85% de la población. La mortalidad intrahospitalaria total fue del 6% y del 1,6% excluidos los pacientes con shock al ingreso; las variables independientes asociadas fueron la edad (OR 1,06, IC 1,03-1,09; p < 0,001), el sexo femenino (OR 3,1, IC 1,5-6,2; p < 0,002), la diabetes mellitus (OR 3,9, IC 1,86-8; p < 0,001) y la enfermedad de tres vasos coronarios (OR 4,3, IC 2,1-8,6; p < 0,001); el flujo final TIMI 3 fue una variable predictora de menor mortalidad intrahospitalaria (OR 0,28, IC 0,08-0,11; p < 0,008). La mortalidad global en el seguimiento fue del 14,3% y los predictores independientes fueron la edad (OR 3,1, IC 1,8-5,5; p < 0,001), la diabetes mellitus (OR 2,3, IC 1,25-4,3; p < 0,007) y la clase C o D de la clasificación de Killip y Kimball (KK) al ingreso (OR 4, IC 1,7-9; p < 0,001); la utilización de stent se asoció con menor mortalidad global alejada (OR 0,35, IC 0,21-0,6; p < 0,001). Conclusiones: En este grupo de pacientes con IAMCST, la ATCP aplicada adecuadamente y una elevada tasa de seguimiento alejado permitió obtener resultados intrahospitalarios favorables que se mantienen en el largo plazo. La edad avanzada al momento del IAMCST, la diabetes mellitus, el sexo femenino y la presencia de lesiones significativas en más de un vaso epicárdico mayor fueron los predictores de mortalidad intrahospitalaria, mientras que los dos primeros (edad y diabetes mellitus) y el KK C o D fueron predictores independientes de mortalidad en el seguimiento. Los pacientes asistidos durante la segunda década mostraron una tendencia no significativa a menor mortalidad intrahospitalaria en comparación con los de la primera década.

Introduction: Acute myocardial infarction (AMI) is one of the leading causes of cardiovascular death. Reperfusion treatments performed within the first hours have contributed to produce a significant reduction in mortality. In our country, there are no long-term follow-up registries of AMI patients treated with primary percutaneous coronary intervention (PCI). Objectives: The aim of this study is to evaluate the in-hospital results and long-term outcome of ST-segment elevation AMI (STEMI) patients undergoing primary PCI and their correlation with the main clinical and therapeutic variables applied in different decades (1993-2002 vs. 2003-2012). Methods: We performed an observational and retrospective study of all STEMI patients undergoing primary PCI in two community hospitals between 1993 and 2012. Results: The study included 851 patients consecutively admitted between 1993 and 2012. Mean age was 61 ± 12 years and median follow-up was 7.8 years in 85% of the population. In-hospital mortality was 6% and 1.6% when patients with shock at admission were excluded. It was independently associated with age (OR 1.06, CI 1.03-1.09; p < 0.001), female sex (OR 3.1, CI 1.5-6.2; p < 0.002), diabetes mellitus (OR 3.9, CI 1.86-8; p < 0.001) and three-vessel disease (OR 4.3, CI 2.1-8.6; p < 0.001). Conversely, final TIMI grade 3 flow predicted lower in-hospital mortality (OR 0.28, CI 0.08-0.11; p < 0.008). During follow-up, overall mortality was 14.3% and the independent predictors were age (OR 3.1, CI 1.8-5.5; p < 0.001), diabetes mellitus (OR 2.3, CI 1.25-4.3; p < 0.007) and Killip and Kimball (KK) class C or D at admission (OR 4, CI 1.7-9; p < 0.001); stent implant was associated with lower overall long-term mortality (OR 0.35, CI 0.21-0.6; p < 0.001). Conclusions: In this group of STEMI patients, the adequate use of primary PCI and the high rate of patients at long-term follow-up allowed the collection of favorable in-hospital and long-term results. Advanced age at the moment of STEMI, diabetes mellitus, female sex and multiple vessel disease were predictors of in-hospital mortality, while age, diabetes mellitus and KK class C or D were independent predictors of mortality during follow-up. Patients treated during the second decade showed a non-significant trend towards reduced in-hospital mortality compared with those of the first decade.

Infarto agudo de miocardio con elevación del segmento ST secundario a oclusión aguda del tronco principal de la coronaria izquierda no protegido / Acute myocardial infarction with ST segment elevation secondary to acute occlusion of the unprotected main trunk of the left coronary artery

La oclusión del tronco principal de la arteria coronaria izquierda (tPi) no protegido es poco observada durante la realización de angioplastia primaria en infarto agudo de miocardio, posiblemente en parte por la baja probabilidad de sobrevivir al evento el tiempo suficiente para llegar a un hospital. reportamos cinco casos de pacientes tratados con angioplastia primaria con presentación y evolución clínica diferentes, resaltando la asociacion con choque cardiogénico, su alta mortalidad y el papel de la reperfusión primaria.

Oclussion of the unprotected left main coronary artery (CFI) is rarely observed during primary angioplasty in acute myocardial infarction, possibly in part because of the low probability of surviving the event long enough to get to a hospital. We report fve cases of patients treated with primary angioplasty with different presentation and clinical evolution, highlighting the association with cardiogenic shock, high mortality and the role of primary reperfusion.

Shock cardiogénico / Cardiogenic shock / Choque cardiogênico

El shock cardiogénico (SC) es un cuadro clínico y hemodinámico severo, pero tratable y con razonable chance de recuperación. La literatura tradicional se ha focalizado en su alta mortalidad. Si bien, ello no deja de ser cierto, cada vez existe mayor evidencia de que una revascularización precoz permite a estos pacientes disfrutar de una sobrevida y una aceptable calidad de vida. En las últimas dos décadas, el tratamiento del infarto de miocardio ha experimentado un progreso constante. La mejor comprensión de la fisiopatología de los síndromes coronarios agudos, la introducción de nuevos fármacos y la aplicación de nuevas estrategias de revascularización miocárdica han permitido una reducción progresiva de la mortalidad por infarto en aquellos pacientes que son admitidos en un centro asistencial preparado para su evaluación, diagnóstico y tratamiento. A pesar de ello, la incidencia del SC postinfarto ha permanecido estable, con cifras que fluctúan entre el 5 y el 15% y es la primer causa de muerte intrahospitalaria en pacientes con infarto agudo de miocardio (IAM). A pesar de que el SC se presenta en forma temprana en el contexto de un IAM, no es diagnosticado con suficiente rapidez y su compromiso hemodinámico usualmente es subestimado. La revascularización temprana arroja beneficios a cualquier nivel de riesgo y constituye un objetivo fundamental en el tratamiento de este grave y no tan infrecuente cuadro clínico.

Cardiogenic shock (CS) is a severe clinical and hemodynamic condition, but treatable and with reasonable chance of recovery. Traditional literature has focused on its high mortality. While it continues to be true, there is growing evidence that early revascularization allows patients to have greater survival and an acceptable quality of life. In the past two decades, the treatment of myocardial infarction has experienced steady progress. A better understanding of the pathophysiology of acute coronary syndromes, the introduction of new drugs and new strategies for myocardial revascularization have allowed a progressive reduction in mortality from stroke in patients who are admitted to a hospital prepared for evaluation , diagnosis and treatment. However, the incidence of CS post infarction has remained stable, with values ranging between 5 and 15% and is the leading cause of hospital death in patients with acute myocardial infarction (AMI). Although the CS is in the form early in the context of an AMI, it is not diagnosed quickly enough and hemodynamic compromise is usually underestimated. The early revascularization yields benefits at any level of risk and is a key aim in the treatment of this severe and not so uncommon clinical condition.

Choque cardiogênico (CC) é uma condição clínica grave e hemodinâmica, mas tratável e com razoável chance de recuperação. Literatura tradicional centrou-se na sua alta mortalidade. Enquanto ele continua a ser verdade, há evidências crescentes de que a revascularização precoce permite que os pacientes a desfrutar de uma sobrevivência e uma qualidade de vida aceitável. Nas últimas duas décadas, o tratamento do enfarte do miocárdio tem experimentado progresso constante. Um melhor entendimento da fisiopatologia das síndromes coronarianas agudas, a introdução de novos medicamentos e novas estratégias para revascularização do miocárdio têm permitido uma redução progressiva na mortalidade por acidente vascular cerebral em pacientes que estão internados em um hospital preparado para avaliação, diagnóstico e tratamento. No entanto, a incidência de CC pós infarto manteve-se estável, com valores variando entre 5 e 15% e é a principal causa de óbito hospitalar em pacientes com infarto agudo do miocárdio (IAM). Embora o CC ocorre numa fase precoce no contexto de um IAM, não é diagnosticada com rapidez suficiente e seu compromisso hemodinâmico é geralmente subestimado. A revascularização precoce traz benefícios em qualquer nível de risco e é um objetivo fundamental no tratamento da este grave e não seja tão raro quadro clínico.

Primary Angioplasty for the Treatment of Acute ST Elevated Myocardial Infarction: Single Centre Experience.

Background: Worldwide primary angioplasty is a recommended strategy of reperfusion in patient with acute myocardial infarction as because it ensures reperfusion of the infarct-related vessels more than 90% where as, with thrombolytics it is only 60-70%. Methods: It is a retrospective observational study includes all patients treated with primary angioplasty at United Hospital from Between March 2007 to August 2010. Total 237 consecutive patients with acute myocardial infarction were treated with primary angioplasty were included. Those presented beyond 12 hours of onset of chest pain, in cardiogenic shock, resuscitate and intubated before the procedural were excluded from the study. Results: Majority (76%) of the patient were male, age was minimum 28 years and maximum 80 years, 41.5% were diabetics, 58.4% were hypertensive, 43.5 %were dyslipidaemic, 17% were smoker, 29.3% with positive family history. Fifty seven percent patients presented with anterior MI, 42 % with inferior MI and 1 % with lateral MI. Left anterior descending (LAD) is the most common vessel involved (S7%), followed by Right coronary artery (RCA) 31 %, Left circumflex artery (LCD 8 %, Ramus 1.3 % and Graft vessel 2.7%. Our door to balloon time was minimum 23 min, maximum 184 min. We used drug eluting stents for most of the patients , GP IIbIIIa receptor Mockers used in 50% cases and thrombus suction device were used when indicated. We faced complications like arrhythmias in 24% hypotension in18 %, no flow or slow flow in 45%, cardiac arrest in 3% and coronary perforation in 1. %. Our overall survival was 97.9 %. Conclusion: Primary angioplasty is a emerging area in the context 149-154of our country . Many of the new centers start this novel strategy which helps to save many lives. Primary angioplasty is feasible and safe method of reperfusion in patient with acute myocardial infarction in our center.

Persistencia del supradesnivel del ST postangioplastia primaria exitosa y morbimortalidad intrahospitalaria / Persistence of ST elevation after successful primary angioplasty and in hospital morbimortality

Introducción: en el contexto del infarto agudo de miocardio con elevación del ST (IAMST), la renivelación del segmento ST es uno de los indicadores de reperfusión luego de una angioplastia primaria (ATC 1º) exitosa. La persistencia del supradesnivel del ST en pacientes en los que se logra la restauración adecuada del flujo coronario epicárdico se vincula a lesión microvascular. Método: se estudió de forma prospectiva a todos los pacientes a quienes se realizó ATC1° exitosa en las primeras 12 horas de un IAMST en el Centro Cardiovascular Casa de Galicia desde el 1 julio del 2009 hasta el 30 de setiembre de 2009. Se consideró como renivelación significativa del ST un descenso mayor o igual a 50% comparando el electrocardiograma (ECG) a 1 hora de la ATC con el ECG previo a la misma. El objetivo principal fue estudiar la asociación entre la persistencia del supradesnivel del ST y los eventos adversos cardiovasculares mayores durante la internación. Resultados: se incluyeron 55 pacientes. Se observó persistencia del supradesnivel del ST en 27,3% (15). No encontramos asociación entre la no renivelación y los eventos por separado, pero sí entre la no renivelación y el end point combinado. La incidencia acumulada de eventos en pacientes que no renivelan es de 46,6% vs 17,5% en los que renivelan; RR 2,67 (IC: 95% 1,12-6,32), chi cuadrado (Mantel Haenszel) 4,80, p = 0,028. Conclusiones: la persistencia del supradesnivel del ST post ATC1° exitosa, tiene implicancia pronóstica en cuanto a complicaciones cardiovasculares intrahospitalarias de los pacientes con IAMST.

Introduction: in the context of acute myocardial infarction with ST elevation, the recovery of ST segment is a reperfusion indicator after a successful primary angioplasty (PCI). Persistent ST segment elevation in patients who achieved adequate restoration of epicardial coronary flow is related to microcirculation injury. Methods: we prospectively studied all patients who underwent successful PCI in the first 12 hours of an infarction with ST elevation in Casa de Galicia’s Cardiovascular Center since 1 July 2009 to 30 September 2009. It was considered significant a ST recovery greater than or equal to 50% comparing the electrocardiogram (ECG) 1 hour after PCI with ECG prior to it. The main objective was to study the association between persistent ST segment elevation and major adverse cardiovascular events during hospitalization. Results: 55 patients were included. There was persistence of ST elevation in 27.3% (15). No association was found between ST persistence and events separately, but it was found association between the persistence and the combined end point. The cumulative incidence of events in patients without ST significant recovery is 46.6% versus 17.5% in those with ST recovery; RR 2,67 (CI 95% 1.12 to 6.32), Chi2 (Mantel Haenszel) 4.80 p = 0.028. Conclusions: the persistence of ST segment elevation after successful PCI has prognostic implication in terms of in-hospital cardiovascular complications in patients with acute myocardial infarction with ST segment elevation.

Reperfusion Strategies in Acute ST-segment Elevation Myocardial Infarction

At the most severe end of the spectrum of acute coronary syndromes is ST-segment elevation myocardial infarction(STEMI), which usually occurs when a fibrin-rich thrombus completely occludes an epicardial coronary artery. Timely reperfusion therapy is the best and the most important component of the treatment for STEMI. Several randomized trials and metaanalysis have shown that primary percutaneous coronary intervention(PPCI) is superior to thrombolysis in STEMI therapy. However, PPCI should be regarded as preferred strategy only within a reasonable time delay from onset to treatment, in contrast to thrombolysis. There is a continuing controversy about the acceptable time-window for PPCI in patients with STEMI. Recent American and European guidelines recommend PPCI if the delay in performing PPCI instead of administering fibrinolysis (PCI-related delay) is 60 minutes and the presentation delay is more than 3 hours. Based on a review of the literature, the evidence supports an acceptable PCI-related delay of 80-120 min and PPCI as a better reperfusion strategy also in the high-, medium- risk patients and early incomers. Furthermore, To maximize the number of patients with STEMI eligible for PPCI, the optimal logistic strategy could be the confirmation of the diagnosis in the prehospital phase, to bypass local hospitals, and to re-route patients directly to facilities that can administer catheterization. To obtain the maximal benefit for survival, the optimal antithrombotics and adjuvant drug therapy is necessary.

La glucemia en ayunas como predictor de mortalidad intrahospitalaria en pacientes con infarto agudo de miocardio sometidos a angioplastia primaria / Fasting Glycemia as a Predictor of In-Hospital Mortality in Patients with Acute Myocardial Infarction Undergoing Primary Angioplasty

Introducción El pronóstico de los pacientes que sufren un infarto agudo de miocardio con supradesnivel del ST (IAMST) ha mejorado notoriamente, en particular como resultado de la terapia de reperfusión. A pesar de estos avances, los pacientes con diabetes mellitus (DM) constituyen un grupo de alto riesgo. La hiperglucemia en pacientes con IAMST se asocia con peor pronóstico, independientemente del diagnóstico previo de DM. Objetivo Evaluar el valor pronóstico de la glucemia en ayunas (GA) durante un IAMST tratado con angioplastia primaria. Material y métodos De 227 pacientes con diagnóstico de IAMST se excluyeron 31 con DM y 7 derivados para terapia de rescate tardío. Se registraron la glucemia en la admisión (GAd) y la GA; la población se dividió según la GA en: grupo A ≥ 110 mg/dl (hiperglucémicos) y grupo B < 110 mg/dl (normoglucémicos). Resultados La población en estudio quedó conformada por 189 pacientes. La edad fue de 62,1 ± 10,5 años, sexo masculino 82%, tabaquistas 40%, el tiempo dolor-balón fue de 2,75 horas (25- 75% intercuartiles 2-4,75), el porcentaje con clasificación de Killip & Kimball (KK) ≥ 3 fue del 12,1% y el 38% presentaron localización anterior. Se registraron 15 (7,9%) muertes intrahospitalarias, todas en pacientes hiperglucémicos. Por análisis multivariado, los predictores independientes de mortalidad intrahospitalaria fueron la edad (p = 0,048) y la GA como variable continua (p = 0,002). Para los eventos cardíacos mayores (muerte, reIAM e insuficiencia cardíaca), la clasificación de KK ≥ 3 (p = 0,001), la GA (p = 0,001) y el deterioro moderado/grave de la función sistólica (p = 0,016) fueron sus únicos predictores independientes. La GAd no resultó predictora independiente de muerte o de eventos cardíacos mayores. Conclusiones Los resultados del presente estudio sugieren que la GA posee valor pronóstico a corto plazo en pacientes no diabéticos que cursan un IAMST. La GA identifica tempranamente y en forma sencilla a una población de riesgo alto.

Background The prognosis of patients with acute ST-segment elevation myocardial infarction (STEMI) has considerably improved, particularly due to reperfusion therapy. However, patients with diabetes mellitus (DM) constitute a high risk group. In patients with STEMI, hyperglycemia is associated with adverse prognosis, regardless of the previous diagnosis of DM. Objective To assess the prognostic value of fasting glycemia (FG) in patients with STEMI undergoing primary angioplasty. Material and Methods From a total of 227 patients admitted with STEMI, 31 patients with DM and 7 patients referred to rescue angioplasty were excluded. Glycemia at admission (GAd) and FG were registered; the population was divided according to FG: group A ≥110 mg/dl (hyperglycemic) and group B <110 mg/dl (normoglycemic). Results The study population comprised 189 patients. Mean age was 62.1±10.5years, 82% were men and 40% were current smokers; pain-to-balloon time was 2.75 hours (25-75% interquartile range: 2-4.75); 12.1% had a Killip & Kimball (KK) class ≥ 3, and 38% were anterior wall infarctions. Fifteen patients (7.9%) died during hospitalization; all deaths occurred in hyperglycemic patients. Multivariate analysis identified age (p=0.048) and FG (p=0,002) as independent predictors of mortality; KK class ≥ 3 (p=0.001), FG (p=0.001), and moderate to severe systolic dysfunction (p=0.016) were independent predictors of major cardiac events (death, reinfarction and heart failure). Glycemia at admission was not identified as an independent predictor of death or major cardiac events. Conclusions The results of the present study suggest that FG has a prognostic value in the short term in non diabetic patients with STEMI. Fasting glycemia is a simple tool for the early identification of a high risk population.

Segurança dos stents farmacológicos no infarto agudo do miocárdio em lesões com trombos visíveis à angiografia / Safety of drug eluting stents in acute myocardial infarction in lesions with angiographically detectable thrombi

Objetivo: Demonstrar a segurança dos stents farmacológicos (SF) no IAM em lesões com elevado risco de trombose quando comparados aos stents convencionais. Métodos: Estudo prospectivo não-randomizado em queforam analisados, de forma consecutiva, 86 pacientes submetidos à angioplastia primária, no período de 01/01/2005 a 31/10/2006, que apresentavam lesões tipo B2 ou C e evidência de trombos à angiografia na lesão culpada, definidos como falha de enchimento visualizadaem mais de uma incidência. Foi comparada a ocorrência de trombose subaguda (TSA) e trombose aguda (TA) em um grupo de pacientes que usou SF (Grupo I) com um grupo que usou SC (Grupo II). As características dos dois grupos são: Grupo I: idade média 64,3±12,69 anos; 57,1% hipertensos; 37,1% diabéticos; 25,7% tabagistas; 51,4% dislipidêmicos; 74,2% do sexo masculino; 88,5% fizeram uso de antagonistas do receptor de IIb/IIIa ; nenhum caso de TA e apenas 1 caso de TSA. Grupo II: idade média 66,54±10,81; 57,1% hipertensos (p=0,19); 15,6% diabéticos (p=0,02); 35,2% tabagistas (p=0,35); 62,7% dislipidêmicos (p=0,29); 84,3% fizeram uso de antagonistas do receptorde IIb/IIIa (p=0,36); nenhum caso de TA e TSA. Resultados: Os grupos analisados foram homogêneos,não apresentando significância estatística para os elementos analisados à exceção do maior número de pacientes diabéticos no Grupo I. A diferença entre os grupos de trombose aguda ou subaguda não atingiu relevância estatística. Conclusão: O uso de SF no IAM em lesões com trombos visualizados à angiografia é seguro e não está associado a um aumento da incidência de trombose quandocomparado ao stent convencional.

Objective: To demonstrate the safety of drug eluting stents (DES) in AMI in lesions with high risk of thrombosis when compared to conventionalstents. Methods: Non-randomized prospective study of 86 consecutive patients submitted to primary angioplasty from January 1st 2005 to October 31st 2006 who presented type B2 or C lesions and evidence of thrombus in angioplasty in the affectedlesion, defined as a filling gap visualized in more than one incidence. The occurrence of subacute thrombosis (SAT) and acute thrombosis (AT) werecompared between a group of patients that used DES (Group I) and a group that used CS (Group II). The characteristics of both groups are: Group I: mean age 64.3±12.69 years; 57.1% hypertensive; 37.1% diabetic; 25.7% tobacco users; 51.4%dyslipidemic; 74.2% males; 88.5% used IIb/IIIa receptor antagonists; no cases of AT and only one case of SAT. Group II: mean age of 66.54±10.81years; 57.1% hypertensive (p=0.19); 15.6% diabetic (p=0.02); 35.2% tobacco users (p=0.35); 62.7%dyslipidemic (p=0.29); 84.3% used IIb/IIIa receptor antagonists (p=0.36); no cases of AT or SAT. Conclusion: The use of DES in AMI in lesions withthrombi visualized in angiography is safe and is not associated with an increase in the incidence of thrombosis when compared to conventional stent.

Leucocitosis y su asociación con eventos cardiovasculares adversos en sujetos con infarto y elevación de ST sometidos a intervención coronaria percutánea / Leucocytosis associated with higher incidence of adverse cardiovascular events in myocardial infarcts

En la fase aguda de un infarto miocárdico los leucocitos se han relacionado con eventos cardiovasculares mayores adversos, (ECMA) esta asociación en pacientes llevados a reperfusión mecánica no se ha determinado con exactitud. Se estudió prospectivamente si existe asociación entre reperfusión mecánica, leucocitos y ECMA. En 5 años se ingresaron 271 pacientes con infarto agudo; 93 con < 10,000/µL leucocitos (8,300 ± 1,254/µL) y 178 tuvieron > 10,000/µL (13,810 + 3,192/µL, p 0.0001). No se observó diferencia estadísticamente significativa entre ambos grupos en las variables demográficas. El grupo con leucocitosis tuvo la mayor incidencia de flujo TIM I 0 - 1, (89% vs 75%, p 0.004) y ECMA hospitalarios (32% vs 14%, p 0.001) y en el seguimiento (5% vs 2%, p 0.04). La regresión logística que incluyó: edad > 60 años, diabetes, infarto anterior o inferior extenso, flujo TIMI (0, 1 y 2), choque cardiogénico, leucocitosis y neutrofilia tuvo mayor relación con mortalidad (p = 0.0007, RM 1.40, IC 95% 0.410-4.841). La regresión múltiple con leucocitosis y neutrofilia tuvo la correlación más fuerte para ECMA (mortalidad, r = 0.34 y choque, r = 0.27) y flujo TIMI basal subóptimo (r = 0.20). Conclusión: Los resultados establecen una asociación entre leucocitosis, trombosis y EMCA y extienden este conocimiento a la fase aguda y en el seguimiento de un infarto con elevación del ST llevado a ICP Estos hallazgos podrían considerarse como una evidencia más de la interacción entre disfunción endotelial (inflamación-aterotrombosis) y enfermedad cardiovascular.

In acute phase leukocytes has been related with higher incidence of major adverse cardiovascular events, (MACE) this evidence in AMI ST elevation after mechanical reperfusion is poor. We study prospectively this group to relationship among mechanical reperfusion, leukocytes and MACE. Two groups were considered < 10,000/µL or > 10,000/µL; 271 patients had full inclusion criteria in a 5 year period; 93 had < 10,000/µL leukocytes. (8,300 ±1,254/µL) and 178 > 10,000/µL (13,810 + 3,192/µL, p 0.0001). We did not observe any difference between both groups regarding demographic characteristics. At beginning leukocytosis group had higher flow TIMI 0 - 1 incidence (89% vs 75%, p 0.004) and in - hospital major cardiovascular adverse events (32% vs 14%, p 0.001) and in follow- up (5% vs 2%, p 0.04). Logistic regression model include > 60 years - old, diabetes, extensive anterior or inferior infarction, TIMI flow 0, 1, or 2, cardiogenic shock, leukocytosis and neuthrophilia, had close relationship with mortality (p = 0.0007, RM 1.40, IC 95% 0.410 -4.841). Multiple regression that include leukocytosis and neuthrophlia had stronger correlation with major cardiovascular adverse events (mortality, r = 0.34 and cardiogenic shock, r = 0.27) and abnormal TIMI flow (r = 0.20). Conclusion: Our results confirm close relationship among leukocitosis, thrombosis and major cardiovascular adverse events and extend this knowledge to acute phase and follow- up in acute myocardial infarction ST elevation under percutaneous coronary intervention. These results could be considered as evidence that connecting between endotelial dysfunction (inflammation-atherothrombosis) and cardiovascular disease.

A Prospective Study of Reperfusion Arrhythmias in Primary Coronary Angioplasty for Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: Arrhythmia is known to be a major cause of death in acute myocardial infarction (AMI). Reperfusion arrhythmias (RA) may also occur during angioplasty or thrombolysis. As yet, the clinical significances of RA and angiographic characteristics of the patients who develop RA during primary angioplasty and stenting are not clearly defined. METHODS: The study group consisted of 60 patients treated with primary angioplasty or stenting for AMI (angioplasty 13, stenting 47 patients). The patients were classified into 2 groups according to RA [RA (-) N=36/RA(+) N=24]: demographic and angiographic characteristics including time to reperfusion and incidence of pre-infarct angina were analyzed. RESULTS: The RA occurred in 40% of patients undergoing primary angioplasty or stenting (24/60 patients). The minor arrhythmias were more common after reperfusion (transient bradycardia 14, accelerated idioventricular rhythm 11, premature ventricular contraction 4 cases): major arrhythmias were uncommon (ventricular tachycardia/fibrillation 5, asystole 1 case). In the two groups, baseline clinical characteristics were similar except for pain to reperfusion time [RA (-): RA (+)=490.8+/-291.7: 252.9+/-109.2 minutes, P=0.001]. There was a trend toward a greater incidence of RA in the right coronary infarct-related artery [RA (-): RA (+)=16.7: 41.7%, P=NS]. The RA occurred in totally occluded artery (TIMI 0) with a giant thrombus and first ballooning in 19/24 patients (79.2%). The RA disappeared with conservative managements including pacemaker insertion and cardiopulmonary resuscitation and there were no differences in major adverse cardiac events in the two groups during follow-up. CONCLUSIONS: These findings suggest that the RA are frequent events during primary angioplasty but unrelated to clinical and angiographic characteristics except for reperfusion time and do not influence short-term prognosis in AMI.

Long or Multiple Stenting in Primary Angioplasty

BACKGROUND: Primary stenting as a direct reperfusion procedure after acute myocardial infarction might reduce recurrent myocardial infarction and target vessel revascularization. However, result of long or multiple stenting in the long or tandem lesions were not known. METHOD: From Jan. 1996 to Dec. 1998, patients with acute myocardial infarction including cardiogenic shock were undergone primary stenting using long or multiple stent. The clinical end points were death, recurrent infarction, subsequent bypass surgery, or repeat angioplasty of the infarct-related vessel. The results were compared with age, sex, lesion, and risk matched standard stenting group. RESULT: Baseline characteristics were similar for the 20 patients who underwent standard length stenting and the 13 patients who underwent long or multiple stenting. Stent diameter was similar in two group (3.4+/-0.3 mm vs. 3.5+/-0.4 mm, p=0.65), but total stent length was longer in long or multiple stenting group (15.5+/-1.8 mm vs. 40.18.4 mm, p=0.01). Average numbers of stent using in multiple stenting were 1.5+/-0.7. Stenting in the infarct-related artery was successful in all patients randomized to stent treatment. At 6 months, the incidence of the primary end point was 25% (5/20) in the standard stent group and 31%(4/13) in the long or multiple stent group (p=0.5). CONCLUSION: Outcomes of long or multiple stenting including mortality, recurrent myocardial infarction and target vessel revascularization was similar to standard stenting. Long or multiple stenting after acute myocardial infarction may possible procedure in some selective cases having long or tandem lesion.