Your browser doesn't support javascript.
Show: 20 | 50 | 100
Results 1 - 20 de 1.612
Article | IMSEAR | ID: sea-220333


Background: Acute coronary syndrome patient outcomes have been improved using early invasive techniques. The aim of this study was to investigate the incidence, location, and severity of bleeding in PCI-treated cases to identify patient risk profiles and increased bleeding occurrences. Methods: This prospective observational study evaluated percutaneous coronary angiography in 80 patients with hypertension and diabetes mellitus who planned to undergo primary or elective PCI. The cases were separated into 2 groups; those who reported bleeding (n=11) and those who did not (n=69). All patients underwent physical examination, laboratory evaluation, 12-lead electrocardiography, and PCI. Results: In univariate regression analysis, age (OR: 1.09, 95% CI: 1.009 – 1.192), female gender (OR: 4.32, 95% CI: 1.157 – 16.131), history of peripheral arterial disease (OR: 7.31, 95% CI: 1.585 – 33.742), and femoral site of vascular access (OR: 9.6, 95% CI: 2.263 – 40.721) were independent predictors of major bleeding after PCI. In multivariate regression analysis, age (OR: 1.12, 95% CI:1.014 – 1.269), female gender (OR: 13.75, 95% CI: 1.983 – 161.2), history of peripheral arterial disease (OR: 43.38, 95% CI: 3.754 - 1042) and femoral site of vascular access (OR: 13.29, 95% CI: 2.233 – 128.5) were independent predictors of major bleeding after PCI. Conclusions: Patients who reported bleeding after PCI had a significantly higher age, prevalence of female sex, serum creatinine, and transfemoral intervention before and after intervention compared to patients who did not report bleeding, while haemoglobin and transradial intervention before and after intervention were significantly lower in the bleeding cases than in the non-bleeding cases.

Article | IMSEAR | ID: sea-220323


Introduction: Coronary bifurcation lesions are considered one of the challenging entities in the field of coronary intervention due to the risk of side branch loss and higher risk of stent thrombosis. However, there is limited data about the proper management of such lesions in the setting of myocardial infarction as most bifurcation lesion studies excluded patients with acute coronary syndromes (ACS). The aim of this study was to compare in-hospital and mid-term outcomes of single-stent and two-stents strategy in the management of bifurcation culprit lesions in patients presenting with anterior STEMI. Methods: This retrospective multi-center study included all patients presented with anterior STEMI who underwent primary PCI between January 2017 and December 2019, coronary angiography showed true bifurcation lesion with sizable side branch that can be managed by stenting. Patients with left main bifurcation, those indicated for urgent CABG, and patients in cardiogenic shock were excluded. Included patients were divided into two groups according to the stenting strategy either single or two stents. Six months follow up data were collected by telephone calls and by examination of medical records. Results: Out of 1355 anterior STEMI patients presented between January 2017 and December 2019, 158 patients (11.6%) were identified to have bifurcation culprit lesions with a sizable diagonal branch. 93 patients (59%) were treated by single stent while 65 patients (41%) were managed by two-stents strategy. The baseline characteristics and angiographic findings were similar in both groups except for higher side branch involvement in the two stents group (83.31%±11.20 vs 71.88%±15.05, t= -5.39, p <0.001). Mean fluoroscopy time (23.96±8.90 vs 17.81±5.72 mins) and contrast volume (259.23± 59.45 vs 232.58± 96.18 ml) were significantly higher in two stents group than single stent group (p=0.049). However, the angiographic success rates (residual stenosis ?30% and restoration of TIMI flow grade II or III) were comparable (96.8% vs 99%, MCp=0.151). There is no significant difference in the overall incidence rate of MACE in both groups 6 months following the index procedure (13.9 % vs 16.9%, FEp=0.698), with no difference between different bifurcation stenting techniques in patients managed with two stents. Conclusion: Although two stents strategy in the setting of STEMI is much complex with more fluoroscopy time and contrast volume, the procedural success rate and the incidence of MACE were comparable to one stent strategy, on medium-term follow up.

Indian Heart J ; 2023 Apr; 75(2): 156-159
Article | IMSEAR | ID: sea-220976


The present study assessed incidence, risk factors, in-hospital and short-term outcomes associated with no-reflow in patients undergoing percutaneous coronary intervention (PCI) in STEMI, NSTEMI, unstable angina and stable angina. Out of 449 patients, 42 (9.3%) developed no-reflow. Hypertension, dyslipidemia, obesity and smoking were significant risk factors. There was significant association of no-reflow with left main disease, multiple stents, target lesion length_x0001_ 20 mm and higher thrombus grade. Interestingly, 93 patients (23.4%) of normal flow had myocardial perfusion grade (MPG) of 0/1 with mortality in 9 (10%) patients. No-reflow is associated with poor in-hospital and short-term outcomes with higher incidence of death, cardiogenic shock, heart failure and MACE. Knowledge of risk factors of no-reflow portends a more meticulous approach to improve final outcomes. MPG could be better predictor of outcomes in these patients.

Arch. cardiol. Méx ; 93(1): 53-61, ene.-mar. 2023. tab, graf
Article in English | LILACS-Express | LILACS | ID: biblio-1429705


Abstract Objective: The purpose was to compare the outcomes of patients with ST-elevation myocardial infarction and multivessel coronary artery disease undergoing one-time multivessel revascularization (OTMVR) versus in-hospital staged complete revascularization with percutaneous coronary intervention. Methods: This was a single-center, retrospective, observational, and cohort study, including data from January 2013 to April 2019. A total of 634 patients were included in the study. Comparisons were made between patients who underwent in-hospital staged complete revascularization versus OTMVR. The primary endpoint was all-cause in-hospital mortality, secondary endpoints included cardiovascular complications, all-cause new hospitalization, and mortality evaluated at 30 days and 1 year. In addition, we constructed a logistic regression model for determining the risk factors that predicted mortality. Results: Of the 634 patients, 328 were treated with staged revascularization and 306 with OTMVR. About 76.7% were men, with a mean age of 63.3 years. Less complex coronary lesions and a higher proportion of the left anterior descending artery as the culprit vessel were found in the OTMVR group. Compared with staged revascularization, the primary and secondary endpoints occurred less frequently with OTMVR strategy. Conclusions: OTMVR did not generate more complications and demonstrate better clinical outcomes than in-hospital staged revascularization.

Resumen Objetivo: El propósito fue comparar resultados de pacientes con infarto agudo de miocardio con elevación del segmento ST y enfermedad coronaria multivaso sometidos a revascularización completa de un solo momento frente a revascularización completa por etapas mediante intervención coronaria percutánea. Métodos: Estudio cohorte observacional, retrospectivo, unicéntrico, con datos de enero de 2013 a abril de 2019, incluyendo 634 pacientes. Se compararon resultados entre pacientes sometidos a revascularización completa por etapas frente a revascularización completa en un solo momento. El objetivo primario fue valorar mortalidad intrahospitalaria por cualquier causa y como objetivos secundarios se evaluaron a 30 días y 1 año las complicaciones cardiovasculares, hospitalizaciones y mortalidad. Se construyó un modelo de regresión logística para determinar los factores de riesgo que predijeron mortalidad. Resultados: De 634 pacientes, 328 fueron tratados con revascularización por etapas y 306 con revascularización en una intervención. El 76.7% fueron hombres, con una media de edad de 63.3 años. En el grupo de revascularización de un solo tiempo se encontraron lesiones coronarias menos complejas y una mayor proporción de la arteria descendente anterior como vaso culpable. Comparado con el grupo de revascularización por etapas, los objetivos primarios y secundarios ocurrieron con menos frecuencia en el grupo de revascularización en un solo tiempo. Conclusiones: Comparada con la revascularización intrahospitalaria por etapas, la revascularización en una intervención lleva a mejores desenlaces clínicos sin generar más complicaciones.

Rev. Assoc. Med. Bras. (1992, Impr.) ; 69(2): 325-329, Feb. 2023. tab
Article in English | LILACS-Express | LILACS | ID: biblio-1422638


SUMMARY BACKGROUND: The simplified Selvester QRS score is a parameter for estimating myocardial damage in ST-elevation myocardial infarction. ST-elevation myocardial infarction leads to varying degrees of impairment in left ventricular systolic and diastolic function. Myocardial performance index is a single parameter that can predict combined left ventricular systolic and diastolic performance. OBJECTIVE: We investigated the relationship between Selvester score and myocardial performance index in patients undergoing primary percutaneous coronary intervention for acute anterior myocardial infarction. METHODS: The study included 58 patients who underwent primary percutaneous coronary intervention for acute anterior myocardial infarction. Selvester score of all patients was also calculated at 72 h. Patients were categorized into two groups according to the Selvester score. Those with a score <6 (low score) were considered group 1 and those with a score ≥6 (high score) were considered group 2. RESULTS: When compared with group 1, patients in group 2 were older (p=0.01) and had lower left ventricular ejection fractions (50.3±4 vs. 35.6±6.9, p=0.001), and conventional myocardial performance index (0.52±0.06 vs. 0.69±0.08, p=0.001), lateral tissue Doppler-derived myocardial performance index (0.57±0.08 vs. 0.72±0.08, p=0.001), and septal tissue Doppler-derived myocardial performance index (0.62±0.07 vs. 0.76±0.08, p=0.001) were higher. There was a high correlation between lateral tissue Doppler-derived myocardial performance index and conventional myocardial performance index and Selvester score (r=0.80, p<0.001; r=0.86, p<0.001, respectively) and a moderate correlation between septal tissue Doppler-derived myocardial performance index and Selvester score (r=0.67, p<0.001). CONCLUSIONS: The post-procedural Selvester score can predict lateral tissue Doppler-derived myocardial performance index and conventional myocardial performance index with high sensitivity and acceptable specificity in patients undergoing primary percutaneous coronary intervention for acute anterior myocardial infarction.

Article | IMSEAR | ID: sea-220339


Background: Revascularization of the coronary arteries is associated with better short term and long term prognosis in patients having multivessel coronary artery disease (MV-CAD) and chronic kidney disease (CKD). However, whether revascularization using coronary artery bypass grafting (CABG) surgery or percutaneous coronary intervention (PCI) using drug eluting stents (DES) is better remains unknown. Objectives: To compare the outcomes of revascularization by multi-vessel PCI using DES versus revascularization by CABG in patients with CKD having multivessel CAD, regarding in-hospital and one-year major adverse cardiovascular and cerebrovascular events (MACCE). Methods: This was a retrospective analysis of the data of a group of patients having CKD with eGFR less than 60 ml/min with multivessel CAD who underwent revascularization by PCI or revascularization by CABG and were compared as regards in-hospital and one-year MAACE. Results: A total of 565 patients were reviewed in this study, 230 patients had multivessel PCI using DES while 335 patients had CABG. Comparing both revascularization groups regarding in-hospital MACCE, patients who had mutli-vessel PCI had significantly lower in-hospital mortality, cerebrovascular events (stroke/TIA) and lower total MACCE than patients who had CABG (P-value = 0.03 & 0.01 & 0.04 respectively). When comparing both revascularization groups regarding one-year MACCE, patients who had mutli-vessel PCI had significantly lower cerebrovascular events and total MACCE than those patients who had CABG (P-value = 0.02 & 0.03 respectively). Conclusion: This is a retrospective study to determine which strategy is better for revascularization of CKD patients having multivessel CAD; we can conclude that multi-vessel PCI using DES for CKD patients and multivessel CAD had advantages over CABG regarding in-hospital and one-year cerebrovascular accidents (TIA/stroke) and regarding total MACCE. Larger randomized controlled trials are required to confirm our findings.

Biosci. j. (Online) ; 39: e39049, 2023.
Article in English | LILACS-Express | LILACS | ID: biblio-1428235


This study aimed to analyze the incidence of vascular complications and associated factors in patients undergoing elective percutaneous transluminal coronary angioplasty. This study is observational, quantitative, and longitudinal, and followed 50 patients undergoing elective percutaneous transluminal coronary angioplasty. An instrument for the sociodemographic, clinical, procedure, and vascular complications characterization was used for data collection. And descriptive statistics, bivariate analysis, and multiple binomial logistic regression were used for data analysis. The level of statistical significance considered was 95%. It was detected the prevalence of male patients (70%), elderly (54%), and diagnosed with systemic arterial hypertension (72%). As for the percutaneous access route prevailed the radial approach (64%). Age and body mass index were identified as possible risk factors for vascular complications. In the 50 procedures performed, there was a prevalence of hematomas (20%) and bleeding (10%). Among the complications prevailed radial Early Discharge After Transradial Stenting of Coronary (60%), large femoral hematoma (20%), small femoral hematoma (20%), and bleeding (Bleeding Academic Research Consortium 2) (100%). The results concluded an elevated incidence of vascular complications in the first 24 hours after elective percutaneous transluminal coronary angioplasty. This study contributes to research, assistance, and training in health and nursing by identifying post-PTCA vascular complications, minimizing their progression, handling their management, and developing health care safety protocols.

Arq. bras. cardiol ; 120(4): e20210462, 2023. tab, graf
Article in Portuguese | LILACS-Express | LILACS | ID: biblio-1439329


Resumo Fundamento Tem sido observado um grande avanço nas técnicas e nos dispositivos para a realização de intervenções coronárias percutâneas (ICP) em oclusões totais coronarianas crônicas (OTC), mas existem poucos dados da prática do mundo real em países em desenvolvimento. Objetivos Relatar as características clínicas e angiográficas, os aspectos dos procedimentos e os resultados clínicos da ICP de OTC em centros dedicados a esse procedimento no Brasil. Métodos Os pacientes incluídos foram submetidos à ICP de OTC em centros participantes do LATAM CTO Registry, um registro multicêntrico latino-americano dedicado à coleta prospectiva desses dados. Os critérios de inclusão foram procedimentos realizados no Brasil, idade acima de 18 anos e presença de OTC com tentativa de ICP. A definição de OTC foi lesão de 100% em uma artéria coronária epicárdica, conhecida ou estimada como tendo pelo menos 3 meses de evolução. Resultados Foram incluídos dados de 1.196 ICPs de OTC. Os procedimentos foram realizados principalmente para controle da angina (85%) e/ou tratamento de uma grande área isquêmica (24%). A taxa de sucesso técnico foi de 84% e foi alcançada com técnicas de fios anterógrados em 81%, dissecção/reentrada anterógrada em 9% e retrógrada em 10% dos procedimentos. Os eventos cardiovasculares adversos intra-hospitalares ocorreram em 2,3% dos casos, sendo a mortalidade de 0,75%. Conclusões As OTC podem ser tratadas no Brasil por intervenção coronária percutânea de forma efetiva e com baixas taxas de complicações. O desenvolvimento científico e tecnológico observado nessa área na última década reflete-se na prática clínica de centros brasileiros dedicados a essa técnica.

Abstract Background Major advances have been seen in techniques and devices for performing percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs), but there are limited real-world practice data from developing countries. Objectives To report clinical and angiographic characteristics, procedural aspects, and clinical outcomes of CTO PCI performed at dedicated centers in Brazil. Methods Included patients underwent CTO PCI at centers participating in the LATAM CTO Registry, a Latin American multicenter registry dedicated to prospective collection of these data. Inclusion criteria were procedures performed in Brazil, age 18 years or over, and presence of CTO with PCI attempt. CTO was defined as a 100% lesion in an epicardial coronary artery, known or estimated to have lasted at least 3 months. Results Data on 1196 CTO PCIs were included. Procedures were performed primarily for angina control (85%) and/or treatment of moderate/severe ischemia (24%). Technical success rate was 84%, being achieved with antegrade wire approaches in 81% of procedures, antegrade dissection and re-entry in 9%, and retrograde approaches in 10%. In-hospital adverse cardiovascular events occurred in 2.3% of cases, with a mortality rate of 0.75%. Conclusions CTOs can be treated effectively in Brazil by using PCI, with low complication rates. The scientific and technological development observed in this area in the past decade is reflected in the clinical practice of dedicated Brazilian centers.

Arq. bras. cardiol ; 120(6): e20220673, 2023. tab, graf
Article in Portuguese | LILACS-Express | LILACS | ID: biblio-1439356


Resumo Fundamento Vários estudos têm mostrado que as mulheres não recebem tratamento adequado e apresentam piores desfechos após infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST). Por isso, é necessário investigar questões relacionadas ao gênero para melhor lidar com esse problema no Brasil. Objetivo Determinar se existe associação entre o sexo feminino e eventos adversos em uma coorte contemporânea de pacientes com IAMCSST submetidos à intervenção coronária percutânea primária (ICPp). Métodos Este foi um estudo prospectivo do tipo coorte de pacientes com IAMCSST submetidos à ICPp em um hospital universitário terciário entre março de 2011 e dezembro de 2021. Os pacientes foram categorizados em grupos de acordo com o sexo ao nascimento. O primeiro desfecho clínico foi ECAM em longo prazo. Os pacientes foram acompanhados por um período máximo de cinco anos. Um nível de significância bilateral de 0,05 foi aplicado em todos os testes de hipóteses. Resultados Entre os 1457 pacientes internados por IAMCSST no período do estudo, 1362 foram incluídos e 468 (34,4%) eram do sexo feminino. As mulheres apresentaram maior prevalência de hipertensão (73% vs. 60%, p<0,001), diabetes (32% vs. 25%, p=0,003) e classe Killip 3-4 na internação (17% vs. 12%, p=0,01); o escore de risco TIMI foi maior nas mulheres [4 (2, 6) vs. 3 (2, 5), p<0.001]. A mortalidade hospitalar não foi diferente entre os grupos (12,8% vs. 10,5%; p=0,20). Os ECAMs foram numericamente maiores nas mulheres que nos homens tanto durante a internação (16,0% vs. 12,6%, p=0,085) como em longo prazo (28,7% vs. 24,4%, p=0,089), com significância limítrofe. Após a análise multivariada, o sexo feminino não foi associado a ECAMs (HR = 1,14; IC95% 0,86 - 1,51; p = 0,36). Conclusão Em uma coorte prospectiva contemporânea de pacientes com IAMCSST submetidos à ICPp, pacientes do sexo feminino apresentaram idade mais avançada e mais comorbidades no basal que os pacientes do sexo masculino, mas não houve diferenças significativas entre os sexos quanto aos desfechos adversos no hospital ou em longo prazo.

Abstract Background Several studies have shown that women are usually undertreated and have worse outcomes after ST-segment elevation myocardial infarction (STEMI), hence the need to investigate questions related to sex in Brazil to better deal with the problem. Objective To determine whether female sex is still associated with adverse events in a contemporary cohort of patients with STEMI undergoing primary percutaneous coronary intervention (pPCI). Methods This was a prospective cohort study of STEMI patients submitted to pPCI in a tertiary university hospital between March 2011 and December 2021. Patients were categorized into groups based on their sex at birth. The primary clinical outcome was long-term MACCE. Patients were followed-up for up to five years. All hypothesis tests had a two-sided significance level of 0.05. Results Among 1457 patients admitted with STEMI in the study period, 1362 were included and 468 (34.4%) were women. Female patients had a higher prevalence of hypertension (73% vs. 60%, p <0.001), diabetes (32% vs. 25%, p=0.003) and Killip class 3-4 at hospital admission (17% vs. 12%, p=0.01); TIMI risk score was higher among women (4 [2, 6] vs. 3 [2, 5], p<0.001). In-hospital mortality was not different between groups (12.8% vs. 10.5%, p=0.20). In-hospital MACCE (16.0% vs. 12.6%, p=0.085) and long-term MACCE (28.7% vs. 24.4%, p=0.089) were numerically higher in women, with borderline significance. After multivariate analysis, female sex was not associated with MACCE (HR = 1.14; 95% CI 0.86 - 1.51; p = 0.36). Conclusion In a prospective cohort of STEMI patients submitted to pPCI, female patients were older and had more comorbidities at baseline, but no significant differences were found in terms of long-term adverse outcomes.

Arq. bras. cardiol ; 120(6): e20220658, 2023. tab, graf
Article in Portuguese | LILACS-Express | LILACS | ID: biblio-1439364


Resumo Fundamento A eficiência do manejo invasivo em pacientes mais velhos (≥75 anos) com infarto do miocárdio sem supradesnivelamento do segmento ST (IAMSSST) permanece ambígua. Objetivos Avaliar a eficiência do tratamento invasivo em pacientes idosos com IAMSSST com base em metanálise e análise sequencial de estudo (TSA). Métodos Ensaios clínicos randomizados relevantes (ECR) e estudos observacionais foram incluídos. Os resultados primários foram morte por todas as causas, infarto do miocárdio, acidente vascular cerebral e hemorragia grave. O odd ratio agrupado (OR) e o intervalo de confiança de 95% (IC) foram calculados. P<0,05 foi considerado estatisticamente significativo. Resultados Cinco ECRs e 22 estudos observacionais com 1.017.374 pacientes foram incluídos.Com base nos resultados de ECR e TSA, o manejo invasivo foi associado a menores riscos de infarto do miocárdio (OR: 0,51; 95% IC: 0,40-0,65; I2=0%), eventos cardiovasculares adversos maiores (MACE; OR: 0,61; 95% IC: 0,49-0,77; I2=27,0%) e revascularização (OR: 0,29; 95% IC: 0,15-0,55; I2=5,3%) em comparação com o tratamento conservador. A combinação de resultados de ECRs e estudos observacionais com ajuste multivariável mostrou riscos consistentemente menores de morte por todas as causas (OR: 0,57; IC 95%: 0,50-0,64; I2 = 86,4%), infarto do miocárdio (OR: 0,63; IC 95%: 0,56 -0,71; I2=0%), acidente vascular cerebral (OR: 0,59; 95% IC: 0,51-0,69; I2=0%) e MACE (OR: 0,64; 95% IC: 0,54-0,76; I2=43,4%). O melhor prognóstico associado ao manejo invasivo também foi observado em cenários do mundo real. No entanto, para pacientes com idade ≥85 anos, o manejo invasivo pode aumentar o risco de sangramento maior (OR: 2,68; IC 95%: 1,12-6,42; I2=0%). Conclusões O manejo invasivo foi associado a menores riscos de infarto do miocárdio, MACE e revascularização em pacientes idosos com IAMSSST,no entanto, pode aumentar o risco de sangramento maior em pacientes com idade ≥85 anos.

Abstract Background The efficiency of invasive management in older patients (≥75 years) with non-ST-segment elevation myocardial infarction (NSTEMI) remains ambiguous. Objectives To assess the efficiency of invasive management in older patients with NSTEMI based on meta-analysis and trial sequential analysis (TSA). Methods Relevant randomized controlled trials (RCT) and observational studies were included. The primary outcomes were all-cause death, myocardial infarction, stroke, and major bleeding. Pooled odd ratio (OR) and 95% confidence interval (CI) were calculated. P <0.05 was considered statistically significant. Results Five RCTs and 22 observational studies with 1017374 patients were included. Based on RCT and TSA results, invasive management was associated with lower risks of myocardial infarction (OR: 0.51; 95% CI: 0.40-0.65; I2=0%), major adverse cardiovascular events (MACE; OR: 0.61; 95% CI: 0.49-0.77; I2=27.0%), and revascularization (OR: 0.29; 95% CI: 0.15-0.55; I2=5.3%) compared with conservative management. Pooling results from RCTs and observational studies with multivariable adjustment showed consistently lower risks of all-cause death (OR: 0.57; 95% CI: 0.50-0.64; I2=86.4%), myocardial infarction (OR: 0.63; 95% CI: 0.56-0.71; I2=0%), stroke (OR: 0.59; 95% CI: 0.51-0.69; I2=0%), and MACE (OR: 0.64; 95% CI: 0.54-0.76; I2=43.4%). The better prognosis associated with invasive management was also observed in real-world scenarios. However, for patients aged ≥85 years, invasive management may increase the risk of major bleeding (OR: 2.68; 95% CI: 1.12-6.42; I2=0%). Conclusions Invasive management was associated with lower risks of myocardial infarction, MACE, and revascularization in older patients with NSTEMI, yet it may increase the risk of major bleeding in patients aged ≥85 years.

J. Transcatheter Interv ; 31: eA202302, 2023. ilus; tab
Article in English, Portuguese | LILACS-Express | LILACS | ID: biblio-1442691


Por várias décadas, a revascularização do miocárdio foi considerada o tratamento padrão-ouro de lesões não protegidas do tronco da coronária esquerda. No entanto, a acessibilidade anatômica e o grande calibre dos vasos tornam as lesões de tronco uma opção atraente para a intervenção coronária percutânea. A aplicação dessa intervenção nesse cenário foi expandida ainda mais como resultado da introdução de novos stents farmacológicos, com rápidos avanços em técnicas, dispositivos e farmacoterapias adjuvantes. As evidências atuais têm demonstrado que pacientes com complexidade coronariana baixa ou intermediária têm desfechos similares com a intervenção coronária percutânea ou a revascularização cirúrgica do miocárdio por até 10 anos. O tratamento das lesões da bifurcação do tronco da coronária esquerda continua tecnicamente complexo, apesar dos recentes avanços. A abordagem provisional é a estratégia padrão na maioria dos tipos de lesões da bifurcação do tronco da coronária esquerda. No entanto, algumas lesões complexas da bifurcação do tronco da coronária esquerda justificariam uma técnica eletiva com implante de dois stents. A abordagem integrada, que incorpora técnicas dedicadas, uma avaliação fisiológica e anatômica adjuvante e agentes farmacológicos, é fundamental para abordar com sucesso esse desafio ímpar e melhorar os desfechos clínicos.

For several decades coronary bypass grafting has been considered the gold standard treatment for unprotected left main coronary artery lesions. However, the anatomic accessibility and the large caliber of the vessel render the percutaneous coronary intervention a very attractive treatment option for left main coronary artery lesions. The use of percutaneous coronary intervention in this subset of lesions has been further expanded as a result of the introduction of newer drug-eluting stents along with rapid advancements in techniques, devices, and adjunctive pharmacotherapies. The current evidence has demonstrated that patients with low or intermediate coronary complexity treated with percutaneous coronary intervention or coronary bypass grafting have comparable outcomes, for up to 10 years. Treatment of left main bifurcation lesions remains technically demanding despite recent developments. The provisional approach is the default strategy in most types of left main bifurcation lesions. However, a few complex left main bifurcation lesions would warrant an elective two-stent technique. An integrated approach incorporating custom- tailored techniques, adjunctive physiological and morphologic evaluation, and pharmacologic agents is critical to tackle this unique challenge and improve clinical outcomes.

Ghana med. j ; 57(1): 37-42, 2023. figures, tables
Article in English | AIM | ID: biblio-1427100


Objectives: This study aimed to examine possible associations between previously undiagnosed subclinical hypothyroidism and short-term outcomes and mortality in a sample of Iraqi patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Design: This is a prospective observational cohort study. Setting: The study was conducted in a single tertiary referral centre in Baghdad, Iraq. Participants: Thyroid-stimulating hormone and free T4 levels were measured in 257 patients hospitalised with STelevation myocardial infarction who underwent primary percutaneous coronary intervention between January 2020 and March 2022. Main outcome measures: Adverse cardiovascular and renal events during hospitalisation and 30-day mortality were observed. Results: Previously undiagnosed subclinical hypothyroidism was detected in 36/257 (14%) ST-elevation myocardial infarction patients and observed more commonly in females than males. Patients with subclinical hypothyroidism had significantly worse short-term outcomes, including higher rates of suboptimal TIMI Flow (< III) (p =0.014), left ventricular ejection fraction ≤ 40% (p=0.035), Killip class >I (p=0.042), cardiogenic shock (p =0.016), cardiac arrest in the hospital (p= 0.01), and acute kidney injury (p= 0.044). Additionally, 30-day mortality was significantly higher in patients with subclinical hypothyroidism (p= 0.029). Conclusion: Subclinical hypothyroidism previously undiagnosed and untreated had a significant association with adverse short-term outcomes and higher short-term mortality within 30 days compared to euthyroid patients undergoing primary percutaneous coronary intervention. Routine thyroid function testing during these patients' hospitalisation may be warranted.

Humans , Thyroid Function Tests , Percutaneous Coronary Intervention , Hypothyroidism , Asymptomatic Infections , ST Elevation Myocardial Infarction , Access to Primary Care
J. Transcatheter Interv ; 31: A202208, 2023. graf, ilus, tab
Article in English, Portuguese | LILACS, CONASS, SES-SP, SESSP-IDPCPROD, SES-SP | ID: biblio-1412824


A fisiologia coronariana tornou-se o padrão de tratamento para avaliar o significado funcional da doença aterosclerótica coronariana. Ela permite identificar isquemia miocárdica em nível de vaso, discriminar os padrões funcionais da doença aterosclerótica e orientar a necessidade de revascularização; complementar o planejamento da intervenção coronária percutânea e confirmar o sucesso funcional dessa última. Em uma edição anterior do Journal of Transcatheter Interventions, apresentamos uma revisão abrangente sobre o fluxo fracionado de reserva do miocárdio. Apesar do robusto corpo de evidências que apoiam seu uso, a aceitação clínica do fluxo fracionado de reserva é variável e excessivamente baixa em muitas áreas do mundo. O aumento percebido no tempo do procedimento, o uso de agentes hiperêmicos com seus correspondentes custos e desconforto do paciente, e a dificuldade de interpretação dos resultados em determinadas situações anatômicas contribuíram para a adoção limitada do método. A introdução do índice de fluxo instantâneo no período livre de ondas superou a maioria dessas limitações. Apoiada por uma validação técnica sólida e dados de desfechos clínicos, o índice de fluxo instantâneo no período livre de ondas recebeu as mesmas indicações clínicas que o fluxo fracionado de reserva nas recomendações mais recentes das diretrizes. Isso foi seguido pela introdução de outros índices pressóricos não hiperêmicos, já comercialmente disponíveis. Neste artigo, revisamos as bases fisiológicas que justificam o uso de índices pressóricos não hiperêmicos, sua validação técnica e clínica e dados de desfechos clínicos, além de discutirmos suas aplicações em situações anatômicas específicas, com exemplos de casos dos autores, sempre que aplicável.

Coronary physiology has become the standard of care to assess the functional significance of coronary atherosclerotic disease. It allows for identification of myocardial ischemia on a vessel level, discrimination of the functional patterns of atherosclerotic disease, guidance for the need of revascularization, complements the planning of percutaneous coronary intervention and verification of the functional success of percutaneous coronary intervention. On a previous issue of the Journal of Transcatheter Interventions, we presented a comprehensive review about fractional flow reserve. Despite the robust body of evidence supporting its use, the clinical use of fractional flow reserve is variable, and unreasonably low in many areas around the globe. The perceived increase in procedure time, the use of hyperemic agents with its related costs and patient discomfort, and difficulty in interpreting results in certain anatomical scenarios have contributed to the limited adoption of fractional flow reserve. The introduction of instantaneous wave-free ratio overcame most of these limitations. Supported by sound technical validation, and clinical outcomes data, instantaneous wave-free ratio received the same clinical indications as fractional flow reserve in the most recent guidelines recommendations. This was followed by the introduction of other non- hyperemic pressure ratios for commercial use. In the current manuscript we review the physiological basis that supports the use of non-hyperemic pressure ratios, their technical and clinical validation, clinical outcomes data, and discuss its applications on specific anatomic scenarios, with examples of cases from the authors, whenever applicable.

Fractional Flow Reserve, Myocardial , Percutaneous Coronary Intervention , Standard of Care
J. Transcatheter Interv ; 31: eA20220023, 2023. tab
Article in English, Portuguese | LILACS, CONASS, SES-SP, SESSP-IDPCPROD, SES-SP | ID: biblio-1418492


Em pacientes que apresentam síndromes coronárias agudas e são tratados com intervenção coronária percutânea, a prescrição do esquema antiplaquetário duplo, composto de ácido acetilsalicílico e um inibidor dos receptores P2Y12, é mandatória, contribuindo para a redução de eventos cardíacos maiores. No entanto, ao mesmo tempo em que previne eventos isquêmicos, essa associação pode precipitar complicações hemorrágicas maiores, o que é mais comumente observado quando são prescritos os medicamentos mais potentes, como o prasugrel ou o ticagrelor. Essas constatações levaram à procura de alternativas terapêuticas capazes de manter a proteção contra eventos isquêmicos e, ao mesmo tempo, prevenir a ocorrência de hemorragias. Uma das estratégias que está em estudo é a de-escalação dos inibidores P2Y12, que consiste no uso dos medicamentos mais potentes numa fase precoce após o procedimento, com substituição deles pelo clopidogrel, após um período de, em geral, 30 dias de evolução; outra possibilidade seria a simples redução da dose do fármaco de maior potência, algo que, até o momento, só pode ser cogitado com o prasugrel. A de-escalação pode ser feita de forma guiada, utilizando testes de mensuração objetiva da agregação plaquetária ou exames para avaliar o perfil genético dos pacientes, ou não guiada, na qual o cardiologista simplesmente faz a substituição ou redução da dose ao fim do período estipulado, sem o auxílio de exames complementares. A literatura contempla ensaios clínicos com essas duas opções de estratégia, os quais são discutidos nesta revisão. Até o momento, nenhuma diretriz médica recomenda de forma explícita o uso regular dessa alternativa terapêutica.

In patients who have acute coronary syndromes and are treated with percutaneous coronary intervention, the prescription of a dual antiplatelet regimen, consisting of acetylsalicylic acid and a P2Y12 receptor inhibitor, is mandatory, contributing to the reduction of major cardiac events. However, while preventing ischemic events, this association may precipitate major bleeding complications, which is more commonly seen when more potent drugs, such as prasugrel or ticagrelor, are prescribed. These findings led to the search for therapeutic alternatives that could maintain the protection against ischemic events and, at the same time, prevent the occurrence of hemorrhages. One of the strategies being studied is de-escalation of P2Y12 inhibitors, which consists of the use of more potent drugs in an early phase after the procedure, replacing them with clopidogrel, after a period of, in general, 30 days of clinical course. Another possibility would be to simply reduce the dose of the most potent drug, which so far can only be considered with prasugrel. De-escalation can be done in a guided way, using objective measuring tests of platelet aggregation or exams to assess the genetic profile of patients, or unguided, in which the cardiologist simply replaces or reduces the dose at the end of the stipulated period, with no ancillary tests. The literature includes clinical trials with these two strategy options, which are discussed in this review. So far, no medical guideline explicitly recommends the regular use of this therapeutic alternative.

Purinergic P2Y Receptor Agonists , Dual Anti-Platelet Therapy , Angina, Unstable , Myocardial Infarction , Prasugrel Hydrochloride
J. Transcatheter Interv ; 31: eA20220015, 2023. ilus; tab
Article in English, Portuguese | LILACS-Express | LILACS | ID: biblio-1426225


Introdução: As diretrizes atuais recomendam o uso da ultrassonografia intravascular de coronárias como ferramenta adjuvante em situações difíceis. Objetivo: Caracterizar a utilização da ultrassonografia intravascular em Portugal e comparar os desfechos após intervenção coronária percutânea no tronco da coronária esquerda, guiada ou não por ultrassonografia intravascular. Métodos: Estudo observacional retrospectivo multicêntrico, que analisou pacientes submetidos à intervenção coronária percutânea entre janeiro de 2012 e dezembro de 2018, incluídos no Portuguese Registry on Interventional Cardiology da Sociedade Portuguesa de Cardiologia. Valor de p bicaudal <0,05 foi considerado estatisticamente significativo. Resultados: Este estudo demonstrou variação significativa na utilização da ultrassonografia intravascular em Portugal (valor de p qui-quadrado para tendência <0,001). O ano com maior utilização foi 2016 (2,4%). Houve aumento progressivo, nos últimos 7 anos, na utilização da ultrassonografia intravascular na intervenção coronária percutânea do tronco da coronária esquerda (valor de p qui-quadrado para tendência <0,001), com importantes diferenças regionais. A população submetida à intervenção coronária percutânea do tronco da coronária esquerda guiada por ultrassonografia intravascular era mais jovem, mas tinha maior prevalência de fatores de risco cardiovascular, disfunção sistólica ventricular e lesões coronárias complexas. Além disso, esse grupo de pacientes teve menor prevalência do desfecho primário intra-hospitalar (1,4% versus 3,9%; p=0,024). Porém, após análise multivariada ajustada para fatores de confusão, este estudo não demonstrou impacto significativo da utilização da ultrassonografia intravascular no desfecho intra-hospitalar. Conclusão: A utilização da ultrassonografia intravascular na intervenção coronária percutânea do tronco da coronária esquerda vem aumentando lentamente nos últimos 7 anos em Portugal. Neste estudo, a utilização desse método não teve impacto estatístico nos desfechos intra-hospitalares.

Background: Current guidelines recommend the use of coronary intravascular ultrasound as an adjunctive tool in challenging situations. Objective: To characterize the use of intravascular ultrasound in Portugal and compare outcomes after left main percutaneous coronary intervention, with or without intravascular ultrasound. Methods: A retrospective multicentric observational study analyzed patients who underwent percutaneous coronary intervention between January 2012 and December 2018 and were included in the Portuguese Registry on Interventional Cardiology of the Sociedade Portuguesa de Cardiologia. A two-sided p-value<0.05 was considered statistically significant. Results: This study revealed significant variation of intravascular ultrasound usage in Portugal over time (p-value Chi-squared for trend <0.001). The year with maximum use was 2016 (2.4%). Regarding left main percutaneous coronary intervention, there was a progressive increase in use of intravascular ultrasound (p-value Chi-squared for trend<0.001) in the last 7 years, with important regional differences. The population submitted to left main percutaneous coronary intervention with intravascular ultrasound was younger, but had a higher prevalence of some cardiovascular risk factors, ventricular systolic dysfunction, and complex coronary lesions. Moreover, this group of patients had lower prevalence of intrahospital primary endpoint (1.4% versus 3.9%; p=0.024). However, after multivariate analysis adjusted to confounding factors, this study did not demonstrate a significant impact of intravascular ultrasound on intrahospital endpoint. Conclusion: The overall use of intravascular ultrasound in left main percutaneous coronary intervention has been slowly increasing in the last seven years, in Portugal. In this study, the use of this method had no statistical impact in intrahospital endpoints.

J. Transcatheter Interv ; 31: eA20230004, 2023. ilus
Article in English, Portuguese | LILACS-Express | LILACS | ID: biblio-1426326


Vários fatores, incluindo intervenções terapêuticas aprimoradas e tecnologias avançadas, levaram a melhores desfechos clínicos nas intervenções coronárias percutâneas complexas. No entanto, ainda podem ocorrer complicações capazes de impactar negativamente na sobrevida do paciente e nos custos de saúde. O risco dessas complicações pode ser reduzido, por meio de operadores experientes e procedimentos preventivos. Este artigo discute uma série de casos de cinco pacientes com problemas específicos relacionados aos procedimentos, como perfuração coronária, dissecções, fechamento abrupto das coronárias e fenômeno de no-reflow.

Various factors, including improved therapeutic interventions and advanced technologies, have led to better clinical outcomes for complex percutaneous coronary interventions. However, complications can still occur and have a negative impact on patient survival and healthcare costs. The risk of these complications can be reduced through experienced operators and preventative procedures. This article discusses a case series of five patients with specific periprocedural issues, such as coronary perforation, dissections, abrupt closure of the coronaries, and no-reflow phenomenon.