Beyond Atherothrombotic Disease in Acute Coronary Syndrome

Abstract Half of the global population over 20 years of age will be affected by cardiovascular disease. Cardiovascular events in young people is challenging. Spontaneous coronary artery dissection is a non-traumatic and non-iatrogenic separation of the coronary arterial wall and is an uncommon and underdiagnosed cause of acute myocardial infarction predominately found in young women. Medical management has been more widely accepted, with percutaneous and surgery treatment reserved for precise indications. Optimal control of individual risk factors is essential in order to avoid recurrences.

Manejo del síndrome coronario agudo durante pandemia por COVID ­ 19 / Management of acute coronary syndrome during COVID ­ 19 pandemic

INTRODUCTION: Acute Myocardial Infarction is a medical emergency, being his early and adequate treatment highly effective mainly in relation to reperfusion therapy. Unfortunately, COVID ­ 19 pandemic, has brought changes in its management due to availability of conditioned hemodynamic rooms, infection risk of the professionals, patient conditions and availability of critical unit beds. A review of the topic was made aimed to give a guide for the management of these patients with the available tools. MATERIALS AND METHOD: A review of the topic was made using the Medline/ Pubmed platform, in English and Spanish. Further, published articles in journals as The journal of the American college of cardiology and Circulation were included. CONCLUSIONS: The reperfusion strategies must be used according to the clinical context of the patient. In the acute myocardial infarction with ST elevation, fibrinolytic treatment may be chosen in low risk and without hemodynamic instability. In patients with hemodynamic instability, not eligible for fibrinolytic treatment or in whom this therapy fails, percutaneous angioplasty is indicated considering the protection of personnel. In the case of acute myocardial infarction without ST elevation, the treatment by urgent percutaneous angioplasty is considered in cases of hemodynamic instability or malignant arrhythmias.

Tratamiento trombolitico en el síndrome coronario agudo con elevación del st / Treatment trombolitico in the sharp coronary syndrome with elevation of the st

RESUMEN Introducción: la cardiopatía isquémica es tan antigua como el hombre. Constituye uno de los problemas de salud más serios a nivel mundial. Entre sus formas clínicas está el infarto agudo de miocardio. Los síndromes isquémicos agudos, representan un espectro clínico continúo sustentado por una fisiopatología común. Objetivo: identificar los factores que causaron retraso en la aplicación del tratamiento trombolítico en los pacientes, los que se traducen en el futuro, en pérdida de calidad de vida, diferentes grados de discapacidad, y hasta del aumento de la mortalidad por esta entidad. Materiales y métodos: se realizó un estudio observacional, con 62 pacientes con criterio de trombolisis atendidos en la Unidad de Cuidados Intensivos del Hospital Docente Clínico Quirúrgico "José Ramón López Tabrane", en el período comprendido entre enero del 2012 y junio del 2014. Se aplicaron métodos empíricos, estadísticos y teóricos. Resultados: de 147 pacientes recibidos con criterios de trombolisis 62 no recibieron el tratamiento trombolítico que representó un 42,2 %. Entre las causas estuvieron falta de entrenamiento de los médicos para la aplicación de dicho tratamiento y la no existencia de transporte para su traslado en el tiempo requerido. Conclusiones: los pacientes no trombolizados con más de 12 h sin diagnóstico con criterio de infacto agudo del miocardo, incidió en el diagnóstico erróneo del médico y valencia de sus propios medios, para llegar a un centro de salud. Con contraindicación absoluta, el accidente vascular isquémico menor de tres meses fue la causante más padecida. Con contraindicación relativa fue la hipertensión arterial no controlada (AU).

SUMMARY Introduction: The Ischemic Cardiopatía is as old as the man. One constitutes from the most serious problems of health to world level and enter their clinical forms the sharp heart attack of miocardio is (IMA), causing in the world population a third of the deaths. The sharp ischemic syndromes SIAs represents a continuous clinical spectrum sustained by a fisiopatología común. Objective: He/she was carried out an observational, descriptive and traverse study, in 62 patients with trombolisis approach assisted in the UCIE of the Surgical Clinical Educational Hospital José Ramón López Tabrane, in the period understood between January of 2012 and June of the 2014.Se they applied the empiric, statistical and theoretical methods. Materials and method: identify the factors that caused delay in the application of the treatment trombolítico in this patients, which are translated in the future in loss of quality of life, different discapacidad grades and until of the increase of the mortality for this entity. Among the causes that were they were: the non training of the doctors for the application of this treatment and the not existence of transport for their transfer in the required time. Conclusion: In patient non trombolizados with more than twelve hours without diagnostic of IMA (19,4%) with approach impacted the doctor's erroneous diagnosis and valency of their own means to arrive to a center of health. With absolute contraindication, the Ischemic Vascular Accident smaller than three months was the causing one more suffered. With relative contraindication it was the arterial hypertension not controlled (AU).

Atención de los síndromes coronarios agudos durante la contingencia sanitaria por brote de SARS-CoV-2 / Care of acute coronary syndromes during the health contingency due to a SARS-CoV-2 outbreak

Resumen Las comunicaciones acumuladas en las últimas semanas dejan claro que no existe un acuerdo para definir la mejor estrategia de tratamiento en los pacientes con un síndrome coronario agudo (SICA). En los pacientes que se presentan con un infarto agudo del miocardio con elevación del segmento ST (IAMCESST) se ha sugerido privilegiar la fibrinólisis (FL) sobre la intervención coronaria percutánea primaria (ICPp), reservando el ICP para los casos de FL fallidar1,2; sin embargo algunas sociedades han mantenido la indicación de la ICPp como el método de repercusión de elecciónr3. En los SICA sin elevación del segmento ST (SICASESST) las recomendaciones son muy similares, favoreciendo el tratamiento medico sobre el intervencionismo coronario percutáneo, en este subgrupo de pacientes1. Varias sociedades consideran el estado de contagio, en particular en los SICASESST, para decidir que estrategia de repercusión seguir3. Anticipando que la curva epidemiológica en México será similar a la observada en la mayoría de los países, recomendamos continuar la atención de los pacientes con SICA, las salas de cateterismo deben mantener su funcionamiento.

Abstract The communications accumulated in the last weeks make it clear that there is no agreement to define the best treatment strategy in patients with acute coronary syndrome (SICA). In patients presenting with an acute myocardial infarction with ST-segment elevation (IAMCESST), it has been suggested to favor fibrinolysis (FL) over primary percutaneous coronary intervention (PCI), reserving ICP for cases of failed FL1,2; however, some societies have maintained the indication of the ICPp as the repercussion method of choice3. In SICAs without ST segment elevation (SICASESST) the recommendations are very similar, favoring medical treatment over percutaneous coronary intervention in this subgroup of patients1. Several companies consider the contagion status, particularly in the SICASESST, to decide which repercussion follow3. Anticipating that the epidemiological curve in Mexico will be similar to that observed in most countries, we recommend continuing the care of patients with SICA, the catheterization rooms must maintain their operation.

Impacto de la contingencia sanitaria por COVID-19 en las estrategias de reperfusión del síndrome coronario agudo / Impact of COVID-19 on reperfusion strategies for acute coronary syndromes

Resumen Las terapias de reperfusión, tales como intervención coronaria y fibrinólisis, son las principales medidas de atención en pacientes con síndromes coronarios agudos. La angioplastia primaria se considera el estándar de oro, sin embargo, en pacientes con infección por coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2), la estrategia de reperfusión más recomendada es la terapia fibrinolítica, debido al menor tiempo requerido para realizarla y menor exposición al agente infeccioso. Esta pandemia representa una problemática de contagio en el personal de salud, ya que los casos van en aumento a nivel mundial, por lo cual es importante conocer las medidas que se deben seguir a fin de evitar la enfermedad por coronavirus 2019 (COVID-19).

Abstract Reperfusion therapy is a measure of care in patients with ST-elevation myocardial infarction (STEMI), which should be performed once we have the diagnosis. Percutaneous coronary intervention is considered the gold standard, however in patients with SARS-CoV-2 infection, the reperfusion strategy is more focused on fibrinolytic therapy due to the shorter time required to perform and less exposure. This pandemic represents a contact problem in health personnel, since cases are increasing worldwide, so it is important to know the measures that must be followed to avoid coronavirus disease (COVID-19).

Implicaciones cardiovasculares de la infección por SARS-CoV-2: revisión de literatura / Cardiovascular implications of SARS-CoV-2 infection: a literature review

En diciembre de 2019 se reportó en Wuhan, China, la aparición de una nueva cepa de coronavirus SARS-CoV-2 que producía un compromiso pulmonar severo y progresaba a estrés respiratorio agudo. A la fecha, son más de diecisiete millones los casos confirmados y más de medio millón los fallecidos en todo el mundo a causa de COVID-19. Los estudios reportan que los pacientes con enfermedad cardiovascular son más susceptibles a contraer esta enfermedad y a presentar más complicaciones. El propósito de esta revisión es proporcionar información actualizada para los profesionales de la salud que atienden a pacientes con COVID-19 y que tienen además enfermedad cardiovascular y por ende un riesgo elevado de complicaciones y mortalidad. Realizamos una búsqueda de bibliografía científica acerca de la asociación de enfermedad cardiovascular y COVID-19 en diferentes bases de datos como Scopus, MEDLINE vía PubMed y Cochrane Library. El tratamiento con inhibidores de la enzima convertidora de angiotensina y bloqueadores del receptor de angiotensina ha sido motivo de discusión y no hay evidencia sólida para contraindicarlo en pacientes con COVID-19. Respecto al tratamiento con hidroxicloroquina asociado o no con azitromicina, hay evidencia que demuestra un mayor riesgo con su utilización, que beneficio clínico y/o disminución de mortalidad. En este contexto, los pacientes con insuficiencia cardíaca representan un grupo importante de riesgo por su condición per se y por el dilema diagnóstico generado al evaluar un paciente con COVID-19, en el que los signos de insuficiencia cardíaca aguda podrían enmascararse. Por otro lado, en los pacientes con síndrome coronario agudo, el enfoque terapéutico inicial podría cambiar en el contexto de la pandemia, aunque sólo sobre la base de opiniones de expertos. Quedan, sin embargo, muchos temas en controversia que serán motivo de investigaciones futuras.

In December 2019, a new strain of the SARS-CoV-2 coronavirus was reported in Wuhan, China, which produced severe lung involvement and progressed to respiratory distress. To date, more than seventeen million confirmed cases and more than half a million died worldwide from COVID-19. Patients with cardiovascular disease are more susceptible to contracting this disease and presenting more complications. We did a literature search on the association of cardiovascular disease and COVID-19 in databases such as Scopus, PubMed/MEDLINE, and the Cochrane Library. The purpose of this review is to provide updated information for health professionals who care for patients with COVID-19 and cardiovascular disease, given that they have a high risk of complications and mortality. Treatment with angiotensin-converting enzyme inhibitors and receptor blockers is controversial, and there is no evidence not to use these medications in patients with COVID-19. Regarding treatment with hydroxychloroquine associated or not with azithromycin, there is evidence of a higher risk with its use than clinical benefit and decreased mortality. Likewise, patients with heart failure are an important risk group due to their condition per se. Patients with heart failure and COVID-19 are a diagnostic dilemma because the signs of acute heart failure could be masked. On the other hand, in patients with acute coronary syndrome, the initial therapeutic approach could change in the context of the pandemic, although only based on expert opinions. Nonetheless, many controversial issues will be the subject of future research.

Knowledge, attitudes, beliefs and responses of type 2 diabetes clients toward acute coronary syndrome / Conhecimento, atitudes, crenças e respostas dos clientes com diabetes tipo 2 em relação à síndrome coronária aguda

Introduction: The response to a health threat, such as acute coronary syndrome symptoms (ACS), is determined by the patient's ability to identify the symptoms, establish the relationship with the disease and respond appropriately. This important ability of people with type 2 diabetes, who are at risk of having this syndrome, can be better understood by assessing the knowledge, attitudes, and beliefs concerning the ACS and the response to it. Objectives: To evaluate the perceived knowledge, attitudes, and beliefs of type 2 diabetes clients toward acute coronary syndrome; to explore the association between the measures of the perceived acute coronary syndrome and their sociodemographic and clinical characteristics; and to explore the correlations between the measures of the perceived acute coronary syndrome and the measures of anxiety and depression symptoms. Methods: The study was carried out at Linden, Guyana, with 60 type 2 diabetes clients using a sociodemographic and clinical data questionnaire, the Hospital Anxiety and Depression Scale questionnaire, and Acute Coronary-Response Index. All questionnaires were completed by the researcher during a face to face interview with each client. Descriptive analyses were performed for all variables. The Mann-Whitney test was used to compare the scores of the ACS Response Index subscales and the HADS anxiety and depression symptoms with sex, age, time since diabetes diagnosis and body mass index (not overweight or overweight). Comparisons were made between the measures of the ACS - Response Index subscales and educational levels (primary, secondary, university and professional) using the Kruskal-Wallis test for multiple comparisons. The Spearman's correlation coefficient was used to calculate the correlations between the scores of the ACS - Response Index subscales and the anxiety and depression symptoms. The significance level for all the tests that were conducted was set at 0.05. Results: The total mean score of the Knowledge subscale was 9.12 (S.D.=3.4). Two participants had more than 70% of the correct answers. The number of participants who recognized the main symptoms of acute coronary syndrome varied from 27.1% to 49.2%. The total mean score of the Attitudes subscale was 11.2 (S.D.=3.5) and for beliefs 21.3 (S.D.=4.5). Clients with university level had better knowledge when compared to clients with clients who had primary level (p=0.043). Strong and positive correlation was found between knowledge and symptoms of depression, but not significant (r=0.63; p=0.67). The correlation between Attitudes and Beliefs was negative and weak and not significant. The correlation between symptoms of anxiety and beliefs was statically significant, negative, and strong (r=-0.53; p<0.001). Conclusions: Type 2 diabetes clients participating in this study showed a low level of knowledge about ACS. There was an effect of the educational level on the Knowledge subscale. The knowledge of the ACS risks improved the patients' ability to identify their signs and symptoms and respond appropriately to a cardiac event.

Introdução: A resposta a uma ameaça à saúde, como os sintomas da síndrome coronariana aguda (SCA), é determinada pela capacidade do paciente de identificar os sintomas, estabelecendo a relação com a doença e de responder apropriadamente. Essa importante habilidade das pessoas com diabetes tipo 2, em risco de ter essa síndrome, pode ser mais bem compreendida avaliando-se o conhecimento percebido, as atitudes e as crenças em relação à SCA e à resposta a ela. Objetivos: Avaliar o conhecimento percebido, atitudes e crenças percebidas de clientes com diabetes tipo 2 em relação à síndrome coronariana aguda; explorar as associações entre as medidas da síndrome coronária aguda percebida e as variáveis sócio demográficas e clínicas; e explorar as correlações entre as medidas da síndrome coronária aguda percebida e os sintomas de ansiedade e depressão. Métodos: O estudo foi realizado em Linden, Guiana, com 60 clientes com diabetes tipo 2, utilizando-se um questionário de dados sócio demográficos e clínicos, o Acute Coronary-Response Index (ACS-Response Index) e a Escala Hospitalar de Ansiedade e Depressão (HADS). Todos os questionários foram preenchidos pela pesquisadora por meio de entrevistas individuais. Análises descritivas foram realizadas para todas as variáveis. O teste de Mann-Whitney foi utilizado para comparar as medidas do ACS-Response Index e dos sintomas de ansiedade e depressão (HADS) com sexo, idade, tempo de diagnóstico e índice de massa corporal. Foram feitas comparações entre as medidas das subescalas do ACS - Índice de Resposta e os níveis de escolaridade (primário, secundário, universitário e profissional) usando o teste de Kruskal-Wallis para comparações múltiplas. Utilizou-se o coeficiente de correlação de Spearman para calcular as correlações entre as medidas do ACS-Response Index e os sintomas de ansiedade e depressão. Para todos os testes, o nível de significância foi estabelecido em 0,05. Resultados: O escore médio total da subescala Conhecimento foi de 9,12 (D.P. = 3,4). Dois participantes tiveram mais que 70% de acertos nessa subescala. O número de participantes que reconheceu os principais sintomas da SCA variou de 27,1% a 49,2%. Os escores médios total das subescalas Atitudes e Crenças foram 11,2 (D.P. = 3,5) e de 21,3 (D.P. = 4,5), respectivamente. Pacientes universitários tiveram melhor conhecimento quando comparados aos clientes com clientes que possuíam nível primário (p = 0,043). Foi encontrada correlação forte e positiva entre a subescala Conhecimento e os sintomas de depressão, mas não estatisticamente significante (r = 0,63; p = 0,67). A correlação entre as subescalas Atitudes e Crenças foi negativa e fraca e não estatisticamente significante. A correlação entre os sintomas de ansiedade e a subescala Crenças foi estatisticamente significante, negativa e forte (r = -0,53; p <0,001). Conclusões: Clientes com diabetes tipo 2, participantes deste estudo, apresentaram baixo nível de conhecimento sobre a SCA. Constatou-se um efeito do nível educacional sobre a subescala Conhecimento. O conhecimento sobre a SCA pode melhorar a capacidade do paciente em identificar os sinais e sintomas do infarto agudo do miocárdio.

Diferencias en el tratamiento antitrombótico y pronóstico en función del sexo en pacientes con síndrome coronario agudo tratados con stent / Sex-specific differences in antithrombotic therapy and prognosis in patients with acute coronary syndrome treated with stent

Resumen Antecedentes y objetivo: El interés sobre la influencia del sexo en pacientes con síndrome coronario agudo (SCA) tratados con stent y nuevos antiagregantes inhibidores de P2Y12 en la práctica clínica es creciente. Se analizan las diferencias en función del sexo en el tratamiento con doble antiagregación plaquetaria (DAPT) y los eventos adversos isquémicos y hemorrágicos Materiales y métodos: Estudio prospectivo de pacientes consecutivos con diagnóstico de SCA tratados con stent coronario desde julio de 2015 hasta enero de 2016. Resultados: De un total de 283 pacientes incluidos, 75 (26.5%) correspondió a mujeres y 208 (73.5%) a hombres. La edad media fue de 71 ± 13 y 66.5 ± 13 años, respectivamente. Un 44% de mujeres se presentó como SCA con elevación del segmento ST contra un 52.4 de los hombres, p = 0.21. Las mujeres mostraron un mayor riesgo de sangrado (CRUSADE), sin diferencias en el riesgo isquémico (GRACE y TIMI). Se usaron stents farmacoactivos con más frecuencia en mujeres (88.9 vs. 75.5%, p = 0.04). Se observó una tendencia de menor prescripción del ticagrelor en mujeres (42.6 vs. 50.9%, p = 0.29) en favor de un mayor uso del clopidogrel. No se identificaron diferencias en cuanto a la prescripción del prasugrel. Las mujeres presentaron al año una menor mortalidad (1.4 vs. 6.7%, p = 0.19), aunque mayor sangrado (23.3 vs. 17.4%, p = 0.27). Conclusiones: En este estudio de pacientes consecutivos con SCA tratados con stent se registró una mayor prescripción de clopidogrel en las mujeres que en los hombres. Las mujeres presentaron una menor incidencia anual de mortalidad, pero mayor sangrado en comparación con los hombres, no significativo.

Abstract Aims and objective: Impact of sex-related differences in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention and treated with new P2Y12 inhibitors is not adequately characterised. We aimed to analyse gender-based differences in dual antiplatelet therapy, and adverse cardiovascular events and bleeding. Materials and methods: Prospective-observational study of the consecutive ACS patients treated with stent from July 2016 to January 2016, with a follow-up of 1 year. Results: We examined 283 patients, 75 (26.5%) women and 208 (73.5%) men. Women were older than men (71 ± 13 vs. 66,5 ± 13 years). There were 44% of women and 52% of men presenting with ST-elevation ACS (p = 0.21). Women had a higher bleeding risk (CRUSADE), without differences in the ischaemic risk (GRACE and TIMI). More women were treated with drug-eluting stent (88.9 vs. 75.5%, p = 0.04). There was a lower rate of ticagrelor prescription in women (42.6 vs. 50.9%, p = 0.29), in favour of clopidogrel. No differences were observed in prasugrel prescription. No significant differences were observed after a year of follow up, but women had a tendency towards lower mortality (1.4 vs. 6.7%, p = 0.19) and higher bleeding rates (23.3 vs. 17.4%, p = 0.27). Conclusions: In our study of patients presenting with ACS treated with stent, clopidogrel was preferred in women, whereas ticagrelor was the most frequent prescription in men. No significant differences were noted in clinical outcomes, but women experienced a tendency towards less mortality and more bleeding events.

Readmission of Patients with Acute Coronary Syndrome and Determinants / Reinternação de Pacientes com Síndrome Coronariana Aguda e seus Determinantes

Abstract Background: Acute coronary syndrome (ACS) is responsible for high rates of hospital admission and readmission, which are associated with increased costs for the patient and the health system, and increased in-hospital mortality rates. Objective: To evaluate readmission in patients with ACS and its determinants. Methods: This was a retrospective cohort study of adult and elderly patients with ACS, readmitted to public and private referral cardiology hospitals within one year after the first hospitalization for ACS. The occurrence of readmissions, the time elapsed from the first to the second admission, and the use of medications at admission were collected from the medical records. Associations between categorical variables were evaluated by the chi-square test or the Fisher's exact test. Multiple logistic regression was used to evaluate predictors for readmissions. A p < 0.05 was set as statistically significant. Results: Readmission rate was 21.5% (n = 115) and mean time between admissions was 122.7 ± 112.1 days. The patients were mostly men (64.0%), mean age of 63.15 ± 12.3 years. Among readmitted patients, 7% had a prognosis of "death", and 68.7% were readmitted more than once within a one-year period. The main reasons of readmission were cardiovascular diseases including ACS. Private health care and the diagnosis of congestive heart failure were associated with multiple logistic regression. Conclusion: ACS was the main cause of readmission, with higher prevalence among users of supplemental health care. Readmissions were associated with previous diagnosis of congestive heart failure and the type of health care provided.

Resumo Fundamento: A síndrome coronariana aguda (SCA) é responsável por elevados números de admissões e readmissões hospitalares, os quais estão associados ao aumento dos custos para o paciente e para o sistema de saúde, bem como à elevação nas taxas de mortalidade hospitalar. Objetivo: Investigar a reinternação entre pacientes com SCA e seus determinantes. Métodos: Trata-se de uma coorte retrospectiva de pacientes de ambos os sexos, adultos e idosos, diagnosticados com SCA. Foram avaliados, a partir dos registros dos hospitais locais públicos e privados de referência em cardiologia, a ocorrência de reinternação em até 1 ano após internação por SCA, o tempo entre as admissões e o uso de medicamentos no momento da reinternação. As variáveis categóricas foram associadas por meio do teste qui-quadrado, ou pelo teste exato de Fisher. Regressão logística múltipla foi utilizada para avaliar as variáveis preditoras da reinternação. Adotou-se como critério de significância estatística um valor de p < 0,05. Resultados: A ocorrência de reinternações foi de 21,46% (n = 115), e o período médio entre as internações foi de 122,74 (DP 112,14) dias. Os pacientes avaliados eram, em sua maioria, do sexo masculino (64,0%), com média de idade de 63,15 anos (DP 12,26). Sete por cento apresentaram óbito como prognóstico da reinternação, e 68,7% tiveram mais de uma reinternação em 1 ano. As causas cardiovasculares, entre elas a recorrência da SCA, foram as mais prevalentes entre as reinternações hospitalares. A assistência privada e o diagnóstico de insuficiência cardíaca congestiva (ICC) foram associados a reinternação após a regressão logística múltipla. Conclusão: Conclui-se que a SCA foi a principal causa de reinternação, sendo mais prevalente entre os usuários da rede suplementar de saúde. As reinternações associaram-se ao diagnóstico prévio de ICC e ao tipo de assitência à saúde.

Behavioral Influence of Known Prognostic Markers on the Cardiologist's Decision following Acute Coronary Syndrome: the GRACE Score Paradox / Influência comportamental da predição de risco no processo de decisão do cardiologista: o paradoxo do Escore GRACE

Abstract Background: Behavioral scientists consistently point out that knowledge does not influence decisions as expected. GRACE Score is a well validated risk model for predicting death of patients with acute coronary syndromes (ACS). However, whether prognostic assessment by this Score modulates medical decision is not known. Objective: To test the hypothesis that the use of a validated risk score rationalizes the choice of invasive strategies for higher risk patients with non-ST-elevation ACS. Methods: ACS patients were consecutively included in this prospective registry. GRACE Score was routinely used by cardiologists as the prognostic risk model. An invasive strategy was defined as an immediate decision of the coronary angiography, which in the selective strategy was only indicated in case of positive non-invasive test or unstable course. Firstly, we evaluated the association between GRACE and invasiviness; secondly, in order to find out the actual determinants of the invasive strategy, we built a propensity model for invasive decision. For this analysis, a p-value < 0.05 was considered as significant. Results: In a sample of 570 patients, an invasive strategy was adopted for 394 (69%). GRACE Score was 118 ± 38 for the invasive group, similar to 116 ± 38 for the selective group (p = 0.64). A propensity score for the invasive strategy was derived from logistic regression: positive troponin and ST-deviation (positive associations) and hemoglobin (negative association). This score predicted an invasive strategy with c-statistics of 0.68 (95%CI: 0.63-0.73), opposed to GRACE Score (AUC 0.51; 95%CI: 0.47-0.57). Conclusion: The dissociation between GRACE Score and invasive decision in ACS suggests that the knowledge of prognostic probabilities might not determine medical decision.

Resumo Fundamento: Cientistas behavioristas ressaltam consistentemente que conhecimento não influencia decisão como esperado. O escore GRACE é um modelo de risco bem validado para prever morte de pacientes com síndromes coronarianas agudas (SCA). Todavia, não se sabe se a avaliação prognóstica pelo GRACE modula decisão médica. Objetivo: Testar a hipótese de que a utilização de escore de risco validado racionaliza a escolha de estratégias invasivas para pacientes de alto risco com SCA sem supradesnivelamento do segmento ST. Métodos: Pacientes com SCA foram consecutivamente incluídos neste registro prospectivo. O escore GRACE foi rotineiramente utilizado pelos cardiologistas como modelo de risco prognóstico. Estratégia invasiva foi definida como decisão imediata de cinecoronariografia, que na conservadora só era indicada se teste não invasivo positivo ou curso instável. Primeiro, avaliamos a associação entre GRACE e invasividade; segundo, a fim de descobrir atuais determinantes da estratégia invasiva, construímos um modelo de propensão para ela. Foi considerado significante um valor de p < 0,05 para esta análise. Resultados: Em amostra de 570 pacientes, estratégia invasiva foi adotada para 394 (69%). O escore GRACE foi de 118 ± 38 para o grupo invasivo, semelhante a 116 ± 38 do conservador (p = 0,64). O escore de propensão para estratégia invasiva foi derivado da regressão logística: troponina positiva e desvio de ST (associações positivas) e hemoglobina (associação negativa). Esse escore predisse estratégia invasiva com estatística-c de 0,68 (IC95%: 0,63-0,73), contrariando o Escore GRACE (AUC 0,51; IC95%: 0,47-0,57). Conclusão: A dissociação observada entre o valor do Escore GRACE e decisão invasiva em SCA sugere que o pensamento probabilístico pode não ser um importante determinante da decisão médica.

Experiencia a 12 años en el manejo antitrombótico de la ectasia coronaria en el Instituto Nacional de Cardiología Ignacio Chávez de México / A 12-year experience with antithrombotic management of patients with coronary ectasia at the Cardiological Institute "I. Chavez" from Mexco

Introducción: No hay lineamientos establecidos acerca del correcto anejo antitrombótico de pacientes con ectasia coronaria. Objetivos: Describir el manejo de pacientes con ectasia coronaria durante 12 años en el Instituto Nacional de Cardiología en la Ciudad de México, México. Métodos: Estudio retrospectivo, observacional. Se analizó una base de datos de 484 pacientes ingresados con síndrome coronario agudo, diagnosticado por angiografía de ectasia coronaria. Se obtuvo la clasificación de Markis y el anejo de los pacientes al alta, así como el seguimiento durante 12 años. La estadística fue descriptiva. Resultados: 14.6% de los pacientes recibieron monoterapia, el mas común fue el ácido acetil salicílico en el 7,8% seguido de acenocumarina en el 4.8% de los pacientes; el 25% fueron manejados con acenocumarina y ácido acetil salícíco más clopidogrel, 5,8% con terapia triple. La más común fue acenocumarina, acido acetil salicílico y clopidogrel en el 5%. conclusión: Solo hay recomendaciones con nivel de evidencia C. El tratamiento al alta de los pacientes con ectasia coronaria conel Instituto Nacional de Cardiología Ignacio Chávez es heterogénico y no está bien estandarizado, es necesario revisar las Guías de Práctica Clínica para estandarizarlo

Introduction: There are no established guidelines about the correct antibrombotic management of patients with coronary ectasia. Objectives: To describe the management of patients with coronary ectasia in a lapse of time of 12 years at the "Instituto Nacional de Cardiología Ignacio Chávez" Mexico. Methods: Observational retrospective study. We analyzed a database of 484 patients admitted to the INCICh diagnosed with coronary acute syndrome and angiographic diagnosis of coronary ectasia. We obtained information about the Markis classification and the treatment at the hospital discharge in a period of time of 12 years. Descriptive statistic was used. Results: 14.6% received monotherapy, the most common was aspirin in 7.8%, followed by acenocoumarin in 4.8% of patients. 25% of the total patients received acenocoumarin , aspirin and clopidogrel in 5%. Conclusions: There are only recommendations about the coronary artery disease treatment with a C level of evidence. The treatment in the Instituto Nacional de Cardiología Ignacio Chavez is heterogneous and is not well standardized

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

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

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

Knock on the right door. How we are treating the patient with acute myocardial infarction / Bata na porta certa. Como estamos tratando o paciente com infarto agudo do miocárdio

Background: To reduce mortality of acute myocardial infarction, medical care must be provided within the first hours of the event. Objective: To identify the "front door" to medical care of acute coronary patients and the time elapsed between patients'admission and performance of myocardial reperfusion in the public health system of the city of Joinville, Brazil. Methods: The study was a retrospective analysis of the medical records of 112 consecutive patients diagnosed with acute myocardial infarction by coronary angiography. We identified the place of the first medical contact and calculated the time between admission to this place and admission to the referral hospital, as well as the time until coronary angiography, with or without percutaneous transluminal angioplasty. A descriptive analysis of data was made using mean and standard deviation, and a p < 0.05 was set as statistically significant. Results: Only 16 (14.3%) patients were admitted through the cardiology referral unit. Door-to-angiography time was shorter than 90 minutes in 50 (44.2%) patients and longer than 270 minutes in 39 (34.5%) patients. No statistically significant difference was observed in door-to-angiography time between patients transported directly to the referral hospital and those transferred from other health units (p < 0.240). Considering the time between pain onset and angiography, only 3 (2.9%) patients may have benefited from myocardial reperfusion performed within less than 240 minutes. Conclusion: Management of patients with acute myocardial infarction is not in conformity with current guidelines for the treatment of this condition. The structure of the healthcare system should be urgently modified so that users in need of emergency services receive adequate care in accordance with local conditions

Correlação entre a complexidade das lesões coronarianas e os níveis de Troponina ultrassensível em pacientes com Síndrome Coronariana Aguda / Correlation between the complexity of coronary lesions and high-sensitivity Troponin levels in patients with Acute Coronary Syndrome

Fundamento: As doenças cardiovasculares são a principal causa de morte no Brasil. Marcadores bioquímicos possuem importância diagnóstica e prognóstica nas síndromes coronarianas agudas (SCAs), sendo a troponina o biomarcador preferido. Estudos já demonstram relação positiva entre elevação da troponina ultrassensível (TnUs) e prognóstico. Entretanto, poucos relacionam seus níveis com a complexidade das lesões coronárias. Objetivos: Comparar níveis de TnUs com a complexidade das lesões coronarianas pelo escore SYNTAX e relacionar os escores TIMI e GRACE com os níveis desse biomarcador em pacientes com SCA. Métodos: Estudo retrospectivo, transversal com 174 indivíduos com SCA. A correlação entre as variáveis foi avaliada pelo teste de correlação linear não paramétrico de Spearman e a análise estatística realizada pelo programa SPSS, com nível de significância de 5%. Resultados: A média de idade foi 63 anos, predominando o sexo feminino (52,9%). A maioria dos pacientes era hipertensa, não diabética e não tabagista. Dos pacientes avaliados, 19,0% apresentaram IAM com SST, 43,1% IAM sem SST e 36,8% angina instável. A maioria encontrava-se em Killip 1 (82,8%). A mediana de TnUs foi de 67pg/ml. As medianas dos escores de risco foram de 3, 121 e 3 pontos nas escalas TIMI, GRACE e SYNTAX, respectivamente. Houve correlação da taxa de TnUs com os escores SYNTAX (p < 0,001, r = 0,440), TIMI (p < 0,001, r = 0,267) e GRACE (p = 0,001, r = 0,261). Conclusão: Encontrada correlação linear positiva entre os níveis de TnUs e complexidade das lesões coronarianas, assim como entre esse biomarcador e os escores clínicos TIMI e GRACE

Background: Cardiovascular diseases are the leading cause of death in Brazil. Biochemical markers have diagnostic and prognostic importance in acute coronary syndromes (ACSs), with troponin as the preferred biomarker. Studies have already demonstrated a positive relationship between increased levels of high-sensitivity troponin (hsTn) and prognosis. However, few studies have correlated hsTn levels with the complexity of coronary lesions. Objectives: To compare hsTn levels with the complexity of coronary lesions according to the SYNTAX score, and to correlate the levels of this biomarker with the TIMI and GRACE scores in patients with ACS. Methods: Retrospective, cross-sectional study with 174 patients with ACS. The correlation between variables was assessed by the nonparametric Spearman's rank correlation, and statistical analysis was performed by the SPSS program, with a significance level of 5%. Results: Mean age was 63 years, and most patients were women (52.9%), hypertensive, non-diabetic and non-smokers. Nineteen percent of the patients had STEMI, 43.1% NSTEMI, and 36.8% unstable angina. Most were in Killip 1 (82.8%). Median hsTn was 67 pg/mL. Median risk scores were 3, 121 and 3 in the TIMI, GRACE and SYNTAX scores, respectively. There was a correlation of hsTn with SYNTAX (p <0.001, r = 0.440), TIMI (p < 0.001, r = 0.267) and GRACE (p = 0.001, r = 0.261) scores. Conclusion: A positive linear correlation was found of hsTn levels with the complexity of coronary lesions, and with the TIMI and GRACE

Registro de síndrome coronariana aguda na enfermaria do Hospital Governador Flávio Ribeiro Coutinho em Santa Rita-PB / Record of Acute Coronary Syndrome in the infirmary at Governador Hospital Flávio Ribeiro Coutinho in Santa Rita-PB

Observamos que no nosso serviço, o uso de AAS e clopidogrel na emergência, a positividade da CKMB e um maior período de internamento estiveram associados a uma maior associação com pontuação intermediária no escore de risco TIMI

Sesgo en la estratificación del síndrome coronario agudo al calcular el grace- score con 1ª, 2ª o troponina Δ / Grace score bias in acute coronary syndrome due to use 1th, 2th or troponin Δ

Introducción: el síndrome coronario agudo (SCA) es la primera causa de mortalidad en Colombia. Una estratificación de riesgo errónea, en la sala de emergencias (ER), afecta las intervenciones realizadas y la tasa de eventos adversos cardiovasculares puede ser mayor. El objetivo de esta investigación fue medir la diferencia en el puntaje GRACE y la estratificación del riesgo coronario, utilizando los resultados de las troponinas medidas secuencialmente durante la atención inicial. Metodología: con un diseño descriptivo retrospectivo, se evaluaron los registros clínicos de pacientes tratados por dolor precordial de probabilidad intermedia para SCA, sin indicación de manejo invasivo inmediato, atendidos en la sala de emergencias de una clínica del tercer nivel de Bogotá, durante el año 2017. Se determinó la diferencia entre la puntuación GRACE calculada con la primera troponina (GRACE-1), la segunda troponina (GRACE-2) o la troponina delta (GRACE-delta) [prueba T pareada], y la proporción de pacientes poco estratificados se midió al usar la primera troponina [X2, puntaje Z]. Resultados: se identificaron 44 pacientes en un período de 6 meses. La mayoría hombres con edad mediana de 73 años. El promedio (DE) de los puntajes GRACE-1, GRACE-2 y GRACE-delta, fue de 114.14 (30.73), 115.55 (30.14) y 111.11 (28.79), respectivamente; al comparar GRACE-delta con GRACE-1 y GRACE-2 se identificaron diferencias significativas (p:<0.05). Se identificó un error en la estratificación del riesgo coronario en 10/44 pacientes (22.7%) y 9/44 (20.4%) presentaron sobreestratificación. Conclusión: la estratificación del riesgo coronario con la primera troponina, a diferencia de la troponina delta (ítem no aclarado en las guías), evidenció una sobreestratificación en al menos 20% de los pacientes, estableciendo la necesidad de procedimientos más invasivos y posiblemente hospitalización más prolongada permanecer.

Background: Acute coronary syndrome (ACS) is the first cause of mortality in Colombia. An erroneous risk stratification, in the emergency room (ER), affects the interventions performed and the rate of major cardiovascular adverse events. We measured the difference in GRACE score and stratification of coronary risk, by using the results of troponins measured sequentially during initial care. Methods: With a retrospective descriptive design, clinical records of patients treated for precordial pain of ≥ intermediate probability for ACS were evaluated, without indication of immediate invasive management, attended in the ER of a clinic of the third level of Bogotá, during 2017. De-termined the difference between the GRACE score calculated with the first (GRACE-1), second (GRACE-2) or troponin delta (GRACE-delta [paired T-test], and the proportion of poorly stratified patients was measured when using the first troponin [X2, Z-score]. Results: 44 patients in a period of 6 months were identified. The majority men, older adults, middle age 73 years. The average (SD) of scores GRACE-1, GRACE-2 and GRACE-delta, was 114.14 (30.73), 115.55 (30.14) and 111.11 (28.79), respectively; when comparing GRACE-delta with GRACE-1 and GRACE-2 significant differences were identified (p:<0.05). Error in the stratification of coronary risk was identified in 10/44 patients (22.7%), and 9/44 (20.4%) presented over-stratification. Conclusion: The stratification of coronary risk using the first troponin, unlike the troponin delta (item not clarified in the guidelines), evidenced an over-stratification in at least 20% of the patients, establishing the need for more invasive procedures and possibly longer hospital stay.