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1.
Arq. bras. cardiol ; 118(3): 556-564, mar. 2022. tab, graf
Article in English, Portuguese | LILACS | ID: biblio-1364349

ABSTRACT

Resumo Fundamento Cerca de 40% dos pacientes com infarto agudo do miocárdio com supradesnível do segmento ST (IAMCSST) no Brasil não recebem terapia de reperfusão. Objetivo A utilização de uma rede de telemedicina baseada no WhatsApp® poderia aumentar a porcentagem de pacientes que recebem terapia de reperfusão. Métodos Estudo transversal do tipo antes e depois da organização de uma rede de telemedicina para envio e análise do eletrocardiograma através do WhatsApp® dos pacientes suspeitos de IAMCSST oriundos dos 25 municípios integrantes do Departamento Regional de Saúde de Ribeirão Preto (DRS−XIII), para hospital terciário que poderia autorizar a transferência imediata do paciente utilizando o mesmo sistema. O desfechos analisados foram a porcentagem de pacientes que receberam terapia de reperfusão e a taxa de mortalidade intra-hospitalar. Considerou-se valor de p <0,05 como estatisticamente significativo. Resultados Foram comparados 82 pacientes antes desta rede (1º de fevereiro de 2016 a 31 de janeiro de 2018) com 196 pacientes depois da implantação da mesma (1º de fevereiro de 2018 a 31 de janeiro de 2020). Após a implantação da rede, houve aumento significativo da proporção de pacientes que receberam terapia de reperfusão (60% vs. 92%), risco relativo (RR): 1,594 [intervalo de confiança (IC) 95% 1,331 - 1,909], p <0,0001 e redução da mortalidade intra-hospitalar (13,4% vs. 5,6%), RR: 0,418 [IC 95% 0,189 - 0,927], p = 0,028. Conclusão Rede de telemedicina baseada no WhatsApp® associou-se a aumento da porcentagem de pacientes com IAMCSST que receberam terapia de reperfusão e a redução na mortalidade intra-hospitalar.


Abstract Background About 40% of patients with ST-segment elevation myocardial infarction (STEMI) in Brazil do not receive reperfusion therapy. Objective The use of a telemedicine network based on WhatsApp® could increase the percentage of patients receiving reperfusion therapy. Methods A cross-sectional study analyzed outcomes before and after the organization of a telemedicine network to send the electrocardiogram via WhatsApp® of patients suspected of STEMI from 25 municipalities that are members of the Regional Health Department of Ribeirão Preto (DRS−XIII) to a tertiary hospital, which could authorize immediate patient transfer using the same system. The analyzed outcomes included the percentage of patients who received reperfusion therapy and the in-hospital mortality rate. A p value < 0.05 was considered statistically significant. Results The study compared 82 patients before (February 1, 2016 to January 31, 2018) with 196 patients after this network implementation (February 1, 2018 to January 31, 2020). After implementing this network, there was a significant increase in the proportion of patients who received reperfusion therapy (60% vs. 92%), relative risk (RR): 1.594 [95% confidence interval (CI) 1.331 - 1.909], p < 0.0001 and decrease in the in-hospital mortality rate (13.4% vs. 5.6%), RR: 0.418 [95%CI 0.189 - 0.927], p = 0.028. Conclusion The use of WhatsApp®-based telemedicine has led to an increase in the percentage of patients with STEMI who received reperfusion therapy and a decrease in the in-hospital mortality rate.


Subject(s)
Humans , Telemedicine , ST Elevation Myocardial Infarction/therapy , Myocardial Infarction/therapy , Myocardial Reperfusion , Cross-Sectional Studies , Hospital Mortality , Electrocardiography
3.
Rev. urug. cardiol ; 36(3): e201, 2021. graf
Article in Spanish | LILACS, BNUY, UY-BNMED | ID: biblio-1366972

ABSTRACT

Introducción: las medidas sanitarias de emergencia impuestas para contener el SARS-CoV-2 pueden tener efectos colaterales en la atención de enfermedades cardiovasculares. Los datos mundiales de los países sobre la incidencia de infarto agudo de miocardio con elevación del segmento ST (IAMCEST) durante la pandemia son fundamentales para la política sanitaria futura. Objetivos: nuestro objetivo fue determinar si las medidas sanitarias de emergencia impuestas en Uruguay tuvieron un impacto directo en la calidad de la atención en la reperfusión del IAMCEST. Métodos: realizamos un estudio retrospectivo poblacional de todo el país para determinar la incidencia de reperfusión de IAMCEST (fibrinolíticos e intervención coronaria percutánea, FBL e ICP respectivamente) durante el período sanitario de emergencia. La tasa de incidencia de la reperfusión, el tiempo hasta la reperfusión y la mortalidad asociada se recopilaron de la base de datos del Fondo Nacional de Recursos (organización gubernamental única a cargo de la financiación de la reperfusión del IAMCEST en Uruguay). Estos mismos datos se recuperaron para 2019, 2018 y 2017. Resultados: se trataron durante el periodo de estudio del 2020 (136 pacientes) en comparación con 2019 (180 pacientes), 2018 (182 pacientes) y 2017 (174 pacientes). Se realizó FBL como tratamiento único en 5,1%, 7,2%, 7,7% y 12,1%, respectivamente. La razón de tasa de incidencia de IAMCEST durante el período estudiado en 2020 fue de 0,7 (IC95%: 0,59-0,91). La mediana del tiempo hasta la reperfusión fue similar en comparación con 2019, 2018 y 2017 (p = 0,4). No hubieron diferencias en la mortalidad a 15 dias entre los años evaluados.


Introduction: the emergency health measures imposed to contain SARS-CoV-2 can have collateral effects in the care of cardiovascular diseases. Global country data on the incidence of ST acute myocardial infarction during the pandemic are critical for future health policy. Objectives: our objective was to determine if the emergency health measures imposed in Uruguay had a direct impact on the quality of ST elevation acute myocardial infarction care. Methods: we carried out a population-based retrospective study of the entire country to determine the incidence of reperfusion of ST elevation acute myocardial infarction (fibrinolytic and percutaneous) during the emergency health period. The incidence rate of reperfusion, time to reperfusion, and associated mortality were collected from the Fondo Nacional de Recursos (the only government organization in charge of the reperfusion of ST elevation myocardial infarction in Uruguay). These same data were recovered for 2019, 2018 and 2017. Results: fewer patients were treated in 2020 (136 patients) compared to 2019 (180 patients), 2018 (182 patients), and 2017 (174 patients). Fibrinolytics was performed as the only treatment in 5.1%, 7.2%, 7.7% and 12.1% respectively. The proportion in incidence rate of ST elevation myocardial infarction during the study period in 2020 was lower (0.74, 95% CI: 0.59-0.91). The median time to reperfusion was similar compared to 2019, 2018, and 2017 (p = 0.4). Mortality at 15 days was similar in 2017 (8%), 2018 (6%), 2019 (11%) and 2020 (8%). Conclusion: emergency health measures were associated with a decrease in the incidence of reperfusion of ST elevation myocardial infarction without affecting the time to reperfusion and mortality.


Introdução: as medidas emergenciais de saúde impostas para conter o SARS-CoV-2 podem ter efeitos colaterais no cuidado das doenças cardiovasculares. Os dados globais do país sobre a incidência de infarto agudo do miocárdio durante a pandemia são essenciais para a futura política de saúde. Objetivos: nosso objetivo foi determinar se as medidas de saúde de emergência impostas no Uruguai tiveram um impacto direto na qualidade do atendimento infarto agudo do miocárdio. Métodos: foi realizado um estudo retrospectivo de base populacional em todo o país para determinar a incidência de reperfusão do infarto agudo do miocárdio (fibrinolítico e percutâneo) durante o período de emergência de saúde. A taxa de incidência de reperfusão, tempo de reperfusão e mortalidade associada foram coletados do Fondo Nacional de Recursos (a única organização governamental responsável pela reperfusão de infarto agudo do miocárdio no Uruguai). Esses mesmos dados foram recuperados para 2019, 2018 e 2017. Resultados: menos pacientes foram tratados em 2020 (136 pacientes) em comparação com 2019 (180 pacientes), 2018 (182 pacientes) e 2017 (174 pacientes). Fibrinolisis foi realizado como o único tratamento em 5,1%, 7,2%, 7,7% e 12,1%, respectivamente. A proporção na taxa de incidência de infarto agudo do miocárdio durante o período estudado em 2020 foi menor (0,74, IC 95%: 0,59-0,91). O tempo médio para reperfusão foi semelhante em comparação com 2019, 2018 e 2017 (p = 0,4). A mortalidade em 15 dias foi semelhante em 2017 (8%), 2018 (6%), 2019 (11%) e 2020 (8%). Conclusão: as medidas emergenciais de saúde foram associadas à diminuição da incidência de reperfusão do infarto agudo do miocárdio, sem afetar o tempo de reperfusão e a mortalidade.


Subject(s)
Humans , Pandemics , ST Elevation Myocardial Infarction/epidemiology , COVID-19/epidemiology , Health Policy , Uruguay/epidemiology , Epidemiology, Descriptive , Incidence , Retrospective Studies , ST Elevation Myocardial Infarction/mortality , ST Elevation Myocardial Infarction/therapy
4.
Arq. bras. cardiol ; 115(5): 916-924, nov. 2020. tab, graf
Article in Portuguese | SES-SP, LILACS, SES-SP | ID: biblio-1142262

ABSTRACT

Resumo Fundamento: O infarto agudo do miocárdio com supradesnivelamento do segmento ST (STEMI) é uma das principais apresentações clínicas da cardiopatia isquêmica. Dados de base populacional são relevantes para entendimento contemporâneo da epidemiologia da doença. Objetivo: Descrever incidência, manejo terapêutico, desfechos clínicos hospitalares e eventos cardiovasculares do primeiro ano de seguimento dos indivíduos hospitalizados por STEMI. Métodos: Estudo de coorte prospectiva de base populacional com registro consecutivo das hospitalizações por STEMI em uma cidade do Sul do Brasil entre 2011 e 2014. Foram incluídos indivíduos com STEMI que apresentaram sintomas de isquemia miocárdica aguda nas últimas 72 horas. Os valores de p < 0,05 foram considerados significativos. Resultados: A incidência anual de hospitalizações por STEMI foi de 108 casos por 100.000 habitantes. A incidência ajustada foi maior entre os mais velhos (risco relativo 64,9; IC95% 26,9 - 156,9; p para tendência linear < 0,001) e entre os homens (risco relativo 2,8; IC95% 2,3 - 3,3; p < 0,001). Ocorreram 530 hospitalizações durante o período avaliado e a taxa de reperfusão foi de 80,9%. A mortalidade hospitalar e a taxa de eventos cardiovasculares em 1 ano foram, respectivamente, 8,9% e 6,1%. Os mais velhos apresentaram maior mortalidade hospitalar (risco relativo 3,72; IC95% 1,57 - 8,82; p para tendência linear = 0,002) e mais eventos cardiovasculares em 1 ano (hazard ratio 2,35; IC95% 1,12 - 4,95; p = 0,03). Conclusão: Este registro demonstra abordagem terapêutica e mortalidade hospitalar semelhante às observadas em países desenvolvidos. Entretanto, a taxa de hospitalizações foi maior comparada com esses países.


Abstract Background: ST-segment elevation myocardial infarction (STEMI) is one of the main clinical manifestations of ischemic heart disease. Population-based data are relevant to better understand the current epidemiology of this condition. Objective: To describe the incidence, therapeutic management, hospital clinical outcomes and cardiovascular events in the first year of follow-up of individuals hospitalized for STEMI. Methods: Population-based prospective cohort study with consecutive registries of hospitalization for STEMI in a city in southern Brazil from 2011 to 2014. It included patients with STEMI who presented acute myocardial ischemia symptoms in the last 72 hours. A p-value < 0.05 was considered significant. Results: The annual incidence of STEMI hospitalizations was 108 cases per 100,000 inhabitants. Adjusted incidence was higher among older individuals (relative risk 64.9; 95% CI 26.9-156.9; p for linear trend < 0.001) and among men (relative risk 2.8; 95% CI 2.3-3.3; p < 0.001). There were 530 hospitalizations in the period under evaluation and the reperfusion rate reached 80.9%. Hospital mortality and the one-year follow-up cardiovascular event rate were, respectively, 8.9% and 6.1%. The oldest patients had higher hospital mortality (relative risk 3.72; 95% CI 1.57-8.82; p for linear trend = 0.002) and more one-year follow-up cardiovascular events (hazard ratio 2.35; 95% CI 1.12-4.95; p = 0.03). Conclusion: This study shows that both the therapeutic approach and hospital mortality are similar to the ones found in developed countries. However, the hospitalization rate was higher in these countries.


Subject(s)
Humans , Male , ST Elevation Myocardial Infarction/therapy , ST Elevation Myocardial Infarction/epidemiology , Myocardial Infarction/therapy , Myocardial Infarction/epidemiology , Brazil/epidemiology , Registries , Prospective Studies , Risk Factors , Treatment Outcome , Hospital Mortality , Hospitalization
5.
Gac. méd. Méx ; 156(5): 372-378, sep.-oct. 2020. graf
Article in Spanish | LILACS | ID: biblio-1249934

ABSTRACT

Resumen Introducción: México es el país con mayor mortalidad por infarto agudo de miocardio con elevación del segmento ST (IAM CEST), por lo que el Instituto Mexicano del Seguro Social desarrolló el protocolo de atención para los servicios de urgencias denominado Código Infarto. En este artículo se discuten aspectos de la medicina traslacional con una perspectiva bioética e integral. Objetivo: Analizar el protocolo Código Infarto desde la perspectiva de la bioética traslacional. Método: Se realizó una aproximación centrada en el problema a través del equilibrio reflexivo, así como la aplicación del método integral para el discernimiento ético. Resultados: El protocolo de atención para los servicios de urgencias Código Infarto se rige por la medicina basada en la evidencia y la medicina basada en valores; se orienta por el principio de integridad que considera las seis dimensiones de la calidad para la atención de pacientes con IAM CEST. Conclusión: El protocolo supera algunos determinantes sociales adversos que afectan la atención médica del IAM CEST, disminuye la mortalidad, la carga económica global de la enfermedad y desarrolla una medicina de excelencia de alto alcance social.


Abstract Introduction: Mexico is the country with the highest mortality due to ST-elevation acute myocardial infarction (STEMI), and the IMSS has therefore developed the protocol of care for emergency departments called Código Infarto (Infarction Code). In this article, aspects of translational medicine are discussed with a bioethical and comprehensive perspective. Objective: To analyze the Código Infarto protocol from the perspective of translational bioethics. Method: A problem-centered approach was carried out through reflective equilibrium (or Rawls' method), as well as by applying the integral method for ethical discernment. Results: The protocol of care for emergency services Código Infarto is governed by evidence-based medicine and value-based medicine; it is guided by a principle of integrity that considers six dimensions of quality for the care of patients with STEMI. Conclusion: The protocol overcomes some adverse social determinants that affect STEMI medical care, reduces mortality and global economic disease burden, and develops medicine of excellence with high social reach.


Subject(s)
Humans , Myocardial Reperfusion/ethics , Clinical Protocols , Bioethical Issues , Emergency Service, Hospital/ethics , ST Elevation Myocardial Infarction/diagnosis , ST Elevation Myocardial Infarction/therapy , Myocardial Reperfusion/statistics & numerical data , Reproducibility of Results , Evidence-Based Medicine , Fibrinolytic Agents/administration & dosage , ST Elevation Myocardial Infarction/mortality , Stakeholder Participation , Mexico
7.
Arch. cardiol. Méx ; 90(2): 137-141, Apr.-Jun. 2020. tab, graf
Article in English | LILACS | ID: biblio-1131022

ABSTRACT

Abstract Objective: The objective of PHASE-MX registry is to validate the efficacy and safety of the pharmacoinvasive strategy in comparison with percutaneous coronary intervention (PCI) in patients with acute myocardial infarction with ST segment elevation (STEMI) in a metropolitan region of Mexico. The primary outcome will consist of the composite of cardiovascular death, re-infarction, stroke and cardiogenic shock. Methods: The PHASE-MX registry will include a prospective cohort of patients with STEMI who received reperfusion treatment (mechanical of pharmacological) in the first 12 h after the onset of symptoms. The registry is designed to compare the efficacy and safety of primary PCI and pharmacoinvasive strategy. The simple size was calculated in 344 patients divided into two groups, with an estimated loss rate of 10%. Patients included in the PHASE-MX cohort will be followed for up to one year. Conclusion: In Mexico, only 5 out of 10 patients with STEMI have access to reperfusion therapy. Pharmacoinvasive strategy is takes advantage of the accessibility of fibrinolysis and the effectiveness of PCI. The present research protocol aims to provide information that serves as a link between information derived from controlled clinical trials and records derived from real world experience.


Resumen Objetivo: El objetivo del registro PHASE-MX es validar la eficacia y seguridad de la estrategia farmacoinvasiva en comparación con la angioplastia coronaria transluminal percutánea primaria (ACTPp) en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) en una región metropolitana de México. El desenlace primario es el compuesto de muerte cardiovascular, reinfarto, accidente vascular cerebral y choque cardiogénico. Métodos: El registro PHASE-MX es una cohorte prospectiva de pacientes con IAMCEST que recibieron tratamiento de reperfusión (mecánico o farmacológico) en las primeras 12 horas desde el inicio de los síntomas, atendidos en el Instituto Nacional de Cardiología Ignacio Chávez. El análisis estadístico se basa en la no inferioridad de la estrategia farmacoinvasiva en comparación con la ACTPp. Se calcula un tamaño de muestra de 344 pacientes divididos en dos grupos (angioplastia primaria y estrategia farmacoinvasiva), considerada una tasa de pérdidas de 10%. Los pacientes incluidos en la cohorte PHASE-MX se seguirán durante un año. Discusión: En México, sólo 5 de cada 10 pacientes con IAMCEST tienen acceso al tratamiento de reperfusión. La estrategia farmacoinvasiva aprovecha la accesibilidad de la fibrinólisis y la efectividad de la ACTPp, por lo que podría resultar el método de elección en el tratamiento del IAMCEST en la mayoría de los casos. El presente protocolo de investigación pretende aportar información que sirva como enlace entre la información derivada de los estudios clínicos controlados y los registros derivados de la experiencia del mundo real.


Subject(s)
Humans , Male , Female , Reperfusion/methods , Percutaneous Coronary Intervention/methods , ST Elevation Myocardial Infarction/therapy , Research Design , Shock, Cardiogenic/epidemiology , Registries , Prospective Studies , Cohort Studies , Follow-Up Studies , Stroke/epidemiology , Percutaneous Coronary Intervention/adverse effects , Mexico
8.
Arq. bras. cardiol ; 114(1): 35-44, Jan. 2020. tab, graf
Article in English | LILACS | ID: biblio-1055080

ABSTRACT

Abstract Background: A significant reduction in the morbidity and mortality related to ST-segment elevation myocardial infarction (STEMI) has been achieved with the development of reperfusion therapies. Early diagnosis and correct initial management are important to ensure this benefit. In Brazil, recent graduates in medicine are responsible for a large part of the initial care provided for these patients. Objective: To assess the clinical competence in the diagnosis and initial treatment of STEMI by newly graduated physicians applying for a medical residency program. Methods: We assessed the performance of 771 applicants for the direct entry selection process of the FMRP-USP Clinical Hospital Medicine Residency Program, performed in a simulated setting of STEMI, with professional actors and medical evaluators, using a standardized checklist following the recommendations of the Brazilian Guidelines for the management of this disease. Results: The general performance score presented a median of 7 and an interquartile range of 5.5-8.0. In relation to the items assessed: 83% required ECG monitoring, 57% requested the insertion of a peripheral venous access catheter, 95% administered acetylsalicylic acid, 80% administered a second antiplatelet agent (p2y12 inhibitor), 66% administered nitrate, 71% administered morphine, 69% recognized the diagnosis of STEMI, 71% assessed the pain duration, 63% recognized the need for immediate transfer, 34% showed adequate communication skills and only 25% insisted on the transfer even in case of non-availability of beds. Conclusions: The initial diagnosis and management of STEMI need to be improved in medical undergraduate courses and inserted into the reality of the hierarchical network structure of the Brazilian Unified Health System (SUS).


Resumo Fundamento: Houve importante redução da morbimortalidade do infarto agudo do miocárdio com supradesnível do segmento ST (IAMCSST) com o desenvolvimento das terapias de reperfusão. Para garantir este benefício é importante o diagnóstico precoce e manejo inicial correto. No Brasil, recém-formados do curso de medicina são responsáveis por grande parte dos atendimentos iniciais a estes pacientes. Objetivo: Avaliar a competência clínica no reconhecimento e manejo inicial do IAMCSST por médico recém-formado candidato à residência médica. Métodos: Realizada análise do desempenho de 771 candidatos do concurso de acesso direto para residência médica do Hospital das Clínicas da FMRP-USP em estação prática de simulação de atendimento de paciente com IAMCSST com atores profissionais e avaliadores médicos com uma lista de checagem padronizada de acordo com recomendações da diretriz brasileira para manejo desta patologia. Resultados: O escore de desempenho geral apresentou mediana de 7 e intervalo interquartil de 5,5-8,0. Em relação aos itens avaliados: 83% solicitou monitorização eletrocardiográfica, 57% solicitou inserção de um acesso venoso periférico, 95% administrou ácido acetilsalicílico, 80% administrou segundo antiagregante (inibidor do P2Y12), 66% administrou nitrato, 71% administrou morfina, 69% reconheceu o diagnóstico de IAMCSST, 71% avaliou o tempo de duração da dor, 63% reconheceu a necessidade de transferência imediata, 34% apresentou habilidade de comunicação adequada e somente 25% insistiu na transferência mesmo na ausência de vaga. Conclusões: O reconhecimento e gerenciamento inicial do IAMCSST precisa ser aprimorado na graduação médica e inserido dentro da realidade da estrutura de rede hierarquizada do sistema de saúde público brasileiro.


Subject(s)
Male , Female , Adult , Young Adult , Clinical Competence/statistics & numerical data , ST Elevation Myocardial Infarction/therapy , Internship and Residency/statistics & numerical data , Cross-Sectional Studies , Checklist , ST Elevation Myocardial Infarction/diagnosis
9.
Arch. cardiol. Méx ; 90(supl.1): 62-66, may. 2020. tab, graf
Article in Spanish | LILACS | ID: biblio-1152846

ABSTRACT

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).


Subject(s)
Humans , Pneumonia, Viral/prevention & control , Myocardial Reperfusion/methods , Health Personnel , Coronavirus Infections/prevention & control , Pandemics/prevention & control , ST Elevation Myocardial Infarction/therapy , Pneumonia, Viral/epidemiology , Thrombolytic Therapy/methods , Coronavirus Infections/epidemiology , Acute Coronary Syndrome/therapy , Percutaneous Coronary Intervention/methods , COVID-19
10.
Arch. cardiol. Méx ; 90(supl.1): 33-35, may. 2020.
Article in Spanish | LILACS | ID: biblio-1152840

ABSTRACT

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.


Subject(s)
Humans , Pneumonia, Viral/epidemiology , Coronavirus Infections/epidemiology , Acute Coronary Syndrome/therapy , Pneumonia, Viral/prevention & control , Cardiac Catheterization , Disease Outbreaks , Coronavirus Infections/prevention & control , Acute Coronary Syndrome/physiopathology , Pandemics/prevention & control , Percutaneous Coronary Intervention/methods , Non-ST Elevated Myocardial Infarction/physiopathology , ST Elevation Myocardial Infarction/physiopathology , ST Elevation Myocardial Infarction/therapy , COVID-19 , Mexico/epidemiology
11.
Arch. cardiol. Méx ; 89(4): 301-307, Oct.-Dec. 2019. tab, graf
Article in English | LILACS | ID: biblio-1149087

ABSTRACT

Abstract Introduction: Radial access is the gold standard for ST-elevation myocardial infarction; nevertheless, there is scarce information in Mexico. Objectives: The objectives of this study were to describe the differences in radiation exposure, intervention time, fluoroscopy time, complications and temporal trends, and risk factors among radial and femoral access for coronary procedures. Materials and Methods: A total of 493 patients underwent coronary interventions by femoral or radial access. Sociodemographic and procedural data were recorded. A logistic regression model to determine risk factors for complications was performed. Results: The population included 346 men and 147 women, with a median age of 63 years, 159 underwent radial and 334 femoral approaches. Complications occurred in 18 patients (3.6%), 11 in radial and 7 in femoral access, with a higher trend in the first 5 months (n = 14). Vasospasm was the most common (n = 9) complication. Median fluoroscopy time was 12 min for radial and 9 min for femoral groups, with a total radiation dose of 2282 µGm2 and 2848 µGm2, respectively. Temporal trends showed that complications occurred most frequently during the first 6 months of the study. The main predictors for complications were intervention time and one-vessel disease. Conclusions: Radial access had higher frequency of complications than femoral approach and they were more common during the first 6 months. The main risk factor was intervention time longer than 60 min.


Resumen Introducción: El abordaje radial es el de elección para infarto de miocardio con elevación del segmento ST, sin embargo se desconoce información en México. Objetivos: Describir las diferencias en exposición a radiación, tiempo de intervención, tiempo de fluoroscopía, complicaciones y sus variaciones temporales, además de los factores de riesgo entre el abordaje radial y el femoral para procedimientos coronarios. Método: Se incluyeron 493 pacientes que fueron sometidos a estudio angiográfico o intervenciones coronarias por abordaje radial o femoral. Se recabaron datos sociodemográficos, antecedentes y variables del procedimiento. Se realizó un modelo de regresión logística para determinar los factores asociados a complicaciones. Resultados: Se incluyeron 346 hombres y 147 mujeres, con mediana de edad de 63 años. A 159 se les realizó acceso radial y a 334 femoral. Las complicaciones ocurrieron en 18 pacientes (3.65%): 11 en radial y 7 en femoral, teniendo mayor incidencia en los primeros 5 meses (n = 14) y siendo el vasoespasmo el más común (n = 9). La mediana de tiempo de fluoroscopía fue de 12 minutos para el radial y de 9 minutos para el femoral, con una dosis total de radiación de 2,282 µGm2 y 2,848 µGm2, respectivamente. Las tendencias temporales indicaron que las complicaciones fueron más frecuentes durante los primeros 6 meses. Los principales predictores fueron el tiempo de intervención y la enfermedad de 1 vaso. Conclusiones: La vía de acceso radial tuvo más complicaciones que la femoral. Se observaron más complicaciones en los primeros 6 meses del estudio. El principal predictor de complicaciones fue el tiempo de intervención mayor a 60 minutos.


Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Aged, 80 and over , Young Adult , Radial Artery , Femoral Artery , Percutaneous Coronary Intervention/methods , ST Elevation Myocardial Infarction/therapy , Time Factors , Cross-Sectional Studies , Risk Factors , Treatment Outcome , Coronary Angiography/methods , Percutaneous Coronary Intervention/adverse effects , Mexico
12.
Arq. bras. cardiol ; 113(5): 948-957, Nov. 2019. tab, graf
Article in English | LILACS | ID: biblio-1055042

ABSTRACT

Abstract Backgrund: New-onset atrial fibrillation complicating acute myocardial infarction represents an important challenge, with prognostic significance. Objective: To study the incidence, impact on therapy and mortality, and to identify predictors of development of new-onset atrial fibrillation during hospital stay for ST-segment elevation myocardial infarction. Methods: We studied all patients with ST-elevation myocardial infarction included consecutively, between 2010 and 2017, in a Portuguese national registry and compared two groups: 1 - no atrial fibrillation and 2 - new-onset atrial fibrillation. We adjusted a logistic regression model data analysis to assess the impact of new-onset atrial fibrillation on in-hospital mortality and to identify independent predictors of its development. A p value < 0.05 was considered significant. Results: We studied 6325 patients, and new-onset atrial fibrillation was found in 365 (5.8%). Reperfusion was successfully accomplished in both groups with no difference regarding type of reperfusion. In group 2, therapy with beta-blockers and angiotensin-conversion enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) was less frequent, 20.6% received anticoagulation at discharge and 16.1% were on triple therapy. New-onset atrial fibrillation was associated with more in-hospital complications and mortality. However, it was not found as an independent predictor of in-hospital mortality. We identified age, prior stroke, inferior myocardial infarction and complete atrioventricular block as independent predictors of new-onset atrial fibrillation. Conclusion: New-onset atrial fibrillation remains a frequent complication of myocardial infarction and is associated with higher rate of complications and in-hospital mortality. Age, prior stroke, inferior myocardial infarction and complete atrioventricular block were independent predictors of new onset atrial fibrillation. Only 36.7% of the patients received anticoagulation at discharge.


Resumo Fundamento: A fibrilação auricular de novo no contexto de infarto agudo do miocárdio representa um importante desafio com potencial impacto prognóstico. Objetivo: Determinar a incidência, impacto na terapêutica e mortalidade, e identificar possíveis preditores do aparecimento de fibrilação auricular de novo durante o internamento por infarto agudo do miocárdio com supradesnivelamento do segmento ST. Métodos: Estudamos todos os pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST inseridos consecutivamente de 2010 a 2017 num registro nacional português e comparamos dois grupos: 1 - sem fibrilação auricular; 2- com fibrilação auricular de novo. Efetuamos análise com modelo de regressão logística para avaliar o impacto de fibrilação auricular de novo na mortalidade intra-hospitalar e identificar preditores independentes para o seu aparecimento. Para teste de hipóteses, considerou-se significativo p < 0,05. Resultados: Estudamos 6325 pacientes, dos quais 365 (5.8%) apresentaram fibrilação auricular de novo. Não houve diferença no número de pacientes reperfundidos nem na estratégia de reperfusão. No grupo 2, terapêutica com betabloqueadores e IECA/ARA foi menos frequente, 20.6% tiveram alta sob anticoagulação oral e 16.1% sob terapêutica tripla. A fibrilação auricular de novo associou-se a maior incidência de complicações e mortalidade intra-hospitalar, mas não foi preditor independente de mortalidade intra-hospitalar. Identificamos idade, acidente vascular cerebral prévio, infarto inferior e bloqueio auriculoventricular completo como preditores independentes de fibrilação auricular de novo. Conclusões: A fibrilação auricular de novo continua sendo uma complicação frequente do infarto agudo do miocárdio, estando associada a aumento das complicações e mortalidade intra-hospitalar. Apenas 36.7% desses pacientes teve alta sob anticoagulação.


Subject(s)
Humans , Male , Female , Middle Aged , Aged , Aged, 80 and over , Atrial Fibrillation/complications , Stents/statistics & numerical data , ST Elevation Myocardial Infarction/complications , Portugal/epidemiology , Recurrence , Atrial Fibrillation/mortality , Atrial Fibrillation/therapy , Cardiovascular Agents/therapeutic use , Myocardial Reperfusion/mortality , Incidence , Predictive Value of Tests , Retrospective Studies , Age Factors , Hospital Mortality , Coronary Angiography , Thrombectomy/mortality , Stroke/complications , ST Elevation Myocardial Infarction/mortality , ST Elevation Myocardial Infarction/therapy , Heart Failure/complications , Hospitalization/statistics & numerical data , Length of Stay
13.
Medicina (B.Aires) ; 79(4): 251-256, ago. 2019. tab
Article in Spanish | LILACS | ID: biblio-1040517

ABSTRACT

Se evaluaron las características clínicas, demoras, resultados y morbimortalidad de 1142 pacientes tratados con angioplastia primaria (AP) dentro de las 36 horas del infarto, incluidos en el registro ARGEN-IAM-ST, de carácter prospectivo, transversal, multicéntrico y de alcance nacional. Edades: 61.2 ± 12 años, 88% varones, 20% diabéticos y 58% hipertensos; 77.6% en Killip y Kimball I y 6.2% en shock cardiogénico. El tiempo desde el inicio del dolor hasta el ingreso fue de 153 (75-316) minutos, y puerta-balón de 91 (60-150) minutos. Los casos derivados (17%) tuvieron mayor demora de ingreso, 200 minutos (195-420; p = 0.0001) y mayor tiempo puerta-balón, 113 minutos (55-207); p = 0.099. En 47.6% de los casos la AP se hizo en arteria descendente anterior, en 36.4% a coronaria derecha, en 14.8% a circunfleja y en 1.2% al tronco de coronaria izquierda; en 95% con stent (29% farmacológico). El 95% fue exitoso. El 1.3% presentó angina post-infarto (APIAM), 1.3% re-infarto, 8.8% shock y 3.2% sangrado. Se asociaron a mayor mortalidad edad > 64 años (OR 6.2 (IC 95%: 3.2-12), p < 0.001), diabetes (OR 2.5, IC 95% 1.6-3.9, p < 0.001), re-infarto o APIAM (OR 3.3, IC 95% 1.3-8.3, p = 0.011) y shock (OR 29.2 (15.6-54.8), p < 0.001). La mortalidad hospitalaria del infarto agudo de miocardio con elevación del segmento ST tratado con AP fue de 7.6%. La derivación se asoció a demora de tratamiento. El shock cardiogénico y la isquemia post-infarto se asociaron a alta mortalidad. No hubo variables del procedimiento asociadas a mortalidad.


Our objective was to evaluate clinical characteristics, results and morbi-mortality in primary angioplasty (PA), of patients treated with PA within 36 hours of a myocardial infarction (MI), included in a prospective, transversal, multicenter and national survey (ARGEN-IAM-ST). A total of 1142 patients treated with PA were registered, 61.2 ± 12 years old, 88% male, 20% diabetics and 58% with hypertension; 77.6% in Killip Kimball I and 6.2% in cardiogenic shock. The time from the onset of pain until admission was 153 (75-316) minutes, and door-balloon of 91 (60-150) minutes. The transferred patients (17%) showed longer delay to admission, 200 minutes (195-420; p = 0.0001) and door-to-balloon 113.5 minutes (55-207); p = 0.099. In 47.6% of the cases, the PA was made in the anterior descending artery, in 36.4% in the right coronary artery, in 14.8% in the circumflex artery and in 1.2% in the left coronary artery; in 95% with stent (29% pharmacological); 95% was successful, 1.3% presented post-infarct angina (APIAM), 1.3% re-infarct, 8.8% shock and 3.2% bleeding. Age > 64 years (OR 6.2 (95% CI: 3.2-12), p <0.001), diabetes (OR 2.5, 95% CI 1.6-3.9, p < 0.001), re-infarction or APIAM (OR 3.3, 95% CI 1.3-8.3, p = 0.011) and shock (OR 29.2 (15.6-54.8), p < 0.001) were independently associated with higher mortality. In-hospital mortality of acute myocardial infarction with ST-segment elevation treated with PA was 7.6%. Transference from other center was associated with delay in the admission and treatment. Cardiogenic shock and post-infarct ischemia were associated with high mortality. There were no procedural variables associated with mortality.


Subject(s)
Humans , Male , Female , Middle Aged , Aged , Angioplasty, Balloon, Coronary/mortality , ST Elevation Myocardial Infarction/therapy , Argentina , Cross-Sectional Studies , Prospective Studies , Treatment Outcome , ST Elevation Myocardial Infarction/mortality
14.
Arq. bras. cardiol ; 112(5): 564-570, May 2019. tab
Article in English | LILACS | ID: biblio-1011185

ABSTRACT

Abstract Background: Primary angioplasty (PA) with placement of either bare metal or drug-eluting stents (DES) represents the main strategy in the treatment of ST-elevation myocardial infarction (STEMI). Diabetic patients, however, represent a special population in STEMI, with high rates of restenosis and unfavorable clinical outcomes, and with the use of DES, level of evidence A and indication class II, being indicated to reduce these damages. Objectives: To evaluate the DES rate of use in patients with STEMI and in the subgroup of diabetics assisted in the public versus private health network in Sergipe. Methods: This is a population-based, cross-sectional study with a quantitative approach using the data from the VICTIM Register. These were collected in the only four hospitals with capacity to perform PA in Sergipe, from December 2014 to March 2017. Results: A total of 707 patients diagnosed with STEMI were evaluated, of which 589 were attended at SUS and 118 at the private network. The use of DES in PA was lower in SUS compared to the private network in both the total sample (10.5% vs 82.4%, p<0.001) and in subgroup diabetic patients (8.7% vs 90.6%, p < 0.001), respectively. In all hypotheses tested, the level of significance was 5% (p < 0.05). Conclusions: The study reveals a disparity in the use of DES during the performance of PA between the public and private network, both in the total sample and the subgroup for diabetics, with lower rates for SUS users, demonstrating the challenges that need to be overcome in order to achieve quality improvements of the services provided.


Resumo Fundamento: A angioplastia primária (AP) com colocação de stent, seja ele convencional ou farmacológico, representa a principal estratégia no tratamento do infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST). Os pacientes diabéticos, entretanto, representam população especial no IAMCSST, com altas taxas de reestenose e desfechos clínicos desfavoráveis, devendo-se indicar o uso de stents farmacológicos (SF), nível de evidência A e classe de indicação II, para redução destes danos. Objetivo: Avaliar a taxa de uso de SF em pacientes com IAMCSST e no subgrupo dos diabéticos assistidos na rede pública versus privada de saúde em Sergipe. Métodos: Trata-se de um estudo populacional, transversal, com abordagem quantitativa, que utilizou os dados do Registro VICTIM. Estes foram coletados nos quatro únicos hospitais com capacidade para realizar AP em Sergipe, no período de dezembro de 2014 a março de 2017. Em todas as hipóteses testadas, o nível de significância adotado foi de 5% (p < 0,05). Resultados: Foram avaliados 707 pacientes diagnosticados com IAMCSST, dos quais 589 foram atendidos pelo SUS e 118 pela rede privada. O uso de SF na AP foi menor no SUS em comparação com a rede privada, tanto no total da amostra (10,5% vs 82,4%; p < 0,001) quanto no subgrupo dos pacientes diabéticos (8,7% vs 90,6%; p < 0,001), respectivamente. Conclusões: O estudo revela disparidade no uso de SF durante a realização de AP entre a rede pública e privada, tanto na amostra total quanto no subgrupo dos diabéticos, com menores taxas para usuários do SUS, demonstrando os desafios que necessitam ser vencidos para se atingir melhorias na qualidade dos serviços prestados.


Subject(s)
Humans , Male , Female , Middle Aged , Angioplasty, Balloon, Coronary/methods , Public Sector/statistics & numerical data , Private Sector/statistics & numerical data , Diabetes Complications/prevention & control , Drug-Eluting Stents/statistics & numerical data , ST Elevation Myocardial Infarction/therapy , Socioeconomic Factors , Time Factors , Cross-Sectional Studies , Treatment Outcome
15.
Rev. chil. cardiol ; 38(1): 46-53, abr. 2019. tab, graf
Article in Spanish | LILACS | ID: biblio-1003637

ABSTRACT

Resumen En Chile, se han logrado avances importantes en el manejo del Infarto Agudo de Miocardio (IAM) con elevación del segmento ST (IAMCEST). Debido a la mejoría en el diagnóstico precoz y tratamiento, particularmente, con el incremento de la Angioplastía Primaria (APP), hoy están dadas las condiciones para seguir progresando por la vía de la combinación de estrategias de reperfusión y la creación de Redes de Manejo del IAM. El siguiente artículo revisa la evidencia que justifica impulsar dicho avance y se esbozan posibles caminos para lograrlo.


Abstract In Chile, important advances have been made in the management of Acute Myocardial Infarction (MI) with ST segment elevation (STEMI). Due to the progress in early diagnosis and treatment, particularly with the increase in Primary Angioplasty (Primary PCI), nowadays there are conditions to improve early management through the combination of reperfusion strategies and the implementation of MI reperfusion networks. The present article reviews the evidence justifying the promotion of this strategy and outlines possible actions to achieve it.


Subject(s)
Humans , Myocardial Reperfusion/methods , Thrombolytic Therapy/methods , Angioplasty/methods , ST Elevation Myocardial Infarction/therapy , Chile , Endovascular Procedures , Fibrinolytic Agents/therapeutic use , ST Elevation Myocardial Infarction/epidemiology
16.
Arq. bras. cardiol ; 112(4): 402-407, Apr. 2019. tab, graf
Article in English | LILACS | ID: biblio-1001282

ABSTRACT

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


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


Subject(s)
Humans , Male , Female , Adolescent , Adult , Middle Aged , Aged , Aged, 80 and over , Young Adult , Referral and Consultation/statistics & numerical data , Patient Transfer/statistics & numerical data , Angioplasty/methods , ST Elevation Myocardial Infarction/therapy , Time Factors , Brazil , Risk Factors , Cohort Studies , Angioplasty/mortality , Statistics, Nonparametric , ST Elevation Myocardial Infarction/mortality , Geography
17.
Arch. cardiol. Méx ; 88(5): 432-440, dic. 2018. graf
Article in Spanish | LILACS | ID: biblio-1142153

ABSTRACT

Resumen Introducción: Un trombo intracorononario largo reclasificado es un predictor independiente de resultados adversos y no reflujo en el infarto agudo de miocardio con elevación del ST. Pacientes con mayor carga de trombo residual tienen peor disfunción microvascular y mayor daño miocárdico. Métodos: Evaluamos retrospectivamente a 833 pacientes que fueron a angioplastia primaria entre enero del 2011 y junio del 2016. La carga de trombo residual final fue reclasificada tras realizar el cruce de la guía, predilatación con balón o tromboaspiración, para restaurar y estabilizar un flujo TIMI 2-3. Las estrategias de stent diferido vs. stent inmediato fueron comparadas, siendo el objetivo primario la incidencia de no reflujo (TIMI ≤ 2, o TIMI 3 con TMP < 2). Resultados: Cuarenta y siete pacientes (6.8%) presentaron una alta carga trombo residual reclasificado. La coronaria derecha fue la arteria culpable en 34 casos. Hubo mayor frecuencia de ectasia coronaria en el grupo de stent diferido (p = 0.005). Se encontraron menores tasas de no reflujo en el stent diferido (36% vs. 58%), con una mayor frecuencia de un TMP 3 (p = 0.005). Tras la nueva cateterización un 56% quedó libre de stent en el grupo diferido y la anticoagulación oral les fue más frecuentemente indicada (p = 0.031). La tasa de eventos cardiacos adversos mayores fue similar entre los grupos. Hubo una tendencia a una mejor función ventricular izquierda en el grupo diferido (p = 0.056). Conclusiones: El stent diferido puede ser una alternativa eficiente en pacientes con IAM CEST y alta carga de trombo residual reclasificado, después de conseguir un flujo TIMI 2-3 estable.


Abstract Background: Reclassification of a large thrombus burden is an independent predictor of major adverse cardiac events and no-reflow in patients with ST- segment elevation myocardial infarction (STEMI). Patients with a greater residual thrombus burden have worse microvascular dysfunction and greater myocardial damage. Methods: A retrospective analysis was performed on 833 STEMI patients who underwent primary percutaneous coronary intervention. The final residual thrombus burden was reclassified after the lesion was wired, and a thrombus aspiration or balloon dilatation was performed to restore and stabilise a thrombolysis in myocardial infarction (TIMI) 2-3 flow. Deferred stenting (DEI) was compared with immediate stenting (ISI) group, and the primary outcome was the incidence of no-/slow-reflow (TIMI ≤ 2, or TIMI 3 with myocardial blush grade < 2). Results: Overall, 47 patients (6.8%) had a residual large thrombus burden reclassified. The right coronary artery was the culprit vessel in 34 cases. More patients had coronary ectasia in the DSI group (P=.005). Fewer patients in the DSI had no-/slow-reflow (36% vs. 58%), and the myocardial blush grade 3 was more frequent in the DSI group (P=.005). After repeat coronary angiography in the DSI group, stenting was not performed in 56%, and oral anticoagulation was more frequent in the follow-up (P=.031). Major cardiac adverse events were similar between groups. There was a tendency to better left ventricular function in the DSI group (P=.056). Conclusions: Deferred stenting may be an efficient option in STEMI patients with a residual large thrombus burden reclassified after achieving a stable TIMI 2-3 flow.


Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Coronary Thrombosis/therapy , Stents , Coronary Angiography/methods , Percutaneous Coronary Intervention/methods , ST Elevation Myocardial Infarction/therapy , Time Factors , Coronary Thrombosis/diagnostic imaging , Retrospective Studies , Follow-Up Studies , Longitudinal Studies , Ventricular Function, Left , Anticoagulants/administration & dosage
18.
Rev. chil. cardiol ; 36(3): 194-199, dic. 2017. tab, graf
Article in Spanish | LILACS | ID: biblio-899586

ABSTRACT

Resumen: Introducción: El implante de dos stents imbricados (SIMB) es una práctica frecuente en el laboratorio de hemodinamia. Sin embargo, evidencia reciente sugiere que en pacientes con infarto con supradesnivel del segmento ST (IAMc/SDST) esta técnica puede asociarse a mejores resultados cuando se utilizan exclusivamente stents medicados. Objetivo: Evaluar en una cohorte de pacientes chilenos las causas, características clínicas y sobrevida a 2 años de los pacientes con IAMc/SDST que son tratados con SIMB, en función del tipo de dispositivo y combinación utilizada; metálico/metálico (BMS/BMS), metálico/medicado (BMS/DES), medicado/medicado (DES/DES). Método: Se realizó un estudio prospectivo, caso incidente, entre enero del año 2012 y mayo del año 2016 en nuestro laboratorio de hemodinamia. Se recolectó la información clínica, angiográfica y sobrevida a 2 años de los pacientes ingresados por IAMc/SDST que fueron tratados con SIMB. Para el análisis estadístico se utilizó chicuadrado, regresión logística y análisis multivariado en programa SPSS, considerando significativa una p<0,05. Resultados: De 2403 pacientes evaluados, el 13% (n=312) recibió tratamiento con SIMB. La edad pro-medio fue de 68 ± 6,6 años y el 71% correspondió a hombres. La presencia de DMII fue de 37%, HTA 65%, tabaquismo 41%, dislipidemia 29% y cardiopatía coronaria previa 18%. Se observó que la fracción de eyección promedio fue de 45 ± 3,5%, medida por método de Simpson. Las causas para imbricar stents fueron la disección post implante de stent en 72%, desplazamiento de placa en 22,5% y extensión de placa más allá de la longitud del stent en un 5,5%. El 38% fue tratado con 2 stents BMS, el 26% con stents BMS/DES y el 36% con DES/DES. El diámetro y largo promedio de SIMB fue de 2,8 ± 2,6 mm y 41,3 ± 6,4 mm, respectivamente. Se observó una mortalidad a 2 años de 11% en el grupo BMS/BMS, 8% BMS/DES y 6% DES/DES (p<0,01) y la necesidad de revascularización fue 8%, 5,2% y 2% respectivamente (p=0,02). El usar la combinación BMS/ BMS se asoció a una mayor mortalidad a 2 años en análisis de regresión logística univariado (OR 5,2, IC 95% 2,0-17,9, p<0,01) y multivariado (ajustado por variables clínicas, número de vasos enfermos y presentación clínica) [OR 5,5, IC 95% 1,9-21,0, p<0,01]). Excluyendo a los pacientes con mortalidad temprana, como marcador de severidad de presentación clínica, la mortalidad a 2 años en el grupo BMS/BMS tuvo un OR de 5.9, 95% CI 2.1- 19.5 (p < 0.01). No se observó diferencia en la mortalidad de pacientes tratados con 2 SIMB DES/DES y los tratados con 1 stent DES. Conclusión: El implantar stents imbricados en pacientes con IAMc/SDST es una práctica común en el laboratorio de hemodinamia. Nuestros resultados sugieren que los resultados a mediano plazo son significativamente mejores cuando al menos uno de los stents utilizados es medicado, lo cual es concordante con reportes recientes.


Abstracts: Background: Coronary angioplasty using two overlapping (OL) stents is a frequent practice at the cath laboratory, however the impact this strategy has on patient prognosis and the preferred stent type are largely unknown. Aim: To evaluate 2-year outcomes of STEMI patients who underwent treatment with OL stents and assess the impact of different types of stents combinations:(BMS/BMS), (BMS/DES), or (DES/DES). Methods: Patients presenting with STEMI undergoing primary angioplasty with 2 OL stents between January 2012 to May 2016 were included. Baseline and procedural information was collected, clinically-driven new revascularizations were recorded, and 2-year survival status was confirmed from the national database registry. OL stents technique was defined as a segment with a double layer of stents of at least 1 mm and less than 5 mm long. Statistical analyses were performed with SPSS v21.0 (IBM, Armonk, NY, USA), at with p<=0.05 being considered significant. Results: Of 2403 STEMI patients treated within this period, in 312 (13%) the OL was used. Mean age was 68 ± 6.6 years. 71% males. Type 2 diabetesmellitus was present in 37%, arterial hypertension in 65%, smoking in 41%, dyslipidemia in 29% and previously treated coronary heart disease (either CABG or PCI) in 18% of patients. Mean left ventricular ejection fraction (LVEF) as assessed by 2D Simpson method was 48±3.5%. Indications for overlapping stents were plaque extension in 72%, edge dissection after stent implantation in 22.5%, and plaque displacement in 5.5%. One, 2 or 3 vessels disease was present in 23%, 34% and 43%, respectively. Thirty-eight percent of patients were treated with 2 BMS stents, 26% with BMS/DES stents and 36% with two DES stents. The mean stent diameter and length were 2.8 ± 2.6 mm and 41.3 ± 6.4 mm, respectively, with no difference between the 3 groups. Post procedure target vessel revascularization was 8% for BMS/BMS, 5.2% for BMS/DES and 2% for DES/DES groups (p=0.02). Two-year cardiovascular mortality was 11% for the BMS/BMS group, 8% for the BMS/DES group and 6% for the DES/DES (p <0.01). BMS/BMS combination was associated with a greater cardiovascular 2-year mortality in both univariate (OR 5.2, 95% CI 2.0-17.9, p <0.01) and multivariate analyses ([OR 5.5, 95% CI 1.9-21.0, p <0.01]). After excluding early mortality cases during the first week (due to their overall severity at presentation), 2-year cardiovascular mortality in the BMS/BMS group had an adjusted OR of 5.9, 95% CI 2.1-19.5 (p< 0.01). There were no differences between the treatment with 2 OL DES stents and the treatment with BMS/DES. Conclusion: Overlapping stent technique is a common practice in our cath lab, mainly driven by an initial unfavorable result with the first stent. The reported findings suggest that midterm results are better when at least on of the imbricated stents is These results are in agreement with recent reports on the subject.


Subject(s)
Humans , Male , Female , Middle Aged , Aged , Angioplasty, Balloon, Coronary , Drug-Eluting Stents , ST Elevation Myocardial Infarction/therapy , Chi-Square Distribution , Logistic Models , Survival Analysis , Multivariate Analysis , Prospective Studies , Treatment Outcome , Self Expandable Metallic Stents , ST Elevation Myocardial Infarction/mortality
19.
Rev. Assoc. Med. Bras. (1992) ; 63(3): 242-247, Mar. 2017. tab, graf
Article in English | LILACS | ID: biblio-956438

ABSTRACT

Summary Introduction: The mortality rate attributed to ST-segment elevation myocardial infarction (STEMI) has decreased in the world. However, this disease is still responsible for high costs for health systems. Several factors could decrease mortality in these patients, including implementation of cardiac intensive care units (CICU). The aim of this study was to evaluate the effect of CICU implementation on prescribed recommended treatments and mortality 30 days after STEMI. Method: We performed a retrospective study with patients admitted to CICU between 2005 and 2006 (after group) and between 2000 and 2002, before CICU implementation (before group). Results: The after group had 101 patients, while the before group had 143 patients. There were no differences in general characteristics between groups. We observed an increase in angiotensin-converting enzyme inhibitors, clopidogrel and statin prescriptions after CICU implementation. We did not find differences regarding number of patients submitted to reperfusion therapy; however, there was an increase in primary percutaneous angioplasty compared with thrombolytic therapy in the after group. There was no difference in 30-day mortality (before: 10.5%; after: 8.9%; p=0.850), but prescription of recommended treatments was high in both groups. Prescription of angiotensin-converting enzyme inhibitors and beta-blocker decreased mortality risk by 4.4 and 4.9 times, respectively. Conclusion: CICU implementation did not reduce mortality after 30 days in patients with STEMI; however, it increased the prescription of standard treatment for these patients.


Resumo Introdução: Apesar da diminuição da mortalidade por infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAM-ST) no mundo, a doença ainda acarreta elevados custos e morbidade. Muitas medidas contribuem para a redução da mortalidade, dentre elas a criação de unidades intensivas coronarianas (UCO). Objetivo: Avaliar o impacto da criação de uma UCO na prescrição de tratamentos preconizados e na mortalidade em 30 dias em pacientes com IAM-ST. Método: Foi realizado estudo retrospectivo e foram coletados dados de prontuários de pacientes internados na UCO de 2005 a 2006 (grupo depois). Esses dados foram comparados com dados do serviço de 2000 a 2002, previamente à criação da UCO (grupo antes). Resultados: Havia 101 e 143 pacientes nos grupos depois e antes, respectivamente. Não houve diferenças em relação às características populacionais e às características do infarto entre os períodos. Observamos aumento na prescrição de iECA, clopidogrel e estatinas. Apesar da ausência de mudanças no número de pacientes que receberam terapia de reperfusão, houve aumento de angioplastias primárias em detrimento ao uso de trombolíticos no período posterior à criação da UCO. Não observamos diminuição da mortalidade em 30 dias após IAM-ST (antes: 10,5%; depois: 8,9%; p=0,850), mas a prescrição de tratamentos preconizados foi alta em ambos os períodos. O uso de iECA e de betabloqueador diminuiu o risco de morte em 4,4 e 4,9 vezes, respectivamente. Conclusão: Em pacientes com IAM-ST, a criação da UCO não reduziu a mortalidade em 30 dias, mas houve aumento na prescrição de tratamentos preconizados.


Subject(s)
Humans , Male , Female , Aged , Coronary Care Units/statistics & numerical data , ST Elevation Myocardial Infarction/mortality , ST Elevation Myocardial Infarction/therapy , Drug Prescriptions/statistics & numerical data , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Logistic Models , Multivariate Analysis , Retrospective Studies , Risk Factors , Treatment Outcome , Hospital Mortality , Adrenergic beta-Antagonists/therapeutic use , Middle Aged
20.
Arch. cardiol. Méx ; 86(2): 130-139, abr.-jun. 2016. tab, graf
Article in English | LILACS | ID: biblio-838362

ABSTRACT

Abstract Objective To assess the features of asymptomatic patients with acute ST segment elevation myocardial infarction who presents to the emergency with more than 12 h of evolution, and if there is a benefit of an invasive versus medical therapy. Methods Retrospective, cohort study from January 2012 to December 2014, we compare the outcomes at 6 and 12 months of follow up of the invasive group versus the conservative group. Results There were no differences in outcomes at 12 months between an invasive versus a conventional strategy; but, looking at the reperfusion state, we found more risk of death and heart failure at 12 months in the no-reperfused group versus the reperfused group (40% versus 0%, OR: 2, CI: 1.2-3.1, p = 0.028 for mortality and 53% versus 0%, OR: 2.2, CI: 1.3-3.98, p = 0.007 for heart failure). Conclusions In patients with ST elevation acute myocardial infarction with more than 12 h of evolution, the invasive strategy with optimal reperfusion is better than the conservative management or no reperfusion in terms of less mortality and heart failure at 12 months of follow up.


Resumen Objetivo Evaluar las características de pacientes con síndrome coronario agudo con elevación del segmento ST asintomáticos con más de 12 horas de evolución y si existe o no beneficio de la terapia invasiva versus el manejo médico en el seguimiento. Método Estudio retrospectivo, de cohortes desde enero 2012 a diciembre 2014, se comparó los eventos adversos a 6 y 12 meses de seguimiento del grupo en terapia invasiva versus manejo conservador. Resultados No se encontró diferencia entre la estrategia invasiva versus convencional al seguimiento a los 12 meses. Sin embargo comparando el resultado de reperfusión, se encontró mayor riesgo de muerte y falla cardiaca a 12 meses en el grupo no reperfundido versus el reperfundido (40% vs 0%, OR 2, IC: 1.2-3.1, p = 0.028 para mortalidad y 53% vs 0%, OR: 2.2, IC: 1.3-3.98, p = 0.007 para falla cardiaca). Conclusiones En pacientes con infarto agudo de miocardio ST elevado de más de 12 horas de evolución asintomáticos, la estrategia invasiva con resultados óptimos de reperfusión es mejor que el manejo conservador o no reperfusión en cuanto a disminución de la mortalidad y falla cardiaca en el seguimiento al año.


Subject(s)
Humans , Male , Female , Middle Aged , Aged , Aged, 80 and over , Registries , ST Elevation Myocardial Infarction/therapy , Peru , Time Factors , Acute Disease , Retrospective Studies , Cohort Studies , Academies and Institutes , Percutaneous Coronary Intervention
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