Síndrome de tako-tsubo, caracterización clínica y evolución a un año plazo / Tako-tsubo syndrome: analysis of 37 cases

Background: Tako-tsubo Syndrome (TTS) is characterized by transient regional systolic dysfunction of the left ventricle (LV), mimicking myocardial infarction. It accounts for 0.9-1.2% of all acute coronary syndromes (ACS). Aim: To describe the incidence and characteristics of TTS within our population. Material and Methods: All patients diagnosed with ACS and TTS were selected from a clinical registry of all the coronary angiographies done in our hospital. Clinical features during initial presentation, hospital evolution and one year follow-up were analyzed. Results: The first case diagnosed in our hospital occurred in 2001. Since then, 4,433 coronary angiographies were done to patients with ACS until 2014 and 37 corresponded to TTS (0.83% incidence). The mean age of patients was 64 years, 73% were female, and 62% had hypertension. All patients had an identifiable trigger factor, abnormal EKG and elevated troponin. The coronary angiography did not show lesions in 97%. However, all had the characteristic extensive segmental-motility alteration with a mean ejection fraction of 44%. All patients were treated initially as an ACS. Seven patients had complications, namely acute cardiac failure in six and stroke in one. No patient died. At one year of follow-up, 100% showed normal segmental motility and ejection fraction, no patient had a new episode of TTS and all were alive. Conclusions: TTS is rare and the incidence found in this study is slightly lower than that reported elsewhere. TTS mimics ACS and it should be suspected by its clinical, electrocardiographic and enzymatic particularities. Coronary angiography helps to rule out other diagnosis. All patients normalize motility and ventricular function, which is the definitive differential feature respect to ACS.

Validación del puntaje de riesgo TIMI como predictor de mortalidad en pacientes chilenos con infarto agudo al miocardio con supradesnivel de ST / Prediction of hospital mortality of ST elevation myocardial infarction using TIMI score

Background: Thrombolysis in myocardial infarction risk score (TIMI-RS) was designed to predict early mortality in patients with a ST elevation acute myocardial infarction (STEAMI). Aim: To evaluate the predictive capacity for hospital mortality of TIMI-RS. Material and Methods: Patients with ≤ 12-hour evolution STEAMI were selected from a prospective registry of all patients hospitalized in our coronary unity within January 1988 and December 2005. Observed mortality was analyzed according to TIMI-RS and its predictive capacity was estimated. Results: We analyzed 1125 consecutive patients aged 61 ± 13 years (76% men). Fifty one percent were smokers, 47% hypertensive and 40% had a history of angina. Fifty eight percent of patients underwent reperfusion therapy. Most patients had TIMI-RS scores ≤ 5 points and only 3.6% had scores ≥ 10 points. Overall mortality was 14.8% and there was an 80% concordance between observed mortality and that predicted with the TIMI-RS score. The area under the curve for the receiver operating characteristic (ROC) curve was 0.7. Conclusions: TIMI-RS was acceptably useful to predict in-hospital mortality in this group of patients with STEAMI. Differences between the observed and originally predicted mortality are explained by the clinical profile and therapeutic protocols applied to patients in different studies. Thus, caution needs to be taken when interpreting the risk associated to a specific score, particularly within non-reperfused patients whose risk might be underestimated.

Fístula coronaria gigante. Presentación clínica, caracterización angiográfica, tratamiento y seguimiento a largo plazo: caso clínico / Giant coronary artery fistula: report of one case

Coronary artery fistulae are abnormal connections between a coronary artery and any cardiac chamber or other vessels. Most of them have a congenital origin. We report a 60 years old woman referring a history of progressive dyspnea and orthopnea during the last year. A continuous heart murmur was audible in the third and fourth intercostal spaces at the left sternal border. Electrocardiogram was normal and echocardiography showed mild dilation of right cavities and an image suggesting a dilated right coronary artery with flow to right atrium. Coronary angiography was performed, showing a normal left coronary artery and a very large, tortuous right coronary artery with an extensive communication to coronary venous sinus. Surgical treatment was decided and was performed without incidents. The patient is well after five years of follow up.

Infarto agudo al miocardio en el adulto mayor: Características clínicas, evolución hospitalaria y a 5 años plazo / Features of acute myocardial infarction among aged patients

Background: Among aged patients, acute myocardial infarction has more complications and there is a tendency to underuse proven treatments. Aim: To report the features of acute myocardial infarction among aged patients. Material and Methods: Analysis of a registry of patients with acute myocardial infarction admitted to a coronary unit. For the purposes of analysis, patients aged 65 years or more were selected. Follow up was made consulting medical records, calling patients by telephone or consulting death records at the National Identification Service. Results: A total of 1.358 patients were admitted in the study period with a diagnosis of acute myocardial infarction and 580 (43%) were aged 65years or more. On admission, this age group had a higher frequency of hemodynamic instability and anterior wall infarctions. Reperfusion therapy and beta blockers were used less commonly in this group. Hospital mortality among patients younger or older than 65 year was 8 and 25%, respectively (p < 0.01). Among aged patients, five years mortality was 33%. Conclusions: Among aged patients, acute myocardial infarction has a higher risk profile on admission, is usually undertreated and has higher mortality than younger subjects.

Angioplastía primaria en infarto agudo al miocardio en arteria coronaria derecha con origen anómalo: Caso clínico / Primary angioplasty for acute myocardial infarction with an anomalous origin of right coronary artery: Report of one case

Anomalous origin of coronary arteries is a rare anatomical defect and its association with acute myocardial infarction is unusual. We report a 58-year-old male with ST-Segment elevation. Myocardial infarction of the inferior wall caused by a total occlusion on the proximal third of an anomalous right coronary artery, that was effectively treated with primary angioplasty with stent placement. The patient had a favorable outcome and is asymptomatic after five years of follow up.

Terapia de reperfusión en infarto agudo al miocardio: Comparación entre trombolisis endovenosa y angioplastía coronaria / Angioplasty compared to thrombolysis as the initial reperfusion therapy in acute myocardial infarction

Background: Primary angioplasty is superior to intravenous thrombolysis as reperfusion therapy for acute myocardial infarction. Aim: To compare the results of available reperfusion strategies for initial management of acute myocardial infarction during hospitalization and 5 years follow up. Patients and Methods: Historical cohort study from a prospective registry of patients admitted with acute myocardial infarction to our center. Patients treated with primary angioplasty were identified and were then matched by age, sex and date of event with patients treated with throm-bolysis. The clinical outcomes were compared including hospitalization and 5-years follow-up. Results: From March 1993 to August 2001, 98 patients were treated with primary angioplasty and matched with 98 thrombolyzed patients. The groups were comparable. Compared to thrombolysis, angioplasty had a higher success rate (68 and 91% respectively), resulted in less complications and reduced mortality (11 and 2% respectively), required less revascularization procedures and shorter hospital stay (17 and 13 days, respectively). During the follow-up of survivors, no differences in events or additional mortality were detected at 1 or 5years. Conclusions: Primary angioplasty is superior as treatment in terms of achieving success and reducing mortality during hospitalization. Evolution after hospitalization is independent of initial therapy.

Hematoma subcapsular esplénico en paciente portador de rasgo falciforme / Sub capsular splenic hematoma in a sickle cell trait carrier. Case report

Drepanocytic anemia is an uncommon hereditary disease in Chile. The heterozygous state of drepanocytic anemia or "sickle trait" has a frequency of 8 percent among Afro-Americans. A small number of patients carrying hemoglobin S are homozygous, with clinical manifestations of hemolytic anemia and thrombotic disease. Sickle trait is usually asymptomatic. We report a 59-year-old male who presented an acute abdominal pain and dyspnea while staying at high altitude. Six days later, an angio CAT scan showed the presence of a subcapsular splenic hematoma that was managed conservatively. Sickle cell induction with sodium metabisulphite was positive. Hemoglobin electrophoresis confirmed the sickle trait.

Nacimiento anómalo de las arterias coronarias en 10.000 pacientes adultos sometidos a coronariografía / Coronary artery origin anomalies. Analysis of 10.000 coronary angiographies

Background: Between 0.3 and 1.3 percent of coronary arteries, have anomalous origins. Circumflex artery has the higher frequency of anomalies. Aim: To study the frequency of congenital anomalous origins of coronary arteries among adult patients subjected to a coronary angiography. Material and Methods: Analysis of reports of 10,000 coronary angiographies performed in a clinical hospital. Patients with congenital heart disease were excluded. Results: One hundred twenty nine patients (1.3 percent), aged 59 ± 12years (70 percent males) had congenital anomalies in the origin of coronary arteries. The most common anomaly was the origin of right coronary artery from the left coronary sinus in 75 percent, followed from the origin of circumflex artery from the right side in 20 percento. No association between origin anomalies and atherosclerosis or aortic valve disease, was observed. Conclusions: In this series of patients, origin anomalies of coronary arteries were not associated with aortic valve disease or atherosclerosis, differing from other published reports. Right coronary artery had the highest frequency of anomalies.

Infarto agudo al miocardio en pacientes de 80 y más años. Evolución hospitalaria y seguimiento / Clinical features and prognosis of acule myocardial infarction among patients aged 80 years or older

Background: Subjects older than 80 years have more complicated acute myocardial infarctions and are subjected to less reperfusion procedures. Aim: To describe the hospital evolution and follow up of patients older than 80 years, suffering an acute myocardial infarction. Material and methods: Patients older than 80 years, were selected from a prospective registry of acute myocardial infarction. Among these, the hospital evolution, mortality and events during a períod ofñve years of follow up, were recorded. Results: Of a total of 1200 patients, 83 (7 percent) were aged 80 years or older. Among these, 59 percent were male and 22 percent were diabetic. The mean lapse between onset of symptoms and admission was 11 hours and 59 percent were admitted with less than 6 hours of evolution. Sixty three percent had a history of a previous infarction and 24 percent had a Killip IV classification on admission. Reperfusion therapy was done in 19 percent and 70 percent had heart failure during evolution. A coronary angiography was done in 22 percent and 6 percent were subjected to revascularization. Mortality was 34 percent, specially due to cardiogenic shock or ventricular rupture. Of 55 patients discharged from the hospital, 31 percent died within one year and 64 percent within five years, mainly due to cardiac causes. Conclusions: Patients aged 80 years or older have more complicated myocardial infarctions, most of them are managed conservatively andlong term mortality is high.

Angiografía coronaria: indicación, resultados y complicaciones en 5.000 pacientes consecutivos / Coronary angiography: indications, results and complications in 5.000 consecutive patients

Background: There are guidelines about equipment, premises, personnel, indications and complications rates for coronary angiography, that every center performing this procedure should adhere. Aim: To report the experience with 5.000 coronary angiographies and to assess the compliance of the center with the current guidelines. Material and methods: Prospective registry of 5.000 patients aged 60±11 years (3.475 males) subjected to coronary angiography since 1992, assessing all aspects of the procedure with special emphasis on complications. Results: The indications for 80 percent of procedures was suspected coronary atherosclerosis. The main risk factors were hypertension and smoking. Coronary atherosclerosis was demonstrated in 62 percent, mainly one vessel disease. These were two deaths due to the procedure (0.04 percent), three patients (0.06 percent) had an acute myocardial infarction or a stroke. These figures are lower than referential values. Conclusions: In this center, coronary angiography is a safe procedure, with complications rates that are even lower than referential values.

Análisis comparativo de las características clínico-angiográficasy de los resultados inmediatos y tardíos de stents liberadores de drogas vs. no liberadores / Immediate and late clinical an angiographic results of coronary stent implantation: comparison of drug eluting versus bare metal stents

Introducción: La reducción de la reestenosis intrastent ha permitido una gran aceptación de los stents liberadores de drogas (DES). El objetivo de este trabajo ha sido evaluar nuestra experiencia clínica inicial con DES y compararla con aquellos que sólo recibieron BMS (stents no liberadores de drogas). Materiales y Métodos: Se compararon 71 pacientes tratados con DES (Cypher® = 32 o Taxus® = 39) con 903 pacientes tratados sólo con BMS. Además del análisis clínico y angiográfico detallado, se efectuó seguimiento clínico de a lo menos 6 meses. Resultados: Los pacientes tratados con DES con mayor frecuencia eran más complejos y tenían características clínicas y angiográficas desfavorables. Sin embargo, no hubo diferencias en la tasa de éxito angiográfico (100 vs. 99,2 por ciento) ni en las complicaciones isquémicas intrahospitalarias (1,3 vs. 0 por ciento). En el seguimiento los tratados con DES tuvieron menor recurrencia de la angina (8,7 vs. 19,0 por ciento), revascularización del vaso tratado (0 vs. 7,5 por ciento) y menos eventos isquémicos (4,4 por ciento vs. 14,6 por ciento). Conclusiones: A pesar de su empleo en pacientes con características clínicas y angiográficas desfavorables, los DES lograron un mejor resultado a largo plazo en comparación con los BMS.

Background: There has been considerable enthusiasm for drug eluting stents (DES) in coronary angioplasty due to the lower restenosis rate associated to their use. Aim: To compare clinical and angiographic results of DES implantation, compared to traditional bare metal stents (BMS) Methods: 71 patients who received DES (Cypher® = 32; Taxus® = 39) were compared to 903 patients who had received BMS. Detailed clinical and angiographic evaluation and 6 month follow up data were analyzed. T test and X2 analysis were used for comparisons. Results: Compared to the BMS group, the DES group had complex clinical (diabetes mellitus, family history, active smokers) and agiographic findings (lower ejection fraction, longer lesions) in a greater proportion of cases (p < 0.05 vs BMS). The immediate angiographic success rate did not differ between groups (100 percent vs 99.2 percent, respectively). Acute ischemic complications occurred in 1.3 percent in DES patients compared to 0 percent in BMS (pNS). At follow-up, angina recurrence (8.7 percent vs 19 percent, p < 0.043), need for revascularization (0 percent vs 7.5 percent, p < 0.02) and new ischemic events (4.4 percent vs 14.6 percent, p < 0.02) were lower in DES as compared to BMS patients. Conclusion: In spite of the greater clinical and angiographic complexity, patients with DES had better long term clinical results than patients who received BMS.

Incidencia y predictores del deterioro de la función renal en pacientes sometidos a angioplastía coronaria / Incidence and predictors of the renal function deterioration in patients submitted to coronary angioplasty

La insuficiencia renal aguda (IRA) puede ser una complicación de la angioplastia coronaria (AC). En su patogenia participan variables inherentes al paciente como relacionadas al procedimiento. El objetivo de este estudio fue evaluar la incidencia y predictores de IRA en pacientes sometidos a AC. Analizamos a 913 pacientes sometidos a AC entre 08/1998 y 07/2003. Sólo 42 (4,6 por ciento) pacientes desarrollaron IRA (aumento de la creatinemia ≥ 0,5 mg/dl respecto del basal). Los predictores independientes de IRA fueron: edad (p=0,002; OR = 1,04), creatininemia basal (p < 0,001; OR = 4,00), caída del hematocrito (p = 0,001; OR = 1,15), insuficiencia cardiaca (p < 0,01; OR = 7,74), shock (p = 0,006; OR = 8,49) y la cantidad de medio de contraste (p = 0,006; OR = 1,005). Conclusiones: La IRA es una complicación poco frecuente de la angioplastia coronaria. La mayor edad, el daño renal previo, la pérdida sanguínea, el estado hemodinámico y el mayor volumen de medio de contraste usado son los predictores independientes de su ocurrencia.

Estudio de hipertensión arterial en un servicio de urgencia / Study in arteria hypertension in an emergency service

La hipertensión arterial (HTA) es una patología de alta prevalencia en la población general y está relacionada directamente con múltiples afecciones que son frecuentemente atendidas en servicios de urgencia. Su manejo agudo si bien ha sido normado, no siempre es llevado a cabo en forma adecuada. Se estudió en forma retrospectiva la incidencia de HTA (definida como PAS>160 y/o PAD>100 mm Hg) en el Servicio de Urgencia del Hospital Clínico Universidad de Chile, entre el 1 de enero y el 30 de junio del año 2000. Se evaluó para cada paciente el peso, la edad, la presión arterial (agrupando hallazgos, urgencias y emergencias hipertensivas) y frecuencia cardíaca al ingreso, diagnóstico, forma de presentación y tratamiento. A partir de los resultados concluimos que la HTA es una patología de presentación frecuente en nuestro Servicio de Urgencia. Un gran porcentaje corresponde a hallazgos hipertensivos que no requieren tratamiento específico. Existe aún un significativo uso de Nifedipino de acción corta, pese a que no es recomendado

Racionalización del drenaje en la colecistectomía / Rationalization of drainage in cholecystectomy

Se analiza en forma prospectiva y randomizada, la evolución postoperatoria de 138 pacientes colecistectomizados con y sin drenaje. Fueron colecistectomizados sin drenaje 79 y con drenaje 59 pacientes. La morbilidad para el grupo sin drenaje fue de 7,6% y para el grupo con drenaje de 13,6%, cifra que no alcanzó significación estadística. La estada postoperatoria promedio fue de 3,98 días para el grupo con drenaje y de 3,65 para el grupo sin drenaje. Respecto a la convalescencia, esta fue significativamente más confortable para los pacientes sin drenaje (14% contra 3,4%). Se discuten las bases para racionalizar el uso del drenaje en ésta cirugía