Angina instável e infarto agudo do miocárdio sem supradesnivelamento de ST: tratamento e prognóstico / Unstable angina and non-ST elevation myocardial infarction: treatmemt and prognosis

Objetivo: As doenças cardiovasculares são responsáveis pela principal causa de óbitos na população adulta mundial, sendo a síndrome coronariana aguda (SCA) a mais prevalente entre elas. Resultados: Sabemos que hoje, do ponto de vista epidemiológico, a coronariopatia aguda sem supradesnivelamento de ST tornou-se a forma mais frequente de apresentação clínica da SCA, aproximadamente, em 62% dos casos. Nos últimos anos, houve importantes avanços em relação à terapêutica antiplaquetária e anticoagu-lante capazes de reduzir a mortalidade associada à doença coronariana. Além disso, a estratificação invasiva precoce teve papel fundamental nesse incremento de prognóstico. Conclusão:Dessa forma, atualmente, a escolha terapêutica e de estratificação devem ser avaliadas individual

Cardiovascular diseases are the main cause of death in the adult population worldwide, with acute coronary syndrome (ACS) being the most prevalent. We know that, presently, from an epidemiological point of view, non-ST elevation ACS is the most frequent form of clinical presentation of ACS, in about 62% of cases. Recently, important advances regarding antiplatelet and anticoagulant therapy exist, capable of reducing mortality associated with coronary heart disease. Moreover, early invasive stratification has played a key role in the improvement in prognosis. Thus, the choice of therapy and stratification should be evaluated individually and can modify short- and long-term outcome

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

Outcomes in patients with non-ST-elevation acute coronary syndrome randomly assigned to invasive versus conservative treatment strategies: A meta-analysis

OBJECTIVE: The goal of the present study was to compare the prognoses of patients with non-ST-elevation acute coronary syndromes who were treated with invasive or conservative treatment strategies. METHODS: We performed a meta-analysis of studies of patients with non-ST-elevation acute coronary syndromes to assess the benefits of an invasive strategy vs. a conservative strategy for short- and long-term survival. We searched PubMed for studies published from 1990 to November 2012 that investigated the effects of an invasive vs. conservative strategy in patients with non-ST-elevation acute coronary syndromes. The following search terms were used: “non-ST-elevation myocardial infarction”, “unstable angina”, “acute coronary syndromes”, “invasive strategy”, and “conservative strategy”. The primary endpoints were all-cause mortality at 30 days and 1 year. RESULTS: Seven published studies were included in the present meta-analysis. The pooled analyses show that an invasive strategy decreased the risk of death (risk ratio [0.839] [95% confidence interval {0.648-1.086}; I 2, 86.46%] compared to a conservative strategy over a 30-day-period. Furthermore, invasive treatment also decreased patient mortality (risk ratio [0.276] [95% confidence interval {0.259-0.294}; I 2, 94.58%]) compared to a conservative strategy for one year. CONCLUSION: In non-ST-elevation acute coronary syndromes, an invasive strategy is comparable to a conservative strategy for decreasing short- and long-term mortality rates. .

Resultados Chilenos del registro internacional de factores de riesgo y tratamiento de angina inestable e infarto al miocardio sin supradesnivel del segmento ST: ACCORD (ACute CORonary syndrome Descriptive study) / Chilean results of the international registry of risk factors and treatment of unstable angina and non ST elevation myocardial infarction: ACCORD (ACute CORonary syndrome Descriptive study)

Background: Guidelines for the management of unstable angina (UA) and non ST elevation myocardial infarction (NSTEMI) have been issued, however cu-rrent practices are unknown in Chile. Aitn: To evalúate in a prospective cohort of NSTEMI patients the current practices, treatments and risk factors. Material and Methods: Oneyear prospective International non interventional registry, conducted in Chile between January 2005 and November 2006. Results: Two hundred thirty three Chilean NSTEMI patients were enrolled. Mortality was 5.5 percent at the end ofthe follow-up. Mean age was 61.6 years, and 30.6 percent were female. Most of the patients had at least one risk factor (98 percent): hypertension (84 percent), previous myocardial infarction (33 percent), dyslipidemia (54 percent), diabetes (33 percent), current smoking (30 percent). Main procedures duringthe hospitalization were coronary angiogram (67 percent), angioplasty (33 percent; 88 percent with stent) and coronary bypass surgery (7 percent). Duringprocedures, 31 percent of patients received clopidogrel, and 4.2 percent glycoprotein Ilb/IIIa antagonists. Medical management was selected for 60 percent of patients. In comparison to men, women received less interventional procedures despite havingmore risk factors. Treatments prescribed at discharge were aspirin (97 percent), clopidogrel (49 percent), beta blockers (78 percent), diuretics (21 percent), lipid lowering agents (78 percent), oral hypoglycemic agents (13 percent) and insulin (9 percent). At the end ofthe 1-year follow-up, treatments were aspirin (84 percent), beta blockers (72 percent), diuretics (19 percent), and dual antiplatelet therapy with clopidogrel (16 percent). Conclusions: A high prevalence of múltiple risk factors for cardiovascular disease in Chilean patients with NSTEMI was observed. More aggressive primary and secondary preventive measures are urgently needed. Use of therapies proposed in the guidelines is high, but dual antiplatelet therapy is less than 50 percent at discharge and decreases during the one year-follow-up.

Fatores associados com os tipos de heparina usados no tratamento da angina instável em um hospital brasileiro / Factors Associated with the Types of Heparin used in the Treatment of Unstable Angina at a Brazilian Hospital

Unfractionated heparin (UFH) and low-molecularweight heparins (LMWHs) are widely used in curative and preventive treatments of thromboembolic disorders. The aim of the study was to investigate factors associated with the choice of these types of heparin to treat patients with unstable angina under real conditions of hospital use. A cross-sectional study was performed in a private general hospital in Belo Horizonte, Brazil, from January 1st to December 31th, 2001. Data were collected from the hospital electronic database. Inpatients with angina who received enoxaparin or UFH were included in the survey. Data for 555 patients were recorded, including 401 treated with enoxaparin and 154 with UFH. Univariate analysis showed that male and elderly people predominated in both groups, with no statistical difference in the proportions (p>0.05). Multivariate analysis showed 4 factors associated with the use of enoxaparin: cardiac revascularization surgery (OR=0.434), arrhythmias (OR=9.343), risk factors for coronary artery disease (OR=1.333) and private health insurance (OR=0.297). Thus, clinical and organizational factors were associated with the type of heparin used by patients with unstable angina at this hospital. Further drug utilization studies are necessary to expand and improve the data available on the use of heparins in the hospital setting.

A heparina não-fracionada (HNF) e heparinas de baixo peso molecular (HBPM) são amplamente utilizadas em tratamentos curativos e preventivos de tromboembolismo. O objetivo do estudo foi investigar os fatores associados com a escolha desses tipos de heparinas para tratar pacientes com angina instável sob as condições reais de uso hospitalar. Trata-se de um estudo transversal realizado em hospital geral privado, na cidade de Belo Horizonte,MG Brasil, no período de Janeiro a Dezembro de 2001. Para a coleta de dados, utilizou-se o banco de dados informatizado do referido hospital. Pacientes internados com angina que receberam enoxaparina ou HNF foram incluídos no estudo. Registrou-se dados de 555 pacientes, incluindo 401 tratados com enoxaparina e 154 com HNF. Na análise univariada, observouse que o gênero masculino e pacientes idosos foram predominantes em ambos os grupos, sem diferença estatística entre as proporções (p>0,05). A análise multivariada revelou quatro fatores associados ao uso de enoxaparina: cirurgia de revascularização cardíaca (OR=0,434), arritmias (OR=9,343), fatores de risco para doença coronariana (OR=1,333) e atendimento por plano de saúde (OR=0,297). Assim, fatores clínicos e organizacionais estão associados com o tipo de heparina usado por pacientes com angina instável, neste hospital. A realização de mais estudos de utilização de medicamentos é necessária para aprimorar o conhecimento sobre o uso de heparinas, em hospitais.

Influência da estenose residual negativa após o implante de stents coronarianos em pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST / Outcomes of patients with non-ST elevation acute coronary syndrome and a negative residual stenosis after coronary stenting

Fundamentos: A presença de estenose residual (ER) negativa após o implante de stents coronarianos em pacientes com infarto do miocárdio está associada a piores desfechos clínicos. A influência da ER no prognóstico de pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST não foi bem estudada. Método: Pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST tratados com implante de stents coronarianos foram incluídos, e a ER e o fluxo coronariano foram avaliados imediatamente após o procedimento. Pacientes com ER < 0% foram comparados a um grupo controle com ER 0-30% quanto à ocorrência de eventos cardíacos adversos maiores (ECAM) em um ano. Resultados: As características clínicas foram semelhantes em ambos os grupos. A ER média foi de -10,3 ± 6,4% no grupo ER < 0% (n = 94) e de 2,1 ± 5,2% nos controles (n = 298) (P < 0,001). Pacientes com ER < 0% tinham vasos menores (P < 0,001) e apresentaram maior escore de agressividade (P < 0,001), que foram preditores independentes de ER negativa, comparativamente aos pacientes com ER 0-30%. Os índices de sucesso clínico do procedimento (100% vs. 98,7%), fluxo coronariano TIMI 3 (100% vs. 99,3%), ECAM intra-hospitalares (0% vs. 0,6%) e trombose subaguda (1,1% vs. 0,3%) não foram estatisticamente diferentes nos pacientes com ER < 0% e nos controles. Os índices de revascularização do vaso-alvo (8,9% vs. 7,9%) e de ECAM em um ano (10% vs. 10%) também foram semelhantes nos pacientes com ER < 0% e nos controles. Conclusões: A ocorrência de ER negativa após o implante de stents coronarianos em pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST foi associada a vasos menores e a estratégias de implante mais agressivas, mas não à piora do fluxo coronariano ou a índices mais elevados de ECAM.

Background: Negative residual stenosis (RS) after coronary stenting is associated with worse antegrade flow and increased mortality in patients with acute myocardial infarction. Its influence on outcomes of patients with nonST elevation acute coronary syndromes is unknown. Methods: Patients with acute coronary syndrome with nonST elevation treated with coronary stenting were included and RS and coronary flow were assessed immediately after the procedure. Patients with RS < 0% were compared to a control group with RS 0-30% for the occurrence of one-year MACE. Results: Baseline clinical characteristics were similar in both groups. Mean residual stenosis was -10.3 ± 6.4% in the < 0% RS group (n = 94) and 2.1 ± 5.2% in controls (n = 298) (P < 0.001). Patients with RS < 0% had smaller vessels (P < 0.001) and were treated with a higher aggressiveness score (P < 0.001), which were independent predictors of the occurrence of negative RS. Clinical procedural success rates (100% vs. 98.7%) and coronary TIMI 3 flow rates (100% vs. 99.3%) were similar in both groups. In-hospital MACE (0% vs. 0.6%) and subacute thrombosis rates (1.1% vs. 0.3%) were not statistically different. One-year target vessel revascularization rates (8.9% vs. 7.9%) and one-year MACE rates (10% vs. 10%) were also similar. Conclusions: Negative residual stenosis after coronary stenting in patients with non-ST elevation acute coronary syndrome was associated with smaller vessels and more aggressive implantation strategies, but not with worse coronary flow or higher MACE rates.

Curso de atualização em cardiologia: aula 9: angina instável e infarto sem supradesnível do segmento ST / Updating cardiology course: class 9: instable angina and non ST element elevation infarction

A doença arterial coronariana é altamente prevalente na população e uma das principais causas de óbito em nossa sociedade. O reconhecimento precoce e o adequado tratamento desta síndrome clínica podem evitar complicações e minimizar os riscos. Em 2007, o American College of Cardiology e a American Heart Association revisaram o Guideline de Manejo de Pacientes com AI e IAM SSST, produzido em 2002, com o intuito de facilitar o reconhecimento, diagnóstico e tratamento desta importante síndrome clínica. O presente artigo tem como objetivo salientar as características principais dessas síndromes clínicas, assim como transmitir os principais aspectos abordados pelo Guideline publicado em 2007 pelo American College of Cardiology e a American Heart Association.

Coronary artery disease is highly prevalent in general population and one of the main causes of death in our society. Early recognition and proper therapy of this syndrome can avoid complications and curtail risks. In 2007 the American College of Cardiology and the American Heart Association reviewed the Guidelines for Patient Management with UA and non-STMI, published in 2002, in order to ease the recognition, diagnosis and therapy of this important clinical condition. This paper aims to give a clear picture of the main characteristics of these syndromes, as well as the highlights of the Guideline published in 2007 by the American College of Cardiology and the American Heart Association.

Diferencias en las características clínicas y en la evolución intrahospitalaria entre la angina inestable primaria y secundaria en ancianos / Differences in the clinical characteristcs and hospital outcome between primary and secondary unstable angina in the elderly

Introducción: La angina inestable (AI) se clasifica en primaria (AP) y secundaria (AS) sobre la base de la presencia o no de causas secundarias de isquemia. Estas condiciones son frecuentes en los ancianos y podrían influir en su pronóstico. Objetivo: El presente trabajo se llevó a cabo con el objetivo de evaluar las características clínicas y la evolución intrahospitalaria de ancianos con AI primaria y secundaria. Material y métodos: Se registraron 298 ancianos (edad ≥ 75 años) con diagnóstico final de AI. La muestra se dividió, según la presencia de causas secundarias de isquemia (anemia, taquicardia,hipertensión no controlada, infección, hipertiroidismo), en dos grupos: AS y AP. Se compararon antecedentes, características clínicas al ingreso, tratamientos, procedimientos y la ocurrencia de muerte y muerte o infarto en la fase intrahospitalaria. Se identificaron predictores univariados de mala evolución. Resultados: Cincuenta y dos pacientes (17,45 por ciento) tenían AS y 246 (82,5 por ciento) padecían AP. Los pacientes con AS eran más añosos y tenían mayores registros de tensión arterial y de frecuencia cardíaca al ingreso. El tratamiento médico, la cinecoronariografía y la revascularización se utilizaron menos en el grupo AS. La mortalidad (7,7 por ciento versus 6,9 por ciento [p = 1,00; OR (IC 95) = 1,12 (0,36-3,48)] AS y AP, respectivamente) y la combinación de muerte o infarto (7,7 por ciento versus 9,7 por ciento[p = 0,79; OR (CI 95) = 0,77 (0,25-2,32)] AS y AP, respectivamente) fueron similares. Los predictores univariados de muerte o infarto fueron infradesnivel del ST y desarrollo de insuficiencia cardíaca para ambos grupos y la refractariedad y necesidad de coronariografía y revascularización para el grupo AP. Conclusión: La AS es una causa común de isquemia en los ancianos y, pese a que requiere un manejo diferente, orientado a su etiología, tiene un pronóstico similar al de la AP.

Intervenção coronariana percutânea em artéria coronariana única em paciente com angina instável de alto risco / Percutaneous coronary intervention in single coronary artery in a patient with hig-risk unstable angina

No presente caso, relatamos a realização de angioplastia coronariana com implante de stent na artéria coronariana direita de paciente com quadro de angina instável de alto risco, portadora de artéria coronariana única com origem no seio coronariano direito. As artérias descendente anterior e circunflexa originavam-se isoladamente no terço proximal da artéria coronariana direita. Trata-se de rara anomalia coronariana com poucos relatos de intervenção coronariana percutânea na literatura. Este caso ilustra a necessidade da avaliação anatômica pormenorizada do trajeto das artérias coronarianas, precedendo a realização da angioplastia transluminal percutânea, objetivando-se a prevenção de complicações.

In the present case, we report the performance of coronary angioplasty with stent implantation in the right coronary artery of a patient with high-risk unstable angina and single coronary artery originating from the right coronary sinus. The anterior descending and circumflex arteries originated separately from the proximal third of the right coronary artery. This is a rare coronary anomaly and few reports of percutaneous coronary intervention are found in the literature. This case illustrates the need for a detailed anatomical assessment of the course of the coronary arteries prior to the performance of a percutaneous transluminal angioplasty, with the purpose of preventing complications.

Pacientes com angina instável tratados por meio de intervenções coronarianas percutâneas no novo milênio: o que os caracteriza? / Unstable angina patients treated with percutaneous coronary intervention in the new millennium: what characterizes them?

OBJETIVO: Identificar os perfis clínico/angiográfico e relacionados ao procedimento de pacientes com angina instável atendidos em um hospital terciário e tratados por meio de intervenções coronarianas percutâneas. MÉTODOS: Estudo de uma casuística consecutiva de 1.413 pacientes, selecionados a partir de um banco de dados informatizado e revascularizados percutaneamente no triênio 2002-2004. Não houve critérios de inclusão/exclusão. RESULTADOS: Hipertensão arterial sistêmica (74 por cento) e hipercolesterolemia (65 por cento) foram os fatores de risco clássicos para doença coronariana mais observados. Antecedentes de infarto do miocárdio e cirurgia de revascularização miocárdica foram respectivamente observados em 28 por cento e 24 por cento dos casos. Os subgrupos mais comumente tratados foram o IIB (48 por cento) e IIIB (28 por cento). O clopidogrel foi prescrito a 51 por cento dos pacientes, enquanto os inibidores IIb IIIa foram utilizados em 7 por cento. Doença coronariana multiarterial na cinecoronariografia diagnóstica ocorreu em 42 por cento dos casos. Lesões-alvo tipo B2 ou C foram tratadas em 64 por cento, das quais 94 por cento situavam-se em vasos naturais. Lesões reestenóticas foram dilatadas em 5 por cento dos pacientes. Todas as intervenções foram realizadas utilizando os stents coronarianos, a maioria dos quais (67 por cento) do tipo convencional. CONCLUSÕES: 1) os subgrupos IIB e IIIB foram os mais comumente tratados (76 por cento); 2) o clopidogrel foi o antitrombótico mais prescrito (51 por cento); 3) a coronariopatia multiarterial foi observada em 42 por cento dos casos, com predomínio de lesões-alvo complexas e situadas em vasos naturais; 4) a técnica de dilatação predominante foi o implante dos stents coronarianos.

OBJECTIVE: To identify clinical and angiographic profiles of patients with unstable angina seen at a tertiary hospital and treated with percutaneous coronary intervention (PCI). METHODS: Study of a consecutive series of 1413 patients, selected from a computerized database, who underwent percutaneous revascularization in the three-year period of 2002-2004. There were no inclusion/exclusion criteria. RESULTS: Systemic arterial hypertension (74 percent) and hypercholesterolemia (65 percent) were the classical risk factors for coronary disease most frequently observed. Coronary artery bypass grafting and history of myocardial infarction were found in 24 percent and 28 percent of the cases, respectively. The subgroups most commonly treated were the IIB (48 percent) and IIIB (28 percent). Clopidogrel was prescribed for 51 percent of the patients and glycoprotein IIb/IIIa inhibitors, for 7 percent. Multivessel disease evidenced by coronary angiography was detected in 42 percent of the cases. Type B2 or C lesions were treated in 64 percent, 94 percent of which in native vessels. Restenotic lesions were dilated in 5 percent of the patients. All interventions were performed using coronary stents, the majority of which (67 percent) were standard bare-metal stents. CONCLUSIONS: 1) Subgroups IIB and IIIB were the most frequently treated (76 percent); 2) Clopidogrel was the most prescribed antithrombotic agent (51 percent); 3) Multivessel coronary artery disease was found in 42 percent of the cases, most of which were complex target lesions located in native vessels; 4) Coronary stent implantation was the chief dilation technique used.

Infarto de miocardio en el paciente diabético / Myocardial infarction in the diabetic patient

Los pacientes diabéticos con enfermedad coronaria aterosclerótica tienen una fisiopatología compleja que empeora el pronóstico de la enfermedad cardíaca. El manejo adecuado, por lo tanto es complejo y requiere estrategias inciales agresivas. En los IAM con ST elevado, la angioplastía es generalmente preferible sobre el tratamiento fibrinolitico, sobre todo en aquellos pacientes que se encuentran dentro de las primeras 4 horas de iniciados los síntomas. Muchos pacientes con IAM sin ST elevado, luego de la angiografía coronaria pueden recibir angioplastía dentro de las 48 horas de presentación del cuadro. Se acumula evidencia de que el By Pass coronario con arteria mamaria izquierda es superior a la angioplastía en enfermedad coronaria múltiple en diabéticos con angina inestable. El periodo preinfarto y el manejo a largo plazo requieren una agresiva modificación de los factores de riesgo, optimización flucémica y rehabilitación cardiovascular.

Anti-inflammatory effect of statins in unstable angina and non st segment elevation myocardial Infarction

Inflammation plays an important role in all stages of inflammation and it appears to be a pivotal component of the process the transform stable to unstable disease because an augmentation of the inflammatory activity takes place during ACS. To study benefits of statins in treatment of unstable angina and non ST segment elevation myocardial infarction during the early days of hospital admission through its anti-inflammatory effect regardless cholesterol level. This study included 50 patients who were divided into two groups, atorvastatin group [group I] [25 patients] and control group [group II] [25 patients]. All patients were subjected to 12 lead electrocardiography, routine laboratory investigations including total cholesterol, LDL-C, HDL-C, triglycerides ,CRP and titre on admission, at the 6[th] and 14[th] day ,also, CPK and CKMB were measured on admission, after 6, 24 and 48 hours respectively. All patients received the traditional treatment of unstable angina and non ST segment elevation myocardial infarction, Atorvastatin 20 mg/day was administered to group I from the first day and continued during the period of follow up. CRP levels decreased significantly at the 6[th]day and 14[th] day in group [I] and increased significantly at the 6[th] day in group [II].Atorvastatin lowered the level of T.C, HDL-C, TO and this decrease was significant as regards LDL-C and TO and increased HDL-C significantly by the end of 14 days. There was no correlation between CRP changes and lipid profile changes. The result of the current study showed that atorvastatin 20 mg had anti- inflammatory effect in addition to its lipid lowering effect appeared in the early days after anti-inflammatory effect appeared in the early days after administration so starting of atorvastatin therapy immediately on admission in patients with UA or NSTEMI, regardless their lipid levels is recommended

Evolução hospitalar e tardia pós-implante de stent coronariano em paciente com angina instável e síndrome mielodisplásica / In-hospital and late outcomes after coronary stenting in patient with unstable angina and myelodysplastic syndrome

Homem de 61 anos de idade, com diagnóstico de síndrome mielodisplásica e angina instável foi submetido a angiografia coronariana e implante de stent. O hemograma revelou 40.000/mm³ plaquetas. A angiografia coronariana, precedida por transfusão de plaquetas, revelou obstrução de 80 por cento no óstio da artéria coronariana direita (ACD). Após o uso de clopidogrel 75mg, o paciente foi submetido à nova transfusão de plaquetas e a implante de stent LEKTON 3,0x10mm na lesão da ACD. Não ocorreram sangramentos após as retiradas dos introdutores. Após seis meses, o teste de esforço foi positivo e nova angiografia, sob as mesmas condições anteriores, mostrou reestenose intra-stent. Esse relato sugere que o implante de stent coronariano em pacientes com plaquetopenia é seguro, contanto que se realize a transfusão profilática de plaquetas, embora em longo prazo possa haver reestenose.

Sixty-one-year-old male patient with diagnosis of myelodysplastic syndrome and unstable angina was submitted to coronary angiography and implant of stent. His Blood vell count revealed 40,000 platelets/mm³. Coronary angiography with previous platelet transfusion showed obstruction of 80 percent of the right coronary artery (RCA). Following the administration of clopidogrel, the patient was submitted to another platelet transfusion and stent implantation in the RCA lesion. No bleeding was observed after the introducers removal. After 6 months, treadmill test was positive and new coronary aniography, in the same conditions, showed in-stent restenosis. This case report suggests that coronary stent implantation in patients with thrombocytopenia is a safe procedure, provided that prophylactic platelet transfusion is performed, although late restenosis may occur.

Registro de síndrome coronariana aguda em um centro de emergências em cardiologia / Acute coronary syndrome registry at a cardiology emergency center

OBJETIVO: Descrever as características de pacientes (P) com suspeita clínica de síndrome coronariana aguda (SCA), identificando-se o tratamento médico e a mortalidade hospitalar. MÉTODOS: Avaliamos 860 pacientes com SCA de janeiro a dezembro de 2003. Analisamos características basais, modalidade de apresentação da SCA, medicamentos durante a internação, indicação de tratamento clínico ou de revascularização miocárdica (RM) e mortalidade hospitalar. RESULTADOS: Foram 503 (58,3 por cento) pacientes do sexo masculino, com média de idade de 62,6 anos (±11,9). O diagnóstico na alta hospitalar foi de infarto agudo do miocárdio (IAM) com supradesnivelamento do segmento ST (SST) em 78 (9,1 por cento), IAM sem SST em 238 (27,7 por cento), angina instável (AI) em 516 (60 por cento), manifestação atípica da SCA (síncope ou dispnéia) em dois (0,2 por cento) e dor torácica não cardíaca em 26 (3 por cento). Foram medicados com betabloqueador em 87,9 por cento, AAS em 95,9 por cento, anti-trombínico em 89,9 por cento, nitroglicerina EV em 86,2 por cento, inibidor do receptor de glicoproteína (IGP) IIb/IIIa em 6,4 por cento, clopidogrel em 35,9 por cento, inibidor da enzima conversora da angiotensina (IECA) em 77,9 por cento e estatina em 70,9 por cento. A cinecoronariografia foi realizada em 72 pacientes (92,3 por cento) com IAM com SST e em 452 (59,8 por cento) com SCA sem SST (p<0,0001). Indicação de cirurgia de RM ocorreu em 12,9 por cento e intervenção coronariana percutânea em 26,6 por cento. A mortalidade hospitalar foi de 4,8 por cento, sem diferença entre a proporção de óbitos em pacientes com IAM com SST e SCA sem SST (6,4 por cento versus 4,8 por cento; p=0,578). CONCLUSÃO: Por meio deste registro apresentamos uma descrição de pacientes com SCA, avaliando características demográficas, tratamento médico e mortalidade hospitalar. O conhecimento da nossa realidade deve auxiliar para a maior aderência da classe médica às condutas recomendadas.

OBJECTIVE: Describe clinical characteristics of patients (P) admitted to hospital with suspected acute coronary syndrome (ACS), identifying medical treatment and in-hospital mortality. METHODS: Evaluated were 860 patients with ACS from January through December, 2003. We evaluated baseline characteristics, ACS mode of presentation, medication during hospital stay, indication for clinical treatment or myocardial revascularization (MR) and in-hospital mortality. RESULTS: Five hundred and three (58.3 percent) were male, mean age 62.6 years (± 11.9). Seventy-eight (9.1 percent) were discharged with the diagnosis of acute ST-elevation myocardial infarction (STEMI), 238 (27.7 percent) with non-ST-elevation myocardial infarction (non-STEMI), 516 (60 percent) with unstable angina (UA), two (0.2 percent) with atypical manifestations of ACS and 26 (3 percent) with non-cardiac chest pain. During hospitalization, 87.9 percent of patients were given a beta-blocker, 95.9 percent acetylsalicylic acid, 89.9 percent anti-thrombin therapy, 86.2 percent intravenous nitroglycerin, 6.4 percent glycoprotein (GP) IIb/IIIa receptor inhibitor, 35.9 percent clopidogrel, 77.9 percent angiotensin-converting enzyme inhibitor, and 70,9 percent statin drugs. Coronary arteriography was performed in 72 patients (92.3 percent) with STEMI, and in 452 (59.8 percent) with non-STEMI ACS (p< 0.0001). Myocardial revascularization (MR) surgery was indicated for 12.9 percent and percutaneous coronary intervention for 26.6 percent. In-hospital mortality was 4.8 percent, and no difference was recorded between the proportion of deaths among patients with STEMI and non-STEMI ACS (6.4 percent versus 4.8 percent; p = 0.578). CONCLUSION: In this registry, we provide a description of ACS patient, which allows the evaluation of the demographic characteristics, medical treatment prescribed, and in-hospital mortality. A greater awareness of our reality may help the medical community to adhere more strictly to...

Registro Mexicano de Síndromes Coronarios Agudos: RENASICA II Mexican Registry of Acute Coronary Syndromes

Objetivo: El registro pretende establecer en México las características clínicas, identificar abordajes terapéuticos y conocer la evolución hospitalaria en pacientes con síndromes coronarios agudos. Métodos y resultados: RENASICA II es un registro prospectivo que incluye 8,098 pacientes con diagnóstico final de síndrome coronario agudo. Tres mil quinientos cuarenta y tres tuvieron angina inestable o infarto sin elevación del ST (AI/IMNEST) y 4,555 con infarto con elevación del ST (IMEST). A su ingreso al hospital se identificó dolor torácico típico de isquemia en 78% y 85% respectivamente. Se consideró de alto riesgo al 36% de los pacientes con AI/IMNEST. En la mayoría de los pacientes con IMEST la localización fue anterior y se encontraban en clase KK I. En AI/IMNEST se utilizó aspirina en el 90%, heparina no fraccionada 50%, heparina de bajo peso molecular 45%, nitratos 58%, bloqueadores beta 50% e inhibidores de enzima convertidora en el 54%. En IMEST estos medicamentos se utilizaron en el 88%, 54%, 44%, 66%, 51% y 64% respectivamente. En pacientes con AI/IMNEST se realizó angiografía en el 62%, angioplastía coronaria 30% y cirugía de revascularización 8%. En el grupo con IMEST estos procedimientos se realizaron en el 44%, 27% y 4% respectivamente. En IMEST el 37% recibió terapia fibrinolítica y 15% fueron llevados a angioplastía primaria o facilitada. La mortalidad hospitalaria global del 7%, en AI/IMNEST fue del 4% y en IMEST del 10%. Conclusión: El más grande registro de síndromes coronarios agudos en Latinoamérica provee información importante sobre el espectro clínico, evolución hospitalaria, calidad de atención e identifica áreas de oportunidad para mejorar la atención médica. El RENASICA II extiende nuestro conocimiento sobre cómo la reperfusión y el tratamiento antitrombótico modifican la evolución y cuáles procesos necesitamos mejorar en la práctica real en México.

Objective: The registry intends to establish the clinical characteristics, identify therapeutic approaches and describe in-hospital outcome of patients with acute coronary syndromes in Mexico. Methods and results: RENASICA II is a prospective registry that included 8,098 patients with final diagnosis of acute coronary syndromes. Three thousand five hundred and forty three patients had unstable angina or non-ST elevation myocardial infarction (UA/NSTEMI) and 4,555 ST elevation myocardial infarction (STEMI). On admission typical chest pain was identified in 78% and 85% respectively. Non-ST elevation high risk group was identified in 36%. In STEMI group anterior myocardial infarction and Killip class I had higher occurrence. The use of aspirin, unfractionated heparin, low molecular weight heparin, nitrates, beta blockers and ACE inhibitors for patients with UA/NSTEMI were 90%, 50%, 45%, 58%, 50% and 54% respectively, with corresponding rates of 88%, 54%, 44%, 66%, 51% and 64% for STEM I patients. Coronary angiography, angioplasty and coronary bypass surgery were performed in 62%, 30% and 8% in UA/NSTEMI patients respectively with corresponding rates of 44%, 27% and 4% for STEMI group. Among patients with STEMI 37% were under fibrinolytic therapy and 15% received primary or facilitated angioplasty. Overall In-hospital mortality was 7%, 4% for UA/NSTEMI and 10% for STEMI. Conclusion: The largest registry on ACS in Latin-America provides important and reliable information on complete spectrum, outcome, quality of care, and identifies areas for further improvement of such quality. RENASICA II broadens our knowledge about how reperfusion and antithrombotic approaches modify the outcome and what needs to be improved in the real practice in Mexico.

Resultados del primer registro chileno de angina inestable: características clínicas, perfil de riesgo y tratamiento / Results of the first Chilean registry of unstable angina: clinical features, risk profile and treatment

Background: From January 2000 to June 2002, the first Chilean registry of unstable angina was carried out, with the participation of 15 hospitals. Aim: To report the clinical and demographic features of 600 patients with unstable angina, their risk profile and prognosis. Material and methods: The inclusion criteria for this prospective registry were a history of recent onset of chest pain (<48 hours) or a change in the character of previous angina, associated to ischemic electrocardiographic changes and/or positive markers of myocardial damage. Results: Mean age of the patients was 65 years and 37 percent were women. Among coronary risk factors, 63 percent had hypertension, 27percent had diabetes, 52percent had dyslipidemia, 31percent smoked and 21percent had a family history of atherosclerosis. On admission 94percent of patients had chest pain, associated to ST segment depression in 44 percent, negative T waves in 28 percent and positive markers of myocardial damage in 30percent. Fifty seven percent received intravenous nitroglycerin, 47 percent received oral nitrates, 69 percent beta blockers and 15 percent, calcium antagonists. Antithrombotic therapy included aspirin in 96 percent, heparin in 74percent, ticlodipine or clopidogrel in 19 percent and IIb/IIIa inhibitors in 12percent. A coronary angiogram was performed in 52percent, angioplasty in 25percent and coronary bypass surgery in 13percent. Hospital mortality was 2.6percent. The incidence of new ischemic events was: myocardial infarction in 2.8percent recurrent ischemia in 9.5percent and refractory ischemia in 2percent. The incidence of adverse events increased according to a higher risk profile. Conclusions: The demographic and clinical features, treatment and mortality of these patients are similar to those reported in international registries, with a low mortality rate.