Comparação entre Dois Escores de Risco quanto à Predição de Obstrução Microvascular Coronariana durante a Intervenção Percutânea Primária / The Comparison between Two Risk Scores as for the Prediction of Coronary Microvascular Obstruction during Primary Percutaneous Intervention

Resumo Fundamento: Para pacientes com infarto do miocárdio com elevação do segmento ST (IAMCST) que sofrem de obstrução coronariana microvascular funcional e estrutural (OCM) subsequente, nenhuma abordagem terapêutica específica e definitiva de atenuação foi comprovada como válida em testes de larga escala atuais, o que destaca a necessidade de abordar seu reconhecimento precoce. Objetivos: Este estudo teve como objetivo comparar o desempenho de dois escores de risco clínico com uma medida objetiva de OCM durante intervenção coronária percutânea (ICP) em casos de IAMCST Métodos: A medição do índice de resistência microcirculatória (IRM) foi realizada e os parâmetros clínicos e angiográficos basais também foram registrados. Os pacientes foram divididos em entre os grupos OM (obstrução microvascular) e NOM (não-obstrução microvascular), de acordo com o valor de IRM pós-procedimento. O risco de OCM foi avaliado para todos os participantes pelos escores preditivos SAK e ATI, respectivamente. Cada sistema foi calculado somando-se as pontuações de todas as variáveis. As curvas de características do operador receptor (ROC) e a área sob a curva (AUC) de dois modelos de risco foram utilizadas para avaliar o desempenho discriminatório. Um ecocardiograma foi realizado sete dias após o procedimento para avaliar a fração de ejeção do ventrículo esquerdo (FEVE). Um valor P bicaudal de <0,05 foi considerado estatisticamente significativo. Resultados: Entre os 65 pacientes elegíveis com IAMCST, 48 foram alocados no grupo NOM e 17 no grupo OM, com uma incidência de OCM de 26,15%. Não houve diferença significativa na AUC entre os dois escores. A FEVE avaliada para o grupo NOM foi maior do que para o grupo OM. Conclusão: Os escores SAK e ATI tiveram bom desempenho para estimar o risco de OCM após ICP primário para pacientes com IAMCST.

Abstract Background: For patients with ST-segment elevation myocardial infarction (STEMI) that are suffering from subsequent coronary microvascular functional and structural obstruction (CMVO), no specific and definitive therapeutic approaches of attenuation have been proven valid in up-to-date large-scale tests, which highlights the urge to address its early recognition. Objectives: This study aimed to compare the performance of two clinical risk scores with an objective measurement of CMVO during percutaneous coronary intervention (PCI) with STEMI. Methods: The Index of Microcirculatory Resistance (IMR) measurement was conducted and the baseline clinical and angiographic parameters were also recorded. The patients were divided into MO (Microvascular obstruction) or NMO (Non-microvascular obstruction) groups according to the post-procedure IMR value. The CMVO risk was evaluated for all participants by SAK and ATI predictive scores, respectively. Each system was calculated by summing the scores of all variables. The receiver operator characteristic (ROC) curves and the area under the curve (AUC) of two risk models were used to evaluate the discriminatory performance. An echocardiography was performed seven days after the procedure to evaluate left ventricular ejection fraction (LVEF). A two-sided P-value of <0.05 was considered statistically significant. Results: Among the 65 eligible STEMI patients, 48 patients were allocated in the NMO group and 17 in the MO group, with a CMVO incidence of 26.15%. There was no significant difference in the AUC between both scores. The LVEF evaluated for the NMO group was higher than that of MO group. Conclusion: Both SAK and ATI scores performed well in estimating CMVO risk after primary PCI for STEMI patients.

Infective Endocarditis with an Infectious Cerebral Aneurysm Rupture and an Acute Myocardial Infarction / 日本心臓血管外科学会雑誌

A 56-year-old woman was referred to our hospital due to anorexia. An echocardiogram demonstrated severe mitral valve regurgitation and vegetation located on the valve. We diagnosed infective endocarditis and started to treat with antibiotics. During antibiotics treatment, cerebral hemorrhage was caused by rupture of an infectious cerebral aneurysm. She was treated by surgical operation. Waiting for cardiac surgery, she had sudden chest pain. Electrocardiogram examination demonstrated an anterior acute myocardial infarction. Emergency coronary angiogram revealed complete obstruction of the left anterior descending coronary artery. She was successfully treated with thrombus aspiration using a catheter device and stenting. However, she was in cardiogenic shock and her blood pressure could not be maintained with catecholamine and IABP. We performed emergency mitral valve replacement. After surgery, the circulation dynamics improved and she was discharged from the hospital.

Relación entre la enzima convertidora de angiotensina, polimorfismo I/D, y obstrucción coronaria en una población del Quindío, Colombia / Relação entre enzima conversora de angiotensina, polimorfismo I/D e obstrução coronária numa população de Quindío, Colômbia / Relationship between angiotensin-converting enzyme, I/D polymorphism, and coronary obstruction in a population of Quindío, Colombia

En varios estudios la actividad de enzima convertidora de angiotensina (ECA) en suero y el polimorfismo inserción/deleción (I/D) se han relacionado con enfermedad cardiovascular. Objetivo. Relacionar la actividad de la ECA y el polimorfismo I/D del gen de la enzima en pacientes con obstrucción coronaria documentada por angiografía. Materiales y métodos. La muestra la constituyeron pacientes que asistieron a un centro de hemodinámia del Quindío, por necesidad de una angiografía coronaria. La actividad de la enzima fue medida por espectrofotometría y el genotipo I/D por medio de la reacción en cadena de la polimerasa. Resultados. 542 pacientes fueron divididos en dos grupos: individuos con obstrucción coronaria ≥50%, (OC≥50) e individuos con obstrucción coronaria menor al 50%, (OC<50%). La actividad de ECA en suero en la población general fue más alta en los individuos con polimorfismo DD, seguido por ID e II con diferencias significativas. Para los dos grupos de estudio el patrón fue similar, pero sin diferencias significativas, aunque la actividad de la enzima siempre fue más alta en los individuos con OC≥50% comparados con los pacientes con OC<50%. El genotipo ID fue el genotipo más frecuente en los dos grupos. No se encontraron diferencias en las frecuencias alélicas y genotípicas en los grupos de estudio. Conclusiones. Se encontraron diferencias significativas en la actividad de la ECA de acuerdo al genotipo. Este estudio, no encontró relación entre actividad de la enzima, los polimorfismos y la obstrucción coronaria...

Relationship between angiotensin-converting enzyme, I/D polymorphism, and coronary obstruction in a population of Quindío, Colombia. Angiotensin-converting enzyme (ACE) activity in serum and insertion/deletion (I/D) polymorphism have been associated to cardiovascular disease in several studies. Objective. To find a relationship between ACE activity and I/D polymorphism in the enzyme gene in patients with coronary obstruction revealed by angiography. Materials and methods. Sample comprised patients attending a hemodynamics center in Quindío in need of a coronary angiography. ACE activity was measured by spectrophotometry and the I/D genotype determined by polymerase chain reaction. Results. 542 patients were divided into two groups: individuals with coronary obstruction higher than or equal to 50% (OC≥50) and individuals with coronary obstruction less than 50% (CO<50%). Serum ACE activity in the global population was higher in individuals with DD polymorphism, followed by ID and II with significant differences. A similar pattern was shown in both study groups but without significant differences, although enzyme activity was always higher in individuals with OC≥50% compared with patients with OC<50%. ID genotype was the most frequent in both groups. No differences were found in allele and genotype frequencies in the study groups. Conclusions. Significant differences in ACE activity were found according to genotype. Our study did not find any relationship between ACE activity, I/D polymorphisms and coronary obstruction...

Relação entre enzima conversora de angiotensina, polimorfismo I/D e obstrução coronária numa população de Quindío, Colômbia. Em vários estudos a atividade da enzima conversora de angiotensina (ECA) no soro e o polimorfismo inserção/deleção (I/D) têm sido associados com doença cardiovascular. Objetivo. Relacionar a atividade da ECA e o polimorfismo I/D do gene da enzima em pacientes com obstrução coronariana documentada por angiograma. Materiais e métodos. A amostra foi composta por pacientes queassistiram num centro de hemodinâmica do Quindío, por necessidade de um angiograma coronario. A atividade da enzima foi medida por espectrofotometria e o genótipo I/D através da reação em cadeia da polimerase. Resultados. 542 pacientes foram divididos em dois grupos: indivíduos com obstrução coronária ≥50% (OC≥50) e indivíduos com obstrução coronariana inferior a 50% (OC<50%). A actividade de ECA no soro na população em geral foi maior em indivíduos com polimorfismo DD, seguido pelo ID e II com diferenças significativas. Para ambos os grupos de estudo o padrão foi semelhante, mas sem diferenças significativas, embora a atividade da enzima foi sempre maior em indivíduos com OC≥50% em comparação com pacientes com OC<50%. O genótipo ID foi o genótipo mais freqüente nos dois grupos. Não houve diferenças nas freqüências alélicas e genotípicas nos grupos de estudo. Conclusões. Houve diferenças significativas na atividade da ECA segundo o genótipo. Este estudo não encontrou relação entre a atividade da enzima, os polimorfismos e a obstrução coronariana...

Presencia de enfermedad coronaria obstructiva en pacientes con SPECT negativo sometidos a coronariografía por tomógrafo de 64 canales / Obstructive coronary artery disease in patients with negative SPECT undergoing coronary angiography with a 64-slice CT angiogram

Objective. To evaluate the presence of obstructive coronary artery disease (OCD) in patients with negative SPECT undergoing 64-slice coronary CT angiography. Material and methods. From July 2007 to January 2010, patients with negative SPECT undergoing CT angiography were assessed. We used a Philips Brilliance 64-slice CT scanner and low osmolality iodinated contrast. Coronary arteries were divided into 16 segments and the presence of OCD (lesion> 50 percent), non-obstructive coronary disease (lesions <50 percent), or absence of coronary disease were evaluated. Results. From a population of 447 patients undergoing coronary angiography, 52 patients with negative SPECT were included in the study. The mean age was 60 years, and 67 percent corresponded to female patients. We observed 13 patients (25 percent) with OCD. Percentages of arterial anomalies were as follows: 92 percent, anterior descending artery; 53.8 percent, right coronary artery; 46.1 percent, circumflex coronary artery; 23 percent, lateroventricular coronary artery; 15.3 percent, posterior descending coronary artery; 7.7 percent, diagonal coronary artery. No lesion was found in the left coronary artery. Conclusion In our analysis, 25 percent of patients with negative SPECT showed significant obstructive lesions.

Objetivo. Evaluar la presencia de enfermedad coronaria obstructiva (ECO) en pacientes con SPECT negativo sometidos a Coronariografía TC64. Material y métodos. Se evaluaron pacientes sometidos a coronariografía TC con SPECT negativo desde julio 2007 a enero 2010.Se utilizó un tomógrafo Philips Brilliance 64 y contraste iodado de baja osmolaridad. Las arterias coronarias se dividieron en 16 segmentos evaluando la presencia de ECO (lesión > 50 por ciento), enfermedad coronaria no obstructiva (lesión < 50 por ciento) o sin enfermedad coronaria. Resultados. Del total de 447 pacientes, se incluyeron 52 pacientes con SPECT negativo. La edad media fue 60 años, 67 por ciento mujeres. Se observaron 13 pacientes (25 por ciento) con ECO. Las afecciones arteriales fueron: arteria descendente anterior en el 92 por ciento, coronaria derecha 53,8 por ciento, circunfleja 46,1 por ciento, lateroventricular 23 por ciento, descendente posterior 15,3 por ciento, diagonal 7,7 por ciento y ninguna en el tronco coronario izquierdo. Conclusión. Según nuestra serie, el 25 por ciento de los pacientes con SPECT negativo presentó lesiones obstructivas significativas.

Relationship between Angiographic Coronary Artery Morphology and Successful Intracoronary Thrombolysis in Acute Myocardial Infarction

BACKGROUND: It is well known that intracoronary thrombolysis during the early period of acute myocardial infarction leads to the limitation of myocardial necrosis, preserves left ventricular function, and improves survivals. The recanalization rate of intracoronary rrokinase infusion into infarct-related coronary artery was known as 62-94 percents in previos studies. The various factors influence the outcome of intracoronary thrombolysis, including total dose of urokinase, time from onsrt of chest pain to thrombolysis. The purpose of this study was to evaluate whether the occlusion site morphology influences recanalization rates of intracoronary thrombolysis. METHODS: We evaluated infarct-related coronary artery morphology of 56 acute mycardial infarction patients who performed intracoronary thrombolytic therapy within 6-12 hours after the onset of acute myocardial infarction. Intracoronary urokinase infusion was performed at a rate of 25000 IU/minute. The presence of calcification, collaterals, side branches and the stump site morphologies(thrombus type, pencil type, cutting type) were identified on magnified 35mm cine frames. RESULTS: Reperfusion was successed in 34 patients and failed in 22 patients. There were no statistically significant difference in the pressure of calcification, collaterals, and side branches between success and failure groups. Intracoronary thrombus was identified in 21 percent of success group, but not in failure group. The reperfusion rates according to stump site morphology were 76% in thrombus type, 58% in cutting type, and 42% in pencil type(p<0.05). CONCLUSION: Our study indicates the presence of intracoronary thrombus and the morphology of thrombus type is more effective in intracoronary thrombolysis in acute myocardial infarction. The identification of types of the coronary obstruction will be helpful for the selection of intracoronary thrombolysis in acute myocardial infarction patients. And the results suggest that the difference of stump composition show different stump morphologies.