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.

1er. Consenso venezolano de angina inestable / Consensus venezuelan of the unstable angina

Desde el pasado año, las Sociedades Venezolanas de Cardiología, Medicina Crítica y Medicina Interna, decidieron en forma conjunta, la realización de un Consenso sobre Síndromes Coronarios Agudos, con miras a lograr una integración de los distintos grupos de trabajo en el diagnóstico y tratamiento de esta importante entidad clínica, primera causa de mortalidad en el país

Correlation of Braunwald's clinical classification of unstable angina pectoris with angiographic extent of disease, lesion morphology and intra-luminal thrombus.

One hundred consecutive patients (81 male and 19 female) with unstable angina pectoris undergoing coronary angiography were divided according to Braunwald's clinical classification. Seventeen (17%) patients had new onset angina (class I), 68 (68%) sub-acute angina (class II) and 15 (15%) had acute rest angina (class III). Twenty-seven (27%) patients had secondary unstable angina pectoris (class A), 49 (49%) primary unstable angina (class B) and 24 (24%) had post-infarction unstable angina (class C). ST-T wave changes on ECG were present in 54 (54%) while absent in 46 (46%) patients. On coronary angiography, 26 (26%) patients had single vessel disease, 30 (30%) double vessel disease and 39 (39%) patients had triple vessel disease. Five (5%) patients were found to have normal coronaries. Classification of patients according to Braunwald's clinical classification showed single vessel disease to be higher in class I as compared to class II (47% vs 22%; p = 0.04) and classes III (47% vs 20%; p<0.01). Single vessel disease was found to be higher in class C as compared to class B (41.7% vs 16.4; p = 0.01). Double vessel disease was higher in class B as compared to class A (40.8% vs 18.5%, p = 0.04). Triple vessel disease incidence was not found to be significantly different among different clinical classes. Morphology of coronary artery lesions was classified according to Ambrose's classification. Out of the total of 248 lesions in the whole study group, there were 68 (27.42%) concentric lesions, 55 (22.18%) eccentric type I lesions, 23 (9.27%) eccentric type II lesions, 42 (16.94%) multiple irregularity lesions and 60 (24.19%) totally occluded lesions. Concentric lesions were found to be higher in class C as compared to class B (40% vs 19.8%; p = 0.014). Statistically significant difference was not present in the distribution of other morphological type of lesions among different clinical classes. In the whole study group, intra-luminal thrombus was found to be present in 17 (17%) of patients. Distribution of intra-luminal thrombus according to Braunwald's classification showed that none of the patients in class I had intra-luminal thrombus, while 13 (19.1%) patients in class II and 4(26.7%) in class III had intra-luminal thrombus. The difference in the occurrence of intra-luminal thrombus between class I and class II (p = 0.004) and class I and class III (p = 0 .03 was found to be significant. Thus, majority of patients undergoing coronary angiography had primary sub-acute rest angina. Single vessel disease was higher in new onset angina. Patients with unstable angina pectoris and ST-T changes on ECG had higher number of lesions per patient and higher eccentric type I lesions. Intra-luminal thrombus was more frequently encountered with acute rest angina. However, the distribution of different morphological type of lesions on coronary angiography did not differ significantly in different clinical classes of unstable angina pectoris divided according to Braunwald's classification.

Angina postinfarto: definición, clasificación, fisiopatología y terapia no tradicional / Postinfarction angina: Definition, classification, physiopathology and no traditional therapy

Es necesario estratificar en grupos de riesgos, luego de un infarto agudo del miocardio, para identificar a aquéllos con más posibilidad de tener otro infarto, muerte súbita o arritmias ventriculares letales. La angina postinfarto (API) es un evento clínico frecuente que identifica a la persona susceptible de tener alguna de estas situaciones con alta mortalidad.Se define como la angina que inicia 24 horas después de la angina que provocó el infarto del miocardio; es temprana durante los primeros 10 días; y tardía hasta 2 meses después. La incidencia varía entre 20 por ciento y 60 por ciento. Es más frecuente en presencia de angina pre-infarto y de infarto del miocardio no. Q. Se desarrolló hasta en el 85 por ciento cuando hubo angina reciente pre-infarto. Los episodios de angina postinfarto se clasifican en 2 tipos : isquemia en la zona del infarto (40 por ciento) e isquemia a distancia (60 por ciento). La enfermedad de tres vasos se encuentra en un 86 por ciento, siendo más frecuente en la isquemia en la zona del infarto. Las lesiones excéntricas tipo II se observan enel 71 por ciento de los casos de API. Las lesiones coronarias por angioscopías sontres: trombo, irregularidad intimal o endotelial, o superficie irregular y la placa xantomatosa. La mortalidad al mes es de 44 por ciento en la isquemia a distancia y del 15 por ciento en la isquemia en la zona del infarto; al año es del 31 por cinto y del 37 por ciento respectivamente. La angioplastía es un procedimiento efectivo que alivia la isquemia miocárdica, pero se asocia a altas tasas de oclusiones agudas y re-estenosis. Se reserva ese procedimiento para los casos cuyos síntomas no pueden controlarse con medicamentos, o aquéllos con anatomía compleja y enfermedad multivasos, particularmente los que tienen muy alto riesgo operativo. A los 15 meses hay recurrencia de la angina, en un 29 por ciento apesar de que el procedimiento fuera exitoso. La cirugía coronaria no está contraindicada en el infarto del miocardio reciente; se recomienda luego de 4 semanas del infarto del miocardio, cuando la fracción de eyección es menor del 50 por ciento. La mortalidad operatoria es 3.5 veces mayor cuando hubo un infarto del miocardio no Q comparado con uno Q