ABSTRACT
Resumen Se presenta el caso de un paciente de 54 años que consulta por angina de esfuerzo de 2 años de evolución en quien se identifica una dilatación ectásica del árbol coronario con lesiones ateroscleróticas críticas y miocardiopatía hipertrófica septal obstructiva. Una revisión bibliográfica revela que es una asociación infrecuente de la cual solo existen reportes de casos aislados.
Abstract We present the case of a 54-year-old patient who presented with a history of 2 years with angina. Invasive studies revealed critical coronary artery stenosis coexisting with obstructive hypertrophic miopathy. This is a rare association with only isolated case reports.
Subject(s)
Humans , Male , Middle Aged , Cardiomyopathy, Hypertrophic/complications , Cardiomyopathy, Hypertrophic/diagnostic imaging , Atherosclerosis/complications , Atherosclerosis/diagnostic imaging , Cardiomyopathy, Hypertrophic/surgery , Echocardiography, Doppler , Dilatation, Pathologic , Atherosclerosis/surgery , Computed Tomography AngiographyABSTRACT
The anomalous origin of the coronary arteries is uncommon and the origin of the right coronary artery from the middle third of the anterior descending artery is a finding of extreme rarity. We report two patients with coronary atherosclerotic disease and with an acute coronary syndrome, in whom a single left coronary artery was found. The clinical and angiographic characteristics and the treatment of these patients are described.
Subject(s)
Humans , Male , Middle Aged , Aged , Coronary Artery Disease/diagnostic imaging , Coronary Vessel Anomalies/diagnostic imaging , Coronary Artery Disease/surgery , Coronary Artery Disease/etiology , Angioplasty, Balloon, Coronary , Coronary Angiography , Coronary Vessel Anomalies/surgery , Coronary Vessel Anomalies/complicationsABSTRACT
The anomalous origin of the coronary arteries is uncommon and the origin of the right coronary artery from the middle third of the anterior descending artery is a finding of extreme rarity. We report two patients with coronary atherosclerotic disease and with an acute coronary syndrome, in whom a single left coronary artery was found. The clinical and angiographic characteristics and the treatment of these patients are described.
Subject(s)
Coronary Artery Disease/diagnostic imaging , Coronary Vessel Anomalies/diagnostic imaging , Aged , Angioplasty, Balloon, Coronary , Coronary Angiography , Coronary Artery Disease/etiology , Coronary Artery Disease/surgery , Coronary Vessel Anomalies/complications , Coronary Vessel Anomalies/surgery , Humans , Male , Middle AgedABSTRACT
The anomalous origin of the coronary arteries is uncommon and the origin of the right coronary artery from the middle third of the anterior descending artery is a finding of extreme rarity. We report two patients with coronary atherosclerotic disease and with an acute coronary syndrome, in whom a single left coronary artery was found. The clinical and angiographic characteristics and the treatment of these patients are described.
Subject(s)
Acute Coronary Syndrome , Coronary Artery Disease , Coronary Vessel Anomalies , Acute Coronary Syndrome/diagnostic imaging , Coronary Angiography , Coronary Artery Disease/diagnostic imaging , HumansABSTRACT
La angiografía coronaria ha sido y continúa siendo el pilar sobre el cual se deciden las intervenciones terapéuticas en la enfermedad coronaria constituyendo el grado de estenosis de las placas ateromatosas uno de los principales marcadores de isquemia miocárdica y por lo tanto del pronóstico de la enfermedad. Sin embargo, es un hecho repetidamente documentado que los fenómenos coronarios agudos se producen con mayor frecuencia en placas con estenosis angiográficamente no significativas; por lo tanto, la vulnerabilidad de las placas no parece tener relación con su grado de estenosis y en consecuencia tampoco con la producción de isquemia miocárdica. Esta conclusión no concuerda con los hallazgos histopatológicos ni con los grados de severidad de las estenosis que comprometen el flujo coronario. El objetivo de la presente comunicación es tratar de aclarar esta controversia analizando la información entregada por la histopatología de las lesiones agudas culpables de los infartos. Precisar si las lesiones coronarias crónicas que producen isquemia (probables causantes de futuros infartos) se correlacionan con el grado de estenosis anatómica; proponer el posible mecanismo que vincula el grado de estenosis a la vulnerabilidad de las placas y esbozar una explicación para conciliar los hallazgos angiográficos con los his-topatológicos y funcionales.
Coronary angiography has long been and is still the basic method for deciding coronary interventions, and the severity of stenosis remains the main prognostic marker of the disease. However, plaque vulnerability does not appear to be associated with a greater degree of angiographic stenosis, which is not consistent with histopathological findings or with physiological assessment of ischemia-producing lesions. The purpose of this article is to briefly review this controversy while suggesting that plaques vulnerability correlate with the degree of anatomical and functional stenosis, and to describe the potential mechanism that could determine this vulnerability as well as to give likely explanations that reconcile angiographic findings with histopathological and functional observations.
Subject(s)
Humans , Coronary Angiography , Coronary Stenosis/diagnostic imaging , Myocardial Infarction/etiology , Severity of Illness Index , Coronary Vessels/injuries , Coronary Stenosis/complications , Coronary Stenosis/physiopathology , Coronary Stenosis/pathology , Plaque, AtheroscleroticABSTRACT
BACKGROUND: Distal embolization of thrombus/platelet aggregates decreases myocardial reperfusion during primary percutaneous coronary intervention (PCI), and is associated with worse immediate and long-term prognosis of patients with ST-elevation myocardial infarction (STEMI). OBJECTIVE: Assess the efficacy of a mesh covered stent (MGuard™ stent, MGS) in preventing distal embolization and microvascular reperfusion impairment during primary PCI, compared with a bare metal stent (BMS). METHODS: Forty patients with STEMI referred for primary PCI were randomized for stenting the culprit lesion with the MGS (n = 20) or a BMS (n = 20). Blinded experts performed off-line measurements of angiographic epicardial and microvascular reperfusion criteria: TIMI flow grade, myocardial blush, corrected TIMI frame count (cTFC). RESULTS: At baseline clinical, angiographic and procedural variables were not different between groups. Post PCI TIMI flow grade was similar in both groups. We observed better myocardial Blush grade in group MGS compared to BMS (median value 3.0 vs 2.5, 2p = 0.006) and cTFC (mean cTFC: MGS 19.65 ± 4.07 vs BMS 27.35 ± 7.15, 2p < 0.001, cTFC mean difference MGS-BMS: 7.7, CI 95%: 3.94 to 11.46). MGS stent group had a higher percentage of successful angioplasty (cTFC ≤ 23: MGS 85% vs BMS 30%, 2p < 0.001). We had two cases of acute stent thrombosis (one for each group) at 30days follow up, but no clinical events at 6 months follow up. CONCLUSIONS: In this exploratory study, MGS significantly improved microvascular reperfusion criteria compared with a BMS in primary PCI. However its safety and impact on clinical outcomes should be verified in larger randomized clinical trials.
Subject(s)
Coronary Circulation , Metals , Microcirculation , Myocardial Infarction/therapy , Percutaneous Coronary Intervention/instrumentation , Stents , Surgical Mesh , Adult , Aged , Chi-Square Distribution , Chile , Coronary Angiography , Embolism/etiology , Embolism/prevention & control , Female , Humans , Male , Middle Aged , Myocardial Infarction/diagnostic imaging , Myocardial Infarction/physiopathology , Percutaneous Coronary Intervention/adverse effects , Prosthesis Design , Thrombosis/etiology , Thrombosis/prevention & control , Time Factors , Treatment OutcomeABSTRACT
Introducción: La revascularización de una estenosis coronaria que induce isquemia mejora el estatus funcional del paciente y su pronóstico. Por el contrario, la angioplastía de una lesión que no provoca isquemia puede implicar complicaciones sin beneficios. La medición de flujo de reserva coronario (FFR) es un índice del significado fisiopatológico de las estenosis coronarias. Objetivos: Comparar los eventos cardiovasculares adversos mayores (MACE) en pacientes en quienes la FFR permitió excluir una o más lesiones de angioplastia (Grupo FFR >0,75) con aquellos en que ésta obligó a la revascularización (grupo FFR < 0,75). Métodos: Estudio observacional en 74 pacientes derivados para angioplastía entre agosto de 2006 y julio de 2010. Se realizó medición de FFR con ade-nosina a lesiones de severidad intermedia (60-70 por ciento). Una FFR translesional <0,75 se consideró significativa para isquemia y subsidiaria de angioplastía. Se hizo un seguimiento de los MACE definidos como: muerte, infarto, necesidad de revascularización y/o presencia de angor. Resultados: 35 pacientes (47,3 por ciento) constituyeron el Grupo FFR >0,75, y en ellos disminuyó el porcentaje de lesiones múltiples angiográficamente significativas (dos o más vasos), desde un 51,4 por ciento (previo a la realización de FFR), a un 25,7 por ciento. En este grupo se utilizó un promedio de 0.7 stents por paciente, mientras que en el grupo FFR <0,75 (39 pacientes), este fue de 1.5 stents. Se efectuó un seguimiento promedio de 21,5 meses. Diecinueve pacientes (25,6 por ciento) desarrollaron MACE (28 eventos). No hubo fallecidos ni diferencias significativas en el análisis multifactorial en cuanto a infartos o angor, pero sí en la necesidad de nueva revascularización, siendo ésta significativamente mayor en el grupo FFR <0,75 (12,8 por ciento versus 2,9 por ciento, p=0,047). Conclusiones: La medición del FFR permite, en caso de descartar isquemia, disminuir la necesidad de angioplastías...
The treatment of coronary stenosis causing myocardial ischemia improves functional capacity and prognosis. Treatment of non-ischemia inducing coronary stenosis may lead to complications with no benefit to the patient Measurement of coronary flow reserve (CFR) may be used to assess the significance of coronary artery stenosis. Aim: To compare major adverse cardiovascular events (MACE) in patients with significant stenosis (CFR < 0.75), with those in which one or more stenosis was not significant (CFR > 0.75) and thus were not subjected to PTCA in the corresponding artery. Methods: 74 patients were included from August 2006 to July 2010. CFR was measured in lesions exhibiting 6070 percent stenosis, using adenosine. A value <0.75 was considered significant and led to PTCA. Patients were followed for death, myocardial infarction, revascularization and/or angina. Results: 35 patients (47 percent) constituted the >0.75 CFR group. After evaluation of CFR the number of significant coronary stenosis decreased from 51.4 percent to 25.7 percent. They received a mean of 0.7 stents per patient. On the other hand, in the group with CFR <0.75 (39 patients) the mean number of stents was 1.5. Patients were followed for a mean of 21.5 months. 28 MACE events were observed in 19 patients (25.6 percent). No deaths were observed. Multivariable analysis revealed no significant difference between groups regarding myocardial infarction or angina. The need for myocardial revascularization was greater in the CFR <0.75 group compared to the CFR >0.75 group (12.8 percent vs 2.9 percent, respectively, p=0.047). Conclusion: The exclusion of myocardial ischemia as inferred by a CFR >0.75 allowed a significantly lower number of PTCAs without increase in MACE at a medium term follow up. A greater number of revascularization procedures was required in patients with CFR <0.75, which is expected from the greater number of lesions subjected to PTCA.
Subject(s)
Humans , Male , Female , Angioplasty, Balloon, Coronary/methods , Coronary Circulation , Coronary Stenosis/physiopathology , Fractional Flow Reserve, Myocardial , Myocardial Ischemia/diagnosis , Clinical Evolution , Coronary Stenosis/therapy , Follow-Up Studies , Severity of Illness IndexABSTRACT
Antecedentes: La Vasculopatía del injerto (VDI) es la principal causa de muerte tardía del trasplante cardiaco (TX). Un diagnóstico precoz de esta complicación tendría un impacto en la terapia y pronóstico de esta afección. El ultrasonido intracoronario (IVUS), permite un diagnóstico precoz y certero de VDI, pero en la mayoría de los centros aún se utiliza la coronariografía. Objetivo: Evaluar la validez de la coronariografía en el diagnostico de VDI en pacientes trasplantados cardiacos, comparado con el IVUS. Metodología: Estudio transversal, en el cual se analizó una muestra de 36 pacientes con un tiempo promedio de trasplante de 3,7 +/- 3,7 años, a quienes se realizó simultáneamente un examen de coronario-grafía y un IVUS. Se evaluó la reproducibilidad contrastando los resultados de la interpretación visual de la coronariografía versus la coronariografía con análisis cuantitativo. Se calculó la Sensibilidad, Especificidad, Valores predictivos (VPP, VPN), Likelihoods y el coeficiente de equivalencia de Spearman-Brown. Resultados: La coronariografía cualitativa mostró ser más exacta que la cuantitativa, con una sensibilidad 30,4 por ciento [95 por ciento IC= 11,6 - 49,2], una especificidad 92,3 por ciento [95 por ciento IC= 77,8 - 106,7], VPP 87,5 por ciento [95 por ciento IC= 64,5 - 110,4], VPN 42,8 por ciento [95 por ciento IC= 24,5 - 61,1], LR (+) 3,9 [95 por ciento IC 0,55 - 28,7] y un LR (-) 0,75 [95 por ciento IC= 0,55 - 1,03]. La coronariografía cualitativa y cuantitativa son moderadamente equivalentes con un coeficiente de equivalencia Spearman Brown de 0,65. Conclusión: La validez y la reproducibilidad de la coronariografía en el paciente con TX es moderada y debería ser complementada con IVUS para el diagnóstico de VDI.
Background: Graft vasculopathy (GV) is the main cause of late death following cardiac transplantation (TX). Early diagnosis of this condition may have an impact upon treatment and prognosis of this complication. Intravascular ultrasound (IVUS) allows an early and accurate diagnosis of GV. However, most centers continue to use coronary angiography for this purpose. Aim: to evaluate coronary angiography for the diagnosis of GV in relation to IVUS in post TX patients. Methods: In a cross-sectional study the results of coronary angiography and IVUS, used as gold standard, were compared in 36 patients with a mean post TX follow up of 3.7 +/- 3.7 years. Results were compared between visual and quantitative coronary angiography. Sensitivity, specificity, positive and negative predictive values (PPV, NPV), likelihood ratios and the equivalence Spearman-Brown coefficient were calculated. Results: Visual evaluation of coronary angiography was more accurate than quantitative coronary angiography. The sensitivity for GV was 30.4 percent (95 percent C.I. 11.6 - 49.2), specificity 92.3 percent (95 percent C.I. 77.8 - 106.7), PPV 87.5 percent (95 percent C.I. 64.5 - 110.4, NPP 42.8 percent (95 percent C.I. 24.5 - 61.1), likelihood ratio (+) 3.9 (95 percent C.I. 0.55 - 28.7), likelihood ratio (-) 0.75 (95 percent C.I. 0.55 -1.03). The Spearman Brown coefficient between visual and quantitative coronary angiography evaluation was 0.65. Conclusion: Accuracy and reproducibility of coronary angiography in the evaluation of GV is limited. IVUS should be used for better identification of GV.
Subject(s)
Humans , Male , Adolescent , Adult , Female , Middle Aged , Coronary Angiography , Vascular Diseases/diagnosis , Heart Transplantation/adverse effects , Ultrasonography , Cross-Sectional Studies , Vascular Diseases/etiology , Predictive Value of Tests , Reference Standards , Reproducibility of Results , Sensitivity and Specificity , Heart Transplantation/methodsABSTRACT
BACKGROUND: The optimal dose of Streptokinase in the treatment of acute myocardial infarction is not well established. Apparently, the thrombolytic efficacy would not increase with doses over 750,000 units. AIM: To compare the effectiveness and safety of treatment with low doses of Streptokinase, ranging from 500,000 to 750,000 units, in patients with ST elevation acute myocardial infarction. PATIENTS AND METHODS: From September 1993 to September 1998, the GEMI register of patients with acute myocardial infarction, was carried out in 37 hospitals, incorporating 4,938 patients. Of these, 1,631 patients received streptokinase. According to the administered dose of Streptokinase, patients were divided in two groups: 1,465 patients who received 1.5 millions U in 60 minutes (classical therapy group), and 166 patients with ischemic chest discomfort and either ST-segment elevation or left bundle-branch block on the electrocardiogram, who received 500,000 to 750,000 U streptokinase administered in no more than 30 minutes, with heparin, within 0 to 6 hours of symptom onset. Successful reperfusion, mortality, complications, and hospital outcome was evaluated in both groups. RESULTS: The low dose group of patients had a better reperfusion criteria profile. No differences between groups were observed in patient evolution, mortality, maximum Killip classification, post myocardial infarction heart failure, ischemic complications, arrhythmias or mechanical complications. CONCLUSIONS: These results suggest that streptokinase in low doses is at least as effective as classical therapy, in the treatment of ST elevation acute myocardial infarction.
Subject(s)
Fibrinolytic Agents/administration & dosage , Myocardial Infarction/drug therapy , Streptokinase/administration & dosage , Thrombolytic Therapy , Aged , Chi-Square Distribution , Creatine Kinase/blood , Electrocardiography , Female , Fibrinolytic Agents/adverse effects , Heparin/administration & dosage , Heparin/adverse effects , Humans , Male , Middle Aged , Myocardial Infarction/complications , Myocardial Reperfusion , Pain Measurement , Prospective Studies , Risk Factors , Streptokinase/adverse effects , Thrombolytic Therapy/adverse effects , Treatment OutcomeABSTRACT
BACKGROUND: Coronary angioplasty was introduced in Chile in 1982, but only after the introduction of stents it became commonplace. However the results of this procedure at the national level remain largely unknown. AIM: To assess the results and characteristics of coronary angioplasty and develop a national registry in Chile (RENAC). PATIENTS AND METHODS: All centers performing angioplasty were invited to contribute prospectively with the clinical, angiographic, procedural characteristics and results of all consecutive coronary angioplasty procedures attempted between June 2001 and October 2002. RESULTS: In 10 centers, 1768 lesions were treated in 1484 procedures (22.98% in women). Mean age was 60.8 +/- 11.3 years old. Diabetes was found in 21.8%, hypertension in 60.2%, dyslipidemia in 52.0%, active smoking in 40.0%, renal failure in 6.2%. Myocardial infarction was recent in 28.4% and acute in 19.7%. Forty eight percent of patients had unstable angina and 15.5% had stable angina. Fifty three percent of patients had single vessel disease and 71%, normal left ventricular eyection fraction. One vessel was treated in 90.6% of patients and 81.7% of lesions were treated with stents, 17.9% only with baloon and in 0.4% with atherectomy. Angiographic success was obtained in 95.2%. Clinical success was obtained in 92.2%, and 95.1% In patients without acute myocardial infarction. Overall inhospital death was 2.2%. In patients without myocardial infarction, the figure was 1.1%. CONCLUSIONS: Coronary angioplasty in Chile is performed mostly for the treatment of acute coronary syndromes. Stents are the most frequently used devices. The high success, low mortality and complications observed are comparable to North American registries.
Subject(s)
Angioplasty, Balloon, Coronary/statistics & numerical data , Coronary Disease/therapy , Registries , Adult , Aged , Aged, 80 and over , Chile , Female , Humans , Male , Middle Aged , Professional Practice , Prospective Studies , Stents/statistics & numerical dataABSTRACT
La cardiopatía isquémica con el infarto agudo al miocardio (IAM), constituyen la causa directa de muerte en aproximadamente un 8 porciento de la población chilena. Hasta hace algunos años no existía en nuestro país un estudio que abarcara los distintos aspéctos clínicos y epidemiológicos del IMA. Desde 1993, el GEMI ( Grupo de Estudio del IAM) se encarga de reloctar esta información a nivel nacional. El objetivo del presente trabajo es estudiar las distintas variables del estudio GEMI en forma retrospectiva, en pacientes ingresados a nuestro hospital, por un período de 15 meses. Se recolectaron antecedentes clínicos y epidemiológicos de 113 pacientes con diagnóstico de IAM. La edad promedio fue de 62 +/- 11 años, 64,6 porciento hombres y 35,4 porciento mujeres. La frecuencia de uso de los fármacos durante los primeros 5 años fue: aspirina 90,8 porciento, nitratos oral 72,4 porciento, inhibidores de la enzima convertidora de angiotensina (I ECA) 62,4 porciento heparina i.v. 45,9 porciento, nitratos i.v. 22,9 porciento, antiarrítmicos 22,0 porciento beta bloqueadores 21,1 porciento y antag. calcio 13,8 porciento. El 45,1 porciento de los pacientes recibió terapia trombolítica, existiendo reperfusión en el 64,7 porciento de los cuales, la mayoría ingresó antes de las seis horas de iniciado sus síntomas. La asociación de aspirina, beta bloq. e I ECA mostró una baja frecuencia al momento del egreso. La mortalidad intrahospitalaria global fue de 11,5 porciento, pero con grandes diferencias entre ambos sexos: 22,5 porciento en mujeres y 5,0 porciento en hombres. Las variables que resultaron determinantes de mortaliad fueron edad, sexo, diabetes, insuficiencia cardiaca y fibrilación ventricular. En conclusión, los datos muestran que en nuestro hospital se siguen las pautas nacionales e internacionales, con respecto a la terapia intrahospitalaria del IAM. La mayoría de las variables de la población estudiada, concuerdan en líneas generales con los datod obtenidos por otros países occidentales y con datos nacionales
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Myocardial Infarction , Pharmacoepidemiology , Risk Factors , Hospital Mortality , Intensive Care Units , Myocardial Infarction/complications , Myocardial Infarction/etiology , Myocardial Infarction/mortality , Organizational Case Studies , Thrombolytic TherapyABSTRACT
Estudiamos 35 pacientes con E.I. entre Enero de 1980 y Diciembre de 1985; 21 eran hombres y la edad promedio fue de 36,7 años (rango 16 a 70). Se definió E.I. como la presencia de un cuadro febril, con soplo cardíaco orgánico, leucocitosis y/o vegetaciones al ecocardiograma modo M. en ausencia de otro cuadro infeccioso extracardíaco. El promedio entre el comienzo de los síntomas y el diagnóstico fue de 38 días. La cardiopatía reumática fue la enfermedad de base más frecuente (29%), seguida de la endocarditis protésica (23%). En un 23% no se objetivó cardiopatía previa. En el grupo de pacientes reumáticos la válcula aórtica fue la que se compometió con mayor frecuencia (6/8). El 49% de los casos tuvo hemocultivos positivos, con desarrollo de estreptococo viridans en 23%. El ecocardiograma modo M mostró vegetaciones en un 60% de los casos. La complicación más frecuente fue la insuficiencia cardíaca (45%). En la mayoría de los casos el tratamiento fue médico y sólo un 14% requerió cirugia por compromiso hemodinámico severo. La mortalidad de la serie fue 26%. la edad y la presencia de complicaciones, especialmente la insuficiencia cardíaca, fueron determinantes en ella