ABSTRACT
BACKGROUND: Developing countries struggle to diagnose and treat ST-segment elevation myocardial infarction (STEMI) patients in a timely manner, and subsequent outcomes are suboptimal. METHODS: The Latin America Telemedicine Network (LATIN) functioned between 2013 to present in four countries-Brazil, Colombia, Mexico, and Argentina. A Hub and Spoke platform was developed to expand access to >100 million population for STEMI care. Patients were triaged at spokes that included small clinics and primary health care centers in remote South American locations. Three telemedicine command sites provided immediate 24/7 electrocardiogram diagnosis and teleconsultation of the STEMI process at 355 centers in four countries. RESULTS: LATIN Spokes (n = 313) screened up to 30,000 patients per month, and a total of 780,234 patients over the study period. Telemedicine experts diagnosed 8395 (1·1%) with STEMI, of which a total of 3872 (46·1%) were urgently treated at 47 Hubs. A total of 3015 patients (78%) were reperfused with percutaneous coronary intervention. Time-to-telemedicine diagnosis averaged 3·5 min. Average door-to-balloon time improved from 120 to 48 min during the study period and overall STEMI mortality was 5·2%. INTERPRETATION: Telemedicine transcends boundaries and enables access to millions of patients for STEMI care. With this initiative, LATIN has created a template for reducing disparities in STEMI management between developed and developing countries.
Subject(s)
Percutaneous Coronary Intervention , ST Elevation Myocardial Infarction , Telemedicine , Electrocardiography , Humans , ST Elevation Myocardial Infarction/diagnosis , ST Elevation Myocardial Infarction/therapy , Treatment OutcomeABSTRACT
INTRODUÇÃO: A dissecção espontânea de artéria coronária (SCAD do inglês spontaneous coronary artery dissection) é uma causa não aterosclerótica de síndrome coronariana aguda que acomete preferencialmente mulheres jovens. De fisiopatologia ainda não completamente conhecida, pode manifestar-se sob a forma de infarto agudo do miocárdio com (IAMCSST) ou sem (IAMSSST) supradesnivelamento do segmento. A SCAD é a principal causa de infarto agudo do miocárdio no ciclo gravídico-puerperal. A descrição demográfica e angiográfica da SCAD de coorte brasileira é pouco explorada. OBJETIVO: Avaliar o perfil demográfico, angiográfico e os gatilhos de SCAD em uma população brasileira. MATERIAL E MÉTODOS: Estudo retrospectivo e prospectivo de pacientes com SCAD envolvendo 22 Hospitais no Brasil. Revisão de base de dados do REDcap no período de 2010-2021. RESULTADOS: Registraram-se 166 pacientes com SCAD, com idade média de 50,15 ± 10,56 anos (29 a 84 anos) com incidência prevalente no gênero feminino (85%). Os pacientes apresentavam nenhum ou poucos fatores de risco para doença arterial coronariana, incluindo hipertensão arterial (25%), história familiar de doença coronariana precoce (22%), dislipidemia mista (16%) e tabagismo ativo (16%). Seis por cento dos casos de SCAD ocorreram no ciclo gravídico puerperal. A maioria dos casos de SCAD manifestou-se como IAMSSST (47%), com IAMCSST (38%) e angina instável (12%) (Tabela). Entre os fatores desencadeantes, presentes em 57,8% dos casos, destacaram-se: estressor emocional (21,08%) e menopausa (18,07%). A displasia fibromuscular, não investigada sistematicamente, foi observada em poucos casos (4,21%), gestação (0,6%), puerpério (10,24%), estressor físico (5,42%), uso de terapia hormonal (3,60%) e doenças psiquiátricas (2,40%). A artéria descendente anterior foi o vaso mais acometido (57%), seguida pela coronária direita (14,45%). Complicações graves mais frequentes foram choque cardiogênico (3,28%) e parada cardiorrespiratória (0,7%). CONCLUSÃO: Nesta grande coorte brasileira, a SCAD acometeu preferencialmente pacientes jovens e mulheres. A frequência de fatores de risco clássicos para doença arterial coronariana foi pouco comum, sendo o gatilho predominante o estressor emocional. Esta entidade deve ser considerada como diagnóstico diferencial na síndrome coronariana aguda, principalmente em mulheres jovens (< 50 anos).
Subject(s)
Humans , Female , Adult , Middle Aged , Aged , Aged, 80 and over , Acute Coronary Syndrome , Dissection , Psychological DistressABSTRACT
OBJECTIVES: This study used optical coherence tomography to investigate the mechanism of false lumen (FL) formation in spontaneous coronary artery dissection (SCAD) by studying: 1) differences between fenestrated and nonfenestrated SCAD; 2) vasa vasorum density; and 3) light attenuation characteristics of the FL. BACKGROUND: SCAD is an increasingly recognized cause of acute coronary syndromes, characterized by FL formation and compression of the true lumen (TL). The mechanisms underlying FL formation remain poorly understood. METHODS: A total of 65 SCAD patients (68 vessels) who underwent acute OCT imaging as part of routine clinical care were included. Images were classified by the absence or presence of a connection (fenestration) between the TL and FL. Indexed measurements of TL stenosis, external elastic lamina (EEL) area, FL area, and light attenuation of the FL were assessed. Vasa vasorum densities of SCAD cases were compared with those in control non-SCAD myocardial infarction cases. RESULTS: In nonfenestrated cases, there was significantly larger expansion of the EEL area (9.1% vs. -1.9%; p <0.05) and a larger FL area (73.6% vs. 53.2%, respectively; p <0.05) in dissected segments. No significant differences were found between vasa vasorum density in SCAD and those in control subjects. The FL contents were heterogeneous but attenuated less light than whole blood or thrombus (4.28 ± 0.55 mm-1 vs. 5.08 ± 0.56 mm-1; p < 0.05; vs. 4.96 ± 0.56 mm-1; p < 0.05). CONCLUSIONS: These observational data suggest that the absence of a fenestration leads to increased FL pressure and compression of the TL. Although vasa vasorum may still be implicated in pathogenesis, increased vasa vasorum density could be an epiphenomenon of vascular healing.
Subject(s)
Coronary Vessel Anomalies/diagnostic imaging , Coronary Vessels/diagnostic imaging , Tomography, Optical Coherence , Vasa Vasorum/diagnostic imaging , Vascular Diseases/congenital , Adult , Coronary Vessel Anomalies/physiopathology , Coronary Vessel Anomalies/therapy , Coronary Vessels/physiopathology , Europe , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Prognosis , Registries , Retrospective Studies , Vasa Vasorum/physiopathology , Vascular Diseases/diagnostic imaging , Vascular Diseases/physiopathology , Vascular Diseases/therapy , Vascular RemodelingABSTRACT
AIMS: We sought to present a series of 13 pregnancy-associated spontaneous coronary artery dissection (P-SCAD), their angiographic and multimodal imaging findings, acute phase treatment, and outcomes. METHODS AND RESULTS: Between 2005 and 2015, 13 cases of P-SCAD were collected from a database of 11 tertiary hospitals. The mean age was 33.8 ± 3.7 years; most patients had no risk factors for coronary artery disease, and the majority were multiparous. P-SCAD occurred during the puerperium in 12 patients with a median time of 10 days. Only one patient presented with P-SCAD in the 37th week of pregnancy, and she was the only patient who died in this series. Six patients (46%) presented with ST-segment elevation acute myocardial infarction (STEMI), six (46%) presented with non-STEMI, and one presented with unstable angina; one-third of women had cardiogenic shock. In 12 patients, the dissection involved the left anterior descending or circumflex artery, and it extended to the left main coronary artery in 6 patients. Intravascular ultrasound or optical coherence tomography helped to confirm diagnosis and guide treatment in 46% of cases. Seven women were managed clinically; percutaneous coronary intervention was performed in five cases, and coronary artery bypass grafting was performed in one patient. CONCLUSION: In these 13 cases of P-SCAD, clinical presentation commonly included acute myocardial infarction and cardiogenic shock. Multivessel dissections and involvement of the left coronary artery and left main coronary artery were highly prevalent. Clinicians must be aware of angiographic appearances of P-SCAD for prompt diagnosis and management in these high-risk patients.
Subject(s)
Coronary Vessel Anomalies/diagnostic imaging , Coronary Vessel Anomalies/therapy , Multimodal Imaging/methods , Pregnancy Complications, Cardiovascular/diagnostic imaging , Pregnancy Outcome , Vascular Diseases/congenital , Adult , Computed Tomography Angiography/methods , Coronary Angiography/methods , Coronary Vessel Anomalies/mortality , Databases, Factual , Female , Follow-Up Studies , Gestational Age , Hospital Mortality , Humans , Percutaneous Coronary Intervention/methods , Percutaneous Coronary Intervention/mortality , Postpartum Period , Pregnancy , Pregnancy Complications, Cardiovascular/therapy , Retrospective Studies , Risk Assessment , Sampling Studies , Tertiary Care Centers , Ultrasonography, Interventional/methods , Vascular Diseases/diagnostic imaging , Vascular Diseases/mortality , Vascular Diseases/therapyABSTRACT
AIMS: We sought to present a series of 13 pregnancy-associated spontaneous coronary artery dissection (P-SCAD), their angiographic and multimodal imaging findings, acute phase treatment, and outcomes. METHODS AND RESULTS: Between 2005 and 2015, 13 cases of P-SCAD were collected from a database of 11 tertiary hospitals. The mean age was 33.8 ± 3.7 years; most patients had no risk factors for coronary artery disease, and the majority were multiparous. P-SCAD occurred during the puerperium in 12 patients with a median time of 10 days. Only one patient presented with P-SCAD in the 37th week of pregnancy, and she was the only patient who died in this series. Six patients (46%) presented with ST-segment elevation acute myocardial infarction (STEMI), six (46%) presented with non-STEMI, and one presented with unstable angina; one-third of women had cardiogenic shock. In 12 patients, the dissection involved the left anterior descending or circumflex artery, and it extended to the left main coronary artery in 6 patients. Intravascular ultrasound or optical coherence tomography helped to confirm diagnosis and guide treatment in 46% of cases. Seven women were managed clinically; percutaneous coronary intervention was performed in five cases, and coronary artery bypass grafting was performed in one patient...
Subject(s)
Carotid Artery, Internal, Dissection , Myocardial Infarction , Ultrasonography, InterventionalABSTRACT
Major disparities exist between developed and developing countries in the management of acute myocardial infarction (AMI). These pronounced differences result in significantly increased morbidity and mortality from AMI in different regions of the world. Lack of infrastructure, insurance, facilities, and skilled personnel are the major constraints. Primary percutaneous coronary intervention has revolutionized the treatment of AMI; however, its global use is limited by the listed constraints. Telemedicine provides an efficient methodology that can hugely increase access and accuracy of AMI management.
Subject(s)
ST Elevation Myocardial Infarction/therapy , Telemedicine/trends , Developed Countries , Developing Countries , Healthcare Disparities , Humans , Myocardial Infarction , Percutaneous Coronary Intervention , Telemedicine/methodsABSTRACT
O ultrassom intracoronário (USIC) é o método adjunto mais utilizado na Cardiologia Intervencionista, e sua análise depende de normas para a aquisição, mensuração e interpretação das imagens. Ao associar a caracterização tecidual, o artefato causado pelo fio-guia pode hiperestimaro porcentual de núcleo necrótico em determinadas lesões, levando à classificação equivocada defibroateroma. Descrevemos os efeitos quantitativos e na análise tecidual resultantes da subtração do efeitodo artefato do fio-guia nas lesões ateroscleróticas em pacientes com síndrome coronária aguda. Métodos: Foram avaliados 21 pacientes com infarto do miocárdio pós-trombólise com USIC em escala de cinzas e com a tecnologia iMAP®, totalizando 76 lesões.Resultados: O USIC em escala de cinzas mostrou que as lesões tinham extensão média de 21,01 ± 18,03 mm e apresentavam elevada carga de placa (52,07 ± 7,56%). A análise pelo iMAP® demonstrou que, após a subtração do artefato do fio-guia, houve redução de todos os componentes teciduais (necrótico, calcífico, lipídico e fibrótico), porém de maneira mais acentuada do núcleo necrótico (diferença média de 3,59%). Além disso, após a subtração do artefato, 12,4% das lesões que inicialmente apresentavam núcleo necrótico ≥ 10% passaram a não ser mais classificadas como fibroateroma.Conclusões: A análise da placa de ateroma pela tecnologia iMAP® mostrou que o artefato do fio-guia superestimou o componente tecidual do núcleo necrótico. Essa interferência pode mudar errônea e categoricamente as características fenotípicas de lesões mais benignas e estáveis (fibróticas) para lesões potencialmente instáveis, como os fibroateromas, na relação de um em cada dez pacientes...
Intravascular ultrasound (IVUS) is the most widely used ancillary method in Interventional Cardiology, and its analysis depends on standards for acquisition, measurement and interpretation of the images. By associating tissue characterization, the artifact caused by the guidewire may overestimate the percentage of necrotic core in certain lesions, leading to misclassification of fibroatheroma. In this paper we described quantitative and tissue analysis effects resulting from subtracting the effect of guidewire artifact on atherosclerotic lesions in patients with acute coronary syndrome. Methods: Twenty-one patients with post-thrombolysis myocardial infarction were evaluated with grayscale IVUS and iMAPTM technology, totaling 76 lesions. Results: Grayscale IVUS showed that the lesions had a mean length of 21.01 ± 18.03 mm and revealed highplaque burden (52.07 ± 7.56%). The analysis by iMAPTM demonstrated that, after subtracting the guidewire artifact, there was a reduction of all tissue (necrotic, calcific, lipid and fibrotic) components, but more markedly in necrotic core (mean difference: 3.59%). In addition, after artifact subtraction 12.4% of the lesions that initially exhibited a necrotic core ≥ 10% ceased to be classified as fibroatheroma.Conclusions: An atheroma analysis by iMAPTM technology showed that the guidewire artifact over estimated the tissue component of the necrotic core. This interference may change, in an erroneous and categoric alway, the phenotypic characteristics of more stable and benign (fibrotic) lesions to potentially unstable lesions, for example, fibroatheromas, in a ratio of one out of ten patients...
Subject(s)
Humans , Male , Female , Evaluation Studies as Topic/methods , Patients , Drug Therapy , Acute Coronary Syndrome/therapy , Ultrasonography/methods , Coronary Angiography/methods , Data Interpretation, Statistical , Risk Factors , Myocardial Infarction/therapy , Plaque, Atherosclerotic/diagnosis , Plaque, Atherosclerotic/therapy , Thrombolytic Therapy/methodsABSTRACT
Coronary pseudoaneurysms are an unusual finding during coronary angiography and there are very little data on their prognosis in the literature. We report the case of a 62-year-old man admitted with an anterior myocardial infarction who developed a pseudoaneurysm in the mid left anterior descending artery some days after a type I coronary perforation during coronary angioplasty. Spontaneous closure of the pseudoaneurysm was observed during hospital follow-up. Spontaneous closure of coronary pseudoaneurysms may be more common in clinical practice than previously thought, but few cases have been reported. As the natural history of post-intervention coronary pseudoaneurysms has been little investigated, reports of their occurrence may help to clarify their evolution.
Subject(s)
Aneurysm, False , Coronary Aneurysm , Aneurysm, False/etiology , Coronary Aneurysm/etiology , Coronary Vessels/injuries , Humans , Male , Middle Aged , Remission, SpontaneousABSTRACT
We read with great interest the case by Sengottuveluand Rajendran (1), published in the Journal regardingvascular scaffolds for spontaneous coronary arterydissection (SCAD). A SCAD is an uncommon cause ofacute myocardial infarction and has an incidence of0.1% to 1.1% of all acute coronary syndromes (2,3). Inaddition to the rarity of this condition, SCAD is alsounderdiagnosed or misdiagnosed because of the lowspatial resolution of angiography along with the lackof physician familiarity with its angiographic variants.
Subject(s)
Angiography , Myocardial Infarction , Acute Coronary SyndromeABSTRACT
Os autores apresentam a experiência inicial do uso de dispositivo mecânico de reanimação AutoPulse®. O dispositivo foi utilizado em caso de parada cardiorrespiratória em sala dehemodinâmica, permitindo a continuidade do procedimentopercutâneo concomitantemente à ressuscitação cardiopulmonar. O dispositivo proporcionou compressões torácicas ininterruptas e efetivas, bem como liberou um médico da equipe paraoutras funções durante o procedimento. Houve dificuldades quanto à rapidez na instalação do dispositivo no momento daemergência e em relação à radiopacidade dos componenteseletrônicos, que impediram algumas projeções angiográficas.O uso de dispositivos mecânicos de compressões torácicasdurante parada cardiorrespiratória é factível, porém ainda nãohá comprovação de seus benefícios em relação à ressuscitaçãocardiopulmonar com compressões manuais.
Subject(s)
Humans , Male , Aged , Angioplasty/methods , Angioplasty , Heart Arrest/complications , Cardiopulmonary Resuscitation/methods , Cardiopulmonary Resuscitation , Electrocardiography/methods , ElectrocardiographyABSTRACT
Pneumomediastino é uma complicação rara e potencialmente fatal, podendo ocorrer após a realização de procedimentos dentários. Relatamos um caso de enfisema subcutâneo agudo após tratamento de canal e uso de compressor de ar. O diagnóstico precoce dessa complicação e a administração imediata de antibióticos profiláticos são de suma importância para reduzir a mortalidade associada a esse quadro.
