Metrics of care and cardiovascular outcomes in patients with ST-elevation myocardial infarction treated with pharmacoinvasive strategy: a decade-long network in a populous city in Brazil.

BACKGROUND: Pharmacoinvasive strategy is an effective myocardial reperfusion therapy when primary percutaneous coronary intervention (p-PCI) cannot be performed in a timely manner. METHODS: Authors sought to evaluate metrics of care and cardiovascular outcomes in a decade-long registry of a pharmacoinvasive strategy network for the treatment of ST-elevation myocardial infarction (STEMI). Data from a local network including patients undergoing fibrinolysis in county hospitals and systematically transferred to the tertiary center were accessed from March 2010 to September 2020. Numerical variables were described as median and interquartile range. Area under the curve (AUC-ROC) was used to analyze the predictive value of TIMI and GRACE scores for in-hospital mortality. RESULTS: A total of 2,710 consecutive STEMI patients aged 59 [51-66] years, 815 women (30.1%) and 837 individuals with diabetes (30.9%) were analyzed. The time from symptom onset to first-medical-contact was 120 [60-210] minutes and the door-to-needle time was 70 [43-115] minutes. Rescue-PCI was required in 929 patients (34.3%), in whom the fibrinolytic-catheterization time was 7.2 [4.9-11.8] hours, compared to 15.7 [6.8-22,7] hours in those who had successful lytic reperfusion. All cause in-hospital mortality occurred in 151 (5.6%) patients, reinfarction in 47 (1.7%) and ischemic stroke in 33 (1.2%). Major bleeding occurred in 73 (2.7%) patients, including 19 (0.7%) cases of intracranial bleeding. C-statistic confirmed that both scores had high predictive values for in-hospital mortality, demonstrated by TIMI AUC-ROC of 0.80 [0,77-0.84] and GRACE AUC-ROC of 0.86 [0.83-0.89]. CONCLUSION: In a real world registry of a decade-long network for the treatment of ST-elevation myocardial infarction based on the pharmacoinvasive strategy, low rates of in-hospital mortality and cardiovascular outcomes were observed, despite prolonged time metrics for both fibrinolytic therapy and rescue-PCI. Register Clinicaltrials.gov NCT02090712 date of first registration 18/03/2014.

Preditores de Mortalidade Hospitalar nos Pacientes Tratados por Angioplastia Primária: Um Estudo de Caso-Controle Multicêntrico / Predictors of Hospital Mortality Based on Primary Angioplasty Treatment: A Multicenter Case-Control Study

Resumo Fundamento A estratificação do risco de morte dos pacientes no contexto da angioplastia primária (ATC) é fundamental. Objetivo Identificar os fatores relacionados ao desfecho morte em pacientes submetidos a ATC. Métodos Estudo de caso-controle, utilizando como fonte de dados um registro brasileiro. A associação entre cada variável e o desfecho óbito foi avaliada via modelo de regressão logística binária. Consideramos significativo p<0,05. Resultados Foram analisados 26.990 registros, sendo 18.834 (69,8%) do sexo masculino, com idade mediana de 61 (17) anos. Na análise multivariada, as principais variáveis relacionadas ao desfecho óbito com seus respectivos odds ratio e intervalos de confiança (IC) com nível de significância de 95% foram a idade avançada 70 - 79 anos (2,46; 1,64 - 3,79) e ≥ 80 anos (3,68; 2,38 - 5,81), p<0,001, classificação de Killip II (2,71; 1,92 - 3,83), Killip III (8,14; 5,67 - 11,64), Killip IV (19,83; 14,85 - 26,69), p<0,001, disfunção global acentuada do ventrículo esquerdo (VE) (3,63; 2,39 - 5,68), p<0,001 e ocorrência de infarto após a intervenção (5,01; 2,57- 9,46), p<0,001. O principal fator protetor foi o fluxo TIMI III pós-intervenção (0,18; 0,13 - 0,24), p<0,001, seguido do TIMI II (0,59; 0,41 - 0,86), p=0,005, sexo masculino (0,79; 0,64 - 0,98), p= 0,032, dislipidemia (0,69; 0,59 - 0,85), p<0,001 e número de lesões tratadas (0,86; 0,9 - 0,94), p<0,001. Conclusão Os preditores de mortalidade nos pacientes submetidos a ATC foram: classificação de Killip, reinfarto, idade, disfunção global acentuada do VE, sexo feminino e fluxo TIMI 0/I pós-intervenção.

Abstract Background Identification of high-risk patients undergoing primary angioplasty (PCI) is essential. Objective Identify factors related to the causes of death in PCI patients. Methods This work consisted of a multicenter case-control study using a Brazilian registry of cardiovascular interventions as the data source. The association between each variable and death was assessed using a binary logistic regression model, p <0.05 was considered significant. Results A total of 26,990 records were analyzed, of which 18,834 (69.8%) were male patients, with a median age of 61 (±17) years. In the multivariate analysis, the main variables related to the causes of death with their respective odds ratios and 95%confidence intervals (CI) were advanced age, 70-79 years (2.46; 1.64-3.79) and ≥ 80 years (3.69; 2.38-5.81), p<0.001; the classification of Killip II (2.71; 1.92-3.83), Killip III (8.14; 5.67-11.64), and Killip IV (19.83; 14.85-26.69), p<0.001; accentuated global dysfunction (3.63; 2,39-5.68), p<0.001; and the occurrence of infarction after intervention (5.01; 2.57-9.46), p<0.001. The main protective factor was the post-intervention thrombolysis in myocardial infarction (TIMI) III flow (0.18; 0.13-0.24), p<0.001, followed by TIMI II (0.59; 0.41 -0.86), p=0.005, and male (0.79; 0.64-0.98), p = 0.032; dyslipidemia (0.69; 0.59-0.85), p<0.001; and number of lesions treated (0.86; 0.9-0.94), p<0.001. Conclusion The predictors of mortality in patients undergoing PCI were Killip's classification, reinfarction, advanced age, severe left ventricular dysfunction, female gender, and post-intervention TIMI 0 / I flow.

Reperfusion Strategies in Acute Myocardial Infarction: State of the Art

Abstract ST elevation myocardial infarction (STEMI) is a highly prevalent condition worldwide. Reperfusion therapy is strongly associated with the prognosis of STEMI and must be performed with a high standard of quality and without delay. A systematic review of different reperfusion strategies for STEMI was conducted, including randomized controlled trials that included major cardiovascular events (MACE), and systematic reviews in the last 5 years through the PRISMA ( Preferred Reporting Items for Systematic Reviews and Meta-Analysis) methodology. The research was done in the PubMed and Cochrane Central Register of Controlled Trials databases, in addition to a few manual searches. After the exclusion criteria were applied, 90 articles were selected for this review. Despite the reestablishment of IRA patency in PCI for STEMI, microvascular lesions occur in a significant proportion of these patients, which can compromise ventricular function and clinical course. Several therapeutic strategies - intracoronary administration of nicorandil, nitrates, melatonin, antioxidant drugs (quercetin, glutathione), anti-inflammatory substances (tocilizumab [an inhibitor of interleukin 6], inclacumab, P-selectin inhibitor), immunosuppressants (cyclosporine), erythropoietin and ischemic pre- and post-conditioning and stem cell therapy - have been tested to reduce reperfusion injury, ventricular remodeling and serious cardiovascular events, with heterogeneous results: These therapies need confirmation in larger studies to be implemented in clinical practice

[Vexillology on the electrocardiogram. South Africa´s flag sign]. / Vexilología en el electrocardiograma. Signo de la bandera de Sudáfrica.

The electrocardiogram (ECG) is a test that will allow making life-saving decisions. It has different patterns, and differential diagnoses, like the pattern of acute coronary syndrome with an elevation of the high lateral ST segment, which is called the sign of the flag of South Africa. We present the case of a 44-year-old patient presented with typical chest pain; the ECG showed ST-segment elevation in the DI, DII, AVL - V2, and ST depression in DIII, corresponding to an acute coronary occlusion with a compromise of the lateral segment of the heart. This ECG pattern is known as the flag sign of South Africa. The early recognition allowed the decision to perform immediately pharmacological reperfusion therapy and rescue angioplasty.

O Pré-Condicionamento com Dexmedetomidina Reduz a Lesão de Isquemia-Reperfusão do Miocárdio em Ratos, Inibindo a Via PERK / Dexmedetomidine Preconditioning Reduces Myocardial Ischemia-Reperfusion Injury in Rats by Inhibiting the PERK Pathway

Resumo Fundamento A cardiopatia isquêmica atraiu muito atenção devido às altas taxas de mortalidade, custos do tratamento e a crescente morbidade na população jovem. Estratégias de reperfusão reduziram a mortalidade. Porém, a reperfusão pode levar à morte do cardiomiócito e subsequente dano irreversível ao miocárdio. No momento, não há um tratamento eficiente e direcionado para a lesão de isquemia-reperfusão (I/R). Objetivos Avaliar se a dexmedetomidina (DEX) tem efeito protetivo na I/R do miocárdio e explorar os possíveis mecanismos por trás dela. Métodos Corações de ratos foram perfundidos com o sistema de perfusão de Langendorff e aleatoriamente distribuídos em cinco grupos: grupo controle, perfundido com solução de Krebs-Henseleit (K-H) por 205 minutos sem isquemia; e quatro grupos de teste que foram submetidos a 40 minutos de isquemia global e 120 minutos de reperfusão. O Grupo DEX, o grupo ioimbina (IO) e o grupo DEX + IO foram perfundidos com DEX (10 nM), IO (1 μM) ou a combinação de DEX e IO antes da reperfusão, respectivamente. A hemodinâmica cardíaca, o tamanho do infarto do miocárdio e a histologia do miocárdio foram avaliados. A expressão da proteína-78 regulada pela glicose (GRP78), a proteína quinase do retículo endoplasmático (PERK), a PERK fosforilada, o fator de iniciação eucariótico 2α (eIF2α), eIF2α fosforilado, o fator de transcrição 4 (TCF-4) e a proteína homóloga à proteína ligadora do acentuador CCAAT (CHOP) foram avaliados. P< 0,05 foi considerado para indicar a diferença estatisticamente significativa. Resultados O pré-condicionamento com DEX melhorou a função cardíaca nos corações com I/R, reduziu o infarto do miocárdio, a apoptose do miocárdio e a expressão de GRP78, p-PERK, eIF2α, p-eIF2α, TCF-4 e CHOP. Conclusões O pré-tratamento com DEX reduziu a lesão de I/R no miocárdio ao suprimir a apoptose, o que foi induzido pela via PERK.

Abstract Background Ischemic heart disease has attracted much attention due to its high mortality rates, treatment costs and the increasing morbidity in the young population. Strategies for reperfusion have reduced mortality. However, reperfusion can lead to cardiomyocyte death and subsequent irreversible myocardial damage. At present, the timely and targeted treatment of ischemia-reperfusion (I/R) injury is often lacking. Objectives To evaluate if dexmedetomidine (DEX) has a protective effect in myocardiual I/R and explore the possible mechanism behind it. Methods Rat hearts were perfused with a Langendorff perfusion system, and randomly assigned to five groups: control group, perfused with Krebs-Henseleit (K-H) solution for 205 minutes without ischemia; and four test groups that underwent 40 minutes of global ischemia and 120 min of reperfusion. The DEX group, the yohimbine (YOH) group and the DEX + YOH group were perfused with DEX (10 nM), YOH (1 μM) or the combination of DEX and YOH prior to reperfusion, respectively. Cardiac hemodynamics, myocardial infarct size, and myocardial histology were evaluated. The expression of glucose-related protein 78 (GRP78), protein kinase R-like ER kinase (PERK), phosphorylated PERK, eukaryotic initiation factor 2α (eIF2α), phosphorylated eIF2α, activating transcription factor 4 (ATF4), and CCAAT/enhancer-binding protein homologous protein (CHOP) were assessed. P<0.05 was considered to indicate a statistically significant difference. Results DEX preconditioning improved the cardiac function of I/R hearts, reduced myocardial infarction, myocardial apoptosis, and the expression of GRP78, p-PERK, eIF2α, p-eIF2α, ATF4 and CHOP. Conclusions DEX pretreatment reduced myocardial I/R injury by suppressing apoptosis, which was induced by the PERK pathway.

Influência da localização geográfica no acesso às terapias de reperfusão e mortalidade de pacientes com IAMcSST em Sergipe: registro VICTIM / Influence of geographical location on access to reperfusion therapies and mortality of patients with STEMI in Sergipe: VICTIM register

Resumo Fundamento A concentração de serviços de alta complexidade em Aracaju/SE pode proporcionar disparidade na qualidade assistencial para os pacientes do SUS com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMcSST) cujos sintomas se iniciaram em outras regiões de saúde do estado. Objetivo Avaliar disparidades no acesso às terapias de reperfusão e mortalidade em 30 dias, entre pacientes com IAMcSST, usuários do SUS, em cada uma das 7 regiões de saúde em Sergipe. Métodos Foram avaliados 844 pacientes com IAMcSST no período de 2014 a 2018 atendidos pelo único hospital com capacidade de ofertar intervenção coronariana percutânea (ICP) primária para usuários do SUS no estado de Sergipe. Os pacientes foram divididos em 7 grupos de acordo com o local de início dos sintomas e obedecendo a divisão já existente das regiões de saúde do Estado. Para comparação entre grupos, foi considerada diferença significativa quando p < 0,05. Resultados Do total de 844 pacientes vítimas de IAMcSST e transferidos ao hospital com ICP que atende pacientes do SUS, 386 pacientes (45,8%) realizaram angioplastia primária. A taxa média do uso de fibrinolítico foi de 2,6%, não havendo diferenças entre as regiões. O tempo médio total de chegada ao hospital com ICP foi de 21h55' com mediana de 10h22' (6h30' - 22h52'). A mortalidade total em 30 dias foi 12,8%, mas sem diferenças entre as regiões, mesmo quando ajustada para idade e sexo. Conclusões Este estudo revela que os fibrinolíticos são subutilizados em todo o estado e que existe um atraso significativo no acesso ao hospital com ICP, em todas as regiões de saúde de Sergipe.

Abstract Background The concentration of high-complexity services in Aracaju, Sergipe can impose certain disparity in the quality of care for the patients with ST-segment elevation acute myocardial infarction (STEMI) (STEMI) who receive care from Brazil's Unified Health System (SUS, acronym in Portuguese) and whose symptoms started in other health regions of the state. Objective To evaluate disparities in access to reperfusion therapies and 30-day mortality, among patients with STEMI, who were users of SUS, in each of the 7 health regions of Sergipe. Methods A total of 844 patients with STEMI in the period from 2014 to 2018, assisted by the only hospital with the capacity to offer primary percutaneous coronary intervention (PPCI) to SUS users in the state of Sergipe, were evaluated. The patients were divided into 7 groups according to the location at the onset of symptoms, following the existing division of health regions in the state. For comparison between groups, a significant difference was considered when p < 0.05. Results Of the total of 844 patients suffering from STEMI who were transferred to the hospital with PPCI that serves SUS patients, 386 patients (45.8%) underwent primary angioplasty. The mean rate of fibrinolytic use was 2.6%, with no differences between the regions. The mean total time of arrival to the hospital with PPCI was 21 hours and 55 minutes, with a median of 10 hours and 22 minutes (6 hours and 30 minutes to 22 hours and 52 minutes). Total 30-day mortality was 12.8%, but without differences between the regions, even when adjusted for age and sex. Conclusions This study reveals that fibrinolytics are underused throughout the state and that there is a significant delay in access to the hospital with PPCI, in all health regions of Sergipe.

Acurácia da redução do segmento-ST pós-trombólise como preditor de reperfusão adequada em estratégia fármaco-invasiva / Accuracy of post-thrombolysis ST-segment reduction as an adequate reperfusion predictor in the pharmaco-invasive aproach

Resumo Fundamento A intervenção coronária percutânea primária é considerada o "padrão-ouro" para reperfusão coronária. Entretanto, quando não disponível, a estratégia fármaco-invasiva é método alternativo, e o eletrocardiograma (ECG) tem sido utilizado para identificar sucesso na reperfusão. Objetivos Nosso estudo teve como objetivo examinar alterações no segmento-ST pós-lise e seu poder de prever a recanalização, usando os escores angiográficos TIMI e blush miocárdio (MBG) como critério de reperfusão ideal. Métodos Foram estudados 2.215 pacientes com infarto agudo do miocárdio com supra-ST submetidos à fibrinólise [(Tenecteplase)-TNK] e encaminhados para angiografia coronária em até 24 h pós-fibrinólise ou imediatamente encaminhados à terapia de resgate. O ECG foi realizado pré-TNK e 60 min-pós. Os pacientes foram categorizados em dois grupos: aqueles com reperfusão ideal (TIMI-3 e MBG-3) e aqueles com reperfusão inadequada (fluxo TIMI <3). Foi definido o critério de reperfusão do ECG pela redução do segmento ST >50%. Consideramos p-valor <0,05 para as análises, com testes bicaudais. Resultados O critério de reperfusão pelo ECG apresentou valor preditivo positivo de 56%; valor preditivo negativo de 66%; sensibilidade de 79%; e especificidade de 40%. Houve fraca correlação positiva entre a redução do segmento-ST e os dados angiográficos de reperfusão ideal (r = 0,21; p <0,001) e baixa precisão diagnóstica, com AUC de 0,60 (IC-95%; 0,57-0,62). Conclusão Em nossos resultados, a redução do segmento-ST não conseguiu identificar com precisão os pacientes com reperfusão angiográfica apropriada. Portanto, mesmo pacientes com reperfusão aparentemente bem-sucedida devem ser encaminhados à angiografia brevemente, a fim de garantir fluxo coronário macro e microvascular adequados.

Abstract Background Primary percutaneous coronary intervention is considered the "gold standard" for coronary reperfusion. However, when not available, the drug-invasive strategy is an alternative method and the electrocardiogram (ECG) has been used to identify reperfusion success. Objectives Our study aimed to assess ST-Segment changes in post-thrombolysis and their power to predict recanalization and using the angiographic scores TIMI-flow and Myocardial Blush Grade (MBG) as an ideal reperfusion criterion. Methods 2,215 patients with ST-Segment Elevation Myocardial Infarction (STEMI) undergoing fibrinolysis [(Tenecteplase)-TNK] and referred to coronary angiography within 24 h post-fibrinolysis or immediately referred to rescue therapy were studied. The ECG was performed pre- and 60 min-post-TNK. The patients were categorized into 2 groups: those with ideal reperfusion (TIMI-3 and MBG-3) and those with inadequate reperfusion (TIMI and MBG <3). The ECG reperfusion criterion was defined by the reduction of the ST-Segment >50%. A p-value <0.05 was considered for the analyses, with bicaudal tests. Results The ECG reperfusion criterion showed a positive predictive value of 56%; negative predictive value of 66%; sensitivity of 79%; and specificity of 40%. There was a weak positive correlation between ST-Segment reduction and ideal reperfusion angiographic data (r = 0.21; p <0.001) and low diagnostic accuracy, with an AUC of 0.60 (95%CI: 0.57-0.62). Conclusion The ST-Segment reduction was not able to accurately identify patients with adequate angiographic reperfusion. Therefore, even patients with apparently successful reperfusion should be referred to angiography soon, to ensure adequate macro and microvascular coronary flow.

Intervenção Coronariana Percutânea em Lesões não Protegidas de Tronco / Percutaneous Coronary Intervention in Unprotected Left Main Coronary Artery Lesions

Resumo Fundamento O advento dos stents farmacológicos permitiu que a intervenção coronariana percutânea apresentasse resultados seguros nas lesões de tronco da artéria coronária esquerda. Objetivos Analisar os resultados do tratamento percutâneo da lesão não protegida de tronco da artéria coronária com a utilização de ultrassom intravascular. Métodos Estudo de série de casos consecutivos realizado no período de janeiro de 2010 a dezembro de 2018. Coletaram-se dados clínicos dos pacientes, assim como escores prognósticos e dados da lesão coronariana. Considerou-se de sucesso a lesão residual menor que 50% à angiografia e a área mínima da luz maior que 6 mm 2 ao ultrassom intravascular. O nível de significância adotado foi de 5%. Resultados Analisaram-se 107 casos. A lesão multiarterial foi predominante, sendo com maior frequência (39,25%) encontradas lesões em três vasos além do tronco coronariano. O escore SYNTAX apresentou média de 46,80 (DP: 22,95), e 70 (65,42%) pacientes tiveram escore SYNTAX acima de 32 pontos. Considerou-se sucesso angiográfico da intervenção percutânea em 106 (99,06%) pacientes. A taxa geral de evento maior cardíaco e cerebrovascular no desfecho hospitalar foi 6,54%, sendo semelhante nos pacientes com escore SYNTAX ≤ 32 (8,10%) e ≥ 33 (5,71%; p = 0,68) . Conclusões A intervenção percutânea em casos de lesão não protegida de tronco coronariano foi realizada com segurança e apresentou ótimos resultados. Atingiu-se alto sucesso angiográfico de tratamento guiado pelo ultrassom intravascular. A taxa de eventos cardíacos e cerebrovasculares maiores foi semelhante entre os pacientes de menor e de maior risco.

Abstract Background The advent of drug-eluting stents allowed the percutaneous coronary intervention to present safe results in lesions in the left main coronary artery. Objectives To analyze the results of the percutaneous treatment of unprotected left main coronary artery lesion with the use of intravascular ultrasound. Methods Study of consecutive case series carried out from January 2010 to December 2018. Clinical data were collected from patients as well as prognostic scores and data on coronary lesion. Low-grade residual lesion (less than 50%) on angiography and minimum luminal area greater than 6 mm2on intravascular ultrasound were considered successful. The adopted significance level was 5%. Results 107 cases were analyzed. The multivessel lesion was predominant, with most (39.25%) of the lesions being found in three vessels in addition to the left main coronary artery. The SYNTAX score had a mean of 46.80 (SD: 22.95), and 70 (65.42%) patients had a SYNTAX score above 32 points. Angiographic success of percutaneous intervention was considered in 106 (99.06%) patients. The overall rate of major cardiac and cerebrovascular events in the hospital outcome was 6.54%, being similar in patients with SYNTAX score ≤ 32 (8.10%) and ≥ 33 (5.71%; p = 0.68). Conclusions Percutaneous intervention in cases of unprotected left main coronary artery lesion was safely performed and presented excellent results. Considerable angiographic success of treatment guided by intravascular ultrasound was achieved. The rate of major cardiac and cerebrovascular events was similar between patients at low and high risks.

Acesso à Terapia de Reperfusão e Mortalidade em Mulheres com Infarto Agudo do Miocárdio com Supradesnivelamento do Segmento ST: Registro VICTIM / Access to Reperfusion Therapy and Mortality in Women with ST-Segment-Elevation Myocardial Infarction: VICTIM Register

Resumo Fundamento: A reperfusão miocárdica é parte fundamental do tratamento para infarto agudo do miocárdio com supradesnivelamento de ST (IAMCSST) e é responsável por reduzir morbimortalidade no paciente acometido. No entanto, as taxas de reperfusão são geralmente mais baixas e as taxas de mortalidade mais altas em mulheres que em homens. Objetivos: Avaliar a prevalência do uso de terapias de reperfusão em mulheres e homens com IAMCSST nos hospitais com capacidade para realizar intervenção coronariana percutânea (ICP) no estado de Sergipe. Métodos: Trata-se de estudo transversal que utilizou dados do Registro VICTIM. Foram avaliados pacientes com diagnóstico de IAMCSST admitidos nos quatro hospitais com capacidade para realizar ICP no estado de Sergipe, sendo um público e três privados, no período de dezembro de 2014 a junho de 2018. Foi aplicada análise multivariada com modelo ajustado utilizando mortalidade como variável dependente. Em todas as análises, o nível de significância adotado foi de 5% (p<0,05). Resultados: Foram incluídos 878 voluntários com diagnóstico confirmado de IAMCSST, dos quais 33,4% eram mulheres. Apenas 53,3% dos pacientes foram submetidos à reperfusão miocárdica (134 mulheres versus 334 homens). A fibrinólise foi realizada somente em 2,3% de todos os pacientes (1,7% das mulheres versus 2,6% dos homens; p=0,422). Nas mulheres, a taxa de ICP primária foi menor (44% versus 54,5%; p=0,003) e a mortalidade hospitalar foi maior (16,1% versus 6,7%; p<0,001) que nos homens. Conclusão: As mulheres apresentam taxas significativamente menores de ICP primária e significativamente maiores de mortalidade hospitalar que os homens. A taxa de reperfusão em ambos os gêneros foi baixa e houve nítida subutilização de agentes trombolíticos.

Abstract Background: Myocardial reperfusion is a fundamental part of the treatment for ST elevation myocardial infarction (STEMI) and is responsible for reducing morbidity and mortality in affected patients. However, reperfusion rates are usually lower and mortality rates higher in women compared to men. Objectives: To evaluate the prevalence of the use of reperfusion therapies among women and men with STEMI in hospitals where percutaneous coronary intervention (PCI) is available in the state of Sergipe. Methods: This is a cross-sectional study that used data from the VICTIM Register. Patients diagnosed with STEMI admitted to the four hospitals (one public and three private) where PCI is available in the state of Sergipe were evaluated, from December 2014 to June 2018. A multivariate analysis with adjusted model using mortality as a dependent variable was made. In all analyses, the level of significance adopted was 5% (p < 0.05). Results: A total of 878 volunteers with a confirmed diagnosis of STEMI, of which 33.4% were women, were included in the study. Only 53.3% of the patients underwent myocardial reperfusion (134 women versus 334 men). Fibrinolysis was performed only in 2.3% of all patients (1.7% of women versus 2.6% of men; p = 0.422). The rate of primary PCI was lower (44% versus 54.5%; p = 0.003) and hospital mortality was higher (16.1% versus 6.7%; p < 0.001) in women than in men. Conclusion: Women have significantly lower rates of primary PCI and higher hospital mortality. Reperfusion rates were low in both sexes and there was a clear underutilization of thrombolytic agents.

[Atypical presentation of the Wellens electrocardiographic pattern associated with coronary bifurcation lesión]. / Presentación atípica del patrón electrocardiográfico de Wellens asociado con lesión de bifurcación coronaria.

We present a patient who was admitted to the emergency room due to unstable angina, with an initial electrocardiogram without signs of acute ischemia and a favorable clinical evolution. During hospitalization, she developed the Wellens electrocardiographic pattern, noted in the literature as an infrequent, poorly identified finding and with an ominous prognosis. This electrocardiographic pattern is described in precordial derivatives, suggesting a significant lesion of a principal epicardial artery; our patient had similar electrocardiographic alterations in the high lateral leads, in whom the coronary bifurcation lesion not previously described in this scenario was confirmed.

[Impact of the COVID-19 pandemic on ST - elevation myocardial infarction management in a reference center of northern Peru]. / Impacto de la pandemia COVID-19 en el abordaje del infarto de miocardio con elevación del segmento ST en un centro de referencia del norte del Perú.

Objective: To evaluate the impact of the COVID-19 pandemic on the ST-Elevation myocardial infarction (STEMI) management in a reference center of northern Peru. Methods: Observational, analytical, retrospective cohort-type study, derivated from the Acute Coronary Syndrome registry of the Almanzor Aguinaga Asenjo National Hospital. The characteristics of the patients with STEMI and their 30-day outcomes were compared in 02 cohorts according to the time of medical care: prior to the pandemic or during the pandemic. Results: During the COVID-19 pandemic, hospitalizations for STEMI decreased by 53%, there was a greater use of fibrinolysis to the detriment of primary angioplasty, with increases in the time of first medical contact (100 vs. 240 minutes, p = 0.006) and ischemic time to percutaneous coronary intervention (900 vs. 2880 minutes, p <0.001). This generated a higher frequency of post-infarction heart failure (21.1% vs. 46.7%, p = 0.002) and a lower left ventricular ejection fraction at discharge (49.2 +/- 8.6 vs 44.8 +/- 9.3, p = 0.009), without an increase in in-hospital cardiovascular mortality. Conclusions: The COVID-19 has had a negative impact on the treatment of patients with STEMI. We found less hospitalizations, prolonged reperfusion times, and higher frequency of post-infarction heart failure and lower left ventricular ejection fraction at discharge.

Cardioprotective effects of pharmacological blockade of the mitochondrial calcium uniporter on myocardial ischemia-reperfusion injury

Purpose To evaluate whether the attenuation of mitochondrial Ca2+ overload produced by pharmacological blockade of mitochondrial Ca2+ uniporter (MCU) protects the myocardium against injuries caused by cardiac ischemia and reperfusion (CIR). Methods CIR was induced in adult male Wistar rats (300-350 g) by occlusion of the left anterior descendent coronary artery (10 min), followed by reperfusion (120 min). Rats were treated with different doses of MCU blocker ruthenium red (RuR), administered 5 min before ischemia or reperfusion. Results In untreated rats, the incidences of ventricular arrhythmias (VA), atrioventricular block (AVB) and the lethality (LET) induced by CIR were 85%, 79% and 70%, respectively. In rats treated with RuR before ischemia, the incidences of VA, AVB and LET were significantly reduced to 62%, 25% and 25%, respectively. In rats treated with RuR after ischemia, the incidences of VA, AVB and LET were significantly reduced to 50%, 25% and 25%, respectively. Conclusion The significant reduction of the incidence of CIR-induced VA, AVB and LET produced by the treatment with RuR indicates that the attenuation of mitochondrial Ca2+ overload produced by pharmacological blockade of MCU can protect the myocardium against injuries caused by CIR.(AU)