Competências do enfermeiro no cuidado a pacientes com acidente vascular cerebral elegíveis à terapia trombolítica / Competencias de enfermería en el cuidado de personas con accidente cerebrovascular elegibles para terapia trombolítica / Nursing competencies in the care of patients with stroke who are eligible for thrombolytic therapy

Resumo Introdução: O acidente vascular cerebral isquêmico tem como tratamento a terapia trombolítica, aplicada ainda na fase aguda, promovendo melhora importante nas sequelas acarretadas por este agravo. Considerando a complexidade da terapia trombolítica, torna-se necessário que os enfermeiros compreendam suas competências para auxiliar no cuidado. Objetivo: Identificar evidências científicas acerca das competências do enfermeiro no cuidado a pacientes com acidente vascular cerebral elegíveis à terapia trombolítica. Metodologia: Revisão integrativa composta por seis etapas em seis etapas (elaboração da questão, busca na literatura, coleta de dados, análise, discussão e apresentação da revisão), realizada nas bases de dados MEDLINE, LILACS, BDENF, IBECS, PubMed, Scopus, Web of Science, Embase e CINAHL. A busca foi realizada entre agosto e setembro de 2022 adotando como critérios de inclusão estudos primários; gratuitos, disponíveis eletronicamente na íntegra; nos idiomas inglês, português e espanhol. Foram obtidos inicialmente 2.830 estudos, os quais passaram por uma seleção, onde foram incluídos aqueles que atendiam os critérios previamente estabelecidos. Resultados: Com base nos doze estudos incluídos nesta revisão identificaram-se competências voltadas à três atividades do cuidado: gestão do cuidado como trabalho em equipe, códigos, fluxos e protocolos, assistência ao paciente antes, durante e após a utilização da terapia trombolítica e educação em saúde para equipe, pacientes e familiares. Conclusão: Os achados desta revisão puderam evidenciar as competências do enfermeiro no cuidado aos pacientes elegíveis a terapia trombolítica, as quais perpassam diferentes áreas de atuação do enfermeiro. Para este estudo prevaleceram as competências assistências, seguida por competências gerenciais.

Resumen Introducción: El accidente cerebrovascular isquémico se trata con terapia trombolítica, aplicada incluso en la fase aguda, que promueve una mejoría significativa de las secuelas provocadas por este padecimiento. Considerando la complejidad de la terapia trombolítica, es necesario que las personas profesionales de enfermería comprendan sus competencias para ayudar en el cuidado. Objetivo: Identificar evidencias científicas sobre las competencias del personal de enfermería en el cuidado de pacientes con accidente cerebrovascular elegibles para terapia trombolítica. Metodología: Revisión integradora que consta de seis etapas (elaboración de la pregunta, búsqueda bibliográfica, recolección de datos, análisis, discusión y presentación de la revisión), realizada en las bases de dados MEDLINE, LILACS, BDENF, IBECS, PubMed, Scopus, Web of Science, Embase y CINAHL. La búsqueda se realizó entre agosto y septiembre de 2022. Los criterio de inclusión fueron: estudios primarios, gratuito, disponible electrónicamente en su totalidad, en inglés, portugués y español. Inicialmente se obtuvieron 2830 estudios, los cuales fueron sometidos a un proceso de selección, que incluyó aquellos que cumplían con los criterios previamente establecidos. Resultados: A partir de los doce estudios incluidos en esta revisión, se identificaron competencias centradas en tres actividades asistenciales: gestión del cuidado como trabajo en equipo, códigos, flujos y protocolos, atención a pacientes antes, durante y después del uso de la terapia trombolítica y educación en salud para personal, pacientes y familias. Conclusión: Los hallazgos de esta revisión pudieron resaltar las competencias de las personas profesionales en enfermería en el cuidado de personas elegibles para terapia trombolítica, que abarcan diferentes áreas de actuación del personal de enfermería. Para este estudio, prevalecieron las habilidades asistenciales, seguidas de las competencias gerenciales.

ABSTRACT Introduction: Ischemic stroke is treated with thrombolytic therapy, applied even in the acute phase, promoting a significant improvement in the after-effects caused by this condition. Considering the complexity of thrombolytic therapy, it is necessary for nurses to understand the skills required to assist in care. Objective: To identify scientific evidence about the competencies of nurses in the care of patients with stroke who are eligible for thrombolytic therapy. Methodology: An integrative review consisting of six stages (elaboration of the question, literature review, data collection, analysis, discussion, and presentation), conducted in MEDLINE, LILACS, BDENF, IBECS, PubMed, Scopus, Web of Science, Embase, and CINAHL databases. The search was carried out between August and September 2022 using primary studies as the inclusion criteria: free of charge, fully available electronically, published in English, Portuguese, or Spanish. Initially, 2.830 studies were obtained, which underwent a selection process that included only those studies that met the previously established criteria. Results: Based on the twelve studies included in this review, competencies focused on three care activities were identified: care management such as teamwork; codes; flows and protocols; patient care before, during, and after the use of thrombolytic therapy; and education health education for staff, patients, and families. Conclusion: The findings of this review highlighted the nurses' competencies in the care of patients eligible for thrombolytic therapy, which encompass different areas of the nurse's work. For this study, assistance competencies prevailed, followed by management competencies.

Desenlace funcional asociado al ataque cerebrovascular menor en una población colombiana: un estudio de cohorte / Functional outcome associated with minor stroke in a colombian population: a cohort study

RESUMEN INTRODUCCIÓN. El ACV menor hace referencia a un evento isquémico que cursa con síntomas leves. Se ha señalado que estos pacientes pueden presentar un desenlace clínico desfavorable. OBJETIVO: Evaluar el desenlace funcional a 90 días de pacientes con ACV isquémico menor, atendidos en dos hospitales de Bucaramanga, Colombia, entre los años 2015 y 2017. MÉTODOS. Estudio de cohorte en pacientes con ACV isquémico agudo y un puntaje NIHSS ≤ 5 puntos. Un desenlace clínico desfavorable a 90 días de seguimiento fue medido como un puntaje Rankin-m ≥ 3 puntos. Se realizó un análisis bivariado a través de modelos de regresión binomial simple y ajustado por edad y sexo. Un valor p <0,05 fue considerado estadísticamente significativo. RESULTADOS. Se incluyeron 90 pacientes (edad de 66,6± 13,5 años, 54,4% (n=49) de sexo masculino). El 36,5% (n=23) de los pacientes presentó un puntaje Rankin-m de 3 a 6 puntos. El antecedente de diabetes mellitus (RR: 2,50 IC 95%:1,33-4,70) y un Rankin-m previo de 2 (RR 2,12 IC 95%:1,39-3,24) fueron variables independientemente asociadas a discapacidad significativa. CONCLUSIÓN. Un estado funcional previamente comprometido, sumado a la disfunción endotelial que genera la diabetes mellitus, contribuye a un desenlace desfavorable en los pacientes con ACV menor.

ABSTRACT INTRODUCTION. Minor stroke refers to an ischemic vascular event that start with discrete symptoms. It has been suggested that these patients may have an unfavorable clinical outcome. AIM. To evaluate the functional outcome at 90 days in patients with minor ischemic stroke in two hospitals in Bucaramanga, between 2015 and 2017. METHODS. Cohort study in patients with acute ischemic stroke and NIHSS ≤ 5 points. An unfavorable clinical outcome was measured according to the modified Rankin Scale as ≥ 3 points. A bivariate analysis was performed through simple binomial regression models adjusted for age and sex. A p-value <0.05 was considered statistically significant. RESULTS. 90 patients were included (Aged 66.6 ± 13.5 years, 49 males (54%); 23 (36,5%) presented a modified Rankin score of 3-6 points. A history of diabetes (RR: 2.50 CI 95%: 1.33-4.70) and a modified Rankin score of 2 points prior to the event (RR 2.12 CI 95%: 1.39-3.24) were independently associated with significant disability CONCLUSION. A previously compromised functional state, added to the endothelial dysfunction generated by diabetes mellitus, contribute significantly to an unfavorable outcome in patients with minor stroke.

Nuevos paradigmas: 12 años de trombólisis sistémica. Unidad ACV, Hospital de Clínicas / New paradigms: 12 years of systemic thrombolysis. Stroke Unit, Clinicas Hospital / Novos paradigmas: 12 anos de trombólise sistêmica. Unidade AVC, Hospital de Clínicas

Introducción: el ACV constituye un problema de salud y la trombólisis sistémica una estrategia de reperfusión con alto nivel de evidencia para su tratamiento. Los reportes nacionales sobre su utilización son escasos. Objetivos: comunicar y analizar los resultados de esta terapia en el Hospital de Clínicas. Establecer predictores de buena evolución, hemorragia intracraneana y mortalidad. Métodos: estudio observacional analítico de los pacientes trombolizados en el Hospital de Clínicas (2010-2021). Resultados: se realizó trombólisis sistémica a 268 pacientes. La mediana del NIHSS al ingreso fue 12 puntos. Un 42% fueron infartos totales de la circulación anterior. La cardioembolia constituyó la etiopatogenia más frecuente. El 59,3% de los pacientes fueron externalizados con independencia funcional y 55,2% con déficit neurológico mínimo. Las tasas de hemorragia intracraneana sintomática y mortalidad fueron 7,1% y 18,7% respectivamente. El 57% de los pacientes se trataron con tiempo puerta aguja ≤60 minutos. El porcentaje de trombólisis en el total de ACV fue 18,9%. La edad, NIHSS al ingreso e internación en unidad de ACV se comportaron como variables importantes para predecir buena evolución, hemorragia intracraneana y muerte. Discusión y conclusiones: se comunicó la mayor casuística nacional sobre el tema. Los parámetros de efectividad y seguridad del tratamiento fueron comparables a los reportados internacionalmente. Se destacaron los buenos tiempos puerta aguja y tasa trombólisis sobre ACV totales como indicadores satisfactorios de calidad asistencial. La internación en unidad de ACV se comportó como un factor predictor de independencia funcional y protector frente a mortalidad hospitalaria.

Introduction: Strokes are a health problem and systemic thrombolysis constitutes a reperfusion strategy backed up by significant evidence on its positive therapeutic impact. National reports on its use are scarce. Objectives: To report and analyze results obtained with this therapeutic approach at the Clinicas Hospital. To establish predictive factors for a good evolution, intracranial hemorrhage and mortality. Method: Observational, analytical study of thrombolysed patients at Clinicas Hospital (2010-2021). Results: Systemic thrombolysis was performed in 268 patients. Average NIHSS score was 12 points when admitted to hospital.42 % of cases were total anterior circulation infarct (TACI). Cardioembolic ischaemmic stroke was the most frequent etiopahogenesis. 59.3% of patients were discharged with functional independence and 55.2% had minimal neurologic deficit. Symptomatic intracranial hemorrhage and mortality rates were 7.1% and 18.7% respectively. 57% of patients were assisted within ≤60 minutes they showed up at the ER. Thrombolysis percentage in total number of strokes was 18.9%. Age, NIHSS score upon arrival to hospital and admission to the stroke unit were significant variables to predict a good evolution, intracranial hemorrhage and death. Discussion and conclusions: The large number of cases in the country was reported. Effectiveness and safety parameters for this treatment were comparable to those reported internationally. The good door-to-needle time and thrombolysis rate versus total number of strokes stood out as satisfactory indicators of healthcare quality. Admission to the stroke unit behaved as a predictive factor of functional independence and it protected patients from hospital mortality.

Introdução: o AVC é um problema de saúde sendo a trombólise sistêmica uma estratégia de reperfusão com alto nível de evidência para seu tratamento. Os dados nacionais sobre seu uso são escassos. Objetivos: comunicar e analisar os resultados desta terapia no Hospital de Clínicas. Estabelecer preditores de boa evolução, hemorragia intracraniana e mortalidade. Métodos: estudo observacional analítico de pacientes trombolisados no Hospital de Clínicas (2010-2021). Resultados: a trombólise sistêmica foi realizada em 268 pacientes. A mediana do índice NIHSS na admissão foi de 12 pontos. 42% eram infartos totais da circulação anterior. A cardioembolia foi a etiopatogenia mais frequente. 59,3% dos pacientes tiveram alta da unidade com independência funcional e 55,2% com déficit neurológico mínimo. As taxas de hemorragia intracraniana sintomática e mortalidade foram de 7,1% e 18,7%, respectivamente. 57% dos pacientes foram tratados com tempo porta-agulha ≤60 minutos. A porcentagem de trombólise no AVC total foi de 18,9%. Idade, NIHSS na admissão e internação na unidade de AVC se comportaram como variáveis importantes para prever boa evolução, hemorragia intracraniana e óbito. Discussão e conclusões: este trabajo inclui a maior casuística nacional sobre o tema. Os parâmetros de eficácia e segurança do tratamento foram comparáveis aos descritos na bibliografia internacional. Foram destacados como indicadores satisfatórios da qualidade do atendimento os bons tempos porta-agulha e taxa de trombólise em relação ao AVC total. A internação em unidade de AVC comportou-se como preditor de independência funcional e protetor contra a mortalidade hospitalar.

Estrategia fármaco-invasiva en el manejo del infarto agudo al miocardio con supradesnivel del ST / Pharmaco-invasive approach in the management of acute myocardial infarction. Analysis of 144 cases

BACKGROUND: In those patients who do not have timely access to primary angioplasty, the pharmaco-invasive approach, that is, the use of thrombolysis as a bridging measure prior to the coronary angiography, is a safe alternative. AIM: To describe the features of patients with an acute ST-elevation myocardial infarction (STEMI) treated with a pharmaco-invasive strategy. MATERIAL AND METHODS: Descriptive observational study of 144 patients with mean age of 46 years with STEMI who received a dose of thrombolytic prior to their referral for primary angioplasty at a public hospital between 2018 and 2021. RESULTS: There were no differences the clinical presentation according to the Killip score at admission between thrombolyzed and non-thrombolyzed patients (p = ns). Fifty-three percent of non-thrombolyzed patients were admitted with an occluded vessel (TIMI 0) compared with 27% of thrombolyzed patients (p < 0.001). The thrombolyzed group required significantly less use of thromboaspiration (3.5 and 8.4% respectively; p = 0.014). Despite this, 91 and 92% of non-thrombolyzed and thrombolyzed patients achieved a post-angioplasty TIMI 3 flow. Long-term survival was 91 and 86% in thrombolyzed and non-thrombolyzed patients, respectively (p = ns). CONCLUSIONS: The pharmaco-invasive strategy is a safe alternative when compared to primary angioplasty in centers that don't have timely access to Interventional Cardiology.

Factores pronósticos de fallo de trombólisis en pacientes con diagnóstico de infarto agudo de miocardio / Prognostic factors of thrombolytic failure in patients diagnosed with acute myocardial infarction

RESUMEN Introducción: La medida terapéutica más importante en pacientes con infarto agudo de miocardio con supradesnivel del segmento ST es la reperfusión del territorio isquémico; la fibrinólisis es la estrategia primaria en muchos hospitales. El diagnóstico temprano de aquellos pacientes con riesgo de fallo de trombólisis es vital. Objetivo: Identificar los factores pronósticos de fallo de trombólisis en pacientes con diagnóstico de infarto agudo de miocardio con supradesnivel del segmento ST. Métodos: Estudio descriptivo y prospectivo que incluyó a pacientes atendidos en la Emergencia del Hospital Clínico-Quirúrgico «Joaquín Albarrán¼, con diagnóstico de la enfermedad antes mencionada, y tratados con estreptoquinasa recombinante, entre noviembre de 2018 hasta mayo de 2020. Fueron incluidos 66 pacientes en la investigación. Las variables analizadas fueron: Edad, sexo, hipertensión arterial, diabetes mellitus, tiempo entre inicio de síntomas y comienzo de fibrinólisis, localización del infarto, duración del complejo QRS, duración y profundidad de onda. Resultados: Hubo fallo de trombólisis en 27 pacientes (40,9 %). Las variables: Tiempo de realización de trombólisis, duración y profundidad de la onda Q, así como la duración del QRS mostraron valores con diferencias significativas entre ambos grupos (p<0,05). El análisis multivariado confirmó la duración y profundidad de la onda Q como factores independientes, predictores de fallo de trombólisis: (OR= 14,50; IC 95 % 1,58-132,33); (OR: 1,69; IC 95 % 1,27-2,26), respectivamente. Conclusiones: El análisis de la profundidad y duración de la onda Q en el electrocardiograma inicial de los pacientes estudiados, permite predecir a una subpoblación de pacientes con riesgo de fallo de trombólisis.

ABSTRACT Introduction: the most important therapeutic measure in patients with ST-segment elevation acute myocardial infarction is reperfusion of the ischemic territory; fibrinolysis is the primary strategy in many hospitals. Early diagnosis of those patients with risk of failed thrombolysis is vital. Objective: to identify prognostic factors of thrombolytic failure in patients diagnosed with ST- segment elevation acute myocardial infarction. Methods: a descriptive and prospective study including patients treated in the Emergency department at "Joaquín Albarrán" Clinical and Surgical Hospital, who were diagnosed with the previously mentioned disease and treated with recombinant streptokinase, between November 2018 and May 2020. A number of 66 patients were included in the investigation. Age, gender, arterial hypertension, diabetes mellitus, time between onset of symptoms and onset of fibrinolysis, location of the infarction, QRS complex duration, duration and depth of the wave were the analyzed variables. Results: thrombolysis failed in 27 patients (40.9%). Time of performing thrombolysis, duration and depth of the Q wave, as well as the QRS duration showed values with significant differences between both groups (p<0.05). The multivariate analysis confirmed the duration and depth of the Q wave as independent factors, predictors of thrombolysis failure: (OR= 14.50; 95% CI 1.58-132.33); (OR: 1.69; 95% CI 1.27-2.26), respectively. Conclusions: the analysis of the depth and duration of the Q wave in the initial electrocardiogram of the studied patients allows us to predict a subpopulation of patients with risk of failed thrombolysis.

Actuación de enfermería en el infarto cerebral agudo / Nursing performance in acute cerebral stroke

La enfermedad vascular cerebral (EVC) es una patología caracterizada por un déficit neurológico súbito, secundario a oclusión o ruptura de un vaso sanguíneo cerebral; se divide en isquémica o infarto cerebral (IC) y hemorrágica. La EVC es reconocida como la primera causa de discapacidad y la quinta causa de muerte en México, registrándose cerca de 170 mil casos nuevos al año. Existe amplia evidencia que demuestra una reducción en los desenlaces negativos, como muerte y discapacidad, al realizar intervenciones rápidas, incluyendo la administración de trombolisis intravenosa con rt-PA (activador tisular de plasminógeno recombinante) y trombectomía mecánica. La coordinación multidisciplinaria del equipo de salud y los cuidados efectivos de enfermería, son vitales durante todas las etapas de atención de la EVC. Esta revisión da a conocer un panorama general del manejo del infarto cerebral e identificar las intervenciones indispensables del profesional de enfermería realiza durante las etapas prehospitalarias, pretrombolisis, durante trombolisis y postrombolisis.

Cerebralvascular disease (CVD) is a pathology characterized by a sudden neurological deficit secondary to occlusion or rupture of a cerebral blood vessel; it is divided into ischemic or cerebral infarction (CI) and hemorrhagic. CVD is recognized as the first cause of disability and the fifth cause of death in Mexico, with nearly 170,000 new cases registered each year. There is ample evidence that shows a reduction in negative outcomes, such as death and disability, with rapid interventions, including the administration of intravenous thrombolysis with rt-PA (recombinant tissue plasminogen activator) and mechanical thrombectomy. Multidisciplinary coordination of the health care team and effective nursing care are vital during all stages of CVD care. This review provides an overview of the management of cerebral infarction and identifies essential nursing interventions during the prehospital, prethrombolysis, during thrombolysis, and postthrombolysis stages.

Aplicación de terapia trombolítica en pacientes con infarto agudo de miocardio durante dos años / Two-year application of thrombolytic therapy in patients with acute myocardial infarction

RESUMEN Introducción: La estrategia trombolítica no solo mejora la esperanza de supervivencia del infarto, sino que también reduce la mortalidad general a un mes en los pacientes que reciben este tratamiento. Objetivo: Caracterizar los pacientes con infarto agudo de miocardio con elevación del segmento ST tratados con estreptoquinasa recombinante en el Hospital Clínico Quirúrgico Docente «Celia Sánchez Manduley». Métodos: Se realizó un estudio descriptivo, longitudinal y retrospectivo en 94 pacientes que recibieron tratamiento trombolítico desde diciembre de 2018 a noviembre de 2020. Las variables utilizadas fueron: edad, sexo, comorbilidades, tiempo de ventana terapéutica, causas de suspensión temporal, complicaciones, topografía, criterios de reperfusión clínico, eléctrico y enzimático y mortalidad. Se calculó la frecuencia absoluta y relativa, y la media aritmética con desviación estándar. Resultados: Predominó el sexo masculino y el grupo de edad entre 61 - 70 años. Prevalecieron los pacientes con antecedentes de hipertensión y diabetes. La hipotensión arterial fue la causa de suspensión más frecuente. El 69,1 % fueron trombolizados pasadas las 6 horas. Solo 27 pacientes sufrieron complicaciones, de las cuales, el bloqueo auriculoventricular y Killip - Kimball II fueron las más vistas. Por otra parte, 9 pacientes no presentaron criterios de reperfusión, y solo el 7,4 % fallecieron. Conclusiones: La trombolisis se realiza en una minoría de los pacientes aun en período de ventana terapéutica. La hipotensión fue la causa más frecuente de suspensión temporal de la trombolisis, y la letalidad fue inferior a la letalidad general por infarto agudo de miocardio.

ABSTRACT Introduction: thrombolytic strategy not only improves survival expectancy after infarction, but also reduces overall one-month mortality in patients receiving this treatment. Objective: to characterize patients with ST-segment elevation acute myocardial infarction treated with recombinant streptokinase at "Celia Sánchez Manduley" Clinical and Surgical Teaching Hospital. Methods: a descriptive, longitudinal and retrospective study was conducted in 94 patients who received thrombolytic treatment from December 2018 to November 2020. Age, gender, comorbidities, time-related therapeutic window, causes of temporary suspension, complications, topography, clinical, electrical and enzymatic reperfusion criteria as well as mortality were the variables used in this study. Absolute and relative frequency and arithmetic mean with standard deviation were calculated. Results: male gender and group aged 61-70 years predominated. Patients with a history of hypertension and diabetes predominated. Arterial hypotension was the most frequent cause of thrombolysis discontinuation. The 69.1 % were thrombolyzed after 6 hours. Only 27 patients suffered complications; atrioventricular block and Killip-Kimball II were the most frequently seen complications. On the other hand, 9 patients did not show reperfusion criteria and only 7.4 % died. Conclusions: thrombolysis is performed in a minority of patients even in the therapeutic window period. Hypotension was the most frequent cause of temporary suspension of thrombolysis, and case fatality was lower than the overall case fatality for acute myocardial infarction.

Calidad de la atención en salud en ataque cerebrovascular en un hospital de referencia en Colombia / Quality of health care in stroke in a reference hospital in Colombia

RESUMEN INTRODUCCIÓN: La evaluación de la calidad de la atención del ataque cerebrovascular (ACV) es una prioridad para los sistemas de salud, debido a su relación con la disminución de la discapacidad y la muerte. En este estudio se analizan los marcadores de calidad en ACV en un hospital de referencia en Nariño, Colombia. OBJETIVO: Evaluar los marcadores de calidad de atención en ACV en el Hospital Universitario Departamental de Nariño E. S. E., entre junio del 2018 y diciembre del 2019. Como referencia se comparó con los registros de Colombia en la plataforma RES-Q. MATERIALES Y MÉTODOS: Estudio descriptivo retrospectivo de pacientes con ACV atendidos intrahospitalariamente. La recolección de datos se realizó mediante la plataforma RES-Q, en tanto que el análisis se efectuó por medio de estadísticos descriptivos y frecuencias absolutas y relativas y las diferencias con pruebas analíticas. RESULTADOS: Se evaluaron 457 pacientes con predominio de ACV isquémico y se llevó a cabo trombólisis endovenosa al 7,2% en el 2018 y al 9,2 % en el 2019, el 27,7 % con tiempo puerta aguja menor a 60 minutos en el 2018 y el 42,8 % en el 2019. Entre los marcadores de calidad, se encontró mejoría en realización de NIHSS, evaluación de disfagia en las primeras 24 horas, realización de doppler carotideo en los primeros siete días. En comparación con Colombia, se encontró un porcentaje inferior en trombólisis endovenosa y trombectomía. La mayoría de los indicadores de atención en ACV es similar al promedio nacional. CONCLUSIONES: La mejoría en el cumplimiento de marcadores de calidad en ACV refleja el impacto de programas de atención en ACV. El monitoreo de los parámetros de calidad permite generar programas para fortalecer la atención integral del ataque cerebrovascular en la región.

ABSTRACT INTRODUCTION: The evaluation of the quality of care for Stroke is a priority for health systems, given its relationship with disability and death. In this study, Stroke quality markers are analyzed in stroke in a referral hospital in Narino, Colombia. OBJECTIVE: To evaluate the markers of quality of care in stroke in the Hospital Departamental Universitario de Narino E.S.E between June 2018 and December 2019. As a reference, the outcomes were compared with the Colombian registries on RES-Q platform. MATERIALS AND METHODS: A retrospective descriptive study of patients treated in-hospital with stroke, data collection was performed using the RES-Q platform. The analysis was carried out using descriptive statistics and absolute and relative frequencies and the differences with analytical tests. RESULTS: 457patients were evaluated, with ischemic stroke predominance, endovenous thrombolysis was performed in 7.2 % in 2018, and 9.2 % in 2019, 27.7 % of patients had door to needle time less than 60 minutes in 2018 and 42.8 % in 2019. Among the quality markers evaluated, an improvement was found in the performance of NIHSS, dysphagia evaluation, and carotid doppler performance in ischemic stroke. Compared with Colombian registry, a lower percentage was found in endovenous thrombolysis and thrombectomy. Most of Stroke Care Markers are similar to national average. CONCLUSIONS: The improvement in compliance of standard of Stroke Care Quality Markers reflects the impact of stroke care programs. The monitoring of quality parameters allows the generation of comprehensivestroke care programs in the region.

Experiencia en el manejo del ataque cerebrovascular isquémico en dos centros de tercer nivel de la ciudad de Ibagué (Colombia) entre junio del 2019 y junio del 2020 / Ischemic stroke management - Experience in two third-level hospitals in Ibague (Colombia) from June 2019 to June 2020

RESUMEN INTRODUCCION: El ataque cerebrovascular (ACV) de etiología isquémica es una patología cuya incidencia y mortalidad aumentaron en la última década. Cuando se maneja oportunamente, mediante trombólisis como terapia inicial, mejora su desenlace y funcionalidad. En el departamento del Tolima (Colombia) no hay registros de esta patología y en el país la bibliografía al respecto es limitada. El objetivo de este estudio es evaluar los desenlaces clínicos del manejo agudo con r-tPA en los pacientes que presentaron ACV isquémico en dos instituciones de la ciudad de Ibagué, capital de dicho departamento, entre junio del 2019 y junio del 2020, e identificar los tiempos de atención hospitalaria y las principales variables asociadas con el grupo de pacientes que fallecieron. MATERIALES Y METODOS: Estudio descriptivo de corte transversal del manejo del ACV isquémico con r-tPA, en el que se describen las variables sociodemográficas, la escala NIHSS como evaluación neurológica inicial, los tiempos de atención (inicio-aguja, puerta-tac y puerta-aguja), los desenlaces postoperatorios y el Rankin modificado al egreso. RESULTADOS: Se incluyeron 38 pacientes con una media de 67,37 años, el 60,53 % fueron mujeres. La escala NIHSS al ingreso fue 13,47 puntos (DE 5,24). Los tiempos de atención fueron 183 minutos (DE 72,63) inicio-aguja, 41 minutos (RIQ 17-72) puerta-TAC y 101,50 minutos (RIQ 77 - 137,25) puerta-aguja. La mortalidad fue del 23,68 %. CONCLUSION: La mortalidad y el desenlace funcional del ACV en nuestra población fueron similares a los reportados en la literatura nacional e internacional, sin embargo, es preciso implementar protocolos de atención del infarto cerebral para incrementar el número de pacientes con desenlace favorable, acortando los tiempos de atención en toda la cadena del tratamiento adecuado del infarto cerebral.

ABSTRACT INTRODUCTION: Ischemic stroke is a growing disease in the last decade, increasing both its incidence and its mortality. However, timely thrombolysis management as initial therapy can improve both disease progression as well as an individual's functionality. In Tolima, there are no registries of this disease and in Colombia in general, the literature is limited. The objective of this study is to investigate the clinical outcomes of the acute management of ischemic stroke using r-tPA as well as identifying in-hospital treatment times, at two institutions in Ibague between 2019 and 2020. METHODS AND MATERIALS: Using a cross-sectional descriptive study, we describe the management of ischemic stroke using r-tPA, describing sociodemographic variables, NIHSS scale as the initial neurological evaluation, in-hospital treatment times (symptoms-to-needle, door-to-TAC, door-to-needle), the clinical outcomes, and lastly the modified Rankin score upon discharge. RESULTS: We included 38 patients with median age of 67,37 years, 60,53 % were females. The initial average NIHSS scale upon admission was 13,47 (DE 5,24). In-hospital attention time averages were: symptoms-to-needle 183 minutes (DE 72,63), door-to-CAT 41 minutes (RIQ 17-72), and door-to-needle 101,50 minutes (RIQ 77-137,25). Overall the rate of mortality was 23,68 %. CONCLUSIONS: Mortality and functionality outcomes of the stroke population observed was similar to previously reported, both nationally and internationally. However, protocols should be implemented for the timely ischemic stroke management to improve the number of patients with favorable outcomes, by reducing the in-hospital attention times in all areas of the management chain.

Epidemiological analysis of stroke patients with emphasis on access to acute-phase therapies / Análise epidemiológica de pacientes com AVC com ênfase no acesso às terapias de fase aguda

ABSTRACT Background: Stroke is a public health problem. For patients with ischemic stroke, venous thrombolysis and mechanical thrombectomy are effective therapeutic options. However, even after the National Stroke Treatment Guidelines were published in 2012, the number of cases treated is still lower than expected. Objective: To identify the determining factors for obtaining access to acute-phase therapies in the state of Espírito Santo (ES) and investigate the profile of stroke patients treated at the Central State Hospital (HEC). Methods: Retrospective data from the medical records of 1078 patients from May 2018 to December 2019 were analyzed. Results: Among the 1,078 patients, 54.9% were men and the most prevalent age group was 60 to 79 years. Systemic arterial hypertension was the main single risk factor. Regarding treatment modality among the patients who arrived at the HEC within the therapeutic window, 47% received some type of acute-phase therapy. Waking up with the deficit was the main contraindication for venous thrombolysis in these cases. Conclusions: Application of the flowchart established by SESA-ES seemed to be effective for enabling responsiveness of care for stroke victims. Public emergency transport services had a fundamental role in this process. In addition, the care provided by the tertiary stroke center provided excellent access to acute-phase therapies. However, despite the efficiency of the service provided at the HEC, it only reached a maximum of 50% of the ES population. This service model therefore needs to be expanded throughout the state.

RESUMO Antecedentes: O acidente vascular cerebral (AVC) é um problema de saúde pública. Nos casos de AVC isquêmico, a trombólise venosa e a trombectomia mecânica são efetivas opções terapêuticas de fase aguda. Entretanto, mesmo com a Diretriz Nacional de AVC publicada desde 2012, o número de casos tratados ainda é baixo. Objetivo: Apurar os fatores determinantes para o acesso às terapias de fase aguda na realidade espírito-santense e investigar o perfil dos pacientes de AVC atendidos no Hospital Estadual Central de Vitória (HEC). Métodos: O presente estudo analisou dados retrospectivos de prontuários de 1.078 pacientes no período de maio de 2018 a dezembro de 2019. Resultados: Dos 1.078 pacientes, 54,9% eram homens e a faixa etária mais prevalente foi a de 60 a 79 anos. A hipertensão arterial sistêmica foi o principal fator de risco isolado. Quanto ao tratamento, identificou-se que entre os pacientes que chegaram ao HEC na janela terapêutica 47% receberam terapia de fase aguda e que acordar com o déficit foi a principal contraindicação para trombólise venosa nesses casos. Conclusões: As análises demonstraram que a aplicação do fluxograma estabelecido pela Secretaria de Estado da Saúde do Espírito Santo parece ser eficaz na agilidade de atendimento das vítimas de AVC e que o Serviço de Atendimento Móvel de Urgência tem um papel fundamental nesse processo. Além disso, a assistência de um centro terciário de AVC permite acesso às terapias de fase aguda com excelência. Todavia, mesmo que o modelo de serviço prestado no HEC seja eficiente, ele atinge no máximo 50% da população do ES, sendo necessária a sua ampliação.

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

Análise do procedimento de trombólise endovenosa em pacientes com acidente vascular encefálico isquêmico / Analysis of the procedure of endovenous thrombolysis in patients with acute ischemic stroke

Objetivo: O Acidente Vascular Encefálico isquêmico é uma das doenças mais prevalentes, de grande mortalidade, e requer trombólise endovenosa quando indicada. Esse trabalho objetivou avaliar a população submetida a terapia trombolítica, aplicada em pacientes com acidente vascular cerebral isquêmico, entre junho de 2018 a junho de 2020, em um hospital do Extremo Sul Catarinense. Métodos: Estudo observacional, transversal, com coleta censitária e análise de dados secundários. Estão incluídos os prontuários hospitalares de todos os pacientes com acidente vascular encefálico isquêmico, que receberam trombólise, entre junho de 2018 a junho de 2020. Análise estatística foi feita pelo Statistical Package for Social Sciences, com intervalo de confiança de 95%. Resultados: Foram incluídos 27 pacientes e desses, 15 eram homens; 24 eram brancos; 15 eram procedentes de Criciúma; média de idade foi 61,89 anos. Vinte e seis tinham fatores de risco prévios; 18 tinham mais de 60 anos; 18 tinham hipertensão; 13 tinham diabetes. Quatorze tiveram tempo porta-tomografia em até 10 minutos; 14 tiveram tempo porta-agulha entre 1 e 2 horas; 13 ficaram internados por 5 a 6 dias. Um teve complicações durante a trombólise. Não houveram óbitos, nem necessidade de trombectomia mecânica. Dezenove tiveram sequelas pós-trombólise. A mediana da National Institutes of Health Stroke Scale foi 12 pontos na entrada hospitalar, e 6 pontos na alta. Conclusão: A cerebrovasculopatia isquêmica é a principal causa de incapacidades, e quanto antes feita a trombólise, melhor o prognóstico. O controle dos fatores de risco e os menores tempos são ideais para a evolução sem sequelas.

Objective: Ischemic stroke is one of the most prevalent and high-mortality diseases in the world, and require intravenous thrombolysis when indicated. This research aimed to evaluate the population undergoing thrombolytic therapy, due to an acute ischemic stroke, from June 2018 to June 2020, in a hospital located in the extreme South of Santa Catarina, Brazil. Methods: A cross-sectional survey was conducted, with censos collection and secondary data analysis. Medical records of all patients who suffered from acute ischemic stroke and received intravenous thrombolysis treatment, from June 2018 to June 2020 were included. Statistical analysis was performed by the Statistical Package for Social Sciences, with 95% confidence intervals. Results: Twenty-seven patients were included and of these, 15 were men; 24 were white; 15 were from Criciúma; mean age was 61,89 years. Twenty-six had previous risk factors; 18 were over 60 years old; 18 had hypertension; 13 had diabetes. Fourteen had a CT scan time of up to 10 minutes; 14 had needle-holder time between 1 and 2 hours; 13 were hospitalized for 5 to 6 days. One had complications during thrombolysis. There were no deaths and not need mechanical thrombectomy. Nineteen had postthrombolysis sequelae. The National Institutes of Health Stroke Scale median was 12 points at hospital admission, and 6 points at discharge. Conclusion: Ischemic cerebrovasculopathy is the main cause of disabilities, and the sooner thrombolysis is done, the better is the prognosis. The control of risk factors and the shortest times are ideal for evolution without sequelae.

Fatores de risco associados ao déficit neurológico em pessoas vítimas de acidente vascular cerebral isquêmico / Risk factors associated with neurological déficit in ischemic stroke victims / Factores de riesgo asociados al déficit neurológico en víctimas de ictus isquémico

Objetivo: Identificar os fatores de risco associados ao déficit neurológico em pessoas vítimas de acidente vascular cerebral isquêmico. Métodos: Trata-se de um estudo retrospectivo descritivo quantitativo realizado em um hospital no interior de Minas Gerais Brasil. Os dados foram coletados em 52 prontuários, através de um instrumento contendo variáveis sociodemográficas, clínicas e janelas de tempo de tratamento. Para avaliação do déficit neurológico utilizou-se National Institutes of Health Stroke Scale. Os testes de Shapiro-Wilk, Quiquadrado de Pearson, T Student e McNemar foram utilizados para a análise estatística. O nível de significância foi de 0,05. Resultados: Na admissão hospitalar houve prevalência do déficit neurológico moderado, e na alta hospitalar, o déficit neurológico leve. O valor do déficit neurológico na admissão hospitalar e alta hospitalar foram, respectivamente 13,10 (±7,2) e 7,58 (±8,3), p = (0,000). O período de internação foi de 7,78 dias para os indivíduos com déficit neurológico leve/moderado e 11,67 dias para déficit neurológico grave (p=0,044). O tempo de janela porta agulha foi 38 minutos nos pacientes com déficit neurológico leve/moderado e 55,3 minutos para o déficit neurológico grave (p=0,025). Conclusão: Destaca-se a influência da condição neurológica no tempo de internação e a importância do atendimento ágil por parte da equipe. (AU)

Objective: To identify the risk factors associated with neurological deficit in people who victims of ischemic stroke. Methods: This is a retrospective quantitative descriptive study carried out in a hospital in the interior of Minas Gerais Brazil. Data were collected from 52 medical records, using an instrument containing sociodemographic and clinical variables and treatment time windows. To assess neurological deficit, the National Institutes of Health Stroke Scale was used. The Shapiro-Wilk, Pearson Chi- square, T Student and McNemar testes were used for statistical analysis. The significance level was 0,05. Results: At hospital admission there was a prevalence of moderate neurological deficit, and at hospital discharge, mild neurological deficit. Neurological deficit values at hospital admission and discharge werw respectively 13,10 (±7,2) and 7,58 (±8,3), p = (0,000). The hospital stay was 7,78 days for individuals with mild/moderate neurological deficit and 11,67 days for severe neurological deficit (p=0,044). The needle door window time was 38 minutes for patients with mild/moderate neurological deficit and 55,3 minutes for severe neurological deficit (p=0,025). Conclusion: The influence of the neurological condition on the length of stay and the importance of prompt care by the team are highlighted. (AU)

Objetivo: Identificar los factores de riesgo asociados al déficit neurológico en personas víctimas de ictus isquémico. Métodos: Se trata de un estudio cuantitativo descriptivo retrospectivo realizado en un hospital del interior de Minas Gerais Brasil. Se recolectaron datos de 52 historias clínicas, utilizando un instrumento que contiene variables sociodemográficas y clínicas y ventanas de tiempo de tratamiento. Para evaluar el déficit neurológico, se utilizó la National Institutes of Health Stroke Scale. Para el análisis estadístico se utilizaron las pruebas de Shapiro-Wilk, Chi-cuadrado de Pearson, T de Student y McNemar. El nivel de significancia fue 0.05. Resultados: al ingreso hospitalario prevaleció déficit neurológico moderado y al alta hospitalaria déficit neurológico leve. Los valores de déficit neurológico al ingreso y al alta hospitalaria fueron respectivamente 13,10 (± 7,2) y 7,58 (± 8,3), p = (0,000). La estancia hospitalaria fue de 7,78 días para individuos con déficit neurológico leve / moderado y de 11,67 días para déficit neurológico severo (p = 0,044). El tiempo de ventana de la puerta de la aguja fue de 38 minutos para pacientes con déficit neurológico leve / moderado y de 55,3 minutos para déficit neurológico severo (p = 0,025). Conclusión: Se destaca la influencia de la afección neurológica en la duración de la estadía y la importancia de una atención inmediata por parte del equipo. (AU)

Trombólisis intravenosa para ataque cerebrovascular isquémico en un hospital de referencia en Nariño - Colombia / Thrombolysis for ischemic stroke in a reference hospital in Nariño - Colombia

RESUMEN INTRODUCCIÓN: El ataque cerebrovascular (ACV) es la segunda causa de muerte y tercera causa de discapacidad en el mundo. La trombólisis intravenosa, como tratamiento agudo del ACV isquémico ha demostrado reducir discapacidad y mortalidad; sin embargo, está directamente ligado al tiempo de administración y un adecuado programa hospitalario. Mediante este trabajo se evalúan los tiempos de atención en trombólisis intravenosa en el Hospital Universitario Departamental de Nariño E.S.E, como institución de referencia departamental en Colombia. MATERIALES Y MÉTODOS: Estudio descriptivo transversal retrospectivo, incluyó pacientes con ACV isquémico que recibieron trombólisis intravenosa entre 2014 y 2019. El análisis se realizó mediante estadísticos descriptivos, y frecuencias absolutas y relativas. Para evaluar las diferencias se dividió en tres periodos de atención. RESULTADOS: Se evaluaron 50 pacientes, con edad promedio 67,6 años, 58% hombres. En 70% se observó una disminución mayor a 3 puntos NIHSS post-trombólisis. El 58 % tuvo escala modificada Rankin (mRS) 0 a 1. Hubo una diferencia significativa entre las medianas del tiempo Puerta-TAC con 36,5 (n=10, 2014-2015 ), 34,5 (n=16, 2016-2017) y 16 minutos (n=24, 2018-2019). Y en el tiempo Puerta-Aguja fue de 154,8; 98,2 y 79,9 minutos en los mismos periodos. En 45,8% el tiempo Puerta-Aguja fue menor a 60 minutos en el tercer periodo. CONCLUSIONES: Se evidencia aumento del número de pacientes que reciben trombólisis intravenosa a través de los años evaluados, así como disminución en tiempo Puerta-TAC y Puerta-Aguja, como marcadores de mejoría en la atención clínica.

ABSTRACT INTRODUCTION: Stroke is the second leading cause of death and third of disability in the world. Intravenous Thrombolysis as a treatment for acute ischemic stroke has been shown to reduce disability and mortality; however, it is directly linked to administration time and adequate stroke care attention. Through this work, the times of attention in thrombolysis are evaluated at the Hospital Universitario Departamental de Narino E.S.E, as a local reference institution in Colombia. METHODS: A retrospective descriptive study included patients with ischemic stroke who received intravenous thrombolysis between 2014 and 2019. The analysis was performed using descriptive statistics and absolute and relative frequencies. To assess the differences, it was divided into three attention periods. RESULTS: 50 patients were evaluated, with an average age of 67.6 years, 58% men. In 70% a decrease greater than 3 NIHSS points was observed post-thrombolysis. The 58% had mRS 0-1. There was a difference between the medians in the Door-CT time with 36.5 (n = 10, 2014-2015), 34.5 (n = 16, 2016-2017) and 16 minutes (n = 24, 2018-2019). And in the Door-Needle time was 154.8; 98.2 and 79.9 minutes in the same periods. In 45.8%, the Door-Needle time was less than 60 minutes in the third period. CONCLUSIONS: There is evidence of an increase in the number of patients receiving intravenous thrombolysis throughout the years evaluated, as well as a decrease in Door-CT and Door-Needle times, as markers of improvement in clinical care.

How much do the Patients with Acute Myocardial Infarction Know about Chest Pain, Thrombolytic Therapy, and Other Factors Affecting the Treatment Time in the Emergency Room?

Abstract Background: Treatment time in the emergency room for acute myocardial infarction is very important and can be life-saving if one understands the importance of a patient's chest pain. Objetice: The aim of this study is to evaluate how much patients entering the emergency room due to acute myocardial infection (AMI) know about chest pain and thrombolytic therapy. Materials and Methods: One hundred fifty patients (126 males,14 females) from three different institutes with complaints of chest pain were randomly chosen to participate in this study. The mean age of the patients was 55.4 ± 11.2 years (71+33). Patients were asked to fill out a questionnaire consisting of 70 questions within the first seven days. All differences in categorical variables were computed using the χ2-test and Fisher Exact test. A two-tailed hypothesis was used in all statistical evaluations, and p<0.05 was considered significant. Results: It was observed that 17% of the patients came to the hospital within the first 30 minutes; 18.3% of them came to the hospital between 30 minutes and 1 hour; 27.5% of them came to the hospital between 1 hour and 3 hours; and 21.4% of them came to the hospital more than 6 hours after symptoms began. It was also observed that 68% of the patients were not aware of the AMI, and 96% of them had no prior knowledge of antithrombolytic therapy. Conclusion: Because the majority of the patients did not have enough information about AMI, a training program should be implemented to ensure that people to come to the hospital earlier. (Int J Cardiovasc Sci. 2021; [online].ahead print, PP.0-0)

Importancia del sistema de preaviso y elección del centro asistencial en el accidente cerebrovascular agudo / Importance of the forewarning system and assistance center selection in acute stroke

Resumen El accidente cerebrovascular (ACV) es una urgencia tiempo dependiente, ya que las conductas de mayor impacto pronóstico dependen del tiempo trascurrido. El objetivo de este trabajo fue analizar nuestros tiempos puerta aguja (TPA), comienzo aguja (TCA) y el efecto que tiene sobre estos el sistema preaviso y la elección adecuada del centro asistencial. Se realizó un estudio observacional con datos obtenidos de histo rias clínicas de pacientes internados en la unidad de ACV. Analizamos el número de tratamientos trombolíticos endovenosos, entre agosto 2015 y diciembre 2019. Comparamos TPA según utilización de pre-aviso, llegada directa por sus propios medios vs. en ambulancia sin pre-aviso, y TCA según llegada directa al centro con unidad de ACV vs. llegada a otro centro para posterior derivación. De 265 pacientes en ventana terapéutica, se realizó tratamiento en 143. Llegaron 137 pacientes derivados de otro centro, 70 recibieron tratamiento trombolítico. El TPA con sistema preaviso y sin preaviso fue 41 ± 23 (media ± DE) y 81 ± 43 minutos, respectivamente (p = 0.001). El TPA con llegada directa por sus propios medios 79 ± 43 y en ambulancia sin preaviso 84 ± 44 minutos (p = 0.7) a unidad de ACV. El TCA en llegada directa a unidad de ACV fue 159 ± 59 y a otro centro para su derivación 199 ± 44 minutos (p = 0.001). La utilización de un sistema de preaviso y la elección directa de un centro con unidad de ACV son medidas clave para reducir los tiempos de tratamiento.

Abstract Acute ischemic stroke (AIS) is a time-dependent emergency, since the greatest impact depends on the time elapsed to treatment. The objective of this work was to analyze door to needle (DTN) and start treatment (STT) times and the effect of pre-notification system (PNS) and the appropriate choice of the healthcare center on these variables. An observational study with data obtained from records of patients admitted to the Stroke Unit (SU) was conducted between August 2015 to December 2019. We analyzed the number of intravenous thrombolytic treatments (IVT), DTN and STT and compared them according to PNS use, direct arrival at the center with SU or arrival at another center for subsequent referral. An overall of 472 patients were hospitalized during the studied period and the treatment was performed in 143 out of 265 patients. One hundred thirty-seven patients arrived from another center, 70 received IVT. Average DNT with PNS and without PNS were 41 ± 23 and 81 ± 44 minutes, respectively (p = 0.001). STT on direct arrival to SU was 159 ± 59 minutes and to another center for referral was 199 ± 44 (p = 0.001). The use of a PNS and the direct choice of a center where IVT is performed significantly improve treatment