Timing of multivessel revascularization in stable patients with STEMI: a systematic review and network meta-analysis.

INTRODUCTION AND OBJECTIVES: Multivessel percutaneous coronary intervention (MV-PCI) is recommended in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD) without cardiogenic shock. The present network meta-analysis investigated the optimal timing of MV-PCI in this context. METHODS: We pooled the aggregated data from randomized trials investigating stable STEMI patients with multivessel cad treated with a strategy of either MV-PCI or culprit vessel-only PCI. The primary outcome was all-cause death. The main secondary outcomes were cardiovascular death, myocardial infarction, and unplanned ischemia-driven revascularization. This study is registered at PROSPERO (CRD42023457794). RESULTS: Among 11 trials, a total of 10 507 patients were randomly assigned to MV-PCI (same sitting, n = 1683; staged during the index hospitalization, n = 3460; staged during a subsequent hospitalization within 45 days, n = 3275) or to culprit vessel-only PCI (n = 2089). The median follow-up was 18.6 months. In comparison with culprit vessel-only PCI, MV-PCI staged during the index hospitalization significantly reduced all-cause death (risk ratio, 0.73; 95%CI, 0.56-0.92; P = .008) and ranked as possibly the best treatment option for this outcome compared with all other strategies. In comparison with culprit vessel-only PCI, a MV-PCI reduced cardiovascular mortality without differences dependent on the timing of revascularization. MV-PCI within the index hospitalization, either in a single procedure or staged, significantly reduced myocardial infarction and unplanned ischemia-driven revascularization, with no significant difference between each other. CONCLUSIONS: In patients with STEMI and multivessel CAD without cardiogenic shock, multivessel PCI within the index hospitalization, either in a single procedure or staged, represents the safest and most efficacious approach. The different timings of multivessel PCI did not result in any significant differences in all-cause death.

Invasive assessment of coronary microvascular dysfunction and cardiovascular outcomes across the full spectrum of CHD: a meta-analysis.

INTRODUCTION AND OBJECTIVES: Coronary microvascular dysfunction (CMD) is highly prevalent and is recognized as an important clinical entity in patients with coronary heart disease (CHD). Nevertheless, the association of CMD with adverse cardiovascular events in the spectrum of CHD has not been systemically quantified. METHODS: We searched electronic databases for studies on patients with CHD in whom coronary microvascular function was measured invasively, and clinical events were recorded. The primary endpoint was major adverse cardiac events (MACE), and the secondary endpoint was all-cause death. Estimates of effect were calculated using a random-effects model from published risk ratios. RESULTS: We included 27 studies with 11 404 patients. Patients with CMD assessed by invasive methods had a higher risk of MACE (RR, 2.18; 95%CI, 1.80-2.64; P<.01) and all-cause death (RR, 1.88; 95%CI, 1.55-2.27; P<.01) than those without CMD. There was no significant difference in the impact of CMD on MACE (interaction P value=.95) among different invasive measurement modalities. The magnitude of risk of CMD assessed by invasive measurements for MACE was greater in acute coronary syndrome patients (RR, 2.84, 95%CI, 2.26-3.57; P<.01) than in chronic coronary syndrome patients (RR, 1.77, 95%CI, 1.44-2.18; P<.01) (interaction P value<.01). CONCLUSIONS: CMD based on invasive measurements was associated with a high incidence of MACE and all-cause death in patients with CHD. The magnitude of risk for cardiovascular events in CMD as assessed by invasive measurements was similar among different methods but varied among CHD populations.

Systematic review and meta-analysis of randomized and nonrandomized studies on fractional flow reserve-guided revascularization.

INTRODUCTION AND OBJECTIVES: Several studies have investigated the effectiveness of fractional flow reserve (FFR) guidance in improving clinical outcomes after myocardial revascularization, yielding conflicting results. The aim of this study was to compare clinical outcomes in patients with coronary artery disease following FFR-guided or angiography-guided revascularization. METHODS: Both randomized controlled trials (RCTs) and nonrandomized intervention studies were included. Coprimary endpoints were all-cause death, myocardial infarction, and major adverse cardiovascular events (MACE). The study is registered with PROSPERO (CRD42022344765). RESULTS: A total of 30 studies enrolling 393 588 patients were included. FFR-guided revascularization was associated with significantly lower rates of all-cause death (OR, 0.63; 95%CI, 0.53-0.73), myocardial infarction (OR, 0.70; 95%CI, 0.59-0.84), and MACE (OR, 0.77; 95%CI, 0.70-0.85). When only RCTs were considered, no significant difference between the 2 strategies was observed for any endpoints. However, the use of FFR was associated with reduced rates of revascularizations and treated lesions. Metaregression suggested that the higher the rate of revascularized patients the lower the benefit of FFR guidance on MACE reduction compared with angiography guidance (P=.012). Similarly, higher rates of patients with acute coronary syndromes were associated with a lower benefit of FFR-guided revascularization (P=.039). CONCLUSIONS: FFR-guided revascularization was associated with lower rates of all-cause death, myocardial infarction and MACE compared with angiographic guidance, with RCTs and nonrandomized intervention studies yielding conflicting data. The benefits of FFR-guidance seem to be less evident in studies with high revascularization rates and with a high prevalence of patients with acute coronary syndrome.

Factors associated with the presence of tendon xanthomas in familial hypercholesterolemia.

INTRODUCTION AND OBJECTIVES: Tendon xanthomas (TX) are lipid deposits highly specific to familial hypercholesterolemia (FH). However, there is significant variability in their presentation among FH patients, primarily due to largely unknown causes. Lipoprotein(a) is a well-established independent risk factor for atherosclerotic cardiovascular disease in the general population as well as in FH. Given the wide variability of lipoprotein(a) among FH individuals and the likelihood that TX may result from a proatherogenic and proinflammatory condition, the objective of this study was to analyze the size of TX in the Achilles tendons of FH participants and the variables associated with their presence, including lipoprotein(a) concentration. METHODS: A cross-sectional study was conducted on 377 participants with a molecular diagnosis of heterozygous FH. Achilles tendon maximum thickness (ATMT) was measured using ultrasonography with standardized equipment and procedures. Demographic variables and lipid profiles were collected. A multivariate linear regression model using a log-Gaussian approach was used to predict TX size. Classical cardiovascular risk factors and lipoprotein(a) were included as explanatory variables. RESULTS: The mean low-density lipoprotein cholesterol level was 277mg/dL without lipid-lowering treatment, and the median ATMT was 5.50mm. We demonstrated that age, sex, low-density lipoprotein cholesterol, and lipoprotein(a) were independently associated with ATMT. However, these 4 variables did not account for most the interindividual variability observed (R2=0.205). CONCLUSIONS: TX, a characteristic hallmark of FH, exhibit heterogeneity in their presentation. Interindividual variability can partially be explained by age, male sex, low-density lipoprotein cholesterol, and lipoprotein(a) but these factors account for only 20% of this heterogeneity.

Carotid artery stiffness and risk of vascular events and mortality: the REGICOR study.

INTRODUCTION AND OBJECTIVES: The aims of this study were to determine the dose-response association of carotid arterial stiffness with vascular outcomes and overall mortality, and to assess their added predictive capacity. METHODS: Population-based cohort study including 6468 individuals, with a median follow-up of 6.5 years. Six carotid artery stiffness indices were assessed: strain, stiffness, Peterson elasticity coefficient, compliance coefficient, distensibility coefficient, and pulse wave velocity (PWV). Incident coronary, cerebrovascular, global vascular, and total fatal events were identified. RESULTS: Carotid compliance and distensibility coefficients were not associated with any of the outcomes. Carotid stiffness, Peterson elasticity coefficient, and PWV showed a direct linear relationship to cerebrovascular disease: the risk increased by 8% (95%CI, 1-16) per stiffness unit increase, by 7% (95%CI, 2-13) per 10-unit Peterson elasticity coefficient increase, and by 26% (95%CI, 8-48) per PWV unit increase. Carotid strain showed a nonlinear association with ischemic heart disease. When strain was ≤ 0.09 units, each 0.01-unit increase was associated with a 15% lower risk of coronary events (95%CI,-33 to 6); above 0.09 units, each 0.01 increase in strain was associated with a 16% higher risk of coronary events (95%CI, 6-27). The addition of the stiffness indices did not improve the predictive capacity of validated risk functions. CONCLUSIONS: Carotid stiffness, Peterson elasticity coefficient, and PWV have a direct linear association with cerebrovascular disease risk. Carotid strain is not linearly related to U-shaped ischemic heart disease risk. The inclusion of these indexes does not improve the predictive capacity of risk functions.

Fenómeno de Milking secundario a puente intramiocárdico en paciente con bloqueo trifascicular

Introducción: los puentes intramiocárdicos son una modificación anatómica de la circulación coronaria que consisten en secciones anormales en el espesor del miocardio que al formar segmentos tunelizados e incorporarse al epicardio, provocan un ordeñamiento vascular llamado fenómeno de Milking durante la compresión sistólica extrínseca, el cual es responsable de las manifestaciones clínicas y las alteraciones electrocardiográficas. Se describe un caso clínico con el objetivo de comunicar a la comunidad científica las características clínicas, eléctricas y coronariográficas de una paciente con síndrome coronario agudo con bloqueo trifascicular y fenómeno de Milking por puente intramiocárdico. Caso clínico: mujer de56 años, con antecedentes de hipertensión arterial, obesidad e historia de ingresos frecuentes por episodios de angina inestables; fue admitida por angina inestable aguda más bloqueo trifascicular y se confirmó puente intramiocárdico en el segmento medio distal de la arteria descendente anterior izquierda. La optimización de la terapia antiisquémica se basó en Carvedilol, previa implantación de marcapaso permanente. Discusión: los puentes intramiocárdicos causan reducción dinámica de la luz del vaso epicárdico coronario y cuando resulta mayor del 50% condiciona el fenómeno de Milking, el cual es más frecuente en los segmentos medio y distal de la arteria descendente anterior izquierda, su evolución es favorable y responden a la terapéutica con ß bloqueadores de forma adecuada. Conclusiones: la correlación diagnóstica facilitó la aplicación de una conducta invasiva con estimulación transvenosa permanente que permitió iniciar tratamiento betabloqueante lo cual no hubiera sido posible por el trastorno de la conducción intraventricular.

Introduction: Intramyocardial bridges are an anatomical modification of the coronary circulation consisting of abnormal sections in the thickness of the myocardium that, when forming tunnel segments and incorporating into the epicardium, cause vascular milking, the so-called milking phenomenon, during extrinsic systolic compression, which is responsible for the clinical manifestations and electrocardiographic alterations. A clinical case is described with the aim of providing the scientific community with the clinical, electrical and coronary angiographic characteristics of a patient with acute coronary syndrome with trifascicular block and milking phenomenon due to intramyocardial bridging. Case Report: A 56-year-old woman with a history of hypertension, obesity, and frequent admissions for episodes of unstable angina was admitted for acute unstable angina plus trifascicular block and intramyocardial bridging was confirmed in the distal middle segment of the left anterior descending artery. Optimization of anti-ischemic therapy was based on carvedilol after implantation of a permanent pacemaker. Discussion: Intramyocardial bridges cause a dynamic reduction of the coronary epicardial vessel lumen and when it is greater than 50% it causes a milking phenomenon, which is more frequent in the middle and distal segments of the left anterior descending artery, its evolution is favorable and responds adequately to ß-blocker therapy. Conclusions: The diagnostic correlation facilitated the application of an invasive approach with permanent transvenous stimulation, allowing the initiation of beta-blocker treatment, which would not have been possible due to the intraventricular conduction disorder.

Introdução: As pontes intramiocárdicas são uma modificação anatómica da circulação coronária constituída por secções anómalas na espessura do miocárdio que, ao formarem segmentos em túnel e ao incorporarem-se no epicárdio, provocam a ordenha vascular, o chamado fenómeno de ordenha, durante a compressão sistólica extrínseca, responsável pelas manifestações clínicas e alterações electrocardiográficas. Descreve-se um caso clínico como objetivo de dar a conhecer à comunidade científica as características clínicas, eléctricas e coronariográficas de um doente com síndrome coronário agudo com bloqueio trifascicular e fenómeno de milking por bridging intramiocárdico. Relato de Caso: Mulher de 56 anos, com antecedentes de hipertensão arterial, obesidade e internamentos frequentes por episódios de angina instável, foi internada por angina aguda instável com bloqueio trifascicular e confirmação de ponte intramiocárdica no segmento médio distal da artéria descendente anterior. A otimização da terapêutica anti-isquémica foi baseada no carvedilol após implantação de pacemaker definitivo. Discussão: As pontes intramiocárdicas provocam uma redução dinâmica do lúmen do vaso epicárdico coronário e quando esta é superior a 50% provoca um fenómeno de ordenha, mais frequente nos segmentos médio e distal da artéria descendente anterior, a sua evolução é favorável e responde adequadamente à terapêutica com ß-bloqueantes. Conclusões: A correlação diagnóstica facilitou a aplicação de uma abordagem invasiva com estimulação transvenosa permanente, permitindo o início do tratamento com beta-bloqueadores, o que não teria sido possível devido ao distúrbio de condução intraventricular.

Herramientas para la toma de decisiones en pacientes con enfermedad de múltiples vasos / Tools for Decision Making in Patients with Multivessel Disease

RESUMEN La decisión sobre la mejor estrategia de revascularización para los pacientes con enfermedad de múltiples vasos se ha tornado una tarea compleja a medida que la angioplastia coronaria ha mejorado sus resultados. En la siguiente revisión nos propusimos evaluar las variables que en nuestra experiencia definen el beneficio de una técnica sobre la otra, entendiendo que de esta manera la decisión del médico tratante se hace más sencilla y objetiva. Por otro lado, y festejando el saludable protagonismo que se le da al paciente, creemos que esta evaluación permite ofrecer argumentos sólidos para ayudarlo en la toma de la decisión.

ABSTRACT The decision on the best revascularization strategy for patients with multivessel disease has become a complex task as coronary angioplasty has improved its results. In the following review, we set out to evaluate the variables that, in our experience, define the benefit of one technique over the other, understanding that in this way the treating physician's decision will become simpler and more objective. On the other hand, and celebrating the healthy prominence given to patients, we believe that this evaluation allows solid arguments to help them in decision making.

[Coronary lithotripsy in calcified lesions: fragmented calcium]. / Litotricia coronaria en lesiones calcificadas: fragmentando el calcio.

Background: Complex calcified coronary lesions are a frequent finding during percutaneous coronary intervention, representing for decades a challenge and limitation in patients with indication of revascularization, due to suboptimal angiographic results, high incidence of perioperative complications and long-term adverse events despite the multiple strategies employed, such as the use of cutting balloon, high-pressure balloons or rotational or orbital atherectomy, interventions with limitations that have hindered its routine use, recently a new plaque modification technique known as coronary intravascular lithotripsy has burst into the treatment of this complex entity, which consists in the use of a specially modified balloon for the emission of pulsatile mechanical energy (sonic pressure waves) that allows modifying the calcified plate. Clinical case: By presenting a series of clinical cases and reviewing the literature, our initial experience is presented, key elements are summarized and discussed in the understanding of this new intervention technique necessary for decision making. Conclusion: Coronary intravascular lithotripsy is projected as a promising technique for the modification and preparation of superficial and deep calcified coronary lesions, through microfractures that allow the apposition and effective expansion of the stent, strategy that according to different trials (Disrupt CAD series, SOLSTICE assay) and records presents a high efficiency and good safety profile, data consistent with our initial experience.

Introducción: las lesiones coronarias calcificadas complejas son un hallazgo frecuente durante el intervencionismo coronario percutáneo, han representado durante décadas un desafío y limitante en pacientes con indicación de revascularización, debido a resultados angiográficos subóptimos, alta incidencia de complicaciones perioperatorias y eventos adversos a largo plazo a pesar de las múltiples estrategias empleadas, como el uso de balones de corte, balones de alta presión o la aterectomía rotacional u orbital, intervenciones con limitantes que han dificultado su uso rutinario. Recientemente, una nueva técnica de modificación de placa conocida como litotricia intravascular coronaria ha irrumpido en el tratamiento de esta compleja entidad, la cual consiste en la utilización de un balón especialmente modificado para la emisión de energía mecánica pulsátil (ondas de presión sónicas) que permite modificar la placa calcificada. Caso clínico: mediante la presentación de una serie de casos clínico y revisión de literatura se presenta nuestra experiencia inicial, se resume y discuten elementos claves en el entendimiento de esta nueva técnica de intervencionismo necesarios para la toma de decisiones. Conclusión: la litotricia intravascular coronaria se proyecta como una técnica prometedora para la modificación y preparación de lesiones coronarias calcificadas superficiales y profundas, mediante microfracturas que permiten la aposición y expansión efectiva del stent; estrategia que de acuerdo con diferentes ensayos (serie Disrupt CAD, ensayo SOLSTICE) y registros presenta una eficacia alta y buen perfil de seguridad, datos concordantes con nuestra experiencia inicial.

Protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad en el diagnóstico del dolor torácico: una revisión sistemática / Accelerated Diagnostic Protocols Based on High-Sensitivity Troponin in the Diagnosis of Thoracic Pain: A Systematic Review

RESUMEN Introducción: Los protocolos de diagnóstico acelerado de dolor torácico, con el avance de la troponina de alta sensibilidad, permiten identificar a los pacientes que ingresan al servicio de urgencias con dolor torácico de bajo riesgo para un evento cardiovascular adverso mayor, que podrían ser dados de alta de forma temprana y segura, con ahorro de tiempo y recursos. Objetivo: Evaluar ensayos clínicos que utilicen protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad. Material y métodos: se realizó una búsqueda de ensayos clínicos aleatorizados que evaluaran protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad en los servicios de urgencias, en las bases de datos MEDLINE/Ovid, Cochrane y EMBASE utilizando los criterios de evaluación del manual Cochrane y la estrategia PRISMA Resultados: Tras una tamización de 3509 estudios se incluyeron 5 ensayos clínicos que incluyeron 1513 pacientes; se identificaron 409 (27%) altas tempranas, el 91% para el protocolo 0/3 h ESC, 72% para el 0/1 h, 48% para el EDACS, 40% para el HEART, 19 y 32% para ADAPT y 8 y 18% para el cuidado usual. El valor predictivo negativo fue alto, en un rango de 99,1 al 100% La duración media de la estancia hospitalaria fue más baja para los protocolos 0/1 h y 0/3 h ESC, con 4,6 y 5,6 horas respectivamente. Conclusiones: Los protocolos de diagnóstico acelerado en dolor torácico que implementan el uso de troponina de alta sensibilidad permiten lograr alta proporción de altas tempranas con baja tasa de eventos cardiovasculares mayores, con disminución del tiempo de estancia y recursos consumidos.

ABSTRACT Background: Accelerated diagnostic protocols for chest pain, with the advancement of high-sensitivity troponin, make it possible to identify patients admitted to the emergency department with chest pain and low risk for a major adverse cardiovascular event, who could be discharged immediately, early and safely, saving time and resources. Objective: The aim of this study was to assess clinical trials using accelerated diagnostic protocols based on high-sensitivity troponin. Methods: A search of randomized clinical trials evaluating accelerated diagnostic protocols based on high-sensitivity troponin in emergency services was carried out in MEDLINE/Ovid, Cochrane and EMBASE database, using the assessment criteria of the Cochrane manual and the PRISMA strategy. Results: After screening 3509 studies, 5 clinical trials, including 1513 patients, were analyzed. Early discharges were identified in 409 (27%) of patients, in 91% of cases for ESC 0/3-h protocols, 72% for 0/1-h, 48% for EDACS, 40% for HEART, 19% and 32% for ADAPT and 8% and 18% for standard care protocols. The negative predictive value was high, in the 99.1-100% range. Mean length of hospital stay was lower for the 0/1-h and ESC 0/3-h protocols, with 4.6 and 5.6 hours, respectively. Conclusions: Accelerated diagnostic protocols in chest pain using high-sensitivity troponin allow a higher proportion of early discharges with a low rate of major cardiovascular events, with reduction in length of hospital stay and resources used.

Aterectomía rotacional complicada en una paciente anciana con enfermedad coronaria multivaso. Reporte de caso

La aterectomía rotacional es un procedimiento específico utilizado para el manejo de lesiones coronarias complejas, especialmente cuando existe calcificación de las arterias coronarias (CAC). Esta técnica fue muy utilizada hasta la última década del siglo pasado; actualmente, aunque es poco usada, juega un papel importante en pacientes que podrían ser candidatos a revascularización quirúrgica pero que, por diferentes patologías ―como la enfermedad ateromatosa difusa, en la que se requieren estents largos, reestenosis in-stent, lesiones ostiales calcificadas y oclusiones totales crónicas―, se rechaza la opción quirúrgica. La aterectomía rotacional es un método que utiliza una fresa recubierta de diamante para reducir el volumen de las placas ateroescleróticas y la calcificación de los vasos. Este dispositivo dispersa la placa en microfragmentos, con lo que se consigue un aumento del diámetro luminal. Estos fragmentos, que tienen un diámetro mínimo, pasan predominantemente a la circulación capilar y luego son absorbidos por el sistema reticuloendotelial. Dentro de las complicaciones de esta técnica destacan la disección arterial, el atrapamiento del dispositivo, la bradicardia y la microperforación de arterias coronarias. Esta última puede ser corregida con el uso de trombina, de grasa subcutánea o de perlas. Este artículo reporta el caso de una paciente anciana con enfermedad coronaria multivaso asociada a calcificación extensa de todas las arterias coronarias, por una historia de radioterapia recibida en años anteriores por cáncer de mama y que, al no ser candidata a terapia quirúrgica por cirugía cardiovascular, requirió manejo con aterectomía rotacional que se vio complicada por microperforación de una arteria coronaria, pero que posteriormente evolucionó de manera satisfactoria.

Rotational atherectomy is a specific procedure for managing complex coronary artery lesions, especially when there is coronary artery calcification (CAC). This technique was widely used until the last decade of the 20th century; however, although it is rarely used, it currently plays an important role in patients who could be candidates for surgical revascularization but reject surgeries due to different pathologies-such as diffuse atheromatous disease requiring long stents, in-stent restenosis, calcified ostial lesions and chronic total occlusions. Rotational atherectomy is a method that uses a diamond-coated burr to reduce the volume of atherosclerotic plaques and calcification of vessels. This device breaks up plaque into microfragments, leading to an increase in lumen diameter. These fragments, which have a tiny diameter, pass predominantly into the capillary circulation and are then absorbed by the reticuloendothelial system. Among the complications of this technique are arterial dissection, device entrapment, bradycardia and microperforation of coronary arteries. The latter can be corrected with the use of thrombin, subcutaneous fat or beads. This article reports the case of an elderly female patient with multivessel coronary artery disease associated with extensive calcification of all the coronary arteries secondary to radiotherapy received in previous years for breast cancer. The patient, not being a candidate for cardiovascular surgery, required a rotational atherectomy that resulted in a microperforation of a coronary artery but with good subsequent progress.

Assessment of long-term cognitive dysfunction in older patients who undergo heart surgery.

INTRODUCTION: Older patients are more likely to have cognitive dysfunction, and a great proportion of patients undergone surgical procedures are older adults. Postoperative cognitive dysfunction (POCD) has been shown as a consistent complication after major surgical procedures such as heart surgery. AIM: To determine the presence of long-term POCD in ≥65-year-old patients undergoing coronary artery bypass grafting and aortic valve replacement, and to establish related risk factors. METHODS: We prospectively and sequentially included 44 patients with coronary disease and aortic stenosis scheduled for heart surgery. Follow-up of all patients was standardized and a neurocognitive evaluation were performed preoperatively and at 1, 6 and 12 months after surgery. RESULTS: Patients experienced a significantly postoperative cognitive dysfunction (33.5%, 63.4% and 38.9% at 1, 6 and 12 months, respectively) from baseline (20.5%). Patient-associated aspects such as age (p<0.01), history of smoking (p<0.01), arterial hypertension (p=0.022), diabetes mellitus (p=0.024), heart failure (p=0.036) and preoperative cognitive dysfunction (p<0.01), and surgery-associated aspects such as EuroSCORE (p<0.01) and operation time (p<0.01) were identified as related risk factors. CONCLUSIONS: Older patients who underwent heart surgery had long-term POCD. Both patient- and surgery-related risk factors were established as related risk factors. These findings suggest that the prevalence of cognitive dysfunction after cardiac surgery in older patients could be related to a possible progression to dementia. In addition, many of the risk factors identified may be modifiable but in practice, these patients are not attended to for their possible cognitive impairment.

Serum and genetic markers related to rapid clinical progression of coronary artery disease.

INTRODUCTION AND OBJECTIVES: Patients with clinically evident coronary artery disease differ in their rate of progression, which impacts prognosis. We aimed to characterize serum and genetic markers in patients with rapid clinical progression (RCP) of coronary artery disease vs those with long standing stable (LSS) disease. METHODS: Retrospective study of cases (RCP) and controls (LSS) (1:2). Patients requiring ≥ 2 revascularizations due to atherosclerotic progression in the 10 years after a first angioplasty were considered to be RCP and those without events during the same period after the first angioplasty were considered to have LSS disease. After patient selection, we analyzed serum values, mRNA expression and genetic polymorphisms of inflammatory markers, including interleukin-6, C-reactive protein, and tumor necrosis factor (TNF)-a, and atherogenic markers consisted of proprotein convertase subtilisin/kexin type 9 (PCSK9), low-density lipoprotein receptor, sterol regulatory element binding transcription factor 2, and apolipoprotein-B. RESULTS: The study included 180 patients (58 RCP and 122 LSS). Demographic characteristics, classic risk factors and the extent of coronary disease were similar in the 2 groups. Patients with RCP showed higher serum levels of interleukin-6 and PCSK9 and higher TNF mRNA expression. Interleukin-6 rs180075C, TNF rs3093664 non-G and PCSK9 rs2483205 T alleles conferred a risk of RCP (P<.05 in all cases). Among patients with RCP, 51.7% had all 3 risk alleles vs 18% of those with LSS (P<.001). CONCLUSIONS: We suggest the existence of specific phenotypic and genotypic markers associated with RCP of coronary artery disease that could help to individualize the type and intensity of treatment.

Angina in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement.

INTRODUCTION AND OBJECTIVES: To evaluate the prevalence, clinical characteristics, and outcomes of patients with angina undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. METHODS: A total of 1687 consecutive patients with severe aortic stenosis undergoing TAVR at our center were included and classified according to patient-reported angina symptoms prior to the TAVR procedure. Baseline, procedural and follow-up data were collected in a dedicated database. RESULTS: A total of 497 patients (29%) had angina prior to the TAVR procedure. Patients with angina at baseline showed a worse New York Heart Association (NYHA) functional class (NYHA class> II: 69% vs 63%; P=.017), a higher rate of coronary artery disease (74% vs 56%; P <.001), and a lower rate of complete revascularization (70% vs 79%; P <.001). Angina at baseline had no impact on all-cause mortality (HR, 1.02; 95%CI, 0.71-1.48; P=.898) and cardiovascular mortality (HR, 1.2; 95%CI, 0.69-2.11; P=.517) at 1 year. However, persistent angina at 30 days post-TAVR was associated with increased all-cause mortality (HR, 4.86; 95%CI, 1.71-13.8; P=.003) and cardiovascular mortality (HR, 20.7; 95%CI, 3.50-122.6; P=.001) at 1-year follow-up. CONCLUSIONS: More than one-fourth of patients with severe aortic stenosis undergoing TAVR had angina prior to the procedure. Angina at baseline did not appear to be a sign of a more advanced valvular disease and had no prognostic impact; however, persistent angina at 30 days post-TAVR was associated with worse clinical outcomes.

Clinical profile and prognosis of young patients with ST-elevation myocardial infarction managed by the emergency-intervention Codi IAM network.

INTRODUCTION AND OBJECTIVES: Data on the clinical profile and outcomes of younger patients with ST-elevation myocardial infarction (STEMI) is scarce. This study compared clinical characteristics and outcomes between patients aged<45 years and those aged ≥ 45 years with STEMI managed by the acute myocardial infarction code (AMI Code) network. Sex-based differences in the younger cohort were also analyzed. METHODS: This multicenter study collected individual data from the Catalonian AMI Code network. Between 2015 and 2020, we enrolled patients with an admission diagnosis of STEMI. Primary endpoints were all-cause mortality within 30 days, 1 year, and 2 years. RESULTS: Overall, 18 933 patients (23% female) were enrolled. Of them, 1403 participants (7.4%) were aged<45 years. Younger patients with STEMI were more frequently smokers (P<.001) and presented with cardiac arrest and TIMI flow 0 before pPCI (P<.05), but the time from first medical contact to wire crossing was shorter than in the older group (P<.05). All-cause mortality rates were lower in patients aged<45 years (P<.001). Among younger patients, cardiogenic shock was most prevalent in women than in their male counterparts (P=.002), with the time from symptom onset to reperfusion being longer (P<.05). Compared with men aged<45 years, younger women were less likely to undergo pPCI (P=.004). CONCLUSIONS: Despite showing high-risk features on admission, young patients exhibit better outcomes than older patients. Differences in ischemia times and treatment were observed between men and women.

Dietary modulation of advanced glycation end products metabolism on carotid intima-media thickness in type 2 diabetes patients: From the CORDIOPREV study.

BACKGROUND: Advanced glycation end products (AGEs) are pro-oxidant and cytotoxic compounds involved in the progression of chronic diseases as cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). The total body burden of AGEs also depend of those consume through the diet. Our aim was to analyze whether the reduction of AGE levels, after the consumption of two-healthy diets were associated with a greater decrease of intima-media thickness of both common carotid arteries (IMT-CC) in patients with T2DM and coronary heart disease (CHD). METHODS: 540 CHD patients with T2DM, at baseline, from the CORDIOPREV study, were divided into two groups: (1) Responders, patients whose IMT-CC was reduced or not changed after dietary intervention and (2) Non-responders, patients whose IMT-CC was increased after dietary intervention. A total of 423 completed baseline and the 5-year follow-up carotid ultrasounds were analyzed in this study. RESULTS: Our data showed that Responders, despite had a higher baseline IMT-CC and serum methylglyoxal (MG) levels than Non-responders, showed a reduction of serum levels of this glycotoxin after dietary intervention. Conversely, in patients whose IMT-CC was increased after dietary intervention (Non-responders), serum MG levels were increased. Moreover, an increase of circulating level of AGEs (and in particular, MG), after dietary intervention, could be considered a risk factor for the progression of atherosclerosis in patients with T2DM and CHD. CONCLUSION: These results support the importance of identifying underlying mechanisms in the context of secondary prevention of CVD that would provide therapeutic targets to reduce the high risk of cardiovascular events of these patients. CLINICAL TRIAL REGISTRATION-URL: https://clinicaltrials.gov/ct2/show/NCT00924937. Unique Identifier: NCT00924937.

Impacto de la rehabilitación cardiaca de 8 vs 12 semanas sobre la calidad de vida de personas con angioplastia. Ensayo clínico aleatorizado / Impact of an 8 and 12-week Cardiac Rehabilitation Program on the Perception of Quality of Life in Patients with Coronary Angioplasty. A Randomized Controlled Trial

Introducción. La evaluación de la calidad de vida es un resultado de salud que comúnmente se asocia con la eficacia de los tratamientos derivados a los pacientes con enfermedad de las arterias coronarias. Específicamente, la literatura no es clara con respecto al papel de la rehabilitación cardíaca sobre la calidad de vida en población sometida a revascularización coronaria. Objetivo. Determinar si existen diferencias en la percepción de calidad de vida relacionada con la salud, después de asistir a un programa de rehabilitación cardiaca de 8 semanas comparado con uno de 12 semanas en personas post revascularización percutánea. Métodos. Ensayo clínico controlado aleatorizado, conformado por personas que asisten a rehabilitación cardíaca, divididas en dos grupos de estudio (8 y 12 semanas), quienes se evaluaron a través del Cuestionario SF-36.Resultados. La muestra estuvo conformada por 17 personas, con edad promedio de 63.1±6.9 años. Al comparar la evaluación pre y posttratamiento en cada grupo, se encontraron diferencias significativas en los dominios función física y rol físico en el grupo de 8 semanas; al realizar la comparación entre grupos hubo diferencias en el dominio emocional. Conclusión. Los resultados del estudio no evidenciaron diferencias en cuanto a la calidad de vida relacionada con la salud entre los grupos de estudio en el resultado global del cuestionario SF-36. Sin embargo, al comparar las dos intervenciones, el grupo de 8 semanas demostró mejores valores sobre el rol emocional

Introduction. The evaluation of quality of life is a health outcome that is commonly associated with the efficacy of treatments derived from patients with coronary artery disease. The literature is unclear regarding the role of cardiac rehabilitation on quality of life in the population undergoing coronary revascularization.Aim. To determine if there are differences in perception of health-related quality of life after attending an 8-week cardiac rehabilitation program compared to a 12-week program in people after coronary angioplasty. Methods. Randomized controlled clinical trial that included people with coronary angioplasty, who attended a cardiac rehabilitation program, divided in two groups (8 and 12 weeks), who were evaluated through the 8 domains of Short Form-36 Health Survey (SF-36). Results. The sample was made up of 17 people, with an average age of 63.1 ± 6.9 years. When comparing the evaluation before and after treatment in each group, sta-tistical differences were found in the physical-functioning and role-physical in 8 weeks group. Comparation between group show differences in role-emotional. Conclusion. The results of the present study did not show differences between the global score on health-related quality of life. However, when comparing the two in-terventions, the 8-week group showed better values on the role-emotional.

Efeitos da intervenção terapêutica de enfermagem em pacientes com doença cardíaca coronária / Efectos de la intervención terapéutica de enfermería en pacientes con enfermedad arterial coronaria / Effects of nursing intervention therapy on patients with coronary heart disease

Resumo Objetivo Avaliar os efeitos da intervenção terapêutica de enfermagem baseada no modelo de trajetória da doença crônica na ansiedade e na qualidade de vida de pacientes com doença cardíaca coronária (DCC). Métodos Um total de 118 pacientes com DCC admitidos entre fevereiro de 2019 e fevereiro de 2021 foram distribuídos aleatoriamente em grupos controle e observação (n = 59). O grupo controle recebeu intervenção de enfermagem de rotina, enquanto o grupo observação recebeu intervenção com base no modelo de trajetória da doença crônica. Os sintomas clínicos, a escala de autoavaliação de ansiedade (SAS), a qualidade de vida (QV) e as pontuações de autoeficácia foram comparados. As taxas de incidência de complicações foram comparadas. A análise de regressão linear multivariada foi realizada para o efeito mediador da autoeficácia na relação entre ansiedade e QV. Um modelo de equação estrutural foi construído e validado. Resultados Após a intervenção, os sintomas clínicos e a pontuação da SAS diminuíram significativamente em ambos os grupos, especialmente no grupo observação (P<0,05). As pontuações de QV e autoeficácia aumentaram significativamente em ambos os grupos, particularmente no grupo de observação (P<0,05). A pontuação de autoeficácia correlacionou-se negativamente com a pontuação SAS e positivamente com a pontuação QV. Houve correlação negativa entre a pontuação SAS e a pontuação QV (P<0,05). O modelo de autoeficácia, ansiedade e QV apresentou boa adequação, e o efeito mediador da autoeficácia na relação entre ansiedade e QV foi de 0,896. A taxa de incidência de complicações foi significativamente menor no grupo observação do que no grupo controle (P <0,05). Conclusão A intervenção de enfermagem baseada no modelo de trajetória da doença crônica alivia significativamente a ansiedade, melhora a QV e aumenta a pontuação de autoeficácia de pacientes com DCC. A autoeficácia é um mediador da relação entre ansiedade e QV.

Resumen Objetivo Evaluar los efectos de la intervención terapéutica de enfermería con base en el modelo de trayectoria de la enfermedad crónica en la ansiedad y en la calidad de vida de pacientes con enfermedad arterial coronaria (EAC). Métodos Un total de 118 pacientes con EAC admitidos entre febrero de 2019 y febrero de 2021 fueron distribuidos aleatoriamente en grupos control y observación (n = 59). El grupo control recibió intervención de enfermería de rutina, mientras el grupo observación recibió intervención con base en el modelo de trayectoria de la enfermedad crónica. Se compararon los síntomas clínicos, la escala de autoevaluación de ansiedad (EAA), la calidad de vida (CV) y el puntaje de autoeficacia. Se compararon las tasas de incidencia de complicaciones. El análisis de regresión lineal multivariado se realizó para el efecto mediador de la autoeficacia en la relación entre ansiedad y CV. Se elaboró y validó un modelo de ecuación estructural. Resultados Después de la intervención, los síntomas clínicos y el puntuaje de la EAA disminuyeron de forma considerable en ambos grupos, especialmente en el grupo observación (P<0,05). Los puntajes de CV y de autoeficacia aumentaron considerablemente en ambos grupos, particularmente en el grupo de observación (P<0,05). El puntaje de autoeficacia se correlacionó negativamente con el puntaje EAA y positivamente con el puntaje CV. Hubo una correlación negativa entre el puntaje EAA y el puntaje CV (P<0,05). El modelo de autoeficacia, ansiedad y CV presentó una buena adecuación y el efecto mediador de la autoeficacia en la relación entre ansiedad y CV fue de 0,896. La tasa de incidencia de complicaciones fue considerablemente inferior en el grupo observación que en el grupo control (P <0,05). Conclusión La intervención de enfermería con base en el modelo de trayectoria de la enfermedad crónica alivia de forma considerable la ansiedad, mejora la CV y aumenta el puntaje de autoeficacia de pacientes con EAC. La autoeficacia es un mediador de la relación entre ansiedad y CV.

Abstract Objective We aimed to assess the effects of nursing intervention therapy based on chronic disease trajectory model on anxiety and quality of life (QOL) of patients with coronary heart disease (CHD). Methods A total of 118 CHD patients admitted from February 2019 to February 2021 were randomly assigned into control and observation groups (n=59). Control group was given routine nursing intervention, while observation group was given intervention based on chronic disease trajectory model. Clinical symptom, self-rating anxiety scale (SAS), QOL and self-efficacy scores were compared. Incidence rates of complications were compared. Multivariate linear regression analysis was performed for the mediating effect of self-efficacy on relationship between anxiety and QOL. A structural equation model was constructed and verified. Results After intervention, clinical symptom and SAS scores significantly declined in both groups, especially in observation group (P<0.05). QOL and self-efficacy scores rose significantly in both groups, particularly in observation group (P<0.05). Self-efficacy score was negatively correlated with SAS score and positively correlated with QOL score, and there was a negative correlation between SAS score and QOL score (P<0.05). The model of self-efficacy, anxiety and QOL had good fitness, and the mediating effect of self-efficacy on relationship between anxiety and QOL was 0.896. The incidence rate of complications was significantly lower in observation group than in control group (P<0.05). Conclusion Nursing intervention based on chronic disease trajectory model significantly relieves the anxiety, improves QOL, and increases the self-efficacy score of CHD patients. Self-efficacy is a mediator for the relationship between anxiety and QOL.

Interacciones en el tratamiento antitrombótico e hipoglucemiante / Interactions in antithrombotic and hypoglycemic therapy

Resumen Esta revisión consiste en una puesta al día del tratamiento antiplaquetario y la interacción que presenta con los hipoglucemiantes orales en pacientes diabéticos con cardiopatía isquémica. Re sumimos los principales mecanismos fisiopatológicos que intervienen en el aumento del riesgo cardiovascular en este grupo, los efectos de la combinación entre los hipoglucemiantes orales, sus efectos antitrombóticos y su interacción con los antiplaquetarios y, por último, los trabajos que estudiaron los beneficios de los antiplaque tarios en pacientes diabéticos en diferentes escenarios de la cardiopatía isquémica. Los variados mecanismos de acción implican una mejora del control de la glucemia, del aumento de la biodisponibilidad del óxido nítrico, reducción del estrés oxidativo y, para ciertas moléculas, una inhibición directa de la activación y de la agregación plaquetaria.

Abstract This review is an update on antiplatelet therapy and its interaction with oral hypoglycemic agents in diabetic patients with ischemic heart disease. We summarize the main pathophysiological mechanisms that intervene in diabetic patients and that increase the ischemic risk, the effects of the combination of oral hypoglycemic agents, their antithrombotic ef fects and their interaction with antiplatelet, and finally the studies that demonstrated the benefits of antiplatelet in diabetic patients in different scenarios of ischemic heart disease. The different mechanisms of action involve improved glycemic control, increased bioavailability of nitric oxide, reduced oxidative stress and, for certain mol ecules, direct inhibition of platelet activation and aggregation.

Infarto agudo de miocardio en mujer joven con diagnóstico de lupus eritematoso sistémico / Acute myocardial infarction in a young woman with systemic lupus erythematosus

Resumen Se presenta un caso de infarto agudo de miocardio con elevación del segmento ST en una paciente de 22 años de edad, con LES, HTA y nefropatía a la cual se le realizó angioplastia coronaria exitosa a tercio medio de arteria descendente anterior. Evolucionó sin signos de insuficiencia cardiaca, sin embargo, debido al retraso en el diagnóstico presentó deterioro grave de la función ventricular. El infarto agudo de miocardio con elevación del ST es un evento muy poco frecuente en mujeres pre menopáusicas pero, en comparación con la población general las pacientes con lupus eritematoso sistémico presentan al menos un 50% más de riesgo de padecerlo independientemente de la edad. En esta población, las etiologías más frecuentes son la vasculitis, la aterosclerosis precoz y la trombosis secundaria a síndrome antifosfolipídico. A su vez, en contexto de lupus, se han descripto condiciones como la presencia de nefritis lúpica, que favorecen aún más a la aparición del infarto de miocardio, constituyendo subgrupos de mayor riesgo. El incremento del riesgo de IAM en los pacientes con LES debe tenerse en cuenta y hay que sospechar como diagnóstico diferencial del dolor precordial aún en mu jeres jóvenes, incluso menores de 25 años, población categorizada como de bajo riesgo cardiovascular según los scores y criterios tradicionales. Esto evitaría las demoras en el diagnóstico y tratamiento con consecuencias pronósticas adversas como la necrosis miocárdica extensa y su impacto negativo sobre la función sistólica ventricular como ocurrió en esta paciente.

Abstract We repor a case of acute ST elevation myocardial infarction in a 22-year-old patient with SLE, hypertension and nephropathy who underwent successful coronary angioplasty to a middle third of the left an terior descending artery. She evolved without signs of heart failure however, due to the delay in diagnosis, she presented severe deterioration of ventricular function. ST segment elevation myocardial infarction is a very rare event in young premenopausal women, but compared to the general population, patients with lupus have at least a 50% higher risk of suffering it regardless their age. In this population, the most frequent causes are vasculitis, early atherosclerosis and secondary thrombosis to antiphospholipid syndrome. In the context of lupus, conditions such as the presence of nephritis have been described as favoring the appearance of myocardial infarction, constituting subgroups of higher risk. The increased risk of AMI in patients with SLE must be taken into account and must be suspected as a differential diagnosis of precordial pain in young women, even those under 25 years of age, a population categorized as having low CV risk according to traditional scores. This would avoid delays in diagnosis and treatment with adverse consequences such as extensive myocardial necrosis and its impact on ventricular systolic function, as occurred in this patient.

Características clínico-epidemiológicas del síndrome coronario agudo

RESUMEN Fundamento: las enfermedades cardiovasculares se consideran un problema de salud a nivel mundial, entre ellas, el infarto agudo de miocardio ocupa un lugar relevante y representa una de las primeras causas de muerte en la mayoría de los países. Objetivo: describir las características clínico-epidemiológicas de los pacientes ingresados por síndrome coronario agudo con elevación del segmento ST en el Servicio de Cardiología y Unidad de Cuidados Coronarios del Hospital General Docente Enrique Cabrera de La Habana. Método: se realizó un estudio descriptivo y transversal en pacientes con diagnóstico de síndrome coronario agudo con elevación del segmento ST ingresados en la unidad de cuidados coronarios desde septiembre de 2018 hasta septiembre 2021. Se estudiaron 423 pacientes y se analizaron las variables sociodemográficas y clínicas. En el análisis estadístico las variables se expresaron como media para las variables continuas y frecuencia y proporción para las variables categóricas utilizando el porcentaje como medida de resumen. Para cuantificar un posible riesgo se utilizó la prueba de Productos Cruzados u Odd Ratio con un intervalo de confianza del 95 % calculado por el método de Woolf. Resultados: se observó predominio del sexo masculino (71,2 %) y la edad promedio fue de 62,31 años. El 74,2 % de los pacientes presentaron hipertensión arterial y 62,2 % fueron fumadores. Se presentó la insuficiencia cardiaca, la hipotensión y la pericarditis como complicaciones más frecuentes. El tratamiento con la terapia trombolítica se administró en la mayoría de los pacientes y la mortalidad se presentó en un 5,6 %. Conclusiones: la hipertensión arterial y el tabaquismo predominaron dentro de los factores de riesgo. La insuficiencia cardiaca fue la complicación más frecuente. Los pacientes con infarto anterior extenso y diabetes mellitus presentaron una probabilidad mayor de complicaciones.

ABSTRACT Background: cardiovascular diseases are considered a health problem worldwide, among them, acute myocardial infarction occupies a relevant place and represents one of the leading causes of death in most countries. Objective: to describe the clinical-epidemiological characteristics of patients admitted for ST-segment elevation acute coronary syndrome in the Cardiology Service and Coronary Care Unit of the Enrique Cabrera General Teaching Hospital in Havana. Method: a descriptive and cross-sectional study was carried out in patients diagnosed with ST-segment elevation acute coronary syndrome admitted to the coronary care unit from September 2018 to September 2021. 423 patients were studied and sociodemographic and clinical variables were analyzed. In the statistical analysis, the variables were expressed as mean for continuous variables and frequency and proportion for categorical variables, using the percentage as a summary measure. To quantify a possible risk, the Cross Products or Odd Ratio test was used with a 95 % confidence interval calculated by the Woolf method. Results: there was a predominance of males (71.2 %) and the average age was 62.31 years. 74.2 % of the patients had high blood pressure and 62.2 % were smokers. Heart failure, hypotension and pericarditis were presented as the most frequent complications. Treatment with thrombolytic therapy was administered in the majority of patients and mortality was 5.6 %. Conclusions: arterial hypertension and smoking predominated within the risk factors. Heart failure was the most frequent complication. Patients with extensive anterior infarction and diabetes mellitus had a higher probability of complications.