Latin-American guidelines of recommendations at discharge from an acute coronary syndrome.

The diagnostic criteria, treatments at the time of admission, and drugs used in patients with acute coronary syndrome are well defined in countless guidelines. However, there is uncertainty about the measures to recommend during patient discharge planning. This document brings together the most recent evidence and the standardized and optimal treatment for patients at the time of discharge from hospitalization for an acute coronary syndrome, for comprehensive and safe care in the patient's transition between care from the acute event to the outpatient care, with the aim of optimizing the recovery of viable myocardium, guaranteeing the most appropriate secondary prevention, reducing the risk of a new coronary event and mortality, as well as the adequate reintegration of patients into daily life.

Los criterios diagnósticos, los tratamientos en el momento de la admisión y los fármacos utilizados en pacientes con síndrome coronario agudo están bien definidos en innumerables guías. Sin embargo, existe incertidumbre acerca de las medidas para recomendar durante la planificación del egreso de los pacientes. Este documento reúne las evidencias más recientes y el tratamiento estandarizado y óptimo para los pacientes al momento del egreso de una hospitalización por un síndrome coronario agudo, para un cuidado integral y seguro en la transición del paciente entre la atención del evento agudo y el cuidado ambulatorio, con el objetivo de optimizar la recuperación de miocardio viable, garantizar la prevención secundaria más adecuada, reducir el riesgo de un nuevo evento coronario y la mortalidad, así como la adecuada reinserción de los pacientes en la vida cotidiana.

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. 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. This study is registered at PROSPERO (CRD42023457794).

Stasis imaging predicts the risk of cardioembolic events related to acute myocardial infarction: the ISBITAMI study.

INTRODUCTION AND OBJECTIVES: In the setting of ST-segment elevation myocardial infarction (STEMI), imaging-based biomarkers could be useful for guiding oral anticoagulation to prevent cardioembolism. Our objective was to test the efficacy of intraventricular blood stasis imaging for predicting a composite primary endpoint of cardioembolic risk during the first 6 months after STEMI. METHODS: We designed a prospective clinical study, Imaging Silent Brain Infarct in Acute Myocardial Infarction (ISBITAMI), including patients with a first STEMI, an ejection fraction ≤ 45% and without atrial fibrillation to assess the performance of stasis metrics to predict cardioembolism. Patients underwent ultrasound-based stasis imaging at enrollment followed by heart and brain magnetic resonance at 1-week and 6-month visits. From the stasis maps, we calculated the average residence time, RT, of blood inside the left ventricle and assessed its performance to predict the primary endpoint. The longitudinal strain of the 4 apical segments was quantified by speckle tracking. RESULTS: A total of 66 patients were assigned to the primary endpoint. Of them, 17 patients had 1 or more events: 3 strokes, 5 silent brain infarctions, and 13 mural thromboses. No systemic embolisms were observed. RT (OR, 3.73; 95%CI, 1.75-7.9; P<.001) and apical strain (OR, 1.47; 95%CI, 1.13-1.92; P=.004) showed complementary prognostic value. The bivariate model showed a c-index=0.86 (95%CI, 0.73-0.95), a negative predictive value of 1.00 (95%CI, 0.94-1.00), and positive predictive value of 0.45 (95%CI, 0.37-0.77). The results were confirmed in a multiple imputation sensitivity analysis. Conventional ultrasound-based metrics were of limited predictive value. CONCLUSIONS: In patients with STEMI and left ventricular systolic dysfunction in sinus rhythm, the risk of cardioembolism may be assessed by echocardiography by combining stasis and strain imaging. Registered at ClinicalTrials.gov (NCT02917213).

La administración de N-acetilcisteína atenúa el remodelado post infarto de miocardio / Administration of N-acetylcysteine Attenuates Post-Myocardial Infarction Remodeling

RESUMEN Introducción: La cardiopatía isquémica es la principal causa de muerte en la República Argentina. La forma de presentación que prevalece es el infarto de miocardio (IM), caracterizado por insuficiente perfusión sanguínea, muerte celular y pérdida de masa contráctil. La evolución del remodelado ventricular provoca dilatación ventricular, deterioro hemodinámico, insuficiencia cardíaca y disminución de la sobrevida. Durante este proceso existe un estrés oxidativo miocárdico que podría ser atenuado mediante la administración de N-acetil cisteína (NAC), a través de un aumento de los niveles de glutatión. Objetivos: Evaluar el efecto de la NAC sobre el remodelado post IM. Material y métodos: Se estudiaron durante 28 días conejos neozelandeses en tres grupos experimentales: Control, IM e IM+NAC. Bajo anestesia general se realizó una toracotomía izquierda y, en los grupos con IM, ligadura de una rama de la coronaria izquierda. Al finalizar el período de seguimiento posterior al infarto, se realizaron estudios ecocardiográficos, hemodinámicos y morfológicos del ventrículo izquierdo (VI). Resultados: En los grupos IM e IM+NAC los infartos estaban ubicados en la pared libre del VI y tuvieron tamaños similares. La administración de NAC evitó el adelgazamiento de la zona no infartada y disminuyó la dilatación provocada por el infarto. También pudo observarse que preservó las funciones sistólica y diastólica del VI, con atenuación del deterioro que las mismas sufrieron como consecuencia del infarto. Conclusión: Estos resultados sugieren que la administración de NAC es una terapéutica promisoria para mitigar los efectos desfavorables del remodelado post IM.

ABSTRACT Background: Ischemic heart disease is the main cause of death in Argentina. The prevailing form of presentation is myocardial infarction (MI), characterized by insufficient blood perfusion, cell death and loss of contractile mass. The evolution of ventricular remodeling causes ventricular dilation, hemodynamic impairment, heart failure, and decreased survival. The oxidative stress occurring during this process could be attenuated by the administration of N-acetyl cysteine (NAC) through increased glutathione levels. Objectives: The aim of this study was to evaluate the effect of NAC administration on post-MI remodeling. Methods: New Zealand rabbits were divided into three experimental groups: Control, MI and MI+NAC. A left thoracotomy was performed under general anesthesia, and in the MI groups a branch of the left coronary artery was ligated. Echocardiographic, hemodynamic and morphological studies of the left ventricle were performed at the end of the 28-day post infarction follow-up period. Results: In the MI and MI+NAC groups, the infarcts were located in the left ventricular free wall and had similar sizes. The administration of NAC prevented non-infarcted area thinning and decreased the dilation caused by the infarction. It also preserved left ventricular systolic and diastolic functions, attenuating the impairment that they suffered as a consequence of the infarction. Conclusion: These results suggest that NAC administration is a promising therapy to mitigate the unfavorable effects of post-MI remodeling.

Ceftriaxone-induced Kounis syndrome: A case report and review of the literature.

Kounis syndrome is defined as cardiovascular symptoms that occur secondary to allergic or hypersensitivity insults, and is also called allergic angina and allergic myocardial infarction. We report a case of pre-operative ceftriaxone-induced Kounis syndrome with no evident dermatological manifestation, and describe our diagnostic dilemma. The patient was symptomatically managed and discharged in stable condition with a warning against future use of ceftriaxone.

Ten-year prognostic impact of target versus non-target vessel failure after STEMI. Insight from the EXAMINATION-EXTEND trial.

INTRODUCTION AND OBJECTIVES: After ST-segment myocardial infarction (STEMI), the impact of different adverse events on prognosis remains unknown. We aimed to assess very long-term predictors of patient-oriented composite endpoints (POCE) and investigate whether the occurrence of target vessel failure (TVF) vs a non-TVF event as the first event could potentially influence subsequent outcomes. METHODS: The EXAMINATION-EXTEND trial randomized STEMI patients to receive either an everolimus-eluting stent or a bare-metal stent. The follow-up period was 10 years. Predictors of POCE (a composite of all-cause death, any myocardial infarction, or any revascularization) were evaluated in the overall study population. The patients were stratified based on the type of first event (TVF-first vs non-TVF-first) and were compared in terms of subsequent POCE. TVF was defined as a composite of cardiac death, TV myocardial infarction, or TV revascularization. RESULTS: Out of the 1498 enrolled patients, 529 (35.3%) experienced a POCE during the 10-year follow-up. Independent predictors of POCE were age, diabetes mellitus, previous myocardial infarction, peripheral arterial disease, and multivessel coronary disease. The first event was a TVF in 296 patients and was a non-TVF in 233 patients. No significant differences were observed between TVF-first and non-TVF-first patients in terms of subsequent POCE (21.7% vs 39.3%, time ratio 1.79; 95%CI, 0.87-3.67;P=.12) or its individual components. CONCLUSIONS: At the 10-year follow-up, approximately one-third of STEMI patients had experienced at least 1 POCE. Independent predictors of these events were age, diabetes, and more extensive atherosclerotic disease. The occurrence of a TVF or a non-TVF as the first event did not seem to influence subsequent outcomes. TRIAL REGISTRATION NUMBER: NCT04462315.

Effect of serum from patients with ST-segment elevation myocardial infarction on endothelial cells.

INTRODUCTION AND OBJECTIVES: Clinical and experimental studies have shown that, in patients with reperfused ST-segment elevation myocardial infarction (STEMI), abnormalities in the endothelial monolayer are initiated during ischemia but rapidly intensify upon restoration of blood perfusion to the ischemic area. We aimed to evaluate the effect of serum isolated after revascularization from STEMI patients on the degree of endothelial permeability in vitro, by promoting endothelial cell apoptosis and necrosis in vitro. We also investigated the association between the percentage of serum-induced endothelial cell apoptosis or necrosis in vitro and the extent of cardiovascular magnetic resonance (CMR)-derived parameters of reperfusion injury (edema, hemorrhage, and microvascular obstruction). METHODS: Human coronary artery endothelial cells were incubated with serum isolated 24hours after revascularization from 43 STEMI patients who underwent CMR and 14 control participants. We assessed the effect of STEMI serum on activation of apoptosis and necrosis, as well as on the permeability and structure of the endothelial monolayer. RESULTS: Serum from STEMI patients increased apoptosis (P <.01) and necrosis (P <.05) in human coronary artery endothelial cells and caused increased permeability of the endothelial monolayer in vitro (P <.01), due to enlarged intercellular spaces (P <.05 vs control in all cases). Higher serum-induced necrosis was associated with greater endothelial permeability in vitro (P <.05) and with more extensive CMR-derived indices of reperfusion injury and infarct size. CONCLUSIONS: Postreperfusion serum activates necrosis and apoptosis in endothelial cells and increases the degree of endothelial permeability in vitro. The more potent the necrosis-triggering effect of serum, the more deleterious the consequences in terms of the resulting cardiac structure.

Defecto septal ventricular postinfarto: complicación devastadora / Post-infarction ventricular septal defect: a devastating complicatio

Introducción: la comunicación interventricular es la complicación mecánica más frecuente después de un infarto agudo del miocardio en especial si cursa con elevación del ST, cuya frecuencia es alrededor de 0.21%, aumentando cuando es extenso y no reperfundido en pacientes con mayor edad, si hay compromiso multivaso y sin colateralidad; es una situación devastadora de mal pronóstico. Presentación de los casos: se describen 2 casos en un hospital universitario de Bogotá posteriores a infarto agudo del miocardio con elevación del ST y sin reperfusión temprana, ambos en choque cardiogénico, el primero con evolución tórpida y mortalidad temprana y la segunda fue llevada a los 10 días a cierre transcatéter, documentándose periprocedimiento un aumento significativo del tamaño del defecto septal, con mayor inestabilidad hemodinámica y muerte posterior al cierre.

Introduction: ventricular septal communication is the most frequent mechanical complication of acute myocardial infarction (MI), especially if associated with ST-segment elevation, featuring a rate of around 0.21%, which increases in older patients with extensive defects and no reperfusion therapy. In patients with multivessel involvement and no collateral circulation; it is a catastrophic situation which carries a poor prognosis. Case reports: two patients admitted to a university hospital in Bogotá, with ST-elevation post-MI VSD, undergoing no early reperfusion, both in cardiogenic shock. The first patient had a torpid evolution and early mortality. The second patient underwent a VSD transcatheter repair 10 days after MI, determining significant periprocedural increase in the size of the septal defect, with greater hemodynamic instability and death.

Timing of cardiac magnetic resonance and diagnostic yield in patients with myocardial infarction with nonobstructive coronary arteries.

INTRODUCTION AND OBJECTIVES: The present study sought to establish the diagnostic yield of cardiovascular magnetic resonance (CMR) in a large cohort of patients admitted with myocardial infarction (MI) with nonobstructive coronary artery disease (MINOCA) based on the timing of referral to CMR. METHODS: Consecutive patients referred to CMR from January 2009 to February 2022 with a working diagnosis of MINOCA were retrospectively evaluated. Cine, T2-weighted, early, and late gadolinium-enhanced images were acquired and analyzed. The frequency of the underlying diagnosis and the association between timing of CMR and relative frequency of each diagnosis were assessed. RESULTS: We included 207 patients (median age 50 years, 60% men). Final diagnosis after CMR was achieved in 91% of the patients (myocarditis in 45%, MI in 20%, tako-tsubo cardiomyopathy in 19%, and other cardiomyopathies in 7%). The performance of CMR within 7 days of admission with MINOCA (median, 5 days; 117 patients) allowed a higher diagnostic yield compared with CMR performed later (median, 10 days; 88 patients) (96% vs 86%, P=.02). Although myocarditis was the most frequent diagnosis in both groups according to time to CMR, its frequency was higher among patients with a CMR performed within the first 7 days (53% vs 35%, P=.02). The frequency of other underlying diagnoses was not influenced by CMR timing. CONCLUSIONS: CMR led to an underlying diagnosis of MINOCA in 91% of patients and its diagnostic yield increased to 96% when CMR was performed within 7 days of admission. The most frequent diagnosis was myocarditis..

Effect of remote ischemic postconditioning on left ventricular ejection fraction in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

BACKGROUND: Ischemic conditioning may help patients with ST-segment elevation myocardial infarction (STEMI) to limit ventricular remodeling. OBJECTIVES: To investigate the effect of remote ischemic postconditioning (RIPC) on left ventricular function during primary percutaneous coronary intervention (PPCI) in patients with STEMI. MATERIAL AND METHODS: Pre- and post-test intervention study with a total of 60 STEMI patients. Patients were divided in two groups: with and without RIPC. RESULTS: During the 6-month follow-up, a significant difference in left ventricular ejection fraction was observed in patients who underwent PPCI, which was higher in the group with RIPC in comparison with the group without RIPC: 1.0% (-1.0 to 4.3) vs. -1.0% (-4.0 to 1.3), p = 0.033. In addition, at 6-month measurement, left ventricular end-systolic volume in patients without RIPC was higher in comparison with their counterparts: 79.3 ± 30.5 mL vs. 64.4 ± 21.4 mL, p = 0.032. CONCLUSIONS: RIPC shows favorable effects on left ventricular function and, therefore, in the future, it could be a potential cardioprotective strategy against ischemia-reperfusion injury in STEMI patients.

ANTECEDENTES: En los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST), el acondicionamiento isquémico puede ayudar a limitar la remodelación ventricular. OBJETIVOS: Investigar el efecto del posacondicionamiento isquémico remoto (PAIR) en la función del ventrículo izquierdo durante la intervención coronaria percutánea primaria (ICPP) en pacientes con IAMCEST. MATERIAL Y MÉTODOS: Estudio de intervención pre y posprueba con un total de 60 pacientes con IAMCEST. Los pacientes fueron divididos en dos grupos: con y sin PAIR. RESULTADOS: En el seguimiento de seis meses se observó una diferencia significativa en la fracción de eyección del ventrículo izquierdo en pacientes con ICPP, la cual fue mayor en el grupo con PAIR en comparación con el grupo sin PAIR: 1.0 (−1.0 a 4.3) versus −1.0 (−4.0 a ­1.3), p = 0.033. En la medición de seis meses, el volumen sistólico final del ventrículo izquierdo en los pacientes sin PAIR fue mayor en comparación con el grupo homólogo: 79.3 ± 30.5 mL versus 64.4 ± 21.4 mL, p = 0.032. CONCLUSIONES: PAIR muestra efectos favorables en la función ventricular izquierda y, por lo tanto, en el futuro podría ser una estrategia cardioprotectora potencial contra la lesión por isquemia-reperfusión en pacientes con IAMCEST.

Infarto de miocardio en Argentina. Tercer reporte del registro ARGEN-IAM-ST y comportamiento de la mortalidad en 8 años / Acute Myocardial Infarction in Argentina. Third ARGEN-IAM-ST Registry Report and 8-Year Mortality Behavior

RESUMEN Introducción. Se presenta el tercer reporte general del registro continuo de infarto ARGEN- IAM-ST. Objetivos. Evaluar los principales marcadores de atención y las complicaciones del infarto agudo de miocardio (IAM) con elevación del segmento ST en el registro continuo de infarto ARGEN-IAM-ST. Conocer la evolución de la terapia de reperfusión y la mortalidad en los últimos 8 años. Material y métodos. Estudio prospectivo multicéntrico, con alcance nacional. Se incluyeron pacientes con IAM con elevación del segmento ST de hasta 36 horas de evolución. Resultados. Se incluyeron 6765 pacientes, con una edad media de 61 ± 12 años, 65 % de género masculino. Se observó una importante carga de factores de riesgo cardiovascular: hipertensión arterial 58 %, diabetes 23 %, dislipidemia 42 %, tabaquismo activo 37 % y antecedentes familiares de enfermedad cardiovascular 17 %. El 13,5 % presentó antecedente de enfermedad coronaria; al ingreso un 49 % presentó IAM de cara anterior y el 23 % falla cardíaca. La mediana de tiempo de dolor a la consulta fue de 120 minutos (rango intercuartílico, RIC, 60-285), el tiempo puerta-aguja fue de 50 minutos (RIC 25-110) y el tiempo puerta balón fue de 100 minutos (RIC 58-190). La mortalidad general intrahospitalaria fue del 8,8 %. Se realizó un análisis exploratorio y descriptivo para observar la variación de la reperfusión y mortalidad durante 8 años donde no se muestran cambios acentuados en la mortalidad a pesar de las altas tasas de reperfusión. Conclusión. En los últimos 8 años la mortalidad registrada en el registro ARGEN IAM-ST se ha mantenido en valores elevados a pesar de las altas tasas de reporte de reperfusión.

ABSTRACT Background. The continuous Argentine ST-segment Elevation Acute Myocardial Infarction (ARGEN-IAM-ST) registry presents its third general report. Objectives. The aim of this study was to evaluate the main ST-segment elevation myocardial infarction (STEMI) markers of care and its complications in the continuous ARGEN-IAM-ST registry, and assess the outcome of reperfusion therapy and mortality in the last 8 years. Methods. This was a national, prospective, multicenter study, including STEMI patients with up to 36-hour evolution. Results. A total of 6765 patients, mean age 61±12 years, 65 % male , were included in the study. A significant burden of cardiovascular risk factors was observed: 58 % of patients had hypertension, 23 % diabetes, 42 % dyslipidemia, 37 % were active smokers, and 17 % had a family history of cardiovascular disease. In 13.5 % of cases, patients had prior history of coronary heart disease. On admission, 49 % presented with anterior AMI and 23 % with heart failure. Median (interquartile range, IQR) pain-consultation time was 120 minutes (IQR 60-285), door-to-needle time 50 minutes (IQR 25-110) and door-to-balloon time 100 minutes (IQR 58-190) Overall in-hospital mortality was 8.8 %. An exploratory and descriptive analysis was performed to assess the variation in reperfusion and mortality over 8 years, showing no marked changes in mortality despite high reperfusion rates. Conclusion. In the last 8 years, the mortality recorded in the ARGEN-IAM-ST registry has remained at high values despite the high reperfusion rates reported.

Registro ARGEN-IAM-ST: infarto de miocardio con elevación del segmento ST en el "nuevo" adulto mayor / ARGEN-IAM-ST Registry: ST-elevation myocardial infarction in "new" older adults

RESUMEN Introducción: La Organización Mundial de la Salud (OMS) considera adulto mayor (AM) a las personas que tienen 60 años o más. Es sabido que la mortalidad por infarto agudo de miocardio (IAM) aumenta a edades más avanzadas, pero siempre se han utilizado umbrales de edad mayores que el propuesto por la OMS, por lo cual describir las características y evolución intrahospitalaria de este subgrupo (de acuerdo con la definición de la OMS) se torna relevante. Objetivos: 1) conocer la prevalencia de los AM según la OMS, con IAM con elevación del segmento ST en Argentina y 2) com- parar sus características, tratamientos de reperfusión y mortalidad con los adultos jóvenes. Material y métodos: Se analizaron los pacientes ingresados en el Registro Nacional de Infarto (ARGEN-IAM-ST). Se compara- ron las características clínicas, tratamientos y evolución de los AM y los adultos jóvenes. Resultados: Se incluyeron 6676 pacientes, de los cuales 3626 (54,3%) eran AM. Los AM fueron más frecuentemente mujeres (37,6% vs. 31,4%, p <0,001), hipertensos (67,8% vs. 47%, p <0,001), diabéticos (26,1% vs. 19,9%, p <0,001), dislipidémicos (45,4% vs. 37%, p <0,001), y tuvieron más antecedentes coronarios (16% vs. 10,3%, p <0,001). El tiempo a la consulta de los AM fue mayor (120 min vs. 105 min, p <0,001) con similar tiempo total de isquemia (314 min vs. 310 min, p = 0,33). Recibi- eron menos tratamiento de reperfusión (89,9% vs. 88,6%, p = 0,04) y más angioplastia primaria (91 % vs. 87,4%, p <0,001). Tuvieron más insuficiencia cardíaca (27,3% vs. 18,5%, p <0,001), similar incidencia de sangrado (3,7 vs. 3,1%, p = 0,33) y una mortalidad significativamente mayor (11,4% vs. 5,5%, p <0,001). Ser AM fue predictor independiente de mortalidad. Conclusiones: Más de la mitad de los IAM en nuestro país ocurren en AM. Los pacientes mayores tienen menor probabilidad de recibir reperfusión, más insuficiencia cardíaca y el doble de la mortalidad que los pacientes menores de 60 años.

ABSTRACT Background: The World Health Organization (WHO) defines an Older Adult (OA) as any individual aged 60 or older. It is known that mortality due to acute myocardial infarction (AMI) increases with age, but age thresholds higher than those proposed by the WHO have been consistently used; therefore, describing the characteristics and in-hospital progress of this subgroup of patients, in accordance with the WHO definition, becomes relevant. Objectives: 1) To know the prevalence of OA with acute ST-elevation myocardial infarction (STEMI) in Argentina according to the WHO, and 2) to compare their characteristics, reperfusion treatments, and mortality against those in young adults. Methods: Patients included in the National Registry of ST- Elevation Myocardial Infarction (Registro Nacional de Infarto con Elevación del ST, ARGEN-IAM-ST) were analyzed. Clinical features, therapies, and progress were compared in OA versus young adults. Results: A total of 6676 patients were enrolled, 3626 of which (54.3%) were OA. OA were mostly female (37.6% vs 31.4%, p <0.001), had hypertension (67.8% vs 47%, p <0.001), diabetes (26.1% vs 19.9%, p <0.001), dyslipidemia (45.4% vs 37%, p <0.001), and a longer coronary artery disease history (16% vs 10.3%, p < 0.001). The time to consultation in OA was longer (120 min vs 105 min, p <0.001), with a similar total ischemic time (314 min vs 310 min, p = 0.33). They received less reperfu- sion treatment (89.9% vs 88.6%, p = 0.04) and more primary angioplasty (91% vs 87.4%, p <0.001). Heart failure was more common in OAs (27.3% vs 18.5%, p <0.001), with a similar bleeding incidence (3.7% vs 3.1%, p = 0.33), and significantly higher mortality (11.4% vs 5.5%, p<0.001). Being an OA was an independent mortality predictor. Conclusions: More than half the cases of AMI in our country occur in OA. Older patients are less likely to receive reperfusion, more likely to have heart failure, and show twice the rate of mortality as compared to patients under 60.

Características metabólicas en infarto agudo de miocardio

Introducción: las alteraciones del control glicémico y los lípidos son causas principales de enfermedad cardiovascular. Sin embargo, los patrones metabólicos en el infarto agudo de miocardio no están bien establecidos. Objetivo: el propósito de esta investigación es describir las características metabólicas en pacientes admitidos con infarto de miocardio. Clasificamos los pacientes según el cociente HDL-c/LDL-c y perfiles lipídicos. Método: estudio observacional, descriptivo, retrospectivo en pacientes admitidos al Servicio de Cardiología con infarto agudo de miocardio durante un año. Resultados: 97 pacientes fueron incluidos, predominó el sexo masculino (67%) y el promedio de edad fue 59 años (SD, ±9.9). Las características metabólicas fueron las siguientes: mediana de hemoglobina glicosilada 6.2% (IQR, 5.8-7.5), glucemia en ayunas 107 mg/dL (IQR, 99-152), colesterol total 201 mg/dL (IQR, 165-223), colesterol asociado a lipoproteínas de baja densidad (LDL-c) 123 mg/dL (IQR, 96-146), colesterol asociado a lipoproteínas de alta densidad (HDL-c) 38.2 mg/dL (IQR, 31.8-45.4) y triglicéridos (TG) 161 mg/dL (IQR, 103-234). El cociente HDL-c/LDL-c <0.4 estuvo presente en 75% de los pacientes. Los patientes fueron clasificados según perfiles lipídicos, donde el perfil L-1 [HDL-c ≤40, LDL-c <150, TG <200] y L-2 [HDL-c >40, LDL-c <150, TG <200] en conjunto representaron la mitad de la muestra. Conclusiones: prediabetes, bajos niveles de HDL-c y un cociente HDL-c/LDL-c <0.4 fueron hallazgos frecuentes en infarto de miocardio. La relación entre patrones metabólicos y el riesgo de infarto de miocardio debe ser investigada. (provisto por Infomedic International)

Introduction: Alterations in glycemic control and lipids are the main causes of cardiovascular disease. However, metabolic patterns in acute myocardial infarction are not well established. Objective: The purpose of this research is to describe the metabolic characteristics of patients admitted with myocardial infarction. We classified patients according to HDL-c/LDL-c ratio and lipid profiles. Method: observational, descriptive, retrospective study in patients admitted to the Cardiology Department with acute myocardial infarction for one year. Results: 97 patients were included, males predominated (67%) and the mean age was 59 years (SD, ±9.9). Metabolic characteristics were as follows: median glycosylated hemoglobin 6.2% (IQR, 5.8-7.5), fasting blood glucose 107 mg/dL (IQR, 99-152), total cholesterol 201 mg/dL (IQR, 165-223), low-density lipoprotein cholesterol (LDL-c) 123 mg/dL (IQR, 96-146), high-density lipoprotein-associated cholesterol (HDL-c) 38.2 mg/dL (IQR, 31.8-45.4) and triglycerides (TG) 161 mg/dL (IQR, 103-234). The HDL-c/LDL-c ratio <0.4 was present in 75% of patients. Patients were classified according to lipid profiles, where the L-1 HDL-c ≤ 40, LDL-c <150, TG <200] and L-2 ]HDL-c >40, LDL-c <150, TG <200] together represented half of the sample. Conclusions: prediabetes, low HDL-c levels, and an HDL-c/LDL-c ratio <0.4 were frequent findings in myocardial infarction. The relationship between metabolic patterns and the risk of myocardial infarction should be investigated. (provided by Infomedic International)

Precondicionamiento isquémico remoto: bases de la protección y resultados clínicos / Remote ischemic preconditioning: Bases and clinical results

El precondicionamiento isquémico remoto es una manera eficaz de disminuir el daño por isquemia y reperfusión en el corazón y otros órganos como cerebro o riñón, en modelos experimentales. Este consiste en realizar entre 3 y 5 ciclos de 5 minutos de isquemia seguidos del mismo tiempo de reperfusión, en un tejido alejado del que se quiere proteger, normalmente una extremidad. Estudios preclínicos en animales indican que la isquemia precondicionante inicia señales nerviosas y humorales en el tejido isquémico remoto, que en el corazón activan mecanismos de protección. La señal nerviosa se origina en fibras sensoriales que a nivel cerebral producen una activación del sistema parasimpático. El nervio vago activa ganglios cardíacos intrínsecos del corazón lo que induce protección. Además, desde el tejido isquémico se liberan a la circulación diferentes mediadores que viajan en forma libre o en vesículas lipídicas (exosomas) que inician vías de señalización protectoras en el corazón. A pesar del éxito del precondicionamiento isquémico remoto en animales de experimentación, su aplicación en seres humanos no ha tenido resultados claros. Esta discrepancia puede deberse a una diversidad de factores tales como la edad, la existencia de otras patologías, uso de fármacos u otros tratamientos que afectan la respuesta de los pacientes. Se requiere un mayor conocimiento de las bases moleculares de este mecanismo de protección para que su aplicación en clínica sea exitosa.

In experimental models, remote ischemic preconditioning effectively decreases ischemia reperfusion injury to the heart and other organs such as the brain or kidney. It consists of 3 to 5 cycles of 5 minutes of ischemia followed by 5 minutes of reperfusion, in a remote tissue, usually a limb. Preclinical studies in animals indicate that preconditioning ischemia initiates neural and humoral signals in the remote ischemic tissue, which activate protective mechanisms in the heart. The nervous signal originates in sensory fibers that activate the parasympathetic system in the brain. The vagus nerve activates the intrinsic cardiac ganglia of the heart, leading to protection from ischemic injury. Furthermore, mediators are released from the ischemic tissue into the circulation that travels freely or in lipid vesicles (exosomes) to the heart where they initiate protective signaling pathways. Despite the success of remote ischemic preconditioning in experimental animals, its application in humans has not produced clear results. This discrepancy may be due to a variety of factors such as age, the existence of other pathologic processes, or the use of drugs or other treatments that affect the patient´s response. An increased knowledge of the molecular bases of this protective mechanism is required for its clinical application to be successful.

Efecto del posacondicionamiento isquémico remoto sobre la fracción de eyección del ventrículo izquierdo en pacientes con infarto de miocardio con elevación del segmento ST sometidos a intervención coronaria percutánea primaria / Effect of remote ischemic postconditioning on left ventricular ejection fraction in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Resumen Antecedentes: En los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST), el acondicionamiento isquémico puede ayudar a limitar la remodelación ventricular. Objetivos: Investigar el efecto del posacondicionamiento isquémico remoto (PAIR) en la función del ventrículo izquierdo durante la intervención coronaria percutánea primaria (ICPP) en pacientes con IAMCEST. Material y métodos: Estudio de intervención pre y posprueba con un total de 60 pacientes con IAMCEST. Los pacientes fueron divididos en dos grupos: con y sin PAIR. Resultados: En el seguimiento de seis meses se observó una diferencia significativa en la fracción de eyección del ventrículo izquierdo en pacientes con ICPP, la cual fue mayor en el grupo con PAIR en comparación con el grupo sin PAIR: 1.0 (−1.0 a 4.3) versus −1.0 (−4.0 a –1.3), p = 0.033. En la medición de seis meses, el volumen sistólico final del ventrículo izquierdo en los pacientes sin PAIR fue mayor en comparación con el grupo homólogo: 79.3 ± 30.5 mL versus 64.4 ± 21.4 mL, p = 0.032. Conclusiones: PAIR muestra efectos favorables en la función ventricular izquierda y, por lo tanto, en el futuro podría ser una estrategia cardioprotectora potencial contra la lesión por isquemia-reperfusión en pacientes con IAMCEST.

Abstract Background: Ischemic conditioning may help patients with ST-segment elevation myocardial infarction (STEMI) to limit ventricular remodeling. Objectives: To investigate the effect of remote ischemic postconditioning (RIPC) on left ventricular function during primary percutaneous coronary intervention (PPCI) in patients with STEMI. Material and methods: Pre- and post-test intervention study with a total of 60 STEMI patients. Patients were divided in two groups: with and without RIPC. Results: At 6-month follow-up evaluation, a significant difference in left ventricular ejection fraction was observed in patients who underwent PPCI, which was higher in the group with RIPC in comparison with the group without RIPC: 1.0 (−1.0 to 4.3) vs. −1.0 (−4.0 to –1.3), p = 0.033. In addition, at 6-month measurement, left ventricular end-systolic volume in patients without RIPC: was higher in comparison with their counterparts: 79.3 ± 30.5 mL versus 64.4 ± 21.4 mL, p = 0.032. Conclusions: RIPC shows favorable effects on left ventricular function and, therefore, in the future, it could be a potential cardioprotective strategy against ischemia-reperfusion injury in STEMI patients.

Utilización de la estrategia farmacoinvasiva en Argentina. Análisis del registro ARGEN-IAM ST / Use of the Pharmacoinvasive Strategy in Argentina. ARGEN-IAM ST Registry Analysis

RESUMEN Introducción : La angioplastia primaria (ATCp) es el tratamiento de elección para el infarto agudo de miocardio con elevación del segmento ST (IAMCEST). En nuestro país, de tanta extensión territorial y con tiempos a la reperfusión subóptimos, la estrategia farmacoinvasiva (Finv) podría considerarse. Material y métodos : El ARGEN-IAM-ST es un registro prospectivo, multicéntrico, nacional y observacional. Se incluyen pacien tes con IAMCEST dentro de las 36 horas de evolución. Se definió en el mismo la utilización de Finv y las variables asociadas. Resultados : Se analizaron 4788 pacientes de los cuales en el 88,56 % se realizó ATCp, en el 8,46 % trombolíticos con reperfusión positiva (TL+), y solo en un 2,98% Finv. La mediana y rango intercuartílico (RIC) del tiempo total de isquemia fueron menores en aquellos que recibieron TL+ (165 min, RIC 100-269) y los que fueron a Finv (191 min, RIC 100-330) que en aquellos que fueron a ATCp (280 min, RIC 179- 520), p <0,001. No existieron diferencias en mortalidad intrahospitalaria, en el grupo Finv 4,9%, 5,2% en el grupo TL + y en el grupo ATCp 7,8% (p = 0,081). No hubo diferencias en término de sangrados mayores. Se observó que un 57% de los pacientes con TL+ reunían características de alto riesgo, y no recibieron Finv acorde a lo recomendado Conclusiones : Solo 3 de cada 100 pacientes con IAMCEST que se reperfunden reciben Finv. Su implementación no está ligada en forma sistemática al alto riesgo de eventos. Pese a esta subutilización, por presentar un menor tiempo total de isquemia que la ATCp, sin aumento en los sangrados clínicamente relevantes persiste como una opción a considerar en nuestra realidad.

ABSTRACT Background : Primary percutaneous coronary intervention (PPCI) is the treatment of choice for acute ST-elevation myocardial infarction (STEMI). In Argentina, a country with a large area and suboptimal reperfusion times, the pharmacoinvasive (PI) strategy might be considered. Methods : ARGEN-IAM-ST is a national prospective, multicenter, and observational registry that includes STEMI patients with less than 36 hours of progression. The PI strategy usage and its associated variables were defined. Results : In this registry, 4788 patients were analyzed, of which 88.56% underwent PPCI, 8.46% received thrombolytics with positive reperfusion (TL+), and only 2.98% received PI strategy. Median and interquartile range (IQR) of total ischemia time were lower in patients receiving TL+ (165 min, IQR 100-269) and PI (191 min, IQR 100-330) than in patients undergoing PPCI (280 min, IQR 179-520), p <0.001. No differences in intra-hospital mortality were observed: 4.9% in the PI strategy group, 5.2% in the TL+ group and 7.8% in the PPCI group (p = 0.081). No differences in major bleeding events were observed. It was observed that 57% of the TL+ patients met the criteria for high cardiovascular risk, but they did not receive PI strategy, as recommended. Conclusions : Only 3 out of 100 reperfused STEMI patients received PI strategy. Its administration is not systematically associated to high cardiovascular risk. Despite the under-usage, it remains an option to be considered due to its total ischemia time lower than in the PPCI, with no increase in clinically significant bleedings.

Registro de síndromes coronarios agudos en centros de alta complejidad de Argentina. ReSCAR 2022 / Acute Coronary Syndromes in High Complexity Centers of Argentina. The ReSCAR Registry

RESUMEN Introducción : Realizamos un registro multicéntrico para analizar el abordaje diagnóstico y terapéutico de todos los tipos de síndromes coronarios agudos; este registro es el primero en abordar en detalle aquellos cuadros que cursan sin enfermedad coronaria epicárdica significativa. Es importante conocer la realidad del actual accionar médico con el objeto de hallar oportunidades de mejora. Material y métodos : Se registraron en forma prospectiva pacientes hospitalizados por síndrome coronario agudo en 15 centros de Argentina, con diagnóstico con troponina ultrasensible, servicio de unidad coronaria y hemodinamia disponible las 24 horas, entre enero y agosto de 2022. Resultados : Se incluyeron 984 pacientes consecutivos, un 22,2% con angina inestable, 39,1% con infarto agudo de miocardio sin elevación del segmento ST (IAMSEST) y 24,1% con infarto agudo de miocardio con elevación del segmento ST (IAMCEST). Por otro lado, el 4,1% se presentó como IAM tipo 2, 1,2% como miocarditis, 0,7% como síndrome de Takotsubo y 8,6% como infarto de miocardio con enfermedad coronaria no obstructiva (MINOCA). La mediana (rango intercuartílico, RIC) de edad fue de 66 años (56,5-74), con un 75,3% de pacientes de sexo masculino. El manejo inicial de los pacientes sin elevación del segmento ST fue invasivo en el 84%, con una tasa de enfermedad coronaria significativa del 76,5%. En cuanto a la evolución intrahospitalaria, las complicaciones isquémicas más relevantes fueron el reinfarto (2,84%), angina recurrente (2,4%), angina post infarto (2%) y trombosis intra stent (0,5%). El porcentaje de eventos hemorrágicos totales fue de 4,4% y la mortalidad intrahospitalaria total fue de 3,76%. Conclusiones : El registro tiene una buena representación del espectro de pacientes con sospecha inicial de síndrome coronario agudo, manejados en centros con una estrategia inicial principalmente invasiva, con una baja tasa de complicaciones hospitalarias y una mortalidad global aceptable.

ABSTRACT Background : We conducted a multicenter registry to analyze the diagnostic and therapeutic approach to all types of acute coronary syndromes; this registry is the first to provide detailed information on conditions without significant epicardial coronary artery disease. Knowing the reality of current medical practice is important to find opportunities for improvement. Methods : Patients hospitalized for acute coronary syndrome between January and August 2022 in 15 centers of Argentina, with high-sensitivity cardiac troponin, coronary care unit, and catheterization laboratory available 24 hours, were prospectively recorded. Results : A total of 984 consecutive patients were included, 22.2% with unstable angina, 39.1% with non-ST-segment elevation myocardial infarction (NSTEMI) and 24.1% with ST-segment elevation myocardial infarction (STEMI). Additionally, 4.1% presented as type 2 AMI, 1.2% as myocarditis, 0.7% as Takotsubo syndrome and 8.6% as myocardial infarction with non-obstructive coronary arteries (MINOCA). Median age was 66 years [interquartile range (IQR) 56.5-74] and 75.3% were men. An early invasive management was used in 84% of patients without ST segment elevation, and 76.5% of them had significant coronary artery disease. During hospitalization, 2.84% of the patients presented reinfarction, 2.43% recurrent angina, 2% postinfarction angina and 0.5% stent thrombosis. Bleeding events occurred in 4.4% of the patients, and overall in-hospital mortality was 3.76%. Conclusions : The registry has a good representation of the spectrum of patients with initial suspicion of "acute coronary syndrome", managed in centers with an invasive initial strategy and with low rate of in-hospital complications and acceptable overall mortality.

Características y evolución clínica de pacientes con infarto agudo de miocardio y elevación del segmento ST con y sin bloqueo interauricular

Fundamento resulta novedoso establecer la relación entre bloqueo interauricular e infarto agudo de miocardio con elevación del segmento ST debido a los pocos estudios que abordan el tema. Objetivo evaluar las características y evolución clínica de pacientes con infarto agudo de miocardio con elevación del segmento ST con y sin bloqueo interauricular. Métodos: se realizó un estudio descriptivo y correlacional en unidades de cuidados progresivos del Hospital General Universitario Dr. Gustavo Aldereguía Lima de Cienfuegos. Se seleccionaron 169 sujetos con diagnóstico de infarto agudo de miocardio con elevación del segmento ST divididos en dos grupos con y sin bloqueo interauricular. Se analizaron como variables demográficas: edad, sexo, color de la piel y entre las clínicas hábitos tóxicos (fumador, exfumador); antecedentes patológicos (infarto de miocardio, angina, enfermedad arterial periférica, hipertensión arterial, diabetes mellitus tipo 2, enfermedad renal crónica; localización del infarto (anterior, inferior, bloqueo de rama izquierda); complicaciones: insuficiencia cardíaca, fibrilación auricular, taquicardia ventricular/fibrilación ventricular, trastornos de conducción aurículo ventricular, complicación mecánica, angina postinfarto, embolismo arterial) y estado al egreso (vivo o fallecido). Resultados el 52,17 % de los pacientes con infarto agudo de miocardio con elevación del segmento ST con bloqueo interauricular desarrollaron insuficiencia cardíaca, vs el 29,45 % de los pacientes sin bloqueo con significación estadística (p = 0.03). La relación entre la ocurrencia o no de complicaciones (así como el estado al egreso) y la presencia o no de bloqueo resultó muy significativa (p=0.01). Conclusiones el análisis minucioso en este contexto, de otros aspectos no habituales como la onda p, debe ser también rutinario, pues la documentación de bloqueo interauricular pudiera relacionarse con el curso clínico de los pacientes.

Foundation: it is novel to establish the relationship between interatrial block and acute myocardial infarction with ST-segment elevation due to the few studies that address the subject. Objective: to evaluate the characteristics and clinical evolution of patients with ST-segment elevation acute myocardial infarction with and without interatrial block. Methods: a descriptive and correlational study was carried out in progressive care units of the Dr. Gustavo Aldereguía Lima University General Hospital in Cienfuegos. 169 subjects with a diagnosis of ST-segment elevation myocardial infarction divided into two groups with and without interatrial block were selected. Demographic variables were analyzed: age, sex, skin color and between clinics: toxic habits (smoker, ex-smoker); medical history (myocardial infarction, angina, peripheral arterial disease, arterial hypertension, type 2 diabetes mellitus, chronic kidney disease; infarct location (anterior, inferior, left bundle branch block); complications: heart failure, atrial fibrillation, ventricular tachycardia/ventricular fibrillation, atrioventricular conduction disorders, mechanical complication, post infarction angina, arterial embolism) and discharge status (alive or deceased). Results: 52.17 % of patients with ST-segment elevation myocardial infarction with interatrial block developed heart failure, vs 29.45 % among patients without block with statistical significance (p = 0.03). The relationship between the occurrence or not of complications (as well as the state at discharge) and the presence or not of blockade was highly significant (p=0.01). Conclusions: the detailed analysis, in this context, of the p wave of the electrocardiogram should be routine, since the documentation of interatrial block could be related to the clinical course of the patients.

Estratificación de riesgo del dolor torácico en el servicio de urgencia / Risk stratification of chest pain in the emergency department

El dolor torácico es un motivo de consulta frecuente en los servicios de urgencia. Su espectro de presentaciones y su diagnóstico diferencial es amplio, con patologías de elevada morbilidad y mortalidad asociadas. Es el síntoma principal en pacientes con un síndrome coronario agudo y, ante su sospecha es mandatorio realizar una evaluación inicial centrada en la estratificación de riesgo de sufrir eventos adversos en cada paciente, para así definir su tratamiento y disposición posterior de forma correcta. Objetivo: presentar los elementos que componen la evaluación inicial del dolor torácico ante una sospecha de síndrome coronario agudo y las herramientas disponibles para realizar la estratificación de riesgo y así guiar la disposición desde el servicio de urgencia. Método: Se realizó una revisión bibliográfica de la literatura sobre la estratificación de riesgo del dolor torácico, buscando la evidencia actual respecto a las herramientas diagnósticas utilizadas habitualmente en el servicio de urgencia. Resultados: Se presenta una revisión con generalidades del dolor torácico, sus diagnósticos diferenciales, los elementos de la evaluación inicial y las herramientas clínicas para la evaluación de riesgo de pacientes con dolor torácico y sospecha de síndrome coronario agudo en el servicio de urgencia. Discusión y conclusiones: La presentación del síndrome coronario agudo es variable en la población. Ante la presencia de un cuadro de dolor atípico y/o un electrocardiograma no diagnóstico, recomendamos el uso de un sistema de puntaje validado como el HEART / HEART pathway para reducir la posibilidad de una inadecuada estratificación de riesgo en el servicio de urgencia

Chest pain is a common complaint in emergency departments. The spectrum of presentation and its differential diagnosis are broad, including pathologies associated with high morbidity and mortality, and it is the main symptom in patients suffering from acute coronary syndrome. If suspected, it is mandatory to work out an initial evaluation focused on the risk stratification of adverse events for each patient to define their correct treatment and disposition. Objective: show the elements that involve the initial evaluation of chest pain suspicious of an acute coronary syndrome, the clinical tools available to perform risk stratification, and guide the disposition from the emergency department. Method: a review of the literature on chest pain risk stratification was performed, looking for current evidence of the most commonly used diagnostic tools in emergency departments. Results: we present a literature review of generalities about chest pain and its differential diagnoses, the elements to consider in the initial evaluation, and clinical tools for risk stratification of patients with suspected acute coronary syndrome at the emergency department. Discussion and conclusions: the presentation of acute coronary syndrome is variable in the population. In the presence of atypical chest pain or a non-diagnostic electrocardiogram, we recommend using a validated score as the HEART / HEART Pathway to reduce the chance of inadequate risk stratification in the emergency department.

Infarto de miocardio con elevación del segmento ST inferior y anterior: ¿doble lesión culpable?

El dolor torácico es uno de los motivos de consulta más frecuente en un servicio de urgencia. Dentro de las hipótesis diagnósticas se deben descartar las patologías de mayor gravedad: el infarto al miocardio (IM), la disección aórtica, el tromboembolismo pulmonar y el neumotórax. El escenario más frecuente es el IM debido a un accidente de placa, pero existen casos en donde la disección aórtica puede verse acompañada de un déficit de perfusión coronaria (síndrome de malaperfusión) generando un IM. Su diagnóstico es difícil, con una mayor mortalidad y complejidad quirúrgica. Presentamos el caso de un hombre de 59 años que cursó con dolor torácico y electrocardiograma con elevación del segmento ST inferior y anterior, derivado a angioplastia primaria y que en el estudio angiográfico se identifica compromiso ostial de coronarias, se sospecha una disección aórtica, confirmándose por angiotomografía computada de aorta, donde se evidencia una disección de aorta ascendente con compromiso de ambos ostium coronarios que se trató quirúrgicamente.

Chest pain is one of the most frequent reasons for consultation in the emergency department. The most severe pathologies must be quickly ruled out within the diagnostic hypotheses: myocardial infarction (MI), aortic dissection, pulmonary thromboembolism, and pneumothorax. A frequent scenario is ST elevation MI due to a plaque accident. However, there are infrequent cases of aortic dissection associated with a deficit in coronary perfusion (malperfusion syndrome) that triggers a MI. The diagnosis of a double artery is difficult, with higher mortality and surgical complexity. We present the case of a 59-year-old man who presented chest pain and an electrocardiogram with inferior and anterior ST-segment elevation who was referred for primary angioplasty. The angiographic study confirmed the presence of a coronary ostium defect and suggested aortic dissection. Computed tomography angiography confirmed the diagnosis, showing the dissection of the ascending aorta with the compromise of both coronary ostia, which was subjected to surgical treatment.