RESUMO
The aim of this study was to describe the changes in strategy of revascularisation in acute coronary syndromes with ST elevation (ACS ST+) since setting up a health care network. The authors analysed the incidence of coronary angioplasty and of intravenous thrombolysis from a prospective permanent hospital register of patients with ACS ST+ in the three Northern Alps departments from october 1st 2002 to december 31st 2004. Respectively, 171 patients were enrolled in 2002 and 675 in 2003, and 588 in 2004. The use of percutaneous coronary intervention increased (57, 69, and 78% in 2002, 2003, 2004, p< 0.01) in relation to the increased use of immediate secondary percutaneous coronary intervention (27, 36, 43%, p< 0.01) although the use of primary percutaneous coronary intervention did not changed (30, 33, 35%, p= 0.17). These results were observed in hospitals with and without Percutaneous Coronary Intervention facilities. An increase in prehospital (49, 67, 68%, p= 0.02) and hospital thrombolysis (48, 68, 73%, p= 0.03) was only observed in patients managed in institutions without Percutaneous Coronary Intervention facilities. The average delay to arterial punction (120. 124, 100 minutes, p< 0.01) and to intravenous thrombolysis (40, 30, 25 minutes, p< 0.01) decreased during the same period. Patients with ACS ST+ more commonly benefit from coronary revascularisation at increasingly shorter intervals to treatment. This would seem to be related to the better coordination of practitioners after the implantation of a health care network.
Assuntos
Angioplastia Coronária com Balão/estatística & dados numéricos , Infarto do Miocárdio/cirurgia , Revascularização Miocárdica , Sistema de Registros/estatística & dados numéricos , Terapia Trombolítica/estatística & dados numéricos , Idoso , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia , Estudos Prospectivos , Fatores de TempoRESUMO
The aim of this study was to compare the mortality associated to primary angioplasty and thrombolysis in patients managed for an elevated ST-segment acute coronary syndrome in less than or more than 3 hours after the onset of symptoms. We analyzed the in-hospital mortality of 846 patients (including 276 [33%] treated by primary angioplasty, 511 [60%] by thrombolysis, and 59 [7%] without revascularisation) included from October 2002 to December 2003 in a registry of patients with an elevated ST-segment acute coronary syndrome managed in less than 12 hours in Northern Alps districts. The overall in-hospital mortality was at 6.0% (51/846). For the 631 managed in <3 hours, the mortality rates were respectively at 5.0%, 4.6% and 11.1% respectively in case of primary angioplasty, thrombolysis and without revascularisation (p=0.21). For the 215 patients with pain lasting more than 3 hours, the mortality rates were at 2.7%, 10.3% and 21.7% in case of primary angioplasty, thrombolysis and no revascularisation, respectively (p=0.01). In the multivariable analysis, the OR of death in case of thrombolysis compared to primary angioplasty was at 1.65 (95% IC: 0.73 - 3.75) for patients with pain " 3 hours, and 4.98 (95% IC: 1.32-18.37) for those with pain > 3 hours. These results are in line with randomized trials conclusions and confirm the international guidelines suggesting primary angioplasty for patients with a chest pain >3 hours and either angioplasty or thrombolysis in case of chest pain < 3 hours.
Assuntos
Eletrocardiografia , Infarto do Miocárdio/cirurgia , Revascularização Miocárdica/efeitos adversos , Idoso , Estudos de Coortes , Feminino , França , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/métodos , Revascularização Miocárdica/mortalidade , Seleção de Pacientes , Fatores de TempoRESUMO
OBJECTIVES: To identify the factors associated with early cardiac catheterization in patients with a non ST-segment elevation acute coronary syndrome. METHODS: We analyzed data collected by retrospective chart review for 208 patients presenting at seven French hospitals with an acute coronary syndrome (chest pain at rest within 24 h prior to presentation with positive cardiac markers and/or electrocardiographic changes) between January and March 2005. RESULTS: Eighty-seven patients (42%) were first admitted to hospitals with cardiac catheterization facilities. One hundred ten patients (53%, 95% confidence interval [95% CI], 46-60) underwent early cardiac catheterization less than 48 h following presentation. In addition to presentation at hospitals with catheterization facilities, factors independently associated with early catheterization included positive cardiac markers in patients first admitted to hospitals without catheterization facilities (adjusted odds ratio [aOR] 34.5, 95% CI, 4.4-268.0) and diabetes mellitus (aOR, 0.4, 95%CI, 0.2-0.9). With the exception of positive cardiac markers, no risk factors comprising the TIMI risk score were associated with increased odds of early cardiac catheterization. During the index hospital stay, six patients (3%) died, seven patients (3%) had pulmonary edema, three patients (1%) had major or minor bleeding, and none had ST segment elevation myocardial infarction. CONCLUSION: Despite the dissemination of international guidelines, the use of early cardiac catheterization remains related to initial presentation at hospitals with catheterization facilities rather than risk assessment in patients with a non ST-segment elevation acute coronary syndrome.
Assuntos
Angina Instável/diagnóstico , Angina Instável/terapia , Cateterismo Cardíaco , Idoso , Angina Instável/mortalidade , Angioplastia Coronária com Balão , Eletrocardiografia , Feminino , França , Humanos , Masculino , Prontuários Médicos , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de RiscoRESUMO
A patient with a history of bronchial carcinoma was admitted to the coronary care unit with chest pain suggestive of infarction and an ECG showing changes compatible with acute lateral wall infarction. The coronary arteries were shown to be normal and echocardiography revealed an intracardiac mass which MRI confirmed to be a direct extension of the pulmonary tumour. Echocardiography should be performed systematically in patients with chest pain and ECG changes of ischaemia who also have progressive oncological disease.
Assuntos
Carcinoma/secundário , Neoplasias Cardíacas/secundário , Neoplasias Pulmonares/patologia , Infarto do Miocárdio/etiologia , Dor no Peito/etiologia , Ecocardiografia , Eletrocardiografia , Neoplasias Cardíacas/complicações , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-IdadeRESUMO
Atrial septal defects usually give rise to left-to right in the absence of obstruction of the pulmonary outflow tract or pulmonary hypertension. The authors report a case of atrial septal defect with a right-to-left shunt despite normal pulmonary pressures at catheterisation in a 56 year-old-man who had undergone left pneumonectomy 6 months previously. The shunt was responsible for major arterial desaturation aggravated by the left lateral or dorsal decubitus position. Surgical closure of the defect resulted in cure with disappearance of cyanosis and normalisation of blood gases. The physiopathological mechanisms of these right-to-left shunts with normal pulmonary pressures are discussed with reference to previously reported cases in the literature.
Assuntos
Cianose/etiologia , Comunicação Interatrial/diagnóstico , Comunicação Interatrial/etiologia , Pneumonectomia/efeitos adversos , Gasometria , Cateterismo Cardíaco , Dispneia/etiologia , Seguimentos , Comunicação Interatrial/fisiopatologia , Comunicação Interatrial/cirurgia , Humanos , Hipóxia/etiologia , Masculino , Pessoa de Meia-Idade , Postura , Pressão Propulsora PulmonarRESUMO
The authors report a case of cardiac arrest occurring in a patient who had just entered the catheter laboratory for coronary angioplasty. Opacification of the left coronary artery revealed a proximal occluding double spasm unrelated to the distal stenoses for which angioplasty had been requested. Resuscitation and antispastic therapy with intracoronary injection of a nitrate derivative resulted in a complete recovery without any sequellae. The role of coronary spasm in sudden death and the value of the ergometrine test in patients with coronary stenosis are discussed.
Assuntos
Angiografia Coronária , Vasoespasmo Coronário/complicações , Morte Súbita/etiologia , Parada Cardíaca/etiologia , Doença das Coronárias/fisiopatologia , Vasoespasmo Coronário/fisiopatologia , Eletrocardiografia , Ergonovina/análogos & derivados , Parada Cardíaca/fisiopatologia , Humanos , Injeções Intra-Arteriais , Dinitrato de Isossorbida/administração & dosagem , Masculino , Pessoa de Meia-IdadeRESUMO
Agenesis of the left main coronary artery is a congenital condition the prognosis of which is reputed to be good in adults, provided no associated heart disease is present. The first case reported here illustrates the benign character of the anomaly. In contrast, the second case shows that when associated with proximal atheromatous stenosis of the single right coronary artery the anomaly may have catastrophic consequences. The anatomical variants and morbid associations of left main coronary artery agenesis are described.
Assuntos
Anomalias dos Vasos Coronários/diagnóstico por imagem , Idoso , Constrição Patológica/complicações , Doença da Artéria Coronariana/complicações , Anomalias dos Vasos Coronários/complicações , Anomalias dos Vasos Coronários/embriologia , Feminino , Humanos , Masculino , RadiografiaRESUMO
The authors report a case of intracoronary rupture of the tip of a guidewire used for angioplasty. They discuss its mechanism and management. The hazards involved in re-using coronary dilatation material are underlined.
Assuntos
Angiocardiografia/instrumentação , Cateterismo Cardíaco/instrumentação , Idoso , Vasos Coronários/cirurgia , Falha de Equipamento , Corpos Estranhos/cirurgia , Humanos , Masculino , RupturaRESUMO
The sinus disease in children with "healthy hearts" is exceptional, and has never been documented by tracing of the sinus node. We are reporting two cases of two children, aged 4 and 14 years. An electrophysiological exploration with measurement of the direct activity of the sinus node, illustrates in one case the mechanism of sinus dysfunction. A review from the literature and our cases specifies some of the characteristics of this disease: 1) there are two forms: sporadic (case n. 1) 59 published cases, and familial (case n. 2) 28 published cases in 13 families; 2) the familial forms have a dominant autosomic transmission with variable penetration; 3) the disease may occur during the first days of life, suggesting a congenital origin (from the pathology findings, this disease may be one of the causes of the unexplained sudden death syndrome in infants; 4) association to atrio-ventricular conduction disorders and atrial and ventricular rhythm disorders; 5) frequent indication of stimulators, emphasizing the severity of this disease with a more severe course in sporadic forms (7 deaths in 59 cases).
Assuntos
Síndrome do Nó Sinusal , Nó Sinoatrial/fisiopatologia , Adolescente , Estimulação Cardíaca Artificial , Criança , Eletrocardiografia , Eletrofisiologia , Feminino , Bloqueio Cardíaco/congênito , Bloqueio Cardíaco/fisiopatologia , Humanos , Masculino , Síndrome do Nó Sinusal/congênito , Síndrome do Nó Sinusal/fisiopatologiaRESUMO
Five fluoro-uracil (5-FU) is a cytotoxic drug which has been extensively used for chemotherapy since 1957. Ischaemic heart disease resulting from its administration is rare. Spontaneous angina during infusions of 5-FU was observed in two patients with electrocardiographic changes suggesting coronary spasm. After treatment, clinical examination, electrocardiogram, echocardiogram, stress test, coronary angiography with left ventriculography were all normal. An Ergonovine test was performed in one patient but failed to elicit coronary spasm. In the other patient, intravenous trinitrin and diltiazem were ineffective in preventing the ischaemic changes. A review of the literature is presented (51 cases). The pathophysiology of 5-FU-induced ischaemic heart disease is not fully understood. In 9 cases, coronary angiography was normal and coronary spasm was suggested as a possible cause. However, antispastic drugs are usually ineffective. It has been shown experimentally that 5-FU has a direct toxic effect on the myocardium.
Assuntos
Vasoespasmo Coronário/induzido quimicamente , Eletrocardiografia , Fluoruracila/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Vasoespasmo Coronário/fisiopatologia , Feminino , Cardiopatias/induzido quimicamente , Cardiopatias/fisiopatologia , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
One hundred and sixteen patients (mean age 46 years) with dilated cardiomyopathy documented by haemodynamic investigations and angiography with normal coronary arteriography were followed up for a mean period of 29 +/- 19 months. During that period, 36% of the patients died after a follow-up of 30 +/- 20 months. The actuarial death rates were 15% at 2 years, 45% at 6 years and 60% at 10 years. The main factors predictive of survival at 10 years were the clinical and haemodynamic markers of left heart failure. The death rate was multiplied by 1.6 in patients in stages III or IV of the NYHA classification (83% vs 51%, p less than 0.01), by 2.6 in patients with left ventricular end-diastolic pressure above 15 mmHg (73% vs 29%, p less than 0.01), by 2.2 when the indexed end-diastolic volume rose above 200 ml/m2 (75% vs 35%, p less than 0.01), by 2.2 when the left ventricular ejection fraction was below 40% (75% vs 35%, p less than 0.05) and by 2.6 when angiographic mitral valve regurgitation was present (75% vs 34%, p less than 0.01). The death rate at 9 years was 2.3 times higher in patients with left bundle branch block (72% vs 36%, p less than 0.05). A cardiothoracic index over 0.60 proved to be of poor prognosis at one year (death rate: 19%). While alcoholism played no part in the prognosis, the death rate in smokers was consistently higher than in non smokers (56% vs 32% at 6 years, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Cardiomiopatia Dilatada/mortalidade , Análise Atuarial , Adolescente , Adulto , Idoso , Angiocardiografia , Cardiomiopatia Dilatada/etiologia , Ecocardiografia , Eletrocardiografia , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , FumarRESUMO
Between October, 1979 and August, 1987, 489 patients with multivessel coronary disease and unstable angina underwent transluminal angioplasty of coronary arteries with the following results: primary success in 90 p. 100 of the patients, emergency bypass surgery of occlusive dissection in 1.8 p. 100, myocardial infarction in 2.9 p. 100, death in 1.4 p. 100. These results were similar to those obtained in 369 patients with stable angina whose coronary vessels were dilated by the same group during the same period. The death rate was significantly higher in elderly people and in women. 398/489 patients were followed up for 2 to 45 months: 1.8 p. 100 died, 2 p. 100 developed myocardial infarction and 2.3 p. 100 underwent coronary bypass. 46 patients had repeat angioplasty for restenosis. After single or repeat angioplasty, 68 p. 100 of the primary success patients followed up were asymptomatic, and 73 p. 100 had lasting clinical improvement. Among 221 patients studied with different numbers of vessels treated, the degree of revascularization did not make any significant difference in the percentage of symptom-free patients. Data from the literature concerning the medical treatment of unstable angina indicate a high incidence of complications and a mediocre long-term functional benefit, while data concerning surgical treatment show a better long-term functional result. Compared with these two types of treatment, transluminal coronary angioplasty appears as a satisfactory method to treat unstable angina in patients with multivessel coronary disease.
Assuntos
Angina Pectoris/terapia , Angina Instável/terapia , Angioplastia com Balão , Adulto , Idoso , Idoso de 80 Anos ou mais , Angina Instável/complicações , Angina Instável/mortalidade , Angina Instável/patologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores de TempoRESUMO
The authors report a case of percutaneous dilatation of a coronary artery performed immediately after a mild myocardial infarction and complicated by occlusive thrombosis without dissection, despite a presumably effective anticoagulant treatment. A second dilatation resulted in rapid recanalization of the artery, but recurrent thrombosis developed at the site of dilatation. The thrombotic process was controlled with an intracoronary infusion of urokinase and higher doses of intravenous heparin, but only after a long delay (80 minutes). This case suggests that in similar circumstances one must wait long enough before referring the patient to a surgical unit for emergency aorto-coronary bypass.
Assuntos
Angioplastia com Balão/efeitos adversos , Doença das Coronárias/tratamento farmacológico , Trombose Coronária/tratamento farmacológico , Ativador de Plasminogênio Tipo Uroquinase/uso terapêutico , Doença das Coronárias/terapia , Trombose Coronária/etiologia , Vasos Coronários , Feminino , Heparina/uso terapêutico , Humanos , Injeções Intra-Arteriais , Pessoa de Meia-Idade , Recidiva , Ativador de Plasminogênio Tipo Uroquinase/administração & dosagemRESUMO
The diagnostic value of phonomechanography in valvular aortic stenosis was reassessed with a rarely used index, the ratio S1-maximum intensity of the systolic murmur/S1-S2, or Thiron's index, the author of which only studied the correlations with the aortic transvalvular pressure gradient. The results obtained by the author being considered inconclusive, we decided to examine its correlations with aortic valve surface area calculated with the Gorlin's formula. The study was carried out in 38 patients with pure aortic stenosis, in whom 4 phonomechanographic parameters, the corrected left ventricular ejection time (Meiners), the carotid pulse half peak time, the S1-maximum intensity of the murmur interval and Thiron's index, were compared with the transvalvular pressure gradient and the aortic valve surface area at catheterisation. The first two parameters mentioned above were of limited value (correlations with aortic valve surface area r = 0.315, p less than 0.05 and r = 0.477, p less than 0.01 respectively). On the other hand, a good correlation was obtained with Thiron's index (r = 0.624, p less than 0.001) which was better than that found with the interval between S1 and maximum intensity of the systolic murmur (r = 0.483, p less than 0.001) in a population not excluding subjects with cardiac failure. These results indicate that: when Thiron's index less than or equal to 0.45, the aortic stenosis is probably mild (aortic surface area greater than 0.8 cm2), when Thiron's index is 0.46 greater than 0.56, the aortic stenosis is likely to be moderately severe (aortic surface area 0.8 less than 0.5 cm2), when Thiron's index is greater than 0.57, the aortic stenosis is probably severe (aortic surface area less than 0.5 cm2). In our series, Thiron's index was the best phonomechanographic parameter for the assessment of pure aortic stenosis. It could not be calculated in 10 out of 48 patients; this drawback was not encountered with the corrected left ventricular ejection time or the carotid pulse half peak time.(ABSTRACT TRUNCATED AT 250 WORDS)