RESUMO
BACKGROUND: The CorMatrix (CorMatrix Cardiovascular, Roswell, Ga) biologic extracellular patch derived from porcine small intestinal mucosa provides a biologic scaffold for cellular ingrowth and eventual tissue regeneration. It has been used in a variety of applications, including cardiac and vascular repair procedures. METHODS: CorMatrix was used as a patch arterioplasty for femoral artery repair in conjunction with endarterectomy for seven separate procedures in six patients (one patient underwent staged, bilateral femoral procedures). RESULTS: Patients were a median age of 67 years (interquartile range, 3.6 years). Six of seven procedures (86%) were performed on male patients. There were no operative deaths. Three of seven procedures (43%) resulted in significant early complications. Two procedures (29%) resulted in catastrophic biologic extracellular matrix patch disruption (11 and 19 days after initial procedure), requiring emergency exploration, patch removal, and definitive repair with vein patch arterioplasty. Both patches demonstrated an absence of growth on culture. One procedure (14%) resulted in groin pseudoaneurysm formation. Use of the CorMatrix patch was suspended upon recognition of significant complications. CONCLUSIONS: Use of CorMatrix patch in the femoral artery position demonstrates a high incidence of early postoperative complications, including catastrophic patch disruption and pseudoaneurysm formation.
Assuntos
Falso Aneurisma/etiologia , Endarterectomia/efeitos adversos , Matriz Extracelular/transplante , Artéria Femoral/cirurgia , Claudicação Intermitente/cirurgia , Mucosa Intestinal/transplante , Doença Arterial Periférica/cirurgia , Idoso , Falso Aneurisma/diagnóstico por imagem , Animais , Biópsia , Endarterectomia/métodos , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/patologia , Xenoenxertos , Humanos , Claudicação Intermitente/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Suínos , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler DuplaRESUMO
Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis minimizes the risk of intracranial bleeding compared with systemic full-dose fibrinolytic therapy for pulmonary embolism (PE). However, major bleeding is nevertheless a potential complication. We analyzed the 150-patient SEATTLE II trial of submassive and massive PE patients to describe those who suffered major bleeding events following ultrasound-facilitated, catheter-directed, low-dose fibrinolysis and to identify risk factors for bleeding. Major bleeding was defined as GUSTO severe/life-threatening or moderate bleeds within 72 hours of initiation of the procedure. Of the 15 patients with major bleeding, four (26.6%) developed access site-related bleeding. Multiple venous access attempts were more frequent in the major bleeding group (27.6% vs 3.6%; p<0.001). All patients with major bleeding had femoral vein access for device delivery. Patients who developed major bleeding had a longer intensive care stay (6.8 days vs 4.7 days; p=0.004) and longer hospital stay (12.9 days vs 8.4 days; p=0.004). The frequency of inferior vena cava filter placement was 40% in patients with major bleeding compared with 13% in those without major bleeding ( p=0.02). Massive PE (adjusted odds ratio 3.6; 95% confidence interval 1.01-12.9; p=0.049) and multiple venous access attempts (adjusted odds ratio 10.09; 95% confidence interval 1.98-51.46; p=0.005) were independently associated with an increased risk of major bleeding. In conclusion, strategies for improving venous access should be implemented to reduce the risk of major bleeding associated with ultrasound-facilitated, catheter-directed, low-dose fibrinolysis. ClinicalTrials.gov Identifier: NCT01513759; EKOS Corporation 10.13039/100006522.
Assuntos
Cateterismo Periférico/efeitos adversos , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Embolia Pulmonar/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/administração & dosagem , Hemorragia/diagnóstico , Hemorragia/epidemiologia , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Embolia Pulmonar/diagnóstico , Punções , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção , Estados Unidos/epidemiologia , Filtros de Veia Cava/efeitos adversosRESUMO
Median arcuate ligament syndrome (MALS) is a rare clinical entity. This condition typically affects women between the ages of 20 and 40 years and causes symptoms of abdominal pain, primarily post-prandial, as well as nausea, vomiting and weight loss. MALS is considered a diagnosis of exclusion. Typically, mesenteric arterial duplex ultrasonography, computed tomography (CT), and magnetic resonance (MR) are highly suggestive, and conventional contrast angiography confirmatory. We explore the role of fractional flow reserve and intravascular ultrasound in the evaluation of MALS. In order to illustrate the utility of these tools, we present the case of a 47-year-old symptomatic woman who underwent angiography, complemented by assessment of fractional flow reserve and intravascular ultrasound. These data convincingly demonstrated the dynamic nature of the obstructive characteristic of MALS.
RESUMO
Chronic mesenteric ischemia (CMI) is a rare condition that is usually the result of atherosclerotic obstructive disease affecting the mesenteric arteries. The classic triad of post-prandial pain, food aversion and weight loss is not always present, often leading to low clinical suspicion for CMI and underdiagnosis. Non-invasive evaluation for CMI usually starts with mesenteric arterial duplex scanning, followed by computed tomography angiography, magnetic resonance angiography or conventional angiography, the latter being the gold standard for establishing its diagnosis. However, angiography alone has been demonstrated in coronary and other vascular beds to be inaccurate in predicting the physiologic and hemodynamic significance of a certain subset of atherosclerotic stenoses. We present the case of a patient with risk factors and symptoms suggestive of CMI who underwent angiography. However, angiography was equivocal and invasive physiologic testing was required to confirm the diagnosis and guide revascularization.
RESUMO
As composition and design have improved the integrity and durability of peripheral stents, vascular stent fracture and embolization have become less frequent complications of endovascular intervention. However, this phenomenon still remains a possibility with potentially catastrophic consequences, either from damage to cardiac structures or from disruption of vessel integrity, infarction, and thrombosis. Advancements in the tools for foreign body retrieval have allowed the skilled interventionalist to intercede without the need for surgical intervention. We report the case of retrieval of a self-expandable SMART (Cordis, Florida) stent that was deployed for relief of superior vena cava syndrome but fractured and embolized to the right ventricle.
Assuntos
Remoção de Dispositivo/métodos , Ventrículos do Coração , Falha de Prótese/efeitos adversos , Embolia Pulmonar/etiologia , Stents/efeitos adversos , Adulto , Humanos , Masculino , Síndrome da Veia Cava Superior/terapiaRESUMO
Technical advances in temporary ventricular assist devices (VADs) continue to progress, allowing for percutaneous implantation during times of hemodynamic instability. However, device delivery systems, i.e., sheaths, lag in their ability to sustain the mechanical demands of these VADs for extended periods. We propose both a novel technique and the implementation of an emergency preparedness plan to be enacted specifically during those times when delivery systems fail thereby leading to potentially catastrophic bleeding complications.
Assuntos
Cardiomiopatias/cirurgia , Falha de Equipamento , Exsanguinação/etiologia , Coração Auxiliar/efeitos adversos , Transplante de Coração , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Complete device and lead removal is recommended for management of infected implantable cardiac device. Management of large lead vegetation (2 cm) is still in debate. METHODS: We report a series of patients involving percutaneous extraction of large vegetations (>2 cm) from ICD/pacing leads using the AngioVac Cannula in patients with infective endocarditis. This approach was used to debulk the ICD/pacing lead vegetations in order to minimize the risk of septic pulmonary embolism during lead explantation. CONCLUSION: AngioVac Cannula can be used safely and effectively as an adjunctive method for patients with large lead vegetation.
Assuntos
Cateterismo Cardíaco/instrumentação , Catéteres , Desfibriladores Implantáveis , Remoção de Dispositivo/instrumentação , Eletrodos Implantados , Endocardite Bacteriana/cirurgia , Corpos Estranhos/cirurgia , Átrios do Coração/cirurgia , Marca-Passo Artificial , Infecções Relacionadas à Prótese/cirurgia , Sucção/instrumentação , Idoso de 80 Anos ou mais , Bacteriemia/diagnóstico , Bacteriemia/microbiologia , Bacteriemia/cirurgia , Comportamento Cooperativo , Desfibriladores Implantáveis/microbiologia , Ecocardiografia , Ecocardiografia Transesofagiana , Eletrodos Implantados/microbiologia , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/microbiologia , Desenho de Equipamento , Feminino , Corpos Estranhos/diagnóstico , Corpos Estranhos/microbiologia , Átrios do Coração/microbiologia , Ventrículos do Coração/microbiologia , Ventrículos do Coração/cirurgia , Humanos , Comunicação Interdisciplinar , Masculino , Staphylococcus aureus Resistente à Meticilina , Pessoa de Meia-Idade , Marca-Passo Artificial/microbiologia , Pacientes , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/microbiologia , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/microbiologia , Infecções Estafilocócicas/cirurgia , Staphylococcus aureus , Infecções Estreptocócicas/diagnóstico , Infecções Estreptocócicas/microbiologia , Infecções Estreptocócicas/cirurgia , Streptococcus agalactiaeRESUMO
BACKGROUND: Previous studies have documented a negative impact of the COVID-19 pandemic on emergent percutaneous treatment of patients with ST-segment elevation myocardial infarction (STEMI), but few have examined recovery of healthcare systems in restoring prepandemic STEMI care. METHODS: Retrospective analysis was performed of data from 789 patients with STEMI from a large tertiary medical center treated with percutaneous coronary intervention between January 1, 2019, and December 31, 2021. RESULTS: For patients with STEMI presenting to the emergency department, median time from door to balloon was 37 minutes in 2019, 53 minutes in 2020, and 48 minutes in 2021 (P < .001), whereas median time from first medical contact to device changed from 70 to 82 to 75 minutes, respectively (P = .002). Treatment time changes in 2020 and 2021 correlated with median emergency department evaluation time (30 to 41 to 22 minutes, respectively; P = .001) but not median catheterization laboratory revascularization time. For transfer patients, median time from first medical contact to device changed from 110 to 133 to 118 minutes, respectively (P = .005). In 2020 and 2021, patients with STEMI had greater late presentation (P = .028) and late mechanical complications (P = .021), with nonsignificant increases in yearly in-hospital mortality (3.6% to 5.2% to 6.4%; P = .352). CONCLUSION: COVID-19 was associated with worsening STEMI treatment times and outcomes in 2020. Despite improving treatment times in 2021, in-hospital mortality had not decreased in the setting of a persistent increase in late patient presentation and associated STEMI complications.
Assuntos
COVID-19 , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Estudos Retrospectivos , Pandemias , Fatores de Tempo , Intervenção Coronária Percutânea/efeitos adversos , Tempo para o TratamentoRESUMO
The clinical impact of prosthesis-patient mismatch (PPM) in patients with small aortic annuli who underwent transcatheter aortic valve (AV) implantation with either balloon-expandable (BE) or self-expanding (SE) valves remains controversial. We assessed in-hospital and intermediate clinical outcomes in 573 patients with transfemoral transcatheter AV implantation with a small AV annulus, defined as an AV annulus area ≤430 mm2. A total of 337 patients treated with a 23-mm BE valve (SAPIEN 3, Ultra) were compared with 236 patients treated with a 26-mm SE valve (Evolut series). Valve-in-valve cases were excluded, and late echo follow-up (mean 674 ± 438 days) was assessed in a subset of 292 patients (51.0%). Well-matched BE and SE cohorts did not differ with respect to major in-hospital outcomes, other than a borderline increase in vascular complications and composite bleeding in patients with SE. Patients with BE had a higher incidence of severe PPM on discharge echocardiography (16.9% vs 6.8%, p <0.002). The mean AV gradient at 30 days was higher for patients with BE (12.2 ± 4.2 vs 6.2 ± 7.9 mm Hg, p <0.001) and at late follow-up (14.0 ± 8.2 vs 7.2 ± 3.5 mm Hg, p <0.001). The follow-up left ventricular ejection fraction and incidence of >mild aortic insufficiency were similar. All-cause mortality for the 2 cohorts was similar, with an overall mean (95% confidence interval) survival time of 61.2 months (57.8 to 64.5; p = 0.98). There were no significant survival differences between combined patients with BE and SE with no, moderate, or severe PPM, with an overall mean (95% confidence interval) survival time of 32.5 (30.5 to 34.5) months combining valve types (p = 0.23). In conclusion, despite an increased incidence of PPM with higher mean AV gradients that persist on late echocardiography in the BE cohort, patients with BE and SE with small aortic annuli have similar clinical outcomes at intermediate follow-up. Moderate and severe PPM had no impact on survival at a mean follow-up of 32.5 months.
Assuntos
Estenose da Valva Aórtica , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Humanos , Substituição da Valva Aórtica Transcateter/métodos , Estenose da Valva Aórtica/cirurgia , Seguimentos , Volume Sistólico , Próteses Valvulares Cardíacas/efeitos adversos , Resultado do Tratamento , Desenho de Prótese , Hemodinâmica , Função Ventricular Esquerda , Valva Aórtica/cirurgiaRESUMO
Vascular closure devices are commonly used to obtain arterial access site closure after cardiovascular procedures. They are popular as they decrease time to hemostasis and ambulation while improving patient comfort by eliminating need for compression. However, complications due to vascular closure devices are not uncommon. We report a case of possible intravascular distal embolization of water-soluble PEG polymer that is deployed extravascular using the Mynx vascular closure device.
Assuntos
Angiografia Coronária/instrumentação , Embolia/etiologia , Artéria Femoral/cirurgia , Técnicas Hemostáticas/instrumentação , Idoso de 80 Anos ou mais , Desenho de Equipamento , Segurança de Equipamentos , Feminino , Humanos , PolietilenoglicóisRESUMO
Acute pulmonary embolism (PE) is a common and potentially lethal condition. Anticoagulation is considered the mainstay therapy while systemic thrombolytic therapy is reserved only for patients who are hemodynamically unstable. However, therapy for PE with evidence of right ventricular strain is not well-defined. We report a case of PE treated successfully with an ultrasound-assisted catheter-directed thrombolytic therapy.
Assuntos
Cateterismo de Swan-Ganz , Fibrinolíticos/administração & dosagem , Embolia Pulmonar/terapia , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Terapia por Ultrassom , Feminino , Humanos , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico por imagem , Radiografia , UltrassonografiaRESUMO
Previous reports comparing transcarotid (TC) versus transfemoral (TF) approaches for patients undergoing transcatheter aortic valve replacement have had inconsistent conclusions. We compared in-hospital and 1-year clinical outcomes, changes in quality of life, and direct hospital costs for 138 TC versus 1,926 TF procedures. Propensity matching based on the Society of Thoracic Surgery Predicted Risk of Mortality was used to compare 130 patients who underwent TC with 813 patients who underwent TF. Matched TC versus TF cohorts did not differ with respect to in-hospital mortality (0.0% vs 1.4%, p = 0.380), stroke (2.3% vs 2.5%, p = 0.917), major vascular complications (0.8% vs 2.2%, p = 0.268), composite bleeding complications (4.6% vs 6.4%, p = 0.647), requirement for permanent pacemaker (14.6% vs 12.9%, p = 0.426), postoperative hospital length of stay (3.3 ± 3.4 vs 3.1 ± 3.3 days, p = 0.467), or direct hospital costs ($52,899 ± 9,560 vs $50,464 ± 10,997, p = 0.230). Similarly, at 1-year, patients who underwent TC versus patients who underwent TF did not differ with respect to all-cause mortality (7.6% vs 6.4%, p = 0.659), hospital readmission (20.0% vs 23.9%, p = 0.635), or quality of life as measured by the Kansas City Cardiomyopathy Questionnaire score (84.0 ± 17.1 vs 88.4 ± 13.9, p = 0.062). Patients who underwent TC and TF did not differ with respect to in-hospital complications, length of hospital stay, and direct hospital costs, as well as 1-year mortality, readmission, and quality of life. These data add to ongoing support for the TC approach as the optimal alternative access for patients with transcatheter aortic valve replacement deferred from a transfemoral approach.
Assuntos
Estenose da Valva Aórtica , Substituição da Valva Aórtica Transcateter , Humanos , Substituição da Valva Aórtica Transcateter/métodos , Estenose da Valva Aórtica/cirurgia , Qualidade de Vida , Artéria Femoral/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/cirurgia , Valva Aórtica/cirurgia , Fatores de RiscoRESUMO
With the COVID-19 pandemic, the fear among patients of contracting it has made them reluctant to seek medical attention on a timely basis even for emergent conditions. We present a case of post infarction ventricular septal rupture due to delayed presentation as a consequence of the fear of COVID-19. (Level of Difficulty: Intermediate.).
Assuntos
Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Dissecção da Aorta Torácica , Procedimentos Endovasculares , Humanos , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Resultado do Tratamento , Stents , Estudos RetrospectivosRESUMO
A 60-year-old male presented 12 months after CABG surgery with a large pulsatile sternal mass. CT scan of the chest demonstrated a pseudoaneurysm originating from the mid saphenous vein graft to the PDA measuring 7.7 x 7.2 x 6.0 cm. After a multidisciplinary consultation, a decision was made to place a Jostent GraftMaster to completely seal the communication of the extravasation.
Assuntos
Falso Aneurisma/cirurgia , Materiais Revestidos Biocompatíveis , Doença da Artéria Coronariana/cirurgia , Oclusão de Enxerto Vascular/cirurgia , Politetrafluoretileno , Veia Safena/transplante , Stents , Falso Aneurisma/diagnóstico , Falso Aneurisma/etiologia , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Oclusão de Enxerto Vascular/complicações , Oclusão de Enxerto Vascular/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Veia Safena/diagnóstico por imagem , Veia Safena/cirurgia , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVES: This study conducted a prospective, single-arm, multicenter trial to evaluate the safety and efficacy of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis, using the EkoSonic Endovascular System (EKOS, Bothell, Washington). BACKGROUND: Systemic fibrinolysis for acute pulmonary embolism (PE) reduces cardiovascular collapse but causes hemorrhagic stroke at a rate exceeding 2%. METHODS: Eligible patients had a proximal PE and a right ventricular (RV)-to-left ventricular (LV) diameter ratio ≥0.9 on chest computed tomography (CT). We included 150 patients with acute massive (n = 31) or submassive (n = 119) PE. We used 24 mg of tissue-plasminogen activator (t-PA) administered either as 1 mg/h for 24 h with a unilateral catheter or 1 mg/h/catheter for 12 h with bilateral catheters. The primary safety outcome was major bleeding within 72 h of procedure initiation. The primary efficacy outcome was the change in the chest CT-measured RV/LV diameter ratio within 48 h of procedure initiation. RESULTS: Mean RV/LV diameter ratio decreased from baseline to 48 h post-procedure (1.55 vs. 1.13; mean difference, -0.42; p < 0.0001). Mean pulmonary artery systolic pressure (51.4 mm Hg vs. 36.9 mm Hg; p < 0.0001) and modified Miller Index score (22.5 vs. 15.8; p < 0.0001) also decreased post-procedure. One GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries)-defined severe bleed (groin hematoma with transient hypotension) and 16 GUSTO-defined moderate bleeding events occurred in 15 patients (10%). No patient experienced intracranial hemorrhage. CONCLUSIONS: Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis decreased RV dilation, reduced pulmonary hypertension, decreased anatomic thrombus burden, and minimized intracranial hemorrhage in patients with acute massive and submassive PE. (A Prospective, Single-arm, Multi-center Trial of EkoSonic® Endovascular System and Activase for Treatment of Acute Pulmonary Embolism (PE) [SEATTLE II]; NCT01513759).
Assuntos
Cateterismo Periférico , Fibrinolíticos/administração & dosagem , Embolia Pulmonar/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Terapia por Ultrassom , Doença Aguda , Adulto , Idoso , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/instrumentação , Cateterismo Periférico/mortalidade , Desenho de Equipamento , Feminino , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Hipertensão Pulmonar/etiologia , Hipertrofia Ventricular Direita/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Embolia Pulmonar/complicações , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/mortalidade , Fatores de Risco , Índice de Gravidade de Doença , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/instrumentação , Terapia Trombolítica/mortalidade , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Terapia por Ultrassom/efeitos adversos , Terapia por Ultrassom/instrumentação , Terapia por Ultrassom/mortalidade , Estados Unidos , Dispositivos de Acesso VascularRESUMO
BACKGROUND: Few data exist from a community-based perspective on the relative effectiveness of primary percutaneous coronary intervention (PCI) as compared with thrombolytic therapy (TT) in elderly patients with ST-elevation myocardial infarction (STEMI), particularly in the current era of coronary stents and newer antithrombotic agents. METHODS: We evaluated data from patients, aged > or =70 years, with STEMI who were enrolled in the Global Registry of Acute Coronary Events study between April 1999, and September 2002. RESULTS: Of the 2975 elderly patients eligible for reperfusion therapy, 365 (12.7%) underwent primary PCI and 769 (26.7%) received TT. The median delay from hospital arrival to therapy was 105 minutes for primary PCI and 40 minutes for TT. Inhospital complications for primary PCI versus TT included mortality (13.5% vs 14.8%), reinfarction (1.1% vs 5.7%), composite of death or reinfarction (14.3% vs 18.7%), cardiogenic shock (11.3% vs 11.6%), major bleeding (8.6% vs 5.9%), and stroke (1.1% vs 2.8%). After adjustment for baseline differences and propensity score, patients receiving primary PCI showed a lower rate of reinfarction (odds ratio [OR], 0.15; 95% CI, 0.05-0.44) and mortality (OR, 0.62; 95% CI, 0.39-0.96) and the composite of reinfarction or death (OR, 0.53; 95% CI, 0.35-0.79), with no difference in other outcome measures. CONCLUSION: Our data suggest that, compared with TT, primary PCI is associated with a decrease in reinfarction and mortality, with no change in other outcome measures, in elderly patients with STEMI. These findings from an observational registry require further confirmation in future randomized clinical trial assessing the optimal reperfusion strategy in the elderly cohort with STEMI.
Assuntos
Angioplastia Coronária com Balão , Infarto do Miocárdio/terapia , Terapia Trombolítica , Idoso , Eletrocardiografia , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Mortalidade Hospitalar , Humanos , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Razão de Chances , Sistema de Registros , Prevenção Secundária , Stents , Estreptoquinase/uso terapêutico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Terapia Trombolítica/efeitos adversosRESUMO
A systematic study that compares the patterns of use of unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) in patients with acute coronary syndromes (ACS) has, to date, not been carried out in the "real-world" setting. The aim of this report is to identify patterns of use of UFH and LMWH and to report their correlates and outcomes in a broad spectrum of ACS patients enrolled in the observational Global Registry of Acute Coronary Events (GRACE). The use of LMWH and UFH was analysed in 13,231 ACS patients according to patient history, concomitant treatment and invasive procedures in US and non-US sites. Frequency of use in hospitals with and without facilities for percutaneous coronary interventions (PCI) was investigated, and outcomes were analysed. Results show that younger patients (<60 years), those receiving antiplatelet therapies, thrombolytics, beta-blockers, angiotensin-converting enzyme inhibitors, patients admitted to hospitals with PCI facilities, and patients undergoing invasive procedures were more likely to receive UFH, or both UFH and LMWH than LMWH alone (80.1% enoxaparin, 19.9% other LMWH). LMWH was used less often in US than non-US sites. After adjusting for confounding variables, patients receiving LMWH had significantly lower rates of hospital mortality (P = 0.009) and major bleeding (P < 0.0001). Similar results were observed in patients with ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction or unstable angina. We can conclude that UFH tends to be used more frequently than LMWH, but hospital outcomes appeared to be better with LMWH after adjusting for covariables.
Assuntos
Doença das Coronárias/tratamento farmacológico , Revisão de Uso de Medicamentos , Heparina , Doença Aguda , Idoso , Angina Instável/complicações , Angina Instável/tratamento farmacológico , Angina Instável/mortalidade , Doença das Coronárias/complicações , Doença das Coronárias/mortalidade , Feminino , Hemorragia/induzido quimicamente , Heparina de Baixo Peso Molecular , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/mortalidade , Sistema de Registros , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Randomized clinical trials have demonstrated a reduction in mortality with early revascularization of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock, and recent single-center studies have particularly suggested further benefit for coronary stenting. The purpose of this study was to examine the use of revascularization and coronary stenting for patients with shock from a multicenter, international perspective. Patients with AMI complicated by cardiogenic shock (n = 583) who enrolled between April 1999 and June 2001 were prospectively identified from the large, multinational, observational Global Registry of Acute Coronary Events. We examined the use of coronary reperfusion strategies, adjunctive therapy, and hospital mortality in this group of patients. Cardiac catheterization (52%) and revascularization (43%) were performed in approximately half of the cardiogenic shock patients. Elderly patients (age >/=75 years) comprised 40% of the shock cohort. Regional differences were seen in the use of revascularization, adjunctive medical therapy, and type of revascularization used (coronary stenting). Total hospital mortality was 59%, but case fatality rates ranged from 35% for patients who underwent coronary stenting to 74% for patients who did not undergo any cardiac catheterization. Percutaneous coronary intervention with coronary stenting was the most powerful predictor of hospital survival (odds ratio 3.99, 95% confidence interval 2.41 to 6.62). Thus, cardiogenic shock continues to be a devastating complication of AMI, and relative underuse of a revascularization strategy may be related to the large proportion of elderly patients in this population. In this multinational registry study, coronary stenting was the most powerful independent predictor of hospital survival.