Impact of creating a haemodynamics room, a coronary unit and a primary angioplasty programme on the prognosis of acute coronary syndrome in a district hospital. / Impacto de la creación de una sala de hemodinámica, una unidad coronaria y un programa de angioplastia primaria en el pronóstico del síndrome coronario agudo en un hospital comarcal.

OBJECTIVE: To analyse the prognosis and mortality of patients hospitalised for acute coronary syndrome before and after the implementation of a coronary unit, haemodynamics room and the Código corazón primary angioplasty programme. METHODS: We conducted an observational and retrospective study that analysed the epidemiological characteristics, reperfusion strategies, adverse cardiovascular events and mortality for 5 years of follow-up. The results of the post-code period (March 1 - December 31, 2012; n=471) were compared with those of the pre-code stage (March 1 - December 31, 2009; n=432). RESULTS: There were no differences in the baseline characteristics of the 2 groups; however, an increase in ST-segment elevation acute coronary syndrome (STE-ACS) from 17.6% to 34.8% (P<.001) was observed during the post-code phase. The use of percutaneous coronary intervention was made widespread at the hospital, achieving rates of 64.8% in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and of 95.5% in STE-ACS. Readmissions were reduced (from 38.2% to 25.1% for NSTE-ACS [P=.001] and from 23.7% to 11.0% for STE-ACS [P=.018]), the combined prognostic variable of adverse cardiovascular events and mortality at 5 years of follow-up was reduced (from 58.7% to 45% [P=.001] for NSTE-ACS and from 40.8% to 23.8% [p=.009] for STE-ACS), and 30-day mortality was decreased for STE-ACS (from 11.8% to 3.7%; P=.021). CONCLUSIONS: With the structural changes in the hospital, the use of percutaneous coronary intervention was made widespread and improved the prognosis of patients with acute coronary syndrome, decreasing admissions, adverse cardiovascular events and mortality.

Coronary angiography in patients without ST-segment elevation following out-of-hospital cardiac arrest. COUPE clinical trial.

INTRODUCTION AND OBJECTIVES: The role of emergency coronary angiography (CAG) and percutaneous coronary intervention (PCI) following out-of-hospital cardiac arrest (OHCA) in patients without ST-segment elevation myocardial infarction (STEMI) remains unclear. We aimed to assess whether emergency CAG and PCI would improve survival with good neurological outcome in this population. METHODS: In this multicenter, randomized, open-label, investigator-initiated clinical trial, we randomly assigned 69 survivors of OHCA without STEMI to undergo immediate CAG or deferred CAG. The primary efficacy endpoint was a composite of in-hospital survival free of severe dependence. The safety endpoint was a composite of major adverse cardiac events including death, reinfarction, bleeding, and ventricular arrhythmias. RESULTS: A total of 66 patients were included in the primary analysis (95.7%). In-hospital survival was 62.5% in the immediate CAG group and 58.8% in the delayed CAG group (HR, 0.96; 95%CI, 0.45-2.09; P=.93). In-hospital survival free of severe dependence was 59.4% in the immediate CAG group and 52.9% in the delayed CAG group (HR, 1.29; 95%CI, 0.60-2.73; P=.4986). No differences were found in the secondary endpoints except for the incidence of acute kidney failure, which was more frequent in the immediate CAG group (15.6% vs 0%, P=.002) and infections, which were higher in the delayed CAG group (46.9% vs 73.5%, P=.003). CONCLUSIONS: In this underpowered randomized trial involving patients resuscitated after OHCA without STEMI, immediate CAG provided no benefit in terms of survival without neurological impairment compared with delayed CAG. CLINICALTRIALS: gov Identifier: NCT02641626.

Performance analysis of a STEMI network: prognostic impact of the type of first medical contact facility.

INTRODUCTION AND OBJECTIVES: Prognosis in ST-elevation myocardial infarction (STEMI) is determined by delay in primary percutaneous coronary intervention (PPCI). The impact of first medical contact (FMC) facility type on reperfusion delays and mortality remains controversial. METHODS: We performed a prospective registry of primary coronary intervention (PCI)-treated STEMI patients (2010-2020) in the Codi Infart STEMI network. We analyzed 1-year all-cause mortality depending on the FMC facility type: emergency medical service (EMS), community hospital (CH), PCI hospital (PCI-H), or primary care center (PCC). RESULTS: We included 18 332 patients (EMS 34.3%; CH 33.5%; PCI-H 12.3%; PCC 20.0%). Patients with Killip-Kimball classes III-IV were: EMS 8.43%, CH 5.54%, PCI-H 7.51%, PCC 3.76% (P <.001). All comorbidities and first medical assistance complications were more frequent in the EMS and PCI-H groups (P <.05) and were less frequent in the PCC group (P <.05 for most variables). The PCI-H group had the shortest FMC-to-PCI delay (median 82 minutes); the EMS group achieved the shortest total ischemic time (median 151 minutes); CH had the longest reperfusion delays (P <.001). In an adjusted logistic regression model, the PCI-H and CH groups were associated with higher 1-year mortality, OR, 1.22 (95%CI, 1.00-1.48; P=.048), and OR, 1.17 (95%CI 1.02-1.36; P=.030), respectively, while the PCC group was associated with lower 1-year mortality than the EMS group, OR, 0.71 (95%CI 0.58-0.86; P <.001). CONCLUSIONS: FMC with PCI-H and CH was associated with higher adjusted 1-year mortality than FMC with EMS. The PCC group had a much lower intrinsic risk and was associated with better outcomes despite longer revascularization delays.

Intracoronary eptifibatide with vasodilators to prevent no-reflow in diabetic STEMI with high thrombus burden. A randomized trial.

INTRODUCTION AND OBJECTIVES: To study the impact of injecting intracoronary eptifibatide plus vasodilators via thrombus aspiration catheter vs thrombus aspiration alone in reducing the risk of no-reflow in acute ST-elevation myocardial infarction (STEMI) with diabetes and high thrombus burden. METHODS: The study involved 413 diabetic STEMI patients with high thrombus burden, randomized to intracoronary injection (distal to the occlusion) of eptifibatide, nitroglycerin and verapamil after thrombus aspiration and prior to balloon inflation (n=206) vs thrombus aspiration alone (n=207). The primary endpoint was post procedural myocardial blush grade and corrected Thrombolysis in Myocardial Infarction (TIMI) frame count (cTFC). Major adverse cardiovascular events were reported at 6 months. RESULTS: The intracoronary eptifibatide and vasodilators arm was superior to thrombus aspiration alone regarding myocardial blush grade-3 (82.1% vs 31.4%; P=.001). The local intracoronary eptifibatide and vasodilators arm had shorter cTFC (18.16±6.54 vs 29.64±5.53, P=.001), and better TIMI 3 flow (91.3% vs 61.65%; P=.001). Intracoronary eptifibatide and vasodilators improved ejection fraction at 6 months (55.2±8.13 vs 43±6.67; P=.005). There was no difference in the rates of major adverse cardiovascular events at 6 months. CONCLUSIONS: Among diabetic patients with STEMI and high thrombus burden, intracoronary eptifibatide plus vasodilators injection was beneficial in preventing no-reflow compared with thrombus aspiration alone. Larger studies are encouraged to investigate the benefit of this strategy in reducing the risk of adverse clinical events.

Impact of creating a hemodynamics room, a coronary care unit, and a primary angioplasty program on the prognosis of acute coronary syndrome in a district hospital.

OBJECTIVE: This work aims to analyze the prognosis and mortality of patients hospitalized for acute coronary syndrome before and after the implementation of a coronary care unit, hemodynamics room, and the Código Corazón [Infarction Code] primary angioplasty program. METHODS: We conducted an observational, retrospective study that analyzed the epidemiological characteristics, reperfusion strategies, adverse cardiovascular events, and mortality over a follow-up period of five years. The results from the post-code period (March 1 - December 31, 2012; n=471) were compared with those from the pre-code period (March 1 - December 31, 2009; n=432). RESULTS: There were no differences in the baseline characteristics of the two groups. However, an increase in ST-elevation acute coronary syndrome (STE-ACS) from 17.6% to 34.8% (p<.001) was observed during the postcode phase. The use of percutaneous coronary intervention was made widespread at the hospital and was used in 64.8% of non-ST-elevation acute coronary syndrome (NSTE-ACS) cases and in 95.5% of STE-ACS cases. A reduction was observed in readmissions (from 38.2% to 25.1% for NSTE-ACS (p=.001) and from 23.7% to 11.0% for STE-ACS (p=.018)), the composite prognostic variable of adverse cardiovascular events and 5-year mortality (from 58.7% to 45% (p=.001) for NSTE-ACS and from 40.8% to 23.8% (p=.009) for STE-ACS), and a decrease in 30-day mortality in STE-ACS (from 11.8% to 3.7%; p=.021). CONCLUSIONS: With the structural changes in the hospital, the use of percutaneous coronary intervention was made widespread and improved the prognosis of patients with acute coronary syndrome, decreasing admissions, adverse cardiovascular events, and mortality.

[Percutaneous coronary intervention of unprotected left main coronary compared with coronary artery bypass grafting; 3 years of experience in the National Institute of Cardiology, Mexico]. / Intervención coronaria percutánea del tronco no protegido de la coronaria izquierda comparada con cirugía de revascularización coronaria; experiencia de 3 años en el Instituto Nacional de Cardiología.

BACKGROUND: The best revascularisation method of the unprotected left main artery is a current and evolving topic. METHODS: A total of 2439 percutaneous coronary interventions (PCI) were registered during a 3-year period. The study included all the patients with PCI of the unprotected left main coronary (n=48) and matched with patients who underwent coronary artery bypass graft (CABG) (n=50). Major adverse cerebral and cardiac events (MACCE) were assessed within the hospital and in outpatients during a 16 month follow up. RESULTS: The cardiovascular risk was greater in the PCI group; logEuroSCORE 16±21 vs. 5±6, P=.001; clinical Syntax 77±74 vs 53±39, P=.04. On admission, the PCI group of patients had a higher frequency of ST segment elevation myocardial infarction (STEMI) and cardiogenic shock. The MACCE were similar in both groups (14% vs. 18%, P=.64). STEMI was less frequent in the PCI group (0% vs. 10%, P=.03). Cardiovascular events were lower in the PCI group (2.3% vs. 18%, P=.01), and there was a decrease in general and cardiac mortality (2.3% vs. 12%, P=.08 y 2.3% vs. 8%, P=.24), on excluding the patients with cardiogenic shock as a presentation. MACCE were similar in both groups in the out-patient phase (15% vs. 12%, P=.46). Survival without MACCE, general and cardiac death were comparable between groups (log rank, P=.38, P=.44 and P=.16, respectively). CONCLUSION: Even though the clinical and peri-procedural risk profile of the PCI patients were higher, the in-hospital and out-hospital efficacy and safety were comparable with CABG.

Experiencia inicial de la revascularización coronaria percutánea mediante el acceso transradial en el Instituto de Cardiología y Cirugía Cardiovascular / Initial experience of percutaneous coronary revascularization through transradial access at the Institute of Cardiology and Cardiovascular Surgery

Introducción: En los últimos años la utilización de la vía radial como forma de acceso para la realización de estudios diagnósticos e intervencionista ha cobrado mayor importancia e interés dentro de los servicios de cardiología intervencionista a nivel mundial. Nuestro país no escapa de este auge por la baja tasa de complicación y la mayor comodidad para el paciente. Objetivo: Caracterizar la intervención coronaria percutánea mediante la vía de acceso radial en pacientes atendidos en el Instituto de Cardiología y Cirugía Cardiovascular. Método: Estudio observacional, descriptivo, transversal. Muestra compuesta por 211 pacientes a los que se les realizó intervencionismo coronario percutáneo mediante la vía de acceso radial. Resultados: Predominó el sexo masculino (61,2 por ciento). La edad media fue 60,1 ±9,8 años. El Síndrome Coronario Crónico (76,3 por ciento ) fue el diagnóstico mayoritario, la hipertensión arterial el factor de riesgo más frecuente (73,9 por ciento ) y entre los antecedentes personales la cardiopatía isquémica (30,3 por ciento ). El intervencionismo de forma electiva se realizó en el 76,3 de los casos, utilizando la vía radial derecha en el 88,2 por ciento . Se demostró enfermedad de 2 y 3 vasos en el 45,1 por ciento de los pacientes. El proceder fue exitoso en el 96,7 por ciento de los pacientes. Las variables que demostraron relación estadísticamente significativa con el fracaso fueron: fracción de eyección del ventrículo izquierdo < 40 por ciento (p<0.0001), filtrado glomerular ≤ 60 ml/min (p=0.002), antecedente de cardiopatía isquémica (p= 0.016) y presencia de enfermedad coronaria de 3 vasos (p= 0.019). Conclusiones: La intervención coronaria percutánea mediante el acceso radial en el ICCCV es segura y eficaz, con una tasa de éxito elevada y escasas complicaciones(AU)

Introduction: In recent years the use of the radial approach as a form of access for diagnostic and interventional studies has become increasingly important and of interest in interventional cardiology services worldwide. Our country has not escaped this boom due to the low complication rate and greater patient comfort. Objective: To characterise percutaneous coronary intervention using the radial access route in patients attended at the Institute of Cardiology and Cardiovascular Surgery. Methods: Observational, descriptive, cross-sectional study. The sample consisted of 211 patients who underwent percutaneous coronary intervention via the radial access route. Results: Male sex predominated (61.2 percent). Mean age was 60.1 ±9.8 years. Chronic coronary syndrome (76.3 percent) was the most common diagnosis, hypertension the most frequent risk factor (73.9) percent and ischaemic heart disease (30.3 percent ). Elective intervention was performed in 76.3 percent of cases, using the right radial approach in 88.2 percent . Two- and three-vessel disease was demonstrated in 45.1 percent of patients. The procedure was successful in 96.7 percent of patients. Variables demonstrating statistically significant relationship with failure were: left ventricular ejection fraction < 40 percent (p(0.0001), glomerular filtration rate ≤ 60 ml/min (p=0.002), history of ischaemic heart disease (p= 0.016) and presence of 3-vessel coronary artery disease (p= 0.019). Conclusions: Percutaneous coronary intervention via radial access in ICCCV is safe and effective, with a high success rate and few complications(AU)

Calidad de vida en pacientes mayores de 75 años con síndrome coronario agudo / Quality of life in patients older than 75 years with acute coronary syndrome

Introducción: La oclusión parcial o total de una arteria coronaria epicárdica es la génesis más frecuente de los síndromes coronarios agudos. Con la intención de medir el impacto de las enfermedades y el tratamiento en el funcionamiento diario, bienestar físico, emocional y social de cada persona se introduce el término calidad de vida relacionada con la salud. Objetivo: Evaluar la calidad de vida en pacientes mayores de 75 años con síndrome coronario agudo. Métodos: Se realizó un estudio observacional de corte prospectivo con componente analítico en 82 pacientes con diagnóstico de síndrome coronario agudo que recibieron el intervencionismo coronario percutáneo, mayores de 75 años, ingresados en la unidad de cuidados intensivos coronarios del Hospital Clínico-Quirúrgico Comandante Manuel Fajardo en el período comprendido entre enero de 2015 y diciembre de 2019. Resultados: La mediana para la edad fue de 80 años con rango intercuartílico de (77-82), no existió diferencias significativas en cuento al sexo, prevaleció la hipertensión arterial (80,5 por ciento) y los antecedentes de infarto agudo de miocardio (41,5 por ciento). En sentido general las medianas y los rangos en los pacientes con síndrome coronario agudo sin elevación del segmento ST fueron superiores a los que presentaron síndrome coronario agudo con elevación del segmento ST. Las mujeres presentaron una peor función social que los hombres. Conclusiones: Se evaluó la calidad de vida en pacientes mayores de 75 años con síndrome coronario agudo con elevación del segmento ST, tuvieron peores puntuaciones en las diferentes dimensiones de la calidad de vida relacionada con la salud, las mujeres presentaron una peor función social en comparación con los hombres(AU)

Introduction: Partial or total occlusion of an epicardial coronary artery is the most frequent genesis of acute coronary syndromes. With the intention of measuring the impact of disease and treatment on the daily functioning, physical, emotional and social well-being of each person, the term health-related quality of life is introduced. Objective: To evaluate the quality of life in patients over 75 years of age with acute coronary syndrome. Methods: A prospective observational study with an analytical component was conducted in 82 patients with a diagnosis of acute coronary syndrome who received percutaneous coronary interventionism, over 75 years of age, admitted to the coronary intensive care unit of the Clinical-Surgical Hospital Comandante Manuel Fajardo from January 2015 to December 2019. Results: The average age was 80 years with an interquartile range of (77-82), there were no significant differences in terms of gender, hypertension (80.5percent) and a history of acute myocardial infarction (41.5percent) prevailed. In general, the averages and ranges in patients with non-ST-segment elevation acute coronary syndrome were higher than those with ST-segment elevation acute coronary syndrome. Women had worse social function than men. Conclusions: Quality of life was assessed in patients older than 75 years with ST-segment elevation acute coronary syndrome. They had worse scores in the different dimensions of health-related quality of life, women presented worse social function compared to men(AU)

Prediabetes and coronary artery disease: Outcome after revascularization procedures.

OBJECTIVE: To assess the long-term association between prediabetes and an increased risk of cardiovascular events in patients with coronary artery disease and percutaneous coronary intervention (PCI). METHODS: A retrospective cohort study. We searched our database to identify all PCI procedures performed in 2010. Patients with no diabetes and HbA1c measurement in the index hospitalization were enrolled and divided into two groups based on HbA1c value: 5.7-6.5% for prediabetes and <5.7% for controls. Demographic, clinical, and procedure-related variables were recorded. Study endpoints were mortality, hospital admissions, myocardial infarction (MI), and revascularization procedures. RESULTS: The study population consisted of 132 subjects (82.6% males, age: 65.26 ± 12.46 years). No difference was found as regards distribution of demographic, clinical, and procedure-related variables. A majority (64.1%) of PCI procedures were performed for ST-segment elevation MI. Prevalence of prediabetes was 40.2%. After a mean follow-up period of 42.3 ± 3.6 months, no differences were found in outcomes between the prediabetes and control groups in total mortality (5.4% vs 1.9%; relative risk [RR] 2.86, 95% confidence interval [95% CI] 0.27-30.44; P=.56), non-cardiovascular mortality (2.7% vs 1.9%; RR 1.43, 95% CI 0.93-22.18; P=.79), hospital admissions (19% vs 25%; RR 1.13, 95%CI 0.73-1.73; P=.57), MI (3% vs 1%; RR 4.28, 95%CI .46-39.52; P=.30), or target lesion revascularization (3% vs 6%); RR .70, 95%CI .18-2.61; P=.72). CONCLUSIONS: Prediabetes, as determined by HbA1c (5.7%-6.5%), is not associated with long-term adverse cardiovascular outcomes in patients with CAD and PCI.

Trombosis muy tardía de stent metálico convencional: Un suceso inesperado

RESUMEN La trombosis muy tardía de stent es un fenómeno de baja frecuencia, pero de elevada morbilidad y mortalidad. Dentro de sus factores predisponentes se encuentran parámetros clínicos, anatómicos y relacionados con el procedimiento. Múltiples son los mecanismos fisiopatológicos que se plantean como responsables de la trombosis de stent. El tratamiento de esta complicación consiste en intentar restaurar el flujo del vaso lo antes posible. Se presenta el caso de un paciente con el diagnóstico de infarto agudo de miocardio con elevación del segmento ST secundario a trombosis muy tardía de stent metálico convencional (20 meses), tratado exitosamente mediante intervencionismo coronario percutáneo con dos stents liberadores de sirolimus.

ABSTRACT Very late stent thrombosis is a rare complication but with high morbidity and mortality. Predisposing factors include clinical, anatomical and procedure-related parameters. Many pathophysiological mechanisms are considered to be responsible for stent thrombosis. The treatment of this complication consists of attempting to restore blood flow as soon as possible. We present the case of an individual diagnosed with ST-segment elevation myocardial infarction after very late thrombosis of conventional bare metal stent (20 months). The patient was successfully treated by percutaneous coronary intervention with two sirolimus-eluting stents.

Prevalence and prognosis of percutaneous coronary intervention-associated nephropathy in patients with acute coronary syndrome and normal kidney function.

INTRODUCTION AND OBJECTIVES: The aim of this study was to analyze the prevalence, risk factors, and short- and long-term prognosis of patients with acute coronary syndrome and normal renal function who developed percutaneous coronary intervention-associated nephropathy. METHODS: This was an observational, retrospective, single-center study with a prospective follow-up of 470 consecutive patients hospitalized for acute coronary syndrome (not in cardiogenic shock) who underwent percutaneous coronary intervention, with no preexisting renal failure (admission creatinine ≤ 1.3mg/dL). Percutaneous coronary intervention-associated was defined as an increase in baseline creatinine ≥ 0.5 mg/dL or ≥ 25% baseline. The mean follow-up was 26.7 (14) months. RESULTS: Of the 470 patients, 30 (6.4%) developed percutaneous coronary intervention-associated nepfhropathy. The independent predictors for acute renal failure were admission hemoglobin level (odds ratio = 0.71) and maximum troponin I level prior to the procedure (odds ratio = 1.02). During the long-term follow-up, the patients whose renal function deteriorated had a higher incidence of total mortality (5 [16.7%] vs 27 [6.1%]; P = .027). In the Cox regression analysis, percutaneous coronary intervention-associated nepfhropathy was not an independent predictor for total mortality, but could be a predictor for cardiac mortality (hazard ratio=5.4; 95% confidence interval 1.35-21.3; P = .017). CONCLUSIONS: Percutaneous coronary intervention-associated nephropathy in patients with acute coronary syndrome and normal preexisting renal function is not uncommon and influences long-term survival.

[Acetylsalicylic acid desensitization in the new era of percutaneous coronary intervention]. / Desensibilización al ácido acetil salicílico en la nueva era del intervencionismo coronario percutáneo.

Dual antiplatelet therapy is essential in patients undergoing percutaneous coronary intervention with stent implantation. Hypersensitivity to acetylsalicylic acid (ASA) limits treatment options. Desensitization to ASA has classically been studied in patients with respiratory tract disease. Over the last years, many protocols have been described about ASA desensitization in patients with ischemic heart disease, including acute coronary syndrome and the need for coronary stent implantation. It is important to know the efficacy and safety of ASA desensitization in these patients.

[The cardiovascular surgeon and the Syntax score]. / El cirujano cardiovascular y la puntuación Syntax.

The Syntax score has been established as a tool to determine the complexity of coronary artery disease and as a guide for decision-making among coronary artery bypass surgery and percutaneous coronary intervention. The purpose of this review is to systematically examine what the Syntax score is, and how the surgeon should integrate the information in the selection and treatment of patients. We reviewed the results of the SYNTAX Trial, the clinical practice guidelines, as well as the benefits and limitations of the score. Finally we discuss the future directions of the Syntax score.

Índice neutrófilo-linfocitario: Una herramienta útil en la cardiología intervencionista / Neutrophil-to-lymphocyte ratio: A useful tool for interventional cardiology

RESUMEN Las enfermedades cardiovasculares son la principal causa de morbilidad y mortalidad en el mundo, y en Cuba han mostrado un incremento en los últimos años. Su causa isquémica constituye la enfermedad aislada más frecuente de muerte en los cubanos, y el intervencionismo coronario percutáneo (ICP) -como parte de su tratamiento- se encuentra entre las áreas de mayor desarrollo dentro de la Cardiología actualmente. Existe un papel creciente de la inflamación en estas enfermedades, por lo que se impone la búsqueda de nuevos marcadores inflamatorios que tengan relación con este procedimiento. El índice neutrófilo-linfocitario se ha relacionado con la aparición de complicaciones durante el ICP y el seguimiento de estos pacientes, por lo que se propone una actualización al respecto. La evidencia muestra una relación significativa entre el aumento de este índice con la aparición de infarto de miocardio peri-procedimiento, así como con los resultados adversos en el seguimiento; de manera que abre una nueva puerta de investigación en la cardiología intervencionista.

ABSTRACT Cardiovascular diseases are the main cause of morbidity and mortality worldwide, and in Cuba, they have increased in recent years. Their ischemic origin represents the most frequent isolated disease causing death in Cuban people. The percutaneous coronary intervention (PCI) -as part of their treatment- is among the most developed areas within current Cardiology. There is a growing role of inflammation in these diseases; therefore, the search for new inflammatory markers, that are related to this procedure, is crucial. The neutrophil-to-lymphocyte ratio has been associated with the occurrence of complications during the PCI and monitoring of these patients, thus, an update in this regard is proposed. The evidence shows a significant relationship between the increase of this ratio, with the appearance of peri-procedure myocardial infarction, as well as with the adverse results in the follow-up; in a way, that opens a new route of research in interventional cardiology.

[New antiplatelet drugs in coronary artery disease]. / Nuevos antiagregantes plaquetarios en cardiopatía isquémica.

The dual antiplatelet therapy with acetylsalicylic acid and clopidogrel has been the mainstay of both acute and chronic phase coronary artery disease, reducing importantly the risk of adverse events. Despite a correct compliance, a non-negligible rate of adverse events still happens. New compounds, with improved properties, are now clinically available (such as prasugrel or ticagrelor) or under advanced development. The aim of the present review is the description of these new compounds, particularly prasugrel and ticagrelor.

Radiación ionizante: revisión de tema y recomendaciones para la práctica / Ionising radiation: A review of the topic and recommendations for using it

Resumen La seguridad en radiación es un tema de actualidad. A diario se evidencian las consecuencias deletéreas de esta herramienta diagnóstica y terapéutica. En su mayoría, las patologías asociadas secundarias a la exposición por radiación podrían prevenirse con una adecuada intervención preventiva y protectora. Se presenta un artículo de revisión con el fin de explicar de forma detallada los aspectos más relevantes acerca de la formación de los rayos X, su definición y clasificación dosimétrica, los efectos biológicos de la radiación, los límites recomendados y las medidas de protección para la exposición de radiación.

Abstract Radiation safety is a current topic. The harmful effects of this diagnostic and therapeutic tool are observed daily. The majority of associated secondary to radiation exposure could be prevented with suitable safety and protective measures. A review article is presented with the aim of explaining the most relevant aspects of radiation in detail, including the formation of x-rays, their dosimetry definition and classification, the biological effects of radiation, the recommended limits, as well as the protection measures for the exposure to radiation.

Contrast induced nephropathy in patients with primary percutaneous coronary intervention with or without metabolic syndrome / Nefropatía inducida por contraste en pacientes con intervención coronaria percutánea primaria con o sin síndrome metabólico

Abstract: Contrast induced nephropathy (CIN) is defined as the absolute increment of serum creatinine ≥ 0.5 mg/dL or an increment more than 25% of basal creatinine, without any other identified cause, within 48 hours after contrast media administration. Objective: Determine the CIN risk in patients with Acute Coronary Syndrome (ACS) with or without metabolic syndrome (MetS) treated with primary percutaneous coronary intervention (PCI). Material and methods: A prospective, observational, longitudinal and comparative study, in patients with ACS admitted to the Coronary Care Unit or Intensive Care Unit. PCI was performed with a serum creatinine (sCr) of ≤ 1.2 mg/dL prior intervention. Serum creatinine determinations were conducted 24-48 hours post PCI. The statistical test for analysis of free distribution quantitative variables was performed with Mann Whitney U test, and for qualitative variables Chi square test (χ2). Likelihood-ratio and confidence interval of 95% with p = 0.05. Results: 420 patients with infarction code were studied, 323 men (76.9%), 97 women (23.1%), with ages between 56-70 years. They were divided into 2 groups: group A 176 (41.9%) with MetS and group B 244 (58%) without MetS. CIN was present in 43 patients (10.2%) group A and in 29 (6.9%) group B. RR: 2.05, CI 95% 1.33-3.15, p = 0.0012. Conclusions: MetS is a risk factor (RF) for the development of CIN in patients with ACS who undergo PCI. Therefore, this syndrome should be kept in mind for an early detection and prevention of the development of CIN.

Resumen: La nefropatía inducida por contraste (NIC) se define como el incremento absoluto de creatinina sérica ≥ 0.5 mg/dL o un incremento del 25% de la creatinina basal, sin otra causa identificada, en un periodo de 48 horas posterior a la exposición al medio de contraste. Objetivo: Determinar el riesgo de NIC en pacientes con síndrome coronario agudo (SCA) con y sin síndrome metabólico (SM) tratados con intervencionismo coronario percutáneo (ICP). Material y métodos: Estudio prospectivo, observacional, longitudinal, comparativo, en pacientes con SCA admitidos a la Unidad de Cuidados Coronarios o a la Unidad de Cuidados Intensivos. La ICP fue realizada con creatinina sérica (Crs) previa ≤ 1.2 mg/dL. Las determinaciones de creatinina sérica se efectuaron 24-48 horas postICP. Para el análisis de las variables cuantitativas se utilizó la prueba de U de Mann-Whitney y para variables cualitativas, prueba de Chi cuadrada (χ2) con nivel de significancia e intervalos de confianza del 95% con p = 0.05. Resultados: 420 pacientes de código infarto fueron estudiados, 323 hombres (76.9%), 97 mujeres (23.1%) con edades de 56 a 70 años. Se dividieron en dos grupos: grupo A 176 (41.9%) con SM, grupo B, 244 (58%) sin SM. Se presentó NIC en 43 pacientes (10.2%) del grupo A y en 29 (6.9%) del grupo B. RR: 2.05, IC 95% 1.33-3.15, p = 0.0012. Conclusiones: El SM es un factor de riesgo (FR) para desarrollar NIC en pacientes con SCA sometidos a ICP. Por lo tanto, debe tenerse en cuenta para la detección temprana y prevención de NIC.

Coronariografía urgente en los pacientes con parada cardiaca extrahospitalaria sin elevación del segmento ST. Ensayo clínico COUPE / Coronary angiography in patients without ST-segment elevation following out-of-hospital cardiac arrest. COUPE clinical trial

Introducción y objetivos El papel de la coronariografía urgente y angioplastia, si procede, en los pacientes con parada cardiaca extrahospitalaria (PCEH) recuperada que no presentan elevación del segmento ST es controvertido. Nuestro objetivo fue evaluar si la coronariografía urgente y la angioplastia mejoran la supervivencia con buen pronóstico neurológico en esta población. Métodos En este ensayo clínico multicéntrico, aleatorizado, abierto, incluimos 69 pacientes supervivientes a una PCEH sin elevación del ST y se aleatorizaron a recibir una coronariografía urgente (CU) o diferida (CD). El objetivo primario de eficacia fue el combinado de supervivencia hospitalaria libre de dependencia. El objetivo de seguridad fue un compuesto de eventos cardiacos mayores, incluyendo muerte, reinfarto, sangrado y arritmias ventriculares. Resultados Se incluyó a 66 pacientes en el análisis primario (95,7%). La supervivencia hospitalaria fue 62,5% en el grupo CU y 58,8% en el grupo CD (HR = 0,96; IC95%, 0,45-2,09; p=0,93). La supervivencia hospitalaria con buen pronóstico neurológico fue 59,4% en el grupo CU y 52,9% en el grupo CD (HR = 1,29; IC95%, 0,60-2,73; p=0,4986). No se encontraron diferencias en los objetivos secundarios, salvo por la incidencia de fracaso renal agudo, que fue más frecuente en el grupo CU (15,6 frente a 0%, p=0,002) y de infecciones, más prevalentes en el grupo CD (46,9 frente a 73,5%, p=0,003). Conclusiones En este estudio aleatorizado de pacientes con una PCEH sin elevación del ST, una CU no fue beneficiosa en términos de supervivencia con buen pronóstico neurológico comparada con una CD (AU)

Introduction and objectives The role of emergency coronary angiography (CAG) and percutaneous coronary intervention (PCI) following out-of-hospital cardiac arrest (OHCA) in patients without ST-segment elevation myocardial infarction (STEMI) remains unclear. We aimed to assess whether emergency CAG and PCI would improve survival with good neurological outcome in this population. Methods In this multicenter, randomized, open-label, investigator-initiated clinical trial, we randomly assigned 69 survivors of OHCA without STEMI to undergo immediate CAG or deferred CAG. The primary efficacy endpoint was a composite of in-hospital survival free of severe dependence. The safety endpoint was a composite of major adverse cardiac events including death, reinfarction, bleeding, and ventricular arrhythmias. Results A total of 66 patients were included in the primary analysis (95.7%). In-hospital survival was 62.5% in the immediate CAG group and 58.8% in the delayed CAG group (HR, 0.96; 95%CI, 0.45-2.09; P=.93). In-hospital survival free of severe dependence was 59.4% in the immediate CAG group and 52.9% in the delayed CAG group (HR, 1.29; 95%CI, 0.60-2.73; P=.4986). No differences were found in the secondary endpoints except for the incidence of acute kidney failure, which was more frequent in the immediate CAG group (15.6% vs 0%, P=.002) and infections, which were higher in the delayed CAG group (46.9% vs 73.5%, P=.003). Conclusions In this underpowered randomized trial involving patients resuscitated after OHCA without STEMI, immediate CAG provided no benefit in terms of survival without neurological impairment compared with delayed CAG (AU)

Intervención coronaria percutánea del tronco no protegido de la coronaria izquierda comparada con cirugía de revascularización coronaria; experiencia de 3 años en el Instituto Nacional de Cardiología / Percutaneous coronary intervention of unprotected left main coronary compared with coronary artery bypass grafting; 3 years of experience in the National Institute of Cardiology, Mexico

Resumen Antecedentes: El mejor método para el tratamiento de la revascularización de la lesión del tronco no protegido de la coronaria izquierda es un tema de creciente interés. Método: Se realizaron un total de 2,439 intervenciones coronarias percutáneas (ICP) durante 3 años; se incluyeron los pacientes con lesión del tronco no protegido de la coronaria izquierda (TCI; n = 48) y se compararon con pacientes a los que se realizó cirugía de revascularización coronaria (CRVC; n = 50). Se analizaron los eventos cardiovasculares en fase hospitalaria y extrahospitalaria. El promedio de seguimiento fue de 16 meses. Resultados: El riesgo cardiovascular fue mayor en pacientes con ICP; log EuroSCORE (16 ± 21 vs. 5 ± 6, p = 0.001), Syntax clínico (77 ± 74 vs. 53 ± 39, p = 0.04). Los pacientes del grupo de ICP presentaron al ingreso con más frecuencia infarto con elevación del ST (IMCEST) y con choque cardiogénico. Los eventos hospitalarios fueron similares en ICP y CRVC (14% vs. 18%, p = 0.64). El IMCEST fue menos frecuente en el grupo de ICP (0% vs. 10%, p = 0.03. Los eventos cardiovasculares fueron menores en el grupo de ICP (2.3% vs. 18%, p = 0.01) y hubo una disminución de la muerte general y cardiaca (2.3% vs. 12%, p = 0.08 y 2.3% vs. 8%, p = 0.24), al excluir los pacientes con choque cardiogénico como presentación. En la fase extrahospitalaria los eventos fueron similares en ICP y CRVC (15% vs. 12%, p = 0.46). La supervivencia sin eventos cardiovasculares, muerte general y cardiaca fueron comparables entre los grupos (log rank, p = 0.38, p = 0.44 y p = 0.16). Conclusión: Pese a que los pacientes de ICP mostraron un perfil de riesgo mayor que los de CRVC, la seguridad y eficacia intrahospitalaria y extrahospitalaria fueron similares. © 2016 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Abstract Background: The best revascularisation method of the unprotected left main artery is a current and evolving topic. Methods: A total of 2439 percutaneous coronary interventions (PCI) were registered during a 3-year period. The study included all the patients with PCI of the unprotected left main coronary (n = 48) and matched with patients who underwent coronary artery bypass graft (CABG) (n = 50). Major adverse cerebral and cardiac events (MACCE) were assessed within the hospital and in outpatients during a 16 month follow up. Results: The cardiovascular risk was greater in the PCI group; logEuroSCORE 16 ± 21 vs. 5 ± 6, P = .001; clinical Syntax 77 ± 74 vs 53 ± 39, P = .04. On admission, the PCI group of patients had a higher frequency of ST segment elevation myocardial infarction (STEMI) and cardiogenic shock. The MACCE were similar in both groups (14% vs. 18%, P = .64). STEMI was less frequent in the PCI group (0% vs. 10%, P = .03). Cardiovascular events were lower in the PCI group (2.3% vs. 18%, P = .01), and there was a decrease in general and cardiac mortality (2.3% vs. 12%, P = .08 y 2.3% vs. 8%, P = .24), on excluding the patients with cardiogenic shock as a presentation. MACCE were similar in both groups in the out-patient phase (15% vs. 12%, P = .46). Survival without MACCE, general and cardiac death were comparable between groups (log rank, P = .38, P = .44 and P = .16, respectively). Conclusion: Even though the clinical and periprocedural risk profile of the PCI patients were higher, the in-hospital and out-hospital efficacy and safety were comparable with CABG. © 2016 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/).

In-hospital mortality due to acute myocardial infarction. relevance of type of hospital and care provided. RECALCAR study.

INTRODUCTION AND OBJECTIVES: To investigate the relationship between in-hospital mortality due to acute myocardial infarction and type of hospital, discharge service, and treatment provided. METHODS: Retrospective analysis of 100 993 hospital discharges with a principal diagnosis of myocardial infarction in hospitals of the Spanish National Health Service. In-hospital mortality was adjusted for risk following the models of the Institute for Clinical Evaluative Sciences (Canada) and the Centers for Medicare & Medicaid Services (United States). RESULTS: Hospital characteristics are relevant to explain the variation in the individual probability of dying from myocardial infarction (median odds ratio: 1.3561). The risk-adjusted in-hospital mortality in cluster 3 and especially in cluster 4 hospitals (500 beds to 1000 beds and medium-high complexity) was significantly lower than in hospitals with less than 200 beds. Cluster 5 (more than 1000 beds), which includes a diverse group of hospitals, had a higher mortality rate than clusters 3 and 4. The adjusted mortality in the groups with the best and worst outcomes was 6.74% (cluster 4) and 8.49% (cluster 1), respectively. Mortality was also lower when the cardiology unit was responsible for the discharge or when angioplasty had been performed. CONCLUSIONS: The typology of the hospital, treatment in a cardiology unit, and percutaneous coronary intervention are significantly associated with the survival of a patient hospitalized for myocardial infarction. We recommend that the Spanish National Health Service establish health care networks that favor percutaneous coronary intervention and the participation of cardiology units in the management of patients with acute myocardial infarction.