El puntaje de Framingham ayudaría en la estratificación del riesgo de pacientes con ergometría positiva y SPECT normal / The Framingham score could help in risk stratification of patients with positive ergometry and normal SPECT

Antecedentes. El valor pronóstico de una ergometría positiva en el contexto de imágenes tomográficas de perfusión miocárdica de estrés y reposo (SPECT) normales no está bien establecido. Objetivos. Documentar la incidencia de infarto, muerte y revascularización coronaria en pacientes con una ergometría positiva de riesgo intermedio e imágenes de perfusión SPECT normales, y explorar el potencial valor del puntaje de riesgo de Framingham en la estratificación pronóstica de estos pacientes. Métodos. Cohorte retrospectiva integrada por pacientes que habían presentado síntomas o hallazgos electrocardiográficos compatibles con enfermedad arterial coronaria durante la prueba de esfuerzo, con criterios de riesgo intermedio en la puntuación de Duke y perfusión miocárdica SPECT normal. Fueron identificados a partir de la base de datos del laboratorio de cardiología nuclear del Instituto de Cardiología y Cirugía Cardiovascular de la ciudad de Posadas, Argentina. Resultados. Fueron elegibles 217 pacientes. El seguimiento fue de 3 1,5 años. La sobrevida libre de eventos (muerte,infarto de miocardio no fatal, angioplastia coronaria o cirugía de bypass de arteria coronaria) a uno, tres y cinco años fue significativamente menor (Log-rank test, p= 0,001) en el grupo con puntaje de Framingham alto o muy alto (77, 71y 59 %, respectivamente) que en el grupo de puntaje bajo o intermedio (89, 87 y 83 %). Tomando como referencia a los pacientes con riesgo bajo en el puntaje de Framingham, luego de ajustar por edad, sexo y puntaje de Duke, los pacientes categorizados en los estratos alto y muy alto riesgo del puntaje de Framingham presentaron una incidencia del evento combinado cercana al triple (hazard ratio [HR] 2,81; intervalo de confianza [IC] del 95 % 0,91 a 8,72; p= 0,07 y HR 3,61;IC 95 % 1,23 a 10,56; p= 0,019 respectivamente). Conclusiones. La estimación de riesgo con el puntaje de Framingham sería de ayuda en la estratificación pronóstica de los pacientes con ergometría positiva y SPECT normal. (AU)

Background. The prognostic value of positive exercise testing with normal SPECT myocardial perfusion imaging is not well established. Objectives. To document the incidence of infarction, death, and coronary revascularization in patients with a positive intermediate-risk exercise test and normal SPECT perfusion images and to explore the potential value of the Framingham Risk Score in the prognostic stratification of these patients. Methods. A retrospective cohort comprised patients who presented symptoms or electrocardiographic findings compatible with coronary artery disease during the stress test, with intermediate risk criteria in the Duke score and normal SPECT myocardial perfusion. They were identified from the database of the nuclear cardiology laboratory of the Instituto de Cardiología y Cirugía Cardiovascular of Posadas, Argentina. Results. 217 patients were eligible. Follow-up was 3 1.5 years. Event-free survival (death, non-fatal myocardial infarction, coronary angioplasty, or coronary artery bypass surgery) at one, three, and five years was significantly lower (Log-ranktest, p: 0.001) in the group with a score of Framingham high or very high (77, 71 and 59 %, respectively) than in the lowor intermediate score group (89, 87 and 83 %). Taking as reference the low-risk patients in the Framingham score, after adjusting for age, sex, and Duke score, the patients categorized in the high-risk and very high-risk strata showed about three times higher incidence of the combined event (hazard ratio [HR] 2.81; 95 % confidence interval [CI] 0.91 to 8.72;p=0.07 and HR 3.61; 95 % CI 1.23 to 10.56; p=0.019 respectively). Conclusions. Risk estimation with the Framingham score would be helpful in the prognostic stratification of patients with positive exercise testing and normal SPECT. (AU)

El dilema clínico frente a los pacientes con ergometría positiva y prueba de perfusión miocárdica con SPECT normal / The clinical dilemma facing patients with positive stress test and normal SPECT myocardial perfusion imaging

La evaluación de la perfusión miocárdica con SPECT combina una prueba de esfuerzo (ergometría o estrés farmacológico) junto a imágenes de perfusión con radioisótopos. Este estudio es útil para establecer el diagnóstico de enfermedad arterial coronaria, estratificar el riesgo de infarto y tomar decisiones terapéuticas. Un resultado normal aporta un alto valor predictivo negativo, es decir, una muy baja probabilidad de que el paciente presente eventos cardiovasculares. El hallazgo de signos de isquemia en la ergometría podría poner en jaque el valor predictivo negativo de una perfusión normal. En presencia de este resultado, el paso siguiente es evaluar los predictores de riesgo en la ergometría, el riesgo propio del paciente en función de los antecedentes clínicos y el puntaje cálcico coronario, cuando este se encuentra disponible. Ante la presencia concomitante de otros marcadores de riesgo se sugiere completar la evaluación con un estudio anatómico.El uso de nuevas tecnologías podría mejorar la precisión en la predicción de eventos. (AU)

Assessment of myocardial perfusion with SPECT combines a stress test (ergometry or pharmacological stress) with radioisotope perfusion imaging. This test is helpful to diagnose coronary artery disease, stratify the risk of heart attack, and make therapeutic decisions. A normal result provides a high negative predictive value; therefore, the probability of cardiovascular events is very low. Signs of ischemia on an ergometry could jeopardize the negative predictive value of normal perfusion. In this clinical setting, the next step is to evaluate the risk predictors in the stress test, the individual risk based on the clinical history, and the coronary calcium score when available. Given the simultaneous presence of other risk markers,completing the evaluation with an anatomical study is suggested. The use of new technologies could improve the accuracy of event prediction. (AU)

Neutrófilos en el diagnóstico de infarto del miocardio tipo 4a / Neutrophils in the Diagnosis of Type 4 Myocardial Infarction

Introducción: El infarto del miocardio tipo 4a es una complicación del intervencionismo coronario percutáneo que incrementa el estado inflamatorio de los pacientes. Objetivo: Evaluar el valor diagnóstico del conteo absoluto de neutrófilos en la aparición de infarto del miocardio tipo 4a. Métodos: Se realizó una cohorte prospectiva en el Hospital Hermanos Ameijeiras. El universo estuvo constituido por 412 pacientes a los que se les realizó intervencionismo coronario percutáneo en el período comprendido de noviembre de 2018 a enero de 2021, la muestra fue de 232 pacientes. Se definieron variables clínicas, anatómicas, e inflamatorias. Resultados: Existieron diferencias significativas entre los pacientes con infarto tipo 4a y los que no tuvieron esta complicación según las variables clínicas: edad, índice de masa corporal, diabetes mellitus, enfermedad renal crónica y disfunción sistólica ventricular. La elevación del conteo absoluto de neutrófilos posterior al proceder con un área bajo la curva de 0,947 tuvo buena capacidad de discriminación de esta complicación (p = 0,000). En el diagnóstico de infarto periproceder el conteo absoluto de neutrófilos fue 7,35 posterior al proceder, tuvo una sensibilidad de 91,3 por ciento una especificidad de 96,2 por ciento. Conclusiones: Los neutrófilos fueron sensibles y específicos para el diagnóstico de infarto del miocardio tipo 4a(AU)

Introduction: Type 4 myocardial infarction is a complication of percutaneous coronary intervention that increases the inflammatory state of patients. Objective: To evaluate the diagnostic value of the absolute neutrophil count in the occurrence of type 4 myocardial infarction. Methods: A prospective cohort was carried out at Hermanos Ameijeiras Clinical Surgical Hospital. The universe consisted of 412 patients who underwent percutaneous coronary intervention from November 2018 to January 2021, two hundred thirty-two (232) patients form the sample. Clinical, anatomical and inflammatory variables were defined. Results: There were significant differences between patients with type 4 infarction and those who did not have this complication according to the clinical variables such as age, body mass index, diabetes mellitus, chronic kidney disease and ventricular systolic dysfunction. The subsequent elevation of the absolute neutrophil count when proceeding with an area under the 0.947 curve had good ability to discriminate this complication (p = 0.000). In the diagnosis of periprocedural infarction, the absolute neutrophil count was ≥ 7.35 after the procedure, it had 91.3percent sensitivity and 96.2percent specificity. Conclusions: Neutrophils were sensitive and specific for the diagnosis of type 4 myocardial infarction(AU)

Interleukin-37 has A Promising Cardioprotective Effect on Isoproterenol-Induced Myocardial Infarction / La Interleucina-37 tiene un Efecto Cardioprotector Prometedor sobre el Infarto de Miocardio Inducido por Isoproterenol

SUMMARY: The main cause of mortality and disability globally is myocardial infarction (MI). Isoproterenol (ISO), a β-adrenoceptor agonist, has been used to induce rat myocardial necrosis. Whereas interleukin-37 (IL-37) has anti-inflammatory and cytoprotective properties. The study aimed to investigate the potential protective effects of IL-37 administration on cardiac architecture, oxidative stress, and inflammatory markers during ISO-induced MI in rats. Three groups of adult male rats were used in this study, the normal control group (n=8), ISO-induced MI group (n=8) that received isoproterenol hydrochloride (ISO) (100 mg/kg/day, SC, for the first 2 consecutive days), and IL-37-treated group (ISO+IL-37) (n=8) that received recombinant human IL-37 (40 µg/kg /day, intraperitoneally, for 2 weeks during and after ISO injections. Heart rate (HR.) and ECG changes were monitored. Some oxidative stress markers such as superoxide dismutase (SOD), nitric oxide (NOx), malondialdehyde (MDA), and glutathione (GSH) tissue levels in the tissue homogenate were assayed. Interleukin- 6 (IL-6), tumor necrosis factor- α (TNF-α), caspase-8, P53, and C- reactive protein (CRP) were among the inflammatory markers examined. In addition, serum levels of creatinine kinase (CK-MB) and lactate dehydrogenase (LDH) were analyzed to evaluate the myocardial injury. For histological analysis, tissues were sectioned, fixed in paraffin, and stained with hematoxylin and eosin (H&E), Masson Trichrome and, immunohistochemical against NF-kB, TNF-α, and Caspase-9. IL-37 improved ECG changes, cardiac enzyme markers, and some inflammatory markers of oxidative stress in ISO-induced MI. It also improved the histopathological and immunohistochemical changes in MI. In conclusion: IL-37 might be a promising therapeutic modality in myocardial infarction.

La principal causa de mortalidad y discapacidad a nivel mundial es el infarto de miocardio (IM). El isoproterenol (ISO), un agonista de los receptores adrenérgicos β, se ha utilizado para inducir necrosis miocárdica en ratas. Mientras que la interleucina-37 (IL-37) tiene propiedades antiinflamatorias y citoprotectoras. El estudio tuvo como objetivo investigar los posibles efectos protectores de la administración de IL-37 en la arquitectura cardíaca, el estrés oxidativo y los marcadores inflamatorios durante el infarto de miocardio inducido por ISO en ratas. En este estudio se utilizaron tres grupos de ratas macho adultas, el grupo control normal (n=8), el grupo con IM inducido por ISO (n=8) que recibió clorhidrato de isoproterenol (ISO) (100 mg/kg/día, SC, durante los primeros 2 días consecutivos) y el grupo tratado con IL-37 (ISO+IL- 37) (n=8) que recibió IL-37 humana recombinante (40 µg/kg/día, por vía intraperitoneal, durante 2 semanas durante y después de las inyecciones de ISO. Se monitorearon la frecuencia cardíaca (FC) y los cambios en el ECG. Se analizaron algunos marcadores de estrés oxidativo como la superóxido dismutasa (SOD), el óxido nítrico (NOx), el malondialdehído (MDA) y los niveles tisulares de glutatión (GSH) en el homogeneizado de tejido. La interleucina-6 (IL-6), el factor de necrosis tumoral-α (TNF-α), la caspasa-8, la P53 y la proteína C reactiva (CRP) se encontraban entre los marcadores inflamatorios examinados. Se analizaron los niveles de creatinoquinasa (CK-MB) y lactato deshidrogenasa (LDH) para evaluar la lesión miocárdica; para el análisis histológico se seccionaron los tejidos, se fijaron en parafina y se tiñeron con hematoxilina y eosina (H&E), Tricromo de Masson e inmunohistoquímica contra NF-kB, TNF-α y Caspasa-9. IL-37 mejoró los cambios de ECG, los marcadores de enzimas cardíacas y algunos marcadores inflamatorios de estrés oxidativo en el IM inducido por ISO. Además mejoró los cambios histopatológicos e inmunohistoquímicos en MI. En conclusión: la IL-37 podría ser una modalidad terapéutica prometedora en el infarto de miocardio.

Intervención psicoeducativa para potenciar la rehabilitación cardiovascular integral en pacientes convalecientes de infarto agudo de miocardio / A psychoeducational intervention to enhance comprehensive cardiovascular rehabilitation in patients convalescent from acute myocardial infarction

Introducción: La rehabilitación cardiovascular integral del paciente con infarto agudo de miocardio resulta fundamental para el logro de su bienestar físico y psicológico, y su reinserción a la vida social. Objetivo: Elaborar una estrategia de intervención psicoeducativa para potenciar la rehabilitación cardiovascular integral en pacientes convalecientes de infarto agudo de miocardio, con la visión de especialistas consultados. Métodos: Se realizó un estudio observacional, descriptivo y de corte transversal en el Hospital Universitario «Dr. Celestino Hernández Robau», de Santa Clara, entre octubre de 2019 y enero de 2021. La muestra estuvo conformada por 27 pacientes que asistieron a la consulta de Cardiología, y 7 especialistas según criterios de inclusión. Las técnicas aplicadas fueron: la revisión de historia clínica, entrevistas semiestructuradas a pacientes y especialistas, la encuesta sobre el conocimiento de la enfermedad, un autorreporte vivencial y la evaluación del estilo vida. Se utilizaron estadísticos descriptivos acorde a la medición de las variables, análisis de contenido y triangulación de la información. Resultados: En los pacientes diagnosticados con estilo de vida poco saludable, predominó un conocimiento medianamente suficiente de la enfermedad; la hipertensión arterial fue el principal factor de riesgo asociado. Se elaboró la estrategia de intervención según las necesidades psicoeducativas identificadas por los pacientes con la visión de especialistas consultados. Se constató que presentan carencia de habilidades para autocontrolar las reacciones emocionales posteriores al suceso cardiovascular. Conclusiones: La estrategia elaborada fue valorada satisfactoriamente por juicio de profesionales, indicándose la posibilidad de ser aplicada en los usuarios a los que está dirigida.

Introduction: comprehensive cardiovascular rehabilitation of patients with acute myocardial infarction is essential to achieve their physical and psychological well-being, and their reintegration into social life. Objective: to develop a psychoeducational intervention strategy to enhance comprehensive cardiovascular rehabilitation in patients convalescent from acute myocardial infarction, with the vision of consulted specialists. Methods: an observational, descriptive and cross-sectional study was carried out at "Dr. Celestino Hernández Robau" University Hospital, in Santa Clara, between October 2019 and January 2021. The sample consisted of 27 patients who come to the Cardiology consultation, and 7 specialists according to inclusion criteria. Medical history review, semi-structured interviews with patients and specialists, a survey on knowledge of the disease, an experiential self-report, and a lifestyle evaluation were the techniques applied. Descriptive statistics were used according to the measurement of the variables as well as content analysis and triangulation of the information. Results: a moderately sufficient knowledge of the disease prevailed in patients diagnosed with an unhealthy lifestyle; arterial hypertension was the main associated risk factor. The intervention strategy was developed according to the psychoeducational needs identified by the patients with the vision of the consulted specialists. We verified that they have a lack of abilities to self-control their emotional reactions after the cardiovascular event. Conclusions: the elaborated strategy was satisfactorily valued by professional judgment, which indicates the possibility of being applied to the users to whom it is directed.

Incidência e fatores de risco associados ao infarto agudo do miocárdio sem obstrução coronariana / Incidence and risk factors associated with acute myocardial infarction with nonobstructive coronary arteries / Incidencia y factores de riesgo associados al infarto agudo de miocardio sin obstrucción coronaria

Objetivo: identificar a incidência, fatores de risco e desfechos associados ao infarto agudo do miocárdio sem obstrução de artérias coronárias (myocardial infarction with nonobstructive coronary arteries ­ MINOCA). Método: estudo de coorte prospectivo em prontuários clínicos num hospital terciário do extremo Sul catarinense. Foram incluídos pacientes diagnosticados com infarto agudo do miocárdico (IAM) submetidos a estudo hemodinâmico nos anos de 2017 e 2018. Resultados: ao analisar 445 prontuários, observou-se a ocorrência de MINOCA em 28 pacientes (6,3%). Comparando o grupo MINOCA com o grupo IAM obstrutivo, os pacientes do grupo MINOCA eram mais jovens, com média de 54 anos (DP ± 14; p=0,007), tinham menor incidência de tabagismo (2 versus 156, p<0,001), hipertensão arterial (10 versus 242; p=0,002), menor tempo médio (dias) de internação hospitalar (5,79 ± 3,05 versus 7,49 ± 5,20; p= 0,02) e menos admissões em unidade de tratamento intensivo (5 versus 212; p=0,002). Conclusão: a incidência de MINOCA estimada dentre o total de IAM no Sul de Santa Catarina foi de 6,3% [IC 95]. Os pacientes do grupo MINOCA tiveram menor prevalência de comorbidades, melhor evolução intra-hospitalar e melhor desfecho.

Objective: to identify the incidence, risk factors and outcomes associated with myocardial infarction with nonobstructive coronary arteries (MINOCA). Method: it is a with prospective cohort study data collection from medical records data. Patients with acute myocardial infarction (AMI) that went through hemodynamic study in 2017 and 2018 were included. Results: when analyzing 445 medical records, the occurrence of MINOCA was observed in 28 patients (6.3%). Comparing the MINOCA group with the obstructive AMI group, patients in the MINOCA group were younger, with a mean age of 54 years (SD ± 14; p=0.007), had a lower incidence of smoking (2 versus 156, p<0.001), hypertension (10 versus 242; p=0.002), shorter mean length of hospital stay (days) (5.79 ± 3.05 versus 7.49 ± 5.20; p= 0.02) and fewer admissions to intensive care unit (5 versus 212; p=0.002). Conclusion: the estimated incidence of MINOCA among the total number of AMI in southern Santa Catarina was 6.3% [CI 95]. Patients in the MINOCA group had a lower prevalence of comorbidities, better in-hospital evolution and better outcome.

Práticas clínicas aplicadas a pacientes com infarto do miocárdio sem obstrução de artéria coronária (minoca) / Clinical Practices Applied To Patients With Myocardial Infarction Non-obstruction Coronary Arteries (Minoca) / Prácticas clínicas aplicadas a pacientes con infarto e miocardio sin obstruccion arteria coronaria (MINOCA)

Objetivo: Identificar práticas clínicas com resultados favoráveis aos pacientes com diagnóstico de infarto agudo do miocárdio sem obstrução de artéria coronária. Método: Revisão integrativa da literatura pela base de dados National Library of Medicine e Biblioteca Virtual de Saúde de estudos publicados entre 2018 e 2022. Resultados:87,5% dos estudos encontrados destacaram estratégias farmacológicas e destes, 62,5% citaram o uso da dupla antiagregaçãoplaquetária como mais utilizada, apesar de nenhum estudo evidenciar benefícios. Os inibidores do sistema renina-angiotensina-aldosterona comprovaram benefícios em três estudos. 75% dos artigos apontaram que esse grupo de pacientes recebem menos medicamentos preventivos comparados aos pacientes com infarto por obstrução coronariana. Outros seis estudos, revelaram condução clínica variável desses pacientes. Conclusão: O uso de inibidores do sistema renina-angiotensina-aldosterona deve ser considerado por ser a única medicação com redução da mortalidade evidenciada. São necessários estudos maiores para orientar com mais segurança à condução do infarto do miocárdio sem obstrução de coronária.(AU)

Objective: To identify clinical practices with favorable results for patients diagnosed with acute myocardial infarction without coronary artery obstruction. Method: Integrative literature review using the National Library of Medicine and Virtual Health Library databases of studies published between 2018 and 2022. Results: 87.5% of the studies found highlighted pharmacological strategies and of these, 62.5% cited the use of dual antiplatelet therapy as the most used, despite no study showing benefits. Inhibitors of the renin-angiotensin-aldosterone system have shown benefits in three studies. 75% of the articles pointed out that this group of patients receive less preventive medication compared to patients with infarction due to coronary obstruction. Another six studies revealed variable clinical management of these patients. Conclusion: The use of renin-angiotensin-aldosterone system inhibitors should be considered as it is the only medication with proven reduction in mortality. Larger studies are needed to guide with more safety the management of myocardial infarction without coronary obstruction.(AU)

Objetivo: Identificar prácticas clínicas con resultados favorables para pacientes con diagnóstico de infarto agudo de miocardio sin obstrucción arterial coronaria. Método: revisión integrativa de la literatura utilizando las bases de datos de la Biblioteca Nacional de Medicina y la Biblioteca Virtual en Salud de estudios publicados entre 2018 y 2022. Resultados: el 87,5% de los estudios encontrados destacaron estrategias farmacológicas y de estos, el 62,5% citó el uso de la terapia antiplaquetaria dual como el más utilizados, a pesar de que ningún estudio muestra beneficios. Los inhibidores del sistema renina-angiotensina-aldosterona han mostrado beneficios en tres estudios. El 75% de los artículos señalaron que este grupo de pacientes recibe menos medicación preventiva en comparación con los pacientes con infarto por obstrucción coronaria. Otros seis estudios revelaron un manejo clínico variable de estos pacientes. Conclusión: Se debe considerar el uso de inhibidores del sistema renina-angiotensina-aldosterona, ya que es el único medicamento con reducción comprobada de la mortalidad. Son necesarios estudios más amplios que orienten con mayor seguridad el manejo del infarto de miocardio sin obstrucción coronaria.(AU)

Simulação in situ de parada cardíaca em fibrilação ventricular para o treinamento de profissionais de enfermagem / In-situ simulation of cardiac arrest in ventricular fibrillation for professional nursing training

Objetivo: Relatar a experiência e a percepção dos profissionais de enfermagem com a utilização de simulação in situnão anunciada de parada cardiorrespiratória (PCR) em ritmo de fibrilação ventricular no ambiente intra-hospitalar. Métodos: Manequim (Laerdal®) de alta fidelidade foi colocado no leito de isolamento de uma Unidade Coronariana que dispõe de central de monitoramento, sem o conhecimento dos profissionais de enfermagem que estavam assumindo o plantão. Um técnico de enfermagem do turno anterior de trabalho passou o caso como um paciente fictício recém-admitido com infarto agudo do miocárdio. Após a passagem do plantão, modificou-se o ritmo cardíaco do manequim de ritmo sinusal para fibrilação ventricular. Registrou-se o tempo (em minutos e segundos) desde a modificação do ritmo até algum profissional da enfermagem desencadear uma ação efetiva relacionada ao fato. Após o profissional perceber que se tratava de um manequim, ele foi orientado a desencadear as intervenções adequadas como se fosse um paciente real. Após o final da simulação, um questionário para avaliação da percepção desses profissionais em relação à atividade foi aplicado. Resultado: Quinze profissionais participaram da simulação in situ. O tempo para reação foi 28 segundos no turno diurno, dois minutos e seis segundos no turno vespertino e quatro minutos e três segundos no período noturno. Todos profissionais (100%) reconheceram a importância do treinamento, todos (100%) acharam que este treinamento aumenta a segurança do profissional e do paciente, a maioria (90%) achou que pode melhorar a comunicação entre a equipe, e todos (100%) acharam que atividades como esta deveriam ser repetidas. Conclusão: A simulação in situ parece ser uma alternativa viável para o treinamento dos profissionais de enfermagem no atendimento inicial da PCR em um hospital de emergência brasileiro. Esta atividade foi avaliada positivamente pelos participantes (AU).

Objective: Report the experience and perception of nursing professionals with an unannounced in-situ simulation of cardiopulmonary arrest (CPA) in ventricular fibrillation in an in-hospital environment. Methods: A high-fidelity mannequin (Laerdal®) was placed on the isolation bed of a Coronary Care Unit with a monitoring center without the knowledge of the nursing professionals taking over the shift. A nurse technician from the previous shift was told to report the case as a fictitious newly admitted patient with acute myocardial infarction. After the care transition, the cardiac rhythm was changed from sinus rhythm to ventricular fibrillation. The time was recorded (in minutes and seconds) from the onset of ventricular fibrillation until a nursing professional triggered an effective action. After the professionals realized it was a mannequin, they were instructed to initiate the appropriate interventions as if the mannequin were an actual patient. After the end of the simulation, a questionnaire was used to assess the professionals' perception of the activity. Results: Fifteen professionals participated in this in-situ simulation. The reaction time was 28 seconds on the morning shift, two minutes and six seconds on the afternoon shift, and four minutes and three seconds on the night shift. All professionals (100%) recognized the importance of this training, and all thought it increased professional and patient safety. Most participants (90%) thought it could improve communication among the team. All professionals (100%) felt that such activities should be repeated. Conclusion: In-situ simulation is a feasible alternative to train nursing professionals in the initial CPA management in a Brazilian emergency hospital. Participants positively evaluated this activity (AU).

Estudio de caso: revascularización de paciente con enfoque en el proceso de atención de enfermería / Case study: Patient revascularization with focus on the nursing care process

Introducción: la cardiopatía isquémica fue la primera causa de muerte en México en el año 2020. Su prevalencia aumenta con la edad y es superior en los hombres que en las mujeres; se presenta mayormente en forma de infarto en edades entre 45 y 94 años. Objetivo: describir el caso de un paciente sometido a revascularización aorto-coronaria por cardiopatía isquémica con enfoque del proceso de atención de enfermería (PAE). Metodología: estudio de caso observacional y descriptivo con aplicación del PAE en el perioperatorio de un hombre de 50 años con cardiopatía isquémica crónica, enfermedad multivascular e hipertensión sistémica controlada de 6 años desde que inició, en un hospital público de tercer nivel en Mérida, Yucatán, México. Resultados: se demostró que si se aplica el PAE hay menor riesgo de shock hipovolémico ocasionado por sangrado activo y disminución de riesgo de infección del sitio de herida quirúrgica, evidenciado por el procedimiento quirúrgico extenso. Conclusiones: la metodología del PAE como método científico facilita innovaciones dentro de los cuidados enfermeros, además de las diferentes alternativas en las acciones a seguir para el tratamiento del paciente quirúrgico cardiovascular. También proporciona un método informativo para la atención de cuidados, desarrolla una autonomía para la enfermería y fomenta la consideración como profesional de salud.

Introduction: Ischemic heart disease was the leading cause of death in Mexico in 2020. Its prevalence increases with age and it is higher in men than in women; it is presented mostly as a heart attack between the ages of 45 and 94 years. Objective: To describe the case of a patient undergoing aorto-coronary revascularization for ischemic heart disease with a nursing care process (NCP) approach. Methodology: Observational and descriptive case study with application of NCP in the perioperative period of a 50-year-old man with chronic ischemic heart disease, multivessel disease and controlled systemic hypertension of 6 years since its onset, in a third level public hospital in Merida, Yucatan, Mexico. Results: It was demonstrated that by applying NCP there is a lower risk of hypovolemic shock caused by active bleeding and decreased risk of surgical wound site infection, evidenced by the extensive surgical procedure. Conclusions: The NCP methodology as a scientific method facilitates innovations within nursing care, in addition to the different alternatives in the actions to follow for the treatment of the cardiovascular surgical patient. It also provides an informative method for care, develops autonomy for nursing and promotes consideration as a health professional.

Caracterización clinicoepidemiológica, ecocardiográfica y terapéutica de pacientes con infarto agudo de miocardio / Clinical, epidemiological, echocardiographic and therapeutic characterization of patients with acute myocardial infarction i: en

Introducción: Aunque la incidencia general de infarto agudo de miocardio ha disminuido en muchos países desarrollados en las últimas décadas, aún genera números elevados de morbilidad y mortalidad en los de bajos ingresos; mostrando cifras mayores en tiempos de la pandemia por coronavirus. Objetivo: Caracterizar a pacientes con diagnóstico de infarto agudo de miocardio según variables clinicoepidemiológicas, ecocardiográficas y terapéuticas. Métodos: Se realizó una investigación descriptiva y retrospectiva, desde enero de 2018 hasta noviembre de 2022, de 263 pacientes con diagnóstico de infarto agudo de miocardio, atendidos en el Centro de Cardiología y Cirugía Cardiovascular de Santiago de Cuba. Entre las variables analizadas figuraron la edad, el sexo, la topografía del infarto, las complicaciones, las alteraciones ecocardiográficas y el tratamiento trombolítico. Resultados: En la serie predominaron el sexo masculino y el grupo etario menor o igual de 65 años. Se observó una mayor frecuencia del infarto en la topografía inferior (177, para 67,3 %); de estos afectados, 52,1 % tuvo complicaciones. Asimismo, la complicación de mayor frecuencia fue la fibrilación auricular paroxística, seguida del infarto de ventrículo derecho; mientras que la fracción de eyección menor de 45 %, el volumen de la aurícula izquierda y la motilidad parietal presentaron significación estadística. Conclusiones: Las características clinicoepidemiológicas, ecocardiográficas y terapéuticas de los pacientes con infarto agudo de miocardio en la provincia de Santiago de Cuba no difieren del contexto epidemiológico mundial.

Introduction: Although the general incidence of acute myocardial infarction has diminished in many developed countries in the last decades, it still generates high numbers of morbidity and mortality in those with low income; showing higher figures in times of coronavirus. Objective: To characterize patients with diagnosis of acute myocardial infarction according to clinical, epidemiological, echocardiographic and therapeutic variables. Methods: A descriptive and retrospective investigation was carried out from January, 2018 to November, 2022, of 835 patients with diagnosis of acute myocardial infarction, assisted in the Cardiology and Cardiovascular Surgery Center of Santiago de Cuba. Among the analyzed variables there were age, sex, topography of infarction, complications, echocardiographic disorders and thrombolytic treatment. Results: In the series there was a prevalence of the male sex and the 65 or less age group. A higher frequency of infarction in the lower topography (177, for 67.3 %) was observed; of these patients, 52.9 % had complications. Also, the complication of more frequency was the paroxysmal atrial fibrillation, followed by the infarction of the right ventricle; while the ejection fraction smaller than 45 %, the volume of the left auricle and the parietal motility presented statistical significance. Conclusions: Clinical, epidemiological, echocardiographic and therapeutic characteristics of patients with acute myocardial infarction in Santiago de Cuba province do not differ from the world epidemiological context.

Infarto agudo do miocárdio: Tempo é músculo / Acute myocardial infarction: Time is muscle

Objetivo: descrever a impotância de uma detecção precoce do Infarto Agudo do Miocárdio (IAM) por meio da equipe multidisciplinar de saúde e expor se o tempo interfere ou não na piora da lesão miocárdica. Método:Trata-se de uma revisão integrativa da literatura com artigos de 2015 e 2020. As bases utilizadas foram LILACS, MEDLINE, SCIELO, BDEFN e Google Acadêmico. Resulatdos: O tempo porta-balão <90 minutos é eficiente no manejo do paciente com IAM, pois quanto mais rápido atendimento melhor o prognóstico, mas ainda existem muitas dificuldades na realização desse manejo, pois muitos sintomas não são detectados precocemente, a busca pelo atendimento é demorada e as instituições não seguem os protocolos corretamente. Conclusão: Diante deste cenário a telemedicina surge como um aliado no prevenção, diagnóstico e tratamento e principalmente o menor tempo para o atendimento, pois trará mais saúde para o miocárdio e consequentemente para o paciente.(AU)

Objetivo: describir la importancia de la detección precoz del Infarto Agudo de Miocardio (IAM) a través del equipo multidisciplinario de salud y exponer si el tiempo interfiere o no en el empeoramiento de la lesión miocárdica. Método: Se trata de una revisión integrativa de la literatura con artículos de 2015 y 2020. Las bases de datos utilizadas fueron LILACS, MEDLINE, SCIELO, BDEFN y Google Scholar. Resultados: El tiempo puerta-balón < 90 minutos es eficiente en el manejo de los pacientes con IAM, pues cuanto más rápido el tratamiento, mejor el pronóstico, pero aún existen muchas dificultades para realizar este manejo, ya que muchos síntomas no se resuelven. detectada a tiempo, la búsqueda de atención lleva mucho tiempo y las instituciones no siguen correctamente los protocolos. Conclusión: Ante este escenario, la telemedicina surge como un aliado en la prevención, diagnóstico y tratamiento y sobre todo en el menor tiempo de atención, ya que traerá más salud al miocardio y consecuentemente al paciente.(AU)

Objective: to describe the importance of an early detection of Acute Myocardial Infarction (AMI) through the multidisciplinary health team and expose whether or not time interferes in the worsening of the myocardial injury. Method: This is an integrative literature review with articles from 2015 and 2020. The databases used were LILACS, MEDLINE, SCIELO, BDEFN and Google Scholar. Results: The door- to-balloon time <90 minutes is efficient in the management of patients with AMI, because the faster the treatment, the better the prognosis, but there are still many difficulties in carrying out this management, since many symptoms are not detected early, the search for care it is time consuming and institutions do not follow protocols correctly. Conclusion: Given this scenario, telemedicine emerges as an ally in prevention, diagnosis and treatment and especially the shortest time for care, as it will bring more health to the myocardium and consequently to the patient.(AU)

Atendimento a pacientes infartados submetidos à angioplastia antes e durante a COVID-19: estudo transversal / Care of infarcted patients undergoing angioplasty before and during COVID-19: a cross-sectional study

OBJETIVO: Comparar o atendimento de infartados submetidos à angioplastia antes e durante a pandemia da COVID-19. MÉTODO: Pesquisa transversal, de abordagem retrospectiva, com 498 pacientes, por meio de prontuários eletrônicos e físicos, referente a atendimentos antes e durante a pandemia, no serviço de hemodinâmica de hospital de referência para doenças cardiovasculares. Dados analisados por estatística descritiva e inferencial. RESULTADOS: Em 2019, pré-pandemia, realizaram-se 157 procedimentos de intervenção coronária percutânea. Em 2020, início da pandemia, 166 procedimentos, aumento de 5,73%. Em 2021, ocorreram 175 procedimentos, acréscimo de 11,46% em comparação a 2019. CONCLUSÃO: Houve aumento no número de procedimentos de ATC, em 11,46% de 2019 a 2021, com consequente elevação da assistência de enfermagem e multiprofissional durante a pandemia da COVID-19.

OBJECTIVE: To compare the care provided to infarcted patients submitted to angioplasty before and during the COVID-19 pandemic. METHOD: Cross-sectional research, with a retrospective approach, conducted with 498 patients through the assessment of electronic and physical medical records, referring to care provided before and during the pandemic in the hemodynamics clinic of a reference hospital for cardiovascular diseases. Descriptive and inferential statistics were used. RESULTS: In 2019, pre-pandemic period, 157 percutaneous coronary angioplasties were performed. In 2020, at the pandemic's beginning, 166 procedures were performed ­ an increase of 5.73%. In 2021, there were 175 procedures ­an increase of 11.46% compared to 2019. CONCLUSION: There was an increase in percutaneous coronary angioplasties by 11.46% from 2019 to 2021, with a consequent increase in nursing and multidisciplinary care during the COVID-19 pandemic.

Remote ischemic preconditioning-induced late cardioprotection: possible role of melatonin-mitoKATP-H2S signaling pathway

Purpose: Remote ischemic preconditioning (RIPC) confers cardioprotection against ischemia reperfusion (IR) injury. However, the precise mechanisms involved in RIPC-induced cardioprotection are not fully explored. The present study was aimed to identify the role of melatonin in RIPC-induced late cardioprotective effects in rats and to explore the role of H2 S, TNF-α and mitoKATP in melatoninmediated effects in RIPC. Methods: Wistar rats were subjected to RIPC in which hind limb was subjected to four alternate cycles of ischemia and reperfusion of 5 min duration by using a neonatal blood pressure cuff. After 24 h of RIPC or ramelteon-induced pharmacological preconditioning, hearts were isolated and subjected to IR injury on the Langendorff apparatus. Results: RIPC and ramelteon preconditioning protected the hearts from IR injury and it was assessed by a decrease in LDH-1, cTnT and increase in left ventricular developed pressure (LVDP). RIPC increased the melatonin levels (in plasma), H2 S (in heart) and decreased TNF-α levels. The effects of RIPC were abolished in the presence of melatonin receptor blocker (luzindole), ganglionic blocker (hexamethonium) and mitochondrial KATP blocker (5-hydroxydecanoic acid). Conclusion: RIPC produce delayed cardioprotection against IR injury through the activation of neuronal pathway, which may increase the plasma melatonin levels to activate the cardioprotective signaling pathway involving the opening of mitochondrial KATP channels, decrease in TNF-α production and increase in H2 S levels. Ramelteon-induced pharmacological preconditioning may also activate the cardioprotective signaling pathway involving the opening of mitochondrial KATP channels, decrease in TNF-α production and increase in H2 S levels.

Comparison of aspirin treatment strategies for primary prevention of cardiovascular diseases: A decision-analytic Markov modelling study / 北京大学学报(医学版)

OBJECTIVE@#To compare the expected population impact of benefit and risk of aspirin treatment strategies for the primary prevention of cardiovascular diseases recommended by different guidelines in the Chinese Electronic Health Records Research in Yinzhou (CHERRY) study.@*METHODS@#A decision-analytic Markov model was used to simulate and compare different strategies of aspirin treatment, including: Strategy ①: Aspirin treatment for Chinese adults aged 40-69 years with a high 10-year cardiovascular risk, recommended by the 2020 Chinese Guideline on the Primary Prevention of Cardiovascular Diseases; Strategy ②: Aspirin treatment for Chinese adults aged 40-59 years with a high 10-year cardiovascular risk, recommended by the 2022 United States Preventive Services Task Force Recommendation Statement on Aspirin Use to Prevent Cardiovascular Disease; Strategy ③: Aspirin treatment for Chinese adults aged 40-69 years with a high 10-year cardiovascular risk and blood pressure well-controlled (< 150/90 mmHg), recommended by the 2019 Guideline on the Assessment and Management of Cardio-vascular Risk in China. The high 10-year cardiovascular risk was defined as the 10-year predicted risk over 10% based on the 2019 World Health Organization non-laboratory model. The Markov model simulated different strategies for ten years (cycles) with parameters mainly from the CHERRY study or published literature. Quality-adjusted life year (QALY) and the number needed to treat (NNT) for each ischemic event (including myocardial infarction and ischemic stroke) were calculated to assess the effectiveness of the different strategies. The number needed to harm (NNH) for each bleeding event (including hemorrhagic stroke and gastrointestinal bleeding) was calculated to assess the safety. The NNT for each net benefit (i.e., the difference of the number of ischemic events could be prevented and the number of bleeding events would be added) was also calculated. One-way sensitivity analysis on the uncertainty of the incidence rate of cardiovascular diseases and probabilistic sensitivity analysis on the uncertainty of hazard ratios of interventions were conducted.@*RESULTS@#A total of 212 153 Chinese adults, were included in this study. The number of people who were recommended for aspirin treatment Strategies ①-③ was 34 235, 2 813, and 25 111, respectively. The Strategy ③ could gain the most QALY of 403 [95% uncertainty interval (UI): 222-511] years. Compared with Strategy ①, Strategy ③ had similar efficiency but better safety, with the extra NNT of 4 (95%UI: 3-4) and NNH of 39 (95%UI: 19-132). The NNT per net benefit was 131 (95%UI: 102-239) for Strategy ①, 256 (95%UI: 181-737) for Strategy ②, and 132 (95%UI: 104-232) for Strategy ③, making Strategy ③ the most favorable option with a better QALY and safety, along with similar efficiency in terms of net benefit. The results were consistent in the sensitivity analyses.@*CONCLUSION@#The aspirin treatment strategies recommended by the updated guidelines on the primary prevention of cardiovascular diseases showed a net benefit for high-risk Chinese adults from developed areas. However, to balance effectiveness and safety, aspirin is suggested to be used for primary prevention of cardiovascular diseases with consideration for blood pressure control, resulting in better intervention efficiency.

Relationship between pyroptosis and cardiovascular diseases and traditional Chinese medicine prevention and treatment research / 中国中药杂志

Pyroptosis is a programmed cell death initiated by the activation of caspases, which is involved in the development and progression of several cardiovascular diseases. The gasdermins, a protein family, are key executive proteins in the development of pyroptosis, which increase cell membrane permeability, mediate the release of inflammatory factors, and aggravate the inflammatory injury. Traditional Chinese medicine(TCM)has shown unique therapeutic advantages in cardiovascular diseases with multi-component and multi-target characteristics. Currently, the effective prevention and treatment of cardiovascular diseases based on the theory of pyroptosis become a new research hotspot in this field. Based on the theories of TCM and modern medicine, this study summarized the role of pyroptosis in cardiovascular diseases such as atherosclerosis, myocardial infarction, diabetic cardiomyopathy, hypertension, and myocarditis. The role of TCM, including active monomers, crude extracts, and compound preparations, in cardiovascular protection through the regulation of pyroptosis was also summarized, providing a theoretical basis for the clinical prevention and treatment of cardiovascular diseases by TCM.

Chinese emergency expert consensus on bedside temporary cardiac pacing (2023) / 中华危重病急救医学

Temporary cardiac pacing is an essential technique in the diagnosis and treatment of arrhythmias. Due to its urgency, complexity, and uncertainty, it is necessary to develop an evidence-based emergency operation norms. Currently, there is no specific consensus guidelines at home or abroad. The Emergency Branch of Chinese Medical Association organized relevant experts to draft the Chinese emergency expert consensus on bedside temporary cardiac pacing (2023) to guide the operation and application of bedside cardiac pacing. The formulation of the consensus adopts the consensus meeting method and the evidentiary basis and recommendation grading of the Oxford Center for Evidence-based Medicine in the United States. A total of 13 recommendations were extracted from the discussion on the methods of bedside temporary cardiac pacing, the puncture site of transvenous temporary cardiac pacing, the selection of leads, the placement and placement of leads, pacemaker parameter settings, indications, complications and postoperative management. The recommended consensus includes the choice between transcutaneous and transvenous pacing, preferred venous access for temporary transvenous pacing, the target and best guidance method for implantation of bedside pacing electrodes, recommended default pacemaker settings, recommended indications for sinoatrial node dysfunction, atrioventricular block, acute myocardial infarction, cardiac arrest, ventricular and supraventricular arrhythmias. They also recommended ultrasound guidance and a shortened temporary pacing support time to reduce complications of temporary transvenous cardiac pacing, recommended bedrest, and anticoagulation after temporary transvenous pacing. Bedside temporary cardiac pacing is generally safe and effective. Accurate assessment, correct selection of the pacing mode, and timely performance of bedside temporary cardiac pacing can further improve the survival rate and prognosis of related emergency patients.

Single-cell analysis reveals an Angpt4-initiated EPDC-EC-CM cellular coordination cascade during heart regeneration

Mammals exhibit limited heart regeneration ability, which can lead to heart failure after myocardial infarction. In contrast, zebrafish exhibit remarkable cardiac regeneration capacity. Several cell types and signaling pathways have been reported to participate in this process. However, a comprehensive analysis of how different cells and signals interact and coordinate to regulate cardiac regeneration is unavailable. We collected major cardiac cell types from zebrafish and performed high-precision single-cell transcriptome analyses during both development and post-injury regeneration. We revealed the cellular heterogeneity as well as the molecular progress of cardiomyocytes during these processes, and identified a subtype of atrial cardiomyocyte exhibiting a stem-like state which may transdifferentiate into ventricular cardiomyocytes during regeneration. Furthermore, we identified a regeneration-induced cell (RIC) population in the epicardium-derived cells (EPDC), and demonstrated Angiopoietin 4 (Angpt4) as a specific regulator of heart regeneration. angpt4 expression is specifically and transiently activated in RIC, which initiates a signaling cascade from EPDC to endocardium through the Tie2-MAPK pathway, and further induces activation of cathepsin K in cardiomyocytes through RA signaling. Loss of angpt4 leads to defects in scar tissue resolution and cardiomyocyte proliferation, while overexpression of angpt4 accelerates regeneration. Furthermore, we found that ANGPT4 could enhance proliferation of neonatal rat cardiomyocytes, and promote cardiac repair in mice after myocardial infarction, indicating that the function of Angpt4 is conserved in mammals. Our study provides a mechanistic understanding of heart regeneration at single-cell precision, identifies Angpt4 as a key regulator of cardiomyocyte proliferation and regeneration, and offers a novel therapeutic target for improved recovery after human heart injuries.

Promising roles of non-exosomal and exosomal non-coding RNAs in the regulatory mechanism and as diagnostic biomarkers in myocardial infarction / 浙江大学学报（英文版）（B辑：生物医学和生物技术）

Non-exosomal non-coding RNAs (non-exo-ncRNAs) and exosomal ncRNAs (exo-ncRNAs) have been associated with the pathological development of myocardial infarction (MI). Accordingly, this analytical review provides an overview of current MI studies on the role of plasma non-exo/exo-ncRNAs. We summarize the features and crucial roles of ncRNAs and reveal their novel biological correlations via bioinformatics analysis. The following contributions are made: (1) we comprehensively describe the expression profile, competing endogenous RNA (ceRNA) network, and "pre-necrotic" biomarkers of non-exo/exo-ncRNAs for MI; (2) functional enrichment analysis indicates that the target genes of ncRNAs are enriched in the regulation of apoptotic signaling pathway and cellular response to chemical stress, etc.; (3) we propose an updated and comprehensive view on the mechanisms, pathophysiology, and biomarker roles of non-exo/exo-ncRNAs in MI, thereby providing a theoretical basis for the clinical management of MI.

Research progress in the cardiac lymphatic system and myocardial repair after myocardial infarction / 中南大学学报(医学版)

The lymphatic system of the heart plays an important role in the repair process after myocardial injury and may regulate normal tissue homeostasis and natural regeneration via maintaining fluid homeostasis and controlling the inflammatory response. The lymphatic system in the heart is activated after myocardial injury and is involved in the scarring process of the heart. Recent studies on the lymphatic system and myocardial repair of the heart have developed rapidly, and the mechanisms for lymphangiogenesis and lymphatic endothelial cell secretion have been elucidated by different animal models. A deep understanding of the structural, molecular, and functional characteristics of the lymphatic system of the heart can help develop therapies that target the lymphatic system in the heart. Summarizing the progress in studies on targets related to myocardial repair and the cardiac lymphatic system is helpful to provide potential new targets and strategies for myocardial repair therapy after myocardial infarction.

Acute inferior myocardial infarction combined with papillary muscle rupture: A case report / 中南大学学报(医学版)

The incidence of acute myocardial infarction (AMI) is increasing. Acute papillary muscle rupture is one of the serious and rare mechanical complications of AMI, which occurs mostly in inferior and posterior myocardial infarction. A patient with acute inferior myocardial infarction developed pulmonary edema and refractory shock, followed by cardiac arrest. After cardiopulmonary resuscitation (CPR), revascularization of criminal vessels was carried out by emergency percutaneous transluminal coronary angioplasty (PTCA) under the support of intra-aortic balloon pump (IABP) and extra corporeal membrane oxygenation (ECMO). Although the patient was given a chance for surgery, his family gave up treatment due to unsuccessful brain resuscitation. It reminds that mechanical complications such as acute papillary muscle rupture, valvular dysfunction and rupture of the heart should be highly suspected when cardiogenic pulmonary edema and cardiogenic shock are difficult to correct in acute inferior myocardial infarction. Echocardiogram and surgery should be put forward when revascularization of criminal vessels is available.