Infarto agudo al miocardio con arterias coronarias sin lesiones obstructivas (MINOCA): características clínicas de pacientes / Myocardial infarction without obstructive coronary artery disease: clinical characteristics in patients hospitalized in a coronary care unit

Introducción: El término MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries) ha cobrado relevancia como diagnóstico de trabajo en el contexto de pacientes con sospecha de isquemia miocárdica y estudio coronario sin lesiones obstructivas. Objetivos: Describir las distintas etiologías y variables clínicas de pacientes con MINOCA hospitalizados en la unidad coronaria de nuestro centro (Hospital de la P Universalidad de Chile) Métodos: Estudio observacional retrospectivo en el que se realizó un análisis descriptivo de las variables estudiadas. Además, se analizó el uso de los métodos de imágenes complementarios y otras variables pronósticas. El seguimiento se realizó dentro del primer año posterior al evento. Resultados: El diagnóstico etiológico más frecuente de los pacientes con MINOCA fue el de miocardiopatía por estrés (MCE). Se incluyeron 55 pacientes, 55% de ellos mujeres. La edad promedio fue 57 años y la frecuencia de factores de riesgo cardiovascular clásicos (FRCV) fue baja. En los pacientes con MCE se observó menores niveles de troponina ultrasensible; mayores niveles de NT-proBNP y mayor mortalidad en comparación a otras etiologías. Conclusiones: El perfil de pacientes con MINOCA hospitalizados en nuestro centro correspondió predominantemente a mujeres postmenopáusicas con baja frecuencia de FRCV. La mortalidad de los pacientes con MINOCA se concentró en el grupo con MCE.

Background: MINOCA (acronym for "Myocardial Infarction with Non-Obstructive Coronary Arteries") is relevant as a working guide in the diagnosis of patients with suspicion of ischemia and absence of obstructive coronary artery disease. Aim: to describe the different causes and clinical variables in patients with MINOCA admitted to a coronary care unit of a University hospital in Santiago, Chile. Methods: this is an observational retrospective analysis of relevant clinical variables in 55 patients finally diagnosed as having MINOCA. Use of image based studies and characteristics related to prognosis were also analyzed. Follow up extended for one year after the event. Results: 55 patients were included, 55% of them women. Mean age was 57 years; presence of traditional risk factors for myocardial infarction was low. The most common eventual etiologic diagnosis was Stress Cardiomyopathy (SCM) in which lower levels of ultrasensitive troponin and higher levels of NT-proBNP were observed. Mortality in SCM was higher than that observed in other etiologies. Conclusion: MINOCA was more frequent in post menopausal women. Mortality was greater in patients with SMC.

Fast Skeletal Muscle Troponin and Tropomyosin as a Dietary Source of Antidiabetic and Antihypertensive Bioactive Peptides: An In Silico Study / Troponina y Tropomiosina de Músculo Esquelético como Fuente Alimentaria de Péptidos Bioactivos Antidiabéticos y Antihipertensivos: Estudio In Silico

Background: The nutraceutical properties of food hydrolysates rely on multiple biochemical interactions involving the modulation of enzymes and cellular receptors. Numerous bioactive peptides released from troponin and tropomyosin digestion have been identified. Their characterization has mostly been performed by hydrolysis catalyzed by proteases unrelated to the human digestive system. Objective: This study aimed to determine the bioactive profile of beef, pork, and chicken meat by analyzing the frequency and pharmacokinetics of biopeptides released from troponin and tropomyosin. Methods:In silico digestion and biopeptide release frequency were studied by three parameters; bioactive fragments release frequency (AE), frequency percentage (W), and mean occurrence (AS), all stated on the BIOPEP-UWM platform. Further on, hydrolysis end-products were screened based on gastrointestinal-absorption probability and pharmacokinetic profiling performed on SwissADME, SwissTargetPrediction, and ADME/Tlab bioinformatics web tools. Statistical analyses were performed using a one-way ANOVA test. Results: Dipeptidyl peptidase-IV (DPP-IV) and angiotensin-converting enzyme (ACE) inhibiting biopeptides exhibited the highest release frequency. Moreover, W and ASparameters showed no significant difference (p>0.05) between the myofibrillar isoforms assessed. Seven biopeptides were classified as highly absorbable and reported optimal drug-likeness compliance. Although biopeptides hold good pharmacokinetic properties, the therapeutic potency of biopeptides showed to be lower than those of DPP-IV and ACE-inhibiting drugs. Conclusions: Troponin and tropomyosin are rich dietary sources of bioactive peptides, mainly DPP-IV and ACE inhibitors. Digestion end-products are mainly dipeptides with optimal pharmacokinetic and drug-like properties, suggesting a potential therapeutic application in hypertensive and hyperglycemic disorders

Antecedentes: Las propiedades nutracéuticas de los hidrolizados de alimentos dependen de múltiples interacciones bioquímicos que involucran la modulación de enzimas y receptores celulares. Se han identificado numerosos péptidos bioactivos liberados de la digestión de troponina y tropomiosina, pero su caracterización se ha llevado a cabo principalmente por hidrólisis catalizada por proteasas ajenas al sistema digestivo humano. Objetivo: Este estudio tuvo como objetivo determinar el perfil bioactivo de la carne de res, cerdo y pollo mediante el análisis de la frecuencia y farmacocinética de los biopéptidos liberados de la troponina y la tropomiosina. Métodos: Se estudió la digestión in silico y la frecuencia de liberación de biopéptidos mediante dos parámetros; frecuencia de liberación de fragmentos bioactivos (AE), frecuencia porcentual (W) y ocurrencia media (AS), ambos indicados en la plataforma BIOPEP-UWM. Más adelante, los productos finales de la hidrólisis se examinaron en función de la probabilidad de absorción gastrointestinal y el perfil farmacocinético realizado en las herramientas bioinformáticas SwissADME, SwissTargetPrediction y ADME/Tlab. El análisis estadístico se llevó a cabo mediante una prueba ANOVA de una vía. Resultados: Los biopéptidos inhibidores de la dipeptidil peptidasa IV (DPP-IV) y la enzima convertidora de angiotensina (ECA) exhibieron la mayor frecuencia de liberación. Además, los parámetros W y ASno mostraron diferencias significativas (p> 0.05) entre las isoformas miofibrilares evaluadas. Siete biopéptidos se clasificaron como altamente absorbibles e informaron un cumplimiento óptimo de similitud con el fármaco. Aunque los biopéptidos tienen propiedades farmacocinéticas adecuadas, su potencia terapéutica demostró ser menor que la de los fármacos inhibidores de la DPP-IV y la ACE. Conclusiones: La troponina y la tropomiosina son una fuente dietética rica en péptidos bioactivos, principalmente DPP-IV e inhibidores de la ACE. Los productos finales de la digestión son principalmente dipéptidos con propiedades farmacocinéticas óptimas y similares a la de los fármacos, lo que sugiere una aplicación terapéutica factible en trastornos hipertensivos e hiperglicémicos

Avaliação de lesão cardíaca e aspectos da assistência farmacêutica em pacientes hospitalizados com COVID-19 / Assessment of cardiac injury and aspects of pharmaceutical care in hospitalized patients with COVID-19

Introdução: Os níveis de troponina são comumente alterados em pacientes hospitalizados com COVID-19 e estão associados a um pior prognóstico. A pandemia da COVID-19 fez com que vários serviços de saúde tivessem que adaptar suas atividades, os serviços farmacêuticos tinham que promover as atividades farmacêuticas assistenciais, ao mesmo tempo em que adaptavam ações para prestar uma assistência de alta qualidade. Este estudo teve como objetivos: i) avaliar a lesão miocárdica como um preditor independente de mortalidade hospitalar e necessidade de ventilação mecânica em pacientes brasileiros hospitalizados com COVID-19 (Artigo 1) e ii) avaliar as ações dos farmacêuticos hospitalares na pandemia de COVID-19 e impactos no cuidado ao paciente (Artigo 2). Métodos: O artigo 1 retrata uma coorte de um subestudo do Registro Brasileiro de COVID-19, realizado em 31 hospitais brasileiros em 17 cidades. Foram incluídos pacientes com diagnóstico de COVID-19 entre março e setembro de 2020. Os prontuários médicos foram revisados para coletar dados demográficos e clínicos. Os modelos para os resultados primários: mortalidade e ventilação mecânica foram estimados por regressão de Poisson com variância robusta. Para as análises multivariadas, dois modelos preditivos foram estimados para avaliar o papel da troponina alterada nos desfechos. O artigo 2 apresenta uma revisão de escopo com pesquisa realizada em janeiro de 2023, registrada no Open Science Framework, sem restrição de data ou idioma de publicação com diferentes bases de dados. As estratégias de pesquisa incluíram combinações de palavras-chave indexadas relacionadas a "SARS-CoV-2", "Segurança do paciente" e "Serviços de farmácia hospitalar". Resultados: Artigo 1: um total de 2.925 pacientes foram incluídos nessa análise com idade média de 60 [Intervalo Interquartil (IQR) 48-71] anos. Os pacientes com lesão miocárdica, representada por níveis alterados de troponina, apresentaram maior risco relativo de morte (2,03 [IQR 1,60-2,58]) e necessidade de ventilação mecânica (1,87 [IQR 1,57-2,23]) comparado aos controles. Artigo 2: Dos 314 estudos identificados, nove foram elegíveis para esta revisão. Os farmacêuticos hospitalares tiveram papel importante em atividades que promoviam: garantia do suprimento de medicamentos e insumos em 89% dos estudos; análises das prescrições e disseminação de informações sobre medicamentos à equipe assistencial e aos pacientes em 67% dos estudos; desenvolvimento de diretrizes de tratamento e serviços de atendimentos remotos de cuidados farmacêuticos em 56% dos estudos; busca de novos fornecedores, novas alternativas farmacêuticas; e atuação junto a equipe multiprofissional em 44% dos estudos. Conclusões: A lesão cardíaca demonstrou ser um preditor independente de mortalidade intra-hospitalar e necessidade de ventilação mecânica em pacientes hospitalizados com COVID-19. A elaboração de estratégias que envolvam o monitoramento frequente dos níveis de troponina como biomarcadores de risco contribui para identificação de pacientes com maior risco de complicações clínicas e morte, melhorando o atendimento a estes pacientes. A revisão de escopo evidenciou que as ações prestadas pela farmácia hospitalar tiveram efeitos positivos em termos de qualidade e segurança dos cuidados prestados durante a pandemia. A avaliação e o registro das atividades farmacêuticas observadas podem servir como ponto de partida para o planejamento do enfrentamento de futuras crises de saúde.

Background: Troponin levels are commonly abnormal in hospitalized patients with COVID­19 and they are associated with poorer prognosis. The COVID-19 pandemic has caused several health services to adapt their activities, in this context, pharmaceutical services had to promote pharmaceutical care activities, while adapting actions necessary to provide high quality care. This study aimed to: i) evaluate myocardial injury as an independent predictor of in-hospital mortality and mechanical ventilation requirement in COVID-19 hospitalized Brazilian patients. (Article 1) and ii) evaluate the actions of hospital pharmacists in the COVID-19 pandemic and impacts on patient care (Article 2). Methods: Article 1 describes cohort study is a substudy of the Brazilian COVID-19 Registry, conducted in 31 Brazilian hospitals in 17 cities. Consecutive patients admitted with confirmed diagnosis of COVID-19 between March and September 2020 were included. Medical records were reviewed to collect patient demographic and clinical data. Models for the primary outcomes: mortality and mechanical ventilation were estimated by Poisson regression with robust variance. For the multivariate analyses, two predictive models were estimated to assess the role of elevated troponin on outcomes. Article 2 presents a scoping review with research conducted in January 2023, registered in the Open Science Framework, without restriction of date or language of publication and with different databases. We used Scopus, Medline, Virtual Health Library, Web of Science and Cochrane databases. Search strategies included combinations of indexed keywords related to "SARS-CoV-2", "Patient safety" and "Hospital pharmacy services". Results: Article 1: A total of 2,925 patients were included in this analysis with median age of 60 [interquartile range (IQR) 48-71] years old. Patients with myocardial injury represented by elevated troponin levels, presented a higher risk of death relative risk (2.03 [1.60-2.58]) and mechanical ventilation requirement relative risk (1.87 [1.57-2.23]) when compared to controls. Article 2: Of the 314 studies identified, nine were eligible for this review. Hospital pharmacists played important role in activities that promoted: ensuring the supply of drugs and supplies in 89% of the studies; analyzing prescriptions and disseminating drug information to the care team and patients in 67% of the studies; developing treatment guidelines and remote pharmaceutical care services in 56% of the studies; searching for new suppliers, new pharmaceutical alternatives and working with the multiprofessional team in 44% of the studies. Conclusion: Cardiac injury showed to be an independent predictor of in-hospital mortality and need of mechanical ventilation in hospitalized COVID-19 patients. The design of strategies involving the monitoring of troponin levels as risk biomarkers helps to identify patients at greater risk of clinical complications and death, improving care for these patients. The scoping review showed that the actions provided by the hospital pharmacy in care units have positive effects in terms of quality and safety of care provided during the pandemic. The evaluation and recording of the pharmaceutical activities observed can serve as a starting point for planning to address future health crises.

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.

Alcalosis respiratoria grave, la transformación de un cuadro funcional en orgánico. Caso clínico / Severe respiratory alkalosis due to psychogenic hyperventilation. Report of one case

Severe respiratory alkalosis is a life-threatening condition, as it induces hypo- calcaemia and extreme adrenergic sensitivity leading to cerebral and myocardial vasoconstriction. We report a 37-year-old woman with previous consultations for a conversion disorder. While she was infected with SARS-CoV-2 (without pulmonary involvement), she consulted in the emergency room due to panic attacks. On admission, she developed a new conversion crisis with progressive clinical deterioration, hyperventilation, and severe respiratory alkalosis (pH 7.68, Bicarbonate 11.8 mEq/L and PaCO2 10 mmHg). Clinically, she was in a coma, with respiratory and heart rates 55 and 180 per min, a blood pressure of 140/90 mmHg, impaired perfusion (generalized lividity, distal coldness, and severe skin mottling) and tetany. She also had electrocardiographic changes and high troponin levels suggestive of ischemia, and hyperlactatemia. She was managed in the hospital with intravenous benzodiazepines. The clinical and laboratory manifestations resolved quickly, without the need for invasive measures and without systemic repercussions.

Principais complicações cardíacas em idosos infectados pelo SARS-CoV-2: uma revisão sistemática / Principales complicaciones cardíacas en ancianos infectados por SARS-CoV-2: una revisión sistemática / Main cardiac complications in elderly infected by SARS-CoV-2: a systematic review

Objetivo: compreender as principais complicações ocasionadas pelo vírus SARS-CoV-2 no sistema cardíaco do público idoso. Métodos: trata-se de uma revisão sistemática da literatura de abordagem qualitativa e característica descritivo-exploratória realizada no ano de 2020. Resultados: as complicações cardíacas mais prevalentes na população idosa foram miocardite, arritmias, insuficiência cardíaca, infarto agudo, choque cardiogênico, lesão miocárdica aguda e parada cardiorrespiratória. O principal biomarcador cardíaco foi a troponina, apresentando elevação superior ao percentil 99°, evidenciando a necessidade de tratamento em Unidade de Terapia Intensiva. Considerações Finais: o aparecimento desse vírus causou grande prejuízo no campo da saúde, especialmente a população idosa, que apresenta risco elevado de óbito ao contrair essa doença. Destarte, é de extrema importância se ater a mensuração da troponina sérica no público alvo e realizar monitorização longitudinal, utilizando para tal a telecardiologia, uma vez que diminuem as chances de contaminação entre infectado e profissional de saúde

Objective: to understand the main complications of SARS-CoV-2 in the elderly cardiac system. Methods: systematic literature review conducted in 2020. Results: the most prevalent cardiac complications in the elderly population were myocarditis, arrhythmias, heart failure, acute infarction, cardiogenic shock, acute myocardial injury and cardiorespiratory arrest. The main cardiac biomarker was troponin, showing an elevation above the 99th percentile, evidencing the need for treatment in the Intensive Care Unit. Final Considerations: the appearance of this virus has caused great damage in the health field, especially the elderly population, who is at high risk of death when contracting this disease. Therefore, it is important to stick to the measurement of serum troponin in the target audience and perform longitudinal monitoring, using telecardiology for this purpose, since they reduce the chances of contamination between infected and health professionals

Objetivo: comprender las principales complicaciones del SARS-CoV-2 en el sistema cardíaco anciano. Métodos: revisión sistemática de la literatura realizada en 2020. Resultados: las complicaciones cardíacas más prevalentes en la población anciana fueron miocarditis, arritmias, insuficiencia cardíaca, infarto agudo, shock cardiogénico, lesión miocárdica aguda y parada cardiorrespiratoria. El principal biomarcador cardíaco fue la troponina, mostrando una elevación por encima del percentil 99, evidenciando la necesidad de tratamiento en la Unidad de Cuidados Intensivos. Consideraciones finales: la aparición de este virus ha provocado un gran daño en el campo de la salud, especialmente en la población anciana, que se encuentra en alto riesgo de muerte al contraer esta enfermedad. Por tanto, es importante ceñirse a la medición de troponina sérica en el público objetivo y realizar un seguimiento longitudinal, utilizando para ello la telecardiología, ya que reducen las posibilidades de contaminación entre los infectados y los profesionales sanitarios

Associação entre Parâmetros Plasmático de Tiol e Níveis de Troponina em Pacientes com Síndrome Coronariana Aguda e Predição de Arritmia Ventricular Hospitalar / Association between Plasma Thiol Parameters and Troponin Levels in Patients with Acute Coronary Syndrome and Prediction of In-Hospital Ventricular Arrhythmia

Resumo Fundamento As arritmias ventriculares (AVs) são a principal causa de mortalidade e morbidade hospitalar em pacientes com síndrome coronariana aguda (SCA) e sua relação com o tiol é desconhecida. Objetivo Investigar a relação entre os níveis plasmáticos de tióis e os níveis de troponina em pacientes com SCA e estimar o desenvolvimento de AV intra-hospitalar durante a internação. Método O estudo incluiu 231 pacientes consecutivos com SCA com supradesnivelamento do segmento ST (SCA-SDST) e pacientes com SCA sem supradesnivelamento do segmento ST (SCA-SSDST). Após a aplicação dos critérios de exclusão, 191 pacientes foram incluídos na análise estatística. Os pacientes foram classificados em dois grupos: grupo SCA-SDST (n=94) e grupo SCA-SSDST (n=97). Os níveis plasmáticos de tiol, dissulfeto e troponina foram medidos e a razão de troponina para tiol nativo (RTTN) foi calculada. Considerou-se estatisticamente significativo um valor de p bilateral inferior a 0,05. Resultados Tiol nativo plasmático, tiol total, dissulfeto e suas razões foram semelhantes entre os grupos. A RTTN se mostrou significativamente maior no grupo SCA-SDST em comparação com o grupo SCA-SSDST. Houve correlação negativa significativa entre os níveis de troponina e tiol. Verificou-se que o tiol nativo é preditor independente do desenvolvimento de AV em pacientes com SCA-SDST e em todos os pacientes com SCA. Verificou-se que o RTTN é preditor independente do desenvolvimento de AV em pacientes com SCA-SSDST e em todos os pacientes com SCA. Conclusão Os níveis plasmáticos de tiol podem ser usados para identificar pacientes com alto risco de desenvolvimento de AV intra-hospitalar em pacientes com SCA. A correlação entre os níveis de troponina e tiol pode sugerir que os tióis possam ser marcadores importantes para o diagnóstico e prognóstico da SCA com a ajuda de estudos futuros.

Abstract Background Ventricular arrhythmias (VAs) are the main cause of in-hospital mortality and morbidity in acute coronary syndrome (ACS) patients and its relationship with thiol is not known. Objective To investigate the relationship between plasma thiol levels and troponin levels in patients with ACS and to estimate in-hospital VA development during hospital stay. Method The study included 231 consecutive ST-segment elevation ACS (STE-ACS) and non-ST-segment elevation ACS (NSTE-ACS) patients. After application of exclusion criteria, 191 patients were included in the statistical analysis. Patients were classified into two groups: STE-ACS group (n=94) and NSTE-ACS group (n=97). Plasma thiol, disulphide and troponin levels were measured and troponin-to-native thiol ratio (TNTR) was calculated. A two-sided p value of less than 0.05 was considered to be statistically significant. Results Plasma native thiol, total thiol, disulphide and their ratios were similar between the groups. TNTR was significantly higher in the STE-ACS group compared to the NSTE-ACS group. Troponin and thiol levels correlated negatively and significantly. Native thiol was found to be an independent predictor of VA development in STE-ACS patients and in all ACS patients. TNTR was found to be an independent predictor of VA development in NSTE-ACS patients and in all ACS patients. Conclusion Plasma thiol levels can be used to identify ACS patients at high risk for in-hospital VA development. Correlation between troponin and thiol levels may suggest that thiols may be an important marker for diagnosis and prognosis of ACS with the help of future studies.

Lesão Miocárdica após Cirurgia Não Cardíaca - Estado da Arte / Myocardial Injury after Non-cardiac Surgery - State of the Art

Resumo Aproximadamente 300 milhões de cirurgias não cardíacas são realizadas anualmente no mundo, e eventos cardiovasculares adversos são as principais causas de morbimortalidade no período perioperatório e pós-operatório. A lesão miocárdica após cirurgia não cardíaca (MINS, do inglês myocardial injury after non-cardiac surgery) é uma nova entidade clínica associada com desfechos cardiovasculares adversos. MINS é definida como uma lesão miocárdica que pode resultar em necrose secundária à isquemia, com elevação dos biomarcadores. A lesão tem importância prognóstica e ocorre em até 30 dias após a cirurgia não cardíaca. Os critérios diagnósticos para MINS são: níveis elevados de troponina durante ou em até 30 dias após a cirurgia não cardíaca, sem evidência de etiologia não isquêmica, sem que haja necessariamente sintomas isquêmicos ou achados eletrocardiográficos de isquemia. Recentemente, pacientes com maior risco para MINS têm sido identificados por variáveis clínicas e biomarcadores, bem como por protocolos de vigilância quanto ao monitoramento eletrocardiográfico e dosagem de troponina cardíaca. Pacientes idosos com doença aterosclerótica prévia necessitam medir troponina diariamente no período pós-operatório. O objetivo deste trabalho é descrever este novo problema de saúde pública, seu impacto clínico e a abordagem terapêutica contemporânea.

Abstract Approximately 300 million non-cardiac surgeries are performed annually worldwide and adverse cardiovascular events are the main cause of morbidity and mortality in the peri- and postoperative period. Myocardial injury after non-cardiac surgery (MINS) is a new clinical entity associated with adverse cardiovascular outcomes. MINS is defined as myocardial injury that can result in necrosis due to ischemia, marked by increase in biomarker levels. It has prognostic relevance and occurs within up to 30 days after non-cardiac surgery. The diagnostic criteria for MINS are an elevated postoperative measure of troponin judged as secondary to myocardial ischemia, i.e., with no evidence of a non-ischemic etiology, during or within 30 days after non-cardiac surgery, and without the requirement of an ischemic symptom or electrocardiographic finding of ischemia. Recently, patients at higher risk for MINS have been recognized using clinical variables and biomarkers and established protocols for greater surveillance in relation to electrocardiographic monitoring and cardiac troponin dosage. Elderly patients with previous atherosclerotic disease need to measure troponin daily in the postoperative period. The aim of the present work is to describe this new public health problem, its clinical impact and contemporary therapeutic approach.

Practical Approach to Acute Coronary Syndrome in Patients with COVID-19

Abstract Acute cardiac injury is associated with higher mortality in patients with the novel coronavirus disease-2019 (COVID-19) and the exact etiology can be challenging to diagnose in the emergency setting during the pandemic. From a pathophysiological perspective, SARS-CoV-2 infection is characterized by an overproduction of inflammatory cytokines (IL-6, TNF-alpha) that leads to systemic inflammation and consequent increased risk of acute myocardial infarction (AMI) caused by atheromatous plaque rupture and significant myocardial oxygen supply-demand imbalance. Moreover, SARS-CoV-2 tropism to the renin-angiotensin-aldosterone system through the ACE2 receptor induces myocarditis that may rapidly progress to left ventricular dysfunction and hemodynamic instability. Myocardial inflammation with pericardial involvement, i.e. , myopericarditis, can progress to cardiac tamponade and obstructive shock. These cardiovascular complications, which are associated with a worse prognosis and higher mortality, can be associated with clinical manifestations, electrocardiographic changes, and troponin values similar to AMI. Thus, the diagnosis and treatment of patients with acute chest pain and dyspnea admitted to the emergency department is a significant challenge during the COVID-19 pandemic. Here, we provide a review of the literature focusing on a practical approach to acute coronary syndrome patients with confirmed or suspected COVID-19.

C-Reactive protein level and left ventricular mass are associated with acute cellular rejection after heart transplant

OBJECTIVES: Acute cellular rejection (ACR) remains a major complication of heart transplant (HT). The gold standard for its diagnosis is endomyocardial biopsy (EMB), whereas the role of non-invasive biomarkers for detecting ACR is unclear. This study aimed to identify non-invasive biomarkers for the diagnosis of ACR in patients undergoing HT and presenting with normal left ventricular function. METHODS: We evaluated patients who underwent HT at a single center between January 2010 and June 2019. Patients were enrolled after HT, and those with left ventricular (LV) systolic dysfunction before EMB were excluded. We included only the results of the first EMB performed at least 30 days after HT (median, 90 days). Troponin, B-type natriuretic peptide (BNP), and C-reactive protein (CRP) levels were measured and echocardiography was performed up to 7 days before EMB. ACR was defined as International Society for Heart and Lung Transplantation grade 2R or 3R on EMB. We performed logistic regression analysis to identify the non-invasive predictors of ACR (2R or 3R) and evaluated the accuracy of each using area under the receiver operator characteristic curve analysis. RESULTS: We analyzed 72 patients after HT (51.31±13.63 years; 25 [34.7%] women); of them, 9 (12.5%) developed ACR. Based on multivariate logistic regression analysis, we performed forward stepwise selection (entry criteria, p<0.05). The only independent predictors that remained in the model were CRP level and LV mass index. The optimal cut-off point for CRP level was ≥15.9 mg/L (odds ratio [OR], 11.7; p=0.007) and that for LV mass index was ≥111 g/m2 (OR, 13.6; p=0.003). The area under the receiver operating characteristic curve derived from this model was 0.87 (95% confidence interval [CI], 0.75-0.99), with sensitivity of 85.7% (95% CI, 42.1%-99.6%), specificity of 78.4% (95% CI, 64.7%-88.7%), positive predictive value of 35.3% (95% CI, 14.3%-61.7%), and negative predictive value of 97.6% (95% CI, 87.1%-99.9%). CONCLUSIONS: Among patients undergoing HT, CRP level and LV mass were directly associated with ACR, but troponin and BNP levels were not.

Dor torácica na emergência: quando pensar em síndrome de Takotsubo? / Emergency chest pain: when to think about Takotsubo syndrome?

A síndrome de Takotsubo é uma cardiomiopatia induzida por estresse, caracterizada por disfunção transitória do ventrículo esquerdo. Essa disfunção pode ser confundida com infarto agudo miocárdio na sala de emergência por ter características clínicas semelhantes ­ principalmente a dor torácica. A fisiopatologia ainda não é bem definida, mas está associada à deficiência de estrogênio e ao aumento de catecolaminas que estimulam o acoplamento dos receptores beta-2 do coração, o que resulta em atividade inotrópica negativa, levando à disfunção contrátil do ventrículo esquerdo. As enzimas cardíacas alteradas dificultam ainda mais o diagnóstico da síndrome de Takotsubo. O exame padrão-ouro, que diferencia a síndrome de Takotsubo do infarto agudo do miocárdio, é a angiografia coronariana. Uma das opções na emergência é o ecocardiograma na beira do leito. Além disso, os critérios de Mayo devem ser usados para diagnosticar a síndrome de Takotsubo. É importante, para o profissional que trabalha no pronto-socorro, ter a síndrome de Takotsubo como diagnóstico diferencial na dor torácica.

Takotsubo syndrome is a stress-induced cardiomyopathy characterized by a transient left ventricular dysfunction. This dysfunction can be confused with acute myocardial infarction in the emergency room as it has similar clinical characteristics, especially chest pain. Its pathophysiology is not yet well defined, but is associated with estrogen deficiency and increased catecholamines that stimulate the coupling of cardiac beta-2 receptors, resulting in negative inotropic activity and leading to contractile dysfunction of the left ventricle. Altered cardiac enzymes make the diagnosis of Takotsubo syndrome even more difficult. The gold standard exam that will differentiate Takotsubo syndrome from acute myocardial infarction is coronary angiography. One of the options in the emergency room is bedside echocardiography. In addition, Mayo criteria should be used to diagnose Takotsubo syndrome. Professionals working in the emergency room shall have Takotsubo syndrome as a differential diagnosis in chest pain.

Clinical-pathological and immunohistochemical evaluations of cardiac lesions in cats with chronic kidney disease / Avaliações clínico-patológica e imuno-histoquímica de lesões cardíacas em gatos com doença renal crônica

Chronic kidney disease (CKD) is characterized by irreversible morphostructural lesions that can progressively evolve to chronic renal insufficiency and kidney failure. It is known that the heart and kidneys are closely related, and that communication between these organs occurs through a variety of pathways; subtle physiological changes in one of them are compensated by the other. Histopathological cardiac evaluation through routine staining presents a limitation to identify specific or discreet lesions in the cardiomyocytes. This study aimed to evaluate serum troponin levels in cats with CKD, associated with clinical and pathological findings, as well as to correlate the morphostructural cardiac lesions to determine their distribution through macroscopic and histological assessments and anti-cardiac troponin C (cTnC) immunohistochemistry (IHC). To this end, 20 cats (18 diagnosed with CKD and two controls) were selected. Anti-human cTnC IHC was conducted after necropsy and separation in eight regions of each collected heart. Heart fragments from two cats without CKD were used as controls. The anti-human cTnC antibody is useful in detecting cardiac lesions and has shown decreased expression in cardiomyocytes of cats with CKD. Serum troponin was above the reference values in 11/18 (61.11%) animals and decreased expression for the cTnC antibody was observed in individual cardiomyocytes in 9/18 (50%) animals. It was verified that the number of regions with decreased expression for the cTnC antibody in cardiomyocytes is significantly correlated with serum troponin. The anti-human cTnC antibody has been found effective in detecting cardiac lesions and has shown decreased expression in the cardiomyocytes of cats with CKD. Correlation was observed between increased serum cTnI and loss of immunoreactivity at anti-cTnC antibody IHC in cats with CKD, which proves damage to cardiomyocytes secondary to kidney disease.(AU)

A doença renal crônica (DRC) é caracterizada por lesões morfoestruturais irreversíveis, que podem evoluir progressivamente para insuficiência renal crônica e falência renal. Sabe-se que o coração e os rins mantêm estreita relação e a comunicação entre esses órgãos ocorre por uma variedade de vias; alterações fisiológicas sutis em um desses órgãos são compensadas pelo outro. A avaliação histopatológica cardíaca mediante a colorações rotineiras são limitadas para identificar lesões específicas ou discretas em cardiomiócitos. O presente trabalho teve como objetivos avaliar os níveis séricos de troponina em gatos com DRC, associados aos achados clínico-patológicos, bem como correlacionar as lesões cardíacas morfoestruturais, a fim de determinar a distribuição destas, por meio da avaliação macroscópica, histológica e imuno-histoquímica com anti-cTnC. Neste estudo foram selecionados 20 gatos (18 diagnosticados com DRC e 2 animais controle). Para a aplicação da técnica de imuno-histoquímica anti-troponina C humana, necropsias foram realizadas e cada coração coletado separadamente em 8 regiões. Fragmentos do coração de 2 gatos sem lesão cardíaca foram utilizados como controle. O anticorpo anti-TnC humano é útil na detecção de lesões cardíacas e apresentou expressão diminuída em cardiomiócitos de gatos com DRC. Em 11/18 animais (61,11%) a troponina sérica encontrava-se acima dos valores de referência e foram observadas diminuição da expressão para anticorpo-cTnC em cardiomiócitos individuais em 9/18 (50%). Notou-se que o número de regiões com diminuição da expressão para anticorpo-cTnC em cardiomiócitos está significativamente correlacionado com a troponina sérica. O anticorpo anti-TnC humano se mostrou eficaz para detectar lesões cardíacas e demonstrou diminuição da expressão nos cardiomiócitos de gatos com DRC. Houve correlação entre o aumento da CTnI sérica e perda da imunorretividade na avaliação imuno-histoquímica com anticorpo anti-TnC em gatos com DRC o que comprova danos em cardiomiócitos secundários a doença renal.(AU)

Valor Prognóstico da Troponina T e do Peptídeo Natriurético Tipo B em Pacientes Internados por COVID-19 / Prognostic Value of Troponin-T and B-Type Natriuretic Peptide in Patients Hospitalized for COVID-19

Resumo Fundamento: A COVID-19 causa grave acometimento pulmonar, porém o sistema cardiovascular também pode ser afetado por miocardite, insuficiência cardíaca e choque. A elevação de biomarcadores cardíacos tem sido associada a um pior prognóstico. Objetivos: Avaliar o valor prognóstico da Troponina T (TnT) e do peptídeo natriurético tipo B (BNP) em pacientes internados por Covid-19. Métodos: Amostra de conveniência de pacientes hospitalizados por COVID-19. Foram coletados dados dos prontuários com o objetivo de avaliar a relação da TnT e o BNP medidos nas primeiras 24h de admissão com o desfecho combinado (DC) óbito ou necessidade de ventilação mecânica. Análise univariada comparou os grupos com e sem DC. Modelo multivariado de Cox foi utilizada para determinar preditores independentes do DC. Resultados: Avaliamos 183 pacientes (idade=66,8±17 anos, sendo 65,6% do sexo masculino). Tempo de acompanhamento foi de 7 dias (1 a 39 dias). O DC ocorreu em 24% dos pacientes. As medianas de TnT e BNP foram 0,011 e 0,041 ng/dl (p<0,001); 64 e 198 pg/dl (p<0,001) respectivamente para os grupos sem e com DC. Na análise univariada, além de TnT e BNP, idade, presença de doença coronariana, saturação de oxigênio, linfócitos, dímero-D, proteína C reativa titulada (PCR-t) e creatinina, foram diferentes entre os grupos com e sem desfechos. Na análise multivariada boostraped apenas TnT (1,12[IC95%1,03-1,47]) e PCR-t (1,04[IC95%1,00-1,10]) foram preditores independentes do DC. Conclusão: Nas primeiras 24h de admissão, TnT, mas não o BNP, foi marcador independente de mortalidade ou necessidade de ventilação mecânica invasiva. Este dado reforça ainda mais a importância clínica do acometimento cardíaco da COVID-19. (AArq Bras Cardiol. 2020; 115(4):660-666)

Abstract Background: COVID-19 causes severe pulmonary involvement, but the cardiovascular system can also be affected by myocarditis, heart failure and shock. The increase in cardiac biomarkers has been associated with a worse prognosis. Objectives: To evaluate the prognostic value of Troponin-T (TNT) and natriuretic peptide (BNP) in patients hospitalized for Covid-19. Methods: This was a convenience sample of patients hospitalized for COVID-19. Data were collected from medical records to assess the association of TnT and BNP measured in the first 24 hours of hospital admission with the combined outcome (CO) of death or need for mechanical ventilation. Univariate analysis was used to compare the groups with and without the CO. Cox's multivariate model was used to determine independent predictors of the CO. Results: We evaluated 183 patients (age = 66.8±17 years, 65.6% of which were males). The time of follow-up was 7 days (range 1 to 39 days). The CO occurred in 24% of the patients. The median troponin-T and BNP levels were 0.011 and 0.041ng/dL (p <0.001); 64 and 198 pg/dL (p <0.001), respectively, for the groups without and with the CO. In the univariate analysis, in addition to TnT and BNP, age, presence of coronary disease, oxygen saturation, lymphocytes, D-dimer, t-CRP and creatinine, were different between groups with and without outcomes. In the bootstrap multivariate analysis, only TnT (1.12 [95% CI 1.03-1.47]) and t-CRP (1.04 [95% CI 1.00-1.10]) were independent predictors of the CO. Conclusion: In the first 24h of admission, TnT, but not BNP, was an independent marker of mortality or need for invasive mechanical ventilation. This finding further reinforces the clinical importance of cardiac involvement in COVID-19. (Arq Bras Cardiol. 2020; 115(4):660-666)

Injuria miocárdica luego de cirugía no cardíaca / Myocardial injury after non-cardiac surgery

Resumen Las complicaciones cardiovasculares mayores en el postoperatorio son frecuentes y el principal factor contribuyente es la injuria miocárdica o infarto (MINS, Myocardial Injury after Noncardiac Surgery) asociado a cirugía no cardíaca. El riesgo de mortalidad a 30 días de los pacientes con injuria miocárdica es 4-5 veces mayor que los pacientes que no lo presentan. Se estima que 85% de los pacientes con MINS no presentan síntomas, por lo que la única manera de detectarlos es mediante screening sistemático de troponinas. Si bien no existen intervenciones de aplicación sistemática que permitan prevenir esta complicación, existen alternativas de tratamiento y manejo, por lo que la pesquisa activa es costo-efectiva y relevante desde el punto de visto clínico.

Major cardiovascular complications in the postoperative period are frequent and the main contributing factor is myocardial injury or infarction (MINS, Myocardial Injury after Noncardiac Surgery) associated with non-cardiac surgery. The 30-day mortality risk in patients with myocardial injury is 4-5 times higher than in patients without this complication. It is estimated that 85% of patients with MINS/infarction are asymptomatic, hence the only way to detect them is through systematic screening of troponins. Although there are no systematic interventions to prevent this complication, there are treatment and management alternatives, so the active early diagnosis is cost effective and relevant from a clinical point of view.

Valor pronóstico de biomarcadores cardíacos en la enfermedad por COVID-19 / value of cardiac biomarkers in COVID-19 disease

Resumen Introducción: En la enfermedad por COVID-19 se ha establecido que los pacientes con enfermedad cardiometabólica de base tienen mayor riesgo de presentar desenlaces adversos. Esto ha incrementado el interés en estudiar variables cardiovasculares relevantes, para plantear su correlación con los desenlaces clínicos en esta población. Objetivo: Describir el valor pronóstico de los biomarcadores cardíacos en la enfermedad por COVID-19. Métodos: Revisión no sistemática de la literatura en bases de datos como PubMed, Google Scholar, Clinical Key, SciELO, entre otras, utilizando palabras clave, términos planos y términos MeSh. Resultados: Se eligieron 22 bibliografías, entre ellas artículos de revisión de tema, revisiones sistemáticas, metaanálisis, estudios observacionales y artículos originales publicados hasta la fecha (mayo 13 de 2020), que en su mayoría describen la alteración de biomarcadores cardiacos y su relación con la evolución clínica de los pacientes con COVID-19. Discusión: Se encontró que la troponina y el péptido natriurético se comportan como factores de riesgo independientes para compromiso clínico severo, requerimiento de soporte ventilatorio o hemodinámico, estancia en la UCI, y aumento de la mortalidad. Conclusiones: Es razonable plantear el uso de estos biomarcadores en la estratificación del riesgo en pacientes con COVID-19 y enfermedad cardiovascular establecida.

Abstract Introduction: It has been established that patients with an underlying cardiometabolic disease and COVID-19 infections, have a higher risk of an adverse outcome. This has led to an increase in the interest of studying relevant cardiovascular variables, in order to establish their association with clinical outcomes in this population. Objective: To describe the prognostic value of cardiac biomarkers in disease caused by COVID-19. Methods: A non-systematic review of the literature was carried out in data bases that included PubMed, Google Scholar, Clinical Key, SciELO, using the key words, plain terms, and MeSH terms. Results: A total of 22 articles were chosen. They consisted of review articles on the subject, systematic reviews, meta-analyses, observational studies, and original articles published up until 13 May 2020. The majority of them described the changes in cardiac biomarkers and their relationship with the clinical outcome of patients COVID-19. Discussion: It was found that Troponin and Natriuretic Peptide behaved as independent risk factors for severe clinical compromise, requiring ventilatory or haemodynamic support, admission to ICU, and an increase in mortality. Conclusions: It is reasonable to recommend the use of these biomarkers in the risk stratification in patients with COVID-19 and an established cardiovascular disease.

Asociación entre troponina y perfil lipídico Niveles en pacientes con insuficiencia cardíaca crónica / Association between Troponin and Lipid Profile Levels in Patients with Chronic Heart Failure

Background: Older women have a high chance of suffering from coronary heart diseases and heart failure. Possessing high-sensitive tests will permit early detection of cardiac troponin and lipid proteins (HDL, LDL, VLDL, & Triglyceride) I in levels that are below the diagnostic endpoint for the acute coronary syndrome. Aim of the study: The intent in this study is to analyze the association among the 3 ranks taking into consideration any future cardiac happening within the community setting and involving elderly women who are aged seventy years and above. Patients and Methods: 212 women were grouped for this study, and this lot was lacking any CHD within the set baseline or the troponin and lipid proteins (HDL, LDL, VLDL, & Triglyceride) established above the analytical limits for the disease to be studied (acute coronary syndrome). These elderly women had a 15-year continuation of hospitalization and mortality measures. Results: The analysis showed 22 percent of the study group to be suffering from CHD, there was 15 percent of myocardial infarction or death brought about by CHD, and 10 percent of the heart failure. The 99 percent of assessed serum illustrations, troponin, and lipid proteins (HDL, LDL, VLDL, & Triglyceride) levels were above recognition. Taking into consideration of the Framingham risk features, the correction done for each SD normal linear changed troponin and lipid proteins (HDL, LDL, VLDL, & Triglyceride) upsurge was connected to an upsurge uncertainty for the coronary heart disease. Conclusions: conclusively, the troponin and lipid profile (HDL, LDL, VLDL, & Triglyceride) I am autonomously linked with the foreseeable cardiac happenings in older women across Iraq without seeming clinical indicators. Adding cardiac troponin and lipid proteins (HDL, LDL, VLDL, & Triglyceride) 1 to the conventional risk factor can greatly enhance the risk prediction in this background.

Os Escores HEART, TIMI e GRACE para Predição de Eventos Cardiovasculares Adversos Maiores no Período de 30 Dias na Era de Troponina I de Alta Sensibilidade / HEART, TIMI, and GRACE Scores for Prediction of 30-Day Major Adverse Cardiovascular Events in the Era of High-Sensitivity Troponin

Resumo Fundamento Múltiplos sistemas de pontuação têm sido elaborados para calcular o risco de eventos cardiovasculares adversos maiores (MACE) em pacientes com dor no peito. Não há dados que avaliem se o escore HEART tem um desempenho superior a TIMI e GRACE para a predição de MACE, especialmente na era de troponina I de alta sensibilidade e em uma população exclusivamente latino-americana. Objetivo Comparar o desempenho dos escores HEART, TIMI e GRACE para a predição de MACE em 30 dias de acompanhamento, em pacientes atendidos com dor no peito no departamento de emergência. Métodos Os escores HEART, TIMI e GRACE foram analisados em 519 pacientes com dor no peito no departamento de emergência. O desfecho primário foi a ocorrência de MACE no período de 30 dias. O desempenho do escore HEART foi comparado com o dos escores TIMI e GRACE utilizando o teste de DeLong, considerando estatisticamente significativos os valores de p de 0,05. Resultados Um total de 224 pacientes (43%) apresentaram MACE no período de 30 dias. A estatística C para os escores HEART, TIMI e GRACE foi de 0,937, 0,844 e 0,797 respectivamente (p < 0,0001). Uma pontuação de 3 ou menos no escore HEART apresentou uma sensibilidade de 99,5% e um valor preditivo negativo de 99% para classificar pacientes de baixo risco de maneira correta; ambos os valores foram mais elevados do que aqueles obtidos pelos outros escores. Conclusão O escore HEART, em um período de 30 dias, prediz eventos cardiovasculares, mais eficazmente, em comparação com os outros escores. Troponinas de alta sensibilidade mantêm a superioridade previamente demonstrada deste escore. Este escore oferece uma identificação mais precisa dos pacientes de baixo risco. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Abstract Background Multiple scoring systems have been designed to calculate the risk of major adverse cardiovascular events (MACE) in patients with chest pain. There is no data on whether the HEART score outperforms TIMI and GRACE in the prediction of MACE, especially in the era of high-sensitivity troponin assay and in an exclusively Latin-American population. Objective To compare the performance of the HEART, TIMI, and GRACE scores for predicting major cardiovascular events at 30 days of follow-up, in patients who consult for chest pain in the emergency department. Methods HEART, TIMI, and GRACE scores were analyzed in 519 patients with chest pain at the emergency department. The primary endpoint was the occurrence of MACE within 30 days. The performance of the HEART score was compared with the TIMI and GRACE scores using the DeLong test with p values of 0.05 considered statistically significant. Results A total of 224 patients (43%) had MACE at 30 days. The C statistic for the HEART, TIMI, and GRACE score was 0.937, 0.844, and 0.797 respectively (p < 0.0001). A HEART score of 3 or less had a sensitivity of 99.5% and a negative predictive value of 99% to classify low risk patients correctly; both values were higher than those obtained by the other scores. Conclusion The HEART score more effectively predicts cardiovascular events at 30 days of follow-up compared to the other scores. High-sensitivity troponins maintain this score's previously demonstrated superiority. This score offers more precise identification of low-risk patients. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Fisiopatología, perfil epidemiológico y manejo terapéutico en el síndrome coronario agudo / Pathophysiology, epidemiological profile and therapeutic management in acute coronary syndrome

Las enfermedades cardiovasculares siguen siendo ampliamente la primera causa de muerte en el mundo actual. La cardiopatía isquémica conlleva a una importante carga de gastos de Salud Pública, por lo cual es importante conocer la prevalencia, epidemiología, fisiopatología y el manejo diagnóstico y terapéutico adecuado del síndrome coronario agudo (SCA). Los hallazgos recientes indican que los primeros pasos en la aterosclerosis son esencialmente inflamatorios. Una respuesta inflamatoria sistémica a menudo acompaña al SCA, y la documentación de su presencia ha sido ampliamente reconocida como un indicador de eventos coronarios a repetición. La medicina basada en la evidencia sugiere fuertemente la importancia de la etiología inflamatoria en el SCA. Los factores tradicionales de riesgo coronario terminan en un pasaje final común que desarrolla un proceso inflamatorio en la pared arterial. El entendimiento mejorado y la comprensión adecuada de la influencia de los procesos inflamatorios en el SCA pueden llevar no solo a una mejor utilización de la terapéutica actualmente disponible sino también al desarrollo de nuevas herramientas terapéuticas. Sin duda alguna los refinamientos constantes en las diferentes estrategias terapéuticas del SCA, sumados a la combinación del entendimiento científico en el uso adecuado de los marcadores inflamatorios, los nuevos agentes farmacológicos y las nuevas técnicas de intervención coronaria percutánea con los nuevos stents y otros dispositivos intracoronarios van a aclarar nuestras dudas y mejorar nuestro manejo diagnóstico y terapéutico del síndrome coronario agudo basado en la evidencia científica

Cardiovascular diseases are still widely the leading cause of death in the world today. Ischemic heart disease leads to a significant burden of public health expenses, which is why it is important to know the prevalence, epidemiology, pathophysiology and the adequate diagnostic and therapeutic management of acute coronary syndrome (ACS). Recent findings indicate that the first steps in atherosclerosis are essentially inflammatory. A systemic inflammatory response often accompanies ACS, and the documentation of its presence has been widely recognized as an indicator of recurrent coronary events. Evidence based medicine strongly suggests the importance of the inflammatory etiology in ACS. The traditional coronary risk factors end in a common final passage that develops an inflammatory process in the arterial wall. Improved and adequate understanding of the influence of inflammatory processes in ACS can lead not only to a better use of currently available therapeutics but also to the development of new therapeutic tools. Undoubtedly the constant refinements in the different therapeutic strategies of the ACS, combined with the addition of scientific understanding in the proper use of inflammatory markers, new pharmacological agents and new techniques of percutaneous coronary intervention with newer stents and other intracoronary devices will clarify our doubts and improve our diagnostic and therapeutic management of acute coronary syndrome based on scientific evidence

Interferencia analítica en la determinación de troponina por anticuerpos heterófilos / Interference in the determination of Troponin due to heterophile antibodies

Resumen Por su elevada especificidad y sensibilidad, y a raíz de la tercera definición universal de infarto estas isoformas cardiacas han sido aceptadas en el ámbito internacional como los biomarcadaores de elección en la práctica clínica para el diagnóstico de síndrome coronario agudo, preferibles a la determinación de las enzimas creatina quinasa y su isoforma MB. Se presenta el caso de un varón de ochenta años, quien, de manera persistente, tuvo valores elevados de troponinas, pese a evolución clínica no compatible con síndrome coronario agudo ni otras causas de elevación de este biomarcador.

Abstract Due to its elevated specificity and sensitivity, and on being the third universal definition of myocardial infarction, these cardiac isoforms have been accepted internationally as the biomarkers of choice in clinical practice for the diagnosis of acute coronary syndrome, and are preferable to the determinations of creatine kinase and its MB isoform. A case is presented on an eighty year-old man, who persistently had elevated Troponin values, despite a clinical course that was incompatible with an acute coronary syndrome or any other causes of elevation of this biomarker.