Structure, Process, and Mortality Associated with Acute Coronary Syndrome Management in Guatemala's National Healthcare System: The ACS-GT Registry.

Background: Acute coronary syndromes (ACS) include ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). The leading cause of mortality in Guatemala is acute myocardial infarction (AMI) and there is no established national policy nor current standard of care. Objective: Describe the factors that influence ACS outcome, evaluating the national healthcare system's quality of care based on the Donabedian health model. Methods: The ACS-Gt study is an observational, multicentre, and prospective national registry. A total of 109 ACS adult patients admitted at six hospitals from Guatemala's National Healthcare System were included. These represent six out of the country's eight geographic regions. Data enrolment took place from February 2020 to January 2021. Data was assessed using chi-square test, Student's t-test, or Mann-Whitney U test, whichever applied. A p-value < 0.05 was considered statistically significant. Results: One hundred and nine patients met inclusion criteria (80.7% STEMI, 19.3% NSTEMI/UA). The population was predominantly male, (68%) hypertensive (49.5%), and diabetic (45.9%). Fifty-nine percent of STEMI patients received fibrinolysis (alteplase 65.4%) and none for primary Percutaneous Coronary Intervention (pPCI). Reperfusion success rate was 65%, and none were taken to PCI afterwards in the recommended time period (2-24 hours). Prognostic delays in STEMI were significantly prolonged in comparison with European guidelines goals. Optimal in-hospital medical therapy was 8.3%, and in-hospital mortality was 20.4%. Conclusions: There is poor access to ACS pharmacological treatment, low reperfusion rate, and no primary, urgent, or rescue PCI available. No patient fulfilled the recommended time period between successful fibrinolysis and PCI. Resources are limited and inefficiently used.

Efficacy and safety of trimetazidine after percutaneous coronary intervention (ATPCI): a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Angina might persist or reoccur despite successful revascularisation with percutaneous coronary intervention (PCI) and antianginal therapy. Additionally, PCI in stable patients has not been shown to improve survival compared with optimal medical therapy. Trimetazidine is an antianginal agent that improves energy metabolism of the ischaemic myocardium and might improve outcomes and symptoms of patients who recently had a PCI. In this study, we aimed to assess the long-term potential benefits and safety of trimetazidine added to standard evidence-based medical treatment in patients who had a recent successful PCI. METHODS: We did a randomised, double-blind, placebo-controlled, event-driven trial of trimetazidine added to standard background therapy in patients who had undergone successful PCI at 365 centres in 27 countries across Europe, South America, Asia, and north Africa. Eligible patients were aged 21-85 years and had had either elective PCI for stable angina or urgent PCI for unstable angina or non-ST segment elevation myocardial infarction less than 30 days before randomisation. Patients were randomly assigned by an interactive web response system to oral trimetazidine 35 mg modified-release twice daily or matching placebo. Participants, study investigators, and all study staff were masked to treatment allocation. The primary efficacy endpoint was a composite of cardiac death; hospital admission for a cardiac event; recurrence or persistence of angina requiring an addition, switch, or increase of the dose of at least one antianginal drug; or recurrence or persistence of angina requiring a coronary angiography. Efficacy analyses were done according to the intention-to-treat principle. Safety was assessed in all patients who had at least one dose of study drug. This study is registered with the EU Clinical Trials Register (EudraCT 2010-022134-89). FINDINGS: From Sept 17, 2014, to June 15, 2016, 6007 patients were enrolled and randomly assigned to receive either trimetazidine (n=2998) or placebo (n=3009). After a median follow-up of 47·5 months (IQR 42·3-53·3), incidence of primary endpoint events was not significantly different between the trimetazidine group (700 [23·3%] patients) and the placebo group (714 [23·7%]; hazard ratio 0·98 [95% CI 0·88-1·09], p=0·73). When analysed individually, there were no significant differences in the incidence of the components of the primary endpoint between the treatment groups. Similar results were obtained when patients were categorised according to whether they had an elective or urgent PCI. 1219 (40·9%) of 2983 patients in the trimetazidine group and 1230 (41·1%) of 2990 patients in the placebo group had serious treatment-emergent adverse events. Frequencies of adverse events of interest were similar between the groups. INTERPRETATION: Our results show that the routine use of oral trimetazidine 35 mg twice daily over several years in patients receiving optimal medical therapy, after successful PCI, does not influence the recurrence of angina or the outcome; these findings should be taken into account when considering the place of trimetazidine in clinical practice. However, the long-term prescription of this treatment does not appear to be associated with any statistically significant safety concerns in the population studied. FUNDING: Servier.

Are there gender differences in acute management and secondary prevention of acute coronary syndromes in Barbados? A cohort study.

OBJECTIVES: In Barbados, high case fatality rates have been reported after myocardial infarction (MI) with higher rates in women than men. To explore this inequality, we examined documented pharmacological interventions for ST-segment elevated myocardial infarction (STEMI), non-STEMI (NSTEMI) and unstable and chronic angina in women and men. DESIGN: Prospective cohort registry data for STEMI and NSTEMI and retrospective chart review for unstable and chronic angina. SETTING: Tertiary care (acute coronary syndromes) and primary care (chronic angina) centres in Barbados. PARTICIPANTS: For the years 2009-2016, a total of 1018 patients with STEMI or NSTEMI were identified via the prospective study. For unstable and chronic angina, 136 and 272 notes were reviewed respectively for the years 2010-2014. OUTCOME MEASURES: The proportions of patients prescribed recommended medication during the first 24 hours after an acute event, at discharge and for chronic care were calculated. Prescribed proportions were analysed by gender after adjustment for age. RESULTS: Between 2009 and 2016, for the acute management of patients with NSTEMI and STEMI, only two (aspirin and clopidogrel) of six drugs had documented prescription rates of 80% or more. Patients with STEMI (n=552) had higher prescription rates than NSTEMI (n=466), with gender differences being more pronounced in the former. Among patients with STEMI, after adjustment for age, diabetes, hypertension and smoking, men were more likely to receive fibrinolytics acutely, OR 2.28 (95% CI 1.24 to 4.21). Compared with men, a higher proportion of women were discharged on all recommended treatments; this was only statistically significant for beta-blockers: age-adjusted OR 1.87 (95% CI 1.16 to 3.00). There were no statistically significant differences in documented prescription of drugs for chronic angina. CONCLUSION: Following acute MI in Barbados, the proportion of patients with documented recommended treatment is relatively low. Although women were less likely to receive appropriate acute care than men, by discharge gender differences were reversed.

Angina instável e infarto agudo do miocárdio sem supradesnivelamento de ST: tratamento e prognóstico / Unstable angina and non-ST elevation myocardial infarction: treatmemt and prognosis

Objetivo: As doenças cardiovasculares são responsáveis pela principal causa de óbitos na população adulta mundial, sendo a síndrome coronariana aguda (SCA) a mais prevalente entre elas. Resultados: Sabemos que hoje, do ponto de vista epidemiológico, a coronariopatia aguda sem supradesnivelamento de ST tornou-se a forma mais frequente de apresentação clínica da SCA, aproximadamente, em 62% dos casos. Nos últimos anos, houve importantes avanços em relação à terapêutica antiplaquetária e anticoagu-lante capazes de reduzir a mortalidade associada à doença coronariana. Além disso, a estratificação invasiva precoce teve papel fundamental nesse incremento de prognóstico. Conclusão:Dessa forma, atualmente, a escolha terapêutica e de estratificação devem ser avaliadas individual

Cardiovascular diseases are the main cause of death in the adult population worldwide, with acute coronary syndrome (ACS) being the most prevalent. We know that, presently, from an epidemiological point of view, non-ST elevation ACS is the most frequent form of clinical presentation of ACS, in about 62% of cases. Recently, important advances regarding antiplatelet and anticoagulant therapy exist, capable of reducing mortality associated with coronary heart disease. Moreover, early invasive stratification has played a key role in the improvement in prognosis. Thus, the choice of therapy and stratification should be evaluated individually and can modify short- and long-term outcome

Correlação entre a complexidade das lesões coronarianas e os níveis de Troponina ultrassensível em pacientes com Síndrome Coronariana Aguda / Correlation between the complexity of coronary lesions and high-sensitivity Troponin levels in patients with Acute Coronary Syndrome

Fundamento: As doenças cardiovasculares são a principal causa de morte no Brasil. Marcadores bioquímicos possuem importância diagnóstica e prognóstica nas síndromes coronarianas agudas (SCAs), sendo a troponina o biomarcador preferido. Estudos já demonstram relação positiva entre elevação da troponina ultrassensível (TnUs) e prognóstico. Entretanto, poucos relacionam seus níveis com a complexidade das lesões coronárias. Objetivos: Comparar níveis de TnUs com a complexidade das lesões coronarianas pelo escore SYNTAX e relacionar os escores TIMI e GRACE com os níveis desse biomarcador em pacientes com SCA. Métodos: Estudo retrospectivo, transversal com 174 indivíduos com SCA. A correlação entre as variáveis foi avaliada pelo teste de correlação linear não paramétrico de Spearman e a análise estatística realizada pelo programa SPSS, com nível de significância de 5%. Resultados: A média de idade foi 63 anos, predominando o sexo feminino (52,9%). A maioria dos pacientes era hipertensa, não diabética e não tabagista. Dos pacientes avaliados, 19,0% apresentaram IAM com SST, 43,1% IAM sem SST e 36,8% angina instável. A maioria encontrava-se em Killip 1 (82,8%). A mediana de TnUs foi de 67pg/ml. As medianas dos escores de risco foram de 3, 121 e 3 pontos nas escalas TIMI, GRACE e SYNTAX, respectivamente. Houve correlação da taxa de TnUs com os escores SYNTAX (p < 0,001, r = 0,440), TIMI (p < 0,001, r = 0,267) e GRACE (p = 0,001, r = 0,261). Conclusão: Encontrada correlação linear positiva entre os níveis de TnUs e complexidade das lesões coronarianas, assim como entre esse biomarcador e os escores clínicos TIMI e GRACE

Background: Cardiovascular diseases are the leading cause of death in Brazil. Biochemical markers have diagnostic and prognostic importance in acute coronary syndromes (ACSs), with troponin as the preferred biomarker. Studies have already demonstrated a positive relationship between increased levels of high-sensitivity troponin (hsTn) and prognosis. However, few studies have correlated hsTn levels with the complexity of coronary lesions. Objectives: To compare hsTn levels with the complexity of coronary lesions according to the SYNTAX score, and to correlate the levels of this biomarker with the TIMI and GRACE scores in patients with ACS. Methods: Retrospective, cross-sectional study with 174 patients with ACS. The correlation between variables was assessed by the nonparametric Spearman's rank correlation, and statistical analysis was performed by the SPSS program, with a significance level of 5%. Results: Mean age was 63 years, and most patients were women (52.9%), hypertensive, non-diabetic and non-smokers. Nineteen percent of the patients had STEMI, 43.1% NSTEMI, and 36.8% unstable angina. Most were in Killip 1 (82.8%). Median hsTn was 67 pg/mL. Median risk scores were 3, 121 and 3 in the TIMI, GRACE and SYNTAX scores, respectively. There was a correlation of hsTn with SYNTAX (p <0.001, r = 0.440), TIMI (p < 0.001, r = 0.267) and GRACE (p = 0.001, r = 0.261) scores. Conclusion: A positive linear correlation was found of hsTn levels with the complexity of coronary lesions, and with the TIMI and GRACE

Successful management of grade III coronary perforation after percutaneous angioplasty in a high-risk patient: a case report.

Coronary perforation is a rare complication in patients undergoing percutaneous coronary angioplasty. The mortality of this complication varies depending on factors related to the patient and the procedure performed, reaching 44% in patients with Ellis type III perforation. We report the case of an 81 year old male with multiple cardiovascular risk factors, who underwent percutaneous angioplasty for unstable angina management. The patient developed grade III coronary perforation in the anterior descending artery, which was successfully managed with balloon inflation to 6 atmospheres for 10 minutes twice in the affected area, with an interval of 5 minutes between each dilatation. The patient improved and was discharged.

La perforación coronaria es una complicación rara en los pacientes sometidos a angioplastia percutánea coronaria. La mortalidad de esta complicación es variable, dependiendo de factores relacionados al paciente y al procedimiento realizado. Alcanza el 44% en pacientes con perforación tipo III, según la escala de Ellis. Presentamos el caso de un varón de 81 años con múltiples factores de riesgo cardiovascular, a quien se le realizó una angioplastia percutánea para manejo de un síndrome isquémico coronario agudo sin elevación del segmento ST (SICA STNE) de alto riesgo. El procedimiento se complicó con una perforación coronaria grado III en la arteria descendente anterior, la cual fue manejada exitosamente con dilatación de balón a 6 atmósferas por 10 minutos en dos oportunidades en la zona afectada, con intervalo de 5 minutos entre insuflaciones. El paciente evolucionó favorablemente y fue dado de alta.

Outcomes in patients with non-ST-elevation acute coronary syndrome randomly assigned to invasive versus conservative treatment strategies: a meta-analysis.

OBJECTIVE: The goal of the present study was to compare the prognoses of patients with non-ST-elevation acute coronary syndromes who were treated with invasive or conservative treatment strategies. METHODS: We performed a meta-analysis of studies of patients with non-ST-elevation acute coronary syndromes to assess the benefits of an invasive strategy vs. a conservative strategy for short- and long-term survival. We searched PubMed for studies published from 1990 to November 2012 that investigated the effects of an invasive vs. conservative strategy in patients with non-ST-elevation acute coronary syndromes. The following search terms were used: "non-ST-elevation myocardial infarction", "unstable angina", "acute coronary syndromes", "invasive strategy", and "conservative strategy". The primary endpoints were all-cause mortality at 30 days and 1 year. RESULTS: Seven published studies were included in the present meta-analysis. The pooled analyses show that an invasive strategy decreased the risk of death (risk ratio [0.839] [95% confidence interval {0.648-1.086}; I 2, 86.46%] compared to a conservative strategy over a 30-day-period. Furthermore, invasive treatment also decreased patient mortality (risk ratio [0.276] [95% confidence interval {0.259-0.294}; I 2, 94.58%]) compared to a conservative strategy for one year. CONCLUSION: In non-ST-elevation acute coronary syndromes, an invasive strategy is comparable to a conservative strategy for decreasing short- and long-term mortality rates.

Outcomes in patients with non-ST-elevation acute coronary syndrome randomly assigned to invasive versus conservative treatment strategies: A meta-analysis

OBJECTIVE: The goal of the present study was to compare the prognoses of patients with non-ST-elevation acute coronary syndromes who were treated with invasive or conservative treatment strategies. METHODS: We performed a meta-analysis of studies of patients with non-ST-elevation acute coronary syndromes to assess the benefits of an invasive strategy vs. a conservative strategy for short- and long-term survival. We searched PubMed for studies published from 1990 to November 2012 that investigated the effects of an invasive vs. conservative strategy in patients with non-ST-elevation acute coronary syndromes. The following search terms were used: “non-ST-elevation myocardial infarction”, “unstable angina”, “acute coronary syndromes”, “invasive strategy”, and “conservative strategy”. The primary endpoints were all-cause mortality at 30 days and 1 year. RESULTS: Seven published studies were included in the present meta-analysis. The pooled analyses show that an invasive strategy decreased the risk of death (risk ratio [0.839] [95% confidence interval {0.648-1.086}; I 2, 86.46%] compared to a conservative strategy over a 30-day-period. Furthermore, invasive treatment also decreased patient mortality (risk ratio [0.276] [95% confidence interval {0.259-0.294}; I 2, 94.58%]) compared to a conservative strategy for one year. CONCLUSION: In non-ST-elevation acute coronary syndromes, an invasive strategy is comparable to a conservative strategy for decreasing short- and long-term mortality rates. .

[Chilean results of the international registry of risk factors and treatment of unstable angina and non ST elevation myocardial infarction: ACCORD (ACute CORonary syndrome Descriptive study)]. / Resultados Chilenos del registro internacional de factores de riesgo y tratamiento de angina inestable e infarto al miocardio sin supradesnivel del segmento ST: ACCORD (ACute CORonary syndrome Descriptive study).

BACKGROUND: Guidelines for the management of unstable angina (UA) and non ST elevation myocardial infarction (NSTEMI) have been issued, however, current practices are unknown in Chile. AIM: To evaluate in a prospective cohort of NSTEMI patients the current practices, treatments and risk factors. MATERIAL AND METHODS: One year prospective International non interventional registry, conducted in Chile between January 2005 and November 2006. RESULTS: Two hundred thirty three Chilean NSTEMI patients were enrolled. Mortality was 5.5% at the end of the follow-up. Mean age was 61.6 years, and 30.6% were female. Most of the patients had at least one risk factor (98%): hypertension (84%), previous myocardial infarction (33%), dyslipidemia (54%), diabetes (33%), current smoking (30%). Main procedures during the hospitalization were coronary angiogram (67%), angioplasty (33%; 88% with stent) and coronary bypass surgery (7%). During procedures, 31% of patients received clopidogrel, and 4.2% glycoprotein Ilb/IIIa antagonists. Medical management was selected for 60% of patients. In comparison to men, women received less interventional procedures despite having more risk factors. Treatments prescribed at discharge were aspirin (97%), clopidogrel (49%), beta blockers (78%), diuretics (21%), lipid lowering agents (78%), oral hypoglycemic agents (13%) and insulin (9%). At the end of the 1-year follow-up, treatments were aspirin (84%), beta blockers (72%), diuretics (19%), and dual antiplatelet therapy with clopidogrel (16%). CONCLUSIONS: A high prevalence of multiple risk factors for cardiovascular disease in Chilean patients with NSTEMI was observed. More aggressive primary and secondary preventive measures are urgently needed. Use of therapies proposed in the guidelines is high, but dual antiplatelet therapy is less than 50% at discharge and decreases during the one year-follow-up.

Resultados Chilenos del registro internacional de factores de riesgo y tratamiento de angina inestable e infarto al miocardio sin supradesnivel del segmento ST: ACCORD (ACute CORonary syndrome Descriptive study) / Chilean results of the international registry of risk factors and treatment of unstable angina and non ST elevation myocardial infarction: ACCORD (ACute CORonary syndrome Descriptive study)

Background: Guidelines for the management of unstable angina (UA) and non ST elevation myocardial infarction (NSTEMI) have been issued, however cu-rrent practices are unknown in Chile. Aitn: To evalúate in a prospective cohort of NSTEMI patients the current practices, treatments and risk factors. Material and Methods: Oneyear prospective International non interventional registry, conducted in Chile between January 2005 and November 2006. Results: Two hundred thirty three Chilean NSTEMI patients were enrolled. Mortality was 5.5 percent at the end ofthe follow-up. Mean age was 61.6 years, and 30.6 percent were female. Most of the patients had at least one risk factor (98 percent): hypertension (84 percent), previous myocardial infarction (33 percent), dyslipidemia (54 percent), diabetes (33 percent), current smoking (30 percent). Main procedures duringthe hospitalization were coronary angiogram (67 percent), angioplasty (33 percent; 88 percent with stent) and coronary bypass surgery (7 percent). Duringprocedures, 31 percent of patients received clopidogrel, and 4.2 percent glycoprotein Ilb/IIIa antagonists. Medical management was selected for 60 percent of patients. In comparison to men, women received less interventional procedures despite havingmore risk factors. Treatments prescribed at discharge were aspirin (97 percent), clopidogrel (49 percent), beta blockers (78 percent), diuretics (21 percent), lipid lowering agents (78 percent), oral hypoglycemic agents (13 percent) and insulin (9 percent). At the end ofthe 1-year follow-up, treatments were aspirin (84 percent), beta blockers (72 percent), diuretics (19 percent), and dual antiplatelet therapy with clopidogrel (16 percent). Conclusions: A high prevalence of múltiple risk factors for cardiovascular disease in Chilean patients with NSTEMI was observed. More aggressive primary and secondary preventive measures are urgently needed. Use of therapies proposed in the guidelines is high, but dual antiplatelet therapy is less than 50 percent at discharge and decreases during the one year-follow-up.

Fatores associados com os tipos de heparina usados no tratamento da angina instável em um hospital brasileiro / Factors Associated with the Types of Heparin used in the Treatment of Unstable Angina at a Brazilian Hospital

Unfractionated heparin (UFH) and low-molecularweight heparins (LMWHs) are widely used in curative and preventive treatments of thromboembolic disorders. The aim of the study was to investigate factors associated with the choice of these types of heparin to treat patients with unstable angina under real conditions of hospital use. A cross-sectional study was performed in a private general hospital in Belo Horizonte, Brazil, from January 1st to December 31th, 2001. Data were collected from the hospital electronic database. Inpatients with angina who received enoxaparin or UFH were included in the survey. Data for 555 patients were recorded, including 401 treated with enoxaparin and 154 with UFH. Univariate analysis showed that male and elderly people predominated in both groups, with no statistical difference in the proportions (p>0.05). Multivariate analysis showed 4 factors associated with the use of enoxaparin: cardiac revascularization surgery (OR=0.434), arrhythmias (OR=9.343), risk factors for coronary artery disease (OR=1.333) and private health insurance (OR=0.297). Thus, clinical and organizational factors were associated with the type of heparin used by patients with unstable angina at this hospital. Further drug utilization studies are necessary to expand and improve the data available on the use of heparins in the hospital setting.

A heparina não-fracionada (HNF) e heparinas de baixo peso molecular (HBPM) são amplamente utilizadas em tratamentos curativos e preventivos de tromboembolismo. O objetivo do estudo foi investigar os fatores associados com a escolha desses tipos de heparinas para tratar pacientes com angina instável sob as condições reais de uso hospitalar. Trata-se de um estudo transversal realizado em hospital geral privado, na cidade de Belo Horizonte,MG Brasil, no período de Janeiro a Dezembro de 2001. Para a coleta de dados, utilizou-se o banco de dados informatizado do referido hospital. Pacientes internados com angina que receberam enoxaparina ou HNF foram incluídos no estudo. Registrou-se dados de 555 pacientes, incluindo 401 tratados com enoxaparina e 154 com HNF. Na análise univariada, observouse que o gênero masculino e pacientes idosos foram predominantes em ambos os grupos, sem diferença estatística entre as proporções (p>0,05). A análise multivariada revelou quatro fatores associados ao uso de enoxaparina: cirurgia de revascularização cardíaca (OR=0,434), arritmias (OR=9,343), fatores de risco para doença coronariana (OR=1,333) e atendimento por plano de saúde (OR=0,297). Assim, fatores clínicos e organizacionais estão associados com o tipo de heparina usado por pacientes com angina instável, neste hospital. A realização de mais estudos de utilização de medicamentos é necessária para aprimorar o conhecimento sobre o uso de heparinas, em hospitais.

Influência da estenose residual negativa após o implante de stents coronarianos em pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST / Outcomes of patients with non-ST elevation acute coronary syndrome and a negative residual stenosis after coronary stenting

Fundamentos: A presença de estenose residual (ER) negativa após o implante de stents coronarianos em pacientes com infarto do miocárdio está associada a piores desfechos clínicos. A influência da ER no prognóstico de pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST não foi bem estudada. Método: Pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST tratados com implante de stents coronarianos foram incluídos, e a ER e o fluxo coronariano foram avaliados imediatamente após o procedimento. Pacientes com ER < 0% foram comparados a um grupo controle com ER 0-30% quanto à ocorrência de eventos cardíacos adversos maiores (ECAM) em um ano. Resultados: As características clínicas foram semelhantes em ambos os grupos. A ER média foi de -10,3 ± 6,4% no grupo ER < 0% (n = 94) e de 2,1 ± 5,2% nos controles (n = 298) (P < 0,001). Pacientes com ER < 0% tinham vasos menores (P < 0,001) e apresentaram maior escore de agressividade (P < 0,001), que foram preditores independentes de ER negativa, comparativamente aos pacientes com ER 0-30%. Os índices de sucesso clínico do procedimento (100% vs. 98,7%), fluxo coronariano TIMI 3 (100% vs. 99,3%), ECAM intra-hospitalares (0% vs. 0,6%) e trombose subaguda (1,1% vs. 0,3%) não foram estatisticamente diferentes nos pacientes com ER < 0% e nos controles. Os índices de revascularização do vaso-alvo (8,9% vs. 7,9%) e de ECAM em um ano (10% vs. 10%) também foram semelhantes nos pacientes com ER < 0% e nos controles. Conclusões: A ocorrência de ER negativa após o implante de stents coronarianos em pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST foi associada a vasos menores e a estratégias de implante mais agressivas, mas não à piora do fluxo coronariano ou a índices mais elevados de ECAM.

Background: Negative residual stenosis (RS) after coronary stenting is associated with worse antegrade flow and increased mortality in patients with acute myocardial infarction. Its influence on outcomes of patients with nonST elevation acute coronary syndromes is unknown. Methods: Patients with acute coronary syndrome with nonST elevation treated with coronary stenting were included and RS and coronary flow were assessed immediately after the procedure. Patients with RS < 0% were compared to a control group with RS 0-30% for the occurrence of one-year MACE. Results: Baseline clinical characteristics were similar in both groups. Mean residual stenosis was -10.3 ± 6.4% in the < 0% RS group (n = 94) and 2.1 ± 5.2% in controls (n = 298) (P < 0.001). Patients with RS < 0% had smaller vessels (P < 0.001) and were treated with a higher aggressiveness score (P < 0.001), which were independent predictors of the occurrence of negative RS. Clinical procedural success rates (100% vs. 98.7%) and coronary TIMI 3 flow rates (100% vs. 99.3%) were similar in both groups. In-hospital MACE (0% vs. 0.6%) and subacute thrombosis rates (1.1% vs. 0.3%) were not statistically different. One-year target vessel revascularization rates (8.9% vs. 7.9%) and one-year MACE rates (10% vs. 10%) were also similar. Conclusions: Negative residual stenosis after coronary stenting in patients with non-ST elevation acute coronary syndrome was associated with smaller vessels and more aggressive implantation strategies, but not with worse coronary flow or higher MACE rates.

Unstable angina and non ST elevation acute coronary syndromes.

Acute coronary syndromes (ACSs) are the most common cause of hospital admission in patients with coronary artery disease (CAD). The term ACS refers to a spectrum of acute life-threatening disorders that includes: unstable angina (UA), non ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). The pathophysiology is similar: coronary atherosclerosis plaque rupture and subsequent thrombus formation. Such plaques usually are lesions with <50% stenosis severity prior to ACS, but are lipid-rich soft plaques (vulnerable plaques). The clinical presentation depends on the degree of partial (UA/NSTEMI) or complete lumen obstruction of the culprit coronary artery (STEMI). This article reviews the UA/NSTEMI ACS, since these two entities are closely related and usually, it is not possible to distinguish them upon presentation at the emergency department (ED). It presents the latest advancement on the pathophysiology, clinical presentations, diagnosis, risk stratification and management. It emphasizes on the selection of the optimal management approach which includes early invasive versus initial conservative strategies. Besides, it discusses the different approaches being used in the light of the information provided by the latest clinical trials. Although, at the present time, the optimal management approach remains unsettled, ACSs are usually managed using an early invasive strategy in tertiary care hospitals in the USA. The application of clinical practice guidelines developed by the American College of Cardiology and the American Heart Association (ACC/AHA) has confirmed definite improvement of patient care. Part of the information presented in this article, particularly in its management, is based on these guidelines (3). Evidence base scientific data insists upon using aggressive medical therapy (statins, anti-platelets, beta blockers [BBs], angiotensin converting enzyme inhibitors [ACE-Is], and control of coronary risk factors) as well as mechanical reperfusion, whether by percutaneous coronary intervention (PCI) or by coronary artery bypass graft (CABG). These approaches are considered complementary rather than as opposing strategies.

Curso de atualização em cardiologia: aula 9: angina instável e infarto sem supradesnível do segmento ST / Updating cardiology course: class 9: instable angina and non ST element elevation infarction

A doença arterial coronariana é altamente prevalente na população e uma das principais causas de óbito em nossa sociedade. O reconhecimento precoce e o adequado tratamento desta síndrome clínica podem evitar complicações e minimizar os riscos. Em 2007, o American College of Cardiology e a American Heart Association revisaram o Guideline de Manejo de Pacientes com AI e IAM SSST, produzido em 2002, com o intuito de facilitar o reconhecimento, diagnóstico e tratamento desta importante síndrome clínica. O presente artigo tem como objetivo salientar as características principais dessas síndromes clínicas, assim como transmitir os principais aspectos abordados pelo Guideline publicado em 2007 pelo American College of Cardiology e a American Heart Association.

Coronary artery disease is highly prevalent in general population and one of the main causes of death in our society. Early recognition and proper therapy of this syndrome can avoid complications and curtail risks. In 2007 the American College of Cardiology and the American Heart Association reviewed the Guidelines for Patient Management with UA and non-STMI, published in 2002, in order to ease the recognition, diagnosis and therapy of this important clinical condition. This paper aims to give a clear picture of the main characteristics of these syndromes, as well as the highlights of the Guideline published in 2007 by the American College of Cardiology and the American Heart Association.

Percutaneous coronary intervention in single coronary artery in a patient with high-risk unstable angina.

In the present case, we report the performance of coronary angioplasty with stent implantation in the right coronary artery of a patient with high-risk unstable angina and single coronary artery originating from the right coronary sinus. The anterior descending and circumflex arteries originated separately from the proximal third of the right coronary artery. This is a rare coronary anomaly and few reports of percutaneous coronary intervention are found in the literature. This case illustrates the need for a detailed anatomical assessment of the course of the coronary arteries prior to the performance of a percutaneous transluminal angioplasty, with the purpose of preventing complications.