Detección de barreras e implementación de procedimientos para reducir la demora en el tratamiento del síndrome coronario agudo con elevación del segmento ST mediante angioplastia primaria / Barriers and Procedures to Reduce Treatment Delay in ST-Segment Elevation Acute Coronary Syndrome with Primary Percutaneous Coronary Intervention

RESUMEN Introducción: La demora a la reperfusión del síndrome coronario agudo con elevación del segmento ST es un factor determinante en el pronóstico. Su reducción podría disminuir la morbimortalidad. Objetivo: Identificar y modificar las barreras detectadas en 20 años de tratamiento del síndrome coronario agudo con elevación del segmento ST en un centro de tercer nivel de una ciudad de alta densidad demográfica para evaluar su efecto en el resultado del procedimiento. Material y métodos: Incluimos prospectiva y consecutivamente del 01/01/2000 al 31/12/2019, 3007 pacientes con síndrome coronario agudo con elevación del segmento ST dentro de las 12 h de iniciados los síntomas para realizar angioplastia primaria. Se dividió el tiempo desde el comienzo de los síntomas hasta la insuflación del balón en intervalos. Luego de identificar las barreras (2000-2009) se incorporaron cambios al procedimiento. Se organizó a la población en 2 grupos (G) G1: preimplementación de cambios (2000-2009) y G2: posimplementación (2010- 2019). Resultados: Se incluyeron en G1 1409 pacientes y en G2 1598. Sin diferencias demográficas, excepto por el tipo de angioplastia. Se identificaron demoras al realizar el diagnóstico, de comunicación entre médicos, del traslado y del ingreso del paciente a hemodinamia. Con los cambios, disminuimos el intervalo consulta-contacto con el hemodinamista [G1: 90 min (36-168) vs. G2: 77 min (36-144) p -0,01] y el intervalo contacto hemodinamista-ingreso a Hemodinamia [G1: 75 min (55-100) vs. G2: 51 min (34-70) p -0,01]. Se redujo la mortalidad intrahospitalaria (G1: 9,2% vs. G2:6,7% p -0,01) y al 6to mes (G1: 13,1% vs. G2: 7,5% p -0,01). Conclusiones: El retraso al diagnóstico, la dificultad en la comunicación y la forma de traslado fueron las principales causas de demora. La implementación de un protocolo de procedimientos permitió reducir las demoras. La evaluación continua de resultados y la educación permanente, constituyen los pilares fundamentales para la optimización de programas de atención en red.

ABSTRACT Background: The delay to reperfusion of ST-segment elevation acute coronary syndrome (STEACS) is a key factor in its prognosis, and its reduction could reduce morbidity and mortality. Objective: The aim of this study was to identify and modify the barriers detected in 20 years of STEACS treatment in a tertiary care center of a densely populated city to evaluate their effect on the outcome of the procedure. Methods: A total of 3007 patients with STEACS within 12 hours of symptoms onset were prospectively and consecutively included to undergo primary percutaneous coronary intervention (PCI) from January 1, 2000 to December 31, 2019. Time from symptoms onset to balloon inflation was divided into intervals. After barriers were identified (2000-2009), the procedure was changed. The population was divided into two groups (G) G1: pre-implementation (2000-2009) and G2: post-implementation (2010-2019) of changes. Results: G1 included 1409 and G2 1598 patients with no demographic differences except for the type of PCI. Delays were identified in diagnosis, communication between physicians, transfer and admission of the patient to the hemodynamics lab. Procedural changes decreased first medical contact-hemodynamic team contact interval [G1: 90 min (36-168) vs. G2: 77 min (36-144) p -0.01] and hemodynamic team contact-hemodynamics lab admission interval [G1: 75 min (55-100) vs. G2: 51 min (34-70) p -0.01] and reduced in-hospital (G1: 9,2% vs. G2: 6,7% p -0,01) and 6-month (G1: 13.1% vs. G2: 7.5% p -0. 01) mortality. Conclusions: Delay in diagnosis, difficulty in communication and type of transfer were the most important causes of delay. Implementing a procedural protocol reduced delays. Continuous evaluation of results and permanent education constitute the fundamental cornerstones for optimizing network care programs.

Impacto de un sistema de evaluación de tiempos a la reperfusión en infarto agudo de miocardio con elevación del ST / Impact of an Evaluation System of Times to Reperfusion in ST-segment Elevation Acute Myocardial Infarction

RESUMEN • Introducción: El tratamiento del infarto con supradesnivel del ST (IAMCEST) es tiempo-dependiente, por lo que los centros con angioplastia primaria (ATCp) deben estar organizados para asegurar una rápida reperfusión. Objetivos: Evaluar el impacto de un sistema de evaluación sistemática de los tiempos de reperfusión y feedback de resultados en la reducción de las demoras. Material y métodos: Estudio observacional, prospectivo, realizado en 46 centros con ATCp 24/7 de la Iniciativa Stent-Save a Life! Argentina. Se incluyeron pacientes con IAMCEST sometidos a ATCp antes de las 12 h desde el inicio de los síntomas, asistidos entre marzo de 2016 y febrero de 2019. La población se dividió en tres etapas consecutivas de 1 año cada una desde la inclusión de cada centro. Resultados: Se incluyeron 3492 pacientes consecutivos (primer año: 1482; segundo año: 1166; tercer año: 844). Se observó una reducción significativa del tiempo puerta-balón (TPB) (68, 60 y 50 min; p < 0,0001) a lo largo de los años considerados, independientemente de dónde haya sido el primer contacto médico (PCM) y del tiempo desde el primer contacto médico (PCM) al balón (115, 112 y 98 min; p < 0,0001), sin diferencias en el tiempo desde el inicio de los síntomas al PCM ni en el tiempo total de isquemia (TTI). Asimismo, en aquellos pacientes que tuvieron su PCM en centros sin hemodinamia y fueron derivados para la realización de ATCp, se observó una disminución del TTI (274, 260 y 235 min; p < 0,001). Conclusiones: La implementación de un programa puerta-balón (PPB) en centros con ATCp permitió reducir los tiempos al tratamiento.

ABSTRACT • Background: Treatment of patients with ST-elevation myocardial infarction (STEMI) is time-dependent; therefore centers with primary percutaneous coronary intervention (pPCI) capability should be organized to achieve rapid reperfusion. Objectives: The aim of this study was to assess the impact of a systematic evaluation of reperfusion times with periodic feed-back of results in reducing delays to treatment. Methods: This was an observational, prospective study conducted in 46 centers with 24/7 pPCI capability participating in the Stent-Save a Life! Argentina Initiative. Patients with STEMI who underwent pPCI within 12 hours from the onset of symptoms were included from March 2016 to February 2019. The population was divided into three consecutive stages lasting one year each since the inclusion of each center in the Stent-Save a Life! Initiative. Results: A total of 3,492 patients were included (1st year: 1,482, 2nd year: 1,166, 3rd year: 844). There was a significant reduction in door-to-balloon (DTB) time (68, 60 and 50 min; p <0.0001), regardless of the type of first medical contact (FMC), and of the time from FMC to reperfusion (115, 112 and 98 min; p<0.0001), without differences in time from the onset of symptoms to FMC or total ischemic time (TIT). In addition, patients with FMC in centers without PCI capability who were referred for pPCI also evidenced a significant reduction of TIT (274, 260 and 235 min; p<0.001). Conclusion: The implementation of a DTB program in centers with pPCI capability resulted in a significant reduction of treatment times.

Iniciativa Stent-Save a Life! Argentina / Stent-Save a Life! Argentina Initiative

RESUMEN 31. Introducción: La iniciativa Stent-Save a Life! (SSL) es un programa europeo que busca mejorar el acceso de pacientes con infarto agudo de miocardio con elevación del ST (IAMCEST) a un tratamiento de reperfusión basado en las recomendaciones de las guías clínicas, reduciendo así su morbimortalidad. Objetivo: Describir los resultados de los primeros tres años de la iniciativa SSL Argentina Material y métodos: Se realizó inicialmente un mapeo para analizar la situación local y luego se desarrolló el Programa Puerta-Balón (PPB) como un proceso de mejora continua para centros con capacidad de realizar angioplastia primaria (ATCp). Resultados: Desde marzo de 2016 hasta marzo de 2018 se trataron 3041 pacientes con IAMCEST en 38 centros participantes del citado programa. El 20% (n = 610) de esos pacientes tuvo su primer contacto médico (PCM) con el servicio de emergencias médicas. Excluyendo los 184 pacientes sin lesiones coronarias (6% del total), el 93% fue reperfundido, principalmente con ATCp (95%). El tiempo global de isquemia fue de 117 minutos, variando según el momento del PCM. La mortalidad global intrahospitalaria fue del 7%. Conclusiones: La falta de una "cultura de reperfusión" fue la barrera en común de centros públicos y privados que motivó el desarrollo del PPB. La identificación de los puntos críticos que impiden un tratamiento a tiempo, junto con la organización de los centros puertas adentro, representan el primer paso para mejorar la atención de estos pacientes. Es necesario el trabajo integrado de todos los actores involucrados a partir de la organización de redes de atención, adaptadas a la realidad local de cada centro y región.

ABSTRACT 39. Introduction: The Stent-Save a Life! (SSL) initiative is a European program that seeks to improve the access of patients with ST-segment elevation acute myocardial infarction (STEMI) to reperfusion therapies based on clinical guideline recommendations, thus reducing morbidity and mortality. Objective: The aim of this study was to describe the results of the first three years of the SSL Argentina initiative. Methods: Initially, a mapping was carried out to analyze the local situation and then the Door-to- Balloon Program (DBP) was developed as a continuous improvement process for centers with primary percutaneous coronary intervention (pPCI) capability. Results: From March 2016 to March 2018, 3,041 patients with STEMI were treated in 38 centers participating in this program. In 20% of cases (n=610) patients had their first medical contact with the emergency medical services. After excluding 184 patients (6%) without coronary lesions, reperfusion therapy was performed in 93% of cases, mainly by pPCI (95%). Total ischemic time was 117 minutes, with differences according to the time of first medical contact. Overall in-hospital mortality was 7%. Conclusions: The lack of a "reperfusion culture" was the common barrier of public and private centers that motivated the development of the DBP. The identification of critical points that prevent treatment on time, together with enhancement of in-hospital organization, represent the first step to improve the care of these patients. The integrated work of all the involved parties is necessary to develop care networks adapted to the local reality of each center and region.

Vitamin D is Related to Markers of Vulnerable Plaque in Acute Myocardial Infarction.

BACKGROUND: Vitamin D is a fat soluble vitamin involved in calcium and bone metabolism; recently its deficiency has been related to cardiovascular disease. In cardiac tissue, vitamin D suppresses metalloproteinases (MMPs) expression, enzymes directly associated with vulnerable plaque. OBJECTIVE: To investigate whether the association between vitamin D and leptin is related to markers of vulnerable plaque, such as MMPs in patients with acute myocardial infarction. METHODS: We studied 66 male patients with acute myocardial infarction, undergoing primary angioplasty. Blood samples were obtained at admission and 24hs after the surgery. Leptin and vitamin D concentrations in serum and MMP-2 and -9 activities in plasma were determined. RESULTS: MMP-2 activity was increased in Vitamin D deficient/insufficient patients at admission (p=0.04) and 24 hs later (p=0.05). In a linear regression model, vitamin D explained 24% of the variance of MMP-2 activity (F=2.839 p=0.04). At admission, vitamin D correlated with serum leptin (r=-0.302 p=0.033), and explained 39.5% of its variation (F=4.432 p=0.003). CONCLUSION: In the studied population, vitamin D was inversely related to MMP-2 and leptin which are involved in coronary artery disease and acute myocardial infarction. The decrease in this hormone levels would be associated with a worse metabolic profile in acute coronary syndrome patients.

[Simple mechanical reperfusion in acute myocardial infarction: determinants, prognostic implications and relation with thrombus histology]. / Reperfusión mecánica simple en el infarto agudo de miocardio. Determinantes, implicaciones en el pronóstico y relación con la histología del trombo.

Simple mechanical reperfusion (SMR) is defined as reperfusion achieved after wire insertion at the occluded infarct-related artery in primary angioplasty. The determinants and prognostic implications of SMR and its relationship with the histopathology of the rescued thrombus were evaluated in 601 patients with acute myocardial infarction showing ST elevation and pre-procedural total occlusion of the infarct-related artery (TIMI flow 0). Two groups were considered according to the presence of SMR, defined as the visualization of contrast material after crossing the occlusion with the guide wire. SMR was achieved in 303 patients (50.4%) and was found to be associated with less time to treatment (248 vs. 286 minutes; p = 0.001), less deteriorated initial left ventricular function and shock at admission (9.2 vs. 16.4%; p = 0.008), higher successful rate (94.7% vs. 78.5%; p < 0,0001) and of higher rate of thrombus rescue: 70/81 vs. 27/79 patients (p < 0.0001). The right coronary artery was the most frequent infarct-related artery. Histopathology of the retrieved thrombi was available for 160 patients treated with thrombus aspiration. SMR was associated with smaller thrombus, lower contents of leukocytes and erythrocytes, and higher thrombus content of inflammatory cells, cholesterol and collagen crystals from the atheromatous plaque. SMR is an independent predictor of procedure success and its relationship with the anatomy of the thrombus could redefine the indication of thrombus aspiration.

Reperfusión mecánica simple en el infarto agudo de miocardio: Determinantes, implicaciones en el pronóstico y relación con la histología del trombo / Simple mechanical reperfusion in acute myocardial infarction: determinants, prognostic implications and relation with thrombus histology

La reperfusión mecánica simple (RMS) es la lograda en la angioplastia primaria al atravesar la oclusión en la arteria responsable de infarto con la guía intracoronaria. Para evaluar los determinantes de la RMS, su implicación en el pronóstico y su relación con la histopatología del trombo rescatado, fueron analizados los casos de 601 pacientes con infarto agudo de miocardio con elevación del segmento ST y oclusión total de la arteria responsable de infarto (flujo TIMI 0). Se consideraron dos grupos según la presencia de RMS, definida por la visualización de contraste distal a la lesión luego de atravesarla con la guía intracoronaria. Se realizó el análisis histopatológico de los trombos en un subgrupo de 160 pacientes tratados con tromboaspiración. En 303 (50.4%) pacientes se obtuvo RMS. La RMS se asoció a menor ventana al tratamiento (248 vs. 286 minutos, p = 0.001), menor deterioro de la función sistólica ventricular izquierda inicial y shock al ingreso (9.2 vs.16.4%, p = 0.008), mayor tasa de éxito (94.7 vs. 78.5%, p < 0.0001) y de rescate de trombos (70/81 vs. 27/79 pacientes, p < 0.0001). La arteria responsable de infarto más frecuente fue la coronaria derecha. La RMS se asoció con menor tamaño del trombo, menor concentración de leucocitos y eritrocitos y mayor contenido de células inflamatorias, cristales de colesterol y colágeno provenientes de la placa. La RMS es un predictor independiente de éxito y su relación con la anatomía del trombo podría redefinir la indicación de la tromboaspiración.

Simple mechanical reperfusion (SMR) is defined as reperfusion achieved after wire insertion at the occluded infarct-related artery in primary angioplasty. The determinants and prognostic implications of SMR and its relationship with the histopathology of the rescued thrombus were evaluated in 601 patients with acute myocardial infarction showing ST elevation and pre-procedural total occlusion of the infarct-related artery (TIMI flow 0). Two groups were considered according to the presence of SMR, defined as the visualization of contrast material after crossing the occlusion with the guide wire. SMR was achieved in 303 patients (50.4%) and was found to be associated with less time to treatment (248 vs. 286 minutes; p = 0.001), less deteriorated initial left ventricular function and shock at admission (9.2 vs. 16.4%; p = 0.008), higher successful rate (94.7% vs. 78.5%; p < 0,0001) and of higher rate of thrombus rescue: 70/81 vs. 27/79 patients (p < 0.0001). The right coronary artery was the most frequent infarct-related artery. Histopathology of the retrieved thrombi was available for 160 patients treated with thrombus aspiration. SMR was associated with smaller thrombus, lower contents of leukocytes and erythrocytes, and higher thrombus content of inflammatory cells, cholesterol and collagen crystals from the atheromatous plaque. SMR is an independent predictor of procedure success and its relationship with the anatomy of the thrombus could redefine the indication of thrombus aspiration.

Initial Results and Long-Term Follow-up of Percutaneous Mitral Valvuloplasty in Patients with Pulmonary Hypertension.

BACKGROUND: Percutaneous balloon mitral valvuloplasty (PMV) is an attractive therapeutic approach in patients with mitral stenosis. The aim of this study was to assess the immediate and long-term clinical, echocardiographic and haemodynamic outcomes of PMV in patients with severe pulmonary hypertension (PAH). METHODS: Percutaneous balloon mitral valvuloplasty was performed in 157 consecutive patients; 60 patients (38.2%) had significant PAH defined as baseline pulmonary artery mean pressure (PAMP) ≥ 30mm Hg (Group 1) and 97 patients (61.8%) had PAMP ≤ 30mmHg (Group 2). Pulmonary artery systolic pressure (PASP), mortality, need for mitral valve replacement or new PMV, and valve restenosis were evaluated during follow-up. RESULTS: Mean age was 44.2 years and 88.5% (139 patients) were women. Primary success was achieved in 79.6% of the patients (125 patients) without differences between the groups. Mitral valve area increased from 0.90cm2 to 1.76cm2, PASP fell from 57mmHg to 35mmHg in Group 1 and from 38mmHg to 30mmHg in Group 2. Median PASP in Group 1 was 35, 32, 36, 38 and 34mmHg at 12, 24, 36, 48 and 60 months. There were no significant differences in mitral valve area, PASP and clinical status between the groups. CONCLUSION: Percutaneous balloon mitral valvuloplasty is a safe and effective technique for the treatment of patients with mitral stenosis and PAH. A significant decrease in pulmonary pressure was observed after valvuloplasty. Although there was a gradual decrease of MVA at long-term follow-up, most patients remained asymptomatic and PASP was stable.

Matrix metalloproteinases and psychosocial factors in acute coronary syndrome patients.

UNLABELLED: Psychosocial factors have been linked to cardiovascular diseases independently of traditional risk factors. The impact of psychosocial factors on plaque destabilizing factors, such as matrix metalloproteinases (MMPs) has been proposed although scarcely studied. OBJECTIVE: To evaluate the relationships between hostility, perceived stress and social support with MMPs activity in patients after an Acute Myocardial Infarction (AMI). METHODS: Blood samples were obtained from 76 patients on admission, post-angioplasty, 24h, 7 days and 3 months after AMI. Hostility, perceived stress and social support were evaluated by validated questionnaires. RESULTS: Social support was positively correlated with patients ejection fraction (r=0.453, p=0.009). Patients with higher infarct size presented increased MMP-2 activity at admission (p=0.04). Patients with one diseased vessel had more social support than those with three diseased vessels (p=0.05). The highest values of MMP-2 and MMP-9 activity were observed at the acute event, decreasing, with the lowest activity at 3 months post-AMI (p<0.001). Only in patients with low social support, hostility correlated with MMP-2 activity, from AMI onset (r=0.645, p=0.013), to 7 days post AMI (r=0.557, p=0.038). Hostility explained up to 28% of the variance in MMP-2 activity (R(2)=0.28, p=0.005). Finally, in patients with high hostility, MMP-9 was positively correlated with IL-1ß (r=0.468, p=0.02). CONCLUSIONS: This study adds weight to the idea that two psychosocial factors, namely hostility and social support, acting jointly, may affect MMP-2 activity. Moreover, in hostile patients, there is a link between IL-1ß and MMP-9. These findings support the role of psychosocial factors in plaque destabilization and in the inflammatory process in AMI.

CoreValve prosthesis causes anterior mitral leaflet perforation resulting in severe mitral regurgitation.

Percutaneous transcatheter aortic valve replacement (TAVR) has become an alternative to surgical therapy for patients with severe aortic stenosis and high operative risk, but it is associated with specific complications. We report the case of a 72-year-old man who underwent the procedure without complications; however, 45 days after the procedure, he was admitted to the hospital with symptoms of heart failure secondary to severe mitral regurgitation. Necropsy findings showed prosthesis malposition and perforation of the anterior mitral leaflet caused by the contact of the stent of the CoreValve prosthesis (Medtronic, Minneapolis, MN). We discuss TAVR complications, specifically regarding low positioning of the prosthetic valve.

Predictores clínicos de no-reflujo en la angioplastia coronaria por infarto agudo de miocardio / Clinical Predictors of No-Reflow in Percutaneous Coronary Intervention for Acute Myocardial Infarction

Introducción El fenómeno de no-reflujo en el contexto de la angioplastia por infarto agudo de miocardio (IAM) es un hecho relativamente frecuente y asociado con peor pronóstico. La detección de variables clínicas vinculadas a este fenómeno antes del inicio del procedimiento podría ayudar a la adopción de medidas preventivas y por consiguiente a mejorar los resultados. Objetivo Determinar predictores clínicos de no-reflujo en el contexto de la angioplastia por IAM con elevación del segmento ST antes del inicio del procedimiento. Material y métodos Se analizaron 742 pacientes con IAM de < 12 horas de evolución tratados con angioplastia primaria. Se excluyeron los pacientes con flujo epicárdico TIMI 0 posintervención y se consideró no-reflujo a la presencia de flujo TIMI 1-2 posangioplastia inmediato en ausencia de lesión residual. Se analizaron variables demográficas, factores de riesgo coronario, antecedentes y demora al tratamiento. Se realizó un análisis multivariado por regresión logística múltiple para determinar el valor pronóstico independiente de las variables relacionadas con el no-reflujo. Resultados Se incluyeron 675 pacientes. Presentaron fenómeno de no-reflujo 119 pacientes (17,6%). Los pacientes con no-reflujo tenían mayor edad (60,8 ± 12 vs. 57,0 ± 11 años; p = 0,0001) y menor frecuencia de tabaquismo activo (58,8% vs. 67,8%; p = 0,03) y de antecedentes familiares (22,7% vs. 37,8%; p = 0,0007), sin diferencias significativas en el resto de los factores de riesgo coronario y antecedentes cardiovasculares. Se observó también con mayor frecuencia localización anterior del IAM (58,8% vs. 43,7%; p = 0,002), signos clínicos de insuficiencia cardíaca al ingreso (17,6% vs. 10,1%; p = 0,01), así como mayor demora al tratamiento [240 (151-360) vs. 195 (120-302) minutos; p = 0,02]. El análisis multivariado determinó que los predictores independientes de no-reflujo fueron: edad > 60 años, localización anterior y demora al tratamiento > 3 horas. Conclusión La edad avanzada, la localización anterior y la demora al tratamiento resultaron predictores clínicos independientes de no-reflujo. La confirmación de estos hallazgos en estudios prospectivos permitiría implementar estrategias para prevenir su aparición y, eventualmente, mejorar los resultados clínicos a largo plazo.

Introduction The no-reflow phenomenon in the setting of primary coronary intervention for acute myocardial infarction (AMI) is relatively common and is associated with adverse outcomes. The detection of clinical variables associated with this phenomenon before the procedure might help to adopt preventive measures and thus improve the results. Objective The aim of this study was to identify clinical predictors of the no-reflow phenomenon in the setting of percutaneous coronary intervention for ST-segment elevation acute myocardial infarction, prior to the procedure. Methods A total of 742 patients with AMI < 12 hours since onset of symptoms treated with primary percutaneous coronary intervention were analyzed. Patients with epicardial TIMI grade 0 flow after the procedure were excluded. No-reflow was considered as the presence of TIMI grade 1-2 flow immediately after the procedure in the absence of residual stenosis. Demographic variables, coronary risk factors, family history and delay to reperfusion were analyzed. Multivariate logistic regression was used to determine the independent prognostic value of the variables associated with no-reflow. Results A total of 675 patients were included. The no-reflow phenomenon was present in 119 patients (17.6%). Patients with no-reflow were older (60.8 ± 12 vs. 57.0 ± 11 years; p = 0.0001) and had less prevalence of current smoking (58.8% vs. 67.8%, p = 0.03) and of previous history (22.7% vs. 37.8%, p = 0.0007), with no significant differences in the rest of coronary risk factors and history of cardiovascular disease. Anterior AMI (58.8% vs. 43.7%, p = 0.002), heart failure at admission (17.6% vs. 10.1%, p = 0.01) and delay to reperfusion (240 [151-360] vs. 195 [120-302] minutes, p=0.02) were more frequent in the no-reflow group. Multivariate analysis identified age > 60 years, anterior infarction and delay to reperfusion > 3 hours as independent predictors of no-reflow. Conclusion Advanced age, anterior infarction and delay to reperfusion were independent clinical predictors of no-reflow. The confirmation of these findings in prospective studies might allow the implementation of strategies to prevent this phenomenon and eventually improve the long-term clinical outcomes.

Predictores clínicos de no-reflujo en la angioplastia coronaria por infarto agudo de miocardio / Clinical Predictors of No-Reflow in Percutaneous Coronary Intervention for Acute Myocardial Infarction

Introducción El fenómeno de no-reflujo en el contexto de la angioplastia por infarto agudo de miocardio (IAM) es un hecho relativamente frecuente y asociado con peor pronóstico. La detección de variables clínicas vinculadas a este fenómeno antes del inicio del procedimiento podría ayudar a la adopción de medidas preventivas y por consiguiente a mejorar los resultados. Objetivo Determinar predictores clínicos de no-reflujo en el contexto de la angioplastia por IAM con elevación del segmento ST antes del inicio del procedimiento. Material y métodos Se analizaron 742 pacientes con IAM de < 12 horas de evolución tratados con angioplastia primaria. Se excluyeron los pacientes con flujo epicárdico TIMI 0 posintervención y se consideró no-reflujo a la presencia de flujo TIMI 1-2 posangioplastia inmediato en ausencia de lesión residual. Se analizaron variables demográficas, factores de riesgo coronario, antecedentes y demora al tratamiento. Se realizó un análisis multivariado por regresión logística múltiple para determinar el valor pronóstico independiente de las variables relacionadas con el no-reflujo. Resultados Se incluyeron 675 pacientes. Presentaron fenómeno de no-reflujo 119 pacientes (17,6%). Los pacientes con no-reflujo tenían mayor edad (60,8 ± 12 vs. 57,0 ± 11 años; p = 0,0001) y menor frecuencia de tabaquismo activo (58,8% vs. 67,8%; p = 0,03) y de antecedentes familiares (22,7% vs. 37,8%; p = 0,0007), sin diferencias significativas en el resto de los factores de riesgo coronario y antecedentes cardiovasculares. Se observó también con mayor frecuencia localización anterior del IAM (58,8% vs. 43,7%; p = 0,002), signos clínicos de insuficiencia cardíaca al ingreso (17,6% vs. 10,1%; p = 0,01), así como mayor demora al tratamiento [240 (151-360) vs. 195 (120-302) minutos; p = 0,02]. El análisis multivariado determinó que los predictores independientes de no-reflujo fueron: edad > 60 años, localización anterior y demora al tratamiento > 3 horas. Conclusión La edad avanzada, la localización anterior y la demora al tratamiento resultaron predictores clínicos independientes de no-reflujo. La confirmación de estos hallazgos en estudios prospectivos permitiría implementar estrategias para prevenir su aparición y, eventualmente, mejorar los resultados clínicos a largo plazo.(AU)

Introduction The no-reflow phenomenon in the setting of primary coronary intervention for acute myocardial infarction (AMI) is relatively common and is associated with adverse outcomes. The detection of clinical variables associated with this phenomenon before the procedure might help to adopt preventive measures and thus improve the results. Objective The aim of this study was to identify clinical predictors of the no-reflow phenomenon in the setting of percutaneous coronary intervention for ST-segment elevation acute myocardial infarction, prior to the procedure. Methods A total of 742 patients with AMI < 12 hours since onset of symptoms treated with primary percutaneous coronary intervention were analyzed. Patients with epicardial TIMI grade 0 flow after the procedure were excluded. No-reflow was considered as the presence of TIMI grade 1-2 flow immediately after the procedure in the absence of residual stenosis. Demographic variables, coronary risk factors, family history and delay to reperfusion were analyzed. Multivariate logistic regression was used to determine the independent prognostic value of the variables associated with no-reflow. Results A total of 675 patients were included. The no-reflow phenomenon was present in 119 patients (17.6%). Patients with no-reflow were older (60.8 ± 12 vs. 57.0 ± 11 years; p = 0.0001) and had less prevalence of current smoking (58.8% vs. 67.8%, p = 0.03) and of previous history (22.7% vs. 37.8%, p = 0.0007), with no significant differences in the rest of coronary risk factors and history of cardiovascular disease. Anterior AMI (58.8% vs. 43.7%, p = 0.002), heart failure at admission (17.6% vs. 10.1%, p = 0.01) and delay to reperfusion (240 [151-360] vs. 195 [120-302] minutes, p=0.02) were more frequent in the no-reflow group. Multivariate analysis identified age > 60 years, anterior infarction and delay to reperfusion > 3 hours as independent predictors of no-reflow. Conclusion Advanced age, anterior infarction and delay to reperfusion were independent clinical predictors of no-reflow. The confirmation of these findings in prospective studies might allow the implementation of strategies to prevent this phenomenon and eventually improve the long-term clinical outcomes.(AU)

Resultados inmediatos y seguimiento a largo plazo de la valvuloplastia mitral percutánea / Immediate Outcomes and Long-Term Follow-Up of Percutaneous Mitral Valvuloplasty

Introducción El tratamiento de la estenosis mitral ha cambiado en las últimas décadas. Se ha demostrado que, frente al tratamiento quirúrgico, la valvuloplastia mitral percutánea (VMP) presenta resultados hemodinámicos comparables y una evolución similar. Objetivo Evaluar la eficacia y la evolución clínica y ecocardiográfica inmediata y a largo plazo de la VMP. Material y métodos Se incluyeron 132 pacientes que habían sido sometidos a VMP, con una mediana de seguimiento de 48 meses. Se consideró éxito primario cuando se obtuvo un área pos-VMP ≥ 1,5 cm². En el seguimiento se evaluaron: muerte, necesidad de reemplazo valvular mitral o de nueva VMP y reestenosis valvular. Resultados La media de edad fue de 44,6 años; el 88,5% de los pacientes (n = 115) eran de sexo femenino. La mediana del área valvular mitral pre-VMP era de 0,90 cm² (IIC 25-75: 0,81-1,00), la presión sistólica de la arteria pulmonar era de 44 mm Hg (IIC 25-75: 35-52) y el puntaje ecocardiográfico, de 7 (IIC 25-75: 6-9). Se obtuvo éxito primario en 104 pacientes (78,8%). En el seguimiento a 4 años, el 86,5% de los pacientes (n = 109) se encontraban asintomáticos. Se registraron tres muertes intrahospitalarias (2,2%) y tres en el seguimiento (2,2%). Se realizó una nueva VMP en 10 pacientes y reemplazo valvular mitral en cuatro. Las variables asociadas con reestenosis en el seguimiento fueron el puntaje ecocardiográfico > 8 (p = 0,04) y el área valvular mitral pos-VMP < 1,8 cm² (p = 0,02). Luego del análisis multivariado, el área valvular mitral pos-VMP < 1,8 cm² fue el único predictor de reestenosis (OR: 2,6; IC 95%: 1,08-6,25). Conclusiones La VMP es segura y eficaz, eficacia que se mantiene a largo plazo. Los mejores resultados inmediatos se obtienen en pacientes con puntaje ecocardiográfico bajo y en ritmo sinusal, mientras que aquellos con un área valvular mitral mayor pos-VMP son los que presentan menor reestenosis en el seguimiento.

Background The treatment of mitral valve stenosis has changed over the last decades. The hemodynamic results and the outcome of percutaneous mitral valvuloplasty (PMV) have proved to be comparable to those of surgical treatment. Objective To evaluate the efficacy and the immediate and long-term clinical and echocardiographic outcome of PMV. Methods A total of 132 patients undergoing PMV were included, with a median follow-up of 48 months. The primary success was defined as a mitral valve area of ≥ 1.5 cm² following PMV. Mortality, need for mitral valve replacement or new PMV and mitral valve restenosis were evaluated during follow-up. Results Mean age was 44.6 years; 88.5% of patients (n=115) were women. Median mitral valve area before PMV was 0.90 cm² (IQR 25-75: 0.81-1.00), systolic pulmonary artery pressure was 44 mm Hg (IQR 25-75: 35-52) and the echocardiographic score was 7 (IQR 25-75: 6-9). Primary success was achieved in 104 patients (78.8%). After four years of follow-up, 86.5% of patients (n=109) were free of symptoms. Three patients (2.2%) died during hospitalization and three (2.2%) during follow-up. A new PMV was performed in 10 patients and four patients underwent mitral valve replacement. During follow-up, an echocardiographic score of >8 (p=0.04) and a mitral valve area following PMV of 2 (p=0.02) were the variables associated with restenosis. After performing multivariate analysis, the only predictor associated with restenosis following PMV was a mitral valve area 2 (OR: 2.6; 95% CI: 1.08-6.25). Conclusions Percutaneous mitral valvuloplasty is a safe and efficient method with long-term efficacy. The best outcomes are achieved in patients with low echocardiographic score and who are in sinus rhythm, and those with greater mitral valve area following PMV have lower restenosis during follow-up.

Resultados inmediatos y seguimiento a largo plazo de la valvuloplastia mitral percutánea / Immediate Outcomes and Long-Term Follow-Up of Percutaneous Mitral Valvuloplasty

Introducción El tratamiento de la estenosis mitral ha cambiado en las últimas décadas. Se ha demostrado que, frente al tratamiento quirúrgico, la valvuloplastia mitral percutánea (VMP) presenta resultados hemodinámicos comparables y una evolución similar. Objetivo Evaluar la eficacia y la evolución clínica y ecocardiográfica inmediata y a largo plazo de la VMP. Material y métodos Se incluyeron 132 pacientes que habían sido sometidos a VMP, con una mediana de seguimiento de 48 meses. Se consideró éxito primario cuando se obtuvo un área pos-VMP ≥ 1,5 cm². En el seguimiento se evaluaron: muerte, necesidad de reemplazo valvular mitral o de nueva VMP y reestenosis valvular. Resultados La media de edad fue de 44,6 años; el 88,5% de los pacientes (n = 115) eran de sexo femenino. La mediana del área valvular mitral pre-VMP era de 0,90 cm² (IIC 25-75: 0,81-1,00), la presión sistólica de la arteria pulmonar era de 44 mm Hg (IIC 25-75: 35-52) y el puntaje ecocardiográfico, de 7 (IIC 25-75: 6-9). Se obtuvo éxito primario en 104 pacientes (78,8%). En el seguimiento a 4 años, el 86,5% de los pacientes (n = 109) se encontraban asintomáticos. Se registraron tres muertes intrahospitalarias (2,2%) y tres en el seguimiento (2,2%). Se realizó una nueva VMP en 10 pacientes y reemplazo valvular mitral en cuatro. Las variables asociadas con reestenosis en el seguimiento fueron el puntaje ecocardiográfico > 8 (p = 0,04) y el área valvular mitral pos-VMP < 1,8 cm² (p = 0,02). Luego del análisis multivariado, el área valvular mitral pos-VMP < 1,8 cm² fue el único predictor de reestenosis (OR: 2,6; IC 95%: 1,08-6,25). Conclusiones La VMP es segura y eficaz, eficacia que se mantiene a largo plazo. Los mejores resultados inmediatos se obtienen en pacientes con puntaje ecocardiográfico bajo y en ritmo sinusal, mientras que aquellos con un área valvular mitral mayor pos-VMP son los que presentan menor reestenosis en el seguimiento.(AU)

Background The treatment of mitral valve stenosis has changed over the last decades. The hemodynamic results and the outcome of percutaneous mitral valvuloplasty (PMV) have proved to be comparable to those of surgical treatment. Objective To evaluate the efficacy and the immediate and long-term clinical and echocardiographic outcome of PMV. Methods A total of 132 patients undergoing PMV were included, with a median follow-up of 48 months. The primary success was defined as a mitral valve area of ≥ 1.5 cm² following PMV. Mortality, need for mitral valve replacement or new PMV and mitral valve restenosis were evaluated during follow-up. Results Mean age was 44.6 years; 88.5% of patients (n=115) were women. Median mitral valve area before PMV was 0.90 cm² (IQR 25-75: 0.81-1.00), systolic pulmonary artery pressure was 44 mm Hg (IQR 25-75: 35-52) and the echocardiographic score was 7 (IQR 25-75: 6-9). Primary success was achieved in 104 patients (78.8%). After four years of follow-up, 86.5% of patients (n=109) were free of symptoms. Three patients (2.2%) died during hospitalization and three (2.2%) during follow-up. A new PMV was performed in 10 patients and four patients underwent mitral valve replacement. During follow-up, an echocardiographic score of >8 (p=0.04) and a mitral valve area following PMV of 2 (p=0.02) were the variables associated with restenosis. After performing multivariate analysis, the only predictor associated with restenosis following PMV was a mitral valve area 2 (OR: 2.6; 95% CI: 1.08-6.25). Conclusions Percutaneous mitral valvuloplasty is a safe and efficient method with long-term efficacy. The best outcomes are achieved in patients with low echocardiographic score and who are in sinus rhythm, and those with greater mitral valve area following PMV have lower restenosis during follow-up.(AU)

Quality of myocardial reperfusion according to ischemic time and infarcted territory.

BACKGROUND: The relationship of the ischemic time to primary angioplasty and the quality of myocardial reperfusion according to infarcted territory among patients with ST-segment elevation myocardial infarction (STEMI) is unclear. METHODS: This study consisted of 140 patients with STEMI within 12 h from the symptom onset and undergoing a primary angioplasty from the Protection of Distal Embolization in High-Risk Patients with Acute ST-Segment Elevation Myocardial Infarction Trial. ST-segment resolution (STR) at 60 min was analyzed by an independent corelab using continuous ST monitoring. Patients were divided according to anterior (n=74) and nonanterior (n=64) locations and according to ischemic time in quartiles (<90, 90-148, 148-241, and 241-635 min). RESULTS: Although there was no significant decrement in the extent of STR with the ischemic time in the entire population (74, 51, 72, and 51%, respectively, P=not significant), patients with anterior location have a significant reduction in the extent of STR after 90 min compared with those coming after 90 min (70.6 vs. 29.2% of complete STR, P=0.003, respectively). CONCLUSION: Patients with anterior STEMI seem to have a stronger impact of ischemic time on the quality of myocardial reperfusion compared with patients with nonanterior location.

Time to stable ST-segment recovery following primary angioplasty is predictive of regional wall motion score and clinical outcome.

We report the time to stable ST-segment reperfusion (TSTR) after primary angioplasty and its relationship with the clinical results; 137 patients who underwent primary angioplasty were included as part of the analysis. All patients had 24 hours ST-segment monitoring. Time to stable STR was defined as the beginning of ST-segment reperfusion (STR) lasting >4 hours without ST-segment reelevation. Six-month mortality was associated with slower TSTR (median 166.5 vs 6 minute, P = .001). Time to stable STR cutoff value of 136.5 minutes was identified as the best mortality predictor (area under the curve: 0.86, P = .001). Multivariate analysis identified Killip class > or = 2 (P = .042), TSTR cutoff value (P = .002), and final thrombolysis myocardial infarction (TIMI) flow grade III (P = .067) as predictors of 6-month mortality. Time to stable STR may be a novel continuous electrocardiogram (ECG) parameter following primary angioplasty, which can identify high-risk patients that need to be considered for additional treatments.

Predictores de reperfusión miocárdica tisular luego de la angioplastia en el infarto agudo de miocardio / Predictors of Myocardial Tissue Reperfusion after Angioplasty in Acute Myocardial Infarction

Introducción La angioplastia primaria tiene una eficacia limitada ya que deja a un grupo considerable de pacientes sin lograr una reperfusión miocárdica tisular adecuada. Los factores clínicos, angiográficos y terapéuticos que influyen en el grado de reperfusión no han sido claramente establecidos. Objetivos Identificar los factores independientes asociados con la ausencia de reperfusión tisular luego de la angioplastia primaria. Material y métodos Se analizaron 140 pacientes incluidos prospectivamente en el estudio aleatorizado Protection of Distal Embolization in High-Risk Patients with Acute ST-Segment Elevation Myocardial Infarction Trial (PREMIAR). Este estudio evaluó la utilización de un filtro de protección distal durante la angioplastia en el infarto agudo de miocardio con supradesnivel del segmento ST en pacientes de alto riesgo trombótico (solamente incluyendo flujo coronario basal TIMI 0-2). El punto final primario fue la resolución completa del segmento ST a los 60 minutos, definida como disminución del ST ≥ 70% con el empleo de monitorización continua del segmento ST. Se desarrolló un modelo de regresión logística para identificar los predictores independientes. Resultados Se observó resolución completa del segmento ST a los 60 minutos luego de la angioplastia en 82 pacientes (63%), mientras que 53 pacientes (37%) presentaron resolución incompleta que se asoció con una tasa de mortalidad, reinfarto y/o insuficiencia cardíaca a los 30 días del 8,5% y 18,9%, respectivamente (p = 0,07). Los pacientes que no lograron una reperfusión tisular adecuada tuvieron con más frecuencia compromiso de localización anterior (79% versus 33%; p = 0,001), mayor frecuencia cardíaca (81 ± 20 versus 70 ± 15; p < 0,001) y menor proporción de fumadores actuales (25% versus 51%; p = 0,002) respecto de aquellos con reperfusión tisular óptima. Se observó además una tendencia a mayor presencia de diabetes (26% versus 16%; p = 0,13), mayor tiempo desde el inicio de los síntomas a la angioplastia (minutos) (217 ± 167 versus 182 ± 134; p = 0,19) y clase Killip > 1 (30% versus 17%; p = 0,07), respectivamente. El análisis multivariado demostró que el infarto de localización anterior (OR 8,22, IC 95% 3,67-18,4; p < 0,001) se asoció con ausencia de reperfusión completa, mientras que el uso de inhibidores de la glicoproteína IIb/IIIa (OR 4,21, IC 95% 1,34-13,22; p = 0,014) y el tabaquismo actual (OR 3,84, IC 95% 1,58-9,50; p = 0,003) se correlacionaron con una reperfusión completa. Conclusiones Una proporción considerable de pacientes sometidos a angioplastia primaria no logran una reperfusión tisular adecuada. Este fenómeno se asocia con peor pronóstico. La presencia de infarto de localización anterior se correlaciona con una extensión menor del grado de reperfusión tisular. Contrariamente, el tabaquismo actual y el uso de inhibidores de la glicoproteína IIb/IIIa se asocian con una reperfusión tisular más profunda luego de la angioplastia primaria.

Background The efficacy of primary angioplasty is limited due to the fact that a considerable number of patients do not achieve adequate levels of myocardial tissue perfusion. The degree of reperfusion depends on multiple clinical, angiographic and therapeutic factors. Objectives To identify the independent factors associated with the absence of myocardial tissue reperfusion after primary angioplasty. Material and Methods A total of 140 patients included in the Protection of Distal Embolization in High-Risk Patients with Acute ST-Segment Elevation Myocardial Infarction Trial (PREMIAR) were analyzed. This study evaluated the use of filter distal protection device during angioplasty in patients with acute STsegment elevation myocardial infarction at high risk of thrombosis (only including baseline TIMI grade 0-2 flow). The primary end point of the study was the rate of complete ST-segment resolution at 60 minutes, defined as ≥ 70% recovery compared with baseline during continuous ST-segment monitoring. A model of logistic regression was developed to identify independent predictors. Results Complete resolution of ST-segment deviation 60 minutes after angioplasty was observed in 82 patients (63%), while 53 patients (37%) presented partial ST-segment resolution which was associated with rates of mortality, reinfarction and/or heart failure at 30 days of 8.5% and 18.9%, respectively (p=0.07). The variables associated with absence of adequate myocardial tissue reperfusion were anterior infarction (79% versus 33%; p=0.001), higher heart rate (81±20 versus 70±15; p=0.001) and history of current smoking (25% versus 51%; p=0.002), compared to optimal tissue reperfusion. In addition, there was a trend towards greater prevalence of diabetes (26% versus 16%; p=0.13), longer time interval from the onset of symptoms to angioplasty (minutes) (217±167 versus 182±134; p=0.19) and Killip class >1 (30% versus 17%; p=0.07), respectively. Multivariate analysis demonstrated that anterior myocardial infarction was associated with absence of complete reperfusion (OR 8.22, 95% CI 3.67-18.4; p<0.001), while the use of glycoprotein IIb/IIIa inhibitors (OR 4.21, 95% CI 1.34-13.22; p=0.014) and current smoking (OR 3.84, 95% CI 1.58-9.50; p=0.003) correlated with complete reperfusion. Conclusions A considerable proportion of patients undergoing primary angioplasty do not achieve adequate myocardial tissue reperfusion. This phenomenon is associated with adverse outcomes. Anterior myocardial infarction correlates with less degree of tissue reperfusion. Conversely, current smoking and the use of glycoprotein IIb/IIIa inhibitors are associated with better tissue reperfusion after primary angioplasty.

Actividad inflamatoria en múltiples placas ateroscleróticas en pacientes fallecidos por infarto agudo de miocardio / Inflammatory Activity in Multiple Atherosclerotic Plaques of Patients Dying of Acute Myocardial Infarction

Introducción Estudios clínicos y anatomopatológicos sugieren que los procesos inflamatorios tienen un papel importante en la inestabilidad de la placa aterosclerótica, dado que en pacientes con síndromes coronarios agudos se observan infiltrados inflamatorios difusos en las arterias coronarias. Objetivos Evaluar y localizar la distribución de placas vulnerables e infiltrados inflamatorios en pacientes fallecidos por infarto agudo de miocardio. Material y métodos Mediante microscopia óptica se estudiaron las arterias coronarias de 58 pacientes fallecidos por infarto de miocardio. En las arterias coronarias relacionadas con el infarto y en las no relacionadas se registraron las siguientes variables: presencia de trombo, rotura de placa, hemorragia intraplaca y presencia de infiltrado inflamatorio. Resultados Al analizar las diferencias existentes entre las arterias responsables del infarto y en las no responsables se encontraron diferencias significativas con respecto a la presencia de trombo (69% versus 38%; p < 0,008) y de hemorragia intraplaca (69% versus 50%; p < 0,03). No se encontró una diferencia significativa entre la arteria responsable y la no responsable al evaluar la presencia de infiltrado inflamatorio en las placas ateroscleróticas (77% versus 71%; p = ns). Conclusión En el infarto agudo de miocardio se comprobó la presencia de actividad inflamatoria que afectaba a más de un vaso, con compromiso de otras arterias además de la responsable del infarto. Se detectó también accidente agudo de placa en más de una arteria coronaria.

Background Data from clinical and histopathologic studies suggest that inflammation plays a key role in instability of atherosclerotic plaque as patients with acute coronary syndromes present diffuse inflammatory infiltrates in the coronary arteries. Objectives To assess and locate the distribution of vulnerable plaques and inflammatory infiltrates in patients who died of acute myocardial infarction. Material and Methods We examined the coronary arteries from 58 patients who died of myocardial infarction using light microscopy. The following variables were evaluated in culprit and non-culprit coronary arteries: presence of thrombus, plaque rupture, intraplaque hemorrhage and inflammatory infiltrate. Results The presence of thrombus and intraplaque hemorrhage was significantly greater in culprit coronary arteries compared to non-culprit vessels (69% versus 38%; p<0.008, and 69% versus 50%; p<0.03, respectively). There were no significant differences in the presence of inflammatory infiltrates in atherosclerotic plaques from culprit and non-culprit coronary arteries (77% versus 71%; p=ns). Conclusion Inflammatory activity was demonstrated in acute myocardial infarction affecting not only the infarct-related artery but also other coronary vessels. Plaque accident was also present in more than one coronary artery.