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2.
Brasília; CONITEC; nov. 2020.
No convencional en Portugués | BRISA/RedTESA | ID: biblio-1145484

RESUMEN

INTRODUÇÃO: A síndrome coronariana aguda (SCA) é um termo abrangente para: infarto agudo do miocárdio (IAM) com supradesnivelamento do segmento ST, IAM sem supradesnivelamento do segmento ST e angina instável (1,2). A incidência é muito variável entre diferentes países e regiões do mundo (3­8). De acordo com a Organização Mundial da Saúde, doenças isquêmicas do coração foram responsáveis por 12% das mortes observadas em países de média e baixa renda, e aproximadamente 16% das mortes em países da alta renda em 2008 (9). Em particular, pacientes com diabetes mellitus (DM) possuem maior potencial pró-trombótico (3,4) e consequente maior potencial de beneficiarem-se de antiagregantes plaquetários (aspirina, clopidogrel) após uma angioplastia. O prasugrel é um anti-agregante plaquetário da mesma classe do clopidogrel, hoje incorporado ao SUS, e do ticagrelor, cuja incorporação foi rejeitada pela CONITEC. PERGUNTA: O prasugrel é eficaz, seguro e custo-efetivo em relação ao clopidogrel para a redução de eventos cardiovasculares em pacientes com síndrome coronariana aguda (SCA) e diabetes mellitus (DM) que realizaram angioplastia? EVIDÊNCIAS CIENTÍFICAS: Um único ensaio clínico randomizado (TRITON TIMI 38) avaliou prasugrel versus clopidogrel, 23% dos participantes eram diabéticos. Estudo patrocinado pelo demandante. Baixo risco de viés. A análise em pacientes diabéticos é baseada em uma análise de subgrupo. A qualidade da evidência é limitada pois não houve randomização para diabéticos e o estudo não foi controlado para o tipo e gravidade da doença. Ainda, a interação para diabetes não foi significativa (P = 0,09), ou seja, a análise deste subgrupo como um grupo independente não é adequada. A razão de chances, que no estudo pivotal era de 0,76 para redução de infarto foi recalculada para 0,60 no subgrupo de diabéticos. Analisando os resultados do subgrupo de pacientes diabéticos para o desfecho primário composto de morte cardiovascular, infarto e AVC, foram observados eventos em 17,0% no grupo clopidogrel e 12,2% no grupo prasugrel (HR=0,70; IC 0,58 - 0,85). Para morte cardiovascular, 4,2% no grupo clopidogrel e 3,4% no grupo prasugrel (HR=0,85; IC 0,58 - 1,24); IAM não fatal: 13,2% no grupo clopidogrel e 8,2% no grupo prasugrel (HR=0,60; IC 0,48 - 0,76); Trombose de stent: 3,6% no grupo clopidogrel e 2,0% no grupo prasugrel (HR=0,52; IC 0,33 - 0,84). O prasugrel apresentou maior risco de sangramentos não relacionada à cirurgia de revascularização miocárdica: 4,3% no grupo clopidogrel e 5,3% no grupo prasugrel (HR=1,30; IC 0,92 - 1,82). AVALIAÇÃO ECONÔMICA: A avaliação econômica do prasugrel apresentada pelo demandante baseou-se nos resultados do estudo pivotal e em um modelo de custo-efetividade e custo-utilidade utilizado previamente no NICE. Como resultados, prasugrel demonstrou-se ser mais efetivo e com maior custo em relação ao clopidogrel, apresentando uma razão de custo-utilidade incremental (RCEI) de R$ 9.325,00 mil/QALY. O modelo foi refeito pelo parecerista externo, obtendo um novo valor de RCEI de R$ 12.324,53/QALY e com 100% das simulações com valor igual ou inferior a R$ 15.591,13/QALY. RECOMENDAÇÃO PRELIMINAR DA CONITEC: A Conitec, em sua 89ª reunião ordinária, no dia 06 de agosto de 2020, recomendou a não incorporação no SUS de prasugrel para tratamento de pacientes diabéticos com síndrome coronariana aguda pós angioplastia. A recomendação levou em consideração que a população alvo foi mal definida, gerando incertezas no impacto orçamentário e na proposta de redução de preços. A operacionalização da proposta de redução de preços necessita de esclarecimentos. RECOMENDAÇÃO PRELIMINAR DA CONITEC: A Conitec, em sua 89ª reunião ordinária, no dia 06 de agosto de 2020, recomendou a não incorporação no SUS de prasugrel para tratamento de pacientes diabéticos com síndrome coronariana aguda pós angioplastia. A recomendação levou em consideração que a população alvo foi mal definida, gerando incertezas no impacto orçamentário e na proposta de redução de preços. A operacionalização da proposta de redução de preços necessita de esclarecimentos. RECOMENDAÇÃO FINAL DA CONITEC: Os membros da CONITEC presentes na 92ª reunião ordinária, no dia 05 de novembro de 2020, deliberaram por recomendar a não incorporação no SUS do cloridrato de prasugrel para pacientes diabéticos com síndrome coronariana aguda submetidos à angioplastia primária. Os membros presentes entenderam que o medicamento atenderia um subgrupo de pacientes específico e que ainda há incertezas quanto ao seu benefício e segurança. Foi assinado o Registro de Deliberação nº 573.


Asunto(s)
Humanos , Angioplastia/instrumentación , Diabetes Mellitus/fisiopatología , Síndrome Coronario Agudo/fisiopatología , Clorhidrato de Prasugrel/uso terapéutico , Evaluación de la Tecnología Biomédica , Sistema Único de Salud , Brasil , Análisis Costo-Beneficio/economía
3.
N Z Med J ; 133(1520): 73-82, 2020 08 21.
Artículo en Inglés | MEDLINE | ID: mdl-32994595

RESUMEN

AIM: Takotsubo syndrome (TS) mimics acute coronary syndrome but has a distinct pathophysiology. This study aimed to compare and contrast the clinical presentation, management and outcomes of patients with TS in five large New Zealand hospitals. METHODS: We identified 632 consecutive patients presenting to the five major tertiary hospitals in New Zealand (Middlemore Hospital, Auckland City Hospital, North Shore Hospital, Christchurch Hospital and Dunedin Hospital) between January 2006 and June 2018 and obtained clinical, laboratory, electrocardiography, echocardiography, coronary angiography and long-term follow-up data. RESULTS: Six hundred and thirty-two consecutive patients with TS (606 women, mean age 65.0+11.1 years) were included. An associated stressor was identified in two-thirds of patients, and emotional triggers were more frequent than physical triggers (62.9% and 37.1%, respectively). Overall, 12.7% of patient had depression and 11.7% anxiety but this was more common in patients from Christchurch Hospital (20.4% and 23.4%, respectively). The in-hospital mortality among the five hospitals ranges between 0 to 2.0%. The mean follow-up was 4.9+3.4 years (median 4.4 years). Fifty-four people died post-discharge, all but one from a non-cardiac cause. Forty patients had recurrent TS. Mortality post-discharge (p=0.63) and TS recurrence (p=0.38) did not differ significantly among the five hospitals. CONCLUSION: In this large New Zealand TS cohort, the clinical characteristics and presentation were similar among the five hospitals. A subset of patients had a complicated in-hospital course, but late deaths were almost all from non-cardiac causes and recurrence was infrequent. Mortality post-discharge and recurrence was similar between the hospitals.


Asunto(s)
Síndrome Coronario Agudo/diagnóstico , Mortalidad Hospitalaria/tendencias , Hospitales Urbanos/estadística & datos numéricos , Cardiomiopatía de Takotsubo/diagnóstico , Cardiomiopatía de Takotsubo/mortalidad , Síndrome Coronario Agudo/fisiopatología , Anciano , Angiografía Coronaria/métodos , Diagnóstico Diferencial , Ecocardiografía/métodos , Electrocardiografía/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Nueva Zelanda/epidemiología , Nueva Zelanda/etnología , Alta del Paciente/tendencias , Estudios Prospectivos , Recurrencia , Estrés Psicológico/epidemiología , Cardiomiopatía de Takotsubo/epidemiología , Cardiomiopatía de Takotsubo/fisiopatología , Centros de Atención Terciaria/estadística & datos numéricos
4.
Med Hypotheses ; 143: 110125, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-32763657

RESUMEN

The novel coronavirus (SARS-CoV-2) is primarily a respiratory pathogen and its clinical manifestations are dominated by respiratory symptoms, the most severe of which is acute respiratory distress syndrome (ARDS). However, COVID-19 is increasingly recognized to cause an overwhelming inflammatory response and cytokine storm leading to end organ damage. End organ damage to heart is one of the most severe complications of COVID-19 that increases the risk of death. We proposed a two-fold mechanism responsible for causing acute coronary events in patients with COVID-19 infection: Cytokine storm leading to rapid onset formation of new coronary plaques along with destabilization of pre-existing plaques and direct myocardial injury secondary to acute systemic viral infection. A well-coordinated immune response is the first line innate immunity against a viral infection. However, an uncoordinated response and hypersecretion of cytokines and chemokines lead to immune related damage to the human body. Human Coronavirus (HCoV) infection causes infiltration of inflammatory cells that cause excessive production of cytokines, proteases, coagulation factors, oxygen radicals and vasoactive molecules causing endothelial damage, disruption of fibrous cap and initiation of formation of thrombus. Systemic viral infections also cause vasoconstriction leading to narrowing of vascular lumen and stimulation of platelet activation via shear stress. The resultant cytokine storm causes secretion of hypercoagulable tissue factor without consequential increase in counter-regulatory pathways such as AT-III, activated protein C and plasminogen activator type 1. Lastly, influx of CD4+ T-cells in cardiac vasculature results in an increased production of cytokines that stimulate smooth muscle cells to migrate into the intima and generate collagen and other fibrous products leading to advancement of fatty streaks to advanced atherosclerotic lesions. Direct myocardial damage and cytokine storm leading to destabilization of pre-existing plaques and accelerated formation of new plaques are the two instigating mechanisms for acute coronary syndromes in COVID-19.


Asunto(s)
Síndrome Coronario Agudo/etiología , Betacoronavirus , Infecciones por Coronavirus/complicaciones , Modelos Cardiovasculares , Pandemias , Neumonía Viral/complicaciones , Síndrome Coronario Agudo/fisiopatología , Linfocitos T CD4-Positivos/inmunología , Quimiocinas/fisiología , Enfermedad de la Arteria Coronaria/etiología , Enfermedad de la Arteria Coronaria/fisiopatología , Vasos Coronarios/metabolismo , Infecciones por Coronavirus/inmunología , Infecciones por Coronavirus/fisiopatología , Síndrome de Liberación de Citoquinas/etiología , Síndrome de Liberación de Citoquinas/fisiopatología , Citocinas/fisiología , Humanos , Inmunidad Innata , Placa Aterosclerótica/etiología , Placa Aterosclerótica/fisiopatología , Activación Plaquetaria , Neumonía Viral/inmunología , Neumonía Viral/fisiopatología , Vasoconstricción , Virosis/complicaciones , Virosis/inmunología
5.
PLoS One ; 15(8): e0237036, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32756583

RESUMEN

BACKGROUND: Despite the use of high-sensitive cardiac troponin there remains a group of high-sensitive cardiac troponin negative patients with unstable angina with a non-neglectable risk for future adverse cardiovascular events, emphasising the need for additional risk stratification. Plasma extracellular vesicles are small bilayer membrane vesicles known for their potential role as biomarker source. Their role in unstable angina remains unexplored. We investigate if extracellular vesicle proteins are associated with unstable angina in patients with chest pain and low high-sensitive cardiac troponin. METHODS: The MINERVA study included patients presenting with acute chest pain but no acute coronary syndrome. We performed an exploratory retrospective case-control analysis among 269 patients. Cases were defined as patients with low high-sensitive cardiac troponin and proven ischemia. Patients without ischemia were selected as controls. Blood samples were fractionated to analyse the EV proteins in three plasma-subfractions: TEX, HDL and LDL. Protein levels were quantified using electrochemiluminescence immunoassay. RESULTS: Lower levels of (adjusted) EV cystatin c in the TEX subfraction were associated with having unstable angina (OR 0.93 95% CI 0.88-0.99). CONCLUSION: In patients with acute chest pain but low high-sensitive cardiac troponin, lower levels of plasma extracellular vesicle cystatin c are associated with having unstable angina. This finding is hypothesis generating only considering the small sample size and needs to be confirmed in larger cohort studies, but still identifies extracellular vesicle proteins as source for additional risk stratification.


Asunto(s)
Angina Inestable/metabolismo , Cistatina C/análisis , Vesículas Extracelulares/metabolismo , Síndrome Coronario Agudo/fisiopatología , Adulto , Anciano , Angina Inestable/sangre , Angina Inestable/fisiopatología , Biomarcadores/sangre , Estudios de Casos y Controles , Dolor en el Pecho/sangre , Dolor en el Pecho/metabolismo , Dolor en el Pecho/fisiopatología , Estudios de Cohortes , Creatina Quinasa/sangre , Cistatina C/sangre , Cistatina C/metabolismo , Electrocardiografía , Vesículas Extracelulares/fisiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/fisiopatología , Estudios Retrospectivos , Troponina/sangre
8.
Arch Cardiol Mex ; 90(Supl): 33-35, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32523135

RESUMEN

The communications accumulated in the last weeks make it clear that there is no agreement to define the best treatment strategy in patients with acute coronary syndrome (SICA). In patients presenting with an acute myocardial infarction with ST-segment elevation (IAMCESST), it has been suggested to favor fibrinolysis (FL) over primary percutaneous coronary intervention (PCI), reserving ICP for cases of failed FL1,2; however, some societies have maintained the indication of the ICPp as the repercussion method of choice3. In SICAs without ST segment elevation (SICASESST) the recommendations are very similar, favoring medical treatment over percutaneous coronary intervention in this subgroup of patients1. Several companies consider the contagion status, particularly in the SICASESST, to decide which repercussion follow3. Anticipating that the epidemiological curve in Mexico will be similar to that observed in most countries, we recommend continuing the care of patients with SICA, the catheterization rooms must maintain their operation.


Asunto(s)
Síndrome Coronario Agudo/terapia , Infecciones por Coronavirus/epidemiología , Neumonía Viral/epidemiología , Síndrome Coronario Agudo/fisiopatología , Cateterismo Cardíaco , Infecciones por Coronavirus/prevención & control , Brotes de Enfermedades , Humanos , México/epidemiología , Infarto del Miocardio sin Elevación del ST/fisiopatología , Infarto del Miocardio sin Elevación del ST/terapia , Pandemias/prevención & control , Intervención Coronaria Percutánea/métodos , Neumonía Viral/prevención & control , Infarto del Miocardio con Elevación del ST/fisiopatología , Infarto del Miocardio con Elevación del ST/terapia
9.
Nat Rev Cardiol ; 17(11): 718-731, 2020 11.
Artículo en Inglés | MEDLINE | ID: mdl-32518358

RESUMEN

Cardiovascular disease complicates 1-4% of pregnancies - with a higher prevalence when including hypertensive disorders - and is the leading cause of maternal death. In women with known cardiovascular pathology, such as congenital heart disease, timely counselling is possible and the outcome is fairly good. By contrast, maternal mortality is high in women with acquired heart disease that presents during pregnancy (such as acute coronary syndrome or aortic dissection). Worryingly, the prevalence of acquired cardiovascular disease during pregnancy is rising as older maternal age, obesity, diabetes mellitus and hypertension become more common in the pregnant population. Management of cardiovascular disease in pregnancy is challenging owing to the unique maternal physiology, characterized by profound changes to multiple organ systems. The presence of the fetus compounds the situation because both the cardiometabolic disease and its management might adversely affect the fetus. Equally, avoiding essential treatment because of potential fetal harm risks a poor outcome for both mother and child. In this Review, we examine how the physiological adaptations during pregnancy can provoke cardiometabolic complications or exacerbate existing cardiometabolic disease and, conversely, how cardiometabolic disease can compromise the adaptations to pregnancy and their intended purpose: the development and growth of the fetus.


Asunto(s)
Fenómenos Fisiológicos Cardiovasculares , Diabetes Gestacional/metabolismo , Hipertensión Inducida en el Embarazo/fisiopatología , Complicaciones Cardiovasculares del Embarazo/fisiopatología , Embarazo/fisiología , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/fisiopatología , Síndrome Coronario Agudo/terapia , Aneurisma Disecante/diagnóstico , Aneurisma Disecante/fisiopatología , Aneurisma Disecante/terapia , Antihipertensivos/uso terapéutico , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatología , Arritmias Cardíacas/terapia , Aspirina/uso terapéutico , Gasto Cardíaco , Cardiomiopatías/diagnóstico , Cardiomiopatías/fisiopatología , Cardiomiopatías/terapia , Diabetes Gestacional/diagnóstico , Diabetes Gestacional/terapia , Progresión de la Enfermedad , Endocarditis/diagnóstico , Endocarditis/fisiopatología , Endocarditis/terapia , Femenino , Humanos , Hipertensión/fisiopatología , Hipertensión Inducida en el Embarazo/diagnóstico , Hipertensión Inducida en el Embarazo/tratamiento farmacológico , Hipoglucemiantes/uso terapéutico , Edad Materna , Obesidad Materna/metabolismo , Obesidad Materna/fisiopatología , Inhibidores de Agregación Plaquetaria/uso terapéutico , Preeclampsia/fisiopatología , Preeclampsia/prevención & control , Preeclampsia/terapia , Embarazo/metabolismo , Complicaciones Cardiovasculares del Embarazo/diagnóstico , Complicaciones Cardiovasculares del Embarazo/terapia , Complicaciones Infecciosas del Embarazo/diagnóstico , Complicaciones Infecciosas del Embarazo/fisiopatología , Complicaciones Infecciosas del Embarazo/terapia , Embarazo en Diabéticas/metabolismo , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/tratamiento farmacológico , Tromboembolia Venosa/fisiopatología
10.
J Cardiovasc Pharmacol Ther ; 25(6): 508-522, 2020 11.
Artículo en Inglés | MEDLINE | ID: mdl-32588641

RESUMEN

Phytogenic cannabinoids from Cannabis sativa and synthetic cannabinoids are commonly used substances for their recreational and medicinal properties. There are increasing reports of cardiotoxicity in close temporal association with cannabinoid use in patients with structurally normal hearts and absence of coronary arterial disease. Associated adverse events include myocardial ischemia, conduction abnormalities, arrhythmias, and sudden death. This review details the effects of phytogenic and synthetic cannabinoids on diverse receptors based on evidence from in vitro, human, and animal studies to establish a molecular basis for these deleterious clinical effects. The synergism between endocannabinoid dysregulation, cannabinoid receptor, and noncannabinoid receptor binding, and impact on cellular ion flux and coronary microvascular circulation is delineated. Pharmacogenetic factors placing certain patients at higher risk for cardiotoxicity are also correlated with the diverse effects of cannabinoids.


Asunto(s)
Síndrome Coronario Agudo/inducido químicamente , Arritmias Cardíacas/inducido químicamente , Agonistas de Receptores de Cannabinoides/efectos adversos , Cannabinoides/efectos adversos , Cannabis/efectos adversos , Corazón/efectos de los fármacos , Abuso de Marihuana/complicaciones , Fumar Marihuana/efectos adversos , Síndrome Coronario Agudo/fisiopatología , Animales , Arritmias Cardíacas/fisiopatología , Agonistas de Receptores de Cannabinoides/síntesis química , Agonistas de Receptores de Cannabinoides/aislamiento & purificación , Cannabinoides/síntesis química , Cannabinoides/aislamiento & purificación , Cannabis/química , Cardiotoxicidad , Corazón/fisiopatología , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Receptores de Cannabinoides/efectos de los fármacos , Medición de Riesgo , Factores de Riesgo , Transducción de Señal
11.
Cardiovasc Ther ; 2020: 4351469, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32405323

RESUMEN

Aim: To evaluate the clinical impact of ß-blocker in patients with adequate left ventricular ejection function (LVEF) who underwent percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Methods: A total of 10,724 consecutive patients who underwent PCI throughout 2013 were prospectively enrolled in the study. Among these, we analyzed 5,631 ACS patients who were discharged with LVEF ≥ 40%. Patients were then compared according to the ß-blocker prescription at discharge. Results: During a 2-year follow-up, no significant association was observed of ß-blocker use with all-cause mortality (with ß-blockers 47/5,043 (0.9%) vs. without ß-blocker use 8/588 (1.4%); hazard ratio (HR) 0.762, 95% confidence interval 0.36 to 1.64; P = 0.485), cardiac death, myocardial infarction (MI), or major adverse cardiovascular and cerebrovascular events. Subgroup analysis demonstrated that the ß-blocker use at discharge reduced the 2-year mortality in patients with unstable angina (UA) (HR 0.42, 95% CI 0.19 to 0.94, P = 0.034). Landmark analysis at 1 year showed that patients with UA who were discharged with ß-blockers had lower mortality (HR 0.17, 95% CI 0.04-0.65, P = 0.010) and cardiac death (HR 0.12, 95% CI 0.01-0.99, P = 0.049) than those discharged without ß-blockers. However, the benefit was lost beyond 1 year. No differences in outcomes were recorded in the AMI or overall population. Conclusions: We present that ß-blocker significantly lowers the rate of all-cause death up to 1 year, in UA patients who have undergone PCI and have adequate LVEF. Its role in patients with AMI also deserves further exploration.


Asunto(s)
Síndrome Coronario Agudo/terapia , Antagonistas Adrenérgicos beta/uso terapéutico , Alta del Paciente , Intervención Coronaria Percutánea , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/fisiopatología , Causas de Muerte , China , Progresión de la Enfermedad , Humanos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Estudios Prospectivos , Factores de Riesgo , Stents , Volumen Sistólico , Factores de Tiempo , Resultado del Tratamiento , Función Ventricular Izquierda
12.
BMC Cardiovasc Disord ; 20(1): 244, 2020 05 25.
Artículo en Inglés | MEDLINE | ID: mdl-32450798

RESUMEN

BACKGROUND: Although timely coronary intervention can result in markedly improved clinical outcomes of patients with acute coronary syndrome (ACS), non-ST-elevation (NSTE)-ACS is sometimes difficult to accurately diagnose. CASE PRESENTATION: A 52-year-old woman complained of acute chest pain with sudden onset. Both electrocardiography (ECG) and echocardiography showed normal results, and we urgently needed to make a differential diagnosis among critical illnesses such as acute coronary syndrome and nonischemic cardiovascular life-threatening diseases. Contrast-enhanced computed tomography (CT) without ECG synchronization showed evidence of neither aortic dissection nor pulmonary embolism, but regionally reduced contrast enhancement in the posterior myocardium, which were suggestive of myocardial ischemia. Emergency coronary angiography demonstrated severe stenosis of the left circumflex artery, and we achieved favorable revascularization with drug-eluting stent deployment. CONCLUSIONS: We diagnosed a patient with NSTE-ACS in whom contrast-enhanced CT without ECG synchronization was effective for visualization of reduced myocardial perfusion, suggesting ischemic heart disease.


Asunto(s)
Síndrome Coronario Agudo/diagnóstico por imagen , Imagen de Perfusión Miocárdica/métodos , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Síndrome Coronario Agudo/fisiopatología , Síndrome Coronario Agudo/terapia , Circulación Coronaria , Stents Liberadores de Fármacos , Femenino , Humanos , Persona de Mediana Edad , Intervención Coronaria Percutánea/instrumentación , Valor Predictivo de las Pruebas , Infarto del Miocardio con Elevación del ST/fisiopatología , Infarto del Miocardio con Elevación del ST/terapia , Resultado del Tratamiento
13.
Nutr Metab Cardiovasc Dis ; 30(7): 1169-1178, 2020 06 25.
Artículo en Inglés | MEDLINE | ID: mdl-32448720

RESUMEN

BACKGROUND AND AIMS: This study aimed to assess possible association of detailed abdominal fat profiles with coronary plaque characteristics in patients with acute coronary syndrome (ACS). METHODS AND RESULTS: In 60 patients with ACS, culprit arteries were evaluated at 1-mm intervals (length analyzed: 66 ± 28 mm) by grayscale and integrated backscatter intravascular ultrasound (IB-IVUS) before percutaneous coronary intervention. Standard IVUS indexes (as a volume index: volume/length), plaque components (as percent tissue volume) and fibrous cap thickness (FCT) were assessed by IB-IVUS. Plain abdominal computed tomography was performed to evaluate subcutaneous adipose tissue (SAT) area, visceral adipose tissue (VAT) area, and VAT/SAT ratio. While SAT area only correlated with vessel volume (r = 0.27, p = 0.04), VAT area correlated positively with vessel (r = 0.30, p = 0.02) and plaque (r = 0.33, p = 0.01) volumes and negatively with FCT (r = -0.26, p = 0.049), but not with percent plaque volume and plaque tissue components. In contrast, higher VAT/SAT ratio significantly correlated with higher percent lipid (r = 0.34, p = 0.008) and lower percent fibrous (r = -0.34, p = 0.007) volumes with a trend toward larger percent plaque volume (r = 0.19, p = 0.15), as well as thinner FCT (r = -0.53, p < 0.0001). In the multiple regression analysis, higher VAT/SAT ratio was independently associated with higher percent lipid with lower percent fibrous volumes (p = 0.03 for both) and thinner fibrous cap thickness (p = 0.0001). CONCLUSION: Coronary plaque vulnerability, defined as increased lipid content with thinner fibrous cap thickness, appears to be more related to abnormal abdominal fat distribution, or so-called hidden obesity, compared with visceral or subcutaneous fat amount alone in patients with ACS.


Asunto(s)
Grasa Abdominal/diagnóstico por imagen , Síndrome Coronario Agudo/diagnóstico por imagen , Adiposidad , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Placa Aterosclerótica , Tomografía Computarizada por Rayos X , Ultrasonografía Intervencional , Grasa Abdominal/fisiopatología , Síndrome Coronario Agudo/fisiopatología , Anciano , Enfermedad de la Arteria Coronaria/fisiopatología , Femenino , Fibrosis , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Rotura Espontánea
14.
BMC Cardiovasc Disord ; 20(1): 153, 2020 03 31.
Artículo en Inglés | MEDLINE | ID: mdl-32234015

RESUMEN

BACKGROUND: Studies have not demonstrated consistent outcomes following thrombus aspiration in Primary Percutaneous Coronary Intervention (PPCI). We investigated the relationship between thrombus aspiration and microvascular obstruction as measured using Index of Microcirculatory Resistance (IMR) immediately following PPCI and Left Ventricle Function Improvement measured using Global Longitudinal Strain (GLS) six months following PPCI. Our aim is to determine microvascular obstruction and left ventricle function improvement six months following thrombus aspiration during PPCI. METHODS: This was a single-center, observational, prospective non-randomized study involving 45 patients with thrombus score 4-5 (defined as high thrombus burden) and Thrombolysis in Myocardial Infarction (TIMI) flow of 0-2 who subsequently underwent PPCI. Thrombus aspiration was conducted based on physician discretion. The IMR was measured immediately following the procedure. All patients underwent echocardiography to measure GLS at 24 h, 3 months and 6 months following PPCI. RESULTS: Thirty-three (73%) patients underwent thrombus aspiration during PPCI and twelve (27%) patients underwent the conventional PPCI. No significant difference in IMR was found between the group that underwent thrombus aspiration and the group that underwent conventional PCI (51.9 ± 41.5 vs 47.1 ± 35.6 p = 0.723). TIMI flow after PPCI was worse in thrombus aspiration group (OR 5.2 [1.2-23.2], p = 0.041). There was no difference in GLS between two groups at 6-month follow-up (- 13.0 ± 3.4 vs - 12.8 ± 4.6, p = 0.912). CONCLUSION: This study indicates no benefit of thrombus aspiration during PPCI in reducing either microvascular obstruction or left ventricular function at 6-month follow-up for patients with high thrombus burden. Nevertheless, further studies are required before definite conclusions can be made.


Asunto(s)
Síndrome Coronario Agudo/terapia , Circulación Coronaria , Trombosis Coronaria/terapia , Microcirculación , Intervención Coronaria Percutánea , Trombectomía , Resistencia Vascular , Función Ventricular Izquierda , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/fisiopatología , Trombosis Coronaria/diagnóstico por imagen , Trombosis Coronaria/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Estudios Prospectivos , Recuperación de la Función , Succión , Trombectomía/efectos adversos , Factores de Tiempo , Resultado del Tratamiento
15.
Cardiovasc Ther ; 2020: 6495036, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32328172

RESUMEN

Conflicting results have been reported so far in pooled analyses and studies evaluating the optimum duration of dual antiplatelet therapy (DAPT) in acute coronary syndrome (ACS) patients. However, randomized clinical trials dedicated to this specific setting of higher thrombotic risk patients have only recently been completed, pointing at the noninferiority of a shorter strategy as compared to the traditional 12-month DAPT, furthermore allowing to reduce the risk of major bleeding complications. Therefore, a reconsideration of current clinical practice and guidelines should be certainly be advocated in light of the most recent updates, especially among ACS patients treated with percutaneous coronary intervention (PCI) and modern drug-eluting stents (DES). Our aim was to provide a comprehensive review of the available evidence on the optimal DAPT duration in ACS patients.


Asunto(s)
Síndrome Coronario Agudo/terapia , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria/administración & dosificación , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/fisiopatología , Toma de Decisiones Clínicas , Esquema de Medicación , Quimioterapia Combinada , Stents Liberadores de Fármacos , Hemorragia/inducido químicamente , Humanos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/mortalidad , Inhibidores de Agregación Plaquetaria/efectos adversos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento
16.
Int J Cardiovasc Imaging ; 36(7): 1191-1192, 2020 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-32189160
17.
Ther Adv Cardiovasc Dis ; 14: 1753944720912071, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32186246

RESUMEN

BACKGROUND: Adherence to treatment after a myocardial infarction (MI) is poor, even in the early postinfarction period. Combining evidence-based drugs into a multicap could improve adherence in this population. No previous randomized trial assessing fixed-dose combination therapy has included patients early after a MI. We aimed to assess if a multicap containing four secondary prevention drugs increases adherence to treatment at 6 months after MI hospitalization. The study was designed as a randomized, parallel, open-label, controlled trial. METHODS: Patients were randomized within 7 days of a MI to either multicap or control group. The multicap group received a capsule containing aspirin, atenolol, ramipril, and simvastatin. The control group received each drug in separate pills. The primary outcome was adherence at 6 months. We also measured blood pressure, heart rate, serum cholesterol levels, C-reactive protein, and platelet aggregation. RESULTS: The study was stopped prematurely when 100 patients were included for futility. At 6 months, 92 (95.8%) patients were adherent to medical treatment: 98.0% in the multicap group and 93.5% in the control group [relative risk (RR) 1.05; 95% confidence interval (CI) 0.96-1.14; p = 0.347]. There were no differences between groups in systolic blood pressure (p = 0.662), diastolic blood pressure (p = 0.784), heart rate (p = 0.533), total cholesterol (p = 0.760), LDL-c (p = 0.979), C-reactive protein (p = 0.399), or in the proportion of patients with adequate platelet aggregation inhibition (p = 0.600). CONCLUSIONS: The study did not find any improvement in the adherence at 6 months after a MI with a multicap-based strategy (Multicap for Increase Adherence After Acute Myocardial Infarction; [ ClinicalTrials.gov identifier: NCT02271178]).


Asunto(s)
Síndrome Coronario Agudo/terapia , Antagonistas de Receptores Adrenérgicos beta 1/administración & dosificación , Inhibidores de la Enzima Convertidora de Angiotensina/administración & dosificación , Aspirina/administración & dosificación , Atenolol/administración & dosificación , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Cumplimiento de la Medicación , Infarto del Miocardio/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/administración & dosificación , Ramipril/administración & dosificación , Simvastatina/administración & dosificación , Síndrome Coronario Agudo/sangre , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/fisiopatología , Administración Oral , Antagonistas de Receptores Adrenérgicos beta 1/efectos adversos , Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Argentina , Aspirina/efectos adversos , Atenolol/efectos adversos , Combinación de Medicamentos , Femenino , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/sangre , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/fisiopatología , Inhibidores de Agregación Plaquetaria/efectos adversos , Ramipril/efectos adversos , Prevención Secundaria , Simvastatina/efectos adversos , Comprimidos , Factores de Tiempo , Resultado del Tratamiento
18.
Cardiovasc J Afr ; 31(4): 58-64, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32191257

RESUMEN

AIM: This study investigated endothelial function in HIV-positive patients with acute coronary syndrome (ACS). Flow-mediated dilatation, pulse-wave velocity, carotid intima-media thickness and endothelial biomarkers were used to non-invasively investigate endothelial dysfunction. METHODS: Twenty HIV-positive patients with ACS (HIV+/ACS) were compared to 20 HIV-negative patients with ACS (HIV-/ACS) and 20 HIV-positive patients without ACS (HIV+/no ACS). RESULTS: Endothelial function measured by flow-mediated dilatation (FMD) was similar in both the HIV+/ACS (5.2; IQR 1.4-13.4%) and HIV-/ACS groups (3.7; IQR 2.3-4.4%) (p = 0.78). Arterial stiffness, measured by pulse-wave velocity (PWV) was low in all three cohorts. Carotid intima-media thickness (CIMT) was also low in all three cohorts. The vascular cellular adhesion molecule-1 (VCAM-1) levels in HIV-positive patients with and without ACS were significantly higher than in the HIV-/ACS cohort (p = 0.033 and 0.024, respectively). CONCLUSIONS: Non-invasive investigations such as FMD, CIMT and PWV did not identify patients with HIV who were at high risk of ACS. Endothelial biomarkers may be more useful markers to identify HIV-positive patients who have endothelial dysfunction and increased risk of ACS.


Asunto(s)
Síndrome Coronario Agudo/etiología , Endotelio Vascular/fisiopatología , Infecciones por VIH/complicaciones , Rigidez Vascular , Vasodilatación , Síndrome Coronario Agudo/sangre , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/fisiopatología , Adulto , Biomarcadores/sangre , Grosor Intima-Media Carotídeo , Estudios de Casos y Controles , Endotelio Vascular/diagnóstico por imagen , Endotelio Vascular/metabolismo , Femenino , Infecciones por VIH/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Análisis de la Onda del Pulso , Medición de Riesgo , Factores de Riesgo , Molécula 1 de Adhesión Celular Vascular/sangre
19.
High Blood Press Cardiovasc Prev ; 27(3): 225-230, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-32219669

RESUMEN

INTRODUCTION: Cardiac rehabilitation (CR) improves the functional capacity and the prognosis of patients with coronary artery disease. AIM: Our study was aimed at assessing the relationship between functional improvement (evaluated with 6-min Walk Test-6MWT) and the improvement in left ventricular ejection fraction (LVEF) after CR. METHODS: We collected data from 249 patients (age 66.79 ± 11.06 years; males 81.52%) with a recent history of Acute Coronary Syndrome that performed CR. The functional improvement after CR was expressed as the Δ between distance covered at the final versus the initial 6-min Walking Test (6-MWT), while LVEF was calculated with transthoracic echocardiogram at the beginning and at the end of the CR. RESULTS: Patients were divided accordingly to their pre-rehab LVEF (≥ 55% vs < 55%). With superimposable age and baseline 6MWT distance covered (434.58 vs 405.12 m, p = 0.08), the latter group presented higher Δ meter values at 6MWT (167.93 vs 193.97 m, p = 0.018). However, no statistically significant positive correlation between Δ meters and Δ LVEF was found. Moreover, linear regression analyses found that nor baseline LVEF nor Δ LVEF were significant determinants of Δ meters when considering the whole group, with age, basal 6MWT and peak CK-MB as additional covariates in the model. CONCLUSION: Although it could be expected that an increase in LVEF is related to the functional improvement after CR, no significant correlation was found in our population.


Asunto(s)
Síndrome Coronario Agudo/rehabilitación , Atención Ambulatoria , Rehabilitación Cardiaca/métodos , Terapia por Ejercicio , Tolerancia al Ejercicio , Volumen Sistólico , Función Ventricular Izquierda , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/fisiopatología , Anciano , Femenino , Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Recuperación de la Función , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Prueba de Paso
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