Utilidad de la tomografía de coherencia óptica como guía en el tratamiento del síndrome coronario agudo: reporte de un caso / Utility of optical coherence tomography to guide treatment in acute coronary syndromes: case report / Utilidade da tomografia de coerência óptica como guia no tratamento da síndrome coronariana aguda: relato de um caso

La tomografía de coherencia óptica (OCT) es una técnica de imagen endovascular con elevada resolución espacial que permite evaluar las diferentes estructuras que componen la pared de las arterias coronarias, caracterizar morfológicamente la placa aterosclerótica y establecer el mecanismo fisiopatológico subyacente en los síndromes coronarios agudos (SCA). Se presenta el caso clínico de un paciente con infarto agudo de miocardio, donde la OCT evidenció que la reducción de la luz arterial estaba determinada principalmente por la presencia de trombo, a la vez que demostró una disrupción endotelial (ruptura de placa) como mecanismo fisiopatológico subyacente. Se adoptó una estrategia invasivo-conservadora, donde finalmente no se implantó stent. La información surgida de la OCT en este caso particular fue fundamental en la toma de decisiones.

Optical coherence tomography (OCT) is an endovascular imaging technique with high spatial resolution. It allows to evaluate the different structures that compose coronary arteries' wall, morphologically characterize atherosclerotic plaques and establish the underlying pathophysiological mechanism in acute coronary syndromes (ACS). The case of a patient with acute myocardial infarction is presented, in which OCT showed that the reduction of arterial lumen was determined mainly by the presence of thrombus, while also demonstrated endothelial disruption (plaque rupture) as the underlying pathophysiological mechanism. An invasive-conservative strategy was adopted and finally stent was not implanted. The information that emerged from the OCT in this particular case was fundamental in decision-making.

A tomografia de coerência óptica (OCT) é uma técnica de imagem endovascular com alta resolução espacial que permite a avaliação das diferentes estruturas que compõem a parede das artérias coronárias, a caracterização morfológica da placa aterosclerótica e o estabelecimento do mecanismo fisiopatológico subjacente de síndrome coronariana aguda (SCA). Apresentamos o caso clínico de um paciente com enfarte agudo do miocárdio, onde a OCT mostrou que a redução do lúmen arterial foi determinada principalmente pela presença de trombo, ao mesmo tempo que demonstrou uma ruptura endotelial (ruptura da placa) como causa fisiopatológica subjacente. Adotou-se uma estratégia invasiva-conservadora, onde finalmente o stent não foi implantado. As informações obtidas da OCT neste caso específico foram fundamentais na tomada de decisão.

Eficacia y seguridad de ticagrelor en pacientes con re-infarto por trombosis de stent for falla a la terapia de soble antiagregación plaquetária clopidogrel más aspirina / Efficacy and safety of ticagrelor in patients with re-infarction due to stent thrombosis for failure of soble antiplatelet therapy clopidogrel plus aspirin

INTRODUCCIÓN: Antecedentes: El presente dictamen expone la evaluación de tecnología sanitaria de la eficacia y seguridad de Ticagrelor en pacientes con re-infarto por trombosis de stent por falla a la terapia de doble antiagregación plaquetaria clopidogrel más aspirina. Aspectos Generales: El síndrome coronario agudo (SCA) es una condición en la que se manifestan síntomas de isquemia cardíaca y, clinicamente, se presentan de manera heterogénea. Los síndromes coronarios agudos como infarto agudo de miocardio con elevación del segmento ST (IAMCEST) y la angina inestable comparten una fisiopatología común: la rotura o erosión de una placa de ateroma con trombosis intracoronaria superpuesta (aterotrombosis). Tecnología Sanitaria de Interés: Dentro de los tratamientos farmacológicos para el síndrome coronario agudo el Ticagrelor: un derivado pirimidínico antiplaquetario oral de nueva generación, el cual se une reversiblemente al receptor adenosino difosfato P2Y inhibiendo así la activación y agregación plaquetaria. Tiene un mecanismo de iniciación, acción y finalización más rápido que su similar clopidogrel y es considerado un tratamiento de primera línea en algunos países del primer mundo. METODOLOGÍA: Estrategia de Búsqueda: Se realizó una estrategia de búsqueda sistemática de la evidencia científica con respecto a Ticagrelor en pacientes con ref-infarto por trombosis de stent y falla a la terapia de doble antiagregación plaquetaria clopidogrel más aspirina. Para la búsqueda primaria se revisó la información disponible por entes reguladoras y normativas como la Food and Drug Administration (FDA), y la Dirección General de Medicamentos y Drogas (DIGEMID). Posteriormente se buscaron Guías de Práctica Clínica a través de los metabuscadores: Translating Research into Practice (TRIPDATABASE), National Library Systems Evidence. Finalmente, se realizó una búsqueda dentro de la información generada por grupos internacionales que realizan revisiones sistemáticas, evaluación de tecnologías sanitarias y guías de práctica clínica, tales como The Cochrane Library, The National Institute for Health and Care Excellence (NICE), The Canadian Agency for Drugs and Technologies in Health (CADTH), The Scottish Medicines Consortium (SMC). Se realizó además una búsqueda manual con una estrategia de bola de nieve mediante la revisión de listas de referencias de las guías, evaluaciones de tecnologías estudios primarios y revisiones narrativas seleccionados. RESULTADOS: Sinopsis de la Evidencia: Se realizó la búsqueda y revisión de la evidencia científica actual para la evaluación de la eficacia y seguridad de Ticagrelor en pacientes con re-infarto por trombosis de stent y falla a la terapia de doble antiagregación plaquetaria clopidogrel más aspirina. La evidencia disponible a la actualidad sobre el uso de ticagrelor recae en un único ensayo clínico aleatorizado (ECA) fase III, el estudio PLATO 2009 de Wallentin et al., a partir del cual se emiten todas las recomendaciones en guías de práctica clínica, evaluaciones de tecnología sanitaria, y análisis exploratórios secundarios. CONCLUSIONES: En la actualidad, el Petitorio Farmacológico de Esalud cuenta con la terapia estándar de tratamiento para síndrome coronario agudo: clopidogrel en combinación con aspirina, terapia que es empleada como primera alternativa de elección para el manejo de pacientes con el diagnóstico mencionado. A la fecha, no existe alternativa de tratamiento a clopidogrel en el petitorio de ESSalud, por lo que es necesario contar con una alternativa para aquellos pacientes en alto riesgo de muerte al haber sufrido re-infarto al miocardio por trombosis de stent a pesar de encotrarse en terapia con clopidogrel más aspirina, a dosis tope y durante un tiempo de tratamiento adecuado. El Instituto de Evaluación de Tecnologías en Salud e Invstigación-IETSI, aprueba el uso de Ticagrelor en pacientes con re-infarto por trombosis de stent y falla a la terapia de doble antiagregación plaquetaria clopidogrel más aspirina.

Platelet antiaggregants in primary and secondary prevention of atherothrombotic events.

Atherothrombosis and its complications are currently the leading cause of worldwide mortality and its incidence is increasing . Platelets play an essential role in the pathogenesis of atherothrombotic events, justifying the use of antiplatelet agents in their prevention. Thus, it is essential to know the efficacy and safety profile of these drugs in primary and secondary prevention of atherothrombotic events. In this context, this review was performed with the aim of describing and summarizing the outcomes of the main trials involving the use of antiplatelet agents in the two levels of prevention, and evaluating the effectiveness and major adverse events related to therapy.

Infarto agudo al miocardio en un hombre joven sin ateromatosis coronaria, como forma de presentación de síndrome antifosfolípido primario: Caso clínico / Acute myocardial infarction in a man without coronary atheromatosis and antiphospholipid syndrome: Report of one case

Coronary thrombosis as a manifestation of the antiphospholipid syndrome is very uncommon. We report a 25 year-old male without known cardiovascular risk factors that suffered an acute myocardial infarction as the initial manifestation of the antiphospholipid syndrome. His coronary angiogram demonstrated a single thrombotic lesion in the anterior descending artery without coronary atheromatosis. Anticardiolipin, anti B2 Glycoprotein I antibodies, and lupus anticoagulant were all positive. Besides the usual management of the coronary thrombosis, the patient was treated with permanent oral anticoagulation. Three months later, a CT coronary angiogram showed complete reperfusion of the involved artery.

[Acute myocardial infarction in a man without coronary atheromatosis and antiphospholipid syndrome: report of one case]. / Infarto agudo al miocardio en un hombre joven sin ateromatosis coronaria, como forma de presentación de síndrome antifosfolípido primario: Caso clínico.

Coronary thrombosis as a manifestation of the antiphospholipid syndrome is very uncommon. We report a 25 year-old male without known cardiovascular risk factors that suffered an acute myocardial infarction as the initial manifestation of the antiphospholipid syndrome. His coronary angiogram demonstrated a single thrombotic lesion in the anterior descending artery without coronary atheromatosis. Anticardiolipin, anti B2 Glycoprotein I antibodies, and lupus anticoagulant were all positive. Besides the usual management of the coronary thrombosis, the patient was treated with permanent oral anticoagulation. Three months later, a CT coronary angiogram showed complete reperfusion of the involved artery .

[Troponins and the indication for treatment with IIb/IIa inhibitors in acute coronary syndromes without ST-segment elevation. Is it time for an "INR" value of troponins?]. / Las troponinas y la indicación de los inhibidores IIb/IIIa en los síndromes coronarios agudos sin elevación del segmento ST. Es tiempo de un valor "INR" de troponinas?

At the present time non-ST elevation acute coronary syndromes are the most important cause of hospital admissions. Troponin determination in clinical practice is a key element of diagnosis, risk evaluation and prognosis, and now, defines the population that will benefit from IIb/IIIa inhibitors treatment. Probably a "universal standard value of Troponins" is needed to uniform our therapeutic criteria. The "minor elevations" for troponin-I are considered < 0.4 ng/dL and 0.5 ng/dL for troponin-T. The treatment of non ST elevation acute myocardial infarction with IIb/IIIa inhibitors may reduce the total amount of troponins and myocardial damage.

Como proceder frente a un síndrome coronario agudo (SCA) / How to proceed in acute coronary syndrome (ACS)

Bajo la denominación de síndrome coronario agudo se incluyen el infarto con y sin onda Q y el angor inestable, cuadros cuya mortalidad oscila entre 5 y 10 por ciento tanto durante como en el curso del primer mes de evolución. En el artículo se describen las medidas que forman parte del manejo de las emergencias coronarias. Entre ellas se incluyen administración inmediata de aspirina y de nitroglicerina, toma de electrocardiograma que es un importante predictor de riesgo; inicio de trombolisis o realización de angioplastía con colocación de stent, terapia anticoagulante. Se discuten las ventajas relativas de la terapia invasiva precoz comparada con la invasora

Aplicaçöes clínicas dos novos antitrombóticos / Clinical use of new antithrombotics

Os autores discutem os novos antitrombóticos descrevendo suas vantagens e desvantagens, ainda com muitas dúvidas quanto ao seu uso e segurança nas síndromes isquêmicas coronarianas, além de outras condiçöes.

Coronary stenting in patients undergoing percutaneous transluminal coronary angioplasty during acute myocardial infarction.

Although coronary stenting has been useful in the treatment of patients with suboptimal results, abrupt closure, and threatening occlusion after percutaneous transluminal coronary angioplasty (PTCA), its use in patients with acute myocardial infarction (AMI) is controversial because of the presence of intracoronary thrombus. In this study intracoronary stenting was used to treat suboptimal results and complications in 30 patients (35 lesions) undergoing PTCA during AMI. There were 28 men and 2 women, mean age 58 +/- 12 years. Thirteen patients (43%) had undergone rescue PTCA because of unsuccessful thrombolysis. Four patients had Killip's grade IV, 5 Killip's grade III, and 21 Killip's grade < or = 2 heart failure. Stents were placed in the 35 lesions because of suboptimal result (n = 19), early loss (n = 9), abrupt closure (n = 2), and coronary dissection with threatening occlusion (n = 5). All stents were deployed successfully. In-hospital complications included 1 in-hospital death (3.0%); no patient required emergency coronary artery bypass graft surgery. One patient (3.0%) developed abrupt closure and was successfully treated with PTCA and intracoronary thrombolysis. Vascular complications requiring blood transfusion developed in 3 of 30 patients (10%). At 11.8 months (range 4 to 24) follow-up, there were no deaths or myocardial infarction. One patient underwent coronary artery bypass grafting. The remaining patients were free of angina at follow-up. Thus, intracoronary stents can be used successfully to treat both suboptimal results and complications occurring in patients undergoing PTCA during AMI.

[Thrombolysis in acute myocardial infarct of embolic origin]. / Trombolisis en infarto agudo del miocardio de origen embólico.

Myocardial infarctions which are derived from embolic source have an incidence of 5-13%. They are at risk of systemic embolism. The pathogenesis of myocardial infarction is similar to that of those myocardial infarction whose etiology is atherosclerosis. This make it susceptible to thrombolysis. We report 3 patients with either inactive rheumatic heart disease, coarctation of the aorta or mechanical valvular prosthesis as the probable causes of an embolic infarction. It was located in the posterior-inferior region with a dorsal extension. These patients were treated with intravenous streptokinase. The three of them fulfilled criteria for myocardial reperfusion. Two of them suffered post-infarction angina. In the first case reocclusion of the righ coronary artery was observed; thus a saphenous vein graft was undertaken. In the second, the persistence of thrombus required three month treatment with anticoagulants. The third patient showed not coronary lesions. In conclusion, thrombolytic therapy with streptokinase in acute infarction of embolic origin prevents the progression of ischemic damage and betters the clinical outcome of the patient. Furthermore such disease should be suspected in patients that have risk factors for systemic embolism and normal coronary arteries and with obstruction of a single vessel.

[Thrombolytic therapy in thrombosis of prosthesis]. / Terapêutica trombolítica nas tromboses de próteses mecânicas.

PURPOSE: To relate our experience with thrombolytic therapy in 8 patients with cardiac metal prosthesis complicated with thrombosis. METHODS: Eight patients with clinical and echocardiographic diagnosis of cardiac valvar prosthesis thrombosis were treated. RESULTS: The treatment efficacy was evaluated by clinical and echocardiographic improvement. The authors recognized improvement in all 8 patients. One case of hemorrhage was observed (coxo-femoral articulation). Late death were observed twice: 24 months after, sudden death and 30 months later by hemorrhagic stroke. CONCLUSION: The results indicated that thrombolytic therapy is best way to treat patients with cardiac valve thrombosis, instead of surgical treatment.

Terapêutica trombolítica nas tromboses de próteses mecânicas / Trombolytic Therapy in Cardiac Metalic Prosthesis Thrombo

PURPOSE--To relate our experience with thrombolytic therapy in 8 patients with cardiac metal prosthesis complicated with thrombosis. METHODS--Eight patients with clinical and echocardiographic diagnosis of cardiac valvar prosthesis thrombosis were treated. RESULTS--The treatment efficacy was evaluated by clinical and echocardiographic improvement. The authors recognized improvement in all 8 patients. One case of hemorrhage was observed (coxo-femoral articulation). Late death were observed twice: 24 months after, sudden death and 30 months later by hemorrhagic stroke. CONCLUSION--The results indicated that thrombolytic therapy is best way to treat patients with cardiac valve thrombosis, instead of surgical treatment