Portal Vein Doppler tracks volume status in patients with severe tricuspid regurgitation: A Proof-of-Concept Study.

BACKGROUND: Renal and liver congestion are associated with adverse outcomes in patients with tricuspid regurgitation (TR). Currently, there are no valid sonographic indicators of fluid status in this population. Intra-renal venous Doppler (IRVD) is a novel method for quantifying renal congestion but its interpretation can be challenging in severe TR due to altered hemodynamics. This study explores the potential of portal vein Doppler (PVD) as an alternative marker for decongestion during volume removal in patients with severe TR. METHODS: 42 patients with severe TR undergoing decongestive therapy were prospectively enrolled. Inferior vena cava diameter (IVCd), PVD and IRVD were sequentially assessed during volume removal. Improvement criteria were Portal Vein Pulsatility Fraction (PVPF) < 70% and Renal Venous Stasis Index (RVSI) < 0.5 for partial improvement, and PVPF <30% and RVSI <0.2 for complete improvement. RESULTS: After volume removal, PVPF significantly improved from 130 ± 39% to 47 ± 44% (p < 0.001), while IRVD improved from 0.72 ± 0.08 to 0.54 ± 0.22 (p < 0.001). A higher proportion of patients displayed improvement in PVD compared to IRVD (partial: 38% vs. 29%, complete: 41% vs. 7%) (p < 0.001). IRVD only improved in patients with concomitant improvement in severe TR. PVD was the only predictor of achieving ≥5 litres of negative fluid balance (AUC 0.83 p = 0.001). CONCLUSIONS: This proof-of-concept study suggests that PVD is the only sonographic marker that can track volume removal in severe TR, offering a potential indicator for decongestion in this population. Further intervention trials are warranted to determine if PVD-guided decongestion improves patient outcomes in severe TR.

Long-Term Outcomes of Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction: A Study from Mexico City.

Although primary percutaneous coronary intervention (pPCI) is the treatment of choice in ST-elevation myocardial infarction (STEMI), challenges may arise in accessing this intervention for certain geodemographic groups. Pharmacoinvasive strategy (PIs) has demonstrated comparable outcomes when delays in pPCI are anticipated, but real-world data on long-term outcomes are limited. The aim of the present study was to compare long-term outcomes among real-world patients with STEMI who underwent either PIs or pPCI. This was a prospective registry including patients with STEMI who received reperfusion during the first 12 hours from symptom onset. The primary objective was cardiovascular mortality at 12 months according to the reperfusion strategy (pPCI vs PIs) and major cardiovascular events (cardiogenic shock, recurrent myocardial infarction, and congestive heart failure), and Bleeding Academic Research Consortium type 3 to 5 bleeding events were also evaluated. A total of 799 patients with STEMI were included; 49.1% underwent pPCI and 50.9% received PIs. Patients in the PIs group presented with more heart failure on admission (Killip-Kimbal >I 48.1 vs 39.7, p = 0.02) and had a lower proportion of pre-existing heart failure (0.2% vs 1.8%, p = 0.02) and atrial fibrillation (0.25% vs 1.2%, p = 0.02). No statistically significant difference was observed in cardiovascular mortality at the 12-month follow-up (hazard ratio for PIs 0.74, 95% confidence interval 0.42 to 1.30, log-rank p = 0.30) according to the reperfusion strategy used. The composite of major cardiovascular events (hazard ratio for PIs 0.98, 95% confidence interval 0.75 to 1.29, p = 0.92) and Bleeding Academic Research Consortium type 3 to 5 bleeding rates were also comparable. A low socioeconomic status, Killip-Kimball >2, age >60 years, and admission creatinine >2.0 mg/100 ml were predictors of the composite end point after multivariate analysis. In conclusion, this prospective real-world registry provides additional support that long-term major cardiovascular outcomes and bleeding are not different between patients who underwent PIs versus primary PCI.

Chagas Heart Disease: Beyond a Single Complication, from Asymptomatic Disease to Heart Failure.

Chagas cardiomyopathy (CC), caused by the protozoan Trypanosoma cruzi, is an important cause of cardiovascular morbidity and mortality in developing countries. It is estimated that 6 to 7 million people worldwide are infected, and it is predicted that it will be responsible for 200,000 deaths by 2025. The World Health Organization (WHO) considers Chagas disease (CD) as a Neglected Tropical Disease (NTD), which must be acknowledged and detected in time, as it remains a clinical and diagnostic challenge in both endemic and non-endemic regions and at different levels of care. The literature on CC was analyzed by searching different databases (Medline, Cochrane Central, EMBASE, PubMed, Google Scholar, EBSCO) from 1968 until October 2022. Multicenter and bioinformatics trials, systematic and bibliographic reviews, international guidelines, and clinical cases were included. The reference lists of the included papers were checked. No linguistic restrictions or study designs were applied. This review is intended to address the current incidence and prevalence of CD and to identify the main pathogenic mechanisms, clinical presentation, and diagnosis of CC.

Saturación de oxígeno y lactato sérico venoso-arterial del posoperatorio de cirugía cardiaca / Venous-arterial oxygen saturation and serum lactate in the postoperative period of cardiac surgery

Resumen Introducción: La saturación de oxígeno y el lactato son marcadores de hipoxia tisular, se obtienen de muestra venosa mezclada en arteria pulmonar o venosa central. Se desconoce el comportamiento simultáneo de estos parámetros en el postoperatorio de cirugía cardiaca. Objetivo: Caracterizar la saturación de oxígeno y lactato del circuito venoso-arterial del paciente postoperado de cirugía cardiaca. Métodos: Diseño transversal analítico. En pacientes consecutivos postoperados de cirugía cardiaca se obtuvieron lactato sérico y saturación de oxígeno del circuito venoso-arterial. Las variables se informaron con mediana (percentiles 25 y 75). Se analizaron con ANOVA de Kruskal-Wallis y ajuste respectivo, correlación de Spearman, el estadístico descriptivo de Bland-Altman y coeficiente de correlación intraclase (intervalo de confianza al 95%). Una p < 0.05 se consideró significativa. Resultados: Se estudiaron 244 muestras sanguíneas de 61 pacientes. Mujeres 30 (49%). Saturación de oxígeno y lactato fueron: arterial 98 (95.3, 99.4)% y 1.7 (1,1, 2.1); venosa periférica 85 (75.4, 94)% y 1.9 (1.35, 2.3); venosa central 68.8 (58.74, 70.2)% y 1.8 (1.3, 2.3); venosa central mezclada 66.8 (61.2, 73.1)% y 1.8 (1.3, 2.2), p < 0.05. El mejor coeficiente de correlación intraclase para la saturación de oxígeno fue de vena central a vena central mezclada: 0.856 (0.760, 0.914); del lactato: 0.954 (0.923, 0.972). Conclusiones: La saturación de oxígeno difiere en el circuito venoso-arterial a diferencia del lactato, donde son similares. Los mejores valores del coeficiente de correlación intraclase para el lactato y la saturación de oxígeno fueron los obtenidos en vena central y vena central mezclada.

Abstract Introduction: Oxygen saturation and lactate are markers of tissue hypoxia; they are obtained from central venous and mixed venous sample of the pulmonary artery. The simultaneous behavior of these parameters in the postoperative period of cardiac surgery is unknown. Objective: To characterize the lactate and oxygen saturation of the venous-arterial circuit of the postoperative patient from cardiac surgery. Methods: Design: Analytical cross-sectional. In consecutive patients after cardiac surgery, serum lactate and oxygen saturation of the venous-arterial circuit were obtained. The variables were reported with median (25.75 percentiles). They were analyzed with Kruskal-Wallis ANOVA and respective adjustment, Spearman correlation, the descriptive Bland-Altman statistic and intraclass correlation coefficient (95% confidence interval). A p < 0.05 was considered significant. Results: 244 blood samples from 61 patients were studied. Women 30 (49%). (Oxygen saturation) [lactate] were: arterial 98 (95.3, 99.4%) and 1.7 (1.1, 2.1); peripheral venous 85 (75.4, 94%) and [1.9 (1.35, 2.3)]; central venous 68.8 (58.74, 70.2%) and 1.8 (1.3, 2.3); mixed central venous 66.8 (61.2, 73.1%) and 1.8 (1.3, 2.2), p < 0.05. The best intraclass correlation coefficient for oxygen saturation were from central vein to mixed central vein 0.856 (0.760,0.914); and lactate: 0.954 (0.923, 0.972). Conclusions: The oxygen saturation differs in the venous-arterial circuit unlike lactate where they are similar. The best values of the intraclass correlation coefficient for lactate and oxygen saturation were those obtained in central vein and mixed central vein.

Venous-arterial oxygen saturation and serum lactate in the postoperative period of cardiac surgery.

INTRODUCTION: Oxygen saturation and lactate are markers of tissue hypoxia; they are obtained from central venous and mixed venous sample of the pulmonary artery. The simultaneous behavior of these parameters in the postoperative period of cardiac surgery is unknown. OBJECTIVE: To characterize the lactate and oxygen saturation of the venous-arterial circuit of the postoperative patient from cardiac surgery. METHODS: Design: Analytical cross-sectional. In consecutive patients after cardiac surgery, serum lactate and oxygen saturation of the venous-arterial circuit were obtained. The variables were reported with median (25.75 percentiles). They were analyzed with Kruskal-Wallis ANOVA and respective adjustment, Spearman correlation, the descriptive Bland-Altman statistic and intraclass correlation coefficient (95% confidence interval). A p < 0.05 was considered significant. RESULTS: 244 blood samples from 61 patients were studied. Women 30 (49%). (Oxygen saturation) [lactate] were: arterial 98 (95.3, 99.4%) and 1.7 (1.1, 2.1); peripheral venous 85 (75.4, 94%) and [1.9 (1.35, 2.3)]; central venous 68.8 (58.74, 70.2%) and 1.8 (1.3, 2.3); mixed central venous 66.8 (61.2, 73.1%) and 1.8 (1.3, 2.2), p < 0.05. The best intraclass correlation coefficient for oxygen saturation were from central vein to mixed central vein 0.856 (0.760,0.914); and lactate: 0.954 (0.923, 0.972). CONCLUSIONS: The oxygen saturation differs in the venous-arterial circuit unlike lactate where they are similar. The best values of the intraclass correlation coefficient for lactate and oxygen saturation were those obtained in central vein and mixed central vein.

INTRODUCCIÓN: La saturación de oxígeno y el lactato son marcadores de hipoxia tisular, se obtienen de muestra venosa mezclada en arteria pulmonar o venosa central. Se desconoce el comportamiento simultáneo de estos parámetros en el postoperatorio de cirugía cardiaca. OBJETIVO: Caracterizar la saturación de oxígeno y lactato del circuito venoso-arterial del paciente postoperado de cirugía cardiaca. MÉTODOS: Diseño transversal analítico. En pacientes consecutivos postoperados de cirugía cardiaca se obtuvieron lactato sérico y saturación de oxígeno del circuito venoso-arterial. Las variables se informaron con mediana (percentiles 25 y 75). Se analizaron con ANOVA de Kruskal-Wallis y ajuste respectivo, correlación de Spearman, el estadístico descriptivo de Bland-Altman y coeficiente de correlación intraclase (intervalo de confianza al 95%). Una p < 0.05 se consideró significativa. RESULTADOS: Se estudiaron 244 muestras sanguíneas de 61 pacientes. Mujeres 30 (49%). Saturación de oxígeno y lactato fueron: arterial 98 (95.3, 99.4)% y 1.7 (1,1, 2.1); venosa periférica 85 (75.4, 94)% y 1.9 (1.35, 2.3); venosa central 68.8 (58.74, 70.2)% y 1.8 (1.3, 2.3); venosa central mezclada 66.8 (61.2, 73.1)% y 1.8 (1.3, 2.2), p < 0.05. El mejor coeficiente de correlación intraclase para la saturación de oxígeno fue de vena central a vena central mezclada: 0.856 (0.760, 0.914); del lactato: 0.954 (0.923, 0.972). CONCLUSIONES: La saturación de oxígeno difiere en el circuito venoso-arterial a diferencia del lactato, donde son similares. Los mejores valores del coeficiente de correlación intraclase para el lactato y la saturación de oxígeno fueron los obtenidos en vena central y vena central mezclada.

Aortic Perforation and Ascending Dissection Due to Intra-Aortic Balloon Counterpulsation Implantation in Cardiac Surgery.

The intra-aortic balloon pump continues to be a useful ventricular assist device in cardiac surgery. Complications are estimated to be 7% to 40%, significantly high to catastrophic. We describe an aortic injury associated with the use of the device and an interdisciplinary management for the diagnostic and therapeutic approach. (Level of Difficulty: Intermediate.).

Pulmonary Congestion Assessed by Lung Ultrasound and Cardiovascular Outcomes in Patients With ST-Elevation Myocardial Infarction.

Background: Lung ultrasound (LUS) shows a higher sensitivity when compared with physical examination for the detection of pulmonary congestion. The objective of our study was to evaluate the association of pulmonary congestion assessed by LUS after reperfusion therapy with cardiovascular outcomes in patients with ST-segment Elevation acute Myocardial Infarction (STEMI) who received reperfusion therapy. Methods: A prospective observational study including patients with STEMI from the PHASE-Mx study. LUS was performed in four thoracic sites (two sites in each hemithorax). We categorized participants according to the presence of pulmonary congestion. The primary endpoint of the study was the composite of death for any cause, new episode or worsening of heart failure, recurrent myocardial infarction and cardiogenic shock at 30 days of follow-up. Results: A total of 226 patients were included, of whom 49 (21.6%) patients were classified within the "LUS-congestion" group and 177 (78.3%) within the "non-LUS-congestion" group. Compared with patients in the "non-LUS-congestion" group, patients in the "LUS-congestion" group were older and had higher levels of blood urea nitrogen and NT-proBNP. Pulmonary congestion assessed by LUS was significantly associated with a higher risk of the primary composite endpoint (HR: 3.8, 95% CI 1.91-7.53, p = 0.001). Differences in the primary endpoint were mainly driven by an increased risk of heart failure (HR 3.91; 95%CI 1.62-9.41, p = 0.002) and cardiogenic shock (HR 3.37; 95%CI 1.30-8.74, p = 0.012). Conclusion: The presence of pulmonary congestion assessed by LUS is associated with increased adverse cardiovascular events, particularly heart failure and cardiogenic shock. The application of LUS should be integrated as part of the initial risk stratification in patients with STEMI as it conveys important prognostic information.

Endotheliitis, Shunts, and Ventilation-Perfusion Mismatch in Coronavirus Disease 2019: A Literature Review of Disease Mechanisms.

The severe acute respiratory syndrome coronavirus 2 pandemic has continued to impact global health. However, while immunity acquired by vaccines has been developed, 40% of the world's population has still not been vaccinated. Economic problems associated with acquiring novel therapies, misinformation, and differences in treatment protocols have generated catastrophic results, especially in low-resource countries. Understanding the pathophysiological aspects of coronavirus disease and the therapeutic strategies that have been validated to date is essential for successful medical care. In this review, I summarize the historical aspects of the virus, molecules involved in infecting the host, and consequences of viral interactions with and in tissues.

Gender differences in mortality in patients with ST-segment elevation myocardial infarction / Diferencias de género en la mortalidad en pacientes con infarto de miocardio con elevación del segmento ST

Abstract Objective: Women with ST-segment elevation myocardial infarction (STEMI) have worst outcomes than men. The objective of the study was to determine gender differences in mortality in patients with STEMI. Methods: Cohort study including patients with STEMI. We recorded demographic and clinical data, laboratory tests, and in-hospital mortality in patients who underwent primary angioplasty and pharmacoinvasive strategy. Kaplan-Meier analysis was used to assess mortality differences between both genders. Results: A total of 340 patients were analyzed, 296 males and 44 females. Mean age of the female group was 64.3 ± 12.3 years. About 98% of females were among Killip-Kimball Class I-II. They had higher risk scores compared to man, longer ischemic time and first medical contact with a difference in comparison to man of 47 and 60 min, respectively. Mortality was 9.1% (4) in the female group. Conclusions: Although the proportion of women had higher mortality than man, we did not found any difference with statistical significance probably due to the lack of representation. We need more awareness in the female population about STEMI, since longer first medical contact time and longer total ischemic time might be one possible explanation of a higher mortality.

Resumen Objetivo: Las mujeres con infarto agudo al miocardio con elevación del segmento ST (SICA CEST) tienen peor pronóstico que los hombres. El objetivo fue determinar las diferencias de mortalidad en género en pacientes con SICA CEST. Metodos: Estudio de cohorte de pacientes con SICA CEST. Se recolectaron datos demográficos, clínicos, de laboratorio y mortalidad intrahospitalaria. Se realizó un análisis de Kaplan-Meier para valorar la mortalidad y determinar diferencias de género. Resultados: Se analizaron 340 pacientes, 296 hombres y 44 mujeres. Se observó que las mujeres tuvieron mayores puntajes en los scores de riesgo, mayor tiempo de primer contacto y tiempo total de isquemia encontrando una diferencia con el grupo de hombres de 47 y 60 minutos respectivamente. La mortalidad intrahospitalaria fue de 9.1% (4) sin diferencia estadísticamente significativa en comparación con los hombres. Conclusiones: Aunque la proporción de mujeres tuvo mayor mortalidad no se encontró diferencia estadísticamente significativa en comparación con los hombres probablemente por el tamaño de la muestra debido a baja representación del grupo femenino. Se necesita mayor conciencia en relación al infarto en el grupo de mujeres, ya que mayor tiempo de primer contacto y mayor tiempo total de isquemia pueden ser una posible explicación de una mayor mortalidad.

Demographic description and outcomes of a metropolitan network for myocardial infarction treatment / Descripción demográfica y desenlaces de una red metropolitana de atención para el infarto agudo de miocardio

Abstract Objective: The objective of the study was to describe the myocardial infarction treatment network and compare in-hospital mortality in patients undergoing either primary angioplasty or pharmacoinvasive strategy in Mexico City and a broad metropolitan area. Methods: Cohort study including patients with ST-elevation myocardial infarction. We recorded demographic and clinical data, laboratory tests and in-hospital mortality in patients that underwent primary angioplasty and pharmacoinvasive strategy. Kaplan-Meier analysis was used to assess mortality and Cox-regression assessed mortality risk factors. Results: Three hundred forty patients from a network of 60 hospitals and 9 states were analyzed. Of the total population, 166 were treated with pharmacoinvasive strategy and 174 with primary angioplasty. Door to thrombolytic time was 54 min and door to wire crossing time was 72.5 min; no differences in total ischemia time were demonstrated. No differences for in-hospital mortality (6.3% vs. 5.4%, p = 0.49) were found when comparing pharmacoinvasive and primary angioplasty groups. The main predictors for in-hospital mortality were: glucose > 180 mg/dl (HR 3.73), total ischemia time > 420 min (HR 3.18), heart rate > 90 bpm (HR 5.46), Killip and Kimball > II (HR 11.03), and left ventricle ejection fraction < 40% (HR 3.21). Conclusions: This myocardial infarction network covers a large area and constitutes one of the biggest in the world. There were no differences regarding in-hospital mortality between pharmacoinvasive strategy and primary angioplasty. Pharmacoinvasive strategy is an effective and safe option for prompt reperfusion in Mexico.

Resumen Objetivo: Describir la red de atención de infarto agudo de miocardio y comparar los desenlaces intrahospitalarios en pacientes tratados con angioplastía coronaria o estrategia farmacoinvasiva en la Ciudad de México y su área metropolitana. Métodos: Estudio de cohorte que incluyó pacientes con infarto agudo de miocardio con elevación del segmento ST. Se recabaron datos demográficos y clínicos, así como estudios de laboratorio y mortalidad intrahospitalaria en los pacientes que fueron tratados con angioplastía coronaria o estrategia farmacoinvasiva. Se realizó un análisis de Kaplan-Meier para describir la mortalidad y un modelo de regresión de Cox para evaluar los factores asociados a mortalidad. Resultados: Se analizaron 340 pacientes provenientes de una red compuesta por 60 hospitales. Del total de la población, 166 fueron tratados con estrategia farmacoinvasiva y 174 con angioplastía primaria. El tiempo puerta-aguja fue 54 min. y el tiempo puerta-dispositivo de 72.5 min.; no se encontraron diferencias en el tiempo total de isquemia. Además, no existieron diferencias en la mortalidad intrahospitalaria (6.3% vs. 5.4%, p = 0.49) al comparar la estrategia farmacoinvasiva y la angioplastía primaria. Los principales predictores de mortalidad intrahospitalaria fueron: glucosa > 180 mg/dl (HR 3.73), tiempo total de isquemia > 420 min. (HR 3.18), frecuencia cardiaca > 90 lpm (HR 5.46), Killip and Kimball > II (HR 11.03) y fracción de eyección < 40% (HR 3.21). Conclusiones: En esta red de atención al infarto agudo de miocardio no se encontraron diferencias en la mortalidad intrahospitalaria entre la estrategia farmacoinvasiva y la angioplastia primaria. La estrategia farmacoinvasiva puede ser una alternativa efectiva y segura para lograr reperfusión adecuada en México.

Pharmacoinvasive Strategy vs Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction: Results From a Study in Mexico City.

BACKGROUND: A low proportion of patients with ST-elevation myocardial infarction (STEMI) in low- to middle-income countries receive reperfusion therapy. Although primary percutaneous coronary intervention (PCI) is the method of choice, a pharmacoinvasive strategy (PIs) is reasonable when primary PCI cannot be delivered on a timely basis. The aim of our study was to assess the efficacy and safety of a PIs compared with primary PCI in a real-world setting. METHODS: This was a prospective registry that included patients with STEMI who received reperfusion during the first 12 hours from symptom onset. The primary composite end point was the occurrence of cardiovascular death, cardiogenic shock, recurrent myocardial infarction, or congestive heart failure at 30 days according to the reperfusion strategy used. The key safety end point was major bleeding (Bleeding Academic Research Consortium [BARC] score 3-5) at 30 days. RESULTS: We included 579 patients with STEMI, 49.7% underwent primary PCI and 50.2% received PIs. Those who received a PIs approach were more likely to present with Killip class > 1 and to have a history of diabetes but were less likely to have a previous cardiovascular disease diagnosis. No statistically significant difference was shown in the primary composite end point according to reperfusion strategy (hazard ratio for PIs, 0.76; 95% confidence interval, 0.48-1.21; P = 0.24). Major bleeding was not different among groups (hazard ratio for PIs, 0.92; 95% confidence interval, 0.45-1.86; P = 0.81). Two patients in the PIs group (0.6%) and no patients in the PCI group had intracranial bleeding (P = 0.15). CONCLUSIONS: In this prospective real-world registry, major cardiovascular outcomes and bleeding were not different among patients who underwent a PIs or primary PCI. The study suggests that a PIs is an effective and safe option for patients with STEMI when access to primary PCI is limited.

CONTEXTE: Une faible proportion des patients qui subissent un infarctus du myocarde avec élévation du segment ST (STEMI) dans les pays à revenus faibles/intermédiaires reçoivent un traitement de reperfusion. Même si l'intervention coronarienne percutanée (ICP) primaire constitue la méthode de prédilection, une stratégie pharmaco-invasive  représente une option raisonnable lorsque l'ICP primaire ne peut être réalisée dans un délai acceptable. Cette étude visait à évaluer l'efficacité et l'innocuité d'une stratégie pharmaco-invasive comparativement à une ICP primaire dans la pratique courante. MÉTHODOLOGIE: Cette étude consistait en une étude de registre prospective et regroupait des patients présentant un STEMI et ayant subi une reperfusion pendant les 12 heures suivant l'apparition des symptômes. Le principal critère d'évaluation regroupé correspondait à l'occurrence du décès cardiovasculaire, du choc cardiogénique, d'une récidive de l'infarctus du myocarde ou d'une insuffisance cardiaque congestive dans les 30 jours suivants, selon la stratégie de reperfusion utilisée. Le principal critère d'évaluation de l'innocuité était les hémorragies majeures (score de 3 à 5 selon le Bleeding Academic Research Consortium [BARC]) à 30 jours. RÉSULTATS: L'étude regroupait 579 patients présentant un STEMI, dont 49,7 % avaient subi une ICP primaire et 50,2 % avaient reçu une stratégie pharmaco-invasive. Les patients ayant reçu une stratégie pharmaco-invasive étaient plus susceptibles de présenter une classe de Killip > 1 et des antécédents de diabète, mais étaient moins susceptibles d'avoir déjà reçu un diagnostic de maladie cardiovasculaire. Aucune différence significative sur le plan statistique n'a été observée pour ce qui est du principal critère d'évaluation regroupé selon la stratégie de reperfusion (rapport des risques instantanés [RRI] de la stratégie pharmaco-invasive : 0,76; intervalle de confiance [IC] à 95 % : 0,48-1,21; p = 0,24). Aucune différence n'a été observée entre les groupes quant aux hémorragies majeures (RRI de la stratégie pharmaco-invasive : 0,92; IC à 95 % : 0,45-1,86; p = 0,81). Deux patients du groupe ayant reçu une stratégie pharmaco-invasive (0,6 %) ont présenté une hémorragie intracrânienne, comparativement à aucun patient du groupe ayant subi une ICP (p = 0,15). CONCLUSIONS: Selon cette étude de registre prospective en pratique courante, les résultats concernant les hémorragies et les événements cardiovasculaires majeurs n'ont pas été différents entre les patients ayant subi une ICP primaire et ceux ayant reçu une stratégie pharmaco-invasive. L'étude suggère que la stratégie pharmaco-invasive constitue une option sûre et efficace pour les patients qui présentent un STEMI, lorsque l'accès à une ICP primaire est limité.

Demographic description and outcomes of a metropolitan network for myocardial infarction treatment.

OBJECTIVE: The objective of the study was to describe the myocardial infarction treatment network and compare in-hospital mortality in patients undergoing either primary angioplasty or pharmacoinvasive strategy in Mexico City and a broad metropolitan area. METHODS: Cohort study including patients with ST-elevation myocardial infarction. We recorded demographic and clinical data, laboratory tests and in-hospital mortality in patients that underwent primary angioplasty and pharmacoinvasive strategy. Kaplan-Meier analysis was used to assess mortality and Cox-regression assessed mortality risk factors. RESULTS: Three hundred forty patients from a network of 60 hospitals and 9 states were analyzed. Of the total population, 166 were treated with pharmacoinvasive strategy and 174 with primary angioplasty. Door to thrombolytic time was 54 min and door to wire crossing time was 72.5 min; no differences in total ischemia time were demonstrated. No differences for in-hospital mortality (6.3% vs. 5.4%, p = 0.49) were found when comparing pharmacoinvasive and primary angioplasty groups. The main predictors for in-hospital mortality were: glucose > 180 mg/dl (HR 3.73), total ischemia time > 420 min (HR 3.18), heart rate > 90 bpm (HR 5.46), Killip and Kimball > II (HR 11.03), and left ventricle ejection fraction < 40% (HR 3.21). CONCLUSIONS: This myocardial infarction network covers a large area and constitutes one of the biggest in the world. There were no differences regarding in-hospital mortality between pharmacoinvasive strategy and primary angioplasty. Pharmacoinvasive strategy is an effective and safe option for prompt reperfusion in Mexico.

Gender differences in mortality in patients with ST-segment elevation myocardial infarction / Diferencias de género en la mortalidad en pacientes con infarto de miocardio con elevación del segmento ST

BACKGROUND: Women with ST-segment elevation myocardial infarction (STEMI) have worst outcomes than men. OBJECTIVE: The objective of the study was to determine gender differences in mortality in patients with STEMI. METHODS: Cohort study including patients with STEMI. We recorded demographic and clinical data, laboratory tests, and in-hospital mortality in patients who underwent primary angioplasty and pharmacoinvasive strategy. Kaplan-Meier analysis was used to assess mortality differences between both genders. RESULTS: A total of 340 patients were analyzed, 296 males and 44 females. Mean age of the female group was 64.3 ± 12.3 years. About 98% of females were among Killip-Kimball Class I-II. They had higher risk scores compared to man, longer ischemic time and first medical contact with a difference in comparison to man of 47 and 60 min, respectively. Mortality was 9.1% (4) in the female group. CONCLUSIONS: Although the proportion of women had higher mortality than man, we did not found any difference with statistical significance probably due to the lack of representation. We need more awareness in the female population about STEMI, since longer first medical contact time and longer total ischemic time might be one possible explanation of a higher mortality.

Evaluation of pharmacoinvasive strategy versus percutaneous coronary intervention in patients with acute myocardial infarction with ST-segment elevation at the National Institute of Cardiology (PHASE-MX).

Objective: The objective of PHASE-MX registry is to validate the efficacy and safety of the pharmacoinvasive strategy in comparison with percutaneous coronary intervention (PCI) in patients with acute myocardial infarction with ST segment elevation (STEMI) in a metropolitan region of Mexico. The primary outcome will consist of the composite of cardiovascular death, re-infarction, stroke and cardiogenic shock. Methods: The PHASE-MX registry will include a prospective cohort of patients with STEMI who received reperfusion treatment (mechanical of pharmacological) in the first 12 h after the onset of symptoms. The registry is designed to compare the efficacy and safety of primary PCI and pharmacoinvasive strategy. The simple size was calculated in 344 patients divided into two groups, with an estimated loss rate of 10%. Patients included in the PHASE-MX cohort will be followed for up to one year. Conclusion: In Mexico, only 5 out of 10 patients with STEMI have access to reperfusion therapy. Pharmacoinvasive strategy is takes advantage of the accessibility of fibrinolysis and the effectiveness of PCI. The present research protocol aims to provide information that serves as a link between information derived from controlled clinical trials and records derived from real world experience.

Objetivo: El objetivo del registro PHASE-MX es validar la eficacia y seguridad de la estrategia farmacoinvasiva en comparación con la angioplastia coronaria transluminal percutánea primaria (ACTPp) en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) en una región metropolitana de México. El desenlace primario es el compuesto de muerte cardiovascular, reinfarto, accidente vascular cerebral y choque cardiogénico. Métodos: El registro PHASE-MX es una cohorte prospectiva de pacientes con IAMCEST que recibieron tratamiento de reperfusión (mecánico o farmacológico) en las primeras 12 horas desde el inicio de los síntomas, atendidos en el Instituto Nacional de Cardiología Ignacio Chávez. El análisis estadístico se basa en la no inferioridad de la estrategia farmacoinvasiva en comparación con la ACTPp. Se calcula un tamaño de muestra de 344 pacientes divididos en dos grupos (angioplastia primaria y estrategia farmacoinvasiva), considerada una tasa de pérdidas de 10%. Los pacientes incluidos en la cohorte PHASE-MX se seguirán durante un año. Discusión: En México, sólo 5 de cada 10 pacientes con IAMCEST tienen acceso al tratamiento de reperfusión. La estrategia farmacoinvasiva aprovecha la accesibilidad de la fibrinólisis y la efectividad de la ACTPp, por lo que podría resultar el método de elección en el tratamiento del IAMCEST en la mayoría de los casos. El presente protocolo de investigación pretende aportar información que sirva como enlace entre la información derivada de los estudios clínicos controlados y los registros derivados de la experiencia del mundo real.

Evaluation of pharmacoinvasive strategy versus percutaneous coronary intervention in patients with acute myocardial infarction with ST-segment elevation at the National Institute of Cardiology (PHASE-MX) / Evaluación de la estrategia farmacoinvasiva versus angioplastia coronaria transluminal percutánea primaria en pacientes con infarto agudo de miocardio con elevación del segmento ST en el Instituto Nacional de Cardiología (PHASE-MX)

Abstract Objective: The objective of PHASE-MX registry is to validate the efficacy and safety of the pharmacoinvasive strategy in comparison with percutaneous coronary intervention (PCI) in patients with acute myocardial infarction with ST segment elevation (STEMI) in a metropolitan region of Mexico. The primary outcome will consist of the composite of cardiovascular death, re-infarction, stroke and cardiogenic shock. Methods: The PHASE-MX registry will include a prospective cohort of patients with STEMI who received reperfusion treatment (mechanical of pharmacological) in the first 12 h after the onset of symptoms. The registry is designed to compare the efficacy and safety of primary PCI and pharmacoinvasive strategy. The simple size was calculated in 344 patients divided into two groups, with an estimated loss rate of 10%. Patients included in the PHASE-MX cohort will be followed for up to one year. Conclusion: In Mexico, only 5 out of 10 patients with STEMI have access to reperfusion therapy. Pharmacoinvasive strategy is takes advantage of the accessibility of fibrinolysis and the effectiveness of PCI. The present research protocol aims to provide information that serves as a link between information derived from controlled clinical trials and records derived from real world experience.

Resumen Objetivo: El objetivo del registro PHASE-MX es validar la eficacia y seguridad de la estrategia farmacoinvasiva en comparación con la angioplastia coronaria transluminal percutánea primaria (ACTPp) en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) en una región metropolitana de México. El desenlace primario es el compuesto de muerte cardiovascular, reinfarto, accidente vascular cerebral y choque cardiogénico. Métodos: El registro PHASE-MX es una cohorte prospectiva de pacientes con IAMCEST que recibieron tratamiento de reperfusión (mecánico o farmacológico) en las primeras 12 horas desde el inicio de los síntomas, atendidos en el Instituto Nacional de Cardiología Ignacio Chávez. El análisis estadístico se basa en la no inferioridad de la estrategia farmacoinvasiva en comparación con la ACTPp. Se calcula un tamaño de muestra de 344 pacientes divididos en dos grupos (angioplastia primaria y estrategia farmacoinvasiva), considerada una tasa de pérdidas de 10%. Los pacientes incluidos en la cohorte PHASE-MX se seguirán durante un año. Discusión: En México, sólo 5 de cada 10 pacientes con IAMCEST tienen acceso al tratamiento de reperfusión. La estrategia farmacoinvasiva aprovecha la accesibilidad de la fibrinólisis y la efectividad de la ACTPp, por lo que podría resultar el método de elección en el tratamiento del IAMCEST en la mayoría de los casos. El presente protocolo de investigación pretende aportar información que sirva como enlace entre la información derivada de los estudios clínicos controlados y los registros derivados de la experiencia del mundo real.

Evaluation of pharmacoinvasive strategy versus percutaneous coronary intervention in patients with acute myocardial infarction with ST segment elevation at the National Institute of Cardiology (PHASE-MX).

Objective: The objective of PHASE-MX registry is to validate the efficacy and safety of the pharmacoinvasive strategy in comparison with percutaneous coronary intervention (PCI) in patients with acute myocardial infarction with ST segment elevation (STEMI) in a metropolitan region of Mexico. The primary outcome will consist of the composite of cardiovascular death, re-infarction, stroke and cardiogenic shock. Methods: The PHASE-MX registry will include a prospective cohort of patients with STEMI who received reperfusion treatment (mechanical of pharmacological) in the first 12 h after the onset of symptoms. The registry is designed to compare the efficacy and safety of primary PCI and pharmacoinvasive strategy. The simple size was calculated in 344 patients divided into two groups, with an estimated loss rate of 10%. Patients included in the PHASE-MX cohort will be followed for up to one year. Conclusion: In Mexico, only 5 out of 10 patients with STEMI have access to reperfusion therapy. Pharmacoinvasive strategy is takes advantage of the accessibility of fibrinolysis and the effectiveness of PCI. The present research protocol aims to provide information that serves as a link between information derived from controlled clinical trials and records derived from real world experience.

Objetivo: El objetivo del registro PHASE-MX es validar la eficacia y seguridad de la estrategia farmacoinvasiva en comparación con la angioplastia coronaria transluminal percutánea primaria (ACTPp) en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) en una región metropolitana de México. El desenlace primario es el compuesto de muerte cardiovascular, reinfarto, accidente vascular cerebral y choque cardiogénico. Métodos: El registro PHASE-MX es una cohorte prospectiva de pacientes con IAMCEST que recibieron tratamiento de reperfusión (mecánico o farmacológico) en las primeras 12 horas desde el inicio de los síntomas, atendidos en el Instituto Nacional de Cardiología Ignacio Chávez. El análisis estadístico se basa en la no inferioridad de la estrategia farmacoinvasiva en comparación con la ACTPp. Se calcula un tamaño de muestra de 344 pacientes divididos en dos grupos (angioplastia primaria y estrategia farmacoinvasiva), considerada una tasa de pérdidas de 10%. Los pacientes incluidos en la cohorte PHASE-MX se seguirán durante un año. Discusión: En México, sólo 5 de cada 10 pacientes con IAMCEST tienen acceso al tratamiento de reperfusión. La estrategia farmacoinvasiva aprovecha la accesibilidad de la fibrinólisis y la efectividad de la ACTPp, por lo que podría resultar el método de elección en el tratamiento del IAMCEST en la mayoría de los casos. El presente protocolo de investigación pretende aportar información que sirva como enlace entre la información derivada de los estudios clínicos controlados y los registros derivados de la experiencia del mundo real.

Atrial fibrillation in cardiac surgery.

Atrial fibrillation is the most frequent arrhythmia in the postoperative period of cardiac surgery. It is associated with heart failure, renal insufficiency, systemic embolism and increase in days of in-hospital and mortality. Atrial fibrillation in the postoperative period of cardiac surgery (FAPCC) usually appears in the first 48 h after surgery. The main mechanisms involved in the appearance and maintenance of FAPCC are the increase in sympathetic tone and the inflammatory response. The associated risk factors are advanced age, chronic obstructive pulmonary disease, chronic kidney disease, valve surgery, fraction of ejection of the left ventricle < 40% and the withdrawal of beta-blocker drugs. There are instruments that have been shown to predict the appearance of FAPCC. Prophylactic treatment with beta-blockers and amiodarone, is associated with a decrease in the appearance of FAPCC. Given its transient nature, it is suggested that the initial treatment of FAPCC be the heart rate control and only if the treatment does not achieve a return to sinus rhythm, the use of electrical cardioversion is suggested. It is unknown what should be the long-term follow-up and complications beyond this period are little known. FAPCC is not a benign or isolated arrhythmia in patients undergoing cardiac surgery, so the identification of risk factors, their prevention, and follow-up in the outpatient setting, should be part of the units dedicated to the care and care of these patients.

La fibrilación auricular es la arritmia más frecuente en el periodo posquirúrgico de la cirugía cardíaca. Se relaciona con insuficiencia cardíaca, insuficiencia renal, embolismo sistémico y más días de estancia y mortalidad. La fibrilación auricular en el periodo posquirúrgico de la cirugía cardíaca (FAPCC) suele aparecer en las primeras 48 horas. Los principales mecanismos que producen la aparición y el mantenimiento de la FAPCC son el aumento del tono simpático y la respuesta inflamatoria. Los factores de riesgo adjuntos son la edad avanzada, enfermedad pulmonar obstructiva crónica, enfermedad renal crónica, cirugía valvular, fracción de expulsión del ventrículo izquierdo menor de 40% e interrupción de fármacos bloqueadores ß. Existen instrumentos que han demostrado predecir la aparición de FAPCC. El tratamiento profiláctico con bloqueadores ß y amiodarona se relaciona con disminución de la aparición de FAPCC. Dada su naturaleza transitoria, se sugiere que el tratamiento inicial de FAPCC sea el control de la frecuencia cardíaca y sólo en caso de que el tratamiento no consiga el retorno al ritmo sinusal está indicada la cardioversión eléctrica. Se desconoce cuál debe ser el seguimiento a largo plazo y sólo se conocen en escasa medida las complicaciones más allá de este periodo. La FAPCC no es una arritmia benigna ni aislada en los pacientes sometidos a operación cardíaca, por lo que la identificación de los factores de riesgo, su prevención y el seguimiento en el ámbito ambulatorio deben formar parte de las unidades dedicadas a la atención y los cuidados de estos pacientes.