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

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

[Deferred versus immediate stenting in patients with ST - segment elevation myocardial infarction and residual large thrombus burden reclassified in the culprit lesion]. / Stent diferido versus inmediato en pacientes con infarto de miocardio ST elevado y alta carga de trombo residual reclasificado en la lesión culpable.

BACKGROUND: Reclassification of a large thrombus burden is an independent predictor of major adverse cardiac events and no-reflow in patients with ST- segment elevation myocardial infarction (STEMI). Patients with a greater residual thrombus burden have worse microvascular dysfunction and greater myocardial damage. METHODS: A retrospective analysis was performed on 833 STEMI patients who underwent primary percutaneous coronary intervention. The final residual thrombus burden was reclassified after the lesion was wired, and a thrombus aspiration or balloon dilatation was performed to restore and stabilise a thrombolysis in myocardial infarction (TIMI) 2-3 flow. Deferred stenting (DEI) was compared with immediate stenting (ISI) group, and the primary outcome was the incidence of no-/slow-reflow (TIMI ≤ 2, or TIMI 3 with myocardial blush grade < 2). RESULTS: Overall, 47 patients (6.8%) had a residual large thrombus burden reclassified. The right coronary artery was the culprit vessel in 34 cases. More patients had coronary ectasia in the DSI group (P=.005). Fewer patients in the DSI had no-/slow-reflow (36% vs. 58%), and the myocardial blush grade 3 was more frequent in the DSI group (P=.005). After repeat coronary angiography in the DSI group, stenting was not performed in 56%, and oral anticoagulation was more frequent in the follow-up (P=.031). Major cardiac adverse events were similar between groups. There was a tendency to better left ventricular function in the DSI group (P=.056). CONCLUSIONS: Deferred stenting may be an efficient option in STEMI patients with a residual large thrombus burden reclassified after achieving a stable TIMI 2-3 flow.

Stent diferido versus inmediato en pacientes con infarto de miocardio ST elevado y alta carga de trombo residual reclasificado en la lesión culpable / Deferred versus immediate stenting in patients with ST - segment elevation myocardial infarction and residual large thrombus burden reclassified in the culprit lesion

Resumen Introducción: Un trombo intracorononario largo reclasificado es un predictor independiente de resultados adversos y no reflujo en el infarto agudo de miocardio con elevación del ST. Pacientes con mayor carga de trombo residual tienen peor disfunción microvascular y mayor daño miocárdico. Métodos: Evaluamos retrospectivamente a 833 pacientes que fueron a angioplastia primaria entre enero del 2011 y junio del 2016. La carga de trombo residual final fue reclasificada tras realizar el cruce de la guía, predilatación con balón o tromboaspiración, para restaurar y estabilizar un flujo TIMI 2-3. Las estrategias de stent diferido vs. stent inmediato fueron comparadas, siendo el objetivo primario la incidencia de no reflujo (TIMI ≤ 2, o TIMI 3 con TMP < 2). Resultados: Cuarenta y siete pacientes (6.8%) presentaron una alta carga trombo residual reclasificado. La coronaria derecha fue la arteria culpable en 34 casos. Hubo mayor frecuencia de ectasia coronaria en el grupo de stent diferido (p = 0.005). Se encontraron menores tasas de no reflujo en el stent diferido (36% vs. 58%), con una mayor frecuencia de un TMP 3 (p = 0.005). Tras la nueva cateterización un 56% quedó libre de stent en el grupo diferido y la anticoagulación oral les fue más frecuentemente indicada (p = 0.031). La tasa de eventos cardiacos adversos mayores fue similar entre los grupos. Hubo una tendencia a una mejor función ventricular izquierda en el grupo diferido (p = 0.056). Conclusiones: El stent diferido puede ser una alternativa eficiente en pacientes con IAM CEST y alta carga de trombo residual reclasificado, después de conseguir un flujo TIMI 2-3 estable.

Abstract Background: Reclassification of a large thrombus burden is an independent predictor of major adverse cardiac events and no-reflow in patients with ST- segment elevation myocardial infarction (STEMI). Patients with a greater residual thrombus burden have worse microvascular dysfunction and greater myocardial damage. Methods: A retrospective analysis was performed on 833 STEMI patients who underwent primary percutaneous coronary intervention. The final residual thrombus burden was reclassified after the lesion was wired, and a thrombus aspiration or balloon dilatation was performed to restore and stabilise a thrombolysis in myocardial infarction (TIMI) 2-3 flow. Deferred stenting (DEI) was compared with immediate stenting (ISI) group, and the primary outcome was the incidence of no-/slow-reflow (TIMI ≤ 2, or TIMI 3 with myocardial blush grade < 2). Results: Overall, 47 patients (6.8%) had a residual large thrombus burden reclassified. The right coronary artery was the culprit vessel in 34 cases. More patients had coronary ectasia in the DSI group (P=.005). Fewer patients in the DSI had no-/slow-reflow (36% vs. 58%), and the myocardial blush grade 3 was more frequent in the DSI group (P=.005). After repeat coronary angiography in the DSI group, stenting was not performed in 56%, and oral anticoagulation was more frequent in the follow-up (P=.031). Major cardiac adverse events were similar between groups. There was a tendency to better left ventricular function in the DSI group (P=.056). Conclusions: Deferred stenting may be an efficient option in STEMI patients with a residual large thrombus burden reclassified after achieving a stable TIMI 2-3 flow.