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2.
Int J Cardiol ; 305: 35-41, 2020 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-32008846

RESUMO

OBJECTIVE: Relationship between STEMI time of presentation, its circadian pattern and cardiovascular outcomes is unclear. Our objective is to analyze clinical outcomes of STEMI according to time of presentation and circadian pattern. METHODS: We analyzed data from patients treated within the regional STEMI Network from January 2010 to December 2015. On-hour group included patients treated between 8:00 h and 19:59 h on weekdays, the rest were catalogued as off-hour group. The primary endpoint was 1-year all-cause mortality. Secondary endpoints were 30-day all-cause mortality and in-hospital complications. RESULTS: A total of 8608 patients were included, 44.1% in the on-hour group and 55.9% in the off-hour group. We observed a shorter patient delay and longer system delay in the off-hour group compared to on-hour group with no difference in total ischemic time. At 30-day and 1-year follow-up there were no differences in adjusted all-cause mortality between groups [OR 0.91 (CI95%: 0.73-1.12; p = 0.35) and OR 0.99 (CI95%: 0.83-1.17; p = 0.87), respectively]. A circadian pattern was observed between 9:00 am and 12:30 pm, with no differences in 30-day and 1-year mortality between patients included in this time interval [OR 1.02 (IC95%: 0.81-1.30; p = 0.85) and OR 1.12 (IC95%: 0.92-1.36; p = 0.25) respectively]. CONCLUSIONS: Off-hour STEMI presentation was associated with a shorter patient delay and longer system delay without an increase in total ischemic time. The off-hour presentation was not related to an increase in 1-year all-cause mortality when compared to on-hour. A circadian pattern was found, without differences in 30-day and 1-year mortality.

3.
Am J Cardiol ; 125(1): 11-18, 2020 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-31732135

RESUMO

Although older adults are the fastest-growing age group among cardiovascular patients, nonagenarians with ST-segment elevation myocardial infarction (STEMI) are under-represented in clinical trials. The aims of this study are to analyze the clinical presentation and outcomes of nonagenarian patients presenting with STEMI and to compare in-hospital and 1-year clinical outcomes between those treated with optimal medical treatment alone and those receiving primary percutaneous coronary intervention (pPCI). We included all consecutive nonagenarians presenting with STEMI admitted in 2 academic centers between 2006 and 2018. There were no exclusion criteria. All-cause mortality was assessed in-hospital and at 1-year follow-up. In total, 167 patients (mean age 91.9 ± 0.17 years; 60% females) were included. Emergent catheterization was performed in 60% of our patients, and pPCI was performed in 50% (n = 83). Overall mortality was 22% in-hospital and 41% at 1-year follow-up. The pPCI group had lower mortality than the medical treatment group: 12% versus 32% in-hospital (p <0.01) and 26% versus 45% at 1-year follow-up (p <0.01), respectively. Multivariable analysis identified 4 independent predictors of all-cause mortality at 1 year: mechanical complications (adjusted odds ratio [OR] 9.25, p <0.01), Killip class III/IV (adjusted OR 4.22, p <0.01), serum creatinine at admission (mg/dl; adjusted OR 1.8, p <0.01), and pPCI (adjusted OR 0.52; p <0.05). In conclusion, STEMI in nonagenarians is becoming increasingly common. pPCI may be the preferred strategy in this high-risk cohort when a high grade of disability is not present. Hemodynamic compromise, the presence of complications related to myocardial infarction, renal impairment, and early revascularization may be related to prognosis in these patients.

5.
BMJ Open ; 9(7): e028114, 2019 07 23.
Artigo em Inglês | MEDLINE | ID: mdl-31340964

RESUMO

OBJECTIVES: Guidelines recommending 12-month dual antiplatelet therapy (DAPT) in patients with ST-elevation acute coronary syndrome (STEACS) undergoing percutaneous coronary intervention (PCI) were published in year 2012. We aimed to describe the influence of guideline implementation on the trend in 12-month persistence with DAPT between 2010 and 2015 and to evaluate its relationship with DAPT duration regimens recommended at discharge from PCI hospitals. DESIGN: Observational study based on region-wide registry data linked to pharmacy billing data for DAPT follow-up. SETTING: All PCI hospitals (10) belonging to the acute myocardial infarction (AMI) code network in Catalonia (Spain). PARTICIPANTS: 10 711 STEACS patients undergoing PCI between 2010 and 2015 were followed up. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was 12-month persistence with DAPT. Calendar year quarter, publication of guidelines, DAPT duration regimen recommended in the hospital discharge report, baseline patient characteristics and significant interactions were included in mixed-effects logistic regression based interrupted time-series models. RESULTS: The proportion of patients on-DAPT at 12 months increased from 58% (56-60) in 2010 to 73% (71-75) in 2015. The rate of 12-month persistence with DAPT significantly increased after the publication of clinical guidelines with a time lag of 1 year (OR=1.20; 95% CI 1.11 to 1.30). A higher risk profile, more extensive and complex coronary disease, use of drug-eluting stents (OR=1.90; 95% CI 1.50 to 2.40) and a 12-month DAPT regimen recommendation at discharge from the PCI hospital (OR=5.76; 95% CI 3.26 to 10.2) were associated with 12-month persistence. CONCLUSION: Persistence with 12-month DAPT has increased since publication of clinical guidelines. Even though most patients were discharged on DAPT, only 73% with potential indication were on-DAPT 12 months after PCI. A guideline-based recommendation at PCI hospital discharge was highly associated with full persistence with DAPT. Establishing evidence-based, common prescribing criteria across hospitals in the AMI-network would favour adherence and reduce variability.

7.
EuroIntervention ; 15(11): e1006-e1013, 2019 Dec 06.
Artigo em Inglês | MEDLINE | ID: mdl-31235458

RESUMO

AIMS: The BIOFLOW-IV clinical trial was designed for regulatory submission in Japan. It assessed the safety and efficacy of a new third-generation sirolimus-eluting stent system with bioresorbable polymer (Orsiro, BP-SES) compared with an everolimus-eluting stent system with permanent polymer (XIENCE Prime/Xpedition, PP-EES). METHODS AND RESULTS: This prospective, international, multicentre, 2:1 randomised, non-inferiority trial enrolled 575 patients (385 BP-SES and 190 PP-EES) with 659 stenotic de novo lesions. Of these, 137 patients (23.8%) were Japanese. Follow-up until five years is ongoing. We herein report outcomes at 12 months. Baseline parameters were well balanced. Device success was 98.9% for BP-SES versus 99.6% for PP-EES, p=0.670. Non-inferiority related to 12-month target vessel failure was met (pnon-inferiority <0.001). Further, there was no significant difference in clinical outcomes between the groups. The target vessel failure rate was 5.5% for BP-SES and 7.5% for PP-EES, the target lesion failure rate was 4.2% versus 5.4%, and the definite or probable stent thrombosis rate was 0.8% versus 0%. CONCLUSIONS: The randomised BIOFLOW-IV trial provides further evidence on the safety and efficacy of the Orsiro BP-SES and its non-inferiority to the current benchmark, an everolimus-eluting permanent polymer stent. ClinicalTrials.gov: NCT01939249.


Assuntos
Doença da Artéria Coronariana , Stents Farmacológicos , Intervenção Coronária Percutânea , Implantes Absorvíveis , Doença da Artéria Coronariana/cirurgia , Vasos Coronários , Humanos , Japão , Estudos Prospectivos , Segurança , Sirolimo , Resultado do Tratamento
8.
Eur Heart J Case Rep ; 3(1): yty168, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31020244

RESUMO

Background: Spontaneous coronary artery dissection (SCAD) is an infrequent and often misdiagnosis of a non-atherosclerotic cause of acute coronary syndrome (ACS). It is an important cause of ACS in young women, responsible for up to 25% of all cases in women <50 years of age without cardiovascular risk factors. Clinical presentation ranges from ST-segment-elevation myocardial infarction (MI) to ventricular fibrillation and sudden death. The treatment of patients with SCAD is a challenge and the ideal management strategy has yet to be determined. Case summary: A 42-year-old woman without family history of cardiac disease and neither traditional atherosclerotic risk factors presented to our centre with an anterior acute ST-segment-elevation MI secondary to multiple spontaneous dissections of the left main, anterior descending, and ramus intermedius coronary arteries. Stenting was performed in the left anterior descending coronary artery and left main coronary artery to resolve its occlusion. Fibromuscular dysplasia was confirmed via computed tomography angiography. Discussion: More cases are now being identified of SCAD due to increased clinical index of suspicion, earlier use of invasive angiography, and intracoronary imaging in patients presenting with acute chest pain. Despite this, the absence of previous cardiovascular risk factors and the ignorance of this pathology delay the start of an adequate medical treatment and the performance of a cardiac catheterization. Prognostic data are limited, partly because of its underdiagnosis and lack of prospective studies, so its knowledge is necessary to improve the prognosis of these patients.

11.
J Heart Valve Dis ; 27(1): 114-116, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30560609

RESUMO

A patient with ischemic myocardiopathy who had undergone resynchronization therapy was admitted to the authors' institution with progressive dyspnea. Echocardiography demonstrated a left ventricular ejection fraction (LVEF) of 25%, with a massive mitral regurgitation (MR) secondary to anterior leaflet prolapse and posterior leaflet restriction. Despite intensive medical treatment, the patient developed cardiogenic shock and required mechanical ventilation, inotropic support and intra-aortic balloon pumping. The patient was rejected for surgery due to the high operative risk, but subsequently underwent a successful percutaneous repair with two MitraClip® devices. Immediately after the intervention there was a progressive improvement that allowed the patient to be discharged, such that the clinical outcome was favorable at the six-month follow up (NYHA class II/IV). This case report describes the benefits of minimally invasive therapy in selected patients who are at very high surgical risk and who, despite being in a critical condition and with low LVEF, experience an outstanding clinical improvement following the resolution of a massive MR.


Assuntos
Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Choque Cardiogênico/cirurgia , Doença Aguda , Humanos , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/fisiopatologia , Choque Cardiogênico/etiologia , Choque Cardiogênico/fisiopatologia , Volume Sistólico , Resultado do Tratamento
12.
EuroIntervention ; 14(11): e1207-e1214, 2018 Dec 07.
Artigo em Inglês | MEDLINE | ID: mdl-30222120

RESUMO

AIMS: The aim of this study was to evaluate the safety and efficacy of the BioMime sirolimus-eluting coronary stent (SES) compared to the XIENCE family of everolimus-eluting coronary stents (EES) in the treatment of patients with de novo native coronary artery lesions. METHODS AND RESULTS: The meriT-V is a prospective, multicentre, randomised, open-label, active-controlled, non-inferiority trial. A total of 256 patients with up to two de novo native coronary artery lesions were enrolled and randomly assigned (2:1) to BioMime SES or XIENCE EES. BioMime SES was non-inferior to XIENCE EES for the primary endpoint of in-stent late lumen loss (0.15±0.27 mm vs. 0.15±0.29 mm; difference: -0.006 mm; 95% confidence interval: -0.085 to 0.072; p=0.87; p for non-inferiority <0.0001) at nine-month follow-up. The major adverse cardiac events rate was numerically lower in the BioMime SES group (2.98% vs. 7.14%; p=0.13), driven by a statistically significant lower risk of any myocardial infarction (0.60% vs. 4.76%; p=0.03), when compared with the XIENCE EES group. There was no difference in target vessel myocardial infarction (p=0.62) between the groups. There was no definite or probable stent thrombosis in either group. CONCLUSIONS: In the treatment of de novo native coronary artery lesions, the biodegradable polymer ultra-thin SES (BioMime) was non-inferior to a durable polymer EES (XIENCE) at nine-month follow-up. Further studies powered for clinical endpoints are needed.


Assuntos
Doença da Artéria Coronariana , Stents Farmacológicos , Intervenção Coronária Percutânea , Implantes Absorvíveis , Everolimo , Humanos , Polímeros , Estudos Prospectivos , Sirolimo , Resultado do Tratamento
13.
JACC Cardiovasc Interv ; 11(10): 981-991, 2018 05 28.
Artigo em Inglês | MEDLINE | ID: mdl-29798776

RESUMO

OBJECTIVES: This study sought to compare the long-term safety and efficacy of drug-eluting balloons (DEB) and everolimus-eluting stents (EES) in patients with in-stent restenosis (ISR) of drug-eluting stents (DES). BACKGROUND: Treatment of patients with DES-ISR remains a challenge. METHODS: The RIBS IV (Restenosis Intra-Stent of Drug-Eluting Stents: Drug-Eluting Balloons vs Everolimus-Eluting Stents) trial is a prospective multicenter randomized clinical trial comparing DEB and EES in patients with DES-ISR. The pre-specified comparison of the 3-year clinical outcomes obtained with these interventions is the main objective of the present study. RESULTS: A total of 309 patients with DES-ISR were randomized to DEB (n = 154) or EES (n = 155). At angiographic follow-up, the in-segment minimal lumen diameter was larger in the EES arm (2.03 ± 0.7 mm vs. 1.80 ± 0.6 mm; p < 0.01). Three-year clinical follow-up was obtained in all enrolled patients (100%). The combined clinical outcome measure of cardiac death, myocardial infarction and target lesion revascularization was significantly reduced in the EES arm (19 [12.3%] vs. 31 [20.1%]; p = 0.04; hazard ratio: 0.57 [95% confidence interval: 0.34 to 0.96]), driven by a lower need for target lesion revascularization (11 [7.1%] vs. 24 [15.6%]; p = 0.015; hazard ratio: 0.43 [95% confidence interval: 0.21 to 0.87]). The need for "late" (>1 year) target lesion revascularization (2.6% vs. 4%) and target vessel revascularization (4% vs. 6.6%) was similar in the 2 arms. Rates of cardiac death (3.9% vs. 3.2%), myocardial infarction (2.6% vs. 4.5%), and stent thrombosis (1.3% vs. 2.6%) at 3 years were also similar in both arms. CONCLUSIONS: The 3-year clinical follow-up of this randomized clinical trial demonstrates that in patients with DES-ISR, EES reduce the need for repeat interventions compared with DEB. (Restenosis Intra-Stent of Drug-Eluting Stents: Drug-Eluting Balloons vs Everolimus-Eluting Stents [RIBS IV]; NCT01239940).


Assuntos
Angioplastia Coronária com Balão/instrumentação , Cateteres Cardíacos , Fármacos Cardiovasculares/administração & dosagem , Materiais Revestidos Biocompatíveis , Doença da Artéria Coronariana/terapia , Reestenose Coronária/terapia , Stents Farmacológicos , Everolimo/administração & dosagem , Intervenção Coronária Percutânea/instrumentação , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Fármacos Cardiovasculares/efeitos adversos , Doença da Artéria Coronariana/diagnóstico por imagem , Reestenose Coronária/diagnóstico por imagem , Reestenose Coronária/etiologia , Everolimo/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Estudos Prospectivos , Retratamento , Fatores de Risco , Espanha , Fatores de Tempo , Resultado do Tratamento
14.
Rev. esp. cardiol. (Ed. impr.) ; 71(4): 243-249, abr. 2018. ilus, tab, graf
Artigo em Espanhol | IBECS | ID: ibc-171751

RESUMO

Introducción y objetivos. Una red para la atención del infarto agudo de miocardio con elevación del segmento ST (IAMCEST) activada por no cardiólogos reduce los retrasos en la atención, pero pueden aumentar los falsos positivos. El objetivo es evaluar la prevalencia, los predictores y el impacto de los diagnósticos falsos positivos dentro de la red catalana para la atención del IAMCEST (Codi Infart). Métodos. Se incluyó a los pacientes atendidos por el Codi Infart entre enero de 2010 y diciembre de 2011. Se consideró activación apropiada si se cumplían los criterios clínicos y electrocardiográficos de IAMCEST. Las activaciones apropiadas se clasificaron como falso positivo según 2 definiciones no excluyentes: a) «angiográfica» si no se identificó una arteria causal, y b) «clínica» si el diagnóstico al alta no era IAMCEST. Resultados. Se incluyó un total de 5.701 activaciones. La activación resultó apropiada en el 87,8% de las veces. Los falsos positivos angiográficos fueron el 14,6% y los clínicos, el 11,6%. El sexo femenino, el bloqueo de rama izquierda y el antecedente de infarto de miocardio se asociaron con el falso positivo. Utilizando la definición clínica, se observó una tasa de falsos positivos mayor en los hospitales sin sala de hemodinámica y los pacientes con complicaciones durante el primer contacto. La mortalidad hospitalaria y a los 30 días fue similar entre los falsos y los verdaderos positivos. Conclusiones. La evolución clínica es similar entre los pacientes con falsos positivos y aquellos con verdaderos positivos. La identificación de predictores de falsos positivos justifica una evaluación cuidadosa para optimizar el uso de las redes de IAMCEST (AU)


Introduction and objectives. ST-segment elevation myocardial infarction (STEMI) network activation by a noncardiologist reduces delay times but may increase the rate of false-positive STEMI diagnoses. We aimed to determine the prevalence, predictors, and clinical impact of false-positive activations within the Catalonian STEMI network (Codi Infart). Methods. From January 2010 through December 2011, all consecutive patients treated within the Codi Infart network were included. Code activations were classified as appropriate if they satisfied both electrocardiogram and clinical STEMI criteria. Appropriate activations were classified as false positives using 2 nonexclusive definitions: a) “angiographic” if a culprit coronary artery was not identified, and b) “clinical” if the discharge diagnosis was other than STEMI. Results. In total, 5701 activations were included. Appropriate activation was performed in 87.8% of the episodes. The rate of angiographic false positives was 14.6%, while the rate of clinical false positives was 11.6%. Irrespective of the definition, female sex, left bundle branch block, and previous myocardial infarction were independent predictors of false-positive STEMI diagnoses. Using the clinical definition, hospitals without percutaneous coronary intervention and patients with complications during the first medical contact also had a false-positive STEMI diagnoses rate higher than the mean. In-hospital and 30-day mortality rates were similar for false-positive and true-positive STEMI patients after adjustment for possible confounders. Conclusions. False-positive STEMI diagnoses were frequent. Outcomes were similar for patients with a true-positive or false-positive STEMI diagnosis treated within a STEMI network. The presence of any modifiable predictors of a false-positive STEMI diagnosis warrants careful assessment to optimize the use of STEMI networks (AU)


Assuntos
Humanos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Angiografia Coronária/estatística & dados numéricos , Eletrocardiografia/estatística & dados numéricos , Cateterismo Cardíaco/estatística & dados numéricos , Angioplastia Coronária com Balão/estatística & dados numéricos , Reações Falso-Positivas , Sensibilidade e Especificidade , Procedimentos Clínicos/organização & administração , Tratamento de Emergência/métodos
15.
Rev Esp Cardiol (Engl Ed) ; 71(4): 243-249, 2018 Apr.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-28711360

RESUMO

INTRODUCTION AND OBJECTIVES: ST-segment elevation myocardial infarction (STEMI) network activation by a noncardiologist reduces delay times but may increase the rate of false-positive STEMI diagnoses. We aimed to determine the prevalence, predictors, and clinical impact of false-positive activations within the Catalonian STEMI network (Codi Infart). METHODS: From January 2010 through December 2011, all consecutive patients treated within the Codi Infart network were included. Code activations were classified as appropriate if they satisfied both electrocardiogram and clinical STEMI criteria. Appropriate activations were classified as false positives using 2 nonexclusive definitions: a) "angiographic" if a culprit coronary artery was not identified, and b) "clinical" if the discharge diagnosis was other than STEMI. RESULTS: In total, 5701 activations were included. Appropriate activation was performed in 87.8% of the episodes. The rate of angiographic false positives was 14.6%, while the rate of clinical false positives was 11.6%. Irrespective of the definition, female sex, left bundle branch block, and previous myocardial infarction were independent predictors of false-positive STEMI diagnoses. Using the clinical definition, hospitals without percutaneous coronary intervention and patients with complications during the first medical contact also had a false-positive STEMI diagnoses rate higher than the mean. In-hospital and 30-day mortality rates were similar for false-positive and true-positive STEMI patients after adjustment for possible confounders. CONCLUSIONS: False-positive STEMI diagnoses were frequent. Outcomes were similar for patients with a true-positive or false-positive STEMI diagnosis treated within a STEMI network. The presence of any modifiable predictors of a false-positive STEMI diagnosis warrants careful assessment to optimize the use of STEMI networks.


Assuntos
Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Codificação Clínica/estatística & dados numéricos , Estudos de Coortes , Angiografia Coronária/estatística & dados numéricos , Reações Falso-Positivas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Espanha
16.
JACC Cardiovasc Interv ; 10(18): 1841-1851, 2017 09 25.
Artigo em Inglês | MEDLINE | ID: mdl-28866036

RESUMO

OBJECTIVES: This study sought to assess the value of bioresorbable vascular scaffolds (BVS) in patients with in-stent restenosis (ISR). BACKGROUND: Currently both drug-eluting stents (DES) and drug-eluting balloons (DEB) are recommended in patients with ISR. However, the value of BVS in this setting remains unclear. METHODS: RIBS VI (Restenosis Intra-stent: drug-eluting Balloon vs everolimus-eluting Stent) was a prospective multicenter study (19 Spanish sites) that included 141 patients treated with BVS for either bare-metal stent (BMS) ISR or DES-ISR. Late angiography was scheduled at 6 to 9 months. Inclusion/exclusion criteria were similar to those used in the RIBS IV (patients with DES-ISR) and RIBS V (patients with BMS-ISR) trials, where DEB (n = 249) was compared with everolimus (EES)-DES (n = 249). Results of BVS in RIBS VI were compared with those obtained with DEB and EES in the RIBS IV and V trials. RESULTS: On late angiography (n = 134; 95% of eligible) the in-segment minimal lumen diameter (primary endpoint) was 1.87 ± 0.5 mm, late lumen loss was 0.23 ± 0.4 mm, and restenosis rate was 11%. At 1-year follow-up (100% of patients) no patient died, 4 (2.8%) experienced a myocardial infarction, and 16 (11.3%) required target lesion revascularization. One patient (0.7%) who discontinued antiplatelet therapy experienced definitive BVS thrombosis. Freedom from cardiac death, myocardial infarction, and target lesion revascularization was 86%. The minimal lumen diameter at follow-up after BVS was similar to that obtained with DEB (1.88 ± 0.6 mm; p = NS) but smaller than that achieved after EES (2.16 ± 0.7 mm; p < 0.001). Likewise, target lesion revascularization rates after BVS were similar to those seen with DEB (10.4%) but higher than with EES (3.2%; p < 0.001). Results remained unchanged after adjusting for potential confounders in baseline characteristics. CONCLUSIONS: This study suggests the safety and efficacy of BVS in patients with ISR. In this challenging anatomic scenario BVS obtained late angiographic and clinical results similar to DEB but inferior to EES. (Restenosis Intrastent: Bioresorbable Vascular Scaffolds Treatment [RIBS VI]; NCT02672878).


Assuntos
Implantes Absorvíveis , Reestenose Coronária/terapia , Intervenção Coronária Percutânea/instrumentação , Stents , Idoso , Angiografia Coronária , Reestenose Coronária/diagnóstico por imagem , Reestenose Coronária/etiologia , Quimioterapia Combinada , Stents Farmacológicos , Feminino , Humanos , Masculino , Metais , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação de Plaquetas/administração & dosagem , Estudos Prospectivos , Desenho de Prótese , Fatores de Risco , Espanha , Fatores de Tempo , Resultado do Tratamento
17.
Rev. esp. cardiol. (Ed. impr.) ; 70(7): 559-566, jul. 2017. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-164691

RESUMO

Introducción y objetivos: Recientemente, un nuevo algoritmo electrocardiográfico ha mostrado resultados esperanzadores para el diagnóstico del infarto agudo de miocardio (IAM) en presencia de bloqueo completo de rama izquierda del haz de His (BRIHH). Se decidió evaluar estos nuevos algoritmos en una cohorte de pacientes remitidos para intervención coronaria percutánea primaria (ICPp). Métodos: Estudio observacional de cohorte retrospectiva que incluyó a todos los pacientes con sospecha de IAM y BRIHH en el ecocardiograma inicial remitidos para ICPp a 4 hospitales terciarios de Barcelona, España. Resultados: Se incluyó a 145 pacientes; 54 (37%) tenían un cuadro clínico equivalente a un IAM con elevación del segmento ST (IAMCEST). Entre los pacientes con IAMCEST, 25 (46%) estaban en Killip III o IV y la mortalidad hospitalaria fue del 15%. Los algoritmos I y II de Smith presentaron mejores resultados que los algoritmos de Sgarbossa y tuvieron buena especificidad (el 90 y el 97% respectivamente); sin embargo, su sensibilidad fue del 67 y el 54% respectivamente. En una estrategia terapéutica guiada por los algoritmos de Smith, 18 (33%) o 25 (46%) pacientes con IAMCEST no habrían recibido ICPp. Por otra parte, la gravedad y el pronóstico de los pacientes con IAMCEST era similar independientemente de la positividad de los algoritmos de Smith. Los marcadores de daño miocárdico fueron positivos en un 54% de los pacientes sin IAMCEST, lo que limita su utilidad para el diagnóstico inicial. Conclusiones: El diagnóstico de IAMCEST en presencia de BRIHH sigue siendo un desafío. Los algoritmos de Smith pueden ser útiles, pero están limitados por una sensibilidad subóptima. Se tiene que promover la búsqueda de nuevos criterios electrocardiográficos para evitar tratamientos agresivos no necesarios a la mayoría de los pacientes y, al mismo tiempo, proporcionar reperfusión emergente a un subgrupo con alto riesgo (AU)


Introduction and objectives: Recently, a new electrocardiography algorithm has shown promising results for the the diagnosis of acute myocardial infarction in the presence of left bundle branch block (LBBB). We aimed to assess these new electrocardiography rules in a cohort of patients referred for primary percutaneous coronary intervention (pPCI). Methods: Retrospective observational cohort study that included all patients with suspected myocardial infarction and LBBB on the presenting electrocardiogram, referred for pPCI to 4 tertiary hospitals in Barcelona, Spain. Results: A total of 145 patients were included. Fifty four (37%) had an ST-segment elevation myocardial infarction (STEMI) equivalent. Among patients with STEMI, 25 (46%) presented in Killip class III or IV, and in-hospital mortality was 15%. Smith I and II rules performed better than Sgarbossa algorithms and showed good specificity (90% and 97%, respectively) but their sensitivity was 67% and 54%, respectively. In a strategy guided by Smith I or Smith II rules, 18 (33%) or 25 (46%) patients with STEMI would have not received a pPCI, respectively. Moreover, the severity and prognosis of STEMI patients was similar regardless of the positivity of Smith rules. Cardiac biomarkers were positive in 54% of non-STEMI patients, limiting their usefulness for initial diagnostic screening. Conclusions: Diagnosis of STEMI in the presence of LBBB remains a challenge. Smith rules can be useful but are limited by suboptimal sensitivity. The search for new electrocardiography algorithms should be encouraged to avoid unnecessary aggressive treatments in the majority of patients, while providing timely reperfusion to a high-risk subgroup of patients (AU)


Assuntos
Humanos , Bloqueio de Ramo/complicações , Infarto do Miocárdio/diagnóstico , Síndrome Coronariana Aguda/diagnóstico , Fascículo Atrioventricular/fisiopatologia , Algoritmos , Eletrocardiografia , Intervenção Coronária Percutânea/estatística & dados numéricos , Estudos Retrospectivos
18.
Resuscitation ; 114: 141-145, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28242212

RESUMO

BACKGROUND: Out-of-Hospital Cardiac Arrest (OHCA) and mild therapeutic hypothermia (MTH) have been linked to increased risk of Stent Thrombosis (ST) in comatose survivors who undergo percutaneous coronary intervention (PCI). In this sense, there is no formal recommendation about which antiplatelet regimen should be used in patients with acute coronary syndromes (ACS) after OHCA. AIMS: To compare the incidence of probable/definite ST and bleeding events between ticagrelor and clopidogrel, in patients with ACS under MTH after an OHCA. METHODS AND RESULTS: From January 2010 to August 2016, 144 patients underwent MTH after an OHCA. Overall, 114 had an ACS (79%) and 98 (67,3%) were treated with primary PCI and stent implantation. Among them, 61 (62,2%) were treated with clopidogrel, and 32 (32,6%) with ticagrelor. During hospitalization, the incidence of probable or definite ST was significantly higher in patients receiving clopidogrel compared to ticagrelor (11,4% vs. 0%; p: 0.04), and no significant differences in any (28,6% vs. 25%; p: 0.645) or major bleeding (BARC 3 or 5) (11,4% vs. 12,5%; p: 0.685) were found. Hospital mortality did not differ between groups (26,2% vs. 25%; p: 0.862). CONCLUSIONS: In this study, as compared to clopidogrel, ticagrelor was associated with a lower rate of ST, without differences in haemorrhagic events in patients with OHCA for an ACS under MTH. Similarly to other settings, ticagrelor might be a valid alternative to clopidogrel in these patients.


Assuntos
Adenosina/análogos & derivados , Trombose Coronária/tratamento farmacológico , Parada Cardíaca Extra-Hospitalar/terapia , Inibidores da Agregação de Plaquetas/uso terapêutico , Stents/efeitos adversos , Ticlopidina/análogos & derivados , Adenosina/uso terapêutico , Idoso , Clopidogrel , Trombose Coronária/etiologia , Humanos , Hipotermia Induzida/efeitos adversos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/complicações , Intervenção Coronária Percutânea/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Ticagrelor , Ticlopidina/uso terapêutico
19.
Int J Cardiol ; 232: 70-75, 2017 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-28087172

RESUMO

BACKGROUND: Therapeutic hypothermia (HT) in out-of-hospital cardiac arrest STEMI patients aims to improve their neurological prognosis, but it has been associated with slow coronary flow and cardiac thrombotic events. We sought to serially assess endothelial function during the first 48h after admission in out-of-hospital cardiac arrest STEMI patients, under therapeutic hypothermia (HT). METHODS: From January 2015 to August 2015, eighteen consecutive out-of-hospital cardiac arrest STEMI patients eligible for primary PCI received HT at admission and were included in the study (HT group). During the same time period, eight consecutive patients with large anterior STEMI who received primary PCI but not HT were included as control group. Serial endothelial function by measuring flow-mediated dilatation (FMD) in the brachial artery, biomarkers of endothelial function and oxidative stress were assessed during the first 48h after admission in both groups. RESULTS: HT group showed worse FMD as compared to the control group (p<0.001). Glutathione peroxidase-3 (GPx-3) values were higher in control as compared to HT group (p=0.019), without any interaction between time of observation and HT (p=0.864). A significant interaction between time and HT was found in the levels of sVCAM-1, which reached an earlier peak in control than in HT group (p=0.019). ET-1 values generally increase overtime (p=0.005), but without any main effect of HT (p=0.175). CONCLUSIONS: HT is associated with endothelial dysfunction in out-of-hospital cardiac arrest STEMI patients during the first 48h after admission. This vascular dysfunction may be related to increased oxidative stress due to deficiency of GPx-3 in HT patients.


Assuntos
Endotélio Vascular/fisiopatologia , Hipotermia Induzida/métodos , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Vasodilatação/fisiologia , Angiografia Coronária , Eletrocardiografia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/etiologia , Parada Cardíaca Extra-Hospitalar/terapia , Prognóstico , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia
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