La proteína meteorin-like se asocia a un perfil de mayor riesgo y predice un peor pronóstico en pacientes con IAMCEST / Meteorin-like protein is associated with a higher risk profile and predicts a worse outcome in patients with STEMI

Introducción y objetivos: La proteína meteorin-like (Metrnl) es una citocina implicada en la atenuación de la inflamación asociada a mal pronóstico en la insuficiencia cardiaca. En este estudio se evalúan los niveles circulantes de Metrnl y su valor pronóstico en el infarto agudo de miocardio con elevación del segmento ST (IAMCEST).Métodos: Se incluyó a pacientes con IAMCEST tratados con angioplastia primaria. Se determinaron los niveles de Metrnl en sangre periférica a las 12 horas del inicio de los síntomas. El criterio de evaluación primario fue muerte por cualquier causa o infarto de miocardio no mortal a 3 años.Resultados: Se estudiaron 381 pacientes (edad media 61 años, 21% mujeres, 8% clase Killip III/IV). Los niveles de Metrnl se asociaron con la edad, los factores de riesgo cardiovascular y la extensión de la enfermedad coronaria, pero también con complicaciones del infarto, especialmente insuficiencia cardíaca y shock cardiogénico. En la regresión multivariante de Cox Metrnl fue un predictor independiente del criterio de evaluación combinado (HR = 1,86; IC95%, 1,23-2,81; p=0,003). Además, los pacientes en el tercil más alto (> 491,6 pg/ml) presentaron mayor riesgo que en los terciles inferiores (HR = 3,24; IC95%, 1,92-5,44; p <0,001), incluso después de ajustar por edad, diabetes, paro cardíaco, clase Killip-Kimball III/IV, fracción de eyección y aclaramiento de creatinina (HR = 1,90; IC95%, 1,10-3,29; p=0,021).Conclusiones: En los pacientes con IAMCEST, los niveles circulantes de Metrnl se asocian con las complicaciones durante la fase aguda y predicen de forma independiente un peor pronóstico.(AU)

Introduction and objectives: Meteorin-like protein (Metrnl) is a cytokine involved in the attenuation of inflammation. In patients with heart failure, high levels of this biomarker are associated with a worse outcome. In this study, we evaluated the circulating levels and prognostic value of Metrnl in patients with ST-segment elevation myocardial infarction (STEMI).Methods: We enrolled STEMI patients undergoing primary percutaneous coronary intervention. Circulating Metrnl levels were measured in peripheral blood 12hours after symptom onset. The primary endpoint was a composite of all-cause mortality or nonfatal myocardial infarction (MI) at 3 years.Results: We studied 381 patients (mean age 61 years, 21% female, 8% Killip class III/IV). Metrnl levels were associated with age, cardiovascular risk factors and the extent of coronary artery disease, as well as with STEMI complications, particularly heart failure and cardiogenic shock. Multivariable Cox regression analysis revealed that Metrnl independently predicted all-cause death or nonfatal MI at 3 years (HR, 1.86; 95%CI, 1.23-2.81; P=.003). Moreover, patients in the highest tertile (> 491.6 pg/mL) were at higher risk for the composite endpoint than those in the lowest tertiles (HR, 3.24; 95%CI, 1.92-5.44; P <.001), even after adjustment by age, diabetes mellitus, cardiac arrest, Killip-Kimball III/IV class, left ventricular ejection fraction, and creatinine clearance (HR, 1.90; 95%CI, 1.10-3.29; P=.021).Conclusions: Circulating Metrnl levels are associated with complications during the acute phase of STEMI and independently predict a worse outcome in these patients.(AU)

Meteorin-like protein is associated with a higher risk profile and predicts a worse outcome in patients with STEMI.

INTRODUCTION AND OBJECTIVES: Meteorin-like protein (Metrnl) is a cytokine involved in the attenuation of inflammation. In patients with heart failure, high levels of this biomarker are associated with a worse outcome. In this study, we evaluated the circulating levels and prognostic value of Metrnl in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: We enrolled STEMI patients undergoing primary percutaneous coronary intervention. Circulating Metrnl levels were measured in peripheral blood 12hours after symptom onset. The primary endpoint was a composite of all-cause mortality or nonfatal myocardial infarction (MI) at 3 years. RESULTS: We studied 381 patients (mean age 61 years, 21% female, 8% Killip class III/IV). Metrnl levels were associated with age, cardiovascular risk factors and the extent of coronary artery disease, as well as with STEMI complications, particularly heart failure and cardiogenic shock. Multivariable Cox regression analysis revealed that Metrnl independently predicted all-cause death or nonfatal MI at 3 years (HR, 1.86; 95%CI, 1.23-2.81; P=.003). Moreover, patients in the highest tertile (> 491.6 pg/mL) were at higher risk for the composite endpoint than those in the lowest tertiles (HR, 3.24; 95%CI, 1.92-5.44; P <.001), even after adjustment by age, diabetes mellitus, cardiac arrest, Killip-Kimball III/IV class, left ventricular ejection fraction, and creatinine clearance (HR, 1.90; 95%CI, 1.10-3.29; P=.021). CONCLUSIONS: Circulating Metrnl levels are associated with complications during the acute phase of STEMI and independently predict a worse outcome in these patients.

Índice de resistencia microcirculatoria y obstrucción microvascular en la resonancia magnética cardiaca tras un IAMCEST / Functional angiography-derived index of microcirculatory resistance validated with microvascular obstruction in cardiac magnetic resonance after STEMI

Introducción y objetivos El índice de resistencia microcirculatoria (IRM) medido tras una angioplastia primaria (ICPp) por infarto agudo de miocardio con elevación del segmento ST (IAMCEST) se asocia con la aparición de obstrucción microvascular (OMV) y eventos clínicos adversos. Para evaluar la OMV tras una ICPp exitosa por IAMCEST sin guías de presión ni administración de agentes hiperémicos, variables que parecen limitar la adopción del IRM en el laboratorio de hemodinámica, se investiga la viabilidad y la utilidad de la medición del IRM mediante resonancia magnética cardiaca (RMC) (angio-IRM). Métodos El estudio incluyó a 285 pacientes con IAMCEST sometidos a ICPp y RMC. Con un programa informático comercial, se calculó el angio-IRM del vaso culpable tras la ICPp exitosa. Se evaluaron la OMV, el tamaño del infarto y el índice de rescate miocárdico medidos una mediana de 3 [rango intercuartílico, 3-5] días después de la ICPp. Resultados De la población total, 154 pacientes (54,0%) mostraron valores de angio-IRM elevados (> 40 U) en el vaso culpable. La OMV fue significativamente más frecuente en los pacientes con angio-IRM> 40 U que en aquellos con angio-IRM ≤ 40 U (el 88,3 frente al 32,1%; p <0,001). El tamaño del infarto, la extensión de la OMV y el área en riesgo fueron significativamente mayores en los pacientes con angio-IRM> 40 U que con angio-IRM ≤ 40 U (p <0,001 para todas las comparaciones). El angio-IRM mostró una capacidad de discriminación de OMV significativamente mayor que el grado de flujo TIMI o de blush miocárdico (área bajo la curva, 0,821, 0,504 y 0,496 respectivamente; p <0,001). Conclusiones El angio-IRM se asoció significativamente con el tamaño del infarto, la extensión de la OMV y el área en riesgo. Cifras altas del angio-IRM (> 40 U) tras una ICPp por IAMCEST fueron muy predictivas de OMV en la RMC (AU)

Introduction and objectives The index of microcirculatory resistance (IMR) measured after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is associated with microvascular obstruction (MVO) and adverse clinical events. To evaluate MVO after successful primary PCI for STEMI without pressure wires or hyperemic agents, we investigated the feasibility and usefulness of functional angiography-derived IMR (angio-IMR). Methods The current study included a total of 285 STEMI patients who underwent primary PCI and cardiac magnetic resonance (CMR). Angio-IMR of the culprit vessel after successful primary PCI was calculated using commercial software. MVO, infarct size, and myocardial salvage index were assessed using CMR, which was obtained a median of 3.0 days [interquartile range, 3.0-5.0] after primary PCI. Results Among the total population, 154 patients (54.0%) showed elevated angio-IMR (> 40 U) in the culprit vessel. MVO was significantly more prevalent in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (88.3% vs 32.1%, P <.001). Infarct size, extent of MVO, and area at risk were significantly larger in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (P <.001 for all). Angio-IMR showed a significantly higher discriminatory ability for the presence of MVO than thrombolysis in myocardial infarction flow grade or myocardial blush grade (area under the curve: 0.821, 0.504, and 0.496, respectively, P <.001). Conclusions Angio-IMR was significantly associated with CMR-derived infarct size, extent of MVO, and area at risk. An elevated angio-IMR (> 40 U) after primary PCI for STEMI was highly predictive of the presence of MVO in CMR (AU)

Tiempos de reperfusión de un programa guiado por telemedicina para la atención del infarto agudo de miocardio con elevación del ST en la Provincia de La Pampa / Reperfusion Times in a Telemedicine-guided Program for the Management of ST-segment Elevation Myocardial Infarction in the Province of La Pampa

RESUMEN Introducción: Los tiempos de atención médica son un factor relevante para la mortalidad por infarto agudo de miocardio con elevación del segmento ST (IAMCEST). Objetivos: Evaluar los tiempos de reperfusión en pacientes con IAMCEST participantes de un programa de atención médica cardiológica basada en telemedicina en la provincia de La Pampa durante el período transcurrido entre agosto de 2018 y diciembre de 2021. Material y Métodos: Este programa consiste en la protocolización de la atención de los pacientes que cursan un síndrome coronario agudo (SCA) en las diferentes localidades de la provincia, con asistencia cardiológica remota las 24 horas del día, que incluye tanto la asistencia diagnóstica como la coordinación de las medidas terapéuticas, incluyendo la posibilidad de administrar trombolíticos a nivel local, con asistencia remota. Resultados: De un total de 72 IAMCEST evaluados, 44 recibieron como terapia de reperfusión trombolisis, 25 angioplastia primaria, y 3 trombolisis seguida de angioplastia de rescate. De los 47 sujetos que recibieron trombolisis, sólo 5 requirieron de traslado al centro de referencia para realizar este procedimiento. La mediana de tiempo puerta-aguja fue de 24 minutos y el tiempo puerta-balón fue de 105 minutos. El 28% de los sujetos con angioplastia primaria tuvieron un tiempo puerta-balón inferior a los 90 minutos y el 53,2% de los tratados con trombolíticos cumplieron con un tiempo puerta-aguja menor a 30 minutos. Conclusiones: La implementación de un programa de atención descentralizada guiada por telemedicina se asoció a un elevado porcentaje de cumplimento de las metas de implementación de la terapia de reperfusión basada en fibrinolíticos.

ABSTRACT Background: Timing of medical care is a relevant factor for ST-segment elevation myocardial infarction (STEMI) mortality. Objectives: The aim of the present study is to evaluate reperfusion times in STEMI patients participating in a telemedicinebased cardiology care program in the province of La Pampa during the period between August 2018 and December 2021. Methods: This program consists of a protocol for the management of patients with acute coronary syndrome (ACS) in the different locations of the province, with 24-hour remote assistance provided by cardiologists including both diagnostic support and coordination of on-site thrombolysis. Results: Of a total of 72 STEMI patients evaluated, 44 received thrombolysis as reperfusion therapy, 25 received primary percutaneous coronary intervention, and 3 received thrombolysis followed by rescue percutaneous coronary intervention. Of the 47 subjects who received thrombolysis, only 5 required to be transferred to the referral center for this procedure. Median door-to-needle time was 24 minutes and door-to balloon-time was 105 minutes. Twenty-five percent of the subjects had a door-to-balloon time <90 minutes and 53.2% fulfilled a door-to-needle time <30 minutes. Conclusions: The implementation of a telemedicine-guided program for decentralized management of STEMI patients was associated with a high percentage of compliance with the goals of implementing fibrinolytic-based reperfusion therapy.

EpCAM y obstrucción microvascular en pacientes con un IAMCEST: estudio con resonancia magnética cardiaca / EpCAM and microvascular obstruction in patients with STEMI: a cardiac magnetic resonance study

Introducción y objetivos: La obstrucción microvascular (OMV) se asocia negativamente con la estructura cardiaca y el pronóstico de los pacientes tras un infarto agudo de miocardio con elevación del segmento ST (IAMCEST). El factor epithelial cell adhesion molecule (EpCAM), implicado en la cohesión de las células epiteliales, está poco estudiado en el contexto de la OMV. Por ello, el objetivo de este estudio es evaluar en una cohorte de pacientes con IAMCEST la asociación entre la concentración de EpCAM circulante con la extensión de la OMV, determinada por resonancia magnética cardiaca (RMC), y la función sistólica en fases crónicas. Métodos: Se incluyó prospectivamente a 106 pacientes con un primer IAMCEST tratados con angioplastia primaria percutánea. La concentración sérica de EpCAM se determinó 24h tras la reperfusión coronaria. Se estudió a todos los pacientes mediante RMC a la semana y a los 6 meses del IAMCEST. Se evaluó la correlación entre los valores de EpCAM circulante con la OMV, los índices de función sistólica y la fracción de eyección del ventrículo izquierdo. Resultados: La media de edad de la cohorte era 59±13 años y el 76% eran varones. Se dicotomizó a los pacientes según la mediana de EpCAM (4,48 pg/ml). Se observó que los pacientes que tenían valores más bajos de EpCAM presentaban una mayor extensión de la OMV (p=0,021) y un mayor tamaño de infarto (p=0,019) en los estudios de RMC realizados 1 semana después del evento cardiovascular. Respecto a las variables de presentación, la concentración de EpCAM se asoció significativamente con la presencia de OMV en análisis de regresión logística binaria univariable (OR=0,58; IC95%, 0,38-0,88; p=0,011) y multivariable (OR=0,55; IC95%, 0,35-0,87; p=0,010). A pesar de que la OMV tiende a resolverse espontáneamente en fases crónicas, unos valores más bajos de EpCAM se correlacionaron con una peor función sistólica (AU)

Introduction and objectives: Microvascular obstruction (MVO) is negatively associated with cardiac structure and worse prognosis after ST-segment elevation myocardial infarction (STEMI). Epithelial cell adhesion molecule (EpCAM), involved in epithelium adhesion, is an understudied area in the MVO setting. We aimed to determine whether EpCAM is associated with the appearance of cardiac magnetic resonance (CMR)-derived MVO and long-term systolic function in reperfused STEMI. Methods: We prospectively included 106 patients with a first STEMI treated with percutaneous coronary intervention, quantifying serum levels of EpCAM 24hours postreperfusion. All patients underwent CMR imaging 1 week and 6 months post-STEMI. The independent correlation of EpCAM with MVO, systolic volume indices, and left ventricular ejection fraction was evaluated. Results: The mean age of the sample was 59±13 years and 76% were male. Patients were dichotomized according to median EpCAM (4.48 pg/mL). At 1-week CMR, lower EpCAM was related to extensive MVO (P=.021) and larger infarct size (P=.019). At presentation, EpCAM values were significantly associated with the presence of MVO in univariate (OR, 0.58; 95%CI, 0.38-0.88; P=.011) and multivariate logistic regression models (OR, 0.55; 95%CI, 0.35-0.87; P=.010). Although MVO tends to resolve at chronic phases, decreased EpCAM was associated with worse systolic function: reduced left ventricular ejection fraction (P=.009) and higher left ventricular end-systolic volume (P=.043). Conclusions: EpCAM is associated with the occurrence of CMR-derived MVO at acute phases and long-term adverse ventricular remodeling post-STEMI

Functional angiography-derived index of microcirculatory resistance validated with microvascular obstruction in cardiac magnetic resonance after STEMI.

INTRODUCTION AND OBJECTIVES: The index of microcirculatory resistance (IMR) measured after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is associated with microvascular obstruction (MVO) and adverse clinical events. To evaluate MVO after successful primary PCI for STEMI without pressure wires or hyperemic agents, we investigated the feasibility and usefulness of functional angiography-derived IMR (angio-IMR). METHODS: The current study included a total of 285 STEMI patients who underwent primary PCI and cardiac magnetic resonance (CMR). Angio-IMR of the culprit vessel after successful primary PCI was calculated using commercial software. MVO, infarct size, and myocardial salvage index were assessed using CMR, which was obtained a median of 3.0 days [interquartile range, 3.0-5.0] after primary PCI. RESULTS: Among the total population, 154 patients (54.0%) showed elevated angio-IMR (> 40 U) in the culprit vessel. MVO was significantly more prevalent in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (88.3% vs 32.1%, P <.001). Infarct size, extent of MVO, and area at risk were significantly larger in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (P <.001 for all). Angio-IMR showed a significantly higher discriminatory ability for the presence of MVO than thrombolysis in myocardial infarction flow grade or myocardial blush grade (area under the curve: 0.821, 0.504, and 0.496, respectively, P <.001). CONCLUSIONS: Angio-IMR was significantly associated with CMR-derived infarct size, extent of MVO, and area at risk. An elevated angio-IMR (> 40 U) after primary PCI for STEMI was highly predictive of the presence of MVO in CMR. This trial was registered at ClnicalTrialsgov (Identifier: NCT04828681).

EpCAM and microvascular obstruction in patients with STEMI: a cardiac magnetic resonance study.

INTRODUCTION AND OBJECTIVES: Microvascular obstruction (MVO) is negatively associated with cardiac structure and worse prognosis after ST-segment elevation myocardial infarction (STEMI). Epithelial cell adhesion molecule (EpCAM), involved in epithelium adhesion, is an understudied area in the MVO setting. We aimed to determine whether EpCAM is associated with the appearance of cardiac magnetic resonance (CMR)-derived MVO and long-term systolic function in reperfused STEMI. METHODS: We prospectively included 106 patients with a first STEMI treated with percutaneous coronary intervention, quantifying serum levels of EpCAM 24hours postreperfusion. All patients underwent CMR imaging 1 week and 6 months post-STEMI. The independent correlation of EpCAM with MVO, systolic volume indices, and left ventricular ejection fraction was evaluated. RESULTS: The mean age of the sample was 59±13 years and 76% were male. Patients were dichotomized according to median EpCAM (4.48 pg/mL). At 1-week CMR, lower EpCAM was related to extensive MVO (P=.021) and larger infarct size (P=.019). At presentation, EpCAM values were significantly associated with the presence of MVO in univariate (OR, 0.58; 95%CI, 0.38-0.88; P=.011) and multivariate logistic regression models (OR, 0.55; 95%CI, 0.35-0.87; P=.010). Although MVO tends to resolve at chronic phases, decreased EpCAM was associated with worse systolic function: reduced left ventricular ejection fraction (P=.009) and higher left ventricular end-systolic volume (P=.043). CONCLUSIONS: EpCAM is associated with the occurrence of CMR-derived MVO at acute phases and long-term adverse ventricular remodeling post-STEMI.

Coronary endothelial and microvascular function distal to polymer-free and endothelial cell-capturing drug-eluting stents. The randomized FUNCOMBO trial.

INTRODUCTION AND OBJECTIVES: The vasomotor function of new-generation drug-eluting stents designed to enhance stent healing and reendothelialization is unknown. This study aimed to compare the endothelial function of the infarct-related artery (IRA) treated with bioactive circulating endothelial progenitor cell-capturing sirolimus-eluting stents (COMBO) vs polymer-free biolimus-eluting stents (BioFreedom) in ST-segment elevation myocardial infarction patients at 6 months. Secondary objectives were to compare the microcirculatory function of the IRA and stent healing at 6 months. METHODS: Sixty patients were randomized to bioactive sirolimus-eluting stent vs polymer-free biolimus-eluting stents implantation. At 6 months, patients underwent coronary angiography with vasomotor, microcirculatory and optical coherence tomography examinations. Endothelial dysfunction of the distal coronary segment was defined as ≥ 4% vasoconstriction to intracoronary acetylcholine infusion. RESULTS: Endothelial dysfunction was similarly observed between groups (64.0% vs 62.5%, respectively; P=.913). Mean lumen diameter decreased by 16.0 ±20.2% vs 16.1 ±21.6% during acetylcholine infusion (P=.983). Microcirculatory function was similar in the 2 groups: coronary flow reserve was 3.23 ±1.77 vs 3.23±1.62 (P=.992) and the index of microcirculatory resistance was 24.8±16.8 vs 21.3±12.0 (P=.440). Optical coherence tomography findings were similar: uncovered struts (2.3% vs 3.2%; P=.466), malapposed struts (0.1% vs 0.3%; P=.519) and major evaginations (7.1% vs 5.6%; P=.708) were observed in few cases. CONCLUSIONS: Endothelial dysfunction of the IRA was frequent and was similarly observed with new-generation drug-eluting stents designed to enhance stent reendothelialization at 6 months. Endothelial dysfunction was observed despite almost preserved microcirculatory function and complete stent coverage. Larger and clinically powered studies are needed to assess the role of residual endothelial dysfunction in ST-segment elevation myocardial infarction patients. Registered in ClinicalTrials.gov: NCT04202172.

Encuesta latinoamericana sobre el grado de variación de la actividad asistencial en los Servicios de Cardiología Intervencionista por la pandemia COVID-19. Subanálisis de la situación de Uruguay / Latin American survey on the degree of variation in healthcare activity in Interventional Cardiology Services due to the COVID-19 pandemic. Sub-analysis of the situation in Uruguay / Pesquisa latino-americana sobre o grau de variação da atividade de saúde nos Serviços de Cardiologia Intervencionista devido à pandemia do COVID-19. Subanálise da situação no Uruguai

Resumen: Introducción y objetivos: como consecuencia de la pandemia COVID-19 se ha comprobado una reducción de la actividad cardiológica intervencionista. El objetivo de esta encuesta fue cuantificar esta disminución y el impacto en el manejo del infarto agudo de miocardio con elevación del segmento ST (IAMceST) en Uruguay. Método: se realizó una encuesta telemática a los centros de hemodinamia de Uruguay, contextualizada en una encuesta latinoamericana. Se registraron los cateterismos diagnósticos, las intervenciones coronarias y estructurales, así como la percepción de la asistencia del IAMceST y sobre la afección por el virus SARS-CoV-2 del personal de cardiología intervencionista. Se compararon dos periodos del año 2020: 24 de febrero al 8 de marzo (pre COVID-19) y 23 de marzo al 5 de abril (COVID-19). Resultados: respondieron todos los centros del país (n=8). Hubo una clara disminución en el número de procedimientos diagnósticos (36,1%), angioplastias coronarias (20,3%), intervenciones estructurales (88,9%) y angioplastias en IAMceST (37,3%). Se observó una disminución del diagnóstico y según la percepción de los encuestados, una mayor demora en reperfundir al IAMceST. Un centro reportó infección por SARS-CoV-2 en su personal. Si bien hubo una disminución de la actividad en todos los centros, el comportamiento fue homogéneo. Conclusiones: se observó una reducción importante de la actividad asistencial cardiológica intervencionista durante el inicio de la epidemia COVID-19 y una gran disminución en el número de pacientes tratados con IAMceST.

Summary: Introduction and objectives: because of the COVID-19 pandemic, a reduction in activity has been verified in interventional cardiology. The objective of this survey was to quantify this decrease and the impact on the management of ST-elevation myocardial infarction in Uruguay. Methods: a telematic survey was carried out in Uruguay, in the context of a Latin American countries survey. Diagnostic catheterizations, coronary and structural interventions were recorded, as well as the perception of STEMI attendance and SARS-CoV-2 involvement of the health care staff. Two periods of 2020 were compared: 1st from February 24th to March 8th (pre COVID-19) and the 2nd from March 23rd to April 5th (COVID-19). Results: response was obtained from all centers (n=8) of the country. There was a significant decrease in the number of diagnostic procedures (36.1%), coronary interventions (20.3%), structural therapy (88.9%) and PCI in STEMI (37.3%). Less use of thrombolysis was indicated and a perception of respondents of longer delay to reperfusion. One center reported SARS-CoV-2 infection. Although there was a varied decrease in activity between the different centers, the behavior was homogeneous. Conclusions: a significant reduction in healthcare activity was observed during the COVID-19 epidemic and a great decrease in the number of patients treated with STEMI.

Resumo: Introdução e objetivos: como conseqüência da pandemia do COVID-19, uma redução na atividade foi observada na cardiologia intervencionista. O objetivo desta pesquisa foi quantificar essa diminuição e o impacto no manejo do infarto agudo do miocárdio com supradesnivelamento de segmento ST no Uruguai. Métodos: uma pesquisa telemática foi realizada em centros hemodinâmicos do Uruguai, no contexto de uma pesquisa latino-americana. Foram registrados cateterismos diagnósticos, intervenções coronárias e estruturais, bem como a percepção de assistência para infarto agudo do miocárdio e sobre a condição COVID-19 da equipe de cardiologia intervencionista. Foram comparados dois períodos do ano 2020: 24 de fevereiro a 8 de março (pré COVID-19) e 23 de março a 5 de abril (COVID-19). Resultados: todos os centros (n = 8) do país responderam. Houve uma diminuição significativa no número de procedimentos diagnósticos (36,1%), angioplastias coronárias (20,3%), intervenções estruturais (88,9%) e angioplastia no IAMEST (37,3%). Foi observada uma diminuição no diagnóstico e uma percepção dos entrevistados de um maior atraso na reperfusão do IAMceST. Um centro relatou infecção por SARS-CoV-2. Embora tenha havido uma diminuição variada da atividade entre os diferentes centros, o comportamento foi homogêneo. Conclusões: observou-se uma redução significativa da atividade assistencial durante a epidemia COVID-19 e uma grande diminuição no número de pacientes tratados com IAMEST.

Impact on mortality after implementation of a network for ST-segment elevation myocardial infarction care. The IPHENAMIC study.

INTRODUCTION AND OBJECTIVES: Little is known about the impact of networks for ST-segment elevation myocardial infarction (STEMI) care on the population. The objective of this study was to determine whether the PROGALIAM (Programa Gallego de Atención al Infarto Agudo de Miocardio) improved survival in northern Galicia. METHODS: We collected all events coded as STEMI between 2001 and 2013. A total of 6783 patients were identified and divided into 2 groups: pre-PROGALIAM (2001-2005), with 2878 patients, and PROGALIAM (2006-2013), with 3905 patients. RESULTS: In the pre-PROGALIAM period, 5-year adjusted mortality was higher both in the total population (HR, 1.22, 95%CI, 1.14-1.29; P <.001) and in each area (A Coruña: HR, 1.12; 95%CI, 1.02-1.23; P=.02; Lugo: HR, 1.34; 95%CI, 1.2-1.49; P <.001 and Ferrol: HR, 1.23; 95%CI, 1.1-1.4; P=.001). Before PROGALIAM, 5-year adjusted mortality was higher in the areas of Lugo (HR, 1.25; 95%CI, 1.05-1.49; P=.02) and Ferrol (HR, 1.32; 95%CI, 1.13-1.55; P=.001) than in A Coruña. These differences disappeared after the creation of the STEMI network (Lugo vs A Coruña: HR, 0.88; 95%CI, 0.72-1.06; P=.18, Ferrol vs A Coruña: HR, 1.04; 95%CI, 0.89-1.22; P=.58. CONCLUSIONS: For patients with STEMI, the creation of PROGALIAM in northern Galicia decreased mortality and increased equity in terms of survival both overall and in each of the areas where it was implemented. This study was registered at ClinicalTrials.gov (Identifier: NCT02501070).

Left bundle branch block as equivalent of ST-segment elevation myocardial infarction: when yes, when not?

A new or presumably new left bundle branch block along with ischemic symptoms has traditionally been considered an electrocardiographic equivalent of ST-segment elevation myocardial infarction, which should be brought to emergent reperfusion. However, several criteria have been proposed for its definition, but none has reached out an optimal diagnostic yield. Below we detail these criteria, their main problems and the advantages they have shown.

La presencia de un bloqueo de rama izquierda del haz de His nuevo o presumiblemente nuevo junto con síntomas isquémicos se ha considerado tradicionalmente un equivalente electrocardiográfico de infarto agudo de miocardio con elevación del segmento ST, el cual debe ser llevado a reperfusión emergente. Para su definición se han propuesto varios criterios, pero ninguno ha alcanzado un rendimiento diagnóstico óptimo. A continuación detallaremos dichos criterios, sus principales problemas y las ventajas que han demostrado.

Left bundle branch block as equivalent of ST-segment elevation myocardial infarction: when yes, when not?

A new or presumably new left bundle branch block along with ischemic symptoms has traditionally been considered an electrocardiographic equivalent of ST-segment elevation myocardial infarction, which should be brought to emergent reperfusion. However, several criteria have been proposed for its definition, but none has reached out an optimal diagnostic yield. Below we detail these criteria, their main problems and the advantages they have shown.

La presencia de un bloqueo de rama izquierda del haz de His nuevo o presumiblemente nuevo junto con síntomas isquémicos se ha considerado tradicionalmente un equivalente electrocardiográfico de infarto agudo de miocardio con elevación del segmento ST, el cual debe ser llevado a reperfusión emergente. Para su definición se han propuesto varios criterios, pero ninguno ha alcanzado un rendimiento diagnóstico óptimo. A continuación detallaremos dichos criterios, sus principales problemas y las ventajas que han demostrado.

Bloqueo de rama izquierda como equivalente ST, ¿cuándo sí, cuándo no? / Left bundle branch block as equivalent of ST-segment elevation myocardial infarction: when yes, when not?

Resumen La presencia de un bloqueo de rama izquierda del haz de His nuevo o presumiblemente nuevo junto con síntomas isquémicos se ha considerado tradicionalmente un equivalente electrocardiográfico de infarto agudo de miocardio con elevación del segmento ST, el cual debe ser llevado a reperfusión emergente. Para su definición se han propuesto varios criterios, pero ninguno ha alcanzado un rendimiento diagnóstico óptimo. A continuación detallaremos dichos criterios, sus principales problemas y las ventajas que han demostrado.

Abstract A new or presumably new left bundle branch block along with ischemic symptoms has traditionally been considered an electrocardiographic equivalent of ST-segment elevation myocardial infarction, which should be brought to emergent reperfusion. However, several criteria have been proposed for its definition, but none has reached out an optimal diagnostic yield. Below we detail these criteria, their main problems and the advantages they have shown.

New-onset or Pre-existing Atrial Fibrillation in Acute Coronary Syndromes: Two Distinct Phenomena With a Similar Prognosis.

INTRODUCTION AND OBJECTIVES: The management and risk stratification of patients with atrial fibrillation (AF) and acute coronary syndromes constitute a challenge. We aimed to evaluate the prognostic impact of AF whether present at admission or occurring during hospitalization for acute coronary syndromes, as well as trends in treatments and outcome. METHODS: Data derived from 35 958 patients enrolled between 2004 and 2015 in the AMIS Plus registry were retrospectively analyzed. RESULTS: Pre-existing AF (pre-AF) was present in 1644 (4.7%) while new-onset AF (new-AF) was evident in 309 (0.8%). Presentation with ST-segment elevation myocardial infarction and need for hemodynamic support was frequent in patients with AF, especially in those with new onset of the arrhythmia. A change of the medical and interventional approaches was observed with a progressive increase in oral anticoagulation prescription and referral for angiography and percutaneous coronary interventions in pre-AF patients. Despite different baseline risk profile and clinical presentations, both AF groups showed high in-hospital and 1-year mortality (in-hospital new-AF vs pre-AF [OR, 0.79; 95%CI, 0.53-1.17; P = .246]; 1-year mortality new-AF vs pre-AF [OR, 0.72; 95%CI, 0.31-1.67; P = .448]) Pre-AF but not new-AF independently predicted in-hospital mortality. While mortality declined over the study period for patients with pre-AF, it remained stable among new-AF patients. CONCLUSIONS: While pre-AF is independently associated with in-hospital mortality, new-AF may reflect a worse hemodynamic impact of the acute coronary syndromes, with the latter ultimately driving the prognosis.

Reperfusion of myocardial infarction in India: Notions for México / Reperfusión del Infarto del Miocardio en India: Nociones para México

Abstract In India and México, cardiovascular diseases are the first cause of death and potential years of life lost. Close similarities exist between these two countries when facing the difficulties to establish a universal reperfusion program for ST elevation myocardial infarction (STEMI). This paper describes the situation of STEMI treatment in both countries, and examines the lessons that Mexico's health care system could adopt from the recent advances accomplished by the STEMI initiative in India. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Resumen En India y México, las enfermedades cardiovasculares constituyen la primera causa de muerte y pérdida de años potenciales de vida. Existen similitudes cercanas entre estos 2 países en cuanto a las dificultades a enfrentar al establecer un programa de reperfusión universal para el infarto agudo de miocardio con elevación del segmento ST (IAMCEST). Este artículo describe la situación del tratamiento del IAMCEST en ambas naciones y explora las lecciones que el sistema de salud de México podría adoptar de los recientes avances logrados por la iniciativa STEMI India. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Appropriate use of noninvasive ischemia testing to guide revascularization decision making following acute ST elevation myocardial infarction in Latin American countries: Results from an expert panel meeting of the International Atomic Energy Agency. / Uso adecuado de las pruebas no invasivas de isquemia para guiar la toma de decisión sobre revascularización tras un infarto agudo de miocardio con elevación del segmento ST en países iberoamericanos: Resultados de la reunión de un panel de expertos de la International Atomic Energy Agency.

Across Latin American and Caribbean countries, cardiovascular disease and especially ischemic heart disease is currently the main cause of death both in men and in women. For most Latin American and Caribbean countries, public and community health efforts aim to define care strategies which are both clinically and cost effective and promote primary and secondary prevention, resulting in improved patient outcomes. The optimal approach to deal with acute events such as ST-elevation myocardial infarction (STEMI) is a matter of controversy; however, there is an expanding role for assessing residual ischemic burden in STEMI patients following primary percutaneous coronary intervention. Although randomized clinical trials have established the value of staged fractional flow reserve-guided revascularization, the use of noninvasive functional imaging modalities may play a similar role at a much lower cost. For LAC, available stress imaging techniques could be applied to define residual ischemia in the non-infarct related artery and to target revascularization in a staged procedure after primary percutaneous coronary intervention The use of nuclear cardiac imaging, supported by its relatively wide availability, moderate cost, and robust quantitative capabilities, may serve to guide effective care and to reduce subsequent cardiac events in patients with coronary artery disease. This noninvasive approach may avert potential safety issues with repeat and lengthy invasive procedures, and serve as a baseline for subsequent follow-up stress testing following the index STEMI event. This consensus document was devised from an expert panel meeting of the International Atomic Energy Agency, highlighting available evidence with a focus on the utility of stress myocardial perfusion imaging in post-STEMI patients. The document could serve as guidance to the prudent and appropriate use of nuclear imaging for targeting therapeutic management and avoiding unnecessary invasive procedures within Latin American and Caribbean countries, where resources could be scarce.

Reperfusion of myocardial infarction in India: Notions for México.

In India and México, cardiovascular diseases are the first cause of death and potential years of life lost. Close similarities exist between these two countries when facing the difficulties to establish a universal reperfusion program for ST elevation myocardial infarction (STEMI). This paper describes the situation of STEMI treatment in both countries, and examines the lessons that Mexico's health care system could adopt from the recent advances accomplished by the STEMI initiative in India.

Bifurcation Culprit Lesions in ST-segment Elevation Myocardial Infarction: Procedural Success and 5-year Outcome Compared With Nonbifurcation Lesions.

INTRODUCTION AND OBJECTIVES: We assessed short- and long-term outcomes of primary angioplasty in ST-segment elevation myocardial infarction by comparing bifurcation culprit lesions (BCL) with non-BCL. METHODS: Observational study with a propensity score matched control group. Among 2746 consecutive ST-segment elevation myocardial infarction patients, we found 274 (10%) patients with BCL. The primary outcome was a composite endpoint including all-cause death, myocardial infarction, coronary artery bypass grafting or target vessel revascularization, assessed at 30-days and 5-years. RESULTS: Baseline characteristics showed no differences after propensity matching (1:1). In the BCL group, the most frequent strategy was provisional stenting of the main branch (84%). Compared with the non-BCL group, the procedures were technically more complex in the BCL group in terms of need for balloon dilatation (71% BCL vs 59% non-BCL; P = .003), longer procedural time (70 ± 29minutes BCL vs 62.8 ± 28.9minutes non-BCL; P = .004) and contrast use (256.2 ± 87.9mL BCL vs 221.1 ± 82.3mL non-BCL; P < .001). Main branch angiographic success was similar (93.4% BCL vs 93.8% non-BCL; P = .86). Thirty-day all-cause mortality was similar between groups: 4.7% BCL vs 5.1% non-BCL; P = .84. At the 5-year follow-up, there were no differences in all-cause death (12% BCL vs 13% non-BCL; P = .95) or the combined event (22% BCL vs 21% non-BCL; P = .43). CONCLUSIONS: Primary angioplasty of a BCL was technically more complex; however, main branch angiographic success was similar, and there were no differences in long-term prognosis compared with non-BCL patients.

Gender gap in medical care in ST segment elevation myocardial infarction networks: Findings from the Catalan network Codi Infart. / Brecha de género en los cuidados médicos en las redes de atención al infarto agudo de miocardio con elevación del segmento ST: hallazgos de la red catalana Codi Infart.

OBJECTIVE: To assess the impact of gender upon the prognosis and medical care in a regional acute ST-elevation myocardial infarction management network. DESIGN: An observational study was made of consecutive patients entered in a prospective database. SCOPE: The Catalan acute ST-elevation myocardial infarction management network. PATIENTS: Patients treated between January 2010 and December 2011. INTERVENTIONS: Primary angioplasty, thrombolysis or conservative management. VARIABLES OF INTEREST: Time intervals, proportion and type of reperfusion, overall mortality, and in-hospital complication and overall mortality at 30 days and one year were compared in relation to gender. RESULTS: Of the 5,831 patients attended by the myocardial infarction network, 4,380 had a diagnosis of acute ST-elevation myocardial infarction, and 961 (21.9%) were women. Women were older (69.8±13.4 vs. 60.6±12.8 years; P<.001), had a higher prevalence of diabetes (27.1 vs. 18.1%, P<.001), Killip class>I (24.9 vs. 17.3%; P<.001) and no reperfusion (8.8 vs. 5.2%; P<.001) versus men. In addition, women had greater delays in medical care (first medical contact-to-balloon: 132 vs. 122min; P<.001, and symptoms onset-to-balloon: 236 vs. 210min; P<.001). Women presented higher percentages of overall in-hospital complications (20.6 vs. 17.4%; P=.031), in-hospital mortality (4.8 vs. 2.6%; P=.001), 30-day mortality (9.1 vs. 4.5%; P<.001) and one-year mortality (14.0 vs. 8.3%; P<.001) versus men. Nevertheless, after multivariate adjustment, no gender differences in 30-day and one-year mortality were observed. CONCLUSIONS: Despite a higher risk profile and poorer medical management, women present similar 30-day and one-year outcomes as their male counterparts in the context of the myocardial infarction management network.

Impact of intra-aortic balloon pump on short-term clinical outcomes in ST-elevation myocardial infarction complicated by cardiogenic shock: A "real life" single center experience.

OBJECTIVE: To analyze the use and impact of the intra-aortic balloon pump (IABP) upon the 30-day mortality rate and short-term clinical outcome of non-selected patients with ST-elevation acute myocardial infarction (acute STEMI) complicated by cardiogenic shock (CS). DESIGN: A single-center retrospective case-control study was carried out. SETTING: Coronary Care Unit. PATIENTS: Data were collected from 825 consecutive patients with acute STEMI admitted to a Coronary Care Unit from January 2009 to August 2015. Seventy-three patients with CS upon admission subjected to emergency percutaneous coronary intervention (PCI) were finally included in the analysis and were stratified according to IABP use (44 patients receiving IABP). VARIABLES: Cardiovascular history, hemodynamic situation upon admission, angiographic and procedural characteristics, and variables derived from admission to the Coronary Care Unit. RESULTS: Cumulative 30-day mortality was similar in the patients subjected to IABP and in those who received conventional medical therapy only (29.5% and 27.6%, respectively; HR with IABP 1.10, 95% CI 0.38-3.11; p=0.85). Similarly, no significant differences were found in terms of the short-term clinical outcome between the groups: time on mechanical ventilation, days to hemodynamic stabilization, vasoactive drug requirements and stay in the Coronary Care Unit. Poorer renal function (HR 3.9, 95% CI 1.4-10.6; p=0.008), known peripheral artery disease (HR 3.3, 95% CI 1.2-9.1; p=0.019) and a history of diabetes mellitus (HR 3.2, 95% CI 1.2-8.1; p=0.018) were the only variables independently associated to increased 30-day mortality. CONCLUSION: In our "real life" experience, IABP does not modify 30-day mortality or the short-term clinical outcome in patients presenting STEMI complicated with CS and subjected to emergency percutaneous coronary revascularization.