Intravascular imaging-guided percutaneous coronary intervention in patients with acute myocardial infarction and cardiogenic shock.

INTRODUCTION AND OBJECTIVES: There are no clinical data on the efficacy of intravascular imaging-guided percutaneous coronary intervention (PCI) compared with angiography-guided PCI in patients with acute myocardial infarction (AMI) and cardiogenic shock. The current study sought to evaluate the impact of intravascular imaging-guided PCI in patients with AMI and cardiogenic shock. METHODS: Among a total of 28 732 patients from the nationwide pooled registry of KAMIR-NIH (November, 2011 to December, 2015) and KAMIR-Ⅴ (January, 2016 to June, 2020), we selected a total of 1833 patients (6.4%) with AMI and cardiogenic shock who underwent PCI of the culprit vessel. The primary endpoint was major adverse cardiovascular events (MACE) at 1 year, a composite of cardiac death, myocardial infarction, repeat revascularization, and definite or probable stent thrombosis. RESULTS: Among the study population, 375 patients (20.5%) underwent intravascular imaging-guided PCI and 1458 patients (79.5%) underwent angiography-guided PCI. Intravascular imaging-guided PCI was associated with a significantly lower risk of 1-year MACE than angiography-guided PCI (19.5% vs 28.2%; HR, 0.59; 95%CI, 0.45-0.77; P < .001), mainly driven by a lower risk of cardiac death (13.7% vs 24.0%; adjusted HR, 0.53; 95%CI, 0.39-0.72; P < .001). These results were consistent in propensity score matching (HR, 0.68; 95%CI, 0.46-0.99), inverse probability weighting (HR, 0.61; 95%CI, 0.45-0.83), and Bayesian analysis (Odds ratio, 0.66, 95% credible interval, 0.49-0.88). CONCLUSIONS: In AMI patients with cardiogenic shock, intravascular imaging-guided PCI was associated with a lower risk of MACE at 1-year than angiography-guided PCI, mainly driven by the lower risk of cardiac death.

Influence of sex on the timing of coronary angiography and the prescription of antiplatelet therapy in patients with nonST-segment elevation myocardial infarction. / Impacto del sexo en los tiempos de cateterismo y en el uso de pretratamiento antiagregante plaquetario en pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST).

OBJECTIVES: To assess differences in the clinical management of nonST-segment elevation myocardial infarction (NSTEMI), including in-hospital events, according to biological sex. MATERIAL AND METHODS: Prospective observational multicenter study of patients diagnosed with NSTEMI and atherosclerosis who underwent coronary angiography. RESULTS: We enrolled 1020 patients in April and May 2022; 240 (23.5%) were women. Women were older than men on average (72.6 vs 66.5 years, P .001), and more women were frail (17.1% vs 5.6%, P .001). No difference was observed in pretreatment with any P2Y12 inhibitor (prescribed in 68.8% of women vs 70.2% of men, P = .67); however, more women than men were prescribed clopidogrel (56% vs 44%, P = .009). Women prescribed clopidogrel were more often under the age of 75 years and not frail. Coronary angiography was performed within 24 hours less corooften in women (29.8% vs 36.9%, P = .03) even when high risk was recognized. Frailty was independently associated with deferring coronary angiography in the adjusted analysis; biological sex by itself was not related. The frequency and type of revascularization were the same in both sexes, and there were no differences in in-hospital cardiovascular events. CONCLUSION: Women were more often prescribed less potent antithrombotic therapy than men. Frailty, but not sex, correlated independently with deferral of coronary angiography. However, we detected no differences in the frequency of coronary revascularization or in-hospital events according to sex.

OBJETIVO: Evaluar las diferencias en el manejo clínico y eventos intrahospitalarios en una cohorte de pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST) en función del sexo. METODO: Estudio observacional, prospectivo y multicéntrico que incluyó pacientes consecutivos con diagnóstico de SCASEST sometidos a coronariografía con enfermedad ateroesclerótica responsable. RESULTADOS: Entre abril y mayo de 2022 se incluyeron 1.020 pacientes; de ellos, 240 eran mujeres (23,5%). En comparación con los hombres, las mujeres fueron mayores (72,6 años vs 66,5 años; p 0,001) y más frágiles (17,1% vs 5,6%; p 0,001). No hubo diferencias en el pretratamiento con un inhibidor del receptor P2Y12 (68,8% vs 70,2%, p = 0,67), aunque las mujeres recibieron más pretratamiento con clopidogrel (56% vs 44%, p = 0,009), principalmente aquellas de edad 75 años y sin fragilidad. En las mujeres se realizaron menos coronariografías precoces (# 24 h) (29,8% vs 36,9%; p = 0,03) a pesar de presentar la misma indicación (criterios de alto riesgo). En el análisis ajustado, la fragilidad, pero no el sexo, se asoció de forma independiente con la realización de una coronariografía diferida. La tasa y el tipo de revascularización fue igual en ambos sexos, y no hubo diferencias en los eventos cardiovasculares intrahospitalarios. CONCLUSIONES: Las mujeres recibieron con mayor frecuencia un tratamiento antitrombótico menos potente. La fragilidad y no el sexo se asoció con la realización de coronariografía diferida. Sin embargo, no hubo diferencias en la tasa de revascularización coronaria ni en los eventos intrahospitalarios en función del sexo.

Timing of coronary angiography and use of antiplatelet pretreatment in patients with NSTEACS in Spain.

INTRODUCTION AND OBJECTIVES: The optimal timing of coronary angiography in patients admitted with non-ST-segment elevation acute coronary syndrome (NSTEACS) as well as the need for pretreatment are controversial. The main objective of the IMPACT-TIMING-GO registry was to assess the proportion of patients undergoing an early invasive strategy (0-24hours) without dual antiplatelet therapy (no pretreatment strategy) in Spain. METHODS: This observational, prospective, and multicenter study included consecutive patients with NSTEACS who underwent coronary angiography that identified a culprit lesion. RESULTS: Between April and May 2022, we included 1021 patients diagnosed with NSTEACS, with a mean age of 67±12 years (23.6% women). A total of 87% of the patients were deemed at high risk (elevated troponin; electrocardiogram changes; GRACE score>140) but only 37.8% underwent an early invasive strategy, and 30.3% did not receive pretreatment. Overall, 13.6% of the patients underwent an early invasive strategy without pretreatment, while the most frequent strategy was a deferred angiography under antiplatelet pretreatment (46%). During admission, 9 patients (0.9%) died, while major bleeding occurred in 34 (3.3%). CONCLUSIONS: In Spain, only 13.6% of patients with NSTEACS undergoing coronary angiography received an early invasive strategy without pretreatment. The incidence of cardiovascular and severe bleeding events during admission was low.

Impacto pronóstico a diez años del fallo del vaso diana tras un IAMCEST. Perspectivas del ensayo EXAMINATION-EXTEND / Ten-year prognostic impact of target versus non-target vessel failure after STEMI. Insight from the EXAMINATION-EXTEND trial

Introducción y objetivos Se desconoce el impacto pronóstico de los diferentes tipos de eventos adversos tras el infarto agudo de miocardio con elevación del segmento ST (IAMCEST). El objetivo de este trabajo es evaluar los predictores a largo plazo del objetivo combinado orientado al paciente (POCE) y si tener un fallo del vaso diana (FVD) como primer evento puede influir en los resultados. Métodos El ensayo EXAMINATION-EXTEND aleatorizó a pacientes con IAMCEST a tratamiento con stents liberadores de everolimus o a stents convencionales, con un seguimiento de hasta 10 años. En la población del estudio, se evaluaron los predictores de POCE (combinado de mortalidad por cualquier causa, infarto de miocardio y cualquier revascularización). Se clasificó a los pacientes según el tipo de primer evento (FVD primero o FDV no primero) y comparado en términos de POCE posterior. El FVD se definió como el compuesto de muerte cardiaca, IAMCEST del vaso diana y revascularización del vaso diana. Resultados De los 1.498 pacientes del estudio, 529 (35,3%) tuvieron POCE durante el seguimiento a los 10 años. Los predictores independientes de POCE fueron la edad, la diabetes mellitus, el infarto de miocardio previo, la enfermedad arterial periférica y la enfermedad coronaria multivaso. El primer evento fue un FVD o no FVD en 296 y 233 casos respectivamente. No hubo diferencias estadísticamente significativas entre quienes tuvieron primero un FVD y los que tuvieron un evento no FVD en cuanto a POCE (el 21,7 frente al 39,3%; razón de tiempo, 1,79; IC95%, 0,87-3,67; p=0,12) o sus componentes individuales. Conclusiones En el seguimiento a 10 años, alrededor de un tercio de los pacientes con IAMCEST tuvo al menos 1 evento de POCE, cuyos predictores independientes fueron la edad, la diabetes mellitus y una mayor extensión de la enfermedad ateroesclerótica... (AU)

Introduction and objectivesAfter ST-segment myocardial infarction (STEMI), the impact of different adverse events on prognosis remains unknown. We aimed to assess very long-term predictors of patient-oriented composite endpoints (POCE) and investigate whether the occurrence of target vessel failure (TVF) vs a non-TVF event as the first event could potentially influence subsequent outcomes. Methods The EXAMINATION.EXTEND trial randomized STEMI patients to receive either an everolimus-eluting stent or a bare-metal stent. The follow-up period was 10 years. Predictors of POCE (a composite of all-cause death, any myocardial infarction, or any revascularization) were evaluated in the overall study population. The patients were stratified based on the type of first event (TVF-first vs non–TVF-first) and were compared in terms of subsequent POCE. TVF was defined as a composite of cardiac death, TV myocardial infarction, or TV revascularization. Results Out of the 1498 enrolled patients, 529 (35.3%) experienced a POCE during the 10-year follow-up. Independent predictors of POCE were age, diabetes mellitus, previous myocardial infarction, peripheral arterial disease, and multivessel coronary disease. The first event was a TVF in 296 patients and was a non-TVF in 233 patients. No significant differences were observed between TVF-first and non–TVF-first patients in terms of subsequent POCE (21.7% vs 39.3%, time ratio 1.79; 95%CI, 0.87-3.67; P=.12) or its individual components. Conclusions At the 10-year follow-up, approximately one-third of STEMI patients had experienced at least 1 POCE. Independent predictors of these events were age, diabetes, and more extensive atherosclerotic disease. The occurrence of a TVF or a non-TVF as the first event did not seem to influence subsequent outcomes. Trial registration number: NCT04462315. (AU)

Tiempos de cateterismo y uso de pretratamiento antiagregante plaquetario en pacientes con SCASEST en España / Timing of coronary angiography and use of antiplatelet pretreatment in patients with NSTEACS in Spain

Introducción y objetivos El momento óptimo para un cateterismo en el síndrome coronario agudo sin elevación del segmento ST (SCASEST) y la necesidad de pretratamiento son motivo de controversia. El objetivo principal del registro IMPACT-TIMING-GO es conocer el porcentaje de pacientes examinados con una coronariografía precoz (0-24 h) y que no recibieron doble antiagregación plaquetaria antes del cateterismo (estrategia sin pretratamiento) en España. Métodos Estudio observacional, prospectivo y multicéntrico, que incluyó a pacientes consecutivos con diagnóstico de SCASEST sometidos a cateterismo en los que se evidenció enfermedad coronaria ateroesclerótica causal. Resultados Entre abril y mayo de 2022 se incluyó a 1.021 pacientes (media de edad, 67±12 años; el 23,6% mujeres). El 86,8% de los pacientes cumplían criterios de alto riesgo (elevación de troponina, cambios electrocardiográficos o puntuación GRACE>140); sin embargo, únicamente el 37,8% se sometió a una estrategia invasiva precoz, y el 30,3% no recibió pretratamiento. Globalmente, solo el 13,6% de los pacientes se sometieron a una estrategia invasiva precoz sin un segundo antiagregante plaquetario, y la estrategia diferida con pretratamiento fue la más utilizada (46%). Durante el ingreso, 9 pacientes (0,9%) fallecieron y 34 (3,3%) presentaron una hemorragia grave. Conclusiones En España, solo el 13,6% de los pacientes con SCASEST sometidos a cateterismo reciben una estrategia invasiva precoz sin pretratamiento. La incidencia de eventos cardiovasculares y hemorragias graves en el ingreso es baja. (AU)

Introduction and objectives The optimal timing of coronary angiography in patients admitted with non–ST-segment elevation acute coronary syndrome (NSTEACS) as well as the need for pretreatment are controversial. The main objective of the IMPACT-TIMING-GO registry was to assess the proportion of patients undergoing an early invasive strategy (0-24hours) without dual antiplatelet therapy (no pretreatment strategy) in Spain. Methods This observational, prospective, and multicenter study included consecutive patients with NSTEACS who underwent coronary angiography that identified a culprit lesion. Results Between April and May 2022, we included 1021 patients diagnosed with NSTEACS, with a mean age of 67±12 years (23.6% women). A total of 87% of the patients were deemed at high risk (elevated troponin; electrocardiogram changes; GRACE score>140) but only 37.8% underwent an early invasive strategy, and 30.3% did not receive pretreatment. Overall, 13.6% of the patients underwent an early invasive strategy without pretreatment, while the most frequent strategy was a deferred angiography under antiplatelet pretreatment (46%). During admission, 9 patients (0.9%) died, while major bleeding occurred in 34 (3.3%). Conclusions In Spain, only 13.6% of patients with NSTEACS undergoing coronary angiography received an early invasive strategy without pretreatment. The incidence of cardiovascular and severe bleeding events during admission was low. (AU)

Efecto del suero aislado de pacientes con infarto agudo de miocardio con elevación del segmento ST en las células endoteliales / Effect of serum from patients with ST-segment elevation myocardial infarction on endothelial cells

Introducción y objetivos La reperfusión coronaria produce un daño en la microcirculación y, en concreto, las células endoteliales. Este estudio evalúa el efecto del suero aislado tras la revascularización de pacientes con un infarto agudo de miocardio con elevación del segmento ST (IAMCEST) en la viabilidad celular, el grado de permeabilidad endotelial in vitro y la asociación de estos parámetros con una mayor extensión de los índices de resonancia magnética cardiaca (RMC) relacionados con el daño por reperfusión (edema, hemorragia y obstrucción microvascular). Métodos Se incubaron células endoteliales de arteria coronaria humana con suero aislado 24 h tras la revascularización de 43 pacientes con IAMCEST evaluados mediante RMC y 14 sujetos de control. Se testó el efecto del suero de pacientes con IAMCEST en la pérdida de viabilidad celular por activación de la apoptosis y la necrosis, así como en la permeabilidad y la estructura de la monocapa endotelial. Resultados El suero de pacientes con IAMCEST aumentó la apoptosis (p <0,01) y la necrosis (p <0,05) de células endoteliales de arteria coronaria humana y causó un incremento de la permeabilidad de la monocapa endotelial in vitro (p <0,01) debido a mayores espacios intercelulares (p <0,05 frente a los controles). Una mayor necrosis inducida por suero se asoció con más permeabilidad endotelial in vitro (p <0,05) y con una mayor extensión de los principales índices de daño tras reperfusión y mayor tamaño de infarto. Conclusiones El suero tras la reperfusión de pacientes con IAMCEST induce la apoptosis y la necrosis in vitro de las células endoteliales y la permeabilidad endotelial. Cuanto más potente sea el efecto inductor de necrosis, más deletéreas son las consecuencias en cuanto al daño estructural resultante. (AU)

Introduction and objectives Clinical and experimental studies have shown that, in patients with reperfused ST-segment elevation myocardial infarction (STEMI), abnormalities in the endothelial monolayer are initiated during ischemia but rapidly intensify upon restoration of blood perfusion to the ischemic area. We aimed to evaluate the effect of serum isolated after revascularization from STEMI patients on the degree of endothelial permeability in vitro, by promoting endothelial cell apoptosis and necrosis in vitro. We also investigated the association between the percentage of serum-induced endothelial cell apoptosis or necrosis in vitro and the extent of cardiovascular magnetic resonance (CMR)-derived parameters of reperfusion injury (edema, hemorrhage, and microvascular obstruction). Methods Human coronary artery endothelial cells were incubated with serum isolated 24hours after revascularization from 43 STEMI patients who underwent CMR and 14 control participants. We assessed the effect of STEMI serum on activation of apoptosis and necrosis, as well as on the permeability and structure of the endothelial monolayer. Results Serum from STEMI patients increased apoptosis (P <.01) and necrosis (P <.05) in human coronary artery endothelial cells and caused increased permeability of the endothelial monolayer in vitro (P <.01), due to enlarged intercellular spaces (P <.05 vs control in all cases). Higher serum-induced necrosis was associated with greater endothelial permeability in vitro (P <.05) and with more extensive CMR-derived indices of reperfusion injury and infarct size. Conclusions Postreperfusion serum activates necrosis and apoptosis in endothelial cells and increases the degree of endothelial permeability in vitro. The more potent the necrosis-triggering effect of serum, the more deleterious the consequences in terms of the resulting cardiac structure. (AU)

CORRELATION OF BLOOD AND SALIVARY TROPONIN IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION: PRELIMINARY STUDY / CORRELAÇÃO DA TROPONINA SANGUÍNEA E SALIVAR EM PACIENTES COM INFARTO AGUDO DO MIOCÁRDIO: ESTUDO PRELIMINAR

Introduction: In the event of myocardial injury, the identification of biomarkers that constitute the cardiac muscle cell, especially troponins, can be observed from blood and saliva samples. The preference for using saliva as a diagnostic fluid is supported by the ease of obtaining it using a non-invasive and potentially pre-hospital method. Objective: To verify the expression of troponin I in salivary fluid in acute myocardial infarction in emergency and pre-hospital screenings and correlate it with plasma troponin I levels. Method: Cross-sectional analytical study of diagnostic testing in 27 patients, 9 women and 18 men, with diagnostic confirmation of acute myocardial infarction. Blood and saliva samples were collected and stored and transported over a period of up to 24 hours for troponina I quantification. Results: The study demonstrated that 44.4% of patients were positive for troponin I in both analyses, with equal dichotomous results in 48.1% of cases. Thus, the salivary troponin test achieved 48% sensitivity and 50% specificity. Conclusion: It was possible to identify troponin in the saliva fluid of patients suffering from acute myocardial infarction, but the probability of a false positive result was 50% and a false negative result was 52%.

Introdução: Na ocorrência da lesão miocárdica, a identificação de biomarcadores constituintes da célula muscular cardíaca, em especial as troponinas, pode ser observada a partir de amostras de sangue e saliva. A preferência pela utilização da saliva como fluído diagnóstico é sustentada pela facilidade de obtenção a partir de método não invasivo e potencialmente pré-hospitalar. Objetivo: Verificar a expressão de troponina I do fluído salivar no infarto agudo do miocárdio em triagens de emergências e pré-hospitalares e correlacioná-la com os níveis plasmáticos da troponina I. Método: Estudo analítico transversal de teste diagnóstico em 27 pacientes, 9 mulheres e 18 homens, com confirmação diagnóstica de infarto agudo do miocárdio. Foram coletadas amostras de sangue e saliva armazenadas e transportadas em período de até 24 h para quantificação da troponina I. Resultados: O estudo demonstrou que 44,4% dos pacientes apresentaram positivação de troponina I em ambas as análises, com igualdade de resultados dicotômicos em 48,1% dos casos. Assim, o teste de troponina salivar obteve 48% de sensibilidade e 50% de especificidade. Conclusão: Foi possível identificar troponina I no fluido da saliva de pacientes em vigência de infarte agudo do miocárdio, mas a probabilidade de ela ter resultado falso positivo foi de 50% e de falso negativo de 52%.

CAN BLOOD AND SALIVARY TROPONIN BE EARLY SIGNALS OF ACUTE MYOCARDIAL INFARCTION? / PODEM A TROPONINA SANGUÍNEA E SALIVAR SER SINALISADORAS PRECOCES DO INFARTO AGUDO DO MIOCÁRDIO?

Introduction: Myocardial injury can be identified by biomarkers extracted from cardiac cells. Troponin is one of them and can be observed in blood and saliva. Saliva is preferred due to its ease of non-invasive and pre-hospital collection. Objective: To review whether the expression of troponin I in salivary fluid in acute myocardial infarction in emergency screening is viable compared to its plasma levels. Method: The literature review was carried out by collecting information published in SciELO, Bibliomed, VHL - Biblioteca Virtual em Saúde, Pubmed and Scopus in Portuguese and English. The search was based on descriptors related to the topic, identified as: "troponin, acute myocardial infarction, cardiac biomarkers, salivary fluid", with AND and OR searches. Results: Were included 109 articles correlated to the theme. Conclusion: Diagnosis based on saliva offers many options and could be a very interesting option for elucidating acute myocardial infarction for general practitioners, nursing homes and transport services quickly, aiding early treatment.

Introdução: A lesão miocárdica pode ser identificada por biomarcadores extraídos das células cardíacas. A troponina é uma delas e pode ser observada no sangue e saliva. A saliva é preferencial pela facilidade de coleta não invasiva e pré-hospitalar. Objetivo: Revisar se a expressão de troponina I do fluído salivar no infarto agudo do miocárdio em triagens de emergências é viável comparado aos seus níveis plasmáticos. Método: A revisão da literatura foi feita colhendo informações publicadas no SciELO, Bibliomed, BVS - Biblioteca Virtual em Saúde, Pubmed e Scopus em português e inglês. A busca foi baseada em descritores relacionados ao tema, identificados como: "troponina, infarto agudo do miocárdio, biomarcadores cardíacos, fluido salivar",  com busca AND e OR. Resultados: Foram incluídos 109 trabalhos. Conclusão: O diagnóstico baseado na saliva oferece muitas opções podendo vir a ser opção muito interessante para elucidação de infarto agudo do miocárdio para o clínico geral, lares de idosos e serviços de transporte com rapidez auxiliando precocidade no tratamento.

Cardiogenic shock as a health issue. Physiology, classification, and detection.

Cardiogenic shock (CS) is a heterogeneous syndrome with high mortality and a growing incidence. It is characterized by an imbalance between the tissue oxygen demands and the capacity of the cardiovascular system to meet these demands, due to acute cardiac dysfunction. Historically, acute coronary syndromes have been the primary cause of CS. However, non-ischemic cases have seen a rise in incidence. The pathophysiology involves ischemic damage of the myocardium and a sympathetic, renin-angiotensin-aldosterone system and inflammatory response, perpetuating the situation of tissue hypoperfusion and ultimately leading to multiorgan dysfunction. The characterization of CS patients through a triaxial assessment and the widespread use of the Society for Cardiovascular Angiography and Interventions (SCAI) scale has allowed standardization of the severity stratification of CS; this, coupled with early detection and the "hub and spoke" approach, could contribute to improving the prognosis of these patients.

Desfechos Hospitalares do Infarto do Miocárdio com Supradesnivelamento do Segmento ST em Pacientes Positivos para COVID-19 que Passaram por Intervenção Percutânea Primária / In-Hospital Outcomes of ST-Segment Elevation Myocardial Infarction in COVID-19 Positive Patients Undergoing Primary Percutaneous Intervention

Resumo Fundamento A infecção concomitante por coronavírus 2019 (COVID-19) e o infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST) estão associados ao aumento de desfechos adversos hospitalares. Objetivos O estudo teve como objetivo avaliar as diferenças angiográficas, de procedimentos, laboratoriais e prognósticas em pacientes positivos e negativos para COVID-19 com IAMCSST submetidos à intervenção coronária percutânea primária (ICP). Métodos Realizamos um estudo observacional retrospectivo e unicêntrico entre novembro de 2020 e agosto de 2022 em um hospital de nível terciário. De acordo com o seu estado, os pacientes foram divididos em dois grupos (positivo ou negativo para COVID-19). Todos os pacientes foram internados por IAMCSST confirmado e foram tratados com ICP primária. Os desfechos hospitalares e angiográficos foram comparados entre os dois grupos. P-valores bilaterais <0,05 foram aceitos como estatisticamente significativos. Resultados Dos 494 pacientes com IAMCSST inscritos nesse estudo, 42 foram identificados como positivos para COVID-19 (8,5%) e 452, como negativos. Os pacientes que testaram positivos para COVID-19 tiveram um tempo isquêmico total maior do que os pacientes que testaram negativos para COVID-19 (p = 0,006). Além disso, esses pacientes apresetaram um aumento na trombose de stent (7,1% vs. 1,7%, p = 0,002), no tempo de internação (4 dias vs. 3 dias, p = 0,018), no choque cardiogênico (14,2% vs. 5,5%, p = 0,023) e na mortalidade hospitalar total e cardíaca (p <0,001 e p = 0,032, respectivamente). Conclusões Pacientes com IAMCSST com infecções concomitantes por COVID-19 foram associados ao aumento de eventos cardíacos adversos maiores. Mais estudos são necessários para compreender os mecanismos exatos dos desfechos adversos nesses pacientes.

Abstract Background Concomitant coronavirus 2019 (COVID-19) infection and ST-segment elevation myocardial infarction (STEMI) are associated with increased adverse in-hospital outcomes. Objectives This study aimded to evaluate the angiographic, procedural, laboratory, and prognostic differences in COVID-19-positive and negative patients with STEMI undergoing primary percutaneous coronary intervention (PCI). Methods A single-center, retrospective, observational study was conducted between November 2020 and August 2022 in a tertiary-level hospital. According to their status, patients were divided into two groups (COVID-19 positive and negative). All patients were admitted due to confirmed STEMI and treated with primary PCI. In-hospital and angiographic outcomes were compared between the two groups. Two-sided p-values < 0.05 were accepted as statistically significant. Results Of the 494 STEMI patients enrolled in this study, 42 were identified as having a positive dagnosis for COVID-19 (8.5%), while 452 were negative. The patients who tested positive for COVID-19 had a longer total ischemic time than did those who tested negative for COVID-19 (p=0.006). Moreover, these patients presented an increase in stent thrombosis (7.1% vs. 1.7%, p=0.002), length of hospitalization (4 days vs. 3 days, p= 0.018), cardiogenic shock (14.2% vs. 5.5 %, p= 0.023), and in-hospital total and cardiac mortality (p<0.001 and p=0.032, respectively). Conclusions Patients with STEMI with concomitant COVID-19 infections were associated with increased major adverse cardiac events. Further studies are needed to understand the exact mechanisms of adverse outcomes in these patients.

Ten-year prognostic impact of target versus non-target vessel failure after STEMI. Insight from the EXAMINATION-EXTEND trial.

INTRODUCTION AND OBJECTIVES: After ST-segment myocardial infarction (STEMI), the impact of different adverse events on prognosis remains unknown. We aimed to assess very long-term predictors of patient-oriented composite endpoints (POCE) and investigate whether the occurrence of target vessel failure (TVF) vs a non-TVF event as the first event could potentially influence subsequent outcomes. METHODS: The EXAMINATION-EXTEND trial randomized STEMI patients to receive either an everolimus-eluting stent or a bare-metal stent. The follow-up period was 10 years. Predictors of POCE (a composite of all-cause death, any myocardial infarction, or any revascularization) were evaluated in the overall study population. The patients were stratified based on the type of first event (TVF-first vs non-TVF-first) and were compared in terms of subsequent POCE. TVF was defined as a composite of cardiac death, TV myocardial infarction, or TV revascularization. RESULTS: Out of the 1498 enrolled patients, 529 (35.3%) experienced a POCE during the 10-year follow-up. Independent predictors of POCE were age, diabetes mellitus, previous myocardial infarction, peripheral arterial disease, and multivessel coronary disease. The first event was a TVF in 296 patients and was a non-TVF in 233 patients. No significant differences were observed between TVF-first and non-TVF-first patients in terms of subsequent POCE (21.7% vs 39.3%, time ratio 1.79; 95%CI, 0.87-3.67;P=.12) or its individual components. CONCLUSIONS: At the 10-year follow-up, approximately one-third of STEMI patients had experienced at least 1 POCE. Independent predictors of these events were age, diabetes, and more extensive atherosclerotic disease. The occurrence of a TVF or a non-TVF as the first event did not seem to influence subsequent outcomes. TRIAL REGISTRATION NUMBER: NCT04462315.

Ceftriaxone-induced Kounis syndrome: A case report and review of the literature.

Kounis syndrome is defined as cardiovascular symptoms that occur secondary to allergic or hypersensitivity insults, and is also called allergic angina and allergic myocardial infarction. We report a case of pre-operative ceftriaxone-induced Kounis syndrome with no evident dermatological manifestation, and describe our diagnostic dilemma. The patient was symptomatically managed and discharged in stable condition with a warning against future use of ceftriaxone.

Effect of serum from patients with ST-segment elevation myocardial infarction on endothelial cells.

INTRODUCTION AND OBJECTIVES: Clinical and experimental studies have shown that, in patients with reperfused ST-segment elevation myocardial infarction (STEMI), abnormalities in the endothelial monolayer are initiated during ischemia but rapidly intensify upon restoration of blood perfusion to the ischemic area. We aimed to evaluate the effect of serum isolated after revascularization from STEMI patients on the degree of endothelial permeability in vitro, by promoting endothelial cell apoptosis and necrosis in vitro. We also investigated the association between the percentage of serum-induced endothelial cell apoptosis or necrosis in vitro and the extent of cardiovascular magnetic resonance (CMR)-derived parameters of reperfusion injury (edema, hemorrhage, and microvascular obstruction). METHODS: Human coronary artery endothelial cells were incubated with serum isolated 24hours after revascularization from 43 STEMI patients who underwent CMR and 14 control participants. We assessed the effect of STEMI serum on activation of apoptosis and necrosis, as well as on the permeability and structure of the endothelial monolayer. RESULTS: Serum from STEMI patients increased apoptosis (P <.01) and necrosis (P <.05) in human coronary artery endothelial cells and caused increased permeability of the endothelial monolayer in vitro (P <.01), due to enlarged intercellular spaces (P <.05 vs control in all cases). Higher serum-induced necrosis was associated with greater endothelial permeability in vitro (P <.05) and with more extensive CMR-derived indices of reperfusion injury and infarct size. CONCLUSIONS: Postreperfusion serum activates necrosis and apoptosis in endothelial cells and increases the degree of endothelial permeability in vitro. The more potent the necrosis-triggering effect of serum, the more deleterious the consequences in terms of the resulting cardiac structure.

Neutrófilos en el diagnóstico de infarto del miocardio tipo 4a / Neutrophils in the Diagnosis of Type 4 Myocardial Infarction

Introducción: El infarto del miocardio tipo 4a es una complicación del intervencionismo coronario percutáneo que incrementa el estado inflamatorio de los pacientes. Objetivo: Evaluar el valor diagnóstico del conteo absoluto de neutrófilos en la aparición de infarto del miocardio tipo 4a. Métodos: Se realizó una cohorte prospectiva en el Hospital Hermanos Ameijeiras. El universo estuvo constituido por 412 pacientes a los que se les realizó intervencionismo coronario percutáneo en el período comprendido de noviembre de 2018 a enero de 2021, la muestra fue de 232 pacientes. Se definieron variables clínicas, anatómicas, e inflamatorias. Resultados: Existieron diferencias significativas entre los pacientes con infarto tipo 4a y los que no tuvieron esta complicación según las variables clínicas: edad, índice de masa corporal, diabetes mellitus, enfermedad renal crónica y disfunción sistólica ventricular. La elevación del conteo absoluto de neutrófilos posterior al proceder con un área bajo la curva de 0,947 tuvo buena capacidad de discriminación de esta complicación (p = 0,000). En el diagnóstico de infarto periproceder el conteo absoluto de neutrófilos fue 7,35 posterior al proceder, tuvo una sensibilidad de 91,3 por ciento una especificidad de 96,2 por ciento. Conclusiones: Los neutrófilos fueron sensibles y específicos para el diagnóstico de infarto del miocardio tipo 4a(AU)

Introduction: Type 4 myocardial infarction is a complication of percutaneous coronary intervention that increases the inflammatory state of patients. Objective: To evaluate the diagnostic value of the absolute neutrophil count in the occurrence of type 4 myocardial infarction. Methods: A prospective cohort was carried out at Hermanos Ameijeiras Clinical Surgical Hospital. The universe consisted of 412 patients who underwent percutaneous coronary intervention from November 2018 to January 2021, two hundred thirty-two (232) patients form the sample. Clinical, anatomical and inflammatory variables were defined. Results: There were significant differences between patients with type 4 infarction and those who did not have this complication according to the clinical variables such as age, body mass index, diabetes mellitus, chronic kidney disease and ventricular systolic dysfunction. The subsequent elevation of the absolute neutrophil count when proceeding with an area under the 0.947 curve had good ability to discriminate this complication (p = 0.000). In the diagnosis of periprocedural infarction, the absolute neutrophil count was ≥ 7.35 after the procedure, it had 91.3percent sensitivity and 96.2percent specificity. Conclusions: Neutrophils were sensitive and specific for the diagnosis of type 4 myocardial infarction(AU)

Timing of cardiac magnetic resonance and diagnostic yield in patients with myocardial infarction with nonobstructive coronary arteries.

INTRODUCTION AND OBJECTIVES: The present study sought to establish the diagnostic yield of cardiovascular magnetic resonance (CMR) in a large cohort of patients admitted with myocardial infarction (MI) with nonobstructive coronary artery disease (MINOCA) based on the timing of referral to CMR. METHODS: Consecutive patients referred to CMR from January 2009 to February 2022 with a working diagnosis of MINOCA were retrospectively evaluated. Cine, T2-weighted, early, and late gadolinium-enhanced images were acquired and analyzed. The frequency of the underlying diagnosis and the association between timing of CMR and relative frequency of each diagnosis were assessed. RESULTS: We included 207 patients (median age 50 years, 60% men). Final diagnosis after CMR was achieved in 91% of the patients (myocarditis in 45%, MI in 20%, tako-tsubo cardiomyopathy in 19%, and other cardiomyopathies in 7%). The performance of CMR within 7 days of admission with MINOCA (median, 5 days; 117 patients) allowed a higher diagnostic yield compared with CMR performed later (median, 10 days; 88 patients) (96% vs 86%, P=.02). Although myocarditis was the most frequent diagnosis in both groups according to time to CMR, its frequency was higher among patients with a CMR performed within the first 7 days (53% vs 35%, P=.02). The frequency of other underlying diagnoses was not influenced by CMR timing. CONCLUSIONS: CMR led to an underlying diagnosis of MINOCA in 91% of patients and its diagnostic yield increased to 96% when CMR was performed within 7 days of admission. The most frequent diagnosis was myocarditis..

¿Existe correlación metabólica hipoglucémica y el síndrome de Percheron? Reporte de caso

Introducción: El síndrome de Percheron es causa de lesiones isquémicas talamicas bilaterales ocasionando una serie de anomalías clínicas como: alteración del estado de conciencia, oftalmoplejias, y alteraciones de la memoria. Caso clínico: Presentamos el caso de una mujer de 49 años con diabetes mellitus, mal control metabólico, episodios hipoglucémicos e hiperglucemicos repetitivos, quien cursa con sintomatologia inespecífica, se realizan estudios imagenológicos no invasivos documentado lesiones talamica bilaterales. Conclusiones: Los cuadros subagudos e isquémicos parciales que involucran la región paramediana del Talamo bilateral podrían tener alguna relación con episodios hipoglucémicos e hiperglucemicos repetitivos, que pueden llegar a cursar con sintomatología leve e inespecífica, lo cual lo convierte un reto diagnóstico para este síndrome.

Introduction: Percheron syndrome is the cause of bilateral thalamic ischemic lesions, causing a series of clinical abnormalities such as an altered state of consciousness, ophthalmoplegia, and memory alterations. Clinical case: We present the case of 49-year-old woman with diabetes mellitus, poor metabolic control, and repetitive hypoglycemic and hyperglycemic episodes with nonspecific symptoms, non-invasive imaging studies were performed, which documented bilateral thalamic lesions. Conclusions: Subacute and partial ischemic symptoms that involve the paramedian region of the bilateral thalamus could have some relationship with repetitive hypoglycemic and hyperglycemic episodes, and can lead to mild and nonspecific symptoms, which makes it a diagnostic challenge for this syndrome.

Infarto agudo de miocardio prematuro con elevación del segmento ST: análisis de una cohorte en la década 2012-2022 / Premature acute myocardial infarction with ST segment elevation: a cohort study in the 2012-2022 decade

Resumen Antecedentes y objetivo: El infarto prematuro tiene un alto impacto socioeconómico y carecemos de estudios contemporáneos que analicen las características asociadas al desarrollo de estos eventos y a su evolución Material y meéodos: En un estudio observacional sobre una cohorte retrospectiva que incluyó pacientes menores de 46 años con un infarto entre junio de 2012 y junio de 2022, se analizaron las características sociodemográficas, factores de riesgo cardiovasculares, tóxicos, características del infarto, datos sobre infección e inmunización por SARS-CoV-2, se realizó un seguimiento retrospectivo a un anÌo mediante la historia electrónica y se compararon los resultados con los reportados en la literatura. Resultados: El 12.1% de las angioplastias primarias corresponded a infartos prematuros (103). Entre los factores de riesgo clásicos destacaron la dislipidemia y el sobrepeso. La hipertensión y la diabetes fueron significativamente menores que las cifras reportadas en población mayor. El consumo de tabaco fue significativamente mayor, aí como el de otros tóxicos entre los que destacaron el cannabis y la ocaína. Los antecedentes familiares estuvieron presentes en 27 pacientes. El 27.2% (28) tuvieron complicaciones durante el ingreso y la mortalidad fue del 4.9% (5). No se identificaron diferencias significativas entre los pacientes que iniciaron con un evento antes o despuéde la pandemia, a excepción de una tendencia a la disminción del hábito tabáquico. Conclusiones: El infarto prematuro es una patología al alza con una morbimortalidad considerable. La concienciación sobre los hábitos tóxicos y prevención de los factores de riesgo clásicos son tareas prioritarias en nuestro medio.

Abstract Background and purpose: Premature infarction has a high socioeconomic impact and we lack contemporary studies that analyze the characteristics associated with its development and evolution. Material and methods: In an observational study on a retrospective cohort of patients younger than 46 years old, who had suffered from an infarction from June 2012 to June 2022, sociodemographic characteristics, cardiovascular and toxic risk factors, infarction characteristics, SARS-CoV-2 infection and immunization data were investigated. Indeed, a one-year retrospective follow-up was performed through their electronic health record and results were compared with the ones reported in literature. Results: 12.1% of primary angioplasties corresponded to premature infarctions (103). Among classical risk factors, dyslipidemia and overweight stood out, while hypertension and diabetes incidence was significantly lower than the one reported in older population. The consumption of tobacco and other drugs (especially cannabis and cocaine) was higher than that reported at older ages. Twenty-seven patients had a family history of ischemic cardiopathy or sudden cardiac death, 27.2% (28) had complications during admission and mortality was 4.9% (5). No significant differences were identified between the patients who debuted with an event before or after the pandemic, except for a tendency to smoking cessation. Conclusions: Premature infarction is a rising pathology with considerable morbidity and mortality. Raising awareness about toxic habits and prevention of the classical risk factors are priority tasks in this setting.

Infarto pulmonar: signos que no debemos dejar pasar en TC de tórax sin contraste / Pulmonary infarction: the signs that we must not miss in chest CT without contrast

Resumen El infarto pulmonar (IP) resulta de la oclusión de las arterias pulmonares distales que generan isquemia, hemorragia y finalmente necrosis del parénquima pulmonar, siendo la causa más frecuente la embolia pulmonar (EP). El diagnóstico oportuno de IP permite el inicio precoz del tratamiento y el respectivo manejo de sostén, disminuyendo así la morbimortalidad asociada. El objetivo de esta revisión es remarcar la importancia de identificar aquellos signos, que en la tomografía computada (TC) sin contraste son altamente sensibles y específicos para el diagnóstico de IP. La TC de alta resolución constituye el método que más información aporta, pudiendo observar signos clásicos de IP como la opacidad en forma de cuña, opacidad con radiolucencia central y el signo del vaso nutricio; así como signos con alto valor predictivo negativo para IP, como la opacidad consolidativa con broncograma aéreo, sugestivo de otras patologías, ya sean infecciosas o tumorales.

Abstract Pulmonary infarction (PI) results from occlusion of the distal pulmonary arteries leading to ischemia, hemorrhage, and necrosis of the pulmonary parenchyma. The most common cause of pulmonary infarction is pulmonary embolism (PE). Early diagnosis of PI allows early initiation of treatment and supportive care, thus reducing the associated morbidity and mortality. This review aims to highlight the importance of identifying signs that are highly sensitive and specific for the diagnosis of PE even without IV contrast. High-resolution computed tomography (CT) is the method that provides the most information, as it observes classic signs of PI such as wedge-shaped opacity, central lucencies in peripheral consolidation, and the feeding vessel sign, as well as signs with high negative predictive value such as consolidating opacity with air bronchogram that are suggestive of other pathologies, whether infectious or tumoural.