Door-to-balloon Time in Cardiovascular Emergency Care in a Hospital of Northern Brazil

Abstract Background The use of an adequate door-to-balloon time (≤ 90 minutes) is crucial in improving the quality of care provided to patients with ST-segment elevation myocardial infarction (STEMI). Objective To determine the door-to-balloon time in the management of STEMI patients in a cardiovascular emergency department in a hospital of northern Brazil. Methods This was a cross-sectional study based on review of medical records. A total of 109 patients with STEMI admitted to the emergency department of a referral cardiology hospital in Pará State, Brazil, between May 2017 and December 2017. Correlations of the door-to-balloon time with length of hospital stay and mortality rate were assessed, as well as whether the time components of the door-to-balloon time affected the delay in performing primary percutaneous coronary intervention. Quantitative variables were analyzed by Spearman correlation and the G test was used for categorical variables. A p<0.05 was set as statistically significant. Results Median door-to-balloon time was 104 minutes. No significant correlation was found between door-to-balloon time and length of hospital stay or deaths, but significant correlations were found between door-to-balloon time and door-to-ECG time (p<0.001) and ECG-to-activation (of an interventional cardiologist) time (p<0.001). Conclusion The door-to-balloon time was longer the recommended and was not correlated with the length of hospital stay or in-hospital mortality. Door-to-ECG time and ECG-to-activation time contributed to the delay in performing the primary percutaneous coronary intervention. Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

Impacto de las políticas de salud en la incidencia de reperfusión de infarto agudo de miocardio durante el inicio de la pandemia por COVID-19 en Uruguay / Impact of public health policies on the incidence of acute myocardial reperfusion during the initial stages of the COVID-19 pandemic in Uruguay / Impacto das políticas de saúde na incidência de infarto do miocárdio durante a pandemia de COVID-19 no Uruguai

Introducción: las medidas sanitarias de emergencia impuestas para contener el SARS-CoV-2 pueden tener efectos colaterales en la atención de enfermedades cardiovasculares. Los datos mundiales de los países sobre la incidencia de infarto agudo de miocardio con elevación del segmento ST (IAMCEST) durante la pandemia son fundamentales para la política sanitaria futura. Objetivos: nuestro objetivo fue determinar si las medidas sanitarias de emergencia impuestas en Uruguay tuvieron un impacto directo en la calidad de la atención en la reperfusión del IAMCEST. Métodos: realizamos un estudio retrospectivo poblacional de todo el país para determinar la incidencia de reperfusión de IAMCEST (fibrinolíticos e intervención coronaria percutánea, FBL e ICP respectivamente) durante el período sanitario de emergencia. La tasa de incidencia de la reperfusión, el tiempo hasta la reperfusión y la mortalidad asociada se recopilaron de la base de datos del Fondo Nacional de Recursos (organización gubernamental única a cargo de la financiación de la reperfusión del IAMCEST en Uruguay). Estos mismos datos se recuperaron para 2019, 2018 y 2017. Resultados: se trataron durante el periodo de estudio del 2020 (136 pacientes) en comparación con 2019 (180 pacientes), 2018 (182 pacientes) y 2017 (174 pacientes). Se realizó FBL como tratamiento único en 5,1%, 7,2%, 7,7% y 12,1%, respectivamente. La razón de tasa de incidencia de IAMCEST durante el período estudiado en 2020 fue de 0,7 (IC95%: 0,59-0,91). La mediana del tiempo hasta la reperfusión fue similar en comparación con 2019, 2018 y 2017 (p = 0,4). No hubieron diferencias en la mortalidad a 15 dias entre los años evaluados.

Introduction: the emergency health measures imposed to contain SARS-CoV-2 can have collateral effects in the care of cardiovascular diseases. Global country data on the incidence of ST acute myocardial infarction during the pandemic are critical for future health policy. Objectives: our objective was to determine if the emergency health measures imposed in Uruguay had a direct impact on the quality of ST elevation acute myocardial infarction care. Methods: we carried out a population-based retrospective study of the entire country to determine the incidence of reperfusion of ST elevation acute myocardial infarction (fibrinolytic and percutaneous) during the emergency health period. The incidence rate of reperfusion, time to reperfusion, and associated mortality were collected from the Fondo Nacional de Recursos (the only government organization in charge of the reperfusion of ST elevation myocardial infarction in Uruguay). These same data were recovered for 2019, 2018 and 2017. Results: fewer patients were treated in 2020 (136 patients) compared to 2019 (180 patients), 2018 (182 patients), and 2017 (174 patients). Fibrinolytics was performed as the only treatment in 5.1%, 7.2%, 7.7% and 12.1% respectively. The proportion in incidence rate of ST elevation myocardial infarction during the study period in 2020 was lower (0.74, 95% CI: 0.59-0.91). The median time to reperfusion was similar compared to 2019, 2018, and 2017 (p = 0.4). Mortality at 15 days was similar in 2017 (8%), 2018 (6%), 2019 (11%) and 2020 (8%). Conclusion: emergency health measures were associated with a decrease in the incidence of reperfusion of ST elevation myocardial infarction without affecting the time to reperfusion and mortality.

Introdução: as medidas emergenciais de saúde impostas para conter o SARS-CoV-2 podem ter efeitos colaterais no cuidado das doenças cardiovasculares. Os dados globais do país sobre a incidência de infarto agudo do miocárdio durante a pandemia são essenciais para a futura política de saúde. Objetivos: nosso objetivo foi determinar se as medidas de saúde de emergência impostas no Uruguai tiveram um impacto direto na qualidade do atendimento infarto agudo do miocárdio. Métodos: foi realizado um estudo retrospectivo de base populacional em todo o país para determinar a incidência de reperfusão do infarto agudo do miocárdio (fibrinolítico e percutâneo) durante o período de emergência de saúde. A taxa de incidência de reperfusão, tempo de reperfusão e mortalidade associada foram coletados do Fondo Nacional de Recursos (a única organização governamental responsável pela reperfusão de infarto agudo do miocárdio no Uruguai). Esses mesmos dados foram recuperados para 2019, 2018 e 2017. Resultados: menos pacientes foram tratados em 2020 (136 pacientes) em comparação com 2019 (180 pacientes), 2018 (182 pacientes) e 2017 (174 pacientes). Fibrinolisis foi realizado como o único tratamento em 5,1%, 7,2%, 7,7% e 12,1%, respectivamente. A proporção na taxa de incidência de infarto agudo do miocárdio durante o período estudado em 2020 foi menor (0,74, IC 95%: 0,59-0,91). O tempo médio para reperfusão foi semelhante em comparação com 2019, 2018 e 2017 (p = 0,4). A mortalidade em 15 dias foi semelhante em 2017 (8%), 2018 (6%), 2019 (11%) e 2020 (8%). Conclusão: as medidas emergenciais de saúde foram associadas à diminuição da incidência de reperfusão do infarto agudo do miocárdio, sem afetar o tempo de reperfusão e a mortalidade.

Caracterización de pacientes con infarto agudo del miocardio con elevación del segmento ST, Baracoa, Guantánamo 2017-2019 / Characterization of the patients with ST-segment elevation myocardial infarction, Baracoa, Guantanamo, in the period 2017-2019

RESUMEN Introducción: En el Hospital General Docente "Dr. Octavio de la Concepción y de la Pedraja" de Baracoa, Guantánamo, hasta la fecha, no se ha caracterizado la morbilidad y mortalidad por infarto agudo del miocardio. Objetivo: Caracterizar la morbilidad y mortalidad por infarto agudo del miocardio en el citado hospital durante el trienio 2017-2019. Método: Se hizo un estudio descriptivo, retrospectivo y de corte transversaldel total de pacientes infartados en el trienio 2017-2019 (n=75). Se estudió la edad, sexo, características del infarto (semiología del dolor, localización, clasificación pronóstica-clínica, complicaciones, estado al egreso y causas de muerte). Resultados: El 72,0 % de los pacientes fueron hombres y el 37,3 % tenía 50 y 59 años de edad. La letalidad representó el 14,7 %. Fue más común el infarto anterior del ventrículo izquierdo (53,4 %). El 28,0 % presentó una clase IV, según criterios de Killip-Kimball y de Forrester. El 49,3 % mostró alto riesgo según la escala GRACE. El 88,0 % tuvo complicaciones, la más común del tipo mecánica (60,0 %). La encefalopatía isquémica-hipóxica posparada cardiorrespiratoria secundaria a fibrilación ventricular (54,5 %) fue la causa directa de muerte más frecuente. Conclusiones: Se elabora un referente que describe el infarto agudo del miocardio en el contexto territorial.

ABSTRACT Introduction: Morbidity and mortality by myocardial infarction has not been characterized so far in the General Teaching Hospital "Dr. Octavio de la Concepcion y la Pedraja" in Baracoa, Guantanamo. Objective: Tocharacterize the morbidity and mortality by myocardial infarction on the institution in the triennium 2017-2019. Method: A descriptive, retrospective and cross-sectional study was carried out in the patients diagnosed with infarction in the triennium 2017-2019 (n=75). Were taken into account the following variables: age, gender, clinical characteristics of infarction (painful symptoms, location, prognostic and clinical classification, complications, status of the patient at the time of discharge and cause of death). Results: 72.0 % of the patients were male, and the 37.3 % had an age ranging from 50 to 59 years old. Lethality represented a 14.7 %. The anterior left ventricle wall infarction was the most common (53.4 %). 28.0 % presented a class IV type, according to the Killip-Kimball and the Forrester classifications. 49.3 % presented high risks according to the GRACE score. 88.0 % had complications, the most common of them being the mechanical type (60.0 %). The most common cause of death was the hypoxic-ischemic encephalopathy caused by secondary atrial fibrillation (54.5 %). Conclusions: A reference to describe the myocardial infarction in the province was elaborated.

Angioplastia primaria en Argentina. Registro ARGEN-IAM-ST (relevamiento nacional del infarto agudo de miocardio con elevación del segmento ST) / Primary angioplasty in Argentina. Results from ARGEN-IAM-ST registr

Se evaluaron las características clínicas, demoras, resultados y morbimortalidad de 1142 pacientes tratados con angioplastia primaria (AP) dentro de las 36 horas del infarto, incluidos en el registro ARGEN-IAM-ST, de carácter prospectivo, transversal, multicéntrico y de alcance nacional. Edades: 61.2 ± 12 años, 88% varones, 20% diabéticos y 58% hipertensos; 77.6% en Killip y Kimball I y 6.2% en shock cardiogénico. El tiempo desde el inicio del dolor hasta el ingreso fue de 153 (75-316) minutos, y puerta-balón de 91 (60-150) minutos. Los casos derivados (17%) tuvieron mayor demora de ingreso, 200 minutos (195-420; p = 0.0001) y mayor tiempo puerta-balón, 113 minutos (55-207); p = 0.099. En 47.6% de los casos la AP se hizo en arteria descendente anterior, en 36.4% a coronaria derecha, en 14.8% a circunfleja y en 1.2% al tronco de coronaria izquierda; en 95% con stent (29% farmacológico). El 95% fue exitoso. El 1.3% presentó angina post-infarto (APIAM), 1.3% re-infarto, 8.8% shock y 3.2% sangrado. Se asociaron a mayor mortalidad edad > 64 años (OR 6.2 (IC 95%: 3.2-12), p < 0.001), diabetes (OR 2.5, IC 95% 1.6-3.9, p < 0.001), re-infarto o APIAM (OR 3.3, IC 95% 1.3-8.3, p = 0.011) y shock (OR 29.2 (15.6-54.8), p < 0.001). La mortalidad hospitalaria del infarto agudo de miocardio con elevación del segmento ST tratado con AP fue de 7.6%. La derivación se asoció a demora de tratamiento. El shock cardiogénico y la isquemia post-infarto se asociaron a alta mortalidad. No hubo variables del procedimiento asociadas a mortalidad.

Our objective was to evaluate clinical characteristics, results and morbi-mortality in primary angioplasty (PA), of patients treated with PA within 36 hours of a myocardial infarction (MI), included in a prospective, transversal, multicenter and national survey (ARGEN-IAM-ST). A total of 1142 patients treated with PA were registered, 61.2 ± 12 years old, 88% male, 20% diabetics and 58% with hypertension; 77.6% in Killip Kimball I and 6.2% in cardiogenic shock. The time from the onset of pain until admission was 153 (75-316) minutes, and door-balloon of 91 (60-150) minutes. The transferred patients (17%) showed longer delay to admission, 200 minutes (195-420; p = 0.0001) and door-to-balloon 113.5 minutes (55-207); p = 0.099. In 47.6% of the cases, the PA was made in the anterior descending artery, in 36.4% in the right coronary artery, in 14.8% in the circumflex artery and in 1.2% in the left coronary artery; in 95% with stent (29% pharmacological); 95% was successful, 1.3% presented post-infarct angina (APIAM), 1.3% re-infarct, 8.8% shock and 3.2% bleeding. Age > 64 years (OR 6.2 (95% CI: 3.2-12), p <0.001), diabetes (OR 2.5, 95% CI 1.6-3.9, p < 0.001), re-infarction or APIAM (OR 3.3, 95% CI 1.3-8.3, p = 0.011) and shock (OR 29.2 (15.6-54.8), p < 0.001) were independently associated with higher mortality. In-hospital mortality of acute myocardial infarction with ST-segment elevation treated with PA was 7.6%. Transference from other center was associated with delay in the admission and treatment. Cardiogenic shock and post-infarct ischemia were associated with high mortality. There were no procedural variables associated with mortality.

Comparative Analysis between Transferred and Self-Referred STEMI Patients Undergoing Primary Angioplasty / Análise Comparativa entre Pacientes com IAMCSST Transferidos e Pacientes de Demanda Espontânea Submetidos à Angioplastia Primária

Abstract Background: Studies have shown the benefits of rapid reperfusion therapy in acute myocardial infarction. However, there are still delays during transport of patients to primary angioplasty. Objective: To evaluate whether there is a difference in total ischemic time between patients transferred from other hospitals compared to self-referred patients in our institution. Methods: Historical cohort study including patients with acute myocardial infarction treated between April 2014 and September 2015. Patients were divided into transferred patients (group A) and self-referred patients (group B). Clinical characteristics of the patients were obtained from our electronic database and the transfer time was estimated based on the time the e-mail requesting patient's transference was received by the emergency department. Results: The sample included 621 patients, 215 in group A and 406 in group B. Population characteristics were similar in both groups. Time from symptom onset to arrival at the emergency department was significantly longer in group A (385 minutes vs. 307 minutes for group B, p < 0.001) with a transfer delay of 147 minutes. There was a significant relationship between the travel distance and increased transport time (R = 0.55, p < 0.001). However, no difference in mortality was found between the groups. Conclusion: In patients transferred from other cities for treatment of infarction, transfer time was longer than that recommended, especially in longer travel distances.

Resumo Fundamento: Estudos mostram o benefício da terapia de reperfusão rápida no infarto agudo do miocárdio. No entanto, ainda ocorrem atrasos durante o transporte de pacientes para angioplastia primária. Objetivo: Definir se existe uma diferença no tempo total de isquemia entre pacientes transferidos de outro hospital comparados aos que procuram o serviço espontaneamente. Método: Estudo de coorte histórico, incluindo pacientes atendidos com infarto entre abril de 2014 e setembro de 2015. Os pacientes foram divididos em pacientes transferidos (grupo A) e por demanda espontânea (grupo B). As características clínicas dos pacientes foram retiradas do banco de dados de infarto e o tempo de transferência foi estimado tendo como base o correio eletrônico de acordo com o horário de contato. O nível de significância adotado foi um p < 0,05%. Resultados: A amostra incluiu 621 pacientes, 215 no grupo A e 406 no grupo B. As características populacionais foram semelhantes nos dois grupos. O delta T foi significativamente maior no grupo de pacientes transferidos (385 minutos vs. 307 minutos para o grupo B, p < 0,001) com um atraso decorrente do transporte de 147 minutos. Houve relação significativa da distância de transferência e aumento do tempo de transporte (R = 0,55; p < 0,001). Entretanto, não houve diferença na mortalidade entre os grupos. Conclusão: Pacientes transferidos de outras cidades para tratamento de infarto tem Delta T de transferência acima do recomendado, com tempo ainda mais longo quanto maior a distância a ser percorrida.

The importance of intra-aortic pulse pressure after anterior ST-segment elevation myocardial infarction

Abstract Objective: To evaluate the association of pulse pressure (PP) with mortality and major adverse cardiac events (MACE) in one-year period after anterior ST-elevation myocardial infarction (A-STEMI). Methods: A total of 261 consecutive patients whose blood pressure was measured with the aid of a catheter before primary percutaneous coronary intervention (PPCI) between August 2016 and February 2017 were included in the study. The patients were divided into three groups according to pulse pressure (PP) (Group 1, PP<35 mmHg; Group 2, 35≤PP≤50 mmHg; Group 3, PP>50 mmHg). Results: The mean age of the patients was 63.4±14.1 years, and 206 of them were male. The groups were similar in terms of age and diastolic blood pressure (DBP). The ratio of female patients in Group 1 was higher, and their systolic blood pressure (SBP) was lower than those from the other groups (P=0.005 vs. P=0.042). The rates of MACE and mortality were higher in Group 1. The predictive PP values were calculated to be 42.5 mmHg for development of MACE and 41.5 mmHg for mortality. One-year survival ratio was worse in Group 1 than in the others according to Kaplan-Meier analysis (P<0.001). Conclusion: The values of PP which was measured intra-aortically in patients with A-STEMI were associated with mortality and MACE in the one-year follow-up period.

Independent Predictors of Late Presentation in Patients with ST-Segment Elevation Myocardial Infarction / Preditores de Apresentação Tardia em Pacientes com Infarto Agudo do Miocárdio com Supradesnivelamento do Segmento ST

Abstract Background: In patients with acute ST-segment elevation myocardial infarction (STEMI), the time elapsed from symptom onset to receiving medical care is one of the main mortality predictors. Objective: To identify independent predictors of late presentation in patients STEMI representative of daily clinical practice. Methods: All patients admitted with a diagnosis of STEMI in a reference center between December 2009 and November 2014 were evaluated and prospectively followed during hospitalization and for 30 days after discharge. Late presentation was defined as a time interval > 6 hours from chest pain onset until hospital arrival. Multiple logistic regression analysis was used to identify independent predictors of late presentation. Values of p < 0.05 were considered statistically significant. Results: A total of 1,297 patients were included, with a mean age of 60.7 ± 11.6 years, of which 71% were males, 85% Caucasians, 72% had a mean income lower than five minimum wages and 66% had systemic arterial hypertension. The median time of clinical presentation was 3.00 [1.40-5.48] hours, and approximately one-quarter of the patients had a late presentation, with their mortality being significantly higher. The independent predictors of late presentation were Black ethnicity, low income and diabetes mellitus, and a history of previous heart disease was a protective factor. Conclusion: Black ethnicity, low income and diabetes mellitus are independent predictors of late presentation in STEMI. The identification of subgroups of patients prone to late presentation may help to stimulate prevention policies for these high-risk individuals.

Resumo Fundamento: Em pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST), o tempo decorrido desde o início dos sintomas até a busca por atendimento médico é um dos principais preditores de mortalidade. Objetivo: Identificar preditores independentes de apresentação tardia em pacientes com IAMCSST representativos da prática clínica diária. Métodos: Todos os pacientes admitidos com diagnóstico de IAMCSST em um centro de referência, no período de dezembro de 2009 a novembro de 2014, foram avaliados e prospectivamente acompanhados, durante a hospitalização e por 30 dias após a alta. A apresentação tardia foi definida como tempo maior que 6 horas desde o início da dor torácica até a chegada ao hospital. Análise de regressão logística múltipla foi usada para identificar os preditores independentes de apresentação tardia. Foi considerado estatisticamente significativo p < 0,05. Resultados: Foram incluídos 1.297 pacientes, com idade média de 60,7 ± 11,6 anos, 71% do sexo masculino, 85% da raça branca, 72% com renda média menor que cinco salários mínimos e 66% com hipertensão arterial sistêmica. A mediana do tempo de apresentação clínica foi de 3,00 [1,40-5,48] horas, sendo que aproximadamente um quarto dos pacientes apresentou-se tardiamente, e a mortalidade deles foi significativamente maior. Os preditores independentes de apresentação tardia foram raça negra, baixa renda e diabetes melito, e história de doença cardíaca prévia foi fator protetor. Conclusão: Raça negra, baixa renda e diabetes melito são preditores independentes de apresentação tardia no IAMCSST. A identificação de subgrupos de pacientes propensos à apresentação tardia pode auxiliar a estimular políticas de prevenção nestes indivíduos de alto risco.

Heart failure complicating myocardial infarction. A report of the Peruvian Registry of ST-elevation myocardial infarction (PERSTEMI) / Insuficiencia cardiaca complicando el infarto de miocardio. Un reporte de Peruvian Registry of ST-elevation Myocardial Infarction (PERSTEMI)

Abstract Objectives: The aim of this study is to determine the incidence, associated factors, and 30-day mortality of patients with heart failure (HF) after ST elevation myocardial infarction (STEMI) in Peru. Methods: Observational, cohort, multicentre study was conducted at the national level on patients enrolled in the Peruvian registry of STEMI, excluding patients with a history of HF. A comparison was made with the epidemiological characteristics, treatment, and 30 day-outcome of patients with (Group 1) and without (Group 2) heart failure after infarction. Results: Of the 388 patients studied, 48.7% had symptoms of HF, or a left ventricular ejection fraction <40% after infarction (Group 1). Age > 75 years, anterior wall infarction, and the absence of electrocardiographic signs of reperfusion were the factors related to a higher incidence of HF. The hospital mortality in Group 1 was 20.6%, and the independent factors related to higher mortality were age > 75 years, and the absence of electrocardiographic signs of reperfusion. Conclusions: Heart failure complicates almost 50% of patients with STEMI, and is associated with higher hospital and 30-day mortality. Age greater than 75 years and the absence of negative T waves in the post-reperfusion ECG are independent factors for a higher incidence of HF and 30-day mortality.

Resumen Objetivos: Se desea saber la incidencia, los factores asociados y la mortalidad a 30 días de los pacientes con insuficiencia cardiaca (IC) postinfarto de miocardio con elevación del segmento ST (IMCEST) en Perú. Métodos: Estudio observacional, de cohortes, multicéntrico a nivel nacional, de pacientes enrolados en el registro peruano de IMCEST, excluyendo los pacientes con antecedente de IC. Se compararon las características epidemiológicas, tratamiento y evolución a 30 días de los pacientes con (grupo 1) y sin (grupo 2) IC postinfarto. Resultados: De 388 pacientes se encontró un 48.7% con síntomas de IC o fracción de eyección de ventrículo izquierdo < 40% postinfarto (grupo 1). La edad > 75 años, el infarto de pared anterior y la ausencia de signos electrocardiográficos de reperfusión fueron los factores relacionados a mayor incidencia de IC. La mortalidad intrahospitalaria en el grupo 1 fue del 20.6% y los factores independientes relacionados a mayor mortalidad fueron la edad > 75 años y la ausencia de signos electrocardiográficos de reperfusión. Conclusiones: La IC complica casi al 50% de pacientes con IMCEST y está asociada a mayor mortalidad intrahospitalaria y a 30 días. La edad > 75 años y la ausencia de ondas T negativas en el electrocardiograma posreperfusión son factores independientes de mayor incidencia de IC y de mortalidad a 30 días.

Resultados a mediano plazo del implante de stents imbricados en pacientes con infarto con supradesnivel del ST: el rol de los stents medicados / Midterm results of overlapping stents implantation in patients with ST elevation myocardial infarction

Resumen: Introducción: El implante de dos stents imbricados (SIMB) es una práctica frecuente en el laboratorio de hemodinamia. Sin embargo, evidencia reciente sugiere que en pacientes con infarto con supradesnivel del segmento ST (IAMc/SDST) esta técnica puede asociarse a mejores resultados cuando se utilizan exclusivamente stents medicados. Objetivo: Evaluar en una cohorte de pacientes chilenos las causas, características clínicas y sobrevida a 2 años de los pacientes con IAMc/SDST que son tratados con SIMB, en función del tipo de dispositivo y combinación utilizada; metálico/metálico (BMS/BMS), metálico/medicado (BMS/DES), medicado/medicado (DES/DES). Método: Se realizó un estudio prospectivo, caso incidente, entre enero del año 2012 y mayo del año 2016 en nuestro laboratorio de hemodinamia. Se recolectó la información clínica, angiográfica y sobrevida a 2 años de los pacientes ingresados por IAMc/SDST que fueron tratados con SIMB. Para el análisis estadístico se utilizó chicuadrado, regresión logística y análisis multivariado en programa SPSS, considerando significativa una p<0,05. Resultados: De 2403 pacientes evaluados, el 13% (n=312) recibió tratamiento con SIMB. La edad pro-medio fue de 68 ± 6,6 años y el 71% correspondió a hombres. La presencia de DMII fue de 37%, HTA 65%, tabaquismo 41%, dislipidemia 29% y cardiopatía coronaria previa 18%. Se observó que la fracción de eyección promedio fue de 45 ± 3,5%, medida por método de Simpson. Las causas para imbricar stents fueron la disección post implante de stent en 72%, desplazamiento de placa en 22,5% y extensión de placa más allá de la longitud del stent en un 5,5%. El 38% fue tratado con 2 stents BMS, el 26% con stents BMS/DES y el 36% con DES/DES. El diámetro y largo promedio de SIMB fue de 2,8 ± 2,6 mm y 41,3 ± 6,4 mm, respectivamente. Se observó una mortalidad a 2 años de 11% en el grupo BMS/BMS, 8% BMS/DES y 6% DES/DES (p<0,01) y la necesidad de revascularización fue 8%, 5,2% y 2% respectivamente (p=0,02). El usar la combinación BMS/ BMS se asoció a una mayor mortalidad a 2 años en análisis de regresión logística univariado (OR 5,2, IC 95% 2,0-17,9, p<0,01) y multivariado (ajustado por variables clínicas, número de vasos enfermos y presentación clínica) [OR 5,5, IC 95% 1,9-21,0, p<0,01]). Excluyendo a los pacientes con mortalidad temprana, como marcador de severidad de presentación clínica, la mortalidad a 2 años en el grupo BMS/BMS tuvo un OR de 5.9, 95% CI 2.1- 19.5 (p < 0.01). No se observó diferencia en la mortalidad de pacientes tratados con 2 SIMB DES/DES y los tratados con 1 stent DES. Conclusión: El implantar stents imbricados en pacientes con IAMc/SDST es una práctica común en el laboratorio de hemodinamia. Nuestros resultados sugieren que los resultados a mediano plazo son significativamente mejores cuando al menos uno de los stents utilizados es medicado, lo cual es concordante con reportes recientes.

Abstracts: Background: Coronary angioplasty using two overlapping (OL) stents is a frequent practice at the cath laboratory, however the impact this strategy has on patient prognosis and the preferred stent type are largely unknown. Aim: To evaluate 2-year outcomes of STEMI patients who underwent treatment with OL stents and assess the impact of different types of stents combinations:(BMS/BMS), (BMS/DES), or (DES/DES). Methods: Patients presenting with STEMI undergoing primary angioplasty with 2 OL stents between January 2012 to May 2016 were included. Baseline and procedural information was collected, clinically-driven new revascularizations were recorded, and 2-year survival status was confirmed from the national database registry. OL stents technique was defined as a segment with a double layer of stents of at least 1 mm and less than 5 mm long. Statistical analyses were performed with SPSS v21.0 (IBM, Armonk, NY, USA), at with p<=0.05 being considered significant. Results: Of 2403 STEMI patients treated within this period, in 312 (13%) the OL was used. Mean age was 68 ± 6.6 years. 71% males. Type 2 diabetesmellitus was present in 37%, arterial hypertension in 65%, smoking in 41%, dyslipidemia in 29% and previously treated coronary heart disease (either CABG or PCI) in 18% of patients. Mean left ventricular ejection fraction (LVEF) as assessed by 2D Simpson method was 48±3.5%. Indications for overlapping stents were plaque extension in 72%, edge dissection after stent implantation in 22.5%, and plaque displacement in 5.5%. One, 2 or 3 vessels disease was present in 23%, 34% and 43%, respectively. Thirty-eight percent of patients were treated with 2 BMS stents, 26% with BMS/DES stents and 36% with two DES stents. The mean stent diameter and length were 2.8 ± 2.6 mm and 41.3 ± 6.4 mm, respectively, with no difference between the 3 groups. Post procedure target vessel revascularization was 8% for BMS/BMS, 5.2% for BMS/DES and 2% for DES/DES groups (p=0.02). Two-year cardiovascular mortality was 11% for the BMS/BMS group, 8% for the BMS/DES group and 6% for the DES/DES (p <0.01). BMS/BMS combination was associated with a greater cardiovascular 2-year mortality in both univariate (OR 5.2, 95% CI 2.0-17.9, p <0.01) and multivariate analyses ([OR 5.5, 95% CI 1.9-21.0, p <0.01]). After excluding early mortality cases during the first week (due to their overall severity at presentation), 2-year cardiovascular mortality in the BMS/BMS group had an adjusted OR of 5.9, 95% CI 2.1-19.5 (p< 0.01). There were no differences between the treatment with 2 OL DES stents and the treatment with BMS/DES. Conclusion: Overlapping stent technique is a common practice in our cath lab, mainly driven by an initial unfavorable result with the first stent. The reported findings suggest that midterm results are better when at least on of the imbricated stents is These results are in agreement with recent reports on the subject.

Cardiogenic shock with ST-segment elevation acute coronary syndrome (ReNa-Shock ST)

Cardiogenic shock (CS) in the setting of an ST-segment elevation myocardial infarction (STEMI) is a severe complication and constitutes one of the principal causes of death associated with this condition. The aim of this study was to describe the clinical characteristics, treatment strategies and hospital outcome of CS associated with STEMI in Argentina. The Argentine Registry of Cardiogenic Shock (ReNA-Shock) was a prospective and multicenter registry of consecutive patients with CS hospitalized in 64 centers in Argentina between July 2013 and May 2015. Only those with ST-segment elevation myocardial infarction (STEMI) were selected for this analysis. Of the 165 patients included in the ReNa-Shock registry, 124 presented STEMI. Median age was 64 years (IQR 25-75: 56.5-75) and 67% were men; median time from symptom onset to admission was 240 minutes (IQR 25-75: 132-720). 63% of the cases presented CS at admission. Eighty-seven percent underwent reperfusion therapy: 80% primary percutaneous intervention with a median door-to-balloon time of 110 minutes (IQR 25-75: 62-184). Inotropic agents were used in 96%; 79% required mechanical ventilation; a Swan Ganz catheter was inserted in 47% and 35% required intra-aortic balloon pumping. Most patients (59%) presented multivessel disease (MV). Hospital mortality was 54%. Multivariate analysis identified that time from symptom onset to admission (> 240 min) was the only independent predictor of mortality (OR: 3.04; CI 95%: 1.18-7.9). Despite using treatment strategies currently available, morbidity and mortality of STEMI complicated with CS remains high.

El shock cardiogénico (SC) en el síndrome coronario agudo con elevación del ST (SCACEST), es una complicación grave y constituye una de las principales causas de muerte. El objetivo del registro fue conocer las características clínicas, estrategias de tratamiento y evolución intrahospitalaria del SC secundario a un SCACEST en Argentina. El Registro Argentino de Shock Cardiogénico (ReNa-Shock) fue prospectivo, multicéntrico y consecutivo de pacientes internados con SC en el periodo 2013/2015 en 64 centros de Argentina. Fueron incluidos 165 pacientes, de los cuales124 presentaban SCACEST. La edad (mediana) fue de 64 [RIC25-75: 56-75] años, 67% hombres. La mediana de tiempo desde el inicio de los síntomas al ingreso hospitalario fue de 240 minutos [RIC25-75: 132-720]. Un 63% de los casos tuvo SC desde el ingreso. El 87% recibió tratamiento de reperfusión, con un 80% de angioplastia primaria y un tiempo puerta-balón (mediana): 110 minutos [RIC25-75: 62-184]. Requirieron inotrópicos un 96%, asistencia respiratoria mecánica el 79%, catéter de Swan Ganz 47%, balón de contrapulsación intraaórtico 35%. El 59% tenía lesión de 2 o 3 vasos. La mortalidad intrahospitalaria fue 54%. En el análisis multivariado, solo el tiempo de evolución al ingreso (345 min [RIC25-75: 135-720] vs. 180 min [RIC25-75: 85-420]; p: 0.03) fue la única variable predictora independiente de mortalidad. La morbimortalidad del SC complicando un SCACEST es elevada a pesar de la utilización de las estrategias de tratamiento actualmente disponibles.

Validación del puntaje de riesgo TIMI como predictor de mortalidad en pacientes chilenos con infarto agudo al miocardio con supradesnivel de ST / Prediction of hospital mortality of ST elevation myocardial infarction using TIMI score

Background: Thrombolysis in myocardial infarction risk score (TIMI-RS) was designed to predict early mortality in patients with a ST elevation acute myocardial infarction (STEAMI). Aim: To evaluate the predictive capacity for hospital mortality of TIMI-RS. Material and Methods: Patients with ≤ 12-hour evolution STEAMI were selected from a prospective registry of all patients hospitalized in our coronary unity within January 1988 and December 2005. Observed mortality was analyzed according to TIMI-RS and its predictive capacity was estimated. Results: We analyzed 1125 consecutive patients aged 61 ± 13 years (76% men). Fifty one percent were smokers, 47% hypertensive and 40% had a history of angina. Fifty eight percent of patients underwent reperfusion therapy. Most patients had TIMI-RS scores ≤ 5 points and only 3.6% had scores ≥ 10 points. Overall mortality was 14.8% and there was an 80% concordance between observed mortality and that predicted with the TIMI-RS score. The area under the curve for the receiver operating characteristic (ROC) curve was 0.7. Conclusions: TIMI-RS was acceptably useful to predict in-hospital mortality in this group of patients with STEAMI. Differences between the observed and originally predicted mortality are explained by the clinical profile and therapeutic protocols applied to patients in different studies. Thus, caution needs to be taken when interpreting the risk associated to a specific score, particularly within non-reperfused patients whose risk might be underestimated.

Impact of coronary intensive care unit in treatment of myocardial infarction / Impacto da unidade coronariana no tratamento do infarto do miocárdio

Summary Introduction: The mortality rate attributed to ST-segment elevation myocardial infarction (STEMI) has decreased in the world. However, this disease is still responsible for high costs for health systems. Several factors could decrease mortality in these patients, including implementation of cardiac intensive care units (CICU). The aim of this study was to evaluate the effect of CICU implementation on prescribed recommended treatments and mortality 30 days after STEMI. Method: We performed a retrospective study with patients admitted to CICU between 2005 and 2006 (after group) and between 2000 and 2002, before CICU implementation (before group). Results: The after group had 101 patients, while the before group had 143 patients. There were no differences in general characteristics between groups. We observed an increase in angiotensin-converting enzyme inhibitors, clopidogrel and statin prescriptions after CICU implementation. We did not find differences regarding number of patients submitted to reperfusion therapy; however, there was an increase in primary percutaneous angioplasty compared with thrombolytic therapy in the after group. There was no difference in 30-day mortality (before: 10.5%; after: 8.9%; p=0.850), but prescription of recommended treatments was high in both groups. Prescription of angiotensin-converting enzyme inhibitors and beta-blocker decreased mortality risk by 4.4 and 4.9 times, respectively. Conclusion: CICU implementation did not reduce mortality after 30 days in patients with STEMI; however, it increased the prescription of standard treatment for these patients.

Resumo Introdução: Apesar da diminuição da mortalidade por infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAM-ST) no mundo, a doença ainda acarreta elevados custos e morbidade. Muitas medidas contribuem para a redução da mortalidade, dentre elas a criação de unidades intensivas coronarianas (UCO). Objetivo: Avaliar o impacto da criação de uma UCO na prescrição de tratamentos preconizados e na mortalidade em 30 dias em pacientes com IAM-ST. Método: Foi realizado estudo retrospectivo e foram coletados dados de prontuários de pacientes internados na UCO de 2005 a 2006 (grupo depois). Esses dados foram comparados com dados do serviço de 2000 a 2002, previamente à criação da UCO (grupo antes). Resultados: Havia 101 e 143 pacientes nos grupos depois e antes, respectivamente. Não houve diferenças em relação às características populacionais e às características do infarto entre os períodos. Observamos aumento na prescrição de iECA, clopidogrel e estatinas. Apesar da ausência de mudanças no número de pacientes que receberam terapia de reperfusão, houve aumento de angioplastias primárias em detrimento ao uso de trombolíticos no período posterior à criação da UCO. Não observamos diminuição da mortalidade em 30 dias após IAM-ST (antes: 10,5%; depois: 8,9%; p=0,850), mas a prescrição de tratamentos preconizados foi alta em ambos os períodos. O uso de iECA e de betabloqueador diminuiu o risco de morte em 4,4 e 4,9 vezes, respectivamente. Conclusão: Em pacientes com IAM-ST, a criação da UCO não reduziu a mortalidade em 30 dias, mas houve aumento na prescrição de tratamentos preconizados.