Assuntos
Serviços Médicos de Emergência , Paramédico , Humanos , Troponina , Pessoal Técnico de SaúdeAssuntos
Angina Pectoris/diagnóstico , Angina Pectoris/etiologia , Angiografia por Tomografia Computadorizada/métodos , Angiografia por Tomografia Computadorizada/normas , Angiografia Coronária/métodos , Angiografia Coronária/normas , Doença das Coronárias/diagnóstico , Análise Custo-Benefício , Ecocardiografia sob Estresse/normas , Eletrocardiografia/normas , Teste de Esforço/normas , Humanos , Isquemia Miocárdica/complicações , Revascularização Miocárdica/métodos , Fatores de Risco , Sensibilidade e EspecificidadeRESUMO
This clinical review paper discusses the pathophysiology of the pulmonary and cardiovascular manifestations of a SARS-CoV-2 infection and the ensuing implications on acute cardiovascular care in patients presenting with a severe COVID-19 syndrome admitted to an intensive acute cardiac care unit. The high prevalence of old age, obesity, diabetes, hypertension, heart failure, and ischaemic heart disease in patients who develop a severe to critical COVID-19 syndrome suggests shared pathophysiological mechanisms. Pre-existing endothelial dysfunction and an impaired innate immune response promote the development by the viral infection of an acute endothelialitis in the pulmonary microcirculation complicated by abnormal vasoconstrictor responses, luminal plugging by inflammatory cells, and intravascular thrombosis. This endothelialitis extends into the systemic circulation what may lead to acute myocardial injury, myocarditis, and thromboembolic complications both in the arterial and venous circulation.
Assuntos
COVID-19/complicações , Doenças Cardiovasculares/etiologia , Endotélio Vascular/patologia , Pandemias , SARS-CoV-2 , COVID-19/epidemiologia , Doenças Cardiovasculares/epidemiologia , Saúde Global , Humanos , IncidênciaRESUMO
AIMS: Quality indicators (QIs) are tools to improve the delivery of evidence-base medicine. In 2017, the European Society of Cardiology (ESC) Association for Acute Cardiovascular Care (ACVC) developed a set of QIs for acute myocardial infarction (AMI), which have been evaluated at national and international levels and across different populations. However, an update of these QIs is needed in light of the accumulated experience and the changes in the supporting evidence. METHODS AND RESULTS: The ESC methodology for the QI development was used to update the 2017 ACVC QIs. We identified key domains of AMI care, conducted a literature review, developed a list of candidate QIs, and used a modified Delphi method to select the final set of indicators. The same seven domains of AMI care identified by the 2017 Study Group were retained for this update. For each domain, main and secondary QIs were developed reflecting the essential and complementary aspects of care, respectively. Overall, 26 QIs are proposed in this document, compared to 20 in the 2017 set. New QIs are proposed in this document (e.g. the centre use of high-sensitivity troponin), some were retained or modified (e.g. the in-hospital risk assessment), and others were retired in accordance with the changes in evidence [e.g. the proportion of patients with non-ST segment elevation myocardial infarction (NSTEMI) treated with fondaparinux] and the feasibility assessments (e.g. the proportion of patients with NSTEMI whom risk assessment is performed using the GRACE and CRUSADE risk scores). CONCLUSION: Updated QIs for the management of AMI were developed according to contemporary knowledge and accumulated experience. These QIs may be applied to evaluate and improve the quality of AMI care.
Assuntos
Infarto do Miocárdio , Infarto do Miocárdio sem Supradesnível do Segmento ST , Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/terapia , Indicadores de Qualidade em Assistência à Saúde , Medição de RiscoRESUMO
BACKGROUND: The impact of ECG presentations of acute myocardial infarction (AMI) in cardiogenic shock is unknown. RESEARCH QUESTION: In myocardial infarction with cardiogenic shock, is there a difference in the outcomes and effect of revascularization strategies between non-ST-segment elevation myocardial infarction (NSTEMI) and left bundle branch block myocardial infarction (LBBBMI) vs ST-segment elevation myocardial infarction (STEMI)? STUDY DESIGN AND METHODS: Cardiogenic shock patients from the CULPRIT-SHOCK trial with NSTEMI or LBBBMI were compared with STEMI patients for 30-day and 1-year all-cause mortality. The interaction between ECG presentation and the effect of revascularization strategies on outcomes was evaluated. RESULTS: Of 665 cardiogenic shock patients analyzed, 55.9% demonstrated STEMI, 29.3% demonstrated NSTEMI, and 14.7% demonstrated LBBBMI. Patients differed in mean age (68.0 years in STEMI patients, 71.0 years in NSTEMI patients, and 73.5 years in LBBBMI patients; P = .015), cardiovascular risk factors, and angiographic severity. No difference was found in the 30-day risk of death between NSTEMI and STEMI patients (48.7% vs 43.0%; adjusted OR [aOR], 1.05; 95% CI, 0.66-1.67; P = .85), nor between LBBBMI and STEMI patients (59.2% vs 43.0%; aOR, 1.31; 95% CI, 0.73-2.34; P = .36). Although the univariate risk of death by 1 year was higher in NSTEMI and LBBBMI patients compared with STEMI patients, ECG presentation was not an independent risk factor of mortality after adjustment (NSTEMI vs STEMI: 56.4% vs 46.8%; aOR, 1.21; 95% CI, 0.76-1.92; P = .42; LBBBMI vs STEMI: 69.4% vs 46.8%; aOR, 1.59; 95% CI, 0.89-2.84; P = .12). ECG presentation did not modify the effect of the revascularization strategy on 30-day and 1-year mortality (P = .91 and P = .97 for interaction). INTERPRETATION: In patients with cardiogenic shock, NSTEMI and LBBBMI presentations reflect higher-risk profiles than STEMI presentations, but are not independent risk factors of mortality. ECG presentations did not modify the treatment effect, supporting culprit-lesion-only percutaneous coronary intervention as the preferred strategy across the AMI spectrum.
Assuntos
Eletrocardiografia , Infarto do Miocárdio/complicações , Infarto do Miocárdio/cirurgia , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Choque Cardiogênico/cirurgia , Idoso , Bloqueio de Ramo/complicações , Bloqueio de Ramo/diagnóstico , Bloqueio de Ramo/cirurgia , Feminino , Humanos , Masculino , Intervenção Coronária PercutâneaAssuntos
Aorta Abdominal , Aorta Torácica , Doenças da Aorta/diagnóstico , Doenças da Aorta/terapia , Doença Aguda , Fatores Etários , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/terapia , Falso Aneurisma/diagnóstico , Falso Aneurisma/terapia , Aorta Abdominal/lesões , Aorta Torácica/lesões , Doenças da Aorta/complicações , Valva Aórtica , Aterosclerose/diagnóstico , Aterosclerose/terapia , Doença da Válvula Aórtica Bicúspide , Fármacos Cardiovasculares/uso terapêutico , Técnicas de Laboratório Clínico/métodos , Diagnóstico por Imagem/métodos , Diagnóstico Precoce , Procedimentos Endovasculares/métodos , Feminino , Doenças Genéticas Inatas/complicações , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/terapia , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/terapia , Hematoma/diagnóstico , Hematoma/terapia , Humanos , Assistência de Longa Duração/métodos , Masculino , Neoplasias de Tecido Vascular/diagnóstico , Neoplasias de Tecido Vascular/terapia , Exame Físico/métodos , Fatores de Risco , Calcificação Vascular/diagnóstico , Calcificação Vascular/terapia , Rigidez Vascular/fisiologia , Procedimentos Cirúrgicos Vasculares/métodosAssuntos
Angina Estável/terapia , Doença da Artéria Coronariana/terapia , Idoso , Angina Estável/diagnóstico , Angina Estável/etiologia , Técnicas de Imagem Cardíaca , Cardiotônicos/uso terapêutico , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/etiologia , Eletrocardiografia/métodos , Medicina Baseada em Evidências , Feminino , Humanos , Masculino , Revascularização Miocárdica/métodos , Intervenção Coronária Percutânea/métodos , Atenção Primária à Saúde , Prognóstico , Medição de Risco , Comportamento de Redução do RiscoAssuntos
Doenças Cardiovasculares/terapia , Desfibriladores Implantáveis , Átrios do Coração/diagnóstico por imagem , Cardiopatias/diagnóstico por imagem , Trombose/diagnóstico por imagem , Anticoagulantes/uso terapêutico , Ecocardiografia Transesofagiana , Cardiopatias/tratamento farmacológico , Transplante de Coração , Humanos , Imageamento por Ressonância Magnética , Trombose/tratamento farmacológico , Tomografia Computadorizada por Raios X , Varfarina/uso terapêuticoAssuntos
Síndrome Coronariana Aguda/terapia , Idoso , Humanos , Sistema de Registros , Medição de RiscoRESUMO
BACKGROUND: Decision processes in heart donation remain difficult and are often based on subjective evaluation. We measured B-type natriuretic peptide (BNP) in heart donors and analyzed its value as a discriminator for early post-transplant cardiac performance. METHODS: Blood samples were prospectively obtained in 94 brain-dead patients, among whom 56 were scheduled for heart donation. BNP values were not available prior to donor selection. BNP of heart donors was related to invasively measured cardiac output and hemodynamic parameters, early after transplantation. RESULTS: BNP, expressed as median (interquartile range), was 65 (32 to 149) pg/ml in brain-dead donors scheduled for heart donation. BNP was higher (287 pg/ml, range 65 to 457; p = 0.0001) in donors considered ineligible for heart donation. In 45 heart recipients, cardiac output (CO) of 5.6 (4.8 to 6.2) liters/min was measured at Day 12 (10-15). In the univariate analysis, recipient CO correlated significantly with donor BNP (r = -0.34, p = 0.025). Stepwise multiple regression, including donor variables such as body mass index, age, BNP, norepinephrine dose, gender and total ischemic time, identified donor BNP and age as the best independent predictors of CO in recipients (p = 0.02 and p = 0.005, respectively, R(2) of the model = 0.27). Donor BNP of >160 pg/ml had 89% accuracy to predict poor cardiac performance in the recipient (cardiac index <2.2 liters/min/m(2)). High donor BNP was independently correlated with a longer hospital stay. CONCLUSIONS: Donor BNP was found to be related to cardiac performance, early after cardiac transplantation. BNP measurement in heart donors could become a useful tool in the evaluation of donor hearts.
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Débito Cardíaco/fisiologia , Transplante de Coração/fisiologia , Hemodinâmica/fisiologia , Peptídeo Natriurético Encefálico/sangue , Doadores de Tecidos , Adulto , Biomarcadores/sangue , Morte Encefálica , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Valor Preditivo dos Testes , Estudos Prospectivos , Estudos RetrospectivosAssuntos
Estenose das Carótidas/prevenção & controle , Circulação Coronária/fisiologia , Microvasos/cirurgia , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/prevenção & controle , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/terapia , Humanos , Intervenção Coronária Percutânea/métodos , Traumatismo por Reperfusão/complicações , Traumatismo por Reperfusão/prevenção & controle , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnósticoAssuntos
Infarto Miocárdico de Parede Anterior/cirurgia , Ruptura Cardíaca/cirurgia , Idoso , Infarto Miocárdico de Parede Anterior/complicações , Infarto Miocárdico de Parede Anterior/diagnóstico , Ruptura Cardíaca/complicações , Ruptura Cardíaca/diagnóstico , Humanos , Masculino , Resultado do TratamentoRESUMO
The no-reflow phenomenon occurs in about one third of the patients treated with primary PCI for acute ST segment elevation myocardial infarction. Our understanding of its pathophysiology has expanded considerably: in addition of the effect of prolonged ischaemia also reperfusion injury contributes significantly to the microvascular damage in the perfusion territory of the infarct-related coronary artery. Lethal reperfusion injury to both the endothelial cells and the cardiomyocytes is mainly related to the effects of oxidative stress and the energy paradox. Paradoxical vasoconstriction caused by endothelial dysfunction, plugging of the capillaries by endothelial blebs and by packed neutrophils and mechanical compression by myocardial oedema all related to the reperfusion injury lead to microvascular obstruction. Iatrogenic embolization of thrombus and/or plaque material during coronary intervention adds further to the development of the no-reflow phenomenon. New insights in the pathophysiology open the way to a new therapeutic approach of the no-reflow phenomenon: preventing embolization during primary coronary intervention by using adjunctive thrombus aspiration before stent deployment and reducing the reperfusion injury by post-conditioning.