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Complex high-risk indicated percutaneous coronary intervention (CHIP-PCI) is a poorly defined concept, which has not been validated in an older population before. This study aimed to evaluate the predictive value of the CHIP-PCI score in a large cohort of elderly patients and to identify potential further risk factors. This is a pooled analysis of 3 registries that included patients aged ≥75 years who underwent percutaneous coronary intervention from 2012 to 2019: the multicenter prospective EPIC05-Sierra 75 study, the multicenter retrospective PACO-PCI (EPIC-15) registry, and the single-center, prospective Elderly-HCD registry. A total of 2,725 patients with a mean age of 81 ± 4 years were included in the study; 269 patients (10%) met the primary end point of 1-year major adverse cardiac and cerebrovascular events (MACCEs), and 51 patients (2%) had in-hospital MACCEs. Of the 12 investigated original CHIP-PCI score variables, 5 were independent predictors: previous myocardial infarction, left ventricular ejection fraction <30%, chronic kidney disease, left main coronary artery percutaneous coronary intervention, and nonradial access. Furthermore, diabetes mellitus, anemia, and severe calcification showed to be significant predictors of MACCEs. The additional variables improved the discriminatory value of the CHIP-PCI score for 1-year MACCEs (modified CHIP-PCI score: area under the curve [AUC] 0.647 vs original CHIP-PCI score: AUC 0.598, p = 0.02) and in-hospital MACCEs (AUC 0.729 vs 0.657, p = 0.003, respectively). In conclusion, the CHIP-PCI score retains its prognostic value in older patients for in-hospital MACCEs; however, it is of limited value at 1-year follow-up. The modified CHIP-PCI score, including the 5 patient-related and 3 procedure-related factors, significantly improved its discriminatory potential.
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Intervención Coronaria Percutánea , Anciano , Humanos , Anciano de 80 o más Años , Estudios Prospectivos , Estudios Retrospectivos , Volumen Sistólico , Función Ventricular Izquierda , PronósticoRESUMEN
OBJECTIVES: Elderly patients show a higher incidence of ischemic and bleeding events after percutaneous transluminal coronary intervention (PCI). We sought to investigate outcomes in elderly patients treated with antithrombotic strategy guided by bleeding and ischemic risks after revascularization with last generation everolimus-eluting stent (EES). METHODS: Prospective multicenter registry including patients over 75 years revascularized with EES and antithrombotic therapy guided by clinical presentation, PCI complexity and PRECISE DAPT score. Co-primary safety endpoints were: (1) composite of cardiac death, myocardial infarction and stent thrombosis and; (2) bleeding (BARC 2-5). Primary efficacy endpoint was target lesion revascularization. A matched group of patients revascularized with current drug-eluting stents and no such tailored antithrombotic therapy was used as control. RESULTS: Finally, 1064 patients were included in SIERRA-75 cohort, 80.8 ± 4.2 years, 36.6% women, 71% acute coronary syndromes (ACS) and 53.6% complex PCI. Co-primary safety endpoint of major adverse cardiovascular events was met in 6.2%, co-primary safety endpoint of bleeding in 7.8% and primary efficacy endpoint of TKLR in 1.5%. The multivariable adjusted model showed no significant association of the prescribed short/long dual antiplatelet therapy (DAPT) durations with any endpoint suggesting a well tailored therapy. No stent thrombosis reported in the subgroup with 1-3 months DAPT duration. As compared to control group, bleeding BARC 2-5 was significantly lower in SIERRA-75 group (7.4% vs. 10.2%, P = 0.04) as well as the net safety-efficacy endpoint (14.3% vs. 18.5%, P = 0.02). CONCLUSIONS: In elderly population, the application of this risks-adjusted antithrombotic protocol after revascularization with last generation EES seems to be associated with an improved prognosis in terms of ischemic and bleeding outcomes.
RESUMEN
BACKGROUND: It is estimated that 5% to 10% of patients with myocardial infarction (MI) present with no obstructive coronary artery lesions. Until now, most studies have focused on acute coronary syndrome, including different clinical entities with a similar presentation encompassed under the term MINOCA (MI with non-obstructive coronary arteries). The aim of this study is to assess the prognosis of patients diagnosed with true infarction, confirmed by cardiovascular magnetic resonance (CMR), in the absence of significant coronary lesions. METHODS: Prospective multicenter registry study, including 120 consecutive patients with a CMR-confirmed MI without obstructive coronary artery lesions. The primary clinical outcome was major adverse cardiovascular events (MACE: death, non-fatal infarction, stroke, or cardiac readmission), assessed over three years. RESULTS: Seventy-six patients (63.3%) were admitted with a diagnosis of acute coronary syndrome, and 44 (36.6%) for other causes (mainly heart failure); the definitive diagnosis was established by CMR. Most patients (64.2%) were men, and the mean age was 58.8 ± 13.5 years. Patients presented with small infarcts: 83 (69.1%) showed late gadolinium enhancement (LGE) in one or two myocardial segments, mainly transmural (in 77.5% of patients) and with a preserved left ventricular ejection fraction (median 54.8%, interquartile range 37-62). The most frequent infarct location was inferolateral (n = 38, 31.7%). During follow-up, 43 patients (35.8%) experienced a MACE, including 9 (7.5%) who died. In multivariable analysis, LGE in two versus one myocardial segment doubled the risk of adverse cardiac events (hazard ratio [HR] 2.32, 95% confidence interval [CI] 0.97-5.83, p = 0.058). Involvement of three or more myocardial segments almost tripled the risk (HR 2.71, 95% CI 1.04-7.04, p = 0.040 respectively). CONCLUSIONS: Patients with true MI but without significant coronary artery lesions predominantly had small infarcts. Myocardial 3-segment LGE involvement is associated with a significantly higher risk of adverse cardiac events.
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Vasos Coronarios , Infarto del Miocardio , Anciano , Medios de Contraste , Gadolinio , Humanos , Imagen por Resonancia Cinemagnética , Espectroscopía de Resonancia Magnética , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Medición de Riesgo , Volumen Sistólico , Función Ventricular IzquierdaAsunto(s)
Enfermedad de la Arteria Coronaria , Stents Liberadores de Fármacos , Reserva del Flujo Fraccional Miocárdico , Infarto del Miocardio con Elevación del ST , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Humanos , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this study was to determine whether drug-eluting stents (DES) are superior to bare-metal stents (BMS) in octogenarian patients with angina. BACKGROUND: Patients ≥80 years of age frequently have complex coronary disease warranting DES but have a higher risk of bleeding from prolonged dual antiplatelet therapy. METHODS: This multicenter randomized trial was conducted in 22 centers in the United Kingdom and Spain. Patients ≥80 years of age underwent stent placement for angina. The primary endpoint was a 1-year composite of death, myocardial infarction, cerebrovascular accident, target vessel revascularization, or major hemorrhage. RESULTS: In total, 800 patients (83.5 ± 3.2 years of age) were randomized to BMS (n = 401) or DES (n = 399) for treatment of stable angina (32%) or acute coronary syndrome (68%). Procedural success did not differ between groups (97.7% for BMS vs. 95.4% for DES; p = 0.07). Thirty-eight percent of patients had ≥2-vessel percutaneous coronary intervention, and 66% underwent complete revascularization. Patients who received BMS had shorter stent implants (24.0 ± 13.4 mm vs. 26.6 ± 14.3 mm; p = 0.01). Rates of dual antiplatelet therapy at 1 year were 32.2% for patients in the BMS group and 94.0% for patients in the DES group. The primary endpoint occurred in 18.7% of patients in the BMS group versus 14.3% of patients in the DES group (p = 0.09). There was no difference in death (7.2% vs. 8.5%; p = 0.50), major hemorrhage (1.7% vs. 2.3%; p = 0.61), or cerebrovascular accident (1.2% vs. 1.5%; p = 0.77). Myocardial infarction (8.7% vs. 4.3%; p = 0.01) and target vessel revascularization (7.0% vs. 2.0%; p = 0.001) occurred more often in patients in the BMS group. CONCLUSIONS: BMS and DES offer good clinical outcomes in this age group. DES were associated with a lower incidence of myocardial infarction and target vessel revascularization without increased incidence of major hemorrhage. (Xience or Vision Stent-Management of Angina in the Elderly [XIMA]; ISRCTN92243650).
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Angina de Pecho/mortalidad , Angina de Pecho/terapia , Angioplastia Coronaria con Balón/instrumentación , Stents Liberadores de Fármacos , Mortalidad Hospitalaria , Metales , Anciano de 80 o más Años , Angina de Pecho/diagnóstico por imagen , Angioplastia Coronaria con Balón/métodos , Angiografía Coronaria/métodos , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/mortalidad , Estenosis Coronaria/terapia , Femenino , Estudios de Seguimiento , Evaluación Geriátrica , Humanos , Estimación de Kaplan-Meier , Masculino , Estudios Prospectivos , Diseño de Prótesis , Medición de Riesgo , Índice de Severidad de la Enfermedad , España , Estadísticas no Paramétricas , Análisis de Supervivencia , Factores de Tiempo , Resultado del Tratamiento , Reino UnidoRESUMEN
AIMS: Assessment of intermediate coronary lesions can be done with fractional flow reserve (FFR) and intravascular ultrasound (IVUS). There are no randomised trials and only a small registry from one centre is available but this is subject to important bias. We sought to evaluate the clinical outcomes of an FFR strategy compared with an IVUS strategy for intermediate lesion assessment. METHODS AND RESULTS: We compared the outcome of patients assessed with FFR and IVUS in two centres with a differential approach. After propensity score matching 400 pairs of patients were included. Revascularisation was done when FFR was <0.75 or minimum lumen area was <4 mm2 in vessels >3 mm, and <3.5 mm2 in vessels 2.5-3 mm, along with plaque burden >50%. After FFR and IVUS, 72% and 51.2% of lesions, respectively, were left untreated (p<0.001). At one and two years no significant differences in MACE-free survival were observed in overall groups (97.7% at one year and 93.1% at two years in the FFR group and 97.7% at one year and 95.6% at two years in the IVUS group; p=0.35) and among those with deferred intervention (97.9% at one year and 94.2% at two years in the FFR group and 96.5% at one year and 93.6% at two years in the IVUS group; p=0.7). CONCLUSIONS: IVUS and FFR may be safely used to defer revascularisation of intermediate lesions. IVUS induces a higher degree of revascularisation but much lower than previously reported and does not affect the clinical outcome.
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Estenosis Coronaria , Reserva del Flujo Fraccional Miocárdico , Angiografía Coronaria , Estenosis Coronaria/diagnóstico por imagen , Humanos , Puntaje de Propensión , Ultrasonografía IntervencionalAsunto(s)
Adenina/análogos & derivados , Síndrome de Fanconi/inducido químicamente , Infecciones por VIH/complicaciones , Hipofosfatemia/inducido químicamente , Debilidad Muscular/etiología , Enfermedades Musculoesqueléticas/etiología , Organofosfonatos/efectos adversos , Osteomalacia/inducido químicamente , Dolor/etiología , Adenina/administración & dosificación , Adenina/efectos adversos , Adenina/uso terapéutico , Alquinos , Fármacos Anti-VIH/administración & dosificación , Fármacos Anti-VIH/uso terapéutico , Benzoxazinas/administración & dosificación , Benzoxazinas/uso terapéutico , Ciclopropanos , Desoxicitidina/administración & dosificación , Desoxicitidina/análogos & derivados , Desoxicitidina/uso terapéutico , Quimioterapia Combinada , Emtricitabina , Síndrome de Fanconi/diagnóstico , Femenino , Infecciones por VIH/tratamiento farmacológico , Hepatitis Viral Humana/complicaciones , Humanos , Hipofosfatemia/diagnóstico , Persona de Mediana Edad , Enfermedades Musculoesqueléticas/diagnóstico por imagen , Organofosfonatos/administración & dosificación , Organofosfonatos/uso terapéutico , Osteomalacia/diagnóstico , Dolor/diagnóstico por imagen , Cintigrafía , Radiofármacos , Abuso de Sustancias por Vía Intravenosa/complicaciones , Medronato de Tecnecio Tc 99m/análogos & derivados , TenofovirRESUMEN
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Humanos , Angiografía Coronaria/métodos , Enfermedad Coronaria/diagnóstico , Ultrasonografía/métodos , Tronco ArterialRESUMEN
A patient who had been previously diagnosed with congenital complete atrioventricular block (CCAVB) twenty years ago developed atrioventricular (AV) conduction through an accessory pathway (AP). With enhanced sympathetic tone (exercise, isoproterenol), 1:1 conduction down the AP occurred. An electrophysiologic study confirmed a suprahissian AV block and the presence of an AP. The AP was located on the left side and posterior. The absence of retrograde conduction through the AP and also a long conduction time were demonstrated.
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Bloqueo Cardíaco/diagnóstico , Cardiopatías Congénitas/diagnóstico , Síndromes de Preexcitación/diagnóstico , Adulto , Nodo Atrioventricular/fisiopatología , Estimulación Cardíaca Artificial , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Femenino , Bloqueo Cardíaco/fisiopatología , Sistema de Conducción Cardíaco/fisiopatología , Cardiopatías Congénitas/fisiopatología , Humanos , Síndromes de Preexcitación/fisiopatologíaRESUMEN
INTRODUCTION AND OBJECTIVES: Implantable cardiac defibrillators (ICD) have been shown to improve survival in patients with myocardial infarctionand LVEF < 0.30 or LVEF < 0.40 + nonsustained ventricular tachycardia + inducible sustained arrhythmias. However, these risk stratification criteria have not been evaluated in patients who are candidates for primary percutaneous transluminal coronary angioplasty (PTCA). The objective of this study was to assess the impact of both strategies on the indication for ICD in a consecutive series of post-infarction patients treated with primary PTCA. PATIENTS AND METHOD: One hundred and two consecutive patients with myocardial infarction (80 men, mean age 63.6 11.5 years) included in a single-center-based regional program of primary PTCA were included in the study. A 24-h continuous ECG recording was obtained 2 to 6 weeks after the acute event, and LVEF was determined by 2D-echocardiography one month after the infarct. Patients with nonsustained ventricular tachycardia and LVEF < 0.40 underwent programmed ventricular stimulation using a standard protocol. RESULTS: Twenty-two patients (21.6%; 95% CI, 13.6-29.6) showed at least one episode of nonsustained ventricular tachycardia in the 24 h recording. Six of them had LVEF < or = 0.40, and sustained ventricular arrhythmia was induced in 2 out of 5. LVEF < or = 0.30 was found in 3 patients, none of whom had nonsustained ventricular tachycardia. Thus, 5 patients had an indication for ICD according to either of the two risk stratification criteria. CONCLUSIONS: The prevalence of nonsustained ventricular tachycardia in post-infarction patients treated with primary PTCA is high. However, because most of them have preserved ventricular function, primary prevention with an ICD is indicated in approximately 5% of the population.
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Angioplastia Coronaria con Balón , Desfibriladores Implantables , Infarto del Miocardio/terapia , Terapia Combinada , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
Introducción y objetivos. El desfibrilador implantable mejora la supervivencia en pacientes postinfarto de miocardio con a) fracción de eyección <= 0,30 y b) fracción de eyección <= 0,40, taquicardias ventriculares no sostenidas y arritmias ventriculares inducibles. Estos criterios no han sido evaluados en el contexto de la angioplastia primaria. El objetivo del estudio es evaluar el impacto de ambos criterios en las indicaciones de desfibrilador en pacientes con infarto revascularizados con angioplastia primaria. Pacientes y método. Se estudió a 102 pacientes postinfarto (80 varones; edad, 63,6 ñ 11,5 años) incluidos en un programa regional de angioplastia primaria. Se realizó un registro Holter de 24 h entre las semanas 2 y 6 postinfarto, al mes, y se estimó la fracción de eyección por ecocardiografía practicando estimulación ventricular programada en el grupo con fracción de eyección <= 0,40 y taquicardia ventricular no sostenida. Resultados. Un total de 22 pacientes (21,6 por ciento; intervalo de confianza [IC] del 95 por ciento, 13,6-29,6) presentaron taquicardia ventricular no sostenida en el Holter. Seis de ellos tuvieron fracción de eyección <= 0,40, siendo inducibles 2 de 5 en el estudio electrofisiológico. La fracción de eyección fue <= 0,30 en 3 pacientes, ninguno de los cuales presentó taquicardia ventricular no sostenida. En total, 5 pacientes (4,9 por ciento) tuvieron indicación de desfibrilador aplicando alguno de los 2 criterios. Conclusiones. La prevalencia de taquicardia ventricular no sostenida en pacientes con infarto tratados con angioplastia primaria es elevada. Sin embargo, la mayoría tiene una función ventricular conservada, por lo que la prevención primaria con desfibrilador estaría indicada en un 5 por ciento aproximadamente utilizando los criterios evaluados en este estudio (AU)
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Persona de Mediana Edad , Masculino , Femenino , Humanos , Angioplastia Coronaria con Balón , Desfibriladores Implantables , Infarto del Miocardio , Estudios Prospectivos , Terapia CombinadaRESUMEN
INTRODUCTION AND OBJECTIVES: Coronary ectasia is characterized by the presence of diffuse dilation of the coronary vessels and is detected in 0.3-5.3% of angiographic studies. Our objective was to evaluate the prevalence of this condition, to analyze its clinical and angiographic characteristics, and to compare patients with ectasia and patients without it. PATIENTS AND METHOD: Coronary angiography was performed in 4.332 patients from October 1998 to June 2001. This population was divided in two groups, patients with and patients without ectasia and patients without ectasia. Angiographic and clinical variables were compared in these groups. RESULTS: The prevalence of ectasia was 3.39%. Most patients with ectasia (77.6%) had coronary stenosis. Ectasia affected a single vessel in 49.7%, most frequently the right coronary artery (132 patients), which also showed the greatest dilation. Most patients with ectasia were men (91.2%), smokers (56.5%), and younger than patients without ectasia (60.8 11.7 vs. 63.3 10.7 years; p = 0.01). They also had a lower prevalence of diabetes (22.4%) and previous revascularization procedures (8.2% angioplasty and 1.4% surgical revascularization).Logistical regression analysis showed that only male sex was associated to the presence of ectasia (OR = 3.33; 95% CI, 1.81-6.13) and that only diabetes was independently associated with absence of ectasia (OR = 0.65; 95% CI, 0.43-0.98). CONCLUSIONS: The prevalence of coronary ectasia in patients who underwent angiography was 3.4%. Coronary ectasia was prevalent in males and associated to the classic cardiovascular risk factors, except diabetes, a pathology that was less frequent than usual.
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Enfermedad de la Arteria Coronaria/patología , Anciano , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/epidemiología , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/epidemiología , Estenosis Coronaria/patología , Dilatación Patológica/patología , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Revascularización Miocárdica , Factores de Riesgo , Factores Sexuales , Fumar/epidemiologíaRESUMEN
Introducción y objetivos. La ectasia coronaria constituye una dilatación difusa del vaso, que aparece en el 0,3-5,3 por ciento de las coronariografías. El objetivo de este artículo es conocer su prevalencia en nuestro medio, analizando sus características y comparándolas con las de la población sin ectasia. Pacientes y método. Desde octubre de 1998, los pacientes remitidos al laboratorio de hemodinámica para coronariografía que presentan coronarias ectásicas son incluidos en un registro prospectivo. Se analizan las distintas variables clínicas y angiográficas de los pacientes con y sin ectasia coronaria. Resultados. La prevalencia de ectasia fue del 3,39 por ciento. Un 77,6 por ciento presentaba estenosis coronarias significativas. Afectaba a un solo vaso en el 49,7 por ciento, siendo la coronaria derecha (n = 132) la más frecuentemente afectada y la que presentaba un mayor grado de dilatación. La mayoría de los sujetos con ectasia fueron varones (91,2 por ciento), fumadores (56,5 por ciento), más jóvenes que los pacientes sin ectasia (60,8 ñ 11,7 frente a 63,3 ñ 10,7 años; p = 0,01), y con menor prevalencia de diabetes (22,4 por ciento) y antecedentes de revascularización (8,2 por ciento angioplastia y 1,4 por ciento cirugía).En el modelo de regresión logística, el sexo masculino fue la única variable asociada a la presencia de ectasia (OR = 3,33; IC del 95 por ciento, 1,81-6,13), mientras que la diabetes se asoció de forma independiente con la ausencia de coronarias ectásicas (OR = 0,65; IC del 95 por ciento, 0,430,98). Conclusiones. La prevalencia de ectasia coronaria entre los pacientes sometidos a coronariografía por sospecha de cardiopatía isquémica es del 3,4 por ciento. Predomina en los varones y se asocia a los clásicos factores de riesgo, con excepción de la diabetes, una enfermedad que aparece con menor frecuencia de lo habitual (AU)
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Persona de Mediana Edad , Anciano , Masculino , Femenino , Humanos , Factores Sexuales , Tabaquismo , Factores de Riesgo , Modelos Logísticos , Angiografía Coronaria , Revascularización Miocárdica , Estenosis Coronaria , Dilatación Patológica , Enfermedad de la Arteria CoronariaRESUMEN
FUNDAMENTO: El tratamiento actual de la fractura de cadera osteoporótica requiere la participación de varias especialidades. El objetivo de este estudio fue conocer el perfil de los pacientes con esta fractura candidatos a la consulta a un equipo de valoración geriátrica (EVG), así como la influencia que tiene el seguimiento geriátrico sobre la evolución intrahospitalaria. PACIENTES Y MÉTODO: Se evaluó a todos los pacientes mayores de 64 años ingresados por fractura de cadera en un hospital universitario durante 12 meses. Al ingreso y al alta se evaluó la situación clínica, funcional, mental y social en los pacientes seguidos por el EVG y en los que no se consultaron al mismo. Se compararon ambos grupos y se aplicó un análisis multivariante para conocer las variables asociadas con un curso hospitalario más favorable. RESULTADOS: Los pacientes que se consultaron al EVG (n = 202) fueron mayores (84,4 frente a 81,7 años), con peor situación funcional previa (índice de Barthel, 72 frente a 79), presentaron mayor frecuencia de enfermedades (5,4 frente a 3,3) y medicaciones previas (3,2 frente a 1,9), deterioro cognitivo (el 52 frente al 41 por ciento), riesgo quirúrgico elevado (el 54 frente al 26 por ciento) y necesidad de ayuda social (el 57 frente al 38 por ciento) que los que no consultaron (n = 200). Al alta, los pacientes seguidos por el EVG presentaban mejor situación funcional (índice de Barthel, 38,5 frente a 34) y, con más frecuencia que los no consultados, habían sido intervenidos quirúrgicamente (el 92 frente al 84 por ciento), recibido fisioterapia (el 83,7 frente al 66,5 por ciento) y deambulaban (el 56,1 frente al 33,8 por ciento). En el análisis multivariante, la intervención del EVG apareció como una variable independiente asociada a ser intervenido (odds ratio [OR], 4,2; intervalo de confianza [IC]: 2,80-6,34), recuperar la deambulación al alta (OR, 8,26; IC, 5,23-13,04) y recibir más diagnósticos (OR, 79,69; IC: 55,48-114,45), y no se asoció a una estancia hospitalaria mayor. CONCLUSIONES: Los pacientes con fractura de cadera en fase aguda que se consultan a geriatría son de mayor complejidad que los no consultados. La intervención del EVG en el seguimiento de estos pacientes mejora su curso clínico y la eficacia del ingreso hospitalario (AU)