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BACKGROUND: Effective treatment of non-ST-segment elevation acute coronary syndromes (NSTEACS) requires careful assessment of both ischaemic and bleeding risks. We aimed to analyse risk distribution and evaluate antiplatelet prescription behaviours in real-life settings. METHODS: Data from 1100 NSTEACS patients in Buenos Aires, Argentina, from the Buenos Aires I Registry, with a 15-month follow-up, were analysed. In-hospital and 6-month GRACE scores, CRUSADE, and Precise DAPT scores were calculated. RESULTS: The mean age was 65.4 ± 11.5 years with a majority being male (77.2%). In-hospital mortality was 2.7%, primarily due to cardiovascular causes (1.8%). Bleeding events occurred in 20.9% of patients, with 4.9% classified as ≥ BARC 3. Predominance of low bleeding (71.3%) and ischaemic (55.8%) risks on admission was observed. At 6 months, the low-risk Precise category (70.9%) and GRACE (44.1%) categories prevailed. Linear correlation analysis showed a moderately positive correlation (r = 0.61, p < .05) between ischaemic-haemorrhagic risks. Regarding the prescription of antiplatelet agents, in the low ischaemic-haemorrhagic risk group, there was a predominance of aspirin + clopidogrel (41.2%) over other high-potency antiplatelet regimens (aspirin + ticagrelor or prasugrel). In the low ischaemic and high haemorrhagic risk group, aspirin and clopidogrel were also predominant (58%). CONCLUSIONS: Our analysis underscores the significant relationship between ischaemic and haemorrhagic risks during NSTEACS hospitalisation. Despite the majority of patients falling into the low-intermediate risk category, the prescription of P2Y12 inhibitors in real-life settings does not consistently align with these risks.
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Síndrome Coronariana Aguda , Hemorragia , Inibidores da Agregação Plaquetária , Sistema de Registros , Humanos , Masculino , Feminino , Idoso , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/complicações , Inibidores da Agregação Plaquetária/efeitos adversos , Inibidores da Agregação Plaquetária/uso terapêutico , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Argentina/epidemiologia , Medição de Risco/métodos , Fatores de Risco , Mortalidade Hospitalar/tendências , Pessoa de Meia-Idade , SeguimentosRESUMO
RESUMEN La decisión sobre la mejor estrategia de revascularización para los pacientes con enfermedad de múltiples vasos se ha tornado una tarea compleja a medida que la angioplastia coronaria ha mejorado sus resultados. En la siguiente revisión nos propusimos evaluar las variables que en nuestra experiencia definen el beneficio de una técnica sobre la otra, entendiendo que de esta manera la decisión del médico tratante se hace más sencilla y objetiva. Por otro lado, y festejando el saludable protagonismo que se le da al paciente, creemos que esta evaluación permite ofrecer argumentos sólidos para ayudarlo en la toma de la decisión.
ABSTRACT The decision on the best revascularization strategy for patients with multivessel disease has become a complex task as coronary angioplasty has improved its results. In the following review, we set out to evaluate the variables that, in our experience, define the benefit of one technique over the other, understanding that in this way the treating physician's decision will become simpler and more objective. On the other hand, and celebrating the healthy prominence given to patients, we believe that this evaluation allows solid arguments to help them in decision making.
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RESUMEN La difusión del reemplazo valvular aórtico percutáneo (TAVI) en la estenosis aórtica (EAo) generó la creación de un Heart Team (HT), para elegir el mejor tratamiento. Existen pocos reportes sobre su utilidad. Objetivos: analizar los resultados del tratamiento de los pacientes con EAo evaluados por un HT durante 10 años Material y métodos: Inclusión consecutiva de todos los pacientes con EAo candidatos a TAVI entre enero del 2012 y julio del 2021 para seleccionar el mejor tratamiento, incluyendo además Cirugía de reemplazo valvular aórtico (CRVA) y Tratamiento médico conservador (TMC). Resultados: De 841 pacientes, se asignaron a TAVI 455 (53%), CRVA 213 (24%) y TMC 183 (23%). El porcentaje asignado a TAVI aumentó con el tiempo de 48 a 62% (p < 0,05). Los pacientes que fueron a TAVI, con respecto a los enviados a CRVA, eran mayores (86 ± 7 vs 83 ± 7 años), con mayor EUROSCORE II (6,2, IC95% 5,7-6,6 vs 5,6, IC95% 4,4-6,5) y más frágiles (1,62 ± 1 vs 0,91 ± 1), en todos los casos p <0,01. La sobrevida actuarial (IC 95%) a 1 y a 2 años fue, para TAVI 88% (84-91%) y 82% (77-86%), para CRVA 83% (76-88%) y 78% (70-84%) y para TMC 70% (60-87%) y 59% (48-68%) respectivamente (p <0,001). Conclusiones: Durante los primeros 10 años de establecido un Heart Team para la toma de decisiones en EAo, se asignaron a TAVI aproximadamente la mitad y el resto se asignó por mitades a cirugía u observación. La sobrevida de los pacientes intervenidos fue similar a 2 años y mayor que la de los no intervenidos.
ABSTRACT As transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) became widespread, the need for a Heart Team (HT) arose to choose the best treatment. There are few reports regarding its usefulness. Objectives: To analyze treatment outcomes in patients with AS evaluated by a HT for 10 years. Methods: Consecutive enrollment of all patients with AS who were candidates for TAVI between January 2012 and July 2021 to choose the best treatment, including surgical aortic valve replacement (SAVR) and conservative medical management (CMM). Results: Out of 841 patients, 455 were assigned to TAVI (53%), 213 to SAVR (24%), and 183 to CMM (23%). The percentage assigned to TAVI has increased from 48% to 62% over time (p <0.05). Patients who underwent TAVI versus those who underwent SAVR were older (86 ± 7 vs. 83 ± 7 years), had a higher EUROSCORE II (6.2, 95% CI 5.7-6.6 vs. 5.6; 95% CI 4.4-6.5) and were frailer (1.62 ± 1 vs. 0.91 ± 1), in all cases p <0.01. Actuarial survival (95% CI) at 1 and 2 years was 88% (84-91%) and 82% (77-86%) for TAVI, 83% (76-88%) and 78% (70-84%) for SAVR, and 70% (60-87%) and 59% (48-68%) for CMM, respectively (p <0.001). Conclusions: For the first 10 years after a Heart Team was established for AS decision-making, approximately half of the patients were assigned to TAVI, and the rest were equally assigned in halves to either surgery or observation. Survival for patients who received interventions was similar at 2 years and higher than in those who did not.
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RESUMEN Introducción : de estar disponible, la angioplastia primaria (ATCp), en tiempos adecuados y en centros con experiencia, es la mejor estrategia de reperfusión para el infarto agudo de miocardio con supradesnivel del segmento ST (IAMCEST). El tiempo puerta-balón (TPB) es una expresión de eficiencia operativa de la institución que realiza la ATCp, con impacto en la evolución del paciente. El objetivo de este trabajo fue analizar los resultados a largo plazo de un programa de mejora continua del proceso TPB. Material y métodos : se incluyeron en forma prospectiva y consecutiva pacientes con diagnóstico de IAMCEST sometidos a ATCp desde enero de 2015 a mayo de 2022. La población se dividió en dos períodos: período de implementación inmediata y período de seguimiento a largo plazo. Resultados : se ingresaron 671 pacientes en forma prospectiva y consecutiva. En el primer período, de implementación, (P1), se incluyeron 91 pacientes, y en el segundo período, de seguimiento del programa, (P2), 580 pacientes. La mediana (rango intercuartilo, RIC) de TPB fue de 46 min (29-59) en P1 vs 42 min(25-52) en el P2, p = 0,055. En el segundo período se evi denció una reducción de las preactivaciones (P1 54,1% vs P2 30%,p = 0,02) y los procedimientos on hours (42% en p1 vs 30% en P2, p = 0,029). Conclusión : el registro mostró el mantenimiento de los buenos resultados a largo plazo a pesar de una reducción de las preactivaciones y los procedimientos on hours.
ABSTRACT Background : If available, primary transluminal coronary angioplasty (PTCA), performed timely and in experienced sites, is the best reperfusion strategy for ST elevation myocardial infarction (STEMI). The door-to-balloon (DTB) time expresses operational efficiency of the site in charge of the PTCA, with an impact on patient's progress. The aim of this study was to analyze the long-term results of a continuous improvement program for the DTB time process. Methods : Patients diagnosed with STEMI who had undergone PTCA from January 2015 to May 2022 were prospectively and consecutively enrolled. The population was divided in two periods: an immediate implementation period and a long-term follow-up period. Results : 671 patients were prospectively and consecutively enrolled. During the implementation period (P1) 91 patients were enrolled, and 580 during the program follow-up (P2). The median (interquartile range, IQR) DTB time was 46 min (29-59) for P1 vs 42 min(25-52) for P2, p=0.055). The second period showed a reduction in pre-activations (P1 54,1% vs P2 30% p=0.02) and on-hour procedures (42% for P1 versus 30% for P2, p=0.029). Conclusion : The registry showed long-term maintenance of good results, despite reduced reactivations and on-hour procedures.
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Heterogeneous catalytic hydrogenation is an interesting alternative to conventional methods that use inorganic hydrides. The hydrogenation of acetophenone under heterogeneous conditions with the supported catalysts based on Ni is the most useful due to its redox properties and lower cost. As is well-known, catalyst support can significantly affect catalyst performance. We have investigated the influence of various physical-chemical parameters on the selective reaction of the hydrogenation of acetophenone by using different nickel catalysts on clinoptilolite supports, in four different forms: natural, previously modified with NH3 (Ni/Z+NH4 +), with HNO3 (Ni/Z+H+), and thermally treated (Ni/Z 500 °C). In particular, our work focuses on determining the influence of the mentioned physical-chemical parameters on the percentages of conversion and the selectivity of the catalysis. This study aims to identify the combination of parameters that allows for obtaining the best catalytic results. The identification of the physical-chemical parameters that determine the percentages of conversion and selectivity allows us to design optimal catalysts.
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BACKGROUND: Between 25% and 30% of patients hospitalised for acute heart failure (AHF) are readmitted within 90 days after discharge, mostly due to persistent congestion on discharge. However, as the optimal evaluation of decongestion is not clearly defined, it is necessary to implement new tools to identify subclinical congestion to guide treatment. OBJECTIVE: To evaluate if inferior vena cava (IVC) and lung ultrasound (CAVAL US)-guided therapy for AHF patients reduces subclinical congestion at discharge. METHODS: CAVAL US-AHF is a single-centre, single-blind randomised controlled trial designed to evaluate if an IVC and lung ultrasound-guided healthcare strategy is superior to standard care to reduce subclinical congestion at discharge. Fifty-eight patients with AHF will be randomised using a block randomisation programme that will assign to either lung and IVC ultrasound-guided decongestion therapy ('intervention group') or clinical-guided decongestion therapy ('control group'), using a quantitative protocol and will be classified in three groups according to the level of congestion observed: none or mild, moderate or severe. The treating physicians will know the result of the test and the subsequent adjustment of treatment in response to those findings guided by a customised therapeutic algorithm. The primary endpoint is the presence of more than five B-lines and/or an increase in the diameter of the IVC, with and without collapsibility. The secondary endpoints are the composite of readmission for HF, unplanned visit for worsening HF or death at 90 days, variation of pro-B-type natriuretic peptide at discharge, length of hospital stay and diuretic dose at 90 days. Analyses will be conducted as between-group by intention to treat. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Institutional Review Board and registered in the PRIISA.BA platform of the Ministry of Health of the City of Buenos Aires. TRIAL REGISTRATION NUMBER: NCT04549701.
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Insuficiência Cardíaca , Veia Cava Inferior , Humanos , Veia Cava Inferior/diagnóstico por imagem , Método Simples-Cego , Doença Aguda , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/tratamento farmacológico , Pulmão/diagnóstico por imagem , Ultrassonografia de IntervençãoRESUMO
RESUMEN El ácido acetilsalicílico, o aspirina, es una de las herramientas farmacológicas más usadas en el cuidado de los pacientes cardiovasculares. Durante años se utilizó ampliamente en prevención primaria y secundaria para disminuir el riesgo cardiovascular. En los últimos tiempos su uso ha sido cuestionado, con nuevos ensayos en diferentes escenarios dentro de la patología cardíaca, como la enfermedad vascular periférica, el accidente cerebrovascular, la prevención primaria en el contexto del tratamiento médico moderno, o en el paciente con un síndrome coronario agudo y necesidad concomitante de anticoagulación. A su vez, nuevos estudios cuestionan la necesidad de mantener la aspirina durante 12 meses junto a una tienopiridina luego de un síndrome coronario agudo, y proponen esquemas abreviados. En esta revisión, evaluamos la evidencia detrás de las indicaciones actuales del uso de aspirina en diferentes escenarios clínicos, y formulamos recomendaciones en cada uno de los casos.
ABSTRACT Acetylsalicylic acid, or aspirin, is one of pharmacological tools most widely used in the care of cardiovascular patients. For years, it has been widely used in primary and secondary prevention to reduce cardiovascular risk. Aspirin utilization has been questioned in recent times, with new trials in different scenarios of cardiovascular disease, such as peripheral vascular disease, stroke, primary prevention in the context of modern medical treatment, or in patients with acute coronary syndrome and concomitant need for anticoagulation. In turn, new studies question the need to maintain aspirin for 12 months together with a thienopyridine after an acute coronary syndrome, suggesting shorter regimens. In this review, we evaluate the evidence behind the current indications for aspirin use in different clinical scenarios and provide recommendations on a case-by-case basis.
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During the COVID-19 pandemic, reductions in heart failure (HF) hospitalizations have been widely reported, and there is an urgent need to understand how HF care has been reorganized in countries with different infection levels, vaccination rates and healthcare services. The OPTIMIZE Heart Failure Care program has a global network of investigators in 42 countries, with first-hand experience of the impact of the pandemic on HF management in different care settings. The national coordinators were surveyed to assess: 1) the challenges of the COVID-19 pandemic for continuity of HF care, from both a hospital and patient perspective; 2) the organizational changes enacted to ensure continued HF care; and 3) lessons learned for the future of HF care. Contributions were obtained from 37 national coordinators in 29 countries. We summarize their input, highlighting the issues raised and using the example of three very different settings (Italy, Brazil, and Taiwan) to illustrate the similarities and differences across the OPTIMIZE program.
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COVID-19 , Insuficiência Cardíaca , Brasil , COVID-19/epidemiologia , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Humanos , Pandemias , Inquéritos e QuestionáriosRESUMO
Resumen El compromiso coronario en la infección COVID-19 se presenta habitualmente como infarto agudo de miocardio (IAM) tipo 2, debido al aumento del consumo y reducción del aporte de oxígeno, y menos frecuentemente como IAM tipo 1, con supradesnivel del ST. Se cree que estos últimos pueden tener relación con la trombogenicidad de la infección. Se presentan dos casos de varones de mediana edad, con pocos o sin factores de riesgo cardiovasculares, que luego de 10 días de internación por neumonía debida a COVID-19 con buena evolución, presentaron IAM con supradesnivel del ST en fase de convalecencia, al día siguiente del alta hospitalaria y de la suspensión de enoxaparina profiláctica. Ambos fueron tratados mediante angioplastia directa con stent farmacológico. Se discute cuál debiera ser el tratamiento al alta del IAM, si agregar anticoagulación a la doble antiagregación plaquetaria y también considerar algún tratamiento antitrombótico profiláctico al alta de neumonía por COVID-19 en ciertos pacientes.
Abstract Coronary involvement in COVID-19 infection usually presents as type 2 acute myocardial infarction (AMI), due to increased 0 consumption and reduction of oxygen supply, and less frequently as type 1 (STEMI). In that cases, thrombogenicity of the infection may contribute to acute coronary occlusion. We present 2 cases of middle-aged men, with few or none cardiovascular risk factors, who were in hospital during 10 days because pneumonia due to COVID-19 with good evolution. In the convalescent phase, one day after hospital discharge, and enoxaparin suspension, they went back to hospital because STEMI. Both were treated by direct angioplasty using pharmacologic stent. Discussion is related to treatment of AMI at discharge, if anticoagulation should be added to double antiplatelet therapy, and if any prophylactic antithrombotic treatment should be considered at discharge from COVID-19 pneumonia in some patients.
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Humanos , Masculino , Pessoa de Meia-Idade , Idoso , Infarto do Miocárdio com Supradesnível do Segmento ST , COVID-19 , Infarto do Miocárdio , SARS-CoV-2RESUMO
INTRODUCTION: A rapid rule-out or rule-in protocol based on the 0-hour/1-hour algorithm using high-sensitivity cardiac troponin (hs-cTn) is recommended by the European Society of Cardiology (ESC); recently multiple studies have validated it in their settings. We aimed to assess the diagnostic accuracy of the 2015 ESC guidelines for management of acute coronary syndrome in patients without ST-segment elevation 0-hour/1-hour algorithm using hs-cTn for the early rule-out and rule-in of acute myocardial infarction (AMI) on presentation. METHODS: Systematic searches were conducted using PubMed, the Cochrane Library and the International Clinical Trials Registry Platform to identify prospective studies from 2015 to October 2019 involving adults presenting to the emergency department with possible acute coronary syndrome in which hs-cTn measurements were obtained according to the ESC algorithm and AMI outcomes were adjudicated during the initial hospitalization. RESULTS: Eleven studies, involving 19,213 patients, were identified. Pooled prevalence of AMI during the index hospitalization was 11.3% (95% confidence interval (CI) 3.9-18.8%). Summary sensitivity and specificity in diagnosing AMI were 99% (95% CI 98-99%; I2 63%) and 91% (95% CI 91-92%; I2 96%) respectively. The summary positive likelihood ratio was 11.6 (95% CI 8.5-15.8; I2 97%) and the pooled likelihood ratio negative 0.02 (0.01-0.03; I2 52%). Cumulative all-cause mortality at 30 days in the rule-out group was 0.11%, and 2.8% in the rule-in group, and 30 days AMI in the rule-out group was 0.08%. CONCLUSION: The ESC 0-hour/1-hour algorithm using high-sensitivity cardiac troponin has high diagnostic accuracy; it allows safe rule-out as well as accurate rule-in of AMI, with low cumulative 30-day mortality and AMI in patients assigned the rule-out zone.
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BACKGROUND: The European Society of Cardiology's 0/1-hour algorithm improves the early triage of patients towards "rule-out" or "rule-in" of non-ST-segment elevation myocardial infarction. The HEART score is a risk stratification tool for patients with undifferentiated chest pain. We sought to evaluate the performance of the European Society of Cardiology 0/1-hour algorithm and the HEART score to evaluate chest pain patients in the emergency department. METHODS: In this prospective study, we applied the European Society of Cardiology 0/1-hour algorithm and the HEART score in 1355 consecutive patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome without ST-segment elevation. Patients were followed for non-ST-segment elevation myocardial infarctions and major adverse cardiac events at 30 days: death, non-ST-segment elevation myocardial infarction, or unplanned coronary revascularization. RESULTS: The European Society of Cardiology 0/1-hour algorithm classified 921 (68.0%) patients as "rule-out" and the HEART score classified 686 (50.6%) patients as "low-risk". The 30-day incidence of non-ST-segment elevation myocardial infarctions was 0.32% in the European Society of Cardiology 0/1-hour algorithm "rule-out" patients versus 0.29% in the HEART score "low-risk" patients (p=0.75). The rate of major adverse cardiac events was 7.7% in the European Society of Cardiology 0/1-hour algorithm "rule-out" patients versus 1.1% in the HEART score "low-risk" patients (p<0.001). CONCLUSION: The European Society of Cardiology 0/1-hour algorithm identified more patients with low risk of non-ST-segment elevation myocardial infarctions at 30 days whereas for major adverse cardiac events, the HEART score had a greater capacity to detect low-risk patients.
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Cardiologia/organização & administração , Dor no Peito/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/mortalidade , Eletrocardiografia/métodos , Serviço Hospitalar de Emergência , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/sangue , Infarto do Miocárdio sem Supradesnível do Segmento ST/fisiopatologia , Intervenção Coronária Percutânea/estatística & dados numéricos , Estudos Prospectivos , Projetos de Pesquisa , Medição de Risco , Triagem/métodos , Troponina/sangueRESUMO
INTRODUCTION: A rapid rule-out or rule-in protocol based on the 0-hour/1-hour algorithm using high-sensitivity cardiac troponin (hs-cTn) is recommended by the European Society of Cardiology (ESC); recently multiple studies have validated it in their settings. We aimed to assess the diagnostic accuracy of the 2015 ESC guidelines for management of acute coronary syndrome in patients without ST-segment elevation 0-hour/1-hour algorithm using hs-cTn for the early rule-out and rule-in of acute myocardial infarction (AMI) on presentation. METHODS: Systematic searches were conducted using PubMed, the Cochrane Library and the International Clinical Trials Registry Platform to identify prospective studies from 2015 to October 2019 involving adults presenting to the emergency department with possible acute coronary syndrome in which hs-cTn measurements were obtained according to the ESC algorithm and AMI outcomes were adjudicated during the initial hospitalization. RESULTS: Eleven studies, involving 19,213 patients, were identified. Pooled prevalence of AMI during the index hospitalization was 11.3% (95% confidence interval (CI) 3.9-18.8%). Summary sensitivity and specificity in diagnosing AMI were 99% (95% CI 98-99%; I2 63%) and 91% (95% CI 91-92%; I2 96%) respectively. The summary positive likelihood ratio was 11.6 (95% CI 8.5-15.8; I2 97%) and the pooled likelihood ratio negative 0.02 (0.01-0.03; I2 52%). Cumulative all-cause mortality at 30 days in the rule-out group was 0.11%, and 2.8% in the rule-in group, and 30 days AMI in the rule-out group was 0.08%. CONCLUSION: The ESC 0-hour/1-hour algorithm using high-sensitivity cardiac troponin has high diagnostic accuracy; it allows safe rule-out as well as accurate rule-in of AMI, with low cumulative 30-day mortality and AMI in patients assigned the rule-out zone.
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Coronary involvement in COVID-19 infection usually presents as type 2 acute myocardial infarction (AMI), due to increased 02 consumption and reduction of oxygen supply, and less frequently as type 1 (STEMI). In that cases, thrombogenicity of the infection may contribute to acute coronary occlusion. We present 2 cases of middle-aged men, with few or none cardiovascular risk factors, who were in hospital during 10 days because pneumonia due to COVID-19 with good evolution. In the convalescent phase, one day after hospital discharge, and enoxaparin suspension, they went back to hospital because STEMI. Both were treated by direct angioplasty using pharmacologic stent. Discussion is related to treatment of AMI at discharge, if anticoagulation should be added to double antiplatelet therapy, and if any prophylactic antithrombotic treatment should be considered at discharge from COVID-19 pneumonia in some patients.
El compromiso coronario en la infección COVID-19 se presenta habitualmente como infarto agudo de miocardio (IAM) tipo 2, debido al aumento del consumo y reducción del aporte de oxígeno, y menos frecuentemente como IAM tipo 1, con supradesnivel del ST. Se cree que estos últimos pueden tener relación con la trombogenicidad de la infección. Se presentan dos casos de varones de mediana edad, con pocos o sin factores de riesgo cardiovasculares, que luego de 10 días de internación por neumonía debida a COVID-19 con buena evolución, presentaron IAM con supradesnivel del ST en fase de convalecencia, al día siguiente del alta hospitalaria y de la suspensión de enoxaparina profiláctica. Ambos fueron tratados mediante angioplastia directa con stent farmacológico. Se discute cuál debiera ser el tratamiento al alta del IAM, si agregar anticoagulación a la doble antiagregación plaquetaria y también considerar algún tratamiento antitrombótico profiláctico al alta de neumonía por COVID-19 en ciertos pacientes.
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COVID-19 , Infarto do Miocárdio , Infarto do Miocárdio com Supradesnível do Segmento ST , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , SARS-CoV-2RESUMO
INTRODUCTION: Elevated levels of cardiac troponin (cTn) indicate underlying heart disease and is known to predict adverse events in multiple conditions. Its role in atrial fibrillation (AF) in the acute setting is still not conclusive. We aimed to assess the prognostic value of c-Tn in patients with AF admitted to an emergency department (ED). METHODS: Systematic searches were conducted using PubMed and the Cochrane Library and the International Clinical Trials Registry Platform to identify studies from year 2009 to October 2019 reporting on the prognostic value of cTn on all-cause mortality or major adverse cardiac events (MACE) in adult patients with AF in the ED. We pooled hazard ratio (HR) and 95% confidence interval (CI) using fixed and random effects models according the heterogeneity. We planned to conduct a sensitivity and subgroup analyses. RESULTS: Five studies involving 5750 patients were identified. The mean follow-up ranged from 12 to 35 months. An increase in mortality was observed in the elevated cTn group compared to the controls, HR=2.7 (95% CI 1.55-4.72), P for effect<0.001, I2=80%). For MACE, the pooled HR was 2.17 (95%CI 1.60-2.94), P for effect<0.001, I2=0%). In the subgroup analysis we found no significant difference in type of troponin used and study design. CONCLUSIONS: The elevation of cardiac troponin was significantly associated with higher mortality and major adverse cardiac events in patients with AF admitted to an ED. In this setting the use of c-Tn could provide prognostic information.
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RESUMEN Objetivo: Presentar los resultados a dos años de seguimiento de la cohorte argentina del estudio EPICOR, un registro internacional, multicéntrico, observacional, prospectivo, diseñado para determinar los patrones de utilización de la terapia antitrombótica en pacientes con síndrome coronario agudo en el contexto de la práctica clínica habitual. Material y métodos: Se enrolaron 438 pacientes consecutivos con infarto de miocardio con supradesnivel del segmento ST (STEMI, 41%) o SCA sin supradesnivel del segmento ST (NSTE-ACS, 59%), externados vivos de centros hospitalarios públicos, privados y de comunidad. La media de edad fue 62 años, el 76% eran varones, el 71% hipertensos, el 64% fumadores, el 19% diabéticos y el 40% tenían antecedentes de patología cardiovascular previa. Resultados: La mortalidad global fue del 4,8% al año y del 7,3% a los 2 años. El uso de doble antiagregación plaquetaria fue del 80% al año y del 53% a los 2 años (p < 0,0001), sin diferencias entre aquellos con supradesnivel del ST o sin este. La incidencia de eventos isquémicos y hemorrágicos mayores a los 2 años fue del 15,3% y del 1,8%, respectivamente. Conclusiones: Se observó un elevado porcentaje de persistencia de la doble antiagregación plaquetaria a los 2 años, más allá del año recomendado por las guías, con baja incidencia de hemorragias mayores, lo que sugiere una selección clínica de riesgo-beneficio.
ABSTRACT Objectives: To present the two-year follow-up resultis of the EPICOR study Argentine cohort, a prospective, international, observational, multicenter registry designed to determine the use of antithrombotic therapy patterns in the routine clinical practice of patientis with acute coronary syndrome (ACS). Methods: The study enrolled a total of 438 consecutive patientis with ST-segment elevation myocardial infarction (STEMI, 41%) or non-ST-segment elevation ACS (NSTE ACS, 59%) discharged alive from public, private, and community hospitals. Mean age was 62 years, 76% of patientis were male, 71% hypertensive, 64% smokers, 19% diabetic and 40% had history of previous cardiovascular disease. Resultis: Overall mortality was 4.8% at 1 year and 7.3% at 2 years. Use of dual antiplatelet therapy was 80% at one year and 53% at 2 years (p<0.0001), with no differences between those with or without ST-segment elevation. The 2-year incidence of ischemic and major bleeding eventis was 15.3% and 1.8%, respectively Conclusions: Beyond the one-year administration recommended by the guidelines, a high percentage of persistent dual antiplatelet therapy was observed at 2 years, with a low incidence of major bleeding eventis, suggesting a clinical risk-benefit selection.
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RESUMEN Introducción: El score HEART consiste en una prueba sencilla que fue diseñada para estratificar a los pacientes que consultan al servicio de emergencias por dolor torácico, según su riesgo de presentar un síndrome coronario agudo a corto plazo. Fue creado inicialmente con troponina de cuarta generación, pero el advenimiento de la troponina de alta sensibilidad impuso su incorporación al score y la reevaluación de su comportamiento. Objetivo: Nos propusimos evaluar el comportamiento del score HEART con troponina de alta sensibilidad. Material y métodos: Se realizó un estudio prospectivo que incluyó 1464 pacientes (p) que consultaron al servicio de emergencia por dolor torácico y que tenían electrocardiograma sin elevación del segmento ST. Se evaluó la incidencia de MACE (combinado de infarto agudo de miocardio, muerte y revascularización) a 30 días. Resultados: El índice clasificó 739 pacientes (50,5 %) como de bajo riesgo, 515 pacientes (35,2%) de riesgo intermedio y 210 pacientes (14,3%) de alto riesgo. La incidencia de la combinación de infarto agudo de miocardio, muerte y revascularización fue del 1,35% en el primer grupo; del 20%, en el segundo; y del 71%, en el tercero (long rank test p < 0,001). El área bajo la curva global para la combinación de infarto agudo de miocardio, muerte y revascularización fue de 0,91 (0,89-0,93). Conclusiones: El score HEART que utiliza troponina de alta sensibilidad tiene una gran capacidad para clasificar pacientes con dolor torácico de acuerdo con su riesgo de presentar eventos cardiovasculares en el corto plazo.
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RESUMEN Introducción: La disección coronaria espontánea (DCE) es una causa infrecuente de síndrome coronario agudo (SCA). Es conocida su mayor frecuencia en mujeres jóvenes; sin embargo, sus características clínicas y evolutivas permanecen insuficientemente estudiadas. Objetivo: Evaluar las características clínicas y la evolución de la DCE y su comparación con el síndrome coronario agudo ateroesclerótico (SCAA) en mujeres jóvenes. Material y métodos: Estudio de cohorte prospectivo, realizado entre 2015 y 2017, en el que se compararon mujeres menores de 60 años que ingresaron por SCA por DCE con otro cohorte que presentaba SCAA. Resultados: Se incluyeron 49 pacientes, 7 (14,29%) presentaban DCE. La mediana de seguimiento fue de 10 meses (Pc 25-75 2-18). La mediana de edad fue de 44 años (Pc 25-75 38-45) en grupo DCE y de 55 (Pc 25-75 49-58) en SCAA (P = 0,002), con mayor prevalencia de hipertensión arterial, dislipemia en grupo SCAA (69% vs. 14,3% P = 0,006 y 71% vs. 14% P = 0,004 respectivamente). En el grupo DCE hubo mayor estrés (57,1% vs. 4,8% P = 0,001) y uso de ergotamina (28,6% vs. 0% P = 0,0001) y se presentaron más frecuentemente como infarto agudo de miocardio con elevación del ST (71,4% vs. 28,6%; P = 0,02. El punto final primario ocurrió en 3 pacientes (42,9%) del grupo con DCE y fue menor en el SCAA (9,5%, P = 0,02. En el seguimiento, el 14,9% del grupo DCE y el 14,8% de SCAA presentaron el punto final secundario (P = 0,9). Conclusiones: Las mujeres con DCE tuvieron menor prevalencia de factores de riesgo cardiovascular y presentaron un SCA con peor impacto hemodinámico y mayores complicaciones. La evolución a largo plazo no mostró diferencias significativas.
ABSTRACT Background: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Its prevalence is higher in young women, but its clinical characteristics and outcome remain insufficiently studied. Objective: The aim of this study was to evaluate the baseline characteristics and outcome of SCAD compared with atheroscle-rotic acute coronary syndrome (AACS) in young women. Methods: This prospective cohort study compared women <60 years admitted with ACS due to SCAD with another cohort with AACS, between 2015 and 2017. Results: A total of 49 patients were included, 7 of which (14.29%) presented SCAD. Median follow-up was 10 months (25-75 IQR: 2-18). Median age was 44 years (25-75 IQR: 38-45) in the SCAD group and 55 years (25-75 IQR: 40-58) in the AACS group (p=0.002), with greater prevalence of hypertension and dyslipidemia (69% vs. 14.3%, p=0.006 and 71% vs. 14% p=0.004, respectively). Episodes of acute stress (57.1% vs. 4.8%, p=0.001) and use of ergotamine (28.6% vs. 0%, p=0.0001) were more common in the SCAD group, and ST-segment elevation myocardial infarction was the most frequent presentation (71.4% vs. 28.6%; p=0.02). The primary endpoint occurred in 3 patients (42.9%) of the SCAD group and was less frequent in the AACS group (9.5%, p=0.02). During follow-up, 14.9% of patients in the SCAD group and 14.8% in the AACS group presented the secondary endpoint (p=0.9). Conclusions: Women with SCAD had lower prevalence of cardiovascular risk factors and presented ACS with worse hemody-namic impact and more complications. The long-term outcome did not show significant differences.
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RESUMEN: Introducción: Actualmente no hay consenso sobre el manejo anestésico más adecuado en el implante valvular aórtico percutáneo por vía transfemoral. Aunque se ha demostrado la factibilidad de concretar el procedimiento bajo anestesia local con sedación consciente o sin esta, los resultados clínicos reportados son controvertidos. Objetivos: Evaluar la seguridad y eficacia del implante valvular aórtico percutáneo por vía transfemoral realizado bajo anestesia general versus anestesia local con sedación consciente. Material y métodos: Análisis unicéntrico y retrospectivo de los pacientes con estenosis aórtica grave sintomática con alto riesgo quirúrgico sometidos a un implante valvular aórtico percutáneo por vía transfemoral desde marzo de 2009 a diciembre de 2016, según el manejo anestésico. Los desenlaces de seguridad y eficacia fueron evaluados a 30 días según las definiciones del Valve Academic Research Consortium-2. Además, se evaluaron los principales tiempos durante la internación. Resultados: Se incluyeron 121 pacientes (Edad 83,2 ± 5,7 años, hombres 48,8%), tratados con un implante valvular aórtico percutáneo por vía transfemoral bajo anestesia general (n = 55, 45,5%) o anestesia local con sedación consciente (n = 66, 54,5%). No se observaron diferencias significativas en los resultados intraprocedimiento ni en los desenlaces de seguridad y eficacia a 30 días. La mortalidad a 30 días fue del 7,3% en el grupo AG y del 3% en el grupo anestesia local con sedación consciente 3%, p log-rank 0,28 (mortalidad global 5%). La necesidad de conversión a anestesia general se presentó en 2 pacientes (3%), por complicaciones vasculares mayores durante el procedimiento. El grupo anestesia local con sedación consciente presentó menor tiempo total de procedimiento, internación en unidad de cuidados intensivos e internación total. Conclusión: El implante valvular aórtico percutáneo por vía transfemoral realizado bajo anestesia local con sedación consciente, parece ser una alternativa segura y eficaz al uso de anestesia general.
Abstract: Background: Currently, there is no consensus about the most adequate anesthetic management in transfemoral transcatheter aortic valve replacement. Although it has been shown that local anesthesia (LA) with or without conscious sedation is feasible, clinical results are controversial. Objective: The aim of this study was to evaluate the safety and efficacy of transfemoral transcatheter aortic valve replacement performed under general anesthesia versus local anesthesia with conscious sedation. Methods: This was a single-center, retrospective study of high risk patients with severe aortic stenosis undergoing transfemoral transcatheter aortic valve replacement between March 2009 and December 2016. The population was divided according to anesthetic management. Safety and efficacy outcomes were evaluated at 30-days and were classified according to definitions of the Valve Academic Research Consortium-2. In addition, key times during hospitalization were evaluated. Results: A total of 121 patients undergoing transfemoral transcatheter aortic valve replacement under general anesthesia (n=55, 45.5%) or local anesthesia with conscious sedation (n=66, 54.5%). were included in this analysis. Mean age was 83.2±5.7 years and 48.8% were men. There were no differences in either the procedural result or in the 30-day efficacy and safety outcomes. The rate of death at 30-days was 7.3% in the group with general anesthesia and 3% in the local anesthesia with conscious sedation group (log-rank p 0.28). The need of conversion to general anesthesia was 3% (2 patients), in all cases due to major vascular complications during the procedure. In the local anesthesia with conscious sedation group shorter procedural time, intensive care unit and hospital length of stay were observed. Conclusions: Transfemoral transcatheter aortic valve replacement performed under local anesthesia with conscious sedation seems to be a safe and effective alternative to the use of general anesthesia.
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Resumen: Se presenta el caso de un paciente de sexo femenino de 42 años sin antecedentes clínicos de relevancia, con hipopotasemia severa y cambios electrocardiográficos imitando isquemia miocárdica con enfermedad corona-ria de múltiples vasos.
Abstracts: A 42-year-old woman with no previous medical history developed severe hypokalemia. The ECG changes suggested multivessel coronary artery disease with ischemia in several territories.
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Humanos , Feminino , Adulto , Isquemia Miocárdica/diagnóstico , Eletrocardiografia , Hipopotassemia/diagnóstico , Potássio/uso terapêutico , Isquemia Miocárdica/etiologia , Diagnóstico Diferencial , Hipopotassemia/complicações , Hipopotassemia/tratamento farmacológicoRESUMO
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