Emili Iràculis

Early dysfunction and long-term improvement in endothelium-dependent vasodilation in the infarct-related artery after thrombolysis☆

OBJECTIVES This study assessed the degree of endothelial dysfunction in post-acute myocardial infarction (AMI) and its subsequent status in the infarct-related artery (IRA) in patients treated with thrombolysis. BACKGROUND Coronary flow reserve alterations in the IRA after thrombolysis have been described, but the endothelium-dependent vasomotion has not been investigated, to date. METHODS Endothelial function in patients after thrombolysis was assessed by infusion of acetylcholine (ACh) at increasing doses in the IRA. Diameter changes in the distal segments were evaluated using quantitative coronary angiography. Patients with coronary atherosclerosis constituted the control group. Clinical variables, electrocardiography and biochemical markers were used to determine the timing of reperfusion and the extent of the infarct. Patients in the AMI group were re-evaluated one year later. RESULTS In the initial assessment, 16 patients showed a vasoconstriction response to ACh in the IRA compared to the control group (-20 +/- 21% vs. 4 +/- 4%; p < 0.01). Significant correlations between the degree of vasoconstriction and maximum value of the creatine kinase-MB fraction and number of new Q waves were observed. Of the 12 patients re-evaluated, 4 had complete occlusion of the IRA. In the remaining eight patients with patent artery, an improvement in response to ACh was observed relative to the initial study (+3 +/- 11%, vs. -19 +/- 15%, p < 0.05). CONCLUSIONS In patients with AMI treated with thrombolysis, severe endothelial dysfunction in the IRA is observed early. In patients who retain patency of the IRA, the endothelial dysfunction improves during the follow-up and suggests a component of stunned endothelium in the first few days post-AMI.

Stent liberador de fármacos en lesiones de tronco coronario izquierdo en pacientes no candidatos a revascularización quirúrgica

Introduccion y objetivos. La cirugia es el tratamiento de eleccion de la estenosis del tronco. Los stents convencionales no son una alternativa debido a la reestenosis e incidencia de muerte subita. Los stents liberadores de farmacos, al disminuir la reestenosis, pueden ser una terapia valida. El objetivo del estudio es describir los resultados del stent con liberacion de farmacos en pacientes con lesion en tronco no candidatos a tratamiento quirurgico. Pacientes y metodo. Se analizo la evolucion de una serie de pacientes consecutivos no candidatos a cirugia a los que se implanto un stent liberador de farmacos entre mayo de 2002 y abril de 2004 por lesion en el tronco. Se analizaron los resultados intrahospitalarios y a largo plazo. Se realizo un seguimiento angiografico y con ultrasonidos intracoronarios. Resultados. Se estudio a 42 pacientes, con una edad de 70,1 ± 10,5 anos, 25 (59,5%) varones, y 14 (33%) diabeticos; 7 (16,7%) tenian tronco protegido. El motivo de imposibilidad de cirugia fue por malos vasos en 19 (45,2%) casos, cirugia previa en 9 (21,4%), edad en 6 (14,3%), angioplastia primaria en 5 (11,4%) y otras causas en 3 (7,2%) pacientes. Cuatro (9,5%) pacientes fallecieron antes del alta; a 3 de ellos se les practico una angioplastia primaria, y no hubo necesidad de nueva revascularizacion. La mediana de seguimiento fue de 288 dias (media, 315 ± 241). Otros 4 (9,5%) fallecieron despues del alta, en los dias 5, 24, 34 y 115. Se repitio la angioplastia en un caso y en otro se practico un trasplante. Conclusiones. Los stents liberadores de farmacos representan una alternativa para los pacientes con lesiones en el tronco que no son candidatos a cirugia. Se deberian hacer estudios aleatorizados con seguimiento a largo plazo para valorar su validez en pacientes elegibles para cirugia.

Drug-Eluting Stents in Patients With Left Main Coronary Lesions Who Are Not Candidates for Surgical Revascularization

INTRODUCTION AND OBJECTIVES Surgical revascularization is the treatment of choice in patients with left main coronary artery stenosis. Conventional stents are not a valid alternative because of the rate of restenosis and sudden cardiac death. Drug-eluting stents, which reduce the rate of restenosis, may represent an alternative to cardiac surgery. The objective of this study was to describe the results with drug-eluting stents in patients with left main coronary artery stenosis who were poor candidates for surgical revascularization. PATIENTS AND METHOD We prospectively followed a consecutive series of patients who were poor candidates for surgical revascularization and were treated with implantation of a drug-eluting stent in the left main coronary artery between May 2002 and April 2004. In-hospital and long-term results were analyzed. Follow-up included angiographic and intravascular ultrasound (IVUS) studies. RESULTS Forty-two patients (25 men, 59.5%) with a mean age of 70.1 (10.5) years were studied. Fourteen (33%) had diabetes, and 7 (16.7%) had a protected left main coronary artery. The reasons for ruling out surgery were poor distal vessels in 19 (45.2%), previous surgery in 9 (21.4%), age in 6 (14.3%), primary angioplasty in 5 (11.4%), and other reasons in 3 (7.2%). Four patients (9.5%) died before discharge, three of them after primary angioplasty. No in-hospital revascularization procedures were needed. Median follow-up time was 288 days; mean follow-up time was 315 (241) days. Another four patients died after discharge (9.5%) on days 5, 24, 34 and 115. Angioplasty was repeated in one patient, and another was referred for heart transplantation. CONCLUSIONS Drug-eluting stents represent a valid alternative in patients with left main coronary artery stenosis who are poor candidates for surgical revascularization. Randomized studies with a longer follow-up should be performed to evaluate their benefits in patients eligible for surgery.

Mejoría de la función endotelial al reducir las concentraciones lipídicas en pacientes con hipercolesterolemia y arterias coronarias normales

Introduccion y objetivos En pacientes con factores de riesgo coronario se ha documentado la presencia de disfuncion endotelial en las arterias epicardicas. El proposito del estudio fue determinar si la disfuncion endotelial en pacientes hipercolesterolemicos y coronarias angiograficamente normales mejoraba despues de reducir y mantener normalizadas las concentraciones lipidicas. Pacientes y metodo En 10 pacientes con hipercolesterolemia y coronarias sin lesiones angiograficas, la vasomotilidad dependiente del endotelio se estudio mediante la administracion intracoronaria de acetilcolina en la arteria descendente anterior. Los cambios vasomotores fueron analizados mediante angiografia cuantitativa. Cinco pacientes sin factores de riesgo y con coronarias normales formaron el grupo control. Los pacientes hipercolesterolemicos fueron tratados con lovastatina y dieta, reevaluandose la funcion endotelial 24 ± 4 meses despues. Resultados En el estudio inicial los pacientes hipercolesterolemicos presentaron una respuesta vasoconstrictora a dosis crecientes de acetilcolina (10–6 M, 10–5 M y 10–4 M) indicativa de disfuncion endotelial (grupo estudio: –0,3 ± 10%, –6 ± 4% y –18 ± 10%, frente al grupo control: –0,6 ± 6%, –2 ± 6% y 3 ± 6%; p Conclusion En pacientes con hipercolesterolemia y coronarias angiograficamente normales en quienes se documenta disfuncion endotelial, la reduccion y normalizacion de las concentraciones lipidicas condiciona una mejoria de dicha disfuncion endotelial.

Minor Myocardial Damage During Percutaneous Coronary Intervention Does Not Affect Long-Term Prognosis

INTRODUCTION AND OBJECTIVES To determine whether long-term prognosis is affected by myocardial damage taking place during percutaneous coronary intervention (PCI). METHODS The study included consecutive patients undergoing PCI. Those with elevated baseline cardiac marker levels were excluded. Cardiac markers were evaluated and an ECG was recorded before and 12 and 24 hours after PCI. Patients were divided into three groups after PCI according to their cardiac marker levels: no myocardial damage (i.e. normal troponin and creatine kinase MB fraction [CK-MB]), minor damage (elevated troponin with normal CK-MB), and myonecrosis (elevated troponin and CK-MB). The occurrence of death, myocardial infarction or repeat revascularization during follow-up was recorded. RESULTS Minor myocardial damage associated with PCI was observed in 127 (16.8%) of the 757 patients included in the study and myonecrosis, in 46 (6.1%). During a follow-up of 45+/-14 months, cardiac events occurred in 151 (19.1%) patients. Mortality during follow-up was significantly higher in patients with myonecrosis (13%) than in the other two groups (4.8% and 3.9%; log rank, 6.83; P=.032). No difference was observed in the rate of myocardial infarction or repeat revascularization during follow-up. CONCLUSIONS Minor myocardial damage during PCI had no effect on long-term prognosis. In contrast, myonecrosis was associated with increased mortality. Consequently, the CK-MB level should be measured after all PCIs because of its prognostic implications, and strategies for reducing the risk of myonecrosis developing should be implemented.

Endothelial-Dependent Vasoconstriction in the Infarct-Related Artery Early After Myocardial Infarction Is Smaller Following Primary Angioplasty Than Thrombolytic Therapy

INTRODUCTION AND OBJECTIVES In patients with ST-elevation acute myocardial infarction treated by thrombolysis, both early endothelial dysfunction and long-term improvement in the infarct-related artery have been reported. Our aims were to assess the degree of endothelial dysfunction present after primary angioplasty and to compare it with that after thrombolysis. METHODS Endothelial function was assessed 9 days after infarction by infusing acetylcholine, at an increasing concentration, and subsequently nitroglycerine into the infarct-related artery in 16 patients who had undergone primary angioplasty and bare-metal stent implantation. In addition, endothelial function was compared with that in a group of 16 patients treated by thrombolysis in a different time period. The mean change in the diameters of segments distal to the culprit lesion or the treated lesion were evaluated by quantitative coronary angiography. RESULTS Baseline characteristics were similar in the two groups, except that patients in the primary angioplasty group were treated with clopidogrel and there were differences in residual stenosis in the infarct-related artery (3% in the primary angioplasty group compared with 62% in the thrombolysis group). At the maximum acetylcholine concentration, the degree of vasoconstriction was less in the primary angioplasty group than in the thrombolysis group (-4+/-5% vs. -20+/-21%; P=.018). CONCLUSIONS Early endothelium-dependent vasoconstriction in the infarct-related artery was lower in acute myocardial infarction patients treated by primary angioplasty and bare-metal stent implantation than in those treated by thrombolysis.

El daño miocárdico mínimo durante el intervencionismo coronario percutáneo no influye en el pronóstico a largo plazo

Introduccion y objetivos Evaluar el pronostico a largo plazo del dano miocardico producido durante el intervencionismo coronario percutaneo (ICP). Metodos Incluimos una serie de pacientes consecutivos a quienes se practico ICP, excluyendo a los que ya presentaban basalmente elevacion de marcadores cardiacos. El ECG y los marcadores de dano miocardico se evaluaron antes y a las 12 y 24 h tras el procedimiento. Segun el valor de dichos marcadores, se clasifico a los pacientes en tres grupos: ausencia de dano miocardico (troponina y CK-MB normal), dano miocardico minimo (elevacion del valor de troponina, con CK-MB normal) y mionecrosis (elevacion de troponina I y CK-MB). Muerte, infarto de miocardio y nueva revascularizacion fueron evaluados durante el seguimiento. Resultados De 757 pacientes incluidos, en 127 (16,8%) se detecto dano miocardico minimo asociado al procedimiento y en 46 (6,1%) mionecrosis. Durante un seguimiento de 45 ± 14 meses, 151 (19,1%) pacientes sufrieron eventos cardiacos. Los pacientes que presentaron mionecrosis tuvieron un significativo incremento de la mortalidad durante el seguimiento (13%) respecto a los otros dos grupos (el 4,8 y el 3,9%; log rank test, 6,83; p = 0,032). No se detectaron diferencias en la tasa de IAM o nueva revascularizacion en el seguimiento. Conclusiones El dano miocardico minimo durante el intervencionismo no influye en el pronostico a largo plazo. Por contra, la mionecrosis se asocia a un incremento de mortalidad. Este hecho implica la necesidad de determinar la CK-MB tras todo ICP debido a su implicacion pronostica y la aplicacion de estrategias que disminuyan la aparicion de mionecrosis.

Tratamiento de la reestenosis intra-stent. Situación actual y perspectivas futuras

In-stent restenosis is an increasing problem due to the frequent use of coronary stent as a form of percutaneous revascularization. The global incidence is near to 28%, and it is well document that a neointimal hyperplasia is its principal mechanism. The most commonly related factors for its appearance are diabetes mellitus, a longer length of the original lesion, a smaller diameter of the reference vessel, the left anterior descending artery location and a smaller luminal diameter at the end of the procedure. Due to a different long term evolution in-stent restenosis has been classified as focal or diffuse, according to the length of the restenotic lesion (focal or = 10 mm). Some strategies have been proven for its treatment, but no randomized-controlled trials have been published comparing these different treatments. In focal in-stent restenosis the practice of a conventional balloon angioplasty is associated with high initial clinical success with a favourable long term evolution (target lesion revascularization between 11-15%). But on the contrary, in diffuse in-stent restenosis, in spite of a high initial success rate, an elevated target lesion revascularization has been detected at the follow-up (up to 43%). Other proved such as atherectomy or excimer laser are associated with a significant procedural non-Q-wave infarction (near to 9%) and a long term target lesion revascularization during follow-up (23-31%). The implantation of an additional stent has been performed with low procedural complications and with a long term target lesion revascularization near to 27%. Patients treated with intracoronary radiation as a complementary technique seem to have a better long term evolution than those having had the other strategies alone. In conclusion, in-stent-restenosis is a new and progressively more frequent problem, requiring complex treatment and of which as been established. Comparative controlled studies need to be performed in order to determine the best treatment for this new entity.

Elevated troponin I levels in patients with acute coronary syndrome without ST elevation are associated with increased complexity of the culprit lesion

INTRODUCTION The prognosis in patients with acute coronary syndrome without persistent ST segment elevation (NSTEACS) differs depending on cardiac troponin levels. Clinical practice guidelines published by the Spanish Society of Cardiology and the ACC/AHA consider patients with NSTEACS and markedly elevated troponin levels as high risk patients. The aim of this study was to identify factors related to markedly elevated troponin I levels in NSTEACS. PATIENTS AND METHOD We measured troponin I levels in 219 consecutive patients with NSTEACS and normal CK-MB values, and identified 2 groups: patients with markedly elevated troponin levels (more than 10-fold the normal upper limit), and patients with normal or slightly elevated troponin levels (less than a 10-fold increase above the normal limit). We also analyzed clinical and angiographic variables. Logistic regression was used to calculate age- and sex-adjusted associations for the main variables. RESULTS Forty-one patients (19%) had markedly elevated troponin levels, and 178 (81%) showed normal or slightly elevated troponin I levels. Patients with markedly elevated levels had more frequently prolonged angina, class IIb angina, more severe ECG changes, a higher number of diseased vessels on coronary angiography, and greater severity of the culprit lesion. The culprit stenosis in these patients was more often characterized as ulcerated, showing visible thrombus, and excentric, bifurcated and irregular. Class IIIb angina (odds ratio [OR] = 3.1; CI 95%, 1.1-8.6), bifurcation (OR=6.04; CI 95%, 2.5-14.3), ulceration (OR=3.2; CI 95%, 1.07-9.7) and visible thrombus (OR=2.7; CI 95%, 1.1-6.3) in the culprit lesion were predictive factors associated with markedly elevated levels of troponin I independently of age or sex. CONCLUSIONS Markedly elevated troponin I levels in patients with NSTEACS are associated with a more severe clinical presentation and increased complexity of the culprit lesion on coronary angiography.

Las elevaciones importantes de troponina I en el síndrome coronario agudo sin elevación del segmento ST se asocian a estenosis coronarias más complejas

Introduccion. Los pacientes con sindrome coronario agudo sin elevacion persistente del segmento ST (SCASEST) presentan un pronostico distinto segun los valores de troponina. Las Guias de Practica Clinica (SEC y ACC/AHA) estratifican a los pacientes con SCASEST y marcada elevacion de troponinas como pacientes de alto riesgo. El objetivo del estudio ha sido identificar los factores asociados a las elevaciones importantes de los valores de troponina en estos pacientes. Pacientes y metodo. Se ha analizado a 219 pacientes con SCASEST y valores de la isoenzima MB de la creatincinasa normales en los que se determinaron los valores de troponina I. Segun estos valores, se diferenciaron en pacientes con troponina marcadamente elevada (= 10 veces el limite superior de la normalidad) y pacientes con troponina normal o ligeramente elevada (< 10 veces el limite normal). Se analizo una serie de variables clinicas y angiograficas. Los analisis principales se realizaron mediante regresion logistica ajustando por sexo y edad. Resultados. Un total de 41 pacientes (19%) presento valores de troponina marcadamente elevados y 178 (81%) mostraron valores normales o ligeramente elevados. Los pacientes con valores marcadamente elevados presentaban con mas frecuencia angina prolongada, angina de clase IIIb, cambios electrocardiograficos mas severos, un mayor numero de vasos afectados en la coronariografia con una mayor gravedad en la lesion causal. Dichas lesiones mostraban una mayor incidencia de ulceracion, trombo visible, excentricidad, localizacion en bifurcacion e irregularidad. La presencia de angina clase IIIb (odds ratio [OR] = 3,1; intervalo de confianza [IC] del 95%, 1,1-8,6), la localizacion en bifurcacion (OR = 6,04; IC del 95%, 2,5-14,3), la presencia de ulceracion (OR = 3,2; IC del 95%, 1,07-9,7) y trombo (OR = 2,7; IC del 95%, 1,1-6,3) en las estenosis causantes fueron factores independientes de la edad y el sexo asociados a valores de troponinas marcadamente elevados. Conclusiones. Las elevaciones importantes de troponina I en pacientes con SCASEST se asocian a presentaciones clinicas mas graves y a estenosis causantes mas complejas en la coronariografia.