Esteban López de Sá

Primary angioplasty versus systemic thrombolysis in anterior myocardial infarction.

OBJECTIVES This study compares the efficacy of primary angioplasty and systemic thrombolysis with t-PA in reducing the in-hospital mortality of patients with anterior AMI. BACKGROUND Controversy still exists about the relative benefit of primary angioplasty over thrombolysis as treatment for AMI. METHODS Two-hundred and twenty patients with anterior AMI were randomly assigned in our institution to primary angioplasty (109 patients) or systemic thrombolysis with accelerated t-PA (111 patients) within the first five hours from the onset of symptoms. RESULTS Baseline characteristics were similar in both groups. Primary angioplasty was independently associated with a lower in-hospital mortality (2.8% vs. 10.8%, p = 0.02, adjusted odds ratio 0.23, 95% confidence interval 0.06 to 0.85). During hospitalization, patients treated by angioplasty had a lower frequency of postinfarction angina or positive stress test (11.9% vs. 25.2%, p = 0.01) and less frequently underwent percutaneous or surgical revascularization after the initial treatment (22.0% vs. 47.7%, p < 0.001) than did patients treated by t-PA. At six month follow-up, patients treated by angioplasty had a lower cumulative rate of death (4.6% vs. 11.7%, p = 0.05) and revascularization (31.2% vs. 55.9%, p < 0.001) than those treated by t-PA. CONCLUSIONS In centers with an experienced and readily available interventional team, primary angioplasty is superior to t-PA for the treatment of anterior AMI.

Primary Angioplasty Reduces the Risk of Left Ventricular Free Wall Rupture Compared With Thrombolysis in Patients With Acute Myocardial Infarction

OBJECTIVES This study aimed to evaluate the effect of primary angioplasty (PA) over the risk of free wall rupture (FWR) in reperfused acute myocardial infarction (AMI). BACKGROUND It has been suggested that PA reduces the risk of FWR compared with thrombolysis. However, few studies have evaluated this issue, and there are no data demonstrating this hypothesis. METHODS A total of 1,375 patients with AMI treated with PA (n = 762, 55.4%) or thrombolysis (n = 613, 44.6%) within 12 h after symptoms onset were included. The diagnosis of FWR was made either in the presence of sudden death due to electromechanical dissociation with large pericardial effusion on an echocardiogram or when demonstrated post mortem or at surgery. A multivariable analysis was performed including type of reperfusion strategy. RESULTS The overall incidence of FWR was 2.5% (n = 34): 1.8% and 3.3% in patients treated with PA and with thrombolysis, respectively (p = 0.686). The following characteristics were associated with a higher rate of FWR in the univariable analysis: age >70 (5.2% vs. 1.2%, p < 0.001), female gender (5.1% vs. 1.8%, p = 0.006), anterior location (3.3% vs. 1.4%, p = 0.020) and treatment >2 h after symptoms onset (3.6% vs. 1.7%, p = 0.043). In the multivariable analysis, age >70 (odds ratio [OR]: 4.12, 95% confidence interval [CI]: 2.04 to 8.62, p < 0.001) and anterior location (OR: 2.91, 95% CI: 1.36 to 6.63, p = 0.008) were independent risk factors of FWR, whereas treatment with PA was an independent protective factor (OR: 0.46, 95% CI: 0.22 to 0.96, p = 0.0371). CONCLUSIONS In patients with AMI, PA reduces the risk of FWR in comparison with thrombolysis.

Guías de actuación clínica de la Sociedad Española de Cardiología en el infarto agudo de miocardio

En los ultimos anos han surgido nuevas posibilidades en el diagnostico y tratamiento del infarto agudo de miocardio con elevacion del segmento ST y sus complicaciones. Ademas, se ha producido una profunda transformacion en la organizacion del sistema sanitario particularmente en aspectos relacionados con la atencion del paciente con dolor toracico no traumatico, tanto en el area prehospitalaria como hospitalaria. Todos estos aspectos justificaban un documento de consenso en Espana sobre el papel que deben ocupar estas novedades en el manejo de los pacientes con infarto agudo de miocardio. Este documento revisa y actualiza todos los aspectos clinicos fundamentales del paciente con infarto agudo desde el momento en el que entra en contacto con el sistema sanitario fuera del hospital, hasta que vuelve a su domicilio, despues de pasar por la unidad coronaria y la planta de hospitalizacion. Y todo ello, tanto en el infarto complicado como en el no complicado. Ademas esta revision incluye un apartado sobre aspectos organizativos y estructurales referidos sobre todo al ambito prehospitalario y de los servicios de urgencia.

Revascularization, Stenting, and Outcomes of Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock

Randomized clinical trials have demonstrated a reduction in mortality with early revascularization of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock, and recent single-center studies have particularly suggested further benefit for coronary stenting. The purpose of this study was to examine the use of revascularization and coronary stenting for patients with shock from a multicenter, international perspective. Patients with AMI complicated by cardiogenic shock (n = 583) who enrolled between April 1999 and June 2001 were prospectively identified from the large, multinational, observational Global Registry of Acute Coronary Events. We examined the use of coronary reperfusion strategies, adjunctive therapy, and hospital mortality in this group of patients. Cardiac catheterization (52%) and revascularization (43%) were performed in approximately half of the cardiogenic shock patients. Elderly patients (age >/=75 years) comprised 40% of the shock cohort. Regional differences were seen in the use of revascularization, adjunctive medical therapy, and type of revascularization used (coronary stenting). Total hospital mortality was 59%, but case fatality rates ranged from 35% for patients who underwent coronary stenting to 74% for patients who did not undergo any cardiac catheterization. Percutaneous coronary intervention with coronary stenting was the most powerful predictor of hospital survival (odds ratio 3.99, 95% confidence interval 2.41 to 6.62). Thus, cardiogenic shock continues to be a devastating complication of AMI, and relative underuse of a revascularization strategy may be related to the large proportion of elderly patients in this population. In this multinational registry study, coronary stenting was the most powerful independent predictor of hospital survival.

Factors related to heart rupture in acute coronary syndromes in the Global Registry of Acute Coronary Events

AIMS To determine the incidence and factors associated with heart rupture (HR) in acute coronary syndrome (ACS) patients. METHODS AND RESULTS Among 60 198 patients, 273 (0.45%) had HR (free wall rupture, n = 118; ventricular septal rupture, n = 155). Incidence was 0.9% for ST-segment elevation myocardial infarction (STEMI), 0.17% for non-STEMI, and 0.25% for unstable angina. Hospital mortality was 58 vs. 4.5% in patients without HR (P < 0.001). The incidence was lower in STEMI patients with primary percutaneous coronary intervention (PCI) than in those without (0.7 vs. 1.1%; P = 0.01), but primary PCI was not independently related to HR in adjusted analysis (P = 0.20). Independent variables associated with HR included: ST-segment elevation (STE)/left bundle branch block; ST-segment deviation; female sex; previous stroke; positive initial cardiac biomarkers; older age; higher heart rate; systolic blood pressure/30 mmHg decrease. Conversely, previous MI and the use of low-molecular-weight heparin and beta-blockers during first 24 h were identified as protective factors for HR. CONCLUSION The incidence of HR is low in patients with ACS, although its incidence is probably underestimated. Heart rupture occurs more frequently in ACS with STE and is associated with high hospital mortality. A number of variables are independently related to HR.

Randomized Comparison of Sirolimus-Eluting and Everolimus-Eluting Coronary Stents in the Treatment of Total Coronary Occlusions Results From the Chronic Coronary Occlusion Treated by Everolimus-Eluting Stent Randomized Trial

Background—Patients with coronary total occlusions are at especially high risk for restenosis and new revascularizations. Sirolimus-eluting stents dramatically improved the clinical outcome of this subset of patients in randomized trials, but other drug-eluting stents, mainly the everolimus-eluting stent (currently the most frequently used stent), have not yet been evaluated in patients with coronary total occlusions. The objective was to compare the second-generation everolimus-eluting stent with the first-generation sirolimus-eluting stent in patients with coronary total occlusions. Methods and Results—A total of 207 patients with coronary total occlusions and estimated time since occlusion >2 weeks were randomized to everolimus- or sirolimus-eluting stent. The primary end point was in-stent late loss at 9-month angiographic follow-up (noninferiority trial). Clinical follow-up was performed at 1 and 12 months. In-stent late loss at 9 months was 0.29±0.60 versus 0.13±0.69 mm in patients allocated to sirolimus- and everolimus-eluting stent, respectively. The observed difference in in-stent late loss between both groups was –0.16 mm (95% confidence interval, 0.04 to –0.36 mm; P for noninferiority <0.01). The rate of binary angiographic restenosis was 10.8% and 9.1% in patients allocated to sirolimus- and everolimus-eluting stent, respectively (P=0.709), whereas the rate of vessel reocclusion was 3.2% and 1.1%, respectively (P=0.339). At 12 months, the rate of major adverse events was 15.9% versus 11.1% with sirolimus- and everolimus-eluting stent, respectively (P=0.335), and probable or definitive stent thrombosis occurred in 3.0% and 0.0% of patients, respectively (P=0.075). Conclusions—In patients with coronary total occlusions, everolimus-eluting stent is as effective as sirolimus-eluting stent. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00793221.

Prognostic value of clinical variables at presentation in patients with non-ST-segment elevation acute coronary syndromes: results of the Proyecto de Estudio del Pronóstico de la Angina (PEPA).

Patients with suspected non-ST-segment elevation acute coronary syndromes (NSTEACS) constitute a heterogeneous population with variable outcomes. Risk stratification in this population of patients is difficult due to the complexity in patient risk profile. We conducted this study to characterize the value of clinical and electrocardiographic variables for risk stratification in an unselected population of consecutive patients with NSTEACS on admission. Thirty-five clinical and electrocardiographic variables at presentation in the emergency room of 18 hospitals were prospectively analyzed in 4,115 patients with NSTEACS and related with the outcomes at 90 days. We also developed a risk score using the variables found to be independent predictors of ischemic events to facilitate risk stratification.Cardiovascular mortality was 4.3% and the rate for the outcome of either cardiovascular death or nonfatal myocardial infarction was 6.9%. The only independent predictors of mortality were age, diabetes, peripheral vascular disease, postinfarction angina, Killip class ≥2, ST-segment depression, and elevation of cardiac markers. A risk profile using the variables found to be independent predictors of events was calculated for cardiovascular mortality and for the combination of either death or nonfatal myocardial infarction. Event rates increased significantly in all subgroups of patients based on the number of independent risk factors as the risk score increased. Using these factors, 90-day mortality ranged from as low as 0.4% in patients with no risk factors to 21.1% for those with more than 4 risk factors.In conclusion, simple clinical and electrocardiographic data obtained at hospital admission allow an accurate risk stratification of patients with NSTEACS. In the PEPA registry, simple variables easy to obtain at admission appear to be a valuable tool in discerning between patients at very low and very high risk according to the cluster of factors for each patient. The risk score developed was obtained from an unselected population, representative of the whole spectrum of patients with NSTEACS, allowing identification of patients at different risks for adverse outcomes, and, therefore, permitting optimization of therapy.

Improved Prognosis After Using Mild Hypothermia to Treat Cardiorespiratory Arrest Due to a Cardiac Cause: Comparison With a Control Group

INTRODUCTION AND OBJECTIVES Patients who survive a cardiac arrest have a poor short-term prognosis in terms of mortality and neurological function. The use of mild hypothermia has been investigated in only a few randomized studies, but appears to be effective for treating these patients. The aim of this study was to investigate the effect of this treatment on survival and neurological outcomes. METHODS We compared mild hypothermia and usual treatment in patients who had experienced a prolonged cardiac arrest due to ventricular fibrillation or tachycardia and who showed signs of neurological damage. Patient were divided into two groups: a control group of 28 patients and a group of 41 patients who were treated with hypothermia. Patients were assessed at discharge and at 6 months. RESULTS There was no significant difference between the two groups in baseline characteristics, including those of the cardiac arrest, or in the time to treatment. At discharge, neurological status was good in 18 patients (43.9%) in the hypothermia group but in only five (17.9%) in the control group (risk ratio=2.46; 95% confidence interval, 1.11-3.98; P=.029). At 6 months after discharge, neurological status was found to be good in 19 patients (46.3%) in the treatment group and six (21.4%) in the control group (risk ratio=2.16; 95% confidence interval, 1.05-3.36; P=.038). The effect of hypothermia may have been affected by various confounding factors. CONCLUSIONS Our findings demonstrate that hypothermic treatment after cardiac arrest prolonged by ventricular fibrillation or tachycardia helps improve the prognosis of anoxic encephalopathy.

Frequency of left ventricular free-wall rupture in patients with acute myocardial infarction treated with primary angioplasty.

A total of 590 patients with myocardial infarction treated with primary angioplasty were studied, to assess the incidence and related factors of free-wall rupture in patients with acute myocardial infarction when treated with primary angioplasty. The incidence of free-wall rupture was 2.2% (13 patients); this incidence was higher in patients >65 years old, women, nonsmokers, as well as in those with anterior location and an initial TIMI grade 0 flow, but it was similar in patients with a successful or unsuccessful angiographic result.

Efficacy of invasive strategy for the management of acute myocardial infarction complicated by cardiogenic shock

This retrospective study evaluates the influence of an invasive strategy of urgent coronary revascularization on the in-hospital mortality of patients with acute myocardial infarction (AMI) complicated early by cardiogenic shock. Among 1,981 patients with AMI admitted to our institution from 1994 to 1997, 162 patients (8.2%) developed cardiogenic shock unrelated to mechanical complications. The strategy of management was considered invasive if an urgent coronary angiography was indicated within 24 hours of symptom onset. Every other strategy was considered conservative. Fifty-seven patients who developed the shock late or after a revascularization procedure, or who died on admission, were excluded. The strategy was invasive in 73 patients (70%). Five of them died before angiography could be performed and 65 underwent angioplasty (success rate 72%). By univariate analysis the invasive strategy was associated with a lower mortality than conservative strategy (71% vs 91%, p = 0.03), but this association disappeared after adjustment for baseline characteristics. Older age, nonsmoking, and previous ischemic heart disease were independent predictors of mortality. In conclusion, we have failed to demonstrate that a strategy of urgent coronary revascularization within 24 hours of symptom onset for patients with AMI complicated by cardiogenic shock is independently associated with a lower in-hospital mortality. This strategy was limited by the high mortality within 1 hour of admission in patients with cardiogenic shock, the modest success rate of angioplasty in this setting, and the powerful influence of some adverse baseline characteristics on prognosis.