Jara F

Risk of thrombosis during coronary angioplasty with low osmolality contrast media

Studies in vitro have suggested that nonionic low osmolar contrast agents produce an increase in thrombogenicity. To determine the incidence of thrombi related to the use of nonionic low osmolar contrast media during coronary angioplasty, a double-blind randomized study was performed in 100 patients. Medication before angioplasty included oral aspirin (250 mg/day) in all cases. At the beginning of the procedure, aspirin (250 mg) and heparin (10,000 U) were intravenously administered. During the procedure patients were randomly assigned to receive either an ionic low osmolar contrast agent ioxaglate (n = 50), or a nonionic low osmolar contrast media iohexol (n = 50). The presence of thrombus was evaluated on the angiogram and on the guidewire immediately after its retrieval from the patients. Clinical, angiographic and procedural variables were similar in the 2 randomized groups. Angiographic evidence of thrombus was observed in 1 patient (2%) assigned to ioxaglate and in 11 patients (22%) assigned to iohexol (p less than 0.005). One patient (2%) from the ioxaglate group and 6 patients (12%) from the iohexol group showed thrombotic residues on the guidewire (p = not significant). Three patients had acute myocardial infarction, 1 patient (2%) receiving ioxaglate and 2 patients (4%) iohexol (p = not significant). There were no deaths. Thus, compared with an ionic low osmolar contrast media ioxaglate, the nonionic low osmolar contrast agent iohexol increases the incidence of thrombus during coronary angioplasty.

Comparative Tolerability of Contrast Media Used for Coronary Interventions

Radiographic contrast media (CM) are necessary to provide x-ray absorption of the bloodstream; all other observed effects need to be regarded as adverse. Four types of CM are currently used in diagnostic and interventional cardiology: ionic high-osmolar CM (HOCM), either ionic or non-ionic low-osmolar CM (LOCM), and non-ionic iso-osmolar CM (IOCM). Focusing on the potential cardiovascular effects caused by the CM, there is a clear difference between HOCM and the LOCM or IOCM. HOCM have a poorer profile due to a higher incidence of hypotension and electrophysiological effects. To prevent contrast-induced nephropathy, HOCM should be avoided and patients should receive the minimal dose of LOCM or IOCM with intravenous hydration before and after the procedure. Clinical hyperthyroidism has been detected after CM use, but the condition appears, ultimately, to be self-limited and to occur mainly in elderly patients. When assessing the need for a CM in terms of improved patient safety, preventing serious complications should be the major factor determining the choice. CM should not be selected on the basis of minor adverse effects since these are, ultimately, of low clinical relevance. Thrombotic events, in contrast, carry a high clinical relevance and we consider that these should be the main issue governing current choice. Ionic LOCM appear to have better profile than other CM with respect to interaction with platelet function and coagulation. In relation to thrombotic events in randomised clinical studies, ionic CM have been associated, mainly, with favourable and some neutral results compared with non-ionic agents. Only one trial indicated a more pronounced antithrombotic effect of the non-ionic IOCM relative to the ionic LOCM. The antithrombotic advantages of ionic over non-ionic LOCM are, in part, balanced by a greater frequency of minor adverse effects such as nausea, vomiting or cutaneous rashes. A matter of concern is the delayed adverse effects observed with non-ionic IOCM. However, severe and life-threatening reactions are exceptional and there are probably no significant differences between IOCM and LOCM whether ionic or non-ionic. However, in patients with known allergies, non-ionic CM are to be recommended. On the basis of the available pre-clinical and clinical data, the ionic LOCM or the non-ionic IOCM are the agents to be recommended in percutaneous coronary interventions because of their antithrombotic advantages over non-ionic LOCM.

Infarto agudo de miocardio tras terapia electroconvulsiva

El infarto de miocardio es un cuadro infrecuente dentro de las complicaciones de la terapia electro-convulsiva. Por ello, a pesar de la existencia en la bibliografia psiquiatrica de algunos estudios sobre este tema, los conocimientos al respecto de la mayoria de cardiologos son escasos. Presentamos el caso de una paciente que, minutos despues de la aplicacion de una sesion de terapia electroconvul-siva, presento un infarto agudo de miocardio. Posteriormente, realizamos revision de la bibliografia en relacion con la incidencia, fisiologia, utilizacion preventiva de diversos farmacos e indicacion o no de trombolisis sistemica del infarto agudo de miocardio posterapia electroconvulsiva.

Penetrating aortic ulcer: Clinical and angiographic characteristics

Abstract“Penetrating aortic ulcer,” an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina and allows hematoma formation within the aortic wall, is rarely considered in the differential diagnosis of patients with sudden onset of severe chest or back pain. It has been suggested that it is a pathologic process that involves elderly hypertensive patients with severe atherosclerosis and rarely has been observed in the ascending aorta. To determine the characteristics of this process, 11 clinical, 2 hemodynamic, 3 angiographic, and 4 surgical variables were compared between 10 consecutive patients with penetrating aortic ulcers and 20 matched patients with classic acute aortic dissection. Clinical and hemodynamic variables were similar in the two compared groups. In the group of patients with penetrating ulcer, mean age was 58±6 years, previous hypertension was observed in six patients and the penetrating ulcer was located in the ascending aorta in six cases. Compared with patients with aortic dissection, more angiographic projections were necessary to obtain the diagnosis in the group of patients with penetrating ulcer (2.4±0.8 vs 1.7±0.6;p<0.05). In addition, the presence of angiographic aortic valve regurgitation was only observed in the group of patients with acute dissection (60% vs 0%;p<0.01). Severe atherosclerosis was not present angiographically in any patient with penetrating ulcer. In conclusion, penetrating aortic ulcer can also affect middle-age patients without severe atherosclerosis and is frequently observed in the ascending aorta. Its form of presentation and clinical characteristics are similar to classic aortic dissection. The lack of confirmatory evidence of dissection with suggestive clinical history should raise the possibility of penetrating aortic ulcer.