José Ángel Ramos-Cuadra

Thrombolysis with recombinant tissue plasminogen activator during cardiopulmonary resuscitation in fulminant pulmonary embolism. A case series

OBJECTIVE To describe our outcomes using thrombolysis during the cardiopulmonary resuscitation (CPR) of patients in cardiorespiratory arrest (CA) caused by fulminant pulmonary embolism (FPE). DESIGN A case series. SETTING Intensive care units of a district hospital and a referral centre. PATIENTS Six patients that suffered CA secondary to an FPE. INTERVENTIONS Administration of recombinant tissue plasminogen activator during usual CPR manoeuvres when there was a strong suspicion of FPE. Permission for the thrombolytic therapy was sought from family members in all cases. RESULTS Four out of the six patients survived and remain symptom-free. The thrombolysis was not associated with any fatal complications. CONCLUSIONS Early thrombolysis during CPR manoeuvres for CA apparently caused by an FPE may reduce the mortality rate among these patients.

Influence of age on clinical course, management and mortality of acute myocardial infarction in the Spanish population

BACKGROUND To assess age-related differences in cardiovascular risk factors, clinical course and management of patients with acute myocardial infarction (AMI) in intensive care (ICU) or coronary care units (CCU). METHODS A retrospective cohort study was conducted of all AMI patients listed in the ARIAM register (Analysis of Delay in AMI), a multi-centre register in which 119 Spanish hospitals participated. The study period was from January 1995 to January 2001. A univariate analysis was carried out to evaluate differences between different age groups. Multivariate analysis was used to assess whether age difference was an independent predisposing factor for mortality and for differences in patient management. RESULTS 17,761 patients were admitted to the ICUs/CCUs with a diagnosis of AMI. The distribution by ages was: <55 years, 3,954 patients (22.3%); 55-64 years, 3,593 (22.2%); 65-74 years, 5,924 (33.4%); 75-84 years, 3,686 (20.8%); and >84 years, 604 (3.4%) (P<0.0001); 24.6% of the patients were female, and the relative proportion of females increased with age. There were clear differences in risk factors between the different age groups, with a predominance of tobacco, cholesterol and family history of heart disease in the younger patients. The incidence of complications, including haemorrhagic complications, increased significantly with age. The older age groups had a lower rate of thrombolysis and less use of revascularisation techniques. The mortality of the above groups was 2.6, 5.4, 10.7, 17.7 and 25.8%, respectively. Age difference was an independent predictive variable for mortality and the administration of thrombolysis. CONCLUSIONS The distinct age groups differed in cardiovascular risk factors, management and mortality. Age is a significant independent predictive variable for mortality and for the administration of thrombolysis.

Estancia media y pronóstico en la angina inestable: resultados del registro ARIAM

Fundamento y objetivo: El proposito de este trabajo es investigar los factores predictores de mortalidad y la estancia media de los pacientes diagnosticados de angina inestable (AI) durante su ingreso en las unidades de cuidados intensivos o unidades de cuidados coronarios (UCI/UCC). Pacientes y metodo: Estudio de cohorte retrospectivo que incluyo a los pacientes del registro espanol ARIAM (Analisis del Retraso en el Infarto Agudo de Miocardio). El periodo de estudio comprendio de junio de 1996 a diciembre de 2003. Su seguimiento se limito a UCI/UCC. Se realizo un analisis univariante entre los pacientes fallecidos y los vivos y otro entre los pacientes con estancia prolongada y no prolongada. Se realizaron ademas 3 analisis multivariantes con el objetivo de evaluar los factores relacionados con la mortalidad, las variables asociadas a la realizacion de intervencion coronaria percutanea (ICP) y los factores asociados a la estancia media prolongada en UCI/UCC. Resultados: Se incluyo a 14.096 pacientes con AI. La mortalidad fue del 1,1% y se asocio a la clase Killip, edad, necesidad de reanimacion cardiopulmonar y presencia de shock cardiogenico, arritmias y diabetes; mientras que los pacientes fumadores se asociaron a una menor mortalidad. Se realizo ICP solo a 1.226 (8,9%) pacientes, aunque su realizacion se incremento con los anos. La ICP se asocio a edad, traslado interhospitalario, tabaquismo, infarto de miocardio previo, shock cardiogenico o ante el bloqueo auriculoventricular de alto grado (BAVAG) y tratamiento con bloqueadores beta. La estancia media (desviacion estandar) fue de 3,15 (18,65) dias. La estancia media prolongada dependio de la edad, haber sido sometido a una coronariografia o ICP, clase Killip, ecocardiografia o ventilacion mecanica y presentar complicaciones graves. Conclusiones: La mortalidad se explica por la comorbilidad y la gravedad de la isquemia. Los pacientes a los que se realiza ICP son una poblacion menos grave, y su realizacion con el tiempo se incrementa. La estancia media prolongada se asocia a la mayor gravedad de la isquemia miocardica y a la ICP.

Evaluation of the performance of echocardiography in acute coronary syndrome patients during their stay in coronary units

Objectives: To evaluate the frequency and the factors associated with performance of echocardiography in acute coronary syndrome (ACS) patients during their stay in intensive care units or coronary care units (ICU/CCU). Methods: Retrospective cohort study including all patients diagnosed with acute coronary syndrome—unstable angina (UA), acute myocardial infarction (AMI)—included in the ‘ARIAM’ Spanish multi-centre register. The study period was from June 1996 to December 2005. The follow-up period is limited to the time of stay in the Intensive Care Units or Coronary Care Units (ICUs/CCUs). A univariate analysis was carried out on the patients with UA and AMI according to whether or not echocardiograms were performed during their stay in ICU/CCU. In addition the data was evaluated for any temporal variation in the performance of echocardiography, and two multivariate analyses were carried out to evaluate the factors associated with performance of echocardiography in UA and AMI patients. Results: The study period included 45 688 AMI patients and 17 277 UA patients. Echocardiograms were performed in 26.87% AMI patients and 16.75% UA patients. In total, 15 172 echocardiograms were performed in ACS patients (23.6%). The multivariate analysis demonstrated that the variables associated with the performance of echocardiography in UA were: Killip and Kimball class, cigarette smoking, family history of cardiovascular events, cardiogenic shock, uncontrolled angina, mechanical ventilation and treatment with ACE inhibitors, while the presence of previous AMI was associated with fewer echocardiograms being performed. In AMI, the multivariate analysis showed the following variables to be associated with the performance of echocardiography: Killip and Kimball class, Q-AMI, right heart failure, the need for insertion of Swan-Ganz catheter, cardiogenic shock, high-degree AV block and the administration of ACE inhibitors, while age was associated with fewer being performed. Over the 10 years of the study period, there was a discrete but significant increase in the use of echocardiography in patients in ICU/CCU. Conclusions: Echocardiography is not commonly used in ACS patients while in ICU/CCU. UA and AMI patients who did have echocardiograms during their stay in ICU/CCU were chiefly those presenting heart failure and major complications, and represent a subpopulation with poor prognosis. The performance of echocardiography in ACS patients increased slightly over the length of their stay in ICU/CCU.

Septic shock secondary to infection of a left ventricular thrombus

We report the case of a 45-year-old woman who developed severe shock with multiorgan failure requiring admission to intensive care. Endomyocardial biopsy was performed and she was diagnosed with sepsis secondary to left ventricular thrombus abscess. Surgery was contraindicated and the patient received exclusively medical treatment; the clinical course was satisfactory and the patient is alive one year later. An apical thrombus may rarely be complicated by infection. Although management normally requires surgical excision, medical management may be effective in situations in which surgery is contraindicated.

Successful administration of alteplase in a venous thromboembolism crossing through a patent foramen ovale

We describe a case report observed via an echocardiography of a venous thromboembolism (VTE) that crosses through the patent foramen ovale to the left atrium and is successfully treated with alteplase. This is a case report of a tertiary care hospital without cardiac surgery facilities. An 81-year-old female seeking medical attention for dyspnoea, arriving at hospital with hypoxaemia, hypotension and prerenal failure. A computed tomographic (CT) pulmonary angiography was carried out, revealing a VTE. A transesophageal echocardiography (TEE) was carried out, exposing emboli in the right cavities, said thrombus crossing through the patent foramen ovale to the left atrium. A systemic thrombolysis is carried out using alteplase which improves the patients condition and results in the disappearance of thrombotic images in the various cardiac cavities. The evolution is positive and there is no evidence of embolic or haemorrhagic complications. When a paradoxical embolism is present, in the context of a serious VTE, carrying out thrombolysis could be a therapeutic option.