Non-ST Elevated Myocardial Infarction

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Editorial

Radial Access and Fondaparinux: A Synergistic Interaction

Pedro Beraldo de Andrade et al. Leonardo Maróstica Alves Silva

The consolidation of antithrombotic treatment based on dual antiplatelet therapy with aspirin and P2Y₁₂ receptor inhibitors, the routine adoption of invasive risk stratification, the technical refinement of percutaneous coronary intervention (PCI), with greater use of intravascular imaging as an adjunctive tool to guide procedures, as well as the technological evolution of coronary stents, culminated in a temporal decline over the last two decades in the occurrence of ischemic complications in patients admitted with non-ST-segment elevation acute coronary syndrome (NSTEMI). In this context, the risk of bleeding is no longer tolerated as an inherent complication of anti-ischemic treatment. Still, it has come to play a central role in the search for a balance between efficacy and safety in the clinical management of this patient profile. The importance of bleeding risk was achieved through publications demonstrating that major bleeding, whether related to PCI arterial access or bleeding in the central nervous system, digestive tract, or genitourinary system, was associated with a worse prognosis, with morbidity and mortality similar to or exceeding recurrent ischemic events.^,

In 2010, the concept of “Bleeding Avoidance Strategies” emerged, consisting of a set of measures associated with high-quality, cost-effective clinical practice, whose metrics demonstrate its ability to mitigate major bleeding rates in patients undergoing invasive risk stratification ()..^,

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Editorial

LBBB and the Paradigm Shift from STEMI to Occlusion MI

Jesse T.T McLaren et al. Hans C. Helseth Stephen W. Smith

The current paradigm for acute coronary syndrome (ACS) is based on ST elevation myocardial infarction (STEMI) electrocardiogram (ECG) criteria. This is defined as ST elevation in the absence of left bundle branch block (LBBB). Nevertheless, this creates an obvious dilemma: what about patients with LBBB? In their systematic review and meta-analysis of 51 studies, Alencar et al. help resolve longstanding debates by comparing guidelines with evidence. This not only clarifies how to address this specific diagnostic dilemma, but also how a paradigm shift from STEMI to Occlusion MI (OMI) could transform patient care.

As Alencar found, LBBB appeared in only 3.3% of ACS, but had higher mortality than acute MI without BBB. The current paradigm creates the twin dangers of unnecessary cath lab activation or even thrombolytics for LBBB without OMI, or delayed reperfusion for LBBB with OMI.

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Letter to the Editor

Invasive Versus Conservative Management of NSTEMI Patients Aged ≥ 75 Years: Commentary

Sérgio Renato da Rosa Decker et al. Luiza Duarte Pittol Regis Goulart Rosa Marciane Maria Rover

Dear Editor,

In the edition of Arquivos Brasileiros de Cardiologia, Mengjin Hu et al. evaluated the benefit of early invasive strategy for elderly patients with non-ST-elevation myocardial infarction (NSTEMI), concluding that this strategy yields positive results in reducing myocardial infarction, major adverse cardiac events, and urgent revascularization outcomes. However, we have concerns regarding the authors’ claim of superiority and the relevance of the chosen outcomes for this specific population. Firstly, these outcomes (ischemia-driven outcomes) are mostly surrogate endpoints based on troponin levels. To establish the surrogacy of one outcome to another, several factors need to be considered, including biological plausibility, associations in observational studies, and, most importantly, proof of concept through trials where improving the surrogate endpoint also enhances clinical outcomes. In this sense, evidence shows that the association between nonfatal myocardial infarction and all-cause or cardiovascular mortality meets the first two levels; however, a meta-analysis of randomized clinical trials did not establish nonfatal myocardial infarction as a surrogate for all-cause or cardiovascular mortality. Indeed, this is a reproducible relationship in short and long term outcomes; the metanalysis of FRISC-II, ICTUS, and RITA-3 showed that, after five years, early invasive strategy for patients with NSTEMI did not result in reduced mortality despite the benefits seen in ischemia-driven outcomes.

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Editorial

Can the Measurement of Big Endothelin-1 Have a Role in Patients Admitted Due to Non-ST Segment Elevation Myocardial Infarction?

João Presume

Endothelin-1 (ET-1) is the main member of the endothelin peptide family and is one of the most potent vasoconstrictor substances known to date. It acts through ET_Areceptors, promoting vasoconstriction, inflammation, and cell proliferation.^, Several cell types synthesize this molecule, particularly the vascular endothelial and smooth muscle cells, macrophages, and fibroblasts, resulting from the cleavage of big endothelin-1 (big ET-1).The latter is an intermediate molecule from the endothelin system, which has a longer half-life (despite lower biological activity), being a more appropriate marker for the quantification of endothelin peptide activity.

In this cross-sectional study, investigators evaluated the levels of big ET-1 in a cohort of patients with non-ST segment elevation myocardial infarction (NSTEMI). Overall, 766 patients were included, and the main objective was to explore the relationship between this marker and coronary disease burden as assessed by the SYNTAX score. After stratifying the cohort into 3 groups according to this score (low, intermediate, and high), they found that the median big ET-1 levels were progressively higher as the coronary disease became more complex (0.30 pmol/L, 0.41 pmol/L, and 0.58 pmol/L, respectively). They also found that this marker had a fair correlation with the SYNTAX score (r=0.378), which met statistical significance, and found good discrimination in identifying patients with moderate-high scores (AUC 0.695).

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Editorial

NSTE-ACS at the Emergency: Can You Guess What is Under the Umbrella?

Bruno Rocha et al. Carlos Aguiar

The reasoning behind the often-difficult task of deciding whether, when and how to treat the patient with established Cardiovascular Disease (CVD) might be based on two simple questions: (1) Are we treating an acute event?, and (2) What is my patient at risk of in the future? Whilst the first question implies an expedite straightforward treatment, the second premise depends mostly on risk stratification and, thus, the capability of one to anticipate the likelihood of an event. Withal, the physician often encounters a scenario in which the two questions must be addressed altogether. Accordingly, the response is more likely one of a probability rather than a categorical (yes or no) answer. This is the outline in umbrella diagnoses, as is non-ST segment elevation (NSTE) Acute Coronary Syndromes (ACS).^,

There are a multitude of clinical tools in Cardiovascular Medicine^– that aid physicians in the decision-making process, often surpassing the “educated guess” in acute settings.^, However, the use of these tools in NSTE-ACS is particularly challenging for a number of reasons:

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Radial Access and Fondaparinux: A Synergistic Interaction

LBBB and the Paradigm Shift from STEMI to Occlusion MI

Invasive Versus Conservative Management of NSTEMI Patients Aged ≥ 75 Years: Commentary

Can the Measurement of Big Endothelin-1 Have a Role in Patients Admitted Due to Non-ST Segment Elevation Myocardial Infarction?

NSTE-ACS at the Emergency: Can You Guess What is Under the Umbrella?

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