Thrombolytic THerapy/methods

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Editorial

Pharmacoinvasive Strategy in ST-elevation Myocardial Infarction: Particularities in the Elderly

Managing myocardial infarction (MI) in older people differs from treating younger individuals. In the elderly, MI presentation is often atypical, more complex, and has a worse prognosis. Not only do the disease severity and the prevalence of comorbidities tend to be higher in the elderly, but adverse events from treatments are also more frequent, particularly bleeding facilitated by different antithrombotic medications. Moreover, decreased renal function and the higher susceptibility to drug interactions due to the concomitant use of multiple medications potentiate the chance of bad outcomes.

In ST-elevation MI (STEMI), fibrinolysis followed by the early percutaneous coronary intervention (PCI) to optimize coronary reperfusion, the so-called pharmacoinvasive strategy, is a guideline-recommended therapy when timely PCI is not available.^–

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Original Article

Pharmaco-invasive Strategy in Myocardial Infarction: Descriptive Analysis, Presentation of Ischemic Symptoms and Mortality Predictors

Henrique Tria Bianco et al. Rui Povoa Maria Cristina Izar Claudia Maria Rodrigues Alves … Adriano Henrique Pereira Barbosa Maria Teresa Nogueira Bombig Iran Gonçalves Jr Bráulio Luna Filho Ana Caroline Aguirre Pedro Ivo de Marqui Moraes Dirceu Almeida Flávio Tocci Moreira Fernando Focaccia Povoa Edson Stefanini Adriano Mendes Caixeta Amanda S. Bacchin Valdir Ambrósio Moisés Francisco A.H. Fonseca

Abstract

Background

ST-segment elevation myocardial infarction (STEMI) is defined by symptoms accompanied by typical electrocardiogram changes. However, the characterization of ischemic symptoms is unclear, especially in subgroups such as women and the elderly.

Objectives

To analyze the typification of ischemic symptoms, temporal metrics and observe the occurrence of in-hospital outcomes, in the analysis of predictive scores, in patients with STEMI, in a drug-invasive strategy.

Methods

Study involving 2,290 patients. Types of predefined clinical presentations: typical pain, atypical pain, dyspnea, syncope. We measured the time between the onset of symptoms and demand for care and the interval between arrival at the medical unit and thrombolysis. Odds-ratios (OR; CI-95%) were estimated in a regression model. ROC curves were constructed for mortality predictors. The adopted significance level (alpha) was 5%.

Results

Women had a high prevalence of atypical symptoms; longer time between the onset of symptoms and seeking care; delay between arrival at the emergency room and fibrinolysis. Hospital mortality was 5.6%. Risk prediction by Killip-Kimball classification: AUC: [0.77 (0.73-0.81)] in class ≥II. Subgroups studied [OR (CI-95%)]: women [2.06 (1.42-2.99); p=0.01]; chronic renal failure [3.39 (2.13-5.42); p<0.001]; elderly [2.09 (1.37-3.19) p<0.001]; diabetics [1.55 (1.04-2.29); p=0.02]; obese 1.56 [(1.01-2.40); p=0.04]: previous stroke [2.01 (1.02-3.96); p=0.04] correlated with higher mortality rates.

Conclusion

Despite higher mortality rates in some subgroups, significant disparity persists in women, with delays in symptom recognition and prompt thrombolysis. We highlight the applicability of the Killip-Kimball score in prediction, regardless of the clinical presentation.

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Image

Left and Right Internal Mammary Artery Angioplasties in a 3-year-old Patient with Kawasaki Disease and Failed Coronary Artery Bypass Graft Surgery

René Hameau et al. Daniel Springmuller Francisco Garay Alberto Fuensalida Gonzalo Martinez

A 3 years and 5 months old boy with a history of Kawasaki disease diagnosed at 6 months of age and a previous Non-ST myocardial infarction (NSTEMI) underwent Coronary Artery Bypass Graft (CABG) surgery due to a large perfusion defect and moderate systolic dysfunction on Single-photon emission computed tomography (SPECT) () and a coronary angiogram showing a partially thrombosed giant aneurysm on the Right coronary artery (RCA) and a complete occlusion of the proximal Left anterior descending artery (LAD) (). A Left internal mammary artery (LIMA) graft to LAD and a free Right internal mammary artery (RIMA) to Posterior descending artery (PDA) anastomosis of RCA was performed.

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Editorial

Reperfusion Criteria in Patients Submitted to Fibrinolysis: Is There Room for Improvement?

Milena Soriano Marcolino et al. Antonio Luiz Pinho Ribeiro

Many ST-elevation acute myocardial infarction (STEMI) patients seek care in hospitals without percutaneous coronary intervention (PCI) capability and cannot be submitted to PCI within the guideline-recommended timelines, and, instead, they are often submitted to fibrinolysis as the initial reperfusion therapy. Rapid, simple and readily available bedside measures are of utmost importance for timely assessment of the efficacy of reperfusion therapy early after fibrinolysis in acute STEMI, in order to immediately identify the ones who require rescue PCI.^,

In an editorial for Circulation in 2001, Gibson stated “In a time of dizzying advances in diagnostic modalities, it is refreshing to see what a useful, simple, noninvasive, broadly accessible, easily repeatable/applied, and affordable tool the electrocardiography (ECG) is”. This is still up to date. Multiple studies have demonstrated improved outcomes among patients who achieve complete ST resolution at 60-90 minutes after fibrinolytic therapy, and it is recommended that the absence of > 50% reduction in ST elevation in the worst lead at 60-90 minutes should prompt strong consideration of coronary angiography and rescue PCI. ^, However, this measure, combined with the absence of reperfusion arrhythmias at 2 hours after treatment, has a positive predictive value of 87% and a negative predictive value of 83% to predict failure of reperfusion, ^, indicating that there is still room for improvement in accuracy.

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Pharmacoinvasive Strategy in ST-elevation Myocardial Infarction: Particularities in the Elderly

Pharmaco-invasive Strategy in Myocardial Infarction: Descriptive Analysis, Presentation of Ischemic Symptoms and Mortality Predictors

Abstract

Background

Objectives

Methods

Results

Conclusion

Left and Right Internal Mammary Artery Angioplasties in a 3-year-old Patient with Kawasaki Disease and Failed Coronary Artery Bypass Graft Surgery

Reperfusion Criteria in Patients Submitted to Fibrinolysis: Is There Room for Improvement?

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