Actualización en cardiología intervencionista 2014

Embolic Protection Devices During TAVI: Current Evidence and Uncertainties

Transcatheter aortic valve implantation (TAVI) is now the principal therapeutic option in patients with severe aortic stenosis deemed inoperable or at high surgical risk. Implementing TAVI in a lower risk profile population could be limited by relatively high cerebrovascular event rates related to the procedure. Diffusion-weighted magnetic resonance imaging studies have demonstrated the ubiquitous presence of silent embolic cerebral infarcts after TAVI, with some data relating these lesions to subsequent cognitive decline. Embolic protection devices provide a mechanical barrier against debris embolizing to the brain during TAVI. We review the current evidence and ongoing uncertainties faced with the 3 currently available devices (Embrella, TriGuard and Claret) in TAVI. Studies evaluated neurological damage at 3 levels: clinical, subclinical, and cognitive. Feasibility and safety were analyzed for the 3 devices. In terms of efficacy, all studies were exploratory, but none demonstrated significant reductions in clinical event rates. The Embrella and Claret devices demonstrated significant reductions of the total cerebral lesion volume on diffusion-weighted magnetic resonance imaging. Studies evaluating the effects on cognition were also somewhat inconclusive. In conclusion, despite embolic protection devices demonstrating reductions in the total cerebral lesion volume on diffusion-weighted magnetic resonance imaging, the clinical efficacy in terms of preventing stroke/cognitive decline requires confirmation in larger studies.

Factors Associated With Delays in Seeking Medical Attention in Patients With ST-segment Elevation Acute Coronary Syndrome

INTRODUCTION AND OBJECTIVES

Prompt coronary reperfusion is crucial in patients with ST-segment elevation acute coronary syndrome. The aim of this study was to determine factors associated with a delay in seeking medical attention after the onset of symptoms in patients with this condition.

METHODS

Prospective cohort study in consecutive patients with ST segment elevation infarction. Multiple logistic regression analysis was used to identify factors independently associated with a longer delay in requesting medical help.

RESULTS

In total, 444 consecutive patients were included (mean age, 63 years; 76% men, 20% with diabetes). Median total ischemia time was 225 (160-317) minutes; median delay in seeking medical attention was 110 (51-190) minutes. Older patients (age > 75 years; odds ratio = 11.6), women (odds ratio = 3.4), individuals with diabetes (odds ratio = 2.3), and those requesting medical care from home (odds ratio = 2.2) showed the longest delays in seeking medical attention. Lengthy delay was associated with higher in-hospital mortality (9.8% vs 2.7%; P<.005) and 1-year mortality (7.3% vs 2.9%; P<.05) than when attention was promptly solicited.

CONCLUSIONS

Elderly patients, women, and diabetic individuals with ST-segment elevation myocardial infarction show longer delays in seeking medical attention for their condition. Delays in seeking medical attention are associated with greater in-hospital and 1-year mortality.