A simple and easy technique to overcome anatomic challenges of transradial access in STEMI patients

BACKGROUND

Transradial access (TRA) is associated with fewer access-related complications, earlier discharge and lower mortality than transfemoral access (TFA), being the preferred route to perform primary percutaneous coronary interventions (PPCIs) in STEMI patients. However, the radial artery is smaller, more superficial and thinner than the femoral artery, which may make PPCIs difficult.

PURPOSE

This study describes a practical solution to overcome several of the anatomical difficulties during the TRA, demonstrating its outcomes during clinical practice.

METHODS

The authors reviewed the clinical records of 1510 STEMI patients who underwent PPCIs over seven years. Of these, 95 (6.3%) patients experienced problems in advancing a 6F guiding catheter and underwent to STR technique. This technique consists in the use of a longer 5Fr STR flush catheter, which can be used as a "child" type rapid exchange catheter inside the 6Fr guiding catheter, adopting a 5-in-6 Fr technique and creating a smooth distal tip transition of the 6Fr guiding catheter.

RESULTS

In 89/95 patients (93.7%), this new technique was successful. The majority of these patients were female (51; 53.7%) and the mean age was 67 ± 14.3 years. The mean reperfusion time since arrival at the catheterization laboratory with STR technique was 24.5 ± 9.9 min, being statistically shorter than when a crossover to TFA was used (29.3 ± 9.5 min; p < 0.017). PPCIs were successfully completed in all different coronary arteries, without complications related to the procedure.

CONCLUSIONS

The STR technique is a simple and useful approach that allowed more successful passage of guiding catheters through difficult TRA, allowing a reduction of crossover to TFA in this study to 2.4 %, which translates into a shorter reperfusion time.

Early versus late cardiac magnetic resonance in the diagnosis of MINOCA

INTRODUCTION AND OBJECTIVES

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is responsible for about 10% of all acute myocardial infarctions (AMI). Therapeutic strategies and prognosis depend on the underlying etiology, and a multimodal approach is essential. Characterize the group of patients diagnosed with MINOCA. Evaluate the diagnostic yield of cardiovascular magnetic resonance (CMR).

METHODS

This was a retrospective, observational, and analytical study, including 516 patients admitted for a non-ST-elevation MI and with no significant coronary disease on coronary angiography between January 2016 and September 2021.

RESULTS

After the inclusion criteria, 163 patients remained of the 516 admitted to the study. They were divided into four groups based on the CMR results: MINOCA (n=51), Takotsubo syndrome (n=37), myocarditis (n=33), and without diagnosis (n=42). Most patients diagnosed with MINOCA were female with a mean age of 61.06±13.83 years. CMR identified the diagnosis in 74.2% of patients admitted for suspected acute MI, in which coronary angiography showed the absence of significant obstructions. The median time between hospital admission and CMR was significantly shorter in the groups that had a diagnosis compared with the group with no diagnosis (p=0.038), with a significant increase in diagnostic profitability if CMR was performed up to 14 days after admission (p=0.022). There were no deaths of cardiovascular etiology during the follow-up period.

CONCLUSIONS

CMR was fundamental as it identified the diagnosis in three out of four patients; it should be performed in the first 14 days.

Impact of the COVID-19 pandemic on percutaneous coronary interventions in Portugal

INTRODUCTION

The COVID-19 pandemic has imposed an unprecedented burden on healthcare systems worldwide, changing the profile of interventional cardiology activity.

OBJECTIVES

To quantify and compare the number of percutaneous coronary interventions (PCIs) performed for acute and chronic coronary syndromes during the first COVID-19 outbreak with the corresponding period in previous years.

METHODS

Data on PCI from the prospective multicenter Portuguese Registry on Interventional Cardiology (RNCI) were used to analyze changes in PCI for ST-elevation myocardial infarction (STEMI), non-ST-elevation acute coronary syndromes (NSTE-ACS) and chronic coronary syndromes (CCS). The number of PCIs performed during the initial period of the COVID-19 outbreak in Portugal, from March 1 to May 2, 2020, was compared with the mean frequency of PCIs performed during the corresponding period in the previous three years (2017-2019).

RESULTS

The total number of PCIs procedures was significantly decreased during the initial COVID-19 outbreak in Portugal (-36%, p<0.001). The reduction in PCI procedures for STEMI, NSTE-ACS and CCS was, respectively, -25% (p<0.019), -20% (p<0.068) and -59% (p<0.001).

CONCLUSIONS

Compared with the corresponding period in the previous three years, the number of PCI procedures performed for STEMI and CCS decreased markedly during the first wave of the COVID-19 pandemic in Portugal.

Syncope in the athlete - Minor changes, major diagnosis!

We report the case of a 17-year-old athlete who resorted to the emergency department for palpitations and dizziness while exercising. He mentioned two exercise-associated episodes of syncope in the last six months. He was tachycardic and hypotensive. The electrocardiogram showed regular wide complex tachycardia, left bundle branch block morphology with superior axis restored to sinus rhythm after electrical cardioversion. In sinus rhythm, it showed T-wave inversion in V1-V5. Transthoracic echocardiography revealed mild dilation and dysfunction of the right ventricle (RV) with global hypocontractility. Cardiac magnetic resonance (CMR) revealed a RV end diastolic volume indexed to body surface area of 180 ml/m², global hypokinesia and RV dyssynchrony, subepicardial late enhancement in the distal septum and in the middle segment of the inferoseptal wall. The patient underwent a genetic study which showed a mutation in the gene that encodes the desmocolin-2 protein (DSC-2), which is involved in the pathogenesis of arrhythmogenic right ventricular cardiomyopathy (ARVC). According to the modified Task Force Criteria for this diagnosis, the patient presented four major criteria for ARVC. Thus, a subcutaneous cardioverter was implanted, and the patient was followed up at the cardiology department. Arrhythmogenic right ventricular cardiomyopathy diagnosis is based on structural, functional, electrophysiological and genetic criteria reflecting underlying histological changes. This case depicts the essential characteristics for disease recognition.

Prognostic impact of iron deficiency in acute coronary syndromes

BACKGROUND

Iron deficiency (IDef) is a prevalent condition in patients with heart disease and in those with heart failure (HF). Evidence has shown that this deficit is associated with worse prognosis. Data in literature are scarce on the prognostic impact of IDef in acute coronary syndromes (ACS), which is the main objective of this study.

METHODS

Observational, retrospective study which included 817 patients admitted for ACS. Two groups were defined according to the presence (n=298) or absence of IDef (n=519) on admission. The clinical event under study was the occurrence of death or severe HF in the long term. Independent predictors of prognosis were determined with logistic regression analysis.

RESULTS

Thirty-six percent of patients had IDef. There was higher mortality (p=0.004), higher incidence of HF (p=0.011) during follow-up and a higher rate of hospital readmissions (p=0.048) in this group. IDef was an independent predictor of death or severe HF in follow-up, along with anemia, left ventricular dysfunction, renal dysfunction and the absence of revascularization. IDef also enabled us to further stratify the prognosis of patients without anemia based on the occurrence of death or severe HF and those with lower Killip classes (≤2) based on the occurrence of death.

CONCLUSION

IDef was an independent predictor of death or severe HF in patients admitted with ACS and enabled additional stratification for those without anemia on admission and in those with Killip classes ≤2.

Prognostic impact of iron deficiency in acute coronary syndromes

BACKGROUND

Iron deficiency (IDef) is a prevalent condition in patients with heart disease and in those with heart failure (HF). Evidence has shown that this deficit is associated with a worse prognosis. There is only a small amount of data in the literature regarding the prognostic impact of IDef in acute coronary syndromes (ACS), which is the main objective of this study.

METHODS

Observational, retrospective study which included 817 patients admitted for ACS. Two groups were defined according to the presence (n = 298) or absence of IDeF (n = 519) on admission. The clinical event under study was the occurrence of death or severe HF in long term. Independent predictors of prognosis were determined with logistic regression analysis.

RESULTS

36% of patients had IDef. These patients had a higher mortality rate (p = 0.004), higher incidence of HF (p = 0.011) during follow-up and a higher rate of hospital readmissions (p = 0.048). IDef was an independent predictor of death or severe HF in follow-up, along with anemia, left ventricular dysfunction, renal dysfunction and the absence of revascularization. Besides, IDef also enabled us to further stratify the prognosis of patients without anemia based on the occurrence of death or severe HF and those with lower Killip classes (≤2) based on the occurrence of death.

CONCLUSION

IDef was an independent predictor of death or severe HF in patients admitted with ACS and enabled additional stratification for those without anemia on admission and in those with Killip classes ≤2.

Modified shock index: A bedside clinical index for risk assessment of ST-segment elevation myocardial infarction at presentation

INTRODUCTION

Prompt identification of higher-risk patients presenting with ST-segment elevation myocardial infarction (STEMI) is crucial to pursue a more aggressive approach.

OBJECTIVE

We aimed to assess whether the modified shock index (MSI), the ratio of heart rate to mean arterial pressure, could predict six-month mortality among patients admitted with STEMI.

METHODS

A retrospective observational cohort study was performed in a single center including 1158 patients diagnosed with STEMI, without cardiogenic shock on admission, between July 2009 and December 2014. They were divided into two groups: group 1 - patients with MSI<0.93 (72%); group 2 - patients with MSI≥0.93 (28%). The primary endpoint was six-month all-cause mortality.

RESULTS

MSI≥0.93 identified patients who were more likely to have signs of heart failure (p=0.002), anemia (p<0.001), renal insufficiency (p=0.014) and left ventricular systolic dysfunction (p=0.045). They more often required inotropic support (p<0.001), intra-aortic balloon pump (p<0.001) and mechanical ventilation (p<0.001). Regarding in-hospital adverse events, they had a higher prevalence of malignant arrhythmias (p=0.01) and mechanical complications (p=0.027). MSI≥0.93 was an independent predictor of overall six-month mortality (adjusted HR 2.00, 95% CI 1.20-3.34, p=0.008).

CONCLUSION

MSI was shown to be a valuable bedside tool which can rapidly identify high-risk STEMI patients at presentation.

Multivessel vs. culprit-only revascularization in patients with non-ST-elevation acute coronary syndromes and multivessel coronary disease

INTRODUCTION

There have been no prospective randomized trials that enable the best strategy and timing to be determined for revascularization in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and multivessel coronary artery disease (CAD).

OBJECTIVES

To compare short- and long-term adverse events following multivessel vs. culprit-only revascularization in patients with NSTE-ACS and multivessel CAD.

METHODS

This was a retrospective observational study that included all patients diagnosed with NSTE-ACS and multivessel CAD who underwent percutaneous coronary intervention (PCI) between January 2010 and June 2013 (n=232). After exclusion of patients with previous coronary artery bypass grafting (n=30), a multivessel revascularization strategy was adopted in 35.1% of patients (n=71); in the others (n=131, 64.9%), only the culprit artery was revascularized. After propensity score matching (PSM), two groups of 66 patients were obtained, matched according to revascularization strategy.

RESULTS

During follow-up (1543±545 days), after PSM, patients undergoing multivessel revascularization had lower rates of reinfarction (4.5% vs. 16.7%; log-rank p=0.018), unplanned revascularization (6.1% vs. 16.7%; log-rank p=0.048), unplanned PCI (3.0% vs. 13.6%; log-rank p=0.023) and the combined endpoint of death, reinfarction and unplanned revascularization (16.7 vs. 31.8%; log-rank p=0.046).

CONCLUSIONS

In real-world patients presenting with NSTE-ACS and multivessel CAD, a multivessel revascularization strategy was associated with lower rates of reinfarction, unplanned revascularization and unplanned PCI, as well as a reduction in the combined endpoint of death, reinfarction and unplanned revascularization.

Multivessel Versus Culprit-only Percutaneous Coronary Intervention in ST-segment Elevation Acute Myocardial Infarction: Analysis of an 8-year Registry

INTRODUCTION AND OBJECTIVES

The optimal treatment of patients with multivessel coronary artery disease and ST-segment elevation acute myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI) is controversial. The aim of this study was to access the prognostic impact of multivessel PCI vs culprit vessel-only PCI in real-world patients with STEMI and multivessel disease.

METHODS

This was a retrospective cohort study of 1499 patients with STEMI diagnosis who underwent primary PCI between January 2008 and December 2015. About 40.8% (n=611) patients had multivessel disease. We performed a propensity score matched analysis to obtain 2 groups of 215 patients paired according to whether or not they had undergone multivessel PCI or culprit vessel-only PCI.

RESULTS

During follow-up (median, 2.36 years), after propensity score matching, patients who underwent multivessel PCI had lower rates of mortality (5.1% vs 11.6%; Peto-Peto P=.014), unplanned repeat revascularization (7.0% vs 12.6%; Peto-Peto P=.043) and major acute cardiovascular events (22.0% vs 30.8%; Peto-Peto P=.049). These patients also showed a trend to a lower incidence of myocardial infarction (4.2% vs 6.1%; Peto-Peto P=.360).

CONCLUSIONS

In real-world patients presenting with STEMI and multivessel coronary artery disease, a multivessel PCI strategy was associated with lower rates of mortality, unplanned repeat revascularization, and major acute cardiovascular events.

"Assessment of effectiveness and security in high pressure postdilatation of bioresorbable vascular scaffolds during percutaneous coronary intervention. Study in a contemporary, non-selected cohort of Spanish patients"

OBJECTIVES

To determine security and benefits of high pressure postdilatation (HPP) of bioresorbable vascular scaffolds (BVS) in percutaneous coronary intervention (PCI) of complex lesions whatever its indication is.

BACKGROUND

Acute scaffold disruption has been proposed as the main limitation of BVS when they are overexpanded. However, clinical implications of this disarray are not yet clear and more evidence is needed.

METHODS

A total of 25 BVS were deployed during PCI of 14 complex lesions after mandatory predilatation. In all cases HPP was performed with NC balloon in a 1:1 relation to the artery. After that, optical coherence tomography (OCT) analyses were performed.

RESULTS

Mean and maximal postdilatation pressure were 17±3.80 and 20 atmospheres (atm) respectively. Postdilatation balloon/scaffold diameter ratio was 1.01. A total of 39,590 struts were analyzed. Mean, minimal and maximal scaffold diameter were respectively: 3.09±0.34mm, 2.88±0.31mm and 3.31±0.40mm. Mean eccentricity index was 0.13±0.05. ISA percentage was 1.42% with a total of 564 malapposed struts. 89 struts were identified as disrupted, which represents a percentage of disrupted struts of 0.22%. At 30days, none of our patients died, suffered from stroke, stent thrombosis or needed target lesion revascularization (TLR).

CONCLUSIONS

NC balloon HPP of BVS at more than 17atm (up to 20atm) is safe during PCI and allows to achieve better angiographic and clinical results.

Plasma cell leukaemia

Plasma cell leukaemia (PCL) is a rare and aggressive disease. Diagnosis is made when there are >2000/#mL circulating plasma cells in peripheral blood or plasmacytosis >20% of total leukocyte count. We report a case of a 51-year old man with generalized bone pain and constitutional symptoms. Blood peripheral smear revealed leukocytosis with 39% plasma cells. Bone marrow biopsy showed plasma cell invasion, which confirmed the diagnosis of PCL. Additionally, the patient had markers of advanced disease. Chemotherapy with vincristine, adriamycin and dexamethasone was started. Despite an initial favourable response, the patient died 2 months later due to an infectious complication. PCL has no established treatment and has a dismal prognosis, requiring the achievement of better data to improve the disease course.

Impact of atrial fibrillation type during acute coronary syndromes: Clinical features and prognosis

INTRODUCTION

Atrial fibrillation (AF) is widely recognized as an adverse prognostic factor during acute myocardial infarction, although the impact of AF type - new-onset (nAF) or pre-existing (pAF) - is still controversial.

OBJECTIVES

To identify the clinical differences and prognosis of nAF and pAF during acute coronary syndromes (ACS).

METHODS

We performed a retrospective observational cohort study including 1373 consecutive patients (mean age 64 years, 77.3% male) admitted to a single center over a three-year period, with a six-month follow-up.

RESULTS

AF rhythm was identified in 14.5% patients, of whom 71.4% presented nAF and 28.6% pAF. When AF types were compared, patients with nAF more frequently presented with ST-elevation ACS (p=0.003). Patients with pAF, in turn, were older (p=0.032), had greater left atrial diameter (p=0.001) and were less likely to have significant coronary lesions (p=0.034). Regarding therapeutic strategy, nAF patients were more often treated by rhythm control during hospital stay (p<0.001) and were less often anticoagulated at discharge (p=0.001). Compared with the population without AF, nAF was a predictor of death during hospital stay in univariate (p<0.001) and multivariate analysis (OR 2.67, p=0.047), but pAF was not. During follow-up, pAF was associated with higher mortality (p=0.014), while nAF patients presented only a trend towards worse prognosis.

CONCLUSIONS

AF during the acute phase of ACS appears to have a negative prognostic impact only in patients with nAF and not in those with pAF.

New-onset atrial fibrillation during acute coronary syndromes: predictors and prognosis

INTRODUCTION

New-onset atrial fibrillation (AF) frequently complicates myocardial infarction, with an incidence of 6-21%.

OBJECTIVE

To assess the predictors and prognosis of new-onset AF during acute coronary syndromes (ACS).

METHODS

We performed a retrospective observational cohort study including 902 consecutive patients (mean age 64 years, 77.5% male) admitted to a single center over a two-year period, with a six-month follow-up.

RESULTS

AF rhythm was identified in 13.8% patients, of whom 73.3% presented new-onset AF and 26.8% pre-existing AF. New-onset AF was more frequent in older (p<0.001) and hypertensive patients (p=0.001) and in those with previous valvular heart disease (p<0.001) and coronary artery bypass grafting (p=0.049). During hospitalization, patients with new-onset AF more often had respiratory infection (p=0.002) and heart failure (p<0.001), and higher values of NT-proBNP (p=0.007) and peak creatinine (p=0.001). On echocardiography they had greater left atrial (LA) diameter (p<0.001) and more frequent significant mitral regurgitation (p<0.001) and left ventricular ejection fraction (LVEF) ≤40% (p<0.001) and were less likely to have significant coronary lesions (p=0.009) or to have undergone coronary revascularization (p<0.001). In multivariate analysis, age (OR 1.06, p=0.021), LVEF ≤40% (OR 4.91, p=0.002) and LA diameter (OR 1.14, p=0.008) remained independent predictors of new-onset AF. Together with age, diabetes and maximum Killip class, this arrhythmia was an independent predictor of overall mortality (OR 3.11, p=0.032).

CONCLUSIONS

Age, LVEF ≤40% and LA diameter are independent predictors of new-onset AF during ACS. This arrhythmia is associated with higher overall mortality (in-hospital and in follow-up).

Mesalamine-induced myocarditis following diagnosis of Crohn's disease: a case report

Mesalamine is a common treatment for Crohn's disease, and can be rarely associated with myocarditis through a mechanism of drug hypersensitivity. We present the case of a 19-year-old male who developed chest pain two weeks after beginning mesalamine therapy. The electrocardiogram showed slight ST-segment elevation with upward concavity in the inferolateral leads; blood tests demonstrated elevated troponin I and the echocardiogram revealed moderately depressed left ventricular systolic function with global hypocontractility. Cardiac magnetic resonance imaging confirmed the diagnosis of myocarditis, revealing multiple areas of subepicardial fibrosis. The onset of symptoms after mesalamine, and improvement of chest pain, cardiac biomarkers and left ventricular systolic function after discontinuing the drug, suggest that our patient suffered from a rare drug-hypersensitivity reaction to mesalamine.

[1986-2001: Ideals and dreams reached in 15 years of campaigns, work and achievements of the Brazilian Association of Nursing-Itajubá region]

The present article reports the trajectory of a regional branch of the Brazilian Association of Nursing (ABEn) in Itajubá. It shows the development of this association since its inception until the present days. The study also depicts how the efforts invested and the success obtained helped on the development and strengthening of the nursing work in the south region of Minas Gerais.

[Transcultural nursing and beliefs: values and practices of the Gypsy population]

It's a question of mini-ethnographic study in nursing where it is emphasized the belief of cares, mettles, way of life, world sight of a group of gypsies of origin ROM. It was exploited the theoretical referential by LEININGER for helping the understanding of this culture, visualizing proposals in procedures and decisions of care, so as to provide cares culturally congruent. The author advocates some definitions referring to the especialty of gypsy culture concerning its cultural approaches when providing care, as subsidized for future studies.