Disección coronaria espontánea y alteraciones tiroideas

Introducción y Objetivos: La hormona tiroidea afecta al metabolismo de todos los tejidos del organismo. El objetivo de este estudio fue analizar la prevalencia y las implicaciones de las alteraciones tiroideas en una cohorte de pacientes consecutivos con disección coronaria espontánea (DCE). Métodos: En una primera fase descriptiva, se evaluaron la totalidad de DCE de 2 centros hospitalarios terciarios, que incluyeron un total de 73 pacientes diagnosticados de dicha patología a lo largo de más de una década. En esta primera fase se analizaron los parámetros demográficos, comorbilidades, clínicos, analíticos, angiográficos y pronósticos. Llamaba notoriamente la atención una prevalencia elevada de patología tiroidea, específicamente hipotiroidismo, lo que dio lugar a una segunda fase investigadora analítica. En esta segunda fase se compararon las características y evolución clínica de los pacientes eutiroideos frente a los hipotiroideos con DCE. Finalmente, se llevó a cabo una tercera fase investigadora para intentar determinar si la prevalencia observada podía ser fruto del azar, para ello se analizó la prevalencia de alteraciones tiroideas y características clínicas de estos pacientes y se compararon en un estudio de caso- control con 73 pacientes con síndrome coronario agudo (SCA) pero sin DCE emparejados por edad, género y presentación clínica. Resultados: La edad media de los pacientes con DCE fue 55±12 años y el 26% tenía hipotiroidismo. Los pacientes con DCE e hipotiroidismo eran más frecuentemente mujeres (100 vs 69%, p=0,01), presentaron disecciones más distales (74 vs 41%, p=0,03), en arterias en tirabuzón (68 vs 41%, p=0,03) y fueron manejados de forma más conservadora (79 vs 41%, p=0,007). Durante un seguimiento medio de 4,1±3,8 años, la frecuencia de eventos adversos fue del 23% sin diferencias según el estado de la función tiroidea. La prevalencia de hipotiroidismo fue significativamente mayor en los pacientes con DCE que en el grupo de pacientes con SCA sin DCE (26 vs 8%, p=0,004). Conclusiones: Existe una elevada prevalencia de hipotiroidismo en pacientes consecutivos no seleccionados con DCE. Los pacientes hipotiroideos con DCE son más frecuentemente mujeres, tienen disecciones más distales, en arterias en tirabuzón y se tratan de forma más conservadora que los pacientes eutiroideos con DCE.Introduction and objectives: Thyroid hormone affects the metabolism of all tissues in the body. The aim of this study was to analyze the prevalence and implications of thyroid disorders in a cohort of consecutive patients with spontaneous coronary artery dissection (SCAD). Methods: In a first descriptive phase, all SCAD from 2 tertiary hospital centers were included, summarizing a total of 73 patients diagnosed with this pathology over more than a decade. In this first phase, demographic, comorbidities, clinical, laboratory, angiographic and prognostic parameters were analyzed. The high prevalence of thyroid disease, specifically hypothyroidism, was strikingly noteworthy, which led to a second analytical research phase. In this second phase, the characteristics and clinical evolution of euthyroid SCAD patients were compared with those of hypothyroid patients with SCAD. Finally, a third investigative phase was carried out to try to determine if the observed prevalence could be the result of chance, for this the prevalence of thyroid alterations and clinical characteristics of these patients were analyzed and compared in a case-control study with 73 patients with acute coronary syndrome (ACS) but without SCAD matched by age, gender and clinical presentation. Results: Mean age was 55 ± 12 years and 26% had hypothyroidism. Compared with patients with normal thyroid function, patients with SCAD and hypothyroidism were all women (100% vs 69%, P = .01), more frequently had dissection in distal (74% vs 41%, P = .03) and tortuous coronary segments (68% vs 41%, p = .03), and more frequently received conservative medical management (79% vs 41%, P = .007). During a mean clinical follow-up of 4.1 ± 3.8 years, 23% of the patients had adverse cardiac events irrespective of thyroid function status. The prevalence of hypothyroidism was higher in patients with SCAD than in matched patients with acute coronary syndrome without SCAD (26% vs 8%, P = .004). Conclusions: There is a high prevalence of hypothyroidism in patients with SCAD. Patients with SCAD and hypothyroidism are more frequently women, more frequently have distal dissections in tortuous vessels, and are more frequently managed with a conservative medical strategy

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Subclavian angioplasty during coronary interventions using radial approach.

In the past years, the percentage of percutaneous coronary angiography and coronary interventions using radial access had significantly increased due to its higher safety, lower risk of major bleeding, and hence lower cardiovascular mortality. Subclavian artery stenosis is one of the challenges that may be met during transradial coronary interventions, which may necessitate femoral access crossover or conversion. To evaluate the feasibility and safety of performing subclavian angioplasty via radial access during complex coronary interventions using the forearm approach. A series of patients with complex radial approach due to subclavian stenosis received subclavian angioplasty during the procedure. We included 48 patients out of 22 500 procedures performed from February 2009 to February 2020. All patients did not have alternative vascular access due to extensive peripheral arterial disease (previous history of iliac stenting or distal aortic occlusion, which makes femoral access crossover difficult; also the contralateral radial/ulnar artery was very faint or not detectable at all). Mean age was 72 (10) years and 67% of patients were males. Subclavian angioplasty was successfully done in all patients via ipsilateral radial access; 44 patients (91.7%) required subclavian stenting, and 4 patients were treated by subclavian angioplasty without stenting. Coronary angiography or intervention was perfectly achieved through the revascularized subclavian artery; coronary stenting was successfully done in 36 patients as indicated. It can be concluded that percutaneous subclavian artery angioplasty can be done safely and effectively to facilitate complex transradial coronary procedures with an acceptable immediate technical success, especially in patients without alternative vascular access. Also, we may conclude that subclavian angioplasty may be successfully performed in patients with symptomatic upper limb ischemia, via the radial approach

Subclavian angioplasty during coronary interventions using radial approach

BACKGROUND: In the past years, the percentage of percutaneous coronary angiography and interventions using the radial access had significantly increased due to its higher safety, lower risk of major bleeding and hence lower cardiovascular mortality. Subclavian artery stenosis is one of the challenges that may be met during transradial coronary interventions, which may necessitate femoral access crossover or conversion. AIMS: To evaluate the feasibility and safety of performing subclavian angioplasty via the radial access, during complex coronary interventions using forearm approach. METHODS: A series of patients with complex radial approach due to subclavian stenosis, for which subclavian angioplasty was performed during the procedure. Forty-eight patients out of 22 500 procedures performed, from February 2009 to February 2020, were included. All patients did not have alternative vascular access due to extensive peripheral arterial disease (previous history of iliac stenting or distal aortic occlusion which makes femoral access crossover difficult, also the contralateral radial/ulnar artery was very faint or not felt at all). RESULTS: Mean age was 72 (10) years and 67% were males. Subclavian angioplasty was successfully done in all patients via the ipsilateral radial access; 91.7% (44 patients) required subclavian stenting and 4 patients were treated by subclavian angioplasty without stenting. Coronary angiography or intervention was perfectly done through the revascularized subclavian artery; coronary stenting was successfully done in 36 patients as indicated. CONCLUSIONS: It can be concluded that percutaneous subclavian artery angioplasty can be done safely and effectively to facilitate complex transradial coronary procedures, with an acceptable immediate technical success, especially in patients without alternative vascular access. Also, we may conclude that subclavian angioplasty may be successfully performed in patients with symptomatic upper limb ischemia, via the radial approac