The pathobiology of human coronary atheroma: contributions of interventional cardiology

The development of coronary angiography facilitated a complete new assessment of coronary circulation in humans, opening a new age in the study and treatment of coronary artery disease. A second revolution came from furrher developments of cardiac catheterisation that made possible the performance of percutaneous therapeutic procedures in the coronary arteries. During the last: 10 years balloon angioplasry has become not only a useful therapeutic tool for clinicians, but also as a model of myocardial ischaemia and vessel wall damage for researchers. More recendy, the development of new percutaneous intracoronary devices has provided new opportunities in the study of the pathophysiology of coronary artery dis

Invasive evaluation of coronary microvascular dysfunction

Coronary microvascular dysfunction (CMD) is a prevalent cause of ischemic heart disease and is associated with poorer quality of life and worse patient outcomes. Both functional and structural abnormalities of the microcirculation can generate ischemia in the absence of epicardial stenosis or worsen concomitant obstructive coronary artery disease (CAD). The invasive assessment of CMD allows for the evaluation of the entirety of the coronary vascular tree, from the large epicardial vessels to the microcirculation, and enables the study of vasomotor function through vasoreactivity testing. The standard evaluation of CMD includes vasomotor assessment with acetylcholine, as well as flow- and resistance-derived indices calculated with either thermodilution or Doppler guidewires. Tailored treatment based upon the information gathered from the invasive evaluation of CMD has been demonstrated to reduce the burden of angina; therefore, a thorough understanding of these procedures is warranted with the aim of improving the quality of life of the patient. This review summarizes the most widespread approaches for the invasive evaluation of CMD, with a focus on patients with ischemia and nonobstructive CAD

Impact of delirium in acute cardiac care unit after transcatheter aortic valve replacement

El delirium es un trastorno cognitivo que se produce con frecuencia durante la hospitalización en unidades de cuidados agudos cardiológicos (UCAC), pero su efecto tras la sustitución percutánea de la válvula aórtica (TAVI) no ha sido bien evaluado. El objetivo de este estudio es determinar la incidencia, los factores predictivos y el impacto pronóstico del delirium tras el implante de una TAVI. Métodos: Se incluyeron 501 pacientes consecutivos ingresados en una UCAC tras el implante de TAVI. Se utilizó el método de evaluación de la confusión para evaluar el delirium durante la estancia en la UCAC. Se evaluaron los factores de riesgo, el tratamiento farmacológico preventivo, las características periprocedimiento y las complicaciones. Se registraron los acontecimientos clínicos con una mediana de seguimiento de 24 meses. Resultados: La incidencia de delirium tras TAVI fue del 22,0% (n = 110). El deterioro cognitivo previo (OR 4,17; IC 95%: 1,11-15,71; p = 0,035), la enfermedad arterial periférica (OR 4,54; IC 95%: 1,79-11,54; p = 0,001), el uso de anestesia general (OR 2,55; IC 95%: 1,32-4,90; p = 0,005) y la ventilación mecánica prolongada (OR 18,86; IC 95%: 1,85-192,58; p = 0,013) se asociaron significativamente con el desarrollo de delirium. Los pacientes con delirium tuvieron una mayor estancia hospitalaria (7,5 [5,5-13,5] frente a 5,6 [4,6-8,2] días, y mayor mortalidad intrahospitalaria (OR 2,68; IC 95% 1,02-6,99; p = 0,045), a 1 año (HR 2,09; IC 95% 1,13-3,87; p = 0,018) y a 2 años (HR 1,94; IC 95% 1,12-3,34; p = 0,017). Conclusiones: El delirium es una complicación frecuente en los pacientes ingresados en la UCAC tras el implante de una TAVI, y se asocia con una estancia hospitalaria prolongada y una mayor mortalidad intrahospitalaria y a medio plazo.Depto. de MedicinaFac. de MedicinaTRUEpu

Platelet function in Takotsubo cardiomyopathy

Estudio observacional prospectivo donde se evaluó en 32 pacientes diagnosticados de miocardiopatía de estrés (Takotsubo) la reactividad plaquetaria, en comparación con pacientes con un síndrome coronario agudo “convencional” y voluntarios sanos. Los pacientes con Takotsubo presentaron mayores niveles de adrenalina, pero no hubo diferencias en la reactividad plaquetaria tras ajustar según el tratamiento antiagregante. Takotsubo cardiomyopathy (TK) includes a transient left ventricular dysfunction without obstructive coronary disease, sometimes after stressful situations with elevated cathecolamines. Since catecholamines activate platelets we aimed to study the platelet influence in a TK setting. We included 32 patients with a TK diagnosis, 13 with an acute coronary syndrome (ACS) and 18 healthy volunteers. Once consent informed was obtained, blood samples were extracted and processed (at admission and after 3 months follow-up). Clinical, ecg, echocardiographic and angiographic features were thoroughly recorded.Previous treatment before admission was similar between groups. No differences were observed in clinical features or any of the acute markers studied regarding platelet reactivity between TK compared to ACS. After follow-up, aggregation levels and platelet reactivity showed differences, mainly due to the antithrombotic therapy prescribed at discharge, but similar to volunteers. Circulating epinephrine during the acute phase was significantly higher in TK (p < 0.001). Patients with higher levels of epinephrine had elevated platelet activation and aggregation after 3 months. No differences were observed in Takotsubo acute platelet aggregation compared to patients with ACS, in spite of higher blood levels of adrenaline. Takotsubo patients had elevated platelet aggregation and activation compared with ACS patients at 3 months follow-up because they were less frequently on chronic clopidogrel and ASA. However, they had similar platelet aggregation and activation levels to healthy volunteers despite treatment with low-dose ASA. Takotsubo patients who had higher levels of adrenaline in the acute phase displayed increased platelet reactivity during follow-up.Depto. de MedicinaFac. de MedicinaTRUEpu

Prognostic Implications of Bundle Branch Block in Patients Undergoing Primary Coronary Angioplasty in the Stent Era

Estudio observacional unicéntrico que evaluó a 913 pacientes con infarto agudo de miocardio con elevación del segmento ST tratados con angioplastia primaria. Se analizaron los trazados electrocardiográficos para valorar aquellos pacientes que se presentaron con un bloqueo de rama (derecha / izquierda) y si tras la reperfusión, éste desaparece o permanece. El estudio concluye que los pacientes con bloqueo de rama persistente fueron aquellos con peor pronóstico.The presence of bundle branch block (BBB) in patients with ST-segment elevation myocardial infarction has been associated with a poor outcome. However, the implications of BBB in patients undergoing primary angioplasty in the stent era are poorly established. Furthermore, the prognostic implications of BBB type (right vs left and previous vs transient or persistent) remain unknown. We analyzed the data from 913 consecutive patients with ST-segment elevation myocardial infarction treated with primary angioplasty. All clinical, electrocardiographic, and angiographic data were prospectively collected. The median follow-up period was 19 months. The primary end point was the combined outcome of death and reinfarction. BBB was documented in 140 patients (15%). Right BBB (RBBB) was present in 119 patients (13%) and was previous in 27 (23%), persistent in 45 (38%), and transient in 47 (39%). Left BBB (LBBB) was present in 21 patients (2%) and was previous in 8 (38%), persistent in 9 (43%), and transient in 4 (19%). Patients with BBB were older, and more frequently had diabetes, anterior infarctions, a greater Killip class, a lower left ventricular ejection fraction, and greater mortality (all p <0.005) than patients without BBB. The short- and long-term primary outcome occurred more frequently in patients with persistent RBBB/LBBB than in those with previous or transient RBBB/LBBB. On multivariate analysis, persistent RBBB/LBBB emerged as an independent predictor of death and reinfarction. In conclusion, in patients undergoing primary angioplasty in the stent era, BBB is associated with poor short- and long-term prognosis. This risk appears to be particularly high among patients with persistent BBBDepto. de MedicinaFac. de MedicinaTRUEpu