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Artículo Original

Estudio descriptivo de síndromes coronarios agudos del Hospital Interzonal General de Agudos de Mar del Plata, Buenos Aires, Argentina

Mirta Cabral, Ana Laura Tufare, Fernanda Petrucci

Revista del Consejo Argentino de Residentes de Cardiología 2021;(160): 0118-0121 


Introducción. El síndrome coronario agudo continúa siendo una de las principales causas de morbimortalidad a nivel global y Argentina no es la excepción.
Objetivo. Realizar un análisis descriptivo de los pacientes con diagnóstico de síndrome coronario agudo.
Materiales y métodos. Se realizó un estudio descriptivo observacional, analítico, retrospectivo y longitudinal que incluyó 250 pacientes con diagnóstico de síndrome coronario agudo ingresados en el Hospital Regional General de Agudos Dr. Oscar Alende, de Mar del Plata, Buenos Aires, Argentina, entre junio de 2018 y diciembre de 2019. Se recabó información sobre características demográficas, variables clínicas, estudios complementarios, medidas terapéuticas y complicaciones.
Resultados: De la población analizada, 74,5% fueron hombres, edad media 60 años, 47.7% con diagnóstico de infarto agudo de miocardio con elevación del ST (IAMCEST), 32.5% infarto agudo de miocardio sin elevación del ST (IAMSEST), y 29.7% angina inestable (AI). Los factores de riesgo cardiovasculares más prevalentes fueron la hipertensión arterial (HTA) (68%) y el tabaquismo (TBQ) (68%). La localización electrocardiográfica más frecuente fue la inferior (24%). De los pacientes ingresados con IAMCEST, más del 60% ingresó en Killip y Kimball (KK) I. El 88% recibió tratamiento de reperfusión, 7% con ATC primaria y 81% trombolíticos, con una mortalidad del 8,5% en este grupo de pacientes. La mortalidad global fue del 7%. Se asociaron a mayor mortalidad la edad mayor a 64 años (OR=6,3; IC95%: 1,95-20,59; p<0,001) y el KK IV (OR=10,2; IC95%: 1,95-53,17; p<0,01). Conclusiones. Las características generales no difieren de los registros nacionales. Una diferencia a destacar es la baja tasa de reperfusión mecánica en el IAMCEST en nuestros pacientes. Si bien la utilidad de la reperfusión mecánica ha sido demostrada ampliamente como el método de elección, llamativamente para nosotros, la mortalidad en nuestro grupo de pacientes fue similar a la descripta en otros registros con mayor utilización de angioplastia primaria.


Palabras clave: síndrome coronario agudo, infarto del miocardio, reperfusión, angioplastia primaria.

Introduction. Acute coronary syndrome is still one of the main causes of morbidity and mortality worldwide and Argentina is no exception.
Aim. To carry out a descriptive analysis of patients with a diagnosis of acute coronary syndrome.
Materials and Methods. An observational, analytical, retrospective and longitudinal descriptive study was carried out that included 250 patients with a diagnosis of Acute Coronary Syndrome admitted to the Hospital Regional General de Agudos Dr. Oscar Alende, of Mar del Plata, Buenos Aires, Argentina, between June 2018 and December 2019. Information was collected on demographic characteristics, clinical variables, supplementary tests, therapeutic measures and complications.
Results. From the analyzed population, 74.5% were men, mean age 60 years, 47.7% with a diagnosis of STEMI, 32.5% NSTEMI, and 29.7% unstable angina. The most prevalent cardiovascular risk factors were hypertension (68%) and smoking (68%). The most frequent electrocardiographic location was inferior (24%). From the patients admitted with STEMI, more than 60% were admitted with Killip and Kimball I. Eighty-eight percent received reperfusion treatment, 7% with primary TCA and 81% thrombolytics, with a mortality of 8.5% in this group of patients. Overall mortality was 7%. Age older than 64 years (OR: 6.3; 95% CI 1.95-20.59; p 0.001) and KK IV (OR: 10.2; 95% CI 1.95- 53.17; p 0.01).
Conclusions. General characteristics do not differ from those from national registries. A notable difference is the low rate of mechanical reperfusion in STEMI in our patients. Although the usefulness of mechanical reperfusion has been widely demonstrated as the method of choice, strikingly for us, mortality in our group of patients was similar to that described in other registries with greater use of primary angioplasty.


Keywords: acute coronary syndrome, myocardial infarction, reperfusion, primary angioplasty.


Los autores declaran no poseer conflictos de intereses.

Fuente de información Consejo Argentino de Residentes de Cardiología. Para solicitudes de reimpresión a Revista del CONAREC hacer click aquí.

Recibido 2021-08-01 | Aceptado 2021-09-01 | Publicado 2021-08-30


Licencia Creative Commons
Esta obra está bajo una Licencia Creative Commons Atribución-NoComercial-SinDerivar 4.0 Internacional.

Tabla 1. Características generales de la población.

Tabla 2. Localización electrocardiográfica del IAM.

Tabla 3. Vasos afectados en el estudio de cateterismo diagnóstico.

Tabla 4. Killip Kimball de ingreso en IAMCEST.

Tabla 5. Mortalidad total y por subgrupos

INTRODUCTION

The prevalence of severe vascular calcification increases with age, atherosclerosis, diabetes mellitus, and chronic kidney disease. (1) It is predictor of poor results because it complicates blood vessel dilatation, increases the use of stents, and the rate of restenosis. (2) Coronary calcium is a very common thing in iliac arteries and increases the rate of complications in endovascular treatments that can be potentially serious like ruptured arteries. (3) Intravascular lithotripsy (Shockwave Medical, Fremont, United States) is a new alternative for blood vessel because preparation it modifies intimal and medial calcification with a low risk of distal embolization. (1) We describe the very first case ever performed in Argentina of lithotripsy for the peripheral endovascular treatment of a patient with severe calcification of the iliac arteries.

CASE PRESENTATION

This is the case of a 71-year-old man who was a former heavy smoker with arterial hypertension, dyslipidemia, diabetes, and chronic kidney disease. The patient’s past medical history included coronary artery disease surgically revascularized, and an abdominal aortic aneurysm (AAA) of 3.9 cm in diameter that remained under strict follow-up. Intermittent claudication of left lower limb after walking for 300 meters treated with daily exercise, cilostazol, atorvastatin, clopidogrel, lercardipine, losartan, and aspirin. During the confinement, the patient’s symptoms became worse until he developed critical limb ischemia.

The angiography of both the abdominal aorta and the lower limbs revealed the presence of a sub-occluded heavily calcified lesion in the proximal third of the left common iliac artery, severe stenoses in the distal segment and the external iliac artery with severe calcification and occlusion of the hypogastric artery (Figure 1).

A coronary computed tomography angiography (CCTA) was used to study the diameters of the abdominal aortic aneurysm and the iliac axis. The study of both diameters confirmed the diagnosis. The maximum load of calcium was used in the most proximal segment of the left common iliac artery with almost total compromise of the entire lumen. (Figure 2).

In view of worsening of symptoms, concomitant conditions, and the patient’s anatomy the heart team decided to use an endovascular approach with intravascular lithotripsy (IVL) followed by and angioplasty with a paclitaxel-drug-coated balloon (DCB).

The IVL device (Shockwave Medical, Fremont, United States) consists of a balloon that inflates at low pressures (4 to 6 atmospheres) and uses high-speed pulsatile sonic pressure waves that run through the vessel wall and modify coronary calcium. The peripheral catheter generates cycles of 30 pulses at a rate of 1 pulse per second with a maximum of 10 cycles. (1) A homolateral retrograde puncture was performed in the left common femoral artery to insert a 7-Fr introducer sheath (Terumo, Tokyo, Japan). The most critical lesion was crossed at proximal level using a 4-Fr vertebral hydrophilic catheter (Terumo, Tokyo, Japan) and a 0.035 in Magic guidewire (Boston Scientifics, Santa Clara, United States). Afterwards, a 4.0 mm x 80 mm 0.035 in peripheral balloon was advanced (Passeo 35 Biotronik, Berlin, Germany) that was dilated at 4 atmospheres to allow the passage of the lithotripsy balloon.

Then, the guidewire was exchanged on the balloon for a peripheral V14 0.014 in x 300 cm floppy guidewire (Boston Scientifics, Santa Clara, United States) on which the 7.0 mm x 60 mm IVL device (Shockwave Medical, Fremont, United States) was advanced. The first 30-pulse cycle at 4 atm was performed from the ostium of the common iliac artery (Figure 3). When the cycle ended, the balloon was inflated at 6 atm for 20 seconds to achieve greater luminal gain. Another 8 cycles were completed in this lesion plus 2 cycles at the level of the ostium of the external iliac artery on another calcified lesion. Then, the IVL catheter was exchanged for an 8.0 mm x 80 mm balloon (PowerFlex Cordis Corporation) that was dilated at the level of the ostium of the common iliac artery until it reached the proximal segment of the external iliac artery at 8 atm for 60 seconds. Afterwards, an angioplasty was performed using an 8.0 mm x 80 mm DCB (IN.Pact Medtronic, Santa Rosa, United States) from the ostium of the common iliac artery with positive results. (Figure 4). The patient’s clinical course improved, and he remained asymptomatic. A control CCTA was performed at the 1-month follow-up that confirmed the modification of the heavily calcified lesion followed by luminal gain at left common iliac artery level. (Figure 5)

DISCUSSION

Severe calcification of the iliac arteries increases the rate of distal embolization and lesions to the blood vessel. (4) Due to the complexity of the lesions at left iliac artery level following the risk of calcified emboli and considering that our patient has an AAA that, in the near future, may require the implantation of a bifurcated stent-graft at infrarenal abdominal aortic level, it was decided to use an adjuvant therapy (IVL) to treat coronary calcium with a low risk of complications. Also, this therapeutic approach minimizes the need for stenting, which may be limiting regarding the aortic endovascular treatment since it complicates the passage of the stent-graft through the iliac artery. Circumferential calcification and lumen compromise in the most critical lesion (Figure 2) would often require high-pressure inflations with the corresponding risk of dissection due to barotrauma. In this case, treatment with IVL fractured coronary calcium, facilitated proper dilatation, and effective luminal gain as former studies have already described (5). Also, it facilitated treatment with an 8.0 mm in diameter DCB with good angiographic results.

Severe calcification is associated with a decreased long-term patency of endovascular treatment; (6) in the iliac territory stent implantation is the most widely used strategy and can even generate suboptimal expansion (3, 7). Intimal calcification is a common trait of atherosclerosis while medial calcification is more common in patients with kidney failure, diabetes mellitus, and old age (1, 6). Our patient’s past medical history puts him at risk in both locations. Several tools have become available like atherotomes, specific balloons (noncompliant, scoring, cutting) to modify the calcium plaque, allow optimal dilatation, and improve the vessel elasticity. However, these techniques have been associated with a higher risk of complications and only allow treating calcium at tunica intimal level. (2) The IVL uses pulsatile sonic waves that fracture the vascular calcium located both at the tunica intima and the intima media layers. (3) The endovascular management of complex lesions for the management of vascular disease has a high incidence rate of restenosis compared to the management of simple lesions (8). That is why the availability of new tools can improve the results. Given the low rate of complications reported, especially emboli, compared to atherotomes (7), and the impossibility of using distal filters via retrograde access we decided to choose this method as our best option. The fracture of this volume of calcium facilitates proper dilatation, an effective luminal gain, and a lower risk of barotrauma as reported in the medical literature. (5) The easiness of use since it is a balloon-mediate therapy that requires no filters allowed us to treat the patient efficiently with good results and without complications.

The main limitation here is that it is a case report of a new therapy of intravascular treatment for heavily calcified lesions in the peripheral territory. Similar therapies need to be compared such as atherectomy in its different versions before assessing the results obtained.

The use of IVL was easy, safe, and effective for the management of lesions with severe calcification and could reduce the need for stenting in the peripheral arterial territory of the lower limbs.

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  2. Ferreira-González I. Epidemiología de la enfermedad coronaria. Rev Esp Cardiol 2014;67(2):139-44.

  3. García Aurelio MJ, Cohen Arazi H, Higa C, Gómez Santa María HR, Mauro VM, Fernández H, et al. Infarto agudo de miocardio con supradesnivel persistente del segmento ST: Registro multicéntrico SCAR (Síndromes Coronarios Agudos en Argentina) de la Sociedad Argentina de Cardiología. Rev Argent Cardiol 2014;82(4):275-84.

  4. Cohen Arazi H, Zapata G, Marturano P, De La Vega MB, Pellizón OA, D’Imperio H. et al. Angioplastia primaria en Argentina. Registro ARGEN-IAM-ST (relevamiento nacional del infarto agudo de miocardio con elevación del segmento ST). MEDICINA 2019;79(4):251-6.

  5. Sociedad Argentina de Cardiología (SAC). Lanzamiento del Registro Nacional de Enfermedad Cardiovasculares. Disponible en https://www.sac.org.ar/actualidad/lanzamiento-del-registro-nacional-de-enfermedades-cardiovasculares/.

  6. Sociedad Argentina de Cardiología. Consenso de síndrome coronarios agudos. Reva Arg Cardiol 2005;73(3):45-62.

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  8. Asseburg C, Vergel YB, Palmer S, Fenwick E, de Belder M, Abrams KR, et al. Assessing the effectiveness of primary angioplasty compared with thrombolysis and its relationship to time delay: a Bayesian evidence synthesis. Heart 2007;93(10):1244-50.

Autores

Mirta Cabral
Residente de Cardiología..
Ana Laura Tufare
Médica Staff de Cardiología..
Fernanda Petrucci
Médica Staff de Cardiología. Servicio de Cardiología, Hospital General de Agudos Dr. Oscar Alende, Mar del Plata, Buenos Aires..

Autor correspondencia

Mirta Cabral
Residente de Cardiología..

Correo electrónico: Mirtaec29@gmail.com

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Titulo
Estudio descriptivo de síndromes coronarios agudos del Hospital Interzonal General de Agudos de Mar del Plata, Buenos Aires, Argentina

Autores
Mirta Cabral, Ana Laura Tufare, Fernanda Petrucci

Publicación
Revista del CONAREC

Editor
Consejo Argentino de Residentes de Cardiología

Fecha de publicación
2021-08-30

Registro de propiedad intelectual
© Consejo Argentino de Residentes de Cardiología

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