Acute Ischemic Coronary Syndromes Research Articles

Concurent Cardio-Cerebral infarction: definition,diagnosis, causes and treatment review article

Acute ischemic stroke and coronary coronary syndrome are the major causes of death worldwide. The prevalence of coronary artery disease has been reported in one fifth of stroke patients. Any acute or recent problem in the heart or ın the brain that could result in an acute infarction of the other. In this review we describe the definitionş causes and treatment of the concurent cardio-cerebral infarction

Performance of the TIMI and GRACE scores in identifying the risk of death from acute coronary ischemic syndrome: a retrospective study in patients with chest pain at a Peruvian Hospital

Background. Acute coronary syndrome (ACS) is one of the significant causes of death in the adult population globally, and mortality risk assessment is essential to improve prevention strategies. This study aimed to determine the performance of the TIMI and GRACE predictive models in identifying the risk of death from acute coronary syndrome (ACS) in patients with chest pain at a public hospital in Tumbes, Peru. Methods. We designed a retrospective cross-sectional study of medical records of patients with ACS treated at the José Alfredo Mendoza Olavarría Regional Hospital in Tumbes, Peru, from May to December 2022. The performance of the scores TIMI and GRACE for risk of death from ACS was evaluated using the receiver operating characteristic (ROC) curve analysis and calculating the area under the ROC curve (AUC) value with its 95% confidence interval. The AUC values of both scores were compared using Pearson's chi-square test. Results. Data from 106 patients were analyzed. The average age of the patients was 65 years (interquartile range [IQR]: 55-73), with 63.2% being male. The AUC values for the TIMI and GRACE scores were 95.1% (CI95: 90.9-99.2%) and 95.2% (85.7-100.0%), respectively, p=0.982. Conclusion. No difference was found in using the TIMI and GRACE scores to assess the risk of death in patients with ACS who attend a hospital for chest pain. Hence, either of the two scores would be helpful for the prognosis of death in patients with ACS.

Migraine and its relation to other risk factors in patients with acute ischemic stroke and acute coronary syndrome

BackgroundMigraine has been recently studied as a risk factor for ischemic stroke (IS) and a possible link to a broader range of ischemic vascular disorders including angina and myocardial infarction is suggested.Objectivesto study migraine and its relation to other risk factors in patients with acute IS and acute coronary syndrome (ACS).Patients and methodsWe studied 200 patients, 114 patients had acute IS and 86 patients with ACS, in addition to 850 control participants. All patients were subjected to detailed clinical and laboratory evaluation; including evaluation of traditional risk factors. All stroke patients were subjected to CT scan. Diagnosis of acute coronary syndrome was established clinically by ECG and cardiac specific enzymes. Migraine was diagnosed according to the international headache society and assessment of migraine severity was measured by the Migraine Disability Assessment (MIDAS) questionnaire.ResultsIn patients with ischemic stroke, Risk Ratios (RR) of migraine was 3.3 for all migrainous patients, higher for migraine with aura (MA). In the cardiovascular group, it was 2.75 and again higher in MA. A positive correlation between migraine severity and both stroke severity and cardiac affection severity was found though non-significant in the cardiovascular group. There was no significant difference in hospital outcome in migrainous patients in both groups.ConclusionsPatients with migraine have higher risk than non-migrainous patients for both cerebrovascular and coronary vascular diseases. Risk is stronger in MA in both conditions. Considering migraine in risk stratification of cerebrovascular and cardiovascular diseases is recommended.

Bone marrow-derived mesenchymal stem cells microvesicles stabilize atherosclerotic plaques by inhibiting NLRP3-mediated macrophage pyroptosis.

Rupture of atherosclerotic plaques constitutes the major cause of thrombosis and acute ischemic coronary syndrome. Bone marrow-derived mesenchymal stem cells microvesicles (BMSCs-MVs) are reported to promote angiogenesis. This study investigated the role of BMSCs-MVs in stabilizing atherosclerotic plaques. BMSCs-MVs in mice were isolated and identified. The mouse model of atherosclerosis was established, and mice were injected with BMSCs-MVs via the tail vein. The macrophage model with high glucose and oxidative damage was established and then incubated with BMSCs-MVs. Nod-like receptor protein 3 (NLRP3) expression, pyroptosis-related proteins, and inflammatory factors were detected. Actinomycin D was used to inhibit the secretion of BMSCs-MVs to verify the source of microRNA-223 (miR-223). The binding relationship between miR-223 and NLRP3 was predicted and verified. BMSCs-MVs with knockdown of miR-223 were cocultured with bone marrow-derived macrophageswith knockdown of NLRP3, and then levels of miR-223, NLRP3, pyroptosis-related proteins, and inflammatory factors were detected. BMSCs-MVs could reduce the vulnerability index of atherosclerotic plaques and intima-media thickness in mice, and inhibit pyroptosis and inflammation. BMSCs-MVs inhibited pyroptosis and inflammatory factors in macrophages. BMSCs-MVs carried miR-223 to inhibit NLRP3 expression and reduce macrophage pyroptosis, thereby stabilizing the atherosclerotic plaques.

Bleeding and Transfusion

This review describes the approaches taken for patient with massive hemorrhage, a derangement of hemostasis, and anemia. For hemorrhage, control of the source of bleeding, restoration of the blood volume, and management of the coagulopathy is presented. Exclusion of technical causes of bleeding, an initial assessment of potential coagulopathy, and an interpretation of coagulation parameters is described for derangements of hemostasis. For anemia, acute coronary artery ischemic syndromes and neurologic conditions are described. Additionally, bleeding disorders are presented. Figures depict various algorithms related to decision-making and treatment. Tables show the management of the patient with an increased International Normalized Ratio, coagulopathy scores, classification and management of Von Willebrand disease, and tests of platelet function. This review contains 83 references.

Case report: Posterior myocardial infarction in presence of right bundle branch block: an old concept with new findings

BackgroundThe diagnosis of acute ischaemic coronary syndromes in presence of an intra-ventricular conduction disturbance represents a clinical challenge. In the cardiac segmentation model the posterior wall is replaced by the basal inferior segment. However, in the clinical scenario of acute coronary syndrome the concept of posterior myocardial infarction (PMI) endures. The association of a PMI and right bundle branch block (RBBB) is a rare condition characterised by broad R waves and ventricular repolarization disorders in right precordial leads in both entities, which could lead to misinterpretation and delay in reperfusion therapy.Case SummaryWe describe a case report of a 74-year-old man with acute chest pain and an electrocardiogram with broad R waves, a 4 mm ST-segment downsloping (excessively discordant) in right precordial leads, RBBB, and ST-segment elevation in posterior leads. There was resolution of ST-segment downsloping in right precordial leads after percutaneous coronary intervention and stenting of the circumflex artery, with disturbance of the repolarization process only attributable to RBBB.DiscussionPatients with acute chest pain with RBBB and a ST segment with an excessive downsloping (out of proportion of what is expected in isolated RBBB) suggest PMI with occlusion of the circumflex coronary artery.

Sistemas de trauma

El trauma grave sigue siendo la principal causa de muerte en gente joven en nuestro medio y siguen siendo los accidentes de tráfico la causa fundamental. Según datos de la DGT en 2016, se produjeron 1160 victimas mortales con 5067 heridos que requirieron hospitalización. La enorme carga económica y social que el trauma ejerce en todo el mundo, ha llevado a avances significativos en los últimos 45 años, en el conocimiento de la fisiopatología, en el manejo prehospitalario y hospitalario, en las técnicas de imagen, en la cirugia y en los cuidados intensivos, en la infraestructura y organización necesaria para atender a estos pacientes. Sin embargo la eficacia del tratamiento puede reducirse si las intervenciones necesarias no están disponibles con prontitud o no existe una buena coordinación entre los elementos implicados en el cuidado de los pacientes1. Para algunos autores el sistema de trauma es el sistema “gold estandar”2 para prestar la atención sanitaria adecuada al paciente traumático. En nuestro medio la organización de la atención al trauma grave se encuentra en un escalón inferior a la atención de otras patologías tiempo dependientes, como el ictus isquémico agudo o el síndrome coronario agudo. En esta revisión, dividida en dos partes, se pretende definir que es un sistema de trauma, sus componentes, resaltar la importancia, la situación y desarrollo a nivel internacional y nacional y los requisitos necesarios para su puesta en marcha.

Aptitud clínica en un servicio de urgencias para la atención del paciente con síndrome isquémico coronario agudo

Objetivo: medir el grado de aptitud clínica para el tratamiento del paciente con síndrome isquémico coronario agudo (sica) en los médicos del servicio de urgencias del hospital general “Dr. Belisario Domínguez” del Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (issste), en Tuxtla Gutiérrez, Chiapas. Métodos: estudio transversal y comparativo; se evaluó la aptitud clínica de 57 médicos en el servicio de urgencias, mediante un instrumento de 30 ítems conformado por siete indicadores. Consistencia de 0.731 (Kuder-Richardson). El análisis estadístico incluyo la prueba de Kruskal Wallis y U de Mann-Whitney, se utilizó la corrección de Bonferroni para establecer una p<0.017 como significativa. Resultados: 77.2% de los médicos demostraron una aptitud clínica explicada por el azar. Al analizar los indicadores que conforman la aptitud clínica, el grupo de médicos internos de pregrado demostró una capacidad mayor de integración diagnóstica (p=0.010) y una menor omisión iatrogénica (p=0.012). Conclusiones: es importante introducir en la unidad un programa de capacitación continua a través de la discusión de casos clínicos problematizados que favorezcan el desarrollo de capacidades complejas como las exploradas en este estudio.

Aptitud clínica en un servicio de urgencias para la atención del paciente con síndrome isquémico coronario agudo

Objective: to measure the level of clinical ability for the treatment of the patient with Acute Ischemic Coronary Syndrome (acs) of physicians in the Emergency Room of the “Dr. Belisario Dominguez” General Hospital of the Institute of Security and Social Services of the State Workers (issste), in Tuxtla Gutierrez, Chiapas. Methods: cross-sectional and comparative study; 57 physicians of the Emergency Room were evaluated, through an instrument of 30 items constitued by seven indicators. Consistency of 0.731 (Kuder-Richardson). The statistical analysis included the Kruskal Wallis test and the U of Mann-Whitney. It was used the correction of Bonferroni to establish a p<0.017 as significant. Results: 77.2% of the physicians showed a clinical ability explained by random. By analyzing the indicators, internal undergraduate medical group showed a greater diagnostic integration capacity (p=0.010) and a less iatrogenic omission (p=0.012). Conclusions: it is important to introduce a program of continuous training, in the er, through the discussion of clinical cases that favor the development of complex capabilities as the explored in this study.

PM142 Index of Inflammation in Patients With Acute Coronary Ischemic Syndrome in Relation With The Syntax Score

PM142 Index of Inflammation in Patients With Acute Coronary Ischemic Syndrome in Relation With The Syntax Score

Lambl's excrescences: A case report and review of the literature.

Lambl's excrescences are filamentous extensions of cardiac valves, mostly asymptomatic but rarely associated with catastrophic thromboembolic events such as acute ischemic stroke and acute coronary syndromes. Numerous case reports cited in the literature have addressed various spectrum of presentation of these syndromes and their outcomes based on therapies used. We encountered such a patient from our own experience who presented with an acute ischemic stroke with no other identifiable cause other than the Lambl's excrescences. We subsequently carried out an extensive literature search and based on our interpretation of the outcomes we decided to treat the patient to the best of our understanding. In the proceeding section we describe the case and the discussion and our rationale to treat the patient accordingly.

Abstract 13709: High-Density Lipoprotein is a Novel Activator of Cardiac Glucose Metabolism in both Healthy and Insulin Resistant Myocardium

Aims: High-density lipoprotein (HDL) is known to increase skeletal muscle glucose uptake, but whether this action extends to the myocardium and has relevance in the setting of ischemia is unknown. This study aimed to determine the effect of HDL on cardiac glucose metabolism both in vitro and in vivo, including during ischemia/reperfusion injury. Methods and Results: HDL treatment (50μg/mL) increased glucose uptake (147±10%), glycolysis (154±11%) and glucose oxidation (130±6%) in neonatal ventricular cardiomyocytes compared to saline control. HDL rapidly activated the Akt pathway and an Akt inhibitor (Akti 1/2) abolished HDL-mediated glucose uptake, suggesting an Akt-dependent mechanism. To determine the upstream receptor mechanism HDL binding to sphingosine-1-phosphate (S1P) receptors was blocked with either 1uM VPC23019 (S1P1&amp;3 antagonist) or 1uM CAY10444 (S1P3 antagonist). Both similarly inhibited HDL-mediated glucose uptake. S1P is a known activator of the Akt pathway, thus our data suggests the S1P component of HDL increases glucose uptake via S1P3 activation of the Akt pathway. The effect of a single intravenous bolus of reconstituted HDL (CSL-111; 80mg/kg) in chow diet (CD) and high fat diet (HFD) insulin resistant C57Bl6 mice was investigated during an oral glucose tolerance test (OGTT). CSL-111 treatment increased cardiac muscle glucose clearance in both CD (168±16%) and HFD (138±11%) mice compared to saline infusion during the OGTT. To assess whether CSL-111 could increase cardiac glucose uptake in an ischemic setting, a single bolus of CSL-111 (80mg/kg) was given at the beginning of reperfusion in mice following left anterior descending artery (LAD) ligation. CSL-111 trended to increase cardiac glucose uptake ([18F]Fluorodeoxyglucose tracer and PET-CT imaging) by 66% (chow) and 81% (HFD) (treatment effect p=0.07) 1 hour post-reperfusion following LAD surgery. Furthermore, CSL-111 improved long term cardiac functional recovery. Conclusion: These data show that HDL increases glucose uptake and utilisation in the heart suggesting a role for HDL therapies in preserving functional myocardium subsequent to acute coronary ischemic syndromes.

Safety of percutaneous coronary intervention in patients with acute ischemic stroke/transient ischemic attack and acute coronary syndrome.

Cardiac events in patients with acute stroke are frequent. Urgent PCI in myocardial infarction is crucial to improve outcome. However, the situation is complex as intracranial hemorrhage is a frequent complication of stroke but antithrombotic medication is indispensable during and after PCI. Therefore in this study, we aimed to investigate the safety of percutaneous coronary intervention (PCI) in patients hospitalized with acute ischemic stroke and concomitant acute coronary syndrome (ACS). In a single-center, case-series study we investigated 80 patients hospitalized with acute stroke/transient ischemic attack (TIA) and concomitant ACS undergoing coronary angiography. Patients with subsequent PCI were compared to patients with medical treatment alone. The primary end point was the composite of death, recurrent MI, coronary re-intervention, recurrent stroke or bleeding during 1-year follow-up. The secondary end point consisted of the components of the primary end point. Age, gender and cardiovascular risk factors did not differ between groups. However, severity of initial stroke and coronary artery disease was higher in the PCI group. Accordingly, antiplatelet medication with aspirin and clopidogrel was prescribed more frequently in the PCI group. Nevertheless, during 1-year follow-up, the primary end point did not differ between groups [38 vs. 50 %, odds ratio (OR) 1.7, CI 0.69-4.07, P = 0.23]. Intracranial hemorrhage was even numerically lower in patients undergoing PCI (5 vs. 3 %, OR 0.4, CI 0.04-5.6, P = 0.46). The primary and secondary end points were not enhanced in patients undergoing PCI. Therefore PCI is safe in patients with stroke/TIA and concomitant ACS.

Imaging of functional and structural alterations of large arteries after acute ischaemic atherothrombotic stroke or acute coronary syndromes

Non-invasive methods allow the evaluation of structural and functional arterial abnormalities. So far, no study has focused on the comparison of vascular parameters by type of cardiovascular event. In this pilot study, cardiovascular risk factors, carotid parameters, carotid-to-femoral pulse wave velocity (PWV), brachial flow-mediated dilation and ambulatory blood pressure were assessed in patients who presented with acute coronary syndromes (ACS) or ischaemic atherothrombotic stroke (IAS). Groups were matched for age and gender. Prevalences of hypertension, diabetes and dyslipidaemia and heredity, smoking and body mass index were similar in the ACS (n=50) and IAS (n=50) groups. Carotid intima-media thickness (IMT) and PWV were significantly higher in the IAS vs. ACS group (769±180 vs. 701±136 μm; P=0.039 and 12.5±3.5 vs. 10.7±2.4 m/s; P=0.006). Carotid distensibility was significantly lower in the IAS vs. ACS group (16.2±3.2 vs. 18.9±7.6 10(-3)/kPa; P=0.02). These differences persisted after adjustment for blood pressure for carotid distensibility but not for PWV. The prevalences of endothelial dysfunction and carotid plaques were not significantly different in the ACS and IAS groups (86% and 74%; 80% and 78%). In a multivariable model, carotid distensibility remained associated with ACS (odds ratio 1.19; 95% confidence interval 1.03-1.38; P=0.016). Stiffness and carotid wall thickness were higher in IAS than in ACS patients. These differences may support the interest in new therapeutic targets for cardiovascular secondary prevention. NCT00926874.

Matrix Metalloproteinases and Vulnerable Atheromatous Plaque

Atherosclerotic coronary artery disease, the underlying basis for ischemic heart disease, is the leading cause of death and disability in the USA and recent trends indicate that coronary artery disease is also becoming a major public health problem in developing countries [1]. Atherosclerosis is a continuous process that is initiated early in life, which gradually progresses with potentially devastating consequences: atherosclerotic plaque rupture is the most common underlying pathological mechanism creating acute ischemic coronary syndromes [2]. This term refers to the process of disruption of the endothelial surface and the exposure of the underlying prothrombotic vessel wall to circulating platelets and coagulation factors. In order to identify the high-risk plaque we need to recognize its specific morphological and functional characteristics. The morphological characteristics have been identified in several human histopathological and in vivo studies, and include: 1) a large lipid core (≥40% plaque volume) composed of free cholesterol crystals, cholesterol esters, and oxidized lipids impregnated with tissue factor, 2) a thin fibrous cap depleted of smooth muscle cells and collagen, 3) an outward (positive) remodeling, 4) inflammatory cell infiltration of fibrous cap and adventitia (mostly monocyte- macrophages, activated T cells and mast cells), and 5) increased neovascularization. The terms vulnerable, unstable or 'high-risk' are now widely used to describe plaques that exhibit such features, irrespective of whether rupture of the fibrous cap is present [3].

Identificación de componentes del síndrome metabólico en pacientes mexicanos hospitalizados por síndrome isquémico coronario agudo: una herramienta para la prevención

ObjectiveTo determine the prevalence of metabolic syndrome (MS) and its risk factors in patients with Acute Ischemic Coronary Syndrome (AICS) in a tertiary hospital. MethodsA total of 65 patients admitted to Cardiac Intensive Care Unit with myocardial infarction or unstable angina participated. MS was diagnosed in accordance to the Adult Treatment Panel III (ATPIII) criteria. ResultsThe total prevalence of MS was 84.6% (95% CI: 75.6 to 93.6). MS was more frequent in women, persons with obesity according to the body mass index (BMI), family background diabetes, and dyslipidemia. Phenotype predictors of MS were: BMI (OR=2.12, 95% CI: 1.24, 3.17) and familiar history of dyslipidemia (OR=0.026, 95% CI: 0.003, 0.587). ConclusionsThe prevalence of MS with AICS is higher than that reported in other populations. This fact is alarming if this risk is maintained in the Mexican population.

Bleeding and Transfusion

This review describes the approaches taken for patient with massive hemorrhage, a derangement of hemostasis, and anemia. For hemorrhage, control of the source of bleeding, restoration of the blood volume, and management of the coagulopathy is presented. Exclusion of technical causes of bleeding, an initial assessment of potential coagulopathy, and an interpretation of coagulation parameters is described for derangements of hemostasis. For anemia, acute coronary artery ischemic syndromes and neurologic conditions are described. Additionally, bleeding disorders are presented. Figures depict various algorithms related to decision-making and treatment. Tables show the management of the patient with an increased International Normalized Ratio, coagulopathy scores, classification and management of Von Willebrand disease, and tests of platelet function. This review contains 83 references.

Bleeding and Transfusion

This review describes the approaches taken for patient with massive hemorrhage, a derangement of hemostasis, and anemia. For hemorrhage, control of the source of bleeding, restoration of the blood volume, and management of the coagulopathy is presented. Exclusion of technical causes of bleeding, an initial assessment of potential coagulopathy, and an interpretation of coagulation parameters is described for derangements of hemostasis. For anemia, acute coronary artery ischemic syndromes and neurologic conditions are described. Additionally, bleeding disorders are presented. Figures depict various algorithms related to decision-making and treatment. Tables show the management of the patient with an increased International Normalized Ratio, coagulopathy scores, classification and management of Von Willebrand disease, and tests of platelet function. This review contains 83 references.

Abstract 4881: Interaction of Genetic and Pharmacologic β -adrenergic Signaling Inhibitors Determines Long-term Mortality after Acute Coronary Ischemia

Introduction: While chronic β-blocker (BB) therapy after myocardial infarction (MI) reduces the long-term risk of death, recent studies suggest that BB within 24h after MI is associated with increased death from cardiogenic shock. We have described a naturally-occurring G-protein Receptor Kinase ( GRK )5 L41 polymorphism that mimics BB effects in experimental models and human heart failure raising the possibility that pre-existing “genetic β-blockade” might also affect outcomes after MI. Methods: 3,244 patients hospitalized with acute coronary ischemic syndromes (ACS; 2,943 MI; 301 unstable angina) were followed for an average of 2.7 years. Primary endpoint was time to death. A sub-cohort (n=973) was followed for time to rehospitalization. Independent variables were antecedent BB therapy (a-BB), discharge BB therapy (d-BB), and GRK5 Q41L genotype. Differences were assessed with Kaplan Meier curves, log-rank tests, and Cox proportional hazards modeling (HR). Results: Complete data were available for 2,732 subjects (24% African American [AA], 33% female, 32% a-BB, 87% d-BB). Overall mortality rate was 12%, and rehospitalization occurred in 41%. AA had increased mortality risk (HR=1.32, CI= 1.017–1.71, p=0.037). a-BB significantly increased mortality in both AA (HR=1.69, CI=1.006–2.84, p=0.047) and Caucasians (HR=1.98, CI=1.523–2.57, p=0.00000033). GRK5 L41 is more common in AA. GRK5 L41 carrier status did not significantly affect mortality in AA or Caucasian non-BB subjects, but protected against death in AA with a-BB (HR=0.456, CI= 0.256 – 0.812, p=0.0076; p value for gene-drug interaction=0.041). In the rehospitalization sub-study, GRK5 L41 protected AA from rehospitalization, independent of BB use (HR=0.605, CI=0.388 – 0.943, p=0.026). d-BB status was not associated with mortality or rehospitalization after discharge. Conclusions: Antecedent, but not discharge, treatment with BB is associated with adverse long-term outcomes in ACS patients requiring hospitalization. In contrast, AA patients carrying the GRK5 L41 polymorphism are protected against death and rehospitalization. “Genetic β-blockade” may have advantages over, and can oppose some untoward consequences of, pharmacological β-receptor antagonism in ACS patients.

Quantitative intravascular ultrasound elasticity imaging as an imaging biomarker in clinical trials

The composition and morphology of an atherosclerotic lesion are currently considered more important determinants of acute coronary ischemic syndromes that the degree of stenosis. When a lesion is unstable, it can rupture and cause an acute thrombotic reaction. An unstable plaque can be characterized by a lipid core that is covered by a thin fibrous cap, which has been locally weakened by inflammatory cells. Intravascular Ultrasound Palpography is an intravascular ultrasound based technique that is capable to measure the local strain in coronaries and atherosclerotic plaque. This strain is induced by varying intraluminal pressure. This lecture will show principles of the technology and how this technology is used in clinical trials. Results from a trial with traditional lipid lowering treatment (IBIS1) and from a trial on the efficacy of a new medication (IBIS2) will be presented. Furthermore the potential of Intravascular Ultrasound Modulography will be discussed. This work is financially supported by the Dutch Technology Foundation, The Dutch Heart Foundation and a research grants from Volcano Corporation and Glaxo Smith Kline