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Sumario Vol. 42 - Nº 3 Julio - Septiembre 2013
Scope of AMI with ST Segment Elevation in México
Carlos Martínez Sánchez

Departamento de Urgencias y Unidad Coronaria.
Instituto Nacional de Cardiología "Ignacio Chávez".
Juan Badiano 1, Sección XVI, Tlalpan,
(14080) Ciudad de México, Distrito Federal, México.
E mail

Recibido el 17-ABRIL-2013 – ACEPTADO el 02-MAYO-2013.

The author declares not having a conflict of interest.

Rev Fed Arg Cardiol. 2013; 42(3): 168-169


Print version Imprimir sólo la columna central

 

The main cause of death in the Western world is currently atherothrombotic disease, which manifests mainly by acute coronary syndrome (ACS), with or without ST segment elevation, with greater prevalence even than infectious diseases and cancer.

At the Instituto Nacional de Cardiología “Ignacio Chávez” from Mexico, reference center of high complexity, in the range of clinical presentation of ACS, STE ACS is more frequent, followed by NSTE ACS, and then unstable angina (UA).

Reperfusion in acute myocardial infarction with ST segment elevation is the cornerstone of cardiological treatment, since it managed to modify the natural history of this entity by decreasing morbi-mortality.

In the Coronary Unit of the Instituto Nacional de Cardiología “Ignacio Chávez”, once the diagnosis of STEMI is made, reperfusion treatment (pharmacological or mechanical) is immediately implemented. Currently, the reperfusion strategy of choice in infarction is percutaneous transluminal coronary angioplasty (PTCA). In the case of not having a hemodynamic lab to perform PTCA, undoubtedly the patient should be thrombolyzed. Reperfusion therapy in AMI is essential, since it reduces the size of the infarcted area, thus preserving left ventricular function and decreasing mortality.

In Mexico, the Registro Nacional de Síndromes Isquémicos Coronarios Agudos (acute coronary ischemic syndrome - ACIS)  - RENASICA, in its second stage until 2005 [1], showed that 37% of patients with STE ACS were pharmacologically reperfused, and just 15% with PTCA, with an overall mortality of 10%. It should be noted that almost 50% of patients were not reperfused and this proportion still persists, becoming a problem of a great magnitude in our country. The 2 main basic reasons for which these patients were reperfused is first the delay and loss of a proper window of reperfusion, and the other is the lack of a proper diagnosis.

RENASICA II also allowed to know more of the clinical features of Mexican patients, with 43% of diabetic patients, 50% of hypertensive patients, and a third part of female gender, with the latter group being of high risk given its higher mortality.

In the ER and Coronary Unit of the Ignacio Chávez Institute, approximately 1400 patients are admitted yearly with diagnosis of ACIS of an approximate total of 140.00 consultations, 35% with history of hypertension and a high percentage of smoking and dyslipidemia.

In Mexico, the “pharmacoinvasive” concept [2], is a project to develop and it is a priority at the Ignacio Chávez Institute. This concept implies that the centers that don’t have a proper hemodynamic lab available 24 hours per day, they should implement early pharmacological reperfusion with a fibrinolytic agent along with the optimal coadjuvant antithrombotic treatment, to perform early angioplasty in the next 8-48 hours, even in those patients with clinical criteria of positive reperfusion. In the case that the pharmacological reperfusion failed, rescue angioplasty should be conducted.

At the Ignacio Chávez Institute, 3 pharmacological reperfusion plans are used: streptokinase (1,500,000/60 minutes); ultrarapid regime of rtPA (20 mg bolus + 80 mg infusion in one hour) and Tenecteplase (dose according to weight). In Mexico, the safety and effectiveness of the ultrarapid rtPA regime in 60 minutes has been validated with a reperfusion rate of 80%, with 0.04% of intracranial bleeding and a survival rate at 30 days of 95% [3]. In Mexico, thrombolysis during the first 25 years has remained the standard treatment for acute myocardial infarction [4.5].

It has been known for a while yet, that the most important reperfusion criterion is ST segment downsloping >50%, preferably >70%, since this relates to the TIMI3 flow and TMP3 flow [6].

In the Coronary Unit of the Ignacio Chávez Institute, the reperfusion algorithm is based on the door-to-balloon time; it this is <90 minutes, primary PTCA is conducted; if the time is >90 minutes and there is no contraindication for thrombolysis, this is made with fibrino-specific agents of choice. If there are reperfusion criteria, the patient will undergo coronary angiography within a period of 24 to 48 hours to fulfill the revascularization. If thrombolysis failed, rescue angioplasty is made.

Currently, an acceptable delay time to perform primary PTCA is considered as a time since the first medical contact until balloon dilatation <120 minutes, and in infarctions with less than 2 hours of evolution, a time of first medical contact-balloon <90 minutes.

In countries such as Mexico, where almost 50% of the population with STEMI cannot be reperfused, and in those countries where pharmacological reperfusion predominates, this strategy should become universal to achieve increasing the practice of myocardial reperfusion [7], to assess later the pharmaco-invasive strategy.

 

BIBLIOGRAPHY

  1. García A, Jerjes-Sánchez C, Martínez BP, et al. RENASICA II. Un registro Mexicano de los síndromes coronarios agudos. Arch Cardiol Mex 2005; Supl 2: S6-S19.
  2. Mele EF. Avances en la reperfusión del infarto agudo de miocardio. Rev Esp Cardiol 2010; 63 (Supl 2): 12-9.
  3. Martínez Sánchez C, Domínguez JL, Aguirre SJ, et al. Tratamiento del infarto agudo de miocardio con rt-PA en 60 minutos. Estudio Cooperativo. Arch Cardiol Mex 1997; 67: 126-31.
  4. Registro Nacional de los Síndromes Coronarios Agudos (RENASICA). Arch Cardiol Mex 2002; 72: S45-S64.
  5. Borrayo G, Madrid A, Arriaga R, et al. Riesgo estratificado de los síndromes coronarios agudos. Resultados del primer RENASCA-IMMS. Rev Med Inst Mex Seguro Soc 2010; 48: 259-64.
  6. Purcel IF, Newall N, Farrer M. Changes in ST segmente elevation 60 minutes after thrombolytic initiation predicts clinical outcome as accuretely al later electrocardiographic changes. Heart 1997; 78: 465-71.
  7. Martínez Ríos MA. En Manual de reperfusión farmacológica del infarto agudo del miocardio con elevación del segmento ST. Carlos R Martínez Sánchez, Héctor González Pacheco Editores. 2013. Intersistemas S.A. de C.V. México DF, México.

Publication: September 2013

 
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