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#32 De: Badiel Marisol < epidemiologia@cardiolili.org >
Enviado: Sábado, 06 de Noviembre de 1999 06:46
Asunto: Infarto agudo de miocardio. Conducta/Acute Myocardial Infarction. Management
Hola Mario:
A proposito de su pregunta. Hasta hoy reforzamos la evidencia de que PTCA es mejor que trombolisis con STK, pues el interesante articulo del Dr. Zijlastra que aparece en NEJM de nov 4-99, nos acerca al beneficio de esta estrategia (PTCA) sobre trombolisis a largo plazo (5 años), pues aunque muy ligera el beneficio en terminos de mortalidad a 30 días con 1% vs 7%  (en PTCA vs STK), se perfilan como mas apropiadas las terapias intervencionistas, mas aun hoy, con el beneficio de otros avances, como inhibidores de GPIIb/IIIa, etc (que no se
tuvieron en cuenta en el trabajo de NEJM, porque fue hecho entre 1990 y 1993) pero que lleva a considerar los beneficios del intervencionismo en este tiempo, Por consiguiente para hoy en dia, la evidencia de este articulo es TIPO I y recomendacion A , hacer PTCA en vez de trombolisis, cuando se disponen de las 2 posibilidades.
ANEXO: VER ARTICULO DE NEJM: http://www.nejm.org/content/1999/0341/0019/1413.asp

Hello, Mario:
About your question. To date, we reinforced evidence that PTCA is better than thrombolysis with STK, since the interesting article by Dr. Zijlastra that appears in NEJM, Nov 4-99, bring us the benefits of this strategy (PTCA) over thrombolysis in long term (5 years), because, even though the benefits are very slight in terms of mortality at 30 days with a 1% vs. 7% (in PTCA vs. STK), interventional therapies look more appropriate, today even more, with the benefits of other advancements, like GPIIb/IIIa inhibitors, etc. (that were not considered in the work in NEJM, because it was performed between 1990 and 1993) but that leads us to consider the benefits from interventionism in this times.
Consequently, nowadays, the evidence of this article is TYPE I and A recommendation, to perform PTCA instead of thrombolysis, when the two possibilities are available.
ATTACHMENT: SEE ARTICLE IN NEJM: http://www.nejm.org/content/1999/0341/0019/1413.asp
MARISOL BADIEL, MD
Oficina de investigaciones y epidemiologia clinica
Unidad cardiovascular
Fundación Clinica Valle del Lili
www.cardiolili.org

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#33 De: Barbosa de Oliviera Marcos Aurelio < maurelio@hotmail.com >
Enviado: Sábado, 06 de Noviembre de 1999 06:43
Asunto: Infarto agudo de miocardio. Conducta/Acute Myocardial Infarction. Management
Caro Dr. Mario:
Recentemente li no New England um trabalho interessante sobre o assunto que compara o uso de angioplastia primaria versus fibrinoliticos
(estreptoquinase) na abordagem de infarto. Ele diz que em um segmento de 5 anos houve uma sobrevida de 87% no grupo que foi submetido a angioplastia primaria, enquanto que no grupo tratado com estreptoquinase foi de 76%, alem disso, foram tambem menores as taxas de reinternacoes por novos eventos isquemicos ou evolucao para insuficiencia cardiaca. Diz tambem que apesar da angioplastia primaria ser mais cara a primeira vista, um acompanhamento mais longo revela que havera uma economia de US$3.112 por paciente. A referencia
do texto e: Long-term outcome better with primary angioplasty than thrombolysis for MI - N Engl J Med 1999;341:1413-1419 Mas mesmo assim acredido que o que deve prevalecer e a experiencia do servico. Assim, se ele ja tem uma boa experiencia com angioplastia primaria, tem um bom servico de hemodinamica, essa seria a melhor indicacao, mas se nao, pensando-se em diminuir os riscos e o tempo que o paciente leva ate receber um tratamento definitivo, a melhor escolha ai seria o tratamento fibrinolitico.
Cordiais saudacoes,

Dear Dr. Mario:
Recently I read in New England an interesting work about the subject, that compares the use of primary angioplasty vs. fibrinolysis (streptokinase) in management of infarction. It says that in a period of 5 years there was an 87% of survival in the group that underwent primary angioplasty, while the group treated with STK had a 76%, besides, rates of readmissions due to new ischemic events or that evolved into heart failure were also lower. It also says that, although primary angioplasty seems more expensive at first sight, a longer follow up reveals that there will be a saving of US$ 3,112 for each patient. The reference of the text is: Long-term outcome better with primary angioplasty than thrombolysis for MI - N Engl J Med 1999;341:1413-1419 I also think that what should prevail is the experience of the service. Thus, if it has a good experience with primary angioplasty, and has a good hemodynamics service, that would be the best indication; but if not so, thinking about diminishing risks of the period of time until the patient receives a definitive treatment, the best choice would be fibrinolysis treatment.
Greetings, Marcos Aurelio
Brasil - FAMERP

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#34 De: Raul Bretal < rbretal@netverk.com.ar >
Enviado: Lunes, 08 de Noviembre de 1999 05:11
Asunto: Infarto agudo de miocardio. Conducta/Acute myocardial infarction. Management
Estimados colegas:
Con respecto al caso presentado por el Dr. Henin (IAM inferior de menos de 1 hora) he observado que la mayor parte de los mensajes refieren que seria importante reperfundirlo. Y de las variantes propuestas, la mas aceptada parece ser la intervencionista (existiendo un operador capacitado capaz de abrir el vaso dentro de una hora). Si esto es valido para un paciente con IAM inferior no complicado, creo que con mayor razon deberia ser aplicable a IAM inferior con infradesnivel del ST en cara anterior, IAM anterior, segundo IAM, IAM no Q, IAM con shock
cardiogenico; ya que en estos casos, o es el trombolitico menos efectivo, o existen evidencias que la ATC primaria seria un tratamiento mas efectivo. Si esto es asi, ¿donde queda la controversia: "tromboliticos vs ATC en IAM"? ¿Podria resumirse con la frase: "En todo IAM esta indicada la ATC primaria, excepto que no exista disponible un equipo de intervencionistas capaces de realizar ATC en forma rapida y eficiente, caso en el cual la segunda opcion serian los tromboliticos"?

Dear collegues:
About the case presented by Dr. Henin (inferior AMI, less than 1 hour) I have observed that most messages state that it would be important to reperfuse it. And among the proposed options, the most accepted one seems to be the interventional (if there is a qualified operator, capable
of opening the vessel within an hour). If this is valid for a patient with inferior AMI not complicated, I think that all the more, it
should be applicable to an inferior AMI with anterior ST subleveling, anterior AMI, second AMI, AMI non Q, AMI with cardiogenic shock; since in these cases, either thrombolysis is less effective, or there is evidence that primary PTCA would be a more effective treatment. If so,
what happens with the controversy: "thrombolysis vs. PTCA in AMI"? Could it be resumed with the sentence: "In all AMI, primary PTCA is indicated, except when there is no team of interventionists available, capable of performing PTCA quickly and efficiently, in which case
the second option would be thrombolysis"?
Dr. Raul Bretal

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#35 De:  Carlos Federico Ziehr <cfziehr@intramed.net.ar>
Enviado: Domingo, 7 de Noviembre de 1999 06:57
Asunto: Tratamiento posterior/AMI. Subsequent treatment
Estimados colegas del FORO:
Estoy de acuerdo con las diferentes opiniones respecto al tratamiento agudo del IAM, pero no olvidar que a los 50 a 60 dias del alta,es necesario poner al paciente en tratamiento de Rehabilitacion Cardiovascularr, junto con la medicación de base. El sujeto es un enfermo complicado con varios factores de riesgo, por lo que necesita un cambio de habitos, tanto alimentarios, como de comportamiento, realizacion de actividad fisica y apoyo psicologico. Esperando que esta opinion sea compartida por
Uds., saludo muy atte.

Dear friends of the FORUM:
I agree with the different opinions expressed regarding acute treatment of AMI, but we shouldnot forget that after 50 or 60 days of discharging, is necessary to give the patient a treatment for Cardiovascular Rehabilitation, along with the basic medication. The subject is a complicated patient with several risk factors, consequently s/he needs a change in habits, both eating as behavioral, performing physical activity, and psychological support. I hope that this opinion is shared by you.
Sincerely,
Dr. Carlos Federico Ziehr

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#36 De: Nazar Rodolfo < nazar@fullnet.com.ar >
Enviado: Domingo, 7 de Noviembre de 1999 08:09
Asunto: Conducta/AMI. Management
Mi estimado colega Mario:
En referencia al caso que Ud. propone, no tendria duda de enviar al paciente a hemodinamia
si dispongo del acceso inmediato a la misma. Se trata de un paciente joven de alto riesgo coronario, que persiste con sintomatologia dolorosa
lo que indicaria clinicamente miocardio isquemico. No rotularia el riesgo por la topografia del IAM ya que muy frecuente de observar en este tipo de pacientes, que debutan como un accidente de placa de vaso unico y en el estudio angiografico presentan enfermedad de multiples vasos, y muchos de ellos terminan en cirugia.  No obstante estan actualmente demostrados los beneficios de la angioplastia sobre la trombolisis. Hay que mantener el vaso abierto por lo que ante la posibilidad de hemodinamia de accesibilidad inmediata tomaria la
determinacion invasiva. (?).    Pero no descarto la trombolisis si no tengo la posibilidad de acceder a ella- Independientemente de ello el enfermo terminaria con estudio angiografico.-
Atentamente,

My dear colleague, Mario:
About the case that you propose, I would not hesitate to send the patient to hemodynamics, if I had immediate access to it.
It is a young patient, with high coronary risk, that persists with painful symptomatology, a fact that would indicate clinically, ischemic myocardium. I would not label the risk based on the AMI topography, since it is very frequent to observe in this kind of patients, that begin
as an accident of platelet of only vessel, and in the angiography study present disease of multiple vessels, and many of them end in surgery.
However, the benefits of angioplasty over thrombolysis are currently demonstrated. The vessel must be kept open, and therefore faced with the possibility of hemodynamics of immediate access, I would take the invasive choice (?). But I do not dismiss thrombolysis if I have the possibility of accessing it. Independently from that, the patient would end with an angiography study.
Sincerely, Dr.Nazar Rodolfo

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#37 De: Edgardo Schapachnik [edgardo@schapachnik.com.ar]
Enviado: Domingo, 7 de Noviembre de 1999
Asunto: Infarto agudo de miocardio. Conducta/Acute myocardial infarction. Management
Estimado Mario:
He seguido con entusiasmo el intercambio de opiniones que ha generado la presentacion del caso del paciente de 50 anios con todos los factores de riesgo y el infarto diafragmatico no complicado. Es vibrante la experiencia en cuanto juego intelectual. Sin embargo no deja
de ser causa de meditacion que un caso tan comun de la practica cardiologica cotidiana, motive conductas tan dispares en colegas de amplia experiencia en el manejo de pacientes agudos. Desde el uso del tratamiento medico convencional, la utilizacion de la estreptokinasa, o la angioplastia primaria, los distintos colegas han fundamentado el tratamiento que indicarian si el presentado fuese su
paciente. Me gustaria "escuchar" en una nueva ronda de opiniones, la fundamentacion inversa. Es decir, quisiera conocer la opinion de los colegas, en relacion a este infarto no complicado de cara inferior:
a) ¿por que NO indicaria STK NI angioplastia?
b) ¿por que NO indicaria STK y SI angioplasia primaria?
c) ¿por que NO indicaria angioplasia primaria y SI STK?
Creo que no esta de mas recordar que la opinion solicitada es para este caso en particular: infarto de cara inferior no complicado. Aprovecho para hacer una segunda pregunta: ¿variaria la conducta de los colegas opinantes, si el caso presentado hubiese tenido un infarto de cara anterior? ¿por que SI o por que NO?
Cordialmente

Dear Mario:
I have followed enthusiastically the exchange of opinions that has generated the case of the 50-year-old patient with all risk factors and non complicated diaphragmatic infarction. The experience is powerful as an intellectual game. However, it is none the less a cause for meditation, that so common a case of daily clinical cardiology, arises such differing managements in colleagues of broad experience in management of acute patients. Since the use of conventional medical treatment, use of streptokinase, or primary angioplasty, our colleagues have founded the treatment they would indicate if the presented case was their patient.
I would like to "listen" in a new round of opinions, to the reverse foundation. That is to say, I would like to know the opinion of the colleagues regarding this non complicated inferior infarction:
A) why would you not indicate STK or angioplasty?
B) why would you not indicate STK and would indicate primary angioplasty?
C) why would you not indicate primary angioplasty and would indicate STK?
I think there is no harm in remembering that the opinion requested is for this particular case: non complicated inferior infarction. I would like to take this opportunity to make a second question: would you change the management of the colleagues that expressed their opinions, if the presented case would have been an anterior infarction?
Why YES or why NOT?
Cordially, Edgardo Schapachnik

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#38 De:  Carlos Enrique Fullone <cef@intramed.net.ar>
Enviado: Martes, 09 de Noviembre de 1999 08:17
Asunto: Infarto agudo de miocardio. Conducta/Acute myocardial infarcion. Management
Estimado colega:
Este infarto como vos lo describis, tiene un excelente pronostico en agudo. En lo personal haria tromboliticos, basado en las siguientes consideraciones
1) Es mas economico.
2) Probablemente se trate de una coronaria derecha, por lo que la angioplastia tiene menor resultado.
3) A pesar de la falta de angina previa, es un paciente con multiples factores de riesgo, y en especial diabetico, por lo cual no descartaria que tuviera enfermedad de tres vasos. Por lo tanto, luego de la evolucion de su IAM, seria muy estricto en el tratamiento de todos esos factores, y en el estudio, camara gamma y eventual CCG, ya que tal vez sea candidato a cirugia de revascularizacion.
4) Con esta presuncion, si en el cateterismo en agudo observamos enfermedad severa de tres vasos, no podriamos practicar en agudo una cirugia de revascularizacion y realizar en este tiempo una angioplastia, podria complicar aun mas la situacion. Pensemos en una posible obstruccion en agudo, lo que seria, y como agrandaria el area de infarto y tal vez hasta comprometiera una circulación colateral vital. Por otro lado, si realizamos la cinecoronario y vemos esto, y decidimos no hacer la angioplastia, habremos perdido la posibilidad de la fibrinolisis.
5) La falta de angina previa siendo un diabetico, no es indicio de salud coronaria previa. Hace unos pocas semanas, realice un riesgo quirurgico para una colecistectomia electiva en un paciente diabetico, que nunca tuvo angor. Tenia una secuela de IAM inferior que por supuesto ignoraba, alto riesgo isquemico en el talio y enfermedad severa de tres vasos. Termino cambiando la cirugia biliar por una revascularizacion.
6) Por otro lado, como cardiologo simple, en este momento hay una controversia que no esta definida entre angioplastia en agudo y fibrinolisis
farmacologica. Por lo tanto para mi, hasta tanto no se logre una supremacia demasiado evidente y perdurable en el tiempo entre uno y otro procedimiento dire que ambos son mas o menos equivalentes, y que es una exquisitez estadistica la diferencia a favor de uno y otro. En este contexto, yo elijo lo mas barato y accesible a todos.
Espero haber contribuido en algo. Un fuerte abrazo.

Dear colleague:
This infarction, as you describe it, has an excellent prognosis in acute. Personally, I would proceed with thrombolysis, based in the following considerations:
1) It is cheaper
2) It is probably a right coronary, consequently angioplasty has better results.
3) In spite of the absence of previous angina, this is a patient with multiple risk factors, and especially, diabetic, because of this I would not dismiss that he had the three vessels disease. Therefore, after his AMI evolution, it would be very strict in the treatment of all these factors, and in the study, scanning and possible CAG, since he may be a candidate for revascularization surgery.
4) With this supposition, if in catheterization in acute we observe severe three vessels disease, we would not be able to perform in acute a revascularization surgery, and to carry out in this period of time an angioplasty, could complicate the situation even more. Let us think of a possible obstruction in acute, what would be, and how it would enlarge the infarction area, and maybe even involve a vital collateral circulation. On the other hand, if we perform coronary angiography, and observe this, and decide not to proceed with angioplasty, we would have missed the chance of fibrinolysis.
5) The lack of previous angina being a diabetic, it is not a hint of previous coronary health. A few weeks ago, I did a preoperative test of surgical risk for an elective cholecystectomy in a diabetic patient, that never suffered angina. He had a sequel of inferior AMI that of course
he ignored, high ischemic risk in the thallium, and severe three vessels disease. I ended up changing biliary surgery for a revascularization.
6) On the other hand, as simple cardiologist, in this moment there is a controversy that is not defined between angioplasty in acute, and pharmacological fibrinolysis. Therefore, to me, until a very evident supremacy, and enduring in time is achieved between both procedures, I will
state that both are more or less equivalent, and that difference in favor of one or another is a statistical delicacy. Within this context, I choose the cheapest and most accessible for everyone.
I hope I have somewhat been useful.
Hugs, Dr. Carlos Enrique Fullone

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#39 De:  Daniel Berrocal < dberrocal@intramed.net.ar  >
Enviado: Lunes, 8 de Noviembre de 1999
Asunto: Infarto agudo de miocardio. Conducta/Acute myocardial
Estimados colegas:
Creo que el ejemplo clinico del Dr. Mario Henin es por demas acertado pues nos pone ante una verdadera disyuntiva sobre que hacer. En principio convengamos que en ausencia de otros predictores de riesgo el infarto inferior estricto es de tan buen pronostico que ni la fibrinolisis parece justificada y mucho menos resistir un analisis costo/beneficio. Asumiendo que el paciente no tiene predictores de riesgo aumentado (infarto previo, compromiso de VD, diabetes, etc.) mi eleccion aunque opinable la basaria en lo precoz del evento y probablemente me inclinaria a realizar una coronariografia. Si se tratase de una arteria CD no muy grande o de una rama de la misma sin otras lesiones coronarias, esto confirmaria el bajo riesgo y no dudaria en no tocarla aun con TIMI 0. Si por el contrario, como ocurre frecuentemente, el tamanio del vaso y su miocardio tributario fuesen mayores que el esperable por el compromiso electrocardiografico, la intervencion estaria por demas justificada.

Dear colleagues:
I think that Dr. Mario Henin's clinic example is extremely appropriate because it faces us with a real dilemma about what to do. To begin with, let us agree in that in absence of other risk predictors, strict inferior infarction is of such good prognosis that not even fibrinolysis seems justified, let alone resisting a cost/benefit analysis. Assuming that the patient does not have increased risk predictors (previous
infarction, involvement of LV, diabetes, etc.) my choice, though arguable, would be based in how early the event is, and probably I would tend to perform a coronary angiography. If it was a right coronary artery, not very large, or a ramus of it without other coronary lesions, this would confirm the low risk, and I would not hesitate in touching it, even with TIMI 0. If, on the contrary, and as it frequently happens, the size of the vessel and its tributary myocardium were large than what is to be expected due to electrocardiographic involvement, the
intervention would be extremely justified.
Dr. Daniel Berrocal

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#40 De:  Alfredo C. Piombo <apiombo@intramed.net.ar>
Enviado: Martes, 9 de Noviembre de 1999 14:59
Asunto: Conducta/AMI. Management
Estimado Mario:
Sinceramente no esperaba que tu pregunta generara tantas respuestas disimiles. Evidentemente la cuestion trasciende al caso anecdotico para remitirnos a una problematica mucho mas profunda: la de la informacion y el manejo de la misma. He notado en la mayoría de los colegas que sus respuestas se basan en su propia experiencia y no en la evidencia cientifica. De lo contrario, ¿como puede postularse el estudio angiografico de un paciente que cursa uno de los infartos de mas bajo riesgo?  ¿Que estudio clinico randomizado avala esta conducta?  ¿Que sociedad cientifica nacional o internacional recomienda una conducta de este tipo?
¿De donde surge que todos los infartos deben ser estudiados angiograficamente? Estados Unidos realiza angiografias coronarias en el IAM en una cifra enormemente superior a la de otros países como el Canada. No obstante, tiene la misma mortalidad. Lo mismo ocurre con la angina
inestable. Al hablar de angioplastia primaria, ¿quienes tienen los mismos resultados del pequeño estudio PAMI ?
¿No sera mas representativo el estudio GUSTO II-b que a los 6 meses no encuentra ninguna diferencia entre tromboliticos y angioplastia ni siquiera en el triple end-point de muerte, reinfarto y stroke? Si el mayor metaanalisis realizado sobre trombolisis en el IAM (el FTT) no encuentra
diferencias en los pacientes con IAM inferior ( 8.4% vs. 7.5%, 2p= 0.08 ) ¿no sera porque todos los infartos inferiores no son iguales, siendo que algunos se benefician y otros no ?  Mucho menos se ha demostrado que la angioplastia reduzca la mortalidad en el infarto inferior. Por lo tanto, mas alla de lo anecdotico del caso, creo que como medicos es nuestra tarea y nuestra obligacion, la de discriminar en nuestros pacientes niveles de riesgo y poder asi administrar racionalmente los recursos de salud, que son siempre limitados (en cualquier pais del mundo). Ningun tratamiento en medicina es para todos, y es bueno que asi sea, de lo contrario nuestra profesion se volveria intolerablemente aburrida.
Los saluda atentamente,

Dear Mario:
Sincerely I did not expect that your question would generate so many different answers. Obviously, the matter goes beyond the anecdote to present us with a situation much deeper: information and its handling. I have noticed in most colleagues that their answers are based in their own experience, and not in scientific evidence. Otherwise, how can it be posed the angiography study in a patient that is in evolution of one of the infarctions of lowest risk? What randomized clinical study supports this management? What scientific society, national or international recommends this kind of management? From where it emerges that all infarctions must be studied by angiography? USA is carrying out
coronary angiographies in AMI in an amount enormously above other countries like Canada. However, they have the same mortality. The same happens with unstable angina. When talking about primary angioplasty, who has the same results as the small PAMI study? The study GUSTO II-b would not be more representative, that after 6 months does not find any difference between thrombolysis and angioplasty, not even in the triple end-point of death, reinfarction, and stroke? If the largest meta-analysis carried out on thrombolysis in AMI (the FTT) does not find differences in patients with inferior AMI (8.4% vs. 7.5%, 2p=0.08), the reason may be that not all inferior infarctions are equal, since some benefit and others do not? Least of all has been demonstrated that angioplasty reduces mortality in inferior infarction. Therefore, beyond the anecdote, I think that as physicians it is our duty and our commitment to distinguish the levels of risk in our patients, so that we can manage rationally the health resources, that are always limited (in any country of the world). No treatment in medicine is for everyone, and it is good that it is so, otherwise our profession would be unbearably boring.
Sincerely, Alfredo C. Piombo

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#41 De:  Jose L. Castellano < jcastel@intramed.net.ar >
Enviado: Martes, 9 de Noviembre de 1999 13:11
Asunto: Conducta/AMI.Management
El Dr. Jose Luis Castellano envia el siguiente aporte en relacion al caso del paciente con infarto agudo de miocardio (IAM) de cara inferior:
La reperfusion coronaria luego de un  IAM debe ser lo mas completa posible para preservar la funcion ventricular y disminuir la mortalidad. En un paciente con IAM de cara inferior que cursa sin complicaciones, el tratamiento trombolitico (TL)  brinda buenos resultados antes de las 3 horas de iniciado el evento y pasado ese lapso la posibilidad de exito decrece progresivamente.
En condiciones favorables es el metodo de eleccion. La posibilidad de contar con personal medico adiestrado para realizar una angioplastia primaria (ATC) abre un interrogante, desde su misma contraindicacion, planteada por CONSENSO, para este caso particular. Cabe destacar que el Consenso de Cardiopatia isquemica de la Sociedad Argentina de Cardiologia considera como una indicacion Clase III para ATC primaria al IAM de cara inferior no complicado (suplemento de la Revista Argentina de Cardiologia, 1997). La evidencia de superioridad de la ATC comparada con TL ha generado controversias, pero el estudio GUSTO IIb que compara ATC vs. TL con TPA ha arrojado luces a favor de la ATC primaria como metodo mas efectivo para alcanzar una reperfusion mas completa con menor incidencia de accidentes cerebrovasculares hemorragicos. Para pacientes de un grupo etario como el del caso y con un IAM no extenso y no complicado, creo sin embargo que la utilizacion de TL redunda en una mejor relacion costo/beneficios.
Cordialmente

Dr. Jose Luis Castellano sends the following contribution regarding the case of the patient
with acute inferior myocardial infarction (AMI):
Coronary reperfusion after AMI must be as complete as possible to preserve ventricular function and diminish mortality. In a patient with inferior AMI that evolves without complications, the thrombolysis treatment provides good results before the 3hs after the event started, and after that period the possibility of success gradually decreases. In favorable conditions is the method of choice. The possibility of having trained medical staff to perform a primary angioplasty (PTCA) poses a question, since the contraindication itself, proposed by CONSENSO, for this particular case. It must be pointed out that the Consenso for Ischemic Heart Disease by the Sociedad Argentina de Cardiologia (Argentine Society of Cardiology) considers as a Class III indication for primary PTCA, the non complicated inferior AMI (supplement of the "Revista Argentina de Cardiologia" (Argentine Journal of Cardiology)), 1977. Evidence of superiority of PTCA when compared to Thrombolysis, has generated controversy, but the GUSTO IIb study that compares PTCA vs. thrombolysis with TPA has thrust light in favor of primary PTCA as a more effective method to reach a more complete reperfusion with less incidence of hemorrhagic strokes. For patients from an age group like the one presented in the case, with a non extensive and non complicated AMI, I, however, believe that use of thrombolysis results in a better cost/benefit ratio.
Cordially,
Dr. Jose Luis Castellano

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