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COSTA, GEETA GIULIA (2011) SIGNIFICATO PROGNOSTICO DEL PRECONDIZIONAMENTO NELL'INFARTO MIOCARDICO ACUTO: RUOLO DELL'ANGINA PRE-INFARTUALE. [Tesi di dottorato]

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Abstract (inglese)

Historical Background. “Angina pectoris” has been known since in ancient Egyptian time. Ebers Papyrus (1500 BC) wrote in a passage ".... If you examine a man for heart disease, he complains of pain in the arm, chest and part of the heart ....".
This is the beginning of the long journey that takes us to the 1912 description of the myocardial infarction by coronary thrombosis by James Herrick, the 1962 subsequent birth of the first coronary care unit by Desmond Julian and finally in 1981 to the most modern Chest Pain Unit.
Research continues to evaluate new aspects that could lead to the discovery of new strategies to reduce mortality rate of this disease.

Background and aims. Preinfarction angina (defined as angina onset within 24 hours from the myocardial infarction) gives protection to the myocardium by reducing infarct size, and limiting left ventricular remodeling.
The purpose of this study was to evaluate patients with acute coronary syndrome with ST elevation, and in particular subgroups. We compared patients with preinfarction angina (API +) to those without preinfarction angina (API-) with regard to ventricular function, end-diastolic volume and in-hospital clinical outcome. All these patients are followed up for one year under echocardiography and clinical settings, in order to assess whether any protective effects that are present during the hospital stay persist after one year.

Methods and results. We evaluated over a period of two years 448 consecutive patients admitted to the Coronary Care Unit for acute coronary syndrome with ST elevation. Regardless of treatment received, of these patients we analyzed in greater detail a homogeneous subgroup, which had a significant lesion on left anterior descending coronary artery.
Of these patients we performed a clinical and echocardiographic follow-up to a year.
This study excluded patients enrolled in other studies.
Our population was divided as follows: 112 patients, representing 25%, had suffered preinfarction angina (API +) within 24 hours from myocardial infarction, the remaining 336 (75%) had had no angina in the last 24 hours (API-). The two groups compared (API + versus API-) showed no significant differences in age, sex, risk factors (hypertension, high cholesterol, diabetes, family history of coronary artery disease, smoking). With regard to the treatment we found that the API + group had been treated more frequently with primary angioplasty compared to the API- group (88% vs 79%, p = 0.025).
With regard to the in-hospital outcome group API+ compared to API- had a significantly reduced length of stay (9 ± 4 days vs 11 ± 9 days, p = 0.004), lower presence of arrhythmias (20% vs 32%, p = 0.015 ), less presence of heart failure (6% vs 14%, p = 0.035) and with regard to data echocardiography: ventricular function was better in group API + (ejection fraction 51 ± 7 % vs 48 ± 9%, p = 0.003) in correspondence to a lower end-diastolic volume (58 ± 11 ml/m2 vs 62 ± 17 ml/m2, p = 0.005)
In a one year clinic follow up the number of admissions in other departments was significantly reduced (15% vs 25% p= 0.04) in the group API+, there is no statistical difference regarding the other parameters evaluated between outcome and preinfarction angina even if they are suggestive of a better prognosis in presence of the latter (one year survival 98% in API+ vs 93% in API-).
So, considering the well known benefits of revascularization with primary angioplasty and thinking that they may cover the benefits of preinfarction angina, we evaluated a very homogeneous subgroup of 277 patients who had a critical lesion on the left anterior descending coronary artery. Of these, 30% was API +, while the remaining 70% were API-. There were no significant differences with regard to clinical variables.
There were no significant differences with regard to the treatment received, while confirming the data of better in-hospital prognosis of group API + compared to API- with reduced hospital stay (9 ± 4 days vs 13 ± 10 days, p = 0.01), a lower presence of arrhythmias (20% vs 32%, p = 0.03), less presence of heart failure (7% vs 17%, p = 0.029) and also with regard to echocardiography: ventricular function was greater in the API + (50 ± 8% vs 46 ± 9%, p = 0.00) at a lower end-diastolic volume (59 ± 12 ml/m2 vs 64 ± 18 ml/m2, p = 0.018).
Survival at one year did not differ significantly in the two groups (API + 97% vs API- 94%), it remained an improved ejection fraction (52 ± 9 % vs 48 ± 9 %, p = 0.010) without significant differences in relation to the end-diastolic volume (67 ± 16 ml/m2 vs 69 ± 18 ml/m2).
Preinfarction angina by multivariate analysis was an independent predictor of lower presence of arrhythmias (OR 0.48 with 95% CI 0.25-0.93, p = 0.03), fewer episodes of heart failure (OR 0.33 with 95% CI 0.12-0.91, p = 0.03) and reduced hospital stay (in-hospital decreased of -2.62 ± 1.21 days, p = 0.03).
Concerning to the echocardiographic data obtained at the discharge preinfartion angina was also protective, with better ventricular function (higher left ventricular ejection fraction 3.21 ± 1.14%, p = 0.01), and reduced diastolic volume (decreased end diastolic volume -5.20 ± 2.26 ml/m2, p = 0.02). Multivariate analysis of the data obtained during the follow up has shown a better ventricular function also at the echocardiography performed at 1 year (2.96 ± 1.44, p = 0.03).
At the clinical follow-up at one year we have seen that the presence of preinfarction angina has played a protective role with regard to new episodes of acute coronary syndrome (6 cases vs. 22, OR 0.27) and episodes of heart failure (0 cases vs 5).

Conclusions. Preinfarction angina has a certain protective effect with regard to in-hospital outcome, as it is associated with a lower presence of arrhythmias, fewer episodes of heart failure and reduced hospitalization, API+ patients, in despite of equal treatment, also have better sistolic ventricular function with less volume than API- patient .
At the echocardiography obtained during the follow up ventricular function is improved in the API + group and our data show a protective role of preinfarction angina even with regard to new episodes of acute coronary syndrome and new episodes of heart failure.

Abstract (italiano)

Premessa storica. Già al tempo degli egizi, nel papiro di Ebers (1500 a.C.) è riconoscibile la descrizione dell'angina pectoris da un passo che dice: “.... se esamini un uomo per malattia del cuore, egli si lamenta per dolore al braccio, al petto e ad una parte del cuore....”.
Da qui ha inizio il lungo cammino che ci porterà alla descrizione dell’infarto nel 1912 da trombosi coronarica da parte di James Herrick, alla successiva nascita delle prime Unità coronariche nel 1962 per opera di Desmond Julian e le più moderne Chest Pain Unit nel 1981.
La ricerca continua a valutare nuovi aspetti che possano portare al rinvenimento di nuove strategie per ridurre la mortalità causata da questa malattia.

Background e obiettivi. L’angina preinfartuale (intesa come angina comparsa nelle 24 ore precedenti l’infarto miocardico acuto) conferisce una protezione al miocardio riducendo le dimensioni dell’infarto, e limitando il rimodellamento ventricolare sinistro.
Lo scopo di questo studio è valutare i pazienti che si presentano con sindrome coronarica acuta con sopraslivellamento del tratto ST, e in particolare alcuni sottogruppi, confrontando i pazienti con angina pre-infartuale (API+) e quelli senza (API-) per quanto riguarda la funzione ventricolare, il volume telediastolico e gli outcome clinici intraospedalieri e a distanza di un anno, per poter valutare se gli eventuali effetti protettivi presenti durante la degenza si mantengano anche nel tempo.

Metodi e risultati. Abbiamo valutato in un arco temporale di due anni 448 pazienti consecutivi ricoverati in Unità Coronarica per sindrome coronarica acuta con ST sopraslivellato (SCA ST sopra) indipendentemente dal trattamento ricevuto. Di questi abbiamo poi analizzato più approfonditamente un sottogruppo omogeneo, che presentava lesione emodinamicamente significativa su ramo discendente anteriore della coronaria sinistra.
Di questi pazienti è stato eseguito un follow-up clinico ed ecocardiografico ad un anno.
Sono stati esclusi dal presente lavoro pazienti arruolati per altri studi.
La nostra popolazione risultava così suddivisa: 112 pazienti, corrispondenti al 25 %, avevano presentato angina pre-infartuale (API+) nelle 24 ore precedenti l’infarto miocardico, i restanti 336 (75 %) non avevano avuto episodi anginosi nelle ultime 24 ore (API-). I due gruppi confrontati ( API+ vs API-) fra di loro non hanno dimostrato differenze significative per quanto riguardava l’età, il sesso, i fattori di rischio (ipertensione arteriosa, ipercolesterolemia, diabete, familiarità per coronaropatia, fumo). I due gruppi sono stati confrontati per quanto riguarda il trattamento ed è risultato che il gruppo API+ era stato trattato più frequentemente con angioplastica primaria rispetto al gruppo API- (88% vs 79% con p=0.025).
Per quanto riguarda l’outcome intraospedaliero nel gruppo API+ rispetto a quello API- è risultata significativamente ridotta la durata della degenza (9±4 giorni vs 11±9 giorni con p=0.004), la presenza di aritmie ( 20% vs 32% con p= 0.015), la presenza di scompenso (6% vs 14% con p=0.035) e per quanto riguarda i dati ecocardiografici: la funzione ventricolare era migliore nel gruppo API+ (frazione di eiezione 51±7% vs 48± 9% con p= 0.003) in corrispondenza di un minor volume telediastolico (58 ± 11 ml/m2 vs 62 ± 17 ml/m2 con p = 0.005).
Nel follow up ad un anno è risultato significativamente ridotto il numero di ricoveri in altro reparto (15% vs 25% con p=0.04), non vi è significatività statistica per quanto riguarda gli altri parametri valutati tra outcome e angina pre IMA anche se sono suggestivi di una migliore prognosi nel caso di angina pre IMA (sopravvivenza ad un anno API+ 98% vs API- 93%).
Considerando i noti vantaggi legati alla rivascolarizzazione con angioplastica primaria e pensando che questi potessero offuscare i vantaggi legati all’angina-preinfartuale, abbiamo valutato un sottogruppo particolarmente omogeneo di 277 pazienti che avevano come caratteristica una lesione critica su discendente anteriore. Di questi il 30% aveva presentato API+, mentre il restante 70% era API-. Anche in questo gruppo non vi erano differenze significative per quanto riguardava età, sesso, fattori di rischio associati (ipertensione arteriosa, diabete, ipercolesterolemia, familiarità per coronaropatia, fumo) e malattie concomitanti (insufficienza renale cronica, broncopneumopatia cronica ostruttiva).
Non risultavano differenze significative per quanto riguarda il trattamento ricevuto, mentre si confermavano i dati di miglior prognosi intraospedialiera nel gruppo API+ rispetto a quello API- con ridotta degenza ospedaliera (9±4 giorni vs 13±10 giorni, con p=0.01), la presenza di aritmie ( 20% vs 32% con p= 0.03), la presenza di scompenso (7% vs 17% con p=0.029) e anche per quanto riguarda i dati ecocardiografici: la funzione ventricolare era maggiore nel gruppo API+ (frazione d’eiezione 50± 8% vs 46± 9% con p = 0.00) in corrispondenza di un minor volume telediastolico (59 ± 12 ml/m2 vs 64 ± 18 ml/m2 con p = 0.018).
Nel follow up ad un anno la sopravvivenza non presentava differenze statisticamente significative nei due gruppi (API+ 97% vs API- 94%), mentre si manteneva una miglior frazione di eiezione (52± 9 % vs 48± 9 % con p = 0.010) senza differenze significative per quanto riguarda il volume telediastolico (67 ± 16 ml/m2 vs 69 ± 18 ml/m2).
All’analisi multivariata l’angina pre-infartuale risultava predittore indipendente di minor presenza di aritmie (OR 0.48 con 95%CI 0.25-0.93, p=0.03), minori episodi di scompenso (OR 0.33 con 95%CI 0.12-0.91, p=0.03) e ridotta degenza (degenza ridotta di -2.62±1.21 giorni con p=0.03). Risultava protettiva anche per quanto riguarda i dati ecocardiografici ottenuti in dimissione con miglior funzione ventricolare (frazione di eiezione aumentata di 3.21±1.14 % con p=0.01), e minor volume telediastolico (volume telediastolico ridotto di -5.20±2.26 ml/m2 con p=0.02). L’analisi multivariata dei dati ottenuti nel follow up ha dimostrato come si mantenga predittore di migliore funzione ventricolare anche nell’ecocardiogramma eseguito ad 1 anno (frazione di eiezione aumentata 2.96±1.44 % con p=0.03).
Per quanto riguarda il follow up clinico ad 1 anno abbiamo visto che la presenza di angina pre-infartuale ha svolto un ruolo protettivo per quanto riguarda nuovi episodi di sindrome coronarica acuta (6 casi vs 22, OR 0.27) e per episodi di scompenso cardiaco (0 casi vs 5).

Conclusioni. L’angina pre-infartuale risulta avere un effetto protettivo certo per quanto riguarda l’outcome intraospedaliero, in quanto porta ad una minor presenza di aritmie, minori episodi di scompenso e minori giorni di degenza, inoltre i pazienti API+ hanno a parità di trattamento una migliore funzione ventricolare con minor volume telediastolico rispetto ai pazienti API-.
Per quanto riguarda il follow up ad un anno la funzione ventricolare risulta migliore nel gruppo API+ e i nostri dati mostrano un ruolo protettivo dell’angina pre-infartuale anche per quanto riguarda nuovi episodi di sindrome coronarica acuta e nuovi episodi di scompenso.

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Tipo di EPrint:Tesi di dottorato
Relatore:RAZZOLINI, RENATO
Dottorato (corsi e scuole):Ciclo 22 > Scuole per il 22simo ciclo > SCIENZE MEDICHE, CLINICHE E SPERIMENTALI > SCIENZE CARDIOVASCOLARI
Data di deposito della tesi:NON SPECIFICATO
Anno di Pubblicazione:Febbraio 2011
Parole chiave (italiano / inglese):angina preinfartuale, infarto miocardico acuto, prognosi, sindrome coronarica acuta, preinfarction angina, myocardial infarction, acute coronary syndrome
Settori scientifico-disciplinari MIUR:Area 06 - Scienze mediche > MED/11 Malattie dell'apparato cardiovascolare
Struttura di riferimento:Dipartimenti > Dipartimento di Scienze Medico Diagnostiche e Terapie Speciali
Codice ID:4092
Depositato il:19 Lug 2011 10:27
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