REPERFUSIÓN CORONARIA: ANALISIS DEL MIOCARDIO. ISQUÉMICO EN . isquemia recurrente, de arritmias malignas y prevenir el remodelado ventricular. y como un dato de recanalización, pueden aparecer arritmias de reperfusión en La angioplastia coronaria transluminal (ACT) 12) se ha practicado como. ABLACION POR CATETER DE ARRITMIAS CARDIACAS Primera Capítulo 1: Fisiopatología de los síndromes isquémicos coronarios agudos. Capítulo 6: Reperfusión farmacológica y tratamiento adjunto en el infarto con elevación del ST.

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Acute myocardial infarction due to coronary embolism in atrial fibrillation: Atrial fibrillation is the most common sustained arrhythmia in the general population, responsible for significant morbidity and mortality due to an increased risk of systemic embolism.

Coronariografía: más allá de la anatomía coronaria

The anatomic and hemodynamic characteristics of the cardiovascular system direct most emboli towards the central nervous system or the peripheral circulation, being coronary embolism an uncommon event. This has led to a reperfusioh in the available medical literature regarding the importance of atrial fibrillation as a cause of acute myocardial infarction and the treatment these patients should be offered, with most of the evidence arising from case reports and small case series.

A case of acute myocardial infarction associated with coronary embolism in a patient with new onset atrial fibrillation who was successfully treated with thrombus aspiration is presented, followed by a systematic review of the topic.

D objective of this review is to establish the clinical characteristics of patients with coronary embolism due to atrial fibrillation and determine the best treatment options based on the available evidence. Acute myocardial infarction; arritmia fibrillation; coagulation; coronary embolism.

Atrial fibrillation AF is the most common sustained arrhythmia worldwide, being the main reason for arrhythmia related hospitalization; AF is also associated with a significant increase in mortality. A case of AF-related coronary embolism is presented, followed by a systematic review of the available medical literature to summarize the best evidence available. The primary objective is to identify the general characteristics of patients who suffer an AMI by coronary embolism associated with AF.

The secondary objective is to define the most appropriate treatment strategy for this group of patients. He described previous episodes of short lasting palpitations, without previous documentation of AF first detected AF.

Coronariografía: más allá de la anatomía coronaria | Revista Española de Cardiología

During the procedure, a fresh thrombus in the proximal portion of the anterior descendent artery ADA with total occlusion of distal circulation was found Figure 2without significant atherosclerosis. Mechanical thrombectomy with aspiration of a red thrombus was performed out, restoring blood flow through the vessel with a residual oclussion at the distal portion of the ADA.

Subsequent attempts coronaaria the same procedure completely restored normal blood flow. Atrial fibrillation lack of a P wave, with variable RR interval without acute ischemic changes. Oclussion of the proximal ADA proximal produced by a croonaria. ADA reperfusion with a residual thrombus in the distal portion. One month after the index event, pulmonary vein ablation was performed to decrease the risk of arrhythmia recurrence.

After a six month follow up, no new episodes of AF have been documented during Holter monitoring, and the patient has had no angina episodes. Publications were included if coronary embolism related to AF was demonstrated by coronary angiography; publications what included patients with prosthetic valves or alternative sources of emboli ateromatosis with suspect of ateroemboli, infective endocarditis were excluded.

Additionally, bibliographic references of the included publications were reviewed, aiming to identify studies which had not been included during the initial search. The PubMed search yielded 32 results, out of which 19 were initially excluded due to an alternative source of embolism because they were unrelated with the study question coronary embolism associated to AF without prosthetic valves or another emboli causes ; another publication was excluded because it was a letter to editor.

The EMBASE search yielded 53 results in total, out of which 30 were excluded due to an alternative source of embolism; 7 were unrelated to the study question including two posters in which there was no demonstration of coronary embolism at coronarography and 11 were excluded because of duplicate publication 10 articles identified in the previous database search and arritmiass with patients included in another publication.


The Cochrane search yielded four results, none of which were related with the topic.

Reperfusiln search in SciELO yielded 26 results in total 24 in English and 2 in Spanish ; all were excluded because they were unrelated with the study question. As a result, 17 articles were analyzed for this review 13 case reports and 4 case series Figure 3. A total of 13 case reports of coronary embolism associated with AF were identified each one with only one patient Table I ; the first of these cases was reported in with the rest of them being reported over the last two decades.

Valor del diagnóstico clínico precoz a través del electrocardiograma – Artículos – IntraMed

In 9 patients AF was paroxysmal, 2 patients had persistent and only 1 had permanent AF; one case report did not establish AF duration. In 7 patients Most case reports agree on the use of anticoagulants and anti-platelet aggregation therapy dual in some cases as an initial treatment. This patient had an anomalous origin of his left coronary artery, arising from the right Valsalva sinus, with total occlusion of left coronary trunk and contained ventricular rupture; the patient presented with cardiogenic shock and finally died during the index hospitalization.

General characteristics of patients included in case reports.

arritmias de reperfusion coronaria pdf file

Medical and interventional treatment in case reports. Interestingly, two publications reported embolism after a direct current DC cardioversion. In one repedfusion them, the patient had been started on dabigatran mg each 12 hours a suboptimal dose according to the patient’s reported characteristics 23 days before the cardioversion. After the reperusion event, most patients were treated on an outpatient basis with oral anticoagulants, most of them without anti-platelet therapy.

The agent most commonly used was warfarin; only one case reported the use of a direct oral anticoagulant. Four case series assessing AF-related coronary embolism were also found. In four patients, coronary embolism was the first manifestation of paroxysmal AF. In a series including 33 patients reported by Hideko et al, 22 acute coronary events caused by AF-related embolism had a higher mortality than other types of STEMI, a finding that had already been described in association with a higher risk of central nervous system embolism.

Finally, Shibata et al 24 reported 52 confirmed coronary embolism events, 30 of which were AF related. Five of these patients required were further treated with stents and 4 with balloon angioplasty. Embolism to the left coronary trunk seems to be an unusual finding.

There is no uniform treatment between different series and even between patients within a same serieswith some patients being treated with aspiration, angioplasty or platelet inhibitors. Patient characteristics and angiographic findings in patients included in case series. Global incidence particularly in men and in the elderly and prevalence reperfuzion both genders of AF has risen during the last decades.

A rise in platelet activation, fibrinogen and D-dimer levels, and other molecules released by platelet granules has also been documented. AF is also associated with histologic changes fibroblastic sub-endocardium infiltration, producing tissue constitutive changes and increased Von Willenbrand’s factor expression, changing the adhesion characteristics of the atrial wall which favors thrombosis.

Most emboli formed during an AF episode will be directed towards the central nervous system, with coronary thromboembolism a rare occurrence due to the hemodynamic characteristics of the circulatory system. First, the lumen size of the coronary vessels and the difference in vascular resistance between the aorta and the coronary arteries favor flow along the aorta and decreases possibilities of flowing into the coronary circulation.

Second, coronary arteries emerge from the aortic root artery and their ostia are partially protected by the aortic valves and Valsalva’s sinus. Lastly, coronary flow occurs mainly during diastole due to pressure differences between the aorta and ventricles but emboli mobilize usually during systole.

It is possible that the incidence of AF-related coronary embolism is higher than reported. An estimated that between a 1. When taking into account patients can present embolism associated with paroxysmal AF being afterwards in sinus rhythm, making it impossible to discover an association between AF and coronary embolismit is clear that the frequency of AF-related embolism can be even higher.

On the other hand, although red thrombus are more resistant to endogenous fibrinolytic mechanisms apparently by a lower fibrin permeability when thrombus pores are occluded by red blood cells36 it is possible that endogenous fibrinolytic mechanisms degrade the clot before coronarography, making it impossible to find evidence of coronary embolism.


In his article, Shibata et al proposed criteria to standardize the diagnosis of coronary embolism Table IV24 applying these criteria to our case, a definitive diagnosis of embolic AMI 1 major criteria: Definition of coronary embolism. Diagnostic criteria for coronary embolism proposed by Shibata et al. Finally, several aspects concerning AF-related coronary embolism cannot be clarified with the available evidence.

It is still to be defined if the reported higher mortality is due to embolic event per se or is rather related to a higher prevalence of comorbidities and recurrent embolism. Additionally, it is currently unknown which should be the preferred anticoagulant in these patients either warfarin or the direct oral anticoagulants dabigatran, riVaroxaban or apixaban.

Similarly, it is unclear whether or not antiplatelet therapy either with just one drug or with dual antiplatelet therapy is beneficial in these patients. This raises several questions:. Should antiplatelet therapy be used in combination with direct oral anticoagulants in these patients? This systematic review has several limitations that should be considered. First, these results cannot be extrapolated to other populations at risk for coronary embolism including patients with prosthetic valves, aortic atheromatosis, endocarditis, and diseases associated with hypercoagulability since the underlying mechanisms of those emboli could differ from those found in AF, which could in turn be associated with differences in treatment strategies and prognosis.

It is possible that somewhere missed during our search. This is a limitation of all systematic reviews; however, by identifying the most relevant results, a clear picture about actual evidence that surrounds the diagnosis and treatment of this condition can be obtained. By performing the search in several data bases, this possibility is decreased. Finally, the low incidence of AF-related coronary embolism is surprising; despite several hemodynamics mechanisms have been proposed to explain this, it is impossible to deny any underlying hypercoagulable state that can explain coronary embolism.

None of our case reports evaluated this possibility, so no clear conclusions can be drawn about this. Acute myocardial infarction due to AF-related coronary embolism is a rare event, with few cases reported in medical literature.

In many patients, this is the first AF manifestation, frequently occurring in patients with low embolic risk according to existing risk stratification scales. Based on current evidence, it is possible that the use of anti-platelet aggregation, anticoagulants and thrombus aspiration could be the optimal treatment strategy in this group of patients, achieving a good rate of vessel reperfusion. Treatment with oral anticoagulants seems necessary to avoid new events. Studies with mid and long term follow-up are required to clarify which should be the optimal treatment of these patients.

Guidelines for the management of atrial fibrillation: Outcome parameters for trials in atrial fibrillation: Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: Extracranial systemic embolic events in patients with nonvalvular atrial fibrillation: Lifetime risk for development of atrial fibrillation: Angiographic evidence of coronary embolism and resolution.

S Afr Med J. Aspiration thrombectomy of a massive thrombotic embolus in acute myocardial infarction caused by coronary embolism. Coronary embolism causing non-ST elevation myocardial infarction in a patient with paroxysmal atrial fibrillation: Patient with atrial fibrillation and myocardial infarction due to coronary artery embolism treated with thrombus aspiration.

Simultaneously presented acute ischemic stroke and non-st elevation myocardial infarction in a patient with paroxysmal atrial fibrillation. Coronary embolization following electrical cardioversion in a patient treated with dabigatran. New-onset chest pain and palpitation. An uncommon complication of atrial fibrillation. Oxford Medical Case Reports. Van de Walle S, Dujardin K.

A case of coronary embolism in a patient with paroxysmal atrial fibrillation receiving tamoxifen. Camaro C, Aengevaeren WR. Acute myocardial infarction due to coronary artery embolism in a patient with atrial fibrillation. Garg RK, Jolly N. Acute myocardial infarction secondary to thromboembolism in a patient with atrial fibrillation.

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