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Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
Sindrome coronario agudo
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Sindrome coronario agudo

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XIV Curso de Residentes de Medicina Interna. Por: James Díaz Betancur. Internista. UdeA. 2013.

XIV Curso de Residentes de Medicina Interna. Por: James Díaz Betancur. Internista. UdeA. 2013.

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  • 1. SÍNDROMECORONARIO AGUDOJames Díaz Betancur
  • 2. Atherosclerosis across 4000 years of human history: the Horus study of four ancient populationsLancet. Online March 10, 2013
  • 3. SCA con ST SCA sin ST
  • 4. Presentaciones atípicas
  • 5. Presentaciones atípicas
  • 6. Presentaciones atípicas
  • 7. Presentaciones atípicas
  • 8. Presentaciones atípicas
  • 9. Presentaciones atípicas
  • 10. *ICP = Intervención coronaria percutánea SCA con ST • < 12 h • Síntomas persistentes • ChoqueSI ¿Es posible hacer *ICP en < 120 min? NO*ICP Fibrinolisis
  • 11. • Dolor / ansiedad • OxigenaciónQué hacer • Bioquímicadespués? – Troponina, ó – CK – MB • Antiagregación • Anticoagulación
  • 12. Los resultados de los estudios patrocinadospor la industria, favorecen a.. .. la industria !
  • 13. Comparison: 1 Results: Industry sponsored versus non-industry sponsored studies Analysis 1.1. Comparison 1 Results: Industry sponsored versus non-industry sponsored studies, Outcome 1 Outcome: 1 Number of studies with favorable efficacy results Number of studies with favorable efficacy results. Review: Industry sponsorship and research outcome Study or subgroup Industry Non-industry Risk Ratio Weight Risk Ratio Comparison: 1 Results: Industry sponsored versus non-industry sponsored studiesIV,Fixed,95%CI n/N n/N IV,Fixed,95%CI Alasbali 2009 7/29 2/10 0.3 % 1.21 [ 0.30, 4.88 ] Outcome: 1 Number of studies with favorable efficacy results Bero 2007 65/94 48/97 11.5 % 1.40 [ 1.10, 1.78 ] Study or subgroup Industry Non-industry Risk Ratio Weight Risk Ratio Booth 2008 49/120 50/165 6.8 % 1.35 [ 0.98, 1.85 ] n/N n/N IV,Fixed,95%CI IV,Fixed,95%CI Bourgeois 2010 222/260 48/85 18.1 % 1.51 [ 1.25, 1.83 ] Alasbali 2009 7/29 2/10 0.3 % 1.21 [ 0.30, 4.88 ] Clifford 2002 46/66 21/34 7.1 % 1.13 [ 0.83, 1.54 ] Bero 2007 65/94 48/97 11.5 % 1.40 [ 1.10, 1.78 ] Etter 2007 25/49 9/41 1.7 % 2.32 [ 1.23, 4.40 ] Booth 2008 49/120 50/165 6.8 % 1.35 [ 0.98, 1.85 ] Kelly 2006 12/13 4/8 1.3 % 1.85 [ 0.91, 3.76 ] Bourgeois 2010 222/260 48/85 18.1 % 1.51 [ 1.25, 1.83 ] Momeni 2009 Clifford 2002 20/24 46/66 69/85 21/34 15.9 % 7.1 % 1.13 [ 0.83, 1.54 ] ] 1.03 [ 0.84, 1.26 Moncrieff 2003 Etter 2007 2/2 25/49 2/7 9/41 0.5 % 1.7 % 2.32 [ 1.23, 4.40 ] ] 2.67 [ 0.85, 8.39 P Kelly 2006 erlis 2005b 93/113 12/13 37/49 4/8 20.7 % 1.3 % 1.85 [ 0.91, 3.76 ] ] 1.09 [ 0.91, 1.31 Rasmussen 2009 Momeni 2009 66/109 20/24 14/28 69/85 4.2 % 15.9 % 1.03 [ 0.84, 1.26 ] ] 1.21 [ 0.81, 1.81 Rattinger 2009 Moncrieff 2003 26/36 2/2 18/25 2/7 6.7 % 0.5 % 2.67 [ 0.85, 8.39 ] ] 1.00 [ 0.73, 1.38 Tulikangas 2006 Perlis 2005b 15/15 93/113 7/9 37/49 5.0 % 20.7 % 1.09 [ 0.91, 1.31 ] ] 1.29 [ 0.89, 1.87 Vlad 2007 Rasmussen 2009 5/11 66/109 0/4 14/28 0.1 % 4.2 % 1.21 [ [ 0.31, 68.24 ] 4.58 0.81, 1.81 ] TotalRattinger CI) (95% 2009 941 26/36 647 18/25 100.0 % 6.7 % 1.24 [ 1.14, 1.38 ] ] 1.00 [ 0.73, 1.35 Total events: 653 (Industry), 329 (Non-industry) Tulikangas 2006 15/15 7/9 5.0 % 1.29 [ 0.89, 1.87 ] Heterogeneity: Chi2 = 20.09, df = 13 (P = 0.09); I2 =35% Vlad 2007 5/11 Test for overall effect: Z = 5.11 (P < 0.00001) 0/4 0.1 % 4.58 [ 0.31, 68.24 ] TestTotal (95%differences: Not applicable for subgroup CI) 941 647 100.0 % 1.24 [ 1.14, 1.35 ] Total events: 653 (Industry), 329 (Non-industry) Heterogeneity: Chi2 = 20.09, df = 13 (P = 0.09); I2 =35% 0.01 0.1 1 10 100 Test for overall effect: Z = 5.11 (P < 0.00001) Industry less favorable Industry more favorableLundh A, Sismondo S, Lexchin J, Busuioc OA, Bero L.Industry sponsorship and research outcome.applicable Test for subgroup differences: NotCochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: MR000033.
  • 14. Doble antiagregación:Una dosis de carga inicial yUna dosis diaria de mantenimiento
  • 15. Clopidogrel ASAPrasugrel Ticagrelor
  • 16. Clopidogrel 300 mg • 12.562 pacientes con SCA sin ST • Clopidogrel (300 mg de carga y 75 mg/día mantenimiento) • Vs. Placebo • Seguimiento: 12 mesesYusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK.Effects of clopi- dogrel in addition to aspirin in patients with acute coronary syndromes without ST-segmentelevation.
  • 17. Clopidogrel 300 mg Muerte cardiovascular, IM no fatal ó ECV: Sangrado: 9.3% vs. 11.4% / RR 0.80; IC 0.72 – 0.90 3.7% vs. 2.7% / RR 1.38; IC 1.13 – 1.67 21 eventos menos por cada 1000 pacientes tratados.Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK.Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation.N Engl J Med 2001;345:494 – 502.
  • 18. Clopidogrel 600 mg • 25.086 pacientes con SCA con ST y SCA sin ST. • Clopidogrel (600 mg de carga y 150 mg/día una semana y luego 75 mg/día mantenimiento). • Vs. clopidogrel (300 mg de carga y 75 mg/día mantenimiento). • Seguimiento: un mesThe CURRENT-OASIS 7 Investigators.Dose comparisons of clopidogrel and aspirin in acute coronary syndromes.N Engl J Med 2010;363:930 – 942
  • 19. Clopidogrel 600 mgThe CURRENT-OASIS 7 Investigators.Dose comparisons of clopidogrel and aspirin in acute coronary syndromes.N Engl J Med 2010;363:930 – 942
  • 20. Clopidogrel 600 mgThe CURRENT-OASIS 7 Investigators.Dose comparisons of clopidogrel and aspirin in acute coronary syndromes.N Engl J Med 2010;363:930 – 942
  • 21. Clopidogrel 600 mg - ICP • 17.263 pacientes con SCA con ST y SCA sin ST, LLEVADOS A ICP. • Clopidogrel (600 mg de carga y 150 mg/día una semana y luego 75 mg/día mantenimiento). • Vs. clopidogrel (300 mg de carga y 75 mg/día mantenimiento). • Seguimiento: 30 díasThe CURRENT-OASIS 7 Investigators.Double-dose versus standard-dose clopidogrel and high-dose versus low-dose aspirin in individuals undergoing percutaneous coronaryintervention for acute coronary syndromes (CURRENT-OASIS 7): a randomised factorial trial.Lancet 2010; 376: 1233–43
  • 22. Clopidogrel 600 mg - ICPThe CURRENT-OASIS 7 Investigators.Double-dose versus standard-dose clopidogrel and high-dose versus low-dose aspirin in individuals undergoing percutaneous coronaryintervention for acute coronary syndromes (CURRENT-OASIS 7): a randomised factorial trial.Lancet 2010; 376: 1233–43
  • 23. Clopidogrel 600 mg - ICPThe CURRENT-OASIS 7 Investigators.Double-dose versus standard-dose clopidogrel and high-dose versus low-dose aspirin in individuals undergoing percutaneous coronaryintervention for acute coronary syndromes (CURRENT-OASIS 7): a randomised factorial trial.Lancet 2010; 376: 1233–43
  • 24. Clopidogrel 600 mg - ICPThe CURRENT-OASIS 7 Investigators.Double-dose versus standard-dose clopidogrel and high-dose versus low-dose aspirin in individuals undergoing percutaneous coronaryintervention for acute coronary syndromes (CURRENT-OASIS 7): a randomised factorial trial.Lancet 2010; 376: 1233–43
  • 25. ASA + Clopidogrel:Administrar una dosis de carga de 600mg solo cuando se tiene certeza que elpaciente va a ser llevado a ICP tempranay usar 300 mg en los demás casos.

  • 26. • El sangrado gastrointestinal es la complicación grave más común del uso prolongado de antiplaquetarios.• El omeprazol inhibe la CYP2C19, disminuye la actividad del clopidogrel ex vivo. Omeprazol?
  • 27. Omeprazol • 3873 pacientes antiagregados con ASA + clopidogrel. • Omeprazol 20 mg/día • Vs. no omeprazol • Mediana de seguimiento: 106 díasBhatt DL, Cryer BL, Contant CF, Cohen M, Lanas A, Schnitzer TJ, et al.Clopidogrel with or witout omeprazole in coronary artery disease.N Engl J Med. 2010;363(20):1909-17
  • 28. Bhatt DL, Cryer BL, Contant CF, Cohen M, Lanas A, Schnitzer TJ, et al.Clopidogrel with or witout omeprazole in coronary artery disease.N Engl J Med. 2010;363(20):1909-17
  • 29. ASA + Clopidogrel + Omeprazol:El estudio fue terminado prematuramente sin completar eltamaño de muestra calculado y el número de eventoscardiovasculares fue muy pequeño.El uso de omeprazol reduce la tasa de sangrado gastrointestinalen pacientes con doble antiagregación, con un perfil deseguridad adecuado. Omeprazol
  • 30. Prasugrel v • 13.608 pacientes con SCA con ST y SCA sin ST llevados a ICP. • Prasugrel (carga de 60 mg y 10 mg/día mantenimiento) • Vs. clopidogrel (carga de 300 mg y 75 mg/día mantenimiento) • Mediana de seguimiento: 15 mesesWiviott S, Braunwald E, McCabe C, Montalescot G, Ruzyllo W, Gottlieb S, Neumann F-J, Ardissino D, De Servi S,Murphy S,. Prasugrel versus clopidogrel in patients with acute coronary syndromes.N Engl J Med 2007;357:2001 – 2015.
  • 31. PrasugrelWiviott S, Braunwald E, McCabe C, Montalescot G, Ruzyllo W, Gottlieb S, Neumann F-J, Ardissino D, De Servi S,Murphy S,. Prasugrel versus clopidogrel in patients with acute coronary syndromes.N Engl J Med 2007;357:2001 – 2015.
  • 32. PrasugrelWiviott S, Braunwald E, McCabe C, Montalescot G, Ruzyllo W, Gottlieb S, Neumann F-J, Ardissino D, De Servi S,Murphy S,. Prasugrel versus clopidogrel in patients with acute coronary syndromes.N Engl J Med 2007;357:2001 – 2015.
  • 33. Prasugrel • El sangrado fue más frecuente en pacientes con: – Peso < 60 kilos – Edad > 75 años – Antecedente de ACV o isquemia cerebral transitoria previa. • En el subgrupo de pacientes diabéticos se observó una mayor eficacia del pragugrel.Wiviott S, Braunwald E, McCabe C, Montalescot G, Ruzyllo W, Gottlieb S, Neumann F-J, Ardissino D, De Servi S,Murphy S,. Prasugrel versus clopidogrel in patients with acute coronary syndromes.N Engl J Med 2007;357:2001 – 2015.
  • 34. Prasugrel • 9.326 pacientes con SCA sin ST y AI, no revascularizados. • Prasugrel 10 mg/día (5m/día en los >75 años) • Vs. Clopidogrel 75mg/día • Mediana seguimiento 15 mesesThe TRILOGY ACS Investigators.Prasugrel versus clopidogrel for acute coronary syndromes without revascularization.N Engl J Med. 2012 Oct 4;367(14):1297-309
  • 35. PrasugrelThe TRILOGY ACS Investigators.Prasugrel versus clopidogrel for acute coronary syndromes without revascularization.N Engl J Med. 2012 Oct 4;367(14):1297-309
  • 36. ASA + Prasugrel:Se podría usar en pacientes que notengan predictores de sangrado comohistoria de ECV ó isquemia cerebraltransitoria, peso <60 kg ni edad >75años.
  • 37. Ticagrelor • 18.624 pacientes con SCA con ST y SCA sin ST • Ticagrelor (180 mg de carga y 90 mg /12h de mantenimiento) • Vs. Clopidogrel (300 a 600 mg de carga y 75 mg/día mantenimiento) • Mediana de seguimiento: 9 mesesThe PLATO Investigators.Ticagrelor versus clopidogrel in patients with acute coronary syndromes.N Engl J Med. 2009 Sep 10;361(11):1045-57
  • 38. TicagrelorThe PLATO Investigators.Ticagrelor versus clopidogrel in patients with acute coronary syndromes.N Engl J Med. 2009 Sep 10;361(11):1045-57
  • 39. TicagrelorThe PLATO Investigators.Ticagrelor versus clopidogrel in patients with acute coronary syndromes.N Engl J Med. 2009 Sep 10;361(11):1045-57
  • 40. No 4564 9.0 11.6 0.79 (0.65, 0.95) Female Yes Ticagrelor10.1 11.7 0.86 (0.78, 0.96) 5288 11.2 13.2 14060 0.83 (0.71, 0.97) Weight Group ACE Inhibitors (Rand.) 0.27 <60 kg 1312 13.1 17.3 0.75 (0.60, 0.99) 0.36 No kg ³60 17256 9.4 11.2 8102 9.5 10.6 0.90 (0.78, 1.03) 0.86 (0.78, 0.94) Hazard Ratios and Rates of Primary End Point10522Predefined Subgroups of0.91) 0.17 Yes kg <80 in 11.4 12.8 0.81 (0.72, 1.01) Patients 9055 10.1 12.5 0.90 (0.79, Study ³80 kg Angiotensin II Receptor Blockers (Rand.) 9513 8.3 10.5 0.79 (0.69, 0.90) 0.37 No Medical History of DM 16981 9.6 % 11.6 KM at 0.83 (0.76, 0.92) 0.49 Yes No Hazard Ratio Total Month 12 13962 11.8 12.8 1643 8.4 10.2 0.96 (0.72, 1.28) P value 0.83 (0.74, 0.92) Characteristic Yes Calcium Channel Blockers (Rand.) (95% CI) Patients 14.1 16.2 4662 Ti. Cl. 0.88 (0.76, 1.03) (Interaction) HR (95% CI) 0.33 Overall Treatment Effect Region No 15888 9.6 11.3 0.86 (0.78, 0.95) 0.05 Yes Endpoint Primary Asia/Australia 18624 1714 2736 10.8 11.7 9.8 14.8 11.4 13.8 0.80 (0.61, 0.92) 0.76 (0.77, 0.95) 0.84 1.04) New ST elevation/LBBB at rand. Central/South America Proton Pump Inhibitors (Rand.) 1237 15.2 17.9 0.86 (0.65, 1.13) 0.69 0.68 No Europe/Middle East/Africa No 11074 13859 12249 10.1 8.8 9.2 12.3 11.0 0.83 (0.74, 0.93) 0.80 (0.72, 0.90) Yes Yes America North 7544 1814 6375 9.4 11.9 11.0 10.8 9.6 12.9 0.87 (0.75, 1.01) 1.25 (0.93, 1.67) 0.86 (0.75, 1.00) First Troponin I Prior to Index Event Antiplatelet Therapy 0.43 0.29 0.2 0.5 1.0 2.0 Positive ± ASA Clopidogrel 15089 15.8 12.3 1397 10.3 17.8 0.95 (0.73, 1.24) 0.85 (0.77, 0.94) Negative ASA Ticagrelor better Clopidogrel better 11.8 14.0 5024 7.0 7.0 2968 1.00 (0.71, 0.98) 0.84 (0.75, 1.32) None Time from Index Event to First IP 12147 8.2 10.0 0.82 (0.73, 0.93) 0.17 <12 hours ASA on Day of Rand. 9556 8.2 10.4 0.79 (0.69, 0.90) 0.86 ³12The PLATO Investigators. hours No 8854 927 11.6 12.9 11.4 13.8 0.90 (0.79, 1.01) 0.87 (0.60, 1.27) Figure 2Ticagrelor versus clopidogrel in patients with acute coronary syndromes. YesN Engl J Med. 2009 Sep 10;361(11):1045-57 Planned Treatment Approach 17697 9.7 11.6 0.84 (0.77, 0.93) 0.88
  • 41. TicagrelorMahaffey KW, Wojdyla DM, Carroll K, et al.Ticagrelor compared with clopidogrel by geographic region in the Platelet Inhibition and Patient Outcomes (PLATO)trial. Circulation. 2011;124:544–54.
  • 42. ASA + Ticagrelor:La FDA advierte que se utilicen dosis bajas de ASAen combinación con ticagrelor.Las guías norteamericanas no recomiendan elticagrelor como la primera elección en los SCA.
  • 43. Comparación: Infarto de miocardio y muerte cardiovascular 40Reducción relativa del riesgo 35 30 25 * Clopidogrel 600 mg * * (CURRENT-OASIS) (%) 20 Prasugrel (TRITON- * TIMI) 15 Ticagrelor (PLATO) 10 5 0 Infarto Muerte CV
  • 44. Comparación: ECV y trombosis del stent 60 * 50Reducción relativa del riesgo (%) 40 * 30 Clopidogrel 600 mg (CURRENT-OASIS) 20 * Prasugrel (TRITON-TIMI) 10 Ticagrelor (PLATO) 0 -10 ECV Trombosis stent -20 -30
  • 45. Comparación: Sangrado mayor y sangrado fatal 100 50Reducción relativa del riesgo (%) 0 * * * -50 Sangrado mayor Sangrado fatal Clopidogrel 600 mg -100 (CURRENT-OASIS) -150 Prasugrel (TRITON-TIMI) -200 -250 Ticagrelor (PLATO) -300 -350 -400 * -450
  • 46. acientes con diagnóstico de un Evento Coronario Agudo. Versión preliminar Agosto 2012. Guía de Atención Integral Basada en la Evidencia, para la Detección temprana, Atención Integral, Seguimiento y Figura 10. Curva de aceptabilidad para la comparación entre ticagrelor y clopidogrelcon diagnóstico de un Evento Coronario Agudo. Versión preliminar Agosto 2012. Rehabilitación de pacientes ©Ministerio de Salud y Protección Social, Colciencias, Universidad de Antioquia. 221 Figura 12. Curva de aceptabilidad para la la comparación entre prasugrel y clopidogrel Figura 12. Curva de aceptabilidad para comparación entre prasugrel y a la comparación entre prasugrel y clopidogrel (Ver Tablas 17 y 18), el costonado es de $79.987.695 en el caso base, de manera que no sería una estrategia a. Si bien el resultado es sensible al horizonte temporal que el decisorlevante, el costo por AVAC ganado con un horizonte de 20 años supera elblecido ($59.241.344), de manera que la conclusión no se modificaría. Sin costo anual del clopidogrel sí modifica sustancialmente la conclusión, puesel costo máximo regulado del clopidogrel, el costo por AVAC ganado con de $29.487.404, con lo cual el prasugrel podría ser una estrategia costo Tabla 19. Prasugrel vs. Clopidogrel: 1 año y 10 años 1.8. Discusión Costo por Costo Efectividad Razón de C/Erategia Efectividad Los resultados de los análisis económicos sugieren que el ticagrelor es una estrategia co C/E paciente incremental incremental incremental efectiva en el SGSSS colombiano, conclusión que se mantiene en los distintos escenario análisis de sensibilidad. Por su parte, las conclusiones son menos claras en la comparac
  • 47. Anticoagulación
  • 48. Vs. • Enoxaparina fue no inferior a HNF en pacientes con SCA con ST 1 y SCA sin ST.2 • Tendencia a < mortalidad. • Menor incidencia de sangrado mayor. • Se puede usar con cualquier estrategia de reperfusión.1. Navarese E, De Luca G, Castriota F, Kozinski M, Gurbel P, Gibson C et al. Low-molecular-weight heparins vs. unfractionated heparin in the setting of percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis Journal of Thrombosis and Haemostasis, 9: 1902–1915
  • 49. Vs. • Fondaparinux fue no inferior a enoxaparina en SCA sin ST.1 • Fondaparinux mejor que HNF en SCA con ST, contra enoxaparina no ha sido estudiado en SCA con ST. • Tendencia menor incidencia de sangrado.1. The Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators. Comparison of Fondaparinux and Enoxaparin in Acute Coronary Syndromes. N Engl J Med 2006;354:1464-76.
  • 50. Vs. • Bivalirudina es un inhibidor directo de la trombina (factor IIa). • En SCA sin ST 1 y en SCA con ST 2 fue no inferior a HNF o HBPM + inhibidor IIb/IIIa. • Menos tasas de sangrado mayor.1. ACUITY Investigators. Bivalirudin for patients with acute coronary syndromes. N Engl J Med 2006; 355:2203–22162. Bivalirudin in patients undergoing primary angioplasty for acute myocardial infarction (HORIZONS-AMI): 1-year results of a randomised controlled trial. Mehran R et al. Lancet. (2009)
  • 51. Metoprolol Early intravenous then oral metoprolol in 45 852 patients with acute myocardial infarction: randomised placebo- controlled trial COMMIT(ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborativegroup* Summary Lancet 2005; 366: 1622–32 Background Despite previous randomised trials of early -blocker therapy in the emergency treatment of myocardial S omment page 1587 eeC infarction (MI), uncertainty has persisted about the value of adding it to current standard interventions (eg, aspirin and fibrinolytic therapy), and the balance of potential benefits and hazards is still unclear in high-risk patients.Dr Zhengming C Correspondence to: hen, Clinical Trial • 45.852 pacientes con SCA (la mayoría con ST).Service Unit and Epidemiological Methods 45 852 patients admitted to 1250 hospitals within 24 h of suspected acute MI onset were randomly allocatedStudies Unit (C U), R TS ichard Doll Building, Old R C oad ampus, metoprolol (up to 15 mg intravenous then 200 mg oral daily; n=22 929) or matching placebo (n=22 923). 93% had ST-segment elevation or bundle branch block, and 7% had ST-segment depression. Treatment was to continue until • Metoprolol (hasta 15 mg IV y luego 200 mg/día) Oxford OX3 7LF, UK zhengming.chen@ctsu.ox.ac. discharge or up to 4 weeks in hospital (mean 15 days in survivors) and 89% completed it. The two prespecified co- uk primary outcomes were: (1) composite of death, reinfarction, or cardiac arrest; and (2) death from any cause during or the scheduled treatment period. Comparisons were by intention to treat, and used the log-rank method. This study is Dr J inxiang Xie, Fuwai hospital, registered with ClinicalTrials.gov, number NCT 00222573. Beijing 100037, PRC ccstwo@public3.bta.net.cn hina • Vs. Placebo Findings Neither of the co-primary outcomes was significantly reduced by allocation to metoprolol. For death, *Collaborators and participating reinfarction, or cardiac arrest, 2166 (9· 4%) patients allocated metoprolol had at least one such event compared with hospitals listed at end of 2261 (9· 9%) allocated placebo (odds ratio [OR] 0· 96, 95% CI 0· 90–1· 01; p=0· 1). For death alone, there were 1774 reference 21 • Seguimiento hasta el alta ó el día 28 (7· 7%) deaths in the metoprolol group versus 1797 (7· 8%) in the placebo group (OR 0· 99, 0· 92–1· 05; p=0· 69). Allocation to metoprolol was associated with five fewer people having reinfarction (464 [2· 0%] metoprolol vs 568 [2· 5%] placebo; OR 0· 82, 0· 72–0· 92; p=0· 001) and five fewer having ventricular fibrillation (581 [2· 5%] vs698 [3· 0%]; OR 0· 83, 0· 75–0· 93; p=0· 001) per 1000 treated. Overall, these reductions were counterbalanced by 11 more per 1000 developing cardiogenic shock (1141 [5· 0%] vs885 [3· 9%]; OR 1· 30, 1· 19–1· 41; p 0· 00001). This excess of cardiogenic shock was mainly during days 0–1 after admission, whereas the reductions in reinfarction and ventricular fibrillation Chen ZM, Pan HC, Chen YP, Peto R, Collins R, Jiang LX, et al. the overall effect on death, reinfarction, arrest, or shock was significantly emerged more gradually. Consequently, Early intravenous then oral metoprololdays 0–1 and significantly beneficial thereafter. There was substantial net hazard in haemodynamically adverse during in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. unstable patients, and moderate net benefit in those who were relatively stable (particularly after days 0–1). Lancet. 2005;366(9497):1622- 32.
  • 52. MetoprololChen ZM, Pan HC, Chen YP, Peto R, Collins R, Jiang LX, et al.Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial.Lancet. 2005;366(9497):1622- 32.
  • 53. Metoprolol • Mayor riesgo de choque con metoprolol: – > 70 años – PAS < 120 mmHg, – Frecuencia cardiaca > 100 Lpm – Killip III • No se recomienda iniciar B-B a pacientes con riesgo de choque.Chen ZM, Pan HC, Chen YP, Peto R, Collins R, Jiang LX, et al.Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial.Lancet. 2005;366(9497):1622- 32.

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