Diretrizes da Sociedade Brasileira de Cardiologia sobre Angina Instável e Infarto Agudo do Miocárdio sem Supradesnível do Segmento ST – 2021

Abstract

Nota: Estas diretrizes se prestam a informar e não a substituir o julgamento clínico do médico que, em última análise, deve determinar o tratamento apropriado para seus pacientes.

Distal transradial access in the anatomic snuffbox: comparison with the proximal transradial access in the styloid process and the transfemoral access

“…PCI in the context of ACS, a situation in which the risk of bleeding is greater due to the widespread use of antiplatelet agents and anticoagulants, also obtained favorable results when performed via TRA. [6][7][8][9][10] The RIVAL clinical trial, which included 7,021 ST-segment elevation and non-ST-segment elevation ACS patients showed similar efficacy results, in a comparison between TRA and TFA, regarding the combined outcome of death, acute myocardial infarction, stroke and major bleeding not related to CABG in 30 days (3.7% versus 4.0%; p=0.50), but with greater benefit in the transradial access group, to reduce major vascular complications, such as local hematomas and pseudoaneurysm requiring intervention (1.4 % versus 3.7%; p<0.0001) and major bleeding rates (1.9% versus 4.5%; p<0.0001). 2 In the RIFLE-STEACS study, which included 1,001 patients diagnosed as of ST-segment elevation ACS, the TRA resulted superior to TFA, with lower 30-day mortality (5.2% versus 9.2%; p=0.02), lower bleeding rate (7.8% versus 12.2%; p=0.026) and lower length of stay (4 to 7 days versus 5 to 8 days; p=0.03).…”

“…[6][7][8][9] The 2021 Sociedade Brasileira de Cardiologia (SBC) guideline on unstable angina and non-ST-segment elevation myocardial infarction, on the other hand, reinforces the recommendation for the preferential use of TRA, with significant evidence in the reduction of bleeding and mortality in patients with ACS. 10 Recently, the TRA punctured in its most distal portion, in the anatomical snuffbox, emerged as an attractive alternative access, since it maintains the already evident benefits of the proximal TRA (pTRA) in its conventional topography, close to the styloid process, with additional advantages, such as lower occlusion rates of the distal portion of the radial artery, 1,11 and greater comfort for patients. 1,12,13 Although apparently interesting, there is limited evidence regarding the potential complications of the distal TRA (dTRA).…”

Fatores que Impactam a Decisão de Realizar Ventriculografia Esquerda em Doença Arterial Coronariana

“…As diretrizes para síndrome coronariana preconizam a avaliação de função ventricular esquerda, recomendando um método não invasivo para essa finalidade. 17 - 26 Apesar de considerar o exame apropriado, a literatura não estabelece, de maneira específica, o papel atual da ventriculografia e em quais situações ela deve ser priorizada em relação às técnicas não invasivas. 2…”

“…Guidelines for management of coronary syndrome recommend the assessment of left ventricular function, preferably via a noninvasive method. 17 - 26 Despite still considering ventriculography to be appropriate, the literature does not specifically establish its current role, nor in which situations it should be prioritized over noninvasive techniques. 2…”

Risk Scores in Acute Coronary Syndrome: Current Applications and Future Perspectives

“…However, patients with non-ST elevation ACS are more heterogenous, and risk stratification models have exerted greater influence on decision making (Table 2). [4][5][6][7] High-risk patients (GRACE score > 140) represent a group of patients who benefit from an invasive approach in the first 24 hours, 6,7 meanwhile patients at low risk may be considered for treatment outside the intensive care unit and early discharge. 8 Other risk models have been developed, as the one developed by the National Cardiovascular Data Registry (NCDR®), whose accuracy can be further improved by the continuous use of a very large and diverse database.…”