Introdução- A hiperglicemia (HG), durante o infarto agudo do miocárdio (IAM), está associada com aumento de mortalidade hospitalar em pacientes diabéticos e não diabéticos. Entretanto, não é conhecido o mecanismo responsável por esta associação. Assim estudou-se, simultaneamente, a correlação entre a glicemia e marcadores bioquímicos relacionados ao sistema neuro-humoral de estresse, metabolismo glicídico e lipídico, sistema de coagulação e inflamatório. Métodos- 80 pacientes foram incluídos consecutiva e prospectivamente. Foram realizadas duas coletas de sangue, a primeira com 24h a 48h do início dos sintomas do IAM (fase aguda) e a segunda após 3 meses do IAM (fase crônica), sempre com 12h de jejum. Foram analisados os seguintes parâmetros: glicose, cortisol, noradrenalina, hemoglobina glicada (HbA1c), insulina, LDL minimamente modificada eletronegativa, ácidos graxos livres (AGL), adiponectina, factor VII da coagulação, fibrinogênio, inibidor do ativação do plasminogênio tipo 1, proteína C reativa ultra-sensível (PCRus), colesterol total (c) e frações e triglicérides. Nas correlações univariadas entre glicemia e as variáveis contínuas empregou-se o teste de correlação de Pearson. As análises multivariadas foram feitas através de regressão logística (variáveis qualitativas) e modelo linear generalizado (quando as variáveis independentes incluídas foram quantitativas e nominais). Resultados- Na fase aguda, a glicemia correlacionou-se significativamente com HbA1c (r=0,75, p<0,001), insulina (r=0,25, p<0,001), AGL (r=0,3, p=0,01), adiponectina (r=-0,22, p=0,05), LDL-c (r=-0,25, p=0,03), VLDL-c (r=0,24, p=0,03) e triglicérides (r=0,27, p=0,01). No modelo multivariado, as variáveis correlacionadas de forma independente com a glicemia, na fase aguda, foram: HbA1c (p<0,001), insulina (p<0,001), e AGL (p=0,013). Para analisar uma variável de confusão, a história de diabetes mellitus (DM), incluiu-se esta variável num modelo, juntamente com as variáveis acima e todas mostraram associação significativas com glicose: HbA1c (p<0,001), insulina (p=0,001), AGL (p=0,013) e história de DM (p=0,027). Na fase crônica, glicose correlacionou-se com: cortisol (r=0,31, p=0,01), noradrenalina (r=0,54, p<0,001), HbA1c (r=0,78, p<0,001) e PCRus (r=0,46, p<0,001). Na análise multivariada, somente HbA1c (p<0,001) e noradrenalina (p<0,001) mantiveram correlação independente. Conclusão- A HbA1c foi a única variável que correlacionou-se de forma significativa e independente com a glicemia, tanto na fase aguda, quanto na crônica, mostrando que a hiperglicemia, durante o IAM, pode representar uma alteração crônica, sub-diagnosticada, do metabolismo glicídico. / Introduction- Hyperglycemia (HG) is an important prognostic factor in acute myocardial infarction (AMI). However, the pathophysiology is poorly understood. So we proposed a simultaneous correlation between glycemia and biochemical markers of stress, glucose and lipid metabolism, coagulation and inflammation system. Methods- Eighty AMI patients were included prospectively. Blood were collected between 24h and 48h from the pain (acute phase), and 3 months post AMI (chronic phase), with 12-h fasting. These parameters were analyzed: glucose, cortisol, norepinephrine, hemoglobin glycated (HbA1c), insulin, minimally modified electronegative LDL, free fatty acids (FFA), adiponectin, factor VII coagulant, fibrinogen, plasminogen activator inhibitor-1, high sensitive C reaction protein (hsCRP), total cholesterol (c) and fractions and triglyceride. The relationships between glucose and continuous variables were assessed by Pearsons correlation coefficient (r) and multivariate analysis with linear regression. Results- At acute phase, glucose correlated significantly with HbA1c (r=0.75, p<0.001), insulin (r=0.25, p<0.001), FFA (r=0.3, p=0.01), adiponectin (r=-0.22, p=0.05), LDL-c (r=-0.25, p=0.03), VLDL-c (r=0.24, p=0.03) and triglyceride (r=0.27, p=0.01). In a multivariate model, variables correlated were: HbA1c (p<0.001), insulin (p<0.001), and FFA (p=0.013). At the chronic phase, glucose correlated significantly with cortisol (r=0.31, p=0.01), norepinephrine (r=0.54, p<0.001), HbA1c (r=0.78, p<0.001) and hsCRP (r=0.46, p<0,001). By multivariable analysis, only HbA1c (p<0.001) and norepinephrine (p<0.001) remained correlated. Conclusion- HbA1c was the main variable that correlated significantly and independently with glycemia at acute and chronic phases, suggesting that HG during AMI can represent an exacerbation of abnormal glucose metabolism previously not diagnosed.

Observational data and alternative estimators with correct interpretations have been used to assess the "right" treatment rates in previous studies. However, no systematic analytical approach has been proposed to examine whether the existing diagnosis rates were right in practice. This study used patients with acute myocardial infarction (AMI) as an example to demonstrate use of observational data to explore the clinical and economic effects of depression diagnosis and the "right" depression diagnosis rates in real-world settings. The objectives of this study were to (1) examine the effects of depression diagnosing on survival, healthcare costs and utilization among elderly patients with AMI; and (2) ascertain bounds on the estimates of the effects of depression diagnosing on survival, healthcare costs and utilization based on chart abstracted data for a subset of patients. Using Medicare claims data, we included a retrospective cohort of all Medicare fee-for-service patients with their first AMI without a depression diagnosis in the previous year during 2007-2008. Depression diagnosis was identified if a patient had a depression diagnosis within 30 days after AMI admission. We also assessed the effects of depression diagnosis within 60 and 90 days after AMI admission. Outcomes were survival, healthcare costs (total costs, Part A, Part B (outpatient, physician fee schedule, and other), and Part D costs), and utilization (hospitalizations, emergency department (ED) visits, outpatient visits, physician visits, and prescription claims) within 1 year after AMI admission. Risk adjustment (RA) and instrumental variables (IV) models were used to estimate the effects of depression diagnosis on AMI patient outcomes. Instruments of local area depression diagnosis styles were created based on area diagnosis ratio (ADR). Using chart abstracted data for a convenience sample, we measured patient physical functional status by difficulties with activities of daily living (ADL) and overall health by adult comorbidity evaluation-27 (ACE-27), AMI severity, and mental illnesses during the index hospitalization. Among 155841 AMI patients in our study sample, 5.9% had a depression diagnosis within 30 days after AMI admission. Our RA estimates showed that depression diagnosis was associated with decreased survival, increased total healthcare costs, Part A costs, Part B outpatient costs, hospitalizations, ED visits, physician visits, and prescription claims in 1 year after AMI admission for patients diagnosed with depression. The ADR-based instruments were strongly related to depression diagnosis (Chow-F values > 10). Our IV estimates showed that higher depression diagnosis rates were associated with increased total healthcare costs, Part A costs, Part B physician fee schedule costs, Part B other costs, Part D costs, and physician visits, but decreased ED visits and prescription claims in 1 year after AMI admission for patients whose depression diagnosis was affected by ADR-based instruments. Since patients diagnosed with depression were more likely to be sicker based on measures in the charts, the RA estimates might be biased toward worse health outcomes and higher healthcare costs and utilization. Across patients grouped by local depression diagnosis styles, the measures in the charts were more evenly distributed across diagnosis groups. However, patients living in areas with stronger preferences of depression diagnosis tended to use more wheelchairs, indicating worse physical function than those living in areas with less stronger preferences. Furthermore, our instruments based on local physician depression diagnosis styles might be correlated with local area practice styles in general (preference to healthcare utilization overall) and local physician supply, and thereby affect healthcare utilization and costs. Therefore, the instruments might not be valid and we could not conclude whether the existing depression diagnosis rates need to be changed.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第18138号 / 医博第3858号 / 新制||医||1002(附属図書館) / 30996 / 京都大学大学院医学研究科医学専攻 / (主査)教授 木村 剛, 教授 坂田 隆造, 教授 羽賀 博典 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Background: During the past 50 years, novel diagnostic tools, interventional approaches, and population-wide changes in the major coronary risk factors have occurred. However, few studies have examined relatively recent trends in the demographic characteristics, clinical profile, and the short-term outcomes of patients hospitalized for acute myocardial infarction (AMI) from the more generalizable perspective of a population-based investigation. Methods:We examined decade long trends (2001 to 2011) in patient’s demographic and clinical characteristics, treatment practices, and hospital outcomes among residents of the Worcester metropolitan area hospitalized with a validated initial AMI (n = 3,730) at all 11 greater Worcester medical centers during 2001, 2003, 2005, 2007, 2009, and 2011. Results:The average age of the study population was 68.5 years and 56.9% were men. Patients hospitalized with a first AMI during the most recent study years were significantly younger (mean age = 69.9 in 2001/03; 65.2 in 2009/11), had lower serum troponin levels, and experienced a shorter hospital stay compared to patients hospitalized during the earliest study years. Hospitalized patients were more likely to received evidence-based medical management practices during the years under study. Multivariable-adjusted regression models showed a considerable decline over-time in the hospital death rate (9.6% in 2001/03; 6.5% in 2009/11), and a significant reduction in the proportion of patients who developed atrial fibrillation, heart failure, and ventricular fibrillation during their acute hospitalization. Conclusions: These results highlight the changing nature of patients hospitalized with an incident AMI, and reinforce the need for surveillance of AMI at the community level.

Bakgrund: Hjärtinfarkt är en av de vanligaste dödsorsakerna i världen och ambulanssjukvården möter patientgruppen ofta. En akut hjärtinfarkt kan innebära lidande för patienten och det kan påverka hur deras upplevelser och erfarenheter blir av att drabbas. God omvårdnad och vård utifrån ett personcentrerat förhållningssätt från första samtal till Percutan Coronar Intervention (PCI) är av största vikt för att motverka lidande. Syfte: Att beskriva patienters upplevelser och erfarenheter av akut hjärtinfarkt i prehospital miljö. Metod: En systematisk litteraturöversikt har genomförts. Insamlingen av data samlades in i databaserna PubMed, CINAHL, Psychinfo samt att manuella fritextsökningar genomfördes för att utöka sökresultatet. Totalt 15 artiklar valdes ut till studien publicerade mellan 2012– 2022. Resultat: Två huvudkategorier tillsammans med fem underkategorier utgjorde resultatet. Det framkom att patienterna ifrågasatte sina symtom, hade felaktiga föreställningar och kunde tillskriva sina symtom med ofarliga anledningar. Det fanns hjälpande faktorer för att tolka symtomen som allvarliga och upplevelserna av symtom och symtomförlopp skiljdes åt mellan patienterna. Emotionella upplevelser var något som också spelade roll i hur patienternas upplevelser och erfarenheter blev vid en akut hjärtinfarkt. Slutsats: Det finns flertalet upplevelser och erfarenheter som uppkommer i samband med en akut hjärtinfarkt. Det skiljer sig även mellan när, hur och var patienterna söker vård. Ambulanssjuksköterskan behöver fortsatt utbildning i hur patienter upplever och erfar en akut hjärtinfarkt. Förslag till fortsatt forskning är att undersöka hur patienters upplevelser och erfarenheter är vid hjärtinfarkt i interaktion med ambulanssjukvården. / Background: Myocardial infarction is one of the most common causes of death in the world, and the ambulance service often encounters this group of patients. A myocardial infarction can mean suffering for the patient and it can affect how their experiences are of being affected. Good care and care based on a person-centered approach from the first call to the Percutan Coronary Intervention (PCI) is of the utmost importance to counteract suffering. Aim: To describe patients' experience of an acute myocardial infarction in a prehospital environment. Method: A systematic literature review has been carried out. The collection of data was collected in the databases PubMed, CINAHL, Psychinfo and that manual free text searches were carried out to expand the search results. Totally 15 articles were selected for the study and were published between 2012-2022. Results: Two main categories together with five subcategories made up the result. It emerged that the patients questioned their symptoms, had misconceptions and were able to attribute their symptoms to harmless reasons. There were factors helping to interpret the symptoms as serious and the experiences of symptoms and the course of symptoms differed between the patients. Emotional experiences were something that also played a role in how the patients' experiences turned out during a myocardial infarction. Conclusion: There are several experiences and experiences that arise in connection with a myocardial infarction. It also differs between when, how and where patients seek care. The ambulance nurse needs continued training in how patients experience and the experiences that arise during a myocardial infarction. A suggestion for further research is to see what patients' experiences are like when they have suffered a myocardial infarction and when care takes place in interaction with the ambulance.

Objectives: To analyze the use and prognostic impact of active mechanical circulatory support (MCS) devices in a large prospective contemporary cohort of patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). Background: Although increasingly used in clinical practice, data on the efficacy and safety of active MCS devices in patients with CS complicating AMI are limited. Methods: This is a predefined subanalysis of the CULPRIT-SHOCK randomized trial and prospective registry. Patients with CS, AMI and multivessel coronary artery disease were categorized in two groups: (1) use of at least one active MCS device vs. (2) no active MCS or use of intra-aortic balloon pump (IABP) only. The primary endpoint was a composite of all-cause death or renal replacement therapy at 30 days. Results: Two hundred of 1055 (19%) patients received at least one active MCS device (n = 112 Impella®; n = 95 extracorporeal membrane oxygenation (ECMO); n = 6 other devices). The primary endpoint occurred significantly more often in patients treated with active MCS devices compared with those without active MCS devices (142 of 197, 72% vs. 374 of 827, 45%; p < 0.001). All-cause mortality and bleeding rates were significantly higher in the active MCS group (all p < 0.001). After multivariable adjustment, the use of active MCS was significantly associated with the primary endpoint (odds ratio (OR) 4.0, 95% confidence interval (CI) 2.7–5.9; p < 0.001). Conclusions: In the CULPRIT-SHOCK trial, active MCS devices were used in approximately one fifth of patients. Patients treated with active MCS devices showed worse outcome at 30 days and 1 year.

京都大学 / 新制・課程博士 / 博士(社会健康医学) / 甲第23822号 / 社医博第122号 / 新制||社医||12(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 木村 剛, 教授 西浦 博, 教授 長尾 美紀 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

[ES] El infarto agudo de miocardio (IAM) es una de las principales causas de morbilidad y mortalidad en los países desarrollados. A lo largo de los últimos años se ha visto que la respuesta inflamatoria que ocurre tras desencadenarse el IAM es muy importante en el desarrollo clínico de esta patología. Si se produce una respuesta inflamatoria exacerbada aumenta el riesgo de remodelado cardiaco adverso y fallo cardiaco, pero el hecho de que no se desencadene la respuesta inflamatoria también tiene consecuencias negativas. Debido a la importancia de la respuesta inflamatoria en el IAM, recientemente se han intentado desarrollar terapias dirigidas frente componentes celulares o moleculares que participan en esta respuesta. Dentro de estas terapias, la terapia celular con células mesenquimales estromales (MSC) se ha postulado como un buen candidato. Las MSC se caracterizan fundamentalmente por su capacidad inmunomoduladora, lo que ha conducido a su empleo como agentes terapéuticos en diferentes enfermedades que cursan con procesos inflamatorios. Sin embargo, a lo largo de los últimos años, numerosos estudios han mostrado que el efecto terapéutico de las MSC está mediado fundamentalmente por las vesículas extracelulares (EVs) que liberan. Estas EVs recapitulan los efectos terapéuticos de las células de origen, por lo que también presentan efectos inmunomoduladores. El empleo de las EVs de MSC como agentes terapéuticos presenta ventajas respecto al uso de las MSC como, por ejemplo, una mayor bioseguridad. No obstante, el uso clínico de las EVs todavía tiene que hacer frente a retos como la obtención de grandes cantidades de EVs que constituyan un producto clínico estable y homogéneo. En este trabajo se ha querido evaluar, por un lado, si las EVs obtenidas de diferentes biopsias de la misma fuente tisular de MSC pueden constituir un producto biológico homogéneo que presente las mismas características y funcionalidad. Por otro lado, se ha evaluado si estas EVs se pueden emplear como agente terapéutico frente a la respuesta inflamatoria que se desencadena tras el IAM. Para ello se ha estudiado el efecto inmunomodulador de las EVs sobre células del sistema inmune, fundamentalmente macrófagos, in vitro y en un modelo in vivo de IAM en ratas. Los resultados mostraron que las EVs favorecen la diferenciación de los macrófagos M1 proinflamatorios hacia un fenotipo similar al M2, aumentando la expresión de marcadores M2 y reduciendo la secreción de citocinas proinflamatorias. Además, las EVs promovieron la activación de neutrófilos in vitro y la reducción de su estrés oxidativo. La administración de EVs en ratas sometidas a IAM amortiguó la caída de la función cardiaca y limitó la extensión de la zona infartada a los 7 y 21 días postinfarto. Las EVs también redujeron el número de macrófagos y neutrófilos proinflamatorios dentro de la zona infartada, favoreciendo la resolución de la inflamación. En conclusión, las EVs empleadas en este trabajo han demostrado ser un producto biológico estable con independencia de la biopsia de la que proceden, y han demostrado ser capaces de ejercer respuestas pro-resolutivas eficaces en un modelo de isquemia miocárdica, lo que las convierte en potenciales agentes terapéuticos para tratar la inflamación en el IAM. / [CA] L'infart agut de miocardi (IAM) és una de les principals causes de morbiditat i mortalitat als països desenvolupats. Al llarg dels darrers anys s'ha vist que la resposta inflamatòria que passa després de desencadenar-se l'IAM és molt important en el desenvolupament clínic d'aquesta patologia. Si es produeix una resposta inflamatòria exacerbada augmenta el risc de remodelat cardíac advers i fallada cardíaca, però el fet que no es desencadeni la resposta inflamatòria també té conseqüències negatives. A causa de la importància de la resposta inflamatòria a l'IAM, recentment s'han intentat desenvolupar teràpies dirigides davant de components cel·lulars o moleculars que participen en aquesta resposta. Dins aquestes teràpies, la teràpia cel·lular amb cèl·lules mesenquimals estromals (MSC) s'ha postulat com un bon candidat. Les MSC es caracteritzen fonamentalment per la seva capacitat immunomoduladora, cosa que ha conduït a la seva ocupació com a agents terapèutics en diferents malalties que cursen amb processos inflamatoris. Tot i això, al llarg dels últims anys, nombrosos estudis han mostrat que l'efecte terapèutic de les MSC està intervingut fonamentalment per les vesícules extracel·lulars (EVs) que alliberen. Aquestes EVs recapitulen els efectes terapèutics de les cèl·lules dorigen, per la qual cosa també presenten efectes immunomoduladors. L'ús de les EVs de MSC com a agents terapèutics presenta avantatges respecte a l'ús de les MSC com, per exemple, una bioseguretat més gran. Tot i això, l'ús clínic de les EVs encara ha de fer front a reptes com l'obtenció de grans quantitats d'EVs que constitueixin un producte clínic estable i homogeni. En aquest treball s'ha volgut avaluar, d'una banda, si les EV obtingudes de diferents biòpsies de la mateixa font tissular de MSC poden constituir un producte biològic homogeni que presenti les mateixes característiques i funcionalitat. D'altra banda, s'ha avaluat si aquestes EVs es poden fer servir com a agent terapèutic davant de la resposta inflamatòria que es desencadena després de l'IAM. Per això s'ha estudiat l'efecte immunomodulador de les EV sobre cèl·lules del sistema immune, fonamentalment macròfags, in vitro i en un model in vivo d'IAM en rates. Els resultats van mostrar que les EVs afavoreixen la diferenciació dels macròfags M1 proinflamatoris cap a un fenotip similar al M2, augmentant l'expressió de marcadors M2 i reduint la secreció de citocines proinflamatòries. A més, les VE van promoure l'activació de neutròfils in vitro i la reducció del seu estrès oxidatiu. L'administració d'EVs en rates sotmeses a IAM va esmorteir la caiguda de la funció cardíaca i va limitar l'extensió de la zona infartada als 7 i 21 dies postinfart. Les EVs també van reduir el nombre de macròfags i neutròfils proinflamatoris dins de la zona infartada, afavorint la resolució de la inflamació. En conclusió, les EVs emprades en aquest treball han demostrat ser un producte biològic estable amb independència de la biòpsia de què procedeixen, i han demostrat ser capaços d'exercir respostes pro-resolutives eficaces en un model d'isquèmia miocàrdica, cosa que les converteix en agents terapèutics potencials per tractar la inflamació a l'IAM. / [EN] Acute myocardial infarction (AMI) is one of the main causes of morbidity and mortality in developed countries. Over the last few years, it has been shown that the inflammatory response that occurs after AMI is triggered is very important in the clinical development of this pathology. If an exacerbated inflammatory response occurs, the risk of adverse cardiac remodeling and heart failure increases, but failure to trigger the inflammatory response also has negative consequences. Because of the importance of the inflammatory response in AMI, recent attempts have been made to develop therapies that target cellular or molecular components involved in this response. Within these therapies, cell therapy with mesenchymal stromal cells (MSC) has been postulated as a good candidate. MSC are mainly characterized by their immunomodulatory capacity, which has led to their use as therapeutic agents in different diseases involving inflammatory processes. However, in recent years, numerous studies have shown that the therapeutic effect of MSCs is mainly mediated by the extracellular vesicles (EVs) they release. These EVs recapitulate the therapeutic effects of the cells of origin and therefore also have immunomodulatory effects. The use of MSC-EVs as therapeutic agents has advantages over the use of MSC, such as increased biosafety. However, the clinical use of EVs still faces challenges such as obtaining large quantities of EVs that constitute a stable and homogeneous clinical product. The aim of this study was to evaluate, on the one hand, whether EVs obtained from different biopsies of the same MSC tissue source can constitute a homogeneous biological product with the same characteristics and functionality. On the other hand, we have evaluated whether these EVs can be used as a therapeutic agent against the inflammatory response triggered after AMI. To this end, the immunomodulatory effect of EVs on immune system cells, mainly macrophages, was studied in vitro and in an in vivo model of AMI in rats. The results showed that EVs favored the differentiation of proinflammatory M1 macrophages towards an M2-like phenotype, increasing the expression of M2 markers and reducing the secretion of proinflammatory cytokines. In addition, EVs promoted the activation of neutrophils in vitro and the reduction of their oxidative stress. The administration of EVs in rats subjected to AMI blunted the decline in cardiac function and limited the extent of the infarct zone at 7- and 21-days post-infarction. EVs also reduced the number of proinflammatory macrophages and neutrophils within the infarct zone, favoring the resolution of inflammation. In conclusion, the EVs used in this work have been shown to be a stable biological product regardless of the biopsy from which they are derived and have been shown to be able to exert effective pro-resolving responses in a model of myocardial ischemia, making them potential therapeutic agents to treat inflammation in AMI. / Amaro Prellezo, E. (2024). Las vesículas extracelulares derivadas de células mesenquimales estromales de pulpa dental como producto terapéutico frente a la respuesta inmune que se desencadena tras el infarto agudo de miocardio [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/202973

Introducción: El infarto agudo de miocardio con coronariografía normal, más conocido por sus siglas en inglés como MINOCA, es un cuadro clínico menos estudiado a diferencia de su contraparte obstructiva. Objetivo: Describir características generales de los pacientes con infarto agudo de miocardio y coronariografía normal en un hospital de tercer nivel del 2016 al 2021. Materiales y métodos: El estudio es de diseño observacional, transversal y descriptivo. Se usaron datos recolectados de las historias clínicas mediante una ficha de datos. Se realizó un muestreo censal que incluyó 54 registros clínicos. Resultados: La mayoría de los pacientes fueron mujeres (62.9%), y mayores de 60 años (61.1%). Como factores de riesgo destacó la hipertensión arterial (63%), seguido de diabetes mellitus (29.6%) y dislipidemia (18.5%). Predominó el sobrepeso y la obesidad (72,3%). En el trazado electrocardiográfico la mayoría presentó un trazado sin elevación del segmento ST (74.1%), y al examen ecocardiográfico la mitad de los pacientes presentaron motilidad cardiaca normal (51,9%) y una FEVI preservada (59,3%). Respecto a los diagnósticos al alta, se encontró en primer lugar el infarto agudo de miocardio tipo 1 (59.3%). Conclusión: Se encontró que el MINOCA afecta principalmente a pacientes que se caracterizan por ser del sexo femenino, mayores de 60 años, con diagnóstico previo de HTA, presentar dolor torácico típico, cursar con sobrepeso, además de registrar electrocardiogramas sin elevación del segmento ST, conservar una motilidad cardiaca normal y FEVI preservada, y la mayoría fue dado de alta con infarto de miocardio tipo 1. / Introduction: Acute myocardial infarction with normal coronary angiography, better known by its acronym in English as MINOCA, is a clinical condition less studied unlike its well-known obstructive counterpart. Objective: To describe general characteristics of patients with acute myocardial infarction and normal coronary angiography in a tertiary hospital from 2016 to 2021. Materials and methods: The study has an observational, cross-sectional, and descriptive design. Data collected from medical records using a data sheet were used. A census sampling was carried out that included 54 clinical records. Results: Most of patients were women (62.9%), and over 60 years of age (61.1%). High blood pressure (63%) stood out as risk factors, followed by diabetes mellitus (29.6%) and dyslipidemia (18.5%). Also, there was a clear predominance of overweight and obesity (72.3%). In the electrocardiographic tracing, the majority presented a tracing without ST segment elevation (74.1%), and in the echocardiographic examination, half of the patients presented normal cardiac motility (51.9%) and a preserved LVEF (59.3%). Regarding the diagnoses at discharge, acute myocardial infarction type 1 was found in first place (59.3%). Conclusion: It was found that MINOCA affects patients who are characterized by being female, over 60 years of age, with a previous diagnosis of arterial hypertension, presenting typical chest pain, being overweight, in addition to recording electrocardiograms without ST segment elevation. maintained normal cardiac motility and preserved LVEF, and the majority were discharged with type 1 myocardial infarction.

Η μοριακή σηματοδότηση κατά την αρχή της επαναιμάτωσης η οποία οδηγεί σε προστασία του μυοκαρδίου περιλαμβάνει το μονοπάτι διάσωσης NO/cGMP/PKG/KATP, το μονοπάτι διάσωσης των κινασών RISK(PI3K/Akt, ERK 1/2, GSK3β) και το μονοπάτι JAK/STAT έχοντας ως τελικό στόχο την αναστολή της διάνοιξης των mPTP, το οποίο θεωρείται το τελικό σημείο της επαγόμενης καρδιοπροστασίας. Η παραγωγή του H2S εμπλέκεται στους μηχανισμούς της ισχαιμικής προετοιμασίας και της μετισχαιμικής προστασίας. Διάφορες μελέτες σε απομονωμένα μυοκάρδια (Langendorff isolated perfused hearts) υποστηρίζουν ότι η επαγωγή της καρδιοπροστασίας από την εξωγενή χορήγηση H2S επιτυγχάνεται μέσω της ενεργοποίησης των KATP διαύλων. Ωστόσο, δεν υπάρχουν ολοκληρωμένες μελέτες οι οποίες να καταδεικνύουν τους μοριακούς μηχανισμούς οι οποίοι εμπλέκονται στην καρδιοπροστατευτική δράση του συγκεκριμένου αέριου διαβιβαστή σε in vivo πειραματικά μοντέλα. Ο σκοπός της παρούσας μελέτης είναι ο έλεγχος της υπόθεσης ότι η θεραπευτική χορήγηση ενός ανόργανου δότη H2S (NaHS) στο τέλος της ισχαιμίας και κατά την επαναιμάτωση μειώνει την έκταση του εμφράγματος του μυοκαρδίου σε αναισθητοποιημένους κόνικλους. Επιπλέον μελετήθηκαν οι υποκείμενοι μοριακοί μηχανισμοί. Αναισθητοποιημένοι αρσενικοί κόνικλοι Νέας Ζηλανδίας διαχωρίσθηκαν σε 7 ομάδες και υπεβλήθησαν σε 30 λεπτά παρατεταμένης/συνεχούς ισχαιμίας του μυοκαρδίου ακολουθούμενης από 3 ώρες επαναιμάτωσης με τις ακόλουθες παρεμβάσεις: 1) Ομάδα ελέγχου (control) : χωρίς περαιτέρω παρεμβάσεις, 2) Ομάδα NaHS: χορήγηση ενός δότη Η2S (ΝaΗS) με IV bolus έγχυση και δόση 100μg/kg στο 20 λεπτό της ισχαιμίας ακολουθούμενη από έγχυση σταθερού ρυθμού με δόση 1mg . kg-1 . h-1 για τα επόμενα 120 λεπτά , 3) Ομάδα ΝaHS και DT-2: χορήγηση ΝaHS όμοια με την ομάδα 2 και DT-2 με IV bolus έγχυση και δόση 0,25 mg. kg-1 10 λεπτά πριν την παρατεταμένη ισχαιμία, 4) Ομάδα TAT και ΝaHS: χορήγηση NaHS όμοια με την ομάδα 2 και ΤΑΤ με IV bolus έγχυση και δόση 0.143 mg. kg-1 10 λεπτά πριν την παρατεταμένη ισχαιμία (Η δόση επελέγει ισομοριακά ως προς το DT-2), 5) Ομάδα NaHS+5-HD: χορήγηση NaHS όμοια με την ομάδα 2 και 5-HD με IV bolus έγχυση σε δόση 5mg/kg 40 λεπτά πριν την παρατεταμένη ισχαιμία., 6) Ομάδα NaHS+L Name: χορήγηση NaHS όμοια με την ομάδα 2 και L Name με IV bolus έγχυση σε δόση 10mg/kg στο 19 λεπτό της παρατεταμένης ισχαιμίας, 7) Ομάδα NaHS+Wortmannin: χορήγηση NaHS όμοια με την ομάδα 2 και Wortmannin με IV bolus έγχυση σε δόση 60μg/kg στο 19 λεπτό της παρατεταμένης ισχαιμίας. Μετά το τέλος των πειραμάτων εκτιμήθηκε η εμφραγματική(Ι) και η περιοχή σε κίνδυνο (R). Σε δεύτερη σειρά πειραμάτων ελέγθηκε η ενεργοποίηση των Akt, ERK 1/2 ,eNOS, GSK3β, STAT3, VASP και της PLB σε δείγμα ισχαιμικού ιστού των ομάδων ελέγχου, NaHS και NaHS + DT-2. Για επιβεβαίωση της μη φωσφορυλίωσης ορισμένων από τις προαναφερθείσες πρωτεΐνες χρησιμοποιήθηκε ως ομάδα αναφοράς, μία πρόσθετη ομάδα PostC η οποία υπεβλήθη σε 30 λεπτά παρατεταμένη ισχαιμίας ακολουθούμενης από 10 λεπτά επαναιμάτωσης στην έναρξη της οποίας εφαρμόσθηκαν 8 κύκλοι των 30 δευτερολέπτων ισχαιμίας/επαναιμάτωσης. Ο δότης H2S, NaHS, μείωσε την έκταση του εμφράγματος σε σύγκριση με την ομάδα ελέγχου(12.3±3.3% vs 46.4±1.8%,p<0.05), ενώ η προσθήκη του DT-2 ανέστειλε την καρδιοπροστατευτική δράση του NaHS(39.8±3.4%,p=NS vs Control). Η χορήγηση του πεπτιδίου ελέγχου ΤΑΤ δεν τροποποίησε τη δράση του NaHS(23.0±3.4%,p=NS vs H2S group). Ο αναστολέας διάνοιξης των mitoKATP (5-HD) και της ενεργότητας της eNOS (L-NAME) δεν μείωσε την ανασταλτική δράση του NaHS στην έκταση του εμφράγματος(14.1±2.0% και 14.7±2.2% αντίστοιχα, p=NS). Ωστόσο, η χορήγηση του αναστολέα των PI3K/Akt (wortmannin) ανέστρεψε την καρδιοπροστατευτική δράση του NaHS(41.8±1.4% vs 12.3±3.3%, p<0.05). Η φωσφορυλίωση των VASP,και PLB ήταν σημαντικά υψηλότερη στην ομάδα NaHS σε σχέση με τις ομάδες ελέγχου και NaHS+DT-2,οι ERΚ 1/2 φωσφορυλιώθηκαν στις ομάδες NaHS και PostC σε σχέση με τις ομάδες ελέγχου και NaHS+DT-2, οι Akt και STAT3 ήταν εξίσου ενεργοποιημένες στις ομάδες NaHS, NaHS+DT-2 και PostC σε σχέση με την ομάδα ελέγχου, ενώ δεν παρατηρήθηκε φωσφορυλίωση των eNOS και GSK3β στις ομάδες ελέγχου, ΝaHS και NaHS+DT-2 σε σχέση με την ομάδα PostC. Η εξωγενής χορήγηση H2S στο τέλος της παρατεταμένης ισχαιμίας και κατά την επαναιμάτωση επάγει φαρμακολογική μετισχαιμική προστασία σε αναισθητοποιημένους κόνικλους μέσω των μονοπατιών Akt/PKG/PLB και PKG/ ERK 1/2 ανεξάρτητα από την eNOS, την GSK3β, το JAK/STAT μονοπάτι και την διάνοιξη των mitoKATP. / The signal transduction pathways which are recruited during early reperfusion include the nitric oxide/cGMP/PKG/KATP pathway, the reperfusion injury salvage kinase pathway (PI3K /Akt, ERK 1/2, GSK3α), and the JAK/STAT pathway targeting the inhibition of mPTP opening which is considered the end-point for inducing cardioprotection. The production of H2S plays a role in myocardial pre-and post-conditioning responses. Several studies in isolated hearts support cardioprotection from exogenous H2S due to KATP channels activation. However, there is a lack of evidence for the molecular mechanism underlying the protection of H2S in in vivo experimental models of ischemia/reperfusion injury. The aim was to elucidate the hypothesis that therapeutic administration of the H2S donor NaHS before and during reperfusion reduces the infarct size in anesthetized rabbits. Additional the molecular mechanisms underlying the induced cardioprotection from exogenous administrated H2S were studied. Anesthetized male rabbits were divided into 7 groups and were subjected to 30 min regional ischemia of the heart and 3 hours reperfusion with the following additional interventions: 1) Control group no further intervention, 2) NaHS group was treated with the H2S donor sodium hydrosulphide (NaHS) at a dose of 100 ιg.Kg-1 bolus on the 20th min of ischemia followed by infusion of 1mg.Kg-1. h-1 for the next 120 min, 3) NaHS +DT-2 group, treated with NaHS and the PKG inhibitor DT-2 that was given at a dose of 0.25 mg.kg-1 bolus 10 min before sustained ischemia, 4) NaHS +TAT group, treated with NaHS and the control peptide TAT that was given at a dose of 0.143 mg.kg-1 bolus 10 min before sustained ischemia, 5) NaHS+5-hydroxydecanoic acid (5-HD) treated with NaHS and mitoKATP channels inhibitors 5-HD iv bolus 40 minutes before occlusion at a dose of 5 mg.kg-1, 6) NaHS+ L-NAME treated with NaHS and the synthase of NO inhibitor L NAME IV bolus on the 19th min of ischemia at a dose of 10 mg.kg-1 and 7) NaHS+ Wortmannin treated with NaHS and the PI3/Akt inhibitor Wortmannin on the 19th min of ischemia at a dose of 60ιg.kg-1. After the end of the experiments the infarct size (I) and the area at risk (R) were estimated. In a second series of experiments, determination of activation of Akt, ERK 1/2 ,eNOS, GSK3α, STAT3, VASP and phopsholamban (PLB) was investigated in tissue samples from ischemic area of myocardium from Control, NaHS and NaHS + DT-2 groups. As positive control of no phosphorylation observed, PostC group was used. In PostC group animals were subjected in 30 minutes sustained ischemia followed by 10 minutes of reperfusion, were 8 cycles of 30 seconds of ischemia/ reperfusion were applied immediately after the onset of reperfusion. H2S donor NaHS reduced the infarct size compared to Control (12.3 ± 3.3% vs 46.4 ± 1.8%, p<0.05), whereas the addition of the PKG inhibitor DT2 abrogated the infarct size limiting effect (39.8 ± 3.4%, p=NS vs Control). Treatment with the control peptide TAT did not alter the effect of NaHS (23.0 ± 3.4%, p=NS vs H2S group). Administration of mitoKATP inhibitor (5-HD) and eNOS inhibitor (L-NAME) did not alter the infract limiting effects of NaHS (14.1±2.0% and 14.7±2.2% respectively, p=NS). However, administration of the PI3K/Akt inhibitor wortmannin reversed this cardioprotection (41.8±1.4% vs 12.3±3.3%, p<0.05). Phosphorylation of VASP, ERK ½ and PLB was significantly higher in NaHS treated group versus control and NaHS+DT-2 groups, in PostC group ERK ½ were phosphorylated respectively to NaHS treated group, Akt and STAT3 were phosphorylated in NaHS, NaHS+DT-2 and PostC groups vs Control group, whereas no phosphorylation of eNOS and GSK3α was observed in NaHS, NaHS+DT-2 and control groups compared to PostC group. Exogenous administration of H2S at the end of ischemia and during reperfusion induces pharmacological postconditioning in anesthetized rabbits due to Akt/PKG/PLB and PKG/ ERK 1/2 activation independently of eNOS, GSK3α, JAK/STAT and mitoKATP activation.