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Vol. 64. Issue S2.
Problemas relevantes en cardiología 2010
Pages 28-33 (July 2011)
(Spanish Only)
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Vol. 64. Issue S2.
Problemas relevantes en cardiología 2010
Pages 28-33 (July 2011)
(Spanish Only)
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Modulación del sistema betaadrenérgico durante el infarto agudo de miocardio: justificación para un nuevo ensayo clínico
Modulation of the Beta-Adrenergic System During Acute Myocardial Infarction: Rationale for a New Clinical Trial
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Borja Ibáñeza,
,b
, Valentín Fustera,c, Carlos Macayab, Jesús Jiménez-Borregueroa,d, Andrés Iñigueze, Antonio Fernández-Ortizb, Ginés Sanza, Vicente Sánchez-Brunetef
a Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, España
b Hospital Clínico San Carlos, Madrid, España
c Mount Sinai School of Medicine, Nueva York, Estados Unidos
d Hospital Universitario de la Princesa, Madrid, España
e Complejo Hospitalario Universitario de Vigo-Meixoeiro, Vigo, Pontevedra, España
f Servicio de Urgencia Médica de Madrid (SUMMA-112), Madrid, España
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El infarto agudo de miocardio es el resultado de una oclusión súbita de una coronaria epicárdica. La isquemia persistente tiene como resultado la necrosis del miocardio irrigado por la coronaria ocluida. El tamaño final del infarto se ha mostrado recientemente como un predictor importante de eventos clínicos futuros y, por lo tanto, se utiliza como objetivo subrogado de variables clínicas en ensayos clínicos. El tiempo de isquemia se ha mostrado como el mayor determinante para aumentar el miocardio rescatado (miocardio en riesgo no necrosado). Más allá de minimizar el tiempo desde el inicio de los síntomas hasta la reperfusión, hay mucho interés en encontrar terapias que puedan limitar aún más el tamaño del infarto (cardioprotección), lo que es objeto de múltiples estudios clínicos. El bloqueo beta oral en las primeras horas del infarto es una indicación de clase IA en las guías de actuación clínica; sin embargo, el bloqueo beta intravenoso precoz, incluso antes de la reperfusión coronaria, no se aconseja de manera sistemática. El metoprolol, un bloqueador beta 1 selectivo, se ha mostrado en modelos preclínicos como un agente capaz de reducir el tamaño del infarto exclusivamente cuando se administra antes de la reperfusión coronaria, lo que indica que su capacidad cardioprotectora es secundaria a una reducción del daño por reperfusión. Datos retrospectivos de ensayos clínicos de infarto muestran un beneficio clínico (menor mortalidad y mejor recuperación de la contractilidad del ventrículo izquierdo) con el inicio precoz del bloqueo beta intravenoso en pacientes sin contraindicaciones. Nuestra hipótesis general es que la administración precoz (intravenosa antes de la reperfusión) de metoprolol, comparada con un inicio de metoprolol oral tras reperfusión, resultará en una reducción del tamaño del infarto. El ensayo Efecto del METOprolol en la CARDioproteCcióN durante el Infarto agudo de mioCardio (METOCARD-CNIC) testará esta hipótesis en pacientes con infarto con elevación del segmento ST.

Palabras clave:
Infarto agudo de miocardio
Bloqueadores beta
Daño por reperfusión
Cardioprotección

Acute myocardial infarction is caused by sudden coronary artery occlusion. Persistent ischemia results in necrosis of the myocardial tissue supplied by the occluded vessel. It has recently been shown that the final size of the infarct is a major predictor of future clinical events, and is, therefore, used as a surrogate outcome in clinical trials. Moreover, it has become clear that the duration of ischemia in the main determinant of the success of myocardial salvage (i.e. of non-necrotic at-risk myocardium). In addition to minimizing the time between symptom onset and reperfusion, there is considerable interest in finding therapies that can further limit the size of the infarction (i.e. cardioprotective therapies) and they are the focus of numerous clinical studies. Oral β-blockade within the first few hours of an AMI is a class-IA indication in clinical practice guidelines. However, early intravenous β-blockade, even before coronary artery reperfusion, is not routinely recommended. Preclinical research has demonstrated that the selectiveβ1-blocker metoprolol is able to reduce the infarct size only when administered before coronary artery reperfusion, which indicates that its cardioprotective properties are secondary to its ability to reduce reperfusion injury. In addition, retrospective studies of AMI suggest that starting intravenous β-blockade early has clinical benefits (i.e. lower mortality and better recovery of left ventricular contractility) in patients without contraindications. Our general hypothesis is that early administration of metoprolol (i.e. intravenously before reperfusion) results in smaller infarcts than administering the drug orally after reperfusion. The Effect of METOprolol in CARDioproteCtioN during an acute myocardial InfarCtion (METOCARD-CNIC) trial will test this hypothesis in patients with ST-segment elevation AMI.

Keywords:
Acute myocardial infarction
Beta-blockers
Reperfusion injury
Cardioprotection
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Revista Española de Cardiología (English Edition)

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