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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The electrocardiographic evidence of injury appears in the presence of evident diastolic depolarization due to an important reduction in blood supply or other non-ischemic causal factors&#46; This in turn leads to a &#8220;defective&#8221; transmembrane action potential reflected upon the ECG tracing as an ST-segment deviation&#46; When diastolic depolarization occurs at subendocardial level&#44; an ST-segment descent appears on the ECG&#44; while depolarization at subepicardial &#40;or transmural&#41; level gives rise to ST-segment elevation&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In patients with acute coronary syndrome &#40;ACS&#41;&#44; the ST-segment elevation pattern is associated to rupture or fissuring of an unstable atheroma plaque&#44; with acute thrombotic occlusion of an epicardial artery in a patient without previous important ischemia &#40;ACS with ST-segment elevation &#91;ACSSTE&#93;&#41;&#46; When occlusion is incomplete or distal flow is present thanks to collateral circulation&#44; ST-segment elevation is not observed &#40;ACS without ST-segment elevation &#91;ACSWSTE&#93;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> The initial management of ACSSTE involves emergency aperture of permeation of the affected artery through pharmacological &#40;thrombolysis&#41; or mechanical means &#40;percutaneous revascularization&#41;&#46; In contrast&#44; thrombolysis is not effective in ACSWSTE&#44; and coronary revascularization in such cases is not an immediate emergency concern&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In a small group of patients ST-segment elevation is transient &#40;less than 20<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; According to the current criteria of the International Society for Holter and Noninvasive Electrocardiology&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> such cases correspond to patients with a &#8220;predominance of ST-segment elevation&#8221; that are in turn subclassified according to the degree of elevation of the myocardial necrosis markers as either &#8220;aborted infarctions&#8221; or &#8220;infarctions without ST-segment elevation&#8221;&#46; The main ACS management guides have not defined a specific designation for these patients&#44; and include ACS with transient ST-segment elevation within the group of ACSWSTE&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this number of <span class="elsevierStyleSmallCaps">Medicina Intensiva</span>&#44; Arroyo-&#218;car et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> report that patients with ACS and transient ST-segment elevation exhibit a characteristic profile that differentiates them from the rest of patients with ACSWSTE&#58; younger age&#44; a greater prevalence of males and smokers&#44; a lesser elevation of the necrosis markers&#44; a greater ejection fraction and a higher prevalence of single-vessel disease&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">These results are consistent with those of the previous studies&#46; In this context&#44; Drew et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> in a study involving continuous ST-segment monitorization&#44; found patients with episodes of ST-segment elevation to have a greater frequency of single-vessel disease&#44; while patients with ST-segment depression showed more frequent multivessel disease&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In turn&#44; Meisel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> found that in comparison with the group of patients with persistent ST-segment elevation&#44; those with ACS and transient ST-segment elevation showed a lesser creatine kinase peak&#44; a greater ejection fraction&#44; less extensive coronary disease&#44; a greater prevalence of TIMI III flow&#44; and fewer coronary events over the course of follow-up&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This profile of limited myocardial damage with normal systolic function refers us to the known good prognosis of patients with ACSSTE that normalize their ST-segment after thrombolysis&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> or to the patients subjected to primary percutaneous coronary revascularization with initial TIMI III flow&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> However&#44; in the recent metaanalysis of individual patients included in the FRISC-II&#44; RITA and ICTUS trials&#44; the cardiovascular mortality or infarction risk was found to be practically identical in the patients with transient elevation of depression of the ST-segment &#40;19&#46;2&#37; versus 19&#46;4&#37;&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Some authors have suggested that initial conservative management may be indicated in these cases&#44; considering their supposedly good prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> However&#44; as correctly commented by Arroyo-&#218;car et al&#46;&#44; the treatment of ACS with transient ST-segment elevation has not been well established&#44; and the ACSWSTE management guides offer no specific recommendations for such cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a> Therefore&#44; an important gap in knowledge is found in this field that must be filled by future research work&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">It should be mentioned that the study of ACS with transient ST-segment elevation poses some specific difficulties&#46; Firstly&#44; transient ST-segment elevation is not a nosologic entity as such but rather a clinical sign that may be due to causes other than coronary thrombosis&#44; such as coronary vasospasm &#40;variant angina&#41; or transient apical dysfunction syndrome &#40;tako-tsubo syndrome&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">13</span></a> among other anecdotal conditions<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;17</span></a> with different therapeutic connotations&#46; On the other hand&#44; the dividing or differentiating lines between some of these disease conditions have not been well defined&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The section of the ARIAM study corresponding to 2010 identified 64 patients with transient ST-segment elevation out of a total of 1379 patients with an initial diagnosis of ACS &#40;4&#46;6&#37;&#41;&#59; of these&#44; 3 were classified as corresponding to Prinzmetal angina&#44; 12 as unstable angina &#40;&#8220;aborted infarctions&#8221;&#41;&#44; 45 as infarctions&#44; and 4 as other conditions&#47;causes &#40;unpublished data&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Secondly&#44; the dynamic nature of ACS must be stressed&#44; with frequent episodes of myocardial ischemia due to thrombus formation and lysis&#44; intermittent vasoconstriction and platelet thrombus embolization&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> As an example&#44; we can consider the case of a patient with persistent subepicardial damage secondary to thrombotic occlusion of an artery&#44; exhibiting spontaneous reperfusion&#46; Depending on the moment of the ECG recording&#44; the patient may be classified as presenting ACSSTE &#40;early ECG&#41;&#44; ACS with transient ST-segment elevation &#40;ECG tracing immediately before reperfusion&#41;&#44; or ACSWSTE &#40;late ECG tracing&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In principle&#44; continuous ST-segment monitoring with multiple leads could obviate the low sensitivity associated with surface ECG recordings in detecting transient ST-segment elevation&#46; Caution is required&#44; however&#44; since studies with conventional ECG and those based on continuous ECG monitorization differ not only in the diagnostic tool used but also in the population under evaluation&#46; In the former case&#44; subjects with transient ST-segment elevation are patients who have probably experienced spontaneous reperfusion&#46; The latter case in turn corresponds to individuals who continue to suffer ischemic episodes&#44; and is therefore at an increased risk of developing coronary events&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In any case&#44; the scientific evidence regarding the management of these patients should be derived from randomized clinical trials involving patients with ACS with transient ST-segment elevation&#46; Until such information becomes available&#44; non-randomized studies fitting for treatment tendencies or systematic reviews of randomized trials &#40;analyses of subgroups according to the initial ECG pattern&#41; could contribute useful evidence for decision taking in this important group of patients&#46;</p></span>"
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Editorial
Clinical Significance of Acute Coronary Syndrome with Transient ST-Segment Elevation
Significado clínico del síndrome coronario agudo con elevación transitoria del segmento ST
J. Latour-Péreza,
Corresponding author
jlatour@coma.es

Corresponding author.
, J.B. Cabellob
a Servicio de Medicina Intensiva, Hospital General Universitario de Elche, Elche, Spain
b Hospital General Universitario de Alicante, Coordinación de CASP-España, Alicante, Spain
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    "titulo" => "Clinical Significance of Acute Coronary Syndrome with Transient ST-Segment Elevation"
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        "titulo" => "Significado cl&#237;nico del s&#237;ndrome coronario agudo con elevaci&#243;n transitoria del segmento ST"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The electrocardiographic evidence of injury appears in the presence of evident diastolic depolarization due to an important reduction in blood supply or other non-ischemic causal factors&#46; This in turn leads to a &#8220;defective&#8221; transmembrane action potential reflected upon the ECG tracing as an ST-segment deviation&#46; When diastolic depolarization occurs at subendocardial level&#44; an ST-segment descent appears on the ECG&#44; while depolarization at subepicardial &#40;or transmural&#41; level gives rise to ST-segment elevation&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In patients with acute coronary syndrome &#40;ACS&#41;&#44; the ST-segment elevation pattern is associated to rupture or fissuring of an unstable atheroma plaque&#44; with acute thrombotic occlusion of an epicardial artery in a patient without previous important ischemia &#40;ACS with ST-segment elevation &#91;ACSSTE&#93;&#41;&#46; When occlusion is incomplete or distal flow is present thanks to collateral circulation&#44; ST-segment elevation is not observed &#40;ACS without ST-segment elevation &#91;ACSWSTE&#93;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> The initial management of ACSSTE involves emergency aperture of permeation of the affected artery through pharmacological &#40;thrombolysis&#41; or mechanical means &#40;percutaneous revascularization&#41;&#46; In contrast&#44; thrombolysis is not effective in ACSWSTE&#44; and coronary revascularization in such cases is not an immediate emergency concern&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In a small group of patients ST-segment elevation is transient &#40;less than 20<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; According to the current criteria of the International Society for Holter and Noninvasive Electrocardiology&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> such cases correspond to patients with a &#8220;predominance of ST-segment elevation&#8221; that are in turn subclassified according to the degree of elevation of the myocardial necrosis markers as either &#8220;aborted infarctions&#8221; or &#8220;infarctions without ST-segment elevation&#8221;&#46; The main ACS management guides have not defined a specific designation for these patients&#44; and include ACS with transient ST-segment elevation within the group of ACSWSTE&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this number of <span class="elsevierStyleSmallCaps">Medicina Intensiva</span>&#44; Arroyo-&#218;car et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> report that patients with ACS and transient ST-segment elevation exhibit a characteristic profile that differentiates them from the rest of patients with ACSWSTE&#58; younger age&#44; a greater prevalence of males and smokers&#44; a lesser elevation of the necrosis markers&#44; a greater ejection fraction and a higher prevalence of single-vessel disease&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">These results are consistent with those of the previous studies&#46; In this context&#44; Drew et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> in a study involving continuous ST-segment monitorization&#44; found patients with episodes of ST-segment elevation to have a greater frequency of single-vessel disease&#44; while patients with ST-segment depression showed more frequent multivessel disease&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In turn&#44; Meisel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> found that in comparison with the group of patients with persistent ST-segment elevation&#44; those with ACS and transient ST-segment elevation showed a lesser creatine kinase peak&#44; a greater ejection fraction&#44; less extensive coronary disease&#44; a greater prevalence of TIMI III flow&#44; and fewer coronary events over the course of follow-up&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This profile of limited myocardial damage with normal systolic function refers us to the known good prognosis of patients with ACSSTE that normalize their ST-segment after thrombolysis&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> or to the patients subjected to primary percutaneous coronary revascularization with initial TIMI III flow&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> However&#44; in the recent metaanalysis of individual patients included in the FRISC-II&#44; RITA and ICTUS trials&#44; the cardiovascular mortality or infarction risk was found to be practically identical in the patients with transient elevation of depression of the ST-segment &#40;19&#46;2&#37; versus 19&#46;4&#37;&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Some authors have suggested that initial conservative management may be indicated in these cases&#44; considering their supposedly good prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> However&#44; as correctly commented by Arroyo-&#218;car et al&#46;&#44; the treatment of ACS with transient ST-segment elevation has not been well established&#44; and the ACSWSTE management guides offer no specific recommendations for such cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a> Therefore&#44; an important gap in knowledge is found in this field that must be filled by future research work&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">It should be mentioned that the study of ACS with transient ST-segment elevation poses some specific difficulties&#46; Firstly&#44; transient ST-segment elevation is not a nosologic entity as such but rather a clinical sign that may be due to causes other than coronary thrombosis&#44; such as coronary vasospasm &#40;variant angina&#41; or transient apical dysfunction syndrome &#40;tako-tsubo syndrome&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">13</span></a> among other anecdotal conditions<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;17</span></a> with different therapeutic connotations&#46; On the other hand&#44; the dividing or differentiating lines between some of these disease conditions have not been well defined&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The section of the ARIAM study corresponding to 2010 identified 64 patients with transient ST-segment elevation out of a total of 1379 patients with an initial diagnosis of ACS &#40;4&#46;6&#37;&#41;&#59; of these&#44; 3 were classified as corresponding to Prinzmetal angina&#44; 12 as unstable angina &#40;&#8220;aborted infarctions&#8221;&#41;&#44; 45 as infarctions&#44; and 4 as other conditions&#47;causes &#40;unpublished data&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Secondly&#44; the dynamic nature of ACS must be stressed&#44; with frequent episodes of myocardial ischemia due to thrombus formation and lysis&#44; intermittent vasoconstriction and platelet thrombus embolization&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> As an example&#44; we can consider the case of a patient with persistent subepicardial damage secondary to thrombotic occlusion of an artery&#44; exhibiting spontaneous reperfusion&#46; Depending on the moment of the ECG recording&#44; the patient may be classified as presenting ACSSTE &#40;early ECG&#41;&#44; ACS with transient ST-segment elevation &#40;ECG tracing immediately before reperfusion&#41;&#44; or ACSWSTE &#40;late ECG tracing&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In principle&#44; continuous ST-segment monitoring with multiple leads could obviate the low sensitivity associated with surface ECG recordings in detecting transient ST-segment elevation&#46; Caution is required&#44; however&#44; since studies with conventional ECG and those based on continuous ECG monitorization differ not only in the diagnostic tool used but also in the population under evaluation&#46; In the former case&#44; subjects with transient ST-segment elevation are patients who have probably experienced spontaneous reperfusion&#46; The latter case in turn corresponds to individuals who continue to suffer ischemic episodes&#44; and is therefore at an increased risk of developing coronary events&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In any case&#44; the scientific evidence regarding the management of these patients should be derived from randomized clinical trials involving patients with ACS with transient ST-segment elevation&#46; Until such information becomes available&#44; non-randomized studies fitting for treatment tendencies or systematic reviews of randomized trials &#40;analyses of subgroups according to the initial ECG pattern&#41; could contribute useful evidence for decision taking in this important group of patients&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Latour-P&#233;rez J&#44; Cabello JB&#46; Significado cl&#237;nico del s&#237;ndrome coronario agudo con elevaci&#243;n transitoria del segmento ST&#46; Med Intensiva&#46; 2011&#59;35&#58;267&#8211;9&#46;</p>"
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