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NEFROPATIA INDUCIDA POR EL CONTRASTE EN PACIENTES SOMETIDOS A ANGIOPLASTIA PRIMARIA POR INFARTO AGUDO DE MIOCARDIO

NEFROPATIA INDUCIDA POR EL CONTRASTE EN PACIENTES SOMETIDOS A ANGIOPLASTIA PRIMARIA POR INFARTO AGUDO DE MIOCARDIO

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La angioplastia primaria es la mejor estrategia para la reperfusión miocárdica en el infarto agudo de miocardio con elevación del segmento ST. Sin embargo, se asocia con riesgo elevado de nefropatía por contraste, una complicación renal que se acompaña de un marcado incremento en el riesgo de morbimortalidad. En este marco, deben llevarse a cabo estrategias farmacológicas de protección renal.
marenzi9.jpg Autor:
Giancarlo Marenzi
Columnista Experto de SIIC
Artículos publicados por Giancarlo Marenzi
Recepción del artículo
16 de Noviembre, 2006
Aprobación
12 de Diciembre, 2006
Primera edición
28 de Mayo, 2007

Resumen
La nefropatía inducida por el contraste (NIC), definida como un incremento absoluto (> 0.5 mg/dl) o relativo (> 25%) en la creatinina sérica que tiene lugar 48-72 horas luego de la administración de medios de contraste, es una complicación frecuente de las intervenciones coronarias percutáneas (ICP) y está asociada con riesgo de morbimortalidad elevado. Los pacientes con infarto agudo de miocardio con elevación del segmento ST (IMEST) tratados con ICP primarias constituyen una población con alto riesgo de NIC debido a su inestabilidad hemodinámica, a la necesidad de administrar importantes volúmenes de contraste y a la ausencia de una profilaxis efectiva. La NIC puede afectar al 20% de estos pacientes y se asocia con un curso clínico intrahospitalario más complicado, hospitalización prolongada y marcado incremento en la tasa de mortalidad. La edad > 75 años, la localización anterior del infarto, un prolongado tiempo de reperfusión, un volumen de contraste > 300 ml y el uso de balón de contrapulsación se asocian en forma independiente con la NIC. Por consiguiente, es necesario probar e implementar estrategias preventivas para la protección renal durante las intervenciones coronarias primarias, particularmente en pacientes de alto riesgo. Recientemente, se demostró que la N-acetilcisteína, administrada en bolo intravenoso antes de la ICP primaria y luego por vía oral durante dos días, puede reducir -en forma dependiente de la dosis- la incidencia de NIC y mejorar la evolución clínica de los pacientes con IMEST tratados con ICP primaria.

Palabras clave
infarto agudo de miocardio, nefropatía inducida por contraste, insuficiencia renal, angioplastia primaria


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Abstract
Contrast-induced nephropathy (CIN), defined as an absolute (> 0.5 mg/dl) or a relative (> 25%) increase in serum creatinine occurring 48-72 hours after contrast medium administration, is a frequent complication of percutaneous coronary interventions (PCI), and is associated with an increased morbidity and mortality risk. Patients with ST-segment elevation acute myocardial infarction (STEMI) treated with primary PCI represent a population at high risk for CIN due to hemodynamic instability, need for high contrast volume, and lack of effective prophylaxis. CIN has been reported to occur in almost 20% of these patients and to be associated with complicated in-hospital clinical course, prolonged hospitalization, and markedly increased mortality rate. Age > 75 years, anterior infarct location, prolonged time-to-reperfusion, contrast agent volume > 300 ml, and use of an intra-aortic balloon pump have been found to be independently associated with CIN. Therefore, preventive strategies for kidney protection during primary PCI need to be developed and tested, particularly in high-risk patients. Recently, N-acetylcysteine, given as an intravenous bolus before primary PCI and followed by oral administration for the following two days, has been shown to reduce the incidence of CIN and improve clinical outcomes of STEMI patients treated with primary PCI, with a dose-dependent effect.

Key words
acute myocardial infarction, contrast-induced nephropathy, renal insufficiency, primary angioplasty


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Clasificación en siicsalud
Artículos originales > Expertos del Mundo >
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Especialidades
Principal: Nefrología y Medio Interno
Relacionadas: Diagnóstico por Imágenes, Farmacología, Medicina Farmacéutica, Medicina Interna



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Enviar correspondencia a:
Giancarlo Marenzi, Centro Cardiologico Monzino, I.R.C.C.S, Institute of Cardiology, University of Milan, 20138, Via Parea 4, Milán, Italia
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