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The field of Cardio-Oncology has grown significantly, especially during the last decade. While awareness of cardiotoxicity due to cancer disease and/or therapies has greatly increased, much of the attention has focused on myocardial systolic disfunction and heart failure. However, coronary and structural heart disease are also a common issue in cancer patients and encompass the full spectrum of cardiotoxicity. While invasive percutaneous or surgical intervention, either is often needed or considered in cancer patients, limited evidence or guidelines are available for dealing with coronary or structural heart disease. The Society for Cardiovascular Angiography and Interventions consensus document published in 2016 is the most comprehensive document regarding this particular issue, but relevant evidence has emerged since, which render some of its considerations outdated. In addition to that, the recent 2022 ESC Guidelines on Cardio-Oncology only briefly discuss this topic.As a result, the Portuguese Association of Cardiovascular Intervention and the Cardio-Oncology Study Group of the Portuguese Society of Cardiology have partnered to produce a position paper to address the issue of cardiac intervention in cancer patients, focusing on percutaneous techniques. A brief review of available evidence is provided, followed by practical considerations. These are based both on the literature as well as accumulated experience with these types of patients, as the authors are either interventional cardiologists, cardiologists with experience in the field of Cardio-Oncology, or both. Resumo: A Cardio-Oncologia cresceu consideravelmente, particularmente ao longo da última década. Não obstante o aumento de sensibilização relativamente à cardiotoxicidade secundária ao cancro e/ou a terapêuticas oncológicas, muita da atenção tem-se focado na disfunção sistólica e insuficiência cardíaca. Todavia, a doença coronária e estrutural cardíaca representam também um desafio comum em doentes oncológicos, fazendo assim parte do abrangente conceito de Cardio-Oncologia. Apesar da necessidade de intervenção invasiva, percutânea ou cirúrgica ser frequentemente necessária ou considerada em doentes com cancro, é escassa a evidência ou recomendações relativas à doença coronária ou estrutural neste subgrupo. O documento de consenso da Society for Cardiovascular Angiography and Interventions, publicado em 2016, é a referência mais completa relativamente a esta problemática. Contudo, alguma evidência que entretanto surgiu torna necessária uma atualização. Adicionalmente, as recentes recomendações de 2022 em Cardio-Oncologia da Sociedade Europeia de Cardiologia abordam este assunto somente de forma muito sucinta.Por este motivo, a Associação Portuguesa de Intervenção Cardiovascular e o Grupo de Estudos de Cardio-Oncologia associaram-se para produzir um Artigo de Posição sobre Intervenção Cardíaca em doentes com cancro, com foco nas técnicas percutâneas. Procedeu-se a uma breve revisão da literatura, seguida de considerações práticas. Estas baseiam-se na evidência disponível, bem como na experiência acumulada dos autores, que são Cardiologistas de Intervenção, Cardiologistas dedicados à área da Cardio-Oncologia, ou ambos.

Introduction and objectives: Although automatic artificial intelligence (AI) coronary angiography (CAG) segmentation is arguably the first step toward future clinical application, it is underexplored. We aimed to (1) develop AI models for CAG segmentation and (2) assess the results using similarity scores and a set of criteria defined by expert physicians. Methods: Patients undergoing CAG were randomly selected in a retrospective study at a single center. Per incidence, an ideal frame was segmented, forming a baseline human dataset (BH), used for training a baseline AI model (BAI). Enhanced human segmentation (EH) was created by combining the best of both. An enhanced AI model (EAI) was trained using the EH. Results were assessed by experts using 11 weighted criteria, combined into a Global Segmentation Score (GSS: 0–100 points). Generalized Dice Score (GDS) and Dice Similarity Coefficient (DSC) were also used for AI models assessment. Results: 1664 processed images were generated. GSS for BH, EH, BAI and EAI were 96.9+/-5.7; 98.9+/-3.1; 86.1+/-10.1 and 90+/-7.6, respectively (95% confidence interval, p

Introduction and Objectives: Coronary artery fistulas (CAFs) are rare abnormalities, often detected incidentally during invasive coronary angiography (ICA). While most are clinically silent, they can cause significant morbidity. We aimed to investigate the clinical, angiographic and management features of CAFs in a population undergoing ICA. Methods: We retrospectively reviewed the data of all ICAs conducted in our department between May 2008 and January 2020 and selected those with CAFs. Clinical, angiographic, therapeutic and follow-up data were obtained from medical records. Results: A total of 55 patients with CAFs (35 male, median age 64 years) were identified among 32 174 ICAs. The majority (n=37) had a single fistula. CAFs arose most frequently from the left anterior descending artery (LAD), followed by the right coronary and left circumflex coronary arteries. The most frequent drainage site was the pulmonary artery. Fourteen patients had fistulas originating from both left and right coronary systems. Seven had concomitant congenital cardiovascular disorders. The majority (n=40) were incidental findings. Chest pain was the most common symptom attributable to CAFs and heart murmur the most frequent sign. Conservative management was the main approach (n=40). Eight patients underwent transcatheter closure and seven underwent surgical ligation (six of those during surgery for another heart condition), with no periprocedural mortality. Conclusions: In our series, the prevalence of CAFs was 0.2%. The majority originated from the LAD and the pulmonary artery was the main drainage site. In patients undergoing intervention, both percutaneous and surgical techniques were safe and effective. Resumo: Introdução e objetivos: As fistulas coronárias (FCs) são anomalias raras, detetadas frequentemente de forma incidental durante a angiografia coronária invasiva (ACI). Embora a maioria não cause sintomatologia, podem gerar morbilidade significativa. O nosso objetivo foi descrever as características clínicas e angiográficas das FCs detetadas numa população submetida a ACI, assim como o tratamento realizado. Métodos: Foram retrospetivamente revistos os dados de todas as ACIs realizadas no nosso Centro de maio de 2008 a janeiro de 2020 e selecionadas as que descreviam FCs. Os dados clínicos, angiográficos, terapêuticos e de follow-up foram obtidos de registos informáticos. Resultados: Entre 32 174 coronariografias, identificámos 55 doentes com FCs (35 homens, idade média 64 anos). A maioria (n=37) tinha uma fístula única. A origem mais frequente foi da artéria coronária descendente anterior (DA), seguido da artéria coronária direita e circunflexa. O local de drenagem mais frequente foi a artéria pulmonar. Catorze doentes tinham fístulas originadas da artéria coronária esquerda e direita. Sete tinham doenças cardiovasculares congénitas concomitantes. A maioria (n=40) foi descoberta incidentalmente. O sintoma e sinal mais frequentes foram a dor torácica e o sopro cardíaco. A abordagem terapêutica foi maioritariamente conservadora (n=40). Oito doentes realizaram encerramento percutâneo e sete tratamento cirúrgico (dos quais seis durante cirurgias por outra patologia cardíaca), sem mortalidade periprocedimento. Conclusões: A prevalência de FCs na nossa série foi de 0,2%. A maioria originou-se da DA, sendo a artéria pulmonar o local de drenagem mais frequente. Em doentes submetidos a intervenção, tanto as técnicas percutâneas como cirúrgicas foram seguras e eficazes.

Introduction and Objectives: The use of mechanical circulatory support is increasing in cases of cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR-PCI). The Impella® is a percutaneous ventricular assist device that unloads the left ventricle by ejecting blood to the ascending aorta. We report our center's experience with the use of the Impella® device in these two clinical settings. Methods: We performed a single-center retrospective study including all consecutive patients implanted with the Impella® between 2007 and 2019 for CS treatment or prophylactic support of HR-PCI. Data on clinical and safety endpoints were collected and analyzed. Results: Twenty-two patients were included: 12 were treated for CS and 10 underwent an HR-PCI procedure. In the CS-treated population, the main cause of CS was acute myocardial infarction (five patients); hemolysis was the most frequent device-related complication (63.7%). In-hospital, cumulative 30-day and one-year mortality were 58.3%, 66.6% and 83.3%, respectively. In the HR-PCI group, all patients had multivessel disease (mean baseline SYNTAX I score: 44.1±13.7). In-hospital, 30-day and one-year mortality were 10.0%, 10.0% and 20.0%, respectively. There were no device- or procedure-related deaths in either group. Conclusion: The short- and long-term results of Impella®-supported HR-PCI were comparable to those in the literature. In the CS group, in-hospital and short-term outcomes were poor, with high mortality and non-negligible complication rates. Resumo: Introdução e objetivos: O uso de suporte mecânico no choque cardiogénico (CS) e intervenção coronária percutânea de alto risco (HR-PCI) tem aumentado. O Impella® é um sistema de suporte ventricular percutâneo que ejeta sangue do ventrículo esquerdo para a aorta ascendente. Reportamos a experiência do nosso centro com o Impella® nestes dois cenários clínicos. Métodos: Estudo retrospetivo unicêntrico incluindo todos os doentes consecutivos submetidos a implantação de Impella® entre 2007 e 2019, para tratamento de CS ou suporte profilático para HR-PCI. Dados sobre endpoints clínicos e de segurança foram analisados. Resultados: Foram incluídos 22 doentes: 12 tratados por CS e 10 submetidos a HR-PCI. Na população de CS, a principal causa de choque foi o enfarte agudo do miocárdio (5 doentes); a hemólise foi a complicação relacionada com o dispositivo mais frequente (63,7%); a mortalidade intra-hospitalar, a 30 dias e um ano, foi, respetivamente, 58,3%, 66,6% e 83,3%. No grupo da HR-PCI, todos os doentes apresentavam doença multivaso (SYNTAX I score médio: 44,1±13,7); a mortalidade intra-hospitalar, a 30 dias e um ano, foi, respetivamente, 10,0%, 10,0% e 20,0%. Não houve mortes relacionadas com o dispositivo ou procedimento em ambos os grupos. Conclusão: Os resultados em curto e longo prazo da HR-PCI protegida por Impella® foram comparáveis aos da literatura disponível. No grupo de CS, os resultados intra-hospitalares e em curto prazo foram desanimadores, com elevada mortalidade e taxas de complicações apreciáveis.

Introduction and Objectives: Use of invasive physiological assessment in patients with coronary artery disease varies widely and is perceived to be low. We aimed to examine adoption rates as well as patterns and determinants of use in an unselected population undergoing invasive coronary angiography over a long time frame. Methods: We retrospectively determined the per-procedure prevalence of physiological assessment in 40 821 coronary cases performed between 2007 and 2018 in two large-volume centers. Adoption was examined according to procedure type and patient- and operator-related variables. Its association with relevant scientific landmarks, such as the release of clinical trial results and practice guidelines, was also assessed. Results: Overall adoption was low, ranging from 0.6% in patients undergoing invasive coronary angiography due to underlying valve disease, to 6% in the setting of stable coronary artery disease (CAD); it was 3.1% in patients sustaining an acute coronary syndrome. Of scientific landmarks, FAME 1, the long-term results of FAME 2 and the 2014 European myocardial revascularization guidelines were associated with changes in practice. Publication of instantaneous wave-free ratio (iFR) trials had no influence on adoption rates, except for a higher proportion of iFR use. In 42.9% of stable CAD patients undergoing percutaneous coronary intervention there was no objective non-invasive evidence of ischemia, nor was physiological assessment performed. Younger operator age (4.5% vs. 4.0% vs. 0.9% for ages 55 years, respectively; p 55 anos, respetivamente; p < 0,001) e a hora de realização do procedimento (2,9% entre as 6-8PM versus 4,4% durante o restante dia) relacionaram-se inversamente com a utilização de fisiologia durante os procedimentos. Conclusões: Esta análise confirma a baixa de utilização da avaliação funcional invasiva na prática clínica. A disponibilidade de evidência sobre o uso de índices não hiperémicos não aumentou a adoção. São necessárias estratégias dirigidas que potenciem a implantação das recomendações, de forma que o manejo dos doentes com doença coronária e os benefícios clínicos da estratificação invasiva possam ser aprimorados.

Our aim was to perform an initial assessment of the polymorphic patterns of the PIN1 gene in patients with coronary heart disease (CHD). The PIN1-encoded protein (Pin1) suppresses eNOS-NO signaling and may impair cardiovascular function. Blood collection, DNA extraction, PCR amplification and gene sequencing were performed for thirty CHD participants living in central China, focusing on nine single nucleotide polymorphisms (SNPs). Their genetic linkages were revealed and their allele frequencies were compared with SNP data from the NCBI. Three major linkage patterns were identified: [1.rs2287839-5.rs2233682], [3.rs2233679-4.rs1077220–8.rs2287838] and [6.rs889162-7.rs2010457], suggesting correlated involvement in CHD and possible simultaneous genetic origin in ancient times. The frequencies of six SNPs are consistent with the NCBI data, while the frequencies of three SNPs (2.rs2233678, 4.rs1077220 and 9.rs4804461) are not consistent with the NCBI. Especially, the 3.rs2233679–4.rs1077220 linkage is different from other populations worldwide and may be an interesting genetic characteristic of Chinese CHD patients. Predictably, 1.rs2287839, 2.rs2233678, 3.rs2233679 and 5.rs2233682 may be strongly associated with CHD risk, although this requires future verification. The PIN1 SNP linkages lay a new genetic foundation for discovering novel molecular mechanisms of CHD and for exploring PIN1-based targeted treatment of CHD with nitric oxide regulatory therapies in clinical practice. Resumo: O objetivo deste estudo é avaliar os polimorfismos do gene PIN1 em doentes com doença arterial coronária (DAC). A proteína codificada pelo gene PIN1 (Pin1) suprime a sinalização eNOS-NO e pode afetar a função cardiovascular. Foram incluídos 30 indivíduos com DAC, residentes na China central, a quem foi recolhido sangue, extraído e amplificado o DNA por PCR. Foram estudados nove polimorfismos de nucleótidos únicos (SNPs) do gene PIN1. As suas associações genéticas foram estudadas e as frequências de alelo foram comparadas com os dados de SNPs do NCBI. Foram identificados três grandes padrões de linkage: [1.rs2287839-5.rs2233682], [3.rs2233679-4.rs107220-8.rs2287838] e [6.rs889162-7.rs2010457], sugerindo o seu envolvimento na DAC e possível origem genética simultânea histórica. As frequências de seis dos SNPs foram consistentes com os dados do NCBI, enquanto as frequências de três dos SNPs (2.rs2233678, 4.rs1077220 e 9.rs4804461) não foram consistentes com o NCBI. Especificamente, a ligação 3.rs2233679-4.rs1077220 é diferente de outras populações mundiais e poderá constituir uma característica genética específica dos doentes chineses com DAC. Previsivelmente, 1.rs2287839, 2.rs2233678, 3.rs2233679 e 5.rs2233682 podem estar particularmente associados ao risco de DAC, requerendo validação ulterior. As ligações PIN1-SNP estabelecem uma nova base genética para a descoberta de novos mecanismos moleculares da DAC e para explorar o tratamento de precisão da DAC com medicamentos reguladores do óxido nítrico, baseado nos polimorfismos do gene PIN1.

Introduction: Compared to bare-metal stents (BMS), drug-eluting stents reduce stent restenosis and improve subsequent revascularization rates. The impact on patients’ survival has been the subject of debate. Objective: To assess the long-term (10-year) survival of patients undergoing percutaneous coronary intervention (PCI) with first-generation sirolimus-eluting stents (SES) in comparison with BMS. Methods: In a single-center registry, 600 consecutive patients who underwent successful PCI with SES between April 2002 and February 2003 were compared to 594 patients who underwent PCI with BMS between January 2002 and April 2002, just before the introduction of SES. Clinical and procedural data were collected at the time of intervention and 10-year survival status was assessed via the national life status database. Results: All baseline characteristics were similar between groups except for smaller stent diameter (2.84±0.38 vs. 3.19±0.49 mm; p

O endotélio cumpre um papel fundamental na vasodilatação fisiológica e na proteção da parede arterial frente aos processos de trombose e aterosclerose, assim como na resposta à lesão provocada pela angioplastia ou implante de stent intracoronário. Essa função protetora é exercida, entre outros mecanismos, através da síntese e liberação de óxido nítrico (NO) pela célula endotelial. O NO inibe a adesão e a agregação plaquetária, assim como provoca a desagregação de agregado plaquetário. Inibe também a mitogênese e a proliferação de células de músculo liso vascular, assim como a quimiotaxia e a adesão de polimorfonucleares neutrófilos ao endotélio. O NO é sintetizado na célula endotelial, a partir da L-Arginina, pela NO sintase endotelial constitutiva (NOSec), uma enzima constitutiva codificada por um gene localizado no cromossomo 7q35-36, contendo 26 éxons que ocupam 21 quilobases. Foram descritos alguns polimorfismos deste gene, entre os quais, o polimorfismo 894G>T, presente no éxon 7 do gene da NOSec. Este polimorfismo consiste na substituição de uma base guanina por uma timina no nucleotídeo 894 do gene; esta mutação resulta na substituição de um aminoácido glutamato por aspartato na posição 298 da NOSec (Glu298Asp). Nesta revisão, descreve-se a possível associação desse polimorfismo com a doença coronária, destacando algumas contribuições de nosso grupo de pesquisa. Unitermos: Óxido nítrico sintase endotelial constitutiva, gene, polimorfismo, doença coronária.

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A Organização Mundial de Saúde (OMS) estimou no seu relatório de 2002 que cerca de 14% da larga da doença nos países mais ricos seja atribuível ao consumo de produtos de tabaco. As doenças mais relacionadas com o consumo de tabaco incluem um conjunto de doenças cardiovasculares, neoplasias e doenças respiratórias. Este artigo estima a carga da doença atribuível ao tabaco em Portugal, tomando como base os dados das estatísticas demográficas e de saúde disponíveis para Portugal em 2005. A conclusão final da analise e que 11,7% das mortes em Portugal se podem atribuir ao consumo de tabaco. Se medirmos a carga da doença através dos anos de vida ajustados por incapacidade - disability adjusted life years (DALY) gerados pela mortalidade, as proporção da carga da doença atribuível ao tabaco e 11,2%. A divisão entre sexos e muito desigual, já que 15,4% da carga da doença masculina e 17,7% das mortes são atribuíveis ao tabaco, mas apenas 4,9% da carga da doença feminina e 5,2% das mortes. Estes números para a mortalidade atribuível são mais elevados do que as estimativas anteriormente disponíveis para Portugal (Peto et al. 2006), as quais apontavam para 14% das mortes masculinas e apenas 0,9% das femininas. O artigo apresenta estimativas sobre a carga da doença redutível, ou seja, as reduções de mortalidade e DALY que ocorreriam se os fumadores abandonassem o tabagismo e passassem a experimentar o risco médio das populações de ex-fumadores, o qual e superior ao dos nunca fumadores mas inferior ao dos fumadores. As estimativas são que a carga da doença medida pelos DALY se reduziria em 5,8% (7,8% dos homens e 2,8% das mulheres) e que as mortes se reduziriam em 5,8% (8,5% homens e 2,9% mulheres). O artigo inclui igualmente estimativas dos DALY perdidos por incapacidade. As doenças relacionadas com o tabagismo geraram 121 643 DALY, dos quais 72 126 (59%) são atribuíveis ao tabagismo e 12 417 (10%) são redutíveis.The World Health Organization’s (WHO) 2002 Annual Report estimated that about 14% of the burden of disease in wealthier countries is attributable to smoking. Smoking related diseases include cardiovascular diseases, cancer and respiratory diseases. This paper presents an estimate of the burden of disease attributable to smoking in Portugal. The estimates are based on the Portuguese demographic and health statistics available for 2005. The most important conclusion of the analysis is that 11.7% of deaths in Portugal are attributable to smoking. If we use disability adjusted life years (DALYs) to measure the burden of disease, we find that 11.2% of death DALYs in Portugal is attributable to smoking. The gender distribution of this amount is very unequal; 15.4% of the male burden of disease and 17.7% of all male deaths can be attributed to smoking, but only 4.9% of the female burden of disease and 5.2% of all female deaths. These estimates are higher than death estimates previously available (Peto et al. 2006); 14% in men and only 0.9% in women. This paper also presents estimates of the burden of reducible disease, that is, the reduction in mortality and DALYs that would occur if all current smokers quit and thus experienced the mean risk of ex-smo kers, which is lower than for current smokers but typically not as low as for never-smokers. Our estimates are that the burden of disease would decrease by 5.8% (7.8% in men and 2.8% in women), and that deaths would decrease by 5.8% as well (with an 8.5% and 2.9% decrease in men and women, respectively). The paper also includes estimates of the burden of disease generated by smoking related disability. Smoking related illnesses generated 121,643 DALYs, 72,126 (59%) of which are attributable to smoking and 12,417 would be reducible if all smokers were to quit.

Introduction and Objective: With recent advances in genome sequencing technology, a large body of evidence has accumulated over the last few years linking alterations in microbiota with cardiovascular disease. In this study, we aimed to compare gut microbial composition using 16S ribosomal DNA (rDNA) sequencing techniques in patients with coronary artery disease (CAD) and stable heart failure (HF) with reduced ejection fraction and patients with CAD but with normal ejection fraction. We also studied the relationship between systemic inflammatory markers and microbial richness and diversity., Methods: A total of 40 patients (19 with HF and CAD, 21 with CAD but without HF) were included in the study. HF was defined as left ventricular ejection fraction <40%. Only stable ambulatory patients were included in the study. Gut microbiota were assessed from the participants' fecal samples. The diversity and richness of microbial populations in each sample were assessed by the Chao1-estimated OTU number and the Shannon index., Results: The Chao1-estimated OTU number and Shannon index were similar between HF and control groups. There was no statistically significant relationship between inflammatory marker levels (tumor necrosis factor-alpha, interleukin 1-beta, endotoxin, C-reactive protein, galectin-3, interleukin 6, and lipopolysaccharide-binding protein) and microbial richness and diversity when analyzed at the phylum level., Conclusion: In the current study, compared to patients with CAD but without HF, stable HF patients with CAD did not show changes in gut microbial richness and diversity. At the genus level Enterococcus sp. was more commonly identified in HF patients, in addition to certain changes in species levels, including increased Lactobacillus letivazi., (Copyright © 2023. Publicado por Elsevier España, S.L.U.)

A maior prevalência das doenças cardiovasculares, particularmente da doença coronária, está bem estabelecida na artrite reumatóide (AR). Este trabalho, envolvendo uma revisão extensa da literatura, analisa as evidências epidemiológicas apontando as doenças cardiovasculares como a maior causa de mortalidade prematura na AR, os fatores de risco para doença coronária, a relação entre aterosclerose e AR, os mecanismos fisiopatológicos desta associação, incluindo o papel direto e indireto do processo inflamatório sistêmico e as características da doença coronária na AR. Finalmente, é destacada a importância dos cuidados preventivos para este paciente reumatóide com alto risco de eventos cardiovasculares.The increased prevalence of cardiovascular disease (CVD) in rheumatoid arthrtis (RA) patients is by now largely recognized. The purpose of this extensive literature review is to analyze the epidemiological evidences of CVD, particularly coronary heart disease (CHD), as the leading cause of early death in RA, the presence of coronary risk factors, the relationship between RA and atherosclerosis, the shared physiopathology mechanisms, including the systemic inflammatory process and the peculiarities of CHD in the rheumatoid population. Lastly, given the burden of cardiovascular disease in this population, it is emphasized the importance of preventive care in these high risk patients.

Atherosclerosis is a chronic inflammatory disease that affects essentially all arterial beds including the aorta, coronaries, carotids, and peripheral arteries. It is the main cause of death in the western hemisphere, due to cardiovascular syndromes such as myocardial infarction, heart failure, and cerebrovascular accidents. Very substantial economic and human resources have been used on treatments of its complications, including imaging studies, coronary bypass surgery, catheter interventions, pacemakers, and medical treatments. Treating complications, however, are remedial actions. A better alternative is to prevent the development of atherosclerosis, or at least to identify patients who are at risk of acute events and intervene before they occur. The aims of this review are to discuss the predictive value of traditional and emerging risk factors, as well as the role of noninvasive diagnostic methods for coronary atherosclerosis, including exercise stress test, echo stress test, duplex ultrasound, computed tomography, and magnetic resonance. A combination of serum biomarkers and noninvasive approaches is of practical utility for identifying early disease. It is to be expected that future developments will soon perfect our ability to identify the vulnerable patient and allow a more individualized approach.A aterosclerose é uma doença inflamatória crônica que afeta essencialmente todas as artérias incluindo a aorta, coronárias, carótidas e artérias periféricas. É a causa principal de morte no hemisfério ocidental, devido as síndromes cardiovasculares, tais como o infarto do miocárdio, insuficiência cardíaca e acidentes cerebrovasculares. Quantidades enormes de recursos econômicos e humanos são usadas em tratamentos de suas complicações, inclusive estudos de imagem, cirurgias coronárias, intervenções com cateteres, marcapasso e tratamentos médicos. Tratar complicações, entretanto, são ações a posteriori. Uma alternativa melhor seria prevenir o desenvolvimento da aterosclerose, ou pelo menos identificar os pacientes que tenham risco de eventos agudos e intervir antes de sua ocorrência. O objetivo desta revisão é discutir o valor prognóstico dos fatores de riscos tradicionais e emergentes, e o papel dos métodos diagnósticos não invasivos para a doença coronária - teste de esforço, eco estresse, ultra-sonografia dúplex, tomografia computadorizada e a ressonância magnética. A combinação de marcadores biológicos e de métodos não invasivos, é de grande utilidade na identificação precoce da doença aterosclerótica. Futuros desenvolvimentos logo aperfeiçoarão nossa capacidade de identificar o paciente vulnerável e nos permitir um manejo mais individualizado.

BACKGROUND: Left internal thoracic artery-to left anterior descending artery grafting has become a fundamental part of coronary artery bypass grafting. This grafting has led to increased use of other arterial conduits, of which the radial artery is most popular. Whether radial grafting can be used in the emergency patient is not known. This study compares the short-term clinical evolution between elective vs emergency coronary artery bypass grafting surgery with left internal thoracic artery and radial artery. METHODS: A retrospective study of 47 patients who underwent elective or emergency coronary artery bypass grafting from 1996 to 2003. All patients had coronary stenosis >70% in all target vessels. Only the left internal thoracic artery and radial artery were used as grafts. Patients were divided into elective group (23 patients) and emergency group (24 patients). Emergency criteria were unstable angina and/or critical coronary stenosis with high risk for acute myocardial infarction. Groups were similar for age and number of diseased vessels. RESULTS: The mean number of left internal thoracic artery grafts per patient in the elective and emergency groups were respectively 1.17 and 1.38 (P = .17). The mean number of radial artery grafts per patient in the elective and emergency groups was respectively 2.26 and 2.08 (P = .48). The 30-day mortality was 0. There was no postoperative cardiogenic shock. The elective group had 1 acute myocardial infarction (4.4%) postoperatively, and emergency group had 5 (20.8%). A nonsignificant trend towards acute myocardial infarction was noted in the emergency group (P = .18). Intensive care unit and postoperative stay were similar in both groups. CONCLUSION: Coronary artery bypass grafting using left internal thoracic artery and radial artery accomplishing complete revascularization can be performed in emergency patients with results similar to those for elective patients.O uso de artéria torácica interna esquerda para descendente anterior se tornou fundamental na revascularização do miocárdio. Este enxerto levou ao aumento da utilização de enxertos arteriais, dos quais a artéria radial é muito popular. O uso de artéria radial em pacientes de emergência foi pouco estudado. Este estudo compara a evolução clínica imediata entre revascularização do miocárdio eletiva vs. emergência com artéria torácica interna esquerda e artéria radial. MATERIAL E MÉTODOS: Estudo retrospectivo de 47 pacientes que se submeteram a revascularização do miocárdio eletiva ou de emergência entre 1996 e 2003. Apresentavam estenose crítica (>70%) em todas as artérias alvo. Apenas a artéria torácica interna esquerda e a artéria radial foram utilizadas. Os pacientes constituíram dois grupos: eletivo (23 casos) e emergência (24 casos). Critérios de emergência foram angina instável e/ou estenose coronariana crítica com alto risco de infarto agudo do miocárdio. Os grupos eram homogêneos para idade e artérias acometidas. RESULTADOS: A média de enxertos de artéria torácica interna esquerda por paciente eletivo e de emergência foi respectivamente 1,17 e 1,38 (P=.17). A média de enxertos de artéria radial por paciente eletivo e de emergência foi respectivamente 2,26 e 2,08 (P=.48). A mortalidade até 30 dias foi zero. No pós-operatòrio não ocorreram casos de choque cardiogênico. Um paciente eletivo (4,4%) e 5pacientes de emergência (20,8%) apresentaram infarto agudo do miocárdio no pós-operatório; tendência não significativa para ocorrência de infarto agudo do miocárdio no grupo de emergência (P=.18). Tempo de internação na unidade de terapia intensiva e hospitalar foi semelhante nos dois grupos. CONCLUSÃO: A revascularização do miocárdio com utilização de artéria torácica interna esquerda e artéria radial pode ser realizada em pacientes de emergência com resultados equivalentes aos pacientes eletivos.

Introduction: The coronary sinus Reducer (CSR) device has emerged as a complementary therapy in patients with severe angina refractory to optimal medical therapy and not amenable to revascularization. Our aim was to assess the safety and efficacy of the CSR in a real-world setting., Methods: Twenty-six patients with refractory angina (RA) and evidence of myocardial ischemia attributable to the left coronary artery considered unsuitable for revascularization were treated with the CSR at two centers between May 2017 and July 2019. Safety endpoints were procedural success and complications. Efficacy endpoints, assessed at six-month follow-up, were reduction in CCS class, improvement in quality of life (QoL) assessed using the short version of the Seattle Angina Questionnaire (SAQ-7), and reduction in antianginal therapy., Results: Twenty-three patients had end-stage coronary artery disease without revascularization targets and three had microvascular disease without epicardial stenosis. Procedural success was achieved in 23 patients, with two device/procedure-related complications and one anatomically-related failure to deliver the device. A total of 24 patients had the device implanted and entered the efficacy analysis. Eighteen patients (75.0%) had a reduction of at least one CCS class, 41.7% had a reduction of at least two classes, and 16.7% became asymptomatic, with a mean reduction in CCS class of 1.3±0.2 (p=0.001) at six-month follow-up. All SAQ-7 domains improved, notably physical limitation (p=0.001), angina frequency (p=0.005) and QoL (p=0.006). There was a mean reduction in anti-ischemic drugs from 3.4±1.1 to 2.9±1.2 (p=0.010)., Conclusion: In this real-world, multicenter experience, implantation of the CSR was associated with improvement in angina and QoL in patients with RA., (Copyright © 2023 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introdução: O doente coronário tem procurado o seu médico de família (MF) em busca de aconselhamento relativo à actividade sexual (AS). Porém, até hoje, a abordagem desta tem permanecido algo deficitária. Descrição do caso: Rui, 56 anos, antecedentes de angina estável classe I. Em Março/2010, na primeira consulta com actual MF, nega queixas, porém a esposa documenta irritabilidade desde 2009, data do diagnóstico da doença coronária. Em Setembro/2010, a esposa refere um agravamento da irritabilidade de Rui, com isolamento social progressivo e prejuízo na relação conjugal. Em Outubro/2010, Rui confirma que esta alteração comportamental coincidiu com o diagnóstico da cardiopatia isquémica. Faz-se um aconselhamento para a prática de exercício, actividade intraconjugal de lazer e sexual e retoma do convívio social. Uma semana depois, volta por dúvidas relativamente às actividades a praticar, questionando «mesmo a actividade sexual !». Diz que o seu médico anterior o teria informado que possuía um risco aumentado de enfarte agudo do miocárdio (EAM) associado à AS e recomendado «ter cuidado!». Uma intervenção precoce é iniciada, explicando o baixo risco absoluto de EAM associado ao acto sexual e reiterando a segurança da AS num doente com angina estável classe I. O casal volta posteriormente, permitindo o reforço da confiança na sua AS. Comentário: O impacto da cardiopatia isquémica na AS é compreendido pela diminuição da auto-estima e pelos efeitos late-rais da farmacoterapia. O aconselhamento constitui importante parte da terapêutica não-farmacológica. Se desadequado, pode ser iatrogénico. Constituindo a sexualidade uma artéria de suprimento afectivo num casal, um aconselhamento inseguro foi o trigger de um processo bloqueador deste suprimento e, assim, de um enfarte da relação conjugal. Uma trombólise foi realizada para eliminar o trombo de receios. A revascularização foi conseguida posteriormente, intervindo-se no casal com a doença afectiva coronária.

Objectivo: Rever enquadramentos, critérios diagnósticos e metodologias de avaliação de factores de risco para doenças cardiovasculares em jovens e adolescentes. Métodos: Revisão crítica da literatura, com especial ênfase nos artigos já com dados colhidos em população portuguesa jovem e adolescente. Conclusões e sugestões: Dado que as doenças cardiovasculares vêm assumindo cada vez maior relevância como causa de morte em Portugal, conclui-se pela necessidade de contínuo estudo da realidade epidemiológica, para uma correcta e eficaz intervenção, quer profiláctica, quer curativa, numa altura da vida em que tal actuação pode ser determinante para o futuro do indivíduo. Sugere-se esquema de actuação, no qual as Equipas de Medicina Geral e Familiar têm especial relevância e em que a actuação junto das famílias, dos organismos responsáveis, como as escolas - em cantinas e bares e nos curricula - é determinante e recomenda-se pressão junto das entidades regulamentadoras de publicidade para ser corrigida e/ou limitada a indução de novos e prejudiciais hábitos alimentares.

Despite constant medical evolution, the reimbursement policy of Portuguese National Health Service (NHS) for the study and risk stratification of coronary heart disease has remained unchanged for several decades. Lack of adjustment to contemporary clinical practice has long been evident. However, the recent publication of the European Guidelines for diagnosis and treatment of chronic coronary syndromes further highlighted this gap and the urgent need for a change. Prompted by these Guidelines, the Working Group on Nuclear Cardiology, Cardiac Magnetic Resonance and Cardiac CT, the Working Group on Echocardiography and the Working Group on Stress Pathophysiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology, began a process of joint reflection on the current limitations and how these recommendations could be applied in Portugal. To this end, the authors suggest that the new imaging methods (stress echocardiogram, cardiac computed tomography and cardiac magnetic resonance), should be added to exercise treadmill stress test and myocardial perfusion scintigraphy in the available exam portfolio within the Portuguese NHS. This change would allow full adoption of European guidelines and a better use of tests, according to clinical context, availability and local specificities. The adoption of clinical guidance standards, based on these assumptions, would translate into a qualitative improvement in the management of these patients and would promote an effective use of the available resources, with potential health and financial gains., (Copyright © 2020. Publicado por Elsevier España, S.L.U.)

Introduction and Objectives: The use of mechanical circulatory support is increasing in cases of cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR-PCI). The Impella® is a percutaneous ventricular assist device that unloads the left ventricle by ejecting blood to the ascending aorta. We report our center's experience with the use of the Impella® device in these two clinical settings., Methods: We performed a single-center retrospective study including all consecutive patients implanted with the Impella® between 2007 and 2019 for CS treatment or prophylactic support of HR-PCI. Data on clinical and safety endpoints were collected and analyzed., Results: Twenty-two patients were included: 12 were treated for CS and 10 underwent an HR-PCI procedure. In the CS-treated population, the main cause of CS was acute myocardial infarction (five patients); hemolysis was the most frequent device-related complication (63.7%). In-hospital, cumulative 30-day and one-year mortality were 58.3%, 66.6% and 83.3%, respectively. In the HR-PCI group, all patients had multivessel disease (mean baseline SYNTAX I score: 44.1±13.7). In-hospital, 30-day and one-year mortality were 10.0%, 10.0% and 20.0%, respectively. There were no device- or procedure-related deaths in either group., Conclusion: The short- and long-term results of Impella®-supported HR-PCI were comparable to those in the literature. In the CS group, in-hospital and short-term outcomes were poor, with high mortality and non-negligible complication rates., (Copyright © 2021 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: Use of invasive physiological assessment in patients with coronary artery disease varies widely and is perceived to be low. We aimed to examine adoption rates as well as patterns and determinants of use in an unselected population undergoing invasive coronary angiography over a long time frame., Methods: We retrospectively determined the per-procedure prevalence of physiological assessment in 40821 coronary cases performed between 2007 and 2018 in two large-volume centers. Adoption was examined according to procedure type and patient- and operator-related variables. Its association with relevant scientific landmarks, such as the release of clinical trial results and practice guidelines, was also assessed., Results: Overall adoption was low, ranging from 0.6% in patients undergoing invasive coronary angiography due to underlying valve disease, to 6% in the setting of stable coronary artery disease (CAD); it was 3.1% in patients sustaining an acute coronary syndrome. Of scientific landmarks, FAME 1, the long-term results of FAME 2 and the 2014 European myocardial revascularization guidelines were associated with changes in practice. Publication of instantaneous wave-free ratio (iFR) trials had no influence on adoption rates, except for a higher proportion of iFR use. In 42.9% of stable CAD patients undergoing percutaneous coronary intervention there was no objective non-invasive evidence of ischemia, nor was physiological assessment performed. Younger operator age (4.5% vs. 4.0% vs. 0.9% for ages <40, 40-55 and >55 years, respectively; p<0.001) and later time of procedure during the day (2.9% between 6 and 8 p.m. vs. 4.4% at other times) were independent correlates of use of invasive physiology., Conclusions: Our study confirms the low use of invasive physiology in routine practice. The availability of resting indices did not increase adoption. Strategies are warranted to promote guideline implementation and to improve patient care and clinical outcomes., (Copyright © 2021 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. All rights reserved.)

A 55-year-old patient presented with stable angina pectoris with normal physical examination on rest electrocardiogram and cardiac echocardiogram. Treadmill test revealed exercise-induced left posterior fascicular block, which is an uncommon and easily unnoticed marker of coronary artery disease. A dobutamine stress echocardiogram was performed, with a clearly positive result. Coronary angiography revealed critical stenosis in the right coronary artery., (Copyright © 2021 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. All rights reserved.)

Refractory angina is defined as persistent angina (≥3 months) despite optimal medical and interventional therapies. It is increasing in frequency, due to the success of current medical and interventional therapies in improving the prognosis of coronary artery disease. Long-term mortality is similar to that of patients with asymptomatic stable disease, but it affects patients' quality of life, and has a significant impact on health care resources. Several therapeutic targets have been investigated, most with disappointing results. Many of the techniques have been abandoned because of lack of efficacy, safety issues, or economic and logistic limitations to wider applicability. The primary focus of this review is the coronary sinus Reducer, supporting evidence for which, although scarce, is promising regarding safety and efficacy in improving anginal symptoms and quality of life. It is also accessible to virtually all interventional cardiology departments., (Copyright © 2021 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Coronary intravascular ultrasound (IVUS) is increasingly important in catheterization laboratories due to its positive prognostic impact. This study aims to characterize the use of IVUS in percutaneous coronary intervention (PCI) in Portugal., Methods: A retrospective observational study was performed based on the Portuguese Registry on Interventional Cardiology of the Portuguese Society of Cardiology. The clinical and angiographic profiles of patients who underwent PCI between 2002 and 2016, the percentage of IVUS use, and the coronary arteries assessed were characterized., Results: A total of 118 706 PCIs were included, in which IVUS was used in 2266 (1.9%). Over time, use of IVUS changed from none in 2002 to generally increasing use from 2003 (0.1%) to 2016 (2.4%). The age of patients in whom coronary IVUS was used was similar to that of patients in whom IVUS was not used, but in the former group there were fewer male patients, and a higher prevalence of cardiovascular risk factors (hypertension, hypercholesterolemia and diabetes), previous myocardial infarction, previous PCI, multivessel coronary disease, C-type or bifurcated coronary lesions, and in-stent restenosis. IVUS was used in 54.8% of elective PCIs and in 19.15% of PCIs of the left main coronary artery., Conclusion: Coronary IVUS has been increasingly used in Portugal since 2003. It is used preferentially in elective PCIs, and in patients with higher cardiovascular risk, with more complex coronary lesions and lesions of the left main coronary artery., (Copyright © 2019 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

We present the case of a patient with Takotsubo syndrome assessed by intracoronary flow and pressure guidewire, showing elevation of intracoronary pressures at the level of the anterior descending artery, and thus demonstrating a new therapeutic target in a still little understood etiopathogenic entity. The results of this test have never been previously reported in Takotsubo patients., (Copyright © 2020 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Obese patients are at higher cardiovascular risk in primary prevention. In secondary prevention, an obesity paradox has been reported. We analyzed a cohort of individuals from a previous cross-sectional study on the impact of metabolic syndrome (MS) on coronary artery disease (CAD), aiming to assess the occurrence of cardiovascular events in a long follow-up., Methods: We analyzed 296 individuals in a mean follow-up of 6.9±2.2 years. Subjects were divided into four groups according to the presence of MS or CAD (defined as ≥70% coronary stenosis)., Results: The study population had a mean age of 65±9 years at the beginning of the study; 59.5% were male, 55.7% had MS and 41.6% had CAD. During follow-up 10.1% of the population suffered all-cause death, 3.7% cardiovascular death, 14.2% cardiovascular readmission and 22.0% the composite outcome (mortality, acute coronary syndrome, coronary revascularization, stroke/transient ischemic attack or heart failure admission). There were no significant differences in any type of mortality. Patients with CAD had more readmissions and composite outcomes (log-rank p<0.001 and p=0.001, respectively), but there was no difference according to the presence of MS. Only CAD was an independent predictor of cardiovascular admission (HR 3.21, 95% CI 1.66-6.21) and composite outcomes (HR 2.41, 95% CI 1.44-4.02)., Conclusions: In patients with high cardiovascular risk or established CAD, the presence of MS is not associated with cerebral or cardiac events in long-term follow-up., (Copyright © 2019 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: The CAD-RADS TM classification was recently introduced in an attempt to standardize coronary computed tomography angiography (CCTA) reports and to provide recommendations for further management. The aim of this study was to assess how additional cardiac investigations were being ordered before the introduction of the CAD-RADS classification in a tertiary hospital's CCTA reports., Methods: We conducted a single-center retrospective analysis of 200 patients (103 women, mean age 59±13 years) who underwent CCTA for suspected or known coronary artery disease prior to the systematic introduction of the CAD-RADS classification in the reports. For each case, we assessed whether further cardiac investigation was requested after CCTA and what type of test was performed (functional testing, invasive coronary angiography or viability testing)., Results: The majority of patients (n=158; 79%) were classified as CAD-RADS 0-2. In patients with lower (0-2) or higher (4 or 5) scores, further testing was in accordance with CAD-RADS recommendations in 98% of cases (n=168). In patients with CAD-RADS 3 (intermediate stenosis), functional testing was requested as recommended in only 36% of cases (n=5), while 50% (n=7) proceeded directly to invasive coronary angiography. In patients in whom CCTA was non-diagnostic, most did not undergo further cardiac investigation., Conclusion: In patients with CAD-RADS classifications at the ends of the spectrum, additional cardiac investigation after CCTA was almost always in accordance with the recommendations. However, in patients with intermediate scores, invasive coronary angiography prevailed over functional testing., (Copyright © 2019 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Coronary artery disease rarely manifests itself in the first decades of life, which explains why this population is underrepresented in clinical studies. The mechanisms and natural history of the disease seem to differ between this population and older patients. Recent studies suggest a more rapid disease progression in youth, presenting more unstable atherosclerotic plaques, although this correlation has yet to be proven. In this paper, we present the case of a 41-year-old man who presented with a non-ST elevation myocardial infarction, with percutaneous coronary intervention of the culprit lesion (70-90% lesion at bifurcation of the circumflex artery with the first marginal obtuse artery and a sub-occlusive lesion of the ramus intermedius). There was also a non-significant lesion (estimated at 30%) located in the left anterior descending coronary artery. Ten days after discharge, the patient suffered another non-ST elevation myocardial infarction. The coronary angiography revealed a surprising sub-occlusive lesion of the left anterior descending coronary artery. Regarding this case, the authors reviewed the literature on the pathophysiology of rapidly progressive coronary artery disease and the approach for non-significant lesions in patients with acute coronary syndrome, especially in the younger population., (Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction and Objective: Coronary artery disease is the leading cause of mortality worldwide. Regular physical activity is part of a comprehensive management strategy for these patients. We investigated the parameters that influence physical activity in patients with a history of coronary revascularization., Methods: We included outpatients with a history of coronary revascularization at least six months prior to enrollment. Data on physical activity, demographics, and clinical characteristics were collected via a questionnaire., Results: A total of 202 consecutive outpatients (age 61.3±11.2 years, 73% male) were enrolled. One hundred and four (51%) patients had previous percutaneous coronary intervention, 67 (33%) had coronary bypass graft surgery, and 31 (15%) had both procedures. Only 46 patients (23%) engaged in regular physical activity. Patients were classified into two subgroups according to their physical activity. There were no significant differences between subgroups in terms of age, comorbid conditions or revascularization type. Multivariate regression analysis revealed that low education level (OR=3.26, 95% CI: 1.31-8.11, p=0.01), and lack of regular follow-up (OR=2.95, 95% CI: 1.01-8.61, p=0.04) were independent predictors of non-adherence to regular physical activity among study subjects., Conclusions: Regular exercise rates were lower in outpatients with previous coronary revascularization. Education level and regular follow-up visits were associated with adherence to physical activity in these patients., (Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)