Search

Em agosto de 1979, dois anos e um mes apos a realizacao da primeira angioplastia no mundo por Andreas Gruntzig (setembro de 1977), recebemos na Santa Casa de Misericordia de Curitiba (SCMC) um paciente (A. S. O.) de 55 anos, sexo masculino, com quadro de angina aos esforcos. O mesmo foi submetido a uma cineangiocoronariografia, que mostrou uma lesao critica (estenose avaliada entre 75-80%), localizada no segmento proximal da arteria coronaria direita (ACD). A arteria coronaria esquerda (ACEsq) apresentava aspecto [...]

Objectives We sought to describe the outcomes of BVS use from a single-center experience in which scaffold implantation was guided by intravascular imaging (ultrasound and/or optical coherence tomography) to identify and treat mechanical factors potentially related to BVS failure. Background The Absorb bioresorbable vascular scaffold (BVS) has been associated with an unexpectedly high incidence of thrombosis. Methods Between 11/2014 and 10/2016, 100 patients were treated with BVS. Intravascular imaging assessment before and after BVS implantation was performed in all cases. Results Mean age was 58.1 years; 88% were male, 31% had diabetes, and 28% presented with acute coronary syndromes. A total of 171 lesions in 141 vessels were treated with 190 BVS (mean 1.9 scaffolds/patient). Further intervention following intravascular imaging to optimize BVS implantation was required in 31% of patients. Procedure success was 100%. All patients completed a 1-year follow-up. The 1-year rate of target lesion failure was 4%, and there were no cases (0%) of scaffold thrombosis, myocardial infarction, or death. Conclusions In this real-world experience, the use of intravascular imaging to guide BVS implantation was associated with a high 1-year event-free survival rate, with no scaffold thrombosis.

Introduction and Objectives: The Stents Coated With the Biodegradable Polymer on Their Abluminal Faces and Elution of Sirolimus Versus Biolimus Elution for the Treatment of de Novo Coronary Lesions – DESTINY Trial is a non-inferiority randomized study that compared the Inspiron™ sirolimus-eluting stent (SES) with the control Biomatrix™ Flex biolimus-eluting stent (BES). Previous reports in the first year showed similar outcomes for both stents, in clinical, angiographic, optical coherence tomography, and intravascular ultrasound assessments. The present analysis aims to compare the clinical performance of these two biodegradable polymer drug-eluting stents five years after the index procedure. Methods: A total of 170 patients (194 lesions) were randomized in a 2:1 ratio for treatment with SES or BES, respectively. The primary endpoint for the present study was the five-year rate of combined major adverse cardiac events, defined as cardiac death, myocardial infarction, or target lesion revascularization. Results: At five years, the primary endpoint occurred in 12.5% and 17.9% of the SES and BES groups, respectively (p=0.4). There was no definite or probable stent thrombosis among patients treated with the novel SES stent during the five years of follow-up, and no stent thrombosis after the first year in the BES group. Conclusions: The novel Inspiron™ stent had similar good clinical performance in long-term follow-up when compared head-to-head with the control latest-generation Biomatrix™ Flex biolimus-eluting stent. Resumo: Introdução e objetivos: Stents Coated with the Biodegradable Polymer on their Abluminal Faces and Elution of Sirolimus Versus Biolimus Elution for the Treatment of de Novo Coronary Lesions (Destiny Trial) é um estudo randomizado de não inferioridade que comparou o stent farmacológico eluído com Sirolimus Inspiron® (SES) ao controle o stent Biomatrix® Flex eluído com biolimus (BES). Relatórios dentro do primeiro ano mostraram resultados semelhantes para ambos os stents, em seguimento clínico, angiográfico e também em análise de tomografia de coerência ótica e ultrassom intracoronário. A presente análise tem como objetivo comparar o desempenho clínico desses dois stents farmacológicos com polímeros biodegradáveis após cinco anos do procedimento índice. Métodos: Foram randomizados 170 pacientes (194 lesões) em uma proporção de 2:1 para tratamento com SES ou BES, respetivamente. O desfecho primário para o presente estudo foi a taxa em cinco anos de eventos cardíacos adversos maiores combinados, definida como morte cardíaca, infarto do miocárdio ou revascularização da lesão-alvo. Resultados: Em cinco anos, o desfecho primário ocorreu em 12,5% e 17,9% para o grupo SES e BES, respectivamente (p=0,4). Não houve trombose de stent definitiva ou provável entre os pacientes tratados com o novo SES durante os cinco anos de seguimento e ausência de trombose de stent após o primeiro ano no grupo BES. Conclusões: O novo stent Inspiron® apresentou uma boa e semelhante performance clínica no seguimento em longo prazo, quando comparado com o controle o stent de última geração Biomatrix® Flex.

The safety and performance of the Absorb Bioresorbable Vascular Scaffold (BVS) has been previously demonstrated with clinical data. However, these trials included patients with simple lesions. The Absorb III trial demonstrated an excess of adverse events following BVS implantation. Aiming to

Background: Physical exercise improves the survival and quality of life of coronary patients, but the ideal way of prescribing these exercises is still controversial. Objective: To create a new periodized model for the prescription of exercises for coronary patients and compare it with a conventional model. Methods: 62 coronary patients under pharmacological treatment were randomized into two groups: conventional (NPG, n = 33) and periodized (PG, n = 29) training. The two groups were submitted to the same exercises during the 36 sessions making up the program, but prescribed in different ways. All patients underwent an evaluation consisting of: medical admission consultancy, cardiopulmonary endurance testing, 1 maximum repetition test (1MR) and body composition evaluation. Results: The VO2 peak improved in both groups, although more effectively in the PG (4% against 1.7%, p < 0.001). In addition, the functional capacity of this group improved by 13%, and there was a significant reduction in the percent body fat (2.1%, p < 0.005) and body weight (1.9 kg, p < 0.005). The muscle strength of both groups improved as diagnosed by the 1RM test for six different muscle groups (quadriceps, hamstrings, brachial biceps, brachial triceps, pectoral and large dorsal), and showed no significant difference between the groups, evidencing that the two models had the same efficiency. Conclusions: The present study showed that periodization of the training of cardiac patients can improve their cardiorespiratory capacity and reduce the percent body fat more effectively than the conventional one.

Summary Aims To evaluate the outcomes of patients treated with a new drug-eluting stent formulation with low doses of sirolimus, built in an ultra-thin-strut platform coated with biodegradable abluminal coating. Methods This study is a randomized trial that tested the main hypothesis that the angiographic late lumen loss of the novel sirolimus-eluting stent is noninferior compared with commercially available biolimus-eluting stent. A final study population comprising 170 patients with one or two de novo lesions was randomized in the ratio 2:1 for sirolimus-eluting stent or biolimus-eluting stent, respectively. The primary endpoint was 9-month angiographic in-stent late lumen loss. Adverse clinical events were prospectively collected for 1 year. Results After 9 months, the novel sirolimus-eluting stent was shown noninferior compared with the biolimus stent for the primary endpoint (angiographic in-stent late lumen loss: 0.20 ± 0.29 mm vs. 0.15 ± 0.20 mm, respectively; P value for noninferiority

Background: Burnout Syndrome is the extreme emotional response to chronic occupational stress, manifesting as physical and mental exhaustion. Although associated with higher prevalence of cardiovascular risk factors, no study so far has evaluated whether the Burnout Syndrome could be a prevalent factor in non-elderly individuals active in the labor market, admitted for acute coronary syndrome (ACS). Objective: To evaluate the prevalence of the Burnout Syndrome in non-elderly, economically active patients, hospitalized with ACS. Methods: Cross-sectional study conducted in a tertiary and private cardiology center, with economically active patients aged

We evaluated the effects of myocardial perfusion after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) on gender-based mortality rates. Research has demonstrated a gender-specific response of cardiomyocytes to ischemia and a potential increase in myocardial salvage in women compared with men. Myocardial blush grade (MBG), an angiographic surrogate of myocardial perfusion, is an independent predictor of early and late survival after AMI. Whether the incidence and prognosis of myocardial perfusion differs according to gender among patients with AMI undergoing PCI is unknown. MBG and short- and long-term mortality were evaluated in 1,301 patients (male = 935; female = 366) with AMI randomized to primary angioplasty ± abciximab versus stent ± abciximab. Following PCI, >96% of patients achieved final Thrombolysis In Myocardial Infarction 3 flow, of which MBG 2/3 was present in 58.3% of women versus 51.1% of men (p = 0.02). Worse MBG was an independent predictor of mortality in women at 30 days (7.4% for MBG 0/1 vs 2.4% for MBG 2/3, p = 0.04) and at 1-year (11.0% for MBG 0/1 vs 3.4% for MBG 2/3, p = 0.01); however, MBG was not associated with differences in mortality for men. In conclusion, impaired myocardial perfusion following PCI for AMI, indicated by worse MBG, is an independent predictor of early and late mortality in women but not in men. These findings imply an enhanced survival benefit from restoring myocardial perfusion for women compared with men during primary angioplasty and may have clinical implications for interventional strategies in women.

BACKGROUND: In individuals with concurrent chronic kidney disease (CKD) and cardiovascular disease (CVD), the association between left atrial volume (LAV) and serum levels of C-reactive protein (CRP) is shown. OBJECTIVE: Verify the presence of associations between systemic inflammation and LA dilation in patients on hemodialysis (HD) without clinically evident CVD. METHODS: This was an observational cross-sectional study of a population on HD (> 3 months), which excluded patients with acute or chronic inflammatory diseases (infections, malignancies, autoimmune diseases) hemodynamic instability, use of anti-inflammatory drugs, hyperparathyroidism, arrhythmias, mitral valve disease and prior cardiovascular (CV) events. CRP and interleukin-6 (IL-6) measurements as well as Doppler echocardiography were obtained. Correlation coefficients were determined to evaluate the associations between variables. RESULTS: A total of 58 patients were included (28 men, aged 55 ± 15 years), on HD for 24 ± 16 months, 45% were hypertensive, 26% diabetic, with median CRP of 5.1 mg/dL and IL-6 of 6.1 pg/dL. CRP significantly correlated with LAV (p = 0.040), LAV index (LAVi, p = 0.02) and mitral inflow E wave (p = 0.014). IL-6, despite the strong association with CRP levels (r = 0.75, p < 0.001), did not correlate with echocardiographic indices. Individuals in the top quartile of CRP had significantly higher LAVi than the others (42 ± 17 versus 32 ± 11 mL/m2, p = 0.015). CONCLUSIONS: In subjects on HD with no prior CV event, there was an association between elevated CRP levels and LA enlargement. The findings suggest an association between physiopathological processes related to left atrial dilation and systemic inflammatory state of patients on HD.

Background: Functional assessment of coronary artery obstruction is used in cardiology practice to correlate anatomic obstructions with flow decrease. Among such assessments, the study of the coronary fractional flow reserve (FFR) has become the most widely used. Objective: To evaluate the correlation between FFR and findings of ischemia obtained by noninvasive methods including stress echocardiography and nuclear medicine and the presence of critical coronary artery obstruction. Methods: Retrospective study of cases treated with systematized and standardized procedures for coronary disease between March 2011 and August 2014. We included 96 patients with 107 critical coronary obstructions (> 50% in the coronary trunk and/or ≥ 70% in other segments) estimated by quantitative coronary angiography (QCA) and intracoronary ultrasound (ICUS). All cases presented ischemia in one of the noninvasive studies. Results: All 96 patients presented ischemia (100%) in one of the functional tests. On FFR study with adenosine 140 g/kg/min, 52% of the cases had values ≤ 0.80. On correlation analysis for FFR ≤ 0.80, the evaluation of sensitivity, specificity, positive and negative predictive values, accuracy, and ROC curve in relation to the stenosis degree and length, and presence of ischemia, no significant values or strong correlation were observed. Conclusion: Coronary FFR using a cut-off value of 0.80 showed no correlation with noninvasive ischemia tests in patients with severe coronary artery obstructions on QCA and ICUS. Resumo Fundamento: A avaliação funcional da obstrução arterial coronariana é empregada na prática cardiológica para correlacionar a obstrução anatômica e a queda de fluxo. Dentre as formas de avaliação, o estudo da reserva fracionada de fluxo (RFF) coronariano se tornou a mais utilizada. Objetivo: Avaliar a correlação entre a RFF com achados de isquemia, obtidos por métodos não invasivos como a ecocardiografia de estresse ou medicina nuclear, e a presença de obstrução crítica da artéria coronária. Métodos: Estudo retrospectivo de casos tratados com procedimentos sistematizados e padronizados para doença coronariana entre março de 2011 e agosto de 2014. Foram incluídos 96 pacientes com 107 obstruções coronarianas críticas (> 50% no tronco da coronária e/ou ≥ 70% nos demais segmentos) estimadas por angiografia coronariana quantitativa (ACQ) e ultrassonografia intracoronariana (USIC). Todos os casos apresentaram isquemia em um dos estudos não invasivos. Resultados: Ao estudo da RFF com adenosina na dose de 140 µg/kg/min, valores ≤ 0,80 foram encontrados em 52% dos casos. Na análise de correlação para RFF ≤ 0,80, avaliando-se sensibilidade/especificidade, valor preditivo positivo/negativo, acurácia e curva ROC em relação ao grau de estenose, extensão da estenose e presença de isquemia, não foram observados valores de significância ou de forte correlação. Conclusão: A RFF coronariana a um valor de corte de 0,80 não apresentou correlação com testes não invasivos de isquemia em pacientes com obstruções coronarianas graves à ACQ e USIC.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (PMAF) is a rare disease, usually secondary to aortic valve endocarditis, particularly in prosthetic valves. Its clinical course is variable and may potentially cause serious complications, such as rupture into the pericardium, aorta or left atrium, systolic compression of the coronary arteries or systolic compression of the mitral valve, leading to severe mitral regurgitation, for which surgical treatment is recommended. This is a case report of a 69 year-old asymptomatic patient, with a prior history of two coronary artery bypass graft surgeries, the latter associated with aortic valve replacement. The PMAF was incidentally diagnosed in the late follow-up, and a decision was made to perform percutaneous therapy with the AmplatzerTM Muscular VSD Occluder.

Objectives The aim of this study was to determine the impact of delay to angioplasty in patients with acute coronary syndromes (ACS). Background There is a paucity of data on the impact of delays to percutaneous coronary intervention (PCI) in patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) undergoing an invasive management strategy. Methods Patients undergoing PCI in the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial were stratified according to timing of PCI after clinical presentation for outcome analysis. Results Percutaneous coronary intervention was performed in 7,749 patients (median age 63 years; 73% male) with NSTE-ACS at a median of 19.5 h after presentation ( 24 h [n = 2,812]). Delay to PCI >24 h after clinical presentation was significantly associated with increased 30-day mortality, myocardial infarction (MI), and composite ischemia (death, MI, and unplanned revascularization). By multivariable analysis, delay to PCI of >24 h was a significant independent predictor of 30-day and 1-year mortality. The incremental risk of death attributable to PCI delay >24 h was greatest in those patients presenting with high-risk features. Conclusions In this large-scale study, delaying revascularization with PCI >24 h in patients with NSTE-ACS was an independent predictor of early and late mortality and adverse ischemic outcomes. These findings suggest that urgent angiography and triage to revascularization should be a priority in NSTE-ACS patients.

Recently, bioresorbable vascular scaffolds (BVS) were related to an unexpected high incidence of thrombosis. The aim of this study was to analyze in a single center experience, the impact of intravascular imaging (intravascular ultrasound-IVUS; optical coherence tomography-OCT) identifying and

FUNDAMENTO: A superioridade da angioplastia primária em relação aos fibrinolíticos já foi amplamente demonstrada em diversos estudos, mas, muitas vezes, por questões logísticas, observamos retardo na incorporação das recomendações nos diversos cenários de vida real. Comparamos o desempenho da angioplastia primária no Registro SOLACI em três períodos a partir de 1995. MÉTODO: O Registro SOLACI incluiu dados de 43.725 angioplastias primárias realizadas nos períodos de 1995-1997 (n = 6.793), 2000-2003 (n = 23.007) e 2007-2008 (n = 13.925). RESULTADOS: Observamos complexidade crescente dos pacientes tratados, com incremento do porcentual de mulheres, diabéticos, e pacientes com infarto agudo do miocárdio prévio e com disfunção ventricular moderada a grave. O sucesso do procedimento manteve-se elevado (> 91%) em todos os períodos, independentemente do instrumental utilizado. Adicionalmente, notamos diminuição expressiva do tempo porta-balão, uso crescente dos stents e redução de 45% na utilização dos inibidores da glicoproteína IIb/IIIa. No que tange à evolução hospitalar, em comparação ao período de 1995-1997, observamos, nos períodos de 20002003 e 2007-2008, decréscimo da mortalidade (9,1% vs. 5,3% e 4,5%) e redução do reinfarto (4,1% vs. 2,6% e 2,7%) e da necessidade urgente de nova revascularização (3,5% vs. 0,7% e 0,7%). CONCLUSÃO: Apesar do perfil de risco mais complexo, a incorporação dos avanços tecnológicos e a redução do tempo porta-balão resultaram em melhora dos desfechos cardíacos hospitalares pós-angioplastia primária na América Latina. INTRODUCTION: The superiority of primary angioplasty compared to fibrinolytic agents has been broadly demonstrated in different studies, but due to logistic issues we have observed a delay in the implementation of the recommendations in real world scenarios. We compared primary angioplasty results at three different timepoints in the SOLACI Registry. METHOD: The SOLACI Registry included data of 43,725 primary angioplasties carried out from 1995-97 (n = 6,793), 2000-03 (n = 23,007) and 2007-08 (n = 13,925). RESULTS: An increasing complexity of treated patients was observed, with an increment in the percentage of women, diabetics, patients with prior myocardial infarction and patients with moderate to severe ventricular dysfunction. Procedural success remained high (> 91%) at all timepoints, regardless of the device used. In addition, we observed a significant decrease of door-to-balloon time, increased use of stents and a 45% decrease in the use of glycoprotein IIb/IIIa inhibitors. Regarding in-hospital outcomes, a decreased mortality (9.1% vs. 5.3% vs. 4.5%), reinfarction (4.1% vs. 2.6% vs. 2.7%) and target vessel revascularization procedures (3.5% vs. 0.7% vs. 0.7%) was observed. CONCLUSION: Despite the more complex risk profile, the incorporation of technological advances and the reduction of door-to-balloon time led to improved inhospital cardiac outcomes after primary angioplasty in Latin America.

INTRODUÇÃO: Apesar da eficácia dos stents farmacológicos de primeira geração em reduzir a necessidade de novas intervenções, seu uso em cenários de maior complexidade, como as síndromes coronárias agudas, pode estar associado a maiores taxas de trombose. Estudos pré-clínicos têm atribuído papel central aos polímeros duráveis na gênese desses eventos adversos. O stent SupralimusTM combina uma plataforma de aço inoxidável com um polímero bioabsorvível com eluição de sirolimus. Esta análise teve por objetivo determinar a eficácia e a segurança clínica desse novo stent farmacológico no tratamento de pacientes não-selecionados com síndrome coronária aguda. MÉTODO: O Registro E-SERIES é um estudo multicêntrico e prospectivo, que inclui pacientes consecutivos tratados com SupralimusTM. Virtualmente todos os subtipos de pacientes e lesões encontram-se representados nesse registro. Toda informação pertinente ao procedimento e aos desfechos clínicos é coletada via internet, sendo os eventos adversos avaliados por comitê independente. RESULTADOS: Foram incluídos, no total, 1.263 pacientes, entre os quais 454 (35,9%) tiveram diagnóstico inicial de síndrome coronária aguda. A maioria era do sexo masculino (68,9%), com média de idade de 63 ± 11,4 anos. A incidência de diabetes melito nessa população foi elevada (36,8%). Em 6% dos casos havia trombo à angiografia pré-intervenção. Ao final do procedimento, fluxo TIMI 3 foi obtido em 96,8% dos procedimentos. A taxa de eventos cardíacos adversos na fase hospitalar foi de 1% (mortalidade de 0,4%). A taxa cumulativa de eventos cardíacos adversos maiores aos seis meses foi de 10%, com 0,4% de trombose do stent. CONCLUSÕES: Quando utilizado para tratar pacientes complexos portadores de síndrome coronária aguda, o stent farmacológico SupralimusTM demonstrou bom desempenho e segurança no seguimento de médio prazo, com baixas taxas de eventos adversos e trombose.

Relatamos o caso de um paciente com reestenose de stent nao-farmacologico, secundaria a hipoexpansao da protese, decorrente de grave calcificacao da placa aterosclerotica subjacente, a qual nao foi adequadamente reconhecida na angiografia. A utilizacao do ultrassom intracoronario foi de grande importância para reconhecer o mecanismo da reestenose e orientar na escolha da estrategia intervencionista mais adequada. A aterectomia rotacional foi realizada com sucesso para debilitar o calcio peristent, permitindo a expansao posterior da protese com baloes de alta pressao.

Aims We sought to investigate the impact of multivessel coronary artery disease (CAD) on reperfusion success and prognosis following primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). The influence of multivessel disease on myocardial reperfusion and subsequent survival after primary PCI has not been studied. Methods and results In the CADILLAC trial, primary PCI was performed in 2082 patients of any age with AMI within 12 h of symptom onset. Myocardial perfusion post-PCI assessed by ST-segment recovery and myocardial blush and clinical outcomes were stratified by the extent of CAD. Single-, double-, and triple-vessel disease were present in 1066 (51.2%), 692 (33.2%), and 324 (15.6%) patients, respectively. Patients with multivessel disease compared with those with single-vessel disease undergoing primary PCI were significantly more likely to have absent ST-segment recovery (13.3 vs. 7.4%, P = 0.01), though the rates of post-procedural TIMI-3 flow (89.7 vs. 88.9%, P = 0.66) and grade 2 or 3 myocardial blush (51.2 vs. 51.5%, P = 0.91) in the infarct vessel were comparable. By 1 year, the cumulative incidence of death for patients with single-, double-, and triple-vessel disease was 3.2, 4.4, and 7.8%, respectively ( P = 0.003), and the composite rate of major adverse cardiac events (MACE) was 14.8, 19.5, and 23.6%, respectively ( P = 0.0006). By multivariable analysis, the presence of triple-vessel disease was the strongest predictor of 1-year death [hazard ratio (HR) = 2.60, P = 0.009], death and re-infarction (HR = 1.88, P = 0.03), and MACE (HR = 1.80, P = 0.0009). Conclusion Patients with extensive CAD in vessels remote from the infarct-related artery have reduced reperfusion success and an adverse prognosis following primary PCI in AMI. Future studies regarding the optimal treatment of patients with multivessel disease and AMI are warranted.

The impact of treatment delays on outcomes after primary percutaneous coronary intervention for acute myocardial infarction is controversial.The CADILLAC trial randomized 2082 patients with acute myocardial infarction to stenting versus percutaneous transluminal coronary angioplasty, each with or without abciximab.Earlier reperfusion (3 vs 3-6 vs6 hours) was associated with lower 1-year mortality (2.6% vs 4.3% vs 4.8%, P = .046 for3 vsor = 3 hours), more frequent grade 2 to 3 myocardial blush (55% vs 53% vs 44%, P = .003), more frequent complete ST-segment resolution (64% vs 68% vs 47%, P = .006), and greater improvement in left ventricular function. Early reperfusion (3 vs 3-6 vsor = 3 hours) was associated with lower mortality in high-risk patients (3.8% vs 6.9% vs 7.0%, P = .051 for3 vsor = 3 hours) but not in low-risk patients (1.4% vs 0.6% vs 1.0%, P = .63). Door-to-balloon times were independently correlated with mortality in patients presenting early after the onset of symptoms (or = 2 hours, hazard ratio 1.24, P = .013) but not late (2 hours, heart rate 0.88, P = .33).Early reperfusion results in superior clinical outcomes, enhanced microvascular reperfusion, and better recovery of left ventricular function. Incremental treatment delays impact mortality more in high-risk versus low-risk patients and more in patients presenting early versus late after the onset of symptoms. These data emphasize the importance of minimizing treatment delays and have implications regarding patient triage for primary percutaneous coronary intervention.

The association between infarct artery location, reperfusion success, and clinical outcomes after primary percutaneous coronary intervention (PCI) has not been characterized. We examined the infarct artery-specific impact of epicardial and myocardial flow and reperfusion after primary PCI for acute myocardial infarction.Among 2082 patients undergoing primary PCI in the CADILLAC trial, myocardial blush grade, TIMI flow grade, ST-segment resolution, and clinical outcomes were analyzed according to the infarct artery.Baseline clinical characteristics did not significantly differ between patients experiencing infarction in the left anterior descending (LAD, 37%) versus left circumflex (18%) and right coronary artery (46%) distributions. Baseline left ventricular function was reduced, and collateral flow was less commonly present in patients with infarction involving the LAD. Achievement of final TIMI-3 flow, grade 3 myocardial blush, and ST-segment resolution70% was also significantly less common in anterior infarction. Patients with anterior versus nonanterior infarction had significantly higher mortality at 30 days (3.4% vs 1.3%, P = .0006) and 1 year (6.5% vs 2.9%, P.0001) and had increased 1-year rates of reinfarction (3.6% vs 1.7%, P = .009) and ischemic target vessel revascularization (16.1% vs 11.7%, P = .006). By multivariate analysis, LAD infarction was a powerful independent predictor of 1-year mortality (odds ratio 2.45, P = .009).Acute myocardial infarction involving the LAD distribution is associated with reduced left ventricular function, less frequent collateral flow, impaired myocardial perfusion and decreased reperfusion success, findings associated with reduced survival, and increased major adverse cardiac events compared with other vascular territories. These data provide mechanistic insights to the adverse prognosis of patients with anterior infarction.

Aims ST-segment recovery (ΣSTR) and myocardial blush (MB) evaluate different elements of microcirculatory integrity after reperfusion therapy in acute myocardial infarction (AMI). We sought to determine whether the combination of ΣSTR and MB after primary percutaneous coronary intervention (PCI) in AMI has greater prognostic utility than either measure alone. Methods and results The 30 days and 1 year clinical outcomes of 456 patients were assessed as a function of ΣSTR and MB after primary PCI from the CADILLAC trial. ΣSTR and MB were concordant (≥70% ΣSTR and MB grade 2/3 or

This study was designed to compare the angiographic outcomes of beta versus gamma vascular brachytherapy (VBT). We reviewed the angiographic results of 636 lesions (212 that underwent beta and 212 that underwent gamma VBT, and 212 that received placebo) with native coronary in-stent restenosis matched for lesion length, vessel size, preprocedure minimum lumen diameter (MLD), and time to angiographic follow-up in the various randomized clinical trials and studies. Baseline lesion complexity was similar in these 3 groups. Final MLD was smaller in the beta VBT group than in the gamma VBT or placebo group. At follow-up, beta and gamma VBT significantly reduced both angiographic restenosis (34.4% for beta VBT, 26.4% for gamma VBT, and 50.9% in the placebo group; p

The prognostic role of the angiographic pattern of in-stent restenosis after gamma vascular brachytherapy was assessed from a pooled data set of 4 clinical trials comprising 295 irradiated patients with matched baseline and follow-up angiograms. The binary angiographic restenosis rate increased with worsening in-stent restenosis patterns; however, target lesion revascularization and major adverse cardiac event rates increased for focal, diffuse, and proliferative patterns of in-stent restenosis but not for total occlusions.

OBJECTIVES We analyzed the effects of vascular brachytherapy (VBT) on ostial in-stent restenosis (ISR). BACKGROUND In-stent restenosis has a high recurrence rate after percutaneous reintervention. The recurrence rate of ostial ISR lesions and the impact of VBT remain unknown. METHODS We evaluated 133 patients with native coronary ostial ISR from a pooled database of 990 patients enrolled in randomized VBT trials. Independent quantitative angiography was performed at baseline and follow-up in 45 gamma, 27 beta, and 61 placebo patients. RESULTS Binary restenosis was significantly higher in placebo than radiated patients (75.4% vs. 17.8% in gamma vs. 22.2% in beta, p < 0.0001). The treatment effect of both gamma (odds ratio [OR] 0.06; 95% confidence interval [CI] 0.02 to 0.17) and beta VBT (OR 0.10; 95% CI 0.03 to 0.31) was maintained after controlling for differences in baseline lesion length. Proximal and distal radiation edge restenosis rates were similar among the groups. Vascular brachytherapy of true aorto-ostial lesions (n = 34) was similarly beneficial: restenosis rates of placebo versus gamma or beta patients of 83.3% versus 6.7% versus 28.6%, p = 0.0002. CONCLUSIONS Conventional treatment of ostial ISR is associated with a recurrence rate of over 75%. Vascular brachytherapy with either gamma or beta sources results in significant and similar reductions in restenosis compared with placebo. Similar benefits after VBT prevail in true aorto-ostial lesions.

The safety and performance of the Absorb Bioresorbable Vascular Scaffold (Absorb) has been previously demonstrated with clinical data. However, these trials included patients with simple lesions. Aiming to evaluate clinical outcomes, we analyzed the treatment of real world patients from a single

Objectives. The goals of this study were to examine the safety and feasibility of a routine (primary) stent strategy in acute myocardial infarction (AMI). Background. Limitations of reperfusion by primary percutaneous transluminal coronary angioplasty (PTCA) in AMI include in-hospital recurrent ischemia or reinfarction in 10% to 15% of patients, restenosis in 37% to 49% and late infarct-related artery reocclusion in 9% to 14%. By lowering the residual stenosis and sealing dissection planes created by PTCA, primary stenting may further improve short- and long-term outcomes after mechanical reperfusion. Methods. Three hundred twelve consecutive patients treated with primary PTCA for AMI at nine international centers were prospectively enrolled. After PTCA, stenting was attempted in all eligible lesions (vessel size 3.0 to 4.0 mm; lesion length ≤2 stents; and the absence of giant thrombus burden after PTCA, major side branch jeopardy or excessive proximal tortuosity or calcification). Patients with stents were treated with aspirin, ticlopidine and a 60-h tapering heparin regimen. Results. Stenting was attempted in 240 (77%) of 312 patients, successfully in 236 (98%), with Thrombolysis in Myocardial Infarction grade 3 flow restored in 230 patients (96%). Patients with stents had low rates of in-hospital death (0.8%), reinfarction (1.7%), recurrent ischemia (3.8%) and predischarge target vessel revascularization for ischemia (1.3%). At 30-day follow-up, no additional deaths or reinfarctions occurred among patients with stents, and target vessel revascularization was required in only one additional patient (0.4%). Conclusions. Primary stenting is safe and feasible in the majority of patients with AMI and results in excellent short-term outcomes.

Objectives. A large, international, multicenter, prospective, randomized trial was performed to determine the role of prophylactic intraaortic balloon pump (IABP) counterpulsation after primary percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction (AMI). Background. Previous studies have suggested that routine IABP use after primary PTCA reduces infarct-related artery reocclusion, augments myocardial recovery and improves clinical outcomes. Methods. Cardiac catheterization was performed in 1,100 patients within 12 h of onset of AMI at 34 clinical centers. Clinical and angiographic variables were used to stratify patients undergoing primary PTCA into high and low risk groups. High risk patients were then randomized to 36 to 48 h of IABP (n = 211) or traditional care (n = 226). The study had 80% power to detect a reduction in the primary end point from 30% to 20%. Results. There was no significant difference in the predefined primary combined end point of death, reinfarction, infarct-related artery reocclusion, stroke or new-onset heart failure or sustained hypotension in patients treated with an IABP versus those treated conservatively (28.9% vs. 29.2%, p = 0.95). The IABP strategy conferred modest benefits in reduction of recurrent ischemia (13.3% vs. 19.6%, p = 0.08) and subsequent unscheduled repeat catheterization (7.6% vs. 13.3%, p = 0.05) but did not reduce the rate of infarct-related artery reocclusion (6.7% vs. 5.5%, p = 0.64), reinfarction (6.2% vs. 8.0%, p = 0.46) or mortality (4.3% vs. 3.1%) and was associated with a higher incidence of stroke (2.4% vs. 0%, p = 0.03). IABP use did not result in enhanced myocardial recovery as assessed by paired admission to predischarge and 6-week rest and exercise left ventricular ejection fraction. Conclusions. In contrast to previous studies, a prophylactic IABP strategy after primary PTCA in hemodynamically stable high risk patients with AMI does not decrease the rates of infarct-related artery reocclusion or reinfarction, promote myocardial recovery or improve overall clinical outcome. (J Am Coll Cardiol 1997;29:1459–67)

FUNDAMENTO: A dilatacao do ventriculo esquerdo (VE) apos infarto agudo do miocardio (IAM) e um importante determinante do prognostico. A razao entre a velocidade diastolica E do fluxo mitral e a velocidade diastolica e' do anel mitral (relacao E/e') e o melhor indice nao invasivo para detectar elevacao aguda da pressao de enchimento do VE. A hipotese deste estudo e que a E/e' possa predizer remodelacao do VE apos IAM tratado. OBJETIVO: Avaliar se a E/e' prediz remodelacao ventricular apos IAM, em comparacao aos dados clinicos, laboratoriais e ecocardiograficos tradicionais. METODO: Ecocardiogramas foram realizados em pacientes consecutivos com primeiro IAM, apos angioplastia transluminal coronariana (ATC) seguida de recanalizacao efetiva, 48 horas e 60 dias apos o evento. A E/e' foi calculada pela media de quatro sitios do anel mitral. Remodelacao do VE foi definida como aumento ≥ 15% do volume sistolico final ao metodo de Simpson. Analises estatisticas incluiram teste t de Student, curvas receptor-operador (ROC) e regressao logistica multivariada, com p significante < 0,05. RESULTADOS: Estudados 55 pacientes, com idade 58 ± 11 anos, 43 homens, observou-se E/e' maior (13 ± 4 versus 8,5 ± 2; p < 0,001) no grupo com remodelacao (n = 13) em relacao ao grupo sem remodelacao (n = 42). A curva ROC indicou E/e' como preditor de remodelacao (area sob a curva = 0,81, p = 0,001). Analises de regressao contendo variaveis clinicas, laboratoriais e Doppler-ecocardiograficas confirmaram E/e' como preditor independente da remodelacao (odds ratio 1,42; p = 0,01). CONCLUSAO: A relacao E/e' e um preditor util de remodelacao do VE apos IAM, indicando pacientes com maior risco cardiovascular.

Objective: To compare models of the postoperative hospital treatment phase after myocardial revascularization. Design: A pilot randomized controlled trial. Setting: Hospital patients in a hospital setting. Subjects: Thirty-two patients with indications for myocardial revascularization were included between January 2008 and December 2009, with a left ventricular ejection fraction (LVEF) ≥50%, 1-second forced expiratory volume (FEV1) ≥60 and forced vital capacity (FVC) ≥60% of predicted value. Interventions: Patients were randomly placed into two groups: one performed prescribed exercises according to the model proposed by the American College of Sports Medicine (ACSM) and the other according to a periodized model. Main measures: Partial pressure of O2 ( Po2) and arterial O2 saturation ( Sao2), percentage of predicted FVC and total distance on the six-minute walking test (6MWT). Results: Twenty-seven patients were re-evaluated upon release from the hospital (ACSM = 14 and PP = 13). Five patients extubated for more than 6 hours in the postoperative period were excluded from the sample. In the preoperative period the variables Po2, Sao2, % FVC and 6MWT were similar. In the postoperative period, a reduction was observed for all parameters in both groups. Upon comparison of the groups, a difference was observed in Po2 (ACSM = 68.0 ± 4.3 vs. PP = 75.9 ± 4.8 mmHg; P < 0.001), Sao2 (ACSM = 93.5 ± 1.4 vs. PP = 94.8 ± 1.2%; P = 0.018) and 6MWT (ACSM = 339.3 ± 41.7 vs. PP = 393.8 ± 25.7 m; P < 0.001). There was no difference in % FVC. Conclusion: Patients after myocardial revascularization following a periodized model of exercise presented a better intra-hospital evolution when compared to those using the ACSM model.

INTRODUÇÃO: Os stents farmacológicos (SFs) melhoraram a evolução clínica dos pacientes submetidos a intervenção coronária percutânea (ICP). Novos SFs foram desenvolvidos com o propósito de superar as atuais limitações da geração mais antiga de SFs. Este estudo teve como objetivo avaliar os aspectos angiográfico e ultrassonográfico tardios do SF eluidor de sirolimus FirebirdTM. MÉTODOS: Entre dezembro de 2007 e março de 2008, 15 pacientes portadores de lesões de novo foram submetidos a ICP com implante de stent FirebirdTM. Avaliação com angiografia e USIC foi realizada em todos os pacientes aos 24 meses de seguimento. O objetivo primário foi a avaliação da perda luminal tardia à angiografia coronária quantitativa e o porcentual de obstrução volumétrica intrastent pelo ultrassom intracoronário (USIC) RESULTADOS: A média de idade foi de 57 ± 7,1 anos, 87% eram do sexo masculino e 27% eram diabéticos. A artéria descendente anterior foi o vaso mais frequentemente tratado (36%) e a maioria das lesões era do tipo B2/C (82%). Aos 24 meses, a perda luminal tardia foi de 0,17 ± 0,36 mm e a revascularização do vaso tratado foi de 6,6%. O porcentual de obstrução volumétrica intrastent foi de 9,6 ± 4,6%. Não houve casos de óbito, infarto ou trombose de stent. CONCLUSÕES: Neste estudo de centro único brasileiro, o stent FirebirdTM apresentou resultados tardios satisfatórios. Esses achados, em conjunto com os disponíveis na literatura, fornecem evidências adicionais para o uso do stent FirebirdTM na prática clínica diária. BACKGROUND: Drug eluting stents (DES) have improved the clinical outcomes of patients undergoing percutaneous coronary interventions (PCI). New DES have been developed with the purpose of overcoming the current limitations of the older generation DES. This study aimed to evaluate the long-term angiographic and intravascular ultrasound (IVUS) findings of the Firebird TM sirolimus eluting stent. METHODS: From December 2007 to March 2008, 15 patients with de novo lesions underwent PCI using the FirebirdTM stent. Angiography and IVUS were performed in all patients at 24 months of follow-up. The primary objective was to assess the late luminal loss by quantitative coronary angiography and in-stent percent volume obstruction by intravascular ultrasound (IVUS). RESULTS: Mean age was 57 ± 7.1 years, 87% were male and 27% were diabetics. The left anterior descending artery was the most frequently treated vessel (36%) and most of the lesions were B2/C type lesions (82%). At 24 months, late luminal loss was 0.17 ± 0.36 mm and target vessel revascularization was 6.6%. In-stent percent volume obstruction was 9.6 ± 4.6%. There were no cases of death, myocardial infarction or stent thrombosis. CONCLUSIONS: In this single center study in Brazil, the FirebirdTM stent showed good late outcomes. These findings, together with the available literature, provide further evidence for the use of the FirebirdTM stent in the daily clinical practice.

INTRODUÇÃO: Recentemente a intervenção coronária percutânea (ICP) com stents farmacológicos (SFs) tem se mostrado uma opção viável em pacientes selecionados com lesão de tronco de coronária esquerda não-protegido (TCE-NP). Este estudo teve como objetivo avaliar a efetividade e a segurança da ICP com SFs em lesões de TCE-NP da prática diária, analisando a ocorrência combinada de eventos cardíacos adversos maiores (ECAM) a longo prazo. MÉTODOS: Foram tratados 142 pacientes consecutivos, com média de seguimento clínico de 917 ± 743 dias. A decisão de utilizar um ou dois stents e inibidor da glicoproteína IIb/IIIa ficou a critério do operador. Angiografia coronária no seguimento não foi realizada de rotina, mas deixada a critério clínico. RESULTADOS: A média de idade foi de 67,5 ± 16 anos, três quartos dos pacientes eram do sexo masculino, 29% eram portadores de diabetes e 39% apresentavam angina instável. Foram utilizados 2,75 ± 1,25 stents por paciente. Lesões com comprometimento da bifurcação foram identificadas em 90,1% e as técnicas mais frequentemente utilizadas foram o provisional stent em 36% e o small crush em 29% dos pacientes. Ultrassom intracoronário foi realizado em 92,3% dos pacientes, e reintervenção ocorreu em 21,3% dos stents, por apresentarem aposição incompleta de suas hastes após o implante. ECAM na evolução tardia ocorreram em 15,4%, óbito cardíaco ocorreu em 3,6%, revascularização do vaso-alvo em 11,2% e trombose definitiva/ provável do stent em 1,4%. CONCLUSÕES: A ICP com SFs em lesões de TCE-NP neste estudo mostrou ser segura e eficaz na evolução tardia, com baixas taxas de óbito cardíaco e de trombose do stent. BACKGROUND: Recently, percutaneous coronary intervention (PCI) with drug-eluting stents (DES) has proven to be a feasible option in selected patients with unprotected left main (LM) disease. This study was aimed at assessing the efficacy and safety of PCI with DES in LM lesions in the daily practice, analyzing the long-term occurrence of major adverse cardiac events (MACE). METHODS: A total of 142 consecutive patients were treated with a mean follow-up of 917 ± 743 days. The decision to use one or two stents or glycoprotein IIb/IIIa inhibitors was left to the operator's discretion. Coronary angiography was not performed routinely in the follow-up. RESULTS: Mean age was 67.5 ± 16 years, 75% of the patients were male, 29% had diabetes and 39% had unstable angina. A total of 2.75 ± 1.25 stents were implanted per patient. Bifurcation lesions were identified in 90.1% and the most frequent techniques were the provisional stent in 36% and small crush in 29% of the patients. Intravascular ultrasound was performed in 92.3% of the patients and reinterventions in 21.3% of the stents due to incomplete apposition of the struts after implantation. In the late follow-up, MACE was observed in 15.4% of the patients, cardiac death in 3.6%, target-vessel revascularization in 11.2% and definitive/probably stent thrombosis in 1.4%. CONCLUSIONS: In this study, PCI with DES proved to be safe and effective in the late follow-up of LM lesions, with low cardiac death and stent thrombosis rates.

FUNDAMENTO: Disfunção diastólica é frequente em pacientes de hemodiálise, mas seu impacto na evolução clínica é incerto. OBJETIVO: Avaliar a prevalência e o impacto prognóstico da disfunção diastólica (DD) avançada (DDA) do ventrículo esquerdo (VE) em pacientes de hemodiálise. MÉTODOS: Ecocardiogramas foram realizados em pacientes no primeiro ano de hemodiálise, em ritmo sinusal, sem doença cardiovascular manifestada, excluindo-se aqueles com valvopatia significativa ou derrame pericárdico. Pela avaliação integrada dos dados ecodopplercardiográficos, a função diastólica foi classificada como: 1) normal, 2) DD discreta (alteração do relaxamento) e 3) DDA (pseudonormalização e fluxo restritivo). Os desfechos pesquisados foram mortalidade geral e eventos cardiovasculares. RESULTADOS: Foram incluídos 129 pacientes (78 homens), com idade 52 ± 16 anos e prevalência de DD de 73% (50% com DD discreta e 23% com DDA). No grupo com DDA, demonstrou-se maior idade (p < 0,01), pressão arterial sistólica (p < 0,01) e diastólica (p = 0,043), massa do VE (p < 0,01), índice do volume do átrio esquerdo (p < 0,01) e proporção de diabéticos (p = 0,019), além de menor fração de ejeção (p < 0,01). Após 17 ± 7 meses, a mortalidade geral foi significativamente maior naqueles com DDA, em comparação aos normais e com DD discreta (p = 0,012, log rank test). Na análise multivariada de Cox, a DDA foi preditiva de eventos cardiovasculares (hazard ratio 2,2, intervalo de confiança 1,1-4,3, p = 0,021) após ajuste para idade, gênero, diabete, massa do VE e fração de ejeção. CONCLUSÃO: A DDA subclínica foi encontrada em aproximadamente um quarto dos pacientes de hemodiálise e acarretou impacto prognóstico, independente de outros dados clínicos e ecocardiográficos. BACKGROUND: Diastolic dysfunction (DD) is frequent in patients on hemodialysis (HD), but its impact on the clinical evolution is yet to be established. OBJECTIVE: To evaluate the prevalence and prognostic impact of left ventricular (LV) advanced diastolic dysfunction (ADD) in patients on hemodialysis. METHODS: The echocardiograms were performed during the first year of HD therapy, in patients with sinus rhythm, with no evidence of cardiovascular disease, excluding those with significant valvopathy or pericardial effusion. The combined assessment of the Doppler echocardiographic data classified the diastolic dysfunction as: 1) normal diastolic function; 2) mild DD (relaxation alteration) and 3) ADD (pseudonormalization and restrictive flow pattern). The assessed outcomes were general mortality and cardiovascular events. RESULTS: A total of 129 patients (78 males), aged 52 ± 16 years, with a DD prevalence of 73% (50% with mild DD and 23% with ADD) were included in the study. The group with ADD was older (p < 0.01) and presented higher systolic (p < 0.01) and diastolic BP (p = 0.043), LV mass (p < 0.01), left atrial volume index (p < 0.01) and number of diabetic patients (p = 0.019), as well as lower ejection fraction (EF) (p < 0.01). After 17 ± 7 months, the general mortality was significantly higher in individuals with ADD, when compared to those with normal function and mild DD (p = 0.012, log rank test). At Cox multivariate analysis, ADD was predictive of cardiovascular events (hazard ratio 2.2; confidence interval: 1.1-4.3; p = 0.021) after adjusted for age, gender, diabetes, LV mass and EF. CONCLUSION: The subclinical ADD was identified in approximately 25% of the patients undergoing hemodialysis and had a prognostic impact, regardless of other clinical and echocardiographic data. FUNDAMENTO: Disfunción diastólica es frecuente en pacientes de hemodiálisis, pero su impacto en la evolución clínica es incierto. OBJETIVO: Evaluar la prevalencia y el impacto pronóstico de la disfunción diastólica (DD) avanzada (DDA) del ventrículo izquierdo (VI) en pacientes de hemodiálisis. MÉTODOS: Se realizaron ecocardiogramas en pacientes en el primer año de hemodiálisis, en ritmo sinusal, sin enfermedad cardiovascular manifestada, excluyéndose aquellos con valvulopatía significativa o derrame pericárdico. Por la evaluación integrada de los datos del ecocardiograma Doppler, la función diastólica fue clasificada como: 1) normal, 2) DD discreta (alteración de la relajación) y 3) DDA (seudonormalización y flujo restrictivo). Los desenlaces investigados fueron mortalidad general y eventos cardiovasculares. RESULTADOS: Fueron incluidos 129 pacientes (78 hombres), con edad 52 ± 16 años y prevalencia de DD del 73% (50% con DD discreta y 23% con DDA). En el grupo con DDA, se presentó mayor edad (p < 0,01), presión arterial sistólica (p < 0,01) y diastólica (p = 0,043), masa del VI (p < 0,01), índice del volumen del atrio izquierdo (p < 0,01) y proporción de diabéticos (p = 0,019), además de menor fracción de eyección (p < 0,01). Después de 17 ± 7 meses, la mortalidad general fue significativamente mayor en aquellos con DDa, en comparación a los normales y con DD discreta (p = 0,012, log rank test). En el análisis multivariado de Cox, la DDA fue predictiva de eventos cardiovasculares (hazard ratio 2,2, intervalo de confianza 1,1-4,3, p = 0,021) después del ajuste para edad, sexo, diabetes, masa del VI y fracción de eyección. CONCLUSIÓN: La DDA sublínica se encontró en aproximadamente un cuarto de los pacientes de hemodiálisis y resultó de impacto pronóstico, independiente de otros datos clínicos y ecocardiográficos.

Diastolic dysfunction (DD) is frequent in patients on hemodialysis (HD), but its impact on the clinical evolution is yet to be established.To evaluate the prevalence and prognostic impact of left ventricular (LV) advanced diastolic dysfunction (ADD) in patients on hemodialysis.The echocardiograms were performed during the first year of HD therapy, in patients with sinus rhythm, with no evidence of cardiovascular disease, excluding those with significant valvopathy or pericardial effusion. The combined assessment of the Doppler echocardiographic data classified the diastolic dysfunction as: 1) normal diastolic function; 2) mild DD (relaxation alteration) and 3) ADD (pseudonormalization and restrictive flow pattern). The assessed outcomes were general mortality and cardiovascular events.A total of 129 patients (78 males), aged 52 +/- 16 years, with a DD prevalence of 73% (50% with mild DD and 23% with ADD) were included in the study. The group with ADD was older (p0.01) and presented higher systolic (p0.01) and diastolic BP (p = 0.043), LV mass (p0.01), left atrial volume index (p0.01) and number of diabetic patients (p = 0.019), as well as lower ejection fraction (EF) (p0.01). After 17 +/- 7 months, the general mortality was significantly higher in individuals with ADD, when compared to those with normal function and mild DD (p = 0.012, log rank test). At Cox multivariate analysis, ADD was predictive of cardiovascular events (hazard ratio 2.2; confidence interval: 1.1-4.3; p = 0.021) after adjusted for age, gender, diabetes, LV mass and EF.The subclinical ADD was identified in approximately 25% of the patients undergoing hemodialysis and had a prognostic impact, regardless of other clinical and echocardiographic data.

FUNDAMENTO: A eficácia dos stents farmacológicos em reduzir os índices de eventos cardíacos não é uniforme a todos os subgrupos de lesões ou pacientes. OBJETIVO: Avaliar a evolução clínica tardia dos pacientes submetidos a implante de stents farmacológicos nas lesões ateroscleróticas da artéria descendente anterior e identificar, entre as características clínicas, angiográficas e do ultra-som intravascular, quais as que permitem predizer risco de eventos cardíacos. MÉTODOS: De maio de 2002 a agosto de 2005, foram tratados 205 pacientes com implante de 236 stents farmacológicos guiados pelo ultra-som intravascular. RESULTADOS: Com um acompanhamento médio de 711 dias, a taxa de trombose do stent foi de 0,48%, a mesma observada para infarto agudo do miocárdio ou cirurgia de revascularização. A taxa de revascularização da lesão tratada foi de 7,31% e a taxa global de eventos de 10,24%. Os indicadores de eventos, conforme análise multivariada, foram o implante de mais de um stent na mesma artéria, lesões concêntricas e área mínima intra-stent medida pelo ultra-som intravascular menor que 3,88 mm². CONCLUSÃO: Baseados nos dados obtidos, concluímos que a revascularização da artéria descendente anterior com implante de stents farmacológicos escolhidos e otimizados pelo ultra-som intravascular apresenta baixo índice de eventos tardios. O implante de dois stents farmacológicos para o tratamento das lesões longas foi o principal fator independente para a ocorrência de eventos tardios. A área luminal final maior que 3,88 mm² obtidos nos segmentos de pequenos diâmetros de referência é um indicador independente de evolução livre de eventos. BACKGROUND: The efficacy of pharmacological stents in decreasing the incidence of cardiac events is not homogeneous for all lesions or patient subgroups. OBJECTIVE: 1) To evaluate the late clinical evolution of patients submitted to pharmacological stent implantation in atherosclerotic lesions of the left anterior descending artery; 2) to identify, among the clinical, angiographic and intravascular ultrasonographic characteristics, the ones predictive of cardiac event risk. METHODS: From May 2002 to August 2005, 205 patients were treated with 236 pharmacological stent implants, guided by the intravascular US (IVUS). RESULTS: After a mean follow-up period of 711 days, the rate of stent thrombosis was 0.48%, the same observed for acute myocardial infarction or revascularization surgery. The revascularization rate of the treated lesion was 7.31% and the general event rate was 10.24%. The event indicators, according to the multivariate analysis were the implant of more than one stent in the same artery, concentric lesions and the minimal intra-stent area measured by IVUS < 3.88 mm². CONCLUSION: Based on the data obtained, we conclude that the revascularization of the left anterior descending artery with pharmacological stent implant, chosen and optimized by IVUS, presents a low incidence of late events. The implant of two pharmacological stents for the treatment of long lesions was the main independent factor for the occurrence of late events. The final luminal area > 3.88 mm² obtained in the small reference-diameter segments is an independent indicator of event-free evolution. FUNDAMENTO: La eficacia de los stents farmacológicos para reducir los índices de eventos cardiacos no es la misma para todos los subgrupos de lesiones o pacientes. OBJETIVO: Evaluar la evolución clínica tardía de los pacientes sometidos a implante de stents farmacológicos en las lesiones ateroscleróticas de la arteria descendente anterior e identificar, entre las características clínicas, angiográficas y de ultrasonido intravascular, cuales son las que permiten predecir riesgos de eventos cardiacos MÉTODOS: De mayo de 2002 a agosto de 2005, se trataron a 205 pacientes con implante de 236 stents farmacológicos guiados por ultrasonido intravascular. RESULTADOS: Con un seguimiento promedio de 711 días, la tasa de trombosis del stent fue del 0,48%, la misma que se observó para infarto agudo de miocardio o cirugía de revascularización. La tasa de revascularización de la lesión tratada fue del 7,31% y la tasa global de eventos fue del 10,24%. Los indicadores de eventos, conforme análisis multivariada, fueron el implante de más de un stent en la misma arteria, lesiones concéntricas y área mínima intrastent medida por el ultrasonido intravascular menor que 3,88 mm². CONCLUSIÓN: Tomando como base los datos obtenidos con esta investigación, concluimos que la revascularización de la arteria descendente anterior con implante de stents farmacológicos, elegidos y optimizados por el ultrasonido intravascular, presenta un bajo índice de eventos tardíos. El implante de dos stents farmacológicos para el tratamiento de las lesiones largas fue el principal factor independiente para la ocurrencia de eventos tardíos. El área luminal final mayor que 3,88 mm², obtenida en los segmentos de pequeños diámetros de referencia es un indicador independiente de evolución libre de eventos.

BACKGROUND Polymorphisms of the receptor for advanced glycation end products (RAGE) gene have been associated with diabetes, coronary artery disease (CAD) and inflammatory processes. The -374T >A RAGE gene promoter polymorphism was shown to affect gene transcription. The aim of this study was to evaluate the association of the -374T >A polymorphism with the severity of CAD in patients with or without type 2 diabetes mellitus. METHODS We studied 246 Euro-Brazilians with angiographically defined CAD (stenosis >50%), comprising type 2 diabetic (n=98) and non-diabetic subjects (n=148). Genotyping was performed by PCR-restriction fragment length polymorphism using Tsp509I restriction enzyme. RESULTS The AA genotype was associated with a significant decrease in CAD severity estimated by the number of diseased vessels (1.43+/-0.5 vs. 2.49+/-1.1; p=0.002) and the Duke score (27.3+/-10.8 vs. 49.3+/-20.1; p=0.001) only in the group of CAD subjects with type 2 diabetes mellitus. The protective effect of the AA genotype against severity of CAD was not observed in the non-diabetic group. CONCLUSION This result confirms that the -374AA genotype of the RAGE gene promoter is a protective factor against the severity of CAD lesions in type 2 diabetic patients.

A small number of patients still need target lesion revascularization (TLR) after drug-eluting stent (DES) implantation. It is important for the management of coronary artery disease to assess the predictors of TLR after DES implantation.Two hundred ninety-seven patients (325 lesions) were treated with Cypher sirolimus-eluting and/or TAXUS paclitaxel-eluting stent implantation at four centers in Japan and Brazil. Among these centers, 20 patients (24 lesions) needed clinically driven TLR. The clinical and angiographic characteristics of TLR patients were compared to those of non-TLR patients. Hemodialysis, prior myocardial infarction (MI) and prior coronary artery bypass grafting (CABG) were more frequent in TLR patients than in non-TLR patients. An ostial stenosis was more frequent in the TLR group than in the non-TLR group (41.7% vs 19.9%, p=0.012). In addition, post-procedure in-stent percentage diameter stenosis (%DS) was higher in TLR patients (21.9% vs 13.3%, p = 0.002). Stepwise logistic regression analysis indicated that all of these variables were independent predictors of TLR after DES implantation.Hemodialysis, prior MI, prior CABG, ostial lesion location and high in-stent %DS may be independent predictors of TLR after DES implantation.

We examined whether leukocytosis is a negative prognostic factor in patients who underwent primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI), and, if so, determined whether it is associated with impaired myocardial perfusion. Previous studies have identified leukocytosis as a predictor of mortality in AMI. Whether this association holds in patients how have undergone primary PCI using contemporary pharmacotherapy and correlates with impaired myocardial perfusion is unknown. Clinical outcomes and reperfusion success, using Thrombolysis In Myocardial Infarction (TIMI) flow and myocardial blush grades, were examined according to tertiles of baseline leukocyte count in 1,268 patients who underwent primary PCI for AMI in the CADILLAC trial. Patients with higher leukocyte count were younger and more likely to be current smokers. Preprocedure TIMI grade 0 flow was more frequent in patients with higher leukocyte counts, but postprocedural TIMI grade 3 flow rates were equally high (94%) in all 3 groups. Myocardial blush grade 2/3 was achieved at similar rates after PCI in patients with low, intermediate, and high baseline leukocyte counts (52.0% vs 51.5% vs 50.1%, p = 0.8). Higher baseline leukocyte counts were associated with greater myonecrosis (p0.0001) and increased mortality at 1 year (2.7% vs 4.6% vs 5.4%, respectively, p = 0.047). By multivariate analysis, baseline leukocyte count (in increments of 1,000, hazard ratio 1.07, 95% confidence interval 1.02 to 1.10, p = 0.005) and peak creatine phosphokinase (hazard ratio 1.22, 95% confidence interval 1.14 to 1.29, p0.001) were independent predictors of 1-year mortality. In conclusion, baseline leukocytosis is an independent correlate of larger infarct and increased mortality after primary PCI in AMI, an effect not explained by decreased myocardial perfusion.

OBJECTIVES We investigated the impact of diabetes mellitus on myocardial perfusion after primary percutaneous coronary intervention (PCI) utilizing myocardial blush grade (MBG) and ST-segment elevation resolution (STR). BACKGROUND Diabetes is an independent predictor of outcomes after primary PCI for acute myocardial infarction (AMI). Whether the poor prognosis is due to lower rates of myocardial reperfusion is unknown. METHODS Reperfusion success in those with and without diabetes mellitus was determined by measuring MBG (n = 1,301) and STR analysis (n = 700) in two substudies of the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial among patients undergoing primary PCI for AMI. RESULTS There were no differences between those with or without diabetes with regard to postprocedural Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 (>95%), distribution of infarct-related artery, and the frequency of stent deployment or abciximab administration. Patients with diabetes mellitus were more likely to have absent myocardial perfusion (MBG 0/1, 56.0% vs. 47.1%, p = 0.01) and absent STR (20.3% vs. 8.1%, p = 0.002). Diabetes mellitus (hazard ratio [HR] 1.63 [95% confidence interval (CI) 1.17 to 2.28], p = 0.004) was an independent predictor of absent myocardial perfusion (MBG 0/1) and absent STR (HR 2.94 [95% CI 1.64 to 5.37], p = 0.005) by multivariate modeling. CONCLUSIONS Despite similar high rates of TIMI flow grade 3 after primary PCI in patients with and without diabetes, patients with diabetes are more likely to have abnormal myocardial perfusion as assessed by both incomplete STR and reduced MBG. Diminished microvascular perfusion in diabetics after primary PCI may contribute to adverse outcomes.

We evaluated the outcomes of 177 consecutive patients (43 women, 134 men)

The purpose of this study was to compare the clinical outcomes of stenting and minimally invasive coronary artery bypass grafting (MIDCAB) in patients with proximal left anterior descending (LAD) coronary artery disease. The Patency, Outcome, Economics of Minimally invasive direct coronary bypass (POEM) study demonstrated that MIDCAB had similar safety and long-term efficacy for LAD revascularization compared with conventional coronary artery bypass grafting. Although LAD stenting is superior to conventional balloon angioplasty, whether it is comparable to MIDCAB is not known. We identified a matched population of 429 consecutive patients with 1-vessel disease who underwent elective proximal LAD stenting and compared their clinical outcomes with those of the 152 patients in the MIDCAB group of the POEM study. The in-hospital event rate was similar in both groups, except for a shorter length of hospital stay with LAD stenting compared with MIDCAB (2.68 vs 4.07 days, p