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Background: Ischemic heart disease may, with the occurrence of acute events, deteriorate to myocardial dysfunction. Compensation mechanisms such as Ischemic Preconditioning (IP), a powerful intrinsic phenomenon of myocardial protection, can minimize the deleterious effects of events. Additionally, coronary artery disease (CAD) associated with diabetes mellitus is associated with worse outcomes. Although experimental studies have shown that diabetes interferes negatively with the development of IP, it's still unknown whether diabetes can influence the expression of IP in patients with chronic CAD. Objective: To evaluate and compare IP in chronic CAD patients with and without diabetes. Methods: Diabetic and non-diabetic patients with chronic, stable CAD and preserved left ventricular systolic function were submitted to two sequential exercise tests (SET) with 30-minute interval between them. Ischemic parameters were compared between diabetic and non-diabetic patients. Ischemic preconditioning was considered present when time to 1mm ST-segment deviation was greater in the second of two SETs. Tests were analyzed by two independent and experienced cardiologists. Results: From 160 CAD patients who underwent SETs, 112 patients developed IP compared with 48 patients who did not (P=0.0001). From all patients, 75 were diabetic (group 1) and 85 were non-diabetic patients (group 2). The two groups were similar in terms of main prognostic parameters, besides previous infarction and cholesterol profile. In group 1, 54 (72%) patients developed IP and in group 2, 58 (68.2%) patients developed IP (P=0.35). When we compared the two groups, the improvement in time to 1mm ST-segment deviation was quite similar (76 vs 66 seconds, respectively for groups 1 and 2; P=0.19). Improvement in time to the onset of angina during SETs were also similar between the groups (45.2 vs 76.7 seconds, respectively for groups 1 and 2; P=0.56). Conclusion: In this study a significant number of diabetic and non-diabetic patients with coronary artery disease developed ischemic preconditioning. Additionally, diabetes mellitus appears not to have affected the magnitude of this protective mechanism.

Background: The effects of coronary interventions on quality of life (QoL) among patients with CAD are still scarcely studied. We evaluated the impact of CABG, PCI or Medical Therapy (MT) on self-perceived QoL among stable CAD patients, participants of MASS II trial. Methods: The Short-Form Health Survey (SF-36 QoL) was applied and the analysis was made at baseline, 5 and 10 years. The questionnaire was administered to 611 patients randomized to 3 treatment options at baseline, 401 patients after 5 years and 334 after 10 years (110 were initially assigned to CABG, 126 to PCI, and 98 to MT). Multiple comparisons were carried out. The data was presented by dimensions and also separated in mental and physical parameters. Results: In this study, after ten years of follow-up, 148 patients (47.3%) had AMI, 97 (25.9%) underwent CABG or PCI, 16 (4.8%) had stroke, and 293 (87%) had angina. At baseline, the physical component of CABG patients presented the worst condition compared with PCI or MT. Regarding the mental component, there was no statistical difference between treatment groups at baseline, five and ten years. On the other hand, in MT patients they scored in the mental component 63, 75 and 78, and in the physical component 54, 73 and 72, respectively at baseline, 5 and 10 years. In CABG patients, the mental component was 59, 79 and 74, and in the physical component 46, 77 and 69, respectively. In the PCI arm, the mental component scored 64, 68 and 76 and in the physical component scored 57, 71 and 77, at baseline, 5 and 10 years. ![Figure][1] Figure 1 Conclusion: Improvement was observed in all dimensions and in the 3 therapeutic options in 5 years and that persisted in 10 years. Comparatively, CABG provided a better QoL in the first 5 years and that persisted in 10-year follow-up. [1]: pending:yes

Background: Epidemiological studies suggest that obesity may confer protection in some common disease settings such as heart failure, atrial fibrillation, sudden death, acute coronary syndrome, and chronic coronary artery disease (ChCAD). However, previous published ChCAD results are based in registry data, and overweight and mild/moderate obesity were more likely to undergo revascularization procedures despite having lower risk coronary anatomy. Objective: To test the hypothesis whether body mass index (BMI) and other risk factors are independent risk factors for total mortality in patients with ChCAD that were randomized to optimized medical therapy (OMT), OMT associated with percutaneous coronary intervention (PCI), or OMT associated with coronary artery by-pass grafting (CABG) in the prospective randomized MASS trial. Methods: From 547 patients with ChCAD 177 were randomized to OMT, 156 to OMT + PCI (95 with non-drug-eluting stent, 61 with drug-eluting stent), and 214 to OMT + CABG. The mean studied follow-up was 1997±868 days. The OMT followed the current guideline orientation. The following risk factors: history of hypertension; current smoking; serum levels of cholesterol, LDL-cholesterol, HDL-cholesterol, triglyceride, fasting glucose, HbA(1c); waist circumference; BMI in kg/m2 (BMI ≤ 24.9; 24.9 34.9); age; sex; and the procedure (OMT or OMT+PCI or OMT + CABG) were tested in univariate and multivariate analysis as independent predictor of total mortality. Results: It was observed statisticaly: no differences in 6 years survival between OMT (81%), OMT+PCI (85%), and OMT+CABG (85%); no differences in survival according the BMI in the total group; no differences according the BMI in OMT+PCI and OMT+CABG groups except tendency (p=0.057) in OMT for higher survival for 24.9 34.9. On univariate analysis systemic hypertension (p=.002), smoking (p=0.02), and age (p=0.00) were associated with mortality in ChCAD. In multivariate analysis only history of systemic hypertension and current smoking were determinants of mortality during the follow-up. Conclusion: BMI and other accepted risk factors for CAD were not identified as independent risk factors for mortality after OMT, OMT+PCI, and OMT+CABG except hypertension, and current smoking. Obesity paradox was not identified. Independently of other risk factors and percutaneous or surgical procedures, the acknowledge of hypertension and current smoking importance is essential in ChCAD management under OMT.

Background Although the release of cardiac biomarkers after percutaneous (PCI) or surgical revascularization (CABG) is common, its prognostic significance is not known. Questions remain about the mechanisms and degree of correlation between the release, the volume of myocardial tissue loss, and the long-term significance. Delayed-enhancement of cardiac magnetic resonance (CMR) consistently quantifies areas of irreversible myocardial injury. To investigate the quantitative relationship between irreversible injury and cardiac biomarkers, we will evaluate the extent of irreversible injury in patients undergoing PCI and CABG and relate it to postprocedural modifications in cardiac biomarkers and long-term prognosis. Methods/Design The study will include 150 patients with multivessel coronary artery disease (CAD) with left ventricle ejection fraction (LVEF) and a formal indication for CABG; 50 patients will undergo CABG with cardiopulmonary bypass (CPB); 50 patients with the same arterial and ventricular condition indicated for myocardial revascularization will undergo CABG without CPB; and another 50 patients with CAD and preserved ventricular function will undergo PCI using stents. All patients will undergo CMR before and after surgery or PCI. We will also evaluate the release of cardiac markers of necrosis immediately before and after each procedure. Primary outcome considered is overall death in a 5-year follow-up. Secondary outcomes are levels of CK-MB isoenzyme and I-Troponin in association with presence of myocardial fibrosis and systolic left ventricle dysfunction assessed by CMR. Discussion The MASS-V Trial aims to establish reliable values for parameters of enzyme markers of myocardial necrosis in the absence of manifest myocardial infarction after mechanical interventions. The establishments of these indices have diagnostic value and clinical prognosis and therefore require relevant and different therapeutic measures. In daily practice, the inappropriate use of these necrosis markers has led to misdiagnosis and therefore wrong treatment. The appearance of a more sensitive tool such as CMR provides an unprecedented diagnostic accuracy of myocardial damage when correlated with necrosis enzyme markers. We aim to correlate laboratory data with imaging, thereby establishing more refined data on the presence or absence of irreversible myocardial injury after the procedure, either percutaneous or surgical, and this, with or without the use of cardiopulmonary bypass.

Objective With progressive aging, coronary artery disease has been diagnosed at more advanced ages. Although patients aged 65 years or more have been referred to surgical or percutaneous coronary interventions, the best option for coronary artery disease treatment remains uncertain. The current study compared the 3 treatment options for coronary artery disease in patients aged 65 years or more and analyzed the impact of age in treatment options. Methods Patients were separated according to age: 65 years or more (n = 200) and less than 65 years (n = 411). All patients were followed for 10 years. The rates of overall mortality, acute myocardial infarction, and new revascularizations were analyzed. Results Of 200 patients aged 65 years or more, 68 were randomized to medical therapy, 68 were randomized to percutaneous coronary intervention, and 64 were randomized to coronary artery bypass grafting. At 10 years, overall survival was 63% (medical therapy), 69% (percutaneous coronary intervention), and 66% (coronary artery bypass grafting) ( P = .93). The survival free of combined events was 43% (medical therapy), 38% (percutaneous coronary intervention ), and 66% (coronary artery bypass grafting) ( P = .007). The survival free of myocardial infarction was 82% (medical therapy), 77% (percutaneous coronary intervention), and 90% (coronary artery bypass grafting) ( P = .17), and survival free of new revascularizations was 59% (medical therapy), 58% (percutaneous coronary intervention ), and 91% (coronary artery bypass grafting) ( P = .0003). When the 2 age groups were compared, survival free of myocardial infarction for patients treated by percutaneous coronary intervention was 77% (older patients) and 92% (younger patients) ( P = .004). Conclusions In this analysis, treatment options for patients aged 65 years or more who have coronary artery disease yield similar overall survival. However, coronary artery bypass grafting was associated with fewer coronary events, and percutaneous coronary intervention was associated with a higher incidence of myocardial infarction.

Background The MASS IV-DM Trial is a large project from a single institution, the Heart Institute (InCor), University of São Paulo Medical School, Brazil to study ventricular function and coronary arteries in patients with type 2 diabetes mellitus. Methods/Design The study will enroll 600 patients with type 2 diabetes who have angiographically normal ventricular function and coronary arteries. The goal of the MASS IV-DM Trial is to achieve a long-term evaluation of the development of coronary atherosclerosis by using angiograms and coronary-artery calcium scan by electron-beam computed tomography at baseline and after 5 years of follow-up. In addition, the incidence of major cardiovascular events, the dysfunction of various organs involved in this disease, particularly microalbuminuria and renal function, will be analyzed through clinical evaluation. In addition, an effort will be made to investigate in depth the presence of major cardiovascular risk factors, especially the biochemical profile, metabolic syndrome inflammatory activity, oxidative stress, endothelial function, prothrombotic factors, and profibrinolytic and platelet activity. An evaluation will be made of the polymorphism as a determinant of disease and its possible role in the genesis of micro- and macrovascular damage. Discussion The MASS IV-DM trial is designed to include diabetic patients with clinically suspected myocardial ischemia in whom conventional angiography shows angiographically normal coronary arteries. The result of extensive investigation including angiographic follow-up by several methods, vascular reactivity, pro-thrombotic mechanisms, genetic and biochemical studies may facilitate the understanding of so-called micro- and macrovascular disease of DM.

Background T1 mapping is a magnetic resonance imaging (MRI) technique that enables the identification of myocardial structural changes during acute ischemic injury. However, it is not known whether these structural changes are present in patients with chronic effort induced ischemia.Thus, we sought to document the possible T1 mapping changes in chronic coronary artery disease (CAD) patients with documented myocardial ischemia. Methods Multivessel CAD patients from MASS V Trial with indication of myocardial revascularization, were evaluated for the presence of ischemia by myocardial scintigraphy. MRI with T1 mapping was performed in all patients. Based on the results of the scintigraphy, the myocardial segments were identified as ischemic and non-ischemic segments. The corresponding segments of scintigraphy and MRI were compared in relation to native T1 map (NT1), post-contrast T1 (CAT1) and extracellular volume (ECV). Results Of the 720 myocardial segments analyzed, there were 161 ischemic and 559 non-ischemic segments. Comparing ischemic vs non-ischemic segments, respectively, NT1 was 1022.7 (980.0–1052.0) versus 1029.3 (985.0–1066.3), p=0.57, ECV results were 25.4 (24.0–28.1) versus 26.4 (25.3–29.9), p=0.75 and CAT1 results were 492 (461.9–515.4) versus 488 (469.2–521.7), p=0.09. Myocardial segments supplied by obstructive coronary arteries were compared to those supplied by non-obstructive coronary arteries in relation to NT1 and ECV. NT1 values in obstructive and non-obstructive territories were, respectively, 1024.7 (998.5–1043.5) versus 1036.8 (1008.6–1046.9), p=0.30 and ECV results were 26.8 (24.4–29.9) versus 26.8 (24.4–30.0), p=0.90. Conclusion In this study, MRI identified structural similarities between chronic ischemic myocardium compared to the non-ischemic myocardium. This finding supports myocardial tissue stability in the presence of stress induced ischemia. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Zerbini Foundation and also by the FAPESP (2011/ 20876-2)

Type 2 diabetes mellitus (T2DM) may impact myocardial tissue structure, however studies that assessed this association using non-invasive methods had conflicting results. We sought to compare the characteristics of myocardium in patients with and without diabetes with multivessel coronary artery

T1 mapping is a magnetic resonance imaging (MRI) technique that enables the identification of myocardial structural changes during acute ischemic injury. However, it is not known whether these structural changes are present in patients with chronic effort induced ischemia. Thus, we sought to

Ventricular function is a major determinant of prognosis in patients with coronary artery disease (CAD). Few data are available to assess the evolution of ventricular function among patients submitted to off-pump coronary artery bypass graft surgery (OPCAB). To compare the evolution of ventricular

Introdução: A liberação anormal de biomarcadores de injúria miocárdica após o procedimento de revascularização é, geralmente, associada a eventos clínicos adversos. Todavia, a elevação dos biomarcadores cardíacos após o procedimento de revascularização não foi associada à gravidade angiográfica da doença arterial coronariana (DAC). O objetivo do presente estudo é investigar a relação entre a complexidade angiográfica da DAC, avaliada pelo SYNTAX Score (SXScore), e a elevação dos biomarcadores cardíacos após procedimentos de revascularização. Métodos: Trata-se de uma análise post-hoc do estudo MASS V, unicêntrico, prospectivo e observacional de pacientes com DAC estável submetidos a procedimentos de revascularização. Foram realizadas dosagens seriadas de troponina I ultra (TnI-u) e creatinoquinase (CK) -MB antes e após os procedimentos. Os SXScores foram calculados antes dos procedimentos de revascularização, por cardiologistas intervencionistas, que desconheciam as características clínicas e laboratoriais dos pacientes. Resultados: Dos 202 pacientes estudados, 136 foram submetidos à revascularização do miocárdio (CRM) e 66, à intervenção coronária percutânea (ICP). A mediana do SXScore nos pacientes revascularizados foi 20,00 (IQR 15,00-26,00), sendo 39,00 (IQR 35,00-44,00) no grupo SXScore alto e 19,0 (IQR 14,00-24,00) no grupo SXScore baixo/intermediário (p < 0,0001). Houve correlações significativas entre o SXScore e as medianas dos picos de TnI-u (r = 0,18, p = 0,009) e CK-MB (r = 0,24, p = 0,001), após procedimentos de revascularização. As medianas dos picos de TnI (p = 0,034) e CK-MB (p = 0,004), após procedimentos, foram maiores nos pacientes com SXScore alto ( >= 33) as aos daqueles com SXScore baixo/intermediário ( < 33). Além disso, a liberação de TnI em 6 horas (p = 0,002), 12 horas (p = 0,008) e 24 horas (p = 0,039), foi maior no grupo SXScore alto que no grupo SXscore baixo/intermediário ( < 33), bem como a liberação de CK-MB em 6 horas (p < 0,0001), 12 horas (p < 0,0001), 24 horas (p = 0,001), 36 horas (p = 0,007), 48 horas (p = 0,008) e 72 horas (p = 0,023), nos mesmos grupos. Após análise multivariada em um modelo incluindo variáveis clínicas, angiográficas, demográficas e laboratoriais, o SXScore alto permaneceu como preditor independente da liberação de CK-MB e TnI acima da mediana. Conclusão: O aumento da liberação de biomarcadores cardíacos foi significativamente associado à extensão da aterosclerose identificada pelo SYNTAX Score. Além disso, o SYNTAX Score alto demonstrou ser preditor independente para a elevação da CKMB acima da mediana mesmo quando ajustado a covariáveis Background: Abnormal cardiac biomarkers release after revascularization procedure has been associated with worse clinical outcomes. However, levels of myocardial biomarkers after revascularization procedural have not been associated with the severity of coronary artery disease (CAD). Our aim was to investigate the relationship between angiographic complexity of CAD as assessed by SYNTAX Score (SXScore) and cardiac biomarkers elevation after revascularization procedures. Methods: This is a post-hoc analyses of MASS V trial, which was a single-center, prospective and observational study among patients with stable CAD who underwent revascularization procedures. High sensitivity troponin (TnI) and creatinekinase (CK) -MB were assessed before and after procedures. Baselines SXscores were calculated by angiographic laboratory investigators blinded to patient characteristics. Results: Of the 202 patients studied, 136 underwent coronary artery bypass grafting (CABG) and 66 percutaneous coronary intervention (PCI). The median SXScore was 20.00 (IQR 15.00-26.00) in revascularized patients, 39.00 (IQR 35.00-44.00) in the high SXscore group and 19.0 (IQR 14.0024.00) in low/mid SXScore group (p < 0.0001). There were positive correlations between SXScore and median peaks after procedural TnI (r =0.18, p=0.009) and CK-MB (r =0.24, p=0.001) levels. In patients with high X (>= 33) k f procedural TnI(p=0.034) and CK-MB (p=0.004) levels were higher than low/mid SXScore( < 33) and the release of TnI at 6 hours (p = 0.002), 12 hours (p=0.008) and 24 hours (p=0.039), was higher in high SXScore group than low/mid SXScore ( < 33), as well as, the release of CK-MB at 6 hours (p < 0.0001), 12 hours (p < 0.0001), 24 hours (p=0.001), 36 hours (p=0.007), 48 hours (p=0.008) and 72 hours (p=0.023), in the same groups. After multivariate analysis, in a model including clinical, angiographic, demographic and laboratorial variables, high SXScore was a significant independent correlate of release of CK-MB and TnI peaks higher than median. Conclusion: The increase of release of cardiac biomarkers was significantly associated with the extent of atherosclerosis identified by the SYNTAX Score. Besides, high SYNTAX Score remained an independent predictor for elevation of CKMB above the median even when adjusted for covariates