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Background: Systemic Arterial Hypertension (SAH) is one of the main risk factors for Coronary Artery Disease (CAD), in addition to male gender. Differences in coronary artery lesions between hypertensive and normotensive individuals of both genders at the Coronary Computed Tomography Angiography (CCTA) have not been clearly determined. Objective: To Investigate the calcium score (CS), CAD extent and characteristics of coronary plaques at CCTA in men and women with and without SAH. Methods: Prospective cross-sectional study of 509 patients undergoing CCTA for CAD diagnosis and risk stratification, from November 2011 to December 2012, at Instituto de Cardiologia Dante Pazzanese. Individuals were stratified according to gender and subdivided according to the presence (HT +) or absence (HT-) of SAH. Results: HT+ women were older (62.3 ± 10.2 vs 57.8 ± 12.8, p = 0.01). As for the assessment of CAD extent, the HT+ individuals of both genders had significant CAD, although multivessel disease is more frequent in HT + men. The regression analysis for significant CAD showed that age and male gender were the determinant factors of multivessel disease and CS ≥ 100. Plaque type analysis showed that SAH was a predictive risk factor for partially calcified plaques (OR = 3.9). Conclusion: Hypertensive men had multivessel disease more often than women. Male gender was a determinant factor of significant CAD, multivessel disease, CS ≥ 100 and calcified and partially calcified plaques, whereas SAH was predictive of partially calcified plaques. Fundamento: Doença Arterial Coronariana (DAC) tem como um dos principais fatores de risco a Hipertensão Arterial Sistêmica (HAS), além do sexo masculino. As diferenças nas lesões de artérias coronarianas entre hipertensos e normotensos de ambos os sexos pela Angiotomografia Computadorizada Coronariana (ATC) ainda não foram claramente determinadas. Objetivo: Investigar Escore de Cálcio (EC), extensão da DAC e as características de placas coronarianas à ATC em homens e mulheres com e sem HAS. Métodos: Estudo transversal prospectivo com 509 pacientes submetidos a ATC para diagnóstico e estratificação de risco de DAC, de novembro de 2011 a dezembro de 2012, no Instituto Dante Pazzanese de Cardiologia. Foram estratificados segundo o gênero e subdivididos de acordo com a presença (HT+) ou ausência (HT-) de HAS. Resultados: As mulheres HT+ apresentaram maior idade (62,3 ± 10,2 vs 57,8 ± 12,8, p = 0,01). Quanto à avaliação de extensão da DAC, os HT+ de ambos os sexos apresentaram DAC significativa, porém a doença multiarterial é mais frequente nos homens HT+. A análise da regressão para DAC significativa mostrou que idade e sexo masculino foram fatores determinantes de doença multiarterial e EC ≥ 100. Já a análise para os tipos de placas mostrou que a HAS se comportou como fator de risco preditor para placas parcialmente calcificadas (OR = 3,9). Conclusão: Homens hipertensos apresentaram mais frequentemente doença multiarterial. O sexo masculino foi fator determinante de DAC significativa, doença multiarterial, EC ≥ 100 e placas calcificadas e parcialmente calcificadas. Enquanto a HAS foi preditora de placas parcialmente calcificadas.

Oropharyngeal dysphagia is a deglutition disorder resulting from neurological and/or structural impairment that may result in in decreased social interaction, loss of pleasure in food consumption, malnutrition, dehydration, infectious pulmonary processes and other high morbidity processes. Patients with heart disease from various causes present a risk of developing oropharyngeal dysphagia. Heart patients are susceptible to neurological disorders such as stroke and transient ischemic attack that may be present with dysphagia. Other possible risk factors for oropharyngeal dysphagia in people with heart disease are: prolonged tracheal intubation, dependence on mechanical ventilation, presence of a tracheostomy tube, manipulation or compression of cranial nerve pairs involved in swallowing and use of drugs that increase dysphagia, in addition to the physiological changes common in elderly patients, especially those with comorbidities, that may interfere in the different phases of deglutition and contribute to the emergence of dysphagic symptoms1,2. The speech therapist is the most qualified professional to assess and rehabilitate patients with dysphagia. Once dysphagia is diagnosed, a therapeutic program must be designed to regain efficient swallowing without the risk of pulmonary, nutritional and psychological complications. Promoting safe swallowing for individuals with dysphagia is a challenge that can be facilitated using therapeutic resources such as diet adaptation, with changes in consistency, volume, temperature and flavor. These strategies used by speech therapists are part of swallowing rehabilitation because they interfere with sensorimotor oral performance and oropharyngeal transit, minimizing the risk of laryngotracheal aspiration3. A change in the consistency of food is an important tool in the treatment of dysphagia, and foods should be modified according to the degree of dysphagia, the patient's nutritional condition, food intake acceptance and patient morbidity. Food thickener is used for liquid thickening, a common practice in speech therapy, since liquid swallowing requires greater control than swallowing of foods with a thicker consistency. The chance of premature spillage of food is one of the biggest risks of penetration and/or larygotracheal aspiration4. According to the standardization of the National Dysphagia Diet (NDD)5, liquids may be thickened into three consistencies: nectar, honey and pudding, which are prescribed by the speech therapist according to the degree of the patient's dysphagia. The viscosity of thickened liquids is measured in centipoises (cP) and is categorized according to the NDD as: thin liquid 1-50 cP, nectar 51-350 cP, honey 351-1750 cP and higher, and pudding 1750 cP. The amount of thickener indicated for each consistency will depend on the makeup of the different brands available on the market. Nutrition (dietary) and medical teams are responsible for the patient's diet in order to maintain or restore the patient's nutritional status. The heart patient often requires sodium restriction, which must be achieved with a maximum amount of 5 g of sodium chloride per day, which is the value of the entire daily intake. The different restriction levels are guided by the patient's individual pathology and the clinical path of each patient. Sodium restriction may be mild, moderate or severe; in the case of moderate restriction, intake should be 2g of salt per day and in the case of severe restriction the patient should eat no added salt, only the salt that is intrinsic in their food6,7. Thus, it is necessary in daily interaction with patients to pay attention to the nutritional information of the adapted diet, especially in regards to thickened liquids and the heart patient. This quality standardization is achieved by the presence of mineral sodium in the composition of the thickeners. The amount of sodium present in the thickeners is not uniform or standardized, varying according to brands available on the market (Table 1). Table 1 Sodium amount in commercialized thickeners The total daily intake of sodium in the thickened liquid will depend on the consistency indicated by the speech therapist, the volume of liquid prescribed by the medical team and the brand of the thickener used. Table 1 shows samples of different brands of thickener and the amount of sodium in the three consistencies: nectar, honey and pudding, for a daily intake of 1500 ml of liquids. Despite the amount of daily sodium intake in the supply of the thickened liquid at the different consistencies, this amount is not high. However, according to the samples in Table 2, this amount could compromise the total sodium intake in moderate or severely restricted diets. Thus, this value must always be considered in the overall diet, taking into account the minimum restriction of 5g sodium chloride; that is, 2,000 mg sodium/day6. Table 2 Daily sodium amount (mg) in thickener in three consistencies: nectar, honey and pudding: (1500 ml of liquid) It is important that the speech therapist, in partnership with medical staff and dietary staff, carefully evaluate the patients who are prescribed thickened liquids, considering that the value of sodium added by the use of thickener in the general diet is liable to impact negatively on the patient's clinical condition. In cases with significant restrictions of sodium intake, the intake related to the thickener can be a significant impact factor. It is essential that the team involved considers this aspect towards better therapeutic management of the case. An opportunity to discontinue the thickener should be evaluated, and the role of the speech therapist is to identify if the patient is able to discontinue use of the thickener, if he will be using it for a long time or even continuously, and to inform the medical staff who will check into the impact in terms of sodium in each case, correlating it with the time of use. Another aspect that should be decided as a team is the possibility of using natural thickeners, such as the use of fruit that provides a thicker consistency in the preparation of juices and vitamins; in addition, it is also possible for the nutrition team to adapt a diet that avoids foods rich in sodium, as well as a reduction in the amount of salt used in the preparation of food, thus reducing the value of the added sodium. Some thickeners show an absence of sodium on their labels and the team may opt for these brands. However, there are many controversies regarding the quality of these thickeners, since sodium participates actively in the process of thickening. The amount of sodium added to the thickener should not be a factor considered separately, but should be considered in the total sodium intake throughout the day. The team needs to observe the patient using thickener closely and be aware of the need to analyze each case separately, taking into account aspects such as basic disease and clinical condition. The optimal treatment for the patient with dysphagia does not aim at guaranteeing the safe intake of food, but also an optimal nutritional and water intake, in addition to consequent improvement of the clinical condition of the patient. For this to occur, it is necessary to have the cooperation of the entire team, aimed at quality care.

OBJETIVO: Avaliar a ocorrência de variáveis detectoras de isquemia miocárdica, durante ou após o tratamento odontológico, sob anestesia com vasoconstritor (adrenalina). MÉTODOS: Foram incluídos 54 pacientes coronariopatas submetidos a exodontia sob anestesia local com ou sem vasoconstritor, divididos em dois grupos (sorteio por envelope): grupo I, composto por 27 que receberam anestésico com vasoconstritor; e grupo II, composto por 27 que receberam anestésico sem vasoconstritor. Todos os pacientes foram submetidos a monitoração eletrocardiográfica com Holter por 24 horas, a Doppler-ecocardiografia realizada antes e após intervenção odontológica, e a dosagem dos marcadores bioquímicos antes e 24 horas após a exodontia (creatina cinase fração MB [CK-MB] massa, CK-MB atividade e troponina T). A freqüência cardíaca e a pressão arterial nas fases pré-anestesia, pós-anestesia e pós-exodontia também foram aferidas. A Doppler-ecocardiografia teve como objetivo avaliar a contratilidade segmentar do ventrículo esquerdo e a eventual ocorrência de insuficiência mitral. Em todos os casos foi mantido o protocolo farmacológico habitual prescrito pelo cardiologista. RESULTADOS: Três pacientes do grupo I apresentaram depressão do segmento ST (1,0 mm) durante a aplicação da anestesia, dois outros pacientes do mesmo grupo tiveram elevação da CK-MB massa, e em nenhum caso foi verificada presença de isquemia avaliada pelos demais métodos. Não houve registro, neste estudo, de precordialgia, arritmias e ocorrência ou agravamento de hipocontratilidade segmentar do ventrículo esquerdo ou insuficiência mitral. CONCLUSÃO: A exodontia praticada sob uso de anestesia com adrenalina 1:100.000 não implica riscos isquêmicos adicionais quando realizada com boa técnica anestésica e manutenção do tratamento farmacológico prescrito pelo cardiologista. OBJECTIVE: To evaluate the occurrence of variables detecting myocardial ischemia during or after dental treatment under anesthesia with vasoconstrictor (epinephrine). METHODS: A total of 54 coronary patients undergoing dental extraction under local anesthesia with or without vasoconstrictor were included. They were divided into two groups (by drawing envelopes): group I (27 patients) using anesthetics with vasoconstrictor, and group II (27 cases) without vasoconstrictor. 24-hour Holter monitoring, Doppler-echocardiogram before and after dental intervention, and determination of biochemical markers (CK-MB mass, CK-MB activity, and troponin T) before and 24 hours after dental extraction were performed in all patients. Heart rate and blood pressure were also measured in the pre, post-anesthesia and post-dental extraction phases. Doppler echocardiography assessed left ventricular segmental contractility and the occasional occurrence of mitral regurgitation. The usual pharmaceutical treatment prescribed by the cardiologist was maintained in all cases. RESULTS: Three patients in group I presented ST-segment depression (1.0 mm) during administration of anesthesia; two other patients in group I had CK-MB mass elevation, and ischemia was not observed in any other case, as assessed by the other methods. No chest pain, arrhythmias, occurrence or worsening of left ventricular segmental hypocontractility or mitral regurgitation were observed in the study. CONCLUSION: Dental extraction performed under anesthesia with 1:100,000 epinephrine does not imply additional ischemic risks, as long as performed with good anesthetic technique and maintenance of the pharmacological treatment prescribed by the cardiologist.

OBJETIVO: Identificar os perfis clínico/angiográfico e relacionados ao procedimento de pacientes com angina instável atendidos em um hospital terciário e tratados por meio de intervenções coronarianas percutâneas. MÉTODOS: Estudo de uma casuística consecutiva de 1.413 pacientes, selecionados a partir de um banco de dados informatizado e revascularizados percutaneamente no triênio 2002-2004. Não houve critérios de inclusão/exclusão. RESULTADOS: Hipertensão arterial sistêmica (74%) e hipercolesterolemia (65%) foram os fatores de risco clássicos para doença coronariana mais observados. Antecedentes de infarto do miocárdio e cirurgia de revascularização miocárdica foram respectivamente observados em 28% e 24% dos casos. Os subgrupos mais comumente tratados foram o IIB (48%) e IIIB (28%). O clopidogrel foi prescrito a 51% dos pacientes, enquanto os inibidores IIb IIIa foram utilizados em 7%. Doença coronariana multiarterial na cinecoronariografia diagnóstica ocorreu em 42% dos casos. Lesões-alvo tipo B2 ou C foram tratadas em 64%, das quais 94% situavam-se em vasos naturais. Lesões reestenóticas foram dilatadas em 5% dos pacientes. Todas as intervenções foram realizadas utilizando os stents coronarianos, a maioria dos quais (67%) do tipo convencional. CONCLUSÕES: 1) os subgrupos IIB e IIIB foram os mais comumente tratados (76%); 2) o clopidogrel foi o antitrombótico mais prescrito (51%); 3) a coronariopatia multiarterial foi observada em 42% dos casos, com predomínio de lesões-alvo complexas e situadas em vasos naturais; 4) a técnica de dilatação predominante foi o implante dos stents coronarianos. OBJECTIVE: To identify clinical and angiographic profiles of patients with unstable angina seen at a tertiary hospital and treated with percutaneous coronary intervention (PCI). METHODS: Study of a consecutive series of 1413 patients, selected from a computerized database, who underwent percutaneous revascularization in the three-year period of 2002-2004. There were no inclusion/exclusion criteria. RESULTS: Systemic arterial hypertension (74%) and hypercholesterolemia (65%) were the classical risk factors for coronary disease most frequently observed. Coronary artery bypass grafting and history of myocardial infarction were found in 24% and 28% of the cases, respectively. The subgroups most commonly treated were the IIB (48%) and IIIB (28%). Clopidogrel was prescribed for 51% of the patients and glycoprotein IIb/IIIa inhibitors, for 7%. Multivessel disease evidenced by coronary angiography was detected in 42% of the cases. Type B2 or C lesions were treated in 64%, 94% of which in native vessels. Restenotic lesions were dilated in 5% of the patients. All interventions were performed using coronary stents, the majority of which (67%) were standard bare-metal stents. CONCLUSIONS: 1) Subgroups IIB and IIIB were the most frequently treated (76%); 2) Clopidogrel was the most prescribed antithrombotic agent (51%); 3) Multivessel coronary artery disease was found in 42% of the cases, most of which were complex target lesions located in native vessels; 4) Coronary stent implantation was the chief dilation technique used.

OBJETIVO: Estabelecer a correlação da cintilografia de perfusão do miocárdio (CPM) com Tecnécio 99m-MIBI (MIBI) e injeção de adenosina, empregando a angiografia coronária quantitativa (ACQ) e o ultra-som intracoronário (UIC) como comparação. MÉTODOS: Estudo de 70 pacientes com doença arterial coronária (DAC), encaminhados à CPM com MIBI e adenosina. As manifestações clínicas, do eletrocardiograma (ECG) e os resultados das imagens foram correlacionadas às variáveis da análise visual e quantitativa da angiografia, bem como ao UIC. RESULTADOS: A média de idades foi de 60,6 anos, com 39 pacientes do sexo masculino. A angiografia coronária evidenciou estenose do diâmetro da luz (E%) de 49,94% em 105 artérias, com reavaliação à ACQ em 83 artérias (79%) e média de 44,20%, p

OBJECTIVE: To assess the safety and efficacy of intracoronary brachytherapy using the Beta-Cath systemTM for preventing recurrence of in-stent restenosis (ISR), by analyzing clinical, angiographic, and intracoronary ultrasound (ICUS) results. METHODS: This study assessed 30 patients with ISR in native coronary arteries who underwent balloon catheter angioplasty followed by intracoronary beta radiation with the Beta-Cath systemTM (90Sr/Y). RESULTS: The study comprised complex, extensive (18.66±4.15 mm) restenotic lesions, 77% of which were of the diffuse-proliferative type. Brachytherapy was successful in 100% of the cases. The mean radiation dose used was 20.7±2.3 Gy, released for a mean period of 3.8±2.1 minutes. On late follow-up, the in-stent minimum luminal diameter (MLD) slightly decreased (from 1.98±0.30 mm to 1.84±0.39 mm at 6 months; P=0.13), with a late loss of 0.14±0.18 mm. The intrasegmentary MLD was significantly smaller than the in-stent diameter (1.55±0.40 mm vs 1.84±0.39 mm; P=0.008), and was associated with a more significant late loss (0.40±0.29 mm vs 0.14±0.18 mm; P=0.0001). On ICUS, a mild increase of 6.8±14.3 mm3 in the neointimal tissue was observed at 6 months (P=0.19), and the percentage of volumetric obstruction increased by 4.7±7.5%. Binary restenosis and revascularization of the target vessel recurred in 17% of the cases; late occlusion associated with myocardial infarction occurred in 1 case (3%). Event-free survival was 80%. CONCLUSION: The management of in-stent restenosis with intracoronary beta radiation proved to be a safe and effective procedure, with a high rate of immediate success, representing a therapeutic option for inhibiting neointimal hyperplasia.

OBJECTIVE - This analysis was undertaken to determine the composite incidence of cumulative adverse events (death, reinfarction, disabling stroke, and target vessel revascularization) at the end of the first year after acute myocardial infarction, in diabetic patients who underwent coronary stenting or primary coronary balloon angioplasty. METHODS - From the STENT PAMI trial, we analyzed the 6-month angiographic and 1-year clinical outcomes of 135 diabetic (112, noninsulin dependent) patients who underwent the randomization process of the trial and compared them with 758 nondiabetic patients. RESULTS - Coronary stenting did not significantly reduce the primary composite clinical end point when compared with PTCA (20 vs. 30%, p=0.2). A significant benefit from stenting was observed in patients with noninsulin dependent diabetes, with a trend toward a lesser need for new revascularization procedures (10 vs. 21%, p

OBJECTIVE: We conducted a comparative analysis of the in-hospital outcomes of patients who underwent primary percutaneous transluminal angioplasty (PTCA) or stent implantation because of an acute myocardial infarction (AMI) related to an acute vein graft occlusion. METHODS: Since 1991 the Brazilian Society of Hemodynamic and Interventional Cardiology has maintained a large database (CENIC). From these, we selected all consecutive patients, who underwent primary PTCA or stenting in the first 24 hours of AMI, with the target vessel being an occluded vein graft. Immediate results and major coronary events occurring up until hospital discharge were analyzed. RESULTS: During this period, 5,932 patients underwent primary PTCA or stenting; 158 (3%) of the procedures were performed because of an acute vein graft occlusion. Stenting was performed in 74 (47%) patients. Patients treated with stents had a higher success rate and lower mean residual stenosis compared with those who underwent primary balloon PTCA. The incidence of reinfarction and death were similar for stenting and balloon PTCA. CONCLUSION: Primary percutaneous treatment of AMI related to acute vein graft occlusion is still an uncommon practice. Primary stenting improved luminal diameter and offered higher rates of success; however, this strategy did not reduce the in-hospital reinfarction and death rate, compared with that occurring with PTCA treatment.

OBJECTIVE - This study compared the early and late results of the use of one single stent with those of the use of multiple stents in patients with lesions longer than 20mm. METHODS - Prospective assessment of patients electively treated with stents, with optimal stent deployment and followed-up for more than 3 months. From February '94 to January '98, 215 patients with lesions >20mm were treated. These patients were divided into 2 groups as follows: Group A - 105 patients (49%) with one stent implanted; Group B - 110 patients (51%) with multiple stents implanted. RESULTS - The mean length of the lesions was 26mm in group A (21-48mm) versus 29mm in group B (21-52mm) (p=0.01). Major complications occurred in one patient (0.9%) in group A (subacute thrombosis, myocardial infarctionand death) and in 2 patients (1.8%) in group B (one emergency surgery and one myocardial infarction) (p=NS). The results of the late follow-up period (>6 months) were similar for both groups (group A = 82% vs group B = 76%; p=NS), and we observed an event-free survical in 89% of the patients in group A and in 91% of the patients in group B (p=NS). Angina (group A = 11% vs group B = 7%) and lesion revascularization (group A = 5% vs group B = 6%; p=NS) also occurred in a similar percentage. No infarction or death was observed in the late follow-up period; restenosis was identified in 33% and 29% of the patients in groups A and B, respectively (p=NS). CONCLUSION - The results obtained using one stent and using multiple stents were similar; the greater cost-effectiveness of one stent implantation, however, seems to make this strategy the first choice.