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SUMMARY The pharmacological therapy for type 2 diabetes mellitus has presented important advances in recent years, which has impacted the treatment of patients with established cardiovascular disease or with high cardiovascular risk. In this scenario, two drug classes have emerged and demonstrated clear clinical benefits: SGLT-2 inhibitors and GLP-1 agonists. The present review discusses the pharmacology, adverse effects, and clinical trials that have demonstrated the benefits of these medications in reducing cardiovascular risk. RESUMO A terapia farmacológica do diabetes mellitus tipo 2 apresentou avanços importantes nos últimos anos, impactando principalmente o tratamento dos pacientes com doença cardiovascular estabelecida ou com alto risco cardiovascular. Nesse cenário, surgiram duas classes de fármacos com claros benefícios clínicos; os inibidores da SGLT-2 e os agonistas do GLP-1. Na presente revisão os autores discutem desde a farmacologia, efeitos adversos e também os estudos clínicos que demonstraram os benefícios dessas medicações na redução de risco cardiovascular.

1. Introducao A pandemia pelo novo coronavirus (SARS-CoV-2) vem gerando debates a respeito do melhor tratamento para a doenca e suas complicacoes. Publicacoes recentes demonstraram que as doencas cardiovasculares (DCV) estao entre os principais fatores de risco para evolucao desfavoravel da doenca, incluindo hipertensao arterial e diabetes mellitus. – Foi demonstrado que pacientes com infeccao pelo novo coronavirus (COVID-19) apresentam mecanismos pro-tromboticos distintamente ativados, com maior possibilidade de eventos tromboticos ocorrerem. Sindrome coronariana aguda (SCA) com e sem supradesnivelamento do [...]

SUMMARY Artificial intelligence (AI) is a field of computer science that aims to mimic human thought processes. AI techniques have been applied in cardiovascular medicine to explore novel genotypes and phenotypes in existing diseases, improve the quality of patient care, enabling cost-effectiveness, and reducing readmission and mortality rates. The potential of AI in cardiovascular medicine is tremendous; however, ignorance of the challenges may overshadow its potential clinical impact. This paper gives a glimpse of AI’s application in cardiovascular clinical care and discusses its potential role in facilitating precision cardiovascular medicine. RESUMO A inteligência artificial (IA) é um campo da ciência da computação que tem como objetivo imitar os processos de pensamento humano. Técnicas de IA têm sido aplicadas na medicina cardiovascular para explorar novos genótipos e fenótipos em doenças existentes, melhorar a qualidade do atendimento ao paciente, possibilitar custo-efetividade e reduzir taxas de readmissão e mortalidade. Existe um grande potencial da IA na medicina cardiovascular; no entanto, a ignorância dos desafios pode ofuscar seu impacto clínico. Esse artigo fornece a aplicação da IA no atendimento clínico cardiovascular e discute seu papel potencial na facilitação da medicina cardiovascular de precisão.

Myocardial ischemia is considered the cornerstone of the treatment of patients with coronary artery disease (CAD). Although the deleterious effects of myocardial infarction, the maximum expression of ischemia, have been extensively studied and described, the clinical effects of chronic, documented myocardial ischemia are not completely clarified. The first studies that compared therapies for coronary disease focused on the presence of anatomical features and assessed ischemia based on the interpretation of the findings of obstructive atherosclerotic lesions. They suggested that revascularization interventions did not confer any clinical advantage over medical therapy (MT), in terms of cardiac or overall death. Other retrospective studies that were dedicated to assessing the impact of documented stress-induced ischemia on cardiovascular outcomes have suggested a prognostic impact of chronic ischemia. However, this has been questioned in recent studies. Moreover, the previous understanding that chronic ischemia could lead to worsening of ventricular function was not confirmed in a recent study. Thus, the prognostic significance of stress-induced ischemia has been questioned. Regarding treatment options, although some previous analyses have suggested that interventional therapies would reduce cardiovascular events in CAD patients with documented ischemia, recent post-hoc studies and metanalysis have shown distinct results. In this review article, the authors discuss myocardial ischemia, the different responses of the myocardium to ischemic insults, ischemic preconditioning, and the main findings of recent studies about the clinical aspects and treatment of patients with chronic, documented myocardial ischemia.

SUMMARY Atrial fibrillation (AF) is the most common arrhythmia in the postoperative period of cardiac surgery, with a prevalence between 15-40% after coronary artery bypass surgery (CABG). Several strategies have been tested for the prevention and management of AF postoperatively. Previous studies and analysis of records have shown higher rates of hospitalization and clinical outcomes associated with this entity, including increased mortality in the short- and long-term. This perspective reviews the topic, and offers recommendations for the management of this arrhythmia in the postoperative period of CABG, with a special focus on anticoagulation strategies.

Background Androgen deprivation therapy (ADT) is widely used in the treatment of testosterone-dependent prostate carcinomas. ADT often increases plasma LDL and HDL cholesterol and triglycerides. The aim was to test whether ADT changes the transfer of lipids to HDL, an important aspect of this metabolism and HDL protective functions, and related parameters. Methods Sixteen volunteers with advanced prostate carcinoma submitted to pharmacological ADT or orchiectomy had plasma collected shortly before and after 6 months of ADT. In vitro transfer of lipids to HDL was performed by incubating plasma with donor emulsion containing radioactive lipids by 1 h at 37 °C. After chemical precipitation of apolipoprotein B-containing lipoprotein, the radioactivity of HDL fraction was counted. Results ADT reduced testosterone to nearly undetectable levels and markedly diminished PSA. ADT increased the body weight but glycemia, triglycerides, LDL and HDL cholesterol, HDL lipid composition and CETP concentration were unchanged. However, ADT increased the plasma unesterified cholesterol concentration (48 ± 12 vs 56 ± 12 mg/dL, p = 0.019) and LCAT concentration (7.15 ± 1.81 vs 8.01 ± 1.55μg/mL, p = 0.020). Transfer of unesterified (7.32 ± 1.09 vs 8.18 ± 1.52%, p p p Conclusion Increase in transfer of unesterified and esterified cholesterol protects against cardiovascular disease, as shown previously, and increased LCAT favors cholesterol esterification and facilitates the reverse cholesterol transport. Thus, our results suggest that ADT may offer anti-atherosclerosis protection by improving HDL functional properties. This could counteract, at least partially, the eventual worse effects on plasma lipids.

Background Ischemic cardiomyopathy and severe left ventricular dysfunction are well established to represent the main determinants of poor survival and premature death compared with preserved ventricular function. However, the role of myocardial revascularization as a therapeutic alternative is not known to improve the long-term prognosis in this group of patients. This study will investigate whether myocardial revascularization contributes to a better prognosis for patients compared with those treated with drugs alone and followed over the long term. Methods The study will include 600 patients with coronary artery disease associated with ischemic cardiomyopathy. The surgical or drug therapy option will be randomized, and the events considered for analysis will be all-cause mortality, nonfatal infarction, unstable angina requiring additional revascularization, and stroke. The events will be analyzed according to the intent-to-treat principle. Patients with multivessel coronary disease and left ventricular ejection fraction measurements of less than 35% will be included. In addition, myocardial ischemia will be documented by myocardial scintigraphy. Markers of myocardial necrosis will be checked at admission and after the procedure. Discussion The role of myocardial revascularization (CABG) in the treatment of patients with coronary artery disease and heart failure is not clearly established. The surgical option of revascularizing the myocardium is a procedure designed to reduce the load of myocardial hibernation in patients with heart failure caused by coronary artery disease. On the other hand, the assessment of myocardial viability is frequently used to identify patients with left ventricular ischemic dysfunction in which CABG may add survival benefit. However, the effectiveness of this option is uncertain. The great difficulty in establishing the efficacy of surgical intervention is based on the understanding of viability without ischemia. Thus, this study will include only patients with viable and truly ischemic myocardium to correct this anomaly. Trial registration Evaluation of a randomized comparison between patients with coronary artery disease associated with ischemic cardiomyopathy submitted to medical or surgical treatment: MASS-VI (HF), ISRCTN77449548, Oct 10th, 2019 (retrospectively registered).

This study investigated the relationship between angiographic complexities of coronary artery disease (CAD) assessed by SYNTAX Score synergy between percutaneous coronary intervention with taxus and cardiac surgery score (SYNTAX Score) and cardiac biomarker elevation after revascularization procedures. This is a post-hoc analysis of the medicine, angioplasty or surgery study V study of patients with stable CAD. High-sensitivity troponin 1 (hs-TnI) and creatinine kinase-muscle/brain (CK-MB) were assessed before and after cardiovascular procedures. Baselines SYNTAX Scores (SXScores) were calculated by blinded investigators to patient characteristics. Of the 202 patients studied, the mean SXScore was 21.25 ± 9.24; 40.10 ± 7.09 in the high SXScore group and 19.06 ± 6.61 in low/mid SXscore group (P

SUMMARY Coronary artery bypass graft (CABG) is a consolidated treatment in patients with coronary artery disease (CAD) for both symptom control and improvement of prognosis. The patency of venous grafts is still the most vulnerable point of the surgical treatment since it presents a high prevalence of occlusion both in the immediate postoperative period and in the long-term follow-up. Aspirin plays a well-established role in this setting, and for a long time, clopidogrel use has been restricted to patients allergic to aspirin. Recently, subgroup analyses of studies with different anti-platelet therapies have shown reduced mortality and cardiovascular events in patients on dual anti-platelet antiplatelet therapy (DAPT) undergoing CABG, although such studies have not been designed to evaluate this patient profile. However, there is still an insufficient number of randomized studies using DAPT in this context, resulting in a disagreement between the European and American cardiology societies guidelines regarding their indication and generating doubts in clinical practice. RESUMO A cirurgia de revascularização miocárdica (CRM) é tratamento fundamental em pacientes com doença arterial coronariana (DAC) tanto para controle de sintomas quanto para melhora do prognóstico. A patência dos enxertos venosos ainda hoje é o ponto mais vulnerável do tratamento cirúrgico, por apresentar alta prevalência de oclusão tanto no pós-operatório imediato como no seguimento em longo prazo. A aspirina tem papel bem estabelecido neste cenário e, por muito tempo, o uso do clopidogrel ficou restrito a pacientes alérgicos a aspirina. Recentemente, análises de subgrupos de estudos com diferentes terapias antiplaquetárias demonstraram redução de mortalidade e eventos cardiovasculares em pacientes em uso de dupla antiagregação plaquetária (Dapt) submetidos à CRM, ainda que tais estudos não tenham sido desenhados para avaliar este perfil de pacientes. Contudo, há ainda uma quantidade insuficiente de estudos randomizados com uso de Dapt nesse contexto, resultando em uma discordância entre as diretrizes europeia e americana de cardiologia quanto à sua indicação e gerando dúvidas na prática clínica.

Background: Low concentrations of high-density lipoprotein cholesterol (HDL-C) represent a well-established cardiovascular risk factor. Paradoxically, extremely high HDL-C levels are equally associated with elevated cardiovascular risk, resulting in the U-shape relationship of HDL-C with cardiovascular disease. Mechanisms underlying this association are presently unknown. We hypothesised that the capacity of high-density lipoprotein (HDL) to acquire free cholesterol upon triglyceride-rich lipoprotein (TGRL) lipolysis by lipoprotein lipase underlies the non-linear relationship between HDL-C and cardiovascular risk. Methods: To assess our hypothesis, we developed a novel assay to evaluate the capacity of HDL to acquire free cholesterol (as fluorescent TopFluor® cholesterol) from TGRL upon in vitro lipolysis by lipoprotein lipase. Results: When the assay was applied to several populations markedly differing in plasma HDL-C levels, transfer of free cholesterol was significantly decreased in low HDL-C patients with acute myocardial infarction (−45%) and type 2 diabetes (–25%), and in subjects with extremely high HDL-C of >2.59 mmol/L (>100 mg/dL) (−20%) versus healthy normolipidaemic controls. When these data were combined and plotted against HDL-C concentrations, an inverse U-shape relationship was observed. Consistent with these findings, animal studies revealed that the capacity of HDL to acquire cholesterol upon lipolysis was reduced in low HDL-C apolipoprotein A-I knock-out mice and was negatively correlated with aortic accumulation of [3H]-cholesterol after oral gavage, attesting this functional characteristic as a negative metric of postprandial atherosclerosis. Conclusions: Free cholesterol transfer to HDL upon TGRL lipolysis may underlie the U-shape relationship between HDL-C and cardiovascular disease, linking HDL-C to triglyceride metabolism and atherosclerosis. Fil: Feng, Ma. Inserm; Francia. Université Pierre et Marie Curie; Francia Fil: Darabi, Maryam. Université Pierre et Marie Curie; Francia. Inserm; Francia Fil: Tubeuf, Emilie. Inserm; Francia. Université Pierre et Marie Curie; Francia Fil: Canicio, Aurélie. Université Pierre et Marie Curie; Francia. Inserm; Francia Fil: Lhomme, Marie. Institute Of Cardiometabolism And Nutrition; Francia Fil: Frisdal, Eric. Inserm; Francia. Université Pierre et Marie Curie; Francia Fil: Lanfranchi Lebreton, Sandrine. Université Pierre et Marie Curie; Francia Fil: Matheron, Lucrèce. Université Pierre et Marie Curie; Francia Fil: Rached, Fabiana. Université Pierre et Marie Curie; Francia. Inserm; Francia Fil: Ponnaiah, Maharajah. Institute Of Cardiometabolism And Nutrition; Francia Fil: Serrano, Carlos V.. Instituto Do Coracao Do Hospital Das Clinicas; Brasil Fil: Santos, Raul D.. Instituto Do Coracao Do Hospital Das Clinicas; Brasil Fil: Brites, Fernando Daniel. Universidad de Buenos Aires; Argentina. Instituto Do Coracao Do Hospital Das Clinicas; Brasil Fil: Bolbach, Gerard. Université Pierre et Marie Curie; Francia Fil: Gautier, Emmanuel. Université Pierre et Marie Curie; Francia. Inserm; Francia Fil: Huby, Thierry. Inserm; Francia. Université Pierre et Marie Curie; Francia Fil: Carrie, Alain. Inserm; Francia. Université Pierre et Marie Curie; Francia Fil: Bruckert, Eric. Inserm; Francia. Université Pierre et Marie Curie; Francia Fil: Guerin, Maryse. Université Pierre et Marie Curie; Francia. Inserm; Francia Fil: Couvert, Philippe. Inserm; Francia. Université Pierre et Marie Curie; Francia Fil: Giral, Philippe. Université Pierre et Marie Curie; Francia. Inserm; Francia Fil: Lesnik, Philippe. Université Pierre et Marie Curie; Francia. Inserm; Francia Fil: Le Goff, Wilfried. Université Pierre et Marie Curie; Francia. Inserm; Francia Fil: Guillas, Isabelle. Inserm; Francia. Université Pierre et Marie Curie; Francia Fil: Kontush, Anatol. Inserm; Francia. Université Pierre et Marie Curie; Francia

Key Points Question Are longitudinal glycated hemoglobin values associated with cardiovascular events in patients with type 2 diabetes and stable multivessel coronary artery disease? Findings In this cohort study of 725 patients with type 2 diabetes and multivessel coronary artery disease, a 1-point increase in glycated hemoglobin values during follow-up was independently associated with higher risk of the combined outcome of death, myocardial infarction, or ischemic stroke, after adjustment for baseline clinical factors. Meaning Longitudinal increase of glycated hemoglobin was associated with higher rates of cardiovascular events in patients with type 2 diabetes and multivessel coronary artery disease, and the mechanisms underlying this association require further investigation., This cohort study examines whether longitudinal variation of glycated hemoglobin (HbA1c) is associated with cardiovascular events in patients with diabetes and multivessel coronary artery disease (CAD)., Importance Glycated hemoglobin (HbA1c) values are used to guide glycemic control, but in patients with type 2 diabetes and multivessel coronary artery disease (CAD), the association of the longitudinal values of HbA1c with cardiovascular outcomes is unclear. Objective To assess whether longitudinal variation of HbA1c is associated with cardiovascular events in long-term follow-up among patients with diabetes and multivessel CAD. Design, Setting, and Participants This cohort study included 888 patients with type 2 diabetes and multivessel CAD in the Medicine, Angioplasty, or Surgery Study (MASS) Registry of the Heart Institute of the University of São Paulo from January 2003 to December 2007. Data were analyzed from January 15, 2018, to October 15, 2019. Exposure Longitudinal HbA1c values. Main Outcomes and Measures The combined outcome of all-cause mortality, myocardial infarction, and ischemic stroke. Results Of 888 patients with type 2 diabetes and multivessel CAD, 725 (81.6%; median [range] age, 62.4 [55.7-68.0] years; 467 [64.4%] men) had complete clinical and HbA1c information during a median (interquartile range) follow-up period of 10.0 (8.0-12.3) years, with a mean (SD) of 9.5 (3.8) HbA1c values for each patient. The composite end point of death, myocardial infarction, or ischemic stroke occurred in 262 patients (36.1%). A 1-point increase in the longitudinal value of HbA1c was significantly associated with a 14% higher risk of the combined end point of all-cause mortality, myocardial infarction, and ischemic stroke (hazard ratio, 1.14; 95% CI, 1.04-1.24; P = .002) in the unadjusted analysis. After adjusting for baseline factors (ie, age, sex, 2-vessel or 3-vessel CAD, initial CAD treatments, ejection fraction, and creatinine and low-density lipoprotein cholesterol levels), a 1-point increase in the longitudinal value of HbA1c was associated with a 22% higher risk of the combined end point (hazard ratio, 1.22; 95% CI, 1.12-1.35; P

Background: There is limited evidence in the literature regarding the administration of clopidogrel to acute coronary syndrome (ACS) in patients over 75 years of age. Most studies excluded this age group, making the subject controversial due to the increased risk of bleeding in this population. Objective: This is a retrospective, unicentric, and observational study aimed at assessing whether the administration of clopidogrel loading dose increases bleeding rates in patients over 75 years of age. Methods: Patients were divided into two groups: group I: 75 mg of clopidogrel; group II: 300-to 600-mg loading dose of clopidogrel. A total of 174 patients (129 in group I and 45 in group II) were included between May 2010 and May 2015. Statistical analysis: The primary outcome was bleeding (major and/or minor). The secondary outcome was combined events (cardiogenic shock, reinfarction, death, stroke and bleeding). The comparison between groups was performed through Q-square and T-test. The multivariate analysis was performed by logistic regression, being considered significant p < 0.05. Results: Comparisons between groups I and II showed differences in the prevalence of diabetes (46.5% vs. 24.4%, p = 0.01), arterial hypertension (90.7% vs. 75, p = 0.01), dyslipidemia (62% vs. 42.2%, p = 0.021), ST segment elevation (11.6% vs. 26.6%, p = 0.016) and coronary intervention percutaneous (16.5% vs. 62.2%, p < 0.0001), respectively. In the multivariate analysis, significant differences were observed between groups I and II in relation to the occurrence of bleeding (8.5% vs. 20%, OR = 0.173, 95% CI: 0.049 - 0.614, p = 0.007). Conclusion: A loading dose of 300 mg or more of clopidogrel.

Summary Coronary artery disease (CAD) associated with left ventricular systolic dysfunction is a condition related to poor prognosis. There is a lack of robust evidence in many aspects related to this condition, from definition to treatment. Ischemic cardiomyopathy is a spectrum ranging from stunned myocardium associated with myocardial fibrosis to hibernating myocardium and repetitive episodes of ischemia. In clinical practice, relevance lies in identifying the myocardium that has the ability to recover its contractile reserve after revascularization. Methods to evaluate cellular integrity tend to have higher sensitivity, while the ones assessing contractile reserve have greater specificity, since a larger mass of viable myocytes is required in order to generate contractility change. Since there are many methods and different ways to detect viability, sensitivity and specificity vary widely. Dobutamine-cardiac magnetic resonance with late gadolinium enhancement has the best accuracy is this setting, giving important predictors of prognostic and revascularization benefit such as scar burden, contractile reserve and end-systolic volume index. The latter has shown differential benefit with revascularization in some recent trials. Finally, authors discuss interventional procedures in this population, focusing on coronary artery bypass grafting and evolution of evidence from CASS to post-STICH era. Resumo A doença arterial coronariana (DAC) associada à disfunção sistólica do ventrículo esquerdo é uma condição relacionada a mau prognóstico. Há uma falta de evidência robusta em muitos aspectos relacionados a essa condição, desde a definição ao tratamento. A cardiomiopatia isquêmica é um espectro que varia de miocárdio atordoado por fibrose miocárdica, passando por miocárdio hibernante, a episódios repetitivos de isquemia. Na prática clínica, a importância do problema é identificar o miocárdio que tem a capacidade de recuperar sua reserva contrátil após revascularização. Métodos para avaliar a integridade celular tendem a ter maior sensibilidade, enquanto os que avaliam a reserva contrátil têm maior especificidade, uma vez que uma maior massa de miócitos viáveis para gerar uma mudança de contratilidade é necessária. Tendo em vista que existem muitos métodos e diferentes formas de detecção de viabilidade, a sensibilidade e a especificidade variam amplamente. O uso da ressonância magnética cardíaca com detecção de realce tardio associada a estresse com dobutamina tem a melhor acurácia na avaliação de viabilidade, além de fornecer importantes preditores de benefício prognóstico com a revascularização, tais como carga de cicatriz, reserva contrátil e índice de volume sistólico final. Finalmente, os autores discutem sobre procedimentos intervencionistas nessa população, com foco na revascularização cirúrgica do miocárdio e na evolução da evidência desde o estudo CASS até os trials da era pós-STICH.

1. Epidemiologia da Parada Cardiorrespiratoria e Apresentacao da Diretriz […] Atualizacao da Diretriz de Ressuscitacao Cardiopulmonar e Cuidados Cardiovasculares de Emergencia da Sociedade Brasileira de Cardiologia – 2019

BACKGROUND: Coronary artery disease is a major cause of morbidity and mortality worldwide, and is a consequence of acute thrombotic events involving activation of platelets and coagulation proteins. Factor Xa inhibitors and aspirin each reduce thrombotic events but have not yet been tested in combination or against each other in patients with stable coronary artery disease.METHODS: In this multicentre, double-blind, randomised, placebo-controlled, outpatient trial, patients with stable coronary artery disease or peripheral artery disease were recruited at 602 hospitals, clinics, or community centres in 33 countries. This paper reports on patients with coronary artery disease. Eligible patients with coronary artery disease had to have had a myocardial infarction in the past 20 years, multi-vessel coronary artery disease, history of stable or unstable angina, previous multi-vessel percutaneous coronary intervention, or previous multi-vessel coronary artery bypass graft surgery. After a 30-day run in period, patients were randomly assigned (1:1:1) to receive rivaroxaban (2·5 mg orally twice a day) plus aspirin (100 mg once a day), rivaroxaban alone (5 mg orally twice a day), or aspirin alone (100 mg orally once a day). Randomisation was computer generated. Each treatment group was double dummy, and the patients, investigators, and central study staff were masked to treatment allocation. The primary outcome of the COMPASS trial was the occurrence of myocardial infarction, stroke, or cardiovascular death. This trial is registered with ClinicalTrials.gov, number NCT01776424, and is closed to new participants.FINDINGS: Between March 12, 2013, and May 10, 2016, 27 395 patients were enrolled to the COMPASS trial, of whom 24 824 patients had stable coronary artery disease from 558 centres. The combination of rivaroxaban plus aspirin reduced the primary outcome more than aspirin alone (347 [4%] of 8313 vs 460 [6%] of 8261; hazard ratio [HR] 0·74, 95% CI 0·65-0·86, pINTERPRETATION: In patients with stable coronary artery disease, addition of rivaroxaban to aspirin lowered major vascular events, but increased major bleeding. There was no significant increase in intracranial bleeding or other critical organ bleeding. There was also a significant net benefit in favour of rivaroxaban plus aspirin and deaths were reduced by 23%. Thus, addition of rivaroxaban to aspirin has the potential to substantially reduce morbidity and mortality from coronary artery disease worldwide.FUNDING: Bayer AG.

Summary Treatment of stable coronary artery disease (CAD) relies on improved prognosis and relief of symptoms. National and international guidelines on CAD support the indication for revascularization in patients with limiting symptoms and refractory to drug treatment. Previous studies attested the efficacy of angioplasty to improve angina as well as the functional capacity of patients with symptomatic stable CAD. The ORBITA trial, recently published in an international journal, showed no benefit in terms of exercise tolerance compared to a placebo procedure in a population of single-vessel patients undergoing contemporary percutaneous coronary intervention. In this point of view article, the authors discuss the ORBITA trial regarding methodological issues, limitations and clinical applicability.

A calcificação vascular na doença arterial coronária está ganhando importância, tanto em pesquisas científicas como em aplicações clínicas e de imagem. A placa calcificada é considerada a forma mais relevante de aterosclerose dentro da árvore arterial coronária e frequentemente apresenta um desafio para a intervenção percutânea. Estudos recentes têm demonstrado que a calcificação da placa é dinâmica e está estreitamente ligada ao grau de inflamação vascular. Vários fatores inflamatórios, produzidos durante as diferentes fases da aterosclerose, induzem a expressão e ativação de células osteoblásticas localizadas na parede arterial, que, por sua vez, promovem a deposição de cálcio. As células do músculo liso vascular possuem uma capacidade extraordinária de sofrer diferenciação fenotípica osteoblástica. Não há dúvida de que o papel desses fatores, bem como os elementos de genômica e proteômica, poderia ser um ponto estratégico fundamental na prevenção e no tratamento. Neste contexto, realizamos uma atualização sobre a calcificação coronária, com foco em fisiopatologia, modelos experimentais e implicações clínicas da calcificação vascular. Vascular calcification in coronary artery disease is gaining importance, both in scientific research and in clinical and imaging applications. The calcified plaque is considered the most relevant form of atherosclerosis within the coronary artery tree and is frequently a challenge for percutaneous intervention. Recent studies showed that plaque calcification is dynamic and is strictly related to the degree of vascular inflammation. Several inflammatory factors produced during the different phases of atherosclerosis induce the expression and activation of osteoblastic cells located within the arterial wall, which, in turn, promote the deposit of calcium. The vascular smooth muscle cells have an extraordinary capacity to undergo osteoblastic phenotypical differentiation. There is no doubt that the role of these factors, as well as the elements of genomics and proteomics, could be a vital strategic point in prevention and treatment. Within this context, we conducted an updating review on coronary calcification focused on pathophysiology, experimental models, and clinical implications of vascular calcification.

Introduction: Despite having higher sensitivity as compared to conventional troponins, sensitive troponins have lower specificity, mainly in patients with renal failure. Objective: Study aimed at assessing the sensitive troponin I levels in patients with chest pain, and relating them to the existence of significant coronary lesions. Methods: Retrospective, single-center, observational. This study included 991 patients divided into two groups: with (N = 681) and without (N = 310) significant coronary lesion. For posterior analysis, the patients were divided into two other groups: with (N = 184) and without (N = 807) chronic renal failure. The commercial ADVIA Centaur® TnI-Ultra assay (Siemens Healthcare Diagnostics) was used. The ROC curve analysis was performed to identify the sensitivity and specificity of the best cutoff point of troponin as a discriminator of the probability of significant coronary lesion. The associations were considered significant when p < 0.05. Results: The median age was 63 years, and 52% of the patients were of the male sex. The area under the ROC curve between the troponin levels and significant coronary lesions was 0.685 (95% CI: 0.65 - 0.72). In patients with or without renal failure, the areas under the ROC curve were 0.703 (95% CI: 0.66 - 0.74) and 0.608 (95% CI: 0.52 - 0.70), respectively. The best cutoff points to discriminate the presence of significant coronary lesion were: in the general population, 0.605 ng/dL (sensitivity, 63.4%; specificity, 67%); in patients without renal failure, 0.605 ng/dL (sensitivity, 62.7%; specificity, 71%); and in patients with chronic renal failure, 0.515 ng/dL (sensitivity, 80.6%; specificity, 42%). Conclusion: In patients with chest pain, sensitive troponin I showed a good correlation with significant coronary lesions when its level was greater than 0.605 ng/dL. In patients with chronic renal failure, a significant decrease in specificity was observed in the correlation of troponin levels and severe coronary lesions.

SUMMARY Atrial fibrillation (AF) is the most common arrhythmia in clinical practice and can lead to significant decline in functional status and quality of life among affected patients. The risk of developing AF increases with age and the presence of structural heart disease. Thus, the attendance of patients with high ventricular response to AF is common, which makes knowledge of its management mandatory. In this context, the choice of heart rate and/or rhythm control therapy is fundamental and complex, with multiple possibilities. Thus, this review aims to assist in the management of these patients, systematizing their care. RESUMO A fibrilação atrial (AF) é a arritmia mais comum da prática clínica e pode levar à redução significativa do estado funcional e da qualidade de vida dos pacientes acometidos. O risco de desenvolvimento de AF aumenta com a idade e com a presença de doença cardíaca estrutural. Dessa forma, o comparecimento de paciente com AF de alta resposta ventricular é frequente, o que torna o conhecimento de seu manejo obrigatório. Nesse âmbito, a escolha da terapia de controle de frequência cardíaca e/ou ritmo é fundamental e complexa, com múltiplas possibilidades. Esta revisão tem o objetivo de auxiliar a abordagem desses pacientes, sistematizando o atendimento.

Introdução: A insuficiência respiratória aguda (IRA) está presente em 5% dos pacientes com infarto agudo do miocárdio (IAM) e é associada à mortalidade de 20% a 30% nesses pacientes. Não está claro o papel da inflamação relacionada ao edema agudo de pulmão (EAP) na gênese da IRA pós IAM. Objetivos: Descrever os dados demográficos, etiológicos e os achados histológicos pulmonares em autópsias realizadas uentre 1990 e 2008, de pacientes que morreram por IRA, sem diagnóstico in-vivo de IAM. Métodos: Este estudo considerou 4223 autópsias de pacientes que morreram de IRA nos quais só foi definida post-mortem sua causa de morte. O diagnóstico de IAM foi feito por autópsia em 218 (4,63%) pacientes, dos quais foram obtidos: idade, sexo e principais doenças associadas. Os achados pulmonares histológicos foram classificados em: dano alveolar difuso (DAD), edema agudo de pulmão (EAP), hemorragia alveolar (HA) e pneumonia intersticial linfo-plasmocitária (PILP). A probabilidade de IAM desenvolver determinado tipo de achado histopatológico pulmonar foi calculada por regressão logística. Resultados: Foram observados 147 homens, e a mediana de idade foi 64 anos. A análise histopatológica pulmonar mostrou, em ordem decrescente: EAP (72,9%), DAD, PILP e HIA. Broncopneumonia bacteriana esteve presente em 11,9%, hipertensão arterial sistêmica em 10,1%, miocardiopatia dilatada em 6,9%, tromboembolismo pulmonar em 6,0%, cardiomiopatia hipertrófica em 4,6%, doença pulmonar obstrutiva crônica em 3,7% e diabetes mellitus em 3,7% dos pacientes. A análise multivariada demonstrou associação significativamente positiva de IAM com EAP e DAD. Conclusões: Pela primeira vez na literatura, demonstramos, por meio de autópsias, que em pacientes com IRA que evoluem à óbito sem diagnóstico estabelecido, IAM esteve presente em aproximadamente 5% dos casos. Nós observamos importante componente inflamatório na histologia pulmonar, nunca antes sugerido

FUNDAMENTO: Alguns estudos têm sugerido redução da atividade do clopidogrel sobre a ativação e adesão plaquetárias em pacientes em uso de estatinas. OBJETIVO: Avaliar se a ativação e agregação plaquetárias diminuem com clopidogrel, e se ocorre redução da ação do clopidogrel quando associado à atorvastatina ou à sinvastatina. MÉTODOS: Estudo prospectivo que incluiu 68 pacientes com angina estável em uso prévio de sinvastatina, atorvastatina, ou nenhuma estatina (grupo controle), com indicação prévia eletiva de realização de intervenção coronária percutânea. Foi analisada a ativação plaquetária através do número de plaquetas, níveis de P-selectina e glucoproteína IIb/IIIa (com e sem estímulo de ADP) através de citometria de fluxo. Os resultados foram analisados antes e após a intervenção coronária percutânea e da administração de clopidogrel. RESULTADOS: Observamos redução da atividade plaquetária com uso de clopidogrel. Além disso, não houve diferenças entre as variáveis analisadas que comprovassem redução da atividade do clopidogrel quando associado à estatinas. Observou-se níveis de p-selectina (pré-angioplastia: 14,23±7,52 x 11,45±8,83 x 7,65±7,09; pós angioplastia: 21,49±23,82 x 4,37±2,71 x 4,82±4,47, ρ

The effects of off-pump (OffPCABG) and on-pump (OnPCABG) coronary artery bypass grafting (CABG) on myocardium and inflammation are unclear.Compare the inflammatory response and myocardial injury from patients (pts) submitted to OffPCABG with those that undergo OnPCABG.Patients with normal left ventricular function were assigned to OffPCABG (n = 40) and OnPCABG (n = 41). Blood samples were collected before and 24 hours after surgery for determination of creatine kinase (CK)-MB (CK-MB), troponin I (cTnI), interleukin (IL)-6, IL-8, P-selectin, intercellular adhesion molecule (ICAM)-1 and C-reactive protein (CRP). Mortalities were registered at 12 months.Preoperative CK-MB and cTnI levels were 3.1 +/- 0.6 IU and 1.2 +/- 0.5 ng/mL for OffPCABG and 3.0 +/- 0.5 IU and 1.0 +/- 0.2 ng/mL for OnPCABG pts. Postoperative CK-MB and cTnI levels were 13.9 +/- 6.5 IU and 19.0 +/- 9.0 ng/mL for OffPCABG vs 29.5 +/- 11.0 IU and 31.5 +/- 10.1 ng/mL for OnPCABG (P.01). OffPCABG and OnPCABG pts had similar preoperative IL-6 (10 +/- 7 and 9 +/- 13 pg/mL), IL-8 (19 +/- 7 and 17 +/- 7 pg/mL), soluble P-selectin (70 +/- 21 and 76 +/- 23 pg/mL), soluble ICAM-1 (117 +/- 50 and 127 +/- 52 ng/mL), and CRP (0.09 +/- 0.05 and 0.11 +/- 0.07 mg/L). At 24 hours, for OffPCABG and OnPCABG: IL-6 was 37 +/- 38 and 42 +/- 41 g/mL; IL-8, 33 +/- 31 and 60 +/- 15 pg/mL; soluble P-selectin, 99 +/- 26 and 172 +/- 30 pg/mL; soluble ICAM-1, 227 +/- 47 and 236 +/- 87 ng/mL; and CRP, 10 +/- 11 and 14 +/- 13 mg/L (P.01 vs preoperation; P.01 vs OffPCABG). Increased 24-hour postoperative CRP levels was the only marker to have significant positive correlations with events and occurred just for the OnPCABG pts. In-hospital and 1-year mortalities for the OnPCABG and OffPCABG pts were 2.0% and 2.2% (P = .1) and 2.7% and 4.7% (P = .06), respectively.Thus, the absence of CPB during CABG preserves better the myocardium and attenuates inflammation-however, without improving survival.

OBJECTIVE: To determine long-term survival, identify preoperative factors predictive of a favorable outcome, and assess functional improvement after coronary artery bypass grafting in patients with advanced left ventricular dysfunction. METHODS: Between 1995 and 2001, 244 patients who underwent coronary artery bypass grafting and had a preoperative left ventricular ejection fraction less than or equal to 35% were included. left ventricular ejection fraction was determined by uniplanar or biplanar ventriculography during left heart catheterization. Indication for surgery was predominance of tissue viability. Functional improvement was evaluated through echocardiography and gated scintigraphy at exercise/ rest. Survival was determined by Kaplan-Meier analysis. RESULTS: Mean left ventricular ejection fraction was 29±4% (ranged from 9% to 35%). An average of 3.01 coronary bypass grafts per patient were performed. In-hospital mortality was 3.7% (9 patients). The 4-year survival rate was 89.7%. Multivariate correlates of favorable short- and long-term outcome were preoperative New York Heart Association Funcional classification for congestive heart failure class I/II, lower PAsP, higher left ventricular ejection fraction and gated left ventricular ejection fraction Ex/Rest ratio >5%. Left ventricular ejection fraction rise from 32±5% to 39±5%, p

Ultimamente o conhecimento sobre arritmias cardíacas tornou-se algo extremamentenecessário a todo médico generalista. É relativamente comum encontrarmos, em todasas especialidades médicas, indivíduos com algum tipo de distúrbio do ritmo cardíaco. Sua altaincidência e potenciais riscos ao paciente fazem com que medidas diagnósticas e terapêuticasdevam ser prontamente realizadas. Neste artigo, relatamos quatro casos clínicos envolvendo odiagnóstico e tratamento de arritmias cardíacas comumente observadas em pronto-socorros,discutindo alguns dos mecanismos fi siopatológicos responsáveis pela sua gênese.

The balance between different immunological stimuli is essential in the progression and stabilization of atherosclerotic plaques. Immune regulation has been suggested as potential target for the treatment of atherosclerotic disease. We sought to determine whether treatment with pentoxifylline, a phosphodiesterase inhibitor with immunomodulating properties, could reduce the pro-inflammatory response observed in patients with acute coronary syndromes (ACS) and increase anti-inflammatory activity. In a double-blind, prospective, placebo-controlled study, 64 patients with ACS were randomized to receive pentoxifylline 400mg TID or placebo for 6 months. Analysis of the pro-inflammatory markers, C-reactive protein (CRP), interleukin (IL)-6, IL-12, interferon-gamma and tumor necrosis factor (TNF)-alpha and the anti-inflammatory cytokines, transforming growth factor (TGF)-beta1 and IL-10 were done at baseline, 1 and 6 months. Pentoxifylline treatment significantly reduced the adjusted levels of CRP and TNF-alpha compared to placebo after 6 months (P=0.04 and P

Introduction: A recently published study raised doubts about the need for percutaneous treatment of nonculprit lesions in patients with acute coronary syndromes (ACS). Methods: Retrospective, unicentric, observational study. Objective: To analyze the long-term outcomes in patients undergoing treatment of the culprit artery, comparing those who remained with significant residual lesions in nonculprit arteries (group I) versus those without residual lesions in other coronary artery beds (group II). The study included 580 patients (284 in group I and 296 in group II) between May 2010 and May 2013. We obtained demographic and clinical data, as well as information regarding the coronary treatment administered to the patients. In the statistical analysis, the primary outcome included combined events (reinfarction/angina, death, heart failure, and need for reintervention). The comparison between groups was performed using the chi-square test and ANOVA. The long-term analysis was conducted with the Kaplan-Meier method, with a mean follow-up of 9.86 months. Results: The mean ages were 63 years in group I and 62 years in group II. On long-term follow-up, there was no significant difference in combined events in groups I and II (31.9% versus 35.6%, respectively, p = 0.76). Conclusion: The strategy of treating the culprit artery alone seems safe. In this study, no long-term differences in combined endpoints were observed between patients who remained with significant lesions compared with those without other obstructions. Resumo Fundamento: Um estudo publicado recentemente levantou dúvidas sobre a necessidade de abordagem percutânea de lesões não culpadas em pacientes com síndromes coronarianas agudas (SCA). Métodos: Estudo retrospectivo, unicêntrico e observacional. Objetivo: Comparar desfechos a longo prazo entre pacientes submetidos à abordagem da artéria culpada, comparando os que permaneceram com lesões residuais significativas em artérias não culpadas (grupo I) versus aqueles sem lesões residuais em outros leitos coronarianos (grupo II). Foram incluídos 580 pacientes (284 no grupo I e 296 no grupo II) entre maio de 2010 e maio de 2013. Foram obtidos dados demográficos e clínicos, além de informações sobre o tratamento coronariano administrado aos pacientes. Na análise estatística, o desfecho primário incluiu eventos combinados (reinfarto/angina, morte, insuficiência cardíaca e necessidade de reintervenção). A comparação entre grupos foi realizada através do teste do qui-quadrado e ANOVA. A análise a longo prazo foi realizada pelo método de Kaplan-Meier, com seguimento médio de 9,86 meses. Resultados: As médias das idades foram de 63 anos no grupo I e 62 anos no grupo II. O seguimento a longo prazo não mostrou diferença significativa em eventos combinados nos grupos I e II (31,9% versus 35,6%, respectivamente, p = 0,76). Conclusão: A estratégia de tratar somente a artéria considerada culpada parece segura. Neste estudo, não houve diferenças a longo prazo em desfechos combinados entre pacientes que permaneceram com lesões significativas comparativamente àqueles sem outras obstruções.

OBJETIVO: Os marcadores da ativacao plaquetaria em geral se apresentam elevados na doenca arterial coronariana. Desse modo, procuramos identificar a presenca e as potenciais associacoes de diferentes marcadores da ativacao plaquetaria. METODOS: Estudamos pacientes com angina instavel (n=28), pacientes com angina estavel (n=36) e pacientes sem doenca arterial coronariana (n=30); sexo e idade foram estratificados. Os niveis sanguineos da molecula de adesao P-selectina, do thromboxane B2 e de serotonina foram medidos por imunoensaios enzimaticos. RESULTADOS: Quando comparamos os grupos, os resultados foram: a P-selectina, o thromboxane B2 e os niveis do serotonina apresentaram-se significativamente mais elevados nos pacientes com angina instavel do que nos pacientes com angina estavel. CONCLUSAO: Estes marcadores da ativacao plaquetaria podem, portanto, identificar formas instaveis de doenca arterial coronariana.

OBJETIVO: Os marcadores da ativação plaquetária estão geralmente elevados na doença arterial coronária. Desse modo, procuramos identificar a presença e as potenciais associações de diferentes marcadores da ativação plaquetária. MÉTODOS: Nós estudamos pacientes com angina instável (n = 28), pacientes com angina estável (n = 36) e pacientes sem doença arterial coronária (n = 30); sexo e idade foram estratificados. Os níveis sangüíneos da molécula de adesão P-selectina, do thromboxane B2 e de serotonina foram medidos por imunoensaios enzimáticos. RESULTADOS: Quando nós comparamos os grupos,os resultados foram: a P-selectina, o thromboxane B2 e os níveis do serotonina apresentaram-se significativamente mais elevados nos pacientes com angina instável do que nos pacientes com angina estável. CONCLUSÃO: Estes marcadores da ativação plaquetária podem, portanto, identificar formas instáveis de doença arterial coronária.

Reduction in cardiovascular events with statins has been in part attributed to their anti-inflammatory properties.Evaluate the effects of atorvastatin on levels of inflammatory markers, such as tumor necrosis factor-alpha (TNF), interleukins (IL-1 and IL-6), soluble intercellular adhesion molecule-1 (sICAM-1) and C-reactive protein (CRP) in hypercholesterolemic patients (LDL-cholesterol160 mg/dL).Two lipid-lowering regimens were taken for 8 weeks. One set of patients (n=45, 26 men, average 50 +/- 2 years of age) was subjected to atorvastatin treatment (20-40 mg/day), plus diet recommendation. Another set of patients (n=23, 12 men, average 53 +/- 3 years of age) went through diet recommendation alone. Both groups were recommended to perform standard physical activity. Plasma samples were collected after overnight fasting at baseline and after 8 weeks for ELISA. The use of atorvastatin when compared to diet alone, resulted in significant (P0.0001) reductions for: LDL-cholesterol (39.9% versus 4.4%), TNF (21.4% versus 2.9%), IL-6 (22.1% versus 2.0%), IL-1 (16.4% versus 2.7%) and sICAM-1 (9.6% versus 0.1%), respectively. The percentage of patients with CRP levels3 mg/dL in the atorvastatin group fell from 25.0 to 6.7% (P0.0001) while in the diet group the reduction was not significant.In hypercholesterolemic patients, atorvastatin, compared to diet alone resulted in significant reductions in levels of proinflammatory cytokines (TNF, IL-1 and IL-6) as well as in sICAM-1 and CRP. Thus, statin-induced inhibition of inflammatory markers may play an important role in the pharmacological and clinical effects of statins seen in cardiovascular diseases.

Background: The prevalence and clinical outcomes of heart failure with preserved left ventricular ejection fraction after acute myocardial infarction have not been well elucidated. Objective: To analyze the prevalence of heart failure with preserved left ventricular ejection fraction in acute myocardial infarction and its association with mortality. Methods: Patients with acute myocardial infarction (n = 1,474) were prospectively included. Patients without heart failure (Killip score = 1), with heart failure with preserved left ventricular ejection fraction (Killip score > 1 and left ventricle ejection fraction ≥ 50%), and with systolic dysfunction (Killip score > 1 and left ventricle ejection fraction < 50%) on admission were compared. The association between systolic dysfunction with preserved left ventricular ejection fraction and in-hospital mortality was tested in adjusted models. Results: Among the patients included, 1,256 (85.2%) were admitted without heart failure (72% men, 67 ± 15 years), 78 (5.3%) with heart failure with preserved left ventricular ejection fraction (59% men, 76 ± 14 years), and 140 (9.5%) with systolic dysfunction (69% men, 76 ± 14 years), with mortality rates of 4.3%, 17.9%, and 27.1%, respectively (p < 0.001). Logistic regression (adjusted for sex, age, troponin, diabetes, and body mass index) demonstrated that heart failure with preserved left ventricular ejection fraction (OR 2.91; 95% CI 1.35–6.27; p = 0.006) and systolic dysfunction (OR 5.38; 95% CI 3.10 to 9.32; p < 0.001) were associated with in-hospital mortality. Conclusion: One-third of patients with acute myocardial infarction admitted with heart failure had preserved left ventricular ejection fraction. Although this subgroup exhibited more favorable outcomes than those with systolic dysfunction, this condition presented a three-fold higher risk of death than the group without heart failure. Patients with acute myocardial infarction and heart failure with preserved left ventricular ejection fraction encounter elevated short-term risk and require special attention and monitoring during hospitalization. Resumo Fundamento: A prevalência e os desfechos clínicos em pacientes com insuficiência cardíaca com fração de ejeção do ventrículo esquerdo preservada pós-infarto agudo do miocárdio ainda não foram bem elucidados. Objetivo: Analisar a prevalência de insuficiência cardíaca com fração de ejeção do ventrículo esquerdo preservada no infarto agudo do miocárdio e sua associação com a mortalidade. Métodos: Pacientes com infarto agudo do miocárdio (n = 1.474) foram incluídos prospectivamente. Pacientes admitidos sem insuficiência cardíaca (Killip = 1), com insuficiência cardíaca com fração de ejeção do ventrículo esquerdo preservada (Killip > 1 e fração de ejeção do ventrículo esquerdo ≥ 50%) e com insuficiência cardíaca sistólica (Killip > 1 e fração de ejeção do ventrículo esquerdo < 50%) foram comparados. A associação entre insuficiência cardíaca sistólica e com fração de ejeção do ventrículo esquerdo preservada, com a mortalidade hospitalar foi testada em modelos ajustados. Resultados: Dentre os incluídos, 1.256 (85,2%) pacientes foram admitidos sem insuficiência cardíaca (72% homens, 67 ± 15 anos), 78 (5,3%) com insuficiência cardíaca com fração de ejeção do ventrículo esquerdo preservada (59% homens, 76 ± 14 anos) e 140 (9,5%) com insuficiência cardíaca sistólica (69% homens, 76 ± 14 anos), com mortalidade, respectivamente, de 4,3; 17,9 e 27,1% (p < 0,001). A regressão logística (ajustada para sexo, idade, troponina, diabetes e índice de massa corporal) demonstrou que insuficiência cardíaca com fração de ejeção do ventrículo esquerdo preservada (odds ratio de 2,91; intervalo de confiança de 95% de 1,35-6,27; p = 0,006) e insuficiência cardíaca sistólica (odds ratio de 5,38; intervalo de confiança de 95% de 3,10-9,32; p < 0,001) se associaram à mortalidade intra-hospitalar. Conclusão: Um terço dos pacientes com infarto agudo do miocárdio admitidos com insuficiência cardíaca apresentou fração de ejeção do ventrículo esquerdo preservada. Apesar de esse subgrupo ter evolução mais favorável que os pacientes com insuficiência cardíaca sistólica, ele apresentou risco de morte três vezes maior do que o grupo sem insuficiência cardíaca. Pacientes com infarto agudo do miocárdio e insuficiência cardíaca com fração de ejeção do ventrículo esquerdo preservada apresentaram elevado risco em curto prazo e mereceram especial atenção e monitorização durante a internação hospitalar.

There is a very well known correlation between diabetes and cardiovascular disease but many health care professionals are just concerned with glycemic control, ignoring the paramount importance of controlling other risk factors involved in the pathogenesis of serious cardiovascular diseases. This Position Statement from the Brazilian Diabetes Society was developed to promote increased awareness in relation to six crucial topics dealing with diabetes and cardiovascular disease: Glicemic Control, Cardiovascular Risk Stratification and Screening Coronary Artery Disease, Treatment of Dyslipidemia, Hypertension, Antiplatelet Therapy and Myocardial Revascularization. The issue of what would be the best algorithm for the use of statins in diabetic patients received a special attention and a new Brazilian algorithm was developed by our editorial committee. This document contains 38 recommendations which were classified by their levels of evidence (A, B, C and D). The Editorial Committee included 22 specialists with recognized expertise in diabetes and cardiology.

Background Assuming that coronary interventions, both coronary bypass surgery (CABG) and percutaneous coronary intervention (PCI), are directed to preserve left ventricular function, it is not known whether medical therapy alone (MT) can achieve this protection. Thus, we evaluated the evolution of LV ejection fraction (LVEF) in patients with stable coronary artery disease (CAD) treated by CABG, PCI, or MT as a post hoc analysis of a randomized controlled trial with a follow-up of 10 years. Methods Left ventricle ejection fraction was assessed with transthoracic echocardiography in patients with multivessel CAD, participants of the MASS II trial before randomization to CABG, PCI, or MT, and re-evaluated after 10 years of follow-up. Results Of the 611 patients, 422 were alive after 10.32 ± 1.43 years. Three hundred and fifty had LVEF reassessed: 108 patients from MT, 111 from CABG, and 131 from PCI. There was no difference in LVEF at the beginning (0.61 ± 0.07, 0.61 ± 0.08, 0.61 ± 0.09, respectively, for PCI, CABG, and MT, P = 0.675) or at the end of follow-up (0.56 ± 0.11, 0.55 ± 0.11, 0.55 ± 0.12, P = 0.675), or in the decline of LVEF (reduction delta of −7.2 ± 17.13, −9.08 ± 18.77, and −7.54 ± 22.74). Acute myocardial infarction (AMI) during the follow-up was associated with greater reduction in LVEF. The presence of previous AMI (OR: 2.50, 95% CI: 1.40–4.45; P = 0.0007) and during the follow-up (OR: 2.73, 95% CI: 1.25–5.92; P = 0.005) was associated with development of LVEF

FUNDAMENTO: A ocorrencia de sangramento aumenta a mortalidade intra-hospitalar em pacientes com sindromes coronarianas agudas (SCAs), e ha uma boa correlacao entre os escores de risco de sangramento e a incidencia de eventos hemorragicos. No entanto, o papel dos escores de risco de sangramento como fatores preditivos de mortalidade e pouco estudado. OBJETIVO: Analisar o papel do escore de risco de sangramento como fator preditivo de mortalidade intra-hospitalar numa coorte de pacientes com SCA tratados num centro terciario de cardiologia. METODOS: Dos 1.655 pacientes com SCA (547 com SCA com supra de ST e 1.118 com SCA sem supra de ST), calculou-se o escore de risco de sangramento ACUITY/HORIZONS prospectivamente em 249 pacientes e retrospectivamente nos demais 1.416. Informacoes sobre mortalidade e complicacoes hemorragicas tambem foram obtidas. RESULTADOS: A idade media da populacao estudada foi 64,3 ± 12,6 anos e o escore de risco de sangramento medio foi 18 ± 7,7. A correlacao entre sangramento e mortalidade foi altamente significativa (p < 0,001; OR = 5,29), assim como a correlacao entre escore de sangramento e hemorragia intra-hospitalar (p < 0,001; OR = 1,058), e entre escore de sangramento e mortalidade intra-hospitalar (OR ajustado = 1,121, p < 0,001, area sob a curva ROC 0,753; p < 0,001). O OR ajustado e a area sob a curva ROC para a populacao com SCA com supra de ST foram 1,046 (p = 0,046) e 0,686 ± 0,040 (p < 0,001), respectivamente, e para SCA sem supra de ST foram 1,150 (p < 0,001) e 0,769 ± 0,036 (p < 0,001), respectivamente. CONCLUSAO: O escore de risco de sangramento e um fator preditivo muito util e altamente confiavel para mortalidade intra-hospitalar em uma grande variedade de pacientes com SCAs, especialmente aqueles com angina instavel ou infarto agudo do miocardio sem supra de ST.

Introducao Arterite de Takayasu (AT) e uma arterite inflamatoria cronica de etiologia desconhecida que acomete grandes vasos, principalmente aorta e seus principais ramos, vasos pulmonares e coronarias1. Devido a raridade dos casos a monitoracao da atividade da doenca e o melhor esquema terapeutico ainda tem sido um desafio para todos os que tratam esses pacientes. Especificamente em casos de sindromes coronarias agudas (SCA), a melhor forma de tratamento intervencionista mantem-se indefinido. Algumas series de casos apresentam sua experiencia com angioplastia coronaria (ATC) e/ou cirurgia de revascularizacao miocardica (CRM), porem com pouca consistencia1. Nesse contexto, o relato da evolucao de uma mesma paciente submetida a implante de stent coronario convencional e, posteriormente, farmacologico de forma consecutiva, associado a estenose coronaria intrastent nos dois procedimentos na ausencia de inflamacao, com subsequente realizacao de CRM, e unico e reforca a dificuldade de manejo de SCA nessa doenca.

Introdução: Diversos estudos na literatura têm relacionado valores elevados de peptídeo natriurético cerebral (BNP) com pior prognóstico em pacientes com síndrome coronária aguda (SCA). No entanto, valores entre 100 pg/mL e 400 pg/mL são considerados limítrofes e ainda questionados em relação à diagnóstico e ocorrência de eventos. Métodos: Trata-se de estudo retrospectivo observacional com objetivo de avaliar se o valor intermediário de BNP na admissão hospitalar é capaz de predizer prognóstico intrahospitalar. Os pacientes foram divididos em dois grupos: grupo I: BNP < 100 pg/mL; grupo II: 100 < BNP < 400 pg/mL. Foram incluídos 405 pacientes (235 no grupo I e 170 no grupo II) com SCA. Obtiveram-se dados referentes à comorbidades e medicações utilizadas. Análise estatística: O desfecho primário foi mortalidade por todas as causas. O desfecho secundário foi eventos combinados (choque cardiogênico, reinfarto, morte, acidente vascular cerebral e sangramento). A comparação entre grupos foi realizada através de Q-quadrado e ANOVA. A análise multivariada foi realizada por regressão logística, sendo considerado significativo p < 0,05. Resultados: Na comparação entre os grupos I e II, observaram-se diferenças em relação à prevalência de diabetes mellitus e angioplastia coronária prévia. Na análise multivariada, observaram-se diferenças significativas entre os grupos I e II em relação à ocorrência de choque cardiogênico (2,55% x 10,59%, OR = 4,09, p = 0,01), respectivamente. Conclusão: Valores intermediários de BNP não foram capazes de predizer mortalidade em pacientes com SCA. No entanto, observou-se uma maior incidência de choque cardiogênico.

Few studies have prospectively addressed the effects of exercise in the inflammatory activity of patients with coronary artery disease (CAD). We sought to evaluate the consequences of an acute bout of exercise on inflammatory markers and BNP in untrained CAD patients before and after randomization to a training program. 34 CAD patients underwent a 50-min acute exercise session on a cycle-ergometer at 65% peak oxygen uptake before and after blood sampling. They were then randomized to a 4-month chronic exercise program (15 patients) or general lifestyle recommendations (19 patients), undergoing a new acute session of exercise after that. In the overall population, acute exercise caused a significant increase in C-reactive protein [CRP; 1.79 (4.49) vs. 1.94 (4.89) mg/L, P

A obesidade vem se tornando uma epidemia global. Cerca de 1,1 bilhões de adultos e 10% das crianças do mundo são atualmente considerados portadores de sobrepeso ou obesos. Classicamente associada a fatores de risco para doença cardiovascular, como diabete melito e hipertensão arterial sistêmica, a obesidade vem sendo cada vez mais encarada como fator de risco independente para doença arterial coronariana (DAC). A aterosclerose coronariana compreende uma série de respostas inflamatórias em nível celular e molecular, cujas reações se encontram mais exacerbadas em pacientes obesos. Antes considerado mero depósito de gordura, o tecido adiposo é visto hoje em dia como órgão endócrino e parácrino ativo, produtor de diversas citocinas inflamatórias, como as adipocinas. Este artigo visa alertar para o grave problema de saúde pública em que a obesidade se tornou nas últimas décadas e correlacionar o processo inflamatório exacerbado nos indivíduos obesos com a maior incidência de DAC nessa população. Obesity is becoming a global epidemic. Around 1.1 billion adults and 10% of the world's children are currently overweight or considered obese. Generally associated with risk factors for cardiovascular disease, such as Diabetes Mellitus and systemic arterial high blood pressure, the obesity has been more and more seen as an independent risk factor for Coronary Artery Disease (CAD). Coronary arteriosclerosis comprises a series of inflammatory responses at cellular and molecular level, whose reactions are stronger in obese patients. In the past, the adipose tissue was regarded as a mere fat deposition. Now it is seen from a totally different standpoint, as an active endocrine and paracrine organ that produces several inflammatory cytokines, such as the adipokines. This article aims to raise awareness about obesity as an increasingly significant public health issue over the past decades, as well as to relate the intense inflammatory process in obese individuals with an increased tendency for this group of individuals to develop CAD. La obesidad se está tornando una epidemia global. Cerca de 1,1 billones de adultos y el 10% de los niños del mundo están considerados actualmente portadores de sobrepeso u obesos. Clásicamente asociada a factores de riesgo para enfermedad cardiovascular, como diabetes melitus e hipertensión arterial sistémica, la obesidad se está considerando cada vez más factor de riesgo independiente para enfermedad arterial coronaria (EAC). La aterosclerosis coronaria comprende una serie de respuestas inflamatorias a nivel celular y molecular, cuyas reacciones se encuentran más exacerbadas en pacientes obesos. Antes considerado mero depósito de grasa, el tejido adiposo está visto hoy en día como órgano endócrino y parácrino activo, productor de diversas citocinas inflamatorias, como las adipocinas. Este artículo apunta a alertar sobre el grave problema de salud pública en que se convirtió la obesidad en las últimas décadas y correlacionar el proceso inflamatorio exacerbado en los individuos obesos con la mayor incidencia de EAC en esta población.

The association of plaques with outward arterial remodeling and acute coronary syndromes (ACS) has been mostly investigated by cross-sectional intravascular ultrasound studies. Magnetic resonance imaging (MRI) has made it possible to noninvasively assess the coronary vessels of patients with chronic coronary artery disease, but no study has been done in patients with ACS. We sought to serially investigate changes in coronary vessel walls of patients with ACS using noninvasive serial MRI.A total of 42 segments of coronary arteries from 22 patients presenting with non-ST-segment elevation ACS were studied at baseline in the acute phase and at 6 months after stabilization and optimization of medical therapy. Patients received routine medical treatment during this period with control of risk factors. Vessel wall area, maximum wall thickness, mean wall thickness, and lumen area were analyzed longitudinally using MRI.Vessel wall area (38.8 +/- 20.0 vs 27.7 +/- 10.4 mm2; P = .001), maximum wall thickness (2.9 +/- 0.7 vs 2.5 +/- 0.6 mm; P.001), and mean wall thickness (2.0 +/- 0.7 vs 1.6 +/- 0.5 mm; P.001) were significantly reduced at 6 months compared with baseline, whereas lumen area did not show significant changes (11.5 +/- 4.8 vs 10.9 +/- 5.0 mm2; P = .52). The wall/lumen ratio was significantly reduced from 3.7 +/- 1.7 to 2.9 +/- 1.3 (P = .01), suggesting a regression of outward remodeling.Patients with ACS have increased coronary vessel wall thickness and area that can regress with stabilization and medical therapy over the period of 6 months. Magnetic resonance imaging can detect and serially follow these changes, monitoring coronary vascular remodeling from the acute to the chronic phase of the disease.

OBJETIVO: Analisar a liberação intracoronariana de marcadores inflamatórios (MI) após intervenções coronarianas percutâneas (ICP) e comparar suas concentrações com relação ao tipo de ICP utilizada (rotablator vs angioplastia por balão). MÉTODOS: Foram randomizados 22 pacientes com média de idade de 60±11,9 anos, 12 do sexo masculino, portadores de síndromes coronarianas estáveis, submetidos ao tratamento eletivo de uma única lesão coronariana utilizando rotablator (N=11) ou pré-dilatação por balão (N=11) para implante de stents. As amostras foram colhidas na raiz da aorta e no seio coronariano, imediatamente antes e 15 minutos após as intervenções. Todas as dosagens foram feitas antes do implante do stent, sendo analisadas as citocinas TNF-a, IL-6 e IL-1 e as moléculas de adesão solúveis ICAM-1, E-selectina e P-selectina, utilizando o método ELISA. RESULTADOS: As concentrações de TNF-a e IL-6 aumentaram após as ICP, passando respectivamente de 9,5±1,5 pg/ml para 9,9±1,8 pg/ml (p=0,017) e de 6,0±2,4 pg/ml para 6,9±3,0 pg/ml (p

Edimar Alcides Bocchi, Fabio Vilas-Boas, Sergio Perrone, Angel G Caamano, Nadine Clausell, Maria da Consolacao VMoreira, Jorge Thierer, Hugo Omar Grancelli, Carlos Vicente Serrano Junior, Denilson Albuquerque, Dirceu Almeida,Fernando Bacal, Luis Felipe Moreira, Adonay Mendonza, Antonio Magana, Arturo Tejeda, Daniel Chafes, Efraim Gomez,Erick Bogantes, Estela Azeka, Evandro Tinoco Mesquita, Francisco Jose Farias B Reis, Hector Mora, Humberto Vilacorta,Jesus Sanches, Joao David de Souza Neto, Jose Luis Vuksovic, Juan Paes Moreno, Julio Aspe y Rosas, Lidia ZytynskiMoura, Luis Antonio de Almeida Campos, Luis Eduardo Rohde, Marcos Parioma Javier, Martin Garrido Garduno, MucioTavares, Pablo Castro Galvez, Raul Spinoza, Reynaldo Castro de Miranda, Ricardo Mourilhe Rocha, Roberto Paganini,Rodolfo Castano Guerra, Salvador Rassi, Sofia Lagudis, Solange Bordignon, Solon Navarette, Waldo Fernandes, AntonioCarlos Pereira Barretto, Victor Issa, Jorge Ilha Guimaraes.

Mulher de 67 anos de idade, apresentando estenose mitral grave, nao-reumatica, apos 18 anos da realizacao de miotomia/miectomia septal cirurgica para correcao de miocardiopatia hipertrofica septal assimetrica. A paciente foi submetida a troca da valva mitral por protese mecânica, tornando-se caso unico, em razao da combinacao das duas sindromes, extremamente rara e com grave prognostico

Increased monocyte adherence to the vessel wall is one of the earliest events in atherosclerosis. The mechanism by which hypercholesterolemia causes alterations in endothelial adhesiveness for monocytes is unclear. This study sought to determine if monocyte adhesion molecule expression is affected by low-density lipoprotein (LDL)-cholesterol levels. Patients with hypercholesterolemia and stable coronary artery disease were compared with those without major cardiovascular risk (control). Patients with hypercholesterolemia were treated with simvastatin 20--40 mg/day for 8--10 weeks. Blood samples were examined with flow cytometry assays at baseline and after cholesterol-lowering therapy. Monocyte CD11b and CD14 adhesion molecule expression, measured as fluorescence intensity, were significantly (P0.0001) higher in hypercholesterolemic patients before the study (176.9+/-9.8 and 138.0+/-4.8, respectively) when compared with that in control subjects (97.2+/-8.1 and 84.0+/-6.4, respectively). Both decreased markedly with treatment: to 118.8+/-6.9 and 103.1+/-3.9, respectively. Monocyte L-selectin expression was significantly lower in patients with hypercholesterolemia before treatment (43.0+/-3.0) when compared with control subjects (79.9+/-2.7), and it increased markedly with treatment (54.2+/-2.5). LDL levels correlated directly with both CD11b and CD14 expression and correlated inversely with L-selectin expression. These data show that hypercholesterolemia affects monocyte adhesion molecule expression which, in turn, decreases with statin-induced plasmatic cholesterol reduction. Such perturbations in monocyte function likely represent a proinflammatory response to hypercholesterolemia and may have a role in the early progression of atherogenesis.

INTRODUCTION Hemophilia patients usually have a lower incidence of coronary artery disease (CAD). However, as their life expectancy increases so does the incidence of CAD. Anti-platelet drugs, diagnostic coronary catheterization, angioplasty and coronary artery bypass surgery (CABG) have rarely been used in this population. […] Coronary artery bypass surgery, angioplasty and long term anti-platelet treatment in a type B hemophilia patient

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.

Depression and coronary artery disease (CAD) are both extremely prevalent diseases. In addition, compromised quality of life and life expectancy are characteristics of both situations. There are several conditions that aggravate depression and facilitate the development of CAD, as well as provoke a worse prognosis in patients with already established CAD: inferior adherence to medical orientations (medications and life style modifications), greater platelet activation and aggregation, endothelial dysfunction, and impaired autonomic dysfunction (lowered heart rate variability). Recent literature has shown that depression alone is becoming an independent risk factor for cardiac events both in primary and secondary prevention. As the diagnosis of depression in patients with heart disease is difficult, due to similarities of symptoms, the health professional should perform a careful evaluation to differentiate the clinical signs of depression from those related with general heart diseases. After a myocardial infarction, depression is an independent risk factor for mortality. Successful therapy of depression has been shown to improve patients' quality of life and cardiovascular outcome. However, multicentric clinical trials are needed to support this inference. A practical liaison between qualified professionals is necessary for the better management of depressed patients with excess risk in developing CAD. Accordingly, pathophysiological and clinical implications between depression and CAD are discussed in this article.

BACKGROUND Previous studies have demonstrated that polymorphonuclear leukocytes (PMNs) are locally activated in reperfused myocardium and contribute to the myocardial cell injury associated with reperfusion. It has been suggested that the adhesion of activated PMNs in reperfused myocardium is mediated by the PMN adhesion molecule CD-18. In the present study, we performed experiments to determine if the specific anti-CD-18 monoclonal antibody (MAb) R15.7 can prevent PMN adhesion and PMN-mediated reperfusion injury in the heart. METHODS AND RESULTS Studies were performed with isolated, Langendorff-perfused rat hearts (nine per group) in which the hearts were subjected to 20 minutes of global ischemia followed by 45 minutes of reperfusion. Human PMNs (50 million) and rat plasma (HNRP) were infused directly into the coronary circulation of nonischemic and postischemic hearts. When HNRP was administered to nonischemic hearts, no significant alterations in coronary flow, left ventricular developed pressure, or left ventricular end-diastolic pressure were observed. When hearts were reperfused in the presence of HNRP, however, marked impairment of contractile function was observed with more than 90% reduction in coronary flow throughout the reperfusion period (P < .001 versus baseline). In addition, left ventricular developed pressure was significantly depressed (P < .001 versus baseline) throughout the reperfusion period in the HNRP group and recovered to only 13.0 +/- 3.0% at 45 minutes of reperfusion. Moreover, left ventricular end-diastolic pressure was significantly elevated (P < .001) in the HNRP group throughout the reperfusion period. Treatment with the anti-CD-18 monoclonal antibody MAb R15.7 (20 micrograms/mL) at the time of reperfusion resulted in a 92.9 +/- 4.9% recovery of coronary flow (P < .001 versus HNRP) as well as a 71.0 +/- 10.1% recovery of left ventricular developed pressure (P < .001 versus HNRP). Administration of MAb R15.7 also very significantly attenuated the elevation in left ventricular end-diastolic pressure that was observed in the untreated HNRP (30.2 +/- 7.8 versus 110.3 +/- 10.3 mm Hg, P < .001) at 45 minutes of reperfusion. Cardiac myeloperoxidase activity, an index of PMN accumulation, was markedly reduced in the MAb R15.7 group at 45 minutes of reperfusion compared with the HNRP group (0.03 +/- 0.01 versus 0.3 +/- 0.05, P < .001). To determine that the protective effect of MAb R15.7 was based on functional blocking of CD-18, additional experiments were performed with identical concentrations of MAb 3.1, which binds to the alpha-subunit of LFA-1. This PMN-binding but non-CD-18-blocking antibody had little effect on the recovery of postischemic function or coronary flow and did not reduce tissue myeloperoxidase activity. CONCLUSIONS The administration of a specific anti-CD-18 monoclonal antibody, MAb R15.7, attenuates much of the PMN-mediated contractile dysfunction associated with this in vitro model of myocardial ischemia-reperfusion injury by limiting PMN accumulation. We conclude that CD-18-mediated adhesion may play a critical role in the pathogenesis of PMN-induced myocardial injury.