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Resumo Fundamento: As doenças cardiovasculares (DCV) e câncer são as principais causas de morte no mundo. Essas doenças apresentam muitos fatores de risco em comum, e o controle de fatores de risco tradicionais para DCV foi associado com menor incidência de câncer. Objetivo: Analisar tendências nas taxas de mortalidade por câncer na população brasileira com idade entre 35 e 74 anos de 1996 a 2017. Métodos: As tendências nas taxas de mortalidade (bruta e ajustada por idade) foram analisadas quanto a todas as causas de morte, DCV e câncer. Os dados foram obtidos do banco de dados de mortalidade do Ministério da Saúde. O programa Joinpoint Regression foi usado para análise das tendências e ajustes nas taxas de saúde. O grau de mudanças nas taxas foi determinado pela variação percentual anual média (VPAM). O nível de significância estatística foi estabelecido em p

Aspectos clinicos Paciente de 55 anos, com hipertensao arterial e insuficiencia cardiaca ha um ano e com dor precordial e parada cardiorrespiratoria havia cinco meses, evoluiu com insuficiencia cardiaca e insuficiencia mitral por prolapso de valva mitral e rotura de cordas. A impressao diagnostica e de que a insuficiencia cardiaca por valvopatia mitral precedeu o episodio de dor precordial e dispneia intensa. […] Caso 1/2020 – Mulher de 55 Anos com Insuficiencia Cardiaca apos Internacao por Diagnostico Presumido de Infarto [...]

Background Ad hoc percutaneous coronary intervention via radial access has become frequent in interventional cardiology services, with reduced bleeding rates, vascular complications and costs. There are few reports in the medical literature on radiological exposure rates (kerma area product − Kap, and incident air kerma − Iak) in these procedures, when they are performed via radial access. The objective of the study was to compare radiological variables in staged percutaneous coronary interventions with ad hoc interventions via radial access. [...]

Introduction: It is well established that moderate consumption of red wine is associated with reduced risk of cardiovascular (CV) events. Many observational studies have shown that this same benefit could be seen with other alcohol beverages different from wine. However, the correlation between the Brazilian sugarcane liquor (“cachaca”) and CV benefit has not been demonstrated in human trials. Hypothesis: Cachaca causes changes in biomarkers of CV risk in the same proportion as wine. Methods: In this crossover randomized study, healthy individuals were initially designated to have daily moderate alcohol consumption (MAC) of either cachaca or red wine for a period of 4 weeks. MAC, for both drinks, was denoted as a daily dose equivalent of 28g of alcohol for men and 14g for women. Then, after an abstinence period of 7 days, drink types were switched for more 4 weeks. Analysis of CV risk biomarkers were determined before and after each intervention, and consisted of C-reactive protein, lipid profile, platelet aggregability and glycid profile. (This research was funded by FAPESP 2018/09675-4). Results: Of the 37 individuals originally enrolled, 2 refused to continue the study. The average age of the individuals was 41.7 (±15.3 years) and 43.2% were men. Adherence to the protocol was considered essentially ideal, with 100% of regular use in both interventions and only 3 individuals reporting abuse during the study period. There was no significant variation in anthropometric measurements during the study, except for a weight gain (0.6kg) with red wine (p = 0.011). As seen in the table, no significant changes were noted in the inflammatory markers, lipid profile, platelet aggregability nor glycid profile before and after each intervention. Conclusions: This study shows that in healthy individuals, neither red wine nor cachaca changed CV biomarkers related to atherosclerotic progression after 4 weeks of MAC. However, there was a marked weight gain with daily wine consumption.

Recently, gut microbiota has emerged as an important mediator of several diseases such as diabetes, atherosclerosis, arterial hypertension, obesity, cancers and neuropsychiatric diseases including Alzheimer, autism and depression. Intestinal microbiota is formed by bacteria, fungi and viruses and its main function is to facilitate the absorption and metabolism of foods (protein, fat and carbohydrate). One example of the multiple actions of the gut microbiota is the bidirectional relationship between the intestine and the brain, the so-called “gut/brain axis”. Furthermore, metabolites produced by gut microbiota can induce effects locally or at distance, which suggests that the intestine is an endocrine organ. Given the participation of the gut microbiota in several diseases, there is great interest in strategies that may positively affect the gut flora and prevent or even treat diseases. Among these strategies, lifestyle change, but specially diet modulation has gained importance. In this article, we review the mechanisms through which intestinal microbiota participates in cardiovascular diseases and possible therapeutic interventions.

It was a randomized trial, and 308 patients undergoing revascularization were randomly assigned: 155 to off-pump coronary artery bypass (OPCAB) and 153 to on-pump coronary artery bypass (ONCAB). End points were freedom from death, myocardial infarction, revascularization, and cerebrovascular accidents. The rates for 10-year, event-free survival for ONCAB versus OPCAB were 69.6% and 64%, (hazard ratio [HR]: 0.88; 95% confidence interval [CI] 0.86-1.02; P = .41), respectively. Adjusted Cox proportional hazard ratio was similar (HR: 0.92; 95% CI 0.61-1.38, P = .68). A difference occurred between the duration of OPCAB and ONCAB, respectively (4.9 ± 1.5 vs 6.6 ± 1.1 h, P < .001). Statistical differences occurred between OPCAB and ONCAB in the length of intensive care unit (ICU) stay (20 ± 2.5 vs 48 ± 10 hours, P < .001), time to extubation (5.5 ± 4.2 vs 10.2 ± 3.5 hours, P < .001), hospital stay (6.7 ± 1.4 vs 9.2 ± 1.3 days, P < .001), higher incidence of atrial fibrillation (AF; 33 vs 5 patients, P < .001), and blood requirements (46 vs 64 patients, P < .001). Grafts per patient was higher in ONCAB (3.15 vs 2.55 grafts, P < .001). No difference existed between the groups in primary composite end points at 10-year follow-up. Although OPCAB surgery was related to a lower number of grafts and higher incidence of AF, it had no effects related to long-term outcomes.

Aspectos clinicos Trata-se de mulher de 59 anos portadora de dupla lesao mitral com hipertensao pulmonar que, enquanto aguardava cirurgia, apresentou quadro de hipotensao arterial, insuficiencia respiratoria com hipotransparencia no campo pulmonar direito. Evoluiu sem melhora com o uso de drogas vasoativas, intubacao orotraqueal e antibioticoterapia, e faleceu em atividade eletrica sem pulso. A etiologia da doenca valvar da paciente deve ser atribuida a febre reumatica, apesar de nao haver descricao de surto agudo dessa doenca. Este e um fato [...]

Body mass index (BMI) is the most commonly used index to categorize a person as obese or non-obese, which is subject to important limitations.To evaluate the direct effect of BMI on cardiovascular outcomes among participants without central obesity.This analysis included 14,983 males and females aged 45-75 years from the Atherosclerosis Risk in Communities Study (ARIC). BMI was measured as general obesity, and waist circumference (WC), waist-to-hip ratio (WHR) and hip circumference as central obesity. Targeted maximum likelihood estimation (TMLE) was used to estimate the total effects (TEs) and the controlled direct effects (CDEs). The proportion of TE that would be eliminated if all participants were non-obese regarding central obesity was computed using the proportion eliminated (PE) index. P0.05 was considered statistically significant. Analyses were performed in the TMLE R package.The risk of cardiovascular outcomes attributed to BMI was significantly reversed by eliminating WHR obesity (p0.001). The proportion eliminated of BMI effects was more tangible for non-obese participants regarding WC (PE=127%; 95%CI (126,128)) and WHR (PE=97%; 95%CI (96,98)) for coronary heart disease (CHD), and WHR (PE=92%; 95%CI (91,94)) for stroke, respectively. With respect to sex, the proportion eliminated of BMI effects was more tangible for non-obese participants regarding WHR (PE=428%; 95%CI (408,439)) for CHD in males, and WC (PE=99%; 95%CI (89,111)) for stroke in females, respectively.These results indicate different potential effects of eliminating central obesity on the association between BMI and cardiovascular outcomes for males and females. (Arq Bras Cardiol. 2021; 116(5):879-886).O índice de massa corporal (IMC) é o índice mais usado para categorizar uma pessoa como obesa ou não-obesa, e está sujeito a limitações importantes.Avaliar o efeito direto do IMC nos desfechos cardiovasculares em participantes sem obesidade central.Esta análise incluiu 14.983 homens e mulheres com idades entre 45-75 anos do Estudo de Risco de Aterosclerose em Comunidades (ARIC). O IMC foi medido como obesidade geral e a circunferência da cintura (CC), a relação cintura-quadril (RCQ) e circunferência do quadril como obesidade central. A estimativa de máxima verossimilhança direcionada (TMLE, no acrônimo em inglês) foi usada para estimar os efeitos totais (TEs) e os efeitos diretos controlados (CDEs). A proporção de ET que seria eliminada se todos os participantes fossem não obesos em relação à obesidade central foi calculada usando o índice de proporção eliminada (PE). P0,05 foi considerado estatisticamente significativo. As análises foram realizadas no pacote TMLE R.O risco de desfechos cardiovasculares atribuídos ao IMC foi significativamente revertido com a eliminação da obesidade na RCQ (p0,001). A proporção eliminada dos efeitos do IMC foi mais tangível para participantes não obesos em relação à CC (PE = 127%; IC95% (126,128)) e RCQ (PE = 97%; IC95% (96,98)) para doença arterial coronariana (DAC), e RCQ (PE = 92%; IC95% (91,94)) para acidente vascular cerebral, respectivamente. Com relação ao sexo, a proporção eliminada dos efeitos do IMC foi mais tangível para participantes não obesos em relação a RCQ (PE = 428%; IC95% (408.439)) para DAC em homens e CC (PE = 99%; IC95% (89,111)) para acidente vascular cerebral em mulheres, respectivamente.Esses resultados indicam diferentes efeitos potenciais da eliminação da obesidade central na associação entre IMC e desfechos cardiovasculares em homens e mulheres. (Arq Bras Cardiol. 2021; 116(5):879-886).

Aspectos clinicos Trata-se de homem de 28 anos, em anasarca. Havia disfuncao sistolica esquerda moderada e aumento acentuado de atrios e ventriculo direito e aumento pouco expressivo da pressao arterial pulmonar coexistindo com insuficiencias moderadas das valvas atrioventriculares. Aparentemente o predominio era de disfuncao diastolica e dilatacao dos ventriculos e disfuncao sistolica de ventriculo direito, o que indica estarmos frente a cardiopatia restritiva. […] Caso 6/2017 – Homem de 28 Anos com Anasarca e Insuficiencia Cardiaca de Padrao Restritivo

Background Evidence suggests that red wine (RW) components can influence favorably gut microbiota. However, Interactions of RW, gut microbiota and plasma metabolomics remain unclear. Purpose The goal of this study was to assess the effects upon gut microbiota and plasma metabolomic profile of short-term, moderate RW intake in patients (pts) with documented coronary artery disease (CAD) Methods Forty-two males aged 60.4±5.4 years (SD) with documented CAD by angiography underwent a randomized, crossover, controlled, interventional trial. They were assigned to either RW treatment or abstinence from any alcoholic beverage, as control. Each treatment was preceded by a 2-week washout period. During the RW intervention, subjects ingested 250 ml of RW per day/ 5 days a week/ 3 weeks. Fasting blood samples and fecal samples were collected 4 times, after washout and at the end of each 3-week intervention. Gut microbiota was analysed by 16 S rRNA gene sequences and plasma metabolomics was performed by Ultrahigh Performance Liquid Chromatography-Tandem Mass Spectroscopy. Twenty pts chosen randomly had their global metabolic profiles examined at all visits. Diet was carefully controlled and quantified by a 3 day/week questionnaire at beginning and end of the study. Prebiotics, probiotics were not allowed during the study. Patients in need for antibiotic therapy were not included. Results In the RW period compared to abstinence, fecal metagenomic revealed a decrease in abundance of Collinsella, a bacterial genus correlated with atherosclerosis; an increase in Eubacterium, genus related to fiber digestion and bile acid metabolism; and a significant increase in alpha diversity (p Conclusions Moderate RW ingestion augmented microbiota diversity, increased the proportion of putative anti-atherosclerotic bacteria and influenced plasma metabolomics. RW influenced energy metabolism through gut microbiota related plasma changes in amino acids, nucleotide profile, bile acids, androgenic steroids and beta-oxidation. These findings furnish some novel insight into mechanisms whereby RW may mitigate atherosclerosis. Acknowledgement/Funding FAPESP (Fundacao de Amparo à Pesquisa do Estado de Sao Paulo), IBRAVIN (Instituto Brasileiro do Vinho), Banco Bradesco SA

Importance The long-term prognostic implications of myocardial ischemia documented during stress testing in patients with multivessel coronary artery disease (CAD) are unclear. Objective To assess whether documented stress testing–induced myocardial ischemia is associated with major adverse cardiovascular events or ventricular function changes in patients with stable multivessel CAD. Design, Setting, and Participants A prospective cohort study was conducted using data from a single-center randomized clinical trial (Medicine, Angioplasty, or Surgery Study [MASS] II) to examine the association of myocardial ischemia documented during stress testing at baseline with cardiovascular events and ventricular function changes during follow-up. Participants were previously randomized (May 1, 1995, to May 31, 2000) to medical therapy, percutaneous coronary intervention with bare metal stents, or coronary artery bypass grafting. Event-free survival was estimated by the Kaplan-Meier method, and multivariable Cox regression models were calculated to assess the association between ischemia and the primary composite end point. The vital status was determined on February 28, 2011. Data were analyzed from February 1, 2016, to April 1, 2017. Main Outcomes and Measures Cardiovascular events (overall mortality, myocardial infarction, and revascularization for refractory angina) were tracked from the time of randomization to the end of the 10-year follow-up (mean [SD] duration, 11.4 [4.3] years). Myocardial ischemia was assessed at baseline and at 1-year intervals by exercise stress testing, and ventricular function (left ventricular ejection fraction) was assessed by echocardiography at baseline and after 10 years. Patients with documented ischemia were compared with those without ischemia regarding the outcomes and changes in ventricular function. Results Of 611 participants, 535 underwent exercise stress testing at baseline: 270 with documented ischemia and 265 without. Of these 535 patients, 373 (69.7%) were men, and the mean (SD) age for the entire cohort was 59.7 (9.2) years. No association was found between the presence of ischemia at baseline and survival free of combined cardiovascular events (hazard ratio, 1.00; 95% CI, 0.80-1.27;P = .95) after multivariable adjustment that included CAD initial randomized treatments. In addition, among 320 patients who underwent echocardiographic evaluation, the slight decline in left ventricular ejection fraction after 10 years was similar in both groups (median [SD] difference, −4.9% [18.7%] vs −6.6% [20.0%], respectively, for groups with and without ischemia;P = .97). Conclusions and Relevance In this study, regardless of the therapeutic strategy applied, the presence of documented myocardial ischemia did not appear to be associated with an increased occurrence of major adverse cardiovascular events or changes in ventricular function in patients with multivessel CAD during a long-term follow-up.

The patient was a 58-year-old male, who sought medical care at InCor complaining of dyspnea and fever.

Background The lack of a correlation between myocardial necrosis biomarkers and electrocardiographic abnormalities after revascularization procedures has resulted in a change in the myocardial infarction (MI) definition. Methods Patients with stable multivessel disease who underwent percutaneous or surgical revascularization were included. Electrocardiograms and concentrations of high-sensitive cardiac troponin I (cTnI) and creatine kinase (CK)-MB were assessed before and after procedures. Cardiac magnetic resonance and late gadolinium enhancement were performed before and after procedures. MI was defined as more than five times the 99th percentile upper reference limit for cTnI and 10 times for CK-MB in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), respectively, and new late gadolinium enhancement for cardiac magnetic resonance. Results Of the 202 patients studied, 69 (34.1%) underwent on-pump CABG, 67 (33.2%) off-pump CABG, and 66 (32.7%) PCI. The receiver operating characteristic curve showed the accuracy of cTnI for on-pump CABG, off-pump CABG, and PCI patients was 21.7%, 28.3%, and 52.4% and for CK-MB was 72.5%, 81.2%, and 90.5%, respectively. The specificity of cTnI was 3.6%, 9.4%, and 42.1% and of CK-MB was 73.2%, 86.8%, and 96.4%, respectively. Sensitivity of cTnI was 100%, 100%, and 100% and of CK-MB was 69.2%, 64.3%, and 44.4%, respectively. The best cutoff of cTnI for on-pump CABG, off-pump CABG, and PCI was 6.5 ng/mL, 4.5 ng/mL, and 4.5 ng/mL (162.5, 112.5, and 112.5 times the 99th percentile upper reference limit) and of CK-MB was 37.5 ng/mL, 22.5 ng/mL, and 11.5 ng/mL (8.5, 5.1, and 2.6 times the 99th percentile upper reference limit), respectively. Conclusions Compared with cardiac magnetic resonance, CK-MB was more accurate than cTnI for diagnosing MI. These data suggest a higher troponin cutoff for the diagnosis of procedure-related MI.

Cardiovascular diseases are accountable for more than 32% of total mortality in Brazil, considered a middle-and-low-income country. Epidemiological and socio-economical issues play a crucial role on the distribution, severity and management of stable ischemic heart disease (SIHD). However

Background Chronic kidney disease (CKD) is associated with a worse prognosis in patients with stable coronary artery disease (CAD); however, there is limited randomized data on long-term outcomes of CAD therapies in these patients. We evaluated long-term outcomes of CKD patients with CAD who underwent randomized therapy with medical treatment (MT) alone, percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). Methods Baseline estimated glomerular filtration rate (eGFR) was obtained in 611 patients randomized to one of three therapeutic strategies in the Medicine, Angioplasty, or Surgery Study II trial. Patients were categorized in preserved renal function and mild or moderate CKD groups depending on their eGFR (≥90, 89–60 and 59–30 mL/min/1.73 m2, respectively). The primary clinical endpoint, a composite of overall death and myocardial infarction, and its individual components were analyzed using proportional hazards regression (Clinical Trial registration information: http://www.controlled-trials.com. Registration number: ISRCTN66068876). Results Of 611 patients, 112 (18%) had preserved eGFR, 349 (57%) mild dysfunction and 150 (25%) moderate dysfunction. The primary endpoint occurred in 29.5, 32.4 and 44.7% (P = 0.02) for preserved eGFR, mild CKD and moderate CKD, respectively. Overall mortality incidence was 18.7, 23.8 and 39.3% for preserved eGFR, mild CKD and moderate CKD, respectively (P = 0.001). For preserved eGFR, there was no significant difference in outcomes between therapies. For mild CKD, the primary event rate was 29.4% for PCI, 29.1% for CABG and 41.1% for MT (P = 0.006) [adjusted hazard ratio (HR) = 0.26, 95% confidence interval (CI) 0.07–0.88; P = 0.03 for PCI versus MT; and adjusted HR = 0.48; 95% CI 0.31–0.76; P = 0.002 for CABG versus MT]. We also observed higher mortality rates in the MT group (28.6%) compared with PCI (24.1%) and CABG (19.0%) groups (P = 0.015) among mild CKD subjects (adjusted HR = 0.44, 95% CI 0.25–0.76; P = 0.003 for CABG versus MT; adjusted HR = 0.56, 95% CI 0.07–4.28; P = 0.58 for PCI versus MT). Results were similar with moderate CKD group but did not achieve significance. Conclusions Coronary interventional therapy, both PCI and CABG, is associated with lower rates of events compared with MT in mild CKD patients >10 years of follow-up. More study is needed to confirm these benefits in moderate CKD.

There is a strong epidemiological association between moderate consumption of alcoholic beverages, such as red wine, and other sources of polyphenols and the reduction of cardiovascular disease and mortality. Also, protective effects against atherogenic lipid profile, platelet activation, and systemic inflammation have been noted in observational studies. Glucose metabolism is also positively affected by polyphenols reducing the incidence of diabetes mellitus. Long-term consumption of moderate amounts of red wine consistently increases HDL. Polyphenols increase endothelial nitric oxide production, and decrease the endothelial abundance of endothelin-1. Resveratrol, the most abundant polyphenol of red wine, has been associated with prolongation of life span in animal experiments, and cognition preservation in humans.

Aspectos clinicos O paciente apresentou sincopes desde a idade de 20 anos, insuficiencia cardiaca desde a idade de 30 anos e foi transplantado aos 36 anos. Desde o inicio dos sintomas, foi detectada cardiopatia com dilatacao acentuada e disfuncao moderada de ventriculo esquerdo. O teste de esforco revelou arritmia ventricular frequente. As sincopes foram atribuidas as arritmias ventriculares malignas e foi implantado desfibrilador. […] Caso 1/2018 – Homem Jovem com Cardiopatia que se Expressou Principalmente por Arritmias Ventriculares, Disfuncao de [...]

Coronary artery calcification (CAC) is associated with atherosclerotic complications. However, elevated CAC may not always imply a worse prognosis. Herein, we report the clinical evolution of long-term red wine (RW) drinkers in relation to CAC. We followed 200 healthy male habitual RW drinkers and compared them to 154 abstainers for a period of 5.5 years. The initial evaluation included coronary computed tomography angiography (CTA), clinical, demographics, and laboratory data. CAC was quantified by the Agatston score. The follow-up process was conducted by telephone calls and/or hospital record review. The composite end-point of total death, acute myocardial infarction (AMI), or coronary revascularization (or major adverse cardiac event - MACE) was assessed. The RW drinkers ingested 28.9±15 g of alcohol/day for 23.4±12.3 years. They had higher high-density lipoprotein and low-density lipoprotein, but lower C-reactive protein than abstainers. Age, total cholesterol, triglycerides, glucose, and liver enzymes were similar. History of diabetes was lower among drinkers, but other risk factors were similar. However, drinkers had higher CAC than abstainers; the mean value was 131.5±362 in drinkers vs 40.5±320 in abstainers (P

Endothelial dysfunction is the link between risk factors and atherosclerosis related diseases. Thus, their evaluation discloses the impact risk factors of upon endothelial functional and it is predictive of cardiovascular outcome in persons affected by them. Endothelial function suffers prejudice proportional to total cholesterol, LDL-cholesterol, and HDL-cholesterol levels, hyperglycemia, physical inactivity, aging, blood pressure, and tobacco smoke exposition as has been observed in several clinical studies. It is also affected by family history for coronary disease and gender. An important feature is that endothelial dysfunction precedes clinical manifestations of coronary artery disease; therefore endothelial dysfunction is a marker of atherosclerosis. Importantly, endothelial dysfunction of peripheral arteries correlates with alterations in coronary circulation. We may use the endothelial function evaluation to assess prognosis the effectiveness of medication or life style modification prescribed to patients. Furthermore corrections of risk factors improves endothelial dysfunction.

Observational studies suggest there are clinical benefits to moderate red wine (RW) consumption. However, the effects on coronary vasculature and overall lifestyle are unclear. We investigated whether a lifestyle of regular long-term RW consumption is associated with changes in coronary plaque burden, calcium score, carotid intima/media thickness, endothelial function, and metabolic variables, compared with alcohol abstinence. Healthy volunteers were evaluated by coronary computed tomography angiography (CTA) as well as carotid and brachial artery ultrasound. Nutritional status, psychological status, and metabolic variables were assessed. The study included 101 drinkers [aged 58.9 ± 7.3 years (means ± SD)], from wine brotherhoods, and 104 abstainers, from Anglican, Evangelical and Catholic churches both in the city of São Paulo, Brazil. No significant differences in demographics were noted. Lesion prevalence per patient assessed by coronary CTA and classified as absent (0), 1-25, 26-49, and ≥ 50% stenosis was similar between groups. When analyzed by individual arteries, i.e., left anterior descending, circumflex, and right coronary, prevalence was also not different. On the other hand, calcium scores were higher among drinkers than abstainers (144.4 ± 362.2 vs 122.0 ± 370.3; P0.01). However, drinkers reported less history of diabetes and exercised more. RW drinkers consumed 2127.9 ± 387.7 kcal/day while abstainers consumed 1836.0 ± 305.0 (P0.0001). HDL cholesterol was significantly higher among drinkers compared to abstainers (46.9 ± 10.9 vs 39.5 ± 9.0 mg/dL; P0.001), while fasting plasma glucose was lower (97.6 ± 18.2 vs 118.4 ± 29.6 mg/dL; P0.02). Liver enzymes were normal in both groups. In conclusion, long-term wine drinkers displayed a similar plaque burden but greater calcium score than abstainers, despite a more atherogenic diet, and the mechanisms for the increased calcium scores in the former remain speculative.

The long-term prognostic impact of glycated hemoglobin (HbA1c) values in patients with type 2 diabetes mellitus (DM) and multivessel coronary artery disease (CAD) has been tested, but the effect of variability in HbA1c is unclear. In a Brazilian cohort of CAD patients with type 2 DM, measures of

Introduction Diabetes mellitus is a major cause of coronary artery disease (CAD). Despite improvement in the management of patients with stable CAD, diabetes remains a major cause of increased morbidity and mortality. There is no conclusive evidence that either modality is better than medical therapy alone for the treatment of stable multivessel CAD in patients with diabetes in a very long-term follow-up. Our aim was to compare 3 therapeutic strategies for stable multivessel CAD in a diabetic population and non-diabetic population. Methods It was compared medical therapy (MT), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in 232 diabetic patients and 379 nondiabetic patients with multivessel CAD. Endpoints evaluated were overall and cardiac mortality. Results Patients (n = 611) were randomized to CABG (n = 203), PCI (n = 205), or MT (n = 203). In a 10-year follow-up, more deaths occurred among patients with diabetes than among patients without diabetes ( P = .001) for overall mortality. In this follow-up, 10-year mortality rates were 32.3% and 23.2% for diabetics and non-diabetics respectively ( P = .024). Regarding cardiac mortality, 10-year cardiac mortality rates were 19.4% and 12.7% respectively ( P = .031).Considering only diabetic patients and stratifying this population by treatment option, we found mortality rates of 31.3% for PCI, 27.5% for CABG and 37.5% for MT ( P = .015 for CABG vs MT) and cardiac mortality rates of 18.8%, 12.5% and 26.1% respectively ( P = .005 for CABG vs MT). Conclusions/interpretation Among patients with stable multivessel CAD and preserved left ventricular ejection fraction, the 3 therapeutic regimens had high rates of overall and cardiac-related deaths among diabetic compared with non-diabetic patients. Moreover, better outcomes were observed in diabetic patients undergoing CABG compared to MT in relation to overall and cardiac mortality in a 10-year follow-up.

Background: Studies have questioned the downward trend in mortality from cardiovascular diseases (CVD) in Brazil in recent years. Objective: to analyze recent trends in mortality from ischemic heart disease (IHD) and stroke in the Brazilian population. Methods: Mortality and population data were obtained from the Brazilian Institute of Geography and Statistics and the Ministry of Health. Risk of death was adjusted by the direct method, using as reference the world population of 2000. We analyzed trends in mortality from CVD, IHD and stroke in women and men in the periods of 1980-2006 and 2007-2012. Results: there was a decrease in CVD mortality and stroke in women and men for both periods (p < 0.001). Annual mortality variations for periods 1980-2006 and 2007-2012 were, respectively: CVD (total): -1.5% and -0.8%; CVD men: -1.4% and -0.6%; CVD women: -1.7% and -1.0%; DIC (men): -1.1% and 0.1%; stroke (men): -1.7% and -1.4%; DIC (women): -1.5% and 0.4%; stroke (women): -2.0% and -1.9%. From 1980 to 2006, there was a decrease in IHD mortality in men and women (p < 0.001), but from 2007 to 2012, changes in IHD mortality were not significant in men [y = 151 + 0.04 (R2 = 0.02; p = 0.779)] and women [y = 88-0.54 (R2 = 0.24; p = 0.320). Conclusion: Trend in mortality from IHD stopped falling in Brazil from 2007 to 2012. Resumo Fundamento: Estudos questionaram a tendência de queda da mortalidade por doenças cardiovasculares (DCV) no Brasil nos últimos anos. Objetivo: analisar as tendências recentes na mortalidade por doença isquêmica do coração (DIC) e doenças cerebrovasculares (DCbV) na população brasileira. Métodos: dados de mortalidade e população foram obtidos do Instituto Brasileiro de Geografia e Estatística e Ministério da Saúde. O risco de morte foi ajustado pelo método direto, tendo como referência a população mundial de 2000. Foram analisadas, nos períodos de 1980-2006 e 2007-2012, as tendências da mortalidade em mulheres e homens. Resultados: houve diminuição da mortalidade por DCV e DCbV em mulheres e homens para ambos os períodos (p < 0,001). As variações anuais de mortalidade para os períodos de 1980-2006 e 2007-2012 foram, respectivamente: DCV total: -1,5% e -0,8%; DCV homens: -1,4% e -0,6%; DCV mulheres: -1,7% e -1,0%; DIC homens: -1,1% e 0,1%; DIC mulheres: -1,5% e 0,4%; DCbV homens: -1,7% e -1,4%; DCbV mulheres: -2,0% e -1,9%. De 1980 a 2006, houve diminuição da mortalidade por DIC em homens e mulheres (p < 0,001), mas de 2007-2012, as mudanças na mortalidade por DIC não foram significativas em homens [y = 151 + 0.04 (R2 = 0.02; p = 0,779)] e mulheres [y = 88-0.54 (R2 = 0,24; p = 0,320)]. Conclusão: A tendência da mortalidade por DIC parou de cair no Brasil de 2007 a 2012.

The primary end points of randomized clinical trials evaluating the outcome of therapeutic strategies for coronary artery disease (CAD) have included nonfatal acute myocardial infarction, the need for further revascularization, and overall mortality. Noncardiac causes of death may distort the interpretation of the long-term effects of coronary revascularization.This post-hoc analysis of the second Medicine, Angioplasty, or Surgery Study evaluates the cause of mortality of patients with multivessel CAD undergoing medical treatment, percutaneous coronary intervention, or surgical myocardial revascularization [coronary artery bypass graft surgery (CABG)] after a 6-year follow-up. Mortality was classified as cardiac and noncardiac death, and the causes of noncardiac death were reported.Patients were randomized into CABG and non-CABG groups (percutaneous coronary intervention plus medical treatment). No statistical differences were observed in overall mortality (P=0.824). A significant difference in the distribution of causes of mortality was observed among the CABG and non-CABG groups (P=0.003). In the CABG group, of the 203 randomized patients, the overall number of deaths was 34. Sixteen patients (47.1%) died of cardiac causes and 18 patients (52.9%) died of noncardiac causes. Of these, seven deaths (20.6%) were due to neoplasia. In the non-CABG group, comprising 408 patients, the overall number of deaths was 69. Fifty-three patients (77%) died of cardiac causes and 16 patients (23%) died of noncardiac causes. Only five deaths (7.2%) were due to neoplasia.Different treatment options for multivessel coronary artery disease have similar overall mortality: CABG patients had the lowest incidence of cardiac death, but the highest incidence of noncardiac causes of death, and specifically a higher tendency toward cancer-related deaths.

BACKGROUND: In Brazil, despite the recommendations of the Brazilian Society of Hemodynamics and Interventional Cardiology, the National Health System has not yet approved the use of drug-eluting stents. In percutaneous coronary interventions performed in the public and part of the private health care system, bare metal stents are used as the only option. Therefore, new information on bare metal stents is of great importance. The primary endpoint was to evaluate the influence of the alloy and the profile of coronary stents on late loss and restenosis rates 6 months after implantation in patients with multivessel coronary disease. METHODS: Single center, randomized and prospective study comparison of cobalt-chromium versus stainless steel stent implantation in 187 patients with multivessel coronary disease. At least one cobalt-chromium and one stainless steel stent were implanted per patient. RESULTS: Mean age of patients was 59.5 + 10.1 years with a prevalence of males (66.3%) and patients with acute coronary syndrome (56%). Baseline clinical characteristics were similar with hypertension in 146 (78%), dyslipidemia in 85 (45.5%) and diabetes in 68 (36.4%). Two hundred and twenty-nine cobalt-chromium and 284 stainless steel stents were implanted. Angiographic variables showed no statistically significant difference. Angiographic follow-up to 6 months after implantation showed similar late loss and restenosis rates. CONCLUSION: The use of two different alloys, stainless steel and cobalt-chrome stents, in the same patient and in the same vessel produced similar 6-month restenosis and late loss rates.

Objectives: Influenza (flu) vaccination has been associated with a reduction in cardiovascular mortality in a metropolitan area of Brazil. Nevertheless, it is unknown whether sex influences this outcome. The aim of the study was analyze the cardiovascular disease (CVD) mortality in women and men before and after the initiation of a flu vaccination program. Methods: We analyzed the mortality of ischemic heart disease (IHD), stroke, and external causes (EC) in women and men at least 60 years of age in the metropolitan area of São Paulo before and after the initiation of a flu vaccination program. Estimates of the population were obtained from the Brazilian Institute of Geography and Statistics and the mortality data from the Ministry of Health for the period between 1980 and 2006. The risk of death was adjusted by the direct method using the 1960 world standard population. Results: Change in trend in mortality after vaccination was significant only for IHD (-9.3% vs -30.2%; P = .022) and remained unchanged for stroke (-31.4% vs -25.3%; P =.931) and EC (-8.5% vs -1.2%; P = .941). The decline in IHD pre- (1980-1995) and post-vaccination (1996-2006) was greater in women (-3.8% vs -28.8%; P = .001) than in men (-12.9% vs -30.4%; P = .054). Conclusion: Flu vaccination was associated with a significant reduction of IHD mortality, more so in women than in men.

BACKGROUND: The Brazilian Public Health System (SUS, acronym in Portuguese) establishes that coronary angioplasty with the double implant stent must not exceed 20% of the angioplasties, resulting in the need of assigning most of the procedures in patients with multiarterial disease. OBJECTIVE: The objective of the present study was to assess the paid values by the SUS in order to obtain the complete percutaneous myocardial revascularization in the SUS patients with the multiarterial disease, related to the number of necessary procedures and of implanted stents. METHODS: A total of 141 patients with multiarterial coronary disease, submitted to a successful complete revascularization, were included by the stent implant with coronariography in a 6-month period of post-implant. The complete revascularization was defined as the percutaneous treatment of all stenosis > 70% in vessels with diameter > 2 mm. For the costs analysis, the values from the Sistema de Informacoes Hospitalares (SIH) of the SUS table were considered as R$ 2,263.77, for the procedure; and R$ 2,034.23, per implanted stent. RESULTS: In the period from 7/2006 to 12/2007, 416 stents were implanted in 141 patients. The mean age was of 59.7 ± 9.9 years old, prevailing the male sex (68.1%). The number of vessels was 356 and the lesions number corresponded to 416. In order to obtain the complete revascularization by the coronary stent implant, it was necessary to stagger in up to four procedures. The mean time between the 1st and 2nd, 2ndand 3rd and 3rd and 4th angioplasties was of 45.8 ± 37.7; 55.4 ± 55.3 and 33.5 ± 19.1 days, respectively. CONCLUSION: The complete percutaneous revascularization in patients from the SUS with the multiarterial coronary disease, carried out in most of them staggered, causes considerable elevation of public expenses due to the increase of procedures' number.

OBJECTIVE: Cardiovascular diseases are the main cause of death in women and men in Brazil, but the trends for the death ratios for ischemic heart disease and stroke in women and men remain unknown. METHOD: In this study, the trends for the death ratios among women and men who were over 30 years of age were analyzed from 1980 to 2005. Data were collected for both the Brazilian population and the metropolitan area of São Paulo. Estimates of the population size and data for mortality were then obtained from the Brazilian Institute of Geography and Statistics and the Ministry of Health. The risk for death was adjusted using a direct method. RESULTS: Death rates due to cardiovascular disease, ischemic heart disease, and stroke have declined in both Brazil and the metropolitan region of São Paulo. A linear regression analysis revealed a similar trend for ischemic heart disease and demonstrated a male/female ratio of 1.653 ± 0.001 (r = 0.228; p = 0.262) in Brazil and 1.763 ± 0.008 (r = 0.863; p

An abnormal ratio of triglycerides to HDL-cholesterol (TG/HDL-c) indicates an atherogenic lipid profile and a risk for the development of coronary disease. OBJECTIVE: To investigate the association between lipid levels, specifically TG/HDL-c, and the extent of coronary disease. METHODS: High-risk patients (n = 374) submitted for coronary angiography had their lipid variables measured and coronary disease extent scored by the Friesinger index. RESULTS: The subjects consisted of 220 males and 154 females, age 57.2 ± 11.1 years, with total cholesterol of 210± 50.3 mg/dL, triglycerides of 173.8 ± 169.8 mg/dL, HDL-cholesterol (HDL-c) of 40.1 ± 12.8 mg/dL, LDL-cholesterol (LDL-c) of 137.3 ± 46.2 mg/dL, TG/HDL-c of 5.1 ± 5.3, and a Friesinger index of 6.6 ± 4.7. The relationship between the extent of coronary disease (dichotomized by a Friesenger index of 5 and lipid levels (normal vs. abnormal) was statistically significant for the following: triglycerides, odds ratio of 2.02 (1.31-3.1; p = 0.0018); HDL-c, odds ratio of 2.21 (1.42-3.43; p = 0.0005); and TG/HDL-c, odds ratio of 2.01(1.30-3.09; p = 0.0018). However, the relationship was not significant between extent of coronary disease and total cholesterol [1.25 (0.82-1.91; p = 0.33)] or LDL-c [1.47 (0.96-2.25; p = 0.0842)]. The chi-square for linear trends for Friesinger >; 4 and lipid quartiles was statistically significant for triglycerides (p = 0.0017), HDL-c (p = 0.0001), and TG/HDL-c (p = 0.0018), but not for total cholesterol (p = 0.393) or LDL-c (p = 0.0568). The multivariate analysis by logistic regression OR gave 1.3 ± 0.79 (p = .0001) for TG/HDL-c, 0.779 ± 0.074 (p = .0001) for HDL-c, and 1.234 ± 0.097 (p = 0.03) for LDL. Analysis of receiver operating characteristic curves showed that only TG/HDL-c and HDL-c were useful for detecting extensive coronary disease, with the former more strongly associated with disease. CONCLUSIONS: Although some lipid variables were associated with the extent of coronary disease, the ratio of triglycerides to HDL-cholesterol showed the strongest association with extent.

Background: In pediatric electrocardiography (ECG), the correct classification of segments in the medical record is subjected to various components. A conventional analysis based either on the cardiologist's skills or a quick reference to a standard normality table may lead to mistakes and to an incorrect final medical diagnosis. In this study, the evaluation of 12 specific ECG segments (ES) is defined as segmental analysis (SA). We hypothesized that a computer-aided SA can provide better results for a correct classification of pediatric ECGs, compared to the conventional analysis. This study aims to evaluate the accuracy of a computer-aided SA ECG diagnosis of pediatric patients by cardiologists. Methods: To validate the software, we selected four normal and one altered ECG as references, all with concordant reports given by two cardiologists using manual planimetry. Nineteen cardiology experts independently examined each of the five standard pediatric ECGs twice. First, the ECG was analyzed in the conventional form. Subsequently, the participants evaluated ECGs with our proposed computer-aided AS, by measuring the 12 specific ES in the grid paper and having their values entered into a custom-made software, in order to compare them with normality standards. Results: The computer-aided SA reduced ECG misreading or ECG misinterpretation errors by 83%. It also showed a more uniform, high-quality analysis of all ES (minimum of 92% correctly reviewed segments from normal pediatric ECGs) by all the participant cardiologists. Conclusions: We consider the computer-aided SA for ECG evaluation in pediatric cardiology an efficient and safe complementary method.

Background Cardiac-specific troponin detected with the new high-sensitivity assays can be chronically elevated in response to cardiovascular comorbidities and confer important prognostic information, in the absence of unstable coronary syndromes. Both diabetes mellitus and coronary artery disease are known predictors of troponin elevation. It is not known whether diabetic patients with coronary artery disease have different levels of troponin compared with diabetic patients with normal coronary arteries. To investigate this question, we determined the concentrations of a level 1 troponin assay in two groups of diabetic patients: those with multivessel coronary artery disease and those with angiographically normal coronary arteries. Methods We studied 95 diabetic patients and compared troponin in serum samples from 50 patients with coronary artery disease (mean age = 63.7, 58 % male) with 45 controls with angiographically normal coronary arteries. Brain natriuretic peptide and the oxidative stress biomarkers myeloperoxidase, nitrotyrosine and oxidized LDL were also determined. Results Diabetic patients with coronary artery disease had higher levels of troponin than did controls (median values, 12.0 pg/mL (95 % CI:10–16) vs 7.0 pg/mL (95 % CI: 5.9-8.5), respectively; p = 0.0001). The area under the ROC curve for the diagnosis of CAD was 0.712 with a sensitivity of 70 % and a specificity of 66 %. Plasma BNP levels and oxidative stress variables (myeloperoxidase, nitrotyrosine, and oxidized LDL) were not different between the two groups. In a multivariate analysis, gender (p = 0.04), serum glucose (0.03) and Troponin I (p = 0.01) had independent statistical significance. Conclusion Troponin elevation is related to the presence of chronic coronary artery disease in diabetic patients with multiple associated cardiovascular risk factors. Troponin may serve as a biomarker in this high-risk population. Trial registration http://www.controlled-trials.com Registration number:ISRCTN26970041

We evaluated the relation between lipids and precocity of coronary artery disease (CAD) in the real world as characterized by increasing statin use. The highest mean values of total cholesterol, low-density lipoprotein cholesterol, triglycerides, non-high-density lipoprotein (HDL) cholesterol, and ratio of triglycerides to HDL cholesterol were found when CAD was detected in patients who were

The aim of the present study was to evaluate the role of magnetic resonance imaging (MRI) for the non-invasive detection of coronary abnormalities and specifically the remodeling process in patients with coronary artery disease (CAD). MRI was performed in 10 control healthy subjects and 26 patients with angiographically proven CAD of the right coronary (RCA) or left anterior descending (LAD) artery; 23 patients were within two months of acute coronary syndromes, and 3 had stable angina with a positive test for ischemia. Wall thickness (WT), vessel wall area (VWA), total vessel area (TVA), and luminal area (LA) were measured. There were significant increases in WT (mean +/- SEM, RCA: 2.62 +/- 0.75 vs 0.53 +/- 0.15 mm; LAD: 2.21 +/- 0.69 vs 0.62 +/- 0.24 mm) and in VWA (RCA: 30.96 +/- 17.57 vs 2.1 +/- 1.2 mm(2); LAD: 19.53 +/- 7.25 vs 3.6 +/- 2.0 mm(2)) patients compared to controls (P0.001 for each variable). TVA values were also greater in patients compared to controls (RCA: 44.56 +/- 21.87 vs 12.3 +/- 4.2 mm(2); LAD: 31.89 +/- 11.31 vs 17.0 +/- 6.2 mm(2); P0.001). In contrast, the LA did not differ between patients and controls for RCA or LAD. When the LA was adjusted for vessel size using the LA/TVA ratio, a significant difference was found: 0.33 +/- 0.16 in patients vs 0.82 +/- 0.09 in controls (RCA) and 0.38 +/- 0.13 vs 0.78 +/- 0.06 (LAD) (P0.001). As opposed to normal controls, positive remodeling was present in all patients with CAD, as indicated by larger VWA. We conclude that MRI detected vessel wall abnormalities and was an effective tool for the noninvasive evaluation of the atherosclerotic process and coronary vessel wall modifications, including positive remodeling that frequently occurs in patients with acute coronary syndromes.

Stroke and ischemic heart disease (IHD) mortality rates were analyzed in Brazilian subjects older than 30 years of age from 1979 to 1996. Population estimates were based on census surveys. Mortality data were obtained from the Ministry of Health. For stroke, the age-adjusted death rate (ADR) dropped from 200 to 164 and from 168 to 130 deaths/100,000 population in men and women, respectively (p < 0.001), in the interval study. For IHD, the ADR dropped from 194 to 164 and from 119 to 105 deaths/100,000 population in men and women, respectively (p < 0.001), in the same time period. Mortality from stroke and IHD combined was greater in men for all age groups (p < 0.001). Stroke was the most frequent cause of death in both women and men except for men aged between 40 and 69 years, in whom IHD was more common. Stroke and IHD were the main causes of death in the Brazilian population.

Aims: We assessed quality of life (QoL) in patients with symptomatic multivessel coronary disease who randomly underwent surgery, angioplasty, or medical treatment. Although the clinical benefits of coronary interventions seem to be confirmed, their effects on QoL are still scarcely studied. Methods and Results: The Short-Form Health Survey (SF-36) questionnaire was applied in patients at baseline, 6 months, and annually until the end of the study. At five years of follow-up, SF-36 had been completed by 483 patients and at 10 years by 334 patients. Of these, 110 underwent surgical revascularization, 126 underwent angioplasty, and 98 were medically treated. All three therapeutic strategies resulted in significant improvement in all dimensions (P

Background : Women usually develop coronary artery disease (CAD) 10 years later than men do. CAD in women is associated with menopausal status and the number and intensity of risk factors. But, when the age gap between men and women narrows, less is known about the influence of risk factors on CAD. Methods : We assessed the prevalence of traditional risk factors in 850 men and 468 women with stable CAD who had mean age, 58.3±8.6 and 58.8±10.3 years ( P =NS), respectively. Results : Univariate analysis of risk factors showed that body mass index (BMI), hypertension (all three stages), diabetes, triglycerides (≥2.8 mmol/l), cholesterol (≥6.2 mmol/l) and family history were more prevalent in women. Smoking and previous myocardial infarction (MI) were more prevalent in men. Multivariable analysis disclosed hypertension, diabetes, dyslipidemia and family history as independent risk factors for women with stable CAD and smoking and previous MI as independent risk factors for men. Conclusion : Clustering of traditional risk factors may explain the precocity of CAD in women who are near in age to men.

The association between angiotensin-converting enzyme (ACE) as well as apolipoprotein B polymorphisms and dyslipidemia and coronary artery disease (CAD) is controversial. We assessed the distribution of ACE insertion and/or deletion, apolipoprotein B signal peptide insertion and/or deletion, and apolipoprotein B Xba I restriction fragment length polymorphisms in 388 nondiabetic patients. We studied 112 patients with angiographically defined asymptomatic CAD or with stable functional classes I and II angina and 139 patients with acute myocardial infarction who were age matched to 137 control subjects. Univariate analysis showed higher prevalence of Xba I X+/X+ genotype in patients with CAD (p = 0.02). ACE and apolipoprotein polymorphisms were not associated with lipid levels and the number of major coronary artery vessels with >50% reduction of lumen diameter. Overall, multivariable regression disclosed traditional risk factors and elevated levels of apolipoprotein B for men and reduced levels of apolipoprotein AI for women as independent variables for CAD. After adjustment for the most important subset of risk factors (age, hypertension, hypercholesterolemia, and smoking), apolipoprotein B Xba I polymorphism was disclosed as an independent variable for CAD. Apolipoprotein B Xba I was also selected as an independent variable for acute myocardial infarction after adjusting for age, hypertension, hypercholesterolemia, and smoking. Thus, in addition to traditional coronary risk factors, apolipoproteins B and AI, and apolipoprotein B Xba I polymorphism could be considered predictors of CAD.

Summary Background: Association between angiotensin-converting enzyme (ACE) as well as apolipoprotein (apo) AI, B, and E polymorphisms and dyslipidemia and coronary artery disease (CAD) is controversial. Hypothesis: This study assessed the distribution of ACE insertioddeletion, apo AI A/G mutation, apo B signal peptide insertioddeletion, apo B XbaI restriction fragment length, and apo E polymorphisms in 388 nondiabetic patients. Methods: The study population included I 12 patients with stable CAD, 139 patients with acute myocardial infarction (MI), and 137 age-matched control subjects. Results: Univariate analysis showed higher prevalence of XbaI X+K+ genotype in patients with CAD (p = 0.02). Angiotensin-converting enzyme and apo polymorphisms were not associated with lipid levels or severity of CAD. When all genotypes known to be related to CAD, such as ACE DD, apo A1 GG, apo B delldel, and XbaI X+X+, and E4 allele of apo E, were pooled, again no significant differences among groups were seen. Multivariate regression analysis disclosed traditional risk factors and elevated levels of apo B for men and reduced levels of apo AI for women as independent variables for CAD. Conclusions: In addition to traditional coronary risk factors, apo B and A1 could be considered predictors of CAD. No association between either form of CAD and polymorphisms was noted.

Editor da Secao: Alfredo Jose Mansur (ajmansur@incor.usp.br) Editores Associados: Desiderio Favarato (dclfavarato@incor.usp.br) Vera Demarchi Aiello (anpvera@incor.usp.br) Homem de 49 anos procurou atendimento medico por dor precordial de tres dias de duracao. Sabia ser portador de hipertensao arterial e era tabagista, com consumo de 30 cigarros diarios. Relatava o paciente que, sem antes nada sentir, comecou a apresentar dor precordial continua e epigastrica, em queimacao, sem relacao com esforcos, e houve aumento da intensidade no 3o dia, quando procurou atendimento medico. O exame fisico (26/06/03) foi normal, a frequencia cardiaca foi 68 bpm e a pressao arterial 130x80 mmHg. O eletrocardiograma (ECG) (26/06/03) revelou ritmo sinusal, frequencia de 83 bpm, SÂP=+50° para frente, SÂQRS=+30 paralelo; sobrecarga ventricular esquerda; ondas Q patologicas em dIII e aVF e discreto supradesnivelamento em aVL e V6, V7 e V8, compativel com infarto agudo do miocardio infero-latero-dorsal (fig. 1). O pico de CKMB foi de 32,8 ng/ml (27/06/03), com volta aos valores normais em 29/06/03 e o pico de troponina foi 67,2 ng/ml. A creatinina era de 1 mg/dl, hemoglobina 12 g/dl, hematocrito 35%, leucocitos 11.400/mm3, sem desvio a esquerda, plaquetas de 405.000/mm3, colesterol=139 mg/dl (HDL-colesterol de 23 mg/dl, LDL-colesterol de 97 mg/dl), triglicerides de 96 mg/dl. Foi feito o diagnostico de infarto do miocardio em evolucao e indicada cineangiocoronariografia (27/06/03), a qual revelou lesao de 95% em segmento proximal da coronaria direita, lesao de 90% no terco medio da descendente anterior, lesoes de 90% na 1a e 2a diagonais, circunflexa com 40%, 1° ramo marginal com lesao de 80% e oclusao de 2° ramo marginal esquerdo (fig. 2A, B, C). Foi realizada angioplastia com cateter-balao no 2° ramo marginal esquerdo, sem interposicao de stent, com baixo fluxo posprocedimento (TIMI 2) (fig. 2D). O ecocardiograma (30/06/03) revelou espessuras de septo e parede posterior normais (10 mm), diâmetro diastolico de ventriculo esquerdo normal (50 mm), fracao de ejecao de ventriculo esquerdo com diminuicao moderada (40%) por acinesia latero-posterior e hipocinesia inferior. O paciente evoluiu em Killip I, sem complicacoes, e permaneceu internado aguardando cirurgia de revascularizacao miocardica. No 20° dia da internacao, apos execucao de enema de rotina no preparo pre-operatorio, apresentou mal-estar geral e parada cardiorespiratoria com atividade eletrica sem pulso, nao havendo resposta as manobras de ressuscitacao, tendo falecido (15/07/03). Aspectos clinicos

Background Ischemic preconditioning is a powerful mechanism of myocardial protection and in humans it can be evaluated by sequential exercise tests. Coronary Artery Disease in the presence of diabetes mellitus may be associated with worse outcomes. In addition, some studies have shown that diabetes interferes negatively with the development of ischemic preconditioning. However, it is still unknown whether diabetes may influence the expression of ischemic preconditioning in patients with stable multivessel coronary artery disease. Methods/Design This study will include 140 diabetic and non-diabetic patients with chronic, stable coronary artery disease and preserved left ventricular systolic function. The patients will be submitted to two sequential exercise tests with 30-minutes interval between them. Ischemic parameters will be compared between diabetic and non-diabetic patients. Ischemic preconditioning will be considered present when time to 1.0 mm ST-segment deviation is greater in the second of two sequential exercise tests. Exercise tests will be analyzed by two independent cardiologists. Discussion Ischemic preconditioning was first demonstrated by Murry et al. in dog’s hearts. Its work was reproduced by other authors, clearly demonstrating that brief periods of myocardial ischemia followed by reperfusion triggers cardioprotective mechanisms against subsequent and severe ischemia. On the other hand, the demonstration of ischemic preconditioning in humans requires the presence of clinical symptoms or physiological changes difficult to be measured. One methodology largely accepted are the sequential exercise tests, in which, the improvement in the time to 1.0 mm ST depression in the second of two sequential tests is considered manifestation of ischemic preconditioning. Diabetes is an important and independent determinant of clinical prognosis. It's a major risk factor for coronary artery disease. Furthermore, the association of diabetes with stable coronary artery disease imposes worse prognosis, irrespective of treatment strategy. It’s still not clearly known the mechanisms responsible by these worse outcomes. Impairment in the mechanisms of ischemic preconditioning may be one major cause of this worse prognosis, but, in the clinical setting, this is not known. The present study aims to evaluate how diabetes mellitus interferes with ischemic preconditioning in patients with stable, multivessel coronary artery disease and preserved systolic ventricular function.

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

Background— The importance of complete revascularization remains unclear and contradictory. This current investigation compares the effect of complete revascularization on 10-year survival of patients with stable multivessel coronary artery disease (CAD) who were randomly assigned to percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). Methods and Results— This is a post hoc analysis of the Second Medicine, Angioplasty, or Surgery Study (MASS II), which is a randomized trial comparing treatments in patients with stable multivessel CAD, and preserved systolic ventricular function. We analyzed patients who underwent surgery (CABG) or stent angioplasty (PCI). The survival free of overall mortality of patients who underwent complete (CR) or incomplete revascularization (IR) was compared. Of the 408 patients randomly assigned to mechanical revascularization, 390 patients (95.6%) underwent the assigned treatment; complete revascularization was achieved in 224 patients (57.4%), 63.8% of those in the CABG group and 36.2% in the PCI group ( P =0.001). The IR group had more prior myocardial infarction than the CR group (56.2%×39.2%, P =0.01). During a 10-year follow-up, the survival free of cardiovascular mortality was significantly different among patients in the 2 groups (CR, 90.6% versus IR, 84.4%; P =0.04). This was mainly driven by an increased cardiovascular specific mortality in individuals with incomplete revascularization submitted to PCI ( P =0.05). Conclusions— Our study suggests that in 10-year follow-up, CR compared with IR was associated with reduced cardiovascular mortality, especially due to a higher increase in cardiovascular-specific mortality in individuals submitted to PCI. Clinical Trial Registration Information— URL: http://www.controlled-trials.com . Registration number: ISRCTN66068876.

To investigate, in male Wistar rats, the effects of long-term moderate red wine (RW) consumption (equivalent to ∼0.15 mg% resveratrol RS), or RS in low (L, 0.15 mg%) or high (H, 400 mg%) doses in chow.Both RW and RS exhibit cardioprotection. RS extends lifespan in obese rats. It is unclear whether RW consumption or low-dose RS delay vascular aging and prolong life span in the absence of overt risk factors.Endpoints were aerobic performance, exercise capacity, aging biomarkers (p53,p16,p21, telomere length and telomerase activity in aortic homogenates), vascular reactivity. Data were compared with controls (C) given regular chow.Expressions of p53 decreased ∼50% ∼with RW and LRS (p0.05 vs. C), p16 by ∼29% with RW (p0.05 vs. C) and p21 was unaltered. RW and LRS increased telomere length6.5-fold vs. C, and telomerase activity increased with LRS and HRS. All treatments increased aerobic capacity (C 32.5 ± 1.2, RW 38.7 ± 1.7, LRS 38.5 ± 1.6, HRS 38.3 ± 1.8 mlO(2) min(-1) kg(-1)), and RW or LRS also improved time of exercise tolerance vs. C (p0.05). Endothelium-dependent relaxation improved with all treatments vs. C. Life span, however, was unaltered with each treatment vs. C = 673 ± 30 days, p = NS.RW and LRS can preserve vascular function indexes in normal rats, although not extending life span. These effects were translated into better aerobic performance and exercise capacity.

FUNDAMENTO: Conhecer fatores de risco e manifestações clínicas da doença arterial coronariana (DAC) permite-nos intervir de maneira mais eficaz junto a uma determinada população. OBJETIVO: Identificar perfis clínicos e angiográficos dos pacientes submetidos a cateterismo cardíaco, atendidos em um hospital terciário e tratados por meio de intervenções coronarianas percutâneas (ICP). MÉTODOS: Casuística de 1.282 pacientes submetidos a 1.410 cateterismos cardíacos, selecionados de mar/2007-mai/2008 em um banco de dados de um hospital geral para diagnóstico de doença arterial coronariana (DAC). Fatores de risco, indicação do exame, detalhes técnicos da ICP e desfechos intra-hospitalares foram prospectivamente coletados. RESULTADOS: Foram 688 (54,0%) pacientes do sexo masculino, com média de idade de 65,4 ± 10,9 anos, sendo 20,0% acima dos 75 anos. O quadro clínico confirmado com mais frequência foi o de síndrome coronariana aguda (SCA) sem supradesnivelamento do segmento ST (SST) (38,7%). A DAC multiarterial ocorreu em 46,4%, foi indicada ICP em 464 pacientes, sendo tratadas 547 lesões-alvo (tipo B2 ou C, em 86,0%), sendo destas, 14,0% tratadas com stent farmacológico. Dentre os IAM com SST, ICP primária foi realizada em 19,0% dos pacientes, sendo que, destes, 77,0% foram transferidos dos hospitais de origem tardiamente (ICP tardia) e não receberam trombolítico prévio, e 4,0% realizaram ICP de resgate. Foi obtido sucesso angiográfico em 94,2% das ICPs. Aconteceu óbito em 5,6% dos pacientes, tendo estes uma média de idade de 75,2 ± 10,2 anos. CONCLUSÃO: Observamos predomínio de idosos (estando 20,1% > 75 anos) e do sexo masculino. Dos fatores de risco para DAC, os mais frequentes foram hipertensão arterial sistêmica e dislipidemia. Ocorreu predomínio da SCA. A idade > 75 anos, DAC multiarterial e a insuficiência renal crônica foram os preditores de óbito intra-hospitalar. BACKGROUND: Knowing the risk factors and clinical manifestations of coronary artery disease (CAD) allows us to intervene more effectively with a particular population. OBJECTIVE: To identify clinical and angiographic profiles of patients undergoing cardiac catheterization, treated at a tertiary hospital and treated by percutaneous coronary interventions (PCI). METHODS: The study of 1,282 patients who underwent 1,410 cardiac catheterizations, selected from March/2007 to May/2008 from a database in a general hospital for diagnosis of coronary artery disease (CAD). Risk factors, indication for examination, technical details of PCI and in-hospital outcomes were prospectively collected. RESULTS: There were 688 (54.0%) males, mean age 65.4 ± 10.9 years and 20.0% above 75 years age. The most frequent clinical condition was acute coronary syndrome (ACS) without ST-segment elevation (STS) (38.7%). The multi artery CAD occurred in 46.4%, PCI was indicated in 464 patients, 547 target lesions were treated (type B2 or C, 86.0%), and of these, 14.0% treated with drug eluting stents. Among those with AMI with STS, primary PCI was performed in 19.0% of the patients, from these, 77.0% were transferred from the origin hospitals late (late PCI) and had not received prior thrombolytic, and 4.0% had PCI rescue. Angiographic success was achieved in 94.2% of PCIs. Death occurred in 5.6% of patients, with average age of 75.2 ± 10.2 years. CONCLUSION: The prevalence of elderly (20.1% being > 75 years) and male was observed. From the risk factors for CAD, the most common were systemic hypertension and dyslipidemia. There was a predominance of ACS. Age > 75 years old, multiarterial CAD and chronic renal failure were predictors of in-hospital deaths. FUNDAMENTO: Conocer factores de riesgo y manifestaciones clínicas de la enfermedad arterial coronaria (EAC) nos permite intervenir de manera más eficaz en una determinada población. OBJETIVO: Identificar perfiles clínicos y angiográficos de los pacientes sometidos a cateterismo cardíaco, atendidos en un hospital terciario y tratados por medio de intervenciones coronarias percutáneas (ICP). MÉTODOS: Casuística de 1.282 pacientes sometidos a 1.410 cateterismos cardíacos, seleccionados de mar/2007-may/2008 en un banco de datos de un hospital general para diagnóstico de enfermedad arterial coronaria (EAC). Factores de riesgo, indicación del examen, detalles técnicos de la ICP y desenlaces intrahospitalarios fueron prospectivamente colectados. RESULTADOS: Fueron 688 (54,0%) pacientes del sexo masculino, con media de edad de 65,4 ± 10,9 años, siendo 20,0% encima de los 75 años. El cuadro clínico confirmado con más frecuencia fue el de síndrome coronario agudo (SCA) sin supradesnivel del segmento ST (SST) (38,7%). La EAC multiarterial ocurrió en 46,4%, fue indicada ICP en 464 pacientes, siendo tratadas 547 lesiones-blanco (tipo B2 o C, en 86,0%), siendo de éstas, 14,0% tratadas con stent farmacológico. Entre los IAM con SST, ICP primaria fue realizada en 19,0% de los pacientes, siendo que, de éstos, 77,0% fueron transferidos de los hospitales de origen tardíamente (ICP tardía) y no recibieron trombolítico previo, y 4,0% realizaron ICP de rescate. Fue obtenido éxito angiográfico en 94,2% de las ICPs. Sucedió óbito en 5,6% de los pacientes, teniendo éstos una media de edad de 75,2 ± 10,2 años. CONCLUSIÓN: Observamos predominio de añosos (siendo 20,1% > 75 años) y del sexo masculino. De los factores de riesgo para EAC, los más frecuentes fueron hipertensión arterial sistémica y dislipidemia. Ocurrió predominio de la SCA. La edad > 75 años, EAC multiarterial y la insuficiencia renal crónica fueron los predictores de óbito intrahospitalario.