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Introduction: Compared to bare-metal stents (BMS), drug-eluting stents reduce stent restenosis and improve subsequent revascularization rates. The impact on patients’ survival has been the subject of debate. Objective: To assess the long-term (10-year) survival of patients undergoing percutaneous coronary intervention (PCI) with first-generation sirolimus-eluting stents (SES) in comparison with BMS. Methods: In a single-center registry, 600 consecutive patients who underwent successful PCI with SES between April 2002 and February 2003 were compared to 594 patients who underwent PCI with BMS between January 2002 and April 2002, just before the introduction of SES. Clinical and procedural data were collected at the time of intervention and 10-year survival status was assessed via the national life status database. Results: All baseline characteristics were similar between groups except for smaller stent diameter (2.84±0.38 vs. 3.19±0.49 mm; p

Introduction Recently during the COVID-19 pandemic there was a general belief in a reduction of hospital admissions due to non-infectious causes, namely cardiovascular diseases. Objectives To evaluate the impact of the pandemic in the admissions by ST elevation acute myocardial infarction (STEMI), during the first pandemic wave. Methods Multicentric and retrospective analysis of consecutive patients presenting in two Portuguese hospital centers with STEMI in two sequential periods – P1 (1st March to 30th April) and P2 (1st May to 30th June). A comparison of patient's clinical and hospital outcomes data was performed between the year 2020 and 2017 to 2019 for both periods. Results A total of 347 consecutive STEMI patients were included in this study. The patient's baseline characteristics and cardiovascular risk factors were similar across the considered periods. During P1 of 2020, in comparison with previous years, a reduction in the number of STEMI patients was observed (26.0±4.2 vs 16.5±4.9 cases per month; p=0.033), contrary to what was observed during P2 (19.5±0.7 vs 20.5±0.7 cases per month; p=0.500). Percutaneous coronary interventions in the setting of failed thrombolysis were more frequent (1.9% vs 9.1%; p=0.033). A global trend in longer delays in time-key bundles of STEMI care was noted, namely pain to first medical contact, door to needle, door to wire crossing and symptoms to wire crossing times, however without statistical significance. Mortality rate was six-fold higher during P1 comparing to previous years (1.9% vs 12.1%; p=0.005), and also an increase in the number of mechanical complications (0.0% vs 3.0%; p=0.029) was observed. Conclusions During the first COVID-19 pandemic wave there were fewer patients presenting with STEMI at catheterization laboratory for coronary angioplasty. These patients presented more mechanical complications and higher mortality rates. Funding Acknowledgement Type of funding sources: None.

Current recommendations on the optimal revascularization strategy in Non-ST-elevation myocardial infarction (NSTEMI) with left main (LM) or multivessel coronary disease (MVD) are based upon randomized clinical trials conducted in stable coronary artery disease. In a real-world contemporary observational registry, we compared the long-term outcome of NSTEMI patients with LM/MVD (n = 1,104) submitted to coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or optimized medical therapy (OMT). The primary end point was 5-year all-cause mortality. Results were assessed in the entire population (CABG 289, PCI 399, and OMT 416) and in a propensity score-matched cohort of CABG (n = 159) and PCI (n = 159). Crude 5-year mortality rates in CABG and PCI were 25.3% versus 29.6%, respectively (unadjusted hazard ratio [HR] 1.2; 95% confidence intervals [CI] 0.9 to 1.6; p = 0.212); OMT, however, was associated with a twofold higher risk of mortality when compared with any revascularization strategy (unadjusted HR 2.0; 95% CI 1.7 to 2.5; p0.001). After propensity score-matching and multivariate analysis, there was a trend toward a higher incidence of the primary end point in patients who underwent PCI versus CABG (31% vs 21%; adjusted HR 1.52; 95% CI 0.93 to 2.50; p = 0.094). This was a consistent finding over subgroups deemed clinically relevant, such as in patients with LM or proximal left anterior descending disease, SYNergy between percutaneous coronary intervention with TAXus ≥23 and left ventricle ejection fraction40%. In conclusion, in a real-world cohort of NSTEMI patients with LM/MVD, those selected for OMT had a dire outcome. Although adjusted 5-year mortality was statistically similar between revascularization strategies, there was a trend favoring CABG, which might be the preferred option in LM, proximal LAD, SYNergy between percutaneous coronary intervention with TAXus ≥23, and left ventricle ejection fraction40% subgroups.

Introduction The evolution of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) techniques made the choice of the optimal revascularization strategy of unprotected left main coronary disease (ULMD) challenging. Scoring systems are useful tools for the decision-making process and for risk stratification. Purpose To evaluate 1) the performance of the SYNTAX score I (SSI) and II (SSII) and Euroscore II (EII) in risk stratification and 2) the outcome predictors of patients (pts) with ULMD, according to the treatment strategy chosen (PCI or CABG). Methods Retrospective single centre cohort study of 440 consecutive pts (age 68±11 years; 76.6% male) with significant ULMD (defined as left main coronary artery stenosis >50%, with no patent arterial or venous bypass graft to left anterior descending artery), who were submitted to PCI (n=135) or CABG (n=307), between January 2006 and December 2018. Median follow-up (FU) was 4.0±1.8 years. The primary outcome was a composite of cardiovascular (CV) death, non-fatal myocardial infarction (MI) and target lesion revascularization (TLR). Results During the FU period, there were 112 (25.5%) CV deaths, 26 (5,9%) non-fatal MI and 53 (12.0%) TLR. Multivariate analysis of pts submitted to PCI showed that SSII and anatomical complete revascularization were independent predictors of the primary outcome (HR 1.045, CI 1.015–1.075, p=0.003 and HR 3,014, CI 1.655–5.489, p In the CABG cohort, only SSII was an independent predictor of the outcome by multivariate analysis (HR 1.061, CI 1.035–1.086, p The ROC curve analysis for all cohort presented no discriminative capacity for SSI (AUC 0.538, CI 0.482–0.593, p=0.186) and a weak discrimination for SSII (AUC 0.659, CI 0.605–0.713, p Conclusion In a real-world ULMD population, the most common risk scores, mainly those integrating anatomical and clinical features, presented a very modest role in the risk stratification, both in chronic and acute coronary syndromes. However, in pts with ULMD submitted to PCI, those risk scores had a more significant role in the risk stratification of these pts. Figure 1. SSI, SSII, EII ROC curves for all cohort Funding Acknowledgement Type of funding source: None

Refractory angina is defined as persistent angina (≥3 months) despite optimal medical and interventional therapies. It is increasing in frequency, due to the success of current medical and interventional therapies in improving the prognosis of coronary artery disease. Long-term mortality is similar to that of patients with asymptomatic stable disease, but it affects patients’ quality of life, and has a significant impact on health care resources. Several therapeutic targets have been investigated, most with disappointing results. Many of the techniques have been abandoned because of lack of efficacy, safety issues, or economic and logistic limitations to wider applicability. The primary focus of this review is the coronary sinus Reducer, supporting evidence for which, although scarce, is promising regarding safety and efficacy in improving anginal symptoms and quality of life. It is also accessible to virtually all interventional cardiology departments.

Introduction: Surgical risk scores are widely used to identify patients at high surgical risk who may benefit from transcatheter aortic valve implantation (TAVI). A multiparametric TAVI mortality risk score based on a French registry (FRANCE-2) has recently been developed. The aim of our study was to compare the 30-day mortality prediction performance of the FRANCE-2, EuroSCORE II and STS scores. Methods: We retrospectively studied 240 patients from a single-center prospective registry who underwent TAVI between January 2008 and December 2015. All scores were assessed for calibration and discrimination using calibration-in-the-large and ROC curve analysis, respectively. Results: The observed mortality was 5.8% (n=14). The median EuroSCORE II, STS and FRANCE-2 scores were 5.0 (IQR 3.2-8.3), 5.1 (IQR 3.6-7.1) and 2.0 (IQR 1.0-3.0), respectively. Discriminative power was greater for EuroSCORE II (C-statistic 0.67) and STS (C-statistic 0.67) than for FRANCE-2 (C-statistic 0.53), but this was not statistically significant (p=0.26). All scores showed adequate calibration. Conclusions: All scores showed modest performance in early mortality prediction after TAVI. Despite being derived from a TAVI population, FRANCE-2 was no better than surgical risk scores in our population. Resumo: Introdução: Os scores de risco cirúrgico têm sido amplamente usados para identificar doentes com alto risco cirúrgico que podem beneficiar da implantação de válvula aórtica por via percutânea (TAVI). Foi recentemente apresentado um «score de risco» multiparamétrico de mortalidade por TAVI com base num registo francês – FRANCE 2. O objetivo do nosso estudo foi comparar o desempenho do FRANCE 2, EuroSCORE II (ES II) e STS-Prom (STS) em prever a mortalidade a 30 dias nos doentes submetidos a TAVI. Métodos: Foram estudados retrospetivamente 240 doentes de um registo prospetivo de centro único que foram submetidos a TAVI entre janeiro de 2008 e dezembro de 2015. Todos os scores foram avaliados para discriminação e calibração, com o uso da análise de curvas ROC e da análise de calibration-in-the-large, respetivamente. Resultados: A mortalidade observada foi de 5,8% (n = 14). A mediana do ES II, STS II e FRANCE II foi de 5,0 (IQR 3,2-8,3), 5,1 (IQR 3,6-7,1) e 2,0 (IQR 1,0-3,0), respetivamente. O poder discriminatório foi maior para ES II (C-statistic 0,67) e STS (C-statistic 0,67) quando comparado com o FRANCE 2 (C-statistic 0,53), embora não fosse estatisticamente significativo (p = 0,26). Todos os scores apresentaram calibração adequada. Conclusões: Todos os scores apresentaram um desempenho modesto em prever a mortalidade precoce após TAVI. Apesar de ser derivado de uma população de doentes submetidos a TAVI, o FRANCE-2 não mostrou ser melhor do que os scores de risco cirúrgicos na nossa população. Keywords: Aortic stenosis, Transcatheter aortic valve implantation, Risk scores, Early mortality, Palavras-chave: Estenose aórtica, TAVI, Scores de risco, Mortalidade precoce

Introduction: Aortic stenosis is the most prevalent type of valvular disease in Europe. Surgical aortic valve replacement (SAVR) is the standard therapy, while transcatheter aortic valve implantation (TAVI) is an alternative in patients at unacceptably high surgical risk. Assessment by a heart team is recommended by the guidelines but there is little published evidence on this subject. The purpose of this paper is to describe the experience of a multidisciplinary TAVI program that began in 2008. Methods: The heart team prospectively assessed 473 patients using a standardized approach. A total of 214 patients were selected for TAVI and 80 for SAVR. Demographic, clinical and procedural characteristics and long-term success rates were compared between the groups. Results: TAVI patients were older than the SAVR group (median 83 vs. 81 years), and had higher surgical risk scores (median EuroSCORE II 5.3 vs. 3.6% and Society of Thoracic Surgeons score 5.1 vs. 3.1%), as did the patients under medical treatment only. These scores were unable to assess multiple comorbidities. Patients’ outcomes were different between the three groups (mortality with SAVR 25% vs. TAVI 37.6% vs. conservative therapy 57.6%, p=0.001). Conclusions: The heart team program was able to select candidates appropriately for TAVI, SAVR and conservative treatment, taking into account the risk of both invasive treatments. The use of a prospective standardized heart team approach is recommended, but requires continuous monitoring to ensure effectiveness in a timely manner. Resumo: Introdução: A estenose aórtica é atualmente a doença valvular mais prevalente na Europa. A substituição valvular aórtica cirúrgica (SVAC) é atualmente considerada a terapêutica de primeira linha, a implantação de válvula aórtica percutânea (VAP) é considerada uma opção em doentes com elevado risco cirúrgico. A avaliação dos doentes pelo Heart Team encontra-se preconizada pelas recentes guidelines publicadas de doenças valvulares, contudo existem poucas publicações acerca dessa temática. O objetivo deste manuscrito é descrever a experiência de um programa multidisciplinar VAP, iniciado em 2008. Métodos: O Heart Team avaliou de forma prospetiva e padronizada 473 doentes. Desses, 214 foram selecionados para VAP e 80 para SVAC. Os grupos foram comparados no que respeita às suas características demográficas, clínicas, de procedimento e quanto à sua evolução (mortalidade). Resultados: O grupo VAP apresentou maior idade do que o grupo SVAC (mediana 83 versus 81 anos) e apresentou scores de risco cirúrgico mais elevados (mediana Euroscore II 5,3 versus 3,6% e STS 5,1 versus 3,1%), tal como o grupo de doentes apenas sob terapêutica médica. Esses scores não foram capazes de avaliar múltiplas comorbilidades. A mortalidade entre os três grupos apresentou diferenças com significado estatístico (SVAC 25% versus VAP 37,6% versus terapêutica conservadora 57,6%, p=0,001). Conclusões: O programa Heart Team foi capaz de selecionar de forma adequada os doentes para as diversas estratégias terapêuticas tendo em conta o risco de ambos os procedimentos invasivos. Uma abordagem eficiente e standardizada pela Heart Team deve ser estimulada, necessitando de reavaliação continua. Keywords: Severe aortic stenosis, Transcatheter aortic valve implantation, Surgical aortic valve replacement, Heart team, Standardization, Palavras-chave: Estenose aórtica grave, Válvula aórtica percutânea, Substituição valvular aórtica cirúrgica, Heart Team, Standardização

Aim High-sensitivity troponin assays (HST) entered the clinical arena to facilitate exclusion of ACS in the emergency department (ER) in patients presenting with chest pain. Due to its higher sensitivity there is the potential for an overestimation of the diagnosis of NSTEMI, and possibly ACS overall. We assessed the impact of HST in the classification of ACS (NSTEMI vs UA) and its ability to predict obstructive coronary disease (CAD), in a population of pts referred to coronary angiography (ICA). Methods Retrospective analysis of 1844 pts with suspected NSTEMI or UA referred for ICA from a single ER between Feb 2013 and Nov 2018. Standard Troponin-I was used until Feb 2016 and HST thereafter. The characteristics of UA and NSTEMI pts before and after the introduction of HST were compared. Multivariate binary logistic regression models were used to access the association of different troponin assays with CAD (>50% for LM and >70% for the remaining). Sensitivity, specificity, NPV and PPV for angiographic CAD were also determined. Results The relative proportion of patients with UA and NSTEMI was similar between study periods: 31% vs 29% and 69% vs 71%, respectively (p=0.3). Clinical and angiographic characteristics did not differ in UA pts before and after the use of HST. NSTEMI patients in the HST era were less frequently women (39% vs 32%, p=0.026), had higher creatinine (0.93 IQR 0.75–1.3 vs 1.0 IQR 0.82–1.38), higher number of lesions (2 IQR 1–4 vs 3 IQR 1–4) and a lower rate of normal coronary arteries (10.5% vs 3.9%, p CAD/PCI in ACS within each period Conclusion The introduction of HST did not result in an increase of the diagnosis of NSTEM vs UA, suggesting that clinical judgment remains an important determinant of the diagnosis of ACS. Also there was no evidence of an increase in PCI rates, despite worse CAD severity in NSTEMI patients.

Background/Purpose In patients with right ventricular pacing, the ECG shows a left bundle branch block (LBBB) pattern. There are several criteria to diagnose ST-elevation myocardial infarction (STEMI) in patients with LBBB. The aim of this study was to validate and compare Sgarbossa's with two new scores – Selvester's and Smith's – in this context. Methods We identified pacemaker patients submitted to coronary angiography due to acute coronary syndrome. ECGs were analyzed by 2 blinded cardiologists. STEMI was defined according to angiographic and biochemical criteria. Sensitivity, specificity, positive and negative predictive values were calculated. Results Forty-three patients with ventricular pacing were included for analysis. STEMI was diagnosed in 26 patients (60%). The most sensitive score was Selvester's (38.5%; 95% CI: 20.2–59.4) while the most specific was Sgarbossa's (100%; 95% CI: 80.5–100). Conclusions The sequential application of these scores proved to be clinically useful in the context of STEMI.

Introduction: Natriuretic peptides are ubiquitously used for diagnosis, follow-up and prognostic assessment in various heart conditions. N-terminal pro-brain natriuretic peptide (NT-proBNP) correlates with aortic stenosis severity, however its significance after transcatheter aortic valve implantation (TAVI) is not well established. Aim: We aimed to assess the prognostic value of NT-proBNP at one year in patients undergoing TAVI. Methods: This single-center retrospective analysis included 151 patients in whom both baseline and one-month post-procedure NT-proBNP were measured, from 206 consecutive patients undergoing TAVI between November 2008 and December 2014. The best cut-off values of both baseline and one-month post-TAVI NT-proBNP for one-year mortality were determined by receiver operating characteristic curve analysis. Independent predictors of one-year mortality were assessed by Cox regression. Results: The areas under the curve of baseline and post-procedural NT-proBNP for one-year mortality were 0.60 and 0.72, with the best cut-off values of 1350 and 2500 pg/ml, respectively. Atrial fibrillation, procedure-related major bleeding, baseline NT-proBNP higher than 1350 pg/ml, post-procedural NT-proBNP higher than 2500 pg/ml, higher creatinine and Society of Thoracic Surgeons score, and lower left ventricular ejection fraction were associated with one-year mortality. Only post-procedural NT-proBNP was independently and negatively associated with one-year survival (HR 5.9, 95% CI 1.6-21.7, p=0.008). Conclusions: Baseline NT-proBNP did not predict one-year mortality; on the other hand one-month post-procedural NT-proBNP higher than 2500 pg/ml may identify a high-risk subset of patients, allowing better management, care and hypothetically outcome. Resumo: Introdução: Os peptídeos natriuréticos são usados de forma ubíqua para o diagnóstico, seguimento e avaliação prognóstica em cardiologia. O NT-ProBNP correlaciona-se com a gravidade da estenose aórtica, porém o seu significado após VAP não está bem estabelecido. Objetivo: Avaliar o valor prognóstico do NT-ProBNP nos doentes submetidos a VAP. Métodos: Análise retrospetiva de 151 doentes, de um registo de 206 doentes consecutivos de novembro de 2008 a dezembro de 2014, com doseamentos de NT-ProBNP basal e após um mês da implantação de VAP. Os preditores independentes de mortalidade a um ano foram avaliados por regressão Cox. Resultados: Os melhores valores discriminativos de NT-ProBNP basal e pós-procedimento foram 1.350 e 2.500, respetivamente. Somente um valor de NT-ProBNP pós-procedimento superior a 2.500pg/ml foi preditor independente e negativamente associado à sobrevida a um ano (HR 5,9; 95% IC 1,6-21,7; p = 0,008). Conclusões: O NT-ProBNP basal não previu a mortalidade a um ano. Por outro lado, o NT-ProBNP superior a 2.500pg/ml após o procedimento identificou um subgrupo de doentes de alto risco, permitiu um melhor manejo, seguimento e possíveis resultados. Keywords: Transcatheter aortic valve replacement, Aortic valve stenosis, N-terminal pro-BNP, Prognosis, Palavras-chave: Válvula aórtica percutânea, Estenose aórtica, N-terminal pro-BNP, Prognóstico

5-Fluorouracil (5-FU) is a first-line agent in several cancer therapy regimens. Cardiotoxicity is common, especially in patients with coronary artery disease. We report the case of an acute coronary syndrome presumably induced by 5-FU in a patient with previously unknown and asymptomatic corotabelnary artery disease and with an estimated intermediate risk for cardiovascular events. Pre-chemotherapy risk assessment and optimal patient care are still not standardized in this clinical scenario. Resumo: O 5-flurouracilo é um agente de primeira linha no tratamento de várias neoplasias. Associa-se frequentemente a toxicidade cardíaca, particularmente em doentes com doença coronária. O caso apresentado ilustra uma síndrome coronária aguda presumivelmente precipitada por 5-FU, num doente com doença coronária previamente assintomática e desconhecida e com risco estimado de eventos cardiovasculares de nível intermédio. A avaliação de risco pré-quimioterapia e a melhor abordagem para a prevenção e manejo desse cenário clínico permanecem por definir. Keywords: 5-Fluorouracil, Angina pectoris, Cardiotoxicity, Palavras-chave: 5-FU, Angina pectoris, Cardiotoxicidade

Resumo: O 5‐flurouracilo é um agente de primeira linha no tratamento de várias neoplasias. Associa‐se frequentemente a toxicidade cardíaca, particularmente em doentes com doença coronária. O caso apresentado ilustra uma síndrome coronária aguda presumivelmente precipitada por 5‐FU, num doente com doença coronária previamente assintomática e desconhecida e com risco estimado de eventos cardiovasculares de nível intermédio. A avaliação de risco pré‐quimioterapia e a melhor abordagem para a prevenção e manejo desse cenário clínico permanecem por definir. Abstract: 5-Fluorouracil is a first‐line agent in several cancer‐therapy regimens. Cardiotoxicity is common, with coronary artery disease being an important risk factor. We report the case of an acute coronary syndrome presumably induced by 5‐FU, in a patient with previously unknown and asymptomatic coronary artery disease, with an estimated intermediate risk for cardiovascular events. Pre‐chemotherapy risk evaluation and optimal patient care are still not standardized in this clinical scenario. Palavras‐chave: 5‐FU, Angina Pectoris, Cardiotoxicidade, Keywords: 5‐FU, Angina pectoris, Cardiotoxicity