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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: 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.

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.

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.

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

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.

Background— Coronary artery bypass graft surgery with cardiopulmonary bypass is a safe, routine procedure. Nevertheless, significant morbidity remains, mostly because of the body’s response to the nonphysiological nature of cardiopulmonary bypass. Few data are available on the effects of off-pump coronary artery bypass graft surgery (OPCAB) on cardiac events and long-term clinical outcomes. Methods and Results— In a single-center randomized trial, 308 patients undergoing coronary artery bypass graft surgery were randomly assigned: 155 to OPCAB and 153 to on-pump CAB (ONCAB). Primary composite end points were death, myocardial infarction, further revascularization (surgery or angioplasty), or stroke. After 5-year follow-up, the primary composite end point was not different between groups (hazard ratio 0.71, 95% CI 0.41 to 1.22; P =0.21). A statistical difference was found between OPCAB and ONCAB groups in the duration of surgery (240±65 versus 300±87.5 minutes; P P P P P P P Conclusions— No difference was found between groups in the primary composite end point at 5-years follow-up. Although OPCAB surgery was related to a lower number of grafts and higher episodes of atrial fibrillation, it had no significant implications related to long-term outcomes. Clinical Trial Registration— URL: http://www.controlled-trials.com. Unique identifier: ISRCTN66068876.

Background— This study compared the 10-year follow-up of percutaneous coronary intervention (PCI), coronary artery surgery (CABG), and medical treatment (MT) in patients with multivessel coronary artery disease, stable angina, and preserved ventricular function. Methods and Results— The primary end points were overall mortality, Q-wave myocardial infarction, or refractory angina that required revascularization. All data were analyzed according to the intention-to-treat principle. At a single institution, 611 patients were randomly assigned to CABG (n=203), PCI (n=205), or MT (n=203). The 10-year survival rates were 74.9% with CABG, 75.1% with PCI, and 69% with MT ( P =0.089). The 10-year rates of myocardial infarction were 10.3% with CABG, 13.3% with PCI, and 20.7% with MT ( P P P Conclusions— Compared with CABG, MT was associated with a significantly higher incidence of subsequent myocardial infarction, a higher rate of additional revascularization, a higher incidence of cardiac death, and consequently a 2.29-fold increased risk of combined events. PCI was associated with an increased need for further revascularization, a higher incidence of myocardial infarction, and a 1.46-fold increased risk of combined events compared with CABG. Additionally, CABG was better than MT at eliminating anginal symptoms. Clinical Trial Registration Information— URL: http://www.controlled-trials.com. Registration number: ISRCTN66068876.

FUNDAMENTO: As doenças circulatórias (DC) são as principais causas de morte no Brasil, com predomínio das doenças cerebrovasculares (DCbV). Nos países desenvolvidos, predominam as doenças isquêmicas do coração (DIC). OBJETIVO: Analisar a relação entre DCbV/DIC em homens e mulheres a partir de 30 anos. MÉTODOS: As estimativas da população e os dados de mortalidade para DC, DIC e DCbV foram obtidos do Ministério da Saúde para o período entre 1980 e 2005. O risco de morte por DIC e DCbV por 100.000 habitantes e a relação entre DCbV/DIC foram analisados nas faixas etárias decenais a partir de 30 anos. O risco de morte foi ajustado pelo método direto, usando como população padrão a população mundial de 1960. RESULTADOS: Observou-se aumento exponencial do risco de morte por DIC e DCbV, com o aumento da faixa etária. DCbV foi a principal causa de morte no Brasil até 1996, quando passou a predominar a DIC. Foi observada redução de 33,25% no risco de morte por DC na população brasileira. Na região metropolitana de São Paulo, houve uma diminuição de 45,44%, entre 1980 e 2005. A relação DCbV/DIC foi maior nas mulheres mais jovens: de 2,53 em 1980 e 2,04 em 2005 para a população brasileira, e de 2,76 em 1980 e 1,96 em 2005 na região metropolitana de São Paulo, com decréscimo nas faixas etárias subsequentes. Nos homens, a relação DCbV/DIC foi próximo de

FUNDAMENTO: A influência da vacinação contra o vírus da gripe na mortalidade por doenças cardiovasculares (DCV) é controversa. OBJETIVO: Analisar a mortalidade por DCV antes e depois do início da vacinação contra a gripe na cidade de São Paulo. MÉTODOS: Analisou-se a mortalidade por doenças isquêmicas do coração (DIC), doenças cerebrovasculares (DCbV) e por causas externas (CE) na população da região metropolitana de São Paulo com idade > 60 anos, antes e depois do programa de vacinação contra a gripe. As estimativas da população e os dados de mortalidade foram, respectivamente, obtidos do Instituto Brasileiro de Geografia e Estatística (IBGE; www.ibge.gov.br) e do Ministério da Saúde (www.datasus.gov.br) para o período entre 1980 e 2006. O risco de morte foi ajustado pelo método direto, em que se utilizou a população padrão (mundial) referente a 1960. RESULTADOS: As comparações entre as inclinações das linhas de regressão foram semelhantes para as DCbV (p = 0,931) e CE (p = 0,941), porém, para as DIC (p = 0,022), observou-se significativa redução da linha do período pós-vacina quando comparada com a linha do período pré-vacina. Mudança na tendência da mortalidade após 1996 foi significativa somente para as DIC (p = 0,022), permanecendo inalterada para as DCbV (p = 0,931) e CE (p = 0,941). CONCLUSÃO: A vacinação contra a gripe associou-se a significativa redução da mortalidade por DIC. BACKGROUND: The effect of vaccination against the influenza virus on the mortality due to cardiovascular diseases (CVD) remains controversial. OBJECTIVE: To analyze the mortality by CVD before and after the start of the vaccination against the Influenza virus in the city of Sao Paulo, Brazil. METHODS: We analyzed the mortality due to ischemic heart diseases (IHD), cerebrovascular diseases (CbVD) and external causes (EC) in the population of the metropolitan region of the city of Sao Paulo, Brazil, aged > 60 years, before and after the start of the vaccination program against Influenza. The population estimates and mortality data were obtained, respectively, from the Brazilian Institute of Geography and Statistics (IBGE; www.ibge.gov.br) and from the Brazilian Ministry of Health (www.datasus.gov.br) for the period between 1980 and 2006. The risk of death was adjusted by the direct method, using the 1960 world standard population. RESULTS: The comparisons between the inclinations of the regression lines were similar for CbVD (p = 0.931) and EC (p = 0.941); however, for IHD (p = 0.022), a significant decrease was observed in the regression line of the post-vaccination period, when compared to the pre-vaccination period. A change in the tendency towards mortality after 1996 was significant only for the IHD (p=0.022), remaining unaltered for the CbVD (p=0.931) and EC (p=0.941). CONCLUSION: The vaccination against the Influenza virus was associated with a significant decrease in the mortality due to IHD. FUNDAMENTO: La influencia de la vacunación contra el virus de la gripe en la mortalidad por enfermedades cardiovasculares (ECV) es controvertida. OBJETIVO: Analizar la mortalidad por ECV antes y después del inicio de la vacunación contra la gripe en la ciudad de São Paulo. MÉTODOS: Se analizó la mortalidad por enfermedades isquémicas del corazón (EIC), enfermedades cerebrovasculares (ECbV) y por causas externas (CE) en la población de la región metropolitana de São Paulo con edad > 60 años, antes y después del programa de vacunación contra la gripe. Las estimativas de la población y los datos de mortalidad fueron, respectivamente, obtenidos del Instituto Brasileño de Geografía y Estadística (IBGE; www.ibge.gov.br) y del Ministerio de la Salud (www.datasus.gov.br) para el período entre el 1980 y 2006. Se estimó el riesgo de muerte por el método directo de ajuste, en el que se utilizó la población estándar (mundial) referente al 1960. RESULTADOS: Las comparaciones entre las inclinaciones de las líneas de regresión resultaron semejantes para las ECbV (p = 0,931) y CE (p = 0,941), sin embargo, para las EIC (p = 0,022), se observó significativa reducción de la línea del período postvacuna cuando comparada con la línea del período prevacuna. El cambio en la tendencia de la mortalidad tras el 1996 fue significativo sólo para las EIC (p = 0,022), permaneciendo inalterada para las ECbV (p = 0,931) y EE (p = 0,941). CONCLUSIÓN: La vacunación contra la gripe se asoció a la significativa reducción de la mortalidad por EIC.

BACKGROUND: Non-invasive detection of atherosclerosis is critical for its prevention. OBJECTIVE: To correlate non-invasively detectable indicators of coronary atherosclerosis, or Coronary Artery Disease (i.e., classical risk factors, hs-CRP test results, carotid intima-media thickness, endothelial function, ankle-brachial index and calcium score by computed tomography) with the extent of coronary disease assessed by the Friesinger index from conventional coronary angiography. METHODS: We conducted a prospective study of 100 consecutive patients, mean age 55.1 ± 10.7 years, 55% men and 45% women. Patients with acute coronary syndrome, renal dialytic insufficiency, collagen disease and cancer were not included. All patients were subjected to clinical evaluation and laboratory tests. Endothelial function of the brachial artery and carotid artery were evaluated by high-resolution ultrasound; ankle-brachial index and computed tomography for coronary determination of calcium score were also performed, and non-HDL cholesterol and TG/HDL-c ratio were calculated. All patients were subjected to coronary angiography at the request of the assistant physician. We considered patients without an obstructive lesion (< 29% stenosis) demonstrated by coronary angiography to be normal. RESULTS: Univariate analysis showed that calcium score, HDL-c, TG/HDL ratio and IMT were significantly correlated with the Friesinger index. However, multivariate analysis indicated that only calcium score and low HDL-c levels correlated significantly with the extension of CAD. On the other hand, hs-CRP, LDL-c, flow-mediated dilation, and Framingham score did not correlate with the Friesinger index. ROC analysis showed that calcium score, HDL-c and TG-HDL ratio accurately predicted extensive CAD in a statistically significant manner. CONCLUSION: It is possible to approximately determine the presence and extent of CAD by non-invasive methods, especially by calcium score, HDL-c and TG/HDL-c ratio assays.

INTRODUCTION: Much evidence indicates the importance of the endothelium and hypercholesterolemia in atherosclerosis, as well as the decline in endothelial function with aging. However, it is unclear if treating dyslipidemia in elderly patients improves endothelial function and reduces C-reactive protein levels. OBJECTIVES: To evaluate vasomotor function, lipids and C-reactive protein in mildly hypertensive and hypercholesterolemic elderly patients treated with atorvastatin. METHODS: Forty-seven elderly Brazilian subjects (>; 65 years old) with LDL cholesterol (LDL-c) >; 130 mg/dL were randomly assigned, in a double-blinded manner, to receive either placebo (n = 23) or 20 mg/day of atorvastatin (n = 24) for 4 weeks. Exclusion criteria included diabetes, serious hypertension, obesity, steroid use, hormone replacement, and statin use within the previous six months. All patients underwent clinical examinations, laboratory tests (glucose, lipids, liver enzymes, creatine phosphokinase and high sensitivity C-reactive protein) and assessment of vasomotor function by high-resolution ultrasound examination of the brachial artery (flow-mediated dilation and sublingual nitrate), both before and after treatment. RESULTS: The patients were 65 to 91 years old; there was no significant difference between basal flow-mediated dilation of placebo (7.3 ± 6.1%) and atorvastatin (4.5 ± 5.1%; p = 0.20). The same was observed after treatment (6.6 ± 6.2 vs. 5.0 ± 5.6; p = 0.55). The initial nitrate dilatation (8.1 ± 5.4% vs. 10.8 ± 7.5%; p = 0.24) and that after 4 week treatment (7.1 ± 4.7% vs. 8.6 ± 5.0%; p = 0.37) were similar. Atorvastatin produced a reduction of 20% of the C-reactive protein and 42% in the LDL-c; however, there were no changes in the flow-mediated dilation. CONCLUSIONS: Atorvastatin produced a significant change of lipids and C-reactive protein; however, there were no changes in vasomotor function, suggesting the existence of intrinsic age-related vessel alterations.

INTRODUÇÃO: Lesões coronárias em bifurcação ainda representam um desafio ao tratamento percutâneo, com sucesso do procedimento abaixo do esperado e altas taxas de reestenose. A técnica de pull-back é uma opção no tratamento de lesões coronárias de bifurcações que apresentam acometimento isolado do óstio de ramos laterais, embora seus resultados a médio prazo ainda não sejam conhecidos. O objetivo deste estudo foi avaliar os resultados angiográficos iniciais e aos seis meses com essa técnica em nossa casuística. MÉTODO: A técnica consiste no posicionamento de duas guias, seguido do stent no ramo lateral e do balão no vaso principal encobrindo a origem do ramo. Após a insuflação do balão no vaso principal, o stent é tracionado em direção ao vaso principal até contato com o balão e, então, liberado. RESULTADOS: Foram tratados 37 pacientes consecutivos. Os ramos diagonais foram os mais freqüentemente abordados (70,3%). O diâmetro de referência dos ramos laterais foi de 2,51 ± 0,37 mm e a extensão da lesão, de 11,1 ± 3,7 mm. A pressão de liberação dos stents no ramo lateral foi de 12,8 ± 1,9 atm e a pressão de insuflação do balão no vaso principal, de 7,8 ± 0,9 atm. O sucesso do implante ocorreu em todos os procedimentos. Foram submetidos a coronariografia tardia 22 (59,5%) pacientes, tendo sido observada reestenose no ramo lateral em nove (40,9%) pacientes e desenvolvimento de lesões > 50% no vaso principal em sete (31,8%). CONCLUSÃO: Lesões isoladas localizadas no óstio de ramos laterais tratadas com stent pela técnica de pull-back apresentaram elevadas taxas de sucesso do procedimento. No seguimento a médio prazo, entretanto, observou-se elevada taxa de reestenose no ramo lateral e alto risco de desenvolvimento de uma nova obstrução no vaso principal. INTRODUCTION: Bifurcated coronary lesions are still a challenge to the percutaneous treatment, with a lower than expected success rate and high rates of restenosis. The pull-back technique is an option for the treatment of coronary lesions in bifurcations that compromises exclusively the ostium of lateral branches, but its middle term results are still not known. The aim of this study is to assess the initial and 6-month angiographic results of this technique in our casuistic. METHOD: The technique consists in the positioning of two guide-wires, followed by the stent in the lateral branch and the balloon in the main vessel, covering the origin of the branch. After insufflating the balloon in the main vessel, the stent is pulled back towards the main vessel until it touches the balloon, and then implanted. RESULTS: Thirty-seven consecutive patients were treated. The diagonal branches were the most commonly treated (70.3%). The reference diameter of the lateral branches was 2.51 ± 0.37 mm and the extension of the lesion 11.1 ± 3.7 mm. The release pressure of the stents within the lateral branch was 12.8 ± 1.9 atm and the insufflation pressure of the balloon in the main vessel was 7.8 ± 0.9 atm. The stent was successfully implanted in all procedures. Twenty-two (59.5%) patients were submitted to late coronariography and restenosis was observed in the lateral branch in 9 (40.9%) patients, and the development of lesions > 50% in the main vessel was observed in 7 (31.8%) patients. CONCLUSION: Isolated lesions found in the ostial of lateral branches treated with the "pull-back" stent implantation technique presented high rates of procedural success. However, in the middle term follow-up, a high restenosis rate in the lateral branch was observed, as well as a high risk of developing a new obstruction in the main vessel.

FUNDAMENTO: Ainda que os benefícios clínicos das intervenções coronarianas parecem confirmados, seus efeitos na qualidade de vida (QV) permanecem pouco estudados. OBJETIVO: Avaliar a qualidade de vida (QV) na doença multiarterial coronariana em pacientes submetidos randomicamente a cirurgia, angioplastia ou tratamento clínico. MÉTODOS: Foi utilizando Short-Form Health Survey (SF36) questionnaire em 483 pacientes. Desses, 161 foram revascularizados; 166 receberam angioplastia e 153 tiveram tratamento clínico. RESULTADOS: Na internação, 86% referiam angina; 34%, infarto; e 32% fumavam. Tratamento clínico: 12 pacientes (7,7%) tiveram infarto agudo do miocárdio (IAM); 24 (15,3%) receberam cirurgia; e 19 (12,1%) morreram. Além disso, cinco (3,2%) sofreram AVC e 40 (25,6%) tinham angina. No componente mental, 64,1% melhoram e 30,8% pioram a condição. No componente físico, 70,5% melhoram e 27,6% pioram a condição. Cirurgia: 13 pacientes (8,1%) tiveram IAM, dois (1,2%) receberam cirurgia; 12 (7,4%) morreram. Em adição, nove (5,6%) sofreram AVC e 30 (18,6%) sofriam angina. No componente mental, 72,7% melhoram e 25,5% pioram a condição. No componente físico, 82,6% melhoram e 16,1% pioram a condição. Angioplastia: 18 pacientes (10,9%) tiveram IAM, 51 (30,7%) receberam intervenções e 18 (19,9%) morreram. Além disso, seis (3,6%) sofreram AVC e 35 (21%) relatavam angina. No componente mental, 66,9% melhoram e 26,5% pioram a condição No componente físico, 77,1% melhoram e 20,5% pioram a condição. CONCLUSÃO: Observou-se melhora em todos os domínios e nas três opções terapêuticas. Comparativamente, a cirurgia ofereceu melhor qualidade de vida após quatro anos de seguimento. BACKGROUND: Although the clinical benefits of coronary interventions seem to be confirmed, their effects on quality of life (QoL) are still scarcely studied. OBJECTIVE: To assess the QoL in multivessel coronary disease in patients randomly undergoing surgery, angioplasty or medical treatment. METHODS: The Short-Form Health Survey (SF-36) questionnaire was answered by 483 patients. Of these, 161 underwent surgical revascularization, 166 underwent angioplasty, and 153 were medically treated. RESULTS: At baseline, 86% of the patients referred angina, 34% referred infarction, and 32% were smokers. Medical Treatment: 12 patients (7.7%) had AMI, 24 (15.3%) underwent surgery, and 19 (12.1%) died. In addition, 5 (3.2%) had stroke, and 40 (25.6%) had angina. As regards the mental component, 64.1% and 30.8% had their condition improved and worsened, respectively. As regards the physical component, 70.5% and 27.6% had their condition improved and worsened, respectively. Surgery: 13 patients (8.1%) had AMI, 2 (1.2%) underwent surgery, and 12(7.4%) died. Also, 9 (5.6%) had stroke and 30 (18.6%) had angina. As regards the mental component, 72.7 % and 25.5% had their condition improved and worsened, respectively. As regards the physical component, 82.6% and 16.1% had their condition improved and worsened, respectively. Angioplasty: 18 patients (10.9%) had AMI, 51 (30.7%) underwent interventions, and 18 (19.9%) died. Additionally, six (3.6%) presented stroke and 35 (21%) reported angina. As regards the mental component, 66.9% and 26.5% had their condition improved and worsened, respectively. As regards the physical component, 77.1% and 20.5% had their condition improved and worsened, respectively. CONCLUSION: Improvement was observed in all domains and in the three therapeutic modalities. Comparatively, surgery had provided a better quality of life after a four-year follow-up.

Although the clinical benefits of coronary interventions seem to be confirmed, their effects on quality of life (QoL) are still scarcely studied.To assess the QoL in multivessel coronary disease in patients randomly undergoing surgery, angioplasty or medical treatment.The Short-Form Health Survey (SF-36) questionnaire was answered by 483 patients. Of these, 161 underwent surgical revascularization, 166 underwent angioplasty, and 153 were medically treated.At baseline, 86% of the patients referred angina, 34% referred infarction, and 32% were smokers. Medical Treatment: 12 patients (7.7%) had AMI, 24 (15.3%) underwent surgery, and 19 (12.1%) died. In addition, 5 (3.2%) had stroke, and 40 (25.6%) had angina. As regards the mental component, 64.1% and 30.8% had their condition improved and worsened, respectively. As regards the physical component, 70.5% and 27.6% had their condition improved and worsened, respectively.13 patients (8.1%) had AMI, 2 (1.2%) underwent surgery, and 12(7.4%) died. Also, 9 (5.6%) had stroke and 30 (18.6%) had angina. As regards the mental component, 72.7 % and 25.5% had their condition improved and worsened, respectively. As regards the physical component, 82.6% and 16.1% had their condition improved and worsened, respectively. Angioplasty: 18 patients (10.9%) had AMI, 51 (30.7%) underwent interventions, and 18 (19.9%) died. Additionally, six (3.6%) presented stroke and 35 (21%) reported angina. As regards the mental component, 66.9% and 26.5% had their condition improved and worsened, respectively. As regards the physical component, 77.1% and 20.5% had their condition improved and worsened, respectively.Improvement was observed in all domains and in the three therapeutic modalities. Comparatively, surgery had provided a better quality of life after a four-year follow-up.

OBJETIVO: Avaliar a qualidade de vida em portadores de doença arterial coronária (DAC) submetidos a um dos três tratamentos: clínico, cirúrgico ou por angioplastia, comparando possíveis diferenças entre gêneros. MÉTODOS: O estudo incluiu 542 sujeitos com DAC submetidos aos tratamentos, sendo 376 homens (58,5 ± 8,7 anos) e 166 mulheres (61,8 ± 9,2 anos). O instrumento de avaliação foi o Questionário Genérico de Avaliação de Qualidade de Vida (SF-36), aplicado no início do tratamento, após 6 e 12 meses. A análise estatística foi realizada pelo teste Anova. RESULTADOS: Em relação aos componentes físicos, o grupo cirúrgico exibiu escores de 46, 63 e 68, respectivamente, na fase inicial, 6 e 12 meses; o clínico 52, 65 e 62 e a angioplastia 57, 66 e 70. Os escores dos componentes mentais do tratamento cirúrgico foram 58, 71 e 74, do clínico 61, 69 e 69 e da angioplastia 64, 74 e 74. As diferenças foram significantes ao longo do tempo e entre tratamentos (p

Atherosclerosis is a chronic inflammatory disease that affects essentially all arterial beds including the aorta, coronaries, carotids, and peripheral arteries. It is the main cause of death in the western hemisphere, due to cardiovascular syndromes such as myocardial infarction, heart failure, and cerebrovascular accidents. Very substantial economic and human resources have been used on treatments of its complications, including imaging studies, coronary bypass surgery, catheter interventions, pacemakers, and medical treatments. Treating complications, however, are remedial actions. A better alternative is to prevent the development of atherosclerosis, or at least to identify patients who are at risk of acute events and intervene before they occur. The aims of this review are to discuss the predictive value of traditional and emerging risk factors, as well as the role of noninvasive diagnostic methods for coronary atherosclerosis, including exercise stress test, echo stress test, duplex ultrasound, computed tomography, and magnetic resonance. A combination of serum biomarkers and noninvasive approaches is of practical utility for identifying early disease. It is to be expected that future developments will soon perfect our ability to identify the vulnerable patient and allow a more individualized approach. A aterosclerose é uma doença inflamatória crônica que afeta essencialmente todas as artérias incluindo a aorta, coronárias, carótidas e artérias periféricas. É a causa principal de morte no hemisfério ocidental, devido as síndromes cardiovasculares, tais como o infarto do miocárdio, insuficiência cardíaca e acidentes cerebrovasculares. Quantidades enormes de recursos econômicos e humanos são usadas em tratamentos de suas complicações, inclusive estudos de imagem, cirurgias coronárias, intervenções com cateteres, marcapasso e tratamentos médicos. Tratar complicações, entretanto, são ações a posteriori. Uma alternativa melhor seria prevenir o desenvolvimento da aterosclerose, ou pelo menos identificar os pacientes que tenham risco de eventos agudos e intervir antes de sua ocorrência. O objetivo desta revisão é discutir o valor prognóstico dos fatores de riscos tradicionais e emergentes, e o papel dos métodos diagnósticos não invasivos para a doença coronária - teste de esforço, eco estresse, ultra-sonografia dúplex, tomografia computadorizada e a ressonância magnética. A combinação de marcadores biológicos e de métodos não invasivos, é de grande utilidade na identificação precoce da doença aterosclerótica. Futuros desenvolvimentos logo aperfeiçoarão nossa capacidade de identificar o paciente vulnerável e nos permitir um manejo mais individualizado.

We evaluated the impact of Coronary Artery Bypass Graft Surgery (CABG), Percutaneous Coronary Intervention (PCI) or Medical Therapy (MT) on self-perceived quality of life among patients with stable Coronary Artery Disease (CAD).The Medicine, Angioplasty and Surgery Study (MASS-II) implemented initial policies of CABG, PCI or continued medical treatment in patients who allow assessment of mid-term health consequences.A total of 542 patients were randomly assigned to CABG (175), to PCI (180) and to MT (187). The short form 36 (SF-36) self-administered quality of life (QoL) questionnaires were applied at baseline, 6 months and 12 months later.All the three therapeutic strategies presented significant improvement in all dimensions of the SF-36 during the follow-up (p0.0001). However, the CABG group was the one that had significantly greater improvement in physical and social functioning, vitality and general health when compared to MT and PCI. Also, men had the best QoL at the beginning of the treatment when compared to women, with a progressive improvement after 6 and 12 months.The quality of life was better in both CABG and PCI groups compared to MT after 1 year of follow-up. However, the patients submitted to CABG were the ones that presented the greater and progressive improvement of QoL. Also, men presented better QoL at the beginning and after treatment when compared to women.

Waiting lists for coronary bypass grafting are of major concern in several countries and prioritisation systems to the surgery have been proposed. The aim of this study was to verify the adequacy of Ontario score in predicting cardiac events during the waiting for elective coronary bypass grafting.A composite end-point (sudden or cardiac death, myocardial infarction, unstable angina or hospital admission) and sudden, cardiac death were analysed in 460 patients referred to the surgery. The relation between Ontario score and events was verified.Median waiting time was 126 days. The composite end-point and sudden, cardiac death occurred in 21.7% and 2.7% of the cases, respectively. In relation to Ontario scoreor = 6.00, considered the lower-risk subset, only patients in score4.00 (7.2% of whole study population) presented a higher chance of the composite end-point during the waiting. ROC curve did not show adequate accuracy of Ontario score in predicting the composite end-point (area under the curve 0.53, p = 0.36). Ontario score could not predict the risk of death. Total complications and death occurred within acceptable waiting times by Ontario recommendation in 47.8% and 36.4% of the cases, respectively. Waiting longer than maximum wait defined by Ontario was not associated with an excess of complications.Ontario score showed a limited value in predicting cardiac events during the waiting for elective coronary bypass grafting. The results emphasise the need for shortening the wait in order to reduce complications in the period.

Fasting hypertriglyceridemia relates with high-density lipoprotein (HDL) cholesterol, but it is not known whether low HDL cholesterol is associated with disturbances of chylomicron metabolism. To clarify this issue this metabolism was studied in subjects with low HDL cholesterol together with vascular reactivity and evaluation of no-flush niacin treatment. Thirty men with HDL1.04 mmol/L and no other risk factors for coronary artery disease (CAD) and 11 normal controls with HDL1.04 mmol/L were studied. The plasma kinetics of a chylomicron-like emulsion labeled with 14C-cholesterol oleate (CO) and 3H-triolein (TG) was determined and the fractional clearance rate (FCR, min(-1)) was calculated. Vascular reactivity was evaluated using high-resolution ultrasonography. CO FCR was markedly reduced in the low HDL group compared to controls (3.6 x 10(-3) +/- 5.1 x 10(-3) min(-1) versus 12.2 x 10(-3) +/- 8.4 x 10(-3) min(-1), p0.001) but TG FCR was similar. Flow-mediated dilation (FMD) was diminished in low HDL (7.4 +/- 4.1 versus 12.8 +/- 4.6%, p0.001), whereas nitrate-mediated dilation was similar. Twenty-two low HDL subjects with reduced FMD were randomized into two groups, one given 1.5 g/day niacin and a placebo group. After 3-month treatment, plasma lipids and chylomicron kinetics were not changed by niacin treatment but FMD improved to normal values (5.44 +/- 1.89 to 11.13 +/- 3.4%, p0.01). In conclusion, isolated low HDL cholesterol subjects may also bear chylomicron remnant accumulation and endothelial dysfunction, which highlight the importance of their preventive treatment.

Objectives: Since waiting lists for coronary artery bypass graft surgery are common and carry a risk of severe events, the purposes of this study were: (1) to analyse the incidence and temporal distribution of cardiac complications during waiting for elective coronary artery bypass grafting; (2) to identify predictive factors of such complications. Methods: Data were collected from 574 patients referred to surgery from 1 January 1998 to 12 July 2001. Two types of complications were defined: (1) a composite end-point, which included cardiac death, myocardial infarction, unstable angina or hospital admission due to cardiac cause; (2) sudden or any cardiac death. Previous cardiac events, risk factors, clinical features, laboratory exams, non-invasive tests for myocardial ischemia, left ventricular function and coronary anatomy were analysed. Kaplan –Meier method, multivariate Cox regression and Student’s t-test were used for statistical analyses. Results: Median time to surgery was 126 days (5– 1022). Among 516 patients consecutively referred to the surgery from 1 January 1998 to 31 December 2000, sudden or cardiac death occurred in 2.5% and the composite end-point in 22.9%. Most complications (72.1%) were observed within 120 days. The main factors predictive of sudden or cardiac death were severe left ventricular dysfunction and heart failure (univariate analysis). Independent predictive factors of the composite end-point were angina, heart failure functional classes and high triglyceride levels. Conclusions: During long delay for coronary artery bypass surgery, cardiac events are frequent and tend to occur early. Severe left ventricular dysfunction, advanced angina, heart failure functional classes and high triglyceride level must be considered when selection is necessary, in order to diminish morbidity and mortality during the waiting period. q 2003 Elsevier B.V. All rights reserved.

Background— Prior comparisons of costs following CABG and PTCA have demonstrated higher initial costs after CABG but following PTCA, recurrent symptoms and repeat revascularization result in increased late costs and over time their costs equilibrate. The MASS II trial provides an opportunity to compare the costs of CABG and PTCA in addition to a strategy of medical therapy. Methods— We studied the 611 patients of MASS II [Medical (203), Angioplasty (205), or Surgery (203) Study], a randomized study to compare treatments for multivessel CAD and preserved left ventricle function. The costs were: CABG US$ 10 650.00; PTCA US$ 6400.00; new AMI hospitalization AMI U$ 2550; angiography not followed-up of PTCA US$ 1900.00; and medication US$ 1200.00 for medical, and US$ 1000.00 for the other groups. We did adjustment for average event-free time, and angina-free proportion. The statistical analysis carried out was chi-square, t test, and analysis of variance. Results— After 1 year, 49% Medical, 79% PTCA, and 88% CABG became angina-free; P P =0.03); PTCA was performed in 7 Medical, 17 PTCA, and 1 CABG, ( P =0.0003), CABG was performed in 15 Medical, 8 PTCA, and zero CABG; P =0.002. The event-free and event and angina-free-costs in the first year were US$ 2453.50 and US$5006.32 for Medical; US$ 10348,43; and US$ 13 099.31 for PTCA; and US$ 12 404.21 and US$ 14 095.09 for CABG group. An increase from expected costs of 317%, 77%, and 21%, respectively. Conclusion— PTCA effective costs were similar to CAGB costs, Medical treatment presented the lowest cost, and however, the greatest increment, and CABG presented the most stable costs.

Hypercholesterolemia causes myocardial ischemia, even in the absence of obstructive coronary artery lesions. Reductions in cholesterol are associated with improved clinical outcomes that may reflect reversal of endothelial dysfunction, lesion regression, or both. This review explores experimental and clinical evidence that supports these observations. These include: 1) mechanisms by which hypercholesterolemia (and other risk factors for coronary artery disease) causes endothelial dysfunction; 2) the role that hypercholesterolemia and endothelial dysfunction play in atherogenesis, lesion complications, and clinical ischemic syndromes; and 3) compelling data that illustrate the benefits of cholesterol control. The latter include transformation of the plaque lipid composition to a more favorable profile, improved blood pressure control, normalization of exercise test results, improved exercise tolerance, and reversal or prevention of myocardial perfusion abnormalities. Collectively, these data support the notion that control of cholesterol is important to both the prevention and treatment of cardiac disease.) (c)2001 CHF, Inc.

OBJECTIVE: To analyze the trends in mortality due to circulatory diseases in men and women aged > or = 30 years in Brazil from 1979 to 1996. METHODS: We analyzed population count data obtained from the IBGE Foundation and mortality data obtained from the System of Information on Mortality of the DATASUS of the Ministry of Health. RESULTS: Circulatory diseases, ischemic heart disease, and cerebrovascular disease were the major causes of death in men and women in Brazil. The standardized age coefficient for circulatory disease in men aged > or = 30 years ranged from 620 to 506 deaths/100,000 inhabitants and in women from 483 to 383 deaths/100,000 inhabitants for the years 1979 and 1996, respectively. In men, the mean coefficient for the period was 586.25 deaths with a significant trend towards a decrease (P

OBJETIVO: Observar a distribuição das drogas em pacientes com doença arterial coronária (DAC) estável, em centros de atendimento (CA) primário e terciário. MÉTODOS: Foram analisados, 300 pacientes, consecutivos, no ambulatório do Grupo de Coronariopatias do INCOR com diagnóstico de DAC, idades entre 31 a 80 (58,5±8,0) anos, sendo 205 (68%) do sexo masculino e 95 (32%) do feminino e estudadas as características clínicas e hemodinâmicas. Avaliaram-se as drogas utilizadas, inicialmente, nos CA primários (comunitários) e, posteriormente, no CA terciário. RESULTADOS: As drogas mais utilizadas nos CA primários foram os b-bloqueadores (50% dos pacientes), nitratos (48%), bloqueadores dos canais de cálcio (46%), ácido acetil-salicílico (44%), diuréticos (30%) e os inibidores da enzima de conversão de angiotensina (ECA), em 11% dos pacientes. No CA terciário as drogas mais utilizadas foram o ácido acetil-salicílico (76% dos casos), nitratos (55%), diuréticos (49%), inibidores da ECA (42%), os antagonistas dos canais de cálcio (37%) e os betabloqueadores (35% dos pacientes). Os b-bloqueadores foram mais prescritos em CA primário, p= 0,02, já os inibidores da ECA, p

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

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