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Resumo Fundamento O infarto do miocárdio com elevação do segmento-ST (IAMCSST) é definido por sintomas acompanhados por alterações típicas do eletrocardiograma. Entretanto, a caracterização dos sintomas isquêmicos não é clara, principalmente em subgrupos, como mulheres e idosos. Objetivos Analisar a tipificação dos sintomas isquêmicos, métricas temporais e observar a ocorrência de desfechos intra-hospitalares, em análise dos escores preditivos, em pacientes com IAMCSST, em estratégia fármaco-invasiva. Métodos Estudo envolvendo 2.290 pacientes. Tipos de apresentações clínicas pré-definidas: dor típica, dor atípica, dispnéia, sincope. Medimos o tempo entre o início dos sintomas à demanda pelo atendimento e o intervalo entre a chegada à unidade-médica e trombólise. Odds-ratios (OR; IC-95%) foram estimadas em modelo de regressão. Curvas ROCs foram construídas para preditores de mortalidade. Nível de significância adotado (alfa) foi de 5%. Resultados Mulheres apresentaram alta prevalência de sintomas atípicos; maior tempo entre o início dos sintomas e a procura por atendimento; atraso entre a chegada ao pronto-socorro e a fibrinólise. A mortalidade hospitalar foi de 5,6%. Predição de risco pela classificação Killip-Kimball: AUC: [0,77 (0,73-0,81)] em classe ≥II. Subgrupos estudados [OR (IC-95%)]: mulheres [2,06 (1,42-2,99); p=0,01]; insuficiência renal crônica [3,39 (2,13-5,42); p

Izo Helber,1 Claudia Maria Rodrigues Alves,1 Stela Maris Grespan,1 Eduardo CA Veiga,2 Pedro IM Moraes,1 José Marconi Souza,1 Adriano H Barbosa,1 Iran Gonçalves Jr,1 Francisco AH Fonseca,1 Antônio Carlos C Carvalho1,†, Adriano Caixeta1,3 1Department of Medicine, Discipline of Cardiology, Escola Paulista de Medicina, Universidade Federal São Paulo, São Paulo, Brazil; 2Department of Gynecology and Obstetrics, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; 3Department of Cardiology, Hospital Israelita Albert Einstein, São Paulo, Brazil†Dr Antonio Carlos De Camargo Carvalho passed away on January 8, 2019Correspondence: Adriano CaixetaEscola Paulista de Medicina, Universidade Federal São Paulo, Av. Napoleão de Barros, 715, São Paulo, CEP: 04024002, BrazilTel +55 11- 5576-4000Email adriano.caixeta@einstein.br Twitter @adrianocaixetaBackground: There is little research in the efficacy and safety of a pharmaco-invasive strategy (PIS) in patients ≥ 75 years versus < 75 years of age. We aimed to evaluate and compare the influence of advanced age on the risk of death and major adverse cardiac events (MACE) in patients undergoing PIS.Methods: Between January 2010 and November 2016, 14 municipal emergency rooms in São Paulo, Brazil, used full-dose tenecteplase to treat patients with STEMI as part of a pharmaco-invasive strategy for a local network implementation.Results: A total of 1852 patients undergoing PIS were evaluated, of which 160 (9%) were ≥ 75 years of age. Compared to patients < 75 years, those ≥ 75 years were more often female, had lower body mass index, higher rates of hypertension; higher incidence of hypothyroidism, chronic renal failure, prior stroke, and diabetes. Compared to patients < 75 years of age, in-hospital MACE and mortality were higher in patients with ≥ 75 years (6.5% versus 19.4%; p< 0.001; and 4.0% versus 18.2%; p< 0.001, respectively). Patients ≥ 75 years had higher rates of in-hospital major bleeding (2.7% versus 5.6%; p=0.04) and higher incidence of cardiogenic shock (7.0% versus 19.6%; p< 0.001). By multivariable analysis, age ≥ 75 years was independent predictor of MACE (OR 3.57, 95% CI 1.72 to 7.42, p=0.001) and death (OR 2.07, 95% CI 1.12– 3.82, p=0.020).Conclusion: In patients with ST-segment elevation myocardial infarction undergoing PIS, age ≥ 75 years was an independent factor that entailed a 3.5-fold higher MACE and 2-fold higher mortality rate compared to patients < 75 years of age.Keywords: acute myocardial infarction, elderly, fibrinolysis, primary percutaneous coronary intervention, pharmaco-invasive strategy

Background A pharmacodynamic comparison between ticagrelor and prasugrel after fibrinolytic therapy has not yet been performed. Methods In the single-center SAMPA trial, 50 consecutive STEMI patients previously treated with clopidogrel and undergoing a pharmacoinvasive strategy were randomized to either a ticagrelor (n=25) 180mg loading dose followed by 90mg bid, or a prasugrel (n=25) 60mg loading dose followed by 10mg/day, initiated after fibrinolytic therapy but before angiography. Platelet reactivity was assessed with the VerifyNow P2Y 12 assay at 0, 2, 6, and 24h after randomization. Results Mean times from fibrinolysis to prasugrel or ticagrelor administration were 11.1±6.9 and 13.3±6.3h, respectively ( p =0.24). The values of PRU decreased significantly from baseline to 2h (all p p Conclusions In patients with STEMI treated with fibrinolytic therapy, platelet inhibition after clopidogrel is suboptimal and can be further increased with more potent agents. Ticagrelor and prasugrel demonstrated a similar extent of P2Y 12 receptor inhibition within 24h, although maximal platelet inhibition after these potent agents was not achieved for 6h.

Objectives We sought to assess a new modality of radiofrequency intravascular ultrasound (IVUS) called iMAP-IVUS (Boston Scientific, Santa Clara, California) during the evaluation of patients presenting with high-risk acute coronary syndromes. Background There are limited data on plaque tissue characterization and phenotype classification using iMAP-IVUS. Methods In the iWonder study patients presenting with ST-elevation myocardial infarction (STEMI) or non-STEMI underwent three-vessel grayscale IVUS and iMAP-IVUS tissue characterization prior to percutaneous intervention. In total 385 lesions from 100 patients were divided into culprit (n = 100) and nonculprit (n = 285) lesions. Lesion phenotype was classified as (i) thin-cap fibroatheroma (iMAP-derived TCFA); (ii) thick-cap fibroatheroma; (iii) pathological intimal thickening; (iv) fibrotic plaque; and (v) fibrocalcific plaque. Results Culprit lesions had smaller minimum lumen cross-sectional area (MLA) with greater plaque burden compared to non-culprit lesions. Volumetric analysis showed that culprit lesions had longer length and larger vessel and plaque volumes compared to non-culprit lesions. iMAP-IVUS revealed that culprit lesions presented more NC and fibrofatty volume, both at lesion level and at the MLA site (all P

Background In the establishment of ST elevation myocardial infarction (STEMI) systems of care, transfer times between primary care units (PCU) and the cardiac catheterization lab (CCL) are pillars to therapeutic success. Objective: To analyze the relationship between PCU-CCL distance with transport time and main clinical outcomes in STEMI patients (p) treated with pharmaco-invasive therapy (PIT) and referred for rescue PCI after failed fibrinolysis. Methods Between January 2010 and December 2018, of the 2241 patients who received tenecteplase in PCU inserted in a large city STEMI network, 801 (35.7%) evolved without reperfusion criteria after 90 minutes (persistence of chest pain, less than 50% reduction on ST elevation or hemodynamic instability), being urgently transferred to the CCL. The PCU were divided according to the distance to the tertiary center in Group 1: between 5 and 9km (N=208p), Group 2: between 16 and 18km (N=315p) and Group 3: between 22 and 30km=266p). Considering an alpha of 0.05, sample size n=801 and an effect size of 0.11, a power of 0.80 was obtained. Results The groups were comparable for baseline features (Table 1). Group 2 (intermediate distances) had the highest median transport time (G1 260 interquartile 145–437 min vs G2 355 interquartile 206–573 min vs G3 241 interquartile 125–418 min; p Table 1. Group's baseline features G1: Short distances G2: Intermediate distances G3: Long distances p value (5–9 km) N=208 (16–18 km) N=315 (22–30 km) N=266 Age (median) 57.5 (51–64) 57 (49–66) 59 (52–67) 0.27 Female 29.7% 28.3% 35.1% 0.19 Hypertension 67.3% 60.9% 64.4% 0.31 Diabetes 37.0% 32.1% 37.8% 0.30 Renal failure 10.3% 9.7% 6.3% 0.21 Anterior STEMI 56.1% 58.4% 62.4% 0.36 Pain-to-needle time (median min) 197.5 (137–330) 195 (120–295) 195 (125–345) 0.38 Conclusion In STEMI patients with failed fibrinolysis treated with pharmaco-invasive therapy, the PCU-CCL distance was not related to transfer time or to outcomes of in-hospital death and cardiogenic shock. The longer transport time of hospitals located at intermediate distance can possibly reflect local logistical difficulties and are not due to hub-spoke distance. Continuous improvement in structuring and coordination of public STEMI networks is aimed.

Background Risk stratification using scores is a valuable tool in cardiogenic shock after ST elevation myocardial infarction (STEMI). During pharmacoinvasive therapy (PIT) their use is unexplored in the literature. Objective: To validate the IABP-SHOCK II (Intra-aortic Balloon Pump in Cardiogenic Shock) score in patients treated with PIT and to analyze the influence of ischemia time on the different risk strata. Methods and results Of 2,143 STEMI patients seen between May 2010 and April 2017, 212 (9.9%) developed cardiogenic shock. Thirty-one patients (14.6%) with incomplete data were excluded from the analysis and the validation cohort included the remaining 181. Mortality rates were similar between the analyzed and excluded patients (42.5% and 45.1% respectively, p=0.77). The 30-day mortality using the IABP-SHOCK II score was 26.6% for low-risk (n=94), 53.2% for moderate-risk (n=62), and 76% for high-risk (n=25) (p 30-day mortality in scored strata Conclusion In patients with cardiogenic shock after STEMI treated with PIT, risk stratification using the IABP-SHOCK II score was adequate. There was no influence of pain-to-needle and fibrinolytic-catheterization times on the ability to the score model stratification.

Aims We sought to present a series of 13 pregnancy-associated spontaneous coronary artery dissection (P-SCAD), their angiographic and multimodal imaging findings, acute phase treatment, and outcomes. Methods and results Between 2005 and 2015, 13 cases of P-SCAD were collected from a database of 11 tertiary hospitals. The mean age was 33.8 ± 3.7 years; most patients had no risk factors for coronary artery disease, and the majority were multiparous. P-SCAD occurred during the puerperium in 12 patients with a median time of 10 days. Only one patient presented with P-SCAD in the 37th week of pregnancy, and she was the only patient who died in this series. Six patients (46%) presented with ST-segment elevation acute myocardial infarction (STEMI), six (46%) presented with non-STEMI, and one presented with unstable angina; one-third of women had cardiogenic shock. In 12 patients, the dissection involved the left anterior descending or circumflex artery, and it extended to the left main coronary artery in 6 patients. Intravascular ultrasound or optical coherence tomography helped to confirm diagnosis and guide treatment in 46% of cases. Seven women were managed clinically; percutaneous coronary intervention was performed in five cases, and coronary artery bypass grafting was performed in one patient. Conclusion In these 13 cases of P-SCAD, clinical presentation commonly included acute myocardial infarction and cardiogenic shock. Multivessel dissections and involvement of the left coronary artery and left main coronary artery were highly prevalent. Clinicians must be aware of angiographic appearances of P-SCAD for prompt diagnosis and management in these high-risk patients.

Introduction Atherosclerotic disease accounts for one-third of deaths annually, as it often leads to complications such as ST-elevation myocardial infarction (STEMI). Rescue percutaneous coronary intervention (PCI) is indicated in case of thrombolytic therapy failure administered in this scenario. However, the benefits regarding mortality rate reduction and the amount of myocardium that is actually salvaged are not well established. The development of new tools, including cardiac magnetic resonance imaging, to identify the myocardium at risk and the infarcted area has increased diagnostic accuracy. Differently from the context of primary PCI, little is known about the association between epicardial and microvascular coronary flow following rescue PCI and the salvaged myocardial area. The aim of this study is to evaluate whether there is an association between coronary flow and the salvaged myocardial area identified by magnetic resonance imaging. Methods This will be a prospective, open, single-center, intervention study. A total of 72 patients with STEMI who underwent rescue PCI after documented failure of the fibrinolytic therapy, and were transferred to our institution, will be selected, observing a pharmacoinvasive strategy. Conclusions At the end of this study, the authors expect to contribute to the knowledge about coronary flow and its association with the amount of salvaged cardiac muscle after rescue PCI. This type of information that can help to understand which cases can benefit the most from rescue PCI.

RESUMO Introducao A doenca aterosclerotica e responsavel por um terco dos obitos ocorridos anualmente, pois frequentemente leva a complicacoes como infarto do miocardio com supradesnivelamento do segmento ST (IMCST). A intervencao coronaria percutânea (ICP) de resgate e indicada caso ocorra falha da terapia trombolitica administrada neste cenario. No entanto, os beneficios, em termos de reducao da taxa de mortalidade e da quantidade de miocardio efetivamente salvo, nao sao bem estabelecidos. O desenvolvimento de novas ferramentas, entre elas a ressonância magnetica cardiaca, para identificar a area miocardica em risco e infartada, elevou a acuracia diagnostica. Diferentemente do contexto da ICP primaria, pouco se sabe sobre a relacao entre o fluxo coronario epicardico e microvascular apos a ICP de resgate e a area de miocardio salva. O objetivo deste estudo e avaliar se existe relacao entre tais fluxos e a area de miocardio salva identificada pela ressonância magnetica. Metodos Estudo prospectivo, aberto, unicentrico, de intervencao. Serao selecionados 72 pacientes com IMCST que tiverem realizado ICP de resgate apos falha documentada da terapia fibrinolitica transferidos para este servico, obedecendo uma estrategia farmaco‐invasiva. Conclusoes Ao termino desta pesquisa, esperamos contribuir para o conhecimento sobre o fluxo coronariano e sua relacao com a quantidade de musculo cardiaco salvo apos a ICP de resgate. Esta e uma informacao que pode ajudar a entender quais casos mais se beneficiam da ICP de resgate.

Objective to compare two compression times of the radial artery after coronary angiography with customized compressive dressing regarding the occurrence of hemostasis and vascular complications. Method a randomized clinical study was carried out in patients undergoing elective transradial coronary angiography in two study groups: (G30), whose compressive dressing was maintained for 30 minutes, and (G60), whose compressive dressing was maintained for 60 minutes, both until the first evaluation of hemostasis. Variables related to patients, procedure, occurrence of hemostasis, and vascular complications were analyzed. Patency of the radial artery was assessed with Doppler vascular ultrasonography, immediately after removing the compressive dressing and 30 days after the procedure. Results the sample consisted of 152 patients in G30 and 151 in G60. Hemostasis was evidenced in the first evaluation in 76.3% of G30 patients and 84.2% of G60 patients (p = 0.063). There were 91 immediate complications, being 53 hematomas and 38 occlusions of the radial artery. We identified 18 late occlusions, 7 (5.5%) in G30 and 11 (8.2%) in G60. Conclusion the different compression times of the radial artery after coronary angiography did not significantly influence the occurrence of hemostasis and vascular complications. Brazilian Registry of Clinical Trials (Rebec): RBR-7VJYMJ. Objetivo comparar dois tempos de compressão da artéria radial pós-cinecoronariografia com curativo compressivo customizado, quanto à ocorrência de hemostasia e de complicações vasculares. Método estudo clínico randomizado realizado em pacientes submetidos a cinecoronariografia eletiva pelo acesso transradial, alocados em dois grupos de estudo: G30, cujo curativo compressivo foi mantido por 30 minutos, e G60, no qual o curativo foi mantido por 60 minutos, ambos até a primeira avaliação de hemostasia. Foram avaliadas variáveis relativas aos pacientes, procedimento, ocorrência de hemostasia e complicações vasculares. A patência da artéria radial foi avaliada com ultrassonografia vascular com Doppler, imediatamente após a retirada da compressão e após 30 dias do procedimento. Resultados a amostra foi composta de 152 pacientes no G30 e 151 no G60. A hemostasia foi evidenciada na primeira avaliação em 76,3% dos pacientes do G30 e em 84,2% do G60 (p=0,063). Ocorreram 91 complicações imediatas, sendo 53 hematomas e 38 oclusões da artéria radial. Foram identificadas 18 oclusões tardias, sendo 7 (5,5%) no G30 e 11 (8,2%) no G60. Conclusão os diferentes tempos de compressão da artéria radial, após cinecoronariografia, não influenciaram significativamente a ocorrência de hemostasia e complicações vasculares. Registro Brasileiro de Ensaios Clínicos (Rebec): RBR-7VJYMJ. Objetivo comparar dos tiempos de compresión de la arteria radial, después de cinecoronariografía con curativo compresivo personalizado, referido a la ocurrencia de hemostasia y de complicaciones vasculares. Método estudio clínico aleatorizado realizado en pacientes sometidos a cinecoronariografía electiva por acceso transradial, asignados en dos grupos de estudio: (G30) cuyo curativo compresivo fue mantenido por 30 minutos y (G60) en el cual el curativo fue mantenido por 60 minutos; ambos hasta la primera evaluación de hemostasia. Fueron evaluadas variables relativas a: pacientes, procedimiento, ocurrencia de hemostasia y complicaciones vasculares. La capacidad de mantener desobstruida la arteria radial fue evaluada con ultrasonografia vascular con Doppler, inmediatamente después de la retirada de la compresión y después de 30 días del procedimiento. Resultados la muestra estuvo compuesta por 152 pacientes en el G30 y 151 en el G60. La hemostasia fue evidenciada en la primera evaluación en 76,3% de los pacientes del G30 y en 84,2% del G60 (p=0,063). Ocurrieron 91 complicaciones inmediatas, siendo 53 hematomas y 38 oclusiones de la arteria radial. Fueron identificadas 18 oclusiones tardías, siendo 7(5,5%%) en el G30 y 11(8,2%) en el G60. Conclusión los diferentes tiempos de compresión de la arteria radial después de cinecoronariografía no influenciaron significativamente la ocurrencia de hemostasia y complicaciones vasculares. Registro Brasileño de Ensayos Clínicos (Rebec): RBR-7VJYMJ.

ObjectiveTo describe and standardize an original protocol for fractional flow reserve (FFR) pre and postangioplasty in an initial series of patients with clinically manifested transplant renal artery stenosis (TRAS). BackgroundThere is no data in the literature about the use of FFR in TRAS. MethodsPatients with TRAS detected in a noninvasive study were referred to diagnostic angiography and stenosis considered visually severe ( 60%) were included. After selective cannulation, a PressureWire 0.014 (CertusSt. Jude Medical) was advanced to the distal portion of the vessel. Resting Pd/Pa ratio (ratio of mean distal to lesion and mean proximal pressures) and translesional systolic pressure gradient were obtained and FFR and hyperemic translesional systolic and mean pressure gradients (HSG and HMG) were registered after papaverine induced maximum hyperemiapre and poststent implantation. Creatinine levels and office blood pressure measurements were registered at the baseline, 6 and 12months after intervention. ResultsTen consecutive patients had successful stent implantation and were included. After treatment, significant increase in FFR (0.760.09 vs. 0.96 +/- 0.04, P

Background Intravascular ultrasound (IVUS) is the most widely used ancillary method in Interventional Cardiology, and its analysis depends on standards for acquisition, measurement and interpretation of the images. By associating tissue characterization, the artifact caused by the guidewire may overestimate the percentage of necrotic core in certain lesions, leading to misclassification of fibroatheroma. In this paper we described quantitative and tissue analysis effects resulting from subtracting the effect of guidewire artifact on atherosclerotic lesions in patients with acute coronary syndrome. Methods Twenty-one patients with post-thrombolysis myocardial infarction were evaluated with grayscale IVUS and iMAP TM technology, totaling 76 lesions. Results Grayscale IVUS showed that the lesions had a mean length of 21.01 ± 18.03 mm and revealed high plaque burden (52.07 ± 7.56%). The analysis by iMAP TM demonstrated that, after subtracting the guidewire artifact, there was a reduction of all tissue (necrotic, calcific, lipid and fibrotic) components, but more markedly in necrotic core (mean difference: 3.59%). In addition, after artifact subtraction 12.4% of the lesions that initially exhibited a necrotic core ≥ 10% ceased to be classified as fibroatheroma. Conclusions An atheroma analysis by iMAP TM technology showed that the guidewire artifact overestimated the tissue component of the necrotic core. This interference may change, in an erroneous and categorical way, the phenotypic characteristics of more stable and benign (fibrotic) lesions to potentially unstable lesions, for example, fibroatheromas, in a ratio of one out of ten patients.

BackgroundPharmacoinvasive therapy (PIT) is feasible in patients with acute myocardial infarction with ST-segment elevation (STEMI) when timely primary percutaneous coronary intervention (PCI) is unavailable. In this study, we compared women who underwent successful reperfusion PIT with those who required rescue PCI, to identify potential predictors of thrombolytic failure.MethodsFrom January 2010 to November 2014, 327 consecutive women with STEMI were referred to a tertiary hospital, 206 after successful thrombolysis (63%) and 121 who required rescue PCI. The groups were compared regarding demographic, clinical and angiographic outcomes, and clinical (TIMI, GRACE, and ZWOLLE CADILLAC) and bleeding (CRUSADE) risk scores. A multivariate logistic regression model was used to identify predictors of thrombolytic failure.ResultsThere was no significant difference between the demographic characteristics or the medical history of the groups. Rescue PCI group had significantly higher values of the evaluated scores. Clinical hospital complications and mortality (2.5% vs. 22.0%; p < 0.0001) were more frequent in rescue PCI group. The independent variables associated with rescue PCI were pain-to-needle time > 3h (OR: 3.07, 95%CI: 1.64 to 5.75; p < 0.0001), ZWOLLE score (OR: 1.25; 95%CI: 1.14 to 1.37; p = 0.0001) and creatinine clearance (OR: 1.009, 95%CI: 1.0 to 1.02; p = 0.04).ConclusionsWomen with STEMI who underwent PIT and who required rescue PCI had significantly higher mortality compared to those who achieved initial success of PIT with elective PCI. Pain-to-needle time > 3h, ZWOLLE score and creatinine clearance were independent predictors of the need for rescue PCI.

O hematoma intramural aortico e uma doenca grave, secundaria a sangramento da vasa vasorum e/ou microulceras aorticas, sem comunicacao com a luz verdadeira do vaso. Seu achado ocasional, na ausencia de sintomas ou trauma aortico, e bastante raro. Neste relato, paciente assintomatica, com comprometimento da aorta ascendente e arco, foi mantida em tratamento clinico, a despeito das recomendacoes predominantes para correcao cirurgica em lesoes classificadas como tipo A de Stanford. Discutimos aspectos pertinentes a caracterizacao da lesao nos diferentes exames de imagem, identificacao de criterios de alto risco anatomico e conducao do caso. A evolucao em 7 meses foi satisfatoria.

Introducao: Atualmente, existe grande debate acerca da fisiopatologia do infarto agudo do miocardio e da composicao tecidual e morfologica das lesoes responsaveis por eventos isquemicos. Entretanto, poucos estudos investigaram a aplicabilidade da tecnologia iMAP® na caracterizacao tecidual desses pacientes. Avaliamos pacientes com infarto agudo do miocardio com supradesnivelamento do segmento ST pos-fibrinolitico com ultrassom intravascular em escala de cinzas e com a tecnologia iMAP®, a fim de descrever a composicao tecidual das lesoes culpadas pelo infarto agudo do miocardio. Metodos: Foram avaliadas tres arterias coronarias epicardicas com ultrassom intravascular em escala de cinzas e com a tecnologia iMAP® de 25 pacientes com infarto agudo do miocardio com supradesnivelamento do segmento ST pos-trombolise, com criterios de reperfusao. Resultados: A media de idade foi de 51 ± 11,5 anos, com predominio do sexo masculino (72%). A arteria mais frequentemente envolvida foi a coronaria direita (48%). O ultrassom intravascular mostrou que as lesoes culpadas eram longas (extensao de 31,0 ± 17,2 mm) e com elevado porcentual de volume de placa (58,5 ± 5,1%). No ponto de maior obstrucao, ou seja, na area luminal minima, a carga de placa foi de 82,5 ± 7,5%. Alem disso, o indice de remodelamento medio foi de 1,4 ± 1,0, denotando remodelamento positivo. As analises pelo iMAP®, tanto da lesao, quanto da area luminal minima, mostraram predominio em termos porcentuais de componentes fibrotico e necrotico, quando comparados aos demais. Conclusoes: As lesoes ateroscleroticas culpadas pelo infarto agudo do miocardio com supradesnivelamento do segmento ST apresentaram predominio de remodelamento arterial positivo e do componente necrotico na composicao da placa culpada, o que corrobora, in vivo, a principal fisiopatologia da doenca aterosclerotica aguda.

Pharmacoinvasive treatment is an acceptable alternative for patients with ST-segment elevation myocardial infarction (STEMI) in developing countries. The present study evaluated the influence of gender on the risks of death and major adverse cardiovascular events (MACE) in this population. Seven municipal emergency rooms and the Emergency Mobile Healthcare Service in Sao Paulo treated STEMI patients with tenecteplase. The patients were subsequently transferred to a tertiary teaching hospital for early (

Inadequate anastomosis of aorto-coronary grafts to the coronary venous system represent an infrequent but potentially serious complication of coronary artery bypass surgery. Different surgical techniques and percutaneous devices have been described for the permanent correction of these fistulas. We report two cases of iatrogenic aorto-coronary fistulas successfully treated with percutaneous occlusion using the self-expandable nitinol device (vascular plug).

Inadequate anastomosis of aorto-coronary grafts to the coronary venous system represents an infrequent but potentially serious complication of coronary artery bypass surgery. Different surgical techniques and percutaneous devices have been described for the permanent correction of these fistulas. We report two cases of iatrogenic aorto-coronary fistulas successfully treated with percutaneous occlusion using the self-expandable nitinol device (vascular plug).

OBJECTIVES: To correlate the importance of the ankle-brachial index in terms of cardiovascular morbimortality and the extent of coronary arterial disease amongst elderly patients without clinical manifestations of lower limb peripheral arterial disease.METHODS: We analyzed prospective data from 100 patients over 65 years of age with coronary arterial disease, as confirmed by coronary angiography, and with over 70% stenosis of at least one sub-epicardial coronary artery. We measured the ankle-brachial index immediately after coronary angiography, and a value of

INTRODUÇÃO: A estenose da artéria do enxerto renal é a complicação vascular mais prevalente após transplante renal. As limitações dos exames não-invasivos para seu diagnóstico são bem definidas e a angiografia permanece como padrão de referência para diagnóstico e definição terapêutica. A utilização da reserva de fluxo fracionada renal para melhor estratificação das estenoses de artéria renal nativa pode ajudar na adequada seleção de pacientes para tratamento percutâneo, porém tal método ainda não está padronizado em pacientes submetidos a transplante. O objetivo deste estudo será descrever e padronizar o protocolo de reserva de fluxo fracionada em pacientes com estenose da artéria do enxerto renal em um grupo de pacientes selecionados para intervenção renal percutânea, correlacionando o método com a angiografia. MÉTODOS: Estudo piloto, prospectivo, transversal, unicêntrico (Hospital São Paulo/Universidade Federal de São Paulo, São Paulo, SP, Brasil), em que serão selecionados 10 pacientes com quadro clínico compatível com estenose da artéria do enxerto renal, com angiografia do enxerto evidenciando estenose > 60%, admitidos para intervenção renal percutânea. Como avaliação da disfunção do enxerto serão realizadas dosagens de biomarcadores da função renal. CONCLUSÕES: No presente estudo, um protocolo original de reserva de fluxo fracionada para avaliação funcional de estenose da artéria do enxerto renal será padronizado, avaliando um método auxiliar na investigação funcional que possa identificar pacientes que realmente se beneficiem com a intervenção renal percutânea.

INTRODUÇÃO: A fibrinólise é frequentemente utilizada no tratamento das síndromes coronárias com supradesnivelamento do segmento ST (SCCSST). Desfechos cardíacos maiores foram reduzidos com a intensificação do tratamento antiplaquetário, porém com aumento do risco de sangramento. Nosso objetivo foi avaliar o risco de sangramentos de origem vascular em pacientes submetidos a intervenção coronária precoce pós-trombólise. MÉTODOS: Entre fevereiro de 2010 e dezembro de 2011, 5 prontos-socorros municipais da cidade de São Paulo e o Serviço de Atendimento Móvel de Urgência (SAMU) utilizaram tenecteplase (TNK) para tratamento de pacientes com SCCSST. Os pacientes foram encaminhados a um único hospital terciário e submetidos a cateterismo cardíaco precoce durante a internação. Todos os exames foram realizados por via femoral e os critérios do BARC foram utilizados para a classificação dos sangramentos. RESULTADOS: Foram avaliados 199 pacientes, dos quais 193 não apresentaram sangramento de origem vascular (grupo 1) e 6 (3%) evoluíram com essa complicação (grupo 2). A mediana de tempo entre a administração do fibrinolítico e o cateterismo foi de 24 horas no grupo 1 e de 14,7 horas no grupo 2. Segundo os critérios do BARC, 1 paciente apresentou sangramento do tipo 3a (hematoma em região inguinal com queda de hemoglobina de 3-5 g/dl), 2 pacientes apresentaram sangramento do tipo 3b (1 não relacionado ao acesso vascular e 1 hematoma de retroperitônio, com queda de hemoglobina ≥ 5 g/dl), e os demais apresentaram sangramentos do tipo 1 (pequenos hematomas em região inguinal). Nesse grupo foram necessárias duas hemotransfusões. Nenhum paciente teve óbito relacionado à complicação vascular pós-intervenção. CONCLUSÕES: Em nosso estudo, a cateterização precoce via femoral como parte de uma estratégia fármaco-invasiva, utilizando TNK como fibrinolítico, apresentou baixa taxa de sangramentos de origem vascular, comparável à das angioplastias eletivas. BACKGROUND: Fibrinolysis is often used in the treatment of acute coronary syndromes with ST segment elevation (STEMI). Major cardiac outcomes were reduced with antiplatelet therapy intensification, but with increased risk of bleeding. Our objective was to assess the risk of vascular bleeding in patients undergoing early percutaneous coronary intervention after thrombolysis. METHODS: Between February 2010 and December 2011, five public emergency rooms in the city of São Paulo and the Emergency Health Care Service (Serviço de Atendimento Móvel de Urgência - SAMU) used tenecteplase (TNK) to treat patients with STEMI. Patients were referred to a single tertiary hospital and were submitted to early cardiac catheterization during hospitalization. All examinations were performed via the femoral artery and BARC criteria were used to classify bleeding. RESULTS: We evaluated 199 patients, of whom 193 had no bleeding of vascular origin (group 1) and 6 (3%) developed this complication (group 2). The median time between the administration of the fibrinolytic agent and catheterization was 24 hours in group 1 and 14.7 hours in group 2. According to BARC criteria, 1 patient had type 3a bleeding (hematoma in the inguinal region with a hemoglobin decrease of 3-5 g/dL), 2 patients had type 3b bleeding (1 not related to vascular access and 1 retroperitoneal hematoma with a hemoglobin decrease ≥ 5 g/dL) and the remaining patients had type 1 bleeding (small inguinal hematomas). Blood transfusions were required in 2 patients. None of the patients died due to vascular complications after the intervention. CONCLUSIONS: In our study, early catheterization via the femoral artery as part of a pharmaco-invasive strategy, using TNK as a fibrinolytic agent, had a low vascular bleeding rate, comparable to that of elective angioplasties.

INTRODUÇÃO: A estenose da artéria do enxerto renal é a complicação vascular mais prevalente após transplante renal. As limitações dos exames não-invasivos para seu diagnóstico são bem definidas e a angiografia permanece como padrão de referência para diagnóstico e definição terapêutica. A utilização da reserva de fluxo fracionada renal para melhor estratificação das estenoses de artéria renal nativa pode ajudar na adequada seleção de pacientes para tratamento percutâneo, porém tal método ainda não está padronizado em pacientes submetidos a transplante. O objetivo deste estudo será descrever e padronizar o protocolo de reserva de fluxo fracionada em pacientes com estenose da artéria do enxerto renal em um grupo de pacientes selecionados para intervenção renal percutânea, correlacionando o método com a angiografia. MÉTODOS: Estudo piloto, prospectivo, transversal, unicêntrico (Hospital São Paulo/Universidade Federal de São Paulo, São Paulo, SP, Brasil), em que serão selecionados 10 pacientes com quadro clínico compatível com estenose da artéria do enxerto renal, com angiografia do enxerto evidenciando estenose > 60%, admitidos para intervenção renal percutânea. Como avaliação da disfunção do enxerto serão realizadas dosagens de biomarcadores da função renal. CONCLUSÕES: No presente estudo, um protocolo original de reserva de fluxo fracionada para avaliação funcional de estenose da artéria do enxerto renal será padronizado, avaliando um método auxiliar na investigação funcional que possa identificar pacientes que realmente se beneficiem com a intervenção renal percutânea. BACKGROUND: Renal allograft artery stenosis is the most prevalent vascular complication after renal transplantation. The diagnostic limitations of noninvasive tests are well defined and angiography remains the gold standard for diagnosis and therapeutic definition. The use of fractional flow reserve for a better stratification of native renal artery stenosis may be useful for an adequate selection of patients for percutaneous treatment, however this method has not yet been validated in patients undergoing transplantation. The objective of this study is to describe and standardize the fractional flow reserve protocol in patients with renal allograft artery stenosis in a group of patients selected for percutaneous renal intervention, correlating the method with angiography METHODS: Cross-sectional, single center pilot study (Hospital São Paulo/Universidade Federal de São Paulo, São Paulo, SP, Brazil), including 10 patients with a clinical picture compatible with renal allograft artery stenosis, with angiography showing graft stenosis > 60% and admitted for percutaneous renal intervention. Graft dysfunction assessment will include biomarkers of renal function. CONCLUSIONS: In this study, a fractional flow reserve protocol for the functional assessment of renal allograft artery stenosis will be standardized, evaluating an alternative method capable of identifying patients most likely to benefit from percutaneous renal intervention.

Background Fibrinolysis is often used in the treatment of acute coronary syndromes with ST segment elevation (STEMI). Major cardiac outcomes were reduced with antiplatele therapy intensification, but with increased risk of bleeding Our objective was to assess the risk of vascular bleeding in patients undergoing early percutaneous coronary intervention after thrombolysis. Methods Between February 2010 and December 2011, five public emergency rooms in the city of Sao Paulo and the Emergency Health Care Service (Servico de Atendimento Movel de Urgencia – SAMU) used tenecteplas (TNK) to treat patients with STEMI. Patients were referred to a single tertiary hospital and were submitted to early cardiacatheterization during hospitalization. All examinations werperformed via the femoral artery and BARC criteria were useto classify bleeding. Results We evaluated 199 patients, of whom 193 had no bleeding of vascular origin (group 1) and 6 (3%) developed this complication (group 2). The median time between the administration of the fibrinolytic agent and catheterization was 24 hours in group 1 and 14.7 hours in group 2. According to BARC criteria, 1 patient had type 3a bleeding (hematoma in the inguinal region with a hemoglobin decrease of 3–5 g/dL), 2 patients had type 3b bleeding (1 not related to vascular access and 1 retroperitoneal hematom with a hemoglobin decrease ≥ 5 g/dL) and the remaining patients had type 1 bleeding (small inguinal hematomas). Blood transfusions were required in 2 patients. None of the patients died due to vascular complications after the intervention. Conclusions In our study, early catheterization via the femoral artery as part of a pharmaco-invasive strategy, using TNK as a fibrinolytic agent, had a low vascular bleeding rate, comparable to that of elective angioplasties.

BackgroundIntravascular ultrasound (IVUS) provides a sensitive and reproducible measurement of the coronary artery dimensions, atherosclerotic plaque, and arterial lumen. Advances in IVUS technology now allow for the characterisation of the composition and morphology of atherosclerotic plaques. Although previous studies have reported data using IVUS with radiofrequency analysis, little is known regarding the use of a new modality (iMap®, Boston Scientific – Santa Clara, CA, USA) of atherosclerotic plaque characterisation. This study aims to analyse the morphological, phenotypic, and tissue characteristics of ‘culprit’ and ‘non-culprit’ atherosclerotic plaques determined by angiography in patients undergoing coronary angiography due to acute myocardial infarction (AMI).MethodsThis will be a prospective, cross-sectional, single centre study (Hospital São Paulo – Escola Paulista de Medicina – Universidade Federal de São Paulo/UNIFESP, São Paulo, SP, Brazil). Fifty patients will be selected for the ultrasound analysis according to the following inclusion criteria: age

OBJETIVO: Avaliar os efeitos da abertura efetiva da valva mitral estenótica através da valvotomia percutânea por cateter balão na função do apêndice atrial esquerdo. MÉTODOS: Foram estudados 12 pacientes com estenose mitral sintomática, em ritmo sinusal, submetidos ao ecocardiograma transesofágico antes e após valvotomia percutânea por cateter balão efetiva. Em relação ao apêndice atrial esquerdo, foram analisadas ao Doppler pulsátil as velocidades máximas e respectivas integrais dos fluxos anterógrado e retrógrado, além da fração de ejeção calculada pela planimetria da área desta estrutura. RESULTADOS: Houve aumento significante das velocidades de fluxo anterógrado do apêndice atrial esquerdo após valvotomia percutânea por cateter balão (pré: média de 0,30 m/s; pós: média de 0,47 m/s; p

ST elevation acute myocardial infarction (STEMI) and recent use of thrombolytics are risk factors for complications related to catheterism, especially in the femoral access. Our goal is to analyze predictors of major complications due to this invasive procedure in patients with STEMI undergoing

The rapid dissemination of endovascular treatment for abdominal aorta aneurysms was a consequence of the excellent, immediate results of the procedure, which caused it to quickly surpass open surgery. 1 In properly selected patients, endovascular treatment can reduce the risk of death and complications in the acute phase compared with surgical treatment, although long-term mortality is similar for both procedures. 2,3 The clinical effectiveness of endovascular treatment is undeniable, as shown by the extremely high five-year survival rate and by the low incidence of late disruption.

Background. Although selection criteria and subgroup analysis are still in the early developmental stages, endovascular treatment of aortic disease has become an alternative to surgery for many patients.Methods. From November 1996 to November 1999, 49 patients were treated with a self-expandable endoprosthesis at our institution. Most patients had acute aortic dissections. Thirteen of these patients did not follow the anatomic selection protocol. We retrospectively analyzed these patients to compare our numerical risk score (which includes clinical and anatomic criteria) between groups with or without success and between groups that followed the anatomic protocol (P) or did not follow the anatomic protocol (E [exception]).Results. Success rates were similar in groups P and E, although mortality rates were higher in group E. Patients from group E had longer procedures and required multiple stents more frequently. the proposed risk score was able to differentiate between groups with or without success, as well as between groups P and E.Conclusions. in order to reduce mortality and morbidity rates, careful selection criteria must be followed when treating patients endovascularly. Although it is time-consuming, using objective criteria can help select patients for endovascular treatment. We propose that patients with a risk score higher than 11 should only undergo percutaneous treatment when they have an unacceptably high surgical risk, and even so only after a detailed discussion of the risks. (C) 2002 by the Society of Thoracic Surgeons. Universidade Federal de São Paulo, Paulista Sch Med, São Paulo, Brazil Universidade Federal de São Paulo, Paulista Sch Med, São Paulo, Brazil Web of Science

The pharmaco-invasive therapy (PIT) is an effective alternative in patients with acute ST-segment elevation myocardial infarction (STEMI), when primary percutaneous coronary intervention (PCI) is not available in a timely manner. One of the most feared complications of the use of fibrinolytics prior

SCAD is an uncommon and under-diagnosed disease and may be a potentially fatal disorder. The few data in medical literature have been based in case reports and small case-series. Besides there is no consensus of the best approach in acute phase treatment and long-term follow-up will be necessary to

Auto antigens such as oxidized LDL have been implicated as atherogenic agents found in atheromatous lesions. It has not been observed whether percutaneous coronary intervention (PCI) can modulate the natural or adaptive humoral immune response to auto antigens according to the degree of

Cardiogenic shock is a condition associated to high mortality rates. For decades, the treatment consisted of vasoactive drugs and intra-aortic balloon pump. Left ventricular assist devices have been recently introduced, however the high costs of these devices have prevented their widespread use in public and private health care systems. Our initial experience with TransCoreTM, a left ventricular assist device manufactured in Brazil, is reported in this study.

OBJETIVO: Apresentar a correção de dissecção da aorta descendente, utilizando stent recoberto com dácron® introduzido através da artéria femoral na sala de hemodinâmica. MÉTODOS: Quatro pacientes foram submetidos à sedação, anestesia local de ambas regiões inguinais e a heparinização sistêmica, com cateter contendo o stent introduzido, através da artéria femoral comum, previamente dissecada, até a aorta descendente no seu terço médio. RESULTADOS: A expansão do stent foi realizada no local onde existia a lesão da íntima, diagnosticada por arteriografia e ecocardiograma. A oclusão da falsa luz foi imediata. O tempo do procedimento foi em média de 1h e 30min. A alta hospitalar ocorreu sem complicações. CONCLUSÃO: Este procedimento poderá proporcionar uma melhora substancial nos resultados do tratamento das dissecções da aorta descendente. PURPOSE: We present four cases of dissection of the thoracic descending aorta that underwent treatment with an auto expandable dácron®-covered stent. METHODS: The stent was deployed through the femoral artery in the hemodinamic laboratory after sedation, local anesthesia in both inguinal areas and systemic heparinization. The catheter with the stent was introduced through a cutdown in the left femoral artery until the area in the thoracic aorta with the previously diagnosed tear. RESULTS: The stent was expanded with immediate occlusion of the false lumen. The whole proccedure took 90 minutes and the patients were discharged without complications. CONCLUSION: Stent utilization is an important step to improve treatment results in type B aortic dissection.