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Background There is no literature evaluating the effect of exercise on patients with aortic stenosis, in which patients with and without coronary artery disease were assessed separately. Objective To assess the effects of isometric exercise on the diastolic function in patients with aortic stenosis (AS). Methods 18 patients with AS, and 5 control patients were studied (group 1, G1). Patients with AS were divided in: group 2 (G2, n =10), without coronary lesion, and group 3 (G3, n =8), with coronary lesion. All patients underwent cardiac catheterization and performed isometric exercise until heart rate increased 32±9%. Left ventricular systolic pressure and end diastolic pressure (LVEDP), t 1/2 (relaxation index), and the +d P /d t max were all measured. Results The +d P /d t max increased in G1, G2, and G3 during exercise returning to their basal values once exercise had concluded. While exercising, the LVEDP increased in G1, G2 and G3, returning to its original baseline value only in G1 and G2. The t 1/2 increased, while exercising, in G2 and G3, and continued to be elevated after the exercise in both groups although it was only statistically significant in G3. The control group did not show significant changes. Conclusions Isometric exercise decreases relaxation rate and increases LVEDP in patients with AS. After exercise, relaxation and LVEDP remained altered only in the patients with coronary lesion. The alteration in lusitropism and increased LVEDP after exercising suggest the presence of stunned myocardium.

BACKGROUND Inflammatory markers have been associated with adverse clinical outcome in patients with acute coronary syndromes (ACS). In addition, angiographic plaque morphology and extension of coronary artery disease has been related to worse prognosis in this group of patients. The aim of the present study was to determine if the clinical prognostic value of C-reactive protein (CRP), an inflammatory marker, can by associated with the angiographic findings in patients with non-ST elevation ACS. METHODS This prospective multicenter cohort study included 1253 patients with non-ST elevation ACS. CRP, which was considered positive (+) if >/=3 mg/l, was measured at a median of 9 h from symptoms onset and were kept blinded until the end of the study. Coronary angiography was performed in 633 patients (50%). The presence of complex coronary lesions (CCLs) was defined as the presence of any of the following: thrombus (+), Thrombolysis In Myocardial Infarction (TIMI) flow

INTRODUÇÃO: A valvuloplastia aórtica por balão voltou a ganhar interesse desde o início da era da substituição percutânea da valva aórtica, por ser um procedimento que pode ser repetido como ponte e também por ser boa estratégia para a seleção de pacientes para o novo procedimento. MÉTODO: De janeiro de 2001 a janeiro de 2009, 174 pacientes consecutivos com estenose aórtica sintomática grave e alto risco cirúrgico calculado pelo EuroSCORE/ STS foram submetidos a valvuloplastia aórtica por balão na França e na Argentina, utilizando-se a mesma técnica. Desse total, 21 (12,1%) precisaram repetir a valvuloplastia aórtica por balão em decorrência de reestenose e os resultados foram comparados aos dos 153 pacientes que realizaram somente o primeiro procedimento. A técnica mais utilizada foi o acesso retrógrado com abordagem femoral utilizando introdutores de 10 F, 12 F ou 14 F, com tamanhos de balão variando de 20 mm a 23 mm. RESULTADOS: A média de idade foi de 80,4 ± 9,7 anos e o EuroSCORE foi de 21 ± 2%. Abordagem femoral retrógrada foi utilizada em 95% dos casos. Os resultados do procedimento primário foram os seguintes: a área valvar aórtica aumentou de 0,9 ± 19 cm² para 1,02 ± 0,20 cm² e o gradiente médio caiu de 50 ± 21 mmHg para 22 ± 11 mmHg. Os resultados foram semelhantes após a repetição da valvuloplastia aórtica por balão em termos da área valvar aórtica, com melhora de 0,60 ± 0,1 cm² para 1,01 ± 0,25 cm² em um período de 13 ± 9 meses entre os dois procedimentos. As taxas de complicações hospitalares foram: morte, 3,3% vs. 9,5% (P = 0,20); acidente vascular cerebral embólico, 1,3% vs. 0 (P = 0,20); regurgitação aórtica maciça, 3,3% vs. 9,5% (P = 0,20); ruptura do balão, 1,3% vs. 0 (P = 0,20); tamponamento pericárdico, 0 vs. 5% (P = 0,12); e complicações vasculares, 3,9% vs. 9,5% (P = 0,25). No total, 48 pacientes (27,5%) foram selecionados como bons candidatos para substituição percutânea da valva aórtica durante o período de acompanhamento nos dois países, dos quais 36 realizaram o procedimento na França e 4, na Argentina. CONCLUSÕES: A repetição da valvuloplastia aórtica por balão é uma estratégia útil em pacientes idosos nãocirúrgicos com estenose aórtica sintomática grave para aliviar os sintomas após reestenose e como ponte para a substituição percutânea da valva aórtica. Essa técnica pode ser repetida com baixa taxa de complicações. BACKGROUND: Balloon aortic valvuloplasty (BAV) has regained interest since the onset of percutaneous aortic valve replacement (PAVR) as it can be repeated as a bridge to transcatheter aortic valve implantation (TAVI) and is also a good strategy for patient selection. METHOD: From January 2001 to January 2009, 174 consecutive patients with severe symptomatic aortic stenosis (AS) and high surgical risk calculated by EuroSCORE/STS underwent BAV in France and Argentina using the same technique. Twenty one (12.1%) of these patients underwent repeat BAV for restenosis and the results were compared with those of the 153 patients undergoing the primary procedure. The most used technique was retrograde access by femoral approach, using 10, 12 or 14 F introducers, with balloons sizes ranging from 20 to 23 mm. RESULTS: Patients' mean age was 80.4 ± 9.7 years and EuroSCORE was 21 ± 2%. The retrograde femoral approach was used in 95% of the cases. Results of the primary procedure were as follows: aortic valve area (AVA) increased from 0.9 ± 19 cm² to 1.02 ± 0.20 cm² and mean gradient decreased from 50 ± 21 mmHg to 22 ± 11 mmHg. The results were similar after repeat BAV in terms of AVA, with an improvement of 0.60 ± 0.1 cm² to 1.01 ± 0.25 cm² in a period of 13 ± 9 months between the two procedures. The rates of complications were: death, 3.3% vs. 9.5% (P = 0.20); embolic stroke, 1.3% vs. 0 (P = 0.20); massive aortic regurgitation, 3.3% vs. 9.5% (P = 0.20); balloon burst, 1.3% vs. 0 (P = 0.20); pericardial tamponade, 0 vs. 5% (P = 0.12); and vascular complications, 3.9% vs. 0.5% (P = 0.25). Forty eight patients (27.5%) were selected as good candidates for PAVR during the follow up period in both countries. Thirty six patients underwent PAVR in France and four patients in Argentina. CONCLUSIONS: Repeat BAV is a useful strategy in nonsurgical elderly patients with severe symptomatic AS to relieve symptoms after restenosis and as a bridge to transcatheter aortic valve implantation. This technique can be repeated with low complication rates.

The optimal duration of treatment with clopidogrel after percutaneous coronary intervention (PCI) with stent placement remains controversial. The Randomized Argentine Clopidogrel Stent (RACS) trial was a prospective, randomized, nonblinded study of 1,004 patients undergoing PCI who were randomized after successful bare metal stent placement to 30 versus 180 days of clopidogrel; all patients also received aspirin. Patients were eligible regardless of whether they had presented with ST-elevation myocardial infarction (MI), acute coronary syndrome, or stable angina. The primary end point was a composite of death, MI, and stroke at 180 days. Baseline clinical characteristics showed no differences between groups in terms of age, gender, history, risk factors, or incidence of diabetes; 72% presented with an acute coronary syndrome and 15% had MI as the indication for PCI. At hospital discharge and 30 days, when the 2 groups received the same treatment, there were no significant differences between groups in frequency of death, MI, or stroke. However, from 30 days to 6 months, patients assigned to 6 months of clopidogrel reached the primary end point of death, MI, and stroke less frequently (4.99% vs 1.74%, p = 0.010, relative risk decrease 65%). No significant between-group differences were found in frequency of total bleeding (0.64% vs 1.52%, p = 0.34) for the control and study groups. In conclusion, after successful placement of a bare metal stent in a coronary artery, patients treated with 6 months of clopidogrel showed a trend toward fewer adverse events compared with those treated for 30 days.

Renal artery stenosis (RAS) is a potentially reversible cause of hypertension and renal insufficiency and is associated with poor prognosis.We aimed to identify simple predictors of significant RAS among patients undergoing coronary angiography. Prospective data were collected on 843 consecutive patients who underwent cardiac catheterization and abdominal aortography. Stenosesor = 75% were considered significant. Multivariable logistic regression was used to assess the relationship between baseline characteristics and coronary anatomy with significant RAS. A simple risk score was derived from the model.The prevalence of RASor = 75% was 11.7%. Independent predictors of significant RAS were older age, higher creatinine levels, peripheral vascular disease, number of cardiovascular drugs, hypertension, female sex, and 3-vessel coronary artery disease or previous coronary artery bypass graft. The concordance index of the model was 0.802. These variables were used to develop a simple predictive score of significant RAS for patients undergoing cardiac catheterization. The prevalence of RAS increased stepwise with increasing score values: 0.6% for a scoreor = 5, 1.5% for 6 to 7, 6.1% for 8 to 9, 12.2% for 10 to 11, 18.7% for 12 to 14, 35.7% for 15 to 17, and 62.1% foror = 18 (P.001). Approximately one third of the patients had a scoreor = 11, which yielded a sensitivity of 76% and a specificity of 71%.Renal artery stenosis is a relatively common finding among patients referred for coronary angiography. A simple score can predict the presence of significant RAS among patients referred for cardiac catheterization.

Primary percutaneous coronary intervention (PCI) has become an alternative to thrombolytic therapy as a reperfusion strategy for ST-elevation acute myocardial infarction (AMI).The main goal of this study was to determine whether PCI and thrombolytic therapy achieve comparable reperfusion rates, as evidenced by ST-segment resolution. Secondary end points included infarct vessel patency rates before hospital discharge and short- and long-term outcomes. Patients with ischemic chest pain with durationor =12 hours and no contraindication for thrombolytic therapy were included.Between October 1993 and August 1995, 58 patients were randomly assigned to streptokinase (SK) and 54 patients to primary PCI. Baseline clinical characteristics and infarct location were well balanced in both groups. Median age (interquartile range) was 68 (58, 75) years, 29% were women, and 78% of the patients met at least one criterion for "not low risk" AMI (anterior location, age70 years old, previous MI, systolic blood pressure100 mm Hg, and/or heart rate100 bpm). The median time from symptom onset to random assignment was 217 (139, 335) minutes in the PCI group and 210 (145, 334) minutes in the SK group. Median random assignment to balloon time was 82 (55, 100) minutes, and median random assignment to needle time was 15 (10, 26) minutes (P.0001). TIMI grade 3 flow after primary PCI was obtained in 85% of patients. The proportion of patients with ST-segment resolutionor =50% at 120 minutes was 80% in the PCI group and 50% in the SK group (P =.001). The predischarge angiogram showed the presence of TIMI 3 flow in 96% of patients who received PCI and 65% of patients who received SK (P.001). A composite of in-hospital death, reinfarction, severe heart failure, stroke, and major bleeding occurred in 15% of patients who received PCI and 21% of patients who received SK (P =.4). At 3 years, freedom from the composite end point of AMI, postdischarge revascularization, and death was 61% in the PCI group and 40% in the SK group (P =.025).Our study shows that primary PCI, as compared with SK, is associated with more effective ST-segment resolution, higher patency rates in the infarct vessel at 7 days, and more favorable clinical outcomes at 3 years of follow-up.

NT-probrain natriuretic peptide (NT-proBNP) has been associated with left ventricular (LV) dysfunction and adverse outcome in patients with non-ST-elevation acute coronary syndromes (NSTEACS). However, the underlying pathophysiological mechanisms responsible for this association have not been well established. We sought to explore the relation between NT-proBNP levels and extension of coronary artery disease (CAD) and the presence of more complex and severe coronary lesions.This prospective, multicenter angiographic substudy included 585 patients admitted with NSTEACS. Blinded measurements of NT-proBNP and troponin T were performed at a median time of 3 hours after admission and analyzed centrally. Angiograms were read at a core laboratory by 2 independent readers blinded to patient data. Complex coronary lesion was defined as the presence of at least one of the following: thrombus (+), TIMI flow2, or ulcerated plaque.NT-probrain natriuretic peptide levels increased proportionally as LV function decreased. The levels of NT-proBNP were directly related to the extent of the CAD. This association was maintained when we analyzed patients with normal LV function (n = 257). Patients with complex coronary lesions or those with at least one of its individual component had higher levels of NT-proBNP compared with those without complex coronary lesions. After adjusting for clinical and electrocardiographic variables and other biomarkers, positive troponin (OR 2.20, 95% CI 1.50-3.22, P.0001) and supramedian NT-proBNP levels (OR 1.72, 95% CI 1.19-2.47, P = .003) independently contributed to the prediction of complex coronary lesions.In this study of patients with NSTEACS, NT-proBNP levels progressively increase with the severity of CAD and degree of LV dysfunction. Increased levels of NT-proBNP independently predict the presence of more complex coronary lesions.