Search

Resumo: Introdução e objetivo: O número e a complexidade dos dispositivos cardíacos implantáveis têm vindo a aumentar assim como as suas complicações, conduzindo frequentemente à remoção dos mesmos. O objetivo deste estudo foi caraterizar a população envolvida e os procedimentos utilizados na remoção transvenosa de eletrocateteres cardíacos num centro de referência. Métodos: Estudo observacional descritivo dos procedimentos de remoção transvenosa de eletrocateteres cardíacos de janeiro de 2009 a maio de 2014. Resultados: A amostra incluiu 109 doentes, com idade média de 64,6 anos (± 16,62), 73,1% do género masculino. A principal indicação para remoção de eletrocateteres foi infeção do dispositivo. O tempo médio desde a primeira implantação à remoção foi de 5,6 anos (± 4,89). As hemoculturas foram positivas em 32,8% dos casos e cerca de 29% dos doentes apresentavam no estudo ecocardiográfico vegetações. Foram removidos 228 eletrocateteres, 58,8% ventriculares, 32,4% auriculares e 8,8% do seio coronário. O sucesso clínico do procedimento foi completo em 97,2%; o sucesso do procedimento foi completo em 93,4% dos casos e parcial em 5,3%. Como complicações registaram‐se três hematomas volumosos da loca, uma trombose da veia subclávia e três tamponamentos cardíacos, tratados eficazmente com pericardiocentese. Conclusões: A explantação/extração transvenosa dos eletrocateteres mostrou‐se altamente eficaz. Contudo, experiência com o sistema é um fator preponderante para o sucesso e segurança do procedimento. Abstract: Introduction and Objective: The number and complexity of cardiac implantable electronic devices (CIEDs) have increased, as has the number of related complications, often leading to removal of the implanted system. The aim of this study was to characterize transvenous explantation/extraction of CIED leads in a reference center. Methods: This was a descriptive observational study of patients consecutively admitted from January 2009 to May 2014 for tranvenous lead extraction. Results: The sample consisted of 109 patients, with a mean age of 64.6±16.62 years, 73.1% male. The main indication for lead extraction was CIED infection. The mean time from first implantation to lead removal was 5.6±4.89 years. Blood cultures were positive in 32.8% of cases and 29% of patients had vegetations on echocardiography. A total of 228 cardiac leads were removed, of which 58.8% were ventricular, 32.4% atrial and 8.8% coronary sinus. Complete clinical success was achieved in 97.2% of cases, while procedural success was complete in 93.4% and partial in 5.3%. The complications reported were three cases of significant pocket hematoma, one of subclavian vein thrombosis and three of cardiac tamponade, effectively treated by pericardiocentesis. Conclusions: Transvenous explantion or extraction of CIED leads was highly effective. A high level of experience is an essential factor in the success and safety of the procedure. Palavras‐chave: Pacemaker, Cardioversor desfibrilhador implantável, Terapia de ressincronização cardíaca, Extração de eletrocateteres, Infeção, Keywords: Pacemaker, Implantable cardioverter‐defibrillator, Cardiac resynchronization therapy, Lead extraction, Infection

Introduction and Objective: The number and complexity of cardiac implantable electronic devices (CIEDs) have increased, as has the number of related complications, often leading to removal of the implanted system. The aim of this study was to characterize transvenous explantation/extraction of CIED leads in a reference center. Methods: This was a descriptive observational study of patients consecutively admitted from January 2009 to May 2014 for transvenous lead extraction. Results: The sample consisted of 109 patients, with a mean age of 64.6±16.62 years, 73.1% male. The main indication for lead extraction was CIED infection. The mean time from first implantation to lead removal was 5.6±4.89 years. Blood cultures were positive in 32.8% of cases and 29% of patients had vegetations on echocardiography. A total of 228 cardiac leads were removed, of which 58.8% were ventricular, 32.4% atrial and 8.8% coronary sinus. Complete clinical success was achieved in 97.2% of cases, while procedural success was complete in 93.4% and partial in 5.3%. The complications reported were three cases of significant pocket hematoma, one of subclavian vein thrombosis and three of cardiac tamponade, effectively treated by pericardiocentesis. Conclusions: Transvenous explantion or extraction of CIED leads was highly effective. A high level of experience is an essential factor in the success and safety of the procedure. Resumo: Introdução e objetivo: O número e a complexidade dos dispositivos cardíacos implantáveis têm vindo a aumentar assim como as suas complicações, conduzindo frequentemente à remoção dos mesmos. O objetivo deste estudo foi caraterizar a população envolvida e os procedimentos utilizados na remoção transvenosa de eletrocateteres cardíacos num centro de referência. Métodos: Estudo observacional descritivo dos procedimentos de remoção transvenosa de eletrocateteres cardíacos de janeiro de 2009 a maio de 2014. Resultados: A amostra incluiu 109 doentes, com idade média de 64,6 anos (± 16,62), 73,1% do género masculino. A principal indicação para remoção de eletrocateteres foi infeção do dispositivo. O tempo médio desde a primeira implantação à remoção foi de 5,6 anos (± 4,89). As hemoculturas foram positivas em 32,8% dos casos e cerca de 29% dos doentes apresentavam no estudo ecocardiográfico vegetações. Foram removidos 228 eletrocateteres, 58,8% ventriculares, 32,4% auriculares e 8,8% do seio coronário. O sucesso clínico do procedimento foi completo em 97,2%; o sucesso do procedimento foi completo em 93,4% dos casos e parcial em 5,3%. Como complicações registaram-se três hematomas volumosos da loca, uma trombose da veia subclávia e três tamponamentos cardíacos, tratados eficazmente com pericardiocentese. Conclusões: A explantação/extração transvenosa dos eletrocateteres mostrou-se altamente eficaz. Contudo, experiência com o sistema é um fator preponderante para o sucesso e segurança do procedimento. Keywords: Pacemaker, Implantable cardioverter-defibrillator, Cardiac resynchronization therapy, Lead extraction, Infection, Palavras-chave: Pacemaker, Cardioversor desfibrilhador implantável, Terapia de ressincronização cardíaca, Extração de eletrocateteres, Infeção

Endothelial progenitor stem cells (EPCs) are mobilized to the peripheral circulation in response to myocardial ischemia, playing a crucial role in vascular repair. Statins have been shown to stimulate EPCs. However, neither the impact of previous statin therapy on EPC response of acute myocardial infarction (AMI) patients nor the effect of post-AMI high-intensity statin therapy on the evolution of circulating EPC levels has yet been addressed. Therefore, we aimed to compare circulating EPC levels between patients receiving long-term statin therapy before the AMI and statin-naive patients and to assess the impact of high-intensity statin therapy at discharge on the evolution of circulating EPCs post-AMI. This is a prospective observational study of 100 AMI patients. Circulating EPCs (CD45dimCD34 + KDR + cells) and their subpopulation coexpressing the homing marker CXCR4 were quantified by the high-performance flow cytometer FACSCanto II in whole blood, in two different moments: within the first 24 h of admission and 3 months post-AMI. Patients were followed up clinically for 2 years. Patients previously treated with statins had significantly higher levels of EPCs coexpressing CXCR4 (1.9 ± 1.4 vs. 1.3 ± 1.0 cells/1,000,000 events, p = 0.031) than statin-naive patients. In addition, the subanalysis of diabetics (N = 38) also revealed that patients previously on statins had significantly greater numbers of both CD45dimCD34 + KDR + CXCR4+ cells (p = 0.024) and CD45dimCD34 + KDR + CD133+ cells (p = 0.022) than statin-naive patients. Regarding the evolution of EPC levels after the AMI, patients not on a high-intensity statin therapy at discharge had a significant reduction of CD45dimCD34 + KDR + and CD45dimCD34 + KDR + CXCR4+ cells from baseline to 3 months follow-up (p = 0.031 and p = 0.005, respectively). However, patients discharged on a high-intensity statin therapy maintained circulating levels of all EPC populations, presenting at 3 months of follow-up significantly higher EPC levels than patients not on an intensive statin therapy. Moreover, the high-intensity statin treatment group had significantly better clinical outcomes during the 2-year follow-up period than patients not discharged on a high-intensity statin therapy. Chronic statin therapy prior to an AMI strongly enhances the response of EPCs to myocardial ischemia, even in diabetic patients. Furthermore, high-intensity statin therapy after an AMI prevents the expected decrease of circulating EPC levels during follow-up. These results reinforce the importance of an early and intensive statin therapy in AMI patients.

Background It would be important to better identify heart failure (HF) patients most likely to respond to cardiac resynchronization therapy (CRT). Because endothelial progenitor cells (EPCs) play a crucial role in the maintenance of vascular endothelium integrity, we hypothesize that patients who have higher circulating EPCs levels have greater neovascularization potential and are more prone to be responders to CRT. Methods Prospective study of 30 consecutive patients, scheduled for CRT. Echocardiographic evaluation was performed before implant and 6 months after. Responders to CRT were defined as patients who were still alive, have not been hospitalized for HF management, and demonstrated ≥15% reduction in left ventricular end-systolic volume (LVESV) at the 6-month follow-up. EPCs were quantified before CRT, from peripheral blood, by flow cytometry using five different conjugated antibodies: anti-CD34, anti-KDR, anti-CD133, anti-CD45, and anti-CXCR4. We quantified five different populations of angiogenic cells: CD133(+) /CD34(+) cells, CD133(+) /KDR(+) cells, CD133(+) /CD34(+) /KDR(+) cells, CD45(dim) CD34(+) /KDR(+) cells, and CD45(dim) CD34(+) /KDR(+) /CXCR4(+) cells. Results The proportion of responders to CRT at the 6-month follow-up was 46.7%. Responders to CRT presented higher baseline EPCs levels than nonresponders (0.0003 ± 0.0006% vs 0.0001 ± 0.0002%, P = 0.04, for CD34(+) /CD133(+) /KDR(+) and 0.0006 ± 0.0005% vs 0.0003 ± 0.0003%, P = 0.009, for CD45(dim) CD34(+) /KDR(+) /CXCR4(+) cells). In addition, baseline levels of CD45(dim) CD34(+) /KDR(+) /CXCR4(+) cells were positively correlated with the reduction of LVESV verified 6 months after CRT (r = 0.497, P = 0.008). Conclusions High circulating EPCs levels may identify the subset of HF patients who are more likely to undergo reverse remodeling and benefit from CRT. Addition of EPCs levels assessment to current selection criteria may improve the ability to predict CRT response.

Background: Pulmonary embolism (PE) is a common cardiovascular emergency that, when combined with chronic thromboembolic pulmonary hypertension (PH), is associated with high mortality and morbidity. We aimed to determine the incidence of and predisposing factors for the development of PH after a PE episode. Methods: A retrospective study was conducted in 213 patients admitted to an intensive care unit with intermediate-to-high risk PE between 2000 and 2010. Clinical data at admission were collected and the incidence of PH as assessed by echocardiography (estimated pulmonary systolic artery pressure over 40 mmHg) was determined. Multivariate analysis was used to determine predictors of development of PH. Results: PH was detected in 12.4% of patients after a mean follow-up of three years. Only age (hazard ratio [HR] 1.09, 95% confidence interval [CI] 1.02–1.20 per year; p=0.012) and body mass index (HR 1.19, 95% CI 1.04–1.36) per kg/m2, p=0.013) emerged as independent predictors of the development of this complication during follow-up. Conclusions: PH after PE was a relatively common complication in our series. We identified advanced age and increased body mass index as predisposing factors. Resumo: Introdução: A tromboembolia pulmonar (TEP) é uma emergência cardiovascular comum que, juntamente com a hipertensão pulmonar tromboembólica crónica (HPTEC), se associa a alta mortalidade e morbilidade. Não há ainda consenso quanto à consecutividade destas patologias. Este estudo pretende determinar a incidência e fatores de risco para o desenvolvimento de hipertensão pulmonar (HTP) após uma TEP de risco intermédio a elevado. Métodos: Estudámos retrospetivamente 213 doentes com TEP de risco intermédio a elevado, entre 2000–2010, e comparamos dados demográficos, clínicos, laboratoriais e imagiológicos entre os doentes que manifestaram HTP durante o seguimento clínico (doentes que, pelo menos três meses após a alta, mantivessem pressões sistólicas na artéria pulmonar acima de 40 mmHg, estimadas por ecocardiografia) com os doentes que mantiveram pressões normais. Resultados: Identificou-se HTP após a TEP em 12,4% dos doentes. Foram fatores preditores para o desenvolvimento desta complicação a idade (hazard ratio [HR] 1,09 [intervalo de confiança {IC} 95% 1,02–1,20] por ano de idade, p=0,012) e o índice de massa corporal (HR 1,19 [IC 95% 1,04-1,36] por kg m−2, p=0,013). Conclusões: A HTP após uma TEP foi uma complicação relativamente comum na nossa série de doentes com um episódio agudo de TEP de risco intermédio a elevado. Identificamos como fatores preditores do desenvolvimento desta complicação a idade avançada e a obesidade. Keywords: Chronic thromboembolic pulmonary hypertension, Pulmonary embolism, Risk factors, Body mass index, Obesity, Age, Palavras-chave: Hipertensão pulmonar tromboembólica crónica, Tromboembolia-pulmonar, Fatores de risco, Índice de massa corporal, Obesidade, Idade

Resumo: Introdução: A tromboembolia pulmonar (TEP) é uma emergência cardiovascular comum que, juntamente com a hipertensão pulmonar tromboembólica crónica (HPTEC), se associa a alta mortalidade e morbilidade. Não há ainda consenso quanto à consecutividade destas patologias. Este estudo pretende determinar a incidência e fatores de risco para o desenvolvimento de hipertensão pulmonar (HTP) após uma TEP de risco intermédio a elevado. Métodos: Estudámos retrospetivamente 213 doentes com TEP de risco intermédio a elevado, entre 2000-2010, e comparamos dados demográficos, clínicos, laboratoriais e imagiológicos entre os doentes que manifestaram HTP durante o seguimento clínico (doentes que, pelo menos três meses após a alta, mantivessem pressões sistólicas na artéria pulmonar acima de 40 mmHg, estimadas por ecocardiografia) com os doentes que mantiveram pressões normais. Resultados: Identificou-se HTP após a TEP em 12,4% dos doentes. Foram fatores preditores para o desenvolvimento desta complicação a idade (hazard ratio [HR] 1,09 [intervalo de confiança {IC} 95% 1,02-1,20] por ano de idade, p = 0,012) e o índice de massa corporal (HR 1,19 [IC 95% 1,04-1,36] por kg m−2, p = 0,013). Conclusões: A HTP após uma TEP foi uma complicação relativamente comum na nossa série de doentes com um episódio agudo de TEP de risco intermédio a elevado. Identificamos como fatores preditores do desenvolvimento desta complicação a idade avançada e a obesidade. Abstract: Background: Pulmonary embolism (PE) is a common cardiovascular emergency that, when combined with chronic thromboembolic pulmonary hypertension (PH), is associated with high mortality and morbidity. We aimed to determine the incidence of and predisposing factors for the development of PH after a PE episode. Methods: A retrospective study was conducted in 213 patients admitted to an intensive care unit with intermediate-to-high risk PE between 2000 and 2010. Clinical data at admission were collected and the incidence of PH as assessed by echocardiography (estimated pulmonary systolic artery pressure over 40 mmHg) was determined. Multivariate analysis was used to determine predictors of development of PH. Results: PH was detected in 12.4% of patients after a mean follow-up of three years. Only age (hazard ratio [HR] 1.09, 95% confidence interval [CI] 1.02-1.20 per year; p=0.012) and body mass index (HR 1.19, 95% CI 1.04-1.36) per kg/m2, p=0.013) emerged as independent predictors of the development of this complication during follow-up. Conclusions: PH after PE was a relatively common complication in our series. We identified advanced age and increased body mass index as predisposing factors. Palavras-chave: Hipertensão pulmonar tromboembólica crónica, Tromboembolia-pulmonar, Fatores de risco, Índice de massa corporal, Obesidade, Idade, Keywords: Chronic thromboembolic pulmonary hypertension, Pulmonary embolism, Risk factors, Body mass index, Obesity, Age

Resumo: Introdução: A ressonância magnética cardíaca (RMC) tem vindo a adquirir grande relevância na avaliação diagnóstica de um espectro cada vez mais amplo de cardiomiopatias, incluindo as que apresentam potencial arritmogénico. Objetivo: Avaliação do valor acrescentado da RMC no diagnóstico etiológico de arritmias ventriculares, quando a investigação convencional inicial com outros métodos complementares de diagnóstico não é conclusiva. Métodos: Estudaram-se retrospetivamente os doentes que realizaram RMC para esclarecimento da etiologia de arritmias ventriculares, entre 2005-2011 (n = 113). Foram incluídos apenas doentes com arritmias ventriculares documentadas. Constituíram critérios de exclusão a obtenção de diagnóstico definitivo por exame complementar, de diagnóstico realizado previamente e a presença de história prévia sugestiva de doença coronária (antecedentes de síndrome coronária aguda ou história de angor típico, de elevação de biomarcadores de necrose miocárdica ou teste de isquemia positivo, quando realizado). Os resultados da RMC foram considerados relevantes quando sugeriram um diagnóstico provável. Resultados: Dos 113 doentes incluídos, 57,5% eram homens. A idade média foi 41,7 ± 16,2 anos. Quanto à arritmia documentada, 38,1% dos doentes foram referenciados por taquicardia ventricular/fibrilhação ventricular (FV/TV mantida) e 61,9% por extrassistolia ventricular com menor complexidade (ESV). A RMC mostrou alterações sugestivas de um diagnóstico específico em 42,5% dos doentes, foi totalmente normal em 36,3% e mostrou alterações inespecíficas nos restantes. Nos casos de referenciação por FV/TV mantida a RMC foi diagnóstica em 60,4% dos casos, enquanto nos casos de ESV foi-o em 31,4%.Os diagnósticos prováveis mais frequentes foram displasia arritmogénica do ventrículo direito, não compactação ventricular e miopericardite. Assinala-se que, apesar da ausência de evidências clínicas sugestivas pelos critérios atrás referidos, 6,2% dos doentes apresentaram áreas de realce tardio com distribuição e características atribuíveis a doença coronária obstrutiva. Conclusão: A RMC proporciona valor acrescentado no diagnóstico etiológico de arritmias ventriculares quando exames mais acessíveis ou realizados previamente não são conclusivos. A percentagem de doentes em que foi conclusiva foi de 42,5% (60,4% nos casos de referenciação por FV/TV mantida) e em que foi totalmente normal foi de 36,3%. Abstract: Introduction: Cardiac magnetic resonance (CMR) imaging is increasingly important in the diagnostic work-up of a wide range of heart diseases, including those with arrhythmogenic potential. Objective: To assess the added value of CMR in etiological diagnosis of ventricular arrhythmias after an inconclusive conventional investigation. Methods: Patients undergoing CMR between 2005 and 2011 for investigation of ventricular arrhythmias were included (n=113). All had documented arrhythmias. Those with a definite diagnosis from a previous investigation and those with evidence of coronary artery disease (acute coronary syndrome, typical angina symptoms, increase in biomarkers or positive stress test) were excluded. CMR results were considered relevant when they fulfilled diagnostic criteria. Results: Of the 113 patients, 57.5% were male and mean age was 41.7±16.2 years. Regarding the initial arrhythmia, 38.1% had ventricular fibrillation/sustained ventricular tachycardia (VF/VT) and 61.9% had less complex ventricular ectopy. CMR imaging showed criteria of a specific diagnosis in 42.5% of patients, was totally normal in 36.3%, and showed non-specific alterations in the remainder. In VF/VT patients, specific criteria were found in 60.4%, and in 31.4% of those with less complex ectopy.The most frequent diagnoses were arrhythmogenic right ventricular dysplasia, ventricular non-compaction and myopericarditis. It is worth noting that, although there was no evidence of previous coronary artery disease, 6.2% of patients had a late gadolinium enhancement distribution pattern compatible with myocardial infarction. Conclusion: CMR gives additional and important information in the diagnostic work-up of ventricular arrhythmias after an inconclusive initial investigation. The proportion of patients with diagnostic criteria was 42.5% (60.0% in those with VF/VT), and CMR was completely normal in 36.6%. Palavras-chave: Ressonância magnética cardíaca, Etiologia de arritmias ventriculares, Substrato arritmogénico, Keywords: Cardiac magnetic resonance, Diagnosis of ventricular arrhythmias, Arrhythmogenic substrate

Introduction: Cardiac magnetic resonance (CMR) imaging is increasingly important in the diagnostic work-up of a wide range of heart diseases, including those with arrhythmogenic potential. Objective: To assess the added value of CMR in etiological diagnosis of ventricular arrhythmias after an inconclusive conventional investigation. Methods: Patients undergoing CMR between 2005 and 2011 for investigation of ventricular arrhythmias were included (n=113). All had documented arrhythmias. Those with a definite diagnosis from a previous investigation and those with evidence of coronary artery disease (acute coronary syndrome, typical angina symptoms, increase in biomarkers or positive stress test) were excluded. CMR results were considered relevant when they fulfilled diagnostic criteria. Results: Of the 113 patients, 57.5% were male and mean age was 41.7±16.2 years. Regarding the initial arrhythmia, 38.1% had ventricular fibrillation/sustained ventricular tachycardia (VF/VT) and 61.9% had less complex ventricular ectopy. CMR imaging showed criteria of a specific diagnosis in 42.5% of patients, was totally normal in 36.3%, and showed non-specific alterations in the remainder. In VF/VT patients, specific criteria were found in 60.4%, and in 31.4% of those with less complex ectopy.The most frequent diagnoses were arrhythmogenic right ventricular dysplasia, ventricular non-compaction and myopericarditis. It is worth noting that, although there was no evidence of previous coronary artery disease, 6.2% of patients had a late gadolinium enhancement distribution pattern compatible with myocardial infarction. Conclusion: CMR gives additional and important information in the diagnostic work-up of ventricular arrhythmias after an inconclusive initial investigation. The proportion of patients with diagnostic criteria was 42.5% (60.0% in those with VF/VT), and CMR was completely normal in 36.6%. Resumo: Introdução: A ressonância magnética cardíaca (RMC) tem vindo a adquirir grande relevância na avaliação diagnóstica de um espectro cada vez mais amplo de cardiomiopatias, incluindo as que apresentam potencial arritmogénico. Objetivo: Avaliação do valor acrescentado da RMC no diagnóstico etiológico de arritmias ventriculares, quando a investigação convencional inicial com outros métodos complementares de diagnóstico não é conclusiva. Métodos: Estudaram-se retrospetivamente os doentes que realizaram RMC para esclarecimento da etiologia de arritmias ventriculares, entre 2005-2011 (n = 113). Foram incluídos apenas doentes com arritmias ventriculares documentadas. Constituíram critérios de exclusão a obtenção de diagnóstico definitivo por exame complementar, de diagnóstico realizado previamente e a presença de história prévia sugestiva de doença coronária (antecedentes de síndrome coronária aguda ou história de angor típico, de elevação de biomarcadores de necrose miocárdica ou teste de isquemia positivo, quando realizado). Os resultados da RMC foram considerados relevantes quando sugeriram um diagnóstico provável. Resultados: Dos 113 doentes incluídos, 57,5% eram homens. A idade média foi 41,7 ± 16,2 anos. Quanto à arritmia documentada, 38,1% dos doentes foram referenciados por taquicardia ventricular/fibrilhação ventricular (FV/TV mantida) e 61,9% por extrassistolia ventricular com menor complexidade (ESV). A RMC mostrou alterações sugestivas de um diagnóstico específico em 42,5% dos doentes, foi totalmente normal em 36,3% e mostrou alterações inespecíficas nos restantes. Nos casos de referenciação por FV/TV mantida a RMC foi diagnóstica em 60,4% dos casos, enquanto nos casos de ESV foi-o em 31,4%.Os diagnósticos prováveis mais frequentes foram displasia arritmogénica do ventrículo direito, não compactação ventricular e miopericardite. Assinala-se que, apesar da ausência de evidências clínicas sugestivas pelos critérios atrás referidos, 6,2% dos doentes apresentaram áreas de realce tardio com distribuição e características atribuíveis a doença coronária obstrutiva. Conclusão: A RMC proporciona valor acrescentado no diagnóstico etiológico de arritmias ventriculares quando exames mais acessíveis ou realizados previamente não são conclusivos. A percentagem de doentes em que foi conclusiva foi de 42,5% (60,4% nos casos de referenciação por FV/TV mantida) e em que foi totalmente normal foi de 36,3%. Keywords: Cardiac magnetic resonance, Diagnosis of ventricular arrhythmias, Arrhythmogenic substrate, Palavras-chave: Ressonância magnética cardíaca, Etiologia de arritmias ventriculares, Substrato arritmogénico

Introduction and Objectives: Cardioembolism is one of the most common causes of ischemic stroke, with an estimated prevalence of 20–30%, and correct diagnosis is essential given the therapeutic implications. Although stroke risk scores (CHADS2 and more recently CHA2DS2-VASc) have been validated in heterogeneous populations of patients with atrial fibrillation, their accuracy has not been ascertained for secondary stroke prevention. We set out to assess the sensitivity and specificity of the CHADS2 and CHA2DS2-VASc stroke risk scores as predictors of cardioembolic sources, documented by transesophageal echocardiography (TEE) in a population with ischemic stroke. Methods: The CHADS2 and CHA2DS2-VASc scores were applied to all patients admitted to the stroke unit/neurology ward of a Portuguese tertiary hospital with atrial fibrillation (diagnosed previously or during or after admission) who underwent TEE between January and August 2011.The presence of a cardioembolic source was defined as the observation by TEE of spontaneous echo contrast in the left atrium and atrial appendage or thrombi in the left cardiac chambers. Results: We studied 94 patients, 66.0% male, mean age 64.4 years (standard deviation 14.2). A cardioembolic source was detected in 20 patients. ROC curve analysis identified as predictors of cardioembolic source CHADS2 score ≥4 (sensitivity of 75.0%, specificity of 66.0%, p=0.014) and CHA2DS2-VASc score ≥5 (sensitivity of 83.3%, specificity of 58.0%, p=0.009). Conclusions: Both scores showed acceptable sensitivity as predictors of embolic risk in the context of secondary prevention of cardioembolic stroke. The CHA2DS2-VASc score has higher sensitivity than CHADS2 but lower specificity. Resumo: Introdução e objetivos: A cardioembolia representa uma das causas mais frequentes de lesões cerebrovasculares isquémicas, com prevalência estimada de 20-30% e implicações terapêuticas diretas que obrigam à sua correta avaliação. Apesar de a validação das escalas de risco cardioembólico (CHADS2 e, mais recentemente, CHA2DS2-VASc) em populações heterogéneas de doentes com fibrilhação furicular, desconhece-se ainda a sua validade em contexto de prevenção secundária cerebrovascular.É objetivo deste trabalho estudar a sensibilidade e especificidade diferencial das escalas de risco cardioembólico como preditoras de fonte cardioembólica documentada por ecocardiograma transesofágico (ETE) numa população de doentes com AVC isquémico. Métodos: Aplicámos as escalas CHADS2 e CHA2DS2-VASc a todos os doentes internados por evento cerebrovascular isquémico na Unidade de AVC/Enfermaria de Neurologia de um hospital central português com diagnóstico de fibrilhação auricular (prévio ou obtido durante/após o internamento), que realizaram ETE entre janeiro e agosto de 2011.Definimos como presença de fonte cardioembólica a observação em ETE de autocontraste espontâneo na aurícula e apêndice auricular esquerdo ou trombos nas cavidades cardíacas esquerdas. Resultados: Analisámos 94 doentes, 66,0% do sexo masculino, idade média: 64,4 anos (desvio padrão: 14,2). Foi detetada fonte cardioembólica em 20 doentes. A análise de curva Receiver Operating Characteristic (ROC) identifica como preditores de fonte cardioembólica pontuação CHADS2 ≥ 4; sensibilidade: 75,0%, especificidade: 66,0%, p = 0,014 e pontuação CHA2DS2-VASc ≥ 5; sensibilidade: 83,3%, especificidade: 58,0%, p = 0,009. Conclusões: Ambas as escalas apresentam sensibilidade significativa como preditoras de risco cardioembólico em contexto de prevenção secundária cerebrovascular. A escala CHA2DS2-VASc possui uma sensibilidade superior à CHADS2, sendo, no entanto, menos específica. Keywords: Stroke, Atrial fibrillation, Thromboembolism, Echocardiography, Anticoagulation, Palavras-chave: Acidente vascular cerebral, Fibrilhação auricular, Tromboembolismo, Ecocardiografia, Anticoagulação

Introduction: Gated SPECT myocardial perfusion imaging (MPI) has been used to quantify mechanical dyssynchrony. Mechanical dyssynchrony appears to be related to response to cardiac resynchronization therapy. Objective: To evaluate the presence and predictors of mechanical dyssynchrony in patients with impaired left ventricular function (LVEF) ≤50%. Methods: The study included 143 consecutive patients referred for gated SPECT MPI with LVEF ≤50%. Gated SPECT MPI was performed according to a stress/rest protocol acquiring images with Tc 99m-tetrofosmin. Emory Cardiac Toolbox software was used for phase analysis and a standard deviation (SD) ≥43° was considered to indicate mechanical dyssynchrony. Results: Mechanical dyssynchrony was present in 53.1% of the patients. Its predictors were diabetes (OR 2.0, p≤0.05), summed stress score (OR 1.1, p≤0.0005), summed rest score (OR 1.1, p≤0.0001), end-diastolic volume (OR 1.0, p≤0.0001), LVEF (OR 0.9, p≤0.0001), LVEF ≤35% (OR 3.1, p≤0.005) and LVEF ≤35% and QRS ≥120 ms (OR 3.5, p≤0.05). In this study QRS width and QRS ≥120 ms were not predictors of mechanical dyssynchrony. Conclusions: Myocardial perfusion imaging can be used to assess mechanical dyssynchrony. In patients with impaired ventricular function mechanical dyssynchrony was highly prevalent and was related to parameters of left ventricular function and perfusion. Resumo: Introdução: A avaliação de dessincronia ventricular mecânica através da análise do histograma de fase na cintigrafia de perfusão miocárdica tem sido descrita na literatura. Segundo a evidência atual, a presença de dessincronia mecânica encontra-se relacionada com a resposta à terapêutica de ressincronização. Objectivos: Avaliar a presença e os preditores de dessincronia ventricular mecânica em pacientes com fração de ejeção ventricular esquerda (FEVE) ≤ 50%. Métodos: Foram incluídos pacientes que realizaram cintigrafia de perfusão miocárdica e cuja FEVE foi inferior ou igual a 50%. A amostra estudada incluiu 143 pacientes. As imagens de perfusão foram adquiridas de acordo com o protocolo esforço seguido de repouso com Tc-99m Tetrafosmina. A avaliação de dessincronia baseou-se na determinação do desvio padrão obtido através da análise do histograma de fase (Emory Toolbox Software). A presença de dessincronia foi considerada quando o desvio-padrão no histograma de fase foi superior ou igual a 43°. Resultados: A presença de dessincronia foi observada 53,1% dos doentes. Foram preditores de dessincronia, a diabetes (OR 2,0, p ≤ 0,05), o score de esforço (OR 1,1, p ≤ 0,0005), o score de repouso (OR 1,1, p ≤ 0,0001), o volume telediastólico (OR 1,0, p ≤ 0,0001), a FEVE (OR 0,9, p ≤ 0,0001), FEVE ≤ 35% (OR 3,1, p ≤ 0,005) e a presença em simultâneo de FEVE ≤ 35% e QRS ≥120 ms (OR 3,5, p ≤ 0,05). Nesta avaliação a duração do QRS ou a presença de QRS ≥ 120 ms não se relacionaram com a presença de dessincronia. Conclusões: A cintigrafia de perfusão miocárdica pode ser usada na avaliação de dessincronia e esta tem uma elevada prevalência em pacientes com FEVE diminuída relacionando-se com parâmetros de função ventricular e perfusão miocárdica. Keywords: Myocardial perfusion imaging, Gated SPECT, Dyssynchrony, Coronary artery disease, Heart failure, Palavras-chave: Cintigrafia de perfusão miocárdica, Gated SPECT, Dessincronia, Doença coronária, Insuficiência cardíaca

Background: The impact of digoxin on outcomes of patients with advanced heart failure (HF) remains uncertain and its effect may be different for patients in atrial fibrillation (AF) or sinus rhythm (SR). Objectives: To determine the impact of digoxin on outcomes of advanced HF patients and to assess whether prognosis differs in patients in AF and SR. Methods: A total of 268 consecutive patients admitted to an intensive care unit with decompensated HF were evaluated. Patients were divided into two groups: A – patients with AF (n=89), and B – patients in SR (n=179). For each group we compared patients medicated and not medicated with digoxin. A mean follow-up of 3.3 years was performed. Results: Addition of digoxin to contemporary standard HF therapy showed no impact on mortality of patients in group B (all-cause mortality in follow-up: 19.1% vs. 22.5%, p=0.788). Regarding group A, we observed significantly lower medium-term mortality for patients on digoxin therapy (18.6% vs. 46.6%, p=0.048). Digoxin therapy did not influence readmissions for decompensated HF. Among AF patients, no differences were found regarding demographic, clinical, echocardiographic and laboratory variables between patients medicated and not medicated with digoxin. Conclusions: Digoxin therapy may improve the prognosis of advanced HF patients with AF under optimal medical therapy. However, no benefit of digoxin was demonstrated for patients in SR. These results may help to improve patient selection for digoxin therapy. Resumo: Introdução: O impacto prognóstico da digoxina na insuficiência cardíaca (IC) avançada permanece mal esclarecido. A relevância da terapêutica digitálica pode ser diferente na fibrilhação auricular (FA) relativamente ao ritmo sinusal (RS). Objectivos: Determinar o impacto prognóstico da digoxina na IC e verificar se este é diferente consoante se encontrem em FA ou em RS. Métodos: Estudaram-se 268 doentes internados numa unidade de cuidados intensivos por IC descompensada. Dividiu-se a população em dois grupos: A – 89 doentes em FA; grupo B – 179 doentes em RS. Para cada grupo compararam-se os doentes medicados com os não medicados com digoxina. Realizou-se um seguimento clínico com a duração mediana de 3,3 anos. Resultados: A digoxina não teve impacto na mortalidade dos doentes com IC avançada que se encontravam em RS (mortalidade a 3,3 anos: 19,1% versus 22,5%, p = 0,788), adicionada à terapêutica médica otimizada. Nos doentes em FA observou-se uma redução significativa da mortalidade nos doentes medicados com digoxina (18,6% versus 46,6%, p = 0,048). A digoxina não alterou a taxa de reinternamentos por IC descompensada. No grupo A não se verificaram diferenças entre os doentes medicados e não medicados com digoxina relativamente aos parâmetros demográficos, clínicos, ecocardiográficos ou laboratoriais. Conclusão: Este estudo sugere que a digoxina pode melhorar o prognóstico dos doentes com IC avançada e FA, sob terapêutica médica optimizada. Contudo, esta não demonstrou benefício nos doentes em RS. Estes resultados podem contribuir para uma melhor seleção dos doentes a medicar com digoxina, otimizando a relação risco/benefício desta terapêutica. Keywords: Advanced heart failure, Digoxin, Atrial fibrillation, Prognosis, Palavras-chave: Insuficiência cardíaca avançada, Digoxina, Fibrilhação auricular, Prognóstico

Introduction: Previous follow-up studies of patients with symptoms and/or non-invasive tests suggestive of ischemia or an acute coronary syndrome and a normal coronary angiogram have reported a good prognosis. Objectives: The aim of this study was to evaluate the clinical characteristics and outcome of a cohort of patients with suspected ischemic heart disease and normal coronary arteries. Methods: A clinical follow-up was performed of 607 patients (mean age 62 ± 11 years) with symptoms or non-invasive tests suggestive of ischemia (544) or myocardial infarction (63) and normal coronary angiography. The occurrence of major cardiac events or of readmission due to chest pain was recorded during a mean follow-up of 33.6 ± 9.5 months after angiography. Results: Patients with myocardial infarction were older (65.4 ± 11.1 vs. 61.9 ± 10.7, p=0.05), and the majority were women (68.3%). Hypertension was reported by 65.5% of patients, diabetes by 17.9%, dyslipidemia by 58.6%, smoking by 14% and family history of coronary artery disease in 11%. During follow-up no patient died from cardiovascular causes; three patients (0.5%) suffered myocardial infarction and 50 (8.3%) had recurrent chest pain leading to emergency admission. Patients with myocardial infarction had more events (20.6%) than those referred for angiography due to symptoms and/or positive non-invasive tests for ischemia (7.4%) (log-rank chi-square test: 13.6, p

Background: Bosentan is recommended for symptomatic patients with Eisenmenger syndrome due to simple congenital lesions such as atrial and ventricular septal defects (VSD). However, its long-term efficacy and safety in patients with pulmonary arterial hypertension (PAH) associated with complex congenital heart disease (CHD) is unknown. Objectives: We examined the short- and long-term effects and safety profile of bosentan in patients with PAH and complex CHD. Methods: We followed 14 patients with PAH and complex CHD for a mean of four years. Demographic parameters, exercise capacity assessed by the six-minute walking test (6MWT) and oxygen saturation were assessed at baseline, six months and at follow-up. Results: Mean age was 37.1±11.7 years; 90% were in WHO class III or IV. The most common diagnosis was pulmonary atresia with VSD (35.7%), followed by truncus arteriosus (28.6%), patent ductus arteriosus (21.4%) and transposition of the great arteries (14.3%). After six months of treatment, six-minute walking distance (6MWD) increased from 371.9 to 428.4 m (p=0.005) and functional class was improved (p=0.005). After four years, one patient discontinued bosentan due to side effects and four patients were started on sildenafil, after a mean 38 months of bosentan treatment. Mean 6MWD for patients on bosentan monotherapy (n=8) was 440.1±103.8 m, whereas for patients on bosentan-sildenafil combination therapy (n=4) it was 428.8±96.9 m, after four years of therapy. Two patients died during follow-up. Conclusions: Bosentan was safe and was associated with improved exercise capacity in patients with PAH and complex CHD. This improvement was sustained for up to four years and the safety profile was similar to simple CHD patients. Resumo: Introdução: O bosentano é recomendado em doentes com hipertensão arterial pulmonar (HAP) associada a lesões congénitas simples, como comunicações interventriculares (CIV). Contudo, a sua eficácia e segurança a longo prazo em doentes com HAP associada a cardiopatias congénitas complexas (HAP-CCC) é desconhecida. Objectivos: Avaliámos a eficácia e segurança a curto e longo-prazo do bosentano na HAP-CCC. Métodos: Estudaram-se 14 doentes com HAP-CCC, relativamente a parâmetros demográficos, capacidade funcional avaliada pelo teste de marcha de seis minutos (TM6M) e saturação de oxigénio, antes de iniciar terapêutica, aos seis meses e durante o período de seguimento clínico a longo-prazo (quatro anos). Resultados: Noventa por cento dos doentes encontravam-se em classe OMS III ou IV, com idade média de 37,1 ± 11,7 anos. O diagnóstico mais frequente foi a atrésia pulmonar com CIV (35,7%), seguida de truncus arteriosus (28,6%), canal arterial patente (21,4%) e transposição de grandes vasos (14,3%). Após seis meses de tratamento, o TM6M aumentou de 371,9 para 428,4 metros (p = 0,005) e a classe funcional melhorou (p = 0,005). Após quatro anos, um doente suspendeu bosentano devido a efeitos secundários e quatro doentes iniciaram sildenafil, após uma duração média de monoterapia de 38 meses. Após quatro anos de terapêutica, nos doentes em monoterapia com bosentano (n = 8) o TM6M foi de 440,1 ± 103,8 metros, enquanto que nos doentes com bosentano-sildenafil (n = 4) foi de 428,8 ± 96,9 metros. Dois doentes faleceram durante o período de seguimento clínico. Conclusões: O bosentano foi seguro e esteve associado a melhoria na capacidade funcional em doentes com HAP-CCC até aos quatro anos de seguimento clínico. Keywords: Bosentan, Congenital heart disease, Pulmonary hypertension, Palavras chave: Bosentan, Cardiopatia congénita, Hipertensão pulmonar

Introduction: Contrast-enhanced multidetector computed tomography (MDCT) is useful for the diagnosis of pulmonary embolism (PE). However, current guidelines do not support its use for risk assessment in acute PE patients. Objectives: We compared the prognostic impact of MDCT-derived indices regarding medium-term mortality in a population of intermediate- to high-risk PE patients, mostly treated by thrombolysis. Methods: Thirty-nine consecutive patients admitted to an intensive care unit with acute PE were studied. All patients had a pulmonary MDCT on admission to the emergency room as part of the diagnostic algorithm. We assessed the following MDCT variables: right ventricular/left ventricular diameter (RV/LV) ratio, arterial obstruction index, pulmonary artery-to-aorta diameter ratio and azygos vein diameter. A 33-month follow-up was performed. Results: Mean age was 59.1±19.6 years, with 80% of patients receiving thrombolysis. Follow-up all-cause mortality was 12.8%. Of the MDCT-derived variables, only the RV/LV ratio had significant predictive value, being higher in patients who suffered the endpoint (1.6±0.5 vs. 1.9±0.4, p=0.046). Patients with an RV/LV ratio ≥1.8 had 11-fold higher medium-term all-cause mortality (3.8% vs. 38.8%, p

Resumo: Introdução e objectivos: A isquémia do miocárdio pode ser avaliada através da ressonância magnética de perfusão (RMp). O objetivo do trabalho foi avaliar o uso clínico da RMp no estudo da doença cardíaca isquémica (DCI). Métodos: Foram estudados 55 doentes através de RMp, num aparelho de 1,5 T (Siemens Symphony), através da injeção de quelato de gadolínio (0,10 mmol/kg), utilizando uma sequência IR-SSFP. O stress foi induzido pela adenosina (140 μg/kg/min durante 4 min). Os resultados foram comparados com os das coronariografias e das cintigrafias de perfusão do miocárdio. A concordância entre as variáveis qualitativas foi a avaliada através do coeficiente kappa. Foi considerada significância estatística a 95%. Efetuou-se um follow-up clínico mínimo de 12 meses. Resultados: Das 55 ressonâncias magnéticas (RM) efetuadas, em 19 (34,5%) não se detetou isquemia ou necrose do miocárdio, em 17 (30,9%) foi diagnosticada área de necrose sem isquemia, em 7 (12,7%) isquemia isolada e em 12 (21,8%) isquemia em doente com enfarte prévio. A comparação específica em função do território de irrigação coronária entre a RMp e a coronariografia foi muito boa: descendente anterior e coronária direita – k = 0,8571; intervalo 0,59-1, circunflexa – k = 0,8108; intervalo 0,59-1. Não se conseguiu obter qualquer razão de concordância entre as RMp e as cintigrafias realizadas. Conclusões: Numa população com elevada prevalência de doença coronária, a RMp mostrou ser um exame capaz de diagnosticar doença coronária significativa, através da identificação de isquemia do miocárdio. Abstract: Introduction and objectives: Myocardial ischemia can be assessed with cardiac magnetic resonance perfusion imaging (MRPI). This study aimed to analyze the clinical utility of MRPI in the diagnosis of significant coronary artery disease. Methods: Fifty-five patients were examined with a 1.5 T MR scanner (Siemens Symphony), with a first pass of 0.10 mmol/kg gadolinium chelate, at rest and during adenosine vasodilatation (140 μg/kg/min for 4 min) using an inversion recovery steady-state free precession sequence. The results were compared with coronary angiography and with SPECT myocardial perfusion images. Agreement for qualitative diagnosis was measured by the kappa coefficient, taking statistical significance as 95%. Minimum clinical follow-up was 12 months. Results: In 19 patients (34.5%) MRPI was negative for myocardial ischemia and necrosis, in 17 (30.9%) it was negative for ischemia but positive for necrosis, in 7 (12.7%) only ischemia was present and in 12 (21.8%) the ischemic area was larger than the necrotic area. The correlation between MRPI and coronary angiography for ischemia detection by coronary artery territory was very good: left anterior descending and right coronary – k=0.8571 (0.59-1), circumflex – k=0.8108 (0.59-1). By contrast, there was no correlation in terms of myocardial ischemia detection between MRPI and SPECT. Conclusions: MRPI is able to diagnose significant coronary disease in a high risk population, by detection of myocardial ischemia. Palavras-chave: Ressonância magnética, Perfusão, Doença coronária, Ressonância magnética de perfusão, Keywords: Magnetic resonance imaging, Perfusion, Coronary disease, Myocardial Perfusion Imaging

Introduction and objectives: Myocardial ischemia can be assessed with cardiac magnetic resonance perfusion imaging (MRPI). This study aimed to analyze the clinical utility of MRPI in the diagnosis of significant coronary artery disease. Methods: Fifty-five patients were examined with a 1.5 T MR scanner (Siemens Symphony), with a first pass of 0.10 mmol/kg gadolinium chelate, at rest and during adenosine vasodilatation (140 μg/kg/min for 4 min) using an inversion recovery steady-state free precession sequence. The results were compared with coronary angiography and with SPECT myocardial perfusion images. Agreement for qualitative diagnosis was measured by the kappa coefficient, taking statistical significance as 95%. Minimum clinical follow-up was 12 months. Results: In 19 patients (34.5%) MRPI was negative for myocardial ischemia and necrosis, in 17 (30.9%) it was negative for ischemia but positive for necrosis, in 7 (12.7%) only ischemia was present and in 12 (21.8%) the ischemic area was larger than the necrotic area. The correlation between MRPI and coronary angiography for ischemia detection by coronary artery territory was very good: left anterior descending and right coronary – k=0.8571 (0.59-1), circumflex – k=0.8108 (0.59-1). By contrast, there was no correlation in terms of myocardial ischemia detection between MRPI and SPECT. Conclusions: MRPI is able to diagnose significant coronary disease in a high risk population, by detection of myocardial ischemia. Resumo: Introdução e objectivos: A isquémia do miocárdio pode ser avaliada através da ressonância magnética de perfusão (RMp). O objetivo do trabalho foi avaliar o uso clínico da RMp no estudo da doença cardíaca isquémica (DCI). Métodos: Foram estudados 55 doentes através de RMp, num aparelho de 1,5 T (Siemens Symphony), através da injeção de quelato de gadolínio (0,10 mmol/kg), utilizando uma sequência IR-SSFP. O stress foi induzido pela adenosina (140 μg/kg/min durante 4 min). Os resultados foram comparados com os das coronariografias e das cintigrafias de perfusão do miocárdio. A concordância entre as variáveis qualitativas foi a avaliada através do coeficiente kappa. Foi considerada significância estatística a 95%. Efetuou-se um follow-up clínico mínimo de 12 meses. Resultados: Das 55 ressonâncias magnéticas (RM) efetuadas, em 19 (34,5%) não se detetou isquemia ou necrose do miocárdio, em 17 (30,9%) foi diagnosticada área de necrose sem isquemia, em 7 (12,7%) isquemia isolada e em 12 (21,8%) isquemia em doente com enfarte prévio. A comparação específica em função do território de irrigação coronária entre a RMp e a coronariografia foi muito boa: descendente anterior e coronária direita – k = 0,8571; intervalo 0,59-1, circunflexa – k = 0,8108; intervalo 0,59-1. Não se conseguiu obter qualquer razão de concordância entre as RMp e as cintigrafias realizadas. Conclusões: Numa população com elevada prevalência de doença coronária, a RMp mostrou ser um exame capaz de diagnosticar doença coronária significativa, através da identificação de isquemia do miocárdio. Keywords: Magnetic resonance imaging, Perfusion, Coronary disease, Myocardial perfusion imaging, Palavras-chave: Ressonância magnética, Perfusão, Doença coronária, Ressonância magnética de perfusão

Cardiac angiosarcomas, although very rare, are the most common primary malignant tumours. They are characterized by no specific clinical findings, rapid growth with frequent metastasis at the time of diagnosis and a reduced response to treatment. We describe the case of a 34-year-old pregnant woman who began to complain of dyspnoea and palpitations at 32 weeks of gestation. The echocardiogram showed a mass in the right atrial cavity and the CT scan showed extensive local invasion and hepatic metastasis. After 4 weeks, because of progressive heart failure due to obstruction of the tricuspid valve by the mass, the patient was submitted to an urgent caesarean section followed, two days later, by palliative cardiac surgery in order to alleviate the symptoms. Adjuvant chemotherapy was performed.

Background Two-dimensional speckle tracking (2D-ST) echocardiography for the measurement of circumferential ascending thoracic aortic strain (CAAS) in the context of aortic stenosis (AS) is not elucidated. Purpose This study assesses the thoracic ascending aortic deformation using 2D-ST echocardiography in AS patients. Population and methods Forty-five consecutive patients with an aortic valvular area (AVA) ≤0.85 cm2/m2 were included. Regarding aortic deformation, the global peak CAAS was the parameter used, and an average of six segments of arterial wall deformation was calculated. The corrected CAAS was calculated as the global CAAS/pulse pressure (PP). Aortic stiffness ( β 2) index was assessed according to ln( P s/ P d)/CAAS. The sample was stratified according to the stroke volume index (SVI) as: Group A (low flow, SVI ≤35 mL/m2; n = 19) and Group B (normal flow, SVI >35 mL/m2; n = 26). Results The mean age was 76.8 ± 10.3 years, 53.3% were male, the mean indexed AVA was 0.43 ± 0.15 cm2/m2, and the mean CAAS was 6.3 ± 3.0%. The CAAS was predicted by SVI ( β = 0.31, P < 0.01) and by valvulo-arterial impedance ( Z va). The corrected CAAS was correlated with the M-mode guided aortic stiffness index (β1) ( r = −0.39, P < 0.01), and was predicted by SVI, Z va, and systemic arterial compliance ( β = 0.15, P < 0.01). The β 2 index was significantly higher for the low-flow patients (16.1 ± 4.8 vs. 9.8 ± 5.3, P < 0.01), and was predicted by SVI ( β −0.58, P < 0.01) and PP ( β = 0.17, P < 0.01). Global CAAS was more accurate to predict low flow than Z va, systolic function and systemic vascular resistance. Conclusion In patients with moderate-to-severe aortic stenosis, SVI and LV afterload-related variables were the most important determinants of 2S-ST global CAAS.

Introduction: Inhibition of platelet aggregation appears two hours after the first dose of clopidogrel, becomes significant after the second dose, and progresses to a steady-state value of 55% by day seven. Low response to clopidogrel has been associated with increased risk of stent thrombosis and ischemic events, particularly in the context of stable heart disease treated by percutaneous coronary intervention. Objective: To stratify medium-term prognosis of an acute coronary syndrome (ACS) population by platelet aggregation. Methods: We performed a prospective longitudinal study of 70 patients admitted for an ACS between May and August 2009. Platelet function was assessed by ADP-induced platelet aggregation using a commercially available kit (Multiplate® analyzer) at discharge. The primary endpoint was a combined outcome of mortality, non-fatal myocardial infarction, or unstable angina, with a median follow-up of 136.0 (79.0–188.0) days. Results: The median value of platelet aggregation was 16.0 U (11.0–22.5 U) with a maximum of 41.0 U and a minimum of 4.0 U (normal value according to the manufacturer: 53–122 U). After ROC curve analysis with respect to the combined endpoint (AUC 0.72), we concluded that a value of 18.5 U conferred a sensitivity of 75.0% and a specificity of 68% to that result. We therefore created two groups based on that level: group A – platelet aggregation

A 46-year-old woman was admitted due to diplopia because of ophthalmoplegia, which improved with corticosteroid therapy. Eight days later, she was admitted with fulminant myocarditis in cardiogenic shock, with severe left ventricular dysfunction and frequent episodes of nonsustained ventricular tachycardia. As there was no clinical improvement, an endomyocardial biopsy was performed that revealed inflammatory infiltrate, vasculitis, and PCR positive for cytomegalovirus, Epstein–Barr virus, parvovirus B19 and enterovirus. Left ventricular function recovered with heart failure treatment and corticosteroids. Three months later, after progressive withdrawal of prednisolone, there was recurrence of myocarditis and left ventricular dysfunction, which was successfully treated by restarting corticosteroid therapy. One month later she was readmitted with fulminant myocarditis which again responded to steroids. She intermittently presented cutaneous purpura lesions. At this time the provisional diagnosis was vasculitis and she started monthly cycles of cyclophosphamide. Before the second cycle, she was admitted with pneumonia and ventricular dysfunction and died. Resumo: Mulher de 46 anos foi internada por diplopia devido a oftalmoplegia, que melhorou com corticoterapia. Oito dias depois, iniciou quadro de miocardite fulminante associada a choque cardiogénico por disfunção ventricular esquerda grave e episódios frequentes de taquicardia ventricular não mantida. Por não apresentar melhoria clínica, foi submetida a biópsia endomiocárdica que revelou infiltrado linfocitário, sinais de vasculite e PCR positiva para citomegalovírus, vírus Epstein-Barr, enterovírus e parvovírus. Após tratamento da insuficiência cardíaca e corticoterapia, recuperou a função ventricular. Três meses depois e após a suspensão de prednisolona, teve recorrência da miocardite com disfunção ventricular, tratada com sucesso após reinício de corticóides. Um mês depois, foi reinternada com o mesmo quadro que respondeu ao aumento da dose de corticóides. Apresentou intermitentemente lesões cutâneas tipo púrpura. Colocou-se a hipótese de vasculite e iniciou tratamento com ciclos mensais de ciclofosfamida. Antes do segundo ciclo, foi internada com pneumonia associada a disfunção ventricular e faleceu. Keywords: Fulminant myocarditis, Corticosteroid therapy, Vasculitis, Palavras-chave: Miocardite fulminante, Corticoterapia, Vasculite

Resumo: Mulher de 46 anos foi internada por diplopia devido a oftalmoplegia, que melhorou com corticoterapia. Oito dias depois, iniciou quadro de miocardite fulminante associada a choque cardiogénico por disfunção ventricular esquerda grave e episódios frequentes de taquicardia ventricular não mantida. Por não apresentar melhoria clínica, foi submetida a biópsia endomiocárdica, que revelou infiltrado linfocitário, sinais de vasculite e PCR positiva para citomegalovírus, vírus Epstein-Barr, enterovírus e parvovírus. Após tratamento da insuficiência cardíaca e corticoterapia, recuperou a função ventricular. Três meses depois e após a suspensão de prednisolona, teve recorrência da miocardite com disfunção ventricular, tratada com sucesso após reinício de corticoides. Um mês depois, foi reinternada com o mesmo quadro, que respondeu ao aumento da dose de corticoides. Apresentou intermitentemente lesões cutâneas tipo púrpura. Colocou-se a hipótese de vasculite e iniciou tratamento com ciclos mensais de ciclofosfamida. Antes do 2.° ciclo, foi internada com pneumonia associada a disfunção ventricular e faleceu. Abstract: A 46-year-old woman was admitted due to diplopia because of ophthalmoplegia, which improved with corticosteroid therapy. Eight days later, she was admitted with fulminant myocarditis in cardiogenic shock, with severe left ventricular dysfunction and frequent episodes of nonsustained ventricular tachycardia. As there was no clinical improvement, an endomyocardial biopsy was performed that revealed inflammatory infiltrate, vasculitis, and PCR positive for cytomegalovirus, Epstein-Barr virus, parvovirus B19 and enterovirus. Left ventricular function recovered with heart failure treatment and corticosteroids. Three months later, after progressive withdrawal of prednisolone, there was recurrence of myocarditis and left ventricular dysfunction, which was successfully treated by restarting corticosteroid therapy. One month later she was readmitted with fulminant myocarditis which again responded to steroids. She intermittently presented cutaneous purpura lesions. At this time the provisional diagnosis was vasculitis and she started monthly cycles of cyclophosphamide. Before the second cycle she was admitted with pneumonia and ventricular dysfunction and died. Palavras-chave: Miocardite fulminante, Corticoterapia, Vasculite, Keywords: Fulminant myocarditis, Corticosteroid therapy, Vasculitis

The frequency and function of T cells, monocytes, and dendritic cell subsets were investigated in 12 patients after acute myocardial infarction (AMI)-(T0), 1 month after the episode (T1), and in 12 healthy individuals (HG). The cell characterization and the functional studies were performed by flow cytometry and by RT-PCR, after cell sorting. The most important findings at T0 moment, when compared with T1 and HG, were: a decrease in the frequency of IL-2-producing T cells; a lower frequency of TNF-α- and IL-6-producing monocytes, myeloid dendritic cells, and CD14(-/low)CD16(+)DCs; and a lower TNF-α mRNA expression, after sorting these cells. Moreover, the regulatory function of Treg cells, at T0 moment, was upregulated, based on the FoxP3, CTLA-4, and TGF-β mRNA expression increase. The majority of these phenotypic and functional alterations disappeared at T1. Our data demonstrate that AMI induces a significant change in the immune system homeostasis.

Background: Clopidogrel requires oxidation dependent on the cytochrome P450 enzyme 2C19 (CYP2C19) to form its active metabolite. The importance of loss-of-function alleles (particularly CYP2C19*2, 681G>A) in poor platelet response to clopidogrel is well recognized. Objective: To investigate the prevalence and prognostic impact of the CYP2C19*2 allele in a local acute coronary syndrome (ACS) population. Methods: We performed a prospective, longitudinal study of 95 patients admitted for an ACS between March and October 2009 to a single coronary care unit. Patients aged under 75 who survived hospital stay and for whom clopidogrel was prescribed were included. At discharge, CYP2C19 was genotyped using a commercially available kit. Patients were divided into two groups: Group A (non-carriers, normal metabolizers, CYP2C19*1/*1), n = 69; and Group B (carriers, slow metabolizers, CYP2C19*2/*1 or *2/*2), n = 26. The primary endpoint was a combined outcome of cardiovascular death, non-fatal myocardial infarction or re-admission for unstable angina; median follow-up was 136.0 (79.0–188.0) days. Results: The median age of the population was 62.0 (51.0–68.0) years, and 83.2% were male. The CYP2C19*2 (A) allele had a frequency of 14.2%. There were no differences between the groups with respect to demographic data or history of cardiovascular disease. Coronary anatomy, left ventricular ejection fraction and renal function were also similar. The groups were also homogenous with respect to GRACE risk score (118.0 (95.0–136.5) vs. 115.0 (96.0–133.0), p = 0.68), medical treatment and percutaneous revascularization during hospital stay. Event-free survival was higher for Group A (94.0% vs. 75.0%, log-rank p = 0.010). Three readmissions for MI were documented, all in the slow metabolizers group. Conclusion: In our ACS population, the CYP2C19*2 allele was a medium-term prognostic marker. Resumo: Introdução: Polimorfismos no complexo enzimático P450, como CYP2C19*2, 681G>A parecem estar na base de fraca resposta ao clopidogrel. Objectivo: Caracterizar a prevalência e o impacto prognóstico do alelo CYP2C19*2(A) numa população local de doentes com síndrome coronária aguda (SCA). População e métodos: Estudo longitudinal, prospectivo, de 95 doentes admitidos por SCA entre Março e Outubro de 2009. Foram incluídos doentes com idade inferior a 75 anos, que sobreviveram à hospitalização, e que tiveram alta medicados com clopidogrel. Foi determinado o genótipo do alelo CYP2C19 no momento da alta hospitalar. Foram criados dois grupos; grupo A (metabolizadores normais, CYP2C19 *1/*1) n = 69 e grupo B (metabolizadores lentos, CYP2C19 *2/*1 ou *2/*2) n = 26. No seguimento foi analisado um resultado combinado de morte cardiovascular, enfarte agudo do miocárdio não fatal, e readmissão por angina instável (tempo mediano de seguimento: 136 (79–188) dias. Resultados: A idade mediana da população era de 62,0 (51,0–68,0) anos, e 83,2% eram do género masculino. O alelo CYP2C19*2(A) teve uma frequência de 14,2%. Não existiram diferenças entres os grupos relativamente a dados demográficos, e antecedentes cardiovasculares. A anatomia coronária, a fracção de ejecção ventricular esquerda e a função renal eram semelhantes. Os grupos eram também homogéneos relativamente ao score GRACE (118,0 (95,0–136,5) versus 115,0 (96,0–133,0), p = 0,68), tratamento médico e taxa de revascularização percutânea durante hospitalização. No final do seguimento clínico a sobrevida livre de eventos foi superior para o grupo A (94,0% versus 75,0%, log rank p = 0,010). Foram documentadas três readmissões por enfarte agudo do miocárdio, todas no grupo B. Conclusões: Na população referida, o alelo CYP2C19*2 (A) foi um marcador de prognóstico a médio prazo. Keywords: CYP2C19*2, Clopidogrel, Acute coronary syndromes, Prognosis, Palavras-chave: CYP2C19*2, Clopidogrel, Síndrome coronária aguda, Prognóstico

Emery-Dreifuss muscular dystrophy type 1 (EDMD1) is a familial disease with X-linked recessive transmission, caused by a mutation in a nuclear envelope protein, emerin. Clinical manifestations usually occur in adolescence and include contractures, muscle atrophy and weakness, and cardiac conduction disturbances. We describe the case of a young male, aged 16, with first-degree atrioventricular (AV) block and limited extension of both forearms. He had elevated CK, and cardiac monitoring showed severe conduction tissue disease, with significant sinus pauses, chronotropic incompetence and periods of AV dissociation during exercise. Immunohistochemical staining using an emerin antibody showed absence of the protein in a fragment of muscle tissue and genetic study identified a mutation associated with EDMD1. Study of his brother, aged 21, also established a diagnosis of EDMD1. Both individuals received a permanent pacemaker but musculoskeletal manifestations at that time did not warrant any other intervention. Screening for certain genetic diseases, including muscular dystrophies, is mandatory following identification of conduction abnormalities in young people. Resumo: A distrofia muscular de Emery Dreifus tipo 1 (DMED1) é uma doença familiar, com transmissão recessiva ligada ao X, resultante da mutação de uma proteína do invólucro nuclear, a emerina. As manifestações clínicas ocorrem geralmente na adolescência e incluem contracturas, atrofia e fraqueza musculares e perturbações da condução cardíaca. Descreve-se o caso clínico de um jovem de sexo masculino, 16 anos, com bloqueio auriculo-ventricular (AV) de primeiro grau e limitação da extensão de ambos os antebraços. Apresentava CK elevada e a monitorização cardíaca demonstrou doença grave do tecido de condução, com pausas sinusais significativas, insuficiência cronotrópica e períodos de dissociação AV durante o esforço. A imunomarcação com anticorpos anti-emerina de um fragmento de tecido muscular confirmou a ausência desta proteína e o estudo genético identificou uma mutação associada à DMED1. O estudo do seu único irmão, de 21 anos, estabeleceu igualmente o diagnóstico de DEMD1. Por apresentarem ambos doença do tecido de condução significativa decidiu-se por implantação de pacemaker definitivo nos dois casos. As manifestações músculo-esqueléticas, de momento, não justificavam qualquer intervenção. A identificação de anomalias da condução em idades jovens obriga à exclusão de determinadas doenças genéticas, nomeadamente, distrofias musculares. Keywords: Muscular dystrophy, Emery-Dreifuss, Emerin, Conduction abnormalities, Palavras-chave: Distrofia muscular, Emery Dreifus, Emerina, Anomalias de condução

Resumo: A distrofia muscular de Emery Dreifuss tipo 1 (DMED1) é uma doença familiar, com transmissão recessiva ligada ao X, resultante da mutação de uma proteína do invólucro nuclear, a emerina. As manifestações clínicas ocorrem geralmente na adolescência e incluem contraturas, atrofia e fraqueza musculares e perturbações da condução cardíaca. Descreve-se o caso clínico de um jovem de sexo masculino, 16 anos, com bloqueio aurículo-ventricular (AV) de primeiro grau e limitação da extensão de ambos os antebraços. Apresentava CK elevada e a monitorização cardíaca demonstrou doença grave do tecido de condução, com pausas sinusais significativas, insuficiência cronotrópica e períodos de dissociação AV durante o esforço. A imunomarcação com anticorpos antiemerina de um fragmento de tecido muscular confirmou a ausência desta proteína e o estudo genético identificou uma mutação associada à DMED1. O estudo do seu único irmão, de 21 anos, estabeleceu igualmente o diagnóstico de DEMD1. Por apresentarem ambos doença do tecido de condução significativa optou-se por implantação de pacemaker definitivo nos dois casos. As manifestações músculo-esqueléticas, de momento, não justificavam qualquer intervenção. A identificação de anomalias da condução em idades jovens obriga à exclusão de determinadas doenças genéticas, nomeadamente, distrofias musculares. Abstract: Emery-Dreifuss muscular dystrophy type 1 (EDMD1) is a familial disease with X-linked recessive transmission, caused by a mutation in a nuclear envelope protein, emerin. Clinical manifestations usually occur in adolescence and include contractures, muscle atrophy and weakness, and cardiac conduction disturbances. We describe the case of a young male, aged 16, with first-degree atrioventricular (AV) block and limited extension of both forearms. He had elevated CK, and cardiac monitoring showed severe conduction tissue disease, with significant sinus pauses, chronotropic incompetence and periods of AV dissociation during exercise. Immunohistochemical staining using an emerin antibody showed absence of the protein in a fragment of muscle tissue and genetic study identified a mutation associated with EDMD1. Study of his brother, aged 21, also established a diagnosis of EDMD1. Both individuals received a permanent pacemaker but musculoskeletal manifestations at that time did not warrant any other intervention. Screening for certain genetic diseases, including muscular dystrophies, is mandatory following identification of conduction abnormalities in young people. Palavras-chave: Distrofia muscular, Emery Dreifuss, Emerina, Anomalias de condução, Keywords: Muscular dystrophy, Emery-Dreifuss, Emerin, Conduction abnormalities

Resumo: Introdução: A anemia tem sido associada a um pior prognóstico, e particularmente a uma mortalidade mais elevada em diversas condições patológicas. Contudo, poucos estudos analisaram especificamente o seu impacto a curto e a longo prazo, em doentes com Síndrome Coronária Aguda. Este artigo tem como objetivo analisar a associação entre diferentes quartis de hemoglobina na admissão hospitalar e o prognóstico a curto e a longo prazo em doentes com síndrome coronária aguda. População e métodos: Estudo retrospetivo de 1303 doentes consecutivamente admitidos com síndrome coronária aguda numa unidade de cuidados intensivos coronários, procurando analisar a associação entre os níveis basais de hemoglobina e a morbilidade e mortalidade intra-hospitalar e num seguimento clínico de 12 meses. Esta população de doentes foi dividida em quartis de concentração da hemoglobina ([Hb]): Q1: 1, e os preditores de mortalidade no follow-up foram: idade ≥ 69,5 anos, classe Killip na admissão> 1, diabetes mellitus, existência de depressão do segmento ST no ECG de admissão hospitalar e uma concentração de hemoglobina inferior a 10,8 g/dL. Discussão e conclusões: Em doentes com síndromes coronárias agudas, os valores mais baixos de hemoglobina encontram-se frequentemente associados a outras comorbilidades, mas por si só, a anemia parece ser um preditor independente de mortalidade um ano após uma síndrome coronária aguda. Abstract: Introduction: Anemia has been shown to be associated with a worse prognosis, especially higher mortality in various pathological conditions. However, few studies have specifically examined its impact in acute coronary syndrome (ACS) patients. The purpose of our study was to assess the association between different quartiles of hemoglobin on admission and short- and long-term prognosis in patients with ACS. Methods: We performed a retrospective analysis of 1303 consecutive ACS patients admitted to a coronary care unit and analyzed the association between baseline hemoglobin and morbidity and mortality, in-hospital and at 12-month follow-up. The population was divided into groups according to quartiles of hemoglobin concentration (Hb): Q1: 1 at admission. The independent predictors of long-term mortality were age ≥69.5 years, Killip class >1 at admission, diabetes mellitus, ST-segment depression on admission ECG and Hb

Introduction: Anemia has been shown to be associated with a worse prognosis, especially higher mortality in various pathological conditions. However, few studies have specifically examined its impact in acute coronary syndrome (ACS) patients. The purpose of our study was to assess the association between different quartiles of hemoglobin on admission and short- and long-term prognosis in patients with ACS. Methods: We performed a retrospective analysis of 1303 consecutive ACS patients admitted to a coronary care unit and analyzed the association between baseline hemoglobin and morbidity and mortality, in-hospital and at 12-month follow-up. The population was divided into groups according to quartiles of hemoglobin concentration (Hb): Q1: 1 at admission. The independent predictors of long-term mortality were age ≥69.5 years, Killip class >1 at admission, diabetes mellitus, ST-segment depression on admission ECG and Hb 1, e os preditores de mortalidade no follow-up foram: idade ≥ 69,5 anos, classe Killip na admissão> 1, diabetes mellitus, existência de depressão do segmento ST no ECG de admissão hospitalar e uma concentração de hemoglobina inferior a 10,8 g/dL. Discussão e conclusões: Em doentes com síndromes coronárias agudas, os valores mais baixos de hemoglobina encontram-se frequentemente associados a outras co-morbilidades, mas por si só, a anemia parece ser um preditor independente de mortalidade um ano após uma síndrome coronária aguda. Keywords: Acute coronary syndrome, Hemoglobin, Risk factors, Mortality, Prognosis, Palavras-chave: Síndromes coronárias agudas, Hemoglobina, Factores de risco, Mortalidade, Prognóstico

Resumo: Introdução: Permanecem dúvidas sobre o impacto prognóstico a longo prazo da pressão telediastólica do ventrículo esquerdo (PTDVE) no contexto de uma síndrome coronária aguda (SCA). Objectivo: Caracterizar a PTDVE e o seu impacto prognóstico numa população de doentes com SCA e fracção de ejecção ventricular esquerda (FEVE) ≥ a 40%. População e métodos: Estudo prospectivo, longitudinal e contínuo de 1329 doentes admitidos (n = 489) numa unidade de cuidados intensivos coronários entre 2004 e 2006. Foram seleccionados os doentes submetidos a uma estratégia invasiva, no qual foi determinada a PTDVE, com FEVE ≥ 40%. A população foi divida em três grupos: A — PTDVE ≤ 19 mmHg (n = 186); grupo B — PTDVE > 19 ≤ 27 mmHg (n = 172) e; grupo C — PTDVE > 27 mmHg (n = 131). O resultado primário desta análise foi a readmissão por insuficiência cardíaca congestiva (ICC) no ano seguinte à SCA. Resultados: A PTDVE média da população foi de 22,8 mmHg ± 7,8 mmHg. Os grupos eram homogéneos entre si no que disse respeito ao género, idade, factores de risco cardiovascular, história cardiovascular e medicação prévia à admissão. Quanto maior a PTDVE maior a probabilidade de uma admissão por enfarte agudo do miocárdio com supradesnivelamento do segmento ST (35,4 versus 45,9 versus 56,7%, p 40% were excluded (n = 489). The population was divided into three groups: A — LVEDP ≤19 mmHg (n = 186); B — LVEDP >19 and ≤27 mmHg (n = 172); and C — LVEDP >27 mmHg (n = 131). The primary endpoint of the analysis was readmission for congestive heart failure in the year following the index admission. Results: Mean LVEDP was 22.8 ± 7.8 mmHg. The groups were similar age, gender, cardiovascular risk factors, cardiovascular history, and medication prior to admission. There was an association between higher LVEDP and: admission for ST-elevation acute myocardial infarction (35.4 vs. 45.9 vs. 56.7%, p

Introduction: There is still debate concerning the impact of left ventricular end-diastolic pressure (LVEDP) on long-term prognosis after an acute coronary syndrome (ACS). Objective: To assess LVEDP and its prognostic implications in ACS patients with left ventricular ejection fraction (LVEF) ≥40%. Methods: We performed a prospective, longitudinal study of 1329 ACS patients from a single center between 2004 and 2006. LVEDP was assessed at the beginning of the coronary angiogram. Patients with LVEF >40% were included (n = 489). The population was divided into three groups: A — LVEDP ≤19 mmHg (n = 186); B — LVEDP >19 and ≤27 mmHg (n = 172); and C — LVEDP >27 mmHg (n = 131). The primary endpoint of the analysis was readmission for congestive heart failure in the year following the index admission. Results: Mean LVEDP was 22.8 ± 7.8 mmHg. The groups were similar age, gender, cardiovascular risk factors, cardiovascular history, and medication prior to admission. There was an association between higher LVEDP and: admission for ST-elevation acute myocardial infarction (35.4 vs. 45.9 vs. 56.7%, p 19 ≤ 27 mmHg (n = 172) e ; grupo C — PTDVE > 27 mmHg (n = 131). O resultado primário desta análise foi a readmissão por insuficiência cardíaca congestiva (ICC) no ano seguinte à SCA. Resultados: A PTDVE média da população foi de 22,8 mmHg ± 7,8 mmHg. Os grupos eram homogéneos entre si no que disse respeito ao género, idade, factores de risco cardiovascular, história cardiovascular e medicação prévia à admissão. Quanto maior a PTDVE maior a probabilidade de uma admissão por enfarte agudo do miocárdio com supradesnivelamento do segmento ST (35,4 versus 45,9 versus 56,7 %, p

Endothelial progenitor cells (EPCs) are a special type of stem cells, derived from bone marrow that can be mobilized to the peripheral circulation in response to many stimuli. EPCs play a crucial role in the vascular repair, as well as in neovascularization processes. Recent studies have shown that EPCs are impaired, both in number and function, in diabetic patients independently of other cardiovascular risk factors. Accelerated atherosclerosis is probably the most devastating among diabetes complications and endothelial dysfunction might be the beginning of the atherosclerosis. The impairment of EPCs seems to significantly contribute to atherogenesis and atherosclerotic disease progression in diabetes. Autologous EPCs therapy is a promising treatment option for vascular complications requiring therapeutic revascularization and vascular repair. Diabetic patients represent a population that may benefit from cell-based therapy; however, the dysfunction of their endogenous cells may limit the feasibility of this approach. In fact, EPCs isolated from these patients for autologous cell transplantation may retain their dysfunctional characteristics in vivo and as a consequence display a reduced capacity to improve therapeutic neovascularization. In the present review, we summarize the most relevant mechanisms underlying EPC dysfunction in diabetes.

Introduccion y objetivos. El pronostico y el tratamiento en el hospital de los pacientes con sindrome coronario agudo (SCA) y antecedentes de cirugia de bypass coronario (CABG) es motivo de controversia. El objetivo de este estudio es caracterizar a los pacientes con SCA que tienen antecedentes de CABG y comparar su evolucion intrahospitalaria y extrahospitalaria con la de los pacientes sin antecedentes de CABG. Metodos. Estudio prospectivo observacional continuo de 1.495 ingresos consecutivos por SCA en una misma unidad coronaria, con un seguimiento medio de 19 meses. Se dividio a los pacientes en dos grupos: grupo A (n = 73) con CABG previa y grupo B (n = 1.223) sin CABG previa. Resultados. Los pacientes del grupo A eran con mayor frecuencia varones (el 86,3 frente al 69,1%; p = 0,002), tenian antecedentes mas frecuentes de diabetes mellitus, infarto de miocardio previo e insuficiencia cardiaca. Los pacientes del grupo B tenian mas infartos agudos de miocardio con elevacion del ST, una fraccion de eyeccion mas alta (53% [47%-60%] frente a 50% [42%-55%]; p < 0,01) y valores superiores de concentracion maxima de troponina I. No se observaron diferencias en cuanto al uso de una estrategia invasiva. Por lo que respecta a la medicacion, los pacientes del grupo B tenian una mayor probabilidad de recibir doble tratamiento antiagregante al alta. No se observaron diferencias significativas en cuanto a la mortalidad hospitalaria (el 9,5 frente al 5,9%; p = 0,2) ni en la mortalidad a 1 mes, 6 meses o 1 ano (el 9,8 frente al 9,1%; log-rank test, p = 0,87), y la ausencia acumulativa de eventos adversos cardiovasculares mayores fue tambien similar en ambos grupos. Los antecedentes de CABG se asociaron a una mayor frecuencia de reingresos por angina inestable (el 11,3 frente al 3,1%; p < 0,01). Conclusiones. En nuestra poblacion con SCA, el antecedente de CABG no influyo de manera significativa en la evolucion a corto y medio plazo en cuanto a la mortalidad por cualquier causa o eventos adversos cardiovasculares mayores.

FUNDAMENTO: O eletrocardiograma (ECG) de admissão tem um grande impacto no diagnóstico e tratamento de síndromes coronarianas agudas (SCA) sem supradesnivelamento do segmento ST. OBJETIVO: Avaliar o impacto do ECG de admissão no prognóstico da SCA sem supradesnivelamento de ST. População: estudo prospectivo, contínuo, observacional, de 802 pacientes com SCA sem supradesnivelamento de ST de um único centro. MÉTODOS: Os pacientes foram divididos em 2 grupos: A (n=538) - ECG Anormal e B (n=264) - ECG Normal. ECG Normal era sinônimo de ritmo sinusal sem alterações isquêmicas agudas. Um seguimento clínico de um ano foi realizado tendo como alvo todas as causas de mortalidade e a taxa de eventos cardíacos adversos maiores (MACE). RESULTADOS: Os pacientes do Grupo A eram mais velhos (68,7±11,7 vs. 63,4±12,7 anos, pFUNDAMENTO: El electrocardiograma (ECG) de ingreso tiene un gran impacto en el diagnóstico y tratamiento de síndromes coronarios agudos (SCA) sin supradesnivel del segmento ST. OBJETIVO: Evaluar el impacto del ECG de ingreso en el pronóstico del SCA sin supradesnivel de ST. MÉTODOS: Población: estudio prospectivo, continuo, observacional, de 802 pacientes con SCA sin supradesnivel de ST de un único centro. Los pacientes se dividieron en 2 grupos: A (n=538) - ECG Anormal y B (n=264) - ECG Normal. ECG Normal era sinónimo de ritmo sinusal sin alteraciones isquémicas agudas. Se realizó un seguimiento clínico de un año teniendo como objetivo todas las causas de mortalidad y la tasa de eventos cardíacos adversos mayores (MACE). RESULTADOS: Los pacientes del Grupo A eran más viejos (68,7±11,7 vs 63,4±12,7 años, pBACKGROUND: Admission ECG has a major impact on the diagnosis and management of non-ST elevation acute coronary syndromes (ACS). OBJECTIVE: To assess the impact of the admission ECG on prognosis over non-ST ACS. Population: prospective, continuous, observational study of 802 non-ST ACS patients from a single center. METHODS: Patients were divided in 2 groups: A (n=538) - Abnormal ECG and B (n=264) - Normal ECG. Normal ECG was synonymous of sinus rhythm and no acute ischemic changes. A one-year clinical follow up was performed targeting all causes of mortality and the MACE rate. RESULTS: Group A patients were older (68.7±11.7 vs. 63.4±12.7Y, p

Introduccion y objetivos Evaluar la relacion entre la magnitud de la variacion de la glucemia durante la hospitalizacion y la mortalidad hospitalaria y a largo plazo y otras variables de valoracion posteriores al alta, en dos poblaciones con sindrome coronario agudo: pacientes con o sin diagnostico previo de diabetes. Metodos Estudiamos a 1.210 pacientes ingresados por sindrome coronario agudo entre mayo de 2004 y julio de 2007. Dividimos la poblacion en dos subgrupos: pacientes con un diagnostico previo de diabetes (n = 386) y pacientes no diabeticos (n = 824). Cada una de estas subpoblaciones se dividio en cuatro grupos, segun los cuartiles de variacion de la glucemia: diabeticos (Q1 Resultados En los pacientes diabeticos no hubo relacion alguna entre la magnitud de variacion de la glucemia y las variables de valoracion intrahospitalarias y posteriores al alta. En los no diabeticos, no se observaron diferencias significativas en cuanto a la morbimortalidad hospitalaria, pero si hubo diferencias estadisticamente significativas en el seguimiento clinico. Tras un analisis de regresion multiple, el cuartil Q4 frente al Q1, la edad ≥ 70 anos y los antecedentes previos de tratamiento con antiagregantes plaquetarios o con inhibidores de la enzima de conversion de angiotensina fueron factores predictivos independientes para las variables de valoracion posteriores al alta en el grupo no diabetico. Conclusiones En los pacientes con sindrome coronario agudo no diabeticos, la magnitud de variacion de la glucemia durante la hospitalizacion es un factor predictivo independiente y potente de las variables de valoracion posteriores al alta.

Combination therapy recently emerged as a potential therapeutic option in order to improve cardiovascular risk in diabetics, since therapies commonly used in monotherapy failed in significantly optimizing this risk. Methods: A type 2 diabetes animal model was used to test the effects of a high-fat diet, atorvastatin and insulin (isolated or in association), in glycemic, lipid and inflammatory profiles, oxidative stress markers and cardiac mitochondrial function in ischemia–reperfusion conditions. Results: High-fat diets significantly worsened fasting glycemia and lipid profile; it also increased C-reactive protein (CRP) and oxidative stress and compromised mitochondrial response to ischemia. Insulin decreased fasting glucose and free fatty acid levels and insulin resistance, while increasing HDL–cholesterol, but had no effect in inflammatory markers. Atorvastatin decreased circulating adiponectin levels and did not improve inflammatory markers, although it improved fasting glycemia, glucose tolerance, free fatty acids and HDL–cholesterol. The combined use of atorvastatin and insulin improved several parameters, as did each of the treatments separately. However, treatment association went beyond these results, by decreasing atherogenicity index and circulating CRP levels. Insulin and its association with atorvastatin significantly prevented mitochondrial dysfunction observed in the high-fat diet group, while atorvastatin showed some beneficial effects but in much less extent. Conclusions: Altogether, these results show that administration of an high-fat diet in a model of type 2 diabetes increases cardiovascular risk and combined use of atorvastatin and insulin provides a superior control of cardiovascular risk markers in diabetic and hyperlipidemic subjects.

The cellular role of mitochondria includes ATP generation and the modulation of cytosolic calcium signals, besides being the "crossroads" for several cell death pathways. The maintenance of optimal mitochondrial functioning during the disease process increases the chances for survival. For example, ischaemia followed by reperfusion is known to negatively affect mitochondrial function, namely by inducing a deleterious condition called mitochondrial permeability transition (MPT). The MPT is responsible for mitochondrial dysfunction and can ultimately lead to cell death. Therefore, it seems important to protect mitochondrial function in cardiac disease. Carvedilol, a beta-adrenergic receptor antagonist with antioxidant properties, has a positive impact on cardiac mitochondria during in vitro, ex-vivo and in vivo models of cardiac dysfunction. Particularly, carvedilol was shown to inhibit MPT in isolated heart mitochondria and protect mitochondria against the oxidative damage induced by the xanthine oxidase/hypoxanthine pro-oxidant system. The observation that carvedilol acts as an inhibitor of mitochondrial complex-I is also of importance, since this mitochondrial system was proposed as cause of the cardiotoxicity associated with the anti-neoplasic drug doxorubicin. This review points out the major findings concerning the positive impact of carvedilol on mitochondrial function and its use in the treatment of myocardial diseases where oxidative stress is known to be involved.

Trimetazidine is an anti-ischemic drug whose cytoprotective mechanisms are not yet fully understood (but until now mainly related to the trimetazidine-induced "metabolic shift" from lipid [beta]-oxidation to glucose aerobic oxidation). We studied the effect of trimetazidine on the mitochondrial function of ischemic Wistar rat hearts perfused with glucose, using a model of ex-vivo perfusion (Langendorff system). We measured the electrical potential of the mitochondrial membrane, O2 consumption by the respiratory chain, energy charges generated and the enzyme activities of the respiratory chain complexes. In this model, trimetazidine had a preferential action on the oxidative system (mainly on complex I), increasing its enzyme activity and decreasing O2 consumption after phosphorylation; this could decrease oxygen free radical production and increase mitochondrial integrity, thus allowing the maintenance of the electrical potential. These results allow us to better understand the cytoprotective effects of trimetazidine in coronary artery disease. http://www.sciencedirect.com/science/article/B6T1J-4DGDFT4-1/1/030adaeaadc6b60cf212eca461b83e30

The effect of statins on endothelial progenitor cells (EPCs) function derived from diabetic patients (DMpts) with acute myocardial infarction (AMI) is unknown. In this study we assess the response of early and late EPCs from diabetic versus non-diabetic patients (NDMpts) with AMI to statins. EPCs were obtained from 10 diabetic and 10 age-matched non-diabetic male patients with AMI. For each patient, cultures of early and late EPCs were performed under 4 different conditions: normal glucose concentration (control); high glucose concentration; normal glucose concentration with atorvastatin supplementation and normal glucose concentration with pravastatin supplementation. To compare the effect of these treatments on EPC function in DMpts versus NDMpts, we performed in vitro: EPC colony-forming units (CFU) assay; cell cycle analysis; viability assessment and expression of the surface markers CXCR4, CD133, CD34 and KDR. Under control conditions, CFU numbers were reduced in DMpts-derived EPCs when compared to those of NDMpts (1.4±0.8 vs 2.6±1.2 CFU/well, P=0.021). When early EPCs from DMpts were cultured in the presence of statins, CFU capacity was restored, surmounting that of NDMpts under control conditions. Statins significantly improved viability of early EPCs and delayed the onset of late EPCs senescence, even in cells from DMpts. In addition, statins induced approximately a 2-fold increase in the proportion of late EPCs in S-phase of the cell cycle (P

The aim of the present study was to investigate the lymphatic cardiac circulation in an experimental model of ischemia plus reperfusion in mongrel dogs (Canis familiaris L). As radiotracer we used 0.2-0.25 ml (111 MBq) of 99mTc-Re2S7 colloid (+/-10 microm), injected subcapsullary below the second diagonal of the descending anterior ligated coronary artery with a special needle. A gamma-camera/Starport + DecStation were used for data acquisition. Four experimental groups with five animals each were established: G I = controls; G II = immediately after acute myocardial infarction (AMI); G III = late infarction (5 days after AMI); G IV = ischemia (90 min) + reperfusion. Four regions of interest (ROIs) were chosen: injection area (ZA), above (ZB), near right (ZD), and far right (ZC) from ZA. Mean disappearance times in ZA and dynamic parameters in the other ROIs were determined from activity/time curves drawn in each area, using homemade software. The results obtained seem to indicate that the methodology is appropriate to a detailed study of lymphatic drainage in pathological situations in animal models.

It would be important to better identify heart failure (HF) patients most likely to respond to cardiac resynchronization therapy (CRT). Because endothelial progenitor cells (EPCs) play a crucial role in the maintenance of vascular endothelium integrity, we hypothesize that patients who have higher circulating EPCs levels have greater neovascularization potential and are more prone to be responders to CRT.Prospective study of 30 consecutive patients, scheduled for CRT. Echocardiographic evaluation was performed before implant and 6 months after. Responders to CRT were defined as patients who were still alive, have not been hospitalized for HF management, and demonstrated ≥15% reduction in left ventricular end-systolic volume (LVESV) at the 6-month follow-up. EPCs were quantified before CRT, from peripheral blood, by flow cytometry using five different conjugated antibodies: anti-CD34, anti-KDR, anti-CD133, anti-CD45, and anti-CXCR4. We quantified five different populations of angiogenic cells: CD133(+) /CD34(+) cells, CD133(+) /KDR(+) cells, CD133(+) /CD34(+) /KDR(+) cells, CD45(dim) CD34(+) /KDR(+) cells, and CD45(dim) CD34(+) /KDR(+) /CXCR4(+) cells.The proportion of responders to CRT at the 6-month follow-up was 46.7%. Responders to CRT presented higher baseline EPCs levels than nonresponders (0.0003 ± 0.0006% vs 0.0001 ± 0.0002%, P = 0.04, for CD34(+) /CD133(+) /KDR(+) and 0.0006 ± 0.0005% vs 0.0003 ± 0.0003%, P = 0.009, for CD45(dim) CD34(+) /KDR(+) /CXCR4(+) cells). In addition, baseline levels of CD45(dim) CD34(+) /KDR(+) /CXCR4(+) cells were positively correlated with the reduction of LVESV verified 6 months after CRT (r = 0.497, P = 0.008).High circulating EPCs levels may identify the subset of HF patients who are more likely to undergo reverse remodeling and benefit from CRT. Addition of EPCs levels assessment to current selection criteria may improve the ability to predict CRT response.

Resumo: Introdução e objetivos: A cardioembolia representa uma das causas mais frequentes de lesões cerebrovasculares isquémicas, com prevalência estimada de 20-30% e implicações terapêuticas diretas que obrigam à sua correta avaliação. Apesar de a validação das escalas de risco cardioembólico (CHADS2 e, mais recentemente, CHA2DS2-VASc) em populações heterogéneas de doentes com fibrilhação furicular, desconhece-se ainda a sua validade em contexto de prevenção secundária cerebrovascular.É objetivo deste trabalho estudar a sensibilidade e especificidade diferencial das escalas de risco cardioembólico como preditoras de fonte cardioembólica documentada por ecocardiograma transesofágico (ETE) numa população de doentes com AVC isquémico. Métodos: Aplicámos as escalas CHADS2 e CHA2DS2-VASc a todos os doentes internados por evento cerebrovascular isquémico na Unidade de AVC/Enfermaria de Neurologia de um hospital central português com diagnóstico de fibrilhação auricular (prévio ou obtido durante/após o internamento), que realizaram ETE entre janeiro e agosto de 2011.Definimos como presença de fonte cardioembólica a observação em ETE de autocontraste espontâneo na aurícula e apêndice auricular esquerdo ou trombos nas cavidades cardíacas esquerdas. Resultados: Analisámos 94 doentes, 66,0% do sexo masculino, idade média: 64,4 anos (desvio padrão: 14,2). Foi detetada fonte cardioembólica em 20 doentes. A análise de curva Receiver Operating Characteristic (ROC) identifica como preditores de fonte cardioembólica pontuação CHADS2 ≥ 4; sensibilidade: 75,0%, especificidade: 66,0%, p = 0,014 e pontuação CHA2DS2-VASc ≥ 5; sensibilidade: 83,3%, especificidade: 58,0%, p = 0,009. Conclusões: Ambas as escalas apresentam sensibilidade significativa como preditoras de risco cardioembólico em contexto de prevenção secundária cerebrovascular. A escala CHA2DS2-VASc possui uma sensibilidade superior à CHADS2, sendo, no entanto, menos específica. Abstract: Introduction and objectives: Cardioembolism is one of the most common causes of ischemic stroke, with an estimated prevalence of 20-30%, and correct diagnosis is essential given the therapeutic implications. Although stroke risk scores (CHADS2 and more recently CHA2DS2-VASc) have been validated in heterogeneous populations of patients with atrial fibrillation, their accuracy has not been ascertained for secondary stroke prevention. We set out to assess the sensitivity and specificity of the CHADS2 and CHA2DS2-VASc stroke risk scores as predictors of cardioembolic sources, documented by transesophageal echocardiography (TEE) in a population with ischemic stroke. Methods: The CHADS2 and CHA2DS2-VASc scores were applied to all patients admitted to the stroke unit/neurology ward of a Portuguese tertiary hospital with atrial fibrillation (diagnosed previously or during or after admission) who underwent TEE between January and August 2011.The presence of a cardioembolic source was defined as the observation by TEE of spontaneous echo contrast in the left atrium and atrial appendage or thrombi in the left cardiac chambers. Results: We studied 94 patients, 66.0% male, mean age 64.4 years (standard deviation 14.2). A cardioembolic source was detected in 20 patients. ROC curve analysis identified as predictors of cardioembolic source CHADS2 score ≥4 (sensitivity of 75.0%, specificity of 66.0%, p=0.014) and CHA2DS2-VASc score ≥5 (sensitivity of 83.3%, specificity of 58.0%, p=0.009). Conclusions: Both scores showed acceptable sensitivity as predictors of embolic risk in the context of secondary prevention of cardioembolic stroke. The CHA2DS2-VASc score has higher sensitivity than CHADS2 but lower specificity. Palavras-chave: Acidente vascular cerebral, Fibrilhação auricular, Tromboembolismo, Ecocardiografia, Anticoagulação, Keywords: Stroke, Atrial fibrillation, Thromboembolism, Echocardiography, Anticoagulation

Aims The TRA·CER trial compared vorapaxar, a novel platelet protease-activated receptor (PAR)-1 antagonist, with placebo in 12 944 patients with high-risk non–ST-segment elevation acute coronary syndromes (NSTE ACS). In this analysis, we explored the effect of vorapaxar on myocardial infarction (MI). Methods and results A blinded, independent central endpoint adjudication committee prospectively defined and classified MI according to the universal MI definition, including peak cardiac marker value (creatine kinase-MB [CK-MB] and/or troponin). Because the trial failed to meet its primary endpoint, these analyses are considered exploratory. During a median follow-up of 502 days, 1580 MIs occurred in 1319 patients. The majority ( n = 1025, 64.9%) were type 1 (spontaneous) MI, followed by type 4a [percutaneous coronary intervention (PCI)-related] MI ( n = 352; 22.3%). Compared with placebo, vorapaxar reduced the hazard of a first MI of any type by 12% [hazard ratio (HR), 0.88; 95% confidence interval (CI), 0.79–0.98; P = 0.021] and the hazard of total number of MIs (first and subsequent) by 14% (HR, 0.86; 95% CI, 0.77–0.97; P = 0.014), an effect that was sustained over time. Vorapaxar reduced type 1 MI by 17% (HR, 0.83; 95% CI, 0.73–0.95; P = 0.007). Type 4a MIs were not significantly reduced by vorapaxar (HR, 0.90; 95% CI, 0.73–1.12; P = 0.35). Vorapaxar effect was consistent across MI sizes defined by peak cardiac marker elevations and across key clinical subgroups; however, in patients not treated with thienopyridine at baseline (HR, 0.65; 95% CI, 0.46–0.92) compared with patients who received thienopyridine (HR, 0.91; 95% CI, 0.81–1.02), there was a trend towards a higher effect ( P int = 0.077). Conclusion The PAR-1 antagonist vorapaxar was associated with a reduction of MI, including total number of infarctions. This reduction was sustained over time and was mostly evident in type 1 MI, the most common type of MI observed.