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Diretrizes da Sociedade Brasileira de Cardiologia sobre Angina Instavel e Infarto Agudo do Miocardio sem Supradesnivel do Segmento ST – 2021

Background Social isolation and marketing campaign to avoid “unnecessary” use of healthcare system to fight against COVID-19 pandemic might impact on the decision to seek medical care. The aim of this study was to evaluate the effect of social isolation during COVID-19 pandemic on trends in numbers of visits to emergency department, non-elective admissions, and percutaneous coronary intervention procedures for treatment of patients with acute myocardial infarction, at a reference cardiology hospital. Methods Daily numbers of visits to emergency [...]

Background Percutaneous intervention for obstructive lesions of the unprotected left main coronary artery is complex. Choosing the vascular access can be decisive to a successful procedure. The objective of the present study was to describe the characteristics and hospital outcomes of patients with unprotected left main coronary artery disease and compare the radial and femoral access approaches. Methods Clinical and angiographic data, access routes and hospital outcomes of patients that have undergone percutaneous coronary intervention of the unprotected left [...]

Few studies have examined the correlation between the presence of peripheral artery disease diagnosed by ankle-brachial-index (ABI) and cumulative target organ damage (kidney, heart and vessels) in hypertensive patients with diabetes. For this purpose, we evaluated the prevalence of target organ damage as evidenced by an echocardiogram, Doppler carotid scan, retinography and glomerular filtration rate according to ABI values in 99 hypertensive diabetic patients. The patients were classified into a normal ABI group (1.4 ≥ ABI > 0.9) and abnormal ABI group (ABI ≤ 0.9 or ABI>1.4). From the data obtained, we analysed cumulative number, mean and frequency (mean) of lesions in target organs. The mean age of the patients was 65.4 ±7 years, and 61.6% were women. There were no differences concerning age, gender, race, body mass index, and metabolic profile between the normal (49 patients) and abnormal ABI group (50 patients), but higher levels of systolic blood pressure were observed in abnormal ABI group compared to normal ABI group (170.3 ± 26 vs. 153.3 ± 18; p = 0.002). In patients with abnormal ABI, it was observed a higher prevalence of left ventricular hipertrophy (56% vs. 26,5%, p = 0,003), internal carotid stenosis > 50% (13,7% vs. 3,2%, p = 0,009) and glomerular filtration rate < 60ml/1,73m 2 /min (33,3% vs. 12,8%, p = 0,018). Abnormal ABI group has a higher frequency of 2 or more lesions (54% vs. 20.4%, p < 0.001), a greater mean number of lesions (2.37 ± 1 vs. 0.71 ± 0.7, p < 0.001), as well as a higher frequency of target organs damage (0.36 ± 0.31 vs. 0.19 ± 0.19, p = 0.001). Multiple linear regression analysis revealed abnormal ABI as an independent factor related to the higher frequency of target organ damage (OR = 13.22; 95% CI = 1.81-24.63; p = 0.024). In conclusion, hypertensive diabetic patients with abnormal ABI values had a higher prevalence of single and cumulative target organ damage.

Background The effect of proximal side branches on the patency of the internal thoracic artery (ITA) is controversial. We used echocardiography and Doppler to verify the effect of ligation of branches on the flow and coronary flow reserve (CFR) of the grafted ITA in patients after coronary artery bypass grafting (CABG). Methods We prospectively investigated 53 patients with preserved left ventricular ejection fraction (LVEF >50%) who underwent CABG of the ITA. In Group I (25 patients), major branches were ligated during ITA anastomosis to the left anterior descending (LAD) coronary artery, whereas no ligation was performed in Group II (28 patients). Systolic flow (SF), diastolic flow (DF), and total flow (TF = SF + DF) were measured by Doppler echocardiography at the proximal level of the ITA preoperatively, at early postoperative stage, and 6 months after surgery. Dobutamine stress echocardiography (DSE) was performed at 6 months to determine CFR. Results The ITA flow was predominantly systolic before surgery and diastolic in the postoperative period. We found no differences between the groups in DF. On DSE, SF (19.5±9 mL/min vs 32.7±19 mL/min; P=.003) and TF (79±21 mL/min vs 101±47 mL/min; P=.037) were higher in Group II. There were no differences in CFR (1.9±0.46 vs 2.11±0.56; P=.143). Conclusion In patients with preserved LVEF, ligation of major side branches during anastomosis to the LAD does not alter ITA flow or CFR.

Contrast echocardiography is based on intravenous injection of microbubbles that act as blood flow tracers and increase ultra-sound signal. Contrast agents have shown to improve cardiac cavities opacification and endocardial border delineation in addition to helping perfusion evaluation. Contrast echocardiography has recently been used to evaluate cardiac masses. In this report we will describe three cases evaluated by contrast echocardiography: a left atrial myxoma (benign tumor), a lung adenocarcinoma metastasis (malign tumor), and one thrombus. Contrast echocardiography showed to be valuable in the diagnosis of the different types of cardiac masses.

Few studies evaluated cardiac or carotid abnormalities in patients with arterial hypertension and diabetes according to the presence of peripheral artery disease detected by abnormal ankle brachial index (ABI). For this purpose, we studied 99 diabetic hypertensive patients with abnormal (n=50, ABI≤0.9 or ABI>1.4) and normal (n=49, ABI>0.9 or ≤1.4) ABI values. All patients underwent successively to echocardiography and carotid ultrasound. From echocardiographic study, we analyzed the occurrence of a composite endpoint that included significant cardiac morphological and functional changes. The mean age was 65.4±7 years and 61.6% were women. It was observed a higher prevalence of left atrial enlargement (46%vs.26,5%, p50% (26,5%vs.6.3%; p

We described a case of left ventricular pseudoaneurysm associated to a severe mitral regurgitation, complicating a inferolaterodorsal acute myocardial infarction. The lesion was found in a routine echocardiogram during the in-hospital follow-up. The well-succeeded surgical strategy and the good clinical evolution of the patient were distinguished.

Disseccao de atrio esquerdo (DAE) e uma entidade rara, definida como a separacao forcada das camadas da parede do atrio esquerdo por sangue, mais comumente associada a cirurgia cardiaca. Apenas casos isolados foram descritos, nao se conhecendo verdadeira incidencia, etiologia e manejo dessa doenca. Descrevemos um caso de disseccao de atrio esquerdo apos endocardite infecciosa de valva mitral nativa. Uma complicacao rara que merece ser reconhecida e tratada com urgencia.

O ensino médico sofreu intensas modificações nos últimos anos. A rápida evolução do conhecimento requer metodologias que estimulem a metacognição, substituindo o excesso de conteúdo pelo"aprender a aprender", formando profissionais construtores ativos do seu conhecimento e capacitados para refletir sobre a própria prática. A importância do conteúdo de emergências é inquestionável, especialmente na graduação, pois se trata de uma área de grande carência de profissionais que vem sendo cada vez mais ocupada pelo médico recém-graduado, quase sempre despreparado para se conduzir diante da gravidade dos casos. Simular a realidade integra o saber ao fazer, aliados ao desenvolvimento de habilidades. O ensino das emergências em cenários reais é insubstituível, contudo limitado por questões de segurança do paciente e pela impossibilidade de repetição de procedimentos.A simulação em laboratório de habilidades propicia contato do aluno com diversas situações em ambiente controlado, permite repetição e favorece o aprendizado significativo mediante discussão dos temas e reflexão sobre a própria prática.Este artigo descreve a inserção longitudinal do conteúdo de emergências médicas no currículo de um curso de Medicina,utilizando técnicas de simulação e reflexão acerca da prática como metodologia de aprendizado, além da vivência em ambientes de prática real. Medical education has undergone substantial changes in recent years. The rapid evolution of knowledge demands new teaching models involving active learning, metacognition and reflexive practice. Training in emergency care is of utmost importance in an undergraduate medical course, since the lack of professionals in this area means that emergency care is often staffed by new graduates, almost always unprepared to deal with the severity of the cases. Training technical medical skills within this scenario is necessary to provide the medical student with a realistic vision of the work,however it is limited due to patient safety and the inability to repeat procedures. Teaching emergency care through high fidelity simulators is an excellent solution that allows procedures to be repeated as many times as necessary and favours meaningful learning through discussion of topics and reflections on the practices. This study describes how emergency care training has been included throughout the curriculum for undergraduate medical training in Brazil, using simulation and reflection on the practice as learning tools, as well as real life experience in emergency care settings.

A detecção de alterações da motilidade segmentar do ventrículo esquerdo (VE) induzidas por um estresse farmacológico ou físico tem seu papel bem estabelecido na determinação não-invasiva de isquemia miocárdica. Entretanto, em sequência temporal, vários eventos secundários à isquemia ocorrem no miocárdio, sendo a heterogeneidade de perfusão um dos mais precoces a aparecer. Associação de parâmetros a serem analisados durante exames indutores de isquemia para diagnóstico de doença arterial coronária (DAC) tem sido amplamente estudada nos últimos anos. Ecocardiografia sob estresse pela dobutamina-atropina quando associada a contraste de microbolhas permite melhor visibilização dos segmentos do VE e análise da perfusão miocárdica. Ressonância magnética cardiovascular (RMC) é uma técnica que vem sendo amplamente utilizada na investigação de DAC tanto pela análise motilidade segmentar quanto pela análise da perfusão miocárdica, embora a combinação destes parâmetros tenha sido pouco estudada. Os objetivos deste estudo foram: determinar o valor incremental da análise de perfusão miocárdica sobre a análise da motilidade segmentar pela ecocardiografia com perfusão miocárdica em tempo real (EPMTR) e pela RMC e comparar, em um mesmo grupo de pacientes, a acurácia diagnóstica da EPMTR e RMC utilizando o mesmo protocolo sob estresse pela dobutamina-atropina, para detecção de DAC angiograficamente significativa. Estudamos 42 pacientes (média etária de 59 ± 7anos, 20 homens) com suspeita clinica de DAC e indicação de angiografia coronária. Todos os pacientes foram submetidos ao protocolo de estresse pela dobutamina-atropina na EPMTR e na RMC com intervalo de três dias a três meses. Para a obtenção da perfusão foi utilizado o contraste ecocardiográfico perflutreno na EPMTR e o contraste paramagnético baseado em gadolínio na RMC. Análise da motilidade segmentar e perfusão miocárdica foram realizadas, tanto na EPMTR quanto na RMC, por análise visual utilizando modelo de 17 segmentos do Joint Commitee on American Heart Association. Todos os pacientes realizaram angiografia coronária invasiva no intervalo máximo de três meses da inclusão, foi considerade DAC significativa a presença de obstrução >50% do diâmetro luminal na análise angiográfica quantitativa. Dos 42 pacientes estudados, 25(60%) apresentaram DAC significativa, sendo 10 uniarteriais e 15 multiarteriais. A análise da motilidade segmentar e perfusão miocárdica, pela EPMTR, apresentaram sensibilidade de 72% e 88% e acurácia de 80% e 88%, respectivamente para o diagnóstico de DAC. A análise da motilidade segmentar e perfusão miocárdica, pela RMC, apresentaram sensibilidade de 80% e 92% e acurácia de 80% e 88%, respectivamente para o diagnóstico de DAC. O valor adicional da perfusão miocárdica sobre a motilidade segmentar para o diagnóstico de DAC foi avaliado em modelo que incluiu motilidade segmentar e associação da motilidade segmentar e perfusão miocárdica, na EPMTR e RMC (2 de 16,16 versus 24,13,repectivamente e 2 de 12,73 versus 27,4; respectivamente), sendo p

FUNDAMENTO: A coronariografia tem sido indicada no pré-operatório para valvopatas >35 anos. Entretanto, a real prevalência de doença arterial coronariana (DAC) obstrutiva nessa população tem sido pouco estudada. OBJETIVO: Avaliar a prevalência e os fatores de risco para DAC em candidatos para cirurgia valvar no Brasil. MÉTODOS: Foi realizada angiocoronariografia em 3.736 pacientes candidatos a cirurgia valvar e avaliados prevalência e fatores de risco para DAC associada a valvopatia. RESULTADOS: A DAC esteve associada a valvopatia em 121 pacientes (prevalência 3,42%). Em 79 (68,1%), o diagnóstico de DAC foi feito apenas por coronariografia pré-operatória. Entre esses 79, 50 (63,3%) tinham valvopatia aórtica isolada ou valvopatia aórtica associada a mitral. Tabagismo foi visto em 54 pacientes (68,3%), hipertensão em quatro (43%), história familiar em 24 (30,3%), diabete melito em 15 (18,9%), e obesidade em oito (10,1%). Idade >50 anos foi observada em 95,7% dos 121 pacientes. Apenas cinco (4,3% dos pacientes com DAC) tinham idade 50 anos. A idade ideal para realização da coronariografia pré-operatória de rotina em portadores de valvopatia deveria ser reavaliada. BACKGROUND: Coronary angiography has been indicated in the preoperative phase for patients with valvopathy over 35 years of age. However, the actual prevalence of obstructive coronary artery disease (CAD) in this population has been little studied. OBJECTIVE: To assess the prevalence of and the risk factors for CAD in candidates for valve surgery in Brazil. METHODS: Coronary angiography was performed in 3,736 patients who were candidates for valve surgery; prevalence of and risk factors for CAD associated with valvopathy were assessed. RESULTS: CAD was associated with valvopathy in 121 patients (prevalence of 3.42%). In 79 patients (68.1%), CAD was diagnosed by means of preoperative coronary angiography. Of these 79 patients, 50 (63.3%) had isolated aortic valvopathy or aortic valvopathy associated with mitral valvopathy. Smoking habit was observed in 54 patients (68.3%), hypertension in four (43%), family history in 24 (30.3%), diabetes mellitus in 15 (18.9%), and obesity in eight (10.1%). Of the 121 patients, 95.7% were over 50 years of age. Only five (4.3% of the patients with CAD) were below 50 years of age, and all of them had at least one risk factor for CAD. CONCLUSION: CAD prevalence was low in the patients studied. Aortic valvopathy was the most frequent valvopathy associated with CAD, and most patients were over 50 years of age. The ideal age for routine preoperative coronary angiography in patients with valvopathy should be reassessed.

Although dobutamine-atropine stress echocardiography (DSE) is an established technique for detecting coronary artery disease (CAD), new echocardiographic parameters have been recently described to influence the prognostic value of this test. Objective: To determine the influence of left atrial anatomical evaluation on the prognostic value of DSE in patients with known or suspected CAD. Methods: From January 2000 to October 2004 we studied 981 pts (61±12 years, 536 men) who underwent DSE with early-atropine injection protocol. Primary end-point was major cardiovascular events, defined as non-fatal myocardial infarction (MI) and cardiac death (CD). Secondary end-point was major cardiovascular events plus revascularization (surgical and percutaneous). Left atrial diameter was determined by two-dimensional echocardiography in longitudinal paraesternal view and left atrial volume in apical 4-chamber view, at rest. Abnormal DSE was defined as fixed or inducible wall motion abnormalities. Pts were followed for a mean of 18 months (6 to 47 months). Results: DSE was abnormal in 330(34%) pts. Mean left atrial diameter was 3.9±0.6 cm (2.2±0.4 cm/m2) while mean left atrial volume was 54.4±18.9 ml (30.7±11.2 ml/m2). Major cardiovascular events occurred in 39(4%) pts (29 CD and 10 non-fatal MI). A total of 120(12%) pts achieved secondary end-point. By univariate analysis the predictors of CD or non-fatal MI were left atrial diameter (p=0.0013), left atrial volume (p Conclusion: Resting left atrial volume is an independent predictor of major cardiovascular events and combined events and can be used as an incremental tool for prognostic evaluation of patients who underwent DSE.