The Influence of Cognitive Behavioral Intervention for Anger Management on Endothelial Function in Patients With Recent Myocardial Infarction: A Randomized Clinical Trial.

OBJECTIVE: Anger may cause adverse cardiovascular responses, but the effects of anger management on clinical cardiovascular outcomes are insufficiently understood. We sought to assess the influence of anger management through a cognitive behavioral intervention on endothelial function in patients with a recent myocardial infarction (MI). METHODS: Patients with ST-elevation MI and a low anger control score were enrolled during hospitalization in a randomized, parallel, controlled clinical trial. Intervention was anger management with cognitive behavioral techniques implemented by a psychologist in two individual monthly sessions. The primary end point was the between-group difference in the variation of flow-mediated dilation (FMD) in the brachial artery from baseline to the 3-month follow-up. The second end point comprised major cardiovascular events at 24-month follow-up. RESULTS: A total of 43 patients (age = 56 [9] years; 23.3% women) were randomized to the intervention group and 47 patients (age = 58 [10] years; 19.1% women) to the control group. Baseline clinical characteristics were not statistically different between groups. Both groups showed a significant improvement in anger control from baseline to end point; however, the difference in intergroup variation was not statistically significant. The difference in FMD variation from baseline to the 3-month follow-up was significantly higher in the intervention group. The partial η2 was 0.057 (p = .024), indicating a medium effect size. There was no difference between groups regarding major cardiovascular events. CONCLUSIONS: Anger management by cognitive behavioral techniques may improve endothelial function in post-MI patients with low anger control, but it remains unclear via which mechanism these effects occurred. Further studies with larger numbers of patients, assessments of changes in anger, improved comparability of preintervention FMD, and longer follow-up are warranted.Trial Registration:ClinicalTrials.gov identifier: NCT02868216.

In-stent chronic total occlusion angioplasty in the LATAM-CTO registry.

OBJECTIVES: To inform about contemporary PCI practice of in-stent (IS) chronic total occlusions (CTO) from a large international registry in Latin America. BACKGROUND: IS-CTO represent a distinctive challenge for PCI, but literature is limited and restricted to high-resource regions of the world. METHODS: Patients undergoing CTO PCI enrolled in the LATAM CTO registry from 42 centers in eight countries were included. We analyzed demographics, angiographic, procedure technique, success and postprocedural outcomes between IS-CTO and non-IS-CTO PCI. RESULTS: From 1,565 patients IS-CTO was present in 181 patients (11.5%). IS-CTO patients had higher prevalence of diabetes and hypertension than patients without IS-CTO. IS-CTOs had less calcification (32.5 vs. 46.7%, p < .001), lower prevalence of a proximal branch (36.3 vs. 50.1%, p < .001), more likely to be ostial (24.4 vs. 18.1%, p = .042), were longer (28.5 vs. 25.2 mm, p = .062), and had less interventional collaterals (49.1 vs. 57.3%, p = .038) compared with non-IS-CTO. CTO complexity scores were similar between both groups. There was no statistically significant difference in the initial or successful strategy between IS-CTO and non-IS-CTO PCI. Technical success rates remained high in IS-CTO (86.7%) and non-IS-CTO (83.1%, p = .230). There was no independent association between IS-CTO and technical success in multivariable analysis. There were no differences between IS-CTO and non-IS-CTO groups for in-hospital clinical outcomes. CONCLUSION: In a contemporary, multicenter, and international registry from Latin America, IS-CTO PCI is frequent and has comparable technical success and safety profile compared to non-IS-CTO PCI.

Immunohistochemical characteristics of coronary thrombi in ST-elevation myocardial infarction.

Background and aims: The dynamics and implications of intracoronary thrombus constituency in patients with ST-segment elevation myocardial infarction (STEMI) are not fully understood. We evaluated the expression of CD34, CD61and factor VIII surface markers in thrombi of patients with STEMI and its association with clinical and angiographic characteristics and major adverse cardiovascular events (MACE). Methods: Patients presenting with STEMI undergoing aspiration thrombectomy during primary percutaneous coronary intervention (pPCI) were included. Morphological, histopathological and immunohistochemical aspects of thrombi were assessed by two pathologists blinded to clinical variables and outcomes. Results: The mean age of the 245 patients included was 58 ± 12 years old, and 70 % were men. Regarding the thrombi microscopic patterns, 61 % were classified as recent, 20 % as lytic and 19 % as organized. There were higher levels of the CD61 index in patients with a history of heart failure. Smokers presented lower CD61 positive cells and CD61 index, but this association did not remain significant after multivariable analysis. There was an inverse correlation between CD61 positive cells and CD61 index with the time from onset of pain to the first medical contact, but no other significant association amongst clinical characteristics and antigenic expression. There was higher expression of the CD61 antigen in patients with in-hospital MACE, but statistical significance was borderline (p = 0.06). Conclusions: In this cohort of patients with STEMI, immunohistochemistry of coronary thrombus showed a significantly higher platelet content in patients with previous heart failure and a trend in those with in-hospital MACE. Thrombus' platelet content was inversely related to ischemic time.

Absolute and Relative Agreement between the Current and Modified Brazilian Cardioprotective Nutritional Program Dietary Index (BALANCE DI) and the American Heart Association Healthy Diet Score (AHA-DS) in Post Myocardial Infarction Patients.

The American Heart Association Diet Score (AHA-DS) defines the cardiovascular health, and the Brazilian Cardioprotective Nutritional Program Dietary Index (BALANCE DI) was designed to evaluate diet quality in secondary cardiovascular prevention settings. Our aim was to assess the absolute and relative agreement between both tools in Brazilian adults after a myocardial infarction (MI). In this cross-sectional study, 473 individuals were included and had their diet assessed by a 24 h food recall and a semi-quantitative Food Frequency Questionnaire. The weighted Kappa between BALANCE DI and primary AHA-DS was 0.66 (95% CI: 0.08-0.21), and between BALANCE DI and total AHA-DS was 0.70 (95% CI: 0.20-0.32). To improve the agreement between the tools, modifications were made to the BALANCE DI scoring system. The weighted Kappa between New BALANCE DI and primary AHA-DS was 0.77 (95% CI: 0.36-0.48), and between BALANCE DI and total AHA-DS was 0.76 (95% CI: 0.34-0.46). The mean bias observed between the New BALANCE DI as compared to the primary and total AHA-DS was -16% (-51 to 19) and -8% (-41 to 24), respectively. Our results suggest that the New BALANCE DI may be a useful tool to evaluate diet quality in post MI patients.

Effects of extra virgin olive oil and pecans on plasma fatty acids in patients with stable coronary artery disease.

OBJECTIVE: The aim of this study was to determine the effects of a healthy diet supplemented with extra virgin olive oil or pecans on plasma fatty acids (PFAs) in patients with stable coronary artery disease (CAD). METHODS: Patients 40 to 80 y of age were randomized to one of three dietary interventions (allocation ratio 1: 1: 1): healthy diet based on guidelines (control group [CG]), healthy diet supplemented with 30 g/d of pecans (PNG), or a healthy diet supplemented with 30 mL/d of extra virgin olive oil (OOG). PFAs were identified at baseline and at the end of follow-up (12 wk), and correlations between dietary fatty acids intake, PFAs, and clinical biomarkers of the lipid profile were also assessed before and after the interventions. RESULTS: Among 149 participants included in the analysis (43 CG; 51 PNG; and 55 OOG), correlations were observed between food intake, PFAs, and lipid profile before and after interventions independent of statins used, but all were considered weak. At the end of the study, the OOG showed increased concentrations of oleic fatty acid independently of the type of statin in use (1.49%; 95% confidence interval, 0.08-2.89; P = 0.029); however, there were no significant differences between the groups regarding the final mean values of oleic fatty acid or in the other PFAs. CONCLUSIONS: In patients with stable CAD, there were no significant differences in PFAs after 12 wk according to dietary interventions evaluated.

Effects of a Brazilian cardioprotective diet and nuts on cardiometabolic parameters after myocardial infarction: study protocol for a randomized controlled clinical trial.

BACKGROUND: Nut consumption has been related to improvements on cardiometabolic parameters and reduction in the severity of atherosclerosis mainly in primary cardiovascular prevention. The objective of this trial is to evaluate the effects of the Brazilian Cardioprotective Diet (DIeta CArdioprotetora Brasileira, DICA Br) based on consumption of inexpensive locally accessible foods supplemented or not with mixed nuts on cardiometabolic features in patients with previous myocardial infarction (MI). METHODS: DICA-NUTS study is a national, multicenter, randomized 16-week follow-up clinical trial. Patients over 40 years old with diagnosis of previous MI in the last 2 to 6 months will be recruited (n = 388). A standardized questionnaire will be applied to data collection and blood samples will be obtained. Patients will be allocated in two groups: Group 1: DICA Br supplemented with 30 g/day of mixed nuts (10 g of peanuts, 10 g of cashew, 10 g of Brazil nuts); and Group 2: only DICA Br. The primary outcome will consist of LDL cholesterol means (in mg/dL) after 16 weeks of intervention. Secondary outcomes will consist of other markers of lipid profile, glycemic profile, and anthropometric data. DISCUSSION: It is expected that DICA Br supplemented with mixed nuts have superior beneficial effects on cardiometabolic parameters in patients after a MI, when compared to DICA Br. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03728127 . First register: November 1, 2018; Last update: June 16, 2021. World Health Organization Universal Trial Number (WHO-UTN): U1111-1259-8105.

Safety and feasibility of transulnar cardiac catheterization.

Recently, ulnar artery cannulation has been described as an alternative to the transfemoral and radial approaches to vascular access for cardiac catheterization. This study was designed to evaluate the safety and feasibility of the ulnar approach.From September 2004 through September 2006, 28 patients in a cohort study underwent cardiac catheterization by the transulnar approach. Patients were eligible if they had scheduled an elective cardiac catheterization or angioplasty procedure and displayed a palpable ulnar pulse and a positive reverse Allen's test (< 10 sec). Further, we enrolled only patients who had stable angina. After cannulation, a 5F or 6F introducer was placed inside the vessel, and cardiac catheterization or angioplasty was performed. The patients underwent clinical examination when discharged from the hospital and again at the 1-week follow up.Mean age, weight, and height of the patients were 60 +/- 14 years, 78 +/- 14 kg, and 148 +/- 55 cm, respectively, and 69% were men. Successful puncture was achieved in 93% (26/28), and in all 26 of these patients the procedure could be completed by the ulnar approach. The femoral approach was used for the remaining 2 patients. No cases of arterial spasm or loss of pulse were observed. Two patients had minor hematoma at the entry site. There were no cases of pseudoaneurysm, bleeding episodes requiring transfusion, or vascular perforation.We conclude that the transulnar approach is a safe and feasible alternative for diagnostic and therapeutic coronary intervention.

Hyperexpansion of coronary stents and clinical outcomes.

The complication rates and late clinical follow-up of patients who experience stent hyperexpansion have not been well studied. We designed this prospective study to evaluate the influence of stent hyperexpansion on clinical outcomes in patients with coronary artery disease. Patients who underwent coronary stenting were divided into 2 groups according to whether or not their stents hyperexpanded (defined as stent/artery luminal diameter ratio of > or =1.1/1.0 with no residual stenosis) during implantation. Clinical, angiographic, and procedural characteristics were evaluated at baseline, and clinical outcomes were analyzed in-hospital and at 1 year. The primary endpoint comprised 1-year major adverse cardiovascular events (MACE): death, myocardial infarction, and target-vessel revascularization. Clinical characteristics were not statistically different between patients with hyperexpansion (n=94) and those without (n=542; controls). The hyperexpansion group had significantly smaller mean target-vessel diameters and less severe stenoses; their stents were implanted at higher pressures (13.51 +/- 12.93; P=0.01); and they had higher balloon/artery ratios (1.07 U vs 0.99 U; P <0.0001) and higher aggressiveness scores (14.5 U vs 12.79 U; P <0.0001). Rates of angiographic success and in-hospital MACE were similar, although the hyperexpansion group more often had occlusions of large side branches (5.3% vs 1.5%; P=0.03). At 1 year, the groups had similar rates of MACE (10.8% vs 10.7%), including target-vessel revascularization (8.2% vs 6.5%). Multivariate analysis revealed associations between stent hyperexpansion and higher aggressiveness scores, higher balloon/artery ratios, and narrower target vessels; the hyperexpansion group also had more target-vessel large-side-branch occlusions. Hyperexpansion was not associated with lower rates of MACE.

Predictive factors of complications after coronary stent implantation.

OBJECTIVE: To analyze the predictive factors of complications after implantation of coronary stents in a consecutive cohort study. METHODS: Clinical and angiographic characteristics related to the procedure were analyzed, and the incidence of major cardiovascular complications (myocardial infarction, urgent surgery, new angioplasty, death) in the in-hospital phase were recorded. Data were stored in an Access database and analyzed by using the SPSS 6.0 statistical program and a stepwise backwards multiple logistic regression model. RESULTS: One thousand eighteen (mean age of 61 +/-11 years, 29% females) patients underwent 1070 stent implantations. The rate of angiographic success was 96.8%, the rate of clinical success was 91%, and the incidence of major cardiovascular complications was 7.9%. The variables independently associated with major cardiovascular complications, with their respective odds ratio (OR) were: rescue stent, OR = 5.1 (2.7-9.6); filamentary stent, OR = 4.5 (2.2-9.1); first-generation tubular stent, OR = 2.4 (1.2-4.6); multiple stents, OR = 3 (1.6-5.6); complexity of the lesion, OR = 2.4 (1.1-5.1); thrombus, OR = 2 (1.1-3.5). CONCLUSION: The results stress the importance of angiographic variables and techniques in the risk of complications and draw attention to the influence of the stent's design on the result of the procedure.

Early sheath removal and ambulation in patients submitted to percutaneous coronary intervention: a randomised clinical trial.

INTRODUCTION: Despite recent technical improvements and device developments, post-percutaneous coronary intervention care in patients submitted to this procedure performed through the femoral approach remains almost unchanged. An earlier sheath removal and ambulation could help to cut costs, save health system resources and prevent patient discomfort. However, this approach has not yet been well assessed. OBJECTIVES: The main objective of this paper was to evaluate a strategy of post-procedure immediate sheath removal and early ambulation. METHODS: A randomised trial was conducted in 347 patients submitted to percutaneous coronary intervention that used a 6 French gauge arterial sheath. The intervention group (IG, n=172) had the arterial sheath removed immediately after the procedure and ambulated after 3 h of bed rest. The control group (CG, n=175) had the arterial sheath removed 4h after the end of the angioplasty and rested for an additional 6 h. The primary end point was the development of major vascular complications: hematoma>10 cm, pseudo-aneurism and arterial bleeding after or during ambulation. Secondary end points were minor vascular complications: hematoma<10 cm, vasovagal reactions after sheath removal, and assessment of patient's comfort during the peri-operative period. RESULTS: Baseline characteristics did not differ statistically between groups, as major bleeding (IG=1.7% vs. CG=0.6%; p=0.31). Regarding other vascular complications and vasovagal reactions, there were also no significant differences. Patients of IG had less pain (26% vs. 41%, p=0.004) than CG, but the frequency of urinary retention was the same in both groups. CONCLUSION: This study, although underpowered, indicates that immediate arterial sheath removal with early ambulation after PCI was not significantly associated with an increase in major vascular complications and was associated with increased patient comfort. Although further studies with larger samples are necessary to confirm these results, this study suggests that immediate arterial sheath removal with early ambulation may be an alternative for selected elective patients submitted to percutaneous coronary interventions and for those with difficulties to endure prolonged bed rest.