Heart rate variability as a biomarker in patients with Chronic Chagas Cardiomyopathy with or without concomitant digestive involvement and its relationship with the Rassi score.

BACKGROUND: Dysautonomia plays an ancillary role in the pathogenesis of Chronic Chagas Cardiomyopathy (CCC), but is the key factor causing digestive organic involvement. We investigated the ability of heart rate variability (HRV) for death risk stratification in CCC and compared alterations of HRV in patients with isolated CCC and in those with the mixed form (CCC + digestive involvement). Thirty-one patients with CCC were classified into three risk groups (low, intermediate and high) according to their Rassi score. A single-lead ECG was recorded for a period of 10-20 min, RR series were generated and 31 HRV indices were calculated. The HRV was compared among the three risk groups and regarding the associated digestive involvement. Four machine learning models were created to predict the risk class of patients. RESULTS: Phase entropy is decreased and the percentage of inflection points is increased in patients from the high-, compared to the low-risk group. Fourteen patients had the mixed form, showing decreased triangular interpolation of the RR histogram and absolute power at the low-frequency band. The best predictive risk model was obtained by the support vector machine algorithm (overall F1-score of 0.61). CONCLUSIONS: The mixed form of Chagas' disease showed a decrease in the slow HRV components. The worst prognosis in CCC is associated with increased heart rate fragmentation. The combination of HRV indices enhanced the accuracy of risk stratification. In patients with the mixed form of Chagas disease, a higher degree of sympathetic autonomic denervation may be associated with parasympathetic impairment.

Long-term follow-up of Chagas heart disease patients receiving an implantable cardioverter-defibrillator for secondary prevention.

BACKGROUND: Chagas heart disease (CHD) is a dilated cardiomyopathy characterized by malignant ventricular arrhythmias and increased risk of sudden cardiac death (SCD). Much controversy exists concerning the efficacy of implantable cardioverter-defibrillator (ICDs) in CHD because of mixed results observed. We report our long-term experience with ICDs for secondary prevention in CHD, with the specific aim of assessing the results in groups with preserved or depressed global left ventricular function. METHODS: 111 patients (75 males; 60 ± 12 years) were followed for 1,948 ± 1,275 days after ICD. Time to death was the primary outcome; LVEF ≤ 45% the exposure; and age, gender, and ICD therapy delivery the potential confounders. We used time-to-event methods and Cox proportional models for analysis, censoring observations at time of death or at 5-year follow-up in survivors. RESULTS: Seventy-two percent of the patients presented at least one sustained ventricular arrhythmia requiring appropriate therapy, and only three patients received inappropriate therapy. Death occurred in 50 (45%) patients, with an annual mortality rate of 8.4%, mostly due to refractory heart failure or noncardiac causes. Unadjusted survival rates were significantly distinct between patients with left ventricular ejection fraction (LVEF) ≤ 45% (26 deaths), 50.5% (95% confidence interval [CI]: 36.2%-63.2%) when compared to patients with LVEF > 45% (10 deaths), 77.6% (95% CI: 62.3%-87.3%, P < 0.01). After adjusting for confounders, low LVEF (hazard ratio [HR]: 5.2, 95% CI: 2.3-11.6), age (HR: 1.04, 95% CI: 1.01-1.07), and female gender (HR: 3.97, 95% CI: 1.85-8.54) were independently associated with the outcome. CONCLUSIONS: ICDs successfully aborted life-threatening arrhythmias in CHD patients. Impaired left ventricular function predicted higher mortality in CHD patients with an ICD for secondary prevention of SCD.

Implantable cardioverter-defibrillators for treatment of sustained ventricular arrhythmias in patients with Chagas' heart disease: comparison with a control group treated with amiodarone alone.

AIMS: Evidence is inconclusive concerning the benefit of implantable cardioverter-defibrillators (ICDs) for secondary prevention of mortality in patients with Chagas' heart disease (ChHD). The aim of this study was to compare the outcomes of ChHD patients with life-threatening ventricular arrhythmias (VAs), who were treated either with ICD implantation plus amiodarone or with amiodarone alone. METHODS AND RESULTS: The ICD group [76 patients; 48 men; age, 57 ± 11 years; left ventricular ejection fraction (LVEF), 39 ± 12%] and the historical control group treated with amiodarone alone (28 patients; 18 men; age, 54 ± 10 years; LVEF, 41 ± 10%) had comparable baseline characteristics, except for a higher use of beta-blockers in the ICD group (P < 0.0001). Amiodarone was also used in 90% of the ICD group. Therapy with ICD plus amiodarone resulted in a 72% reduced risk of all-cause mortality (P = 0.007) and a 95% reduced risk of sudden death (P = 0.006) compared with amiodarone-only therapy. The survival benefit of ICD was greatest in patients with LVEF < 40% (P = 0.01) and was not significant in those with LVEF ≥ 40% (P = 0.15). Appropriate ICD therapies occurred in 72% of patients and the rates of interventions were similar across patients with LVEF < 40% and ≥40%. CONCLUSION: Compared with amiodarone-only therapy, ICD implantation plus amiodarone reduced the risk of all-cause mortality and sudden death in ChHD patients with life-threatening VAs. Patients with LVEF < 40% derived significantly more survival benefit from ICD therapy. The majority of ICD-treated patients received appropriate therapies regardless of the LV systolic function.

Three vs twelve months of dual antiplatelet therapy after zotarolimus-eluting stents: the OPTIMIZE randomized trial.

IMPORTANCE: The current recommendation is for at least 12 months of dual antiplatelet therapy after implantation of a drug-eluting stent. However, the optimal duration of dual antiplatelet therapy with specific types of drug-eluting stents remains unknown. OBJECTIVE: To assess the clinical noninferiority of 3 months (short-term) vs 12 months (long-term) of dual antiplatelet therapy in patients undergoing percutaneous coronary intervention (PCI) with zotarolimus-eluting stents. DESIGN, SETTING, AND PATIENTS: The OPTIMIZE trial was an open-label, active-controlled, 1:1 randomized noninferiority study including 3119 patients in 33 sites in Brazil between April 2010 and March 2012. Clinical follow-up was performed at 1, 3, 6, and 12 months. Eligible patients were those with stable coronary artery disease or history of low-risk acute coronary syndrome (ACS) undergoing PCI with zotarolimus-eluting stents. INTERVENTIONS: After PCI with zotarolimus-eluting stents, patients were prescribed aspirin (100-200 mg daily) and clopidogrel (75 mg daily) for 3 months (n = 1563) or 12 months (n = 1556), unless contraindicated because of occurrence of an end point. MAIN OUTCOMES AND MEASURES: The primary end point was net adverse clinical and cerebral events (NACCE; a composite of all-cause death, myocardial infarction [MI], stroke, or major bleeding); the expected event rate at 1 year was 9%, with a noninferiority margin of 2.7%. Secondary end points were major adverse cardiac events (MACE; a composite of all-cause death, MI, emergent coronary artery bypass graft surgery, or target lesion revascularization) and Academic Research Consortium definite or probable stent thrombosis. RESULTS: NACCE occurred in 93 patients receiving short-term and 90 patients receiving long-term therapy (6.0% vs 5.8%, respectively; risk difference, 0.17 [95% CI, -1.52 to 1.86]; P = .002 for noninferiority). Kaplan-Meier estimates demonstrated MACE rates at 1 year of 8.3% (128) in the short-term group and 7.4% (114) in the long-term group (HR, 1.12 [95% CI, 0.87-1.45]). Between 91 and 360 days, no statistically significant association was observed for NACCE (39 [2.6%] vs 38 [2.6%] for the short- and long-term groups, respectively; HR, 1.03 [95% CI, 0.66-1.60]), MACE (78 [5.3%] vs 64 [4.3%]; HR, 1.22 [95% CI, 0.88-1.70]), or stent thrombosis (4 [0.3%] vs 1 [0.1%]; HR, 3.97 [95% CI, 0.44-35.49]). CONCLUSIONS AND RELEVANCE: In patients with stable coronary artery disease or low-risk ACS treated with zotarolimus-eluting stents, 3 months of dual antiplatelet therapy was noninferior to 12 months for NACCE, without significantly increasing the risk of stent thrombosis. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01113372.

Optimized duration of clopidogrel therapy following treatment with the Endeavor zotarolimus-eluting stent in real-world clinical practice (OPTIMIZE) trial: rationale and design of a large-scale, randomized, multicenter study.

BACKGROUND: Current recommendations for antithrombotic therapy after drug-eluting stent (DES) implantation include prolonged dual antiplatelet therapy (DAPT) with aspirin and clopidogrel ≥12 months. However, the impact of such a regimen for all patients receiving any DES system remains unclear based on scientific evidence available to date. Also, several other shortcomings have been identified with prolonged DAPT, including bleeding complications, compliance, and cost. The second-generation Endeavor zotarolimus-eluting stent (E-ZES) has demonstrated efficacy and safety, despite short duration DAPT (3 months) in the majority of studies. Still, the safety and clinical impact of short-term DAPT with E-ZES in the real world is yet to be determined. METHODS: The OPTIMIZE trial is a large, prospective, multicenter, randomized (1:1) non-inferiority clinical evaluation of short-term (3 months) vs long-term (12-months) DAPT in patients undergoing E-ZES implantation in daily clinical practice. Overall, 3,120 patients were enrolled at 33 clinical sites in Brazil. The primary composite endpoint is death (any cause), myocardial infarction, cerebral vascular accident, and major bleeding at 12-month clinical follow-up post-index procedure. CONCLUSIONS: The OPTIMIZE clinical trial will determine the clinical implications of DAPT duration with the second generation E-ZES in real-world patients undergoing percutaneous coronary intervention.

Intra-Discrete Typing Unit TcV Genetic Variability of Trypanosoma cruzi in Chronic Chagas' Disease Bolivian Immigrant Patients in Barcelona, Spain.

Background: Trypanosoma cruzi has a high rate of biological and genetic variability, and its population structure is divided into seven distinct genetic groups (TcI-TcVI and Tcbat). Due to immigration, Chagas disease (ChD), caused by T. cruzi, has become a serious global health problem including in Europe. Therefore, the aim of this study was to evaluate the existence of genetic variability within discrete typing unit (DTU) TcV of T. cruzi in Bolivian patients with chronic ChD residing in Barcelona, Spain. Methods: The DNA was extracted from the peripheral blood of 27 patients infected with T. cruzi DTU TcV and the fragments of the genetic material were amplificated through the low stringency single primer-polymerase chain reaction (LSSP-PCR). The data generated after amplification were submitted to bioinformatics analysis. Results: Of the 27 patients evaluated in the study, 8/27 (29.6%) were male and 19/27 (70.4%) female, 17/27 (62.9%) were previously classified with the indeterminate clinical form of Chagas disease and 10/27 (37.1%) with Chagas cardiomyopathy. The LSSP-PCR detected 432 band fragments from 80 to 1,500 bp. The unweighted pair-group method analysis and principal coordinated analysis data demonstrated the existence of three distinct genetic groups with moderate-high rates of intraspecific genetic variability/diversity that had shared parasite's alleles in patients with the indeterminate and cardiomyopathy forms of ChD. Conclusions: This study demonstrated the existence of a moderate to high rate of intra-DTU TcV variability in T. cruzi. Certain alleles of the parasite were associated with the absence of clinical manifestations in patients harboring the indeterminate form of ChD. These results support the need to search for increasingly specific targets in the genome of T. cruzi to be correlated with its main biological properties and clinical features in patients with chronic ChD.

Aspirin plus verapamil relieves angina and perfusion abnormalities in patients with coronary microvascular dysfunction and Chagas disease: a pilot non-randomized study.

INTRODUCTION: Most patients with chronic cardiomyopathy of Chagas disease (CCCD) harbor a secondary cause of coronary microvascular dysfunction (CMD), for which there is no evidence-based therapy. We evaluated the impact of verapamil plus aspirin on symptoms and perfusion abnormalities in patients with CCCD and CMD. METHODS: Consecutive patients with angina pectoris, who had neither coronary artery obstructions nor moderate-severe left ventricular dysfunction (left ventricular ejection fraction > 40%) despite showing wall motion abnormalities on ventriculography, were referred for invasive angiography and tested for Chagas disease. Thirty-two patients with confirmed CCCD and ischemia on stress-rest SPECT myocardial perfusion scintigraphy (MPS) were included. Clinical evaluation, quality of life (EQ-5D/ Seattle Angina Questionnaire), and MPS were assessed before and after 3 months of treatment with oral verapamil plus aspirin (n=26) or placebo (n=6). RESULTS: The mean patient age was 64 years, and 18 (56%) were female. The ischemic index summed difference score (SDS) in MPS was significantly reduced by 55.6% after aspirin+verapamil treatment. A decrease in SDS was observed in 20 (77%) participants, and in 10 participants, no more ischemia could be detected. Enhancements in quality of life were also detected. No change in symptoms or MPS was observed in the placebo group. CONCLUSIONS: This low-cost 3-month treatment for patients diagnosed with CCCD and CMD was safe and resulted in a 55.6% reduction in ischemic burden, symptomatic improvement, and better quality of life.

Quantification of parasite burden of Trypanosoma cruzi and identification of Discrete Typing Units (DTUs) in blood samples of Latin American immigrants residing in Barcelona, Spain.

BACKGROUND: Trypanosoma cruzi has a high genetic and biological diversity and has been subdivided into seven genetic lineages, named TcI-TcVI and TcBat. DTUs TcI-TcII-TcV and TcVI are agents of ChD in different regions of Latin America. Due to population movements, the disease is an emergent global public health problem. Thus, the aim of this study was to quantify the parasitic load and identify the presence of T. cruzi DTUs in 101 Latin American immigrants with chronic ChD, residing in Barcelona, Spain. METHODOLOGY / PRINCIPAL FINDINGS: 5ml of peripheral blood were collected in guanidine/EDTA from each patient for DNA extraction, quantification of the parasitic load and genotyping. A great variation of the parasitic load of the patients was verified: from 0.001 to 22.2 T. cruzi DNA (fg) / Blood DNA (ng). In patients from Bolivia the parasitic load was 3.76±4.43 T. cruzi DNA (fg) / Blood DNA (ng) (mean ± SD), in patients of other countries was 0.95±1.38 T. cruzi DNA (fg) / Blood DNA (ng). No statistically significant difference was observed in the parasitic load between patients with the indeterminate and cardiac forms of ChD (p = 0,57). Parasite genotyping was performed by multilocus conventional PCR. In patients from Bolivia there was a nearly equal prevalence of DTUs TcV (27/77), TcII/TcV/TcVI (26/77), and TcII/TcVI (22/77). TcVI was detected in only 2 samples (2/77). A higher prevalence of TcII/TcVI (19/24) was verified in patients of other countries, with low prevalence of TcII/TcV/TcVI (4/24) and TcV (1/24). CONCLUSIONS/SIGNIFICANCE: In this study, low/medium parasitic load was found in all patients evaluated. Our data corroborate previous conclusions indicating that patients from the Bolivia, living in Spain, are predominantly infected by TcV, and TcVI DTUs. On the other hand, in Non-Bolivians patients TcII/TcVI predominated. Surprisingly, in our cohort of 101 patients no infection by TcI DTU was observed.

The BENEFIT trial: testing the hypothesis that trypanocidal therapy is beneficial for patients with chronic Chagas heart disease.

Among the pathophysiological derangements operating in the chronic phase of Chagas disease, parasite persistence is likely to constitute the main mechanism of myocardial injury in patients with chronic chagasic cardiomyopathy. The presence of Trypanosoma cruzi in the heart causes a low-grade, but relentless, inflammatory process and induces myocardial autoimmune injury. These facts suggest that trypanocidal therapy may positively impact the clinical course of patients with chronic Chagas heart disease. However, the experimental and clinical evidence currently available is insufficient to support the routine use of etiologic treatment in these patients. The BENEFIT project--Benznidazole Evaluation for Interrupting Trypanosomiasis--is an international, multicenter, double-blind, placebo-controlled trial of trypanocidal treatment with benznidazole in patients with chronic Chagas heart disease. This project is actually comprised of two studies. The pilot study investigates whether etiologic treatment significantly reduces parasite burden, as assessed by polymerase chain reaction-based techniques and also determines the safety and tolerability profile of the trypanocidal drug in this type of chagasic population. The full-scale study determines whether antitrypanosomal therapy with benznidazole reduces mortality and other major cardiovascular clinical outcomes in patients with chronic Chagas heart disease.

Multimodality imaging evaluation of Chagas disease: an expert consensus of Brazilian Cardiovascular Imaging Department (DIC) and the European Association of Cardiovascular Imaging (EACVI).

Aims: To develop a document by Brazilian Cardiovascular Imaging Department (DIC) and the European Association of Cardiovascular Imaging (EACVI) to review and summarize the most recent evidences about the non-invasive assessment of patients with Chagas disease, with the intent to set up a framework for standardized cardiovascular imaging to assess cardiovascular morphologic and functional disturbances, as well as to guide the subsequent process of clinical decision-making. Methods and results: Chagas disease remains one of the most prevalent infectious diseases in Latin America, and has become a health problem in non-endemic countries. Dilated cardiomyopathy is the most severe manifestation of Chagas disease, which causes substantial disability and early mortality in the socially most productive population leading to a significant economical burden. Prompt and correct diagnosis of Chagas disease requires specialized clinical expertise to recognize the unique features of this disease. The appropriate and efficient use of cardiac imaging is pivotal for diagnosing the cardiac involvement in Chagas disease, to stage the disease, assess patients' prognosis and address management. Echocardiography is the most common imaging modality used to assess, and follow-up patients with Chagas disease. The presence of echocardiographic abnormalities is of utmost importance, since it allows to stage patients according to disease progression. In early stages of cardiac involvement, echocardiography may demonstrate segmental left ventricuar wall motion abnormalities, mainly in the basal segments of inferior, inferolateral walls, and the apex, which cannot be attributed to obstructive coronary artery arteries. The prevalence of segmental wall motion abnormalities varies according to the stage of the disease, reaching about 50% in patients with left ventricular dilatation and dysfunction. Speckle tracking echocardiography allows a more precise and quantitative measurement of the regional myocardial function. Since segmental wall motion abnormalities are frequent in Chagas disease, speckle tracking echocardiography may have an important clinical application in these patients, particularly in the indeterminate forms when abnormalities are more subtle. Speckle tracking echocardiography can also quantify the heterogeneity of systolic contraction, which is associated with the risk of arrhythmic events. Three-dimensional (3D) echocardiography is superior to conventional two-dimensional (2D) echocardiography for assessing more accurately the left ventricular apex and thus to detect apical aneurysms and thrombus in patients in whom ventricular foreshortening is suspected by 2D echocardiography. In addition, 3D echocardiography is more accurate than 2D Simpson s biplane rule for assessing left ventricular volumes and function in patients with significant wall motion abnormalities, including aneurysms with distorted ventricular geometry. Contrast echocardiography has the advantage to enhancement of left ventricular endocardial border, allowing for more accurate detection of ventricular aneurysms and thrombus in Chagas disease. Diastolic dysfunction is an important hallmark of Chagas disease even in its early phases. In general, left ventricular diastolic and systolic dysfunction coexist and isolated diastolic dysfunction is uncommon but may be present in patients with the indeterminate form. Right ventricular dysfunction may be detected early in the disease course, but in general, the clinical manifestations occur late at advanced stages of Chagas cardiomyopathy. Several echocardiographic parameters have been used to assess right ventricular function in Chagas disease, including qualitative evaluation, myocardial performance index, tissue Doppler imaging, tricuspid annular plane systolic excursion, and speckle tracking strain. Cardiac magnetic resonance (CMR) is useful to assess global and regional left ventricular function in patients with Chagas diseases. Myocardial fibrosis is a striking feature of Chagas cardiomyopathy and late gadolinium enhancement (LGE) is used to detect and quantify the extension of myocardial fibrosis. Myocardial fibrosis might have a role in risk stratification of patients with Chagas disease. Limited data are available regarding right ventricular function assessed by CMR in Chagas disease. Radionuclide ventriculography is used for global biventricular function assessment in patients with suspected or definite cardiac involvement in Chagas disease with suboptimal acoustic window and contraindication to CMR. Myocardial perfusion scintigraphy may improve risk stratification to define cardiac involvement in Chagas disease, especially in the patients with devices who cannot be submitted to CMR and in the clinical setting of Chagas patients whose main complaint is atypical chest pain. Detection of reversible ischemic defects predicts further deterioration of left ventricular systolic function and helps to avoid unnecessary cardiac catheterization and coronary angiography. Conclusion: Cardiac imaging is crucial to detect the cardiac involvement in patients with Chagas disease, stage the disease and stratify patient risk and address management. Unfortunately, most patients live in regions with limited access to imaging methods and point-of-care, simplified protocols, could improve the access of these remote populations to important information that could impact in the clinical management of the disease. Therefore, there are many fields for further research in cardiac imaging in Chagas disease. How to better provide an earlier diagnosis of cardiac involvement and improve patients risk stratification remains to be addressed using different images modalities.

Aspirin plus verapamil relieves angina and perfusion abnormalities in patients with coronary microvascular dysfunction and Chagas disease: a pilot non-randomized study

Abstract INTRODUCTION: Most patients with chronic cardiomyopathy of Chagas disease (CCCD) harbor a secondary cause of coronary microvascular dysfunction (CMD), for which there is no evidence-based therapy. We evaluated the impact of verapamil plus aspirin on symptoms and perfusion abnormalities in patients with CCCD and CMD. METHODS: Consecutive patients with angina pectoris, who had neither coronary artery obstructions nor moderate-severe left ventricular dysfunction (left ventricular ejection fraction > 40%) despite showing wall motion abnormalities on ventriculography, were referred for invasive angiography and tested for Chagas disease. Thirty-two patients with confirmed CCCD and ischemia on stress-rest SPECT myocardial perfusion scintigraphy (MPS) were included. Clinical evaluation, quality of life (EQ-5D/ Seattle Angina Questionnaire), and MPS were assessed before and after 3 months of treatment with oral verapamil plus aspirin (n=26) or placebo (n=6). RESULTS: The mean patient age was 64 years, and 18 (56%) were female. The ischemic index summed difference score (SDS) in MPS was significantly reduced by 55.6% after aspirin+verapamil treatment. A decrease in SDS was observed in 20 (77%) participants, and in 10 participants, no more ischemia could be detected. Enhancements in quality of life were also detected. No change in symptoms or MPS was observed in the placebo group. CONCLUSIONS: This low-cost 3-month treatment for patients diagnosed with CCCD and CMD was safe and resulted in a 55.6% reduction in ischemic burden, symptomatic improvement, and better quality of life.

A Inibição da Via Final Comum da Agregação Plaquetária Reduz o Fenômeno de Não Reperfusão Durante a Intervenção Coronária Percutânea Primária? Tirofiban no Infarto Agudo do miocárdio e a não ReperfusÃo (TIARA) / Does the Inhibition of the Final Common Pathway of Platelet Aggregation Reduce the No-Reflow Phenomenon During Primary Percutaneous Coronary Intervention? Tirofiban no Infarto Agudo do miocárdio e a não ReperfusÃo (TIARA)

Introdução: A intervenção coronária percutânea primária é hoje o método preferencial de reperfusão na abordagem de pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST. Em boa parte desses casos, ocorre o fenômeno de não reperfusão, que é a incapacidade de se reperfundir uma região do miocárdio após o restabelecimento da patência de uma artéria coronária epicárdica previamente ocluída. O benefício de inibidores da glicoproteína IIb/IIIa, bloqueando a via final comum da agregação plaquetária, tem sido sugerido em estudos de síndromes coronárias agudas, mas persistem pontos obscuros quanto à sua real eficácia, no contexto da não reperfusão, em pacientes tratados com intervenção coronária percutânea primária. Métodos: Investigação multicêntrica que avaliou o impacto da administração precoce do inibidor da glicoproteína IIb/IIIa de baixo peso molecular tirofiban, em forma duplo-mascarada, controlada por placebo, sobre a ocorrência de não reperfusão, empregando métodos angiográficos e eletrocardiográfico para documentar (1) os fluxos coronário epicárdico, pelo escore TIMI, e microcirculatório, pelo escore MBG de opacificação e escoamento miocárdicos; (2) a resolução do supradesnivelamento do segmento ST, como índice final do sucesso da reperfusão. Conclusões: Se comprovada redução da incidência de não reperfusão tanto 90 minutos como 24 horas após a intervenção coronária percutânea primária, este estudo-piloto, deve nortear a implementação de estudo mais abrangente, para investigar o possível impacto do bloqueio sistemático ...

Background: Primary percutaneous coronary intervention is currently the preferred method to treat patients with ST-segment elevation acute myocardial infarction. The no-reflow phenomenon, which is the inability to reperfuse a region of the myocardium after restoration of patency of a previously occluded epicardial coronary artery, is observed in a considerable proportion of these patients. The benefit of IIb/IIIa glycoprotein inhibitors, blocking the final common pathway of platelet aggregation, has been suggested in studies of acute coronary syndromes, but their actual efficacy in the context of no-reflow in patients treated with primary percutaneous coronary intervention remains unclear. Methods: The aim of this multicenter, double-blinded, placebo controlled study is to assess the impact of the early administration of the low molecular weight glycoprotein IIb/ IIIa inhibitor tirofiban on the incidence of no-reflow using angiographic and electrocardiographic methods to determine: (1) the epicardial coronary flow, using the TIMI score, and the microcirculatory flow, using the MBG score of opacification and myocardial flow; (2) the resolution of the ST segment elevation, as the final index of the success of reperfusion. Conclusions: If the decrease in no-reflow incidence at 90 minutes and 24 hours after primary percutaneous coronary intervention is confirmed, this pilot study should guide the implementation of a larger study to investigate the possible impact of the systematic inhibition of the final common pathway of platelet aggregation on the mortality of ST-segment elevation acute myocardial infarction patients. .

Relato preliminar sobre a concentração sanguínea de níquel após oclusão percutânea de comunicação interatrial com a prótese cocoon® / Preliminary report of serum nickel concentration after atrial septal defect occlusion with the cocoonTM device

Introdução: A possibilidade de ocorrer liberação de níquel na corrente sanguínea após implante de dispositivos oclusores de comunicação interatrial de última geração (Cocoon Septal Occluder®), cujo principal componente é o nitinol (55% de níquel e 45% de titânio), ainda permanece controversa, principalmente em determinados grupos de pacientes, como crianças e mulheres em idade fértil. Dessa maneira, o objetivo do presente estudo foi avaliar a correlação entre o implante da prótese e os níveis séricos de níquel. Métodos: Estudo prospectivo de coorte, longitudinal e observacional, realizado em um hospital público. Pacientes submetidos à oclusão percutânea de comunicação interatrial foram avaliados clinicamente, por meio de ecocardiograma transtorácico, e foi feita coleta de amostras de sangue em veia periférica, para a dosagem do níquel antes e após (1 dia, 1 e 3 meses) o implante. Resultados: O procedimento e os exames subsequentes foram realizados com sucesso em dez pacientes, com média de idade de 34,4 anos (variação de 5 a 60 anos). O ecocardiograma seriado comprovou a manutenção dos resultados adequados do implante dos dispositivos. Os pacientes não apresentaram manifestações que pudessem sugerir reação ao metal, como rash cutâneo, dispneia, desconforto torácico, palpitações ou migrânea. Níveis séricos de níquel não apresentaram variação significativa e se mantiveram dentro dos limites de normalidade populacional dos métodos de dosagem até os 3 meses decorridos do procedimento. Conclusões: Os resultados preliminares desta investigação com a prótese Cocoon demonstraram que, durante o período inicial de endotelização após o procedimento, não ocorreu liberação apreciável de níquel para a corrente sanguínea...

Background: The possibility of nickel release to the bloodstream after implantation of latest generation atrial septal defect occlusion devices (Cocoon Septal OccluderTM), whose main component is nitinol (55% nickel and 45% titanium), remains controversial, especially in certain groups of patients such as children and women of childbearing age. Thus, the aim of this study was to evaluate the correlation between the device implantation and serum levels of nickel. Methods: This was a prospective longitudinal observational study conducted at a public hospital. Patients undergoing percutaneous atrial septal defect occlusion were clinically evaluated using transthoracic echocardiography and peripheral vein blood sampling for serum nickel before and after (1 day, 1 and 3 months) implantation. Results: The procedure and subsequent examinations were successfully performed in ten patients, with mean age of 34.4 years (range 5 to 60 years). Serial echocardiography confirmed the maintenance of adequate results of the procedure. Patients did not show manifestations that might suggest a reaction to metal, such as skin rash, dyspnea, thoracic discomfort, palpitations or migraine. Serum nickel levels did not show any significant changes and remained within the normal range for the population, according to the dosing methods within 3 months of the procedure. Conclusions: Preliminary results of this investigation with the Cocoon device have shown that during the initial period of endothelization after the procedure there was no significant nickel release into the bloodstream...

Fase Piloto do Estudo SPECTRUM. Reserva de Fluxo Fracionada Versus Angiografia para Avaliação e Conduta em Pacientes com Lesões Obstrutivas Coronárias de Grau Moderado: Racional e Desenho do Estudo / Pilot Phase of the SPECTRUM Trial. Fractional Flow Reserve vs. Angiography for Evaluation and Management of Patients with Intermediate Coronary Stenosis: Rationale and Study Design

Introdução: A despeito de suas reconhecidas limitações, a angiografia coronária invasiva é o método mais usado (muitas vezes único) para a adoção de estratégias terapêuticas em pacientes submetidos a cateterismo cardíaco diagnóstico. A mensuração de reserva de fluxo fracionada (FFR) tem sido empregada em diversos estudos, fundamentalmente no contexto de pacientes em que a avaliação angiográfica per se indica a necessidade de intervenção sobre as lesões coronárias. No entanto, o método praticamente não foi ainda testado em condições opostas, no cenário clínico em que as obstruções, angiograficamente, não indicariam intervenções. O propósito deste trabalho, a ser realizado de forma piloto em dois centros, é testar a hipótese de que também para lesões intermediárias, nas quais a angiografia não demonstra necessidade de intervenção coronária, a medida de FFR resultaria em alteração da conduta terapêutica baseada em angiografia. Métodos: Serão incluídos pacientes consecutivos e clinicamente estáveis, com doença coronária em segmento proximal e/ou médio de um ou mais vasos epicárdicos (diâmetro > 2,5 mm), apresentando obstruções entre 40 e 70%, por estimativa visual. Em seguida, a conduta terapêutica (clínica ou intervencionista) baseada em angiografia, relativamente a essas lesões, será ...

Background: Despite its well-known limitations, invasive coronary angiography remains the most used, and often times the only method used to define treatment strategies in patients undergoing diagnostic cardiac catheterization. Measurement of coronary fractional flow reserve (FFR) has been used in several studies in patients for whom an interventional the rapy strategy was determined based on angiography. However, this method has not been tested in the opposite scenario, in which the angiographic evaluation does not indicate the need for interventions. The purpose of this pilot study, to be performed in two sites, is to test the hypothesis that for intermediate injuries, in which angiography does not indicate the need for coronary intervention, measurement of FFR might change the therapeutic approach based on angiography. Methods: Consecutive clinically stable patients, with coronary disease in the proximal or middle segment of one or more epicardial vessels (diameter > 2.5 mm), with injuries between 40 and 70% by visual estimation will be enrolled in this trial. The treatment approach (clinical or interventional) based on angiography will be defined independently and by consensus of two observers. Thereafter, patients in both groups will be randomized into two subgroups: (1) maintenance of the angiography-based therapeutic strategy; and (2) use of FFR to define therapeutic strategy. Patients with FFR < 0.80 will be treated by percutaneous or surgical revascularization, whereas patients with FFR ≥ 0.80 ...

Implante por cateter de bioprótese valvular aórtica para tratamento de estenose valvar aórtica grave em pacientes inoperáveis sob perspectiva da saúde suplementar: análise de custo-efetividade / Transcatheter aortic valve implantation for the treatment of severe aortic valve stenosis in inoperable patients under the perspective of the brazilian supplemental health system: cost-effectiveness analysis

INTRODUÇÃO: O implante por cateter de bioprótese valvular aórtica (TAVI, do inglês transcatheter aortic valve implantation) constitui nova modalidade de tratamento destinada, sobretudo, aos pacientes com elevado risco cirúrgico. Para esses pacientes, o TAVI resultou em aumento da sobrevivência e melhora da qualidade de vida, comparativamente ao tratamento padrão (medicamentoso, com ou sem valvuloplastia aórtica percutânea). Nosso objetivo foi realizar análise de custo-efetividade da implementação do TAVI no Sistema de Saúde Suplementar brasileiro. MÉTODOS: Foram desenvolvidos um modelo preditivo, para avaliar custo-efetividade real do procedimento em longo prazo, e uma regressão de Weibull com tempo horizonte de 5 e 10 anos, para estimar dados de sobrevida por mais de 24 meses. Adicionalmente, foi desenvolvido modelo de Markov sequencial e determinístico. Resultados foram expressos como razão de custo-efetividade incremental (RCEI) por anos de vida ganhos e anos de vida livres de progressão. RESULTADOS: Para o cenário padrão, no qual o custo da TAVI foi estipulado em R$ 65 mil, o valor da RCEI (custo/ano de vida salvo) em 5 anos foi de R$ 72.520,65. Alterando-se o tempo horizonte para 10 anos, esse valor diminuiu para R$ 41.653,01. CONCLUSÕES: O modelo apontou que o TAVI apresenta efetividade superior e maior custo incremental. Além disso, a incorporação do TAVI no Rol de Procedimentos e Eventos em Saúde da Agência Nacional de Saúde Suplementar acarretaria impacto orçamentário incremental nos próximos 5 anos, variando de R$ 70 milhões a R$ 121 milhões, compatível com o de outras tecnologias já incorporadas no âmbito da Saúde Suplementar.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a new modality of treatment especially dedicated to patients with high surgical risk. In these patients, TAVI increased survival and improved quality of life when compared to standard treatment (drug therapy with or without percutaneous aortic balloon valvuloplasty). Our objective was to perform a cost-efficacy analysis of the implementation of TAVI in the Brazilian Supplemental Health System. METHODS: We developed a predictive model to assess the cost-effectiveness of the procedure in the long-term, and a Weibull regression analysis with a time horizon of 5 and 10 years, to estimate survival data for over 24 months. In addition, a deterministic sequential Markov model was developed. Results were expressed as incremental cost-effectiveness ratio (ICER) per years of life saved and progression-free years of life. RESULTS: In a standard scenario, where the cost of TAVI was estimated as R$ 65 millions, the ICER value (cost/year of life saved) in 5 years was R$ 72,520.65. When the time horizon was adjusted for 10 years, this amount decreased to R$ 41,653.01. CONCLUSIONS: The model indicated that TAVI has superior effectiveness and higher incremental cost. Furthermore, the incorporation of TAVI in the List of Health Procedures and Events of the Brazilian Supplemental Health System would have an incremental budgetary impact over the next 5 years, ranging from R$ 70 millions to R$ 121 millions, consistent with other technologies which have already been incorporated by the system.

Oclusão percutânea de comunicação interatrial tipo ostium secundum com prótese memopart® / Percutaneous closure of ostium secundum atrial septal defect using the memopart™ occlusion device

INTRODUÇÃO: Os autores relatam a experiência inicial da oclusão da comunicação interatrial ostium secundum (CIA) com a utilização da prótese Memopart® (Shanghai Shape Memory Alloy Co Ltd, Shanghai, China). MÉTODOS: Estudo prospectivo observacional, no qual uma série de pacientes portadores de defeitos com significativa repercussão hemodinâmica e características anatômicas favoráveis ao implante foi submetida à oclusão percutânea de CIA. O procedimento foi realizado por via femoral percutânea, pela técnica habitual. O período de seguimento foi de 10,3 ± 5 meses, com controles clínicos e ecocardiográficos 24 horas (ou antes da alta hospitalar), 1, 3, 6 e 12 meses após o implante. RESULTADOS: No período de fevereiro de 2012 a abril de 2013, foram submetidos à oclusão percutânea de CIA 21 pacientes, sendo 16 do sexo feminino, com idade média de 33,1 ± 18,7 anos. O diâmetro médio do defeito foi de 19,04 ± 6,25 mm e o tamanho da prótese foi de 21,42 ± 6,73 mm (8 a 34 mm). O implante foi realizado com êxito em todos os casos, verificando-se oclusão total no controle antes da alta hospitalar. No seguimento, todos os pacientes estiveram assintomáticos e comprovou-se a persistência da oclusão total do defeito. Não houve mortalidade e nem outras complicações na série. CONCLUSÕES: A oclusão percutânea da CIA utilizando-se prótese Memopart® é um procedimento eficaz e seguro, dentro dos limites desta investigação. O implante da prótese é simples e apresenta alto índice de oclusão imediata, inclusive de defeitos de grandes dimensões.

BACKGROUND: The authors report their initial experience with the Memopart™ device (Shanghai Shape Memory Alloy Co Ltd, Shanghai, China) for the occlusion of secundum atrial septal defect (ASD). METHODS: This was a prospective observational study of a series of patients undergoing percutaneous occlusion of ASD with right ventricle volume overload and favorable anatomic characteristics. The procedure was performed by percutaneous femoral approach. The mean follow-up was 10.3 ± 5 months, with clinical and 24-hour echocardiographic evaluations (or before hospital discharge), 1, 3, 6, and 12 months after implantation. RESULTS: From February/2012 to April/2013, 21 patients, 16 females, mean age 33.1 ± 18.7 years, were submitted to percutaneous occlusion of an ASD. The average diameter of the defect was 19.04 ± 6.25 mm and the device size was 21.42 ± 6.73 mm (8 to 34 mm). Total occlusion of the defect was observed in all cases before hospital discharge. During follow-up, all patients were asymptomatic and without residual shunt. There was no deaths or any other complications in the series. CONCLUSIONS: The percutaneous closure of ASD using a Memopart™ device is an effective and safe procedure within the limits of this investigation. The device is user-friendly and has a high rate of immediate occlusion, even in large defects.

Base racional e plano de estudo prospectivo para avaliar o efeito de terapêutica antiplaquetária e vasodilatadora microcirculatória em pacientes com cardiopatia chagásica crônica e distúrbios microvasculares coronários / Rationale and design of a prospective study to assess the effect of microcirculatory antiplatelet and vasodilation therapy in patients with chronic chagas heart disease and coronary microvascular disease

Introdução: Há evidência, embasada por estudos em modelos experimentais de infecção pelo Trypanosoma cruzi, e também por investigações histopatológicas em humanos com a doença de Chagas, de que distúrbios de natureza isquêmica participem da patogênese de lesões miocárdicas na fase crônica da moléstia. Esses distúrbios isquêmicos derivam de desregulação microcirculatória. Dor precordial atípica é sintoma comum em pacientes na fase crônica da doença de Chagas. Em substancial proporção desses pacientes, apesar da inexistência de obstruções coronárias angiograficamente detectáveis, documenta-se com cintilografia miocárdica a ocorrência de distúrbios perfusionais durante o estresse, que são reversíveis após repouso. Métodos: Estudo unicêntrico, prospectivo, de coorte única, com intervenção terapêutica seguida de reavaliação quantitativa, após 90 dias, da área ventricular apresentando alterações perfusionais isquêmicas inicialmente detectadas em pacientes cardiopatas chagásicos com coronárias angiograficamente normais. A cintilografia miocárdica de perfusão será executada com o método SPECT,antes e após 90 dias da intervenção terapêutica, tendo os estamibi-Tc99m como radiotraçador e o esforço físico ou o estímulo vasodilatador com dipiridamol como estressores. A intervenção terapêutica consistirá de ácido acetilsalicílico (dose de 100 mg diária) associado a verapamil (dose diária de160 mg, em duas tomadas de 80 mg). O desfecho primário do estudo será redução > 50% da área ventricular de isquemia miocárdica reversível calculada pelo mapa polar da cintilografia miocárdica de perfusão. Conclusões: Este é o primeiro estudo de intervenção terapêutica para atenuar ou reverter alterações miocárdicas isquêmicas de origem microvascular em pacientes com cardiopatia chagásica crônica.

The BENEFIT trial: testing the hypothesis that trypanocidal therapy is beneficial for patients with chronic Chagas heart disease

Among the pathophysiological derangements operating in the chronic phase of Chagas disease, parasite persistence is likely to constitute the main mechanism of myocardial injury in patients with chronic chagasic cardiomyopathy. The presence of Trypanosoma cruzi in the heart causes a low-grade, but relentless, inflammatory process and induces myocardial autoimmune injury. These facts suggest that trypanocidal therapy may positively impact the clinical course of patients with chronic Chagas heart disease. However, the experimental and clinical evidence currently available is insufficient to support the routine use of etiologic treatment in these patients. The BENEFIT project - Benznidazole Evaluation for Interrupting Trypanosomiasis - is an international, multicenter, double-blind, placebo-controlled trial of trypanocidal treatment with benznidazole in patients with chronic Chagas heart disease. This project is actually comprised of two studies. The pilot study investigates whether etiologic treatment significantly reduces parasite burden, as assessed by polymerase chain reaction-based techniques and also determines the safety and tolerability profile of the trypanocidal drug in this type of chagasic population. The full-scale study determines whether antitrypanosomal therapy with benznidazole reduces mortality and other major cardiovascular clinical outcomes in patients with chronic Chagas heart disease.