RESUMO
BACKGROUND: Single-center reports on percutaneous transluminal septal myocardial ablation (PTSMA) in patients with hypertrophic obstructive cardiomyopathy have shown considerable differences in outcome. METHODS AND RESULTS: We report the long-term outcome of 313 PTSMA procedures performed in 279 patients with hypertrophic obstructive cardiomyopathy aged 59±14 years from 1999 to 2010 in 4 Scandinavian centers. Sixty-nine percent of patients had ≥1 comorbidity at baseline. The median (interquartile range) of left ventricular outflow tract gradient at rest was reduced from 58 mm Hg (34 to 89 mm Hg) at baseline to 12 mm Hg (8 to 24 mm Hg) at 1-year (P<0.001) and during Valsalva maneuver from 93 mm Hg (70 to 140 mm Hg) to 21 mm Hg (11 to 42 mm Hg) (P<0.001). The proportion of patients with syncope was reduced from 18% to 2% (P<0.001), and the proportion in New York Heart Association class III/IV was reduced from 94% to 21% (P<0.001). All treatment effects remained stable during the follow-up. New York Heart Association class III/IV at the most recent follow-up (2.9±2.6 years) was associated with diabetes mellitus (P=0.03), chronic obstructive pulmonary disease (P=0.02), and valve disease unrelated to hypertrophic cardiomyopathy (P<0.01). In-hospital mortality was 0.3%. The 1-, 5- and 10-year survival rates were 97%, 87%, and 67%, respectively (P=0.06 versus an age- and sex-matched background population) in all patients and 99%, 94%, and 88%, respectively (P=0.12) in patients aged <60 years (48±9 years, n=141). Age (hazard ratio, 1.07; 95% CI, 1.03 to 1.1) was the only predictor of survival. CONCLUSIONS: In this multicenter study, the in-hospital mortality after PTSMA was low despite considerable comorbidities. The hemodynamic and symptomatic effects were sustained long term. The long-term symptomatic outcome was associated with baseline comorbidities. The 10-year survival rate was comparable to that in an age- and sex-matched background population, and age was the only predictor of survival.
Assuntos
Cardiomiopatia Hipertrófica/cirurgia , Ablação por Cateter/métodos , Fatores Etários , Idoso , Cardiomiopatia Hipertrófica/mortalidade , Cardiomiopatia Hipertrófica/fisiopatologia , Ablação por Cateter/efeitos adversos , Feminino , Hemodinâmica , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Resultado do TratamentoRESUMO
OBJECTIVE: We investigated the impact of glucose control on target lesion restenosis after PCI in patients with type 2 diabetes. METHODS: Ninety-three consecutive patients with type 2 diabetes accepted for PCI were randomised to intensified glucose control based on insulin (I-group; n=44) or to continue ongoing glucose-lowering treatment (C-group; n=49).The treatment target was a FBG of 5-7 mmol/L and HbA1c <6.5%. Information on target lesion restenosis after six months was available in 82 patients. RESULTS: At baseline HbA1c and FBG did not differ between the I- and C-groups, respectively (HbA1c: 6.5 vs. 6.5%; p=1.0 and FBG: 7.0 vs. 7.3 mmol/L; p=0.3). After six months there was no significant change in HbA1c or FBG in either group (change in HbA1c: -0.2 vs.-0.1%; p=0.3 and in FBG: +0.2 vs. -0.3 mmol/L; p=0.3 in the I- and C-groups, respectively). Target lesion restenosis at six months did not differ, I vs. C = 41 and 44% (p=0.8). Independent predictors for restenosis were previous myocardial infarction (OR 8.0, 95% CI 2.5-25.7; p=<0.001) and FBG at baseline (OR for an increase by 1 mmol/L = 1.4, 95% CI 1.1-1.9; p=0.015). CONCLUSIONS: Restenosis was predicted by baseline FBG suggesting that it would be of interest to target glucose normalisation in future trials. Intensified insulin treatment did not influence the rate of restenosis indicating that the main focus should be on lowering glucose rather than the tool to normalise glucose.
Assuntos
Angioplastia Coronária com Balão , Glicemia/metabolismo , Reestenose Coronária/etiologia , Estenose Coronária/terapia , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hemoglobinas Glicadas/metabolismo , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/instrumentação , Biomarcadores/sangue , Angiografia Coronária , Reestenose Coronária/sangue , Reestenose Coronária/diagnóstico por imagem , Estenose Coronária/sangue , Estenose Coronária/complicações , Estenose Coronária/diagnóstico por imagem , Diabetes Mellitus Tipo 2/sangue , Quimioterapia Combinada , Jejum/sangue , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Medição de Risco , Fatores de Risco , Stents , Fatores de Tempo , Resultado do TratamentoRESUMO
Endothelin (ET)-1 receptor blockade improves endothelial function in the forearm of patients with atherosclerosis. The aim was to investigate whether intracoronary ET receptor blockade improves coronary endothelial function and increases blood flow in patients with coronary artery disease. Ten patients received a 60-minute infusion of either the selective ETA receptor antagonist BQ123 (40 nmol/min, n = 6) or BQ123 + the ETB receptor antagonist BQ788 (40 nmol/min, n = 4). In all patients, substance P, an endothelium-dependent vasodilator, did not increase baseline coronary flow reserve with thermodilution (CFRThermo) (0.71 +/- 0.14 s during NaCl versus 0.59 +/- 0.14 s during substance P) or baseline quantitative coronary angiography (QCA) (2.74 +/- 0.16 mm versus 2.83 +/- 0.20 mm). After ET receptor blockade, however, the response to substance P was significantly improved as determined both by CFRThermo (0.62 +/- 0.14 s during NaCl versus 0.48 +/- 0.10 s during substance P, p < 0.05) and by QCA (2.70 +/- 0.18 mm versus 2.85 +/- 0.19 mm, p < 0.05). In addition, ET blockade increased blood flow in all patients by 16% +/- 10% (n = 10, p < 0.05) and in the BQ123 group by 22% +/- 16% (n = 6, p < 0.05). Furthermore, ETA blockade increased blood flow significantly more than did dual ETA/ETB blockade (p < 0.05). These findings indicate that ET receptor blockade may be a new therapeutic strategy to improve coronary vascular function in patients with coronary artery disease.
Assuntos
Doença da Artéria Coronariana/tratamento farmacológico , Doença da Artéria Coronariana/fisiopatologia , Vasos Coronários/efeitos dos fármacos , Vasos Coronários/fisiopatologia , Antagonistas dos Receptores de Endotelina , Endotélio Vascular/efeitos dos fármacos , Idoso , Aorta Torácica/efeitos dos fármacos , Aorta Torácica/fisiologia , Aterosclerose/patologia , Pressão Sanguínea/efeitos dos fármacos , Proteína C-Reativa/metabolismo , Capilares/fisiologia , Cateterismo Cardíaco , Angiografia Coronária , Circulação Coronária/efeitos dos fármacos , Antagonistas do Receptor de Endotelina A , Antagonistas do Receptor de Endotelina B , Endotelina-1/sangue , Feminino , Humanos , Lipídeos/sangue , Masculino , Oligopeptídeos/farmacologia , Peptídeos Cíclicos/farmacologia , Piperidinas/farmacologiaRESUMO
Congenital malformations causing mild cyanosis can be overlooked. A large intrapulmonary right pulmonary artery to left atrium connection was the unusual etiology of arterial oxygen desaturation and erythrocytosis in an asymptomatic 30-year-old patient. The shunt was not possible to detect at echocardiography. It was closed via a median sternotomy without the aid of cardiopulmonary bypass. A novel technique was to use an angiographic catheter inserted through the wide shunt into the left atrium before the operation to securely identify it at the surgical dissection.
Assuntos
Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Átrios do Coração/anormalidades , Artéria Pulmonar/anormalidades , Adulto , Circulação Coronária , Cianose/etiologia , Humanos , Ligadura , Angiografia por Ressonância Magnética , Masculino , Oxigênio/sangue , Policitemia/etiologiaRESUMO
The objectives of this study were to investigate whether the systemic inflammatory response differs, in patients undergoing coronary angiography, among the arterial closure devices FemoStop, AngioSeal, and Perclose. The study is a prospective and randomized study. We measured pre- and postprocedural C-reactive protein (CRP), fibrinogen, and interleukin-6 (IL-6) plasma levels and collected clinical and procedural data on 77 patients who underwent coronary angiography because of stable angina pectoris. Patients were randomized to the following device: FemoStop (mechanical compression), AngioSeal (anchor and collagen sponge), or Perclose (nonabsorbable suture). No patient group experienced an increased incidence of vascular complications. There were no differences among the three groups regarding CRP, fibrinogen, or IL-6 values before or after coronary angiography. IL-6 levels increased 6 h after the procedure in all groups (p < 0.01), however, the increase did not differ among the groups. After 30 days there were no increased values of CRP or fibrinogen. We conclude that the femoral arterial closure devices AngioSeal and Perclose do not enhance an inflammatory response after a diagnostic coronary angiography, measured by CRP, fibrinogen, and IL-6, compared to femoral arterial closure using a mechanical compression device.
Assuntos
Angina Pectoris/diagnóstico por imagem , Cateterismo Periférico/instrumentação , Angiografia Coronária/efeitos adversos , Artéria Femoral , Técnicas Hemostáticas/instrumentação , Mediadores da Inflamação/sangue , Inflamação/prevenção & controle , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/métodos , Proteína C-Reativa/metabolismo , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/métodos , Angiografia Coronária/métodos , Desenho de Equipamento , Segurança de Equipamentos , Feminino , Fibrinogênio/metabolismo , Técnicas Hemostáticas/efeitos adversos , Humanos , Inflamação/sangue , Inflamação/diagnóstico , Inflamação/etiologia , Interleucina-6/sangue , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco , Sensibilidade e Especificidade , Estatísticas não ParamétricasAssuntos
Angiografia Coronária , Infarto do Miocárdio/diagnóstico , Adulto , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/epidemiologia , Prognóstico , Fatores Sexuais , Suécia/epidemiologia , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/epidemiologiaRESUMO
BACKGROUND: Data are sparse regarding the association between C-reactive protein (CRP) and percutaneous coronary intervention (PCI) in long-term prognosis. Previous studies have shown that PCI evokes an inflammatory response. We tested the hypothesis that the CRP response to PCI has a prognostic value. METHODS: We investigated 891 consecutive patients presenting with stable or unstable angina pectoris, with serum concentrations of cardiac troponin T < or =0.03 microg/L, who were undergoing a variety of PCIs. Serum concentrations of CRP and cardiac troponin T were determined before and the day after PCI. The mean follow-up time after PCI was 2.6 years, and the endpoint was death or nonfatal myocardial infarction. RESULTS: Seventy-six patients reached the endpoint (4.6% death, 3.9% nonfatal myocardial infarction), whereas 21% developed myocardial infarction during the procedure. CRP increased more than 2-fold after the procedure. Patients in the third tertile of the CRP response to PCI had an increased risk for death or nonfatal myocardial infarction in multivariate analysis. CONCLUSIONS: Increased serum CRP in response to PCI is an independent predictor of death or nonfatal myocardial infarction independent of myocardial injury during the procedure. CRP determinations might be of value in risk stratification after PCI.
Assuntos
Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/mortalidade , Proteína C-Reativa/metabolismo , Infarto do Miocárdio/diagnóstico , Angina Pectoris/terapia , Determinação de Ponto Final , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/etiologia , Prognóstico , Medição de RiscoRESUMO
BACKGROUND: The systemic inflammatory response to percutaneous coronary intervention (PCI) is associated with recurrent cardiac events; however, the pathophysiology of this inflammatory response is not well understood. The present study was performed to investigate the role of pathogen burden of infection in determining the magnitude of C-reactive protein (CRP) and interleukin 6 (IL-6) response to PCI. METHODS: One hundred patients with stable angina pectoris undergoing elective PCI at a single center were recruited. Antibodies against cytomegalovirus, Chlamydia pneumoniae , Epstein-Barr virus, Helicobacter pylori , and herpes simplex virus types 1 and 2 were determined before PCI. Plasma CRP and IL-6 levels were measured before and 6, 24, 48, 72 hours after PCI and data presented as area under the curve. RESULTS: Plasma CRP and IL-6 concentrations increased significantly after PCI. Neither antibodies against single nor multiple pathogens were associated with the CRP or IL-6 response to PCI. No correlations were found between the inflammatory markers and troponin T levels after PCI. With the exception for CRP and body mass index (R = 0.20, P < .05), neither risk factors for coronary heart disease nor medication but stent implantation was associated with increased plasma CRP (76 vs 61 mg/L, P < .005) and IL-6 (74 vs 64 pg/mL, P < .005) levels after PCI. CONCLUSION: Stent implantation, but not pathogen burden, is associated with the plasma CRP and IL-6 response to PCI.
Assuntos
Angina Pectoris/sangue , Angina Pectoris/microbiologia , Angioplastia Coronária com Balão/efeitos adversos , Proteína C-Reativa/metabolismo , Interleucina-6/sangue , Stents/efeitos adversos , Idoso , Angina Pectoris/terapia , Área Sob a Curva , Reestenose Coronária/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Troponina T/sangueRESUMO
OBJECTIVE: To assess the association of alcohol intake with progression of coronary atherosclerosis. Although moderate drinkers have a lower risk of coronary heart disease than abstainers, the relation of alcohol use and coronary atherosclerosis has not been well studied. METHODS AND RESULTS: In the Stockholm Female Coronary Risk Angiographic Study, we evaluated 103 women, aged 65 years or younger, hospitalized with acute myocardial infarction or unstable angina pectoris who underwent serial quantitative coronary angiography 3-6 months following their index event and repeated an average of 3 years and 3 months (range 2-5 years) later. Individual alcoholic beverage consumption was assessed by a standardized questionnaire. We used mixed model analysis to estimate the effect of alcohol consumption on progression of coronary atherosclerosis, as measured by mean luminal diameter change, controlling for age, smoking, body-mass index, education, physical activity, index cardiac event, menopausal status, diabetes, and history of dyslipidemia. Of the 93 women with complete information on alcohol intake, 14 consumed no alcohol (abstainers), 55 consumed up to 5 g of alcohol per day (light drinkers), and 24 consumed more than 5 g of alcohol per day (moderate drinkers). Coronary atherosclerosis progressed by a multivariate-adjusted average of 0.138 mm (95% confidence interval (CI): 0.027-0.249) among abstainers, 0.137 mm (95% CI: 0.057-0.217) among light drinkers, and -0.054 mm (95% CI: -0.154 to 0.047) among moderate drinkers (P < 0.001). The inverse association persisted in analyses stratified by index event. No beverage type appeared to confer particular benefit. CONCLUSIONS: Among middle-aged women with coronary heart disease, moderate alcohol consumption (over 5 g/day) was protective of coronary atherosclerosis progression.
Assuntos
Consumo de Bebidas Alcoólicas , Doença da Artéria Coronariana/prevenção & controle , Doença da Artéria Coronariana/fisiopatologia , Adulto , Idoso , Angina Pectoris , Angiografia Coronária , Doença da Artéria Coronariana/etiologia , Estudos Transversais , Progressão da Doença , Feminino , Humanos , Pessoa de Meia-Idade , Infarto do Miocárdio , Suécia/epidemiologiaRESUMO
BACKGROUND: The role of chronic stress in coronary artery disease (CAD) is not well known. Conflicting results have been obtained with regard to the stress hormone cortisol and 'vital exhaustion', a psychological construct defining the effects of long-term stress. We investigated the relationship between chronic stress, assessed by serum cortisol and vital exhaustion, and coronary artery stenosis and the importance of chronic stress in relation to standard risk factors of CAD. METHODS AND RESULTS: Women,
Assuntos
Doença das Coronárias/fisiopatologia , Fadiga , Hidrocortisona/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , HDL-Colesterol/sangue , Angiografia Coronária , Estenose Coronária/fisiopatologia , Depressão , Feminino , Humanos , Humor Irritável , Estilo de Vida , Pessoa de Meia-Idade , Razão de Chances , Fatores de Risco , Estresse Fisiológico/fisiopatologiaRESUMO
OBJECTIVE: To compare the diagnostic accuracy of contrast medium enhanced spiral computed tomography of the pulmonary arteries (s-CTPA) and a latex agglutination D-dimer assay in patients with suspected acute pulmonary embolism (PE) by using pulmonary arteriography (PA) and clinical follow-up as reference method. DESIGN: Ninety hemodynamically stable patients with symptoms of acute pulmonary embolism were prospectively evaluated with s-CTPA and pulmonary arteriography (PA) within 24 h from admission. Plasma D-dimer levels on admittance were analyzed using a rapid latex agglutination D-dimer assay. The outcome of D-dimer concentrations in plasma below 0.25 and 0.5 mg/l was studied. RESULTS: All PA and s-CTPA investigations were regarded as of acceptable diagnostic quality in a consensus reading. Thirty-three patients had a positive PA (37%). Three patients had false negative and two patients had false positive s-CTPA findings. s-CTPA had 91% sensitivity, 96% specificity, 94% positive predictive value (PPV) and 95% negative predictive value (NPV). The sensitivity and specificity for D-dimer below 0.5 mg/l were 79 and 88%, respectively. The PPV and NPV were 81 and 87%. If a cut-off level of 0.25 mg/l was used the corresponding figures were 91, 65, 63 and 92%. CONCLUSION: s-CTPA has a higher sensitivity and specificity than latex agglutination D-dimer. A cut-off level of 0.25 mg/l can be used as screening method, but s-CTPA must be performed to exclude false positive cases.
Assuntos
Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Testes de Fixação do Látex/métodos , Embolia Pulmonar/diagnóstico , Tomografia Computadorizada Espiral/métodos , Adolescente , Adulto , Idoso , Biomarcadores/sangue , Reações Falso-Positivas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Artéria Pulmonar/diagnóstico por imagem , Embolia Pulmonar/diagnóstico por imagem , Sensibilidade e EspecificidadeRESUMO
BACKGROUND AND HYPOTHESIS: Dobutamine stress echocardiography is a well-established diagnostic method for investigating patients with suspected ischemic coronary disease. A positive test result is based on systolic parameters, but left ventricular filling parameters also are affected by myocardial ischemia. The aim of the present study was to study changes in both systolic and diastolic left ventricular variables throughout the test, including the period following it. METHODS AND RESULTS: Seven healthy control subjects (group I), 10 patients with chest pain but without significant coronary stenosis (group II), and 17 patients with significant coronary stenosis (group III) were entered in the study. Dobutamine stress echocardiography was performed according to a preset standardized protocol. Two-dimensional echocardiography and transmitral pulsed-Doppler images were stored for later analysis at rest, low dose, peak dose, and 5 minutes after termination of the dobutamine infusion. The wall motion score index increased from rest to low dose by 6.7% +/- 6.4% (P < 0.05) and to the peak dose by 39.1% +/- 9.9% (P < 0.001) in all three groups. The increase from rest to peak dose was significantly higher in groups I and II than in group III (P < 0.01). There was a significant increase in the atrial velocity-time integral (A-VTI) at peak dose in groups I and II (64.8% +/- 52.1% and 103.8% +/- 68.7%, respectively; P < 0.05 and <0.001), but no change in group III was noted. At the peak dose, A-VTI was significantly greater in groups I and II than in group III (P < 0.05). Among the 17 patients with proved coronary stenosis, 15 (88.2%) had a positive systolic response and 14 (82.3%) had a positive diastolic response, expressed as an A-VTI increase of =2.5 cm. Among patients without significant stenosis, 9 (52.9%) had a negative systolic response, and 12 (70.6%) had a negative diastolic response. CONCLUSION: Changes in systolic parameters are the most sensitive ones to identify in a patient with significant coronary stenosis, but diastolic changes indicated by changes in A-VTI from rest to peak dose might contribute to decreasing the number of false-positive dobutamine stress echocardiography tests.