Safety and Efficacy of PCSK9 Inhibitors in Patients with Acute Coronary Syndrome Who Underwent Coronary Artery Bypass Grafts: A Comparative Retrospective Analysis.

Background. The in-hospital reduction in low-density lipoprotein cholesterol (LDL-C) levels following acute coronary syndrome (ACS) is recommended in the current clinical guidelines. However, the efficacy of proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors in those patients undergoing coronary artery bypass graft (CABG) has never been demonstrated. Methods. From January 2022 to July 2023, we retrospectively analyzed 74 ACS patients characterized by higher LDL-C levels than guideline targets and who underwent coronary bypass surgery. In the first period (January 2022-January 2023), the patients increased their statin dosage and/or added Ezetimibe (Group STEZE, 43 patients). At a later time (February 2023-July 2023), the patients received not only statins and Ezetimibe but also Evolocumab 140 mg every 2 weeks starting as early as possible (Group STEVO, 31 patients). After one and three months post-discharge, the patients underwent clinical and laboratory controls with an evaluation of the efficacy lipid measurements and every adverse event. Results. The two groups did not differ in terms of preoperative risk factors and Euroscore II (STEVO: 2.14 ± 0.75 vs. STEZE: 2.05 ± 0.6, p = 0.29). Also, there was no difference between the groups in terms of ACS (ST-, Instable angina, or NSTE) and time of symptoms onset regarding total cholesterol, LDL-C, and HDL-C trends from the preprocedural period to 3-month follow-up, but there was a more significant reduction in LDL-C and total cholesterol in the STEVO group (p = 0.01 and p = 0.04, respectively) and no difference in HDL-C rise (p = 0.12). No deaths were reported. In three STEZE group patients, angina recurrence posed the need for percutaneous re-revascularization. No STEVO patients developed significant adverse events. The statistical difference in these serious events, 7% in STEZE vs. 0% in STEVO, was not significant (p = 0.26). Conclusions. Evolocumab initiated "as soon as possible" in ACS patients submitted to CABG with high-intensity statin therapy and Ezetimibe was well tolerated and resulted in a substantial and significant reduction in LDL-C levels at discharge, 1 month, and 3 months. This result is associated with a reduction but without a statistical difference between groups.

Modelo alternativo para o treinamento de técnicas de microssuturas em "patch" de pericárdio bovino / Alternative model for training microsuture techniques in bovine pericardium patches

Introdução: As técnicas microcirúrgicas caracterizam-se pela aplicação de manobras e suturas em estruturas milimétricas com o auxílio de lentes de aumento. São técnicas complexas, utilizadas em diversas especialidades médicas, que demandam grande habilidade e treinamento antes da aplicação em humanos. O objetivo é desenvolver um modelo de baixo custo e alta fidelidade, para o treinamento de técnicas de microcirurgia, utilizando um fragmento de patch de pericárdio bovino. Método: São utilizados para a confecção deste modelo segmentos remanescentes de uma placa de pericárdio bovino, previamente utilizado em reparos vasculares. O material é recortado em duas partes simétricas e suas extremidades fixadas aos campos cirúrgicos, com auxílio de clamps. A borda superior de cada uma das partes é, então, suturada à borda inferior com fio de Prolene 8-0, de maneira que cada uma forme uma estrutura tubular. Posteriormente, as extremidades tubulares livres passam pela dissecção da camada adventícia e são suturadas entre si, mimetizando uma anastomose vascular término-terminal. Resultados: Com o modelo, simulam-se os mesmos inconvenientes/ dificuldades presentes nas suturas vasculares humanas, como a delaminação de camadas, excesso da camada adventícia e risco de sutura inadvertida da parede posterior, provando sua utilidade na aquisição de habilidades microcirúrgicas básicas, sem necessidade de manipulação de tecidos humanos ou animais. A prática neste modelo pode ocorrer dentro do próprio centro cirúrgico e emprega materiais que seriam descartados. Conclusão: A utilização do pericárdio bovino para confecção de suturas milimétricas mimetiza o tecido vascular humano e é um procedimento de baixo custo, que possibilita o treinamento de habilidades microcirúrgicas.

Introduction: Microsurgical techniques are characterized by the application of maneuvers and sutures to millimetric structures with the aid of magnifying lenses. These are complex techniques, used in various medical specialties, which require great skill and training before applying them to humans. The objective is to develop a lowcost and high-fidelity model for training microsurgery techniques using a fragment of bovine pericardium patch. Method: Remaining segments of a bovine pericardium plate, previously used in vascular repairs, are used to create this model. The material is cut into two symmetrical parts, and its ends are fixed to the surgical drapes with the aid of clamps. The upper edge of each part is then sutured to the lower edge with 8-0 Prolene thread so that each one forms a tubular structure. Subsequently, the free tubular ends undergo dissection of the adventitial layer and are sutured together, mimicking an end-to-end vascular anastomosis. Results: With the model, the same inconveniences/ difficulties present in human vascular sutures are simulated, such as delamination of layers, excess of the adventitial layer, and risk of inadvertent suturing of the posterior wall, proving its usefulness in the acquisition of basic microsurgical skills, without need to manipulate human or animal tissues. Practice in this model can take place within the surgical center itself and uses materials that would otherwise be discarded. Conclusion: The use of bovine pericardium to create millimetric sutures mimics human vascular tissue and is a low-cost procedure that allows the training of microsurgical skills.

How many clues make an evidence? An unusual case of aborted cardiac arrest due to mitral valve prolapse.

There is an increasing awareness on the association between mitral valve prolapse (MVP) and sudden cardiac death. Mitral annular disjunction (MAD) is a phenotypic risk feature that can help in risk stratification. We present a case of a 58-year-old woman who experienced an out-of-hospital cardiac arrest caused by ventricular fibrillation interrupted by a direct current shock. No coronary lesions were documented. Echocardiogram showed myxomatous MVP. Nonsustained ventricular tachycardia have been registered during hospital stay. Interestingly, cardiac magnetic resonance revealed MAD and a late gadolinium enhancement area in inferior wall. Finally, a defibrillator has been implanted. For arrhythmic risk stratification of MVP with MAD, multimodality imaging is the diagnostic tool to find out the disease behind many cardiac arrests of unknown cause.

Realidade epidemiológica da morbimortalidade hospitalar por acidente vascular cerebral no nordeste brasileiro, de 2015 a 2019 / Epidemiological reality of hospital morbimortality due to cerebral vascular accident in northeast brazil, from 2015 to 2019 / Realidad epidemiológica de la morbimortalidad hospitalaria por accidente vascular cerebral en el noreste de brasil, de 2015 a 2019

Com grande impacto social por alta mortalidade e morbidade no Brasil e no Mundo, o AVC continua em destaque dentre as Doenças Crônicas Não transmissíveis. Visando oferecer subsídios técnico-científicos sobre o perfil epidemiológico desta patologia no Nordeste, este artigo consiste em um estudo de corte transversal, quantitativo, epidemiológico, de série temporal, entre os anos de 2015 a 2019, tendo por base os dados disponibilizados na plataforma DATASUS. Evidenciou-se que o ano de 2019 foi o ano com maior número de internações por esta patologia, predominando em homens. No entanto, as mulheres tiveram mais óbitos. A raça mais acometida foi a parda, com mais de 82% das internações e mais de 83% dos óbitos. Os óbitos ocorreram em todas as faixas etárias, predominando nos mais idosos. O Estado com maior quantitativo de óbitos foi a Bahia, também o mais populoso do estudo. O perfil epidemiológico geral, do paciente acometido por AVC na região Nordeste do Brasil no período avaliado, foi, homem, com idade mais avançada (a partir de 60 anos), pardo, permanecendo cerca de 7,8 dias internados. O custo total desse período, com internações por AVC, foi de R$278.874.426.3, certamente, um custo bastante oneroso ao nosso sistema de saúde. As unidades federativas com maior acometimento são também as mais populosas. Percebendo-se que, por se tratar de uma doença prevenível, com graves sequelas e que causam grandes prejuízos pessoais, sociais e econômicos, torna-se relevante que o sistema público de saúde adote rigorosas medidas para sua prevenção.

With a great social impact due to high mortality and morbidity in Brazil and the world, stroke continues to be highlighted among Chronic Non-communicable Diseases. Aiming to offer technical-scientific support on the epidemiological profile of this pathology in the Northeast, this article consists of a cross-sectional, quantitative, epidemiological, time series study, between the years 2015 and 2019, based on data available on the DATASUS platform . It was evident that 2019 was the year with the highest number of hospitalizations for this pathology, predominantly in men. However, women had more deaths. The most affected race was the mixed race, with more than 82% of hospitalizations and more than 83% of deaths. Deaths occurred in all age groups, predominantly among the elderly. The State with the highest number of deaths was Bahia, also the most populous in the study. The general epidemiological profile of the patient affected by stroke in the Northeast region of Brazil during the period evaluated was male, older (60 years and older), mixed race, and remained hospitalized for approximately 7.8 days. The total cost of this period, with hospitalizations for stroke, was R$278,874,426.3, certainly a very costly cost to our health system. The federative units most affected are also the most populous. Realizing that, as it is a preventable disease, with serious consequences and causing great personal, social and economic losses, it is important that the public health system adopts strict measures for its prevention.

Con gran impacto social debido a la alta mortalidad y morbilidad en Brasil y el mundo, el accidente cerebrovascular sigue destacándose entre las Enfermedades Crónicas No Transmisibles. Con el objetivo de ofrecer soporte técnico-científico sobre el perfil epidemiológico de esta patología en el Nordeste, este artículo consiste en un estudio transversal, cuantitativo, epidemiológico, de series temporales, entre los años 2015 y 2019, con base en datos disponibles en la plataforma DATASUS. . Se evidenció que 2019 fue el año con mayor número de hospitalizaciones por esta patología, predominantemente en hombres. Sin embargo, las mujeres tuvieron más muertes. La raza más afectada fue la mestiza, con más del 82% de las hospitalizaciones y más del 83% de las muertes. Las muertes se produjeron en todos los grupos de edad, predominantemente entre los ancianos. El estado con mayor número de muertes fue Bahía, también el más poblado del estudio. El perfil epidemiológico general del paciente afectado por accidente cerebrovascular en la región Nordeste de Brasil durante el período evaluado fue masculino, mayor (60 años y más), mestizo y permaneció hospitalizado durante aproximadamente 7,8 días. El costo total de este período, con las hospitalizaciones por accidente cerebrovascular, fue de R$ 278.874.426,3, ciertamente un costo muy costoso para nuestro sistema de salud. Las unidades federativas más afectadas son también las más pobladas. Al ser conscientes de que, al tratarse de una enfermedad prevenible, de graves consecuencias y que provoca grandes pérdidas personales, sociales y económicas, es importante que el sistema público de salud adopte medidas estrictas para su prevención. PALABRAS CLAVE: Accidente Cerebrovascular; Epidemiología; Salud Pública.

Type C botulism in dogs from rural properties located in Goiânia, Brazil

Botulism is a disease usually fatal, caused by the ingestion of neurotoxins produced by Clostridium botulinum. In dogs, intoxication is caused by the ingestion of botulinum toxin type C, and animals often recover spontaneously. The present study describes the occurrence of type C botulism in two dogs domiciled on neighboring rural properties in the municipality of Goiânia, state of Goiás, Brazil, probably associated with ingestion of decomposing bovine carcass. Upon clinical evaluation, the dogs were alert in the lateral decubitus position with ascending flaccid paralysis, absence of eyelid reflexes, and reduced muscle tone. Due to their worsening clinical symptoms, the animals died within 12 h and 3 days after supportive treatment. Botulinum toxin type C was identified, in the serum and feces of both dogs, by seroneutralization in mice with homologous monovalent antitoxin. The results of the high-throughput gene sequencing showed that the abundance of C. botulinum in the fecal microbiota of one of the affected dogs was low (0.53%). In this way, the present study highlights the need of sanitary practices related to the appropriate collection and disposal of bovine carcasses in rural areas since they represent a risk factor for the occurrence of botulism in dogs domiciled on rural properties.

Classic cardiovascular risk factors improve in very elderly hypopituitary patients treated on standard hormone replacement in long term follow- up.

BACKGROUND: Hypopituitarism in the elderly population is an underdiagnosed condition and may increase comorbidities related to glucose metabolism, dyslipidemia, and cardiovascular risk factors. Optimization of hormone replacement that considers alterations in clearance rates of hormones, interaction with other medications, and evaluation of the risk-benefit ratio of treatment is a big challenge for clinical practice. OBJECTIVES: This study aimed to evaluate classic cardiovascular risk factors in hypopituitary septuagenarians and octagenarians by diagnosis and after long-term hormone replacement. METHODS: This is a retrospective observational study, with patients recruited and selected from a registry in a tertiary medical center. We included patients aged 70-99 years with hypopituitarism, evaluated hormonal and biochemical parameters, and cardiovascular risk scores were calculated by diagnosis and compared after long-term follow-up. All patients gave informed consent. Patient data were compared to a sex and age-matched control group, with long-term geriatric follow-up, without endocrine diseases. RESULTS: Thirty-five patients were included, 16 patients aged 70-75 years (72.61), 12 patients 76-80 years (72.28), 7 patients 81-99 years (89.28). Pituitary macroadenomas were the main cause of hypopituitarism, mean maximal diameter 3.4 cm (2.9-4.3), and invasive craniopharyngiomas. At the moment of diagnosis, most patients were overweight, and abdominal adiposity was observed in 76.9% of women and 36.4% of men, primarily in octagenarians and nonagenarians. Comorbidities were frequent; 85.7% presented hypertension, 37.1% diabetes, 53.1% low HDL, 51.5% hypertriglyceridemia. Most patients presented more than two combined pituitary deficiencies; hypogonadism in 88.6%, central hypothyroidism in 82.9%, GH deficiency in 65.7%, and adrenal insufficiency in 25.7%. Analysis of cardiovascular risk prediction in the total cohort showed that 57.1% of patients presented a reduction in the General Cardiovascular Disease (CVD) Risk Prediction Score and 45.7% in atherosclerotic CVD risk estimated by ACC/AHA 2013 Pooled Cohort Equation, despite being submitted to conventional hormone replacement, during the mean follow-up of 14.5 years. This reduction was not observed in the control group. DISCUSSION AND CONCLUSION: In this study, aged hypopituitary patients presented a reduction in estimated general CVD risk during long-term follow-up, despite replacement with corticosteroids, levothyroxine, or gonadal steroids. Early diagnosis and treatment of hypopituitarism in the elderly remain challenging. Larger studies should be performed to assess the risk-benefit ratio of hormone replacement on the metabolic profile in septuagenarian and octogenarian patients.

Cardiac arrest in type II Kounis syndrome after oral intake of amoxicilline.

BACKGROUND: Kounis syndrome (KS) is defined as the occurrence of an acute coronary syndrome related to allergic or hypersensitivity reaction. KS is currently classified into three variants, based on coronary arteries status. This syndrome is often neglected or misdiagnosed in clinical practice. METHODS AND RESULTS: We described a type II KS case. This acute coronary syndrome (ACS) began with cardiac arrest (an uncommon clinical expression for KS) immediately after oral intake of amoxicilline. Coronary angiography revealed coronary arteries stenoses which were considered unsuitable for revascularization. Optimization of medical therapies was the goal of the management for this patient. Follow-up visits revealed normal echocardiographic findings and no malignant arrhythmias at ECG Holter monitoring. CONCLUSIONS: KS can be a rare case for ACS, sometimes occurring with sudden cardiac arrest. Physicians should pay attention to the history of the patients in order to identify the correct cause of ACSs.

PFO closure with only fluoroscopic guidance: 7 years real-world single centre experience.

AIMS: To evaluate the safety and the efficacy of fluoroscopy-guided only (Fluo-G) and of echocardiography-guided (Echo-G; trans-esophageal echocardiography-TEE-or intracardiac echocardiography-ICE) percutaneous closure of patent foramen ovale (PFO). METHODS AND RESULTS: Single center retrospective registry enrolling 368 consecutive patients (mean age 50.5 years) who underwent PFO closure between June 2004 and December 2011. Most patients had prior cryptogenic stroke (n = 126; 34.2%), TIA (n = 218; 51.1%); some of these had recurrent neurological events [multiple strokes n = 28 (7.8%); multiple TIAs n = 72 (18.6%)]. All the patients underwent a preprocedure TEE. PFO closure was performed with Echo-G in 187 patients (50.8%) (TEE n = 69, 36.8% and ICE n = 124, 66.3%). In Fluo-G cases, PFO with atrial septal aneurysm (ASA) was significantly less present (P < 0.005) and smaller devices (<25 mm) were implanted more frequently (P < 0.001). Both fluoroscopy and total procedural time were lower in the Fluo-G group (P < 0.0001). No differences were found in terms of successful device deployment (98.3% Fluo-G vs. 98.3% Echo-G) and RtL-shunt at follow-up (11.7% Fluo-G vs. 7.6% Echo-G). The rate of conversion from Fluoro-G to Echo-G procedure was 4.4% (n = 8). At a median follow-up of 4 years, freedom from recurrent embolic events rate was similar between the two groups (Echo-G 94.5 vs. Fluo-G 95.7%). CONCLUSIONS: In our experience Fluoro-G PFO closure was performed mainly in cases of simple anatomy, with similar results in terms of safety and efficacy compared to Echo-G cases. Both fluoroscopy and total procedural times were lower in the Fluo-G cases.

Role of plaque calcification regulators osteoprotegerin and matrix Gla-proteins in stable angina and acute myocardial infarction.

AIM: To assess serum levels of the plaque calcification regulators osteoprotegerin (OPG) and Matrix Gla-proteins (MGP) in individuals with stable angina and acute myocardial infarction submitted to coronary angiography and their relation to coronary artery disease burden. METHODS: The study included 40 individuals affected by ST-elevation myocardial infarction (STEMI) and 40 individuals with stable angina who all underwent coronary angiography, with evaluation of the extent of coronary artery disease by Syntax Score calculation and measurement of serum OPG and MGP levels. Osteoporosis was excluded by femoral and vertebral computerized bone mineralometry. RESULTS: Serum OPG and MGP levels were respectively 3.87 ±â€Š1.07 pmol/l and 6.80 ±â€Š2.43 nmol/l in the stable angina group, 7.57 ±â€Š1.5 pmol/l and 7.18 ±â€Š1.93 nmol/l in the STEMI group (P < 0.01 and P = 0.33, respectively). Pearson correlation coefficient for OPG and Syntax Score, MGP and Syntax score was respectively 0.79 (P < 0.01) and 0.18 (P = 0.22) in the stable angina group, -0.03 (P = 0.43) and 0.10 (P = 0.5) in the STEMI group.Serum OPG and MGP levels were respectively 5.52 ±â€Š1.02 pmol/l and 7.56 ±â€Š1.42 nmol/l in diabetics, 4.3 ±â€Š0.8 pmol/l and 6.52 ±â€Š1.14 nmol/l in nondiabetics (P < 0.05; P < 0.05). CONCLUSION: OPG, in a relatively small group of patients with stable angina, correlates proportionally with the extent of coronary artery disease (CAD), as evaluated by the Syntax Score. Higher serum OPG levels can be observed in individuals with STEMI regardless of CAD burden. As for MGP, a potential role as marker of plaque calcification remains unproven.

Successful transradial removal of an inflated coronary stent dislodged from the right coronary ostium.

We describe our solution to the unusual situation of an inflated, large coronary stent (3.5 mm diameter) which became dislodged from the ostium of the right coronary artery after deployment during a transradial procedure. We discussed tips for retrieval from the radial artery while preserving the access for completion of the procedure.

Unrepaired tetralogy of fallot in an 85-year-old man.

Tetralogy of Fallot is the most common cyanotic congenital heart defect and accounts for about 5% of all congenital cardiopathies. The definitive treatment modality for tetralogy of Fallot is reparative surgery, which is recommended to be performed by the time of diagnosis. Without surgical repair, most patients would die during their childhood. In the past, survival data indicated that 66% of persons with tetralogy of Fallot not surgically treated lived until the age of 1, 49% lived until the age of 3, and 24% lived until the age of 10. We now present a rare case of a man with unrepaired tetralogy of Fallot who survived until the age of 85. He presented to our emergency room for dyspnea and palpitations due to a new-onset high-frequency atrial fibrillation and acute heart failure; transthoracic echocardiography showed the presence of tetralogy of Fallot. By consulting the scientific literature, we can say that this is the second patient who survived more than 80 years without surgical intervention.