Chronic total occlusion percutaneous coronary intervention in Latin America.

OBJECTIVES: To report clinical, angiographic characteristics, outcomes, and predictors of unsuccessful procedures in patients who underwent chronic total occlusion (CTO) percutaneous coronary interventions (PCI) in Latin America. BACKGROUND: CTO PCI has been increasingly performed worldwide, but there is a lack of information in this region. METHODS: An international multicenter registry was developed to collect data on CTO PCI performed in centers in Latin America. Patient, angiographic, procedural and outcome data were evaluated. Predictors of unsuccessful procedures were assessed by multivariable analysis. RESULTS: We have included data related to 1,040 CTO PCIs performed in seven countries in Latin America (Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, and Puerto Rico). The mean age was 64 ± 10 years, and CTO PCI was performed mainly for angina control (81%) or treatment of a large ischemic area (30%). Overall technical success rate was 82.5%, and it was achieved with antegrade wire escalation in 81%, antegrade dissection/re-entry in 8% and with retrograde techniques in 11% of the successful procedures. Multivariable analysis identified moderate/severe calcification, a blunt proximal cap and a previous attempt as independent predictors of unsuccessful procedures. In-hospital major adverse cardiovascular events (MACE) occurred in 3.1% of the cases, death in 1% and cardiac tamponade in 0.9% CONCLUSIONS: CTO PCI in Latin America has been performed mainly for ischemia relief. Procedures were associated with a success rate above 80% and low incidence of MACE. Predictors of unsuccessful procedures were similar to those previously reported in the literature.

Quality of life and health status after percutaneous coronary intervention in stable angina patients: results from the real-world practice.

BACKGROUND: Percutaneous coronary interventions (PCI) are associated with quality of life (QoL) and health status improvements in stable angina patients. There are few studies assessing the magnitude of this effect and its predictors in contemporary daily practice. METHODS: Prospective cohort study with stable angina patients submitted to PCI in a tertiary interventional cardiology center. The clinical characteristics and the Seattle Angina Questionnaire (SAQ) were assessed before PCI, and patients were followed-up for 1 year. Mixed linear regression and ANOVA were used to compare SAQ indices, and multivariate analysis to identify predictors of QoL improvement. RESULTS: Between September 2006 and May 2007, 110 patients were included. The mean age of the study population was 62.8 ± 8.7 years, and 62% of the patients were of the male gender. Diabetes mellitus was present in 29%, arterial hypertension in 82%, previous myocardial infarction in 32%, and previous PCI in 29%. Before PCI, only 5% of the patients were free of angina, and this rate improved to 68% in the one-year followup (P < 0.001). There was improvement in all SAQ scales in the one-year followup, which was already shown in the 6-month assessment (P < 0.0001). Quality of life before the procedure was the main predictor of QoL improvement by multivariate analysis (P < 0.001). CONCLUSIONS: Patients with stable angina submitted to PCI in the real-world practice present significant improvement in one-year health status, as assessed by the SAQ. Quality of life before the procedure is the main determinant of improvement in QoL.

Creation and Implementation of a Prospective and Multicentric Database of Patients with Acute Myocardial Infarction: RIAM. / Criação e Implementação de um Banco de Dados Prospectivo e Multicêntrico de Pacientes com Infarto Agudo do Miocárdio: RIAM.

BACKGROUND: Multicenter registries representing the real world can be a significant source of information, but few studies exist describing the methodology to implement these tools. OBJECTIVE: To describe the process of implementing a database of ST-segment elevation acute myocardial infarction (STEMI) at a reference hospital, and the application of this process to other centers by means of an online platform. METHODS: In 2009, our institution implemented an Registry of Acute Myocardial Infarction (RIAM), with the prospective and consecutive inclusion of every patient admitted to the institution who received a diagnosis of STEMI. From March 2014 to April 2016, the registries were uploaded to a web-based system using the REDCap software and the registry was expanded to other centers. Upon subscription, the REDCap platform is a noncommercial software made available by Vanderbilt University to institutions interested in research. RESULTS: The following steps were taken to improve and expand the registry: 1. Standardization of variables; 2. Implementation of institutional REDCap (Research Electronic Data Capture); 3. Development of data collection forms (Case Report Form - CRF); 4. Expansion of registry to other reference centers using the REDCap software; 5. Training of teams and participating centers following an SOP (Standard Operating Procedure). CONCLUSION: The description of the methodology used to implement and expand the RIAM may help other centers and researchers to conduct similar studies, share information between institutions, develop new health technologies, and assist public policies regarding cardiovascular diseases. (Arq Bras Cardiol. 2020; 114(3):446-455).

FUNDAMENTO: Registros multicêntricos representativos do mundo real podem fornecer informações importantes, mas existem poucos estudos descrevendo como implementar estas ferramentas. OBJETIVO: Descrever o processo de implementação de um banco de dados em infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCST) em um hospital de referência e sua aplicação para outros centros com uma plataforma online . MÉTODOS: Nossa instituição implementou em 2009 um Registro de Infarto Agudo do Miocárdio (RIAM), com a inclusão prospectiva e consecutiva de todos os pacientes com diagnóstico de IAMCST que internaram na instituição. No período de março de 2014 a abril de 2016 foi realizada a migração para o sistema online com o software REDCap e expansão do registro para outros centros. A plataforma REDCap é um software de uso gratuito disponibilizado pela Universidade Vanderbilt a instituições interessadas em pesquisa, mediante cadastramento prévio. RESULTADOS: Foram realizadas as seguintes etapas do aprimoramento e expansão do registro: 1. Padronização das variáveis; 2. Implementação do software REDCap ( Research Electronic Data Capture ) institucional; 3. Desenvolvimento de formulários de coleta de dados ( Case Report Form - CRF); 4. Expansão do registro para outros centros de referência utilizando o software REDCap; 5. Treinamento da equipe e dos centros participantes pelo POP (Procedimento Operacional Padrão). CONCLUSÕES: A descrição da metodologia utilizada para implementar e expandir o RIAM pode auxiliar outros centros e pesquisadores a realizar estudos semelhantes, compartilhar informações entre instituições, o desenvolvimento de novas tecnologias em saúde e auxiliar nas políticas públicas em doenças cardiovasculares. (Arq Bras Cardiol. 2020; 114(3):446-455).

Treating periodontal disease in patients with myocardial infarction: A randomized clinical trial.

BACKGROUND: Periodontitis has been associated with coronary artery disease, but the impact of a periodontal treatment on the endothelial function of patients with a recent ST-segment elevation myocardial infarction (STEMI) was not investigated. METHODS: Randomized controlled trial (NCT02543502). Patients admitted between August 2012 and January 2015 were included. Patients were screened during the index hospitalization for STEMI, and those with severe periodontal disease were randomized 2 weeks later to periodontal treatment or to control. The primary endpoint of this trial was the between group difference in the variation of flow-mediated vasodilation (FMD) in the brachial artery assessed by ultrasound from baseline to the 6-month follow-up. Secondary outcomes were cardiovascular events, adverse effects of periodontal treatment and inflammatory markers. RESULTS: Baseline characteristics were balanced between patients in the intervention (n = 24) and control groups (n = 24). There was a significant FMD improvement in the intervention group (3.05%; p = .01), but not in the control group (-0.29%; p = .79) (p = .03 for the intergroup comparison). Periodontal treatment was not associated with any adverse events and the inflammatory profile and cardiovascular events were not significantly different between both groups. CONCLUSIONS: Treatment of periodontal disease improves the endothelial function of patients with a recent myocardial infarction, without adverse clinical events. Larger trials are needed to assess the benefit of periodontal treatment on clinical outcomes. CLINICAL TRIAL REGISTRATION: NCT02543502 (https://clinicaltrials.gov/ct2/show/NCT02543502?term=NCT02543502&rank=1).

[Percutaneous coronary intervention in diabetes mellitus: an updated analysis of medical practice]. / Intervenção coronária percutânea no diabetes mellitus: análise da prática médica atual.

Patients with diabetes and coronary artery disease are frequently considered for myocardial revascularization procedures, aiming at cardiovascular events risk reduction and a better quality of life. In clinical practice, decisions concerning surgery or percutaneous coronary intervention are frequently difficult, because of cases' severity, disease extension and co-morbidities association. Beyond that, the bulk of literature information was generated by subgroup analysis of randomized clinical trials, which were designed for the general population, not for diabetics. The aim of this study was to review literature on coronary percutaneous intervention in diabetic patients, and also to show recent data from the experience in this procedure at the Catheterization Laboratory of the Cardiology Institute of RS.

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.

[Diabetes and coronary stent implantation: experience from a reference center in interventional cardiology]. / Diabetes e implante de stents coronarianos: experiência de um centro de referência em cardiologia intervencionista.

We evaluated the influence of diabetes mellitus (DM) on clinical outcomes in patients with coronary artery disease treated with stent implantation. Between 1996 and 2000, 934 stents were implanted in 893 patients in our institution; 23% of them had DM. Clinical and angiographic characteristics and clinical outcomes of the patients with and without DM were prospectively included in a computerized database. Diabetics were older (61.5 +/- 10 vs. 59.8 +/- 11 years; p = 0.04) and had a higher prevalence of hypertension (69% vs. 62%; p = 0.09). The procedural clinical success rate (successful coronary stenting with residual stenosis < 30%, TIMI 3 flow and no in-hospital adverse clinical event) was lower in the diabetic group (88% vs. 92%; p = 0.05). In the 1-year follow up, diabetic patients showed higher rates of new target vessel revascularization (12.3% vs. 8%; p = 0.06), death (5.4% vs. 2.5%; p = 0.03) and major adverse cardiovascular events (MACE, new angioplasty, surgery, acute myocardial infarction or death: 16.3% vs. 9.3%; p = 0.003). Diabetes was independently associated to 1-year MACE on multivariate analysis (OR: 2.00; IC: 1.25-3.24; = 0.004). We concluded that DM is associated with higher complication and restenosis rates and a higher risk of long-term major cardiovascular events in patients treated with coronary stent implantation.

Criação e Implementação de um Banco de Dados Prospectivo e Multicêntrico de Pacientes com Infarto Agudo do Miocárdio: RIAM / Creation and Implementation of a Prospective and Multicentric Database of Patients with Acute Myocardial Infarction: RIAM

Resumo Fundamento Registros multicêntricos representativos do mundo real podem fornecer informações importantes, mas existem poucos estudos descrevendo como implementar estas ferramentas. Objetivo Descrever o processo de implementação de um banco de dados em infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCST) em um hospital de referência e sua aplicação para outros centros com uma plataforma online . Métodos Nossa instituição implementou em 2009 um Registro de Infarto Agudo do Miocárdio (RIAM), com a inclusão prospectiva e consecutiva de todos os pacientes com diagnóstico de IAMCST que internaram na instituição. No período de março de 2014 a abril de 2016 foi realizada a migração para o sistema online com o software REDCap e expansão do registro para outros centros. A plataforma REDCap é um software de uso gratuito disponibilizado pela Universidade Vanderbilt a instituições interessadas em pesquisa, mediante cadastramento prévio. Resultados Foram realizadas as seguintes etapas do aprimoramento e expansão do registro: 1. Padronização das variáveis; 2. Implementação do software REDCap ( Research Electronic Data Capture ) institucional; 3. Desenvolvimento de formulários de coleta de dados ( Case Report Form - CRF); 4. Expansão do registro para outros centros de referência utilizando o software REDCap; 5. Treinamento da equipe e dos centros participantes pelo POP (Procedimento Operacional Padrão). Conclusões A descrição da metodologia utilizada para implementar e expandir o RIAM pode auxiliar outros centros e pesquisadores a realizar estudos semelhantes, compartilhar informações entre instituições, o desenvolvimento de novas tecnologias em saúde e auxiliar nas políticas públicas em doenças cardiovasculares. (Arq Bras Cardiol. 2020; 114(3):446-455)

Abstract Background Multicenter registries representing the real world can be a significant source of information, but few studies exist describing the methodology to implement these tools. Objective To describe the process of implementing a database of ST-segment elevation acute myocardial infarction (STEMI) at a reference hospital, and the application of this process to other centers by means of an online platform. Methods In 2009, our institution implemented an Registry of Acute Myocardial Infarction (RIAM), with the prospective and consecutive inclusion of every patient admitted to the institution who received a diagnosis of STEMI. From March 2014 to April 2016, the registries were uploaded to a web-based system using the REDCap software and the registry was expanded to other centers. Upon subscription, the REDCap platform is a noncommercial software made available by Vanderbilt University to institutions interested in research. Results The following steps were taken to improve and expand the registry: 1. Standardization of variables; 2. Implementation of institutional REDCap (Research Electronic Data Capture); 3. Development of data collection forms (Case Report Form - CRF); 4. Expansion of registry to other reference centers using the REDCap software; 5. Training of teams and participating centers following an SOP (Standard Operating Procedure). Conclusion The description of the methodology used to implement and expand the RIAM may help other centers and researchers to conduct similar studies, share information between institutions, develop new health technologies, and assist public policies regarding cardiovascular diseases. (Arq Bras Cardiol. 2020; 114(3):446-455)

Clinical meaning of uncomplicated coronary dissections after stent implantation.

OBJECTIVE: To assess the influence of uncomplicated coronary dissections in the incidence of target vessel revascularization and cardiovascular events after 1 year. METHODS: Patients treated from June 1996 to December 2000, with data prospectively collected and uncomplicated dissections (G1, n=36), were compared with those patients without dissections (G2, n=871). Data were assessed with SPSS 8.0 statistical software, the outcomes were compared with the Kaplan-Meier curve, and the significance level was assessed using the log-rank test. RESULTS: Clinical features were similar in both groups: G1 had lower mean reference diameters (P<0.0001), a greater number of patients with type C lesions (P=0.01), a lower final lumen diameter at the end of the procedure (P=0.003), and a greater balloon/artery ratio (P<0.0001). In the multivariate analysis, only the reference diameter and the artery/balloon ratio were independently associated with the presence of residual dissections. No statistically significant difference existed in the incidence of revascularization of the target vessel and major cardiovascular events, at 1-year clinical follow-up, between the 2 groups of patients. Predictors of adverse clinical events at 1 year were the reference diameter, lesion extension, and residual stenosis, rather than the presence of residual dissection. CONCLUSION: Uncomplicated residual dissections after coronary stents are associated with narrower vessels and a higher balloon/artery ratio. Residual dissections are not associated with worse outcomes at 1-year clinical follow-up.

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.

[Short- and long- term results of percutaneous balloon valvuloplasty in pulmonary valve stenosis]. / Resultados imediatos e tardios da valvoplastia percutânea com balão na estenose valvar pulmonar.

OBJECTIVE: To assess the long-term results of percutaneous balloon valvuloplasty at a single institution. METHODS: This study comprised 189 patients with pulmonary valve stenosis undergoing percutaneous balloon valvuloplasty from 1984 to 1996, whose mean age was 7.97+/-9.25 years. The procedure was classified as successful when the RV-PA gradient was reduced to levels < 36 mmHg; restenosis was indicated by RV-PA gradients > 36 mmHg after an effective procedure. RESULTS: After the procedure, the peak-to-peak transvalvular gradient decreased from 70.12+/-30.06 to 25.11 +/-20.23 mmHg (P<0.001). Immediate success was obtained in 148 (78.72%) patients. A later reduction in the gradient to values < 36 mmHg was obtained in 24 other patients previously categorized as unsuccessful. Therefore, percutaneous balloon valvuloplasty was considered effective in 172 (91.01%) patients. Effectiveness increased to 93.53% (159/170) in the cases of typical morphology. Follow-up ranged from 4.39+/-3 years to 13.01 years. Restenosis was observed in 24 (13.95%) patients. Pulmonary regurgitation was detected in 95.1% of the patients, being more intense than mild in 29.5% of the patients. The probability of maintaining an appropriate result, at any time point, with no restenosis was 92.29% in 2 years, 87.38% in 5 years, 82.46% in 8 years, and 64.48% in 10 years. CONCLUSION: Percutaneous balloon valvuloplasty was effective and safe for the treatment of pulmonary valve stenosis with excellent short- and long-term results.

Psychological characteristics of patients undergoing percutaneous coronary interventions.

BACKGROUND: There is few data evaluating the prevalence and influence of adverse psychological characteristics on the prognosis of individuals submitted to percutaneous coronary interventions. No study has addressed this issue in Brazil. OBJECTIVE: To investigate the prevalence of depression, anxiety, psychological stress, and Type D personality and its association with cardiovascular events in patients undergoing percutaneous coronary interventions. METHODS: Psychological characteristics were evaluated by scales: Beck Depression Inventory, Beck Anxiety Inventory, Lipp Inventory for Stress Symptoms for Adults and Type D Personality Scale. The end-point of this study was the occurrence of major cardiovascular events in one-year follow-up. RESULTS: During March and May 2006, 137 patients were included. Type D personality was identified in 34% of the cases, 29% presented anxiety, 25% presented depression and 70% of the patients presented stress. In relation to the frequency of psychological characteristics according to the occurrence of major adverse cardiovascular events, there was no statistical difference between both groups of patients regarding depression (29% vs. 26% p = 0.8), anxiety (33% vs. 23% p = 0.3), stress (76% vs. 65% p = 0.3), and Type D personality (33% vs. 32% p = 0.9). However, the negative affectivity score was significantly higher in the group of patients presenting events (13.9 vs. 9.8 p = 0.01). CONCLUSION: In patients submitted to percutaneous coronary interventions, the prevalence of adverse psychological characteristics was high. One-year major cardiovascular adverse events were associated with baseline negative affectivity, but not with the other psychological characteristics studied.

Serum bilirubin concentration in patients with an established coronary artery disease.

Bilirubin has been considered an antioxidant, with capacity to remove reactive species of oxygen. Studies have suggested that an increased bilirubin level promotes protection against atherosclerosis. The case group was composed of 100 patients with coronary artery disease and the control group 100 patients with normal coronaries. Blood samples were collected to determine bilirubin concentrations. Bivariate analysis, multiple logistic regression models, and Spearman's correlation index were performed. A P value < 0.05 was considered to be significant. The case group was predominantly composed of men and the control group of women, with a mean age of 60 +/- 8.8 versus 56 +/- 10.9 (P = 0.015). The total bilirubin average was significantly higher in the control group than in the case group (0.76 mg/dL versus 0.39 mg/dL, P < 0.001). The level of ultrasensitive C reactive protein (us-CRP) was increased in the case group (3.63 mg/L versus 0.93 mg/L, P < 0.001). Although the correlation index for this inverse association has been weak, both are independently associated with a higher prevalence of coronary artery disease, total bilirubin 3 mg/L (OR: 1.17; IC: 1.04-1.33; P = 0.009). Reduced serum levels of bilirubin were shown to be associated with a higher prevalence of coronary artery disease emerging as a new potential risk factor marker. Additional studies are still necessary to confirm and demonstrate the association of these findings with clinical outcomes.

Validation of a risk score for target vessel revascularization after coronary stent implantation.

OBJECTIVE: Our aim was to validate a risk score for new target vessel revascularization (TVR) after bare-metal stent (BMS) implantation. METHODS: The risk score was developed in a cohort of patients previously treated with BMS at our institution. This risk score ranges from 0 to 5 points, according to the presence of diabetes mellitus (1 point), reference vessel diameter (> 3.5 mm = 0 points; 3-3.5 mm = 1; < 3 mm = 2) and lesion length (< or = 10 mm = 0 points; 10-20 mm = 1; > 20 mm = 2). Patients included in the validation cohort were treated between January and December 2005. Patient characteristics and 1-year clinical follow up were prospectively recorded into a dedicated database. A new coronary angiography was performed only when recurrent ischemia was suspected. RESULTS: The mean age of the 491 patients included was 61 +/- 10.5 years, and 35% were women. Diabetes mellitus was present in 22%, a previous percutaneous coronary intervention in 12% and previous myocardial infarction in 35%. The mean reference vessel diameter was 2.80 +/- 0.56 mm and the mean lesion length was 12.45 +/- 6.3 mm. The overall 1-year TVR rate was 13.9%. TVR rates increased with each score level: Score = 0, TVR = 0% (n = 16); Score 1 = 5.3% (n = 48); Score 2 = 12% (n = 170); Score 3 = 14% (n = 146); and Score 4/5 = 25% (n = 54); (p = 0.008). CONCLUSIONS: The risk score was significantly associated with TVR rates and can be used as a simple clinical tool to identify those patients at a low risk for a new revascularization procedure.

Determination of the minimum inflation time necessary for total stent expansion and apposition: an in vitro study.

OBJECTIVE: Determine minimum inflation time necessary for total stent expansion and apposition. BACKGROUND: Complete stent expansion is needed to adequately support the increase in artery lumen and to accommodate neointimal growth. METHODS: Experimental in vitro study. Twenty-five silicon carbide-coated stainless steel stents (3.5 x 20 mm) were released (14 atm) in plastic vials with a 3.5 mm internal diameter. Five groups, with 5 stents each, were set. Stents from Group A were released with 5 seconds of inflation; stents from Group B, with 15 seconds; stents from Group C, with 30 seconds; stents from Group D, with 60 seconds; and stents from Group E, with 90 seconds. Immediately after release, an intrastent ultrasound evaluation was performed for analysis of intrastent volume and apposition. Data were analyzed by Tukey's test and Fisher's exact test. RESULTS: Group A, mean intrastent volume (MIV) was 161.1 +/- 7.5 mm3, 60% complete apposition; Group B, MIV was 180.2 +/- 6.0 mm3, and 80% complete apposition; Group C, MIV was 183.0 +/- 1.1 mm3, 100% complete apposition; Group D, MIV was 183.2 +/- 1.8 mm3 and 100% complete apposition; and Group E, MIV was 183.5 +/- 0.7 mm3, and 100% complete apposition. MIV was significantly different only in Group A, as compared to all other groups, and only stents in Groups A and B were nonapposed. The exponential curve of the relationship between inflation time/volume obtained showed maximum efficiency starting at 30 seconds. CONCLUSION: The experimental models used in this study showed that 15 seconds may be adequate, but 30 seconds and more appear very adequate for optimum stent deployment, expansion and apposition.

Preditores de insucesso de tromboaspiração em pacientes submetidos à intervenção coronária percutânea primária / Predictors of failed thrombus aspiration in patients undergoing primary percutaneous coronary intervention

INTRODUÇÃO: A tromboaspiração é recomendada como método adjunto à intervenção coronária percutânea (ICP) primária, mas o insucesso em recuperar trombos é relativamente frequente. O objetivo deste estudo foi avaliar as taxas de insucesso de tromboaspiração e identificar seus preditores, em uma série contemporânea de pacientes. MÉTODOS: Estudo de coorte prospectivo que incluiu pacientes consecutivos atendidos com infarto agudo do miocárdio com elevação do segmento ST e submetidos à ICP primária com tromboaspiração no período de dezembro de 2009 a dezembro de 2011. Os procedimentos de tromboaspiração foram realizados por decisão do operador, e o sucesso foi definido como aspiração efetiva de trombo pelo cateter dedicado, com recuperação do fluxo coronário (fluxo TIMI > 0). RESULTADOS: Foram realizadas 1.055 ICPs primárias, sendo que a tromboaspiração foi utilizada em 37% dos casos, com taxa de sucesso de 70%. Foram identificados 254 pacientes com sucesso e 107 com insucesso da tromboaspiração. Insucesso de tromboaspiração foi associado a: idade, hipertensão, diabetes mellitus, dislipidemia, ICP prévia, escore de risco TIMI, Killip IV, contagem de leucócitos, fibrinogênio sérico, diâmetro de referência do vaso-alvo e TIMI 3 pré-procedimento. Pacientes com insucesso da tromboaspiração apresentaram tendência a maior mortalidade (11,6% vs. 5,9%; P = 0,09). CONCLUSÕES: Insucesso de tromboaspiração durante ICP primária ocorreu em 30% dos casos e esteve associado a tendência de maior mortalidade. A identificação de preditores clínicos, laboratoriais e angiográficos pode auxiliar no aprimoramento desses dispositivos e em sua técnica, além da escolha de pacientes mais adequados para seu emprego.

BACKGROUND: Aspiration thrombectomy is recommended as an adjunctive method in patients undergoing primary percutaneous coronary intervention (PCI), however, thrombus aspiration failure is relatively frequent. The objective of this study was to evaluate the rate and identify predictors of failed thrombus aspiration in a contemporaneous series of patients. METHODS: Prospective cohort study including consecutive patients with acute ST-segment elevation myocardial infarction undergoing primary PCI with thrombus aspiration from December 2009 to December 2011. Aspiration thrombectomy was performed at the operator's discretion and success was defined as effective thrombus aspiration by a dedicated catheter with the achievement of a final TIMI flow > 0. RESULTS: 1,055 primary PCIs were performed and aspiration thrombectomy was used in 37% of cases with a success rate of 70%. Aspiration thrombectomy success was observed in 254 patients whereas failure was observed in 107 patients. Aspiration thrombectomy failure was associated with age, hypertension, diabetes mellitus, dyslipidemia, previous PCI, TIMI risk score, Killip IV, leukocyte count, serum fibrinogen, target vessel reference diameter and preprocedural TIMI 3 flow. Patients with failed thrombus aspiration had a trend towards higher mortality (11.6% vs. 5.9%; P = 0.09). CONCLUSIONS: Aspiration thrombectomy failure during primary PCI was observed in 30% of the cases and was associated with a trend towards higher mortality. The identification of clinical, laboratory and angiographic predictors may help improve these devices and the technique and enable better patient selection.

Predictive score for target vessel revascularization after bare metal coronary stenting.

BACKGROUND: The ability to estimate the rate of a new target vessel revascularization (TVR) after bare metal coronary stenting is an important issue, as the systematic use of drug-eluting stents is still limited by its high costs. OBJECTIVE: We sought to create a predictive score for the possibility of a new TVR after bare metal stenting. METHODS: Clinical and angiographic characteristics of a prospective cohort of 848 patients were included in a dedicated database. Independent predictors of 1-year TVR were identified by multivariate analysis, and the score points were assigned according to the relative risk ratio of 1-year TVR. RESULTS: The 1-year TVR rate in the 848 patients was 7.4%. By multivariate analysis, reference diameter, lesion length and diabetes mellitus were retained in the final model (Hosmer-Lemeshow goodness-of-fit test = 2.339; p = 0.969). The increase of 1-year TVR rates was almost linear, with each score level (0 = 1.4%, 1 = 4.5%, 2 = 7.1%, 3 = 10.4% and 4 of 5 = 15.7%; r = 0.90; p < 0.001), and the p of the Chi-square test for trend was < 0.0001. CONCLUSIONS: This score can stratify patients with very low and high TVR rates and can be used as a simple clinical tool for the prediction of a new revascularization procedure in daily practice.

Avaliação do estado de saúde pelo questionário de angina de seattle em pacientes com síndrome coronária aguda / Health status assessment by the seattle angina questionnaire in acute coronary syndromes

Introdução: Estudos que analisaram o estado de saúde não avaliaram diferenças entre pacientes com angina instável e infarto agudo do miocárdio com (IAMCST) e sem (IAMSST) elevação do segmento ST. Este estudo teve como objetivo comparar índices do estado de saúde, de acordo com o Questionário de Angina de Seattle (QAS), em pacientes com síndrome coronária aguda (SCA). Métodos: O QAS foi aplicado na admissão hospitalar e aos seis meses de acompanhamento em 391 pacientes com SCA. Foram analisados três domínios: limitação física (D1), frequência da angina (D3) e qualidade de vida (D5). Índices maiores em D1, D3 e D5 significam menor limitação física, menor frequência da angina e melhor qualidade de vida, respectivamente. Resultados: Na internação hospitalar, pacientes com angina instável apresentaram piores índices de frequência da angina e de qualidade de vida que os portadores de IAMSST, e piores índices de atividade física, frequência da angina e qualidade de vida que aqueles com IAMCST. Aos seis meses de seguimento, os pacientes com angina instável ainda apresentaram piores índices de atividade física, frequência da angina e qualidade de vida que os portadores de IAMCST, mas sem diferença significativa em relação aos pacientes com IAMSST. Pacientes com angina instável foram aqueles que apresentaram maior ganho em todos os domínios do QAS. Conclusões: No espectro da SCA, os pacientes com angina instável demonstraram pior estado de saúde, tanto na internação hospitalar como aos seis meses de acompanhamento, mas, por outro lado, foram os que apresentaram o maior ganho em cada um dos domínios avaliados pelo QAS.

Background: Studies assessing health status have not addressed differences among patients with unstable angina, non- ST elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI). This study was aimed at comparing health status scores according to the Seattle Angina Questionnaire (SAQ) in patients with acute coronary syndromes (ACS). Methods: SAQ was applied at hospitaladmission and at 6-month follow-up in 391 patients with ACS. Three domains were analyzed: physical limitation (D1),anginal frequency (D3) and disease perception (D5). Higher D1, D3 and D5 scores indicated less physical limitation,lower frequency of angina and better quality of life, respectively. Results: At hospital admission, patients with unstable angina presented significantly lower scores of anginal frequencyand disease perception than those with NSTEMI, and significantly lower scores of physical activity, anginal frequency and disease perception than those with STEMI. At the 6-month follow-up, patients with unstable angina still presented lower scores of physical activity, anginal frequency and disease perception than those with STEMI,but there were no significant differences when compared to those with NSTEMI. The SAQ domains increased to a greater extent in patients with unstable angina. Conclusions:Patients with unstable angina had worse health status at hospital admission and at the 6-month follow-up but, on the other hand, showed the largest improvements for each one of the SAQ domains analyzed.