Desfechos tardios da intervenção coronária percutânea com stent farmacológico em pontes de veia safena: dados do Registro InCor / Late percutaneous coronary intervention outcomes with drug-eluting stent in saphenous vein grafts: data from the InCor Registry

Introdução: A segurança e a eficácia do uso de stent farmacológico para o tratamento de lesões em ponte de veia safena (PVS) ainda é motivo de controvérsia. Este estudo avaliou a evolução tardia de pacientes com lesões em PVS tratados com stent farmacológico. Métodos: Registro unicêntrico que incluiu todos os pacientes submetidos a intervenção em PVS com stent farmacológico (n = 82), sem restrições clínicas ou angiográficas, no período de 2003 a 2009. Foram avaliadas as taxas de eventos cardíacos adversos maiores (ECAM), óbito, infarto agudo do miocárdio (IAM), revascularização do vaso-alvo (RVA) e trombose de stent. Resultados: A média de idade foi de 67,8 + 10,2 anos, a maioria era do sexo masculino (85,4%), 40,2% eram diabéticos e 52,4% eram portadores de angina estável. Foi utilizado 1,45 + 0,5 stent por paciente, empregando-se ostent CypherTM na maioria (61%) dos casos. O diâmetro dos stents foi de 3,22 + 0,39 mm e o comprimento, de 20,1 +7,3 mm. A taxa de sucesso angiográfico foi de 96,3%. No seguimento de 4,1 anos, a taxa de ECAM foi de 28%, com 6% de óbito, 19,5% de IAM e 18,2% de RVA. Nesse período ocorreram dois casos de trombose de stent definitiva ou provável (2,4%). Conclusões: Os resultados demonstraram, em seguimento muito tardio, altas taxas de ECAM em pacientes com lesões de PVS tratados com stent farmacológico, provavelmente pelo aspecto mais agressivo da doença vascular em enxertos venosos.

Background: The safety and efficacy of drug-eluting stents in the treatment of saphenous vein graft (SVG) lesions remains controversial. This study assessed the late follow-up of patients with SVG lesions treated with drug-eluting stents. Methods: Single center registry including patients undergoingSVG interventions using drug-eluting stents (n = 82), without clinical or angiographic exclusion criteria, from 2003 to 2009. The rates of major adverse cardiac events (MACE), death, acute myocardial infarction (AMI), target vessel revascularization (TVR) and stent thrombosis were evaluated. Results: Mean age was 67.8 + 10.2 years, most of them were male (85.4%), 40.2% were diabetic and 52.4% had stable angina. An average of 1.45 + 0.5 stents per patient were implanted and CypherTM was the stent used in most ofthe cases (61%). Stent diameter was 3.22 + 0.39 mm and stent length was 20.1 + 7.3 mm. Angiographic success rate was 96.3%. In the 4.1-year follow-up, the rate of MACE was 28%, death 6%, AMI 19.5% and TVR 18.2%. Therewere two cases of definitive or probable stent thrombosis (2.4%) within the follow-up period. Conclusions: Longtermfollow-up showed high MACE rates in patients with SVG lesions treated with drug-eluting stents, probably due tothe accelerated atherosclerosis that develops within the grafted vein conduits.

Evolução clínica de pacientes de alto risco cirúrgico submetidos a intervenção coronária percutânea em tronco da coronária esquerda não-protegido / Clinical outcome in high-surgical-risk patients undergoing percutaneous coronary intervention for unprotected left main coronary artery disease

INTRODUÇÃO: Recentemente, a intervenção coronária percutânea (ICP) em tronco de coronária esquerda (TCE) não-protegido tem se mostrado uma alternativa real à cirurgia de revascularização miocárdica. Os resultados clínicos tardios da ICP nesses pacientes são escassos na literatura, especialmente em nosso meio. Método: Registro de um centro terciário de atenção em cardiologia, que avaliou o seguimento clínico de pacientes com contraindicação à revascularização miocárdica cirúrgica submetidos A ICP em TCE, no período de 2002 a 2009. Nosso objetivo foi avaliar a mortalidade ao final de um ano. Resultados: No total, foram incluídos 77 indivíduos nesta análise, com média de idade de 65,4 +- 13,7 anos, dos quais 59,2 por cento eram do sexo masculino, 25 por cento eram diabéticos e 3,9 por cento eram portadores de insuficiência renal crônica dialítica. Com relação às características angiográficas, 79,6 por cento das lesões eram do tipo B2/C, com envolvimento do óstio em 47,4 por cento e da bifurcação distal em 62,3 por cento. Na maioria dos casos, a indicação de ICP foi emergencial (85,5 por cento) e os stents farmacológicos foram utilizados em 17,5 por cento dos pacientes. Suporte hemodinâmico por meio de balão intra-aórtico foi utilizado em 28,2 por cento da população. Ao final de um ano a probabilidade de sobrevivência...

BACKGROUND: Percutaneous coronary intervention (PCI) in unprotected left main coronary artery (LMCA) disease has proven to be an alternative to coronary artery bypass graft surgery (CABG). However, late clinical results of PCI in these patients are scarce in the literature, especially in our country. METHOD: Data from a tertiary cardiology center registry, which included patients with contraindications to CABG undergoing LMCA PCI, from 2002 to 2009, were analyzed. Our objective was to evaluate the 1-year mortality. RESULTS: A total of 77 subjects were included in this analysis, mean age was 65.4 ± 13.7 years, 59.2% were male, 25% were diabetic, and 3.9% had renal failure requiring dialysis. Regarding the angiographic characteristics, 79.6% of lesions were type B2/C, with involvement of the ostium in 47.4% and distal bifurcation in 62.3%. In most cases PCI was performed as an emergency procedure (85.5%) and drug eluting stents were used in 17.5% of the patients. Hemodynamic support using an intraaortic balloon pump was used in 28.2% of the population. At the end of 1 year the probability of overall survival was 69.7% and almost all of the deaths occurred in the first month of follow-up. CONCLUSION: In this highly selected population with unprotected LMCA disease, including high-surgi

Prognostic heterogeneity among patients with chronic stable coronary disease: determinants of long-term mortality after treatment with percutaneous intervention.

AIMS: To evaluate the risk and predictors of death in a large population of patients with stable coronary disease treated with percutaneous intervention. METHODS AND RESULTS: The study population comprised 1,276 patients with chronic angina or silent ischaemia who underwent elective coronary angioplasty. Baseline and in-hospital mortality data were prospectively collected for all patients during the index hospitalisation. Post-discharge outcome was assessed at out-patient clinic, by review of the patients' records, or direct phone contact. Deaths were classified as cardiac and non-cardiac. Age, peripheral arterial disease, congestive heart failure with NYHA class >or= III, triple-vessel disease, and procedural success (i.e. angiographic success for all lesions in the absence of peri-procedural infarction) remained as multivariate independent predictors of death. For the entire population 4-year cumulative all-cause and cardiac mortality were respectively 5.4% and 4.1%. Four-year mortality for patients without any multivariate predictor was 2.4%, while for patients with two or more predictors the death rate was 16.3% after four years. CONCLUSIONS: Patients with stable coronary disease undergoing percutaneous treatment have an overall low mortality rate after four years. Nevertheless, stable patients comprise a heterogeneous population in terms of risk profile, ranging from patients at very low risk of late death to individuals with a poor long-term prognosis.

Muito baixo peso ponderal em pacientes tratados com angioplastia coronária: impacto na mortalidade precoce e tardia / Very low ponderal weight in patients treated with coronary angioplasty: impact on early and late mortality

Fundamentos: Pacientes de muito baixo peso tratados com intervenção coronária percutânea têm maior risco de complicações durante a internação. Até o momento, não existem estudos para avaliar o efeito a longo prazo do baixo peso após angioplastia coronária na população brasileira. Método: Um total de 3.687 pacientes foi separado em dois grupos, de acordo com o índice de massa corporal (IMC), calculado como peso (em quilogramas) dividido pela altura (em metros) ao quadrado: grupo baixo peso (IMC ≤ 20 kg/m²; 125 pacientes) e grupo não-baixo peso (IMC > 20 kg/m², 3.562 pacientes). A mortalidade intrahospitalar foi avaliada prospectivamente durante a internação inicial. Após a alta, a ocorrência de óbito foi acessada por meio da revisão dos registros hospitalares e contato telefônico. Resultados: Pacientes com IMC ≤ 20 kg/m² apresentavam peso, altura e IMC médios de 49,4 ± 7,1 kg, 1,62 ± 0,10 m, e 18,7 ± 1,1 kg/m², respectivamente. O peso, a altura e o IMC de pacientes com IMC > 20 kg/m² foram de 74,4 ± 13,8 kg, 1,64 ± 0,09 m, e 27,3 ± 4,3 kg/m², respectivamente (p < 0,01 para todas as características). Pacientes do grupo baixo peso apresentaram mortalidade significativamente maior que pacientes com IMC > 20 kg/m² após 2,5 anos da angioplastia (19,4% vs. 6,9%, respectivamente; hazard ratio [HR]: 2,51, intervalo de confiança de 95% [IC 95%]: 1,61-3,91; p < 0,01). Após o ajuste multivariado para a presença de outros fatores de risco, a presença de IMC ≤ 20 kg/m² persistiu como fator independente associado a aumento da mortalidade (HR: 2,04; IC 95%: 1,28-3,25; p < 0,01)...

Background: Patients with very low weight treated with percutaneous coronary intervention have a greater risk of complications during hospitalization. So far, there have been no studies to evaluate the long-term effect of low weight after coronary angioplasty in the Brazilian population. Methods: A total of 3,687 patients were divided into two groups according to their body mass index (BMI), calculated by dividing the weight in kilograms by the height in metres squared: low-weight group (BMI < 20 kg/m²; 125 patients), and non-low-weight group (BMI > 20 kg/m²; 3,562 patients). The in-hospital mortality was evaluated prospectively during first admission. After discharge, death occurrence was assessed by reviewing hospital records and through telephone contact. Results: Patients with BMI ≤ 20 kg/m² presented weight, height, and BMI averages of 49.4 ± 7.1 kg, 1.62 ± 0.10 m, and 18.7 ± 1.1 kg/m², respectively. The weight, height and BMI of patients with BMI > 20 kg/m² was 74.4 ± 13.8 kg, 1.64 ± 0.09 m, and 27.3 ± 4.3 kg/m², respectively (p < 0.01 for all characteristics). Patients from the low-weight group showed significantly higher mortality than patients with BMI > 20 kg/m² 2.5 years after angioplasty (19.4% vs. 6.9%, respectively; hazard ratio [HR]: 2.51; 95% confidence interval [95% CI]: 1.61-3.91; p < 0.01). After multivariate adjustment for other risk factors, the presence of BMI ≤ 20 kg/m² persisted as an independent factor associated to increased mortality (HR: 2.04; 95% CI: 1.28-3.25; p < 0.01)...

Perfil de segurança dos stents farmacológicos nas síndromes agudas: dados do registro INCOR / Drug eluting stents safety in acute coronary syndromes: the INCOR registry

Fundamentos: Os stents farmacológicos constituem um grande avanço no tratamento da doença coronária. No entanto , seu emprego nas síndromes coronárias agudas tem sido objeto de intensa discussão científica. Método: Entre maio e 2002 e setembro de 2006, 910 pacientes consecutivos foram tratados com implante de pelo menos um stent farmacológico e incluídos na presente análise. Os pacientes foram divididos em dois grupos: grupo estável (635 portadores de angina estável) e grupo agudo (275 pacientes com síndrome coronária aguda sem supra de ST). Analisamos as características clínicas e angiográficas e a ocorrência tardia de eventos adversos. Resultados: As características clínicas foram semelhantes, exceto pela maior frequência de tabagistas nos instáveis e de intervenção percutânea prévia nos estáveis. Após 588 dias (mediana do seguimento), os grupos, estável e agudo, tiveram índices semelhantes de reinfarto (2,8 por cento vs. 5,0 por cento; p = 0,1), revascularização do vaso-alvo (6,0 por cento vs. 7,7 por cento, p = 0,4, óbito (4,5 por cento vs. 6,5 por cento; p= 0,2) e eventos maiores combinados (9,9 por cento, p = 0,4), respectivamente. No entanto, a ocorrência de trombose foi significativamente mais frequênte nos pacientes com quadros coronários agudos...

Background: Drug-eluting stents are a great advance in the treatment of coronary disease. However, their use in patients with acute coronary syndromes has been the subject of intense scientific debate. Methods: 910 consecutive patients treated with at least one drug-eluting stent between May 2002 and September 2006 were enrolled in the present analysis. The patients were assigned to 2 groups according to their clinical condition at the time of admission: 1) Stable group (635 patients with stable angina) and 2) Acute group (275 patients with NSTEMI). We analyzed the clinical and angiographic characteristics as well as the occurrence of late adverse events. Results: The clinical characteristics of the groups were similar, except for the highest incidence of smokers in the acute group and previous percutaneous intervention in the stable group. After 588 days (median follow-up period), the stable and acute groups had similar rates of re-infarction (2.8 vs. 5.0%; p = 0.1), target vessel revascularization (6.0 vs. 7.7%; p = 0.4), death (4.5 vs. 6.5%; p = 0.2) and composite major adverse cardiac events (9.9 vs. 11.9%; p = 0.4), respectively. However, the occurrence of in-stent thrombosis was more frequent in patients with acute coronary diseases (1.4 vs. 4.4%; p = 0.02), mainly due to the occurrence of thrombosis within the first year after implantation (1.1 vs. 4.4%; p = 0.01). Conclusion: Drug-eluting stents have shown a good safety profile in patients with acute coronary syndromes compared to those with chronic coronary disease, despite the higher incidence of late in-stent thrombosis.

Incidência e preditores de óbito precoce e tardio em octagenários brasileiros tratados com intervenção coronária percutânea / Brazilian octogenarians treated with coronary intervention: incidence and predictors for early and late death

Introdução: Pacientes idosos com coronariopatia obstrutiva apresentam-se, freqüentemente, como um dilema clínico de difícil manejo, comumente necessitando o controle concomitante de múltiplas comorbidades. O presente estudo objetiva avaliar a sobrevida precoce e tardia de pacientes octagenários brasileiros tratados com angioplastia coronária. Método: Um total de 246 pacientes consecutivos com idade ≥ 80 anos, tratados pelo Sistema Único de Saúde brasileiro, com intervenção coronária percutânea, foram incluídos. Características basais e do procedimento foram coletadas, prospectivamente. Após a alta, a ocorrência de óbito foi avaliada por meio da revisão dos registros hospitalares e de contato telefônico. Resultados: A idade média dos pacientes era de 83,7 ± 3,0 anos (mínimo 80 anos, máximo 94 anos). A sobrevida global aos 30 dias, 1 ano e 2 anos foi de 86,7%, 78,1% e 76,0%, respectivamente. Somente o infarto agudo à admissão e a presença de doença coronária triarterial foram identificados como preditores multivariados de óbito (Infarto à admissão: HR ajustado 1,76; IC95% 1,08 ­ 2,87; p=0,02. Doença triarterial: HR ajustado 1,83; IC95% 1,12 ­ 2,99; p=0,02). Pacientes sem infarto à admissão ou doença triarterial apresentaram sobrevida de 85,7% após 2 anos, enquanto somente 56,8% com ambas as características estavam vivos ao término do seguimento. Conclusão: Octagenários tratados com angioplastia coronária apresentam mortalidade geral relativamente alta, principalmente no primeiro ano após o procedimento. No entanto, o subgrupo de pacientes sem características de risco apresentam boa sobrevida pósprocedimento, ao longo dos dois primeiros anos de evolução.

Background: Elderly patients with obstructive coronary disease are frequently a clinical dilemma, usually in need of management for multiple comorbidities. The present study aims at evaluating the short- and long-term survival of Brazilian octogenarians treated with coronary angioplasty. Methods: A total of 246 consecutive patients aged ≥ 80 years, treated with percutaneous coronary intervention in the Brazilian Public Health System comprise the study population. Baseline and procedural characteristics were collected prospectively. After discharge the occurrence of death was evaluated through the review of medical records and phone contact. Results: Mean age was 83.7 ± 3.0 years (range 80 years to 94 years). The overall survival at 30 days, 1 year, and 2 years were 86.7%, 78.1% and 76.0%, respectively. Only acute infarction at admission and the presence of triplevessel disease were identified as multivariate predictors of death (Infarction at admission: adjusted HR 1.76; 95%CI 1.08 ­ 2.87; p=0.02. Triple-vessel disease: adjusted HR 1.83; 95%CI 1.12 ­ 2.99; p=0.02). Patients without infarction at admission or triple-vessel disease reported an 85.7% survival rate after 2 years, while only 56.8% were alive after 2 years when both conditions were present. Conclusions: Octogenarians treated with coronary angioplasty report an overall high mortality rate, especially in the first year postprocedure. However, the subgroup of patients who are not high risk shows good survival rate along the first two years after the procedure.

Myocardial bridging causing transmural ischemia. Successful coronary artery bypass surgery.

Myocardial bridging is a common and usually benign inborn coronary anomaly. We report on a 51-year-old man who presented with recent angina on minimum physical effort. Cineangiography showed myocardial bridging of the mid-left anterior descending artery (LAD), and intracoronary ultrasonography excluded atherosclerotic disease. Gated single-photon emission computed tomography (SPECT), with exercise stress, showed an extensive anterior perfusion defect, and remarkable ST-segment elevation (up to 10 mm) in recovery. Vasospasm of the LAD was the main hypothesis. Additional oral drugs did not bring about improvement, as indicated on a new SPECT; disabling angina persisted. Surgical revascularization of the LAD by left internal mammary artery graft was performed. Two years later, SPECT and exercise tests returned to normal. The patient remains asymptomatic.

Angiographic segment size in patients referred for coronary intervention is influenced by constitutional, anatomical, and clinical features.

BACKGROUND: Factors influencing the size of target vessels of patients referred for coronary intervention are poorly defined. We aimed to investigate in a large series of patients undergoing percutaneous intervention the relation of constitutional, anatomical, and clinical features with the reference diameter of coronary vessels treated with stenting. METHODS: A total of 4,850 de novo coronary lesions, non-ostial and non-bifurcational, located in native vessels were analyzed. The following pre-specified characteristics were analyzed to reflect the relation between constitutional, anatomical, and clinical features on reference vessel diameter: age, gender, height, weight, proximal location, vessel, diabetes, hypertension, multivessel disease, and clinical presentation. RESULTS: The average reference diameter was 2.66+/-0.50 mm. All pre-specified markers had a significant relation with the vessel reference diameter at univariate analysis, except by hypertension which showed a strong tendency. However, at multivariate analysis, only diabetes, proximal location, multivessel disease, clinical presentation, vessel, weight, and height were identified as independent predictors of reference vessel diameter. CONCLUSION: Reference diameter of coronary vessels at the site of lesions treated by stenting is significantly influenced by a variety of characteristics. We hypothesize that the treated segment size of patients undergoing stenting ultimately reflects the conjoint effect of several different factors, including constitutional, anatomical, and clinical features.

Stenting vs. balloon angioplasty with provisional stenting for the treatment of vessels with small reference diameter.

A consecutive series of interventions in vessels with reference diameter < or = 2.75 mm was retrospectively analyzed according to preprocedure strategy: balloon angioplasty with provisional stenting (PTCA group, 73 patients) and primary stenting (PS group, 122 patients). In the PS group, there were more patients with single-vessel disease (54.1% vs. 37.0%; P = 0.021), less patients with three-vessel disease (9.0% vs. 24.7%; P = 0.003), more LAD interventions (54.9% vs. 31.5; P = 0.002), and less left circumflex interventions (22.1% vs. 45.2%; P < 0.001). Reference diameter was larger in the PS group (2.28 +/- 0.35 mm vs. 2.11 +/- 0.36 mm; P = 0.001). Provisional stenting was performed in 39.7% of PTCA group. At long-term outcome, the incidence of composite major events was similar between the PTCA and the PS groups (20.5% vs. 17.2%, respectively; P = NS). Treatment of small vessels with balloon dilatation and provisional stenting or with primary stenting yielded similar late outcomes. Operators' choice of treatment strategy was based on particular angiographic characteristics.

Isquemia silenciosa após infarto do miocárdio näo complicado: estudo em pacientes assintomáticos / Silent Myocardial Ischemia After Uncomplicated Myocardial Infarction

Objetivo - Verificar o valor prognóstico da isquemiasilenciosa após o infarto do miocárdio (IAM) não complicado. Métodos - Quarenta pacientes, assintomáticos após o 1° episódio de IAM não complicado, foram estudados através da eletrocardiografia dinâmica (48 h) e de esforço, na 2ª e 8ª semanas de evolução. Trinta e nove doentes foram submetidos ao estudo hemodinâmico e cinecoronariográfico e uma paciente à necrópsia. A eletrocardiografia identificou 11 (27,5%) indivíduos com isquemia silenciosa (grupo A); os demais constituiram o grupo B. Resultados - Os pacientes do grupos A e B não diferiram quanto a caracteres clínicos, localização eletrocardiográfica do infarto e função ventricular; os doentes do grupo A apresentaram doença arterial coronária significantemente mais extensa que os do grupo B; ao final de dois anos, os eventos coronários predominaram significantemente no grupo A (36,3%) em relação ao grupo B (3,4%). A análise pelas curvas de Kaplan-Meier mostrou maior probabilidade cumulativa de não ocorrência de eventos no grupo B em relação ao grupo A. Conclusão - A isquemia silenciosa parace ter valor prognóstico nos pacientes após o IAM não complicado, assim como nas outras modalidades de insuficiência coronária

Purpose - To verify the prognostic value of silent myocardial ischemia (SMI) after an uncomplicated myocardial infarction (MI). Methods - Forty asymptomatic patients were studied after afirst uncomplicated MI. They were submitted to 48 hour ambulatory eletrocardiographic monitoring and exercise-testing, during the 2nd and 8th weeks after the acute event. Thirty-nine patients were submitted to cardiac catheterization and coronary arteriography; one patient was submitted to necropsy. The eletrocardiographic study identified 11 (27,5%) individuals with SMI (group A); the other 29 patients were considered group B. Results - Groups A and B were similar in relation to clinical characteristics, infarct site and ventricular function. Group A had significantly more extensive coronary artery disease when comparad to group B. After a two-year follow-tip, patients from group A had significantly more coronary events (36,3%) when comparad to group B (3,4%). Kaplan-Meier analysis demonstrated a significantly higher cumulative probability of not experiencing a new coronary evens for the group B patients. Conclusion - SMI may have a prognostic value after uncomplicated MI, as in other clinical manifestations of coronary artery disease