Coronary artery complications after left bundle branch area pacing: An increasingly reported issue in the era of physiologic pacing.

Coronary artery lesions related to pacemaker implantation are rare complications. With the increasing adoption of the technique of permanent transseptal pacing of the left bundle branch area pacing (LBBAP), an increase in the incidence of these complications may be expected. We report two cases of coronary lesions after permanent transeptal pacing of the LBBAP: the first with a small coronary artery fistula, and the second with an extrinsic coronary compression. Both complications occurred with stylet-driven pacing leads with extendable helix. In the first case, since the shunt volume was small and no major complications were reported, the patient was treated conservatively with good outcome. The second case required lead repositioning due to acute decompensated heart failure.

In-Hospital influenza vaccination to prevent cardiorespiratory events in the first 45 days after acute coronary syndrome: A prespecified analysis of the VIP-ACS trial.

BACKGROUND: Influenza vaccination prevents major cardiovascular events in individuals presenting a recent acute coronary syndrome (ACS), however the early effect of an in-hospital double-dose vaccination strategy remains uncertain. METHODS: The VIP-ACS was a randomized, pragmatic, multicenter, open-label trial with a blinded-adjudication endpoint. Patients with ACS ≤ 7 days of hospitalization were randomized to an in-hospital double-dose quadrivalent inactivated influenza vaccine (double-dose) or a standard-dose influenza vaccine at 30 days post-randomization. The primary endpoint was a hierarchical composite of death, myocardial infarction, stroke, hospitalization for unstable angina, hospitalization for heart failure, urgent coronary revascularization, and hospitalization for respiratory infections, analyzed with the win ratio (WR) method in short-term follow-up (45-days after randomization). RESULTS: The trial enrolled 1,801 patients (≥18 years old). Median participant age was 57 years, 70 % were male. There were no significant differences between groups on the primary hierarchical endpoint: there were 5.7 % wins in the double-dose in-hospital group and 5.5 % wins in the standard-dose delayed vaccination group (WR: 1.03; 95 % CI: 0.70---1.53; P = 0.85). In a sensitivity analysis including COVID-19 infection in the hospitalizations for respiratory infections endpoint, overall results were maintained (WR: 1.03; 95 % CI 0.71---1.51; P = 0.87). Results were consistent for major cardiovascular events only (WR: 0.82; 95 % CI: 0.48---1.39; P = 0.46). No serious adverse events were observed. CONCLUSION: In patients with recent ACS, in-hospital double-dose influenza vaccination did not significantly reduce cardiorespiratory events at 45 days compared with standard-dose vaccination at 30 days post-randomization.

Permanent Pacing After Transcatheter Aortic Valve Implantation: Incidence, Predictors and Evolution of Left Ventricular Function / Marca-passo Definitivo após Implante Valvar Aórtico Transcateter: Incidência, Preditores e Evolução da Função Ventricular Esquerda

Abstract Background: Transcatheter aortic valve implantation (TAVI) is a well-established procedure; however, atrioventricular block requiring permanent pacemaker implantation (PPI) is a common complication. Objectives: To determine the incidence, predictors and clinical outcomes of PPI after TAVI, focusing on how PPI affects left ventricular ejection fraction (LVEF) after TAVI. Methods: The Brazilian Multicenter TAVI Registry included 819 patients submitted to TAVI due to severe aortic stenosis from 22 centers from January/2008 to January/2015. After exclusions, the predictors of PPI were assessed in 670 patients by use of multivariate regression. Analysis of the ROC curve was used to measure the ability of the predictors; p < 0.05 was the significance level adopted. Results: Within 30 days from TAVI, 135 patients (20.1%) required PPI. Those patients were older (82.5 vs. 81.1 years; p = 0.047) and mainly of the male sex (59.3% vs 45%; p = 0.003). Hospital length of stay was longer in patients submitted to PPI (mean = 15.7 ± 25.7 vs. 11.8 ± 22.9 days; p < 0.001), but PPI affected neither all-cause death (26.7% vs. 25.6%; p = 0.80) nor cardiovascular death (14.1% vs. 14.8%; p = 0.84). By use of multivariate analysis, the previous presence of right bundle-branch block (RBBB) (OR, 6.19; 3.56-10.75; p ≤ 0.001), the use of CoreValve® prosthesis (OR, 3.16; 1.74-5.72; p ≤ 0.001) and baseline transaortic gradient > 50 mm Hg (OR, 1.86; 1.08-3.2; p = 0.025) were predictors of PPI. The estimated risk of PPI ranged from 4%, when none of those predictors was present, to 63%, in the presence of all of them. The model showed good ability to predict the need for PPI: 0.69 (95%CI: 0.64 - 0.74) in the ROC curve. The substudy of 287 echocardiograms during the 1-year follow-up showed worse LVEF course in patients submitted to PPI (p = 0.01). Conclusion: BRD prévio, gradiente aórtico médio > 50 mmHg e CoreValve® são preditores independentes de implante de MPD pós-TAVI. Ocorreu implante de MPD em aproximadamente 20% dos casos de TAVI, o que prolongou a internação hospitalar, mas não afetou a mortalidade. O implante de MPD afetou negativamente a FEVE pós-TAVI.

Resumo Fundamento: O implante valvar aórtico transcateter (TAVI) está bem estabelecido, porém, o bloqueio atrioventricular, com necessidade de marca-passo definitivo (MPD), é complicação frequente. Objetivo: Determinar a incidência, preditores e desfechos clínicos de implante de MPD após TAVI, focando em como a evolução da fração de ejeção do ventrículo esquerdo (FEVE), após o TAVI, é afetada pelo MPD. Métodos: No registro brasileiro foram incluídos 819 pacientes submetidos a TAVI por estenose aórtica severa em 22 centros entre janeiro/2008 e janeiro/2015. Após exclusões, os preditores de implante de MPD foram avaliados em 670 pacientes por regressão multivariada. Análise da curva ROC foi utilizada para medir a habilidade dos preditores; p < 0,05 foi considerado significativo. Resultados: Aos 30 dias, 135 pacientes (20,1%) necessitaram de MPD. Tais pacientes eram mais velhos (82,5 vs. 81,1 anos; p = 0,047) e predominantemente homens (59,3% vs 45%; p = 0,003). A permanência hospitalar foi maior no Grupo MPD (média= 15,7 ± 25,7 vs. 11,8 ± 22,9 dias; p < 0,001), mas o implante não afetou morte por qualquer causa (26,7% vs. 25,6%; p = 0,80) nem morte cardiovascular (14,1% vs. 14,8%; p = 0,84). Por análise multivariada, a presença prévia de bloqueio de ramo direito (BRD) (OR, 6,19; 3,56-10,75; p ≤ 0,001), o uso da prótese CoreValve® (OR, 3,16; 1,74-5,72; p ≤ 0,001) e gradiente transaórtico basal > 50 mmHg (OR, 1,86; 1,08-3,2; p= 0,025) foram preditores de implante de MPD. O risco estimado de implante de MPD foi 4%, quando nenhum dos fatores de risco estava presente, e 63% na presença de todos. O modelo mostrou boa habilidade de prever a necessidade de MPD: 0,69 (IC95%: 0,64 - 0,74) na curva ROC. Subestudo de 287 ecocardiogramas durante o seguimento de 1 ano mostrou pior evolução da FEVE no Grupo MPD (p = 0,01). Conclusão: Em crianças de 6 a 11 anos, circunferência da cintura aumentada está associada à PA elevada, mesmo quando o IMC é normal. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

Permanent Pacing After Transcatheter Aortic Valve Implantation: Incidence, Predictors and Evolution of Left Ventricular Function.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a well-established procedure; however, atrioventricular block requiring permanent pacemaker implantation (PPI) is a common complication. OBJECTIVES: To determine the incidence, predictors and clinical outcomes of PPI after TAVI, focusing on how PPI affects left ventricular ejection fraction (LVEF) after TAVI. METHODS: The Brazilian Multicenter TAVI Registry included 819 patients submitted to TAVI due to severe aortic stenosis from 22 centers from January/2008 to January/2015. After exclusions, the predictors of PPI were assessed in 670 patients by use of multivariate regression. Analysis of the ROC curve was used to measure the ability of the predictors; p < 0.05 was the significance level adopted. RESULTS: Within 30 days from TAVI, 135 patients (20.1%) required PPI. Those patients were older (82.5 vs. 81.1 years; p = 0.047) and mainly of the male sex (59.3% vs 45%; p = 0.003). Hospital length of stay was longer in patients submitted to PPI (mean = 15.7 ± 25.7 vs. 11.8 ± 22.9 days; p < 0.001), but PPI affected neither all-cause death (26.7% vs. 25.6%; p = 0.80) nor cardiovascular death (14.1% vs. 14.8%; p = 0.84). By use of multivariate analysis, the previous presence of right bundle-branch block (RBBB) (OR, 6.19; 3.56-10.75; p ≤ 0.001), the use of CoreValve® prosthesis (OR, 3.16; 1.74-5.72; p ≤ 0.001) and baseline transaortic gradient > 50 mm Hg (OR, 1.86; 1.08-3.2; p = 0.025) were predictors of PPI. The estimated risk of PPI ranged from 4%, when none of those predictors was present, to 63%, in the presence of all of them. The model showed good ability to predict the need for PPI: 0.69 (95%CI: 0.64 - 0.74) in the ROC curve. The substudy of 287 echocardiograms during the 1-year follow-up showed worse LVEF course in patients submitted to PPI (p = 0.01). CONCLUSION: BRD prévio, gradiente aórtico médio > 50 mmHg e CoreValve® são preditores independentes de implante de MPD pós-TAVI. Ocorreu implante de MPD em aproximadamente 20% dos casos de TAVI, o que prolongou a internação hospitalar, mas não afetou a mortalidade. O implante de MPD afetou negativamente a FEVE pós-TAVI.

Association of alcohol consumption with coronary artery disease severity.

BACKGROUND & AIMS: The ingestion of small to moderate alcohol consumption amounts has been associated to cardiovascular protection. This study aimed to evaluate the association between alcohol consumption and coronary artery disease severity. MATERIAL AND METHODS: Cross-sectional Study with patients undergoing coronary angiography. Age, cardiovascular risk factors (smoking, systemic arterial hypertension, dyslipidemia and diabetes) and alcohol drinking habit were investigated. Alcohol consumption was divided in three categories: nondrinker, moderate alcohol consumption (less than 15 g ethanol/day for women or 30 g ethanol/day for men) and heavy alcohol consumption. Coronary artery disease severity was assessed through the Friesinger Score (FS) in the coronary angiography, by interventional cardiologists blinded to alcohol consumption. RESULTS: The final sample included 363 adults; of those, 228 were men (62.81%). Mean age was 60.5 ± 10.9 y. Unadjusted analyses identified sex, age, hypertension, diabetes, dyslipidemia and alcohol consumption as the main covariates associated with the Friesinger score. Lower Friesinger scores were also observed in moderate alcohol consumption when comparing to those who do not drink (RR 0.86; 95% CI 0.79-0.95). CONCLUSION: Among patients with suspected coronary artery disease undergoing coronary angiography, moderate alcohol consumption is associated to a lower coronary artery disease severity than heavy drinking.

Desempenho de Escores de Risco Cirúrgico para Prever Mortalidade após Implante Transcateter de Valva Aórtica / Performance of Surgical Risk Scores to Predict Mortality after Transcatheter Aortic Valve Implantation

AbstractBackground:Predicting mortality in patients undergoing transcatheter aortic valve implantation (TAVI) remains a challenge.Objectives:To evaluate the performance of 5 risk scores for cardiac surgery in predicting the 30-day mortality among patients of the Brazilian Registry of TAVI.Methods:The Brazilian Multicenter Registry prospectively enrolled 418 patients undergoing TAVI in 18 centers between 2008 and 2013. The 30-day mortality risk was calculated using the following surgical scores: the logistic EuroSCORE I (ESI), EuroSCORE II (ESII), Society of Thoracic Surgeons (STS) score, Ambler score (AS) and Guaragna score (GS). The performance of the risk scores was evaluated in terms of their calibration (Hosmer–Lemeshow test) and discrimination [area under the receiver–operating characteristic curve (AUC)].Results:The mean age was 81.5 ± 7.7 years. The CoreValve (Medtronic) was used in 86.1% of the cohort, and the transfemoral approach was used in 96.2%. The observed 30-day mortality was 9.1%. The 30-day mortality predicted by the scores was as follows: ESI, 20.2 ± 13.8%; ESII, 6.5 ± 13.8%; STS score, 14.7 ± 4.4%; AS, 7.0 ± 3.8%; GS, 17.3 ± 10.8%. Using AUC, none of the tested scores could accurately predict the 30-day mortality. AUC for the scores was as follows: 0.58 [95% confidence interval (CI): 0.49 to 0.68, p = 0.09] for ESI; 0.54 (95% CI: 0.44 to 0.64, p = 0.42) for ESII; 0.57 (95% CI: 0.47 to 0.67, p = 0.16) for AS; 0.48 (95% IC: 0.38 to 0.57, p = 0.68) for STS score; and 0.52 (95% CI: 0.42 to 0.62, p = 0.64) for GS. The Hosmer–Lemeshow test indicated acceptable calibration for all scores (p > 0.05).Conclusions:In this real world Brazilian registry, the surgical risk scores were inaccurate in predicting mortality after TAVI. Risk models specifically developed for TAVI are required.

ResumoFundamento:Ainda é desafiador prever a mortalidade de pacientes que se submetem ao TAVI (sigla do inglês Transcatheter Aortic Valve Implantation).Objetivos:Avaliar o desempenho de cinco escores de risco para cirurgia cardíaca em prever mortalidade em 30 dias de pacientes inscritos no Registro Brasileiro de TAVI.Métodos:O Registro Multicêntrico Brasileiro inscreveu prospectivamente 418 pacientes submetidos ao TAVI em 18 centros entre 2008 e 2013. Os seguintes escores cirúrgicos foram usados para calcular o risco de mortalidade no período de 30 dias: EuroSCORE I (ESI) logístico, EuroSCORE II (ESII), STS Score (STS), Ambler Score (AS) e Guaragna Score (GS). O desempenho dos escores de risco foram avaliados através de sua calibração (teste Hosmer-Lemeshow) e discriminação [área sob a curva (AUC) do inglês receiver-operating characteristic curve)].Resultados:A idade média foi de 81,5 ± 7,7 anos. A prótese aórtica CoreValve (Medtronic) foi usada em 86,1% da coorte e a abordagem transfemural usada em 96,2%. A mortalidade observada no período de 30 dias foi de 9,1%. A mortalidade no período de 30 dias prevista pelos escores foi: ESI, 20,2 ± 13,8%; ESII, 6,5 ± 13,8%; STS, 14,7 ± 4,4%; AS, 7,0 ± 3,8%; GS, 17,3 ± 10,8%. Nenhum dos escores testados com a AUC foi capaz de prever a mortalidade no período de 30 dias de forma precisa. As AUC para os escores foram: 0,58 [95% de intervalo de confiança (IC): 0,49 a 0,68, p = 0,09] para ESI; 0,54 (IC de 95%: 0,44 a 0,64, p = 0,42) para ESII; 0,57 (IC de 95%: 0,47 a 0,67, p = 0,16) para AS; 0,48 (IC de 95%: 0,38 a 0,57, p = 0,68) para STS e 0,52 (IC de 95%: 0,42 a 0,62, p = 0,64) para GS. O teste Hosmer-Lemeshow indicou uma calibração aceitável para todos os escores (p > 0,05).Conclusões:Neste registro brasileiro de mundo real, os escores de risco cirúrgico foram imprecisos para prever a mortalidade após o TAVI. São necessários modelos de risco desenvolvidos especificamente para o TAVI.

Performance of surgical risk scores to predict mortality after transcatheter aortic valve implantation.

BACKGROUND: Predicting mortality in patients undergoing transcatheter aortic valve implantation (TAVI) remains a challenge. OBJECTIVES: To evaluate the performance of 5 risk scores for cardiac surgery in predicting the 30-day mortality among patients of the Brazilian Registry of TAVI. METHODS: The Brazilian Multicenter Registry prospectively enrolled 418 patients undergoing TAVI in 18 centers between 2008 and 2013. The 30-day mortality risk was calculated using the following surgical scores: the logistic EuroSCORE I (ESI), EuroSCORE II (ESII), Society of Thoracic Surgeons (STS) score, Ambler score (AS) and Guaragna score (GS). The performance of the risk scores was evaluated in terms of their calibration (Hosmer-Lemeshow test) and discrimination [area under the receiver-operating characteristic curve (AUC)]. RESULTS: The mean age was 81.5 ± 7.7 years. The CoreValve (Medtronic) was used in 86.1% of the cohort, and the transfemoral approach was used in 96.2%. The observed 30-day mortality was 9.1%. The 30-day mortality predicted by the scores was as follows: ESI, 20.2 ± 13.8%; ESII, 6.5 ± 13.8%; STS score, 14.7 ± 4.4%; AS, 7.0 ± 3.8%; GS, 17.3 ± 10.8%. Using AUC, none of the tested scores could accurately predict the 30-day mortality. AUC for the scores was as follows: 0.58 [95% confidence interval (CI): 0.49 to 0.68, p = 0.09] for ESI; 0.54 (95% CI: 0.44 to 0.64, p = 0.42) for ESII; 0.57 (95% CI: 0.47 to 0.67, p = 0.16) for AS; 0.48 (95% IC: 0.38 to 0.57, p = 0.68) for STS score; and 0.52 (95% CI: 0.42 to 0.62, p = 0.64) for GS. The Hosmer-Lemeshow test indicated acceptable calibration for all scores (p > 0.05). CONCLUSIONS: In this real world Brazilian registry, the surgical risk scores were inaccurate in predicting mortality after TAVI. Risk models specifically developed for TAVI are required.

Há uma associação entre anti-inflamatórios não-esteroides e nefropatia induzida por contraste? / Is there an association between non-steroidal anti-inflammatory drugs and contrast nephropathy? / ¿Hay una asociación entre antiinflamatorios no esteroides y nefropatía inducida por contraste?

FUNDAMENTO: A associação entre o uso de anti-inflamatórios não-esteroides (AINEs) e insuficiência renal aguda ou crônica é bem documentada, mas evidências sobre a associação entre AINEs e nefropatia induzida por contraste (NIC) não são encontradas na literatura. OBJETIVO: Avaliar uma possível associação entre AINEs e NIC. MÉTODOS: Em um estudo de coorte, através da entrevista clínica de pacientes que foram submetidos à cateterização cardíaca, analisamos o uso de AINEs e sua associação com desenvolvimento de NIC, através da alteração dos níveis de creatinina sérica ou taxa de filtração glomerular em 48 ou 72 horas. RESULTADOS: No período de julho de 2005 a julho de 2006, 236 pacientes foram incluídos no estudo, dos quais 29 foram posteriormente excluídos. A incidência de NIC foi 10,37 por cento (20 de 207) e 42 por cento dos pacientes estavam recebendo AINEs até o momento da avaliação. Não houve associação entre o uso de AINEs e o desenvolvimento de NIC com OR de 1,293; IC95 por cento (0,46-4,2). O estudo detectou fatores de risco conhecidos para o desenvolvimento de NIC, tais como diabete, com OR de 2,77; IC95 por cento (1,05-7,47) e insuficiência renal crônica com OR de 3,48; IC95 por cento (1,1-11,07) e também sugeriu uma ação protetora da hidratação com solução salina com OR de 0,166; IC95 por cento (0,03-0,92). CONCLUSÃO: Com base nos dados obtidos, concluímos que não houve associação entre NIC e uso prévio de AINEs, pelo menos com um OR > 2,85, o qual nossa amostra detectou.

BACKGROUND: The association between the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and acute or chronic renal failure is well documented, but evidence of such association between NSAIDs and Contrast-Induced Nephropathies (CIN) is not found in the indexed literature. OBJECTIVE: To evaluate the possible association between NSAIDs and CIN. METHODS: In a cohort study, through clinical interviews of patients that underwent cardiac catheterization, we analyzed the use of NSAIDs and its association with the development of CIN, through alterations in serum creatinine or glomerular filtration rate in 48 or 72 hours. RESULTS: From July 2005 to July 2006, 236 patients were enrolled in the study, of which 29 were later excluded. The incidence of CIN was 10.37 percent (20 of 207) and 42 percent of the patients were using NSAIDs until the moment of the evaluation. There was no association between the use of NSAIDs and the development of CIN with OR of 1.293 95 percent CI (0.46-4.2). The study detected known risk factors for the development of CIN, such as diabetes with OR of 2.77 95 percentCI (1.05-7.47) and chronic renal failure with OR 3.48 95 percentCI (1.1-11.07). A protective action of saline solution hydrationis also suggested, with OR of 0.166 95 percentCI (0.03-0.92). CONCLUSION: Based on the data obtained, we conclude that there was no association between CIN and previous use of NSAIDs, at least with an OR higher then 2.85, which our sample detected.

FUNDAMENTO: La asociación entre el uso de antiinflamatorios no esteroides (AINEs) e insuficiencia renal aguda o crónica está bien documentada, pero evidencias sobre la asociación entre AINEs y nefropatía inducida por contraste (NIC) no son encontradas en la literatura. OBJETIVO: Evaluar una posible asociación entre AINEs y NIC. MÉTODOS: En un estudio de cohorte, a través de la entrevista clínica de pacientes que fueron sometidos a cateterismo cardíaco, analizamos el uso de AINEs y su asociación con desarrollo de NIC, a través de la alteración de los niveles de creatinina sérica o tasa de filtrado glomerular en 48 o 72 horas. RESULTADOS: En el período de julio de 2005 a julio de 2006, 236 pacientes fueron incluidos en el estudio, de los cuales 29 fueron posteriormente excluidos. La incidencia de NIC fue 10,37 por ciento (20 de 207) y 42 por ciento de los pacientes estaban recibiendo AINEs hasta el momento de la evaluación. No hubo asociación entre el uso de AINEs y el desarrollo de NIC con OR de 1,293; IC95 por ciento (0,46-4,2). El estudio detectó factores de riesgo conocidos para el desarrollo de NIC, tales como diabetes, con OR de 2,77; IC95 por ciento (1,05-7,47) e insuficiencia renal crónica con OR de 3,48; IC95 por ciento (1,1-11,07) y también sugirió una acción protectora de la hidratación con solución salina con OR de 0,166; IC95 por ciento (0,03-0,92). CONCLUSIÓN: Con base en los datos obtenidos, concluimos que no hubo asociación entre NIC y uso previo de AINEs, por lo menos con un OR > 2,85, el cual nuestra muestra detectó.

Is there an association between non-steroidal anti-inflammatory drugs and contrast nephropathy?

BACKGROUND: The association between the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and acute or chronic renal failure is well documented, but evidence of such association between NSAIDs and Contrast-Induced Nephropathies (CIN) is not found in the indexed literature. OBJECTIVE: To evaluate the possible association between NSAIDs and CIN. METHODS: In a cohort study, through clinical interviews of patients that underwent cardiac catheterization, we analyzed the use of NSAIDs and its association with the development of CIN, through alterations in serum creatinine or glomerular filtration rate in 48 or 72 hours. RESULTS: From July 2005 to July 2006, 236 patients were enrolled in the study, of which 29 were later excluded. The incidence of CIN was 10.37% (20 of 207) and 42% of the patients were using NSAIDs until the moment of the evaluation. There was no association between the use of NSAIDs and the development of CIN with OR of 1.293 95% CI (0.46-4.2). The study detected known risk factors for the development of CIN, such as diabetes with OR of 2.77 95%CI (1.05-7.47) and chronic renal failure with OR 3.48 95%CI (1.1-11.07). A protective action of saline solution hydration is also suggested, with OR of 0.166 95%CI (0.03-0.92). CONCLUSION: Based on the data obtained, we conclude that there was no association between CIN and previous use of NSAIDs, at least with an OR higher then 2.85, which our sample detected.

Reestenose tardia associada à fratura de stent Cypher / Late restenosis related to Cypher stent fracture / Reestenosis tardía asociada a fractura de stent Cypher

Os stents farmacológicos representam um importante avanço na terapêutica da doença aterosclerótica coronariana. Recentemente tem sido descrita a fratura de stents farmacológicos, associada à reestenose e trombose. Relataremos aqui um caso de fratura de um stent farmacológico 18 meses após o seu implante, associada com reestenose.

Drug-eluting stents represent a significant evolution in the therapy of coronary artery disease. Recently, restenosis and thrombosis related to drug-eluting stent fractures have been described. This work reports a case of fracture of a drug-eluting stent 18 months after implantation, associated with restenosis.

Los stents farmacológicos representan un importante avance en la terapéutica de la enfermedad aterosclerótica coronaria. Recientemente se ha descrito la fractura de stents farmacológicos, asociada a la reestenosis y trombosis. Relataremos aquí un caso de fractura de un stent farmacológico 18 meses después de su implante, asociada con reestenosis.

Late restenosis related to cypher stent fracture.

Drug-eluting stents represent a significant evolution in the therapy of coronary artery disease. Recently, restenosis and thrombosis related to drug-eluting stent fractures have been described. This work reports a case of fracture of a drug-eluting stent 18 months after implantation, associated with restenosis.

Impacto dos meios de contraste iodixanol e loxaglato na repercussão miocárdica em pacientes submetidos a angioplastia no infarto agudo do miocárdio / Impact of contrast media iodixanol and loxaglate in myocardil reperfusion in patients submitted to primary coronary angioplasty in acute myocardial infarction

Introdução: Apesar do excelente desenpenho e da segurança da angioplastia primária em restabelecer o fluxo sanguíneo normal (fluxo TIMI, grau 3), uma significante proporção desses pacientes com infarto agudo do miocárdio (IAM) tem prejuízo na integridade microvascular e na perfusão miocárdica. É possível que os meios de contraste utilizados durante o procedimento interferiram na perfusão miocárdica. por alterarem mecanismos celulares implicados nesse processo. Objetivo: Comparar os meios de contraste iodixanol (não-iônico isomolar) e ioxaglato (iônico de baixa osmolaridade) na perfusão miocárdica tecidual em pacientes com IAM submetidos a intervenção coronária percutânea primária (ICPP). Método: Ensaio clínico randomizado com uma população de 201 pacientes com IAM, com tempo dor-porta maior menor 12 horas, submetidos a ICPP. O desfecho primário do estudo foi a presença de no-reflow, definido como corrected TIMI frame count (CTFC) menor ou menos 40 quadros, e o desfecho secundário foi a composição de morte cardíaca, reinfarto e acidente vascular cerebral (AVC) durante a hospitalização . Resultados: CTFC menor menos após ICPP ocorreu em 22,9 por cento dos pacientes mo grupo do ioxaglato...

Background: Despite the excellent performance and safety of primary angioplasty in reestablishing normal epicardial blood flow (TIMI flow, grade 3), a significant proportion of these patients with acute myocardial infarction (AMI) have damage in the microvascular integrity and impaired myocardial perfusion. It is possible that the contrast media used during the procedure interferes in myocardial perfusion by altering cell mechanisms involved in this process. Our objective was to compare contrast media iodixanol (nonionic isosmolar) and ioxaglate (ionic, low osmolality) in myocardial tissue perfusion in patients with AMI submitted to primary percutaneous coronary intervention (primary PCI). Methods: A randomized study with a population of 201 patients with AMI with a pain-door time ≤ 12 hours submitted to primary PCI. The primary end point of the study was the presence of no-reflow defined as corrected TIMI frame count (CTFC) ≥ 40 frames and the secondary end point was the composition of cardiac death, reinfarction and stroke during hospitalization. Results: CTFC ≥ 40 frames after primary PCI occurred in 22.9% of patients in the ioxaglate group and 19.8% in the iodixanol group (p = 0.611). The secondary end point occurred in 9.5% of patients in the ioxaglate group and 9.4% in the iodixanol group (p > 0.99). Conclusion: The current study did not demonstrate significant differences in the no-reflow incidence between the contrast media ioxaglate and iodixanol in patients with AMI submitted to primary PCI. Also significant differences were not observed in the incidence of the combined clinical outcomes of death, reinfarction or stroke.

Disfunção endotelial em pacientes submetidos à terapia com nitroglicerina e à intervenção coronária percutânea / Endothelial dysfunction in patients submitted to nitroglycerin therapy and percutaneous coronary interventions

A terapia com nitroglicerina está associada a modificações bioquímicas na vasculatura que podem levar à alterações na função endotelial. De modo análogo, as intervenções coronárias percutâneas causam intensa lesão mecânica na parede vascular que pode determinar disfunção endotelial...

Psicose induzida por corticoides / Corticoid induced psychosis

O transtorno mental induzido por corticoides e um dos efeitos colaterais mais frequentemente associados ao uso destas drogas. Tende a ocorrer nos primeiros dias de terapia, sendo principal fator de risco o uso de doses superiores a 40 mg/dia de prednisona ou equivalente. O quadro psicotico tende a apresentar-se com grande variedade de sintomas esquizofrenicos, afetivos, ou cerebrais organicos, podendo alterar seu padrao durante a mesma crise, nao havendo uma forma tipica. A profilaxia, utilizando a menor dose de esteroides compativel com o efeito clinico desejado, e fundamental. Com o desenvolvimento do surto, esta indicada a retirada do farmaco. Abordam-se as possibilidades terapeuticas, caso a retirada do corticoide seja contra-indicada ou inefetiva. Tambem sao discutidas outras medidas profilaticas.

Ruído: fator de risco no gênese da hipertensäo arterial? / Noise: a risk fator withe origins of arterial hypertension ?

O ruído ambiental tem sido implicado como um possível agente etiológico na hipertensäo arterial sistêmica. Face a importância deste aspecto ecológico, revisamos a literatura quanto aos efeitos agudos e crônicos da exposiçäo ao estresse sonoro sobre o aparelho cardiovascular, bem como os prováveis mecanismos fisisológicos capazes de participar na gênese destas alteraçöes. Discute-se a associaçäo entre a exposiçäo ao ruído e os aspectos epidemiológicos referentes a este problema, assim como a necessidade de adoçäo de medidas sanitárias capazes de permitir um melhor equacionamento do problema

Estudo de alguns fatores na gênese do tabagismo / Some factors in the genesis of smoking

Foram estudados 573 alunos adolescentes com a finalidade de se conhecer os principais motivos pelos quais eles começam a fumar. Nossa amostra foi obtida em dois colégios de Porto Alegre, um deles freqüentado por alunos de classe alta (52,5% dos entrevistados) e outro, por alunos de classe média-baixa (47,5% dos entrevistados), sendo composta por jovens de 12 a 20 anos de idade (16 anos em média). Os principais motivos que incentivaram a adesäo ao hábito de fumar foram: "Curiosidade" (57,3%), "Influência de amigos" (10,5%) e "Auto-afirmaçäo" (6,5%). Observou-se que a maior parte dos estudantes (71,6%) iniciou a fumar na faixa etária dos 12 aos 15 anos. Houve maior prevalência do hábito de fumar entre alunos com familiares fumantes (p<0,01) e no sexo feminino (p<0,01). O nível sócio-econômico näo demonstrou relaçäo significativa com história de tabagismo

Simulaçöes clínicas en medicina interna / Clinical simulations in internal medicine

Simulaçöes säo um instrumento didático valioso para o treinamento da tomada de decisöes clínicas, aspecto fundamental na formaçäo médica. O uso do computador pode tornar esse método mais ágil e eficiente. É nosso objetivo implementá-lo nas disciplinas do departamento de Medicina Interna da Faculdade de Medicina da Universidade Federal do Rio Grande do Sul. Com o auxílio de um microcomputador, dezessete simulaçöes clínicas estäo sendo experimentalmente aplicadas em uma turma do sexto semestre cursando a disciplina de Medicina Interna. A experiência inicial näo permite uma avaliaçäo da efetividade do método

Sucralfato: uma terapêutica esquecida / Sucralfate: a forgotten therapy

Säo revisados os aspectos farmacológicos do sucralfato e, enfatizados o seu uso clínico no tratamento da esofagite de refluxo, úlceras duodenal e gástrica, e na profilaxia da ulceraçäo de "stress"

Níveis tensionais e hipertensäo arterial sistêmica entre brancos e pretos numa vila de Porto Alegre / Pressure levels and systemic arterial hypertension among whites and blacks in a district of Porto Alegre

Relata-se a prevalência de hipertensäo arterial sistêmica (HAS) entre homens brancos e pretos numa vila periférica de Porto Alegre (POA), encontrando com significaçäo estatística uma maior freqüência de HAS no grupo de indivíduos pretos. A partir dos dados encontrados e dos resultados referidos na literatura concluímos que os homens pretos possuem uma maior predisposiçäo a esta anormalidade, quando comparados com os indivíduos brancos. Esta diferença é de provável origem multifatorial. Näo foi observada maior severidade na HAS dos indivíduos pretos, quando aferida em relaçäo a pressäo arterial diastólica (Pad)