Coronary atherosclerotic burden assessed by SYNTAX scores and outcomes in surgical, percutaneous or medical strategies: a retrospective cohort study.

INTRODUCTION: Coronary atherosclerotic burden and SYNTAX Score (SS) are predictors of cardiovascular events. OBJECTIVES: To investigate the value of SYNTAX scores (SS, SYNTAX Score II (SSII) and residual SYNTAX Score (rSS)) for predicting cardiovascular events in patients with coronary artery disease (CAD). DESIGN: Retrospective cohort study. SETTING: Single tertiary centre. PARTICIPANTS: Medicine, Angioplasty or Surgery Study database patients with stable multivessel CAD and preserved ejection fraction. INTERVENTIONS: Patients with CAD undergoing coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI) or medical treatment (MT) alone from January 2002 to December 2015. PRIMARY AND SECONDARY OUTCOMES: Primary: 5-year all-cause mortality. Secondary: composite of all-cause death, myocardial infarction, stroke and subsequent coronary revascularisation at 5 years. RESULTS: A total of 1719 patients underwent PCI (n=573), CABG (n=572) or MT (n=574) alone. The SS was not considered an independent predictor of 5-year mortality in the PCI (low, intermediate and high SS at 6.5%, 6.8% and 4.3%, respectively, p=0.745), CABG (low, intermediate and high SS at 5.7%, 8.0% and 12.1%, respectively, p=0.194) and MT (low, intermediate and high SS at 6.8%, 6.9% and 6.5%, respectively, p=0.993) cohorts. The SSII (low, intermediate and high SSII at 3.6% vs 7.9% vs 10.5%, respectively, p<0.001) was associated with a higher mortality risk in the overall population. Within each treatment strategy, SSII was associated with a significant 5-year mortality rate, especially in CABG patients with higher SSII (low, intermediate and high SSII at 1.8%, 9.7% and 10.0%, respectively, p=0.004) and in MT patients with high SSII (low, intermediate and high SSII at 5.0%, 4.7% and 10.8%, respectively, p=0.031). SSII demonstrated a better predictive accuracy for mortality compared with SS and rSS (c-index=0.62). CONCLUSIONS: Coronary atherosclerotic burden alone was not associated with significantly increased risk of all-cause mortality. The SSII better discriminates the risk of death. TRIAL REGISTRATION NUMBER: ISRCTN66068876.

Late myocardial reperfusion in ST-elevation myocardial infarction: protocol for a systematic review and meta-analysis.

INTRODUCTION: ST-segment elevation myocardial infarction (STEMI) is the most severe clinical form of acute myocardial infarction, for which the current treatment consists of effective and timely myocardial reperfusion (within 12 hours of symptom onset). However, between 10% and 15% of patients with STEMI arrive at hospital facilities 12 hours after the onset of symptoms (late presentation). Therefore, the objective of the present study will be to determine if late revascularisation (12-72 hours after the onset of symptoms) affects the indicators of cardiovascular mortality, reinfarction, recurrent infarction, hospitalisation for heart failure and post infarction angina compared with no late revascularisation in patients with STEMI. METHODS AND ANALYSIS: A systematic literature search of PubMed, The Cochrane Library, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Scopus and Global Health will be conducted. Publications in English, Portuguese or Spanish that report the clinical results of primary percutaneous revascularisation (primary PCI) in adult patients with STEMI 12-72 hours after the onset of symptoms will be included. Studies with participants with a diagnosis other than STEMI or patients with STEMI of >12 hours complicated by heart failure, cardiogenic shock or ventricular arrhythmias, and studies of combined interventions (pharmacoinvasive strategy) were excluded. Two independent authors will identify the relevant publications, and discrepancies will be adjudicated by a third author. Data extraction will be performed by two independent authors and verified by a third author. Risk of bias of studies will be assessed using the Cochrane 'risk of bias' tool (RoB 2) or Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool. If appropriate, a meta-analysis will be performed in order to examine the effect of late revascularisation in clinical outcomes of interest. ETHICS AND DISCUSSION: This study will use published data only, thus, ethical approval will not be required. The results will be disseminated through peer-reviewed publication and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42021283429.

Self-efficacy instruments for individuals with coronary artery disease: a systematic review protocol.

INTRODUCTION: Self-efficacy is associated with management of diseases, psychological well-being, improved quality of life and rehabilitation adherence. Several instruments related to behaviour or specific disease (eg, coronary artery disease (CAD)) assess self-efficacy. The evaluation of cardiac self-efficacy in individuals with CAD will support healthcare professionals to improve self-efficacy via interventions; therefore, a suitable instrument is crucial. This systematic review aims to assess measurement properties, methodological quality and content of outcome measures of cardiac self-efficacy instruments for individuals with CAD. METHODS AND ANALYSIS: The study has been developed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol and Consensus Norms for Selection of Health Measuring Instruments (COSMIN). The following databases will be searched: MEDLINE (Ovid), Web of Science, EMBASE and PsycINFO. Studies assessing measurement properties of cardiac self-efficacy instruments for individuals with CAD will be included. No date or language restrictions will be applied to the search. Two independent authors will be responsible for assessing the eligibility of studies. Methodological quality of studies will be assessed using the COSMIN RoB Checklist, and the Grading of Recommendations, Assessment, Development and Assessment will be used to assess the quality of each study. Two authors will independently evaluate the content of instruments and link this to the International Classification of Functioning, Disability and Health. ETHICS AND DISSEMINATION: This study does not require ethics committee approval since it is based on previously published data. Evidence from this systematic review will be disseminated through publication in peer-reviewed journals and presentation at scientific conferences. PROSPERO REGISTRATION NUMBER: CRD42021262613.

Projected impact of change in the percentage of energy from each NOVA group intake on cardiovascular disease mortality in Brazil: a modelling study.

OBJECTIVE: Estimate reductions in cardiovascular mortality achievable through improvement in nutrient intakes according to processing level (NOVA classification), that is, reducing consumption of culinary ingredients (G2), processed (G3) and ultra-processed foods (G4) while encouraging consumption of unprocessed and minimally processed foods (G1). DESIGN: Modelling study. SETTING: General adult population of Brazil. PARTICIPANTS: Men and women aged 25 or more years (34 003) investigated in the Household Budget Survey 2017-2018, in the consumption data module. MAIN OUTCOME MEASURES: We used the IMPACT Food Policy Model to estimate the reduction in deaths from cardiovascular diseases (CVD) up to 2048 in five scenarios with reductions in saturated fat, trans fat, salt and added sugar intakes resulting from changes in NOVA groups. (1) The optimistic scenario modelised an increase in the energy intake provided by G1 and a reduction in the energy intake from G2, G3 and G4, return to previous levels. (2) The minimal scenario modelised a 3.7% increase in the energy intake from G1, and a reduction in the energy intake from G4 to the 2008-2009 level. (3) The modest scenario only modelised a 25.0% reduction of the energy intake from G2 and G3. (4) The intermediary scenario modelised the minimal scenario plus a 25.0% reduction in the energy intake from G2. (5) Finally, the advanced scenario modelised the minimal scenario plus a 25.0% reduction in the energy intake from G2 and G3. RESULTS: Proposed changes in the optimistic scenario could prevent or delay 52.8% CVD-related deaths by 2048. Changes modelled in the minimal, modest, intermediary and advanced scenarios may result in a 10.1%, 28.4%, 31.4% and 38.6% reduction in 2048 CVD mortality, respectively. CONCLUSIONS: Substantial health gains can be achieved by improving the diet, through plausible modifications aimed at the level of processing as a tool for Brazilian food policies.

Ranolazina en cardiopatía isquémica crónica: un factor protector frente a la fibrilación auricular de novo / Ranolazine in chronic ischaemic heart disease: a protective factor against de novo atrial fibrillation

Resumen Introducción: en pacientes con cardiopatía isquémica crónica, ranolazina se ha mostrado eficaz ante casos de angina. Estudios recientes la valoran como fármaco para prevenir la fibrilación auricular poscardioversión eléctrica, posquirúrgica o posinfarto. Objetivos: valorar la presencia a largo plazo de episodios de fibrilación auricular de novo en pacientes con cardiopatía isquémica crónica y nuevo episodio de angina inestable que inician ranolazina 350 o 500 mg/12 h, en comparación con el tratamiento habitual. Métodos: estudio observacional retrospectivo que compara la incidencia de fibrilación auricular de novo en 77 pacientes consecutivos, con diagnóstico de cardiopatía isquémica no revascularizable y nuevo ingreso por síndrome coronario agudo durante el año 2013, en comparación con los que iniciaron ranolazina frente a tratamiento convencional, en los 12 meses siguientes al evento. La detección de fibrilación auricular se basó en su presencia en un primer registro electrocardiográfico. Resultados: de 77 pacientes, 38 iniciaron ranolazina, sin diferencias en cuanto a las características basales de las dos poblaciones, con similares tasas de factores de riesgo cardiovascular clásicos, datos ecocardiográficos como tamaño auricular, o tratamiento previo empleado. Se observó una tasa de fibrilación auricular de novo del 5,3% en los pacientes tratados con ranolazina, frente al 23,1% en el grupo sin ranolazina (p<0,001). Al analizar el subgrupo de pacientes que presentó fibrilación auricular en su seguimiento, únicamente es significativa la no toma de ranolazina (p<0,001). Conclusión: el uso de ranolazina en pacientes con cardiopatía isquémica crónica no revascularizable podría suponer un efecto protector para el desarrollo de fibrilación auricular durante un seguimiento de al menos doce meses.

Abstract Introduction: Ranolazine has shown to be effective in cases of angina in patients with chronic ischaemic heart disease. Recent studies have evaluated it as a drug to prevent electrical post-cardioversion, post-surgical or post-infarction atrial fibrillation. Objectives: To perform a long-term evaluation of de novo atrial fibrillation episodes in patients with chronic ischaemic heart disease and a new episode of unstable angina that are taking 350 or 500 mg/12 h of ranolazine, in comparison with usual treatment. Methods: An observational, retrospective study was performed to compare the incidence of de novo atrial fibrillation in 77 consecutive patients with a diagnosis of non-revascularisable ischaemic heart disease and a new hospital admission due to acute coronary syndrome during the year 2013. These were compared with those that started with ranolazine and those on conventional treatment in the 12 months following the event. The detection of atrial fibrillation was based on its presence in a first electrocardiographic register. Results: Of the 77 patients, 38 were started on ranolazine, with no differences as regards the baseline characteristics of the two populations. They had similar rates of classic cardiovascular risk factors, echocardiographic data, such as atrial size, or previous treatment employed. A de novo atrial fibrillation rate of 5.3% was observed in the patients treated with ranolazine, compared to 23.1% in the non-ranolazine group (P<.001). On analysing the sub-group of patients that had an atrial fibrillation in their follow-up, only not taking of ranolazine was significant (P<.001). Conclusion: The use of ranolazine in patients with non-revascularisable ischaemic heart disease could have a protective effect against the development of atrial fibrillation during a 12 months follow-up.

Infarto de miocardio tras la administración de adrenalina intragingival ¿Una nueva causa de infarto agudo de miocardio sin enfermedad coronaria aterosclerótica obstructiva? / Myocardial infarction after intra-gingival administration of adrenaline. A new cause of myocardial infarction without obstructive coronary atherosclerosis?

Resumen Es frecuente la relación entre la adrenalina administrada por vía intramuscular y el desarrollo de cardiopatía isquémica. La adrenalina potencia las hemostasias primaria y secundaria -puede producir trombosis intracoronaria- y causa vasoconstricción transitoria arteriolar. Se presenta un caso clínico de una paciente que acudió a urgencias por dolor torácico pocas horas después de una intervención dentaria. En el estudio posterior se descubrió un infarto de miocardio por trombosis intracoronaria de la descendente anterior distal.

Abstract There is a relationship between adrenaline administered intramuscularly and the development of ischaemic heart disease. Adrenaline promotes primary and secondary haemostasis, which can produce a coronary thrombosis and cause a transient arteriolar vasoconstriction. A case is presented of a patient who was seen in the Emergency Department with chest pain a few hours after dental treatment. In the subsequent work-up, it was discovered that she had a myocardial infarction due to a coronary thrombosis of the left anterior distal artery.

Takayasu arteritis with multiple coronary involvement and early graft relapse.

Coronary artery disease (CAD) due to Takayasu arteritis (TA) is rare. This article reports a case of severe involvement of multiple coronary arteries in a young woman. She was treated with coronary artery bypass grafting and had an early venous graft stenosis despite immunosuppressants. She became asymptomatic one year after a drug-eluting stent placement. This report shows the complexity of the diagnostic and therapeutic approach to TA with complex CAD.

Temperature variability and hospitalization for ischaemic heart disease in Brazil: A nationwide case-crossover study during 2000-2015.

BACKGROUND: Previous studies have suggested a potential relationship between temperature variability (TV) and ischaemic heart disease (IHD) but the nature and strength differ between studies. We quantify the association between TV and risk of hospitalization for IHD across Brazilian regions and examine how the relationship varies across important population subgroups. METHODS: Data on hospitalization for IHD and meteorological parameters were collected from 1814 cities during 2000-2015. TV was defined as the standard deviation of daily minimum and maximum temperatures during exposure days. City-specific estimates were quantified using a time-stratified case-crossover approach, and then pooled at the national level using a random-effect meta-analysis. Stratified analyses were performed by region, sex and three age-groups. RESULTS: There were 2,864,904 IHD hospitalizations during 2000-2015. The estimate of TV effect was strongest on 0-1 days' exposure: odds ratio was 1.019 [95% confidence interval (CI): 1.013-1.025] per 5 °C increase in TV. The relationship was stronger in men [1.025 (95%CI: 1.017-1.033)] than in women [1.011 (95%CI: 1.002-1.019)] and in successively older age groups [1.034 (95%CI: 1.018-1.050)]. Regional differences existed, with the association only apparent in the most ageing parts of Brazil. CONCLUSIONS: Exposure to TV is associated with increased risk of hospitalization for IHD, particularly in men and in older age groups. Our findings add to the growing evidence regarding the potential impact of climatic factors on important health outcomes.

Histology of atherosclerotic plaque from coronary arteries of deceased patients after coronary artery bypass graft surgery. / Histología de la placa de ateroma en arterias coronarias de fallecidos después de una revascularización miocárdica quirúrgica.

BACKGROUND AND AIM: Ischaemic heart disease is an important health problem. The characteristics of atherosclerotic plaques determine patient outcome. The aim of this study was to determine the histological grade of coronary atherosclerotic lesions in deceased patients after coronary artery bypass graft surgery, and to identify the complications of the severe plaques. METHOD: A descriptive, cross-sectional, prospective study was carried out on 21 anatomical pieces of deceased patients over a period of 3 years. The epicardial coronary arteries were sectioned transversally every 1cm, and the odd numbered fragments and the regions of the anastomosis with the grafts were selected. They were embedded in paraffin, stained with haematoxylin-eosin, and the histological slides were studied using an Olympus BHM microscope. RESULTS: An age over 50 years (85.7%), male gender (81.0%), and smoking (66.7%) predominated. Peri-operative infarction (38.1%) and cardiogenic shock (33.3%) were the main direct causes of death. The majority of the grafts were of venous origin (64.6%), and 149 lesions were detected, of which 116 (77.8%) were severe plaques, and 47.4% of them were located in the left anterior descending artery. The large majority (81.9%) of the lesions were located in the arterial segments proximal to the graft. A total of 255 histological complications were detected in the severe plaques, with 75.0% showing calcification. Hypertensive patients had more plaques with more complications, but no statistically significant association was found between these variables. CONCLUSIONS: Severe plaques predominated, mostly located in the proximal segments of the coronary arteries, and the left anterior descending was the most affected artery. Calcification was the most observed complication in the severe plaques.

Chronic Kidney Disease in the Caribbean Island of Antigua: Causes, Morbidity and Mortality Factors / Enfermedad renal crónica en la isla caribeña de Antigua: causas, morbilidad y factores de mortalidad

ABSTRACT Background: Chronic kidney disease (CKD) and its associated high morbidity and mortality cause a significant economic burden and decreased quality of life in affected patients in Antigua, the rest of the Caribbean and globally. The causes of CKD in Antigua, morbidity and mortality factors affecting the sampled patients were evaluated with a view to formulating interventions to minimize the occurrence and the impact of these factors. Objective: To determine the causes of CKD over a nine-year period and the causes of morbidity and mortality among patients with CKD at the two main hospitals in Antigua. Methods: A retrospective review was done of the medical records of patients with CKD who were diagnosed between January 1, 2005 and December 1, 2013. Chronic kidney disease was defined as a glomerular filtration rate of less than 60 mL/minute/1.73 m2. The causes of CKD, the patients 'admission diagnoses, the causes of death and laboratory investigations were evaluated. Results: The documented causes of CKD in these patients were diabetes mellitus (51% of the patients), hypertension (26%), glomerulonephritis (5%) and lupus nephritis (4%). The causes of morbidity among the patients with CKD were myocardial infarction (5.1%), unstable angina (12.7%) and ischaemic stroke (12%). Contributing significantly to the patients 'morbidity were catheter-associated sepsis (8.1%, p < 0.001) and lower respiratory tract infections (5.4%). The main factors contributing to the patients 'mortality were myocardial infarction (16.7%) and catheter-associated sepsis (16.7%). Conclusion: This study documented that the most common causes of CKD among the sampled patients in Antigua were diabetes mellitus and hypertension. Ischaemic heart disease and infections were the major causes of morbidity and mortality among the patients. Early recognition and aggressive management of CKD and its risk factors and complications are important in reducing the clinical and economic burden associated with CKD.

RESUMEN Antecedentes: La enfermedad renal crónica (ERC) y su alta morbilidad y mortalidad asociadas, son causa de una importante carga económica y disminución de la calidad de vida entre los pacientes afectados en Antigua, el resto del Caribe y en todo el mundo. Se evaluaron las causas de la ERC en Antigua, así como los factores de morbilidad y mortalidad que afectan a los pacientes muestreados, con el fin de formular intervenciones encaminadas a minimizar la ocurrencia y el impacto de estos factores. Objetivo: Determinar las causas de la ERC durante un período de nueve años y las causas de morbilidad y mortalidad entre pacientes con ERC en los dos principales hospitales de Antigua. Métodos: Se realizó una revisión retrospectiva de las historias clínicas de los pacientes con ERC diagnosticados entre el 1 de enero de 2005 y el 1 de diciembre de 2013. La enfermedad renal crónica se definió como una tasa de filtración glomerular inferior a 60 ml/minuto/1.73 m2. Se evaluaron las causas de la ERC, los diagnósticos de admisión de los pacientes, así como las causas de muerte y las investigaciones de laboratorio. Resultados: Las causas documentadas de la ERC en estos pacientes fueron la diabetes mellitus (51% de los pacientes), la hipertensión (26%), la glomerulonefritis (5%), y la nefritis lúpica (4%). Las causas de morbilidad entre los pacientes con ERC fueron el infarto de miocardio (5.1%), la angina inestable (12.7%) y el accidente cerebrovascular isquémico (12%). La sepsis asociada con catéter (8.1%, p < 0.001) y las infecciones de las vías respiratorias inferiores (5.4%) contribuyeron significativamente a la morbilidad de los pacientes. Los principales factores que contribuyeron a la mortalidad de los pacientes fueron el infarto del miocardio (16.7%) y la sepsis asociada con catéter (16.7%). Conclusión: Este estudio documentó que las causas más comunes de ERC entre los pacientes incluidos en la muestra en Antigua fueron la diabetes mellitus y la hipertensión. La enfermedad cardíaca isquémica y las infecciones fueron las principales causas de morbilidad y mortalidad entre los pacientes. El diagnóstico temprano y el tratamiento agresivo de la ERC y sus factores y complicaciones de riesgo, son asuntos de importancia a la hora de reducir la carga clínica y económica asociadas con ERC.

Situación futura de la cardiopatía isquémica en el estado de San Luis Potosí: un modelo dinámico predictivo / Future status of ischaemic heart disease in the state of San Luis Potosí: A predictive dynamic model

Resumen Objetivo: Desarrollar un modelo dinámico predictivo para generar y analizar la situación futura de la tasa de incidencia de la enfermedad isquémica del corazón en población de 25 años y mayores en México, en función de la variación en el tiempo de algunos factores de riesgo. Método: Estudio ecológico retrospectivo durante el periodo 2013-2015, en la ciudad de San Luis Potosí (México). Se utilizaron bases de datos secundarias con indicadores oficiales de los 58 municipios que conforman el estado de San Luis Potosí, los cuales corresponden a los años 2000, 2005 y 2010. Se analizaron 8 indicadores a nivel municipio, por medio de los métodos de análisis de componentes principales, modelos de ecuaciones estructurales, modelaje dinámico y software de simulación. Resultados: Fueron extraídos 3 componentes que en conjunto explican el 80.43% de la varianza total de los indicadores oficiales utilizados; el segundo componente tiene un peso de 16.36 unidades que favorecen el incremento de la enfermedad analizada; este componente está integrado solo por el indicador EDAD 60-64 y el escenario esperado del mismo va en aumento. El modelo estructural confirma que los indicadores explican el 42% de la variación de esta enfermedad; los posibles escenarios para los años 2015, 2020 y 2025 son de 195.7, 240.7 y 298, respectivamente, por cada 100,000 habitantes de 25 años y mayores. Conclusiones: Se espera un incremento exponencial en la tasa de incidencia de la enfermedad isquémica del corazón; la edad de 60-64 años se identificó como el factor de riesgo de más peso. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Abstract Objective: To develop a predictive dynamic model to generate and analyse the future status of the incidence rate of ischaemic heart disease in a population of 25 years and over in Mexico, according to the variation in time of some risk factors. Method: Retrospective ecological study performed during the period 2013-2015, in San Luis Potosí City, Mexico. Secondary databases that corresponded to the years 2000, 2005, and 2010, were used along with official indicators of the 58 municipalities of the state of San Luis Potosí. Eight indicators were analysed at municipality level, using principal components analysis, structural equation modelling, dynamic modelling, and simulation software methods. Results: Three components were extracted, which together explained 80.43% of the total variance of the official indicators used. The second component had a weight of 16.36 units that favoured an increase of the disease analysed. This component was integrated only by the indicator AGE 60-64 and the expected stage of it increasing. The structural model confirmed that the indicators explain 42% of the variation of this disease. The possible stages for the years 2015, 2020, and 2025 are 195.7, 240.7, and 298.0, respectively for every 100,000 inhabitants aged 25 and over. Conclusions: An exponential increase in the incidence rate of ischaemic heart disease is expected, with the age of 60-64 years being identified as the highest risk factor. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/).

[Future status of ischaemic heart disease in the state of San Luis Potosí: A predictive dynamic model]. / Situación futura de la cardiopatía isquémica en el estado de San Luis Potosí: un modelo dinámico predictivo.

OBJECTIVE: To develop a predictive dynamic model to generate and analyse the future status of the incidence rate of ischaemic heart disease in a population of 25 years and over in Mexico, according to the variation in time of some risk factors. METHOD: Retrospective ecological study performed during the period 2013-2015, in San Luis Potosí City, Mexico. Secondary databases that corresponded to the years 2000, 2005, and 2010, were used along with official indicators of the 58 municipalities of the state of San Luis Potosí. Eight indicators were analysed at municipality level, using principal components analysis, structural equation modelling, dynamic modelling, and simulation software methods. RESULTS: Three components were extracted, which together explained 80.43% of the total variance of the official indicators used. The second component had a weight of 16.36 units that favoured an increase of the disease analysed. This component was integrated only by the indicator AGE 60-64 and the expected stage of it increasing. The structural model confirmed that the indicators explain 42% of the variation of this disease. The possible stages for the years 2015, 2020, and 2025 are 195.7, 240.7, and 298.0, respectively for every 100,000 inhabitants aged 25 and over. CONCLUSIONS: An exponential increase in the incidence rate of ischaemic heart disease is expected, with the age of 60-64 years being identified as the highest risk factor.

Cardiogenic shock as the first manifestation of large vessel vasculitis in a young patient: case report.

BACKGROUND: Cardiogenic shock secondary to coronary involvement in large vessel vasculitis (LVV) is an unsuspected finding, even more, when no other vascular territories are compromised and when it constitutes the initial clinical manifestation. This case report illustrates a case in which a complete diagnostic study uncovered this aetiology. CASE SUMMARY: A 33-year-old woman with cough and chest pain who was diagnosed with acute bronchitis returned with worsening dyspnoea, chest pain, and developed cardiogenic shock. The initial differential diagnoses included myocarditis and takotsubo cardiomyopathy (TCM) owing to a positive troponin I, and echocardiogram with left ventricular dilation, dyskinesia in mid-ventricular and apical segments, systolic dysfunction, and functional mitral regurgitation. A cardiac magnetic resonance showed contractility abnormalities resembling the pattern of TCM but lacked the characteristic myocardial oedema. Subsequently, a coronary angiography expected to result without obstructions showed a critical narrowing of the left main coronary artery. Surgical management consisted of a pericardium patch grafted in the stenotic ostium to restore adequate perfusion. The surgical specimens were sent to the pathology laboratory that reported findings compatible with LVV. Four days after the surgical intervention the patient was discharged alive with a complete recovery of left ventricular systolic function. DISCUSSION: Chest pain symptoms in a young woman, could be caused by multiple entities, and an ischaemic aetiology from a non-atherosclerotic origin should be kept in mind. A complete study with coronary angiography is crucial to rule out an ischaemic cause even in low-risk groups for atherosclerotic coronary heart disease.

Threats to security and ischaemic heart disease deaths: the case of homicides in Mexico.

Background: Ischaemic heart disease (IHD) ranks as the leading cause of death worldwide. Whereas much attention focuses on behavioural and lifestyle factors, less research examines the role of acute, ambient stressors. An unprecedented rise in homicides in Mexico over the past decade and the attendant media coverage and publicity have raised international concern regarding its potential health sequelae. We hypothesize that the rise in homicides in Mexico acts as an ecological threat to security and elevates the risk of both transient ischaemic events and myocardial infarctions, thereby increasing IHD deaths. Methods: We applied time-series methods to monthly counts of IHD deaths and homicides in Mexico for 156 months spanning January 2000 to December 2012. Methods controlled for strong temporal patterns in IHD deaths, the unemployment rate and changes in the population size at risk. Results: After controlling for trend and seasonality in IHD deaths, a 1-unit increase in the logged count of homicides coincides with a 7% increase in the odds of IHD death in that same month (95% confidence interval: 0.04 - 0.10). Inference remains robust to additional sensitivity checks, including a state-level fixed effects analysis. Conclusions: Our findings indicate that the elevated level of homicides in Mexico serves as a population-level stressor that acutely increases the risk of IHD death. This research adds to the growing literature documenting the role of ambient threats, or perceived threats, to security on cardiovascular health.

Diabetes mellitus e doença isquêmica do coraçäo. Comparaçäo por sexo / Diabetes mellitus and ischaemic heart disease. Comparison by gender

Objetivo - testar a associaçäo do diabetes mellitus com a doença isquêmica do coraçäo (DIC), em cada sexo, procedendo-se ao ajustamento simultâneio para possíveis variáveis de confusäo e/ou modificadoras de efeito. Métodos - O estudo teve um delineamento tipo caos controle e a coleta de dados foi processada entre março/93 e fevereiro/94. Utilizou-se a estratégia de compor dois bancos de dados (um para cada sexo) que permitiram analisar, separadamente, a associaçäo de principal interesse. Os respecvos tamanhos das amostras foram de 547 indivíduos para o sexo masculino e 286 para o feminino. Cada um dos bancos foi composto por indivíduos na faixa etária de 30 a 69 anso, residentes no município de Säo Paulo. A técnica estatística utilizada para a análise dos dados foi a regressäo logística multivariada. Resultados - foram identificadas medidas de efeito semelhantes em cada uma das composiçöes do estudo, näo se constituindo o diabetes em fator de risco independente para a DIC. Verificou-se, em ambasa composiçöes , um efeito independente para as variáveis hipertensäo arterial, hipercolesterolemia, hábito de fumar e antecedente familiares de cardiopatia. As interaçöes entre o diabetes e as categorias de exposiçäo de outras variáveis näo apresentaram significância estatística. Conclusäo- conlcuiu-se que o desaparecimento da associaçäo diabetes mellitus vs DIC foi decorrente da presença, nos modelos de potentes fatores de risco para a DIC.