Angiographic and intravascular ultrasound predictors of sidebranch failure during PCI with provisional side branch stentingapproach in complex coronary bifurcation lesions

Previous randomised trials comparing single vs. double stenting inbifurcation lesions demonstrated cross-over from one to two stent strategy up to30% when single “provisional” stenting was primarily attempted. We sought toinvestigate the predictors of side branch (SB) failure in complex bifurcation lesionstreated with provisional stenting...

Avaliação do atendimento pelo programa Aprendendo com Saúde na Coordenadoria Regional de Saúde Sul da Secretaria Municipal de Saúde de São Paulo / Evaluation of the program by learning from the Health Regional Health South Municipal Health Secretariat of Sao Paulo

O Programa Aprendendo com Saúde (APD) têm como objetivo a promoção, prevenção e a assistência à saúde do escolar, sendo normatizado em setembro de 2007 com o objetivo de ampliar e aperfeiçoar o Programa Municipal de Atenção á Saúde do Escolar(AU)

Avaliação do atendimento pelo programa Aprendendo com Saúde na Coordenadoria Regional de Saúde Sul da Secretaria Municipal de Saúde de São Paulo

O Programa Aprendendo com Saúde (APD) têm como objetivo a promoção, prevenção e a assistência à saúde do escolar, sendo normatizado em setembro de 2007 com o objetivo de ampliar e aperfeiçoar o Programa Municipal de Atenção á Saúde do Escolar

Avaliação do atendimento pelo programa aprendendo com saúde na coordenadoria regional de saúde sul da secretaria municipal de saúde de São Paulo / Evaluation of the program by learning from the health regional health south municipal health secretariat of Sao Paulo

O Programa Aprendendo com Saúde (APD) têm como objetivo a promoção, prevenção e a assistência à saúde do escolar, sendo normatizado em setembro de 2007 com o objetivo de ampliar e aperfeiçoar o Programa Municipal de Atenção á Saúde do Escolar.

Importance of time to reperfusion on outcomes with primary coronary angioplasty for acute myocardial infarction (results from the Stent Primary Angioplasty in Myocardial Infarction Trial).

The mortality benefit of thrombolytic therapy for acute myocardial infarction (AMI) is strongly dependent on time to treatment. Recent observations suggest that time to treatment may be less important with primary percutaneous transluminal coronary angioplasty (PTCA). Patients with AMI of <12 hours duration, without cardiogenic shock, who were treated with primary PTCA from the Stent PAMI Trial (n = 1,232) were evaluated to assess the effect of time to reperfusion on outcomes. Thrombolysis In Myocardial Infarction grade 3 flow was achieved in a high proportion of patients regardless of time to treatment. Improvement in ejection fraction from baseline to 6 months was substantial with reperfusion at <2 hours but was modest and relatively independent of time to reperfusion after 2 hours (<2 hours, 12.3% vs > or =2 hours, 4.2%, p = 0.004). There were no differences in 1- or 6-month mortality by time to reperfusion (6-month mortality: <2 hours [5.5%], 2 to <4 hours [4.6%], 4 to <6 hours [4.5%], >6 hours [4.2%], p = 0.97). There were also no differences in other clinical outcomes by time to reperfusion, except that reinfarction and infarct artery reocclusion at 6 months were more frequent with later reperfusion. The lack of correlation between time to treatment and mortality in patients without cardiogenic shock suggests that the survival benefit of primary PTCA may be related principally to factors other than myocardial salvage. These data may also have implications regarding the triage of patients with AMI for primary PTCA.

The use of primary stenting or balloon percutaneous transluminal coronary angioplasty for the treatment of acutely occluded saphenous vein grafts. Results from the Brazilian National Registry--CENIC. Central Nacional de Intervenções Cardiovasculares.

OBJECTIVE: We conducted a comparative analysis of the in-hospital outcomes of patients who underwent primary percutaneous transluminal angioplasty (PTCA) or stent implantation because of an acute myocardial infarction (AMI) related to an acute vein graft occlusion. METHODS: Since 1991 the Brazilian Society of Hemodynamic and Interventional Cardiology has maintained a large database (CENIC). From these, we selected all consecutive patients, who underwent primary PTCA or stenting in the first 24 hours of AMI, with the target vessel being an occluded vein graft. Immediate results and major coronary events occurring up until hospital discharge were analyzed. RESULTS: During this period, 5,932 patients underwent primary PTCA or stenting; 158 (3%) of the procedures were performed because of an acute vein graft occlusion. Stenting was performed in 74 (47%) patients. Patients treated with stents had a higher success rate and lower mean residual stenosis compared with those who underwent primary balloon PTCA. The incidence of reinfarction and death were similar for stenting and balloon PTCA. CONCLUSION: Primary percutaneous treatment of AMI related to acute vein graft occlusion is still an uncommon practice. Primary stenting improved luminal diameter and offered higher rates of success; however, this strategy did not reduce the in-hospital reinfarction and death rate, compared with that occurring with PTCA treatment.

Lack of neointimal proliferation after implantation of sirolimus-coated stents in human coronary arteries: a quantitative coronary angiography and three-dimensional intravascular ultrasound study.

BACKGROUND: Restenosis remains an important limitation of interventional cardiology. Therefore, we aimed to determine the safety and efficacy of sirolimus (a cell-cycle inhibitor)-coated BX Velocity stents. METHODS AND RESULTS: Thirty patients with angina pectoris were electively treated with 2 different formulations of sirolimus-coated stents (slow release [SR], n=15, and fast release [FR], n=15). All stents were successfully delivered, and patients were discharged without clinical complications. Independent core laboratories analyzed angiographic and 3D volumetric intravascular ultrasound data (immediately after procedure and at 4-month follow-up). Eight-month clinical follow-up was obtained for all patients. There was minimal neointimal hyperplasia in both groups (11.0+/-3.0% in the SR group and 10.4+/-3.0% in the FR group, P:=NS) by ultrasound and quantitative coronary angiography (in-stent late loss, 0.09+/-0.3 mm [SR] and -0.02+/-0.3 mm [FR]; in-lesion late loss, 0.16+/-0.3 mm [SR] and -0.1+/-0.3 mm [FR]). No in-stent or edge restenosis (diameter stenosis >or=50%) was observed. No major clinical events (stent thrombosis, repeat revascularization, myocardial infarction, or death) had occurred by 8 months. CONCLUSIONS: The implantation of sirolimus-coated BX Velocity stents is feasible and safe and elicits minimal neointimal proliferation. Additional placebo-controlled trials are required to confirm these promising results.

Acute myocardial infarction in progressively elderly patients. A comparative analysis of immediate results in patients who underwent primary percutaneous coronary intervention.

OBJECTIVE: Analysis of the in-hospital results, in progressively elderly patients who undergo primary percutaneous coronary intervention (PCI) in the first 24 hours of AMI. METHODS: The patients were divided into three different age groups (60/69, 70/79, and > or =80 years) and were treated from 7/95 until 12/99. The primary success rate and the occurrence of major clinical events were analyzed at the end of the in-hospital phase. Coronary stent implantation and abciximab use were employed at the interventionist discretion. RESULTS: We analyzed 201 patients with age ranging from 60 to 93 years, who underwent primary PCI. Patients with ages above 70 were more often female (p=.015). Those with ages above 80 were treated later with PCI (p=.054), and all of them presented with total occlusion of the infarct-related artery. Coronary stents were implanted in 30% of the patients. Procedural success was lower in > or =80 year old patients (p=.022), and the death rate was higher in > or =70 years olds (p=.019). Reinfarction and coronary bypass surgery were uncommon events. A trend occurred toward a higher combined incidence of major in-hospital events according to increased age (p=.064). CONCLUSION: Elderly patients (> or =70 years) presented with adverse clinical and angiographic profiles and patients > or =80 years of age obtained reduced TIMI 3 flow success rates after primary PTCA, and those > or =70 years had a higher death rate.

One-year follow-up after primary coronary intervention for acute myocardial infarction in diabetic patients. A substudy of the STENT PAMI trial.

OBJECTIVE: This analysis was undertaken to determine the composite incidence of cumulative adverse events (death, reinfarction, disabling stroke, and target vessel revascularization) at the end of the first year after acute myocardial infarction, in diabetic patients who underwent coronary stenting or primary coronary balloon angioplasty. METHODS: From the STENT PAMI trial, we analyzed the 6-month angiographic and 1-year clinical outcomes of 135 diabetic (112, noninsulin dependent) patients who underwent the randomization process of the trial and compared them with 758 nondiabetic patients. RESULTS: Coronary stenting did not significantly reduce the primary composite clinical end point when compared with PTCA (20 vs. 30%, p=0.2). A significant benefit from stenting was observed in patients with noninsulin dependent diabetes, with a trend toward a lesser need for new revascularization procedures (10 vs. 21%, p<.001), with a significant reduction in the primary composite clinical end point at 1 year (12 vs. 28%, p=. 04). At 6 months, the restenosis rate were significantly reduced only in nondiabetic patients (18 vs. 33%, p<. 001). Diabetic patients had the same restenosis rate (38%) either with stenting or balloon PTCA. CONCLUSIONS: Coronary Stenting in diabetics noninsulin dependent offered a significant reduction in the composite incidence of major clinical adverse events compared with balloon PTCA.

A comparative analysis of primary stenting and optimal balloon coronary angioplasty in acute myocardial infarction. Six month results from the STENT PAMI trial.

OBJECTIVE: To compare the outcome of balloon PTCA with final coronary stenosis diameter (SD) < or =30 %, with elective coronary stenting. METHODS: We performed a comparative analysis of the 6 month outcomes in patients treated with primary stenting and those who obtained an optimal balloon PTCA result treated during the first 12 hours of AMI onset included in the STENT PAMI randomized trial. RESULTS: The results were analysed into 3 groups: primary stenting (441 patients, SD=22+/-6 %), optimal PTCA (245 patients), and non-optimal PTCA (182 patients, SD= 37+/-5 %). At the end of the 6 months primary stent group presented with the lowest restenosis(23 vs. 31 vs. 45 %, p=0.001, respectively). Ischemia-driven target vessel revascularization rate (TVR) (7 vs. 15.5 vs. 19 %, p=0.001, respectively). CONCLUSION: At the 6 month follow-up, primary stenting offered the lowest restenosis and ischemia-driven TVR rates. Compared to optimal balloon PTCA. Non-optimal primary balloon PTCA pts (SD=31-50 %), had the worst late angiographic outcomes and should be treated more actively with coronary stent implantation.

Coronary angioplasty with or without stent implantation for acute myocardial infarction. Stent Primary Angioplasty in Myocardial Infarction Study Group.

BACKGROUND: Coronary-stent implantation is frequently performed for treatment of acute myocardial infarction. However, few studies have compared stent implantation with primary angioplasty alone. METHODS: We designed a multicenter study to compare primary angioplasty with angioplasty accompanied by implantation of a heparin-coated Palmaz-Schatz stent. Patients with acute myocardial infarction underwent emergency catheterization and angioplasty. Those with vessels suitable for stenting were randomly assigned to undergo angioplasty with stenting (452 patients) or angioplasty alone (448 patients). RESULTS: The mean (+/-SD) minimal luminal diameter was larger after stenting than after angioplasty alone (2.56+/-0.44 mm vs. 2.12+/-0.45 mm, P<0.001), although fewer patients assigned to stenting had grade 3 blood flow (according to the classification of the Thrombolysis in Myocardial Infarction trial) (89.4 percent, vs. 92.7 percent in the angioplasty group; P=0.10). After six months, fewer patients in the stent group than in the angioplasty group had angina (11.3 percent vs. 16.9 percent, P=0.02) or needed target-vessel revascularization because of ischemia (7.7 percent vs. 17.0 percent, P<0.001). In addition, the combined primary end point of death, reinfarction, disabling stroke, or target-vessel revascularization because of ischemia occurred in fewer patients in the stent group than in the angioplasty group (12.6 percent vs. 20.1 percent, P<0.01). The decrease in the combined end point was due entirely to the decreased need for target-vessel revascularization. The six-month mortality rates were 4.2 percent in the stent group and 2.7 percent in the angioplasty group (P=0.27). Angiographic follow-up at 6.5 months demonstrated a lower incidence of restenosis in the stent group than in the angioplasty group (20.3 percent vs. 33.5 percent, P<0.001). CONCLUSIONS: In patients with acute myocardial infarction, routine implantation of a stent has clinical benefits beyond those of primary coronary angioplasty alone.

Coronary angioplasty in Brazil.

In 1979, the first transluminal coronary angioplasty (PTCA) was performed in Brazil, two years after the original contribution of Andreas Gruentzig, in Zurich. In the years which followed, the development of PTCA in the country grew and in the mid eighties several centres had already had the experience of more than 600 cases. In the beginning of the nineties, PTCA underwent an additional promotion with a large number of procedures, now subventioned by the bodies of public health. In addition to this, the introduction of new technologies such as directional atherectomy, rotablator, laser and stents. In 1991, the Brazilian Society of Interventional Cardiology created a national registry (CENIC) to gather data on the coronary procedures performed in the country. The CENIC data for the 1992/1993 and 1996/1997 bienniums were compared and it was observed that there had been a significant increase in the number of cases treated (from 16,429 in 92/93 to 22,025 in 96/97), complex lesions of the B/C type (from 71.4% to 92.3%), patients with previous revascularisation (from 22% to 28.3%), acute myocardial infarction (from 16% to 17.4%) and multiarterial lesions (from 34.4% to 38.8%). However, despite a greater clinical and angiographic complexity, the success of the procedure grew (from 89.7% to 92.8%) and complications reduced: acute occlusion (from 3.2% to 1.5%); acute myocardial infarction (from 2.5% to 1.2%) and death (from 1.8% to 1.4%). Interventional cardiology in Brazil has consequently progressed at the same rate as that of other countries. The incorporation of new technologies, particularly coronary endoprostheses has increased, guaranteeing better success rates, better results and a decrease in complications arising from acute occlusion of the target vessel.

Safety and efficacy of coronary stent implantation. Acute and six month outcomes of 1,126 consecutive patients treated in 1996 and 1997.

PURPOSE: The authors analyzed the 30-day and 6-month outcomes of 1,126 consecutive patients who underwent coronary stent implantation in 1996 and 1997. METHODS: The 30-day results and 6-month angiographic follow-up were analyzed in patients treated with coronary stents in 1996 and 1997. All patients underwent coronary stenting with high-pressure implantation (> 12 atm) and antiplatelet drug regimen (aspirin plus ticlopidine). RESULTS: During the study period, 1,390 coronary stents were implanted in 1,200 vessels of 1,126 patients; 477 patients were treated in the year 1996 and 649 in 1997. The number of percutaneous procedures performed using stents increased significantly in 1997 compared to 1996 (64% vs 48%, p = 0.0001). The 30-day results were similar in both years: the success and stent thrombosis rates were equal (97% and 0.8%, respectively). The occurrence of new Q wave MI (1.3% vs 1.1%, 1996 vs 1997, p = NS), emergency coronary bypass surgery (1% vs 0.6%, 1996 vs 1997, p = NS) and 30-day death rates (0.2% vs 0.5%, 1996 vs 1997, p = NS) were similar. The 6-month restenosis rate was 25% in 1996 and 27% in 1997 (p = NS); the target vessel revascularization rate was 15% in 1996 and 16% in 1997 (p = NS). CONCLUSIONS: Intracoronary stenting showed a high success rate and a low incidence of 30-day occurrence of new major coronary events in both periods, despite the greater angiographic complexity of the patients treated with in 1997. These adverse variables did not have a negative influence at the 6-month clinical and angiographic follow-up, with similar rates of restenosis and ischemia-driven target lesion revascularization rates.

Primary coronary angioplasty and stent implantation in acute myocardial infarction. Comparative analysis of the in-hospital results in the CENIC/SBHCI registry. National Center of Cardiovascular Interventions members.

OBJECTIVE: Comparative analysis of the in-hospital results after primary implantation of stents or coronary balloon angioplasty in patients with acute myocardial infarction (MI). METHODS: CENIC (National Center of Cardiovascular Interventions) gathered data on 3, 924 patients undergoing coronary angioplasty (in the primary form, without the previous use of thrombolytic agents) in the first 24 hours after a MI, during the period of 1996-1998. From these 3,924 patients, 1,337 (34%) underwent stent implantation. We analyzed the success of the procedure and the occurrence of adverse cardiac events. RESULTS: In patients undergoing stent implantation there were more males (77% vs 69%, p=0.001), previous by pass surgery (6. 3% vs. 4.5%, p=0.01), anterior MI and stent implantation in left descending artery (55% vs. 48% vs. p=0.009), and saphenous vein bypass grafts (3.3% vs. 1.9%). the procedure was more succesful in the group of stents (97% vs. 84%, p=0.001) and reinfarction rate (2. 5 vs. 4%, p=0.002). The need for emergency revascularization was similar (1% vs. 1.1%, NS). Total in-hospital mortality was lower in stent group (3.4% vs. 7. 2%, p=0.0001) and this effect was in patients Killip class III/V (19.5% vs. 32.5%, p= 0.002) because there was no difference in patients class I/II (1.7% vs. 2.8%, p=0. 9). CONCLUSION: Primary stent implantation in acute myocardial infarction showed better early results than balloon angioplasty alome.

Percutaneous handling of coronary lesions >20mm through stents. Is there a first choice strategy?

OBJECTIVE - This study compared the early and late results of the use of one single stent with those of the use of multiple stents in patients with lesions longer than 20mm. METHODS - Prospective assessment of patients electively treated with stents, with optimal stent deployment and followed-up for more than 3 months. From February '94 to January '98, 215 patients with lesions >20mm were treated. These patients were divided into 2 groups as follows: Group A - 105 patients (49%) with one stent implanted; Group B - 110 patients (51%) with multiple stents implanted. RESULTS - The mean length of the lesions was 26mm in group A (21-48mm) versus 29mm in group B (21-52mm) (p=0.01). Major complications occurred in one patient (0.9%) in group A (subacute thrombosis, myocardial infarctionand death) and in 2 patients (1.8%) in group B (one emergency surgery and one myocardial infarction) (p=NS). The results of the late follow-up period (>6 months) were similar for both groups (group A = 82% vs group B = 76%; p=NS), and we observed an event-free survical in 89% of the patients in group A and in 91% of the patients in group B (p=NS). Angina (group A = 11% vs group B = 7%) and lesion revascularization (group A = 5% vs group B = 6%; p=NS) also occurred in a similar percentage. No infarction or death was observed in the late follow-up period; restenosis was identified in 33% and 29% of the patients in groups A and B, respectively (p=NS). CONCLUSION - The results obtained using one stent and using multiple stents were similar; the greater cost-effectiveness of one stent implantation, however, seems to make this strategy the first choice.

[Percutaneous myocardial revascularization procedures in Brazil in 1996-1997 compared to the 1992-1993 period. A report of the National Registry--National Center for Cardiovascular Interventions (CENIC)]. / Intervenções percutâneas para revascularização do miocárdio no Brasil em 1996 e 1997 comparadas as do biênio 1992 e 1993. Relatório do registro CENIC (Central Nacional de Intervenoes Cardiovasculares).

PURPOSE: To report the results of percutaneous coronary interventions, in Brazil, in the years 1996-97, comparing them to those of 1992-93. METHODS: Data were collected in a standard form and the 1996-97 results were compared to those of 1992-93. RESULTS: The current Registry received data from 79% effective members of the SBHCI in 127 hospitals, including 22,025 patients, 60.67% of whom underwent PTCA, 36.57% stent implantation, 2.3% PTRA, 0.06% DCA and 0.4% laser angioplasty. Balloon angioplasty was the most frequent procedure in 1996-97, but its overall rate fell from 6.75% to 55.8% (p = 0.0001) concomitantly, there was a 35% relative increase in the use of stents from 1992-93 to 1996-97. The success rate of the later period was higher (89.7% vs 92.8%, p = 0.000001), with lower residual stenosis (22% vs 19%, p = 0.001). Besides, there were lower major complications rates: acute myocardial infarction (2.5% vs 1.2%, p = 0.002) and death (1.8% vs 1.4%, p = 0.0003). CONCLUSION: The procedures most often carried out in both periods were balloon angioplasty (60.67%) and implantation of stents (36.57%); the success rate high, abrupt closure rate was low (1.5%). These favorable results corroborate the high standards of the Brazilian Interventional Cardiology.

[Coronary arteriography with a very low profile catheter: efficacy and safety of the procedure and of the 60 minute hospital discharge]. / Arteriografia coronária com cateter de muito baixo perfil. Eficácia e segurança do procedimento e da alta hospitalar aos 60 minutos.

PURPOSE: To evaluate the feasibility, efficacy and safety of the use of 4F Judkins catheters for coronary angiography. METHODS: From August/95 to January/96, 70 patients with suspected coronary artery disease underwent coronary cineangiography by the Judkins technique, with 4F catheters. Following puncture of the right femoral artery, 4F sheaths were introduced. At the end of the procedure, the sheath was removed and manual compression was applied for 15 min. Patients were oriented to walk under specialized supervision, 60 min after the procedure, and discharged after 4h. RESULTS: Thirty nine (56%) patients were male, the age ranged from 31 to 83 (mean 57) years and weight from 43 to 101 (mean 69) kg. Optimal quality images were obtained in 62 patients (88%). It was necessary to use larger caliber catheters (6 and 8F) in 8 patients, due to femoral tortuosity or inadequate opacification of coronary arteries. There were no vascular complications nor major bleedings. In only 2 cases (3%) there was a minor bleeding, treated by new local compression. Sixty (85%) patients walked after 60 +/- 5 min and were discharged after 4h. CONCLUSION: The use of 4F catheters for coronary angiography by femoral approach allowed early deambulation with no major bleeding. Image quality was good, with little contrast used and short hospital stay. This technique may lead to a simpler less traumatic and less invasive coronary angiography.

Arteriografia coronária com cateter de muito baixo perfil. Eficácia e segurança do procedimento e da alta hospitalar aos 60 minutos / Coronary arteriography with a very low profile catheter. Efficacy and safety of the procedure and of the 60 minute hospital

OBJETIVO - Avaliar a eficiência, a segurança e a praticidade de angiografia coronária com cateteres 4 French (F), pela técnica de Judkins. MÉtodos - De agosto/95 a janeiro/96, 70 pacientes com suspeita de insuficiência coronária submeteram-se à cinecoronariografia, utilizando introdutores e cateteres 4F. Após o exame, realizava-se compressäo local por 15 min e , 6§ min após, os pacientes eram orientados a caminhar, sob vigilância, sendo dada a alta hospitalar após 4h. RESULTADOS - A idade variou de 31 a 83 (m=57) anos, sendo 39 (56 por cento) homens, com peso entre 43 a 101 (m=69) kg. Obteve-se ótima qualidade de imagem em 62 casos (88 por cento), havendo a necessidade de substituiçäo por cateteres de maior calibre (6 a 8F) em 8 (12 por cento) pacientes. Näo ocorreram complicaçöes vasculares ou sangramentos maiores. Em apenas 2 (3 por cento) casos, houve discreto sangramento, resolvido com nova compressäo local. Sessenta pacientes (85 por cento) deambularam aos 60ñ5 min e tiveram alta hospitalar com 4h, em média

[Influence of the clinical presentation on immediate and long-term results after rotational atherectomy]. / Influência do quadro clínico nos resultados imediatos e tardios após aterectomia rotacional.

PURPOSE: To analyse the influence of unstable coronary syndromes (UCS) in the early and late prognosis after rotational atherectomy (RA). METHODS: We treated 236 patients with RA between Aug/1992 and May/1996. Patients were divided into two groups: A) stable coronary syndromes 120 (51%) patients; B) UCS: 116 (49%) patients. DEFINITIONS: 1) procedure success (PS)--lesion success in all locations were RA use was attempted, without a major complication; 2) late coronary events (LCE)--angina, MI, additional revascularization or death. RESULTS: There was a significant predominance of age > 70 (A = 14% x B = 24%, p = 0.03) in B and previous MI (A = 32% x B = 11%, p = 0.0001) in A. Other characteristics were similar in both groups, including complex lesions (type B2/C), which were observed in 77% A stenosis and 80% B lesions. PS was 95% in A and 92% in B (p = NS). In-hospital major complications were observed in 2.5% A and 4.3% B patients, (p = NS). One patient died in each group. A and B patients had similar time of follow-up. LCE occurred in 25% A and 39% B patients (p = 0.002). Recurrence of angina (36% x 23%; p = 0.01) and target lesion revascularization (29% x 18%; p = 0.03) were also more frequently required in B cases. CONCLUSION: This study suggests that UCS (group A) does not implicate in worse acute results after RA. However, UCS patients present greater incidence of late coronary events, particularly recurrence of angina and target-lesion revascularization.