The Role of the Heart Team in Patients with Diffuse Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting.

BACKGROUND: In patients eligible for coronary artery bypass grafting, no data assess the importance of the Heart Team in programming the best surgical strategy for patients with diffuse coronary artery disease (CAD). This study aims to determine the contribution of the Heart Team in predicting the feasibility of coronary artery bypass graft and angiographic surgical success in these patients based on visual angiographic analysis. METHODS: Patients with diffuse and severe CAD undergoing incomplete coronary artery bypass graft surgery were prospectively included. One-year postoperative coronary angiograms were obtained to evaluate graft occlusion. Two clinical cardiologists, two cardiovascular surgeons, and one interventional cardiologist retrospectively analyzed preoperative angiograms. A subjective scale was applied at a single moment to quantify the chance of successful coronary artery bypass grafting for each coronary territory with anatomical indication for revascularization. Based on individual scores, the Heart Team's and the specialists' scores were calculated and compared. RESULTS: The examiners evaluated 154 coronary territories, of which 85 (55.2%) were protected. The Heart Team's accuracy for predicting the angiographic success of the surgery was 74.9%, almost equal to that of the surgeons alone (73.2%). Only the interventional cardiologist predicted left anterior descending territory grafting success. The Heart Team had good specificity and reasonable sensitivity, and the surgeons had high sensitivity and low specificity in predicting angiographic success. CONCLUSION: The multispecialty Heart Team achieved good accuracy in predicting the angiographic coronary artery bypass graft success in patients with diffuse CAD, with a high specificity and reasonable sensitivity.

Impact of OSA on cardiovascular events after coronary artery bypass surgery.

BACKGROUND: The impact of OSA on new cardiovascular events in patients undergoing coronary artery bypass graft (CABG) surgery is poorly explored. METHODS: Consecutive patients referred for CABG underwent clinical evaluation and standard polysomnography in the preoperative period. CABG surgery data, including percentage of off-pump and on-pump CABG, number of grafts, and intraoperative complications, were collected. The primary end point was major adverse cardiac or cerebrovascular events (MACCEs) (combined events of all-cause death, myocardial infarction, repeated revascularization, and cerebrovascular events). Secondary end points included individual MACCEs, typical angina, and arrhythmias. Patients were evaluated at 30 days (short-term) and up to 6.1 years (long term) after CABG. RESULTS: We studied 67 patients (50 men; mean age, 58 ± 8 years; mean BMI, 28.5 ± 4.1 kg/m2). OSA (apnea-hypopnea index ≥ 15 events/h) was present in 56% of the population. The patients were followed for a mean of 4.5 years (range, 3.2-6.1 years). No differences were observed in the short-term follow-up. In contrast, MACCE (35% vs 16%, P = .02), new revascularization (19% vs 0%, P = .01), episodes of typical angina (30% vs 7%, P = .02), and atrial fibrillation (22% vs 0%, P = .0068) were more common in patients with than without OSA in the long-term follow-up. OSA was an independent factor associated with the occurrence of MACCE, repeated revascularization, typical angina, and atrial fibrillation in the multivariate analysis. CONCLUSIONS: OSA is independently associated with a higher rate of long-term cardiovascular events after CABG and may have prognostic and economic significance in CABG surgery.

Ex-vivo Assessment of Coronary Artery Atherosclerosis by Magnetic Resonance Imaging: Correlation with Histopathology.

INTRODUCTION: In recent years, high-resolution magnetic resonance imaging (MRI) has emerged as a very promising technique for studying atherosclerotic disease in humans. AIM: In the present study we sought to determine whether MRI allowed for the morphological characterization of the coronary vessel wall and atherosclerotic plaques using histopathological assessment as the reference standard. METHODS: The study population consisted of 13 patients who died of acute myocardial infarction and underwent autopsy. The proximal portions of the coronary arteries were excised and were evaluated both by MRI and by histopathology. For each arterial segment, the following parameters were calculated through manual planimetry: 1. total vessel area (TVA); 2. luminal area (LA) and 3. plaque area (PA). RESULTS: A total of 207 coronary artery cross-sections were found to be suitable for analysis by both MRI and histopathology and were included in the final analyses. Both methods demonstrated moderate to good agreement for the quantification of TVA (mean difference = 2.4±2.4 mm(2), 95‰ limits of agreement from -2.4 to +7.2 mm(2); CCC = 0.69, 95‰ CI from 0.63 to 0.75), LA (mean difference = 0.0±1.7 mm(2), 95‰ limits of agreement from -3.3 to + 3.3 mm(2); CCC = 0.84, 95‰ CI from 0.80 to 0.88) and PA (mean difference = 2.4±2.4 mm(2), 95‰ limits of agreement from -2.3 to + 7.1 mm(2); CCC = 0.64, 95‰ CI from 0.58 to 0.71). CONCLUSION: In this ex vivo experimental model we demonstrated good agreement between coronary artery morphometrical measurements obtained by high-resolution MRI and by histopathology.

The involvement of multiple thrombogenic and atherogenic markers in premature coronary artery disease

OBJECTIVE: To examine the association of atherogenic and thrombogenic markers and lymphotoxin-alfa gene mutations with the risk of premature coronary disease. METHODS: This cross-sectional, case-control, age-adjusted study was conducted in 336 patients with premature coronary disease (<50 years old) and 189 healthy controls. The control subjects had normal clinical, resting, and exercise stress electrocardiographic assessments. The coronary disease group patients had either angiographically documented disease (>50% luminal reduction) or a previous myocardial infarction. The laboratory data evaluated included thrombogenic factors (fibrinogen, protein C, protein S, and antithrombin III), atherogenic factors (glucose and lipid profiles, lipoprotein(a), and apolipoproteins AI and B), and lymphotoxin-alfa mutations. Genetic variability of lymphotoxin-alfa was determined by polymerase chain reaction analysis. RESULTS: Coronary disease patients exhibited lower concentrations of HDL-cholesterol and higher levels of glucose, lipoprotein(a), and protein S. The frequencies of AA, AG, and GG lymphotoxin-alfa mutation genotypes were 55.0%, 37.6%, and 7.4% for controls and 42.7%, 46.0%, and 11.3% for coronary disease patients (p = 0.02), respectively. Smoking, dyslipidemia, family history, and lipoprotein(a) and lymphotoxin-alfa mutations in men were independent variables associated with coronary disease. The area under the curve (C-statistic) increased from 0.779 to 0.802 (p<0.05) with the inclusion of lipoprotein(a) and lymphotoxin-alfa mutations in the set of conventional risk factors. CONCLUSIONS: The inclusion of lipoprotein(a) and lymphotoxin-alfa mutations in the set of conventional risk factors showed an additive but small increase in the risk prediction of premature coronary disease. .

The involvement of multiple thrombogenic and atherogenic markers in premature coronary artery disease.

OBJECTIVE: To examine the association of atherogenic and thrombogenic markers and lymphotoxin-alfa gene mutations with the risk of premature coronary disease. METHODS: This cross-sectional, case-control, age-adjusted study was conducted in 336 patients with premature coronary disease (<50 years old) and 189 healthy controls. The control subjects had normal clinical, resting, and exercise stress electrocardiographic assessments. The coronary disease group patients had either angiographically documented disease (>50% luminal reduction) or a previous myocardial infarction. The laboratory data evaluated included thrombogenic factors (fibrinogen, protein C, protein S, and antithrombin III), atherogenic factors (glucose and lipid profiles, lipoprotein(a), and apolipoproteins AI and B), and lymphotoxin-alfa mutations. Genetic variability of lymphotoxin-alfa was determined by polymerase chain reaction analysis. RESULTS: Coronary disease patients exhibited lower concentrations of HDL-cholesterol and higher levels of glucose, lipoprotein(a), and protein S. The frequencies of AA, AG, and GG lymphotoxin-alfa mutation genotypes were 55.0%, 37.6%, and 7.4% for controls and 42.7%, 46.0%, and 11.3% for coronary disease patients (p = 0.02), respectively. Smoking, dyslipidemia, family history, and lipoprotein(a) and lymphotoxin-alfa mutations in men were independent variables associated with coronary disease. The area under the curve (C-statistic) increased from 0.779 to 0.802 (p<0.05) with the inclusion of lipoprotein(a) and lymphotoxin-alfa mutations in the set of conventional risk factors. CONCLUSIONS: The inclusion of lipoprotein(a) and lymphotoxin-alfa mutations in the set of conventional risk factors showed an additive but small increase in the risk prediction of premature coronary disease.

Efficacy of aneurysmectomy in patients with severe left ventricular dysfunction: favorable short-and long-term results in ischemic cardiomyopathy.

INTRODUCTION: The purpose of this study was to (1) identify the functional results after aneurysm surgery in patients with ischemic cardiomyopathy and (2) identify predictors of favorable outcomes. METHODS AND MATERIAL: Patients (n = 169) with angiographic left ventricular ejection fraction of 22 ± 5% underwent aneurysm surgery and were prospectively followed for three years. Prior to surgery, 40% and 60% of the patients were in congestive heart failure NYHA class I/II and III/IV, respectively. Concomitant revascularization was performed on 95% of the patients. RESULTS: Cumulative in-hospital and 36-month mortalities were 7% and 15%, respectively. These respective rates varied according to preoperative parameters: CHF class I-II, 4% and 13%; CHF class III-IV, 8% and 16%; LVEF,20%, 12% and 26%; LVEF 21-30%, 2% and 6%; gated LVEF exercise/rest .5%, ,1% and 4%; and gated LVEF exercise/rest #5%, 17% and 38%. Higher LVEF ex/rest ratio (p = 0.01), male sex (p = 0.05), and a higher number of grafts (p = 0.01) were predictive of improvement in CHF class at follow-up based on the results of a multivariate analysis. After three years of follow-up, 84% of the patients were in class I/II, LVEF was 45 ± 7%, and gated LVEF ex/rest ratio was 13% higher (p,0.01) compared to the beginning of the study. CONCLUSIONS: These data suggest that aneurysmectomy among patients with severe LV dysfunction result in short and long-term favorable functional outcome and survival. Selection of appropriate surgical candidates may substantially improve survival rates among these patients.

Treatment of coronary artery disease in hemodialysis patients evaluated for transplant-a registry study.

BACKGROUND: We assessed the results of a noninvasive therapeutic strategy on the long-term occurrence of cardiac events and death in a registry of patients with chronic kidney disease (CKD) and coronary artery disease (CAD). METHODS: We analyzed 519 patients with CKD (56+/-9 years, 67% men, 67% whites) on maintenance hemodialysis with clinical or scintigraphic evidence of CAD by using coronary angiography. RESULTS: In 230 (44%) patients, coronary angiography revealed significant CAD (lumen reduction > or =70%). Subjects with significant CAD were kept on medical treatment (MT; n=184) or referred for myocardial revascularization (percutaneous transluminal coronary angioplasty/coronary artery bypass graft-intervention; n=30) according to American College of Cardiology/American Heart Association guidelines. In addition, 16 subjects refused intervention and were also followed-up. Event-free survival for patients on MT at 12, 36, and 60 months was 86%, 71%, and 57%, whereas overall survival was 89%, 71%, and 50% in the same period, respectively. Patients who refused intervention had a significantly worse prognosis compared with those who actually underwent intervention (events: hazard ratio=4.50; % confidence interval=1.48-15.10; death: hazard ratio=3.39; % confidence interval 1.41-8.45). CONCLUSIONS: In patients with CKD and significant CAD, MT promotes adequate long-term event-free survival. However, failure to perform a coronary intervention when necessary results in an accentuated increased risk of events and death.

Efficacy of aneurysmectomy in patients with severe left ventricular dysfunction: favorable short-and long-term results in ischemic cardiomyopathy

INTRODUCTION: The purpose of this study was to (1) identify the functional results after aneurysm surgery in patients with ischemic cardiomyopathy and (2) identify predictors of favorable outcomes. METHODS AND MATERIAL: Patients (n = 169) with angiographic left ventricular ejection fraction of 22±5 percent underwent aneurysm surgery and were prospectively followed for three years. Prior to surgery, 40 percent and 60 percent of the patients were in congestive heart failure NYHA class I/II and III/IV, respectively. Concomitant revascularization was performed on 95 percent of the patients. RESULTS: Cumulative in-hospital and 36-month mortalities were 7 percent and 15 percent, respectively. These respective rates varied according to preoperative parameters: CHF class I-II, 4 percent and 13 percent; CHF class III-IV, 8 percent and 16 percent; LVEF,20 percent, 12 percent and 26 percent; LVEF 21-30 percent, 2 percent and 6 percent; gated LVEF exercise/rest .5 percent, ,1 percent and 4 percent; and gated LVEF exercise/rest #5 percent, 17 percent and 38 percent. Higher LVEF ex/rest ratio (p = 0.01), male sex (p = 0.05), and a higher number of grafts (p = 0.01) were predictive of improvement in CHF class at follow-up based on the results of a multivariate analysis. After three years of follow-up, 84 percent of the patients were in class I/II, LVEF was 45±7 percent, and gated LVEF ex/rest ratio was 13 percent higher (p,0.01) compared to the beginning of the study. CONCLUSIONS: These data suggest that aneurysmectomy among patients with severe LV dysfunction result in shortand long-term favorable functional outcome and survival. Selection of appropriate surgical candidates may substantially improve survival rates among these patients.

Transição epidemiológica da mortalidade por doenças circulatórias no Brasil / Epidemiologic transition in mortality rate from circulatory diseases in Brazil / Transición epidemiológica de la mortalidad por enfermedades circulatorias en Brasil

FUNDAMENTO: As doenças circulatórias (DC) são as principais causas de morte no Brasil, com predomínio das doenças cerebrovasculares (DCbV). Nos países desenvolvidos, predominam as doenças isquêmicas do coração (DIC). OBJETIVO: Analisar a relação entre DCbV/DIC em homens e mulheres a partir de 30 anos. MÉTODOS: As estimativas da população e os dados de mortalidade para DC, DIC e DCbV foram obtidos do Ministério da Saúde para o período entre 1980 e 2005. O risco de morte por DIC e DCbV por 100.000 habitantes e a relação entre DCbV/DIC foram analisados nas faixas etárias decenais a partir de 30 anos. O risco de morte foi ajustado pelo método direto, usando como população padrão a população mundial de 1960. RESULTADOS: Observou-se aumento exponencial do risco de morte por DIC e DCbV, com o aumento da faixa etária. DCbV foi a principal causa de morte no Brasil até 1996, quando passou a predominar a DIC. Foi observada redução de 33,25 por cento no risco de morte por DC na população brasileira. Na região metropolitana de São Paulo, houve uma diminuição de 45,44 por cento, entre 1980 e 2005. A relação DCbV/DIC foi maior nas mulheres mais jovens: de 2,53 em 1980 e 2,04 em 2005 para a população brasileira, e de 2,76 em 1980 e 1,96 em 2005 na região metropolitana de São Paulo, com decréscimo nas faixas etárias subsequentes. Nos homens, a relação DCbV/DIC foi próximo de <1 para todas as faixas etárias. CONCLUSÃO: Observou-se, no Brasil, uma transição do risco de morte por DC, com predomínio atual das DIC.

BACKGROUND: Circulatory diseases (CD) are the major cause of death in Brazil, being cerebrovascular diseases (CVD) predominant. In developed countries ischemic heart diseases (IHD) predominate. OBJECTIVE: The objective of the present study was to investigate the ratio between cerebrovascular diseases/ischemic heart diseases (CVD/IHD) in males and females who were 30 years of age and older. METHODS: Population estimates and mortality data for CD, IHD and CVD were provided by the Ministry of Health for the period between 1980 and 2005. The risk of death from IHD and CVD per 100,000 Brazilians and CVD/IHD ratio were analyzed in 10-year age ranges as of 30 years of age. The risk of death was adjusted by direct method by using 1960 world population as the standard population. RESULTS: It was observed that the risk of death from IHD and CVD increased exponentially as age advanced. CVD was the major cause of death in Brazil until 1996, when IHD took the lead. In the period between 1980 and 2005 a 33.25 percent reduction in death risk from CD was observed in the Brazilian population. In that same period, the metropolitan area of the capital city of São Paulo reported a 45.44 percent reduction. The CVD/IHD ratio was shown to be higher among younger women - from 2.53 in 1980 down to 2.04 in 2005 in the Brazilian population, and from 2.76 in 1980 down to 1.96 in the metropolitan area of the capital city of São Paulo, with decreasing figures for subsequent age ranges. Among males, the CVD/IHD ratio was close to < 1 in all age ranges. CONCLUSION: A transition in death risk from CD could be observed in Brazil, with current predominance of IHD.

FUNDAMENTO: Las enfermedades circulatorias (EC) son las principales causas de muerte en Brasil, con el predominio de las enfermedades cerebrovasculares (ECbV). En los países desarrollados predominan las enfermedades isquémicas del corazón (EIC). OBJETIVO: Analizar la relación entre ECbV/EIC en varones y mujeres a partir de 30 años. MÉTODOS: Se obtuvieron en el Ministério de la Salud las estimaciones de la población y los datos de mortalidad para EC, EIC y ECbV para el periodo entre 1980 y 2005. Se analizaron el riesgo de muerte por EIC y ECbV por 100.000 habitantes y la relación entre ECbV/EIC en los grupos de edad decenales a partir de 30 años. Se ajustó el riesgo de muerte por el método directo, usándose como población estándar la población mundial de 1960. RESULTADOS: Se observó un aumento exponencial del riesgo de muerte por EIC y ECbV, con el aumento del grupo de edad. La ECbV fue la principal causa de muerte en Brasil hasta 1996, cuando pasó a predominar la EIC. Se observó una reducción del 33,25 por ciento en el riesgo de muerte por EC en la población brasileña. En la región metropolitana de São Paulo, hubo una disminución del 45,44 por ciento entre 1980 y 2005. La relación ECbV/EIC fue mayor en las mujeres más jóvenes: del 2,53 por ciento en 1980 y del 2,04 por ciento en 2005 para la población brasileña, y del 2,76 por ciento en 1980 y del 1,96 por ciento en 2005 en la región metropolitana de São Paulo, con reducción en los grupos de edad subsiguientes. En los varones, la relación ECbV/EIC fue cerca de <1 para todas los grupos de edad. CONCLUSIÓN: Se observó en Brasil una transición del riesgo de muerte por EC con predominio actual de las EIC.

Epidemiologic transition in mortality rate from circulatory diseases in Brazil.

BACKGROUND: Circulatory diseases (CD) are the major cause of death in Brazil, being cerebrovascular diseases (CVD) predominant. In developed countries ischemic heart diseases (IHD) predominate. OBJECTIVE: The objective of the present study was to investigate the ratio between cerebrovascular diseases/ischemic heart diseases (CVD/IHD) in males and females who were 30 years of age and older. METHODS: Population estimates and mortality data for CD, IHD and CVD were provided by the Ministry of Health for the period between 1980 and 2005. The risk of death from IHD and CVD per 100,000 Brazilians and CVD/IHD ratio were analyzed in 10-year age ranges as of 30 years of age. The risk of death was adjusted by direct method by using 1960 world population as the standard population. RESULTS: It was observed that the risk of death from IHD and CVD increased exponentially as age advanced. CVD was the major cause of death in Brazil until 1996, when IHD took the lead. In the period between 1980 and 2005 a 33.25% reduction in death risk from CD was observed in the Brazilian population. In that same period, the metropolitan area of the capital city of São Paulo reported a 45.44% reduction. The CVD/IHD ratio was shown to be higher among younger women - from 2.53 in 1980 down to 2.04 in 2005 in the Brazilian population, and from 2.76 in 1980 down to 1.96 in the metropolitan area of the capital city of São Paulo, with decreasing figures for subsequent age ranges. Among males, the CVD/IHD ratio was close to < 1 in all age ranges. CONCLUSION: A transition in death risk from CD could be observed in Brazil, with current predominance of IHD.

Intramyocardial injection of autologous bone marrow cells as an adjunctive therapy to incomplete myocardial revascularization--safety issues.

OBJECTIVES: To determine the safety of intramyocardial injection of autologous bone marrow cells in patients undergoing surgical myocardial revascularization (CABG) for severe coronary artery disease. INTRODUCTION: There is little data available regarding the safety profile of autologous bone marrow cells injected during surgical myocardial revascularization. Potential risks include arrythmias, fibrosis in the injected sites and growth of non-cardiac tissues. METHODS: Ten patients (eight men) were enrolled; they were 59+/-5 years old with limiting angina and were non-optimal candidates for complete CABG. Bone marrow cells (1.3+/-0.3x10(8)) were obtained prior to surgery, and the lymphomonocytic fraction (CD34+ =1.8+/-0.3%) was separated by density gradient centrifugation. During surgery, bone marrow cells were injected in non-grafted areas of ischemic myocardium. During the first year after surgery, the patients underwent laboratory tests, cardiac imaging, and 24-hour ECG monitoring. RESULTS: Injected segments: inferior (n=7), anterior (n=2), septal (n=1), apical (n=1), and lateral (n=1) walls. Except for a transient elevation of C-reactive protein at one month post-surgery (P=0.01), laboratory tests results were within normal ranges; neither complex arrhythmias nor structural abnormalities were detected during follow-up. There was a reduction in functional class of angina from 3.6+/-0.8 (baseline) to 1.2+/-0.4 (one year) (P<0.0001). Also, patients had a significant decrease in the ischemic score assessed by magnetic resonance, not only globally from 0.65+/-0.14 (baseline) to 0.17+/-0.05 (one year) (P=0.002), but also in the injected areas from 1.11+/-0.20 (baseline) to 0.34+/-0.13 (one year) (P=0.0009). CONCLUSIONS: Intramyocardial injection of bone marrow cells combined with CABG appears to be safe. Theoretical concerns with arrhythmias and/or structural abnormalities after cell therapy were not confirmed in this safety trial.

Transmyocardial laser revascularization plus cell therapy for refractory angina.

We report that the use of transmyocardial laser revascularization combined with intramyocardial injection is a therapeutic option for patients with severe ischemic heart disease (IHD) not amenable to conventional myocardial revascularization. Recently, cell therapy with autologous bone marrow cells (BMC) has been tested in clinical trials for severe IHD. We tested the hypothesis that TMLR combined with intramyocardial injection of BMC is safe, and may help increase the functional capacity and myocardial perfusion in patients with refractory angina. We enrolled 8 patients (7 men), 64+/-4 years old, with refractory angina, non-candidates for another procedure. TMLR (8+/-2 laser drills) was performed via a limited thoracotomy. BMC were obtained prior to surgery, and the lymphomonocytic fraction was separated by density gradient centrifugation. During surgery, 5 mL containing approximately 1.6+/-0.2 x 10(8) BMC (CD34+=1.7+/-0.4%) was delivered by multiple injections in the ischemic myocardium. We observed a reduction in the ischemic score as assessed by MRI from 1.56+/-0.09 (B) to 0.93+/-0.10 (6M) (P=0.01), as well as a reduction in functional class of angina from 3.6+/-0.2 (B) to 1.4+/-0.2 (6M) (P<0.0001). We concluded that, in this early experience, the combined strategy of TMLR plus cell therapy appeared to be safe, and may have synergistically acted to reduce myocardial ischemia, with clinically relevant improvement in functional capacity.

Intramyocardial injection of autologous bone marrow cells as an adjunctive therapy to incomplete myocardial revascularization: safety issues

OBJECTIVES: To determine the safety of intramyocardial injection of autologous bone marrow cells in patients undergoing surgical myocardial revascularization (CABG) for severe coronary artery disease. INTRODUCTION: There is little data available regarding the safety profile of autologous bone marrow cells injected during surgical myocardial revascularization. Potential risks include arrythmias, fibrosis in the injected sites and growth of non-cardiac tissues. METHODS: Ten patients (eight men) were enrolled; they were 59±5 years old with limiting angina and were non-optimal candidates for complete CABG. Bone marrow cells (1.3±0.3x10(8)) were obtained prior to surgery, and the lymphomonocytic fraction (CD34+=1.8±0.3 percent) was separated by density gradient centrifugation. During surgery, bone marrow cells were injected in non-grafted areas of ischemic myocardium. During the first year after surgery, the patients underwent laboratory tests, cardiac imaging, and 24-hour ECG monitoring. RESULTS: Injected segments: inferior (n=7), anterior (n=2), septal (n=1), apical (n=1), and lateral (n=1) walls. Except for a transient elevation of C-reactive protein at one month post-surgery (P=0.01), laboratory tests results were within normal ranges; neither complex arrhythmias nor structural abnormalities were detected during follow-up. There was a reduction in functional class of angina from 3.6±0.8 (baseline) to 1.2±0.4 (one year) (P<0.0001). Also, patients had a significant decrease in the ischemic score assessed by magnetic resonance, not only globally from 0.65±0.14 (baseline) to 0.17±0.05 (one year) (P=0.002), but also in the injected areas from 1.11±0.20 (baseline) to 0.34±0.13 (one year) (P=0.0009). CONCLUSIONS: Intramyocardial injection of bone marrow cells combined with CABG appears to be safe. Theoretical concerns with arrhythmias and/or structural abnormalities after cell therapy...

Screening for significant coronary artery disease in high-risk renal transplant candidates.

BACKGROUND: Renal transplant candidates are at an increased risk for coronary artery disease (CAD), a strong predictor of cardiovascular events [major adverse coronary events (MACE)]. Coronary angiography is a costly, risky, invasive procedure. We sought to determine clinical predictors of significant CAD (stenosis > or =70%) in high-risk renal transplant candidates. METHODS: Clinical evaluation and coronary angiography were performed in 301 patients (57+/-8 years, 73% men) on hemodialysis for 32 months (median). Patients were followed-up for 22 months (median). Inclusion criteria were diabetes (type 1 or 2), evidence of cardiovascular disease, or age > or =50 years. Risk factors included hypertension (93.7%), overweight/obesity (54.3%), dyslipidemia (44.9%), diabetes (42.1%), and smoking (24.3%). Cardiovascular disease was found as follows: peripheral arterial disease (PAD) (31.2%), angina (28.1%), stroke (12.9%), myocardial infarction (MI) (10.3%), and heart failure (9.3%). RESULTS: Significant CAD was found in 136 individuals (45.2%). Diabetes [odds ratio (OR)=1.82; 95% confidence interval (CI)=1.08-3.07], PAD (OR=2.50; 95% CI=1.44-4.37), and previous MI (OR=7.75; 95% CI=3.03-23.98) were associated with significant CAD. The prevalence of significant CAD increased with the number of clinical predictors from 26% (none) to 100% (all present) (P<0.0001). The incidence of fatal/nonfatal MACE increased two, four, and sixfold in those with diabetes, PAD, or previous MI, respectively (P<0.0001). CONCLUSIONS: In high-risk patients with end-stage renal disease, the prevalence of CAD and the incidence of MACE were high. Significant CAD or cardiovascular complications were not related to the majority of classic risk factors. Patients with diabetes, PAD, or previous MI are at higher risk of CAD, MACE, or both and, thus, must be referred for invasive diagnostic procedures.

Cell therapy plus transmyocardial laser revascularization for refractory angina.

We describe the use of autologous bone marrow cells combined with transmyocardial laser revascularization in a 74-year-old man with refractory angina. Baseline cardiac magnetic resonance imaging revealed a markedly depressed left ventricle systolic function and an extensive area of myocardial ischemia. During surgery, 11 laser shots using a CO2 Heart Laser System (PLC Medical Systems, Milford, MA) were fired and a 5-mL cell suspension containing 21.5 x 10(6) bone marrow cells/mL was delivered by multiple injections into the myocardium. At 6 months after the procedure, another cardiac magnetic resonance imaging showed an almost complete resolution of the perfusion defect and an improvement in left ventricular contractility.

Distribution of risk factors in parents and siblings of patients with early coronary artery disease.

OBJECTIVE: Early coronary artery disease (CAD) is associated with risk factors (RF). Offspring of parents with a RF have a greater prevalence of them. However, the distribution of RF in parents and siblings of patients with early CAD is unknown. METHODS: The study comprised the parents and siblings of 42 patients with early CAD (< 45 years), 29 males. Their mean age was 39.5 +/- 3.7 years. The following major RF were analyzed: smoking (> 5 cigarretes/day), hypercholesterolemia (total cholesterol > 200 mg/dL), hypertension (diastolic blood pressure > 90 mmHg), and diabetes (glycemia > 126 mg/dL). RESULTS: Of a total of 102 RF, 4, 3, 2, and 1 were observed in, respectively, 5, 15, 15, and 7 patients with early CAD, the most prevalent being smoking (86%) and hypercholesterolemia (83%). Diabetes was observed in 15 (36%) and hypertension in 16 (38%) patients. Smoking was more prevalent in the fathers (76%) and hypercholesterolemia in the mothers (30%). In 183 siblings, 131 RF were observed (1 patient with the disease had a mean of 4.7 siblings). The prevalences of smoking, hypertension, hypercholesterolemia, and diabetes in the siblings were, respectively, 32%, 18%, 14%, and 9%. The incidence of RF was as follows: 72 (39%) siblings had 1 RF, 25 (14%) siblings had 2 RF, and 3 (2%) siblings had 3 RF. In parents and their offspring, smoking was moderately correlated (r=0.43; P=0.02) with CAD. CONCLUSION: Smoking habit of parents is passed on to offspring, and, in association with hypercholesterolemia, it was the major cause of early CAD in offspring. High prevalence of smoking in offspring shows the potential responsibility of parents in the incidence of the disease in offspring.

Distribuiçäo dos fatores de risco em pais e irmäos de pacientes com doença arterial coronariana / Distribution of risk factors in parents and siblings of patients with early coronary artery disease

OBJECTIVE: Early coronary artery disease (CAD) is associated with risk factors (RF). Offspring of parents with a RF have a greater prevalence of them. However, the distribution of RF in parents and siblings of patients with early CAD is unknown. METHODS: The study comprised the parents and siblings of 42 patients with early CAD (< 45 years), 29 males. Their mean age was 39.5±3.7 years. The following major RF were analyzed: smoking (> 5 cigarretes/day), hypercholesterolemia (total cholesterol > 200 mg/dL), hypertension (diastolic blood pressure > 90 mmHg), and diabetes (glycemia > 126 mg/dL). RESULTS: Of a total of 102 RF, 4, 3, 2, and 1 were observed in, respectively, 5, 15, 15, and 7 patients with early CAD, the most prevalent being smoking (86 percent) and hypercholesterolemia (83 percent). Diabetes was observed in 15 (36 percent) and hypertension in 16 (38 percent) patients. Smoking was more prevalent in the fathers (76 percent) and hypercholesterolemia in the mothers (30 percent). In 183 siblings, 131 RF were observed (1 patient with the disease had a mean of 4.7 siblings). The prevalences of smoking, hypertension, hypercholesterolemia, and diabetes in the siblings were, respectively, 32 percent, 18 percent, 14 percent, and 9 percent. The incidence of RF was as follows: 72 (39 percent) siblings had 1 RF, 25 (14 percent) siblings had 2 RF, and 3 (2 percent) siblings had 3 RF. In parents and their offspring, smoking was moderately correlated (r=0.43; P=0.02) with CAD. CONCLUSION: Smoking habit of parents is passed on to offspring, and, in association with hypercholesterolemia, it was the major cause of early CAD in offspring. High prevalence of smoking in offspring shows the potential responsibility of parents in the incidence of the disease in offspring

Disfunçäo endotelial e as síndromes coronárias agudas / Endothelial dysfunction and acute coronary syndromes

Revisamos os mecanismos que contribuem para a instabilizaçäo da placa aterosclerótica com conqüente isquemia aguda do miocárdio, manifestando-se clinicamente como angina instável e infarto do miocárdio näo-Q. Sao descritas as interaçöes entre o endotélio, a placa os agentes vasomotores, as plaquetas e as células sanguíneas. Os mecanismos dessa instabilizaçäo säo confrontados com os achado clínicos, angiográficos, e anatomoplatológicos de vários estudos, desde a década de 1970 até a atual, podendo-se propor um raciocínio lógico, que elucida resultados prévios sem explicaçäo convincente bem como a integraçäo dos resultados de estudos experimentais recentes confirmados por pesquisas no ser humano.

Fibrilação atrial aguda na unidade de emergência: qual a droga ideal para rápida reversäo ao ritmo sinusal? / Acute Atrial Fibrillation. Which is the Best Drug for Sinus Rhythm Conversion in the Emergency Room ?

Objetivo - Comparar o tempo e o índice de sucesso para reversäo da fibrilaçäo atrial (FA) aguda, com o uso de amiodarona, procainamida ou quinidina. Métodos - Aleatoriamente, 60 pacientes com FA aguda foram divididos em três grupos, recebendo o grupo quinidina (GQ), constituído de 21 pacientes, digital EV + quinidina até 600mg VO; o grupo procainamida (GP) com 23 pacientes, digital EV + 10mg/kg de procainamida EV e o grupo amiodarona (GA), com 16 pacientes 5mg/kg de amiodarona EV. O período de observaçäo foi de no máximo 4h, através de Holter. Na análise estatíca foi utilizado o teste de x2 com o método de Kruskall-Wallis, considerando-se significativo p<0,05. Resultados - Os três grupos foram similares quanto a idade, sexo e tempo de instalaçäo da FA. A reversäo ocorreu em 71,4 por cento dos casos no GQ, em 47,8 por cento no GP e em 50 por cento no GA, (p>0,05). O tempo para reversäo em minutos foi de 112 + ou - 43 no G!, de 44,1 + ou - 28 no GP, de 20 + ou - 13 no GA, sendo menor e estatisticamente significante no GP e, principalmente, no GA (p= 0,001) em relaçäo ao GQ. Os efeitos colaterais foram mais freqüentes no GP, embora sem significância estatística. Conclusäo - A amiodarona, especialmente na ausência de cardiopatia de base, é uma boa opçäo para maior rapidez na reversäo da FA, enquanto a quinidina propicia maior taxa de reversäo, com menos efeitos colaterais

Relação entre o ECG convencional e a artéria coronária responsável no infarto agudo do miocárdio / The relationship between conventional ECG and the culprit coronary artery in acute myocardial infarct

PURPOSE--To evaluate electrocardiogram (ECG) in detecting acute myocardial infarction (AMI) during the first 12 hours of symptoms and its relationship to the culprit coronary artery. METHODS--We studied 68 patients aged 55.6 (30 to 76) years, 61 males, with AMI confirmed by elevated CKMB isoenzyme and cinecoronariography (CINE). In all of them we obtained two ECG: first (i), with < 12 hours of symptoms and a second, > or = 5 days during evolution. ECG were analyzed in order to disclose up and downward ST-T segments > or = 1 mm, new Q waves > or = 0.04 s and R/S > or = 1 plus downward ST-T segment in leads V1 and V2. Then we have done correlation between these and the culprit coronary lesions at CINE. RESULTS--The culprit coronary lesions were: right coronary artery (RCA) in 16, left circumflex (LC) in 26 and left anterior descending (LAD) in 31 cases. According to the ECG, the RCA determined inferior AMI in all patients and the LC only in 62 por cento of cases. Posterior AMI due to LC was seen in 81 por cento of cases at ECG and, associated with lateral AMI, in 52 por cento . Lone lateral AMI was seen in 5 por cento and true posterior in 14 por cento of cases, all of them due to LC. CONCLUSION--False negative ECG (i) in AMI is in fact due to LC occlusion which, frequently, causes posterior wall more then inferior wall myocardial infarction at ECG