Fifteen years of coronary intravascular ultrasound in percutaneous coronary intervention in Portugal. / Quinze anos de ecografia intravascular coronária em intervenção coronária percutânea em Portugal.

INTRODUCTION: Coronary intravascular ultrasound (IVUS) is increasingly important in catheterization laboratories due to its positive prognostic impact. This study aims to characterize the use of IVUS in percutaneous coronary intervention (PCI) in Portugal. METHODS: A retrospective observational study was performed based on the Portuguese Registry on Interventional Cardiology of the Portuguese Society of Cardiology. The clinical and angiographic profiles of patients who underwent PCI between 2002 and 2016, the percentage of IVUS use, and the coronary arteries assessed were characterized. RESULTS: A total of 118 706 PCIs were included, in which IVUS was used in 2266 (1.9%). Over time, use of IVUS changed from none in 2002 to generally increasing use from 2003 (0.1%) to 2016 (2.4%). The age of patients in whom coronary IVUS was used was similar to that of patients in whom IVUS was not used, but in the former group there were fewer male patients, and a higher prevalence of cardiovascular risk factors (hypertension, hypercholesterolemia and diabetes), previous myocardial infarction, previous PCI, multivessel coronary disease, C-type or bifurcated coronary lesions, and in-stent restenosis. IVUS was used in 54.8% of elective PCIs and in 19.15% of PCIs of the left main coronary artery. CONCLUSION: Coronary IVUS has been increasingly used in Portugal since 2003. It is used preferentially in elective PCIs, and in patients with higher cardiovascular risk, with more complex coronary lesions and lesions of the left main coronary artery.

Thrombus aspiration in patients with ST-elevation myocardial infarction: results of a national registry of interventional cardiology.

BACKGROUND: We aimed to evaluate the impact of thrombus aspiration (TA) during primary percutaneous coronary intervention (P-PCI) in 'real-world' settings. METHODS: We performed a retrospective study, using data from the National Registry of Interventional Cardiology (RNCI 2006-2012, Portugal) with ST-elevation myocardial infarction (STEMI) patients treated with P-PCI. The primary outcome, in-hospital mortality, was analysed through adjusted odds ratio (aOR) and 95% confidence intervals (95%CI). RESULTS: We assessed data for 9458 STEMI patients that undergone P-PCI (35% treated with TA). The risk of in-hospital mortality with TA (aOR 0.93, 95%CI:0.54-1.60) was not significantly decreased. After matching patients through the propensity score, TA reduced significantly the risk of in-hospital mortality (OR 0.58, 95%CI:0.35-0.98; 3500 patients). CONCLUSIONS: The whole cohort data does not support the routine use of TA in P-PCI, but the results of the propensity-score matched cohort suggests that the use of selective TA may improve the short-term risks of STEMI.

Trends in primary angioplasty in Portugal from 2002 to 2013 according to the Portuguese National Registry of Interventional Cardiology. / Angioplastia primária em Portugal entre 2002-2013. Atividade segundo o Registo Nacional de Cardiologia de Intervenção.

INTRODUCTION AND OBJECTIVES: The aim of the present paper was to report trends in coronary angioplasty for the treatment of ST-elevation myocardial infarction (STEMI) in Portugal. METHODS: Prospective multicenter data from the Portuguese National Registry of Interventional Cardiology (RNCI) and official data from the Directorate-General for Health (DGS) were studied to analyze percutaneous coronary intervention (PCI) procedures for STEMI from 2002 to 2013. RESULTS: In 2013, 3524 primary percutaneous coronary intervention (p-PCI) procedures were performed (25% of all procedures), an increase of 315% in comparison to 2002 (16% of all interventions). Between 2002 and 2013 the rate increased from 106 to 338 p-PCIs per million population per year. Rescue angioplasty decreased from 70.7% in 2002 to 2% in 2013. During this period, the use of drug-eluting stents grew from 9.9% to 69.5%. After 2008, the use of aspiration thrombectomy increased, reaching 46.7% in 2013. Glycoprotein IIb-IIIa inhibitor use decreased from 73.2% in 2002 to 23.6% in the last year of the study. Use of a radial approach increased steadily from 8.3% in 2008 to 54.6% in 2013. CONCLUSION: During the reporting period there was a three-fold increase in primary angioplasty rates per million population. Rescue angioplasty has been overtaken by p-PCI as the predominant procedure since 2006. New trends in the treatment of STEMI were observed, notably the use of drug-eluting stents and radial access as the predominant approach.

Trends in percutaneous coronary intervention from 2004 to 2013 according to the Portuguese National Registry of Interventional Cardiology.

INTRODUCTION AND OBJECTIVES: The aim of the present paper is to report trends in Portuguese interventional cardiology from 2004 to 2013 and to compare them with other European countries. METHODS: Based on the Portuguese National Registry of Interventional Cardiology and on official data from the Directorate-General of Health, we give an overview of developments in coronary interventions from 2004 to 2013. RESULTS: In 2013, 36 810 diagnostic catheterization procedures were performed, representing an increase of 34% compared to 2007 and a rate of 3529 coronary angiograms per million population. Coronary interventions increased by 65% in the decade from 2004 to 2013, with a total of 13 897 procedures and a rate of 1333 coronary interventions per million population in 2013. Primary percutaneous coronary intervention (PCI) increased by 265% from 2004 to 2013 (1328 vs. 3524), an adjusted rate of 338 primary PCIs per million, representing 25% of total angioplasties. Stents were the most frequently used devices, drug-eluting stents being used in 73% in 2013. Radial access increased from 4.1% in 2004 to 57.9% in 2013. CONCLUSION: Interventional cardiology in Portugal has been expanding since 2004. We would emphasize the fact that in 2013 all Portuguese interventional cardiology centers were participating in the National Registry of Interventional Cardiology, as well as the growth in primary PCI and increased use of radial access.

Performance of traditional risk factors in identifying a higher than expected coronary atherosclerotic burden.

OBJECTIVE: To evaluate the performance of traditional cardiovascular (CV) risk factors in identifying a higher than expected coronary atherosclerotic burden. METHODS: We assessed 2069 patients undergoing coronary CT angiography, with assessment of calcium score (CS), for suspected coronary artery disease. A higher than expected atherosclerotic burden was defined as CS >75th percentile (CS >P75) according to age and gender-adjusted monograms. The ability of traditional CV risk factors to predict a CS >P75 was assessed in a customized logistic regression model ("Clinical Score") and by the calculation of SCORE (Systemic Coronary Risk Evaluation). The population attributable risk (PAR) of risk factors for CS >P75 was calculated. RESULTS: The median CS was 3.0 (IQR 0.0-98.0); 362 patients had CS >P75. The median SCORE was 3.0 (IQR 1.0-4.0). With the exception of hypertension, all traditional CV risk factors were independent predictors of CS >P75: diabetes, dyslipidemia, smoking and family history (OR 1.3-2.2, p≤0.026). The areas under the ROC curves for CS >P75 were 0.64 for the Clinical Score (95% CI 0.61-0.67, p<0.001) and 0.53 for SCORE (95% CI 0.50-0.56, p=0.088). About a quarter of patients with CS >P75 were in the two lower quartiles of the Clinical Score. Altogether, the traditional risk factors explain 56% of the prevalence of CS >P75 (adjusted PAR 0.56). CONCLUSION: Despite the association of CV risk factors with a higher than expected atherosclerotic burden, they appear to explain only half of its prevalence. Even when integrated in scores, the predictive power of these risk factors was modest, exposing the limitations of risk stratification based solely on demographic and clinical risk factors.

Takayasu arteritis revisited.

Takayasu arteritis is a large vessel vasculitis with various clinical presentations depending on the territories affected. We report the case of a 47-year-old woman who was diagnosed with Takayasu arteritis following rapid progression of coronary disease. The condition evolved rapidly under corticosteroid therapy, with formation of new arterial stenoses within the carotid and splanchnic circulations. Disease remission was achieved with cyclophosphamide pulses and percutaneous angioplasty of the affected vessels was performed.

Renal denervation in patients with resistant hypertension: six-month results.

INTRODUCTION: Increased activation of the sympathetic nervous system plays a central role in the pathophysiology of hypertension (HTN). Catheter-based renal denervation (RDN) was recently developed for the treatment of resistant HTN. AIM: To assess the safety and efficacy of RDN for blood pressure (BP) reduction at six months in patients with resistant HTN. METHODS: In this prospective registry of patients with essential resistant HTN who underwent RDN between July 2011 and May 2013, the efficacy of RDN was defined as ≥ 10 mm Hg reduction in office systolic blood pressure (SBP) six months after the intervention. RESULTS: In a resistant HTN outpatient clinic, 177 consecutive patients were evaluated, of whom 34 underwent RDN (age 62.7 ± 7.6 years; 50.0% male). There were no vascular complications, either at the access site or in the renal arteries. Of the 22 patients with complete six-month follow-up, the response rate was 81.8% (n=18). The mean office SBP reduction was 22 mm Hg (174 ± 23 vs. 152 ± 22 mm Hg; p<0.001) and 9 mm Hg in diastolic BP (89 ± 16 vs. 80 ± 11 mm Hg; p=0.006). The number of antihypertensive drugs (5.5 ± 1.0 vs. 4.6 ± 1.1; p=0.010) and pharmacological classes (5.4 ± 0.7 vs. 4.6 ± 1.1; p=0.009) also decreased significantly. Of the 24-hour ambulatory BP monitoring and echocardiographic parameters analyzed, there were significant reductions in diastolic load (45 ± 29 vs. 27 ± 26%; p=0.049) and in left ventricular mass index (174 ± 56 vs. 158 ± 60 g/m(2); p=0.014). CONCLUSION: In this cohort of patients with resistant HTN, RDN was safe and effective, with a significant BP reduction at six-month follow-up.

[Non-obstructive coronary artery disease documented by cardiac computed tomography: Discrepancy between atherosclerotic burden and cardiovascular risk]. / Doença coronária não obstrutiva documentada por tomografia computorizada cardíaca: contraste entre a carga aterosclerótica e o risco cardiovascular.

Cardiac computed tomography (CT) documents the presence of coronary artery disease, regardless of the degree of stenosis. The prognostic value of non-obstructive coronary artery disease documented by cardiac CT has recently been validated. However, there are still no clear guidelines on the management of such patients, particularly concerning initiation of more aggressive pharmacological measures for primary prevention. The approach to these patients remains controversial, especially in cases in which there is a discrepancy between cardiovascular risk and the atherosclerotic burden as documented by cardiac CT. The authors describe the case of a patient with a discrepancy between the extent of documented coronary atherosclerosis and that estimated according to pretest probability and cardiovascular risk scores. As this individual had more severe coronary atherosclerosis than expected (calcium score above the 90th percentile and non-obstructive coronary artery disease on cardiac CT) but was a competitive athlete and otherwise asymptomatic and without risk factors or cardiovascular history, with a very low estimated cardiovascular risk, it was difficult to decide on the risks and benefits of pharmacological primary prevention.

Coronary computed tomography angiography-adapted Leaman score as a tool to noninvasively quantify total coronary atherosclerotic burden.

To describe a coronary computed tomography angiography (CCTA)-adapted Leaman score (CT-LeSc) as a tool to quantify total coronary atherosclerotic burden with information regarding localization, type of plaque and degree of stenosis and to identify clinical predictors of a high coronary atherosclerotic burden as assessed by the CT-LeSc. Single center prospective registry including a total of 772 consecutive patients undergoing CCTA (Dual-source CT) from April 2011 to March 2012. For the purpose of this study, 581 stable patients referred for suspected coronary artery disease (CAD) without previous myocardial infarction or revascularization procedures were included. Pre-test CAD probability was determined using both the Diamond-Forrester extended CAD consortium method (DF-CAD consortium model) and the Morise score. Cardiovascular risk was assessed with the HeartScore. The cut-off for the 3rd tercile (CT-LeSc ≥8.3) was used to define a population with a high coronary atherosclerotic burden. The median CT-LeSc in this population (n = 581, 8,136 coronary segments evaluated; mean age 57.6 ± 11.1; 55.8 % males; 14.6 % with diabetes) was 2.2 (IQR 0-6.8). In patients with CAD (n = 341), the median CT-LeSc was 5.8 (IQR 3.2-9.6). Among patients with nonobstructive CAD, most were classified in the lowest terciles (T1, 43.0 %; T2, 36.1 %), but 20.9 % were in the highest tercile (T3). The majority of the patients with obstructive CAD were classified in T3 (78.2 %), but 21.8 % had a CT-LeSc in lower terciles (T1 or T2). The independent predictors of a high CT-LeSc were: Male sex (OR 1.73; 95 % CI 1.04-2.90) diabetes (OR 2.91; 95 % CI 1.61-5.23), hypertension (OR 2.54; 95 % CI 1.40-4.63), Morise score ≥ 16 (OR 1.97; 95 % CI 1.06-3.67) and HeartScore ≥ 5 (OR 2.42; 95 % CI 1.41-4.14). We described a cardiac CT adapted Leaman score as a tool to quantify total (obstructive and nonobstructive) coronary atherosclerotic burden, reflecting the comprehensive information about localization, degree of stenosis and type of plaque provided by CCTA. Male sex, hypertension, diabetes, a HeartScore ≥5 % and a Morise score ≥ 16 were associated with a high coronary atherosclerotic burden, as assessed by the CT-LeSc. About one fifth of the patients with nonobstructive CAD had a CT-LeSc in the highest tercile, and this could potentially lead to a reclassification of the risk profile of this subset of patients identified by CCTA, once the prognostic value of the CT-LeSc is validated.

Are intraventricular gradients a cause of false positive treadmill exercise tests?

BACKGROUND: Treadmill exercise testing has low specificity for the detection of significant epicardial coronary artery disease (CAD). A possible mechanism to explain some of the false positives is transient subendocardial ischemia induced by intraventricular gradients (IVG) during stress. The development of IVG during dobutamine stress echocardiography (DSE) occurs in 8-38% of non-selected populations. OBJECTIVES: To determine: 1. the prevalence of IVG in a selected population of false positives on treadmill stress testing; 2. whether this prevalence is different from that described for non-selected populations; 3. whether patient characteristics are related to the presence of IVG; 4. the relation between the presence of IVG and the occurrence of ECG abnormalities, symptoms and blood pressure. METHODS AND RESULTS: We evaluated 50 consecutive patients with false positive treadmill stress tests (normal CT coronary angiography, nuclear perfusion tests or angiography) with DSE (2D and Doppler evaluation). All DSE exams were negative for ischemia. Stress-induced IVG was seen in 34 of the 50 patients (68%) and 16 patients (32%) did not develop IVG (p<0.05). The prevalence of IVG in our selected population (68%) was significantly higher than that described for non-selected populations (8-38%) (p<0.001). Most patient characteristics (gender, age, risk factors for CAD, treatment with beta-blockers/calcium antagonists, significant valvular disease/left ventricular hypertrophy [LVH], symptoms, and blood pressure during stress) were not statistically associated with the prevalence of IVG (p>0.05). However, the presence of IVG was associated with the occurrence of ischemic ST depression during dobutamine stress echo (p<0.05). CONCLUSIONS: 1. The prevalence of IVG during dobutamine stress echocardiography in a selected population of false positives on treadmill stress testing is very high, occurring in more than two-thirds of patients. 2. This prevalence is significantly higher than that described for non-selected populations. 3. Age, gender, risk factors for CAD, treatment with beta-blockers/calcium channel antagonists, significant valvular disesase/LVH, symptoms and blood pressure during stress were not associated with the presence or absence of IVG. 4. The presence of IVG is associated with the occurrence of ischemic ST changes during dobutamine stress echocardiography.