Cardiovascular prevention in coronary heart disease patients: guidelines implementation in clinical practice.

OBJECTIVE: To demonstrate the utilization of a clinical improvement program in stable coronary artery disease patients to increase the evidence-proven treatment utilization, and to describe the ongoing clinical practice and lifestyle change counseling. METHODS: Cross-sectional study followed by a longitudinal component in which the tools utilization to improve clinical practice was assessed by means of additional cross-sectional data collection. 710 consecutive patients were included (Phase 1). After tools implementation, within 6 months period, 705 patients were included (Phase 2) for comparative analysis. Randomly, 318 patients from Phase 1 were selected, 6-12 months after the first evaluation (Phase 3). RESULTS: Phase 1 to Phase 2: there were improvement on smoking cessation (P=0.019), dyslipidemia (P<0.001), hypertension and physical activity (P<0.001). There was significant difference on angiotensin converting enzyme inhibitors - ACEI (67.2% vs. 56.8%, P<0.001); angiotensin II receptor blockers - ARB II (25.4% vs. 32.9%, P=0.002) and beta-blocker (88.7% vs. 91.9%, P=0.047). Phase 1 to Phase 3: there was both weight (P=0.044), and blood pressure reduction (P<0.001). There was statistical significant difference on ACEI (64.8% vs. 61.6%, P=0.011) and ARB II (27.0% vs. 31.3%, P=0.035). CONCLUSION: There was no significant change on the evidence-based pharmacological treatment utilization between pre and post-intervention phases; there was significant improvement concerning smoking and physical activity in phase 2; substantial improvement on blood pressure levels in both comparisons (Phase 1 to 2 and Phase 1 to 3). The inclusion of a case-manager for the process management was crucial for program efficacy. Comprehensive programs for clinical practice should be pursued for longer follow-up period.

Prevenção cardiovascular abrangente em pacientes com doença arterial coronária: implementação das diretrizes na prática clínica / Cardiovascular prevention in coronary heart disease patients: guidelines implementation in clinical practice

OBJETIVO: Demonstrar a eficácia de um programa de otimização da prática clínica em pacientes com doença arterial coronária para prescrição de medicamentos e documentar a prática clínica vigente quanto aos medicamentos e medidas para a mudança do estilo de vida. MÉTODOS: Estudo de corte transversal, seguido de componente longitudinal. Foram incluídos 710 pacientes consecutivos (Fase 1). Após aplicação de ferramentas para melhoria da prática clínica, foram incluídos, após seis meses, 705 pacientes com coleta dos mesmos dados (Fase 2). Foram selecionados aleatoriamente, a partir do primeiro grupo, 318 prontuários para comparação desses mesmos pacientes (Fase 3). RESULTADOS: Comparação entre as Fases 1 e 2: melhora em relação a tabagismo (P=0,019), dislipidemia (P<0,001), hipertensão arterial e atividade física regular (P<0,001). Diferença significativa para inibidores da enzima de conversão da angiotensina - IECA (67,2% vs. 56,8%, P<0,001); antagonistas do receptor da angiotensina II - ARA II (25,4% vs. 32,9%, P=0,002) e betabloqueador (88,7% vs. 91,9%, P=0,047). Comparação entre as Fases 1 e 3: houve redução do peso (P=0,044) e pressão arterial (P<0,001). Em relação à prescrição de medicamentos recomendados, diferença para IECA (64,8% vs. 61,6%, P=0,011) e ARA II (27,0% vs. 31,3%, P=0,035). CONCLUSÃO: Não houve mudança significativa na utilização de medicamentos; entretanto, observou-se melhora significativa em relação ao tabagismo e atividade física na Fase 2; melhora substancial nos níveis de pressão arterial, na comparação tanto entre as Fases 1 e 2 como entre as Fases 1 e 3. A inclusão de enfermeiro treinado para gerenciar o processo foi fundamental. Programas abrangentes de melhoria de qualidade assistencial, provavelmente, devem ser continuados por período de seguimento maior.

OBJECTIVE: To demonstrate the utilization of a clinical improvement program in stable coronary artery disease patients to increase the evidence-proven treatment utilization, and to describe the ongoing clinical practice and lifestyle change counseling. METHODS: Cross-sectional study followed by a longitudinal component in which the tools utilization to improve clinical practice was assessed by means of additional cross-sectional data collection. 710 consecutive patients were included (Phase 1). After tools implementation, within 6 months period, 705 patients were included (Phase 2) for comparative analysis. Randomly, 318 patients from Phase 1 were selected, 6-12 months after the first evaluation (Phase 3). RESULTS: Phase 1 to Phase 2: there were improvement on smoking cessation (P=0.019), dyslipidemia (P<0.001), hypertension and physical activity (P<0.001). There was significant difference on angiotensin converting enzyme inhibitors - ACEI (67.2% vs. 56.8%, P<0.001); angiotensin II receptor blockers - ARB II (25.4% vs. 32.9%, P=0.002) and beta-blocker (88.7% vs. 91.9%, P=0.047). Phase 1 to Phase 3: there was both weight (P=0.044), and blood pressure reduction (P<0.001). There was statistical significant difference on ACEI (64.8% vs. 61.6%, P=0.011) and ARB II (27.0% vs. 31.3%, P=0.035). CONCLUSION: There was no significant change on the evidence-based pharmacological treatment utilization between pre and post-intervention phases; there was significant improvement concerning smoking and physical activity in phase 2; substantial improvement on blood pressure levels in both comparisons (Phase 1 to 2 and Phase 1 to 3). The inclusion of a case-manager for the process management was crucial for program efficacy. Comprehensive programs for clinical practice should be pursued for longer follow-up period.

Drug-eluting stents vs bare metal stents for the treatment of large coronary vessels.

BACKGROUND: Lately drug-eluting stents (DES) have dramatically reduced restenosis rates and need for repeat revascularization in a wide subset of lesion and patients. However, their benefit for the treatment of large vessels (> 3.0 mm) has yet to be established. OBJECTIVE: We investigated whether DES are superior to bare metal stents (BMS) in terms of clinical outcomes for the treatment of large coronary vessels. METHODS: This study assessed the long-term outcomes (cardiac death, acute myocardial infarction, and need for repeat intervention in the treated vessel) of patients treated with either a DES (Cypher and Taxus) or a BMS of > or = 3.5 mm in diameter. A total of 250 consecutive patients who underwent DES implantation were clinically followed for 1 year and compared to 250 patients who were treated with BMS. Interventions in the setting of acute ST elevation myocardial infarction and treatment of bypass grafts were excluded. RESULTS: Cypher was the DES deployed in 70.8% of cases. Most of the enrolled patients were men (78%) with single vessel disease (65.6%). The left anterior descending artery was the culprit vessel in 34.2% of cases. Bare metal stent and DES cohorts had equivalent interpolated reference vessel diameter (3.19 +/- 0.3 mm for BMS vs 3.18 +/- 0.2 for DES; P = .1). Lesion was significantly longer in the group treated with DES (13.4 +/- 5.1 mm for BMS group vs 14.3 +/- 3.5 for DES; P = .0018). After 1 year of clinical follow-up, 95.2% of patients treated with DES and 91.2% of the patients who received BMS were free of major events (P = .2). A trend toward higher target-lesion revascularization was noticed in the group treated with BMS (4.8% vs 1.6%; P = .07). CONCLUSION: Percutaneous treatment of large coronary vessels carries a low risk of clinical events irrespective of the type of stent used.

A three-dimensional intravascular ultrasound comparison between the new zotarolimus-eluting stent (ZoMaxx) and the non-drug-eluting TriMaxx stent.

BACKGROUND: Despite the effectiveness of sirolimus- and paclitaxel-eluting stents in reducing intimal hyperplasia (IH) and the need for repeat revascularization, concerns about their long-term safety have motivated the search for new drug-eluting stents (DES). Recently developed, the ZoMaxx stent combines a sirolimus-analogous agent (zotarolimus), featuring a phosphorycoline polymer and stainless steel and tantalum platform. We sought to assess the efficacy of this new DES in reducing IH. METHODS: A total of 40 patients were treated with the ZoMaxx stent and compared to 50 patients treated with its non-drug-eluting equivalent, the TriMaxx stent. Only single de novo lesions in native coronary vessels greater than or equal to 3.0 mm were enrolled. Serial quantitative coronary angiography and intravascular ultrasound (IVUS) images were obtained at baseline and 6- month follow up. All patients were clinically followed for 1 year. This analysis aimed to compare the percent of IH between the 2 stents. Secondarily, we assessed in-segment late loss, binary restenosis and major adverse cardiac events. RESULTS: Baseline patient and lesion characteristics were comparable between the 2 groups. At follow up, zotarolimus efficiently suppressed neointimal hyperplasia formation with a marked reduction in the percentage of stent obstruction by IVUS (4.6 +/- 3.6% vs. 31.2 +/- 16%; p < 0.0001). Almost 90% of the segments stented with ZoMaxx did not exhibit more than 10% of obstruction. After 1 year, 12 patients treated with the TriMaxx and 2 patients treated with the ZoMaxx presented in-segment binary restenosis (p = 0.03). CONCLUSIONS: In this initial experience, ZoMaxx proved to be clinically safe and superior to its non-drug-coated equivalent in reducing in-stent IH formation and restenosis.

Implante de múltiplos stents farmacológicos para o tratamento da doença multiarterial em paciente diabética / Use of multiple drug-eluting stents for the treatment of multivessel disease in a diabetic patient

A incidência de diabetes mellitus tem aumentado continuamente nos últimos anos. Os pacientes acometidos por esta enfermidde crônica têm maior risco de desenvolver doença aterosclerótica coronária. Infelizmente, devido ao frequente envolvimento difuso de multiplos vasos, a intervenção percutânea, quer seja com cateter-balçao ou com stent não farmacológico, tem sido associada a pior prognóstico, quando comparada à cirurgia de revascularização miocárdica neste grupo de pacientes. Recentemente, a introdução dos stents farmacológicos renovou o entusiasmo para o tratamento percutâneo de pacientes com lesões mais complexas. Neste artigo, reportamos um caso de uma paciente de 63 anos, portadora de diabetes em uso de insulina, tratada percutaneamente com nove stents farmacológicos (Taxus, Boston Scientific).

The incidence of diabetes mellitus has continuously risen over recent years. Patients with this chronic condition have a higher risk of developing coronary artery disease. Unfortunately, due to the frequent diffuse involvement of multiple vessels, the long term outcomes after percutaneous intervention, whether by balloon catheter or bare-metal stent, has always been poor and frequently inferior to cardiac surgery for this subset of patients. Recently, the introduction of drug-eluting stents (DES) has brought new hope to treat patients with more complex diseases percutaneously. In this paper we report a successful percutaneous approach of a 63-year-old insulin dependent diabetic patient treated with nine DES (TaxusTM, Boston Scientific).

Estimation of right ventricular mass by two-dimensional echocardiography.

BACKGROUND: This report describes two original echocardiographic approaches to measure right ventricular (RV) mass (RVM). METHODS: In the bullet formula (5/24 pi D1 D2 L), where D1 and D2 are short axes and L the log axis, the RVM is obtained by subtracting the cavity volume from the RV total volume and subsequently multiplying the difference by myocardium density. The second method uses 3 endocardium segments measured at: (1) short axis plane of the aortic valve and left atrium (b1); (2) short axis plane at the midpoint between the tricuspid valve annulus and the apex (b2); and (3) 4-chamber view (h). Those segment lengths are applying in the formula A = [(b1 + b2)/2] x h. The result is multiplied by the wall thickness and by myocardium density. RESULTS: Both formulas were primarily tested in 30 mongrel dogs and have shown good correlation with the true mass ( r = 0.869 with the segments formula and r = 0.819 with the bullet formula). The same method was used in 20 human patients before heart transplant with similar results ( r = 0.810 with the segments formula and r = 0.836 with the bullet formula). CONCLUSIONS: The RVM can be satisfactorily estimated by 2-dimensional echocardiography. The linear regression between the calculated mass (using the smoothest and thinner myocardium thickness) and the actual mass may provide the correction factor for the RVM calculation. Two echocardiographic methods were used to measure right ventricular mass. One of them used a bullet formula variant (5/24 pi D1 D2 L). The second method used 3 endocardium segments measured in 3 2-dimensional echocardiographic planes (short axis of aortic valve and left ventricle, and 4-chamber view), and applied in the formula A = [(b1 + b2)/2] x h. Both formulas have shown good correlation with the true mass in 30 mongrel dogs ( r = 0.869 with the segments formula and r = 0.819 with the bullet formula) and in 20 human patients before heart transplant ( r = 0.810 and r = 0.836, respectively).

Estimation of Right Ventricular Mass by Two-dimensional Echocardiography

Background: This report describes two original echocardiographic approaches to measure right ventricular (RV) mass (RVM).Methods: In the bullet formula (5/24 D1 D2 L), where D1 and D2 are short axes and L the log axis, the RVM is obtained by subtracting the cavity volume from the RV total volume and subsequently multiplying the difference by myocardium density. The second method uses 3 endocardium segments measured at: (1) short axis plane of the aortic valve and left atrium (b1); (2) short axis plane at the midpoint between the tricuspid valve annulus and the apex (b2); and (3) 4-chamber view (h). Thosesegment lengths are applying in the formula A [(b1 b2)/2] h. The result is multiplied by the wallthickness and by myocardium density. Results: Both formulas were primarily tested in 30 mongrel dogs and have shown good correlation with the true mass (r 0.869 with the segments formula and r 0.819 with the bullet formula). The same method was used in 20 human patients before heart transplant with similar results (r 0.810 with the segments formula and r 0.836 with the bulletformula).Conclusions: The RVM can be satisfactorily estimated by 2-dimensional echocardiography. The linear regression between the calculated mass (using the smoothest and thinner myocardium thickness) and the actual mass may provide the correction factor for the RVM calculation.Two echocardiographic methods were used to measure right ventricular mass. One of them used a bullet formula variant (5/24 D1 D2 L). The second method used 3 endocardium segments measured in 3 2-dimensional echocardiographic planes (short axis of aortic valve and left ventricle, and 4-chamber view), and applied in the formula A [(b1 b2)/2] h. Both formulas have shown good correlation with the true mass in 30 mongrel dogs (r 0.869 with the segments formula and r 0.819 with thebullet formula) and in 20 human patients before heart transplant (r 0.810 and r 0.836, respectively).

Eficácia da redilatação coronária em portadores de reestenose da artéria descendente anterior / Efficacy of repeat percutaneous transluminal coronary angioplasty for coronary restenosis of the proximal left anterior descending coronary artery

PURPOSE: To analyze the clinical characteristics, acute and long term results of repeat percutaneous transluminal coronary angioplasty (PTCA) for restenosis of the proximal left anterior descending coronary artery (LDA) METHODS: We studied 113 patients, 79 male, mean age 59 years, 49.5 had stable angina, with single vessel proximal LDA disease undergoing repeat PTCA for a first restenosis from January/88 to December/92. We examined the in hospital outcome (success rate and complications) and long term follow up (angina status, occurrence of myocardial infarction (MI), death and need for repeat PTCA or coronary artery bypass graft (CABG) of this subgroup. RESULTS: Primary success was 96. Complications included: 1 MI, 1 emergency CABG and 1 procedural death. Follow up data (mean 42 months) was available in 102 (94) out of 109 patients with successful repeat PTCA: 64 (63) patients were asymptomatic, 5 (5) had a MI and 28 (27) required repeat PTCA or CABG. Actuarial 5 year freedom from death was 94, freedom from death and MI was 91 and freedom from death, MI and repeat PTCA or CABG was 52. CONCLUSION: Repeat PTCA is an effective treatment for proximal LAD restenosis with a high success rate, low incidence of procedural complications and provides excellent long term cardiac survival, however repeat revascularization is frequently required.

Objetivo - Analisar as características clínicas e angiográficas, e a evolução hospitalar e tardia dos pacientes submetidos à redilatação pós-reestenose da artéria coronária descendente anterior (DA). Métodos - Cento e treze pacientes uniarteriais, sendo 89 (79%) homens, com média de idade de 59 anos, 49,5% com quadro de angina estável, foram submetidos a angioplastia coronária eletiva da DA e redilatados no período de janeiro/88 a dezembro/92. Foram analisados quanto à evolução hospitalar (sucesso e complicações) e tardia (ocorrência de infarto agudo do miocárdio (IAM), óbito e necessidade de novos procedimentos de revascularização - NPR). Resultados - O sucesso primário foi de 96%, ocorrendo 1% de JAM, 1% de cirurgia de emergência (CE) e 1% de óbito. Foram seguidos 102 (94%) pacientes, em média por 42 meses, sendo que 63% estavam assintomáticos, 5% apresentaram IAM, 5% morreram e 27% necessitaram NPR (aterectomia ou cirurgia). As curvas actuariais de 5 anos revelaram 94% de sobrevida global, 91% de sobrevida livre de IAM e 52% de sobrevida livre de IAM e NPR. Conclusão -A redilatação coronária pós-reestenose da DA é procedimento seguro e eficaz. As curvas actuariais revelaram excelente prognóstico, embora NPR sejam freqüentes