Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 19 de 19
Filtrar
Filtros adicionais











País/Região como assunto
Intervalo de ano
2.
Heart ; 105(18): 1423-1431, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31018955

RESUMO

OBJECTIVE: Assess the relative incidence and compare characteristics and outcome of unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI). DESIGN: Two independent prospective multicentre diagnostic studies (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] and High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome [High-STEACS]) enrolling patients with acute chest discomfort presenting to the emergency department. Central adjudication of the final diagnosis was done by two independent cardiologists using all clinical information including serial measurements of high-sensitivity cardiac troponin (hs-cTn). All-cause death and future non-fatal MI were assessed at 30 days and 1 year. RESULTS: 8992 patients were enrolled at 11 centres. UA was adjudicated in 8.9%(95% CI 8.0 to 9.7) and 2.8% (95% CI 2.3 to 3.3) patients in APACE and High-STEACS, respectively, and NSTEMI in 15.1% (95% CI 14.0 to 16.2) and 13.4% (95% CI 12.4 to 14.3). Coronary artery disease was pre-existing in 73% and 76% of patients with UA. At 30 days, all-cause mortality in UA was substantially lower as compared with NSTEMI (0.5% vs 3.7%, p=0.002 in APACE, 0.7% vs 7.4%, p=0.004 in High-STEACS). Similarly, at 1 year in UA all-cause mortality was 3.3% (95% CI 1.2 to 5.3) vs 10.4% (95% CI 7.9 to 12.9) in APACE, and 5.1% (95% CI 0.7 to 9.5) vs 22.9% (95% CI 19.3 to 26.4) in High-STEACS, and similar to non-cardiac chest pain (NCCP). In contrast, future non-fatal MI in APACE was comparable in UA and NSTEMI (11.2%, 95% CI 7.8 to 14.6 and 7.9%, 95% CI 5.7 to 10.2), and higher than in NCCP (0.6%, 95% CI 0.2 to 1.0). CONCLUSIONS: The relative incidence and mortality of UA is substantially lower than that of NSTEMI, while the rate of future non-fatal MI is similar.

3.
Int J Cardiol ; 275: 20-25, 2019 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-30340850

RESUMO

BACKGROUND: Inflammation plays a major role in the pathogenesis of coronary artery disease (CAD). METHODS: We hypothesized, that quantifying inflammation by measuring circulating interleukin-6 concentrations help in the diagnosis and/or prediction of functionally relevant CAD. Among consecutive patients with symptoms suggestive of CAD, functionally relevant CAD was adjudicated in two domains: first, diagnosis according to myocardial perfusion single photon emission tomography (MPI-SPECT) and coronary angiography; second, cardiovascular death and all-cause death during 2-years follow-up. Adjudication was done blinded to the interleukin-6 concentrations. RESULTS: Among 1553 patients, symptoms were adjudicated to be causally related to CAD in 43% (665/1553). Interleukin-6 concentrations were higher in patients with functionally relevant CAD as compared to those without (1.56 pg/mL versus 1.30 pg/mL, p < 0.001), but overall had only low-to-modest diagnostic accuracy (area under the curve [AUC]: 0.57, 95%CI 0.55-0.61) and were no independent predictor of functionally relevant CAD after multivariable adjustment (p = 0.068). Interleukin-6 concentrations had moderate-to-high accuracy in the prediction of cardiovascular death (AUC 0.75, 95%CI 0.69-0.82) and all-cause death (AUC 0.72, 95%CI 0.66-0.78) at 2-years, and remained a significant predictor after multivariable adjustment (p < 0.001). Compared to patients with interleukin-6 concentrations below the median (1.41 pg/mL), patients with concentrations above the median had a significantly higher cumulative incidence of cardiovascular death (1% vs. 4%, log-rank p < 0.001) and all-cause death (2% vs. 8%, log-rank p < 0.001) at 2 years. CONCLUSION: Interleukin-6 concentrations are strong and independent predictors of cardiovascular death and all-cause death.


Assuntos
Doença da Artéria Coronariana/diagnóstico , Diagnóstico Precoce , Interleucina-6/sangue , Idoso , Biomarcadores/sangue , Causas de Morte/tendências , Angiografia Coronária , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/mortalidade , Teste de Esforço , Feminino , Seguimentos , Humanos , Imunoensaio , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Taxa de Sobrevida/tendências , Suíça/epidemiologia , Tomografia Computadorizada de Emissão de Fóton Único/métodos
5.
Artigo em Inglês | MEDLINE | ID: mdl-29680355

RESUMO

OBJECTIVES: This study aimed to compare the value of the index of microcirculatory resistance (IMR) and microvascular obstruction (MVO) measured by cardiac magnetic resonance (CMR) in patients treated for and recovering from ST-segment elevation myocardial infarction. BACKGROUND: IMR can identify patients with microvascular dysfunction acutely after primary percutaneous coronary intervention (pPCI), and a threshold of >40 has been shown to be associated with an adverse clinical outcome. Similarly, MVO is recognized as an adverse feature in patients with ST-segment elevation myocardial infarction. Even though both IMR and MVO reflect coronary microvascular status, the interaction between these 2 parameters is uncertain. METHODS: A total of 110 patients treated with pPCI were included, and IMR was measured immediately at completion of pPCI. Infarct size (IS) as a percentage of left ventricular mass was quantified at 48 h (38.4 ± 12.0 h) and 6 months (194.0 ± 20.0 days) using CMR. MVO was identified and quantified at 48 h by CMR. RESULTS: Overall, a discordance between IMR and MVO was observed in 36.7% of cases, with 31 patients having MVO and IMR ≤40. Compared with patients with MVO and IMR ≤40, patients with both MVO and IMR >40 had an 11.9-fold increased risk of final IS >25% at 6 months (p = 0.001). Patients with MVO and IMR ≤40 had a significantly smaller IS at 6 months (p = 0.001), with significant regression in IS over time (34.4% [interquartile range: 27.3% to 41.0%] vs. 22.3% [interquartile range: 16.0% to 30.0%]; p = 0.001). CONCLUSIONS: Discordant prognostic information was obtained from IMR and MVO in nearly one-third of cases; however, IMR can be helpful in grading the degree and severity of MVO.

6.
Heart ; 104(2): 127-134, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28663361

RESUMO

OBJECTIVES: Early detection of microvascular dysfunction after acute myocardial infarction (AMI) could identify patients at high risk of adverse clinical outcome, who may benefit from adjunctive treatment. Our objective was to compare invasively measured coronary flow reserve (CFR) and hyperaemic microvascular resistance (HMR) for their predictive power of long-term clinical outcome and cardiac magnetic resonance (CMR)-defined microvascular injury (MVI). METHODS: Simultaneous intracoronary Doppler flow velocity and pressure measurements acquired immediately after revascularisation for AMI from five centres were pooled. Clinical follow-up was completed for 176 patients (mean age 60±10 years; 140(80%) male; ST-elevation myocardial infarction (STEMI) 130(74%) and non-ST-segment elevation myocardial infarction 46(26%)) with median follow-up time of 3.2 years. In 110 patients with STEMI, additional CMR was performed. RESULTS: The composite end point of death and hospitalisation for heart failure occurred in 17 patients (10%). Optimal cut-off values to predict the composite end point were 1.5 for CFR and 3.0 mm Hg cm-1•s for HMR. CFR <1.5 was predictive for the composite end point (HR 3.5;95% CI 1.1 to 10.8), but not for its individual components. HMR ≥3.0 mm Hg cm-1 s was predictive for the composite end point (HR 7.0;95% CI 1.5 to 33.7) as well as both individual components. HMR had significantly greater area under the receiver operating characteristic curve for MVI than CFR. HMR remained an independent predictor of adverse clinical outcome and MVI, whereas CFR did not. CONCLUSIONS: HMR measured immediately following percutaneous coronary intervention for AMI with a cut-off value of 3.0 mm Hg cm-1 s, identifies patients with MVI who are at high risk of adverse clinical outcome. For this purpose, HMR is superior to CFR.


Assuntos
Circulação Coronária , Imagem Cinética por Ressonância Magnética/métodos , Microcirculação , Microvasos , Infarto do Miocárdio , Intervenção Coronária Percutânea , Idoso , Velocidade do Fluxo Sanguíneo , Feminino , Humanos , Masculino , Microvasos/diagnóstico por imagem , Microvasos/patologia , Microvasos/fisiopatologia , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia , Infarto do Miocárdio/cirurgia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Cuidados Pós-Operatórios/métodos , Valor Preditivo dos Testes , Curva ROC , Medição de Risco/métodos , Resultado do Tratamento
7.
J Am Heart Assoc ; 6(11)2017 Nov 07.
Artigo em Inglês | MEDLINE | ID: mdl-29113999

RESUMO

BACKGROUND: Early risk stratification after primary percutaneous coronary intervention (PPCI) for ST-segment-elevation myocardial infarction is currently challenging. Identification of a low-risk group may improve triage of patients to alternative clinical pathways and support early hospital discharge. Our aim was to assess whether the index of microcirculatory resistance (IMR) at the time of PPCI can identify patients at low risk of early major cardiac complications and to compare its performance against guideline-recommended risk scores. METHODS AND RESULTS: IMR was measured using a pressure-temperature sensor wire. Cardiac complications were defined as the composite of cardiac death, cardiogenic shock, pulmonary edema, malignant arrhythmias, cardiac rupture, and presence of left ventricular thrombus either before hospital discharge or within 30-day follow-up. In total, 261 patients undergoing PPCI who were eligible for coronary physiology assessment were prospectively enrolled. Twenty-two major cardiac complications were reported. Receiver operating characteristic curve analysis confirmed the utility of IMR in predicting complications and showed significantly better performance than coronary flow reserve, the Primary Angioplasty in Myocardial Infarction II (PAMI-II), and Zwolle score (P≤0.006). Low microvascular resistance (IMR ≤40) was measured in 159 patients (61%) of the study population and identified all patients who were free of major cardiac complications (sensitivity: 100%; 95% CI, 80.5-100%). CONCLUSIONS: IMR immediately at the end of PPCI for ST-segment-elevation myocardial infarction reliably predicts early major cardiac complications and performed significantly better than recommended risk scores. These novel data have implications for early risk stratification after PPCI.


Assuntos
Circulação Coronária/fisiologia , Vasos Coronários/fisiopatologia , Microcirculação/fisiologia , Intervenção Coronária Percutânea , Complicações Pós-Operatórias/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Resistência Vascular/fisiologia , Angiografia Coronária , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/cirurgia , Eletrocardiografia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Curva ROC , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Taxa de Sobrevida/tendências , Resultado do Tratamento , Reino Unido/epidemiologia
8.
Circ Cardiovasc Imaging ; 10(8)2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28798137

RESUMO

BACKGROUND: CMR T1 mapping is a quantitative imaging technique allowing the assessment of myocardial injury early after ST-segment-elevation myocardial infarction. We sought to investigate the ability of acute native T1 mapping to differentiate reversible and irreversible myocardial injury and its predictive value for left ventricular remodeling. METHODS AND RESULTS: Sixty ST-segment-elevation myocardial infarction patients underwent acute and 6-month 3T CMR, including cine, T2-weighted (T2W) imaging, native shortened modified look-locker inversion recovery T1 mapping, rest first pass perfusion, and late gadolinium enhancement. T1 cutoff values for oedematous versus necrotic myocardium were identified as 1251 ms and 1400 ms, respectively, with prediction accuracy of 96.7% (95% confidence interval, 82.8% to 99.9%). Using the proposed threshold of 1400 ms, the volume of irreversibly damaged tissue was in good agreement with the 6-month late gadolinium enhancement volume (r=0.99) and correlated strongly with the log area under the curve troponin (r=0.80) and strongly with 6-month ejection fraction (r=-0.73). Acute T1 values were a strong predictor of 6-month wall thickening compared with late gadolinium enhancement. CONCLUSIONS: Acute native shortened modified look-locker inversion recovery T1 mapping differentiates reversible and irreversible myocardial injury, and it is a strong predictor of left ventricular remodeling in ST-segment-elevation myocardial infarction. A single CMR acquisition of native T1 mapping could potentially represent a fast, safe, and accurate method for early stratification of acute patients in need of more aggressive treatment. Further confirmatory studies will be needed.


Assuntos
Edema Cardíaco/diagnóstico por imagem , Imagem Cinética por Ressonância Magnética , Miocárdio/patologia , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Função Ventricular Esquerda , Remodelação Ventricular , Idoso , Área Sob a Curva , Biomarcadores/sangue , Meios de Contraste/administração & dosagem , Diagnóstico Diferencial , Edema Cardíaco/patologia , Edema Cardíaco/fisiopatologia , Edema Cardíaco/terapia , Inglaterra , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Necrose , Intervenção Coronária Percutânea , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Recuperação de Função Fisiológica , Reprodutibilidade dos Testes , Infarto do Miocárdio com Supradesnível do Segmento ST/patologia , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Troponina I/sangue
9.
EuroIntervention ; 13(8): 935-943, 2017 Oct 20.
Artigo em Inglês | MEDLINE | ID: mdl-28649956

RESUMO

AIMS: The age-thrombus burden-index of microcirculatory resistance (ATI) score is a diagnostic tool able to predict suboptimal myocardial reperfusion before stenting, in patients with ST-elevation myocardial infarction (STEMI). We aimed to validate the ATI score against cardiac magnetic resonance imaging (cMRI). METHODS AND RESULTS: The ATI score was calculated prospectively in 80 STEMI patients. cMRI was performed within 48 hours in all patients and in 50 patients at six-month follow-up to assess the extent of infarct size (IS%) and microvascular obstruction (MVO%). The ATI score was calculated using age (>50=1 point), pre-stenting index of microcirculatory resistance (IMR) (>40 and <100=1 point; ≥100=2 points) and angiographic thrombus score (4=1 point; 5=3 points). ATI score was closely related to final IS% (ATI.


Assuntos
Imagem por Ressonância Magnética , Microcirculação/fisiologia , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Circulação Coronária/fisiologia , Feminino , Humanos , Imagem por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/fisiopatologia , Reperfusão Miocárdica/métodos , Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Resultado do Tratamento
10.
EuroIntervention ; 13(Z): Z75-Z79, 2017 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-28504236

RESUMO

In 2015, Switzerland had a population of 8.3 million inhabitants. Since the first coronary angioplasty performed by Andreas Grüntzig in Zurich in 1977, the number of percutaneous procedures has steadily increased. The aim of this report is to summarise the current state of catheter-based cardiac interventions in adults in the country and to detail trends between 2010 and 2015. Since 1987, the Working Group for Interventional Cardiology of the Swiss Society of Cardiology has collected annually aggregate data from all facilities with cardiac catheterisation laboratories in the country. In 2015, a total of 37 institutions covered 17 of the 26 Swiss cantons. Over the six-year period, there was a continuous increase in the number of coronary angiography and percutaneous coronary interventions (PCI) (median increase rate of 3.2%/year for coronary angiography and of 2.6%/year for PCI). Notable was the adoption of the transradial approach for PCI, going from a median rate of 17% in 2012 to 51.9% in 2015. With respect to structural heart interventions, the number of patent foramen ovale as well as atrial septal defect closures has remained stable, while the number of transcatheter aortic valve implantations and transcatheter mitral valve repairs has shown a fourfold increase.


Assuntos
Angioplastia Coronária com Balão , Cateterismo Cardíaco , Cardiopatias/cirurgia , Intervenção Coronária Percutânea , Cateterismo Cardíaco/métodos , Angiografia Coronária/métodos , Humanos , Intervenção Coronária Percutânea/métodos , Sistema de Registros/estatística & dados numéricos , Stents/efeitos adversos , Suíça
11.
Coron Artery Dis ; 28(3): 198-208, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-27926579

RESUMO

OBJECTIVES: The index of microcirculatory resistance (IMR) provides a reproducible assessment of the status of coronary microvasculature in patients with ST-elevation myocardial infarction (STEMI). Frequency-domain optical coherence tomography (FD-OCT) enables detailed assessment of the morphology of coronary plaque.We sought to determine the influence of the initial culprit coronary plaque anatomy within the infarct-related artery on IMR after stenting in STEMI. PATIENTS AND METHODS: In 25 STEMI patients IMR was measured immediately before and after stent implantation. FD-OCT imaging was performed at the same time points and atherothrombotic volume (ATV) before stenting, prolapsed+floating ATV after stenting and ΔATV was measured using three different strategies. RESULTS: There were no relationships between preprocedural IMR and FD-OCT parameters. Prestenting IMR was related only to pain to wire time (P: 0.02). Irrespective of the method adopted, the final IMR was related to prestenting ATV (ρ: 0.44, P: 0.03 for method I, ρ: 0.48, P: 0.02 for method II and ρ: 0.30, P: 0.06 for method III) and ΔATV (ρ: 0.41, P: 0.04 for method II and ρ: 0.44, P: 0.03 for method III). CONCLUSION: IMR measured before stenting is independent of the appearances of the culprit coronary plaque within the infarct-related artery. IMR after stenting, and more importantly, the change in IMR after stenting, reflect the degree of distal embolization during stent implantation.


Assuntos
Angioplastia Coronária com Balão/instrumentação , Circulação Coronária , Vasos Coronários/diagnóstico por imagem , Microcirculação , Placa Aterosclerótica , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Stents , Tomografia de Coerência Óptica , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Cateterismo Cardíaco , Angiografia Coronária , Vasos Coronários/patologia , Vasos Coronários/fisiopatologia , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/patologia , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Resistência Vascular
12.
EuroIntervention ; 12(10): 1223-1230, 2016 Nov 20.
Artigo em Inglês | MEDLINE | ID: mdl-27866132

RESUMO

AIMS: Restoration of effective myocardial reperfusion by primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction is difficult to predict. A method to assess the likelihood of a suboptimal response to conventional pharmacomechanical therapies could be beneficial. We aimed to derive and validate a scoring system that can be used acutely at the time of coronary reopening to predict the likelihood of downstream microvascular impairment in patients with STEMI. METHODS AND RESULTS: A score estimating the risk of post-procedural microvascular injury defined by an index of microcirculatory resistance (IMR) >40 was initially derived in a cohort of 85 STEMI patients (derivation cohort). This score was then tested and validated in three further cohorts of patients (retrospective [30 patients], prospective [42 patients] and external [29 patients]). The ATI score (age [>50=1]; pre-stenting IMR [>40 and <100=1; ≥100=2]; thrombus score [4=1; 5=3]) was highly predictive of a post-stenting IMR >40 in all four cohorts (AUC: 0.87; p<0.001-derivation cohort, 0.84; p=0.002-retrospective cohort, 0.92; p<0.001-prospective cohort and 0.81; p=0.006-external cohort). In the whole population, an ATI score ≥4 presented a 95.1% risk of final IMR >40, while no cases of final IMR >40 occurred in the presence of an ATI score <2. CONCLUSIONS: The ATI score appears to be a promising tool capable of identifying patients during PPCI who are at the highest risk of coronary microvascular impairment following revascularisation. This procedural risk stratification has a number of potential research and clinical applications and warrants further investigation.


Assuntos
Microcirculação/fisiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Trombose/complicações , Resistência Vascular/fisiologia , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Circulação Coronária , Vasos Coronários/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reperfusão Miocárdica/métodos , Estudos Prospectivos , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Resultado do Tratamento , Adulto Jovem
13.
BMC Cardiovasc Disord ; 16(1): 177, 2016 09 08.
Artigo em Inglês | MEDLINE | ID: mdl-27608682

RESUMO

BACKGROUND: FFR is routinely used to guide percutaneous coronary interventions (PCI). Visual assessment of the angiographic result after PCI has limited efficacy. Even when the angiographic result seems satisfactory FFR after a PCI might be useful for identifying patients with a suboptimal interventional result and higher risk for poor clinical outcome who might benefit from additional procedures. The aim of this meta-analysis was to investigate available data of studies that examined clinical outcomes of patients with impaired vs. satisfactory fractional flow reserve (FFR) after percutaneous coronary interventions (PCI). METHODS: This meta-analysis was carried out according to the Cochrane Handbook for Systematic Reviews. The Mantel-Haenszel method using the fixed-effect meta-analysis model was used for combining the results. Studies were identified by searching the literature through mid-January, 2016, using the following search terms: fractional flow reserve, coronary circulation, after, percutaneous coronary intervention, balloon angioplasty, stent implantation, and stenting. Primary endpoint was the rate of major adverse cardiac events (MACE). Secondary endpoints included rates of death, myocardial infarction (MI), repeated revascularisation. RESULTS: Eight relevant studies were found including a total of 1337 patients. Of those, 492 (36.8 %) had an impaired FFR after PCI, and 853 (63.2 %) had a satisfactory FFR after PCI. Odds ratios indicated that a low FFR following PCI was associated with an impaired outcome: major adverse cardiac events (MACE, OR: 4.95, 95 % confidence interval [CI]: 3.39-7.22, p <0.001); death (OR: 3.23, 95 % CI: 1.19-8.76, p = 0.022); myocardial infarction (OR: 13.83, 95 % CI: 4.75-40.24, p <0.0001) and repeated revascularisation (OR: 4.42, 95 % CI: 2.73-7.15, p <0.0001). CONCLUSIONS: Compared to a satisfactory FFR, a persistently low FFR following PCI is associated with a worse clinical outcome. Prospective studies are needed to identify underlying causes, determine an optimal threshold for post-PCI FFR, and clarify whether simple additional procedures can influence the post-PCI FFR and clinical outcome.


Assuntos
Doença da Artéria Coronariana/terapia , Reserva Fracionada de Fluxo Miocárdico , Intervenção Coronária Percutânea/efeitos adversos , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Humanos , Infarto do Miocárdio/etiologia , Razão de Chances , Intervenção Coronária Percutânea/mortalidade , Valor Preditivo dos Testes , Retratamento , Medição de Risco , Fatores de Risco , Resultado do Tratamento
14.
J Am Heart Assoc ; 5(7)2016 07 22.
Artigo em Inglês | MEDLINE | ID: mdl-27451466

RESUMO

BACKGROUND: The optimal antithrombotic therapy in patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI) remains a matter of debate. This updated meta-analysis investigated the impact of (1) bivalirudin (with and without prolonged infusion) and (2) prolonged PCI-dose (1.75 mg/hg per hour) bivalirudin infusion compared with conventional antithrombotic therapy on clinical outcomes in patients undergoing primary PCI. METHODS AND RESULTS: Eligible randomized trials were searched through MEDLINE, EMBASE, Cochrane database, and proceedings of major congresses. Prespecified outcomes were major bleeding (thrombolysis in myocardial infarction major and Bleeding Academic Research Consortium 3-5), acute stent thrombosis, as well as all-cause and cardiac mortality at 30 days. Six randomized trials (n=17 294) were included. Bivalirudin compared with heparin (+/- glycoprotein-IIb/IIIa inhibitor) was associated with reduction in major bleeding (odds ratio [OR]: 0.65, 95% CI: 0.48-0.88, P=0.006, derived from all 6 trials), increase in acute stent thrombosis (OR: 2.75, 95% CI: 1.46-5.18, P=0.002, 5 trials), and lower rate of all-cause mortality (OR: 0.81, 95% CI: 0.67-0.98, P=0.03, 6 trials) as well as cardiac mortality (OR: 0.69, 95% CI: 0.55-0.87, P=0.001, 5 trials). The incidence of acute stent thrombosis did not differ between the prolonged PCI-dose bivalirudin and comparator group (OR: 0.81, 95% CI: 0.27-2.46, P=0.71, 3 trials), whereas the risk of bleeding was reduced despite treatment with high-dose bivalirudin infusion (OR: 0.28, 95% CI: 0.13-0.60, P=0.001, 3 trials). CONCLUSIONS: Bivalirudin (with and without prolonged infusion) compared with conventional antithrombotic therapy in ST-segment-elevation myocardial infarction patients undergoing primary PCI reduces major bleeding and death, but increases the rate of acute stent thrombosis. However, prolonging the bivalirudin infusion at PCI-dose (1.75 mg/kg per hour) for 3 hours eliminates the excess risk of acute stent thrombosis, while maintaining the bleeding benefits.


Assuntos
Antitrombinas/efeitos adversos , Hemorragia/induzido quimicamente , Hirudinas/efeitos adversos , Fragmentos de Peptídeos/efeitos adversos , Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Stents , Trombose/prevenção & controle , Antitrombinas/administração & dosagem , Hirudinas/administração & dosagem , Humanos , Infusões Intravenosas , Razão de Chances , Fragmentos de Peptídeos/administração & dosagem , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos
15.
Curr Opin Cardiol ; 30(6): 663-70, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26352245

RESUMO

PURPOSE OF REVIEW: The purpose of this review was to summarize the healing processes after myocardial infarction (MI) and to relate these temporal changes to data from serial imaging obtained by cardiac magnetic resonance, and then to relate these findings to the invasive measures of the indices of coronary physiology (e.g., fractional flow reserve, coronary flow reserve and index of microcirculatory resistance). RECENT FINDINGS: Indices of coronary physiology measured with an intracoronary wire represent an easily and readily available diagnostic tool for the management of coronary artery disease. Additionally, they give insight into the functional status of the coronary microvasculature. Recent evidence has confirmed initial observations that microvascular recovery occurs after MI and that this is reflected by a progressive improvement of all the indices of coronary physiology over time. More importantly, it has been clarified that this process is variable, but probably predictable as it is affected by the degree of microvascular injury occurring in the acute phase of MI. SUMMARY: Microvascular recovery after acute MI affects the measurement of the indices of coronary physiology. Use of fractional flow reserve, coronary flow reserve and index of microcirculatory resistance requires an understanding of how microvasculature evolves after MI. This understanding allows appropriate application of intracoronary physiology both clinically and in research settings.


Assuntos
Vasos Coronários/fisiopatologia , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Microcirculação/fisiologia , Infarto do Miocárdio/fisiopatologia , Recuperação de Função Fisiológica , Resistência Vascular , Velocidade do Fluxo Sanguíneo/fisiologia , Humanos , Fatores de Tempo
16.
Eur Heart J ; 36(45): 3165-77, 2015 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-26254178

RESUMO

AIMS: Primary percutaneous coronary intervention (PPCI) is the optimal treatment for patients presenting with ST-elevation myocardial infarction (STEMI). An elevated index of microcirculatory resistance (IMR) reflects microvascular function and when measured after PPCI, it can predict an adverse clinical outcome. We measured coronary microvascular function in STEMI patients and compared sequential changes before and after stent implantation. METHODS AND RESULTS: In 85 STEMI patients, fractional flow reserve, coronary flow reserve, and IMR were measured using a pressure wire (Certus, St Jude Medical, St Paul, MN, USA) immediately before and after stent implantation. Stenting significantly improved all of the measured parameters of coronary physiology including IMR from 67.7 [interquartile range (IQR): 56.2-95.8] to 36.7 (IQR: 22.7-59.5), P < 0.001. However, after stenting, IMR remained elevated (>40) in 28 (32.9%) patients. In 15 of these patients (17.6% of the cohort), only a partial reduction in IMR occurred and these patients were more likely to be late presenters (pain to wire time >6 h). The extent of jeopardized myocardium [standardized beta: -0.26 (IMR unit/Bypass Angioplasty Revascularization Investigation score unit), P: 0.009] and pre-stenting IMR [standardized beta: -0.34 (IMR unit), P: 0.001] predicted a reduction in IMR after stenting (ΔIMR = post-stenting IMR - pre-stenting IMR), whereas thrombotic burden [standardized beta: 0.24 (IMR unit/thrombus score unit), P: 0.01] and deployed stent volume [standardized beta: 0.26 (IMR unit/mm(3) of stent), P: 0.01] were associated with a potentially deleterious increase in IMR. CONCLUSION: Improved perfusion of the myocardium by stent deployment during PPCI is not universal. The causes of impaired microvascular function at the completion of PPCI treatment are heterogeneous, but can reflect a later clinical presentation and/or the location and extent of the thrombotic burden.


Assuntos
Circulação Coronária/fisiologia , Microcirculação/fisiologia , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea , Stents , Anticoagulantes/uso terapêutico , Trombose Coronária/fisiopatologia , Trombose Coronária/terapia , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia , Revascularização Miocárdica/métodos , Estudos Prospectivos , Resultado do Tratamento , Resistência Vascular/fisiologia
17.
JACC Cardiovasc Interv ; 7(6): 615-21, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24835324

RESUMO

OBJECTIVE: This study sought to evaluate the prognostic value of routine stress myocardial perfusion scintigraphy (MPS) 5 years after percutaneous coronary intervention (PCI). BACKGROUND: Current appropriate use criteria define routine cardiac stress imaging <2 years after PCI as inappropriate and >2 years as uncertain in asymptomatic patients. METHODS: All 339 of 683 BASKET (Basel Stent Kosteneffektivitäts Trial) 5-year survivors (55%) consenting to undergo protocol-mandated MPS and subsequent evaluation irrespective of symptoms were followed for major adverse cardiac events (MACE) (cardiac death, myocardial infarction [MI], or revascularization). For MPS, summed perfusion scores were calculated and perfusion defects were related to treated-vessel or remote myocardial areas. RESULTS: Patients were 72 ± 10 years of age, 18% were female, and 90% were free of angina. MPS findings were abnormal in 205 of 339 patients (60%) with complete follow-up. During 3.7 ± 0.3 years, there were 7 cardiac deaths, 18 MIs, and 47 revascularizations, resulting in a MACE rate of 4.4% and a cardiac mortality rate of 0.6% per year. Patients with abnormal MPS findings had higher hazard ratios (HR) for MACE (HR: 1.95; 95% confidence interval [CI]: 1.06 to 3.59; p = 0.032), and cardiac death/MI (HR: 2.50; 95% CI: 0.93 to 6.69; p = 0.066) than patients with normal MPS finding. MACE rates were similar in patients with symptomatic and silent ischemia (p = 0.61) but higher than in patients with normal MPS findings (p < 0.05 for both comparisons). MACE rates were independently predicted by remote ischemia but not by treated-vessel ischemia or scar. CONCLUSIONS: Abnormal MPS findings 5 years after PCI are frequent irrespective of symptoms. The predictive power of abnormal MPS lies more in the detection of persistent or progressing coronary artery disease in remote vessel areas than in the diagnosis of late intervention-related problems in treated vessels.


Assuntos
Teste de Esforço/métodos , Infarto do Miocárdio/cirurgia , Imagem de Perfusão do Miocárdio/métodos , Intervenção Coronária Percutânea/métodos , Stents , Tomografia Computadorizada de Emissão de Fóton Único/métodos , Idoso , Feminino , Seguimentos , Humanos , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Prognóstico , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Suíça/epidemiologia , Fatores de Tempo
18.
Int J Cardiol ; 168(4): 3802-6, 2013 Oct 09.
Artigo em Inglês | MEDLINE | ID: mdl-23849965

RESUMO

BACKGROUND: Elevated heart rate (HR) is associated with mortality in a number of heart diseases. We examined the long-term prognostic significance of HR at discharge in a contemporary population of patients with stable angina (SAP), non-ST-segment elevation acute coronary syndromes (NSTE-ACS), and ST-segment elevation myocardial infarction (STEMI) revascularized with percutaneous coronary intervention (PCI). METHODS: Patients from the BASKET-PROVE trial, an 11-center randomized all-comers trial comparing bare-metal and drug-eluting stenting in large coronary vessels, were included. Discharge HR was determined from a resting ECG. Long-term outcomes (7 days to 2 years) were evaluated for all-cause mortality and cardiovascular death and non-fatal myocardial infarction. RESULTS: A total of 2029 patients with sinus rhythm were included, 722 (35.6%) SAP, 647 (31.9%) NSTE-ACS, and 660 (32.5%) STEMI. Elevated discharge HR was associated significantly with all-cause mortality: when compared to a reference of <60 beats per minute (bpm), the adjusted hazard ratios were (95% CI) 4.5 (1.5-13.5, p=0.006) for 60-69 bpm, 3.8 (1.2-11.9, p=0.022) for 70-79 bpm, 4.3 (1.2-15.6, p=0.025) for 80-89 bpm, and 16.9 (5.2-55.0, p<0.001) for >90 bpm. For cardiovascular death/myocardial infarction, a discharge HR >90 bpm was associated with a hazard ratio of 6.2 (2.5-15.5, p<0.001) compared to a HR <60 bpm. No interaction was found for disease presentation, diabetes or betablocker use. CONCLUSION: In patients revascularized with PCI for stable angina or acute coronary syndromes an elevated discharge HR was independently associated with poor prognosis. Conversely, a HR <60 bpm at discharge was associated with a good long-term prognosis irrespective of indication for PCI.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/fisiopatologia , Frequência Cardíaca/fisiologia , Alta do Paciente/tendências , Intervenção Coronária Percutânea/tendências , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Fatores de Tempo , Resultado do Tratamento
19.
Stroke ; 37(10): 2499-503, 2006 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-16960096

RESUMO

BACKGROUND AND PURPOSE: Few data exist about clinical, radiologic findings, clinical outcome, and its predictors in patients with spontaneous vertebral artery dissection (sVAD). METHODS: Clinical characteristics, imaging findings, 3-month outcomes, and its predictors were investigated in consecutive patients with sVAD. RESULTS: One hundred sixty-nine patients with 195 sVAD were identified. Brain ischemia occurred in 131 patients (77%; ischemic stroke, n=114, 67%; transient ischemic attack, n=17, 10%). Three patients with ischemic stroke showed also signs of subarachnoid hemorrhage (SAH); 3 (2%) had SAH without ischemia. The 134 patients with brain ischemia or SAH had head and/or neck pain in 118 (88%) and pulsatile tinnitus in seven (5%) patients. The remaining 35 patients (21%) had isolated head and/or neck pain in 21 (12%) cases, asymptomatic sVAD in 13 (8%), and cervical radiculopathy in one case (1%). Location of sVAD was more often in the pars transversaria (V2; 35%) or atlas loop (V3; 34%) than in the prevertebral (V1; 20%) or intracranial (V4; 11%) segment (P=0.0001). Outcome was favorable (modified Rankin scale score 0 or 1) in 88 (82%) of 107 ischemic stroke patients with follow up. Two (2%) patients died. Low baseline National Institutes of Health Stroke Scale score (P<0.0001) and younger age (P=0.007) were independent predictors of favorable outcome. CONCLUSIONS: sVAD is predominantly located in the pars transversaria (V2) or the atlas loop (V3). Most patients show posterior circulation ischemia. Favorable outcome is observed in most ischemic strokes and independently predicted by low National Institutes of Health Stroke Scale score and younger age.


Assuntos
Dissecação da Artéria Vertebral/epidemiologia , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/etiologia , Comorbidade , Bases de Dados Factuais , Diagnóstico por Imagem/métodos , Diagnóstico por Imagem/estatística & dados numéricos , Feminino , Fibrinolíticos/uso terapêutico , Seguimentos , Humanos , Hipercolesterolemia/epidemiologia , Hipertensão/epidemiologia , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Imagem por Ressonância Magnética , Masculino , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Ruptura Espontânea , Índice de Gravidade de Doença , Hemorragia Subaracnóidea/epidemiologia , Hemorragia Subaracnóidea/etiologia , Terapia Trombolítica , Zumbido/epidemiologia , Zumbido/etiologia , Resultado do Tratamento , Dissecação da Artéria Vertebral/diagnóstico , Dissecação da Artéria Vertebral/tratamento farmacológico
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA