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1.
J Am Coll Cardiol ; 73(22): 2832-2842, 2019 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-30894317

RESUMO

BACKGROUND: Preclinical studies have demonstrated that high mechanical index (MI) impulses from a diagnostic ultrasound transducer during an intravenous microbubble infusion (sonothrombolysis) can restore epicardial and microvascular flow in acute ST-segment elevation myocardial infarction (STEMI). OBJECTIVES: This study tested the clinical effectiveness of sonothrombolysis in patients with STEMI. METHODS: Patients with their first STEMI were prospectively randomized to either diagnostic ultrasound-guided high MI impulses during an intravenous Definity (Lantheus Medical Imaging, North Billerica, Massachusetts) infusion before, and following, emergent percutaneous coronary intervention (PCI), or to a control group that received PCI only (n = 50 in each group). A reference first STEMI group (n = 203) who arrived outside the randomization window was also analyzed. Angiographic recanalization before PCI, ST-segment resolution, infarct size by magnetic resonance imaging, and systolic function (LVEF) at 6 months were compared. RESULTS: ST-segment resolution occurred in 16 (32%) high MI PCI versus 2 (4%) PCI-only patients before PCI, and angiographic recanalization was 48% in high MI/PCI versus 20% in PCI only and 21% in the reference group (p < 0.001). Infarct size was reduced (29 ± 22 g high MI/PCI vs. 40 ± 20 g PCI only; p = 0.026). LVEF was not different between groups before treatment (44 ± 11% vs. 43 ± 10%), but increased immediately after PCI in the high MI/PCI group (p = 0.03), and remained higher at 6 months (p = 0.015). Need for implantable defibrillator (LVEF ≤30%) was reduced in the high MI/PCI group (5% vs. 18% PCI only; p = 0.045). CONCLUSIONS: Sonothrombolysis added to PCI improves recanalization rates and reduces infarct size, resulting in sustained improvements in systolic function after STEMI. (Therapeutic Use of Ultrasound in Acute Coronary Artery Disease; NCT02410330).

2.
J Vasc Surg ; 66(6): 1826-1835.e1, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28807383

RESUMO

OBJECTIVE: Predicting cardiac events is essential to provide patients with the best medical care and to assess the risk-benefit ratio of surgical procedures. The aim of our study was to evaluate the performance of the Revised Cardiac Risk Index (Lee) and the Vascular Study Group of New England Cardiac Risk Index (VSG) scores for the prediction of major cardiac events in unselected patients undergoing arterial surgery and to determine whether the inclusion of additional risk factors improved their accuracy. METHODS: The study prospectively enrolled 954 consecutive patients undergoing arterial vascular surgery, and the Lee and VSG scores were calculated. Receiver operating characteristic curves for each cardiac risk score were constructed and the areas under the curve (AUCs) compared. Two logistic regression models were done to determine new variables related to the occurrence of major cardiac events (myocardial infarction, heart failure, arrhythmias, and cardiac arrest). RESULTS: Cardiac events occurred in 120 (12.6%) patients. Both scores underestimated the rate of cardiac events across all risk strata. The VSG score had AUC of 0.63 (95% confidence interval [CI], 0.58-0.68), which was higher than the AUC of the Lee score (0.58; 95% CI, 0.52-0.63; P = .03). Addition of preoperative anemia significantly improved the accuracy of the Lee score to an AUC of 0.61 (95% CI, 0.58-0.67; P = .002) but not that of the VSG score. CONCLUSIONS: The Lee and VSG scores have low accuracy and underestimate the risk of major perioperative cardiac events in unselected patients undergoing vascular surgery. The Lee score's accuracy can be increased by adding preoperative anemia. Underestimation of major cardiac complications may lead to incorrect risk-benefit assessments regarding the planned operation.


Assuntos
Artérias/cirurgia , Técnicas de Apoio para a Decisão , Cardiopatias/etiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Área Sob a Curva , Brasil , Distribuição de Qui-Quadrado , Feminino , Cardiopatias/diagnóstico , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Sistema de Registros , Medição de Risco , Fatores de Risco , Suíça , Resultado do Tratamento
3.
J Am Coll Cardiol ; 67(21): 2506-15, 2016 May 31.
Artigo em Inglês | MEDLINE | ID: mdl-27230046

RESUMO

BACKGROUND: Pre-clinical trials have demonstrated that, during intravenous microbubble infusion, high mechanical index (HMI) impulses from a diagnostic ultrasound (DUS) transducer might restore epicardial and microvascular flow in acute ST-segment elevation myocardial infarction (STEMI). OBJECTIVES: The purpose of this study was to test the safety and efficacy of this adjunctive approach in humans. METHODS: From May 2014 through September 2015, patients arriving with their first STEMI were randomized to either DUS intermittent HMI impulses (n = 20) just prior to emergent percutaneous coronary intervention (PCI) and for an additional 30 min post-PCI (HMI + PCI), or low mechanical index (LMI) imaging only (n = 10) for perfusion assessments before and after PCI (LMI + PCI). All studies were conducted during an intravenous perflutren lipid microsphere infusion. A control reference group (n = 70) arrived outside of the time window of ultrasound availability and received emergent PCI alone (PCI only). Initial epicardial recanalization rates prior to emergent PCI and improvements in microvascular flow were compared between ultrasound-treated groups. RESULTS: Median door-to-dilation times were 82 ± 26 min in the LMI + PCI group, 72 ± 15 min in the HMI + PCI group, and 103 ± 42 min in the PCI-only group (p = NS). Angiographic recanalization prior to PCI was seen in 12 of 20 HMI + PCI patients (60%) compared with 10% of LMI + PCI and 23% of PCI-only patients (p = 0.002). There were no differences in microvascular obstructed segments prior to treatment, but there were significantly smaller proportions of obstructed segments in the HMI + PCI group at 1 month (p = 0.001) and significant improvements in left ventricular ejection fraction (p < 0.005). CONCLUSIONS: HMI impulses from a diagnostic transducer, combined with a commercial microbubble infusion, can prevent microvascular obstruction and improve functional outcome when added to the contemporary PCI management of acute STEMI. (Therapeutic Use of Ultrasound in Acute Coronary Artery Disease; NCT02410330).


Assuntos
Trombólise Mecânica/métodos , Microbolhas , Microcirculação , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Terapia por Ultrassom , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/terapia , Circulação Coronária , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea , Volume Sistólico
4.
Int J Cardiol ; 201: 650-7, 2015 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-26355241

RESUMO

BACKGROUND: Renal function, as quantified by the estimated glomerular filtration rate (eGFR), is a predictor of death in acute heart failure (AHF). It is unknown whether one of the clinically-available serum creatinine-based formulas to calculate eGFR is superior to the others for predicting mortality. METHODS AND RESULTS: We quantified renal function using five different formulas (Cockroft-Gault, MDRD-4, MDRD-6, CKD-EPI in patients<70 years, and BIS-1 in patients≥70 years) in 1104 unselected AHF patients presenting to the emergency department and enrolled in a multicenter study. Two independent cardiologists adjudicated the diagnosis of AHF. The primary endpoint was the accuracy of the five eGFR equations to predict death as quantified by the time-dependent area under the receiver-operating characteristics curve (AUC). The secondary endpoint was the accuracy to predict all-cause readmissions and readmissions due to AHF. In a median follow-up of 374 days (IQR: 221 to 687 days), 445 patients (40.3%) died. eGFR as calculated by all equations was an independent predictor of mortality. The Cockcroft-Gault formula showed the highest prognostic accuracy (AUC 0.70 versus 0.65 for MDRD-4, 0.55 for MDRD-6, and 0.67 for the combined formula CKD-EPI/BIS-1, p<0.05). These findings were confirmed in patients with varying degrees of renal function and in three vulnerable subgroups: women, patients with severe left ventricular dysfunction, and the elderly. The prognostic accuracy for readmission was poor for all equations, with an AUC around 0.5. CONCLUSIONS: Calculating eGFR using the Cockcroft-Gault formula assesses the risk of mortality in patients with AHF more accurately than other commonly used formulas.


Assuntos
Taxa de Filtração Glomerular/fisiologia , Insuficiência Cardíaca/mortalidade , Testes de Função Renal/métodos , Insuficiência Renal Crônica/fisiopatologia , Medição de Risco/métodos , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico , Humanos , Masculino , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Curva ROC , Insuficiência Renal Crônica/etiologia , Fatores de Risco , Taxa de Sobrevida/tendências
6.
Int J Cardiol ; 137(3): 252-9, 2009 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-18723231

RESUMO

BACKGROUND: The progression of heart failure in Chagas' disease has been explained by remodeling, leading to neurohumoral activation, or by the direct parasite damage to parasympathetic neurons during acute phase, leading to early sympathetic activation and progressive heart failure. To help distinguish between these hypotheses we studied muscle sympathetic nerve activity (MSNA) at rest and during handgrip exercise (30% of maximal voluntary contraction) in patients with Chagas' disease and normal ejection fraction vs. patients with heart failure. METHODS: A consecutive study of 72 eligible out-patients/subjects was conducted between July 1998 and November 2004. The participants were classified in three advanced heart failure groups (New York Heart Association Functional Classes II-III): Chagas' disease (n=15), ischemic (n=15) and idiopathic cardiomyopathy (n=15). Twelve Chagas' disease patients without heart failure and normal ejection fraction, and 15 normal controls were also studied. MSNA was recorded directly from the peroneal nerve by microneurography technique. RESULTS: MSNA was greater in heart failure patients when compared with Chagas' disease patients without heart failure (51+/-3 vs. 20+/-2 bursts/min P=0.0001). MSNA in Chagas' patients with normal ejection fraction and normal controls was not different. During exercise, MSNA was similar in all 3 heart failure groups. And, was lower in the Chagas' patients with normal ejection fraction than in patients with Chagas' disease and heart failure (28+/-1 vs. 63+/-5 bursts/min, respectively). CONCLUSION: MSNA is not elevated in patients with Chagas' disease with normal ejection fraction. These findings support the concept of remodeling and neurohumoral activation as a common pathway following significant cardiac injury.


Assuntos
Cardiomiopatia Chagásica/fisiopatologia , Músculo Esquelético/inervação , Sistema Nervoso Simpático/fisiopatologia , Análise de Variância , Pressão Sanguínea/fisiologia , Estudos de Casos e Controles , Feminino , Antebraço/irrigação sanguínea , Força da Mão/fisiologia , Frequência Cardíaca/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Contração Muscular/fisiologia , Miocárdio
7.
Endocrine ; 32(2): 175-81, 2007 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-18026694

RESUMO

Treatment of large multinodular goiter (MNG) with radioiodine preceded by recombinant human thyrotropin (0.1 mg rhTSH) has been shown to be a safe alternative for patients with comorbidities that preclude surgery. However, the increase in serum thyroid hormones that follows both treatments may be harmful for some patients, particularly those with underlying cardiovascular disease. In this study, we evaluated cardiac parameters (clinical, ECG, 24-h Holter, Doppler echocardiogram, treadmill stress test) in 27 of 42 patients (ages 42-80 years) with large MNGs who were treated with rhTSH before receiving 30 mCi radioiodine therapy. At baseline, 18 patients had subclinical and six patients had overt iodine-induced hyperthyroidism. All patients had a transient surge in serum levels of free T4 and total T3 into the hyperthyroid range after therapy. However, repeated cardiac evaluation did not show significant changes as compared with baseline evaluation. In conclusion, rhTSH stimulated RAI treatment of MNG did not affect structural and functional parameters of the heart, despite transient high-serum levels of thyroid hormones.


Assuntos
Sistema Cardiovascular/fisiopatologia , Bócio Nodular/tratamento farmacológico , Bócio Nodular/radioterapia , Hipertireoidismo/tratamento farmacológico , Hipertireoidismo/radioterapia , Radioisótopos do Iodo/uso terapêutico , Tireotropina/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Sistema Cardiovascular/efeitos dos fármacos , Sistema Cardiovascular/efeitos da radiação , Terapia Combinada , Relação Dose-Resposta a Droga , Ecocardiografia Doppler , Eletrocardiografia , Teste de Esforço , Feminino , Bócio Nodular/complicações , Humanos , Hipertireoidismo/etiologia , Masculino , Pessoa de Meia-Idade , Proteínas Recombinantes/uso terapêutico , Hormônios Tireóideos/sangue
8.
Arq Bras Cardiol ; 85(1): 63-4, 2005 Jul.
Artigo em Português | MEDLINE | ID: mdl-16041457

RESUMO

The HACEK microorganisms (Haemophilus spp, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) account for 3% of the cases of endocarditis. They have the following similar clinical and microbiological properties: are Gram-negative bacilli, more easily isolated in aerobic media; their cultures require prolonged incubation time for growing (mean, 3.3 days); and may be considered part of normal flora of upper respiratory tract and oropharynx. The following characteristics have been identified in endocarditis caused by the HACEK microorganisms: insidious clinical findings; difficult diagnosis due to the fastidious nature of the microorganisms; and negative cultures. The Eikenella corrodens endocarditis was first described in 1972. That microorganism continues to be a rare etiological agent. We report the case of a female patient with native valve, who had Eikenella corrodens infective endocarditis.


Assuntos
Eikenella corrodens/isolamento & purificação , Endocardite Bacteriana/microbiologia , Infecções por Bactérias Gram-Negativas , Adulto , Eikenella corrodens/crescimento & desenvolvimento , Endocardite Bacteriana/diagnóstico , Feminino , Humanos
9.
Eur J Heart Fail ; 7(4): 468-74, 2005 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-15921781

RESUMO

OBJECTIVE: To evaluate uric acid renal excretion, hyperuricemia, renal dysfunction, and prognosis in patients with decompensated severe heart failure, as there are few data available. METHODS: One hundred and twenty-two patients, hospitalized for heart failure decompensation, in NYHA class IV, were classified into 3 groups as follows. Pilot group [ejection fraction (EF)0.45 and valvular dysfunction, n=16). The patients in groups 1 and 2 underwent assessment of creatinine and uric acid clearance before and after pyrazinamide, to estimate uric acid tubular secretion. Uric acid clearance <6.8 mL/min and secretion <170 microg/min were considered reduced. In groups 1 and pilot (n=106), mortality was analyzed by Cox regression model, and the prognostic value of hyperuricemia was assessed by ROC curve. RESULTS: In groups 1 and 2, respectively, serum uric acid was 511.7 and 422.5 micromol/L, and creatinine clearance was 46.7 and 61.4 mL/min. Uric acid clearance (3.2 vs. 3.9 mL/min) and tubular secretion (116 vs. 128 microg/min) were not different, but lower than normal values. In groups 1 and pilot, the 12-month mortality was 46.4% (CI 95%: 36.7%-56.0%). At end of follow-up, mortality was associated with impaired creatinine clearance (p<0.001), but not with hyperuricemia (p=0.236). CONCLUSIONS: In patients with decompensated severe heart failure, the tubular secretion and the clearance of uric acid were reduced. Renal dysfunction was associated with mortality, but hyperuricemia was not.


Assuntos
Insuficiência Cardíaca/metabolismo , Insuficiência Renal/fisiopatologia , Ácido Úrico/metabolismo , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Curva ROC , Insuficiência Renal/epidemiologia , Ácido Úrico/sangue , Ácido Úrico/urina
10.
Arq Bras Cardiol ; 78(1): 83-9, 2002 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-11826349

RESUMO

OBJECTIVE: To evaluate the relationship between 24-hour ambulatory arterial blood pressure monitoring and the prognosis of patients with advanced congestive heart failure. METHODS: We studied 38 patients with NYHA functional class IV congestive heart failure, and analyzed left ventricular ejection fraction, diastolic diameter, and ambulatory blood pressure monitoring data. RESULTS: Twelve deaths occurred. Left ventricular ejection fraction (35.2 +/-7.3%) and diastolic diameter (72.2 +/- 7.8mm) were not correlated with the survival. The mean 24-hour (SBP24), waking (SBPw), and sleeping (SBPs) systolic pressures of the living patients were higher than those of the deceased patients and were significant for predicting survival. Patients with mean SBP24, SBPv, and SBPs >/=105mmHg had longer survival (p=0.002, p=0.01 and p=0.0007, respectively). Patients with diastolic blood pressure sleep decrements (dip) and patients with mean blood pressure dip /= 105 mmHg CONCLUSION: Ambulatory blood pressure monitoring appears to be a useful method for evaluating patients with congestive heart failure.


Assuntos
Monitorização Ambulatorial da Pressão Arterial/métodos , Insuficiência Cardíaca/fisiopatologia , Adulto , Idoso , Feminino , Insuficiência Cardíaca/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Sono/fisiologia , Volume Sistólico/fisiologia , Análise de Sobrevida , Caminhada/fisiologia
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