Adriano Henrique Pereira Barbosa

Rede de infarto com supradesnivelamento de ST: sistematização em 205 casos diminui eventos clínicos na rede pública

BACKGROUND: The major cause of death in the city of Sao Paulo (SP) is cardiac events. At its periphery, in-hospital mortality in acute myocardial infarction is estimated to range between 15% and 20% due to difficulties inherent in large metropoles. OBJECTIVE:To describe in-hospital mortality in ST-segment elevation acute myocardial infarction (STEMI) of patients admitted via ambulance or peripheral hospitals, which are part of a structured training network (STEMI Network). METHODS: Health care teams of four emergency services (Ermelino Matarazzo, Campo Limpo, Tatuape and Saboya) of the periphery of the city of Sao Paulo and advanced ambulances of the Emergency Mobile Health Care Service (abbreviation in Portuguese, SAMU) were trained to use tenecteplase or to refer for primary angioplasty. A central office for electrocardiogram reading was used. After thrombolysis, the patient was sent to a tertiary reference hospital to undergo cardiac catheterization immediately (in case of failed thrombolysis) or in 6 to 24 hours, if the patient was stable. Quantitative and qualitative variables were assessed by use of uni- and multivariate analysis. RESULTS: From January 2010 to June 2011, 205 consecutive patients used the STEMI Network, and the findings were as follows: 87 anterior wall infarctions; 11 left bundle-branch blocks; 14 complete atrioventricular blocks; and 14 resuscitations after initial cardiorespiratory arrest. In-hospital mortality was 6.8% (14 patients), most of which due to cardiogenic shock, one hemorrhagic cerebrovascular accident, and one bleeding. CONCLUSION: The organization in the public health care system of a network for the treatment of STEMI, involving diagnosis, reperfusion, immediate transfer, and tertiary reference hospital, resulted in immediate improvement of STEMI outcomes.

Effect of systemic immunosuppression on coronary in-stent intimal hyperplasia in renal transplant patients

Cyclosporin, combined with other agents, is an immunosuppressive agent approved for prophylaxis of renal transplant rejection. In experimental studies, cyclosporin has been shown to inhibit smooth muscle cell proliferation in the vascular response to injury. 1,2 Similar experimental results have been observed with systemic use of rapamycin. 3,4 The aim of this clinical investigation was to test the hypothesis that systemic immunosuppression therapy inhibits in-stent restenosis in renal transplant patients with coronary artery disease treated with stenting.

Predictors of in-hospital mortality in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive treatment

OBJECTIVES: To identify predictors of in-hospital mortality in patients with acute myocardial infarction undergoing pharmacoinvasive treatment. METHODS: This was an observational, prospective study that included 398 patients admitted to a tertiary center for percutaneous coronary intervention within 3 to 24 hours after thrombolysis with tenecteplase. ClinicalTrials.gov: NCT01791764 RESULTS: The overall in-hospital mortality rate was 5.8%. Compared with patients who survived, patients who died were more likely to be older, have higher rates of diabetes and chronic renal failure, have a lower left ventricular ejection fraction, and demonstrate more evidence of heart failure (Killip class III or IV). Patients who died had significantly lower rates of successful thrombolysis (39% vs. 68%; p = 0.005) and final myocardial blush grade 3 (13.0% vs. 61.9%; p<0.0001). Based on the multivariate analysis, the Global Registry of Acute Coronary Events score (odds ratio 1.05, 95% confidence interval (CI) 1.02-1.09; p = 0.001), left ventricular ejection fraction (odds ratio 0.9, 95% CI 0.89-0.97; p = 0.001), and final myocardial blush grade of 0-2 (odds ratio 8.85, 95% CI 1.34-58.57; p = 0.02) were independent predictors of mortality. CONCLUSIONS: In this prospective study that evaluated patients with ST-segment elevation myocardial infarction treated by a pharmacoinvasive strategy, the in-hospital mortality rate was 5.8%. The Global Registry of Acute Coronary Events score, left ventricular ejection fraction, and myocardial blush were independent predictors of mortality in this high-risk group of acute coronary syndrome patients.

TCT-366 Predictors of major complications secondary to cardiac catheterization through femoral access in ST elevation in acute myocardial infarction during Pharmaco-Invasive Therapy.

ST elevation acute myocardial infarction (STEMI) and recent use of thrombolytics are risk factors for complications related to catheterism, especially in the femoral access. Our goal is to analyze predictors of major complications due to this invasive procedure in patients with STEMI undergoing

Complicações vasculares em pacientes submetidos a intervenção coronária percutânea precoce por via femoral após fibrinólise com tenecteplase: registro de 199 pacientes

BACKGROUND: Fibrinolysis is often used in the treatment of acute coronary syndromes with ST segment elevation (STEMI). Major cardiac outcomes were reduced with antiplatelet therapy intensification, but with increased risk of bleeding. Our objective was to assess the risk of vascular bleeding in patients undergoing early percutaneous coronary intervention after thrombolysis. METHODS: Between February 2010 and December 2011, five public emergency rooms in the city of Sao Paulo and the Emergency Health Care Service (Servico de Atendimento Movel de Urgencia - SAMU) used tenecteplase (TNK) to treat patients with STEMI. Patients were referred to a single tertiary hospital and were submitted to early cardiac catheterization during hospitalization. All examinations were performed via the femoral artery and BARC criteria were used to classify bleeding. RESULTS: We evaluated 199 patients, of whom 193 had no bleeding of vascular origin (group 1) and 6 (3%) developed this complication (group 2). The median time between the administration of the fibrinolytic agent and catheterization was 24 hours in group 1 and 14.7 hours in group 2. According to BARC criteria, 1 patient had type 3a bleeding (hematoma in the inguinal region with a hemoglobin decrease of 3-5 g/dL), 2 patients had type 3b bleeding (1 not related to vascular access and 1 retroperitoneal hematoma with a hemoglobin decrease ≥ 5 g/dL) and the remaining patients had type 1 bleeding (small inguinal hematomas). Blood transfusions were required in 2 patients. None of the patients died due to vascular complications after the intervention. CONCLUSIONS: In our study, early catheterization via the femoral artery as part of a pharmaco-invasive strategy, using TNK as a fibrinolytic agent, had a low vascular bleeding rate, comparable to that of elective angioplasties.

Simultaneous Thrombosis in Two Epicardial Coronary Arteries During Acute Myocardial Infarction

Young patient with a history of smoking, hypertension and use of illicit drugs (cannabis, cocaine and crack) was admitted with precordial pain after physical exercise within the previous two hours. Electrocardiogram demonstrated ST segment elevation in leads V1 to V4 and the patient was referred to cardiac catheterization, which showed total occlusion of the left anterior descending artery and a large amount of thrombi in the right coronary artery. The patient was treated with direct stenting in the left anterior descending artery and triple antiplatelet therapy with aspirin, clopidogrel and abciximab in combination with non-fractioned heparin for 24 hours. Angiography and intravascular ultrasound assessment after 48 hours demonstrated a complete resolution of thrombi in both coronary arteries.

Angiografia rotacional com reconstrução tridimensional (3D-RA) como ferramenta diagnóstica em pacientes com estenose da artéria do rim transplantado

INTRODUCAO: A estenose da arteria do rim transplantado (EART) e a principal complicacao vascular associada a eventos adversos em pacientes portadores de enxerto renal, cuja incidencia varia de 1% a 23%. A arteriografia e o padrao de referencia para o diagnostico, possibilitando tratamento imediato; porem, em decorrencia da anatomia variavel e da localizacao da anastomose, muitas vezes sao necessarias projecoes adicionais, levando a maior exposicao ao contraste e a radiacao. A angiografia rotacional com reconstrucao tridimensional (tridimensional rotational angiography - 3D-RA) surge como ferramenta para o diagnostico e o tratamento da EART. O objetivo deste estudo foi avaliar a acuracia das medidas obtidas pela 3D-RA, comparativamente a obtida pela angiografia convencional. METODOS: De abril de 2010 a janeiro de 2011, foram realizadas 41 3D-RA em pacientes com alta suspeita clinica de EART. As imagens foram analisadas por observadores independentes, sendo as medidas da arteriografia convencional obtidas no momento do procedimento e as da 3D-RA, apos o processamento das imagens pelo software Philips Allure 3D-RA. RESULTADOS: Foram analisadas 35 3D-RA (84%) consideradas adequadas para a realizacao das medidas angiograficas, das quais 20% contribuiram com informacoes adicionais relevantes para a estrategia terapeutica. Nao houve diferenca estatisticamente significante entre as medidas dos diâmetros de referencia e luminal minimo da arteria obtidas pela 3D-RA e pela angiografia convencional, alem de ter havido forte correlacao entre elas. CONCLUSOES: A 3D-RA surge como ferramenta util para o diagnostico da EART, ao obter medidas acuradas, oferecer informacoes complementares e relevantes para o diagnostico e tratamento, alem de potencialmente reduzir o tempo do procedimento e a exposicao ao contraste e a radiacao.

Initial experience with the use of fractional flow reserve in the hemodynamic evaluation of transplant renal artery stenosis

To describe and standardize an original protocol for fractional flow reserve (FFR) pre and postangioplasty in an initial series of patients with clinically manifested transplant renal artery stenosis (TRAS).

Development of bioanalytical assays for variegin, a peptide-based bivalent direct thrombin inhibitor

AIM Variegin is an anticoagulant peptide that will be tested in porcine models of percutaneous coronary intervention. We developed three bioanalytical assays for variegin quantitation and utilized these methods to evaluate pharmacokinetics of variegin in pigs. Results & methodology: The LC-MS/MS, thrombin amidolytic and modified thrombin time assays had a quantitation range of 21.6-5541.7, 10.8-5541.7 and 5.4-5541.7 nM in human plasma, respectively. The elimination half-lives obtained using the LC-MS/MS, modified thrombin time and thrombin amidolytic assays were 52.3 ± 4.4, 50.4 ± 5.9 and 67.7 ± 6.3 min, respectively. CONCLUSION We developed three bioanalytical assays for a novel direct thrombin inhibitor, variegin. The thrombin time assay is optimized for variegin quantitation during future porcine studies and clinical trials.

TCT-525 Initial experience with the use of fractional flow reserve in percutaneous intervention of transplant renal artery stenosis

RESULTS In Cohort 1, CFR was significantly lower (2.12 0.79 vs. 2.56 0.63; p<0.001) and HMR was significantly higher (2.61 1.22 vs. 2.31 0.89; p1⁄40.04) in vessels with CAD than the vessels without CAD, within the same patient. mMR was equivalent in obstructed and nonobstructed vessels: 1.54 0.77 vs. 1.53 0.57; p1⁄40.90. Cohort 2 confirmed these findings, showing a significant relationship for CFR and HMR with diameter stenosis % (b1⁄4-0.013, 95%CI [-0.016 to -0.010]; p<0.001 for CFR and b1⁄40.008, 95%CI [0.004 to 0.011]; p<0.001 for HMR per 1%), while mMR was independent of diameter stenosis % (b1⁄40.002, 95%CI [-0.001 to 0.004] per 1%; p1⁄40.15). No association was found between mMR and any of the risk factors for cardiovascular disease.