Aecio F. T. Gois

Qualidade de vida após revascularização cirúrgica do miocárdio, angioplastia ou tratamento clínico

BACKGROUND: Although the clinical benefits of coronary interventions seem to be confirmed, their effects on quality of life (QoL) are still scarcely studied. OBJECTIVE: To assess the QoL in multivessel coronary disease in patients randomly undergoing surgery, angioplasty or medical treatment. METHODS: The Short-Form Health Survey (SF-36) questionnaire was answered by 483 patients. Of these, 161 underwent surgical revascularization, 166 underwent angioplasty, and 153 were medically treated. RESULTS: At baseline, 86% of the patients referred angina, 34% referred infarction, and 32% were smokers. Medical Treatment: 12 patients (7.7%) had AMI, 24 (15.3%) underwent surgery, and 19 (12.1%) died. In addition, 5 (3.2%) had stroke, and 40 (25.6%) had angina. As regards the mental component, 64.1% and 30.8% had their condition improved and worsened, respectively. As regards the physical component, 70.5% and 27.6% had their condition improved and worsened, respectively. Surgery: 13 patients (8.1%) had AMI, 2 (1.2%) underwent surgery, and 12(7.4%) died. Also, 9 (5.6%) had stroke and 30 (18.6%) had angina. As regards the mental component, 72.7 % and 25.5% had their condition improved and worsened, respectively. As regards the physical component, 82.6% and 16.1% had their condition improved and worsened, respectively. Angioplasty: 18 patients (10.9%) had AMI, 51 (30.7%) underwent interventions, and 18 (19.9%) died. Additionally, six (3.6%) presented stroke and 35 (21%) reported angina. As regards the mental component, 66.9% and 26.5% had their condition improved and worsened, respectively. As regards the physical component, 77.1% and 20.5% had their condition improved and worsened, respectively. CONCLUSION: Improvement was observed in all domains and in the three therapeutic modalities. Comparatively, surgery had provided a better quality of life after a four-year follow-up.

Qualidade de vida após revascularização cirúrgica do miocárdio com e sem circulação extracorpórea

BACKGROUND: Coronary artery bypass grafting techniques without using cardiopulmonary bypass (off-pump CABG) result in less systemic damage, less clinical complications, less time spent in the intensive care unit, and shorter hospital stays, thereby raising the perspective of improved quality of life (QOL) for patients. OBJECTIVE: To assess quality of life in patients who underwent on-pump and off-pump CABG. METHODS: The Short-Form Health Survey (SF-36) Questionnaire was administered to patients with stable multivessel coronary artery disease (CAD) and preserved ventricular function before and at six and 12 months after surgery. RESULTS: Between January 2002 and December 2006, a total of 202 patients were randomized to either on-pump or off-pump CABG. Demographic, clinical, laboratory, and angiographic characteristics were similar in both groups. One hundred and five patients underwent off-pump CABG and 97 underwent on-pump CABG. In the postoperative course, 22 patients had myocardial infarction, 29 reported angina, one was reoperated, and three experienced stroke. No patient died. Quality of life, as measured by the SF-36 questionnaire, was shown to be similar in both groups regarding physical and mental components. However, male patients showed a significant improvement in physical functioning and role limitations due to physical problems. Also, a large number of patients in both groups returned to work. CONCLUSION: Progressive enhancement in quality of life and early return to work were observed for all patients, regardless of the surgical technique used. Save for a greater improvement in physical functioning and role limitations due to physical problems experienced by male patients, no statistically significant differences were found in the other domains between groups.

Five-year follow-up of angiographic disease progression after medicine, angioplasty, or surgery.

BackgroundProgression of atherosclerosis in coronary artery disease is observed through consecutive angiograms. Prognosis of this progression in patients randomized to different treatments has not been established. This study compared progression of coronary artery disease in native coronary arteries in patients undergoing surgery, angioplasty, or medical treatment.MethodsPatients (611) with stable multivessel coronary artery disease and preserved ventricular function were randomly assigned to CABG, PCI, or medical treatment alone (MT). After 5-year follow-up, 392 patients (64%) underwent new angiography. Progression was considered a new stenosis of ≥ 50% in an arterial segment previously considered normal or an increased grade of previous stenosis > 20% in nontreated vessels.ResultsOf the 392 patients, 136 underwent CABG, 146 PCI, and 110 MT. Baseline characteristics were similar among treatment groups, except for more smokers and statin users in the MT group, more hypertensives and lower LDL-cholesterol levels in the CABG group, and more angina in the PCI group at study entry. Analysis showed greater progression in at least one native vessel in PCI patients (84%) compared with CABG (57%) and MT (74%) patients (p < 0.001). LAD coronary territory had higher progression compared with LCX and RCA (P < 0.001). PCI treatment, hypertension, male sex, and previous MI were independent risk factors for progression. No statistical difference existed between coronary events and the development of progression.ConclusionThe angioplasty treatment conferred greater progression in native coronary arteries, especially in the left anterior descending territories and treated vessels. The progression was independently associated with hypertension, male sex, and previous myocardial infarction.

Impact of number of vessels disease on outcome of patients with stable coronary artery disease: 5-year follow-up of the Medical, Angioplasty, and bypass Surgery Study (MASS)

OBJECTIVE To evaluate whether the number of vessels disease has an impact on clinical outcomes as well as on therapeutic results accordingly to medical, percutaneous, or surgery treatment in chronic coronary artery disease. METHODS We evaluated 825 individuals enrolled in MASS study, a randomized study to compare treatment options for single or multivessel coronary artery disease with preserved left ventricular function, prospectively followed during 5 years. The incidence of overall mortality and the composite end-point of death, myocardial infarction, and refractory angina were compared in three groups: single vessel disease (SVD n=214), two-vessel disease (2VD n=253) and three-vessel disease (3VD n=358). The relationship between baseline variables and the composite end-point was assessed using a Cox proportional hazards survival model. RESULTS Most baseline characteristics were similar among groups, except age (younger in SVD and older in 3VD, p<0.001), lower incidence of hypertension in SVD (p<0.0001), and lower levels of total and LDL-cholesterol in 3VD (p=0.004 and p=0.005, respectively). There were no statistical differences in composite end-point in 5 years among groups independent of the kind of treatment; however, there was a higher mortality rate in 3VD (p<0.001). When we stratified our analysis for each treatment option, bypass surgery was associated with a lower number of composite end-point in all groups (SVD p<0.001, 2VD p=0.002, 3VD p<0.001). In multivariate analysis, we found higher mortality risk in 3VD comparing to SVD (p=0.005, HR 3.14, 95%CI 1.4-7.0). CONCLUSION Three-vessel disease was associated with worse prognosis compared to single- or two-vessel disease in patients with stable coronary disease and preserved ventricular function at 5-year follow-up. In addition, event-free survival rates were higher after bypass surgery, independent of the number of vessels diseased in these subsets of patients.

Impact of metabolic syndrome on the outcome of patients with stable coronary artery disease: 2-year follow-up of the MASS II study.

ObjectiveWe characterized the impact of the metabolic syndrome (MetS) and its components on cardiovascular adverse events in patients with symptomatic chronic multivessel coronary artery disease, which have been followed prospectively for 2 years. MethodsPatients enrolled in the MASS II study were evaluated for each component of the MetS, as well as the full syndrome. ResultsThe criteria for MetS were fulfilled in 52% of patients. The presence of MetS (P<0.05), glucose intolerance (P=0.007), and diabetes (P=0.04) was associated with an increased mortality in our studied population. Moreover, despite a clear tendency for each of its components to increase the mortality risk, only the presence of the MetS significantly increased the risk of mortality among nondiabetic study participants in a multivariate model (P=0.03, relative risk 3.5, 95% confidence interval 1.1–6). Finally, MetS was still associated with increased mortality even after adjustment for diabetes status. These results indicate a strong and consistent relationship of the MetS with mortality in patients with stable coronary artery disease. ConclusionAlthough glucose homeostasis seems to be the major force driving the increased risk of MetS, the operational diagnosis of MetS still has information for stratifying patients when diabetes information is taken into account.

Custos comparativos entre a revascularização miocárdica com e sem circulação extracorpórea

BACKGROUND: Surgical techniques of myocardial revascularization without the use of extracorporeal circulation (ECC) have raised hopes of attaining operative results with less systemic damage, lower occurrence of clinical complications and shorter hospital stay duration, generating expectations of lower hospital costs. OBJECTIVE: To evaluate the hospital costs in patients submitted to myocardial revascularization with and without ECC and in those with stable multiarterial coronary disease with preserved ventricular function. METHODS: The hospital costs were based on the existing governmental reimbursement. The costs included that of ortheses and prostheses and clinical complications. The time and costs of ICU stay and hospital stay duration were considered. RESULTS: Between January 2002 and August 2006, 131 patients were randomized to surgery with ECC (SECC), whereas 128 were randomized to surgery without ECC (WECC). The basal characteristics were similar for both groups. The costs of surgical complications were significantly lower (p < 0.001) in patients from the WECC when compared to the SECC group (606.00 ± 525.00 vs. 945.90 ± 440.00), as well as ICU costs: 432.20 ± 391.70 vs. 717.70 ± 257.70, respectively. The duration of the operating room stay were 4.9 ± 1.1 h vs. 3.9 ± 1.0 h, p < 0.001; at the ICU it was 48.2 ± 17.2 h vs. 29.2 ± 26.1h) (p < 0.001), with intubation time of 9.2 ± 4.5 h vs. 6.4 ± 5.1h, p < 0.001 for patients from the group with and without ECC, respectively. CONCLUSION: The present study allowed us to conclude that the myocardial revascularization surgery without extracorporeal circulation results in the decrease of operational costs and duration of the stay in each section related to the surgical treatment.

Análise da dispersão do intervalo QT em pacientes com infarto agudo do miocárdio: efeito da reperfusão coronariana

OBJECTIVE To study the effect of early reperfusion of infarct-related artery on QT(DeltaQT) dispersion interval, as well as how valuable it is as a marker for coronary reperfusion and ventricular arrhythmias. METHODS One hundred and six patients with reperfusion (WR) and 48 without reperfusion (WtR) who have received thrombolytic therapy in the acute phase of infarction were studied. ECG carried out on admission as well as on day 4 of patients course were analyzed. DeltaQT - defined as the difference between maximum and minimum QT interval - was measured by 12-lead ECG. RESULTS The reperfusion group showed significant DeltaQT reduction - from 89.66+/-20.47ms down to 70.95+/-21.65ms (p<0.001). On the other hand, the group without reperfusion showed DeltaQT significant increase - from 81.27+/-20.52ms up to 91.85+/-24.66ms (p<0.001). Logistic regression analysis showed that reduction magnitude between pre- and post-thrombolysis DeltaQT was the independent factor to most effectively identify coronary reperfusion (OR 1.045, p<0.0001; CI 95%). No significant difference was found in dispersion measures when patients with ventricular arrhythmias were compared with those with no arrhythmias in the course of the first 48 hours. CONCLUSION The study shows that DeltaQT is significantly reduced in patients with acute myocardial infarction submitted to successful thrombolysis, and is increased in infarcted patients with closed artery. DeltaQT reduction between the pre- and post-thrombolysis condition was a predictor for coronary reperfusion of those patients, and did not show correlation to ventricular arrhythmias.

Grande fístula bilateral da artéria coronária: a escolha do tratamento clínico

We report the case of an asymptomatic female patient, with a large non-complicated bilateral coronary-pulmonary artery fistula. Clinical monitoring was the choice of treatment. We discuss the therapeutic options in depth, emphasizing the excessive tendency of the surgical approach and the great scarcity of reports on long-term clinical follow-up in asymptomatic patients.

Large bilateral coronary artery fistula: the choice of clinical treatment

We report the case of an asymptomatic female patient, with a large non-complicated bilateral coronary-pulmonary artery fistula. Clinical monitoring was the choice of treatment. We discuss the therapeutic options in depth, emphasizing the excessive tendency of the surgical approach and the great scarcity of reports on long-term clinical follow-up in asymptomatic patients.

Gran fístula bilateral de la arteria coronaria: la selección del tratamiento clínico

We report the case of an asymptomatic female patient, with a large non-complicated bilateral coronary-pulmonary artery fistula. Clinical monitoring was the choice of treatment. We discuss the therapeutic options in depth, emphasizing the excessive tendency of the surgical approach and the great scarcity of reports on long-term clinical follow-up in asymptomatic patients.