Alexandre Schaan de Quadros

Identifying Patients at Risk for Premature Discontinuation of Thienopyridine After Coronary Stent Implantation

We sought to identify patients at risk for premature discontinuation of thienopyridines and to develop a risk score for thienopyridine adherence after coronary stent implantation. Patients were prospectively included from December 2007 to March 2008. At 1-month follow-up, all patients were given the Morisky questionnaire and asked if they had stopped taking thienopyridines. Multivariate analysis identified predictors of thienopyridine discontinuation; points were assigned to each variable according to the odds ratios and the c-statistic of the score was calculated. Mean age of the 400 patients included was 61.0 ± 10.4 years; 66 patients (16.5%) stopped thienopyridines after 1 month. Reasons for discontinuation were cost (62%), lack of information (17%), and recommendation by another doctor to stop treatment (15%). Factors associated with discontinuation included unmarried status (odds ratio 2.48, p = 0.046), lack of private health insurance (odds ratio 4.68, p = 0.041), acute coronary syndrome (odds ratio 2.31, p = 0.004), nondiabetics (odds ratio 2.20, p = 0.041), and patients who earned <2 times (odds ratio 8.23, p <0.001) and 2 to 3 times (odds ratio 4.46, p = 0.021) the minimum wage. Total risk score was 0 to 14 points and was strongly associated with thienopyridine discontinuation. For total scores of 0 to 4, 5 to 8, 9 to 12, and ≥13, 0%, 7%, 20%, and 37% of patients, respectively, stopped thienopyridines (c-statistic 0.76, p <0.0001). Risk score was also significantly associated with complete adherence as assessed by the Morisky questionnaire (c-statistic 0.74, p <0.001). In conclusion, we have identified patients at risk for premature discontinuation of thienopyridines using variables obtained before stent implantation and developed a risk score that accurately predicts premature thienopyridine discontinuation.

Early sheath removal and ambulation in patients submitted to percutaneous coronary intervention: A randomised clinical trial

INTRODUCTION Despite recent technical improvements and device developments, post-percutaneous coronary intervention care in patients submitted to this procedure performed through the femoral approach remains almost unchanged. An earlier sheath removal and ambulation could help to cut costs, save health system resources and prevent patient discomfort. However, this approach has not yet been well assessed. OBJECTIVES The main objective of this paper was to evaluate a strategy of post-procedure immediate sheath removal and early ambulation. METHODS A randomised trial was conducted in 347 patients submitted to percutaneous coronary intervention that used a 6 French gauge arterial sheath. The intervention group (IG, n=172) had the arterial sheath removed immediately after the procedure and ambulated after 3 h of bed rest. The control group (CG, n=175) had the arterial sheath removed 4h after the end of the angioplasty and rested for an additional 6 h. The primary end point was the development of major vascular complications: hematoma>10 cm, pseudo-aneurism and arterial bleeding after or during ambulation. Secondary end points were minor vascular complications: hematoma<10 cm, vasovagal reactions after sheath removal, and assessment of patients comfort during the peri-operative period. RESULTS Baseline characteristics did not differ statistically between groups, as major bleeding (IG=1.7% vs. CG=0.6%; p=0.31). Regarding other vascular complications and vasovagal reactions, there were also no significant differences. Patients of IG had less pain (26% vs. 41%, p=0.004) than CG, but the frequency of urinary retention was the same in both groups. CONCLUSION This study, although underpowered, indicates that immediate arterial sheath removal with early ambulation after PCI was not significantly associated with an increase in major vascular complications and was associated with increased patient comfort. Although further studies with larger samples are necessary to confirm these results, this study suggests that immediate arterial sheath removal with early ambulation may be an alternative for selected elective patients submitted to percutaneous coronary interventions and for those with difficulties to endure prolonged bed rest.

Insulin resistance and triglyceride/HDLc index are associated with coronary artery disease

BackgroundInsulin-resistance is associated with cardiovascular disease but it is not used as a marker for disease in clinical practice.AimsTo study the association between the homeostatic model assessment (HOMA-IR) and triglyceride/HDLc ratio (TG/HDLc) with the presence of coronary artery disease in patients submitted to cardiac catheterization.MethodsIn a cross-sectional study, 131 patients (57.0 ± 10 years-old, 51.5% men) underwent clinical, laboratory and angiographic evaluation and were classified as No CAD (absence of coronary artery disease) or CAD (stenosis of more than 30% in at least one major coronary artery).ResultsPrevalence of coronary artery disease was 56.7%. HOMA-IR and TG/HDLc index were higher in the CAD vs No CAD group, respectively: HOMA-IR: 3.19 (1.70-5.62) vs. 2.33 (1.44-4.06), p = 0.015 and TG/HDLc: 3.20 (2.38-5.59) vs. 2.80 (1.98-4.59) p = 0.045) - median (p25-75). After a ROC curve analysis, cut-off values were selected based on the best positive predictive value for each variable: HOMA-IR = 6.0, TG/HDLc = 8.5 and [HOMA-IR×TG/HDLc] = 28. Positive predictive value for coronary artery disease for HOMA-IR>6.0 was 82.6%, for TG/HDLc>8.5 was 85.7% and for [HOMA-IR×TG/HDLc]>28 was 88.0%. Adjusted relative risk (age, gender, diabetes, body mass index, systolic blood pressure) for the presence of coronary artery disease was: for HOMA-IR>6.0, 1.47 (95.CI: 1.06-2.04, p = 0.027), for TG/HDLc>8.5, 1.46 (95% CI:1.07-1.98), p = 0.015) and for [HOMA-IR × TG/HDLc] >28, 1.64 (95%CI: 1.28-2.09), p < 0.001).ConclusionsIncreased HOMA-IR, TG/HDLc and their product are positively associated with angiographic coronary artery disease, and may be useful for risk stratification as a high-specificity test for coronary artery disease.

Preditores de mudança na qualidade de vida após um evento coronariano agudo

BACKGROUND The assessment of quality of life (QOL), identifying functional capacity and frequency of angina and other cardiac symptoms, are key issues in the treatment of chronic patients or in those with disease instability. OBJECTIVE To identify predictors of quality of life (QOL) improvement in patients with non-ST segment elevation acute coronary syndrome (NSTEACS). METHODS Patients hospitalized in a cardiology reference hospital were assessed with the Seattle Angina Questionnaire (SAQ) at the time of admission and after 6 months. The analyzed outcome was the variation of the QOL score, resulting from the difference between the score after six months and the score at the time of admission. Differences between patients with or without 6-month QOL improvements regarding the demographic, clinical and therapeutic characteristics were assessed by univariate and multivariate analysis. RESULTS Hypertensive patients presented lower improvement in QOL scores when compared to non-hypertensive ones [8.3(0-25) vs. 16.6(0-33.3); P=0.05], as well as patients with dyslipidemia, when compared to non-dyslipidemic ones [8.3(0-25) vs. 16.6(0-33.3); P=0.02]. Patients with unstable angina presented greater improvements in QOL in relation to those with NSTE myocardial infarction [16.6(0-33.3) vs. 8.3(-8.3-25); P=0.03]. By multivariate analysis, myocardial revascularization in the first 30-days was associated with the greater improvement in the QOL score (8.47 points; P=0.005). On the other side, the presence of dyslipidemia at the baseline evaluation was an independent predictor of worse QOL scores (-7.2 points; P=0.01). CONCLUSION Myocardial revascularization was associated with improvement in the 6-month QOL scores, while dyslipidemia was associated with worse scores.

'Correction:' Serum transforming growth factor beta-1 (TGF-beta-1) levels in diabetic patients are not associated with pre-existent coronary artery disease

BackgroundThe association between TGF-β1 levels and long-term major adverse cardiovascular events (MACE) in patients with coronary artery disease (CAD) is controversial. No study specifically addressed patients with CAD and diabetes mellitus (DM). The association between TGF-β1 levels and long-term major adverse cardiovascular events (MACE) in patients with coronary artery disease (CAD) is controversial. No study specifically addressed patients with CAD and diabetes mellitus (DM).MethodsPatients (n = 135, 30–80 years) referred for coronary angiography were submitted to clinical and laboratory evaluation, and the coronary angiograms were evaluated by two operators blinded to clinical characteristics. CAD was defined as the presence of a 70% stenosis in one major coronary artery, and DM was characterized as a fasting glycemia > 126 mg/dl or known diabetics (personal history of diabetes or previous use of anti-hyperglycemic drugs or insulin). Based on these criteria, study patients were classified into four groups: no DM and no CAD (controls, C n = 61), DM without CAD (D n = 23), CAD without DM (C-CAD n = 28), and CAD with DM (D-CAD n = 23). Baseline differences between the 4 groups were evaluated by the χ2 test for trend (categorical variables) and by ANOVA (continuous variables, post-hoc Tukey). Patients were then followed-up during two years for the occurrence of MACE (cardiac death, stroke, myocardial infarction or myocardial revascularization). The association of candidate variables with the occurrence of 2-year MACE was assessed by univariate analysis.ResultsThe mean age was 58.2 ± 0.9 years, and 51% were men. Patients with CAD had a higher mean age (p = 0.011) and a higher percentage were male (p = 0.040). There were no significant baseline differences between the 4 groups regarding hypertension, smoking status, blood pressure levels, lipid levels or inflammatory markers. TGF-β1 was similar between patients with or without CAD or DM (35.1 ×/÷ 1.3, 33.6 ×/÷ 1.6, 33.9 ×/÷ 1.4 and 31.8 ×/÷ 1.4 ng/ml in C, D, C-CAD and D-CAD, respectively, p = 0.547). In the 2-year follow-ip, independent predictors of 2-year MACE were age (p = 0.007), C-reactive protein (p = 0.048) and systolic blood pressure (p = 0.008), but not TGF-β1.ConclusionSerum TGF-β1 was not associated with CAD or MACE occurrence in patients with or without DM.

Quality of life and health status after percutaneous coronary intervention in stable angina patients: results from the real-world practice.

Background: Percutaneous coronary interventions (PCI) are associated with quality of life (QoL) and health status improvements in stable angina patients. There are few studies assessing the magnitude of this effect and its predictors in contemporary daily practice. Methods: Prospective cohort study with stable angina patients submitted to PCI in a tertiary interventional cardiology center. The clinical characteristics and the Seattle Angina Questionnaire (SAQ) were assessed before PCI, and patients were followed‐up for 1 year. Mixed linear regression and ANOVA were used to compare SAQ indices, and multivariate analysis to identify predictors of QoL improvement. Results: Between September 2006 and May 2007, 110 patients were included. The mean age of the study population was 62.8 ± 8.7 years, and 62% of the patients were of the male gender. Diabetes mellitus was present in 29%, arterial hypertension in 82%, previous myocardial infarction in 32%, and previous PCI in 29%. Before PCI, only 5% of the patients were free of angina, and this rate improved to 68% in the one‐year followup (P < 0.001). There was improvement in all SAQ scales in the one‐year followup, which was already shown in the 6‐month assessment (P < 0.0001). Quality of life before the procedure was the main predictor of QoL improvement by multivariate analysis (P < 0.001). Conclusions: Patients with stable angina submitted to PCI in the real‐world practice present significant improvement in one‐year health status, as assessed by the SAQ. Quality of life before the procedure is the main determinant of improvement in QoL.

Use of drug-eluting stents in Brazil: the CENIC (National Registry of Cardiovascular Interventions) registry

BACKGROUND Drug-eluting stents (DES) represent a major advance in the management of ischemic heart disease, but the extrapolation of favorable results from clinical trials to the real-world practice has been criticized. OBJECTIVE To assess the use of DES in Brazil between 2000 and 2005. METHODS Using the database of the National Registry of Cardiovascular Interventions (CENIC - Central Nacional de Intervenções Cardiovasculares) of the Brazilian Society of Hemodynamics and Interventional Cardiology (SBHCI - Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista), all PCI procedures with DES implantation performed between 2000 and 2005 were analyzed. The groups were divided into the following biennia: 2000-2001(A), 2002-2003 (B), and 2004-2005 (C), and patients clinical and angiographic characteristics were compared, as well as their short-term clinical outcome. Statistical analyses were performed using the chi-square test or ANOVA, and p values of less than 0.05 were considered to be statistically significant. RESULTS A total of 154,406 PCI procedures were studied, and DES was used in 10,426 (7%) interventions. A progressive and statistically significant increase was found in the use of DES during the period studied: 0.14% from 2000 to 2001, 5% from 2002 to 2003, and 14% from 2004 to 2005 (p < 0.0001). After 2001, there was an increase in success rates (96.58% in 2000-2001 (A), 99.69% in 2002-2003 (B), and 99.56% in 2004-2005 (C), A x B with p < 0.001; B x C with p = 0.015) and a decrease in hospital mortality rates (1.59% in group A, 0.38% in group B, and 0.66% in group C, with p = 0.59 for A x B and p < 0.0001 for B x C). CONCLUSION In Brazil, the use of drug-eluting stents increased significantly during recent years, resulting in higher success rates and lower hospital mortality.

Implante valvular aórtico percutâneo: experiência inicial do Sul do Brasil

BACKGROUND: Severe aortic stenosis is a prevalent disease with high rates of morbidity and mortality. The classic approach to its treatment is through heart valve replacement surgery. However, elderly patients and others with different comorbidities present high surgical risk. The percutaneous aortic valve implantation through a retrograde approach has emerged as a feasible and effective alternative treatment for this issue. We describe the first series of cases treated with this new approach in the South of Brazil. METHODS: Series of three cases describing the procedure and immediate results of CoreValve device implantation. This device consists in a bioprosthesis with three porcine leafs mounted and sutured in a self-expandable nitinol stent introduced through the femoral or iliac artery. RESULTS: Three female patients aged 81, 85 and 90 years with a logistic EuroSCORE varying from 20% to 36% were successfully submitted to the implantation of this device. A significant reduction in all gradients between the left ventricle and the aorta was observed. There were no reports of major cardiovascular complications, although in two patients the implantation of a permanent pacemaker was needed due to an atrioventricular conduction disorder. All patients were discharged asymptomatic and were kept in a long-term clinical follow-up evaluation program. CONCLUSION: The initial short-term experience with the percutaneous retrograde aortic valve implantation in the south of Brazil was feasible and safe. Additional studies and long-term follow-up are still necessary in order to define the precise role and adequate indications for this new and very promising technique.

Endothelial function in patients with slow coronary flow and normal coronary angiography

Atherosclerotic heart disease usually manifests as angina and is diagnosed by stress imaging tests and coronary angiography (1), but some patients with typical angina and documented myocardial ischemia have normal coronary arteries (2), a clinical picture called cardiac syndrome X (3). Endothelial (4) and microvascular (5) dysfunction have been suggested to play a pathogenic role in this situation. Patients with slow coronary flow (SCF) (6) and endothelial dysfunction (7) are both at increased risk for cardiovascular events. Several methods to measure endothelial injury can provide clinical opportunities to identify these patients (8), but the evaluation of endothelial function in arterial and venous vascular beds has not yet been performed. The aim of this study was to evaluate the arterial and venous endothelial functions in patients with stable angina and normal coronary anatomy but SCF on a cardiac angiogram.

Análise das complicações hospitalares relacionadas ao cateterismo cardíaco

INTRODUCAO: As complicacoes relacionadas ao cateterismo cardiaco sao os principais limitantes desta tecnica, e podem variar desde eventos adversos leves e transitorios ate eventos graves, como infarto do miocardio ou morte. OBJETIVO: Avaliar a incidencia de complicacoes imediatas do cateterismo cardiaco diagnostico em adultos, conforme um modelo de categorizacao das complicacoes em tipo e gravidade. METODO: Estudo de coorte prospectivo em um centro de referencia. As caracteristicas dos pacientes foram registradas, e estes foram acompanhados ate a alta hospitalar. As complicacoes foram categorizadas em nove modalidades: alergica, isquemica, vascular, arritmica, vaso-vagal, pirogenica, neurologica, embolica e congestivas, e estratificadas em leves (intercorrencias), moderadas (resolvidas em ate 24 horas) ou graves (necessitou internacao ou intervencao). Os fatores preditivos de complicacoes foram identificados por analise multivariada. RESULTADOS: Foram incluidos 1916 individuos, sendo 59,4% do sexo masculino e com media de idade de 58,3±11,1 anos. Complicacoes ocorreram em 175 pacientes (190 eventos), sendo que 62,5% foram intercorrencias leves, 24% moderadas e 13,5% graves. Foi registrado apenas um obito (0,05% dos individuos). As complicacoes vasculares foram as mais incidentes (35,6%), seguidas das vagais (18,3%), isquemicas (15,4%) e alergicas (14,4%). Os fatores de risco para complicacoes pela analise multivariada foram uso de anticoagulante (3,59; 1,67-7,74; p=0,006) e duracao prolongada do exame (1,03; 1,02-1,04; p<0,001). CONCLUSAO: As complicacoes relacionadas ao cateterismo cardiaco sao geralmente intercorrencias sem gravidade, sendo que as complicacoes vasculares, reacoes vagais e isquemicas foram as mais frequentes. O uso de anticoagulantes e o tempo de exame prolongado foram os principais fatores preditivos de complicacoes.