Ana Maria Rocha Krepsky

Safety and Efficacy of Second-Generation Everolimus-Eluting Stents

The second-generation everolimus-eluting stents (EES) are loaded with everolimus, which is a powerful analog of sirolimus; the drug carrier consists of a thin layer of durable and biocompatible fluorocopolymer, and the platform is made of cobalt-chromium alloy to allow thinner struts as well as to enhance stent radial strengh, delivery, and percutaneous coronary intervention success rates. EES are safe and efficient for the treatment of coronary artery disease in a wide range of anatomic settings, where several trials show EES superior to paclitaxel-eluting stents (PES); however, the superiority of EES over sirolimus-eluting stents (SES) is not so clear as over PES. In specific profiles of subjects such as diabetic patients, women, and patients presenting acute myocardial infarction (AMI), EES are also safe and efficient. In diabetic patients, the expected superiority of EES over PES and SES has not been confirmed. EES are equally safe and effective for women as for the general population. In the AMI setting, EES promote safety and efficacy outcomes similar to those found in non-AMI patients, as well as lower stent thrombosis rates in comparison with SES and PES. In conclusion, second-generation EES are safe and efficient for treatment of coronary artery disease in a wide range of anatomic and clinical settings.

On- vs. off-hours admission of patients with ST-elevation acute myocardial infarction undergoing percutaneous coronary interventions: data from a tertiary university Brazilian hospital

Introduction: Early reperfusion therapy is crucial in patients with ST-elevation myocardial infarction (STEMI). Off-hours hospital presentation may increase the time from pain to coronary reperfusion, and it may be responsible for increased cardiovascular outcomes. The aim of this study was to compare the effect of different times of presentation (on- and off-hours) on early mortality and major cardiovascular outcomes in patients with STEMI who underwent primary percutaneous coronary intervention (PCI). Methods: We have included consecutive patients with STEMI who underwent primary PCI between April 2011 and November 2016 in a tertiary university hospital in southern Brazil. Patients were divided into on- and off-hours admission. In-hospital and 30-day outcomes were evaluated. Results: A total of 301 patients (57.4%) were admitted during off-hours, and 223 (42.5%) during on-hours. Baseline characteristics were well balanced between the two groups. Median door-to-balloon time was higher in the off-hours group than in the on-hours group: 75 min (IQR 60-95) vs. 60 min (IQR 50-73.7) respectively (p < 0.001). In-hospital mortality was similar between groups (odds ratio [OR] = 0.56; 95% confidence interval [95%CI] 0.31-1.03; p = 0.06) and at 30-day follow-up (OR = 0.2; 95%CI 0.02-1.72 p = 0.14). In the matched cohort, no difference was found in the rates of in-hospital mortality (OR = 2.0; 95%CI 0.75-5.32; p = 0.16) and 30-day MACE (OR= 0.9; 95%CI 0.49-1.66; p = 0.75). Conclusions: In our center with PCI available 24/7 – without in-house staff – we did not observe any difference in patient characteristics, management, and outcomes, although a significant longer door-to-balloon time was found in patients treated during night shifts. Our results are consistent with those of other trials. Keywords: Myocardial infarction; percutaneous coronary intervention; system delay

Multiple Culprit Coronary Artery Thrombosis in a Patient with Coronary Ectasia

We here report a case of ST-elevation myocardial infarction (STEMI) due to simultaneous acute coronary artery occlusions of two major coronary arteries in a patient with coronary ectasia. The patient had been previously submitted to percutaneous coronary angioplasty with bare metal stent implantation in both culprit vessels. Very late stent thrombosis could be the cause of the first occlusion, triggering the event in the other vessel. In addition, concomitant embolic sources were not identified. Although routine aspiration thrombectomy in STEMI was not proven to be beneficial in randomized clinical trials, it was of great value in this case. We also discuss the relation between coronary ectasia, chronic inflammatory status, and increased platelet activity which may have caused plaque disruption in another already vulnerable vessel.

Comparison of Anatomical and Clinical Scores in Predicting Outcomes in Primary Percutaneous Coronary Intervention

Fundamento: Diferentes escores baseados em variaveis anatomicas e/ou clinicas tem sido desenvolvidos para estratificacao de risco em pacientes submetidos a intervencao coronariana percutânea (ICP). Estudos comparando a capacidade desses modelos na predicao de eventos cardiacos e cerebrovasculares adversos maiores (ECCAM) em pacientes submetidos a ICP primaria sao escassos. Objetivo: O objetivo desse estudo foi o de comparar os escores SYNTAX (SS), Clinical SYNTAX (CSS), ACEF e ACEF modificado (ACEFMod) na predicao de ECCAM em pacientes com infarto agudo do miocardico com supradesnivelamento do segmento ST (IAMCSST) submetidos a ICP primaria. Metodos: Foram analisados 311 pacientes consecutivos com IAMCSST submetidos a ICP primaria entre abril/2011 e dezembro/2015. As areas sob a curva caracteristica de operacao do receptor (ROC) foram calculadas para avaliar a habilidade desses escores em predizer ECCAM. O nivel de significância adotado em todos os testes foi de 5%. Resultados: Os pacientes apresentaram idade media de 60,2 ± 12,0 anos, 35,4% eram do sexo feminino e 22,5% eram diabeticos. A ocorrencia de ECCAM foi observada em 23,8% dos participantes. A area sob a curva ROC foi 0,586 (p = 0,028) para ACEF, 0,616 (p = 0,003) para SS, 0,623 (p = 0,002) para ACEFMod e 0,658 (p < 0,001) para CSS. Na analise multivariada, apenas SS (p = 0,011) e CSS (p = 0,002) foram preditores independentes de ECCAM. Conclusoes: SS e CSS elevados foram preditores independentes de ECCAM. Em nossa coorte de pacientes com IAMCSST submetidos a ICP primaria, o SS calculado a cineangiocoronariografia inicial mostrou-se uma ferramenta util para predizer ECCAM. (Int J Cardiovasc Sci. 2017; [online].ahead print, PP.0-0)

Infarto com Supradesnivelamento do Segmento ST e Trombo Coronariano Extenso em Paciente com Anemia Falciforme

Myocardial infarction in patients with sickle cell anemia is often underdiagnosed due to confounding factors (e.g., vasoocclusive disease leading to painful crisis). In the majority of reported cases, the coronary arteries were pervious and without stenotic lesions. In this case report, we describe the presence of an extensive coronary thrombus in a patient with sickle cell anemia presenting with ST elevation myocardial infarction, managed satisfactorily with the association of anticoagulants and antiplatelet drugs.

Volume Plaquetário Médio Como Preditor de Desfechos Cardiovasculares Maiores e Fluxo Coronariano Final em Pacientes Submetidos à Intervenção Coronária Percutânea Primária

Introducao: As plaquetas desempenham papel fundamental na fisiopatologia do infarto agudo do miocardio. Existem evidencias de que plaquetas de maior volume apresentem potencial pro- -trombotico aumentado. O objetivo deste estudo foi avaliar se o volume plaquetario medio pode predizer o fluxo coronariano do vaso tratado e os desfechos cardiovasculares adversos em pacientes com infarto do miocardio com supradesnivelamento do segmento ST submetidos a intervencao coronaria percutânea primaria. Metodos: Desfecho primario foi considerado como a ocorrencia de eventos cardiovasculares adversos (morte, acidente vascular cerebral, infarto agudo do miocardio, trombose de stent, angina e insuficiencia cardiaca classes 3 ou 4) em 30 dias. Desfecho secundario foi avaliado por meio da analise angiografica do fluxo TIMI pos-procedimento. Resultados: Dos 215 pacientes incluidos no registro de intervencao coronaria percutânea primaria, 168 (78,6%) tiveram volume plaquetario medio calculado antes do procedimento e foram analisados no presente estudo. Valores do volume plaquetario medio foram estratificados em tercis, sendo considerado um valor elevado > 11 fentolitros (fl). Volume plaquetario medio > 11 fl foi preditor independente de eventos cardiovasculares em 30 dias (p = 0,02). Observou-se que pacientes com fluxo final TIMI zero ou 1 demonstraram tendencia a apresentar volume plaquetario medio maior em relacao aqueles com fluxo final TIMI 2 ou 3 (11,3 ± 0,9 fl vs. 10,5 ± 1,3 fl; p = 0,06). Conclusoes: O volume plaquetario medio basal e um marcador simples, de facil afericao e util para predizer risco de eventos cardiovasculares em 30 dias em pacientes com infarto do miocardio com supradesnivelamento do segmento ST submetidos a intervencao coronaria percutânea primaria. Estudos futuros podem responder se a terapia antitrombotica mais agressiva resulta em melhores desfechos angiograficos e/ou clinicos nos pacientes com plaquetas maiores e mais ativas.

Cardiomiopatia Hipertrófica Obstrutiva Médio-Ventricular

A cardiomiopatia hipertrofica obstrutiva medio-ventricular e uma variante rara (1%) da cardiomiopatia hipertrofica obstrutiva. Neste relato de caso, apresentamos uma paciente encaminhada para realizacao de cateterismo cardiaco eletivo por angina e dispneia aos moderados esforcos, sem obstrucao coronariana significativa e com ventriculografia esquerda, demostrando cardiomiopatia hipertrofica obstrutiva medio-ventricular com um gradiente pressorico intraventricular de 130 mmHg.

TCT-329 Cardiovascular Imaging Radiation in Coronary Artery Disease: Is It a Real Concern?

The number of cardiac diagnostic and therapeutic procedures involving ionizing radiation has increased rapidly in recent years, raising concerns about patients (pts) radiation exposure. The annual pts effective radiation dose (ED) should not exceed 1mSv, which is equivalent to 50 chest X-rays. We

Impacto do diabetes melito na eficácia e na segurança dos stents farmacológicos: registro com até cinco anos de seguimento

BACKGROUND: Diabetic patients are at high risk of recurrent coronary events. Drug eluting stents (DES) reduce restenosis and target lesion revascularization in both diabetic and non-diabetic patients. However, there are limited data on the long-term safety and efficacy of DES in diabetic patients. The objective of this study was to evaluate the long-term clinical outcome in this high risk population. METHOD: From May 2002 to April 2007, all patients undergoing coronary intervention with DES in two hospitals were included in the study and were followed-up for up to 5 years. RESULTS: A total of 611 patients with mean age of 63.5 ± 11.2 years were included in the registry. Diabetic patients (n = 204, 33.4%) included a smaller proportion of males, greater prevalence of hypertension, chronic renal failure, and smaller coronary reference diameter when compared to non-diabetic patients. During the follow-up, diabetics had a higher probability of combined adverse cardiac events (19.7% vs. 13.4%; P = 0.04), as a result of death (7.4% vs. 2.3%; P = 0.003), acute myocardial infarction (5.9% vs. 3.1%; P = 0.10) and definitive/probable stent thrombosis (3.9% vs. 1.3%; P = 0.04). Target vessel and target lesion revascularization, however, were not different between the groups (10.9% vs. 9.8%; P = 0.68 and 3.4% vs. 5.1%; P= 0.35, respectively). The presence of diabetes mellitus was an independent predictor of death [odds ratio (OR) 2.41; 95% confidence interval (95% CI) 1.02-5.78; P = 0.05) but not of stent thrombosis (OR 2.41; 95% CI 0.76-7.61; P = 0.13) in our patients. CONCLUSIONS: The outcomes of this study show that in patients undergoing DES implantation, the presence of diabetes was associated to higher mortality rates, acute myocardial infarction and stent thrombosis when compared to non-diabetics. The finding of similar target lesion revascularization rates in diabetic and non-diabetic patients is promising and suggests the efficacy of percutaneous revascularization with DES implantation in this population.