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The Medicine, Angioplasty or Surgery Study (MASS): A prospective, randomized trial of medical therapy, balloon angioplasty or bypass surgery for single proximal left anterior descending artery stenoses

OBJECTIVES This study sought to evaluate, in a prospective and randomized trial, the relative efficacies of three possible therapeutic strategies for patients with a single severe proximal stenosis of the left anterior descending coronary artery and stable angina. BACKGROUND Although percutaneous transluminal coronary angioplasty and coronary artery bypass surgery are often performed in patients with a single proximal stenosis of the left anterior descending coronary artery, it is unclear whether revascularization offers greater clinical benefit than medical therapy alone. METHODS At a single center, 214 patients with stable angina, normal ventricular function and a proximal stenosis of the left anterior descending coronary artery > 80% were randomly assigned to undergo mammary bypass surgery (n = 70), balloon angioplasty (n = 72) or medical therapy alone (n = 72). Angioplasty had to be considered technically feasible in every case. The predefined primary study end point was the combined incidence of cardiac death, myocardial infarction or refractory angina requiring revascularization. RESULTS At an average follow-up period of 3 years, a primary end point had occurred in only 2 patients (3%) assigned to bypass surgery compared with 17 assigned to angioplasty (24%) and 12 assigned to medical therapy (17%) (p = 0.0002, angioplasty vs. bypass surgery; p = 0.006, bypass surgery vs. medical treatment; p = 0.28, angioplasty vs. medical treatment, all by log-rank test). There was no difference in mortality or infarction rates among the groups. However, no patient allocated to bypass surgery needed revascularization, compared with eight and seven patients assigned, respectively, to coronary angioplasty and medical treatment (p = 0.019). Both revascularization techniques resulted in greater symptomatic relief and a lower incidence of ischemia on the treadmill test; however, all three strategies eventually resulted in the abolition of limiting angina. CONCLUSIONS The more aggressive therapeutic approach with initial bypass surgery for patients with a single severe proximal stenosis of the left anterior descending coronary artery is associated with a lower incidence of medium-term adverse events than coronary angioplasty or medical treatment. However, all three strategies resulted in a similar incidence of death and infarction during an average follow-up period of 3 years. This information should be taken into consideration when physicians and patients make therapeutic choices in this setting.

Effects of acute hormone therapy on recurrent ischemia in postmenopausal women with unstable angina

OBJECTIVES We tested whether acute hormone therapy reduces ambulatory electrocardiographic ischemia in postmenopausal (PMP) women with unstable angina (UA). BACKGROUND Endothelial dysfunction contributes to the pathophysiology of UA. Acute estrogen administration improves endothelial function in PMP women with coronary artery disease and increases coronary artery blood flow. METHODS Two hundred ninety-three PMP women with UA (mean age 69.7 years), treated with standard anti-ischemic therapy, were enrolled within 24 h of symptom onset. In a double-blind fashion, subjects were randomized to receive intravenous followed by oral conjugated estrogen for 21 days, intravenous estrogen followed by oral conjugated estrogen plus medroxyprogesterone for 21 days or placebo. The primary end point was the number of ambulatory electrocardiographic ischemic events over the first 48 h. Clinical events were also determined over six months of follow-up. RESULTS Electrocardiographic ischemia did not differ among the three randomized groups. The mean number of ischemic events per patient over 48 h was 0.74 for estrogen, 0.86 for estrogen plus progesterone and 0.74 for the placebo groups (p = 0.87). The percentage of patients with ischemic events and the mean duration of ischemia did not differ between hormone- and placebo-treated patients. In-hospital and six-month rates of adverse clinical events were also similar among the three randomized groups. CONCLUSIONS Acute hormone therapy does not reduce ischemia in PMP women with UA when added to standard anti-ischemic therapy.

Diagonal earlobe crease as a marker of the presence and extent of coronary atherosclerosis

This study evaluates the association between the presence of diagonal earlobe creases (ELC) and coronary artery disease (CAD). One thousand four hundred twenty-four patients (760 men and 664 women, aged 30 to 80 years) were examined for the presence of ELC and classified into 2 groups: group I control--1,086 consecutive patients who denied symptoms of myocardial ischemia and were admitted to a general hospital for other reasons; group II CAD--338 patients with documented CAD (presence of > or = 70% coronary diameter stenosis at angiography). ELC was present in 304 patients (28%) in group I and 220 (65%) in group II (p < 0.0001). The patients were stratified in age groups to isolate the influence of age because the prevalence of ELC and CAD increased with advancing age (p < 0.0001 for both). This association remained statistically significant in all decades, except for patients aged > 70 years. To further remove the confounding effect of different age and sex distributions between the groups, a direct adjustment of the ELC prevalence was performed. When adjusted for age and sex, the prevalence of creases was still 58% higher in patients with CAD than in control subjects (p < 0.001). The presence of ELC was also related to the extent of CAD as measured by the number of major arteries narrowed (p = 0.015). The observed sensitivity of the sign for the diagnosis of CAD was 65%, the specificity 72%, the positive predictive value 42% and the negative predictive value 87%.

Mortality and Embolic Potential of Cardiac Tumors

Background Cardiac tumors are rare, mostly benign with high embolic potential. Objectives To correlate the histological type of cardiac masses with their embolic potential, implantation site and long term follow up in patients undergoing surgery. Methods Between January 1986 and December 2011, we retrospectively analyzed 185 consecutive patients who underwent excision of intracardiac mass (119 females, mean age 48±20 years). In 145 patients, the left atrium was the origin site. 72% were asymptomatic and prior embolization was often observed (19.8%). The diagnosis was established by echocardiography, magnetic resonance and histological examination. Results Most tumors were located in the left side of the heart. Myxoma was the most common (72.6%), followed by fibromas (6.9%), thrombi (6.4%) and sarcomas (6.4%). Ranging from 0.6cm to 15cm (mean 4.6 ± 2.5cm) 37 (19.8%) patients had prior embolization, stroke 10.2%, coronary 4.8%, peripheral 4.3% 5.4% of hospital death, with a predominance of malignant tumors (40% p < 0.0001). The histological type was a predictor of mortality (rhabdomyomas and sarcomas p = 0.002) and embolic event (sarcoma, lipoma and fibroelastoma p = 0.006), but not recurrence. Tumor size, atrial fibrillation, cavity and valve impairment were not associated with the embolic event. During follow-up (mean 80±63 months), there were 2 deaths (1.1%) and two recurrences 1 and 11 years after the operation, to the same cavity. Conclusion Most tumors were located in the left side of the heart. The histological type was predictor of death and preoperative embolic event, while the implantation site carries no relation with mortality or to embolic event.

Considerações sobre o processo de revisão pelos pares nos Arquivos

1e com a publicacao, tambem em ingles dos artigos originais e relatos de caso, ha uma melhor possibilidade de exposicao internacional do conteudo da revista e por consequencia da producao cientifica cardiologica nacional. Ressaltamos tambem os esforcos em curso para incluila na base de dados do ISI / Current contents o que resultara com certeza em significativo aumento do fator de impacto da Revista. As reflexoes que se seguem sao resultado da experiencia como editor associado e executivo ao longo dos ultimos 9 anos e do relacionamento frutifero com cinco diferentes equipes que nestes anos assumiram a editoracao da revista, as vezes com visoes diferentes, mas sempre com o mesmo intuito do aprimoramento constante dos Arquivos. Nao poderia deixar de mencionar, tambem, a importância do convivio com nossa assessora executiva, Dona Gloria Cardoso, que com elegância e competencia tantas vezes nos emprestou sua experiencia de 45 anos de envolvimento intimo com os Arquivos. Estas consideracoes tambem procuram espelhar uma busca cada vez mais ativa por parte dos editores das melhores revistas cientificas internacionais de um melhor conhecimento do processo de revisao editorial e de seu aprimoramento constante. A nossa revista e plural, aceitando diversos tipos de contribuicoes intelectuais. Todavia, sao os artigos originais que lhe conferem o maior peso cientifico dentre as contribuicoes recebidas e as seguintes consideracoes se aplicam naturalmente mais a estes. Um dos primeiros marcos na procura de uma melhor e mais uniforme comunicacao cientifica na area medica surgiu a partir do encontro de alguns dos mais importantes editores de revistas medicas em 1978, em Vancouver no Canada que, posteriormente, se transformaria no Comite Internacional de Editores de Revistas Medicas e estabeleceria normas e diretrizes para a comunicacao medico-cientifica, seguidas hoje pela maioria das revistas medicas e, tambem, pelos Arquivos. Outra tentativa que merece destaque, como evolucao da homogeneizacao da comunicacao medica, foi a