Costantino R. Costantini

Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction

OBJECTIVES The second Primary Angioplasty in Myocardial Infarction (PAMI-II) study evaluated the hypothesis that primary percutaneous transluminal coronary angioplasty (PTCA), with subsequent discharge from the hospital 3 days later, is safe and cost-effective in low risk patients. BACKGROUND In low risk patients with myocardial infarction (MI), few data exist regarding the need for intensive care and noninvasive testing or the appropriate length of hospital stay. METHODS Patients with acute MI underwent emergency catheterization with primary PTCA when appropriate. Low risk patients (age <70 years, left ventricular ejection fraction >45%, one- or two-vessel disease, successful PTCA, no persistent arrhythmias) were randomized to receive accelerated care (admission to a nonintensive care unit and day 3 hospital discharge without noninvasive testing [n = 237] or traditional care [n = 234]). RESULTS Patients who received accelerated care had similar in-hospital outcomes but were discharged 3 days earlier (4.2+/-2.3 vs. 7.1+/-4.7 days, p = 0.0001) and had lower hospital costs (

Prevalence and prognostic impact of diastolic dysfunction in patients with chronic kidney disease on hemodialysis

9,658+/-5,287 vs.

Prevalência e impacto prognóstico da disfunção diastólica na doença renal crônica em hemodiálise

11,604+/-6,125 p = 0.002) than the patients who received traditional care. At 6 months, accelerated and traditional care groups had a similar rate of mortality (0.8% vs. 0.4%, p = 1.00), unstable ischemia (10.1% vs. 12.0%, p = 0.52), reinfarction (0.8% vs. 0.4%, p = 1.00), stroke (0.4% vs. 2.6%, p = 0.07), congestive heart failure (4.6% vs. 4.3%, p = 0.85) or their combined occurrence (15.2% vs. 17.5%, p = 0.49). The study was designed to detect a 10% difference in event rates; at 6 months, only a 2.3% difference was measured between groups, indicating an actual power of 0.19. CONCLUSIONS Early identification of low risk patients with MI allowed safe omission of the intensive care phase and noninvasive testing, and a day 3 hospital discharge strategy, resulting in substantial cost savings.

Efeitos agudos do exercício físico prolongado: avaliação após ultramaratona de 24 horas

FUNDAMENTO: Disfuncao diastolica e frequente em pacientes de hemodialise, mas seu impacto na evolucao clinica e incerto. OBJETIVO: Avaliar a prevalencia e o impacto prognostico da disfuncao diastolica (DD) avancada (DDA) do ventriculo esquerdo (VE) em pacientes de hemodialise. METODOS: Ecocardiogramas foram realizados em pacientes no primeiro ano de hemodialise, em ritmo sinusal, sem doenca cardiovascular manifestada, excluindo-se aqueles com valvopatia significativa ou derrame pericardico. Pela avaliacao integrada dos dados ecodopplercardiograficos, a funcao diastolica foi classificada como: 1) normal, 2) DD discreta (alteracao do relaxamento) e 3) DDA (pseudonormalizacao e fluxo restritivo). Os desfechos pesquisados foram mortalidade geral e eventos cardiovasculares. RESULTADOS: Foram incluidos 129 pacientes (78 homens), com idade 52 ± 16 anos e prevalencia de DD de 73% (50% com DD discreta e 23% com DDA). No grupo com DDA, demonstrou-se maior idade (p < 0,01), pressao arterial sistolica (p < 0,01) e diastolica (p = 0,043), massa do VE (p < 0,01), indice do volume do atrio esquerdo (p < 0,01) e proporcao de diabeticos (p = 0,019), alem de menor fracao de ejecao (p < 0,01). Apos 17 ± 7 meses, a mortalidade geral foi significativamente maior naqueles com DDA, em comparacao aos normais e com DD discreta (p = 0,012, log rank test). Na analise multivariada de Cox, a DDA foi preditiva de eventos cardiovasculares (hazard ratio 2,2, intervalo de confianca 1,1-4,3, p = 0,021) apos ajuste para idade, genero, diabete, massa do VE e fracao de ejecao. CONCLUSAO: A DDA subclinica foi encontrada em aproximadamente um quarto dos pacientes de hemodialise e acarretou impacto prognostico, independente de outros dados clinicos e ecocardiograficos.BACKGROUND Diastolic dysfunction (DD) is frequent in patients on hemodialysis (HD), but its impact on the clinical evolution is yet to be established. OBJECTIVE To evaluate the prevalence and prognostic impact of left ventricular (LV) advanced diastolic dysfunction (ADD) in patients on hemodialysis. METHODS The echocardiograms were performed during the first year of HD therapy, in patients with sinus rhythm, with no evidence of cardiovascular disease, excluding those with significant valvopathy or pericardial effusion. The combined assessment of the Doppler echocardiographic data classified the diastolic dysfunction as: 1) normal diastolic function; 2) mild DD (relaxation alteration) and 3) ADD (pseudonormalization and restrictive flow pattern). The assessed outcomes were general mortality and cardiovascular events. RESULTS A total of 129 patients (78 males), aged 52 +/- 16 years, with a DD prevalence of 73% (50% with mild DD and 23% with ADD) were included in the study. The group with ADD was older (p < 0.01) and presented higher systolic (p < 0.01) and diastolic BP (p = 0.043), LV mass (p < 0.01), left atrial volume index (p < 0.01) and number of diabetic patients (p = 0.019), as well as lower ejection fraction (EF) (p < 0.01). After 17 +/- 7 months, the general mortality was significantly higher in individuals with ADD, when compared to those with normal function and mild DD (p = 0.012, log rank test). At Cox multivariate analysis, ADD was predictive of cardiovascular events (hazard ratio 2.2; confidence interval: 1.1-4.3; p = 0.021) after adjusted for age, gender, diabetes, LV mass and EF. CONCLUSION The subclinical ADD was identified in approximately 25% of the patients undergoing hemodialysis and had a prognostic impact, regardless of other clinical and echocardiographic data.

Efeitos de curto prazo de um programa de atividade física moderada em pacientes com síndrome metabólica

FUNDAMENTO: Disfuncao diastolica e frequente em pacientes de hemodialise, mas seu impacto na evolucao clinica e incerto. OBJETIVO: Avaliar a prevalencia e o impacto prognostico da disfuncao diastolica (DD) avancada (DDA) do ventriculo esquerdo (VE) em pacientes de hemodialise. METODOS: Ecocardiogramas foram realizados em pacientes no primeiro ano de hemodialise, em ritmo sinusal, sem doenca cardiovascular manifestada, excluindo-se aqueles com valvopatia significativa ou derrame pericardico. Pela avaliacao integrada dos dados ecodopplercardiograficos, a funcao diastolica foi classificada como: 1) normal, 2) DD discreta (alteracao do relaxamento) e 3) DDA (pseudonormalizacao e fluxo restritivo). Os desfechos pesquisados foram mortalidade geral e eventos cardiovasculares. RESULTADOS: Foram incluidos 129 pacientes (78 homens), com idade 52 ± 16 anos e prevalencia de DD de 73% (50% com DD discreta e 23% com DDA). No grupo com DDA, demonstrou-se maior idade (p < 0,01), pressao arterial sistolica (p < 0,01) e diastolica (p = 0,043), massa do VE (p < 0,01), indice do volume do atrio esquerdo (p < 0,01) e proporcao de diabeticos (p = 0,019), alem de menor fracao de ejecao (p < 0,01). Apos 17 ± 7 meses, a mortalidade geral foi significativamente maior naqueles com DDA, em comparacao aos normais e com DD discreta (p = 0,012, log rank test). Na analise multivariada de Cox, a DDA foi preditiva de eventos cardiovasculares (hazard ratio 2,2, intervalo de confianca 1,1-4,3, p = 0,021) apos ajuste para idade, genero, diabete, massa do VE e fracao de ejecao. CONCLUSAO: A DDA subclinica foi encontrada em aproximadamente um quarto dos pacientes de hemodialise e acarretou impacto prognostico, independente de outros dados clinicos e ecocardiograficos.BACKGROUND Diastolic dysfunction (DD) is frequent in patients on hemodialysis (HD), but its impact on the clinical evolution is yet to be established. OBJECTIVE To evaluate the prevalence and prognostic impact of left ventricular (LV) advanced diastolic dysfunction (ADD) in patients on hemodialysis. METHODS The echocardiograms were performed during the first year of HD therapy, in patients with sinus rhythm, with no evidence of cardiovascular disease, excluding those with significant valvopathy or pericardial effusion. The combined assessment of the Doppler echocardiographic data classified the diastolic dysfunction as: 1) normal diastolic function; 2) mild DD (relaxation alteration) and 3) ADD (pseudonormalization and restrictive flow pattern). The assessed outcomes were general mortality and cardiovascular events. RESULTS A total of 129 patients (78 males), aged 52 +/- 16 years, with a DD prevalence of 73% (50% with mild DD and 23% with ADD) were included in the study. The group with ADD was older (p < 0.01) and presented higher systolic (p < 0.01) and diastolic BP (p = 0.043), LV mass (p < 0.01), left atrial volume index (p < 0.01) and number of diabetic patients (p = 0.019), as well as lower ejection fraction (EF) (p < 0.01). After 17 +/- 7 months, the general mortality was significantly higher in individuals with ADD, when compared to those with normal function and mild DD (p = 0.012, log rank test). At Cox multivariate analysis, ADD was predictive of cardiovascular events (hazard ratio 2.2; confidence interval: 1.1-4.3; p = 0.021) after adjusted for age, gender, diabetes, LV mass and EF. CONCLUSION The subclinical ADD was identified in approximately 25% of the patients undergoing hemodialysis and had a prognostic impact, regardless of other clinical and echocardiographic data.

Associação entre marcadores de inflamação e aumento do átrio esquerdo em pacientes de hemodiálise

BACKGROUND The consequences and risks of prolonged physical exercise are not well established. OBJECTIVE To evaluate the effects of prolonged physical exercise on the participants of a 24-hour ultramarathon race. METHODS Twenty male runners were selected for evaluation a day before and immediately after the race, where the athletes had to cover the most distance in 24 hours. Clinical, laboratory and echocardiographic data were obtained at both evaluations. RESULTS Mean distance covered was 140.3 ± 18.7 km. Runners showed weight loss (p < 0.001) and decrease in systolic (p < 0.001) and diastolic (p = 0.004) blood pressure. Hematological changes were compatible with the physiological stress. Plasma levels of creatine phosphokinase strikingly increased post-race (163.4 ± 56.8 vs. 2978.4 ± 1921.9 U/L; p < 0.001) and was inversely correlated with distance covered: those who covered the longest distances showed the lowest CPK levels (Pearson r = 0.69, p = 0.02). After the race, 2 runners showed a slight increase in Troponin levels. One of them also had simultaneous decrease in left ventricular ejection fraction (coronary artery disease was subsequently ruled out). Basal echocardiography assessment had shown LV hypertrophy in one and increased left atrial volume in five runners. After the race, there was a decrease in E/A ratio (p < 0.01). CONCLUSION Prolonged physical exercise is associated with metabolic and cardiovascular alterations. Cardiac abnormalities found in our study suggest that cardiac fatigue may occur in this specific race modality. The long-term effect of these alterations, while maintaining the routine practice of prolonged strenuous physical activity, is still unknown.

A periodized model for exercise improves the intra-hospital evolution of patients after myocardial revascularization: a pilot randomized controlled trial

ABSTRACT Objectives: To evaluate whether a short-term moderate intensity exercise program could change inflammatory parameters, and improve different components of metabolic syndrome in sedentary patients. Methods: Sixteen patients completed the 12-week program of supervised exercise, which consisted of a 40 to 50 minutes of walking, 3 times a week, reaching 50 to 60% of the heart rate reserve. The parameters evaluated before and after intervention were waist circumference, systolic and diastolic blood pressure, triglycerides, LDL cholesterol, HDL cholesterol, total cholesterol, C-reactive protein and interleukin 8. Results: There was a significant reduction in waist circumference (102.1±7.5cm to 100.8±7.4cm; p=0.03) and in body mass index (29.7±3.2kg/m2 versus 29.3±3.5kg/m2; p=0.03). Systolic blood pressure dropped from 141±18 to 129±13mmHg and diastolic from 79±12 to 71±10mmHg (with p<0.05 for both). No changes were observed on total cholesterol, LDL cholesterol and triglycerides, although HDL cholesterol levels improved, from 45.5±6.0 to 49.5±9.8mg/dL (p=0.02). There was a trend toward reduction of C-reactive protein (8.3%; p=0.07) and interleukin 8 levels (17.4%; p=0.058). The improvement in cardiovascular capacity was demonstrated by an increase of 13% in estimated volume of oxygen (p<0.001). Conclusion: Benefits of aerobic exercise of moderate intensity were seen within only 12 weeks of training in sedentary patients with metabolic syndrome. Considering the easy self-applicability and proven metabolic effects, an exercise program could be a first approach to sedentary patients with metabolic syndrome.

Análise Ultrassonográfica Tardia do Stent Eluidor de Sirolimus Firebird TM

BACKGROUND In individuals with concurrent chronic kidney disease (CKD) and cardiovascular disease (CVD), the association between left atrial volume (LAV) and serum levels of C-reactive protein (CRP) is shown. OBJECTIVE Verify the presence of associations between systemic inflammation and LA dilation in patients on hemodialysis (HD) without clinically evident CVD. METHODS This was an observational cross-sectional study of a population on HD (> 3 months), which excluded patients with acute or chronic inflammatory diseases (infections, malignancies, autoimmune diseases) hemodynamic instability, use of anti-inflammatory drugs, hyperparathyroidism, arrhythmias, mitral valve disease and prior cardiovascular (CV) events. CRP and interleukin-6 (IL-6) measurements as well as Doppler echocardiography were obtained. Correlation coefficients were determined to evaluate the associations between variables. RESULTS A total of 58 patients were included (28 men, aged 55 ± 15 years), on HD for 24 ± 16 months, 45% were hypertensive, 26% diabetic, with median CRP of 5.1 mg/dL and IL-6 of 6.1 pg/dL. CRP significantly correlated with LAV (p = 0.040), LAV index (LAVi, p = 0.02) and mitral inflow E wave (p = 0.014). IL-6, despite the strong association with CRP levels (r = 0.75, p < 0.001), did not correlate with echocardiographic indices. Individuals in the top quartile of CRP had significantly higher LAVi than the others (42 ± 17 versus 32 ± 11 mL/m², p = 0.015). CONCLUSIONS In subjects on HD with no prior CV event, there was an association between elevated CRP levels and LA enlargement. The findings suggest an association between physiopathological processes related to left atrial dilation and systemic inflammatory state of patients on HD.

Prevalencia e impacto pronóstico de la disfunción diastólica en la enfermedad renal crónica en hemodiálisis

Objective: To compare models of the postoperative hospital treatment phase after myocardial revascularization. Design: A pilot randomized controlled trial. Setting: Hospital patients in a hospital setting. Subjects: Thirty-two patients with indications for myocardial revascularization were included between January 2008 and December 2009, with a left ventricular ejection fraction (LVEF) ≥50%, 1-second forced expiratory volume (FEV1) ≥60 and forced vital capacity (FVC) ≥60% of predicted value. Interventions: Patients were randomly placed into two groups: one performed prescribed exercises according to the model proposed by the American College of Sports Medicine (ACSM) and the other according to a periodized model. Main measures: Partial pressure of O2 (Po2) and arterial O2 saturation (Sao2), percentage of predicted FVC and total distance on the six-minute walking test (6MWT). Results: Twenty-seven patients were re-evaluated upon release from the hospital (ACSM = 14 and PP = 13). Five patients extubated for more than 6 hours in the postoperative period were excluded from the sample. In the preoperative period the variables Po2, Sao2, % FVC and 6MWT were similar. In the postoperative period, a reduction was observed for all parameters in both groups. Upon comparison of the groups, a difference was observed in Po2 (ACSM = 68.0 ± 4.3 vs. PP = 75.9 ± 4.8 mmHg; P < 0.001), Sao2 (ACSM = 93.5 ± 1.4 vs. PP = 94.8 ± 1.2%; P = 0.018) and 6MWT (ACSM = 339.3 ± 41.7 vs. PP = 393.8 ± 25.7 m; P < 0.001). There was no difference in % FVC. Conclusion: Patients after myocardial revascularization following a periodized model of exercise presented a better intra-hospital evolution when compared to those using the ACSM model.

CRT-300.05 Impact of Intravascular Imaging Methods for Optimal Scaffold Implantation Reducing Thrombosis After Absorb Bvs in a Real World Setting: Identification of Factors Related to Stent Failure

ABSTRACT Long-Term Ultrasound Analysis ofthe Firebird TM Sirolimus Eluting Stent Background: Drug eluting stents (DES) have improved theclinical outcomes of patients undergoing percutaneouscoronary interventions (PCI). New DES have been developedwith the purpose of overcoming the current limitations ofthe older generation DES. This study aimed to evaluatethe long-term angiographic and intravascular ultrasound(IVUS) findings of the Firebird TM sirolimus eluting stent. Methods: From December 2007 to March 2008, 15 patientswith de novo lesions underwent PCI using the Firebird TM stent. Angiography and IVUS were performed in all patientsat 24 months of follow-up. The primary objective was toassess the late luminal loss by quantitative coronary angio-graphy and in-stent percent volume obstruction by intra-vascular ultrasound (IVUS). Results: Mean age was 57 +7.1 years, 87% were male and 27% were diabetics. The leftanterior descending artery was the most frequently treatedvessel (36%) and most of the lesions were B2/C typelesions (82%). At 24 months, late luminal loss was 0.17 +0.36 mm and target vessel revascularization was 6.6%.In-stent percent volume obstruction was 9.6 + 4.6%. Therewere no cases of death, myocardial infarction or stentthrombosis.