Flavio Correa Pivatelli

Sensitivity, specificity and predictive values of linear and nonlinear indices of heart rate variability in stable angina patients

Background Decreased heart rate variability (HRV) is related to higher morbidity and mortality. In this study we evaluated the linear and nonlinear indices of the HRV in stable angina patients submitted to coronary angiography. Methods We studied 77 unselected patients for elective coronary angiography, which were divided into two groups: coronary artery disease (CAD) and non-CAD groups. For analysis of HRV indices, HRV was recorded beat by beat with the volunteers in the supine position for 40 minutes. We analyzed the linear indices in the time (SDNN [standard deviation of normal to normal], NN50 [total number of adjacent RR intervals with a difference of duration greater than 50ms] and RMSSD [root-mean square of differences]) and frequency domains ultra-low frequency (ULF) ≤ 0,003 Hz, very low frequency (VLF) 0,003 – 0,04 Hz, low frequency (LF) (0.04–0.15 Hz), and high frequency (HF) (0.15–0.40 Hz) as well as the ratio between LF and HF components (LF/HF). In relation to the nonlinear indices we evaluated SD1, SD2, SD1/SD2, approximate entropy (−ApEn), α1, α2, Lyapunov Exponent, Hurst Exponent, autocorrelation and dimension correlation. The definition of the cutoff point of the variables for predictive tests was obtained by the Receiver Operating Characteristic curve (ROC). The area under the ROC curve was calculated by the extended trapezoidal rule, assuming as relevant areas under the curve ≥ 0.650. Results Coronary arterial disease patients presented reduced values of SDNN, RMSSD, NN50, HF, SD1, SD2 and -ApEn. HF ≤ 66 ms2, RMSSD ≤ 23.9 ms, ApEn ≤−0.296 and NN50 ≤ 16 presented the best discriminatory power for the presence of significant coronary obstruction. Conclusion We suggest the use of Heart Rate Variability Analysis in linear and nonlinear domains, for prognostic purposes in patients with stable angina pectoris, in view of their overall impairment.

Eventos adversos e motivos de descarte relacionados ao reuso de produtos médicos hospitalares em angioplastia coronária

Objective: To describe the adverse effects that occur during and after percutaneous transluminal coronary angioplasty (PTCA) possibly related to the reuse of medical equipment. An additional objective is to quantify and identify the reasons of discard in respect to the brand-new and reuse of medical equipment. Method: Sixty patients were studied (48.3% with unstable angina, 45% with acute myocardial infarction and 6.7% with other diagnoses). During the procedure and stay in the Intensive Coronary Unit, the occurrence of fever, hypotension or hypertension, chills, sudoresis, bleeding, nausea and vomits were observed. Seven products were evaluated: catheter introducer, catheter guides (0.35 and 0.014), catheter balloons for angioplasty, indeflator inflation device and manifolds. In total, 76 brand-new and 410 reused apparatuses were studied to verify the occurrence of discard, whether this happened before or during the procedure and for what reason. P-values = 0.05 were considered significant. Results: Twenty-six patients presented adverse effects. Hypotension was the most common seen in 11 (18.3%) cases. There was no significant association between this adverse effect and reuse or not of the equipment. Three brand-new products and 55 of the reused products were discarded as they were incomplete. Conclusion: The adverse effects presented by patients submitted to coronary vessel angioplasty were not associated to the reuse of medical equipment. The integrity and functionality were the main reasons of discard.

Doença coronária obstrutiva em hepatopatas crônicos que aguardam transplante hepático

BACKGROUND Advanced liver failure (ALF) usually presents hypocholesterolemia. Nevertheless, some patients with ALF develops major coronary obstructive diseases with consequent increased risk or contraindication to liver transplantation. OBJECTIVE To analyze the contribution of classical risk factors for coronary artery disease (CAD) in patients with ALF with and without obstructive coronary disease. METHODS Evaluation of risk factors for CAD in 119 patients in a referral center for liver transplantation, with the following characteristics: patients older than 40 years of age with ALV who underwent coronary angiography. RESULTS Obstructive coronary disease was detected in 21 (17.6%) of the cases. These patients had really low cholesterol levels, of which 129.0 ± 53.5 mg/dl averaging 117.0 mg/dl in liver disease patients with normal coronary arteries and 135.4 ± 51.7 mg/dl averaging 122.0 mg/dl in liver disease patients with obstructive coronary artery disease (P = 0.8215). In multivariate logistic regression, age, sex, body mass index and the presence of diabetes, smoking and alcohol consumption were not statistically significant in distinguishing groups. Nor was there an association with the etiology of the ALF. In turn, hypertension was proven to be relevant in association with CAD (P = 0.0474). CONCLUSION Only hypertension was a risk factor with statistical significance for the development of CAD in patients with ALF awaiting liver transplantation. Because it is a modifiable risk factor, this finding guides the practice of therapeutic attitudes in an attempt to prevent or delay the development of CAD in these patients.FUNDAMENTO: La insuficiencia hepatica avanzada (IHA) generalmente cursa con hipocolesterolemia. A pesar de eso, una parcela de los pacientes con IHA desarrolla coronariopatia obstructiva de grado importante con consecuente aumento de riesgo o incluso contraindicacion para trasplante hepatico. OBJETIVOS: Analizar la contribucion de los factores de riesgo clasicos para la enfermedad arterial coronaria (EAC) en pacientes portadores de IHA con y sin coronariopatia obstructiva. METODOS: Evaluacion de los factores de riesgo para EAC en 119 pacientes, en un servicio de referencia para trasplante hepatico, con las siguientes caracteristicas: mas de 40 anos de edad, portadores de IHA y sometidos a cinecoronariografia. RESULTADOS: Coronariopatia obstructiva fue detectada en 21 (17,6%) de los casos. Estos pacientes presentaban realmente niveles bajos de colesterol, siendo de 129,0±53,5mg/dL con mediana de 117,0mg/dL en los hepatopatas con coronarias normales y 135,4±51,7mg/dL con mediana de 122,0mg/dL en los hepatopatas con coronariopatia obstructiva (P=0,8215). En la regresion logistica multivariada, la edad, el sexo, el indice de masa corporal, asi como las presencias de diabetes, de tabaquismo y de etilismo no tuvieron significancia estadistica aislada en la diferenciacion entre los grupos. Tambien no hubo asociacion con la etiologia de la IHA. A su vez, la hipertension arterial se mostro relevante en la asociacion con EAC (P=0,0474). CONCLUSION: Solo la hipertension arterial fue factor de riesgo con significancia estadistica para el desarrollo de EAC en pacientes con IHA aguardando trasplante hepatico. Por ser un factor de riesgo cambiable, este hallazgo orienta hacia una practica de actitudes terapeuticas en la tentativa de evitarse o retardar el desarrollo de la EAC en estos pacientes.

Obstructive coronary disease in patients with chronic liver disease awaiting liver transplantation

BACKGROUND Advanced liver failure (ALF) usually presents hypocholesterolemia. Nevertheless, some patients with ALF develops major coronary obstructive diseases with consequent increased risk or contraindication to liver transplantation. OBJECTIVE To analyze the contribution of classical risk factors for coronary artery disease (CAD) in patients with ALF with and without obstructive coronary disease. METHODS Evaluation of risk factors for CAD in 119 patients in a referral center for liver transplantation, with the following characteristics: patients older than 40 years of age with ALV who underwent coronary angiography. RESULTS Obstructive coronary disease was detected in 21 (17.6%) of the cases. These patients had really low cholesterol levels, of which 129.0 ± 53.5 mg/dl averaging 117.0 mg/dl in liver disease patients with normal coronary arteries and 135.4 ± 51.7 mg/dl averaging 122.0 mg/dl in liver disease patients with obstructive coronary artery disease (P = 0.8215). In multivariate logistic regression, age, sex, body mass index and the presence of diabetes, smoking and alcohol consumption were not statistically significant in distinguishing groups. Nor was there an association with the etiology of the ALF. In turn, hypertension was proven to be relevant in association with CAD (P = 0.0474). CONCLUSION Only hypertension was a risk factor with statistical significance for the development of CAD in patients with ALF awaiting liver transplantation. Because it is a modifiable risk factor, this finding guides the practice of therapeutic attitudes in an attempt to prevent or delay the development of CAD in these patients.FUNDAMENTO: La insuficiencia hepatica avanzada (IHA) generalmente cursa con hipocolesterolemia. A pesar de eso, una parcela de los pacientes con IHA desarrolla coronariopatia obstructiva de grado importante con consecuente aumento de riesgo o incluso contraindicacion para trasplante hepatico. OBJETIVOS: Analizar la contribucion de los factores de riesgo clasicos para la enfermedad arterial coronaria (EAC) en pacientes portadores de IHA con y sin coronariopatia obstructiva. METODOS: Evaluacion de los factores de riesgo para EAC en 119 pacientes, en un servicio de referencia para trasplante hepatico, con las siguientes caracteristicas: mas de 40 anos de edad, portadores de IHA y sometidos a cinecoronariografia. RESULTADOS: Coronariopatia obstructiva fue detectada en 21 (17,6%) de los casos. Estos pacientes presentaban realmente niveles bajos de colesterol, siendo de 129,0±53,5mg/dL con mediana de 117,0mg/dL en los hepatopatas con coronarias normales y 135,4±51,7mg/dL con mediana de 122,0mg/dL en los hepatopatas con coronariopatia obstructiva (P=0,8215). En la regresion logistica multivariada, la edad, el sexo, el indice de masa corporal, asi como las presencias de diabetes, de tabaquismo y de etilismo no tuvieron significancia estadistica aislada en la diferenciacion entre los grupos. Tambien no hubo asociacion con la etiologia de la IHA. A su vez, la hipertension arterial se mostro relevante en la asociacion con EAC (P=0,0474). CONCLUSION: Solo la hipertension arterial fue factor de riesgo con significancia estadistica para el desarrollo de EAC en pacientes con IHA aguardando trasplante hepatico. Por ser un factor de riesgo cambiable, este hallazgo orienta hacia una practica de actitudes terapeuticas en la tentativa de evitarse o retardar el desarrollo de la EAC en estos pacientes.

Retirada de corpo estranho na artéria pulmonar de neonato por técnica intravascular

The removal of intravascular foreign body by percutaneous interventional technique is a highly safe and effective procedure that has a low rate of complications even in children and premature infants. We describe a case of foreign body retrieval from the right branch pulmonary artery in an 18-day-old premature newborn.

Evaluation of the impact of chronic kidney disease on the survival of octogenarian patients submitted to percutaneous coronary intervention

Objective To evaluate the impact of chronic kidney disease on the survival of patients – 80 years of age undergoing percutaneous coronary intervention (PCI) in the long term. Methods 273 subjects who underwent PCI between January 2010 and January 2016 were divided into four categories: (1) stable angina (SA) and creatinine clearance – 30 (n = 24); (2) patients with SA and CrCl <30 (n = 70); (3) patients with acute coronary syndrome (ACS) and CrCl – 30 (n = 51); (4) patients with ACS and ICC <30 (n = 128). Mortality curves were evaluated using the Kaplan-Meier method and differences between groups were compared by log-rank statistic. Multivariate analysis was performed using the Cox proportional hazards method. The 4 groups were compared and the survival between the groups was evaluated. Results Octogenarian patients with CrCl <30 with SA and ACS have lower long-term survival (p < 0.0001). Conclusion CKD has a worse long-term prognosis for patients undergoing PCI.

Recurrence Plots: a New Tool for Quantification of Cardiac AutonomicNervous System Recovery after Transplant

Objective To evaluate a possible evolutionary post-heart transplant return of autonomic function using quantitative and qualitative information from recurrence plots. Methods Using electrocardiography, 102 RR tachograms of 45 patients (64.4% male) who underwent heart transplantation and that were available in the database were analyzed at different follow-up periods. The RR tachograms were collected from patients in the supine position for about 20 minutes. A time series with 1000 RR intervals was analyzed, a recurrence plot was created, and the following quantitative variables were evaluated: percentage of determinism, percentage of recurrence, average diagonal length, Shannon entropy, and sample entropy, as well as the visual qualitative aspect. Results Quantitative and qualitative signs of heart rate variability recovery were observed after transplantation. Conclusion There is evidence that autonomic innervation of the heart begins to happen gradually after transplantation. Quantitative and qualitative analyses of recurrence can be useful tools for monitoring cardiac transplant patients and detecting the gradual return of heart rate variability.

Management of multivessel coronary disease after primary angioplasty: staged reintervention versus optimized clinical treatment and two-year follow-up

Objective In the clinical scenario of ST-segment elevation acute myocardial infarction, several patients with multivessel coronary atherosclerotic disease are discharged without a defined strategy to monitor the residual atherosclerotic lesions. The clinical endpoints evaluated were cardiovascular death, symptoms of angina pectoris, rehospitalization for a new acute coronary syndrome, and the necessity of reintervention during the two-year follow-up. Methods This observational, prospective, and historical study included multivessel coronary atherosclerotic disease patients who were admitted to a tertiary care university hospital with ST-segment elevation acute myocardial infarction and underwent primary percutaneous coronary intervention with stent implantation only at the culprit lesion site; these patients were monitored in the outpatient clinic according to two treatments: the Clinical Group - CG (optimized pharmacological therapy associated with counseling for a healthy diet and cardiac rehabilitation) or the Intervention Group - IG (new staged percutaneous coronary intervention or surgical coronary artery bypass graft surgery combined with the previously prescribed treatment). Results Of 143 patients consecutively admitted with ST-segment elevation acute myocardial infarction, 57 were eligible for the study (CG=44 and IG=13). Regarding the clinical endpoints, the cardiovascular death rate did not differ between the CG and IG. The symptom of angina pectoris and the rehospitalization rate for a new episode of acute coronary syndrome were accentuated in the CG (P=0.020 and P=0.049, respectively) mainly in individuals with evidence of ischemia evidenced by myocardial scintigraphy (P<0.001 and P=0.001, respectively) which culminated in an even greater need for reintervention (P=0.001) in this subgroup of patients. Conclusion The staged intervention was demonstrated to be safe and able to reduce angina pectoris and rehospitalization for a new episode of acute coronary syndrome. In addition, it decreases the likelihood of unplanned reinterventions of patients without ischemia evidenced by myocardial scintigraphy.

Enfermedad coronaria obstructiva en hepatópatas crónicos que aguardan trasplante hepático

BACKGROUND Advanced liver failure (ALF) usually presents hypocholesterolemia. Nevertheless, some patients with ALF develops major coronary obstructive diseases with consequent increased risk or contraindication to liver transplantation. OBJECTIVE To analyze the contribution of classical risk factors for coronary artery disease (CAD) in patients with ALF with and without obstructive coronary disease. METHODS Evaluation of risk factors for CAD in 119 patients in a referral center for liver transplantation, with the following characteristics: patients older than 40 years of age with ALV who underwent coronary angiography. RESULTS Obstructive coronary disease was detected in 21 (17.6%) of the cases. These patients had really low cholesterol levels, of which 129.0 ± 53.5 mg/dl averaging 117.0 mg/dl in liver disease patients with normal coronary arteries and 135.4 ± 51.7 mg/dl averaging 122.0 mg/dl in liver disease patients with obstructive coronary artery disease (P = 0.8215). In multivariate logistic regression, age, sex, body mass index and the presence of diabetes, smoking and alcohol consumption were not statistically significant in distinguishing groups. Nor was there an association with the etiology of the ALF. In turn, hypertension was proven to be relevant in association with CAD (P = 0.0474). CONCLUSION Only hypertension was a risk factor with statistical significance for the development of CAD in patients with ALF awaiting liver transplantation. Because it is a modifiable risk factor, this finding guides the practice of therapeutic attitudes in an attempt to prevent or delay the development of CAD in these patients.FUNDAMENTO: La insuficiencia hepatica avanzada (IHA) generalmente cursa con hipocolesterolemia. A pesar de eso, una parcela de los pacientes con IHA desarrolla coronariopatia obstructiva de grado importante con consecuente aumento de riesgo o incluso contraindicacion para trasplante hepatico. OBJETIVOS: Analizar la contribucion de los factores de riesgo clasicos para la enfermedad arterial coronaria (EAC) en pacientes portadores de IHA con y sin coronariopatia obstructiva. METODOS: Evaluacion de los factores de riesgo para EAC en 119 pacientes, en un servicio de referencia para trasplante hepatico, con las siguientes caracteristicas: mas de 40 anos de edad, portadores de IHA y sometidos a cinecoronariografia. RESULTADOS: Coronariopatia obstructiva fue detectada en 21 (17,6%) de los casos. Estos pacientes presentaban realmente niveles bajos de colesterol, siendo de 129,0±53,5mg/dL con mediana de 117,0mg/dL en los hepatopatas con coronarias normales y 135,4±51,7mg/dL con mediana de 122,0mg/dL en los hepatopatas con coronariopatia obstructiva (P=0,8215). En la regresion logistica multivariada, la edad, el sexo, el indice de masa corporal, asi como las presencias de diabetes, de tabaquismo y de etilismo no tuvieron significancia estadistica aislada en la diferenciacion entre los grupos. Tambien no hubo asociacion con la etiologia de la IHA. A su vez, la hipertension arterial se mostro relevante en la asociacion con EAC (P=0,0474). CONCLUSION: Solo la hipertension arterial fue factor de riesgo con significancia estadistica para el desarrollo de EAC en pacientes con IHA aguardando trasplante hepatico. Por ser un factor de riesgo cambiable, este hallazgo orienta hacia una practica de actitudes terapeuticas en la tentativa de evitarse o retardar el desarrollo de la EAC en estos pacientes.