Gustavo Luiz Gouvêa de Almeida Junior

Resistência ao clopidogrel: prevalência e variáveis associadas

BACKGROUND The dual antiplatelet therapy with acetylsalicylic acid (ASA) and clopidogrel is the cornerstone of treatment for patients undergoing angioplasty with coronary stent implantation. However, some of these patients, despite the use of aspirin and clopidogrel, are not effectively anti-aggregated, a phenomenon known as resistance to antiplatelet agents. Its prevalence, as well as the conditions associated with it, is unknown in our country. OBJECTIVE To determine the prevalence of clopidogrel resistance, as well as variables associated with it. METHODS Patients admitted for elective angioplasty in chronic use of ASA and clopidogrel between January 2007 and January 2010 were studied. One hour after the procedure, platelet aggregation was measured using optical aggregometry with adenosine diphosphate 5 mmoles / l as agonist. At that moment, in a cross-sectional cohort, we determined the prevalence of clopidogrel resistance, defined as the value of platelet aggregation ≥ 43% and a logistic regression model to the variables associated with it. RESULTS A total of 205 patients were analyzed (66.4 ± 11 years, 61.5% males). The prevalence of clopidogrel resistance was 38.5% (95% CI: 31.9 - 45.2%). Blood glucose (OR = 1.014; 95%CI: 1.004 - 1.023), previous myocardial infarction (OR = 2.320; 95%CI: 1.1103 - 4.892) and therapeutic response to ASA (OR = 1.057; 95%CI: 1.017 - 1.099) were the variables independently associated with clopidogrel resistance. CONCLUSION The prevalence of clopidogrel resistance was high. Glycemia, acute myocardial infarction and response to ASA were variables associated with it. A better understanding of this phenomenon is necessary considering the new antiplatelet aggregant agents.

Hemodynamic assessment in heart failure: role of physical examination and noninvasive methods

Entre as doencas cardiovasculares, a insuficiencia cardiaca (IC) apresenta elevada taxa de internacao hospitalar, morbidade e mortalidade, consumindo grandes recursos financeiros do sistema de saude no Brasil e em outros paises. A correta determinacao das pressoes de enchimento do ventriculo esquerdo, por avaliacao invasiva ou nao invasiva, e fundamental para o adequado tratamento dos pacientes com IC cronica descompensada, considerando que a congestao e o principal fator determinante dos sintomas e da hospitalizacao. O exame fisico tem se mostrado inadequado para prever o padrao hemodinâmico. Varios estudos sugerem que a concordância em achados de exame fisico por diferentes medicos e pequena e que, por fim, as proprias alteracoes fisiologicas adaptativas na IC cronica mascaram importantes aspectos do exame fisico. Como a avaliacao clinica falha em prever a hemodinâmica e pelo fato de a utilizacao do cateter de Swan-Ganz de rotina nao ser recomendada para esse fim em pacientes com IC, metodos de avaliacao hemodinâmica nao invasivos, como o BNP, o ecocardiograma e a bioimpedância cardiografica, vem sendo crescentemente utilizados. O presente trabalho tem por objetivo realizar, para o clinico, uma revisao da funcao de cada uma dessas ferramentas, na definicao da condicao hemodinâmica em que se encontram os pacientes com IC descompensada, visando a um tratamento mais racional e individualizado.Among the cardiovascular diseases, heart failure (HF) has a high rate of hospitalization, morbidity and mortality, consuming vast resources of the public health system in Brazil and other countries. The correct determination of the filling pressures of the left ventricle by noninvasive or invasive assessment is critical to the proper treatment of patients with decompensated chronic HF, considering that congestion is the main determinant of symptoms and hospitalization. Physical examination has shown to be inadequate to predict the hemodynamic pattern. Several studies have suggested that agreement on physical findings by different physicians is small and that, ultimately, adaptive physiological alterations in chronic HF mask important aspects of the physical examination. As the clinical assessment fails to predict hemodynamic aspects and because the use of Swan-Ganz catheter is not routinely recommended for this purpose in patients with HF, noninvasive hemodynamic assessment methods, such as BNP, echocardiography and cardiographic bioimpedance, are being increasingly used. The present study intends to carry out, for the clinician, a review of the role of each of these tools when defining the hemodynamic status of patients with decompensated heart failure, aiming at a more rational and individualized treatment.

Fístula de enxerto coronariano da artéria torácica interna esquerda para artéria pulmonar esquerda após cirurgia de revascularização miocárdica: causa rara de isquemia miocárdica

We report a patient who developed dyspnea on mild exertion six years after coronary artery bypass graft surgery (CABG). Myocardial ischemia was documented by radionuclide imaging, and coronary angiography showed patency of all grafts and a large fistula between the left internal thoracic artery (LITA) and the left pulmonary artery (LPA). The patient was submitted to surgical closure of the fistula and made an excellent recovery.

Terapia da insuficiência cardíaca avançada ajustada por objetivos hemodinâmicos obtidos pela monitorização invasiva

OBJECTIVE To assess advanced heart failure (HF) treatment in relation to reduction of ventricular filling pressures, with the use of greater doses of vasodilators, through invasive hemodynamic monitoring. METHODS Nineteen advanced HF patients were studied, in whom Swan-Ganz catheter was inserted to direct administration of diuretic intravenously (IV) and sodium nitroprusside, with the aim of significantly reduce ventricular filling pressures. After achieving such objective or 48 hours, oral drugs were introduced until venous medicines were removed, keeping hemodynamic benefit. RESULTS From 19 patients studied, 16 (84%) were of male sex. The average age was 66 +/- 11.4 years old; average ejection fraction was 26 +/- 6.3%; 2 patients (10.5%) showed functional class (FC) III and 17 (89.5%), FC IV. There was a decrease of pulmonary artery occlusion pressure from 23 +/- 11.50 mmHg to 16 +/- 4.05 mmHg (p = 0.008), of systemic vascular resistance index from 3,023 +/- 1,153.71 dynes/s/cm-5/m(2) to 1,834 +/- 719.34 dynes/s/cm-5/m(2) (p = 0.0001) and an increase of cardiac index from 2.1 +/- 0.56 l/min/m(2) to 2.8 +/- 0.73 l/min/m(2) (p = 0.0003). A subgroup with hypovolemia was identified. CONCLUSION It was possible to reduce ventricular filling pressures to significantly lower values, obtaining a significant improvement of cardiac index, systemic vascular resistance index and pulmonary artery mean pressure, by using significantly higher doses of vasodilators.OBJECTIVE: To assess advanced heart failure (HF) treatment in relation to reduction of ventricular filling pressures, with the use of greater doses of vasodilators, through invasive hemodynamic monitoring. METHODS: Nineteen advanced HF patients were studied, in whom Swan-Ganz catheter was inserted to direct administration of diuretic intravenously (IV) and sodium nitroprusside, with the aim of significantly reduce ventricular filling pressures. After achieving such objective or 48 hours, oral drugs were introduced until venous medicines were removed, keeping hemodynamic benefit. RESULTS: From 19 patients studied, 16 (84%) were of male sex. The average age was 66 ± 11.4 years old; average ejection fraction was 26 ± 6.3%; 2 patients (10.5%) showed functional class (FC) III and 17 (89.5%), FC IV. There was a decrease of pulmonary artery occlusion pressure from 23 ± 11.50 mmHg to 16 ± 4.05 mmHg (p = 0.008), of systemic vascular resistance index from 3,023 ± 1,153.71 dynes/s/cm-5/m2 to 1,834 ± 719.34 dynes/s/cm-5/m2 (p = 0.0001) and an increase of cardiac index from 2.1 ± 0.56 l/min/m2 to 2.8 ± 0.73 l/min/m2 (p = 0.0003). A subgroup with hypovolemia was identified. CONCLUSION: It was possible to reduce ventricular filling pressures to significantly lower values, obtaining a significant improvement of cardiac index, systemic vascular resistance index and pulmonary artery mean pressure, by using significantly higher doses of vasodilators.

Mortality and Survival in Aortic Arch Surgeries with Preservation of Supra-aortic Vessels: Thirteen Years of Experience

Mailing Address: Paula Ferraz de Oliveira Rua Almirante Baltazar, 131, apto 303. Postal Code: 20941-150. São Cristóvão, Rio de Janeiro RJ Brazil. E-mail: ferrazpaulade@gmail.com Mortality and Survival in Aortic Arch Surgeries with Preservation of Supra-aortic Vessels: Thirteen Years of Experience Paula Ferraz de Oliveira,1,2 Gustavo Luiz Gouvêa de Almeida Junior,1,2 Fabrício Braga da Silva,1,2 Mauro Paes Leme de Sá,3 Valdo José Carreira,1 Bruno Soares da Silva Rangel,1,3 Sicilia Pacheco e Silva1 Casa de Saúde São José,1 Rio de Janeiro, RJ Brazil Instituto de Cardiologia Edson Saad da Universidade Federal do Rio de Janeiro,2 Rio de Janeiro, RJ Brazil Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ),3 Rio de Janeiro, RJ Brazil

Diretriz Brasileira de Insuficiência Cardíaca Crônica e Aguda

Parte 1: Diretriz Brasileira de Insuficiencia Cardiaca Cronica […] Diretriz Brasileira de Insuficiencia Cardiaca Cronica e Aguda

Natriuretic Peptide and Clinical Evaluation in the Diagnosis of Heart Failure Hemodynamic Profile: Comparison with Tissue Doppler Echocardiography

Background Physical examination and B-type natriuretic peptide (BNP) have been used to estimate hemodynamics and tailor therapy of acute decompensated heart failure (ADHF) patients. However, correlation between these parameters and left ventricular filling pressures is controversial. Objective This study was designed to evaluate the diagnostic accuracy of physical examination, chest radiography (CR) and BNP in estimating left atrial pressure (LAP) as assessed by tissue Doppler echocardiogram. Methods Patients admitted with ADHF were prospectively assessed. Diagnostic characteristics of physical signs of heart failure, CR and BNP in predicting elevation (> 15 mm Hg) of LAP, alone or combined, were calculated. Spearman test was used to analyze the correlation between non-normal distribution variables. The level of significance was 5%. Results Forty-three patients were included, with mean age of 69.9 ± 11.1years, left ventricular ejection fraction of 25 ± 8.0%, and BNP of 1057 ± 1024.21 pg/mL. Individually, all clinical, CR or BNP parameters had a poor performance in predicting LAP ≥ 15 mm Hg. A clinical score of congestion had the poorest performance [area under the receiver operating characteristic curve (AUC) 0.53], followed by clinical score + CR (AUC 0.60), clinical score + CR + BNP > 400 pg/mL (AUC 0.62), and clinical score + CR + BNP > 1000 pg/mL (AUC 0.66). Conclusion Physical examination, CR and BNP had a poor performance in predicting a LAP ≥ 15 mm Hg. Using these parameters alone or in combination may lead to inaccurate estimation of hemodynamics.

Dual-Energy Computed Tomography with Material Decomposition: Before and after Thrombolysis in Massive PTE

DOI: 10.5935/2318-8219.20180009 Paciente do sexo feminino, 31 anos, em uso de anticoncepcional oral, admitida na Emergência com quadro de dispneia após síncope (terceiro episódio em um mês). Exames laboratoriais revelaram D-dímero de 6650. Submetida à Tomografia Computadorizada de Dupla Energia. As imagens espectrais com decomposição de materiais, e reconstrução do iodo e supressão de água (imagens perfusionais), demostraram hipoatenuação compatível com oligoemia em grande parte do pulmão esquerdo e em parte dos lobos superior, médio e inferior do pulmão direito. Após trombólise, há nítida melhora perfusional nos lobos superior e inferior esquerdos e superior direito, com discreta melhora no lobo médio direito. O protocolo de Tomografia Computadorizada de dupla energia com imagem espectral permite reconstrução de imagens de iodo com subtração de água, o que proporciona, além da visualização do fluxo, a avaliação da perfusão do parênquima pulmonar. Deste modo, talvez seja possível obter maior sensibilidade na detecção de pequenos trombos, especialmente subsegmentares, que podem não ser vistos em uma análise angiográfica usual. No entanto, mais evidências científicas ainda se fazem necessárias.

Aspirin resistance in stable coronary disease

Coronary artery disease (CAD) is the leading cause of death in the world1; in Brazil, it accounts for 28.9% of all deaths2. In stable CAD, the use of acetylsalicylic acid (ASA) in patients undergoing elective percutaneous coronary intervention (PCI) is a grade of recommendation I, and level of evidence A3. For these patients, resistance to ASA is related to the worst outcome possible4. Therefore, a better understanding of the factors associated with ASA resistance is required. ASA resistance or a high platelet reactivity to ASA or a non-response to ASA are common names for the same laboratory phenomenon, which can set a higher incidence of treatment failure related to this antiplatelet5. Treatment failure is a broader phenomenon, which refers to cases in which, even with proper use of the antiplatelet, the patient suffers a cardiovascular event potentially preventable by the use of antiplatelet6.

Evaluación hemodinámica en la insuficiencia cardíaca: papel del examen físico y de los métodos no invasivos

Entre as doencas cardiovasculares, a insuficiencia cardiaca (IC) apresenta elevada taxa de internacao hospitalar, morbidade e mortalidade, consumindo grandes recursos financeiros do sistema de saude no Brasil e em outros paises. A correta determinacao das pressoes de enchimento do ventriculo esquerdo, por avaliacao invasiva ou nao invasiva, e fundamental para o adequado tratamento dos pacientes com IC cronica descompensada, considerando que a congestao e o principal fator determinante dos sintomas e da hospitalizacao. O exame fisico tem se mostrado inadequado para prever o padrao hemodinâmico. Varios estudos sugerem que a concordância em achados de exame fisico por diferentes medicos e pequena e que, por fim, as proprias alteracoes fisiologicas adaptativas na IC cronica mascaram importantes aspectos do exame fisico. Como a avaliacao clinica falha em prever a hemodinâmica e pelo fato de a utilizacao do cateter de Swan-Ganz de rotina nao ser recomendada para esse fim em pacientes com IC, metodos de avaliacao hemodinâmica nao invasivos, como o BNP, o ecocardiograma e a bioimpedância cardiografica, vem sendo crescentemente utilizados. O presente trabalho tem por objetivo realizar, para o clinico, uma revisao da funcao de cada uma dessas ferramentas, na definicao da condicao hemodinâmica em que se encontram os pacientes com IC descompensada, visando a um tratamento mais racional e individualizado.Among the cardiovascular diseases, heart failure (HF) has a high rate of hospitalization, morbidity and mortality, consuming vast resources of the public health system in Brazil and other countries. The correct determination of the filling pressures of the left ventricle by noninvasive or invasive assessment is critical to the proper treatment of patients with decompensated chronic HF, considering that congestion is the main determinant of symptoms and hospitalization. Physical examination has shown to be inadequate to predict the hemodynamic pattern. Several studies have suggested that agreement on physical findings by different physicians is small and that, ultimately, adaptive physiological alterations in chronic HF mask important aspects of the physical examination. As the clinical assessment fails to predict hemodynamic aspects and because the use of Swan-Ganz catheter is not routinely recommended for this purpose in patients with HF, noninvasive hemodynamic assessment methods, such as BNP, echocardiography and cardiographic bioimpedance, are being increasingly used. The present study intends to carry out, for the clinician, a review of the role of each of these tools when defining the hemodynamic status of patients with decompensated heart failure, aiming at a more rational and individualized treatment.