Gustavo Neves de Araújo

Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) Equation Pronouncedly Underestimates Glomerular Filtration Rate in Type 2 Diabetes

OBJECTIVE To evaluate the performance of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation to estimate glomerular filtration rate (GFR) in type 2 diabetic patients with GFR >60 mL/min/1.73 m2. RESEARCH DESIGN AND METHODS This was a cross-sectional study including 105 type 2 diabetic patients. GFR was measured by 51Cr-EDTA method and estimated by the MDRD and CKD-EPI equations. Serum creatinine was measured by the traceable Jaffe method. Bland-Altman plots were used. Bias, accuracy (P30), and precision were evaluated. RESULTS The mean age of patients was 57 ± 8 years; 53 (50%) were men and 90 (86%) were white. Forty-six (44%) patients had microalbuminuria, and 14 (13%) had macroalbuminuria. 51Cr-EDTA GFR was 103 ± 23, CKD-EPI GFR was 83 ± 15, and MDRD-GFR was 78 ± 17 mL/min/1.73 m2 (P < 0.001). Accuracy (95% CI) was 67% (58–74) for CKD-EPI and 64% (56–75) for MDRD. Precision was 21 and 22, respectively. CONCLUSIONS The CKD-EPI and MDRD equations pronouncedly underestimated GFR in type 2 diabetic patients.

Comparison of Two Risk Models in Predicting the Incidence of Contrast-Induced Nephropathy after Percutaneous Coronary Intervention

OBJECTIVES We sought to compare 2 contrast-induced nephropathy (CIN) risk prediction models in a validation cohort using a consensus definition. BACKGROUND Contrast-induced nephropathy (CIN) is independently associated with mortality following percutaneous coronary intervention (PCI). Multiple prediction models for the development of CIN have been published using heterogeneous outcome definitions. METHODS We analyzed 5,540 patients who underwent PCI from January 2005 to June 2012 at a single academic medical center. The primary outcome was development of CIN, defined as an increase in serum creatinine of ≥0.5 mg/dl or a relative increase of ≥25% from baseline. Receiver operator characteristic (ROC) curves were used to evaluate the discriminatory power of Mehran and WBH prediction models. RESULTS The mean age of our cohort was 68 ± 12 years. The mean baseline creatinine was 1.2 ± 0.53 mg/dl (eGFR 73 ± 27 ml/min). The mean contrast volume used was 212 ± 92 ml. CIN occurred in 436 patients (7.9%). The Mehran risk score demonstrated better discrimination than the William Beaumont Hospital (WBH) risk score to predict the occurrence of CIN (c statistic: 0.82 vs. 0.73, respectively). Mortality at 30 days was approximately 8 times higher among patients with CIN as compared to those without (14.7% vs. 1.8% P < 0.01). CONCLUSIONS In an independent validation cohort, the Mehran risk model demonstrates greater discriminatory power than the WBH model in predicting the incidence of CIN. Mortality was significantly higher in patients who developed CIN after PCI.

The Effects of a Flavonoid-Rich Diet on Oxidative Stress, Inflammation, and Lipid Profile after Elective Percutaneous Coronary Intervention : A Randomized Clinical Trial

Antioxidant-rich foods may decrease oxidative stress and have a direct impact on atherosclerosis by reducing low-density lipoprotein (LDL) oxidation. Our aim was to assess the impact of a flavonoid-rich diet on oxidative stress, inflammatory response, and lipid profile in patients with coronary artery disease submitted to elective percutaneous coronary intervention (PCI). Thirty-three patients submitted to elective PCI were randomly allocated to follow either a flavonoid rich antioxidant (AOX) diet or a control diet based on National Cholesterol Education Program Adult Treatment Panel III recommendations. Patients were followed for 6 months. Dietary intake was recorded at the start and at the end of the follow-up period, as were oxidative stress markers (ferric reducing ability of plasma and protein sulphydryl) and C-reactive protein (CRP). Patients randomized to follow the AOX diet had a reduction in energy, carbohydrate, and lipid intake, as well as increased flavonoid intake. Compared to the control group, there were no changes in oxidative stress markers or CRP in the patients following the AOX diet, but these patients had a significant decrease in LDL cholesterol levels. In conclusion, the findings of this study suggest that a flavonoid-based antioxidant-rich diet is not associated with reductions in oxidative stress or inflammatory markers 6 months after percutaneous coronary intervention. Nonetheless, patients in the intervention group experienced significant reductions in LDL cholesterol, which may indicate cardiovascular benefits of AOX diets despite of inflammation and oxidative stress markers.

An Overview of Care Changes in the Last 6 Year in Primary PCI in ST-Elevation Myocardial Infarction in a Tertiary University Brazilian Hospital

Mailing Address: Guilherme Pinheiro Machado Rua Domingos Crescencio, 545. Postal Code: Santana, Porto Alegre, RS Brazil. E-mail: gpmachado89@gmail.com, guimachado@hcpa.edu.br An Overview of Care Changes in the Last 6 Year in Primary PCI in ST-Elevation Myocardial Infarction in a Tertiary University Brazilian Hospital Guilherme Pinheiro Machado,1,2 Fernando Pivatto Junior,2 Rodrigo Wainstein,2 Gustavo Neves de Araujo,2 Christian Kunde Carpes,1,2 Mateus Correa Lech,1,2 Felipe Homem Valle,2 Luiz Carlos Corsetti Bergoli,2 Sandro Cadaval Gonçalves,2 Marco Vugman Wainstein1,2 Faculdade de Medicina, Universidade Federal do Rio Grande do Sul,1 RS Brazil Serviço de Cardiologia, Hospital de Clínicas de Porto Alegre,2 RS Brazil

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 neutrophil-to-lymphocyte ratio and mean platelet volume in the prediction of adverse events after primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction

BACKGROUND AND AIMS Elevated neutrophil-to-lymphocyte ratio (NLR) and mean platelet volume (MPV) are indirect inflammatory markers. There is some evidence that both are associated with worse outcomes in ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PCI). The aim of the present study was to compare the capacity of NLR and MPV to predict adverse events after primary PCI. METHODS In a prospective cohort study, 625 consecutive patients with STEMI, who underwent primary PCI, were followed. Receiver operating characteristic (ROC) curve analysis was performed to calculate the area under the curve (AUC) for the occurrence of procedural complications, mortality and major adverse cardiovascular events (MACE). RESULTS Mean age was 60.7 (±12.1) years, 67.5% were male. The median of NLR was 6.17 (3.8-9.4) and MPV was 10.7 (10.0-11.3). In multivariate analysis, both NLR and MPV remained independent predictors of no-reflow (relative risk [RR] = 2.26; 95%confidence interval [95%CI] = 1.16-4.32; p = 0.01 and RR = 2.68; 95%CI = 1.40-5.10; p < 0.01, respectively), but only NLR remained an independent predictor of in-hospital MACE (RR = 1.01; 95%CI = 1.00-1.06; p = 0.02). The AUC for in-hospital MACE was 0.57 for NLR (95%CI = 0.53-0.60; p = 0.03) and 0.56 for MPV (95%CI = 0.52-0.60; p = 0.07). However, when AUC were compared with DeLong test, there was no statistically significant difference for these outcomes (p > 0.05). NLR had an excellent negative predictive value (NPV) of 96.7 for no-reflow and 89.0 for in-hospital MACE. CONCLUSIONS Despite no difference in the ROC curve comparison with MPV, only NLR remained an independent predictor for in-hospital MACE. A low NLR has an excellent NPV for no-reflow and in-hospital MACE, and this could be of clinical relevance in the management of low-risk patients.

Case Report: Catheter-Related Interatrial Septum Endocarditis Caused by Candida Parapsilosis

Mailing Address: Felipe Martins Lampa Hospital de Clínicas de Porto Alegre. Rua Ramiro Barcelos, 2350. Postal Code: 90035-003, Porto Alegre, RS – Brazil E-mail: lampabr@yahoo.com Case Report: Catheter-Related Interatrial Septum Endocarditis Caused by Candida Parapsilosis Gustavo Neves de Araújo,1,2 Felipe H. Valle,1,2 Douglas M. Freitas,1,2 Felipe Martins Lampa,1,2 Miguel Gus,1,2 Luis E. Rohde1,2 Hospital de Clínicas de Porto Alegre1, Divisão de Cardiologia; Universidade Federal do Rio Grande do Sul2, Faculdade de Medicina, Porto Alegre, RS – Brazil

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)

Effectiveness of Medical and Revascularization Procedures as the Initial Strategy in Stable Coronary Artery Disease: A Cohort Study

Fundamento: A cirurgia de revascularizacao miocardica (CRM) e a intervencao coronaria percutânea (ICP) sao estrategias amplamente utilizadas no manejo da doenca arterial coronariana (DAC) estavel. Objetivo: Avaliar o prognostico de pacientes com DAC estavel inicialmente tratada com terapia medica (TM), em comparacao com os pacientes submetidos a procedimentos de revascularizacao. Metodos: Estudo prospectivo de coorte com 560 pacientes ambulatoriais de um hospital terciario com seguimento medio de 5 anos. Os pacientes foram classificados nos grupos TM (n = 288), ICP (n = 159) e CRM (n = 113) de acordo com sua estrategia inicial de tratamento. Os desfechos primarios foram mortalidade global e eventos combinados de morte, sindrome coronaria aguda e AVC. Resultados: Durante o seguimento, as taxas de mortalidade foram de 11,1% em TM, 11,9% em ICP e 15,9% em pacientes submetidos a CRM, sem diferenca estatistica (Hazard Ratio [HR] para ICP, 1,05; Intervalo de Confianca de 95% [IC95%], 0,59 a 1,84; e HR para CRM, 1,20; IC95%, 0,68 a 2,15). Os desfechos combinados ocorreram com maior frequencia entre os pacientes inicialmente submetidos a ICP em relacao a TM (HR 1,50, IC 95% 1,05 a 2,14) e nao diferiram entre TM e CRM (HR 1,24, IC95% 0,84 a 1,83). Entre os pacientes com diabetes (n = 198), a ICP foi a unica estrategia terapeutica preditiva de desfechos combinados (HR 2,14; IC 95%: 1,25 a 3,63). Conclusao: Neste estudo observacional de doenca arterial coronariana estavel, nao houve diferenca na mortalidade global entre as estrategias iniciais de terapia medico ou de cirurgia de revascularizacao. Os pacientes inicialmente tratados com ICP tiveram maior chance de desenvolver eventos cardiovasculares maiores combinados.