Hélder Dores

Impact of ESC/ACCF/AHA/WHF universal definition of myocardial infarction on mortality at 10 years

AIMS Redefinition of myocardial infarction (MI) based on specific cardiac troponins (cTn) was universally accepted in 2007. The new definition has been widely discussed for including a large spectrum of quantitative myocardial necrosis and their clinical implications remain under debate. Our aim was to assess the impact of the universal definition of MI on mortality at 10 years. METHODS AND RESULTS We studied 676 consecutive patients (Pts) admitted to our intensive cardiac care unit for acute coronary syndrome (ACS) between January 1999 and December 2000. We calculated the relative risk of the total death at 10 years adjusted with the Cox proportional hazards model, between the presence and absence of MI following different definitions: (1), typical symptoms and persistent ST-segment elevation or left bundle branch block (ST-segment elevation definition); (2), typical symptoms and CK-MB activity rise and/or fall >ULN (old definition); and (3), typical symptoms and cTn I rise and/or fall >99th percentile (universal definition). The total mortality at 10 years was 23.8%. The proportion of Pts with AMI was 33.6% for ST-segment elevation definition, 55.8% for old definition, and 70.1% for universal definition. The adjusted hazard ratio of death at 10 years between the presence and absence of AMI was 0.71 (95% confidence interval (CI): 0.46-1.08; P = 0.11) for ST-segment elevation definition, 0.84 (95% CI: 0.55-1.27; P = 0.40) for old definition, and 1.58 (95% CI: 1.07-2.40; P = 0.03) for universal definition. Patients submitted to myocardial revascularization during the initial hospital stay (72%) presented a significantly lower mortality at 10 years, compared with patients not revascularized (adjusted hazard ratio: 0.63, 95% CI: 0.44-0.91; P = 0.014). CONCLUSIONS In a population with the entire spectrum of ACSs, the universal definition of MI increased this diagnosis by one-quarter and was an independent predictor of mortality at 10 years. Furthermore, myocardial revascularization was associated with a significantly lower mortality at 10 years.

Impact of Renal Sympathetic Denervation on Left Ventricular Structure and Function at 1-Year Follow-Up

Background Catheter-based sympathetic renal denervation (RDN) is a recent therapeutic option for patients with resistant hypertension. However, the impact of RDN in left ventricular (LV) mass and function is not completely established. Our aim was to evaluate the effects of RDN on LV structure and function (systolic and diastolic) in patients with resistant hypertension (HTN). Methods and Results From a single centre prospective registry including 65 consecutive patients with resistant HTN submitted to RDN between July-2011 and April-2015, 31 patients with baseline and 1-year follow-up echocardiogram were included in this analysis. Mean age was 65±7 years, 48% were males, 71% had type 2 diabetes. Most had hypertension lasting for more than 10 years (90%), and were being treated with a median number of 6 anti-hypertensive drugs, including 74% on spironolactone. At 1-year, there was a significant decrease both on office SBP (176±24 to 149±13mmHg, p<0.001) and DBP (90±14 to 79±11mmHg, p<0.001), and also in 24h ABPM SBP (150±20 to 132±14mmhg, p<0.001) and DBP (83±10 to 74±9mmHg, p<0.001). There was also a significant decrease in LV mass from 152±32 to 136±34g/m2 (p<0.001), an increase in LV end diastolic volume (93±18 to 111±27 mL, p = 0.004), an increase in LV ejection fraction (65±9 to 68±9%, p = 0.001) and mitral valve E deceleration time (225±49 to 247±51ms, p = 0.015) at 1-year follow up. There were no significant changes in left atrium volume index or in the distribution of patients among the different left ventricle geometric patterns and diastolic function subgroups. Conclusions In this single centre registry of patients with resistant hypertension, renal denervation was associated with significant reduction in both office and ABPM blood pressure and a significant decrease in left ventricle mass evaluated by transthoracic echocardiogram at 1 year follow-up.

Effective radiation dose of three diagnostic tests in cardiology: Single photon emission computed tomography, invasive coronary angiography and cardiac computed tomography angiography

INTRODUCTION Diagnostic tests that use ionizing radiation play a central role in cardiology and their use has grown in recent years, leading to increasing concerns about their potential stochastic effects. The aims of this study were to compare the radiation dose of three diagnostic tests: single photon emission computed tomography (SPECT), invasive coronary angiography (ICA) and cardiac computed tomography (cardiac CT) and their evolution over time, and to assess the influence of body mass index on radiation dose. METHODS We assessed consecutive patients included in three prospective registries (SPECT, ICA and cardiac CT) over a period of two years. Radiation dose was converted to mSv and compared between the three registries. Differences over time were evaluated by comparing the first with the fourth semester. RESULTS A total of 6196 exams were evaluated: 35% SPECT, 53% ICA and 22% cardiac CT. Mean radiation dose was 10.7±1.2 mSv for SPECT, 8.1±6.4 mSv for ICA, and 5.4±3.8 mSv for cardiac CT (p<0.001 for all). With regard to the radiation dose over time, there was a very small reduction in SPECT (10.7 to 10.5 mSv, p=0.004), a significant increase (25%) in ICA (7.0 to 8.8 mSv; p<0.001), and a significant reduction (29%) in cardiac CT (6.5 to 4.6 mSv, p<0.001). Obesity was associated with a significantly higher radiation dose in all three exams. CONCLUSIONS Cardiac CT had a lower mean effective radiation dose than invasive coronary angiography, which in turn had a lower mean effective dose than SPECT. There was a significant increase in radiation doses in the ICA registry and a significant decrease in the cardiac CT registry over time.

Nonobstructive coronary disease leading to Stemi: assessment of residual stenosis after thrombus aspiration

AimsNonobstructive coronary atherosclerotic lesions can lead to ST-elevation myocardial infarction (STEMI). Thrombus aspiration during a primary percutaneous coronary intervention provides a setting to evaluate the degree of stenosis of culprit lesions leading to STEMI. The aim of this study was to assess the degree of culprit lesion residual stenosis after thrombus aspiration and to compare the demographic, clinical, and angiographic characteristics between patients with obstructive versus nonobstructive residual stenosis. Methods and resultsFrom a single-center registry of 483 consecutive patients with STEMI undergoing a primary percutaneous coronary intervention, 172 patients underwent thrombus aspiration and were eligible for our study. We defined two groups according to the residual stenosis after thrombus aspiration: group A (n=119, 69%) with residual stenosis greater than or equal to 50%, and group B (n=53, 31%) with residual stenosis less than 50%.In terms of the baseline angiographic characteristics, patients with residual stenosis less than 50% had significantly lower prevalence of multivessel disease (15.1 vs. 46.2%, P<0.001). On multivariable analysis of the preprocedural variables, absence of vascular disease (odds ratio 4.99, 95% confidence interval 1.08–23.12, P=0.040) and age less than 59 years (odds ratio 2.67, 95% confidence interval 1.25–5.73, P=0.011) were independent predictors of culprit residual stenosis less than 50%. ConclusionIn this population, a significant proportion of patients with STEMI had nonobstructive residual stenosis after thrombus aspiration. These patients were younger, had a lower prevalence of vascular disease in other vascular territories, and less multivessel disease, suggesting an earlier stage of atherosclerosis.

Uncommon acquired Gerbode defect following extensive bicuspid aortic valve endocarditis

Gerbode defect is a rare type of left ventricle to right atrium shunt. It is usually congenital in origin, but acquired cases are also described, mainly following infective endocarditis, valve replacement, trauma or acute myocardial infarction. We report a case of a 50-year-old man who suffered an extensive and complex infective endocarditis involving a bicuspid aortic valve, the mitral-aortic intervalvular fibrosa and the anterior leaflet of the mitral valve. After dual valve replacement and annular reconstruction, a shunt between the left ventricle and the right atrium - Gerbode defect, and a severe leak of the mitral prosthesis were detected. Reintervention was performed with successful shunt closure with an autologous pericardial patch and paravalvular leak correction. No major complications occurred denying the immediate post-surgery period and the follow-up at the first year was uneventful.

Body mass index as a predictor of the presence but not the severity of coronary artery disease evaluated by cardiac computed tomography

Background The relation between body mass index (BMI) and coronary artery disease (CAD) extension remains controversial. The aim of this study was to evaluate the correlation between BMI and CAD extension documented by coronary computed tomography angiography (CCTA). Methods and results Prospective registry including 1706 consecutive stable patients that performed CCTA (dual source scanner) for the evaluation of CAD. The population was stratified by BMI: normal 530 (31.1%), overweight 802 (47.0%) and obesity 374 (21.9%). BMI was significantly higher in patients with CAD (27.7 ± 4.3 vs 26.8 ± 4.3 kg/m2, p < 0.001); these patients were also older, more often male and had higher prevalence of diabetes, hypertension and dyslipidemia. By multivariate analysis (logistic regression) BMI remains an independent predictor of CAD (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01–1.06; p = 0.012). Regarding the severity of CAD, BMI was not significantly different among patients with and without obstructive CAD (27.7 ± 4.3 vs 27.2 ± 4.3 kg/m2, p = 0.120). In 319 patients (4516 segments; 4077 evaluable), a detailed atherosclerotic burden was evaluated and compared among BMI classes, defined according to the presence of plaque and the degree of stenosis. Obstructive CAD was identified in 16.9% of the patients and 45.1% had non-obstructive CAD. The discriminative threshold for high burden, established by the segment involvement score (SIS), was >5 segments with plaque (15.4% patients). The prevalence of SIS >5 among the BMI classes was: 18.7%, 13.7% and 13.6% for normal, overweight and obesity respectively (p values for the specific classes versus all other patients: 0.241, 0.450 and 0.663). Conclusions In this population of stable patients undergoing CCTA for suspected CAD, BMI was an independent predictor of its presence, but was not correlated with the coronary disease severity.

Second-generation versus first-generation drug-eluting stents for the treatment of patients with acute coronary syndromes and obstructive coronary artery disease.

Introduction and aimsRandomized trials and registries have shown that drug-eluting stents (DES) have an overall better performance than bare-metal stents in patients treated in the setting of both ST-segment and non-ST-segment elevation acute coronary syndromes, mainly by reducing restenosis. Whether or not the use of newer second-generation devices (vs. first-generation DES) differs in these high-risk patients remains to be determined. Methods and resultsIn a single-centre prospective registry, 3266 patients underwent a percutaneous coronary intervention with at least one DES from January 2003 to December 2009. Of these, 1423 (43.6%) were treated in the setting of an acute coronary syndrome, using either first-generation-only DES [paclitaxel or sirolimus; n=923 (64.9%)] or second-generation-only [zotarolimus or everolimus; n=500 (35.1%)]. The occurrence of death from any cause, nonfatal myocardial infarction or target vessel failure (composite primary endpoint) was compared between these two groups; repeat revascularization of the index stented lesion and definite stent thrombosis [according to the academic research consortium (ARC) definition] were assessed as isolated secondary outcomes. At a median follow-up of 598 days (interquartile range 453–1206), the incidence of death was 10.7% (152), 136 patients (9.6%) had a new myocardial infarction and target vessel failure events occurred in 147 patients (10.3%). Disparity in the follow-up duration was accounted for by considering only the 1-year major adverse cardiac event rate (n=161; 11.3%). After adjustment for baseline characteristics using a Cox proportional hazard model, we could not find a significant difference in the incidence of the composite primary endpoint at 1-year between first-generation (10.8%) and second-generation DES (12.2%) [hazard ratio (HR): 1.1; 95% confidence interval (CI): 0.82–1.57, P=0.463], nor in the occurrence of repeat target lesion revascularization (3.6 vs. 4.4%; HR 1.35; 95% CI 0.77–2.34; P=0.293). In a per patient analysis, at 1 year, ARC-definite ST was documented in 1.0% of patients treated with second-generation DES versus 2.8% in those treated with first-generation DES (corrected HR 0.36; 95% CI 0.14–0.94; P=0.037), owing mostly to a higher difference in late ST. ConclusionOur results suggest that both first-generation and second-generation DES seem to be similarly effective in patients undergoing a percutaneous coronary intervention in the setting of acute coronary syndromes. However, newer second-generation devices may offer potential advantages because of a significantly lower incidence of ARC-definite ST.

NT-proBNP na estratificação de risco no tromboembolismo pulmonar

INTRODUCTION Pulmonary embolism (PE) is an entity with high mortality and morbidity, in which risk stratification for adverse events is essential. N-terminal brain natriuretic peptide (NT-proBNP), a right ventricular dysfunction marker, may be useful in assessing the short-term prognosis of patients with PE. AIMS To characterize a sample of patients hospitalized with PE according to NT-proBNP level at hospital admission and to assess the impact of this biomarker on short-term evolution. METHODS We performed a retrospective analysis of consecutive patients admitted with PE over a period of 3.5 years. Based on the median NT-proBNP at hospital admission, patients were divided into two groups (Group 1: NT-proBNP<median and Group 2: NT-proBNP ≥ median). The two groups were compared in terms of demographic characteristics, personal history, clinical presentation, laboratory, electrocardiographic and echocardiographic data, drug therapy, in-hospital course (catecholamine support, invasive ventilation and in-hospital death and the combined endpoint of these events) and 30-day all-cause mortality. A receiver operating characteristic (ROC) curve was constructed to determine the discriminatory power and cut-off value of NT-proBNP for 30-day all-cause mortality. RESULTS Ninety-one patients, mean age 69±16.4 years (51.6% aged ≥75 years), 53.8% male, were analyzed. Of the total sample, 41.8% had no etiological or predisposing factors for PE and most (84.6%) were stratified as intermediate-risk PE. Median NT-proBNP was 2440 pg/ml. Patients in Group 2 were significantly older (74.8±13.2 vs. 62.8±17.2 years, p=0.003) and more had a history of heart failure (35.5% vs. 3.3%, p=0.002) and chronic kidney disease (32.3% vs. 6.7%, p=0.012). They had more tachypnea on initial clinical evaluation (74.2% vs. 44.8, p=0.02), less chest pain (16.1% vs. 46.7%, p=0.01) and higher creatininemia (1.7±0.9 vs. 1.1±0.5mg/dl, p=0.004). Group 2 also more frequently had right chamber dilatation (85.7% vs. 56.7%, p=0.015) and lower left ventricular ejection fraction (56.4±17.6% vs. 66.2±13.5%, p=0.036) on echocardiography. There were no significant differences in drug therapy between the two groups. Regarding the studied endpoints, Group 2 patients needed more catecholamine support (25.8% vs. 6.7%, p=0.044), had higher in-hospital mortality (16.1% vs. 0.0%, p=0.022) and more frequently had the combined endpoint (32.3% vs. 10.0%, p=0.034). All-cause mortality at 30 days was seen only in Group 2 patients (24.1% vs. 0.0%, p=0.034). By ROC curve analysis, NT-proBNP had excellent discriminatory power for this event, with an area under the curve of 0.848. The best NT-proBNP cut-off value was 4740 pg/ml. CONCLUSION Elevated NT-proBNP levels identified PE patients with worse short-term prognosis, and showed excellent power to predict 30-day all-cause mortality. The results of this study may have important clinical implications. The inclusion of NT-proBNP measurement in the initial evaluation of patients with PE can add valuable prognostic information.

Inter-Rater Reliability and Downstream Financial Implications of Electrocardiography Screening in Young Athletes

Background— Preparticipation screening for cardiovascular disease in young athletes with electrocardiography is endorsed by the European Society of Cardiology and several major sporting organizations. One of the concerns of the ECG as a screening test in young athletes relates to the potential for variation in interpretation. We investigated the degree of variation in ECG interpretation in athletes and its financial impact among cardiologists of differing experience. Methods and Results— Eight cardiologists (4 with experience in screening athletes) each reported 400 ECGs of consecutively screened young athletes according to the 2010 European Society of Cardiology recommendations, Seattle criteria, and refined criteria. Cohen &kgr; coefficient was used to calculate interobserver reliability. Cardiologists proposed secondary investigations after ECG interpretation, the costs of which were based on the UK National Health Service tariffs. Inexperienced cardiologists were more likely to classify an ECG as abnormal compared with experienced cardiologists (odds ratio, 1.44; 95% confidence interval, 1.03–2.02). Modification of ECG interpretation criteria improved interobserver reliability for categorizing an ECG as abnormal from poor (2010 European Society of Cardiology recommendations; &kgr;=0.15) to moderate (refined criteria; &kgr;=0.41) among inexperienced cardiologists; however, interobserver reliability was moderate for all 3 criteria among experienced cardiologists (&kgr;=0.40–0.53). Inexperienced cardiologists were more likely to refer athletes for further evaluation compared with experienced cardiologists (odds ratio, 4.74; 95% confidence interval, 3.50–6.43) with poorer interobserver reliability (&kgr;=0.22 versus &kgr;=0.47). Interobserver reliability for secondary investigations after ECG interpretation ranged from poor to fair among inexperienced cardiologists (&kgr;=0.15–0.30) and fair to moderate among experienced cardiologists (&kgr;=0.21–0.46). The cost of cardiovascular evaluation per athlete was

Desnervação renal em doentes com hipertensão arterial resistente: resultados aos seis meses de seguimento

175 (95% confidence interval,