Henrique Carvalho

Renal sympathetic denervation in resistant hypertension

Resistant hypertension remains a major clinical problem despite the available multidrug therapy. Over the next decades, its incidence will likely increase given that it is strongly associated with older age and obesity. Resistant hypertension patients have an increased cardiovascular risk, thus effective antihypertensive treatment will provide substantial health benefits. The crosstalk between sympathetic nervous system and kidneys plays a crucial role in hypertension. It influences several pathophysiological mechanisms such as the central sympathetic tone, the sodium balance and the systemic neurohumoral activation. In fact, studies using several animal models demonstrated that the renal denervation prevented and attenuated hypertension in multiple species. Large reductions in blood pressure were also observed in malignant hypertension patients submitted to sympathectomy surgeries. However, these approaches had an unacceptably high rates of periprocedural complications and disabling adverse events. Recently, an innovative non-pharmacological therapy that modulates sympathetic activation has been successfully developed. Renal sympathetic percutaneous denervation is an endovascular procedure that uses radiofrequency energy to destroy the autonomic renal nerves running inside the adventitia of renal arteries. This method represents a promising new approach to the strategy of inhibiting the sympathetic nervous system. The aim of this review is to examine the background knowledge that resulted in the development of this hypertension treatment and to critically appraise the available clinical evidence.

Lack of Benefit of Ischemic Postconditioning After Routine Thrombus Aspiration During Reperfusion Immediate and Midterm Results

Objectives: The underutilization of manual thrombus aspiration (MTA) may have reduced the benefits of ischemic postconditioning (PostCon), as it reduces thrombus embolization. We aimed to assess the benefits of PostCon in patients with ST-segment elevation myocardial infarction (STEMI) after the systematic utilization of MTA. Methods: A total of 87 patients were enrolled in a prospective, randomized trial (43 PostCon and 44 controls). After MTA, PostCon was performed on the treatment group by applying 4 cycles of alternate reperfusion and reocclusion (60 seconds each) using the angioplasty balloon. The primary end point was infarct size assessed by the area under the curve (AUC) of troponin T (TnT) activity. The secondary end points were left ventricle ejection fraction (LVEF) and major cardiac events (new myocardial infarction or cardiac death) both at discharge and at follow-up. Results: The AUC for TnT was no different with respect to study arms (median [interquartile range]): PostCon = 8.9 (10.6) versus control = 8.2 (10.6), P = .68. Left ventricle ejection fraction improved from in-hospital to follow-up (9 ± 3 months) for the entire cohort (46.3% ± 7.3% vs 52.2% ± 10.7%, P < .001), with no differences between PostCon and controls (51.6% ± 9.5% vs 52.7% ± 11.9%, P = .89); major cardiac events at 14 ± 4 months of follow-up were also no different (PostCon = 1.0 (2.3%) vs control = 0, P = .49). Conclusion: In patients with STEMI treated with MTA, PostCon offered no benefits to infarct size, LVEF, or major cardiac events.

High-Sensitivity Troponin T: A Biomarker for Diuretic Response in Decompensated Heart Failure Patients

Background. Patients presenting with acutely decompensated heart failure (ADHF) and positive circulating cardiac troponins were found to be a high-risk cohort. The advent of high-sensitive troponins resulted in a detection of positive troponins in a great proportion of heart failure patients. However, the pathophysiological significance of this phenomenon is not completely clear. Objectives. The aim of this study is to determine the early evolution and clinical significance of high-sensitivity troponin T (hsTnT) in ADHF. Methods. Retrospective, secondary analysis of a prospective study including 100 patients with ADHF. Results. Globally, high-sensitivity troponin T decreased from day 1 to day 3 (P = 0,039). However, in the subgroup of patients who remained decompensated no significant differences in hsTnT from day 1 to day 3 were observed (P = 0,955), whereas in successfully compensated patients a significant reduction in hsTnT levels was observed (P = 0,025). High-sensitivity troponin T decrease was correlated with NTproBNP reduction (P = 0,007). Patients with hsTnT increase had longer length of stay (P = 0,033). Conclusions. Episodes of ADHF are associated with transient increases in the blood levels of hsTnT that are reduced with effective acute episode treatment. The decrease in hsTnT can translate less myocardial damage along with favourable ADHF treatment.

Posição sobre suportes vasculares restaurativos transitórios coronários em Portugal

BACKGROUND Bioresorbable vascular scaffolds (BVS) were recently approved for percutaneous coronary intervention in Europe. The aim of this position statement is to review the information and studies on available BVS, to stimulate discussion on their use and to propose guidelines for this treatment option in Portugal. METHODS AND RESULTS A working group was set up to reach a consensus based on current evidence, discussion of clinical case models and individual experience. The evidence suggests that currently available BVS can produce physiological and clinical improvements in selected patients. There are encouraging data on their durability and long-term safety. Initial indications were grouped into three categories: (a) consensual and appropriate - young patients, diabetic patients, left anterior descending artery, long lesions, diffuse disease, and hybrid strategy; (b) less consensual but possible - small collateral branches, stabilized acute coronary syndromes; and (c) inappropriate - left main disease, tortuosity, severe calcification. CONCLUSION BVS are a viable treatment option based on the encouraging evidence of their applicability and physiological and clinical results. They should be used in appropriate indications and will require technical adaptations. Outcome monitoring and evaluation is essential to avoid inappropriate use. It is recommended that medical societies produce clinical guidelines based on high-quality registries as soon as possible.

Hyponatremia – an unusual trigger of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is an acute cardiac entity with clinical manifestations similar to myocardial infarction, accounting for 1-2% of acute coronary syndrome admissions. Its underlying pathophysiology is not yet well established. It is usually associated with acute physical or emotional stress, but the list of potential triggers has grown as the condition attracts the attention of the medical community. In order to diagnose the condition correctly and to gain new insights into it, we need to know its potential triggers as well as its clinical presentation and diagnostic criteria. We report a case of takotsubo cardiomyopathy triggered by hyponatremia.

Portugal: coronary and structural heart interventions from 2010 to 2015

The aim of the present paper is to report trends in Portuguese interventional cardiology from 2010 to 2015. We studied data from the prospective multicentre Portuguese National Registry of Interventional Cardiology (RNCI) to analyse percutaneous coronary intervention (PCI) procedures and structural heart interventions from 2010 to 2015. A total of 73,977 PCIs and 780 transcatheter aortic valve implants were performed during the study period. Since 2010 there has been a 60% increase in PCI procedures and a twofold increase in primary angioplasty rates reaching 316 per million population. Significant PCI trends were observed, notably the increase of radial access, a reduction in restenosis indications, as well as an increase in stent use, including DES, in imaging and in functional techniques. Importantly, there was a fourfold increase in the TAVI rates reaching 29 per million population.

Preinfarction angina: clinical significance and relationship with total ischemic time in patients with ST-elevation myocardial infarction.

ObjectivesPreinfarction angina (PIA) may play a protective role in patients with ST-elevation myocardial infarction. Data on the relationship between PIA and time to reperfusion are scarce. We aimed to assess infarct size by peak troponin-T (TnT) in patients with or without PIA in three different time intervals to a primary percutaneous coronary intervention (PPCI), the relationship between PIA and left ventricular ejection fraction, and its impact on midterm survival. Patients and methodsSingle-center, retrospective analyses were carried out of 575 consecutive PPCI-treated patients, divided into three groups from symptom onset to reperfusion: less than 3, 3–6, and greater than 6 h. ResultsPatients with PIA had smaller infarct size [TnT=3.76 (5.07) vs. 5 (6.12) ng/ml, P=0.024]. Infarct size of patients with PIA versus no-PIA was lower for patients presenting within 3–6 h from onset of symptoms [3.73 (5.38) vs. 5.53 (6.9) ng/ml, P=0.028], but not different for those who presented less than 3 h [4.15 (5.53) vs. 4.0 (3.96) ng/ml, P=0.702] nor for those who presented greater than 6 h [3.65 (4.24) vs. 5.0 (5.9) ng/ml, P=0.141]. On multivariate analyses, only PIA protected from moderate to severe left ventricle dysfunction (odds ratio=0.557, 95% confidence interval: 0.352–0.881, P=0.012), but failed to reduce overall mortality [hazard ratio=0.784, 95% confidence interval: 0.356–1.724, P=0.545; median follow-up time=23 (20) months]. ConclusionPPCI-treated patients within 3–6 h from symptom onset had smaller infarcts if they had experienced PIA, with no benefit for those who presented less than 3 h nor for those who presented greater than 6 h from symptom onset. Moderate to severe left ventricle dysfunction was less prevalent in PIA patients. However, PIA failed to have an independent impact on midterm survival.

A trombectomia aspirativa na reperfusão do enfarte agudo de miocárdio: preditores e impacto clínico da sua ineficácia

INTRODUCTION AND OBJECTIVES The benefit of manual thrombus aspiration (TA) in the reperfusion of patients with ST-elevation myocardial infarction (STEMI) has been hotly debated. In most series, failure of TA has been largely unreported. Our objectives were to assess the rate, predictors, and impact on cumulative mortality of failed TA during primary percutaneous coronary intervention (PPCI). METHODS This was a single-center, retrospective study of consecutive STEMI patients undergoing PPCI with TA. TA was considered ineffective if, before angioplasty, coronary flow was TIMI <2. Independent predictors of TA failure were assessed by logistic regression, and predictors of cumulative mortality were assessed by Cox regression analysis. RESULTS Of 574 patients, TA was used in 417 (72.6%), and was effective in 365 (87.5%) and ineffective in 52 (12.5%). On multivariate analysis, SYNTAX score (OR=1.049, 95% CI: 1.015-1.084, p=0.005) and total ischemic time (OR=1.001, 95% CI: 1.000-1.003, p=0.02) were independent predictors of TA failure. Moderate or severe left ventricular dysfunction (HR=6.256, 95% CI: 1.896-20.644, p=0.003), APPROACH score (HR=1.094, 95% CI: 1.016-1.177, p=0.017), Killip class III/IV (HR=2.953, 95% CI: 1.122-7.770, p=0.028) and creatinine clearance on admission (HR=0.973, 95% CI: 0.953-0.994, p=0.011) were independently related to cumulative mortality at 24 ± 0.82 months. CONCLUSIONS Total ischemic time and SYNTAX score were independent predictors of TA failure. However, in medium-term follow-up, ineffective manual TA was not independently related to cumulative mortality.

The role of albuminuria as a non-invasive marker for congestive acutely decompensated chronic heart failure and the spironolactone effect in elderly Portuguese: a non-randomized trial

Albuminuria is a robust, validated cardiovascular risk factor. It is a simple and widely available test that was shown to be a powerful and independent predictor of prognosis in chronic heart failure. Mineralocorticoid receptor antagonists may reduce the acute and chronic harmful effects of mineralocorticoid receptor activation on the kidney. The objectives of the trial were to compare the effect of spironolactone versus standard acutely decompensated heart failure (ADHF) therapy on albuminuria and to investigate the role of albuminuria as a prognostic marker in patients with ADHF.

Influence of Spironolactone on Matrix Metalloproteinase-2 in Acute Decompensated Heart Failure

Background Matrix metalloproteinases (MMPs) are a family of enzymes important for the resorption of extracellular matrices, control of vascular remodeling and repair. Increased activity of MMP2 has been demonstrated in heart failure, and in acutely decompensated heart failure (ADHF) a decrease in circulating MMPs has been demonstrated along with successful treatment. Objective Our aim was to test the influence of spironolactone in MMP2 levels. Methods Secondary analysis of a prospective, interventional study including 100 patients with ADHF. Fifty patients were non-randomly assigned to spironolactone (100 mg/day) plus standard ADHF therapy (spironolactone group) or standard ADHF therapy alone (control group). Results Spironolactone group patients were younger and had lower creatinine and urea levels (all p < 0.05). Baseline MMP2, NT-pro BNP and weight did not differ between spironolactone and control groups. A trend towards a more pronounced decrease in MMP2 from baseline to day 3 was observed in the spironolactone group (-21 [-50 to 19] vs 1.5 [-26 to 38] ng/mL, p = 0.06). NT-pro BNP and weight also had a greater decrease in the spironolactone group. The proportion of patients with a decrease in MMP2 levels from baseline to day 3 was also likely to be greater in the spironolactone group (50% vs 66.7%), but without statistical significance. Correlations between MMP2, NT-pro BNP and weight variation were not statistically significant. Conclusion MMP2 levels are increased in ADHF. Patients treated with spironolactone may have a greater reduction in MMP2 levels.