José Geraldo de Castro Amino

Atrioventricular block in acute inferior wall myocardial infarction: Harbinger of associated obstruction of the left anterior descending coronary artery

In a prospective study 51 consecutive patients who survived the acute phase of inferior wall myocardial infarction underwent coronary arteriography. Eleven patients developed some degree of atrioventricular (AV) block in the acute phase of infarction that disappeared within a few days and was considered by electrocardiographic analysis to be located in the AV node. Patients with AV block during acute myocardial infarction had a significantly higher prevalence of left anterior descending coronary artery obstruction (91 versus 55%, p less than 0.05) than did patients without AV block and the obstruction preceded the exit of the first septal perforator branch in 73% of cases with heart block and in 30% of cases without block (p less than 0.01). The sensitivity, specificity and predictive values were 31, 95 and 91%, respectively, for the existence of left anterior descending coronary artery obstruction when AV block occurred during acute inferior myocardial infarction, and 40, 90 and 73%, respectively, for the occurrence of the coronary artery obstruction before the exit of the first septal perforator branch. Patients with inferior myocardial infarction and left anterior descending coronary artery obstruction have a sixfold greater chance of developing heart block in the acute phase of infarction than do patients with inferior infarction without such obstruction (p less than 0.05). These findings also support the observations that the proximal AV conduction system usually has a dual arterial blood supply from both the right and left anterior descending coronary arteries, and may explain the transient behavior of heart block and lack of necrosis of the AV node seen in these patients.

Stem cell therapy with retrograde coronary perfusion in acute myocardial infarction: a new technique

The patient is a 63-year-old, obese man with diabetes, hy-pertension, dyslipemia, and a positive familial history of coronaryartery disease and previous myocardial infarction in the inferiorwall 4 years earlier. Twelve days previously, the patient had anacute myocardial infarction in the anterior wall, which evolvedfor 14 hours. The patient underwent angioplasty and successfulstent implantation but began to complain of fatigue on mild effortand nocturnal paroxysmal dyspnea.The electrocardiogram showed third-degree left bundle-branchblock. The echocardiogram showed cavitary enlargement, anteriorand inferior akinesia, and an ejection fraction of 24%. Thallium-201 myocardial scintigraphy showed anterior and inferior fibrosis.The cardiac catheterization evidenced a significantly enlarged ven-tricle due to anterior and inferior akinesis, and apical dyskinesis.On angiography, the ejection fraction was 25%, and the left ven-tricular Pd2 was 34 mmHg. The right coronary artery showed adiffuse lesion in its proximal segment and distal occlusion. Theleft main coronary artery had no obstruction, the circumflex arteryhad parietal irregularities and occluded marginal branches, andwas opacified through the homocollaterals. The anterior descen-ding artery was diffusely damaged from the junction of the middleand distal segments onwards. The first medium-caliber diagonalbranch had a severe lesion in its origin.Taking all this into consideration, the patient and his familywere presented with the possibility of retrograde bone-marrowstem cell injection through the anterior descending vein to causemyogenesis and angiogenesis. The patient agreed with the pro-cedure proposed, as did the committee on ethics subordinate tothe Argentinean government and Health Ministry.With the patient under general anesthesia, puncture of theiliac crest and bone marrow aspiration were performed.The upper layer (leukocyte concentrate containing mononuclearcells) was separated from the erythrocytes by centrifugation, andthe latter were reinfused into the patient. Then the leukocytic

Análise de custo-efetividade dos stents farmacológicos e não farmacológicos na doença coronariana

BACKGROUND: There is a scarcity of cost-effectiveness analyses in the national literature comparing drug-eluting stents (DES) with bare-metal stents (BMS), at late follow-up. OBJECTIVE: To estimate the Incremental Cost-Effectiveness Ratio (ICER) between DES and BMS in uniarterial coronariopathy. METHODS: 217 patients (130 DES and 87 BMS), with 48 months of follow-up (mean = 26 months) were assessed. Primary outcome: cost per prevented restenosis, with effectiveness being defined as the decrease in major events. The analytical model of decision was based on the study by Polanczyk et al. The direct costs were those used directly in the interventions. RESULTS: The sample was homogenous for age and sex. The DES was more used in diabetic patients: 59 (45.4%) vs 16 (18.4%)(p<0.0001) and with a history of coronary artery disease (CAD): 53 (40.7%) vs 13 (14.9%)(p<0.0001). The BMS was more used in simple lesions, but with worse ventricular function. The DES were implanted preferentially in proximal lesions: (p=0.0428) and the BMS in the mid-third (p=0.0001). Event-free survival: DES = 118 (90.8%) vs BMS=74 (85.0%) (p=0.19); Angina: DES=9 (6.9%) vs BMS=9 (10.3%) (NS): Clinical restenosis: DES=3 (2.3%) vs BMS=10 (10.3%) (p=0.0253). Cardiac deaths: 2 (1.5%) in DES and 3 (3.5%) in BMS (NS). Costs: the tree of decision was modeled based on restenosis. The net benefit for the DES needed an increment of R

Correlação entre marcadores bioquímicos e a cineangiocoronariografia em portadores de síndromes isquêmicas agudas sem supradesnivelamento de segmento ST

7,238.16. The ICER was R

Diretrizes de doença coronariana crônica angina estável

131,647.84 per prevented restenosis (above the WHO threshold). CONCLUSIONS: The DES was used in more complex lesions. The clinical results were similar. The restenosis rate was higher in the BMS group. The DES was a non-cost-effective strategy.

III Diretriz sobre tratamento do infarto agudo do miocárdio

OBJECTIVE Investigate the correlation between biochemical markers (TNI, CRP and fibrinogen) and anatomical coronary angiographic findings in patients with non-ST elevation acute coronary syndromes (NSTE-ACS). METHODS One blood sample was obtained to test for markers, and coronary angiography was performed within the first 72 hours after hospitalization. Univariate analysis was used to search for correlations between the 3 markers and the angiographic findings in the group of patients with an identified ischemia-related artery (IRA), and multivariate analysis was performed to investigate the correlation between these markers and the presence of unstable atherosclerotic lesions solely in the group with a coronary obstruction > 50%. RESULTS Prospective study conducted with 84 patients, 65.5% of whom were men. In the IRA-identified group, blood levels of the three markers were higher than in the groups with no IRA-identified or with normal coronary arteries. The analysis used to evaluate the IRA-identified group showed significant correlations between TIMI flow and TN-I (p = 0.006), unstable atherosclerotic lesions and TN-I and fibrinogen (p = 0.02 and p = 0.01, respectively), and multivessel disease and CRP (p = 0.0005). The multivariate analysis showed that CRP, fibrinogen and TN-I were independent predictors of unstable atherosclerotic lesions (p = 0.002; p = 0.003 and p = 0.007, respectively). CONCLUSION In NSTE-ACS patients, TN-I, CRP and fibrinogen blood levels within the first 10 hours after hospitalization correlated with coronary angiographic findings.