Luis C. L. Correia

Intravascular Magnetic Resonance Imaging of Aortic Atherosclerotic Plaque Composition

Magnetic resonance imaging (MRI) may be an excellent tool to define atherosclerotic plaque composition, but surface MRI (SMRI) suffers from a low signal-to-noise ratio and low resolution of arterial images. Intravascular MRI (IVMRI) represents a potential solution for acquiring high-quality in vivo images of atherosclerotic plaques. Isolated segments of 11 thoracic human aortas obtained at autopsy were imaged by IVMRI using an intravascular receiver catheter coil designed and built at our institution. Images obtained by IVMRI were compared with corresponding images obtained by SMRI and with histopathological aortic cross sections. The intensity of intimal thickness and plaque components was graded by IVMRI and histopathology using a score of 1 for mild, 2 for moderate, and 3 for severe intensity. IVMRI had an agreement of 75% with histopathology in fibrous cap grading (37.5% expected, kappa = 0.60, P < 0.001) and of 74% in necrotic core grading (39% expected, kappa = 0.57, P < 0.001). Intraplaque calcification was correctly graded by IVMRI in six of the eight plaques in which histopathology recognized calcium. The analysis of intimal thickness showed 80% agreement between IVMRI and histopathology (52% expected, kappa = 0.59, P < 0.001). IVMRI image features were similar to those of SMRI. In addition, IVMRI accurately determined atherosclerotic plaque size in comparison with histopathology and SMRI (slope = 1.25 cm2, r = 0.99, P < 0.001 for luminal area by IVMRI vs histopathology; slope = 0.97 cm2, r = 0.996, P < 0.001 for luminal area by IVMRI vs SMRI). IVMRI has the potential to provide important prognostic information in patients with atherosclerosis because of its ability to accurately assess both plaque composition and size.

Prognostic value of cytokines and chemokines in addition to the GRACE Score in non-ST-elevation acute coronary syndromes.

BACKGROUND Increased cytokine and chemokine levels are associated with cardiovascular events in patients with non-ST-elevation acute coronary syndromes (ACS), but the incremental prognostic value of these inflammatory markers is not known. We determined if cytokine and chemokine assessment adds prognostic information to the GRACE Score in patients with ACS. METHODS Five cytokines (interleukin (IL)-1beta, IL-6, IL-10, IL-12p70, and tumor necrosis factor (TNF)-alpha soluble receptor I), five chemokines (IL-8, CCL5, CXCL9, CCL2, and CXCL10) and C-reactive protein (CRP) were measured at admission of 87 patients admitted with ACS. RESULTS During hospitalization, the incidence of cardiovascular events was 13% (7 deaths, 1 nonfatal acute myocardial infarction, and 3 refractory unstable angina). Individuals who developed events had significantly greater levels of CRP, IL-1beta, IL-12, TNF-alpha, IL-8, CXCL9 and CCL2, compared with those free of events. Thus, these markers were used to build an Inflammatory Score, by the input of one point for each of these variables above the 75th percentile. After adjustment for the GRACE Score, the Inflammatory Score independently predicted events (OR=1.80; 95% CI=1.12-1.88). Incorporation of the Inflammatory Score into the GRACE Score promoted a C-statistics improvement from 0.77 (95% CI=0.58-0.96) to 0.85 (95% CI=0.71-1.0). Net reclassification improvement obtained with GRACE-Inflammatory Score was 13% (P=0.007), indicating a significant reclassification. When only CRP was incorporated into GRACE, the increase on C-statistics was not relevant (from 0.77 to 0.80). CONCLUSION Cytokines and chemokines measured at admission add prognostic information to the GRACE Score in patients admitted with ACS.

Absent coronary artery calcium excludes inducible myocardial ischemia on computed tomography/positron emission tomography.

OBJECTIVE We set out to determine whether a coronary artery calcium (CAC) score of zero on computed tomography (CT) would predict a normal myocardial perfusion positron emission tomography (PET) in a population mostly at intermediate pretest likelihood of coronary artery disease (CAD). METHODS We enrolled 206 outpatients (36% men, mean age 60 ± 13 years) referred for Rb-82 myocardial perfusion PET/CT for suspected CAD. CAC scoring was performed by the Agatston method. The PET images were scored on a 5-point scale using a 17-segment left ventricular model. A summed stress score ≥ 2 was considered abnormal. Multivariable logistic regression analysis was used to test the independent predictive value of a CAC score of zero to exclude inducible myocardial ischemia. RESULTS Ninety-nine of 206 patients (48%) had a CAC score of zero and of these only 1 had inducible ischemia on PET. This yielded a negative predictive value of 99% (95% CI 95%-100%). CAC score of zero was the strongest independent predictor of a normal myocardial perfusion PET (OR = 0.05; 95% CI = 0.006-0.38; p = 0.004). CONCLUSION In a population of predominately intermediate likelihood of CAD, a CAC score of zero excludes inducible ischemia on myocardial perfusion PET.

HDL-cholesterol level provides additional prognosis in acute coronary syndromes☆

In the setting of acute coronary syndromes, plasma lipids have not been defined as prognostic variables, however little research has been dedicated to this specific issue. In order to test the independent predictive value for in-hospital events of low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol and triglycerides measured at hospital admission, 97 individuals with unstable angina or non-ST-elevation acute myocardial infarction were evaluated. In-hospital events, defined as death, non-fatal myocardial infarction or recurrent unstable angina, were significantly predicted by HDL-cholesterol (C-statistics=0.69; 95% CI=0.55-0.83, P=0.018), contrary to LDL-cholesterol (C-statistics=0.40; 95% CI=0.24-0.56, P=0.23) and triglycerides (C-statistics=0.48; 95% CI=0.31-0.65, P=0.83). The best HDL-cholesterol cut-off point was 32 mg/dl, with a 33% incidence of events in patients with HDL-cholesterol < or =32 mg/dl, compared with only 9% in those with HDL-cholesterol>32 mg/dl (P=0.003). Logistic regression analysis showed HDL-cholesterol< or =32 mg/dl (OR=3.6; 95% CI=1.0-14; P=0.05) and TIMI Risk Score (OR=2.3; 95% CI=1.4-2.9, P=0.001) as the independent predictors of events. Furthermore, the addition of HDL-cholesterol to TIMI Risk Score improved its C-statistic from 0.81 to 0.85. In conclusion, as opposed to LDL-cholesterol and triglycerides, HDL-cholesterol level adds prognostic value to the prediction of in-hospital recurrent events during non-ST-elevation acute coronary syndromes.

Prognostic value of GRACE scores versus TIMI score in acute coronary syndromes

BACKGROUND Although the TIMI score is the one most frequently used in acute coronary syndromes (ACS) without ST-segment elevation, the GRACE score has potential prognostic superiority, as it was created based on an observational registry, part of the variables is treated in a semi-quantitative form and renal function is taken into account in its calculation. OBJECTIVE To test the hypothesis that the GRACE risk score has superior in-hospital prognostic value, when compared to the TIMI score in patients admitted with ACS. METHODS Individuals with unstable angina or myocardial infarction without ST-segment elevation, consecutively admitted at the Coronary Unit between August 2007 and January 2009, were included in the study. RESULTS A total of 154 patients aged 71 +/- 13 years, of which 56% were females, with a GRACE median of 117 and a TIMI median of 3 were studied. During the hospitalization period, the incidence of events was 8.4% (12 deaths and 1 non-fatal infarction). The Hosmer-Lemeshow test applied to the GRACE score presented an chi2 of 5.3 (P = 0.72), whereas the TIMI score presented an chi2 of 1.85 (P = 0.60). Therefore, both scores presented good calibration. As for the analysis of discrimination, the GRACE score presented a C-statistics of 0.91 (95%CI= 0.86 - 0.97), significantly superior to the C-statistics of 0.69 of the TIMI score (95%CI = 0.55 - 0.84) - P = 0.02 for the difference between the scores. CONCLUSION Regarding the prediction of hospital events in patients with ACS, the GRACE score has superior prognostic capacity when compared to the TIMI score.Resumen Fundamento: Aunque el Score de Riesgo TIMI sea el mas utilizado en sindromes coronarios agudos sin supradesnivel del segmento ST (SCA), el Score GRACE tiene potencial superioridad pronostica, pues fue creado a partir de un registro observacional, parte de las variables son tratadas de forma semicuantitativa y la funcion renal se computa en su calculo.Objetivo: Probar la hipotesis de que el Score de Riesgo GRACE tiene superior valor pronostico hospitalario, comparado con el Score TIMI en pacientes ingresados con SCA.Metodos: Fueron incluidos individuos con angina inestable o infarto de miocardio sin supradesnivel del segmento ST, consecutivamente internados en Unidad Coronaria entre agosto de 2007 y enero de 2009.Resultados: Fueron estudiados 154 pacientes, edad 71 ± 13 anos, el 56% del sexo femenino, mediana de GRACE de 117 y mediana de TIMI de 3. Durante el periodo de internacion, la incidencia de eventos fue del 8,4% (12 fallecimientos y 1 infarto no fatal). El test de Hosmer-Lemeshow aplicado al Score GRACE presento χ

Valor prognóstico do Escore de Risco GRACE versus Escore de Risco TIMI em síndromes coronarianas agudas

BACKGROUND Although the TIMI score is the one most frequently used in acute coronary syndromes (ACS) without ST-segment elevation, the GRACE score has potential prognostic superiority, as it was created based on an observational registry, part of the variables is treated in a semi-quantitative form and renal function is taken into account in its calculation. OBJECTIVE To test the hypothesis that the GRACE risk score has superior in-hospital prognostic value, when compared to the TIMI score in patients admitted with ACS. METHODS Individuals with unstable angina or myocardial infarction without ST-segment elevation, consecutively admitted at the Coronary Unit between August 2007 and January 2009, were included in the study. RESULTS A total of 154 patients aged 71 +/- 13 years, of which 56% were females, with a GRACE median of 117 and a TIMI median of 3 were studied. During the hospitalization period, the incidence of events was 8.4% (12 deaths and 1 non-fatal infarction). The Hosmer-Lemeshow test applied to the GRACE score presented an chi2 of 5.3 (P = 0.72), whereas the TIMI score presented an chi2 of 1.85 (P = 0.60). Therefore, both scores presented good calibration. As for the analysis of discrimination, the GRACE score presented a C-statistics of 0.91 (95%CI= 0.86 - 0.97), significantly superior to the C-statistics of 0.69 of the TIMI score (95%CI = 0.55 - 0.84) - P = 0.02 for the difference between the scores. CONCLUSION Regarding the prediction of hospital events in patients with ACS, the GRACE score has superior prognostic capacity when compared to the TIMI score.Resumen Fundamento: Aunque el Score de Riesgo TIMI sea el mas utilizado en sindromes coronarios agudos sin supradesnivel del segmento ST (SCA), el Score GRACE tiene potencial superioridad pronostica, pues fue creado a partir de un registro observacional, parte de las variables son tratadas de forma semicuantitativa y la funcion renal se computa en su calculo.Objetivo: Probar la hipotesis de que el Score de Riesgo GRACE tiene superior valor pronostico hospitalario, comparado con el Score TIMI en pacientes ingresados con SCA.Metodos: Fueron incluidos individuos con angina inestable o infarto de miocardio sin supradesnivel del segmento ST, consecutivamente internados en Unidad Coronaria entre agosto de 2007 y enero de 2009.Resultados: Fueron estudiados 154 pacientes, edad 71 ± 13 anos, el 56% del sexo femenino, mediana de GRACE de 117 y mediana de TIMI de 3. Durante el periodo de internacion, la incidencia de eventos fue del 8,4% (12 fallecimientos y 1 infarto no fatal). El test de Hosmer-Lemeshow aplicado al Score GRACE presento χ

Does acute hyperglycemia add prognostic value to the GRACE score in individuals with non-ST elevation acute coronary syndromes?

BACKGROUND It is not known in what extent admission glucose improves risk stratification of the GRACE Score in patients with non-ST-segment elevation acute coronary syndromes (ACS). We tested the hypothesis that admission glucose adds relevant prognostic information to the GRACE Score. METHODS Consecutive patients admitted with ACS had plasma glucose measured at admission and cardiovascular events were defined as death, non-fatal myocardial infarction or non-fatal refractory angina during hospitalization. RESULTS Among the 148 patients studied, 11.5% developed cardiovascular events. Patients in the forth quartile of admission glucose (> or =175mg/dl) had a greater incidence of events, compared with those in the first 3 quartiles (22% vs. 8.1%; RR=2.7; 95%CI 1.1-6.4; P=0.03). Plasma glucose remained a predictor of events, after adjustment for diabetes (P=0.03). After adjustment for the GRACE Score, glucose in the forth quartile lost its predictive value (P=0.29). Plasma glucose added to GRACE did not improve the C-statistics (0.82; 95%CI 0.75-0.88), as compared with the original Score (0.81; 95%CI 0.74-0.87). Net reclassification improvement by new score was -0.03 (P=0.86), indicating no useful reclassification. CONCLUSION Despite its association with adverse events, admission plasma glucose does not improve GRACEs accuracy to predict in-hospital events in patients with ACS.

Ocorrência e preditores clínicos de pseudocrise hipertensiva no atendimento de emergência

OBJETIVOS: Descrever a prevalencia de pseudocrise hipertensiva em pacientes atendidos em unidade de emergencia com niveis de pressao arterial substancialmente elevados, comparando-a entre servicos privado e publico; descrever a frequencia de tratamento indevido para essa condicao; identificar, no momento da triagem, preditores independentes de pseudocrise; e avaliar o prognostico dos pacientes com pseudocrise. METODOS: Durante seis meses, foram incluidos pacientes com idade > 18 anos, atendidos nas Emergencias de dois hospitais (privado e publico), com pressao arterial diastolica > 120 mmHg. Pseudocrise hipertensiva foi definida na ausencia de criterios para crise hipertensiva, segundo as Diretrizes da Sociedade Brasileira de Cardiologia. RESULTADOS: Em 110 pacientes estudados, a prevalencia de pseudocrise hipertensiva foi de 48% (intervalo de confianca de 95% [IC 95%] = 39%-58%), predominando no servico privado (59% vs 37%; p = 0,02). A frequencia de tratamento indevido foi semelhante nos dois servicos (94% vs 95%; p = 0,87). Apos analise multivariada, a presenca de cefaleia na admissao (odds ratio = 5,4; IC 95% = 5,1-13; p < 0,001) e o nivel da pressao arterial diastolica (odds ratio = 0,93; IC 95% = 0,89-0,97; p = 0,002) foram preditores independentes de pseudocrise. A mortalidade em cinco meses foi menor no grupo pseudocrise em relacao a crise hipertensiva (0% vs 21%; p = 0,0004). CONCLUSOES: A prevalencia de pseudocrise hipertensiva e elevada em pacientes com suspeita de crise hipertensiva, especialmente em servico privado. A frequencia de tratamento indevido e semelhante nos servicos privado e publico. A presenca de cefaleia e o nivel da PA diastolica sao preditores independentes dessa condicao clinica. A pseudocrise hipertensiva e uma situacao clinica de baixa letalidade.

Correlation between turbidimetric and nephelometric methods of measuring C-reactive protein in patients with unstable angina or non-ST elevation acute myocardial infarction

OBJECTIVE To evaluate the performance of the turbidimetric method of C-reactive protein (CRP) as a measure of low-grade inflammation in patients admitted with non-ST elevation acute coronary syndromes (ACS). METHODS Serum samples obtained at hospital arrival from 68 patients (66 11 years, 40 men), admitted with unstable angina or non-ST elevation acute myocardial infarction were used to measure CRP by the methods of nephelometry and turbidimetry. RESULTS The medians of C-reactive protein by the turbidimetric and nephelometric methods were 0.5 mg/dL and 0.47 mg/dL, respectively. A strong linear association existed between the 2 methods, according to the regression coefficient (b=0.75; 95% C.I.=0.70-0.80) and correlation coefficient (r=0.96; P<0.001). The mean difference between the nephelometric and turbidimetric CRP was 0.02 0.91 mg/dL, and 100% agreement between the methods in the detection of high CRP was observed. CONCLUSION In patients with non-ST elevation ACS, CRP values obtained by turbidimetry show a strong linear association with the method of nephelometry and perfect agreement in the detection of high CRP.

I Diretriz de Ressonância e Tomografia Cardiovascular da Sociedade Brasileira de Cardiologia Sumário Executivo

Cesar Augusto Mastrofrancisco Cattani, Dany Jasinowodolinsk, Fabiano Lucchesi, Fabio Berezowsky Rocha, Fatima Cristina Pedroti, Gilberto Szarf, Guilherme Urpia Monte, Iugiro Roberto Kuroki , Joalbo Andrade, Jose Rodrigues Parga Filho, Luis Claudio Correia, Luiz Francisco Avila, Marcelo Hadlich, Marcelo Zapparoli, Marcia Barbosa, Marcia Lima Mugnaini, Maria Helena Albernaz Siqueira, Marly Maria Uellendhal, Miguel Abraao Rosario Neto, Paulo R. Schwarzman, Raul Dias dos Santos Filho, Ricardo Loureiro, Roberto Kalil Filho, Robson de Macedo Vieira