Marcio Antonio dos Santos

Sensitivity, specificity and predictive values of linear and nonlinear indices of heart rate variability in stable angina patients

Background Decreased heart rate variability (HRV) is related to higher morbidity and mortality. In this study we evaluated the linear and nonlinear indices of the HRV in stable angina patients submitted to coronary angiography. Methods We studied 77 unselected patients for elective coronary angiography, which were divided into two groups: coronary artery disease (CAD) and non-CAD groups. For analysis of HRV indices, HRV was recorded beat by beat with the volunteers in the supine position for 40 minutes. We analyzed the linear indices in the time (SDNN [standard deviation of normal to normal], NN50 [total number of adjacent RR intervals with a difference of duration greater than 50ms] and RMSSD [root-mean square of differences]) and frequency domains ultra-low frequency (ULF) ≤ 0,003 Hz, very low frequency (VLF) 0,003 – 0,04 Hz, low frequency (LF) (0.04–0.15 Hz), and high frequency (HF) (0.15–0.40 Hz) as well as the ratio between LF and HF components (LF/HF). In relation to the nonlinear indices we evaluated SD1, SD2, SD1/SD2, approximate entropy (−ApEn), α1, α2, Lyapunov Exponent, Hurst Exponent, autocorrelation and dimension correlation. The definition of the cutoff point of the variables for predictive tests was obtained by the Receiver Operating Characteristic curve (ROC). The area under the ROC curve was calculated by the extended trapezoidal rule, assuming as relevant areas under the curve ≥ 0.650. Results Coronary arterial disease patients presented reduced values of SDNN, RMSSD, NN50, HF, SD1, SD2 and -ApEn. HF ≤ 66 ms2, RMSSD ≤ 23.9 ms, ApEn ≤−0.296 and NN50 ≤ 16 presented the best discriminatory power for the presence of significant coronary obstruction. Conclusion We suggest the use of Heart Rate Variability Analysis in linear and nonlinear domains, for prognostic purposes in patients with stable angina pectoris, in view of their overall impairment.

Desfechos clínicos em 30 dias dos pacientes submetidos a intervenção coronária percutânea eletiva com alta no mesmo dia

BACKGROUND: Percutaneous coronary intervention (PCI) has become one of the most commonly performed cardiac procedures in clinical practice. Due to improvement in outcomes, reduced acute complication rates, the need to reduce costs and the limited availability of hospital beds, elective PCI with same-day discharge has become an interesting option. METHODS: Single-center registry with a retrospective evaluation of all patients undergoing elective PCI who were discharged on the same day, from January 2009 to March 2012. The rates of major adverse cardiac events (death, myocardial infarction, target-vessel revascularization and stroke), in addition to stent thrombosis, vascular complications and re-hospitalization between hospital discharge and the first 30 days of follow-up were determined. RESULTS: Sixty-nine patients were evaluated with mean age of 64.5 ± 11.2 years, most of them were male (82%), and 28% were diabetics. All patients had stable coronary artery disease and type A or B1 lesions (36% and 36% respectively). Radial access was the most commonly used approach (89%), with 5 F introducer sheaths in 56% and 6 F in the remaining patients. Procedure success was obtained in 98.5%. No clinical events were observed at the 30-day follow-up. CONCLUSIONS: Our results demonstrated that same-day discharge was safe for patients with low clinical and angiographic risk undergoing elective PCI with no procedure-related complications.

Eventos adversos e motivos de descarte relacionados ao reuso de produtos médicos hospitalares em angioplastia coronária

Objective: To describe the adverse effects that occur during and after percutaneous transluminal coronary angioplasty (PTCA) possibly related to the reuse of medical equipment. An additional objective is to quantify and identify the reasons of discard in respect to the brand-new and reuse of medical equipment. Method: Sixty patients were studied (48.3% with unstable angina, 45% with acute myocardial infarction and 6.7% with other diagnoses). During the procedure and stay in the Intensive Coronary Unit, the occurrence of fever, hypotension or hypertension, chills, sudoresis, bleeding, nausea and vomits were observed. Seven products were evaluated: catheter introducer, catheter guides (0.35 and 0.014), catheter balloons for angioplasty, indeflator inflation device and manifolds. In total, 76 brand-new and 410 reused apparatuses were studied to verify the occurrence of discard, whether this happened before or during the procedure and for what reason. P-values = 0.05 were considered significant. Results: Twenty-six patients presented adverse effects. Hypotension was the most common seen in 11 (18.3%) cases. There was no significant association between this adverse effect and reuse or not of the equipment. Three brand-new products and 55 of the reused products were discarded as they were incomplete. Conclusion: The adverse effects presented by patients submitted to coronary vessel angioplasty were not associated to the reuse of medical equipment. The integrity and functionality were the main reasons of discard.

Doença coronária obstrutiva em hepatopatas crônicos que aguardam transplante hepático

BACKGROUND Advanced liver failure (ALF) usually presents hypocholesterolemia. Nevertheless, some patients with ALF develops major coronary obstructive diseases with consequent increased risk or contraindication to liver transplantation. OBJECTIVE To analyze the contribution of classical risk factors for coronary artery disease (CAD) in patients with ALF with and without obstructive coronary disease. METHODS Evaluation of risk factors for CAD in 119 patients in a referral center for liver transplantation, with the following characteristics: patients older than 40 years of age with ALV who underwent coronary angiography. RESULTS Obstructive coronary disease was detected in 21 (17.6%) of the cases. These patients had really low cholesterol levels, of which 129.0 ± 53.5 mg/dl averaging 117.0 mg/dl in liver disease patients with normal coronary arteries and 135.4 ± 51.7 mg/dl averaging 122.0 mg/dl in liver disease patients with obstructive coronary artery disease (P = 0.8215). In multivariate logistic regression, age, sex, body mass index and the presence of diabetes, smoking and alcohol consumption were not statistically significant in distinguishing groups. Nor was there an association with the etiology of the ALF. In turn, hypertension was proven to be relevant in association with CAD (P = 0.0474). CONCLUSION Only hypertension was a risk factor with statistical significance for the development of CAD in patients with ALF awaiting liver transplantation. Because it is a modifiable risk factor, this finding guides the practice of therapeutic attitudes in an attempt to prevent or delay the development of CAD in these patients.FUNDAMENTO: La insuficiencia hepatica avanzada (IHA) generalmente cursa con hipocolesterolemia. A pesar de eso, una parcela de los pacientes con IHA desarrolla coronariopatia obstructiva de grado importante con consecuente aumento de riesgo o incluso contraindicacion para trasplante hepatico. OBJETIVOS: Analizar la contribucion de los factores de riesgo clasicos para la enfermedad arterial coronaria (EAC) en pacientes portadores de IHA con y sin coronariopatia obstructiva. METODOS: Evaluacion de los factores de riesgo para EAC en 119 pacientes, en un servicio de referencia para trasplante hepatico, con las siguientes caracteristicas: mas de 40 anos de edad, portadores de IHA y sometidos a cinecoronariografia. RESULTADOS: Coronariopatia obstructiva fue detectada en 21 (17,6%) de los casos. Estos pacientes presentaban realmente niveles bajos de colesterol, siendo de 129,0±53,5mg/dL con mediana de 117,0mg/dL en los hepatopatas con coronarias normales y 135,4±51,7mg/dL con mediana de 122,0mg/dL en los hepatopatas con coronariopatia obstructiva (P=0,8215). En la regresion logistica multivariada, la edad, el sexo, el indice de masa corporal, asi como las presencias de diabetes, de tabaquismo y de etilismo no tuvieron significancia estadistica aislada en la diferenciacion entre los grupos. Tambien no hubo asociacion con la etiologia de la IHA. A su vez, la hipertension arterial se mostro relevante en la asociacion con EAC (P=0,0474). CONCLUSION: Solo la hipertension arterial fue factor de riesgo con significancia estadistica para el desarrollo de EAC en pacientes con IHA aguardando trasplante hepatico. Por ser un factor de riesgo cambiable, este hallazgo orienta hacia una practica de actitudes terapeuticas en la tentativa de evitarse o retardar el desarrollo de la EAC en estos pacientes.

Obstructive coronary disease in patients with chronic liver disease awaiting liver transplantation

BACKGROUND Advanced liver failure (ALF) usually presents hypocholesterolemia. Nevertheless, some patients with ALF develops major coronary obstructive diseases with consequent increased risk or contraindication to liver transplantation. OBJECTIVE To analyze the contribution of classical risk factors for coronary artery disease (CAD) in patients with ALF with and without obstructive coronary disease. METHODS Evaluation of risk factors for CAD in 119 patients in a referral center for liver transplantation, with the following characteristics: patients older than 40 years of age with ALV who underwent coronary angiography. RESULTS Obstructive coronary disease was detected in 21 (17.6%) of the cases. These patients had really low cholesterol levels, of which 129.0 ± 53.5 mg/dl averaging 117.0 mg/dl in liver disease patients with normal coronary arteries and 135.4 ± 51.7 mg/dl averaging 122.0 mg/dl in liver disease patients with obstructive coronary artery disease (P = 0.8215). In multivariate logistic regression, age, sex, body mass index and the presence of diabetes, smoking and alcohol consumption were not statistically significant in distinguishing groups. Nor was there an association with the etiology of the ALF. In turn, hypertension was proven to be relevant in association with CAD (P = 0.0474). CONCLUSION Only hypertension was a risk factor with statistical significance for the development of CAD in patients with ALF awaiting liver transplantation. Because it is a modifiable risk factor, this finding guides the practice of therapeutic attitudes in an attempt to prevent or delay the development of CAD in these patients.FUNDAMENTO: La insuficiencia hepatica avanzada (IHA) generalmente cursa con hipocolesterolemia. A pesar de eso, una parcela de los pacientes con IHA desarrolla coronariopatia obstructiva de grado importante con consecuente aumento de riesgo o incluso contraindicacion para trasplante hepatico. OBJETIVOS: Analizar la contribucion de los factores de riesgo clasicos para la enfermedad arterial coronaria (EAC) en pacientes portadores de IHA con y sin coronariopatia obstructiva. METODOS: Evaluacion de los factores de riesgo para EAC en 119 pacientes, en un servicio de referencia para trasplante hepatico, con las siguientes caracteristicas: mas de 40 anos de edad, portadores de IHA y sometidos a cinecoronariografia. RESULTADOS: Coronariopatia obstructiva fue detectada en 21 (17,6%) de los casos. Estos pacientes presentaban realmente niveles bajos de colesterol, siendo de 129,0±53,5mg/dL con mediana de 117,0mg/dL en los hepatopatas con coronarias normales y 135,4±51,7mg/dL con mediana de 122,0mg/dL en los hepatopatas con coronariopatia obstructiva (P=0,8215). En la regresion logistica multivariada, la edad, el sexo, el indice de masa corporal, asi como las presencias de diabetes, de tabaquismo y de etilismo no tuvieron significancia estadistica aislada en la diferenciacion entre los grupos. Tambien no hubo asociacion con la etiologia de la IHA. A su vez, la hipertension arterial se mostro relevante en la asociacion con EAC (P=0,0474). CONCLUSION: Solo la hipertension arterial fue factor de riesgo con significancia estadistica para el desarrollo de EAC en pacientes con IHA aguardando trasplante hepatico. Por ser un factor de riesgo cambiable, este hallazgo orienta hacia una practica de actitudes terapeuticas en la tentativa de evitarse o retardar el desarrollo de la EAC en estos pacientes.

Retirada de corpo estranho na artéria pulmonar de neonato por técnica intravascular

The removal of intravascular foreign body by percutaneous interventional technique is a highly safe and effective procedure that has a low rate of complications even in children and premature infants. We describe a case of foreign body retrieval from the right branch pulmonary artery in an 18-day-old premature newborn.

Evaluation of the impact of chronic kidney disease on the survival of octogenarian patients submitted to percutaneous coronary intervention

Objective To evaluate the impact of chronic kidney disease on the survival of patients – 80 years of age undergoing percutaneous coronary intervention (PCI) in the long term. Methods 273 subjects who underwent PCI between January 2010 and January 2016 were divided into four categories: (1) stable angina (SA) and creatinine clearance – 30 (n = 24); (2) patients with SA and CrCl <30 (n = 70); (3) patients with acute coronary syndrome (ACS) and CrCl – 30 (n = 51); (4) patients with ACS and ICC <30 (n = 128). Mortality curves were evaluated using the Kaplan-Meier method and differences between groups were compared by log-rank statistic. Multivariate analysis was performed using the Cox proportional hazards method. The 4 groups were compared and the survival between the groups was evaluated. Results Octogenarian patients with CrCl <30 with SA and ACS have lower long-term survival (p < 0.0001). Conclusion CKD has a worse long-term prognosis for patients undergoing PCI.

Late Diagnosis of Anomalous Aortic Origin of a Coronary Artery from the Inappropriate Sinus of Valsalva during Investigation of Chest Pain

In this work are reported two cases of anomalous aortic origin of a coronary artery (AAOCA), with the left main coronary artery (LMCA) arising at the right sinus of Valsalva in a 77-year-old woman and in a 79-year-old man submitted to angiography after positive ischemic tests. The origin of the LMCA or the left descendant artery (LDA) from the right sinus of Valsalva has a prevalence of 0.2%, the origin of the circumflex artery (CXA) from the right sinus 0.5%, and the origin of the right coronary artery (RCA) from the left sinus of Valsalva has a prevalence of 0.3%. It is the subgroup of the coronary anomalies that has the greatest potential for clinical repercussions, especially the sudden cardiac death (SCD). We discuss the diagnostic methods and treatment options for this kind of coronary anomaly in symptomatic cases.

Bloqueio atrioventricular avançando no hiperparatireoidismo: uma complicação rara e irreversível

1. Membro titular da Sociedade Brasileira de Cardiologia, médico residente em Hemodinâmica e Cardiologia Invasiva pela Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brasil. 2. Livre-docente em Cirurgia Cardiovascular, professor adjunto do Departamento de Cardiologia e Cirurgia Cardiovascular da FAMERP, São José do Rio Preto, SP, Brasil. 3. Médico cardiologista, residente em Ecocardiografia pela FAMERP, São José do Rio Preto, SP, Brasil. 4. Membro titular da Sociedade Brasileira de Cardiologia, residente em Ecocardiografia pela FAMERP, São José do Rio Preto, SP, Brasil. 5. Doutor em Ciências da Saúde, professor assistente da FAMERP, São José do Rio Preto, SP, Brasil. Correspondência: Júlio César Queiroz de França Avenida Brigadeiro Faria Lima, 5.416 – Vila São Pedro São José do Rio Preto, SP, Brasil – CEP 15090-000 E-mail: jucequdefr@hotmail.com Artigo submetido em 5/2017. Artigo publicado em 12/2017. RESUMO Hiperparatireoidismo associado a hipercalcemia causando bradicardia significativa é uma combinação rara. Relatamos o caso de uma paciente de 62 anos de idade em pré-operatório de paratireoidectomia total decorrente de hiperparatireoidismo primário sintomático, que evoluiu com bloqueio atrioventricular avançado percebido durante a internação. A paciente necessitou de implante de marcapasso definitivo, pois permaneceu com bloqueio cardíaco avançado mesmo após correção da hipercalcemia. DESCRITORES: Bradicardia; Hipercalcemia; Hiperparatireoidismo. ABSTRACT The combination of hyperparathyroidism and hypercalcemia leading to significant bradycardia is rare. Here we report the case of a 62-year -old female patient in the preoperatory of a total parathyroidectomy due to symptomatic primary hyperparathyroidism, which evolved with an advanced atrioventricular block during hospitalization. The patient required a definitive pacemaker implantation, since the advanced heart block persisted after the correction of hypercalcemia.

Recurrence Plots: a New Tool for Quantification of Cardiac AutonomicNervous System Recovery after Transplant

Objective To evaluate a possible evolutionary post-heart transplant return of autonomic function using quantitative and qualitative information from recurrence plots. Methods Using electrocardiography, 102 RR tachograms of 45 patients (64.4% male) who underwent heart transplantation and that were available in the database were analyzed at different follow-up periods. The RR tachograms were collected from patients in the supine position for about 20 minutes. A time series with 1000 RR intervals was analyzed, a recurrence plot was created, and the following quantitative variables were evaluated: percentage of determinism, percentage of recurrence, average diagonal length, Shannon entropy, and sample entropy, as well as the visual qualitative aspect. Results Quantitative and qualitative signs of heart rate variability recovery were observed after transplantation. Conclusion There is evidence that autonomic innervation of the heart begins to happen gradually after transplantation. Quantitative and qualitative analyses of recurrence can be useful tools for monitoring cardiac transplant patients and detecting the gradual return of heart rate variability.