Paulo Ricardo Avancini Caramori

Endothelial Dysfunction and Coronary Artery Disease

For several decades, the vascular endothelium was considered a unicellular layer acting as a semipermeable membrane between the blood and the interstitium. Recently, it has been demonstrated that the endothelium performs a large range of important biological functions, participating in several metabolic and regulatory pathways. Along with long-known specialized functions like gaseous exchange in the pulmonary circulation and phagocytosis in the hepatic and splenic circulation, the vascular endothelium performs universal roles in the circulation that include participation in thrombosis and thrombolytic control, vascular growth, platelet and leukocyte interactions with the vascular wall, and vasomotor tone. The study of endothelium-dependent vasomotor reactivity has produced over the years, scientific evidence fundamental for the understanding of the endothelium’s role in physiological and pathological situations. In 1977, Moncada et al, published the first report indicating that the endothelium plays a central role in the control of vascular tone via the production of vasoactive substances . In 1980, Furchgott and Zawadzki 2 demonstrated in an experimental preparation of the rabbit aorta, the obligatory role played by endothelial cells in vascular relaxation in response to effectors like acetylcholine, and postulated the existence of a vascular relaxing factor derived from the endothelium. In 1987, two research groups, lead by Ignarro et al , and by Palmer et al , demonstrated that the relaxing factor derived from the endothelium was nitric oxide, an odorless gas until then considered as a mere pollutant. Endothelial dysfunction was first characterized in humans in 1986 by Ludmer et al, 5 who demonstrated that atherosclerotic coronary arteries contracted in response to intracoronary infusion of acetylcholine, while normal coronaries showed dilatation. In 1992, endothelial dysfunction was documented by Celermajer et al 6 in children and otherwise healthy young adults with risk factors for atherosclerosis. Under physiological conditions, the endothelium keeps a reduced vasomotor tone, prevents leukocyte and platelet adhesion, and inhibits the proliferation of vascular smooth muscle cells. In contrast, endothelial dysfunction appears to play a pathogenic role in the initial development of atherosclerosis 7-9 and of unstable coronary syndromes , being associated with atherosclerotic disease risk factors , and being present even before vascular involvement becomes evident . Recent clinical studies have demonstrated that some drugs well known to reduce the incidence of cardiovascular events, improve endothelial function . On the other hand, clinical interventions like the continuous administration of organic nitrates and percutaneous coronary interventions may be associated with adverse effects on the vascular endothelium. In the present article, we will discuss vascular endothelial function versus dysfunction, and their impact on cardiovascular disease, in particular atherosclerosis.

Hidratação com bicarbonato de sódio não previne a nefropatia de contraste: ensaio clínico multicêntrico

BACKGROUNDnRadiographic contrast media exposition can cause acute renal function impairment. There is limited and conflicting evidence that hydration with sodium bicarbonate prevents contrast-induced nephropathy (CIN) in patients undergoing cardiac catheterization.nnnOBJECTIVEnThe present study was aimed at determining whether sodium bicarbonate is superior to hydration with saline to prevent nephropathy in patients at risk undergoing cardiac catheterization.nnnMETHODSnThree hundred and one patients undergoing coronary angiography or percutaneous coronary intervention with serum creatinine > 1.2mg/dL or glomerular filtration rate (GFR) < 50 ml/min were randomized to receive hydration with sodium bicarbonate starting 1 hour before the procedure and 6 hours after the procedure, or hydration with 0.9% saline. CIN was defined as an increase of 0.5mg/dL in creatinine in 48 hnnnRESULTSnEighteen patients (5.9%) developed contrast induced nephropathy: 9 patients in the bicarbonate group (6.1%) and 9 patients in the saline group (6.0%), p = 0.97. The change in serum creatinine was similar in both groups, 0.01 ± 0.26 mg/dL in the bicarbonate group and 0.01 ± 0.35 mg/dL in the saline group, p = 0.9. No statistical difference was observed between the change in glomerular filtration rate (0.89 ± 9 ml/min vs. 2.29 ± 10 ml/min, p = 0.2 bicarbonate group and saline group, respectively).nnnCONCLUSIONnHydration with sodium bicarbonate was not superior to saline to prevent contrast media induced nephropathy in patients at risk undergoing cardiac catheterization.

Hemodynamic effects of sildenafil in patients with stable ischemic heart disease

BACKGROUNDnRecently the new specific phosphodiesterase-5 inhibitor sildenafil was introduced into therapy for erectile dysfunction. The hemodynamic effects of sildenafil may be potentially hazardous for patients with cardiac disease. Sildenafil has been reported to augment the hypotensive effects of nitrates. There is sparse information regarding the systemic and pulmonary hemodynamic effects of a single oral dose of sildenafil in patients with stable angina.nnnMETHODSnMale patients referred for coronary angiography with diagnosis of chronic stable angina were enrolled in this study to assess the acute hemodynamic effects of sildenafil. Patients receiving long-acting or sublingual nitrates for the last 6 h before the study were excluded. Hemodynamic measurement were taken during right and left heart catheterization in the basal state and 60 min after 50 mg of oral sildenafil.nnnRESULTSnTwelve patients (age 53+/-7 years) were studied. All had stable angina CCS class II or III. Four had previous myocardial infarction. By coronary angiography, seven patients had at least one coronary artery with >70% stenosis, four had at least one with 50-70% stenosis, and one had only intimal irregularities. There were no significant effects of sildenafil on systemic or pulmonary arterial pressure, left ventricle end diastolic pressure, cardiac output, and systemic or pulmonary vascular resistance (P>0.05 for all). No adverse events were observed.nnnCONCLUSIONnA single oral dose of sildenafil had no significant hemodynamic effect in supine patients with stable angina. Isolated administration of sildenafil does not appear to be associated to adverse cardiovascular effects.

Does serum ferritin correlate with coronary angiography findings

BACKGROUNDnA number of epidemiological studies have described a positive relationship between serum ferritin levels and coronary heart disease. In this prospective study, we evaluated the association between serum ferritin levels and the angiographic extent of coronary atherosclerosis.nnnMETHODnWe studied 307 consecutive patients (60.9% male, age 60.1+/-11.0 years) referred for diagnostic coronary angiography. Risk factors for coronary artery disease, lipids and ferritin levels, as well clinical characteristics were recorded from all patients. Two experienced cardiologists blinded for clinical and laboratory data reviewed the cinefilms. Angiographic significant coronary artery disease (CAD) was defined as any more than a 50% diameter stenosis.nnnRESULTSnFrom the 307 patients, 196 (63.8%) were found to have angiographic significant CAD. The presence of significant CAD was associated with ferritin levels (P=0.015) as well as patient age (P<0.001), male sex (P<0.001), smoking (P<0.002), and cholesterol levels (P=0.028). By multivariate analysis, however, ferritin level was not an independent risk factor for CAD (P=0.27), while the association with all the other factors remained significant.nnnCONCLUSIONnIn patients referred for coronary angiography no independent relationship was found between angiographic significant coronary artery disease and serum ferritin levels.

Is there an association between non-steroidal anti-inflammatory drugs and contrast nephropathy?

FUNDAMENTO: A associacao entre o uso de anti-inflamatorios nao-esteroides (AINEs) e insuficiencia renal aguda ou cronica e bem documentada, mas evidencias sobre a associacao entre AINEs e nefropatia induzida por contraste (NIC) nao sao encontradas na literatura. OBJETIVO: Avaliar uma possivel associacao entre AINEs e NIC. METODOS: Em um estudo de coorte, atraves da entrevista clinica de pacientes que foram submetidos a cateterizacao cardiaca, analisamos o uso de AINEs e sua associacao com desenvolvimento de NIC, atraves da alteracao dos niveis de creatinina serica ou taxa de filtracao glomerular em 48 ou 72 horas. RESULTADOS: No periodo de julho de 2005 a julho de 2006, 236 pacientes foram incluidos no estudo, dos quais 29 foram posteriormente excluidos. A incidencia de NIC foi 10,37% (20 de 207) e 42% dos pacientes estavam recebendo AINEs ate o momento da avaliacao. Nao houve associacao entre o uso de AINEs e o desenvolvimento de NIC com OR de 1,293; IC95% (0,46-4,2). O estudo detectou fatores de risco conhecidos para o desenvolvimento de NIC, tais como diabete, com OR de 2,77; IC95% (1,05-7,47) e insuficiencia renal cronica com OR de 3,48; IC95% (1,1-11,07) e tambem sugeriu uma acao protetora da hidratacao com solucao salina com OR de 0,166; IC95% (0,03-0,92). CONCLUSAO: Com base nos dados obtidos, concluimos que nao houve associacao entre NIC e uso previo de AINEs, pelo menos com um OR > 2,85, o qual nossa amostra detectou.BACKGROUNDnThe association between the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and acute or chronic renal failure is well documented, but evidence of such association between NSAIDs and Contrast-Induced Nephropathies (CIN) is not found in the indexed literature.nnnOBJECTIVEnTo evaluate the possible association between NSAIDs and CIN.nnnMETHODSnIn a cohort study, through clinical interviews of patients that underwent cardiac catheterization, we analyzed the use of NSAIDs and its association with the development of CIN, through alterations in serum creatinine or glomerular filtration rate in 48 or 72 hours.nnnRESULTSnFrom July 2005 to July 2006, 236 patients were enrolled in the study, of which 29 were later excluded. The incidence of CIN was 10.37% (20 of 207) and 42% of the patients were using NSAIDs until the moment of the evaluation. There was no association between the use of NSAIDs and the development of CIN with OR of 1.293 95% CI (0.46-4.2). The study detected known risk factors for the development of CIN, such as diabetes with OR of 2.77 95%CI (1.05-7.47) and chronic renal failure with OR 3.48 95%CI (1.1-11.07). A protective action of saline solution hydration is also suggested, with OR of 0.166 95%CI (0.03-0.92).nnnCONCLUSIONnBased on the data obtained, we conclude that there was no association between CIN and previous use of NSAIDs, at least with an OR higher then 2.85, which our sample detected.

Impact of chronic kidney disease on the efficacy of drug-eluting stents: long-term follow-up study

BACKGROUND: Patients with chronic kidney disease (CKD) submitted to coronary angioplasty have higher rates of target lesion revascularization (TLR) and mortality. Drug-eluting stents (DES) are associated with a lower rate of restenosis, compared to bare metal stents (BMS), although data on DES efficacy and safety is limited in patients with CKD. OBJECTIVE: We sought to evaluate the safety and efficacy of DES in patients with significant CKD as compared to patients without normal renal function in a real world registry. METHODS: 504 patients who underwent percutaneous coronary intervention with DES in two centers were included. Outcomes were stratified based on the presence of CKD, defined as a baseline glomerular filtration rate (GFR) < 60 ml/min/1.73 m². RESULTS: The mean follow-up was 22.7 months. CKD was present in 165 patients (32.7%). Patients with CKD were older, had a higher incidence of hypertension and diabetes. CKD patients presented an increased incidence of death (12.3% vs 2.4%, p < 0.001) and myocardial infarction (MI) (7.4% vs 3.3%, p = 0.04) compared to patients without CKD. TLR rates were similar between groups (4.8% vs 5.6%, p = 0.7, CKD and no CKD patients, respectively). Independent predictors of death were CKD (HR 6.93; 2.4 - 19.5, p < 0.001), current smoking (HR 3.66; 1.20 - 11.10, p = 0.02) and diabetes (HR 2.66; 1.03 - 6.60, p = 0.045). CONCLUSION: In this registry, coronary intervention with DES in patients with CKD was associated with similar TLR compared to patients without CKD, demonstrating the efficacy of DES in preventing in-stent restenosis in this patient population. CKD was related to significantly increased MI and mortality rates.BACKGROUNDnPatients with chronic kidney disease (CKD) submitted to coronary angioplasty have higher rates of target lesion revascularization (TLR) and mortality. Drug-eluting stents (DES) are associated with a lower rate of restenosis, compared to bare metal stents (BMS), although data on DES efficacy and safety is limited in patients with CKD.nnnOBJECTIVEnWe sought to evaluate the safety and efficacy of DES in patients with significant CKD as compared to patients without normal renal function in a real world registry.nnnMETHODSn504 patients who underwent percutaneous coronary intervention with DES in two centers were included. Outcomes were stratified based on the presence of CKD, defined as a baseline glomerular filtration rate (GFR) < 60 ml/min/1.73 m².nnnRESULTSnThe mean follow-up was 22.7 months. CKD was present in 165 patients (32.7%). Patients with CKD were older, had a higher incidence of hypertension and diabetes. CKD patients presented an increased incidence of death (12.3% vs 2.4%, p < 0.001) and myocardial infarction (MI) (7.4% vs 3.3%, p = 0.04) compared to patients without CKD. TLR rates were similar between groups (4.8% vs 5.6%, p = 0.7, CKD and no CKD patients, respectively). Independent predictors of death were CKD (HR 6.93; 2.4 - 19.5, p < 0.001), current smoking (HR 3.66; 1.20 - 11.10, p = 0.02) and diabetes (HR 2.66; 1.03 - 6.60, p = 0.045).nnnCONCLUSIONnIn this registry, coronary intervention with DES in patients with CKD was associated with similar TLR compared to patients without CKD, demonstrating the efficacy of DES in preventing in-stent restenosis in this patient population. CKD was related to significantly increased MI and mortality rates.

Há uma associação entre anti-inflamatórios não-esteroides e nefropatia induzida por contraste?

FUNDAMENTO: A associacao entre o uso de anti-inflamatorios nao-esteroides (AINEs) e insuficiencia renal aguda ou cronica e bem documentada, mas evidencias sobre a associacao entre AINEs e nefropatia induzida por contraste (NIC) nao sao encontradas na literatura. OBJETIVO: Avaliar uma possivel associacao entre AINEs e NIC. METODOS: Em um estudo de coorte, atraves da entrevista clinica de pacientes que foram submetidos a cateterizacao cardiaca, analisamos o uso de AINEs e sua associacao com desenvolvimento de NIC, atraves da alteracao dos niveis de creatinina serica ou taxa de filtracao glomerular em 48 ou 72 horas. RESULTADOS: No periodo de julho de 2005 a julho de 2006, 236 pacientes foram incluidos no estudo, dos quais 29 foram posteriormente excluidos. A incidencia de NIC foi 10,37% (20 de 207) e 42% dos pacientes estavam recebendo AINEs ate o momento da avaliacao. Nao houve associacao entre o uso de AINEs e o desenvolvimento de NIC com OR de 1,293; IC95% (0,46-4,2). O estudo detectou fatores de risco conhecidos para o desenvolvimento de NIC, tais como diabete, com OR de 2,77; IC95% (1,05-7,47) e insuficiencia renal cronica com OR de 3,48; IC95% (1,1-11,07) e tambem sugeriu uma acao protetora da hidratacao com solucao salina com OR de 0,166; IC95% (0,03-0,92). CONCLUSAO: Com base nos dados obtidos, concluimos que nao houve associacao entre NIC e uso previo de AINEs, pelo menos com um OR > 2,85, o qual nossa amostra detectou.BACKGROUNDnThe association between the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and acute or chronic renal failure is well documented, but evidence of such association between NSAIDs and Contrast-Induced Nephropathies (CIN) is not found in the indexed literature.nnnOBJECTIVEnTo evaluate the possible association between NSAIDs and CIN.nnnMETHODSnIn a cohort study, through clinical interviews of patients that underwent cardiac catheterization, we analyzed the use of NSAIDs and its association with the development of CIN, through alterations in serum creatinine or glomerular filtration rate in 48 or 72 hours.nnnRESULTSnFrom July 2005 to July 2006, 236 patients were enrolled in the study, of which 29 were later excluded. The incidence of CIN was 10.37% (20 of 207) and 42% of the patients were using NSAIDs until the moment of the evaluation. There was no association between the use of NSAIDs and the development of CIN with OR of 1.293 95% CI (0.46-4.2). The study detected known risk factors for the development of CIN, such as diabetes with OR of 2.77 95%CI (1.05-7.47) and chronic renal failure with OR 3.48 95%CI (1.1-11.07). A protective action of saline solution hydration is also suggested, with OR of 0.166 95%CI (0.03-0.92).nnnCONCLUSIONnBased on the data obtained, we conclude that there was no association between CIN and previous use of NSAIDs, at least with an OR higher then 2.85, which our sample detected.

Impacto da insuficiência renal crônica na eficácia de stents farmacológicos: estudo de seguimento de longo prazo

BACKGROUND: Patients with chronic kidney disease (CKD) submitted to coronary angioplasty have higher rates of target lesion revascularization (TLR) and mortality. Drug-eluting stents (DES) are associated with a lower rate of restenosis, compared to bare metal stents (BMS), although data on DES efficacy and safety is limited in patients with CKD. OBJECTIVE: We sought to evaluate the safety and efficacy of DES in patients with significant CKD as compared to patients without normal renal function in a real world registry. METHODS: 504 patients who underwent percutaneous coronary intervention with DES in two centers were included. Outcomes were stratified based on the presence of CKD, defined as a baseline glomerular filtration rate (GFR) < 60 ml/min/1.73 m². RESULTS: The mean follow-up was 22.7 months. CKD was present in 165 patients (32.7%). Patients with CKD were older, had a higher incidence of hypertension and diabetes. CKD patients presented an increased incidence of death (12.3% vs 2.4%, p < 0.001) and myocardial infarction (MI) (7.4% vs 3.3%, p = 0.04) compared to patients without CKD. TLR rates were similar between groups (4.8% vs 5.6%, p = 0.7, CKD and no CKD patients, respectively). Independent predictors of death were CKD (HR 6.93; 2.4 - 19.5, p < 0.001), current smoking (HR 3.66; 1.20 - 11.10, p = 0.02) and diabetes (HR 2.66; 1.03 - 6.60, p = 0.045). CONCLUSION: In this registry, coronary intervention with DES in patients with CKD was associated with similar TLR compared to patients without CKD, demonstrating the efficacy of DES in preventing in-stent restenosis in this patient population. CKD was related to significantly increased MI and mortality rates.BACKGROUNDnPatients with chronic kidney disease (CKD) submitted to coronary angioplasty have higher rates of target lesion revascularization (TLR) and mortality. Drug-eluting stents (DES) are associated with a lower rate of restenosis, compared to bare metal stents (BMS), although data on DES efficacy and safety is limited in patients with CKD.nnnOBJECTIVEnWe sought to evaluate the safety and efficacy of DES in patients with significant CKD as compared to patients without normal renal function in a real world registry.nnnMETHODSn504 patients who underwent percutaneous coronary intervention with DES in two centers were included. Outcomes were stratified based on the presence of CKD, defined as a baseline glomerular filtration rate (GFR) < 60 ml/min/1.73 m².nnnRESULTSnThe mean follow-up was 22.7 months. CKD was present in 165 patients (32.7%). Patients with CKD were older, had a higher incidence of hypertension and diabetes. CKD patients presented an increased incidence of death (12.3% vs 2.4%, p < 0.001) and myocardial infarction (MI) (7.4% vs 3.3%, p = 0.04) compared to patients without CKD. TLR rates were similar between groups (4.8% vs 5.6%, p = 0.7, CKD and no CKD patients, respectively). Independent predictors of death were CKD (HR 6.93; 2.4 - 19.5, p < 0.001), current smoking (HR 3.66; 1.20 - 11.10, p = 0.02) and diabetes (HR 2.66; 1.03 - 6.60, p = 0.045).nnnCONCLUSIONnIn this registry, coronary intervention with DES in patients with CKD was associated with similar TLR compared to patients without CKD, demonstrating the efficacy of DES in preventing in-stent restenosis in this patient population. CKD was related to significantly increased MI and mortality rates.

Stages of change for fruit and vegetable intake among patients with atherosclerotic disease.

This paper describes the stages of change in fruit and vegetable intake among patients with atherosclerotic disease, identifying demographic, socioeconomic, and health predictive factors for each stage of change. It is a cross-sectional study of 290 consecutive patients with atherosclerotic disease submitted to endovascular procedures in two referral hospitals. The staging algorithm included intentional and behavioral criteria, and patients were categorized into pre-action (pre-contemplation, contemplation, and preparation), or action (action, non-reflective action, and maintenance). Most of the patients were in action for the fruits intake (67.9%) and pre-action for the vegetables intake (69.1%). The logistic regression analysis for the stages of action change for fruits intake has identified as predictive factors, the higher level of education and consultation with a cardiologist. For the stages of action change for vegetable intake, absence of abdominal obesity, previous cardiac surgery, and consultation with dietitian have shown significant association. This study has shown differences in the distribution of stages of change for the fruits and vegetable intake among the patients with atherosclerotic disease. The different predictive factors for the stage of changes for fruits and vegetables suggest that approaches of nutritional orientation of the individuals must be distinct for each eating behavior.

Hay una asociación entre antiinflamatorios no esteroides y nefropatía inducida por contraste

FUNDAMENTO: A associacao entre o uso de anti-inflamatorios nao-esteroides (AINEs) e insuficiencia renal aguda ou cronica e bem documentada, mas evidencias sobre a associacao entre AINEs e nefropatia induzida por contraste (NIC) nao sao encontradas na literatura. OBJETIVO: Avaliar uma possivel associacao entre AINEs e NIC. METODOS: Em um estudo de coorte, atraves da entrevista clinica de pacientes que foram submetidos a cateterizacao cardiaca, analisamos o uso de AINEs e sua associacao com desenvolvimento de NIC, atraves da alteracao dos niveis de creatinina serica ou taxa de filtracao glomerular em 48 ou 72 horas. RESULTADOS: No periodo de julho de 2005 a julho de 2006, 236 pacientes foram incluidos no estudo, dos quais 29 foram posteriormente excluidos. A incidencia de NIC foi 10,37% (20 de 207) e 42% dos pacientes estavam recebendo AINEs ate o momento da avaliacao. Nao houve associacao entre o uso de AINEs e o desenvolvimento de NIC com OR de 1,293; IC95% (0,46-4,2). O estudo detectou fatores de risco conhecidos para o desenvolvimento de NIC, tais como diabete, com OR de 2,77; IC95% (1,05-7,47) e insuficiencia renal cronica com OR de 3,48; IC95% (1,1-11,07) e tambem sugeriu uma acao protetora da hidratacao com solucao salina com OR de 0,166; IC95% (0,03-0,92). CONCLUSAO: Com base nos dados obtidos, concluimos que nao houve associacao entre NIC e uso previo de AINEs, pelo menos com um OR > 2,85, o qual nossa amostra detectou.BACKGROUNDnThe association between the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and acute or chronic renal failure is well documented, but evidence of such association between NSAIDs and Contrast-Induced Nephropathies (CIN) is not found in the indexed literature.nnnOBJECTIVEnTo evaluate the possible association between NSAIDs and CIN.nnnMETHODSnIn a cohort study, through clinical interviews of patients that underwent cardiac catheterization, we analyzed the use of NSAIDs and its association with the development of CIN, through alterations in serum creatinine or glomerular filtration rate in 48 or 72 hours.nnnRESULTSnFrom July 2005 to July 2006, 236 patients were enrolled in the study, of which 29 were later excluded. The incidence of CIN was 10.37% (20 of 207) and 42% of the patients were using NSAIDs until the moment of the evaluation. There was no association between the use of NSAIDs and the development of CIN with OR of 1.293 95% CI (0.46-4.2). The study detected known risk factors for the development of CIN, such as diabetes with OR of 2.77 95%CI (1.05-7.47) and chronic renal failure with OR 3.48 95%CI (1.1-11.07). A protective action of saline solution hydration is also suggested, with OR of 0.166 95%CI (0.03-0.92).nnnCONCLUSIONnBased on the data obtained, we conclude that there was no association between CIN and previous use of NSAIDs, at least with an OR higher then 2.85, which our sample detected.