Renato Fernandes

Trends in primary angioplasty in Portugal from 2002 to 2013 according to the Portuguese National Registry of Interventional Cardiology

INTRODUCTION AND OBJECTIVES The aim of the present paper was to report trends in coronary angioplasty for the treatment of ST-elevation myocardial infarction (STEMI) in Portugal. METHODS Prospective multicenter data from the Portuguese National Registry of Interventional Cardiology (RNCI) and official data from the Directorate-General for Health (DGS) were studied to analyze percutaneous coronary intervention (PCI) procedures for STEMI from 2002 to 2013. RESULTS In 2013, 3524 primary percutaneous coronary intervention (p-PCI) procedures were performed (25% of all procedures), an increase of 315% in comparison to 2002 (16% of all interventions). Between 2002 and 2013 the rate increased from 106 to 338 p-PCIs per million population per year. Rescue angioplasty decreased from 70.7% in 2002 to 2% in 2013. During this period, the use of drug-eluting stents grew from 9.9% to 69.5%. After 2008, the use of aspiration thrombectomy increased, reaching 46.7% in 2013. Glycoprotein IIb-IIIa inhibitor use decreased from 73.2% in 2002 to 23.6% in the last year of the study. Use of a radial approach increased steadily from 8.3% in 2008 to 54.6% in 2013. CONCLUSION During the reporting period there was a three-fold increase in primary angioplasty rates per million population. Rescue angioplasty has been overtaken by p-PCI as the predominant procedure since 2006. New trends in the treatment of STEMI were observed, notably the use of drug-eluting stents and radial access as the predominant approach.

Impact of Routine Fractional Flow Reserve Evaluation During Coronary Angiography on Management Strategy and Clinical Outcome: One-Year Results of the POST-IT.

Background—Penetration of fractional flow reserve (FFR) in clinical practice varies extensively, and the applicability of results from randomized trials is understudied. We describe the extent to which the information gained from routine FFR affects patient management strategy and clinical outcome. Methods and Results—Nonselected patients undergoing coronary angiography, in which at least 1 lesion was interrogated by FFR, were prospectively enrolled in a multicenter registry. FFR-driven change in management strategy (medical therapy, revascularization, or additional stress imaging) was assessed per-lesion and per-patient, and the agreement between final and initial strategies was recorded. Cardiovascular death, myocardial infarction, or unplanned revascularization (MACE) at 1 year was recorded. A total of 1293 lesions were evaluated in 918 patients (mean FFR, 0.81±0.1). Management plan changed in 406 patients (44.2%) and 584 lesions (45.2%). One-year MACE was 6.9%; patients in whom all lesions were deferred had a lower MACE rate (5.3%) than those with at least 1 lesion revascularized (7.3%) or left untreated despite FFR⩽0.80 (13.6%; log-rank P=0.014). At the lesion level, deferral of those with an FFR⩽0.80 was associated with a 3.1-fold increase in the hazard of cardiovascular death/myocardial infarction/target lesion revascularization (P=0.012). Independent predictors of target lesion revascularization in the deferred lesions were proximal location of the lesion, B2/C type and FFR. Conclusions—Routine FFR assessment of coronary lesions safely changes management strategy in almost half of the cases. Also, it accurately identifies patients and lesions with a low likelihood of events, in which revascularization can be safely deferred, as opposed to those at high risk when ischemic lesions are left untreated, thus confirming results from randomized trials. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01835808.

Spherical `Top-Hat' Collapse in general Chaplygin gas dominated universes

We expand previous works on the spherical ‘top-hat’ collapse (SC-TH) framework in generalized Chaplygin gas (gCg) dominated universes. Here we allow the collapse in all energetic components within the system. We analyze the non-linear stages of collapse for various choices of parameter � of the gCg model introducing an exact formulation for the so-called effective sound speed, c 2 . We show that, within the SC-TH framework, the growth of the structure becomes faster with increasing values of �. This partially contradicts previous results obtained using an approximation in the context of linear perturbation theory.

Impact of Routine Fractional Flow Reserve Evaluation During Coronary Angiography on Management Strategy and Clinical Outcome

Background—Penetration of fractional flow reserve (FFR) in clinical practice varies extensively, and the applicability of results from randomized trials is understudied. We describe the extent to which the information gained from routine FFR affects patient management strategy and clinical outcome. Methods and Results—Nonselected patients undergoing coronary angiography, in which at least 1 lesion was interrogated by FFR, were prospectively enrolled in a multicenter registry. FFR-driven change in management strategy (medical therapy, revascularization, or additional stress imaging) was assessed per-lesion and per-patient, and the agreement between final and initial strategies was recorded. Cardiovascular death, myocardial infarction, or unplanned revascularization (MACE) at 1 year was recorded. A total of 1293 lesions were evaluated in 918 patients (mean FFR, 0.81±0.1). Management plan changed in 406 patients (44.2%) and 584 lesions (45.2%). One-year MACE was 6.9%; patients in whom all lesions were deferred had a lower MACE rate (5.3%) than those with at least 1 lesion revascularized (7.3%) or left untreated despite FFR⩽0.80 (13.6%; log-rank P=0.014). At the lesion level, deferral of those with an FFR⩽0.80 was associated with a 3.1-fold increase in the hazard of cardiovascular death/myocardial infarction/target lesion revascularization (P=0.012). Independent predictors of target lesion revascularization in the deferred lesions were proximal location of the lesion, B2/C type and FFR. Conclusions—Routine FFR assessment of coronary lesions safely changes management strategy in almost half of the cases. Also, it accurately identifies patients and lesions with a low likelihood of events, in which revascularization can be safely deferred, as opposed to those at high risk when ischemic lesions are left untreated, thus confirming results from randomized trials. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01835808.

Prader-Willi syndrome: a nest for premature coronary artery disease?

Individuals affected by Prader-Willi syndrome (PWS) may show increased risk for coronary artery disease (CAD), which probably relates, at least, with high burden of cardiovascular risk factors. A 27-year-old man with PWS, obesity, hypertension, diabetes mellitus and dyslipidaemia attended the emergency department with complaints of flu-like condition and chest pain. The ECG revealed a mild ST-segment elevation in inferior leads, followed by positive myocardial necrosis biomarkers. Attending to the high cardiovascular risk profile, ST-segment elevation in inferior territory and wall motion abnormalities, a coronary angiogram was performed. The latter showed a three-vessel CAD, 60% stenosis in midanterior descending artery, total occlusion (100%) of the obtuse marginal artery and 99% stenosis with high thrombi burden in the proximal right coronary artery. The present case report emphasises the plausibility of premature CAD in patients with PWS, a possible underdiagnosed feature of this condition.

Thrombus aspiration in patients with ST-elevation myocardial infarction: results of a national registry of interventional cardiology

BackgroundWe aimed to evaluate the impact of thrombus aspiration (TA) during primary percutaneous coronary intervention (P-PCI) in ‘real-world’ settings.MethodsWe performed a retrospective study, using data from the National Registry of Interventional Cardiology (RNCI 2006–2012, Portugal) with ST-elevation myocardial infarction (STEMI) patients treated with P-PCI. The primary outcome, in-hospital mortality, was analysed through adjusted odds ratio (aOR) and 95% confidence intervals (95%CI).ResultsWe assessed data for 9458 STEMI patients that undergone P-PCI (35% treated with TA). The risk of in-hospital mortality with TA (aOR 0.93, 95%CI:0.54–1.60) was not significantly decreased. After matching patients through the propensity score, TA reduced significantly the risk of in-hospital mortality (OR 0.58, 95%CI:0.35–0.98; 3500 patients).ConclusionsThe whole cohort data does not support the routine use of TA in P-PCI, but the results of the propensity-score matched cohort suggests that the use of selective TA may improve the short-term risks of STEMI.

MPS 15-07 INVASIVE SYSTOLIC BLOOD PRESSURE ASSOCIATES WITH SEVERITY OF CORONARY ARTERY DISEASE IN PATIENTS WITH MYOCARDIAL INFARCTION

Objective: Hypertension is a risk factor for cardiovascular diseases and its magnitude is associated with the severity of coronary artery disease. In patients with myocardial infarction (MI) presenting to the catheterization laboratory for angioplasty, patients blood pressure previous profile is usually unknown. The objective of this study is to assess if there is an association between invasive systolic blood pressure during catheterization and the severity of coronary artery disease in patients with MI, presenting to the catheterization laboratory for angioplasty. Design and Method: Retrospective observational study with 2060 consecutive patients with MI presenting to the catheterization laboratory for angioplasty. Patients in cardiogenic shock were excluded. Multiple linear regression was used to assess association between invasive systolic blood pressure and the severity of coronary artery disease [number of coronary arteries with lesions (1, 2 or 3 vessels) and total number of coronary lesions], controlling for age, sex, diabetes, smoking and hyperlipidaemia. Results: Study population of 2060 patients, mean age of 67.26 ± 13.3 years, 68.3% masculine. The authors found an association between higher invasive systolic blood pressure and higher severity of coronary artery disease, controlling for age, sex, diabetes, smoking and hyperlipidaemia. For every 10 mmHg increase in systolic blood pressure, number of coronary arteries with lesions increased by 0.036 and total number of coronary lesions increased by 0.047 (p < 0.001). For example, a 70-year-old male patient with 80 mmHg of systolic blood pressure, without diabetes, smoking or hyperlipidaemia would have a mean of 1.2 coronary arteries with lesions and 1.8 total number of coronary lesions. The same patient with 220 mmHg of systolic blood pressure would have a mean of 1.7 coronary arteries with lesions and 2.5 total number of coronary lesions. Conclusions: There is an association between higher invasive systolic blood pressure in the catheterization laboratory during angioplasty and higher severity of coronary artery disease in patients with MI. Figure. No caption available.

Impact of Routine Fractional Flow Reserve Evaluation During Coronary Angiography on Management Strategy and Clinical Outcome: One-Year Results of the POST-IT Multicenter Registry

Background—Penetration of fractional flow reserve (FFR) in clinical practice varies extensively, and the applicability of results from randomized trials is understudied. We describe the extent to which the information gained from routine FFR affects patient management strategy and clinical outcome. Methods and Results—Nonselected patients undergoing coronary angiography, in which at least 1 lesion was interrogated by FFR, were prospectively enrolled in a multicenter registry. FFR-driven change in management strategy (medical therapy, revascularization, or additional stress imaging) was assessed per-lesion and per-patient, and the agreement between final and initial strategies was recorded. Cardiovascular death, myocardial infarction, or unplanned revascularization (MACE) at 1 year was recorded. A total of 1293 lesions were evaluated in 918 patients (mean FFR, 0.81±0.1). Management plan changed in 406 patients (44.2%) and 584 lesions (45.2%). One-year MACE was 6.9%; patients in whom all lesions were deferred had a lower MACE rate (5.3%) than those with at least 1 lesion revascularized (7.3%) or left untreated despite FFR⩽0.80 (13.6%; log-rank P=0.014). At the lesion level, deferral of those with an FFR⩽0.80 was associated with a 3.1-fold increase in the hazard of cardiovascular death/myocardial infarction/target lesion revascularization (P=0.012). Independent predictors of target lesion revascularization in the deferred lesions were proximal location of the lesion, B2/C type and FFR. Conclusions—Routine FFR assessment of coronary lesions safely changes management strategy in almost half of the cases. Also, it accurately identifies patients and lesions with a low likelihood of events, in which revascularization can be safely deferred, as opposed to those at high risk when ischemic lesions are left untreated, thus confirming results from randomized trials. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01835808.