Sílvia Monteiro

CYP2C19*2 and prognosis after an acute coronary syndrome, Insights from a Portuguese center

BACKGROUNDnClopidogrel requires oxidation dependent on the cytochrome P450 enzyme 2C19 (CYP2C19) to form its active metabolite. The importance of loss-of-function alleles (particularly CYP2C19*2, 681G>A) in poor platelet response to clopidogrel is well recognized.nnnOBJECTIVEnTo investigate the prevalence and prognostic impact of the CYP2C19*2 allele in a local acute coronary syndrome (ACS) population.nnnMETHODSnWe performed a prospective, longitudinal study of 95 patients admitted for an ACS between March and October 2009 to a single coronary care unit. Patients aged under 75 who survived hospital stay and for whom clopidogrel was prescribed were included. At discharge, CYP2C19 was genotyped using a commercially available kit. Patients were divided into two groups: Group A (non-carriers, normal metabolizers, CYP2C19*1/*1), n=69; and Group B (carriers, slow metabolizers, CYP2C19*2/*1 or *2/*2), n=26. The primary endpoint was a combined outcome of cardiovascular death, non-fatal myocardial infarction or re-admission for unstable angina; median follow-up was 136.0 (79.0-188.0) days.nnnRESULTSnThe median age of the population was 62.0 (51.0-68.0) years, and 83.2% were male. The CYP2C19*2 (A) allele had a frequency of 14.2%. There were no differences between the groups with respect to demographic data or history of cardiovascular disease. Coronary anatomy, left ventricular ejection fraction and renal function were also similar. The groups were also homogenous with respect to GRACE risk score (118.0 (95.0-136.5) vs. 115.0 (96.0-133.0), p=0.68), medical treatment and percutaneous revascularization during hospital stay. Event-free survival was higher for Group A (94.0% vs. 75.0%, log-rank p=0.010). Three readmissions for MI were documented, all in the slow metabolizers group.nnnCONCLUSIONnIn our ACS population, the CYP2C19*2 allele was a medium-term prognostic marker.

Prognostic implications of left ventricular end-diastolic pressure in acute coronary syndromes with left ventricular ejection fraction of 40% or over

Abstract Introduction There is still debate concerning the impact of left ventricular end-diastolic pressure (LVEDP) on long-term prognosis after an acute coronary syndrome (ACS). Objective To assess LVEDP and its prognostic implications in ACS patients with left ventricular ejection fraction (LVEF) ≥40%. Methods We performed a prospective, longitudinal study of 1329 ACS patients from a single center between 2004 and 2006. LVEDP was assessed at the beginning of the coronary angiogram. Patients with LVEF >40% were included (nxa0=xa0489). The population was divided into three groups: A — LVEDP ≤19xa0mmHg (nxa0=xa0186); B — LVEDP >19 and ≤27xa0mmHg (nxa0=xa0172); and C — LVEDP >27xa0mmHg (nxa0=xa0131). The primary endpoint of the analysis was readmission for congestive heart failure in the year following the index admission. Results Mean LVEDP was 22.8xa0±xa07.8xa0mmHg. The groups were similar age, gender, cardiovascular risk factors, cardiovascular history, and medication prior to admission. There was an association between higher LVEDP and: admission for ST-elevation acute myocardial infarction (35.4 vs. 45.9 vs. 56.7%, pxa0 Conclusion In selected population LVEDP was a significant prognostic marker of future admission for congestive heart failure.

Pulse pressure can predict mortality in advanced heart failure

INTRODUCTIONnPulse pressure (PP) is the difference between systolic and diastolic blood pressure (BP). PP rises markedly after the fifth decade of life. High PP is a risk factor for the development of coronary heart disease and heart failure. The aim of this study was to assess whether PP can be used as a prognostic marker in advanced heart failure.nnnMETHODSnWe retrospectively studied patients in NYHA class III-IV who were hospitalized in a single heart failure unit between January 2003 and August 2012. Demographic characteristics, laboratory tests, and cardiovascular risk factors were recorded. PP was calculated as the difference between systolic and diastolic BP at admission, and the patients were divided into two groups (group 1: PP >40 mmHg and group 2: PP ≤40 mmHg). Median follow-up was 666 ± 50 days for the occurrence of cardiovascular death and heart transplantation.nnnRESULTSnDuring follow-up 914 patients in NYHA class III-IV were hospitalized, 520 in group 1 and 394 in group 2. The most important difference between the groups was in left ventricular dysfunction, which was greater in patients with lower PP. On Kaplan-Meier analysis, group 2 had higher mortality (38 vs. 24 patients, log-rank p=0.002).nnnCONCLUSIONSnPP is easily calculated, and enables prediction of cardiovascular death in patients with advanced heart failure.

Multiple coronary artery aneurysms

A 71-year-old woman was admitted electively to our hospital in October 2013 for vascular surgery of an abdominal aortic aneurysm, diagnosed two months before through abdominal ultrasound performed on an outpatient basis due to recurrent abdominal pain. Her medical history included hypertension and dyslipidemia. No other cardiovascular disease was known. During the surgical procedure, the patient developed acute pulmonary edema and was transferred to the intensive care unit. The physical exam was notable for a harsh, grade IV/VI mitral systolic murmur and diffuse lung crackles. Transthoracic echocardiography performed at the patient’s bedside showed moderate depression of left ventricular systolic function (40% ejection fraction) and severe mitral regurgitation. Since abdominal aortic aneurysms are frequently associated with clinically significant coexisting coronary artery disease, after hemodynamic stabilization coronary angiography was performed. This showed multiple aneurysms involving all the main coronary arteries without significant stenosis (Figure 1). To better assess the coronary arteries cardiac computed tomography was performed, which showed a large aneurysm involving the anterior descending and circumflex arteries. The right coronary artery also had an aneurysm, smaller than in the left coronary (Figures 2 and 3). It is still not known how best to handle such aneurysms, and the type of surgical intervention should be

A rare aortic wall vegetation

A 69-year-old man was admitted to the emergency room due to acute pulmonary edema. He had no known history of cardiovascular disease. The physical exam was notable for a harsh, grade IV/VI aortic systolic murmur and diffuse lung crackles. A transthoracic echocardiogram showed severe aortic stenosis, with normal biventricular systolic function. Coronary angiography was performed, as aortic valve surgery was envisioned. The next day the patient presented with fever and no other symptoms. Empirical antibiotic therapy was started. Blood cultures were drawn and methicillin-sensitive Staphylococcus aureus was identified, prompting a change in antibiotic therapy to vancomycin and gentamicin. Endocarditis was suspected and a transesophageal echocardiogram was performed. The exam showed a 14 mm pedunculated and highly mobile mass attached to the intima, protruding from the posterior wall of the ascending aorta, at the level of the sinotubular junction (Figures 1 and 2). Given the high embolic risk and to avoid the development of a mycotic aneurysm, the case was discussed with the cardiac surgeon and the patient was operated the next day. An inflamed ascending aorta was detected in the operating theater; the mass was excised and the ascending aorta and aortic valve were replaced. The histopathology was notable for aortic endarteritis, with granulocyte infiltration (Figure 3). After the operation, antibiotics were continued to complete an eight-week course. The patient was discharged thereafter. Our case illustrates a very rare location of a vegetation

Unusual form of tricuspid stenosis

We report the case of a 72-year-old man who, in 1982, in Switzerland, underwent surgical ablation for WolfParkinson-White syndrome. The procedure was complicated by complete atrioventricular block. Permanent pacemaker was implanted. In 1992, in Portugal, the patient was hospitalized due to an infection and necrosis of the pacemaker pocket and its leads. While in hospital, the generator was removed and there was an unsuccessful attempt to extract the leads of the permanent pacemaker, which remained inside the right ventricle. Patient follow-up was lost after hospital discharge.

Diabetes e síndromes coronárias agudas: uma abordagem prática

Resumo A diabetes mellitus tipo 2 e actualmente reconhecida como um importante factor de risco de morbilidade e mortalidade cardiovascular, particularmente em doentes admitidos com sindromes coronarias agudas (SCA). Apesar dos recentes avancos do diagnostico, estratificacao de risco e tratamento destas entidades clinicas, a sua associacao no mesmo doente continua a representar um prognostico sombrio. O objectivo deste artigo e sistematizar a caracterizacao e abordagem da diabetes no contexto das SCA, em termos de diagnostico, estratificacao de risco e prognostico a curto e longo prazo, visando desta forma contribuir para a disseminacao das boas praticas clinicas na abordagem da diabetes no âmbito das SCA. A diabetes e importante factor de risco cardiovascular, sendo os diabeticos uma relevante populacao no contexto das SCA. Estrategias como a revascularizacao precoce e completa, o recurso a insulinoterapia intensiva aguda, a realizacao sistematica de PTGO em doentes sem diagnostico previo de diabetes e um enfoque particular na identificacao e mitigacao de comorbilidades e factores de risco, complementados por uma terapeutica antidiabetica, antitrombotica e anti-isquemica optimizadas e o recurso frequente a reabilitacao cardiaca e a promocao multidisciplinar da compliance terapeutica e de estilos de vida saudaveis sao traves mestras de uma estrategia bem sucedida para a optimizacao do prognostico das SCA no contexto de diabetes.

Implicações prognósticas da pressão telediastólica do ventrículo esquerdo nas síndromes coronárias agudas com fracção de ejecção maior ou igual a 40

INTRODUCTIONnThere is still debate concerning the impact of left ventricular end-diastolic pressure (LVEDP) on long-term prognosis after an acute coronary syndrome (ACS).nnnOBJECTIVEnTo assess LVEDP and its prognostic implications in ACS patients with left ventricular ejection fraction (LVEF) ≥40%.nnnMETHODSnWe performed a prospective, longitudinal study of 1329 ACS patients from a single center between 2004 and 2006. LVEDP was assessed at the beginning of the coronary angiogram. Patients with LVEF >40% were excluded (n=489). The population was divided into three groups: A - LVEDP ≤19 mmHg (n=186); B - LVEDP >19 and ≤27 mmHg (n=172); and C - LVEDP >27 mmHg (n=131). The primary endpoint of the analysis was readmission for congestive heart failure in the year following the index admission.nnnRESULTSnMean LVEDP was 22.8±7.8 mmHg. The groups were similar age, gender, cardiovascular risk factors, cardiovascular history, and medication prior to admission. There was an association between higher LVEDP and: admission for ST-elevation acute myocardial infarction (35.4 vs. 45.9 vs. 56.7%, p<0.01), higher peak levels of cardiac biomarkers, and lower LVEF (56.5±7.0 vs. 55.3±7.6 vs. 53.0±7.5%, p<0.01). There were no significant differences between the groups in terms of coronary anatomy, medical therapy during hospital stay and at discharge, or in-hospital mortality. With regard to the primary endpoint, cumulative freedom from congestive heart failure was higher in group A patients (99.4 vs. 97.6 vs. 94.4%, log rank p=0.02). In a multivariate Cox regression model, a 5-mmHg increase in LVEDP (HR 1.97, 95% CI 1.10-3.54, p=0.02) remained an independent predictor of the primary endpoint when adjusted for age, systolic function, atrial fibrillation, peak troponin I, renal function, and prescription of diuretics and beta-blockers.nnnCONCLUSIONnIn selected population LVEDP was a significant prognostic marker of future admission for congestive heart failure.Resumo Introducao Permanecem duvidas sobre o impacto prognostico a longo prazo da pressao telediastolica do ventriculo esquerdo (PTDVE) no contexto de uma sindrome coronaria aguda (SCA). Objectivo Caracterizar a PTDVE e o seu impacto prognostico numa populacao de doentes com SCA e fraccao de ejeccao ventricular esquerda (FEVE) ≥ a 40%. Populacao e metodos Estudo prospectivo, longitudinal e continuo de 1329 doentes admitidos (nxa0=xa0489) numa unidade de cuidados intensivos coronarios entre 2004 e 2006. Foram seleccionados os doentes submetidos a uma estrategia invasiva, no qual foi determinada a PTDVE, com FEVE ≥ 40%. A populacao foi divida em tres grupos: A — PTDVE ≤ 19xa0mmHg (nxa0=xa0186); grupo B — PTDVE > 19 ≤ 27xa0mmHg (nxa0=xa0172) e; grupo C — PTDVE > 27xa0mmHg (nxa0=xa0131). O resultado primario desta analise foi a readmissao por insuficiencia cardiaca congestiva (ICC) no ano seguinte a SCA. Resultados A PTDVE media da populacao foi de 22,8xa0mmHgxa0±xa07,8 mmHg. Os grupos eram homogeneos entre si no que disse respeito ao genero, idade, factores de risco cardiovascular, historia cardiovascular e medicacao previa a admissao. Quanto maior a PTDVE maior a probabilidade de uma admissao por enfarte agudo do miocardio com supradesnivelamento do segmento ST (35,4 versus 45,9 versus 56,7%, pxa0 Conclusao Na populacao referida a PTDVE teve um impacto prognostico importante a longo prazo relativamente a readmissao, hospitalar por ICC.