Thiago Luis Scudeler

Recurrent Angina Caused by Coronary Subclavian Steal Syndrome Confirmed by Positron Emission Tomography

Coronary subclavian steal syndrome is a rare cause of recurrent angina after coronary artery bypass grafting. Identification of the myocardial ischemic region is crucial because it guides revascularization interventions to improve symptoms and myocardial ischemia. Positron emission computed tomography (PET) with rubidium might be a helpful tool because it identifies ischemia, localizes more precisely the ischemic region, and evaluates coronary flow reserve. Here, we report a case of recurrence of angina after coronary artery bypass grafting caused by an obstruction in the left subclavian artery and consequently by coronary steal syndrome confirmed by PET.

Comparison between off-pump and on-pump coronary artery bypass grafting in patients with severe lesions at the circumflex artery territory: 5-year follow-up of the MASS III trial.

OBJECTIVES The technical difficulty in the revascularization of the circumflex artery territory with off-pump surgery may compromise the outcome of this method in clinical follow-up. We aimed to evaluate cardiac events in patients with stable coronary artery disease and severe obstruction of the circumflex system, undergoing coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass. METHODS MASS III was a single-centre study that evaluated 308 patients with multivessel coronary artery disease randomized to on-pump (153) or off-pump (155) CABG. Of this total, 260 (84.4%) patients had, on coronary angiography, at least one 70% obstruction in the circumflex territory (141 on-pump and 119 off-pump). The combined outcome was death, myocardial infarction, target vessel revascularization (angioplasty or surgery) or hospitalization for cardiac causes. Variables with possible associations (P < 0.1) were included in the multivariate analysis. RESULTS The two groups were well matched for demographics and clinical and angiographic characteristics. After 5 years of follow-up, off-pump CABG had higher combined events than on-pump had: 25 (21%) vs 17 (12%), hazard ratio 1.88, 95% confidence interval 1.02-3.48, P = 0.041. In the multivariate model with the inclusion of the following variables: age (P = 0.09) and complete revascularization (P = 0.68), off-pump surgery remained as a predictor of combined events in 5 years, P = 0.03. CONCLUSIONS In patients with multivessel coronary artery disease and severe lesions in the circumflex territory, off-pump coronary artery bypass surgery resulted in a higher incidence of cardiac events at 5-year follow-up. CLINICAL TRIAL REGISTRATION NUMBER ISRCTN59539154 (http://www.controlled-trials.com).

The cost-effectiveness of strategies in coronary artery disease.

Coronary artery disease has significant social and economic implications. Health expenditures have increased in recent decades, more than the economy itself, with significant consequences, either reducing spending in other areas or increasing the budget deficit. It is necessary to create tools to identify the most cost-effective treatments, which can assist clinicians in their therapeutic decisions so that the maximum possible benefit is reached with the lowest possible cost. Efficiency must be measured by final treatment goals in which the most effective interventions are those with the lowest costs. We analyzed the cost–effectiveness of coronary artery disease treatment strategies, medical treatment, percutaneous coronary intervention and coronary artery bypass surgery, with a focus on comparative analyses between these treatment modalities.

Conservative strategy for treatment of stable coronary artery disease.

Patients with coronary artery disease vary widely in terms of prognosis, which is mainly dependent on ventricular function. In relation to the major outcomes of death and myocardial infarction, it is not clear in the literature if an invasive strategy of myocardial revascularization is superior to a conservative strategy of optimized medical therapy. Moreover, with the exception of patients with left main coronary disease, this similarity in prognosis also occurs in different subgroups of patients.

Role of Trimetazidine in Ischemic Preconditioning in Patients With Symptomatic Coronary Artery Disease.

AbstractIschemic preconditioning (IP) is a powerful cardioprotective cellular mechanism that has been related to the “warm-up phenomenon” or “walk-through” angina, and has been documented through the use of sequential exercise tests (ETs). It is known that several drugs, for example, cromokalim, pinacidil, adenosine, and nicorandil, can interfere with the cellular pathways of IP. The purpose of this article is to report the effect of the anti-ischemic agent trimetazidine (TMZ) on IP in symptomatic coronary artery disease (CAD) patients.We conducted a prospective study evaluating IP by the analysis of ischemic parameters in 2 sequential ETs. In phase I, without TMZ, patients underwent ET1 and ET2 with a 30-minute interval between them. In phase II, after 1 week of TMZ 35 mg twice daily, all patients underwent 2 consecutive ETs (ET3 and ET4). IP was considered present when the time to 1.0-mm segment ST on electrocardiogram deviation (T-1.0 mm) and rate pressure product (RPP) were greater in the second of 2 tests. The improvement in T-1.0 mm and RPP were compared in the 2 phases: without TMZ and after 1-week TMZ to assess the action of such drug in myocardial protective mechanisms. ETs were analyzed by 2 independent cardiologists.From 135 CAD patients screened, 96 met inclusion criteria and 62 completed the study protocol. Forty patients manifested IP by demonstrating an improvement in T-1.0 mm in ET2 compared with ET1, without the use of any drugs (phase I). In phase II, after 1-week TMZ, 26 patients (65%) did not show any incremental result in ischemic parameters in ET4 compared with ET3. Furthermore, of these patients, 8 (20%) had IP blockage.In this study, TMZ did not add any benefit to IP in patients with stable symptomatic CAD.

Quality of Life in Patients with Multivessel Coronary Artery Disease: Ten-year Follow-up of a Comparison of Surgical, Angioplasty or MedicalStrategies - MASS II Trial

Aims: We assessed quality of life (QoL) in patients with symptomatic multivessel coronary disease who randomly underwent surgery, angioplasty, or medical treatment. Although the clinical benefits of coronary interventions seem to be confirmed, their effects on QoL are still scarcely studied. Methods and Results: The Short-Form Health Survey (SF-36) questionnaire was applied in patients at baseline, 6 months, and annually until the end of the study. At five years of follow-up, SF-36 had been completed by 483 patients and at 10 years by 334 patients. Of these, 110 underwent surgical revascularization, 126 underwent angioplasty, and 98 were medically treated. All three therapeutic strategies resulted in significant improvement in all dimensions (P<0.001). The improvement reached similar levels in the three treatment groups. However, this increase did not reveal differences between the physical and mental components between the three therapeutic groups. Medical Treatment: In this group, the mental component improved in 83.7% of patients, whereas in relation to the physical component there was an improvement in 84.7% of them. Surgery: Regarding the mental component, there was an improvement in 85.4% of patients, whereas in relation to the physical component there was an improvement in 92.7% of them. Angioplasty: In this group, the mental component improved in 77.8% of patients, whereas in relation to the physical component there was an improvement in 73.0% of them. Conclusion: Improvement was observed in all domains and in the three therapeutic modalities. Regarding the beginning of the study and compared with medical therapy or angioplasty, surgery provided better quality of life after 5 years of follow-up and that remained in up to ten years of follow-up.

Cost-effectiveness of on-pump and off-pump coronary artery bypass grafting for patients with coronary artery disease: Results from the MASS III trial

BACKGROUND Recent trials have reported similar clinical outcomes between on-pump and off-pump coronary artery bypass graft (CABG). However, long-term cost-effectiveness of these strategies is unknown. METHODS A prespecified economic study was performed based on the MASS III trial. Costs were estimated for all patients based on observed healthcare resource usage over a 5-year follow-up. Health state utilities were evaluated with the SF-6D questionnaire. Cost-effectiveness was assessed as cost per quality-adjusted life-year (QALY) gained using a Markov model. Probabilistic sensitivity analysis with the Monte-Carlo simulation and cost-effectiveness acceptability curve were used to address uncertainty. RESULTS Quality of life improved significantly in both groups during follow-up compared with baseline. At 5 years, when comparing on-pump and off-pump CABG groups, no differences were found in cumulative life-years (4.851 and 4.766 years, P = .319) and QALY gained (4.150 and 4.105 QALYs, P = .332). Mean cost in US dollars per patient during the trial did not differ significantly between the on-pump and off-pump groups (

A case of mid-apical obstructive hypertrophic cardiomyopathy treated with a transapical myectomy approach: a case report

5890.29 and

Type 2 diabetes mellitus and myocardial ischemic preconditioning in symptomatic coronary artery disease patients.

5674.75, respectively, P = .409). Over a lifetime horizon, the incremental cost-effectiveness ratio of on-pump versus off-pump CABG was

Hypotheses, rationale, design, and methods for evaluation of ischemic preconditioning assessed by sequential exercise tests in diabetic and non-diabetic patients with stable coronary artery disease – a prospective study

12,576 per QALY gained, which is above the suggested cost-effectiveness threshold range (from