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Hueb W. Better Technology, More Spending, Worse Outcomes. Arq Bras Cardiol 2018; 110:331-332. [PMID: 29791571 PMCID: PMC5941954 DOI: 10.5935/abc.20180055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Batista DV, Hueb W, Filho JL, Lima E, Rezende P, Azevedo D, Martins E, Hueb A, Silva E, Ramires J, Filho RK. IMPACT OF CHRONIC KIDNEY DISEASE AMONG DIABETIC PATIENTS WITH STABLE CORONARY DISEASE UNDERGOING SURGERY, ANGIOPLASTY OR MEDICAL TREATMENT IN A 10 YEAR FOLLOW-UP. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)30803-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Soeiro ADM, Mansur ADP, Schaan BD, Caramelli B, Rochitte CE, Serrano CV, Garzillo CL, Calderaro D, Gualandro DM, Lima EG, Marcondes-Braga FG, Lima FG, Oliveira FMD, Azevedo FR, Chauhan H, Salles JEN, Soares J, Cardoso JN, Pellanda LC, Sacilotto L, Baracioli L, Bortolotto LA, César LAM, Ochiai ME, Minami MH, Pinheiro MB, Moretti MA, Oliveira MTD, Rezende PC, Lemos PA, Admoni SN, Lottenberg SA, Rocha VZ, Hueb W, Mathias W. I Diretriz sobre Aspectos Específicos de Diabetes (tipo 2) Relacionados à Cardiologia. Arq Bras Cardiol 2018; 102:1-41. [PMID: 27223869 DOI: 10.5935/abc.2014s002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Oikawa FTC, Hueb W, Nomura CH, Hueb AC, Villa AV, da Costa LMA, de Melo RMV, Rezende PC, Segre CAW, Garzillo CL, Lima EG, Ramires JAF, Filho RK. Abnormal elevation of myocardial necrosis biomarkers after coronary artery bypass grafting without established myocardial infarction assessed by cardiac magnetic resonance. J Cardiothorac Surg 2017; 12:122. [PMID: 29284532 PMCID: PMC5747262 DOI: 10.1186/s13019-017-0684-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The diagnosis of peri-procedural myocardial infarction is complex, especially after the emergence of high-sensitivity markers of myocardial necrosis. METHODS In this study, patients with normal baseline cardiac biomarkers and formal indication for elective on-pump coronary bypass surgery were evaluated. Electrocardiograms, cardiac biomarkers, and cardiac magnetic resonance imaging with late gadolinium enhancement were performed before and after procedures. Myocardial infarction was defined as more than ten times the upper reference limit of the 99th percentile for troponin I and for creatine kinase isoform (CK-MB) and by the findings of new late gadolinium enhancement on cardiac magnetic resonance. We assessed the release of cardiac biomarkers in patients with no evidence of myocardial infarction on cardiac magnetic resonance. RESULTS Of 75 patients referred for on-pump coronary bypass surgery, 54 (100%) did not have evidence of myocardial infarction on cardiac magnetic resonance. However, all had a peak troponin I above the 99th percentile; 52 (96%) had an elevation 10 times higher than the 99th percentile. Regarding CK-MB, 54 (100%) patients had a peak CK-MB above the 99th percentile limit, and only 13 (24%) had an elevation greater than 10 times the 99th percentile. The median value of troponin I peak was 3.15 (1.2 to 3.9) ng/mL, which represented 78.7 times the 99th percentile. CONCLUSION In this study, different from CK-MB findings, troponin was significantly increased in the absence of myocardial infarction on cardiac magnetic resonance. Thus, CK-MB was more accurate than troponin I for excluding procedure-related myocardial infarction. These data suggest a higher troponin cutoff for the diagnosis of coronary bypass surgery related myocardial infarction. CLINICAL TRIAL REGISTRATION http://www.isrctn.com/ISRCTN09454308 . Registered 08 May 2012.
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Brandão SMG, Hueb W, Ju YT, de Lima ACP, Polanczyk CA, Cruz LN, Garcia RMR, Takiuti ME, Bocchi EA. Utility and quality-adjusted life-years in coronary artery disease: Five-year follow-up of the MASS II trial. Medicine (Baltimore) 2017; 96:e9113. [PMID: 29390308 PMCID: PMC5815720 DOI: 10.1097/md.0000000000009113] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES This study evaluated the utility and quality-of-life year measurements for patients with coronary artery disease who underwent any of 3 therapeutic strategies with a 5-year follow-up. METHODS Quality-of-life data were obtained from the Medicine, Angioplasty, or Surgery Study II trial. To obtain utilities, the 36-Item Short-Form questionnaire was converted to a 6-Dimensional Health State Classification System. RESULTS Of the 611 initial patients, 579 completed the questionnaire. In all, 188 patients received the surgical treatment-194 the percutaneous, and the remaining 197 the medical. The median utility scores for the 5 years analyzed were 0.809 (95% confidence interval [CI] 0.794-0.842) for patients assigned to percutaneous coronary intervention, 0.755 (95% CI 0.723-0.774) for medical treatment, and 0.780 (95% CI 0.761-0.809) for coronary artery bypass graft surgery. The difference between percutaneous coronary intervention and medical treatment was statistically significant (P < .05, Dunn test). The median cumulative quality-of-life years across the 5 years were 3.802 (95% CI 3.668-3.936) for percutaneous, 3.540 (95% CI 3.399-3.681) for medical, and 3.764 (95% CI 3.638-3.890) for surgery. Additionally, the median quality-of-life years between percutaneous and medical treatment was 0.262 (95% CI 0.068-0.456), between surgery and medical treatment it was 0.224 (95% CI 0.036-0.413), and between surgery and percutaneous coronary intervention it was -0.038 (95% CI -0.221 to -0.146). CONCLUSION Coronary artery bypass surgery and percutaneous coronary intervention were similar regarding cumulative quality-of-life years; however, they were both superior to that of medical treatment. The results presented are valuable data for further cost-utility studies.
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Rezende PC, Hueb W, Rahmi RM, Scudeler TL, de Azevedo DFC, Garzillo CL, Segre CAW, Ramires JAF, Filho RK. Myocardial injury in diabetic patients with multivessel coronary artery disease after revascularization interventions. Diabetol Metab Syndr 2017; 9:92. [PMID: 29201152 PMCID: PMC5697213 DOI: 10.1186/s13098-017-0292-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/15/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Diabetic patients may be more susceptible to myocardial injury after coronary interventions. Thus, the aim of this study was to assess the release of cardiac biomarkers, CK-MB and troponin, and the findings of new late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) in patients with type 2 diabetes mellitus after elective revascularization procedures for multivessel coronary artery disease (CAD). METHODS Patients with multivessel CAD and preserved systolic ventricular function underwent either elective percutaneous coronary intervention (PCI), off-pump or on-pump bypass surgery (CABG). Troponin and CK-MB were systematically collected at baseline, 6, 12, 24, 36, 48 and 72 h after the procedures. CMR with LGE was performed before and after the interventions. Patients were stratified according to diabetes status at study entry. Biomarkers and CMR results were compared between diabetic and nondiabetics patients. Analyses of correlation were also performed among glycemic and glycated hemoglobin (A1c) levels and troponin and CK-MB peak levels. Patients were also stratified into tertiles of fasting glycemia and A1c levels and were compared in terms of periprocedural myocardial infarction (PMI) on CMR. RESULTS Ninety (44.5%) of the 202 patients had diabetes mellitus at study entry. After interventions, median peak troponin was 2.18 (0.47, 5.14) and 2.24 (0.69, 5.42) ng/mL (P = 0.81), and median peak CK-MB was 14.1 (6.8, 31.7) and 14.0 (4.2, 29.8) ng/mL (P = 0.43), in diabetic and nondiabetic patients, respectively. The release of troponin and CK-MB over time was statistically similar in both groups and in the three treatments, besides PCI. New LGE on CMR indicated that new myocardial fibrosis was present in 18.9 and 17.3% (P = 0.91), and myocardial edema in 15.5 and 22.9% (P = 0.39) in diabetic and nondiabetic patients, respectively. The incidence of PMI in the glycemia tertiles was 17.9% versus 19.3% versus 18.7% (P = 0.98), and in the A1c tertiles was 19.1% versus 13.3% versus 22.2% (P = 0.88). CONCLUSIONS In this study, diabetes mellitus did not add risk of myocardial injury after revascularization interventions in patients with multivessel coronary artery disease. Trial Registration Name of Registry: Evaluation of cardiac biomarker elevation after percutaneous coronary intervention or coronary artery bypass graft; URL: http://www.controlled-trials.com.ISRCTN09454308.
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Scudeler T, Hueb W, De Soarez P, Campolina A, Rezende P, Lima E, Garzillo C, Azevedo D, Costa L, Oikawa F, Ramires J, Kalil Filho R. 2204Quality of life and economic outcomes of on-pump and off-pump stable multivessel coronary artery bypass grafting - MASS III trial 5-year follow-up. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx502.2204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lima E, Hueb W, Garzillo C, Favarato D, Segre C, Azevedo D, Hueb A, Rezende P, Silva E, Garcia R, Scudeler T, Ramires J, Kalil Filho R. P6475Impact of chronic kidney dysfunction among patients with stable coronary artery disease: ten-year follow-up of mass II trial. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.p6475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hueb T, Martinelli Filho M, Garcia R, Peixoto G, Siqueira S, Silva M, Cesar L, Lima E, Azevedo D, Hueb W, Ramires J, Kalil Filho R. P6162Impact of left ventricular function in coronary artery disease patients with and without diabetes. Long-term follow-up - REVISION-DM2 Trial. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.p6162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Azevedo D, Hueb W, Lima E, Rezende P, Garzillo C, Strunz C, Nomura C, Segre C, Favarato D, Scudeler T, Hueb A, Silva E, Garcia R, Ramires J, Kalil Filho R. P5808Impact of SYNTAX score on release of cardiac biomarkers in post-revascularization procedures among patients with stable multivessel disease: MASS-V insights. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.p5808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Vieira de Melo RM, Hueb W, Nomura CH, Ribeiro da Silva EE, Villa AV, Oikawa FTC, da Costa LMA, Rezende PC, Garzillo CL, Lima EG, Franchini Ramires JA, Kalil Filho R. Biomarker release after percutaneous coronary intervention in patients without established myocardial infarction as assessed by cardiac magnetic resonance with late gadolinium enhancement. Catheter Cardiovasc Interv 2017; 90:87-93. [DOI: 10.1002/ccd.27125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 04/05/2017] [Accepted: 04/23/2017] [Indexed: 12/24/2022]
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Scudeler T, Hueb W, de Soarez PC, Campolina AG, Rezende P, Lima E, Garzillo CL, Freitas DFC, Costa L, Oikawa FT, Ramires J, Filho RK. COST-EFFECTIVENESS ANALYSIS AND QUALITY OF LIFE OF ON-PUMP AND OFF-PUMP STABLE MULTIVESSEL CORONARY ARTERY BYPASS GRAFTING: MASS III TRIAL 5-YEAR FOLLOW-UP. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)33489-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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da Costa LMA, Hueb W, Nomura CH, Hueb AC, Villa AV, Oikawa FTC, Vieira de Melo RM, Rezende PC, Segre CAW, Garzillo CL, Lima EG, Ramires JAF, Kalil Filho R. Significant elevation of biomarkers of myocardial necrosis after coronary artery bypass grafting without myocardial infarction established assessed by cardiac magnetic resonance. Medicine (Baltimore) 2017; 96:e6053. [PMID: 28178154 PMCID: PMC5313011 DOI: 10.1097/md.0000000000006053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The release of myocardial necrosis biomarkers after off-pump coronary artery bypass grafting (OPCAB) frequently occurs. However, the correlation between biomarker release and the diagnosis of procedure-related myocardial infarction (MI) (type 5) has been controversial. This study aimed to evaluate the amount and pattern of cardiac biomarker release after elective OPCAB in patients without evidence of a new MI on cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE).Patients with normal baseline cardiac biomarkers referred for elective OPCAB were prospectively included. CMR with LGE was performed in all patients before and after interventions. Measurements of troponin I (cTnI) and creatine kinase MB fraction (CK-MB) were systematically performed before and after the procedure. Patients with new LGE on the postprocedure CMR were excluded.All of the 53 patients without CMR evidence of a procedure-related MI after OPCAB exhibited a cTnI elevation peak above the 99th percentile. In 48 (91%), the peak value was >10 times this threshold. However, 41 (77%) had a CK-MB peak above the limit of the 99th percentile, and this peak was >10 times the 99th percentile in only 7 patients (13%). The median peak release of cTnI was 0.290 (0.8-3.7) ng/mL, which is 50-fold higher than the 99th percentile.In contrast with CK-MB, considerable cTnI release often occurs after an elective OPCAB procedure, despite the absence of new LGE on CMR.
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Rezende PC, de Azevedo DFC, Hueb W. Interventional therapies in ischemic ventricular dysfunction: facts and versions! ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:S27. [PMID: 27867995 DOI: 10.21037/atm.2016.10.65] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Rezende PC, Hueb W. The challenge of treating elderly coronary artery disease patients. J Thorac Dis 2016; 8:1434-6. [PMID: 27500632 DOI: 10.21037/jtd.2016.05.40] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Charytan DM, Desai M, Mathur M, Stern NM, Brooks MM, Krzych LJ, Schuler GC, Kaehler J, Rodriguez-Granillo AM, Hueb W, Reeves BC, Thiele H, Rodriguez AE, Buszman PP, Buszman PE, Maurer R, Winkelmayer WC. Reduced risk of myocardial infarct and revascularization following coronary artery bypass grafting compared with percutaneous coronary intervention in patients with chronic kidney disease. Kidney Int 2016; 90:411-421. [PMID: 27259368 DOI: 10.1016/j.kint.2016.03.033] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 03/02/2016] [Accepted: 03/24/2016] [Indexed: 10/21/2022]
Abstract
Coronary atherosclerotic disease is highly prevalent in chronic kidney disease (CKD). Although revascularization improves outcomes, procedural risks are increased in CKD, and unbiased data comparing coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) in CKD are sparse. To compare outcomes of CABG and PCI in stage 3 to 5 CKD, we identified randomized trials comparing these procedures. Investigators were contacted to obtain individual, patient-level data. Ten of 27 trials meeting inclusion criteria provided data. These trials enrolled 3993 patients encompassing 526 patients with stage 3 to 5 CKD of whom 137 were stage 3b-5 CKD. Among individuals with stage 3 to 5 CKD, mortality through 5 years was not different after CABG compared with PCI (hazard ratio [HR] 0.99, 95% confidence interval [CI] 0.67-1.46) or stage 3b-5 CKD (HR 1.29, CI 0.68-2.46). However, CKD modified the impact on survival free of myocardial infarction: it was not different between CABG and PCI for individuals with preserved kidney function (HR 0.97, CI 0.80-1.17), but was significantly lower after CABG in stage 3-5 CKD (HR 0.49, CI 0.29-0.82) and stage 3b-5 CKD (HR 0.23, CI 0.09-0.58). Repeat revascularization was reduced after CABG compared with PCI regardless, of baseline kidney function. Results were limited by unavailability of data from several trials and paucity of enrolled patients with stage 4-5 CKD. Thus, our patient-level meta-analysis of individuals with CKD randomized to CABG versus PCI suggests that CABG significantly reduces the risk of subsequent myocardial infarction and revascularization without affecting survival in these patients.
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Lima EG, Hueb W, Gersh BJ, Rezende PC, Garzillo CL, Favarato D, Hueb AC, Rahmi Garcia RM, Franchini Ramires JA, Filho RK. Impact of Chronic Kidney Disease on Long-Term Outcomes in Type 2 Diabetic Patients With Coronary Artery Disease on Surgical, Angioplasty, or Medical Treatment. Ann Thorac Surg 2016; 101:1735-44. [DOI: 10.1016/j.athoracsur.2015.10.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 10/01/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
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Hueb W, Gersh BJ, Alves da Costa LM, Costa Oikawa FT, Vieira de Melo RM, Rezende PC, Garzillo CL, Lima EG, Nomura CH, Villa AV, Hueb AC, Cassaro Strunz CM, Favarato D, Takiuti ME, de Albuquerque CP, Ribeiro da Silva EE, Franchini Ramires JA, Kalil Filho R. Accuracy of Myocardial Biomarkers in the Diagnosis of Myocardial Infarction After Revascularization as Assessed by Cardiac Resonance: The Medicine, Angioplasty, Surgery Study V (MASS-V) Trial. Ann Thorac Surg 2016; 101:2202-8. [PMID: 26912303 DOI: 10.1016/j.athoracsur.2015.11.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 10/14/2015] [Accepted: 11/13/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND The lack of a correlation between myocardial necrosis biomarkers and electrocardiographic abnormalities after revascularization procedures has resulted in a change in the myocardial infarction (MI) definition. METHODS Patients with stable multivessel disease who underwent percutaneous or surgical revascularization were included. Electrocardiograms and concentrations of high-sensitive cardiac troponin I (cTnI) and creatine kinase (CK)-MB were assessed before and after procedures. Cardiac magnetic resonance and late gadolinium enhancement were performed before and after procedures. MI was defined as more than five times the 99th percentile upper reference limit for cTnI and 10 times for CK-MB in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), respectively, and new late gadolinium enhancement for cardiac magnetic resonance. RESULTS Of the 202 patients studied, 69 (34.1%) underwent on-pump CABG, 67 (33.2%) off-pump CABG, and 66 (32.7%) PCI. The receiver operating characteristic curve showed the accuracy of cTnI for on-pump CABG, off-pump CABG, and PCI patients was 21.7%, 28.3%, and 52.4% and for CK-MB was 72.5%, 81.2%, and 90.5%, respectively. The specificity of cTnI was 3.6%, 9.4%, and 42.1% and of CK-MB was 73.2%, 86.8%, and 96.4%, respectively. Sensitivity of cTnI was 100%, 100%, and 100% and of CK-MB was 69.2%, 64.3%, and 44.4%, respectively. The best cutoff of cTnI for on-pump CABG, off-pump CABG, and PCI was 6.5 ng/mL, 4.5 ng/mL, and 4.5 ng/mL (162.5, 112.5, and 112.5 times the 99th percentile upper reference limit) and of CK-MB was 37.5 ng/mL, 22.5 ng/mL, and 11.5 ng/mL (8.5, 5.1, and 2.6 times the 99th percentile upper reference limit), respectively. CONCLUSIONS Compared with cardiac magnetic resonance, CK-MB was more accurate than cTnI for diagnosing MI. These data suggest a higher troponin cutoff for the diagnosis of procedure-related MI.
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Rezende PC, Rahmi RM, Hueb W. The Influence of Diabetes Mellitus in Myocardial Ischemic Preconditioning. J Diabetes Res 2016; 2016:8963403. [PMID: 27656659 PMCID: PMC5021496 DOI: 10.1155/2016/8963403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/14/2016] [Indexed: 11/24/2022] Open
Abstract
Ischemic preconditioning (IP) is a powerful mechanism of protection discovered in the heart in which ischemia paradoxically protects the myocardium against other ischemic insults. Many factors such as diseases and medications may influence IP expression. Although diabetes poses higher cardiovascular risk, the physiopathology underlying this condition is uncertain. Moreover, although diabetes is believed to alter intracellular pathways related to myocardial protective mechanisms, it is still controversial whether diabetes may interfere with ischemic preconditioning and whether this might influence clinical outcomes. This review article looks at published reports with animal models and humans that tried to evaluate the possible influence of diabetes in myocardial ischemic preconditioning.
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Costa LMA, Rezende PC, Garcia RMR, Uchida AH, Seguro LFBC, Scudeler TL, Bocchi EA, Krieger JE, Hueb W, Ramires JAF, Filho RK. Role of Trimetazidine in Ischemic Preconditioning in Patients With Symptomatic Coronary Artery Disease. Medicine (Baltimore) 2015; 94:e1161. [PMID: 26287407 PMCID: PMC4616436 DOI: 10.1097/md.0000000000001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Ischemic 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.
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Segre CAW, Hueb W, Garcia RMR, Rezende PC, Favarato D, Strunz CMC, Sprandel MDCO, Roggério A, Carvalho ALDO, Maranhão RC, Ramires JAF, Kalil Filho R. Troponin in diabetic patients with and without chronic coronary artery disease. BMC Cardiovasc Disord 2015. [PMID: 26195004 PMCID: PMC4508806 DOI: 10.1186/s12872-015-0051-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Cardiac-specific troponin detected with the new high-sensitivity assays can be chronically elevated in response to cardiovascular comorbidities and confer important prognostic information, in the absence of unstable coronary syndromes. Both diabetes mellitus and coronary artery disease are known predictors of troponin elevation. It is not known whether diabetic patients with coronary artery disease have different levels of troponin compared with diabetic patients with normal coronary arteries. To investigate this question, we determined the concentrations of a level 1 troponin assay in two groups of diabetic patients: those with multivessel coronary artery disease and those with angiographically normal coronary arteries. METHODS We studied 95 diabetic patients and compared troponin in serum samples from 50 patients with coronary artery disease (mean age = 63.7, 58 % male) with 45 controls with angiographically normal coronary arteries. Brain natriuretic peptide and the oxidative stress biomarkers myeloperoxidase, nitrotyrosine and oxidized LDL were also determined. RESULTS Diabetic patients with coronary artery disease had higher levels of troponin than did controls (median values, 12.0 pg/mL (95 % CI:10-16) vs 7.0 pg/mL (95 % CI: 5.9-8.5), respectively; p = 0.0001). The area under the ROC curve for the diagnosis of CAD was 0.712 with a sensitivity of 70 % and a specificity of 66 %. Plasma BNP levels and oxidative stress variables (myeloperoxidase, nitrotyrosine, and oxidized LDL) were not different between the two groups. In a multivariate analysis, gender (p = 0.04), serum glucose (0.03) and Troponin I (p = 0.01) had independent statistical significance. CONCLUSION Troponin elevation is related to the presence of chronic coronary artery disease in diabetic patients with multiple associated cardiovascular risk factors. Troponin may serve as a biomarker in this high-risk population. TRIAL REGISTRATION http://www.controlled-trials.com REGISTRATION NUMBER ISRCTN26970041.
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Rezende PC, Rahmi RM, Uchida AH, da Costa LMA, Scudeler TL, Garzillo CL, Lima EG, Segre CAW, Girardi P, Takiuti M, Silva MF, Hueb W, Ramires JAF, Kalil Filho R. Type 2 diabetes mellitus and myocardial ischemic preconditioning in symptomatic coronary artery disease patients. Cardiovasc Diabetol 2015; 14:66. [PMID: 26025451 PMCID: PMC4451743 DOI: 10.1186/s12933-015-0228-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 05/21/2015] [Indexed: 01/10/2023] Open
Abstract
Background The influence of diabetes mellitus on myocardial ischemic preconditioning is not clearly defined. Experimental studies are conflicting and human studies are scarce and inconclusive. Objectives Identify whether diabetes mellitus intervenes on ischemic preconditioning in symptomatic coronary artery disease patients. Methods Symptomatic multivessel coronary artery disease patients with preserved systolic ventricular function and a positive exercise test underwent two sequential exercise tests to demonstrate ischemic preconditioning. Ischemic parameters were compared among patients with and without type 2 diabetes mellitus. Ischemic preconditioning was considered present when the time to 1.0 mm ST deviation and rate pressure-product were greater in the second of 2 exercise tests. Sequential exercise tests were analyzed by 2 independent cardiologists. Results Of the 2,140 consecutive coronary artery disease patients screened, 361 met inclusion criteria, and 174 patients (64.2 ± 7.6 years) completed the study protocol. Of these, 86 had the diagnosis of type 2 diabetes. Among diabetic patients, 62 (72 %) manifested an improvement in ischemic parameters consistent with ischemic preconditioning, whereas among nondiabetic patients, 60 (68 %) manifested ischemic preconditioning (p = 0.62). The analysis of patients who demonstrated ischemic preconditioning showed similar improvement in the time to 1.0 mm ST deviation between diabetic and nondiabetic groups (79.4 ± 47.6 vs 65.5 ± 36.4 s, respectively, p = 0.12). Regarding rate pressure-product, the improvement was greater in diabetic compared to nondiabetic patients (3011 ± 2430 vs 2081 ± 2139 bpm x mmHg, respectively, p = 0.01). Conclusions In this study, diabetes mellitus was not associated with impairment in ischemic preconditioning in symptomatic coronary artery disease patients. Furthermore, diabetic patients experienced an improvement in this significant mechanism of myocardial protection.
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Rezende PC, da Costa LMA, Scudeler TL, Nakamura D, Giorgi MCP, Hueb W. Recurrent angina caused by coronary subclavian steal syndrome confirmed by positron emission tomography. Ann Thorac Surg 2015; 99:e111-4. [PMID: 25952243 DOI: 10.1016/j.athoracsur.2015.01.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 12/29/2014] [Accepted: 01/16/2015] [Indexed: 11/19/2022]
Abstract
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.
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Segre C, Junior ANA, Nomura C, Villa A, Strunz C, Rezende P, Parga J, Takiuti ME, Hueb W, Ramires J, Kalil-Filho R. HIGH SENSITIVITY CARDIAC TROPONIN I CHANGES RELATED WITH T1 MAPPING IN PATIENTS WITH CHRONIC ISCHAEMIC HEART DISEASE WITHOUT LATE ENHANCEMENT GADOLINIUM BY CRM. J Am Coll Cardiol 2015. [DOI: 10.1016/s0735-1097(15)61194-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Rezende PC, Scudeler TL, da Costa LMA, Hueb W. Conservative strategy for treatment of stable coronary artery disease. World J Clin Cases 2015; 3:163-170. [PMID: 25685763 PMCID: PMC4317610 DOI: 10.12998/wjcc.v3.i2.163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/25/2014] [Indexed: 02/05/2023] Open
Abstract
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.
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