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Andrade VC, Rezende PC, Hueb W, Ramires JAF. Interpreting Acute Myocardial Infarction 40 Years Later. Evolution of Knowledge: What is the Best Explanation? Arq Bras Cardiol 2024; 121:e20230757. [PMID: 38695441 PMCID: PMC11081065 DOI: 10.36660/abc.20230757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/01/2023] [Accepted: 01/18/2024] [Indexed: 05/12/2024] Open
Affiliation(s)
- Vitor Coutinho Andrade
- Universidade de São PauloFaculdade de MedicinaInstituto do Coração do Hospital das ClínicasSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Paulo Cury Rezende
- Universidade de São PauloFaculdade de MedicinaInstituto do Coração do Hospital das ClínicasSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Whady Hueb
- Universidade de São PauloFaculdade de MedicinaInstituto do Coração do Hospital das ClínicasSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - José Antonio Franchini Ramires
- Universidade de São PauloFaculdade de MedicinaInstituto do Coração do Hospital das ClínicasSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
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Cheng Y, Meng X, Gao H, Yang C, Li P, Li H, Chatterjee S, Rezende PC, Bonnet M, Li H, Zhang Z, Ji F, Zhang W. Long-term all-cause death prediction by coronary, aortic, and valvular calcification in patients with acute ST-segment elevation myocardial infarction. BMC Cardiovasc Disord 2024; 24:117. [PMID: 38373881 PMCID: PMC10877850 DOI: 10.1186/s12872-024-03758-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/01/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND To determine the prognostic value of cumulative calcification score of coronary artery calcification (CAC), thoracic aortic calcification (TAC) and aortic valve calcification (AVC) in acute ST segment elevation myocardial infarction (STEMI) patients. METHODS This was a retrospective, single-center cohort study. A total of 332 STEMI patients who received primary percutaneous coronary intervention (PPCI) were enrolled in this study between January 2010 to October 2018. We assessed the calcification in the left anterior descending branch (LAD), left circumflex branch (LCX), right coronary artery (RCA), thoracic aorta, and aortic valve. Calcification of each part was counted as 1 point, and the cumulative calcification score was calculated as the sum of all points. The primary endpoint was all-cause mortality. Multivariate Cox proportional hazards models were used to determine association of cumulative calcification score with end points. The performance of the score was evaluated by receiver operating characteristic (ROC) curve analysis and absolute net reclassification improvement (NRI), compared with the Global Registry of Acute Coronary Events (GRACE) risk score. RESULTS The overall population's calcification score was 2.0 ± 1.6. During a mean follow-up time of 69.8 ± 29.3 months, the all-cause mortality rate was 12.1%. Kaplan-Meier curve showed that the score was significantly associated with mortality (log-rank p < 0.001). The multivariable Cox proportional hazard analyses showed that a calcification score of 4-5 was independently associated with all-cause death in STEMI patients [hazard ratio (HR) = 2.32, 95% confidence interval (CI): 1.01-5.31, p = 0.046]. The area under the ROC curve (AUC) of the calcification score was 0.67 (95% CI: 0.61-0.72), and the AUC of the GRACE score was 0.80 (95% CI: 0.75-0.84). There was no statistical difference in the predictive value between both scores for 3-year mortality in STEMI patients after PPCI (p = 0.06). Based on the NRI analysis, the calcification score showed better risk classification compared with the GRACE score (absolute NRI = 6.63%, P = 0.027). CONCLUSION The cumulative calcification score is independently associated with the long-term prognosis of STEMI patients after PPCI.
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Affiliation(s)
- Yalin Cheng
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xuyang Meng
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Haiyang Gao
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Chenguang Yang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Peng Li
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Hongfei Li
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Saurav Chatterjee
- Clinical Assistant Professor of Medicine, Northwell Health, Zucker School of Medicine, Hempstead, NY, USA
| | - Paulo Cury Rezende
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Marc Bonnet
- Cardiology Department, Hospital of Annecy, Annecy, France
| | - Huimin Li
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Zunlei Zhang
- Department of Cardiology, People's Hospital of Weishan County, Jining, Shandong, 277600, China
| | - Fusui Ji
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Wenduo Zhang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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Strunz CMC, Hueb W, Rezende PC, Vendramini SPDA, de Assis ACR, Roggerio A, Tairova MS, Silva MF, Oliveira SA, Kisser GDCA, Kalil Filho R. High-Sensitivity Troponin I and Cardiovascular Events in Stable Coronary Artery Disease: Insights from a Longitudinal Outpatient Study. Int J Mol Sci 2023; 24:17286. [PMID: 38139114 PMCID: PMC10743542 DOI: 10.3390/ijms242417286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Numerous studies have been published suggesting that troponin levels are related to adverse outcomes in chronic cardiac and non-cardiac conditions. Our study investigated whether troponin levels gathered from unselected blood samples taken during outpatient care are associated with adverse outcomes in a population with stable coronary artery disease. In a cohort of 949 patients with stable coronary artery disease, an average age of 67.5 ± 9.5 years, 69.5% male, 52.1% diabetics, 51.6% with previous myocardial infarction, and 57.9% with triple-vessel disease, 21.7% of patients encountered new events during an average period of monitoring of 2.07 ± 0.81 years. Troponin I/99th percentile categorized into tertiles emerged as an independent predictor of death and combined events risk (hazard ratio: 2.02 (1.13-3.60), p = 0.017; 2.30 (1.37-3.88, p = 0.002, respectively). A troponin ratio > 0.24 was able to identify 53.3% of patients at risk of death and heart failure hospitalization. In patients with stable coronary artery disease who are adherent to treatment, troponin levels are independently associated with death and heart failure hospitalization in a medium-term follow-up.
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Affiliation(s)
- Celia Maria Cassaro Strunz
- Clinical Laboratory, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil; (S.P.d.A.V.); (A.R.); (S.A.O.); (G.d.C.A.K.)
| | - Whady Hueb
- Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil; (W.H.); (P.C.R.); (A.C.R.d.A.); (M.S.T.); (M.F.S.); (R.K.F.)
| | - Paulo Cury Rezende
- Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil; (W.H.); (P.C.R.); (A.C.R.d.A.); (M.S.T.); (M.F.S.); (R.K.F.)
| | - Sabrina Pacheco do Amaral Vendramini
- Clinical Laboratory, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil; (S.P.d.A.V.); (A.R.); (S.A.O.); (G.d.C.A.K.)
| | - Arthur Cicupira Rodrigues de Assis
- Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil; (W.H.); (P.C.R.); (A.C.R.d.A.); (M.S.T.); (M.F.S.); (R.K.F.)
| | - Alessandra Roggerio
- Clinical Laboratory, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil; (S.P.d.A.V.); (A.R.); (S.A.O.); (G.d.C.A.K.)
| | - Maria Stanislavovna Tairova
- Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil; (W.H.); (P.C.R.); (A.C.R.d.A.); (M.S.T.); (M.F.S.); (R.K.F.)
| | - Marcela Francisca Silva
- Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil; (W.H.); (P.C.R.); (A.C.R.d.A.); (M.S.T.); (M.F.S.); (R.K.F.)
| | - Senili Avila Oliveira
- Clinical Laboratory, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil; (S.P.d.A.V.); (A.R.); (S.A.O.); (G.d.C.A.K.)
| | - Gyovanna de Cassia Agreste Kisser
- Clinical Laboratory, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil; (S.P.d.A.V.); (A.R.); (S.A.O.); (G.d.C.A.K.)
| | - Roberto Kalil Filho
- Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil; (W.H.); (P.C.R.); (A.C.R.d.A.); (M.S.T.); (M.F.S.); (R.K.F.)
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Ribas FF, Hueb W, Rezende PC, Rochitte CE, Nomura CH, Villa AV, Morais TC, Lima EG, Boeing Boros GA, Ribeiro MDOL, Linhares-Filho JPP, Dallazen AR, Silva RRM, Franchini Ramires JA, Kalil-Filho R. Abnormal release of cardiac biomarkers in the presence of myocardial oedema evaluated by cardiac magnetic resonance after uncomplicated revascularization procedures. Eur Heart J Cardiovasc Imaging 2023; 24:1700-1709. [PMID: 37453130 DOI: 10.1093/ehjci/jead171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/15/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023] Open
Abstract
AIMS To analyse the association of myocardial oedema (ME), observed as high T2 signal intensity (HT2) in cardiac magnetic resonance imaging, with the release of cardiac biomarkers, ventricular ejection, and clinical outcomes after revascularization. METHODS AND RESULTS Patients with stable coronary artery disease with the indication for revascularization were included. Biomarker levels [troponin I (cTnI) and creatine kinase MB (CK-MB)] and T2-weighted and late gadolinium enhancement (LGE) images were obtained before and after the percutaneous or surgical revascularization procedures. The association of HT2 with the levels of biomarkers, with and without LGE, evolution of left ventricular ejection fraction (LVEF), and 5-year clinical outcomes were assessed. A total of 196 patients were divided into 2 groups: Group 1 (HT2, 40) and Group 2 (no HT2, 156). Both peak cTnI (8.9 and 1.6 ng/mL) and peak CK-MB values (44.7 and 12.1 ng/mL) were significantly higher in Group 1. Based on the presence of new LGE, patients were stratified into Groups A (no HT2/LGE, 149), B (HT2, 9), C (LGE, 7), and D (both HT2/LGE, 31). The peak cTnI and CK-MB values were 1.5 and 12.0, 5.4 and 44.7, 5.0 and 18.3, and 9.8 and 42.8 ng/mL in Groups A, B, C, and D, respectively, and were significantly different. The average LVEF decreased by 4.4% in Group 1 and increased by 2.2% in Group 2 (P = 0.057). CONCLUSION ME after revascularization procedures was associated with increased release of cardiac necrosis biomarkers, and a trend towards a difference in LVEF, indicating a role of ME in cardiac injury after interventions.
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Affiliation(s)
- Fernando Faglioni Ribas
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Whady Hueb
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Paulo Cury Rezende
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Carlos Eduardo Rochitte
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Cesar Higa Nomura
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Alexandre Volney Villa
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Thamara Carvalho Morais
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Eduardo Gomes Lima
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Gustavo André Boeing Boros
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Matheus de Oliveira Laterza Ribeiro
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Jaime Paula Pessoa Linhares-Filho
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Anderson Roberto Dallazen
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Rafael Rocha Mol Silva
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Jose Antonio Franchini Ramires
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
| | - Roberto Kalil-Filho
- Divisão Clínica Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Eneas de Carvalho Aguiar 44, AB floor, Room 114, Cerqueira César, São Paulo 05403-000, Brazil
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Dallazen AR, Rezende PC, Hueb W, Hlatky MA, Nomura CH, Rochitte CE, Boros GAB, Ribas FF, de Oliveira Laterza Ribeiro M, Scudeler TL, Nery Dantas Junior R, Ramires JAF, Kalil Filho R. Myocardial microstructure assessed by T1 mapping after on-pump and off-pump coronary artery bypass grafting. J Thorac Dis 2023; 15:3208-3217. [PMID: 37426129 PMCID: PMC10323545 DOI: 10.21037/jtd-23-101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/12/2023] [Indexed: 07/11/2023]
Abstract
Background The correlation between the release of cardiac biomarkers after revascularization, in the absence of late gadolinium enhancement (LGE) or myocardial edema, and the development of myocardial tissue damage remains unclear. This study sought to identify whether the release of biomarkers is associated with cardiac damage by assessing myocardial microstructure on T1 mapping after on-pump (ONCAB) and off-pump coronary artery bypass grafting (OPCAB). Methods Seventy-six patients with stable multivessel coronary artery disease (CAD) and preserved systolic ventricular function were included. T1 mapping, high-sensitive cardiac troponin I (cTnI), creatine kinase myocardial band (CK-MB) mass, and ventricular dimensions and function were measured before and after procedures. Results Of the 76 patients, 44 underwent OPCAB, and 32 ONCAB; 52 were men (68.4%), and the mean age was 63±8.5 years. In both OPCAB and ONCAB the native T1 values were similar before and after surgeries. An increase in extracellular volume (ECV) values after the procedures was observed, due to the decrease in hematocrit levels during the second cardiac resonance. However, the lambda partition coefficient showed no significant difference after the surgeries. The median peak release of cTnI and CK-MB were higher after ONCAB than after OPCAB [3.55 (2.12-4.9) vs. 2.19 (0.69-3.4) ng/mL, P=0.009 and 28.7 (18.2-55.4) vs. 14.3 (9.3-29.2) ng/mL, P=0.009, respectively]. Left ventricular ejection fraction (LVEF) was similar in both groups before and after surgery. Conclusions In the absence of documented myocardial infarction, T1 mapping did not identify structural tissue damage after surgical revascularization with or without cardiopulmonary bypass (CPB), despite the excessive release of cardiac biomarkers.
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Affiliation(s)
- Anderson Roberto Dallazen
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Paulo Cury Rezende
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Whady Hueb
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Cesar Higa Nomura
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Eduardo Rochitte
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Gustavo Andre Boeing Boros
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Fernando Faglioni Ribas
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Thiago Luis Scudeler
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Roberto Nery Dantas Junior
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - José Antonio Franchini Ramires
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Roberto Kalil Filho
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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de Oliveira Laterza Ribeiro M, Hueb W, Rezende PC, Lima EG, Nomura CH, Rochitte CE, da Silva Selistre L, Boros GAB, Ramires JAF, Filho RK. Myocardial tissue microstructure with and without stress-induced ischemia assessed by T1 mapping in patients with stable coronary artery disease. Clin Imaging 2023; 101:142-149. [PMID: 37348160 DOI: 10.1016/j.clinimag.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/28/2023] [Accepted: 06/05/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Stress-induced myocardial ischemia seems not to be associated with cardiovascular events. However, its effects on myocardial tissue characteristics remain under debate. Thus, we sought to assess whether documented stress-induced ischemia is associated with changes in myocardial microstructure evaluated by magnetic resonance native T1 map and extracellular volume fraction (ECV). METHODS This is a single-center, analysis of the previously published MASS V Trial. Multivessel patients with a formal indication for myocardial revascularization and with documented stress-induced ischemia were included in this study. Native T1 and ECV values evaluated by cardiac magnetic resonance imaging of ischemic and nonischemic myocardial segments at rest and after stress were compared. Myocardial ischemia was detected by either nuclear scintigraphy or stress magnetic cardiac resonance protocol. RESULTS Between May 2012 and March 2014, 326 prospective patients were eligible for isolated CABG or PCI and 219 were included in the MASS V trial. All patients underwent resting cardiac magnetic resonance imaging. Of a total of 840 myocardial segments, 654 were nonischemic segments and 186 were ischemic segments. Native T1 and ECV values of ischemic segments were not significantly different from nonischemic segments, both at rest and after stress induction. In addition, native T1 and ECV values of myocardial segments supplied by vessels with obstructive lesions were similar to those supplied by nonobstructive ones. CONCLUSION AND RELEVANCE In this study, cardiac magnetic resonance identified similar T1 mapping values between ischemic and nonischemic myocardial segments. This finding suggests integrity and stability of myocardial tissue in the presence of stress-induced ischemia.
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Affiliation(s)
| | - Whady Hueb
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil.
| | - Paulo Cury Rezende
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Eduardo Gomes Lima
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Cesar Higa Nomura
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Carlos Eduardo Rochitte
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | | | - Gustavo André Boeing Boros
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Jose Antonio Franchini Ramires
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Roberto Kalil Filho
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
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Segre CAW, de Lemos JA, Assunção Junior AN, Nomura CH, Favarato D, Strunz CMC, Villa AV, Parga Filho JR, Rezende PC, Hueb W, Ramires JAF, Kalil Filho R, Serrano Junior CV. Chronic troponin elevation assessed by myocardial T1 mapping in patients with stable coronary artery disease. Medicine (Baltimore) 2023; 102:e33548. [PMID: 37083772 PMCID: PMC10118361 DOI: 10.1097/md.0000000000033548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/27/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Cardiac troponin detected with sensitive assays can be chronically elevated, in the absence of unstable coronary syndromes. In patients with chronic coronary artery disease, clinically silent ischemic episodes may cause chronic troponin release. T1 mapping is a cardiovascular magnetic resonance technique useful in quantitative cardiac tissue characterization. We selected patients with anatomically and functionally normal hearts to investigate associations between chronic troponin release and myocardial tissue characteristics assessed by T1 mapping. METHODS We investigated the relationship between cardiac troponin I concentrations and cardiovascular magnetic resonance T1 mapping parameters in patients with stable coronary artery disease enrolled in MASS V study before elective revascularization. Participants had no previous myocardial infarction, negative late gadolinium enhancement, normal left ventricular function, chamber dimensions and wall thickness. RESULTS A total of 56 patients were analyzed in troponin tertiles: nativeT1 and extracellular volume (ECV) values (expressed as means ± standard deviations) increased across tertiles: nativeT1 (1006 ± 27 ms vs 1016 ± 27 ms vs 1034 ± 37 ms, ptrend = 0.006) and ECV (22 ± 3% vs 23 ± 1.9% vs 25 ± 3%, ptrend = 0.007). Cardiac troponin I concentrations correlated with native T1(R = 0.33, P = .012) and ECV (R = 0.3, P = .025), and were independently associated with nativeT1 (P = .049) and ventricular mass index (P = .041) in multivariable analysis. CONCLUSION In patients with chronic coronary artery disease and structurally normal hearts, troponin I concentrations correlated with T1 mapping parameters, suggesting that diffuse edema or fibrosis scattered in normal myocardium might be associated with chronic troponin release.
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Affiliation(s)
| | - James A. de Lemos
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Cesar Higa Nomura
- Heart Institute (InCor) University of São Paulo Clinics Hospital, Sao Paulo, Brazil
| | - Desiderio Favarato
- Heart Institute (InCor) University of São Paulo Clinics Hospital, Sao Paulo, Brazil
| | | | | | | | - Paulo Cury Rezende
- Heart Institute (InCor) University of São Paulo Clinics Hospital, Sao Paulo, Brazil
| | - Whady Hueb
- Heart Institute (InCor) University of São Paulo Clinics Hospital, Sao Paulo, Brazil
| | | | - Roberto Kalil Filho
- Heart Institute (InCor) University of São Paulo Clinics Hospital, Sao Paulo, Brazil
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Carvalho FPCD, Hueb W, Lima EG, Rezende PC, Linhares Filho JPP, Garcia RMR, Soares PR, Ramires JAF, Kalil Filho R. Cardiovascular events in patients with coronary artery disease with and without myocardial ischemia: Long-term follow-up. Am Heart J 2023; 256:95-103. [PMID: 36400185 DOI: 10.1016/j.ahj.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND After the results of the ISCHEMIA Trial, the role of myocardial ischemia in the prognosis of coronary artery disease (CAD) was under debate. We sought to comparatively evaluate the long-term prognosis of patients with multivessel CAD with or without documented myocardial ischemia. METHODS This is a single-center, retrospective, observational cohort study that included patients with CAD obtained from the research protocols database of "The Medicine, Angioplasty or Surgery Study," the MASS Study Group. Patients were stratified according to the presence or absence of myocardial ischemia. Cardiovascular events (overall mortality and myocardial infarction) were tracked from the registry entry up to a median follow-up of 8.7 years. Myocardial ischemia was assessed at baseline by a functional test with or without imaging. RESULTS From 1995 to 2018, 2015 patients with multivessel CAD were included. Of these, 1001 presented with conclusive tests at registry entry, 790 (79%) presenting with ischemia and 211 (21%) without ischemia. The median follow-up was 8.7 years (IQR 4.04 to 10.07). The primary outcome occurred in 228 (28.9%) patients with ischemia and in 64 (30.3%) patients without ischemia (plog-rank=0.60). No significant interaction was observed with the presence of myocardial ischemia and treatment strategies in the occurrence of the combined primary outcome (pinteration=0.14). CONCLUSIONS In this sample, myocardial ischemia was not associated with a worse prognosis compared with no ischemia in patients with multivessel CAD. These results refer to debates about the role of myocardial ischemia in the occurrence of cardiovascular events.
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Affiliation(s)
| | - Whady Hueb
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil.
| | - Eduardo Gomes Lima
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Paulo Cury Rezende
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | | | - Rosa Maria Rahmi Garcia
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Paulo Rogério Soares
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Jose Antonio Franchini Ramires
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Roberto Kalil Filho
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
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Silva RRM, Hueb W, Lima EG, Rezende PC, Soares PR, Ramires JAF, Filho RK. Long-term analysis of ventricular function in patients with symptomatic coronary disease who underwent on-pump or off-pump coronary artery bypass grafting. J Cardiothorac Surg 2022; 17:326. [PMID: 36536451 PMCID: PMC9762065 DOI: 10.1186/s13019-022-02069-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Systemic deleterious effects of cardiopulmonary bypass have been observed in the postprocedural period. Long-term assessment, including ventricular function (VF), is unclear. The objective of this study was to compare the change of left ventricular ejection fractions (LVEFs) during a long-term follow-up of coronary artery disease (CAD) patients who underwent off-pump (OPCAB) or on-pump coronary artery bypass grafting (ONCAB). METHODS This study is a prespecified analysis of the MASS III trial, which was a single-center and prospective study that enrolled stable CAD patients with preserved VF. The CAD patients in our study were randomized to OPCAB or ONCAB. A transthoracic echocardiogram was performed during follow-up and a LVEF value was obtained. The primary endpoint was the difference between the final LVEF and the baseline LVEF. RESULTS Of the 308 randomized patients, ventricular function were observed in 225 over a mean of 5.9 years of follow-up: 113 in the ONCAB group and 112 in the OPCAB group. Baseline characteristics were similar between the two groups, but there was a larger proportion of subjects with 3-vessel disease in the ONCAB group. There was no difference in the LVEF at the beginning (P = 0.08), but there was a slight decrease in the LVEF in the ONCAB and OPCAB groups (P < 0.001 in both groups) at 5.9 years. The decline was not significantly different between the two groups (delta of -6% for ONCAB and -5% for OPCAB; P = 0.78). In a multivariate analysis, myocardial infarction in the follow-up was a predictor of an LVEF < 40%. CONCLUSIONS There was no difference in the long-term development of ventricular function between the surgical techniques, despite a decline in the LVEF in both groups. Trial registration Clinical Trial Registration Information-URL: http://www.controlled-trials.com . REGISTRATION NUMBER ISRCTN59539154. Date of first registration: 10/03/2008.
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Affiliation(s)
- Rafael Rocha Mol Silva
- grid.11899.380000 0004 1937 0722Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar 44 – AB 1 S114 Cerqueira Cesar, São Paulo, SP CEP – 05403-000 Brazil
| | - Whady Hueb
- grid.11899.380000 0004 1937 0722Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar 44 – AB 1 S114 Cerqueira Cesar, São Paulo, SP CEP – 05403-000 Brazil
| | - Eduardo Gomes Lima
- grid.11899.380000 0004 1937 0722Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar 44 – AB 1 S114 Cerqueira Cesar, São Paulo, SP CEP – 05403-000 Brazil
| | - Paulo Cury Rezende
- grid.11899.380000 0004 1937 0722Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar 44 – AB 1 S114 Cerqueira Cesar, São Paulo, SP CEP – 05403-000 Brazil
| | - Paulo Rogério Soares
- grid.11899.380000 0004 1937 0722Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar 44 – AB 1 S114 Cerqueira Cesar, São Paulo, SP CEP – 05403-000 Brazil
| | - José Antonio Franchini Ramires
- grid.11899.380000 0004 1937 0722Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar 44 – AB 1 S114 Cerqueira Cesar, São Paulo, SP CEP – 05403-000 Brazil
| | - Roberto Kalil Filho
- grid.11899.380000 0004 1937 0722Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar 44 – AB 1 S114 Cerqueira Cesar, São Paulo, SP CEP – 05403-000 Brazil
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de Paula LJC, Uchida AH, Rezende PC, Soares P, Scudeler TL. Protective or Inhibitory Effect of Pharmacological Therapy on Cardiac Ischemic Preconditioning: A Literature Review. Curr Vasc Pharmacol 2022; 20:409-428. [PMID: 35986546 DOI: 10.2174/1570161120666220819163025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/23/2022] [Accepted: 05/31/2022] [Indexed: 01/25/2023]
Abstract
Ischemic preconditioning (IP) is an innate phenomenon, triggered by brief, non-lethal cycles of ischemia/reperfusion applied to a tissue or organ that confers tolerance to a subsequent more prolonged ischemic event. Once started, it can reduce the severity of myocardial ischemia associated with some clinical situations, such as percutaneous coronary intervention (PCI) and intermittent aortic clamping during coronary artery bypass graft surgery (CABG). Although the mechanisms underlying IP have not been completely elucidated, several studies have shown that this phenomenon involves the participation of cell triggers, intracellular signaling pathways, and end-effectors. Understanding this mechanism enables the development of preconditioning mimetic agents. It is known that a range of medications that activate the signaling cascades at different cellular levels can interfere with both the stimulation and the blockade of IP. Investigations of signaling pathways underlying ischemic conditioning have identified a number of therapeutic targets for pharmacological manipulation. This review aims to present and discuss the effects of several medications on myocardial IP.
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Affiliation(s)
| | | | - Paulo Cury Rezende
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Paulo Soares
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Thiago Luis Scudeler
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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11
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Martins EB, Hueb W, Brown DL, Scudeler TL, Lima EG, Rezende PC, Soares PR, Garzillo CL, Filho JPPL, Batista DV, Ramires JAF, Filho RK. Surgical and percutaneous revascularization outcomes based on SYNTAX I, II, and residual scores: a long-term follow-up study. J Cardiothorac Surg 2021; 16:248. [PMID: 34479587 PMCID: PMC8418036 DOI: 10.1186/s13019-021-01616-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/11/2021] [Indexed: 11/10/2022] Open
Abstract
Background The objective of this study was to evaluate the association of SYNTAX scores I, II, and residual with cardiovascular outcomes of patients undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) and compare both procedures in a long-term follow-up. Methods This is a retrospective single-center study from the MASS registry at the Heart Institute of the University of São Paulo, Brazil in which 969 patients with stable coronary artery disease undergoing CABG (559) or PCI (410) were included. We assessed the SYNTAX scores I, II and residual in both interventions. Clinical endpoints were the first occurrence of a composite of overall death, myocardial infarction, stroke, or repeat revascularization (MACCE) and the total occurrence of each component of MACCE. Results In the CABG sample, SSI had a median of 23 (IQR 17–29.5), median SSII of 25.4 (IQR 19.2–32.8), and median rSS of 2 (IQR 0–6.5); in PCI SSI had a median of 14 (IQR 10–19.1), median SSII of 28.7 (IQR 23–34.2), and median rSS of 4.7 (IQR 0–9). Total of 174 events were documented and CABG patients had a lower rate of MACCE (15.6% vs. 21.2%; adjusted HR 1.98; 95% CI 1.13–3.47; P = 0.016) and repeat revascularization (3.8% vs. 11.5%; adjusted HR 4.35; CI 95% 1.74–10.85; P = 0.002) compared with PCI. No SYNTAX score tertile found a difference in death rate between procedures. In a multivariate analysis, the rSS was an independent predictor for MACCE (HR 1.04; 95% CI 1.01–1.06; P = 0.001). Regarding death, the only independent predictors were ejection fraction and renal function. Conclusion Surgical revascularization resulted in a more complete revascularization and lower rates of major cardiac or cerebrovascular events in a long-term follow-up. Also, grading the incompleteness of revascularization through the residual SYNTAX score identified a higher event rate, suggesting that complete revascularization is associated with a better prognosis. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01616-6.
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Affiliation(s)
- Eduardo Bello Martins
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Whady Hueb
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
| | - David L Brown
- Washington University School of Medicine, St. Louis, MO, USA
| | - Thiago Luis Scudeler
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Eduardo Gomes Lima
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Paulo Cury Rezende
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Paulo Rogério Soares
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Cibele Larrosa Garzillo
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Jaime Paula Pessoa Linhares Filho
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Daniel Valente Batista
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Jose Antonio Franchini Ramires
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Roberto Kalil Filho
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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12
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Batista DV, Hueb W, Lima EG, Rezende PC, Garzillo CL, Garcia RMR, Filho JPPL, Martins EB, Junior CVS, Ramires JAF, Filho RK. Effect of diabetic kidney disease on therapeutic strategies for coronary artery disease: ten year follow-up. Aging (Albany NY) 2021; 13:20081-20093. [PMID: 34433133 PMCID: PMC8436946 DOI: 10.18632/aging.203476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 08/16/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The best treatment for coronary artery disease (CAD) in patients with type 2 diabetes (DM2) and chronic kidney disease is unknown. METHODS This retrospective study included MASS registry patients with DM2 and multivessel CAD, stratified by kidney function. Primary endpoint was combined of mortality, myocardial infarction, or additional revascularization. RESULTS Median follow-up was 9.5 years. Primary endpoint occurrences among strata 1 and 2 were 53.4% and 40.7%, respectively (P=.020). Mortality rates were 37.4% and 24.6% in strata 1 and 2, respectively (P<.001). We observed a lower rate of major adverse cardiovascular events (MACE) (P=.027 for stratum 1 and P<.001 for stratum 2) and additional revascularization (P=.001 for stratum 1 and P<.001 for stratum 2) for those in the surgical group. In a multivariate analysis, eGFR was an independent predictor of MACE (P=.034) and mortality (P=.020). CONCLUSIONS Among subjects with DM2 and CAD the presence of lower eGFR rate was associated with higher rates of MACE and mortality, irrespective of treatment choice. CABG was associated with lower rates of MACE in both renal function strata. eGFR was an independent predictor of MACE and mortality in a 10-year follow-up.
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Affiliation(s)
- Daniel Valente Batista
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR
| | - Whady Hueb
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR
| | - Eduardo Gomes Lima
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR
| | - Paulo Cury Rezende
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR
| | - Cibele Larrosa Garzillo
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR
| | - Rosa Maria Rahmi Garcia
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR
| | | | - Eduardo Bello Martins
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR
| | - Carlos Vicente Serrano Junior
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR
| | | | - Roberto Kalil Filho
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR
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13
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Lima EG, Charytan DM, Hueb W, de Azevedo DFC, Garzillo CL, Favarato D, Linhares Filho JPP, Martins EB, Batista DV, Rezende PC, Hueb AC, Ramires JAF, Kalil Filho R. Long-term outcomes of patients with stable coronary disease and chronic kidney dysfunction: 10-year follow-up of the Medicine, Angioplasty, or Surgery Study II Trial. Nephrol Dial Transplant 2020; 35:1369-1376. [PMID: 30590726 DOI: 10.1093/ndt/gfy379] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/12/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with a worse prognosis in patients with stable coronary artery disease (CAD); however, there is limited randomized data on long-term outcomes of CAD therapies in these patients. We evaluated long-term outcomes of CKD patients with CAD who underwent randomized therapy with medical treatment (MT) alone, percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). METHODS Baseline estimated glomerular filtration rate (eGFR) was obtained in 611 patients randomized to one of three therapeutic strategies in the Medicine, Angioplasty, or Surgery Study II trial. Patients were categorized in preserved renal function and mild or moderate CKD groups depending on their eGFR (≥90, 89-60 and 59-30 mL/min/1.73 m2, respectively). The primary clinical endpoint, a composite of overall death and myocardial infarction, and its individual components were analyzed using proportional hazards regression (Clinical Trial registration information: http://www.controlled-trials.com. Registration number: ISRCTN66068876). RESULTS Of 611 patients, 112 (18%) had preserved eGFR, 349 (57%) mild dysfunction and 150 (25%) moderate dysfunction. The primary endpoint occurred in 29.5, 32.4 and 44.7% (P = 0.02) for preserved eGFR, mild CKD and moderate CKD, respectively. Overall mortality incidence was 18.7, 23.8 and 39.3% for preserved eGFR, mild CKD and moderate CKD, respectively (P = 0.001). For preserved eGFR, there was no significant difference in outcomes between therapies. For mild CKD, the primary event rate was 29.4% for PCI, 29.1% for CABG and 41.1% for MT (P = 0.006) [adjusted hazard ratio (HR) = 0.26, 95% confidence interval (CI) 0.07-0.88; P = 0.03 for PCI versus MT; and adjusted HR = 0.48; 95% CI 0.31-0.76; P = 0.002 for CABG versus MT]. We also observed higher mortality rates in the MT group (28.6%) compared with PCI (24.1%) and CABG (19.0%) groups (P = 0.015) among mild CKD subjects (adjusted HR = 0.44, 95% CI 0.25-0.76; P = 0.003 for CABG versus MT; adjusted HR = 0.56, 95% CI 0.07-4.28; P = 0.58 for PCI versus MT). Results were similar with moderate CKD group but did not achieve significance. CONCLUSIONS Coronary interventional therapy, both PCI and CABG, is associated with lower rates of events compared with MT in mild CKD patients >10 years of follow-up. More study is needed to confirm these benefits in moderate CKD.
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Affiliation(s)
- Eduardo Gomes Lima
- Department of Clinical Cardiology, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | - David M Charytan
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Whady Hueb
- Department of Clinical Cardiology, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | | | - Cibele Larrosa Garzillo
- Department of Clinical Cardiology, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | - Desiderio Favarato
- Department of Clinical Cardiology, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | | | - Eduardo Bello Martins
- Department of Clinical Cardiology, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | - Daniel Valente Batista
- Department of Clinical Cardiology, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | - Paulo Cury Rezende
- Department of Clinical Cardiology, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | - Alexandre Ciappina Hueb
- Department of Clinical Cardiology, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | | | - Roberto Kalil Filho
- Department of Clinical Cardiology, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
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14
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Rezende PC, Hueb W, Bocchi EA, Farkouh M, Junior CVS, Lima EG, Silva EER, Dallan LAO, Gaiotto FA, Garzillo CL, Rochitte CE, Nomura CH, Scudeler TL, Soares PR, Jatene FB, Ramires JAF, Filho RK. Hypotheses, rationale, design, and methods for prognostic evaluation of a randomized comparison between patients with coronary artery disease associated with ischemic cardiomyopathy who undergo medical or surgical treatment: MASS-VI (HF). Trials 2020; 21:337. [PMID: 32299458 PMCID: PMC7164251 DOI: 10.1186/s13063-020-04270-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/20/2020] [Indexed: 12/03/2022] Open
Abstract
Background Ischemic cardiomyopathy and severe left ventricular dysfunction are well established to represent the main determinants of poor survival and premature death compared with preserved ventricular function. However, the role of myocardial revascularization as a therapeutic alternative is not known to improve the long-term prognosis in this group of patients. This study will investigate whether myocardial revascularization contributes to a better prognosis for patients compared with those treated with drugs alone and followed over the long term. Methods The study will include 600 patients with coronary artery disease associated with ischemic cardiomyopathy. The surgical or drug therapy option will be randomized, and the events considered for analysis will be all-cause mortality, nonfatal infarction, unstable angina requiring additional revascularization, and stroke. The events will be analyzed according to the intent-to-treat principle. Patients with multivessel coronary disease and left ventricular ejection fraction measurements of less than 35% will be included. In addition, myocardial ischemia will be documented by myocardial scintigraphy. Markers of myocardial necrosis will be checked at admission and after the procedure. Discussion The role of myocardial revascularization (CABG) in the treatment of patients with coronary artery disease and heart failure is not clearly established. The surgical option of revascularizing the myocardium is a procedure designed to reduce the load of myocardial hibernation in patients with heart failure caused by coronary artery disease. On the other hand, the assessment of myocardial viability is frequently used to identify patients with left ventricular ischemic dysfunction in which CABG may add survival benefit. However, the effectiveness of this option is uncertain. The great difficulty in establishing the efficacy of surgical intervention is based on the understanding of viability without ischemia. Thus, this study will include only patients with viable and truly ischemic myocardium to correct this anomaly. Trial registration Evaluation of a randomized comparison between patients with coronary artery disease associated with ischemic cardiomyopathy submitted to medical or surgical treatment: MASS-VI (HF), ISRCTN77449548, Oct 10th, 2019 (retrospectively registered).
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Affiliation(s)
- Paulo Cury Rezende
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Whady Hueb
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Edimar Alcides Bocchi
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Michael Farkouh
- Toronto General Hospital Research Institute (TGHRI), Toronto, Ontario, Canada
| | - Carlos Vicente Serrano Junior
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Eduardo Gomes Lima
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Expedito Eustáquio Ribeiro Silva
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Luis Alberto Oliveira Dallan
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Fabio Antonio Gaiotto
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Cibele Larrosa Garzillo
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Carlos Eduardo Rochitte
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Cesar Higa Nomura
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Thiago Luis Scudeler
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Paulo Rogério Soares
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Fabio Biscegli Jatene
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - José Antonio Franchini Ramires
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Roberto Kalil Filho
- Instituto do Coraçao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, São Paulo, SP, 05403-000, Brazil
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15
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de Azevedo DFC, Hueb W, Lima EG, Rezende PC, Linhares Filho JPP, de Carvalho GF, Martins EB, Nomura CH, Strunz CMC, Serrano Junior CV, Ramires JAF, Kalil Filho R. Significant association of SYNTAX score on release of cardiac biomarkers in uncomplicated post-revascularization procedures among patients with stable multivessel disease: MASS-V Study group. Medicine (Baltimore) 2020; 99:e18973. [PMID: 32080075 PMCID: PMC7034737 DOI: 10.1097/md.0000000000018973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [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
This study investigated the relationship between angiographic complexities of coronary artery disease (CAD) assessed by SYNTAX Score synergy between percutaneous coronary intervention with taxus and cardiac surgery score (SYNTAX Score) and cardiac biomarker elevation after revascularization procedures.This is a post-hoc analysis of the medicine, angioplasty or surgery study V study of patients with stable CAD. High-sensitivity troponin 1 (hs-TnI) and creatinine kinase-muscle/brain (CK-MB) were assessed before and after cardiovascular procedures. Baselines SYNTAX Scores (SXScores) were calculated by blinded investigators to patient characteristics.Of the 202 patients studied, the mean SXScore was 21.25 ± 9.24; 40.10 ± 7.09 in the high SXScore group and 19.06 ± 6.61 in low/mid SXscore group (P < .0001). Positive correlations existed between SXScore and median peaks after procedural hs-TnI (r = 0.18, P = .009) and CK-MB (r = 0.24, P = .001) levels. In patients with high SXScores (≥33), the median peaks of post-procedural hs-TnI (P = .034)and CK-MB (P = .004) levels were higher than in low/mid SXScore group (<33).The release of hs-TnI at 6 (P = .002), 12 (P = .008), and 24 hours (P = .039) was higher in high SXScore group than in low/mid SXscore group (<33) as was the release of CK-MB at 6 (P < .0001), 12 (P < .0001), 24 (P = .001), 36 (P = .007), 48 (P = .008), and 72 hours (P = .023). After multivariable analysis, high SXScore was a significant independent predictor of release of CK-MB and hs-TnI peaks higher than the median.The increase in release of cardiac biomarkers was significantly associated with the extent of atherosclerosis identified by the SYNTAX Score.
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Rezende PC, Hlatky MA, Hueb W, Garcia RMR, da Silva Selistre L, Lima EG, Garzillo CL, Scudeler TL, Boros GAB, Ribas FF, Serrano CV, Ramires JAF, Kalil Filho R. Association of Longitudinal Values of Glycated Hemoglobin With Cardiovascular Events in Patients With Type 2 Diabetes and Multivessel Coronary Artery Disease. JAMA Netw Open 2020; 3:e1919666. [PMID: 31968117 PMCID: PMC6991270 DOI: 10.1001/jamanetworkopen.2019.19666] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Glycated hemoglobin (HbA1c) values are used to guide glycemic control, but in patients with type 2 diabetes and multivessel coronary artery disease (CAD), the association of the longitudinal values of HbA1c with cardiovascular outcomes is unclear. OBJECTIVE To assess whether longitudinal variation of HbA1c is associated with cardiovascular events in long-term follow-up among patients with diabetes and multivessel CAD. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 888 patients with type 2 diabetes and multivessel CAD in the Medicine, Angioplasty, or Surgery Study (MASS) Registry of the Heart Institute of the University of São Paulo from January 2003 to December 2007. Data were analyzed from January 15, 2018, to October 15, 2019. EXPOSURE Longitudinal HbA1c values. MAIN OUTCOMES AND MEASURES The combined outcome of all-cause mortality, myocardial infarction, and ischemic stroke. RESULTS Of 888 patients with type 2 diabetes and multivessel CAD, 725 (81.6%; median [range] age, 62.4 [55.7-68.0] years; 467 [64.4%] men) had complete clinical and HbA1c information during a median (interquartile range) follow-up period of 10.0 (8.0-12.3) years, with a mean (SD) of 9.5 (3.8) HbA1c values for each patient. The composite end point of death, myocardial infarction, or ischemic stroke occurred in 262 patients (36.1%). A 1-point increase in the longitudinal value of HbA1c was significantly associated with a 14% higher risk of the combined end point of all-cause mortality, myocardial infarction, and ischemic stroke (hazard ratio, 1.14; 95% CI, 1.04-1.24; P = .002) in the unadjusted analysis. After adjusting for baseline factors (ie, age, sex, 2-vessel or 3-vessel CAD, initial CAD treatments, ejection fraction, and creatinine and low-density lipoprotein cholesterol levels), a 1-point increase in the longitudinal value of HbA1c was associated with a 22% higher risk of the combined end point (hazard ratio, 1.22; 95% CI, 1.12-1.35; P < .001). CONCLUSIONS AND RELEVANCE Longitudinal increase of HbA1c was independently associated with higher rates of cardiovascular events in patients with type 2 diabetes and multivessel CAD.
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Affiliation(s)
- Paulo Cury Rezende
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Whady Hueb
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Rosa Maria Rahmi Garcia
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Eduardo Gomes Lima
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Cibele Larrosa Garzillo
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Thiago Luis Scudeler
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Gustavo Andre Boeing Boros
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Fernando Faglioni Ribas
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Vicente Serrano
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Jose Antonio Franchini Ramires
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Roberto Kalil Filho
- Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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17
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Garzillo CL, Rezende PC, Hueb W. Stress Testing and Risk Prediction in People With Known Symptomatic Multivessel Coronary Artery Disease-Reply. JAMA Intern Med 2020; 180:166-167. [PMID: 31904792 DOI: 10.1001/jamainternmed.2019.5857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Cibele Larrosa Garzillo
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Paulo Cury Rezende
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Whady Hueb
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Boros GAB, Hueb W, Rezende PC, Ribas FF, Dallazen AR, Ribeiro MOL, Garcia RMR, Garzillo CL, Lima EG, Morais T, Nomura CH, Rochitte CE, Serrano Junior CV, Ramires JAF, Kalil Filho R. P598T1 mapping and myocardial extracellular volume assessed by cardiac magnetic resonance in diabetic patients with stable coronary artery disease. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
T1 mapping is a quantitative technique of cardiac magnetic resonance (CMR) increasingly used for characterization of the myocardium. Type 2 diabetes mellitus (T2DM) may impact myocardial tissue structure, however studies that assessed this association using non-invasive methods have conflicting results.
Purpose
We sought to compare the tissue characteristics of the non-infarcted myocardium of patients with and without diabetes with multivessel CAD.
Methods
Patients with stable multivessel CAD and preserved left ventricular ejection fraction (LVEF), included in the MASS V trial, underwent contrast-enhanced CMR before revascularization procedures. Patients were stratified according to the T2DM diagnosis at baseline. Values of myocardial native T1, post-contrast T1 and extracellular volume fraction (ECV) were compared between diabetic and non-diabetic patients. Only myocardial tissue without late gadolinium enhancement were assessed.
Results
Of 155 patients studied, 67 (43%) were diabetic and 88 (57%) non-diabetic. Baseline characteristics were similiar between groups (age 70±10 vs 69±11; 69% vs 68% males; LVEF 65±13 vs 67±9). Mean Syntax score was 21.2±8.5 and 20.4±8.5 (p=0.52) in diabetic and non-diabetic, respectively. Myocardial native T1 values showed no diference in diabetic and non-diabetic (1013±67.9 vs 1015±61.4, p=0.72). However, in diabetic patients values of post-contrast T1 were significantly lower (482.2±43.8 vs 499.4±47.2, p=0.024) and ECV were higher (29.62±6.61 vs 27.08. ± 4.22, p=0.004). Multivariable analyses adjusted for age, sex, BMI, hypertension and Syntax score showed no differences in the results.
Figure1
Conclusion
In this study, T2DM was associated with higher ECV and lower post-contrast T1 values in the myocardial tissue. These findings suggest an increase in the myocardial intersticial matrix in patients with diabetes and stable multivessel CAD.
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Affiliation(s)
- G A B Boros
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - W Hueb
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - P C Rezende
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - F F Ribas
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - A R Dallazen
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - M O L Ribeiro
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - R M R Garcia
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - C L Garzillo
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - E G Lima
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - T Morais
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - C H Nomura
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - C E Rochitte
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - C V Serrano Junior
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - J A F Ramires
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - R Kalil Filho
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
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Dallazen AR, Hueb W, Rezende PC, Boros GAB, Ribas FF, Nomura CH, Rochitte CE, Morais T, Lima EG, Martins EB, Carvalho GF, Ribeiro MOL, Serrano Junior CV, Ramires JAF, Kalil Filho R. P1832Myocardial injury assessed by T1 mapping after on-pump and off-pump coronary artery bypass grafting. a pre-specified analysis of mass V trial. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Myocardial structural damage may occur during coronary artery bypass grafting (CABG) surgery and is identified by the significant release of cardiac biomarkers. However, the evidence of these structural myocardial changes after CABG by current imaging methods remains unknown. To evaluate myocardial structure, we used the T1 mapping of cardiac magnetic resonance (CMR) before and after on-pump and off-pump CABG.
Methods
Patients with multivessel coronary artery disease and preserved ventricular function were included and underwent on or off-pump CABG. CMR and T1 mapping were performed using the MOLLI technique (modified Look-Locker inversion-recovery). Values of native T1 and extracellular volume fraction (ECV) were compared before and after on and off-pump procedures.
Results
Of 110 eligible patients, 34 were excluded due to the presence of new late enhancement or edema. Of 76 patients remained, 32 (42%) underwent on-pump (Group A) and 44 (58%) off-pump CABG (Group B). All baseline characteristics were similar between groups, besides the Syntax Score that was higher in Group A (25 × 21, p=0.002). For group A, native T1 before and after procedures was 1013 ms (998–1043) and 1004 ms (793–1048), p=0.19, and ECV was 26.4 (23.9–27.6) and 31.2 (27.6–33.9), p<0.001. For group B, native T1 before and after procedures was 1015 ms (970–1044) and 992 ms (867–1051), p=0.003, and ECV 27.5 (25.3–29.9) and 30.3 (26.5–34.3), p=0.02. The comparison of native T1 difference before and after procedures between groups A and B was not significant (Delta T1 −9.8 (−102 to 51.8) × −25.4 (−119 to 51,2), p=0.87. However, the difference of ECV between groups was statistically significant (ECV Delta 3.8 (2.2 to 7.1) × 1.3 (−1.1 to 4.9), p=0.039, respectively, for groups A and B.
Figure 1
Conclusion
In this sample, T1 mapping identified significant myocardial structural changes in both surgical revascularization procedures. Additionally, a marked myocardial injury generated by ECV changes were observed after on-pump CABG.
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Affiliation(s)
- A R Dallazen
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - W Hueb
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - P C Rezende
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - G A B Boros
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - F F Ribas
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - C H Nomura
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - C E Rochitte
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - T Morais
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - E G Lima
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - E B Martins
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - G F Carvalho
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - M O L Ribeiro
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - C V Serrano Junior
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - J A F Ramires
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - R Kalil Filho
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
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20
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Martins EB, Hueb W, Lima EG, Rezende PC, Garzillo CL, Carvalho GF, Carvalho FPC, Linhares Filho JPP, Batista DV, Silva RR, Boros GAB, Azevedo DFC, Serrano Junior CV, Ramires JAF, Kalil Filho R. P1835Application of SYNTAX score I, II and residual SYNTAX as predictors of long-term clinical outcomes after coronary artery bypass grafting. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The evaluation of coronary disease by SYNTAX score I (SSI) is used to grade coronary complexity. Following SSI, two other scores were developed: SYNTAX score II (SSII) and residual SYNTAX score (rSS). Nevertheless, there is still a lack of evidence about the prognostic significance of these scores among patients undergoing CABG.
Purpose
Our aim was to evaluate the relation of the SSI, SSII and rSS score with outcomes in a long-term follow-up after elective CABG.
Methods
This is a single center, registry-based study. Baseline SSI was calculated from patients undergoing CABG by interventional cardiologists. SSI results were considered as usual: <23, 23–32 and >32. SSII and rSRR were then calculated and categorized in tertiles: <21.4, 21.4–29.4 and >29.4 for SSII and 0, 1–5 and >5 for rSS. Primary outcome was a composite of overall death, myocardial infarction, additional revascularization, or stroke (MACCE).
Results
Data were obtained from 559 patients. Median follow-up was 6 years (IQR: 4.9–9.8) and 170 events were documented. The Kaplan-Meier curves (figure 1) showed significant differences of MACCE in higher SSI, SSII and rSS (p=0.039, 0.033, <0.001 respectively). After multivariate adjustment, rSS, ejection fraction (EF) and age were found to be independent predictors of MACCE (p<0.001, 0.034 and 0.006, respectively).
Figure 1
Conclusion
In this sample SSI, II and residual were associated with the occurrence of events. However, just the rSS remained an independent predictor of MACCE together with age and EF.
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Affiliation(s)
- E B Martins
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - W Hueb
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - E G Lima
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - P C Rezende
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - C L Garzillo
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - G F Carvalho
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - F P C Carvalho
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - J P P Linhares Filho
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - D V Batista
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - R R Silva
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - G A B Boros
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - D F C Azevedo
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - C V Serrano Junior
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - J A F Ramires
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
| | - R Kalil Filho
- Instituto do Coracao InCor Hospital das Clinicas Faculdade de Medicina Universidade de Sao Paulo SP, Sao Paulo, Brazil
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Garzillo CL, Hueb W, Gersh B, Rezende PC, Lima EG, Favarato D, Franchini Ramires JA, Kalil Filho R. Association Between Stress Testing-Induced Myocardial Ischemia and Clinical Events in Patients With Multivessel Coronary Artery Disease. JAMA Intern Med 2019; 179:1345-1351. [PMID: 31329221 PMCID: PMC6647357 DOI: 10.1001/jamainternmed.2019.2227] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The long-term prognostic implications of myocardial ischemia documented during stress testing in patients with multivessel coronary artery disease (CAD) are unclear. OBJECTIVE To assess whether documented stress testing-induced myocardial ischemia is associated with major adverse cardiovascular events or ventricular function changes in patients with stable multivessel CAD. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort study was conducted using data from a single-center randomized clinical trial (Medicine, Angioplasty, or Surgery Study [MASS] II) to examine the association of myocardial ischemia documented during stress testing at baseline with cardiovascular events and ventricular function changes during follow-up. Participants were previously randomized (May 1, 1995, to May 31, 2000) to medical therapy, percutaneous coronary intervention with bare metal stents, or coronary artery bypass grafting. Event-free survival was estimated by the Kaplan-Meier method, and multivariable Cox regression models were calculated to assess the association between ischemia and the primary composite end point. The vital status was determined on February 28, 2011. Data were analyzed from February 1, 2016, to April 1, 2017. MAIN OUTCOMES AND MEASURES Cardiovascular events (overall mortality, myocardial infarction, and revascularization for refractory angina) were tracked from the time of randomization to the end of the 10-year follow-up (mean [SD] duration, 11.4 [4.3] years). Myocardial ischemia was assessed at baseline and at 1-year intervals by exercise stress testing, and ventricular function (left ventricular ejection fraction) was assessed by echocardiography at baseline and after 10 years. Patients with documented ischemia were compared with those without ischemia regarding the outcomes and changes in ventricular function. RESULTS Of 611 participants, 535 underwent exercise stress testing at baseline: 270 with documented ischemia and 265 without. Of these 535 patients, 373 (69.7%) were men, and the mean (SD) age for the entire cohort was 59.7 (9.2) years. No association was found between the presence of ischemia at baseline and survival free of combined cardiovascular events (hazard ratio, 1.00; 95% CI, 0.80-1.27; P = .95) after multivariable adjustment that included CAD initial randomized treatments. In addition, among 320 patients who underwent echocardiographic evaluation, the slight decline in left ventricular ejection fraction after 10 years was similar in both groups (median [SD] difference, -4.9% [18.7%] vs -6.6% [20.0%], respectively, for groups with and without ischemia; P = .97). CONCLUSIONS AND RELEVANCE In this study, regardless of the therapeutic strategy applied, the presence of documented myocardial ischemia did not appear to be associated with an increased occurrence of major adverse cardiovascular events or changes in ventricular function in patients with multivessel CAD during a long-term follow-up.
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Affiliation(s)
- Cibele Larrosa Garzillo
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Whady Hueb
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Bernard Gersh
- Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Paulo Cury Rezende
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Gomes Lima
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Desiderio Favarato
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - José Antônio Franchini Ramires
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Roberto Kalil Filho
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Abstract
Myocardial ischemia is considered the cornerstone of the treatment of patients with coronary artery disease (CAD). Although the deleterious effects of myocardial infarction, the maximum expression of ischemia, have been extensively studied and described, the clinical effects of chronic, documented myocardial ischemia are not completely clarified. The first studies that compared therapies for coronary disease focused on the presence of anatomical features and assessed ischemia based on the interpretation of the findings of obstructive atherosclerotic lesions. They suggested that revascularization interventions did not confer any clinical advantage over medical therapy (MT), in terms of cardiac or overall death. Other retrospective studies that were dedicated to assessing the impact of documented stress-induced ischemia on cardiovascular outcomes have suggested a prognostic impact of chronic ischemia. However, this has been questioned in recent studies. Moreover, the previous understanding that chronic ischemia could lead to worsening of ventricular function was not confirmed in a recent study. Thus, the prognostic significance of stress-induced ischemia has been questioned. Regarding treatment options, although some previous analyses have suggested that interventional therapies would reduce cardiovascular events in CAD patients with documented ischemia, recent post-hoc studies and metanalysis have shown distinct results. In this review article, the authors discuss myocardial ischemia, the different responses of the myocardium to ischemic insults, ischemic preconditioning, and the main findings of recent studies about the clinical aspects and treatment of patients with chronic, documented myocardial ischemia.
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Affiliation(s)
- Paulo Cury Rezende
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Fernando Faglioni Ribas
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Vicente Serrano
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Whady Hueb
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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23
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Scudeler TL, Hueb WA, Farkouh ME, Maron DJ, de Soárez PC, Campolina AG, Takiuti ME, Rezende PC, Godoy LC, Hueb AC, Lima EG, Garzillo CL, Ramires JAF, Kalil Filho R. Cost-effectiveness of on-pump and off-pump coronary artery bypass grafting for patients with coronary artery disease: Results from the MASS III trial. Int J Cardiol 2018; 273:63-68. [DOI: 10.1016/j.ijcard.2018.08.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/08/2018] [Accepted: 08/13/2018] [Indexed: 11/25/2022]
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Brandão SMG, Rezende PC, Rocca HPBL, Ju YT, de Lima ACP, Takiuti ME, Hueb W, Bocchi EA. Comparative cost-effectiveness of surgery, angioplasty, or medical therapy in patients with multivessel coronary artery disease: MASS II trial. Cost Eff Resour Alloc 2018; 16:55. [PMID: 30410425 PMCID: PMC6215652 DOI: 10.1186/s12962-018-0158-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 10/24/2018] [Indexed: 02/08/2023] Open
Abstract
Background The costs for treating coronary artery disease (CAD) are high worldwide. We performed a prespecified analyses of cost-effectiveness of three therapeutic strategies for multivessel CAD. Methods From May 1995 to May 2000, a total of 611 patients were randomly assigned to coronary artery bypass graft (CABG), n = 203; percutaneous coronary intervention (PCI), n = 205; or medical treatment (MT), n = 203. This cost analysis study was based on the perspective of the Public Health Care System. Initial procedural and follow-up costs for medications, cardiology examinations, and hospitalizations for complications were calculated after randomization. Life-years and quality-adjusted life years (QALYs) were used as effectiveness measures. Incremental cost-effectiveness ratios (ICER) were obtained by using nonparametric bootstrapping methods with 5000 resamples. Results Initial procedural costs were lower for MT. However, the subsequent 5-year cumulative costs were lower for CABG. Compared with baseline, the three treatment options produced significant improvements in QALYs. After 5 years, PCI and CABG had better QALYs results compared with MT. The ICER results favored CABG and PCI, and favored PCI over CABG in 61% of the drawings. On the other hand, sensitivity analysis showed MT as the preferred therapy compared with CABG and PCI, in the analysis considering higher costs. Conclusions At 5-year follow-up, the three treatment options yielded improvements in quality of life, with comparable and acceptable costs. However, despite higher initial costs, the comparison of cost-effectiveness after 5 years of follow-up among the three treatments showed both interventions (CABG and PCI) to be cost-effective strategies compared with MT.Trial registration ISRCTN, ISRCTN66068876, Registered 06/10/1994, http://www.controlled-trials.com/ISRCTN66068876.
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Affiliation(s)
- Sara Michelly Gonçalves Brandão
- 1Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av Dr Eneas de Carvalho Aguiar 44 - Cerqueira Cesar, São Paulo, SP CEP 05403-000 Brazil
| | - Paulo Cury Rezende
- 1Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av Dr Eneas de Carvalho Aguiar 44 - Cerqueira Cesar, São Paulo, SP CEP 05403-000 Brazil
| | - Hans-Peter Brunner-La Rocca
- 2Heart Failure Clinic, Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Yang Ting Ju
- 3Department of Statistics, Institute of Mathematics and Statistics, University of São Paulo, São Paulo, SP Brazil
| | | | - Myrthes Emy Takiuti
- 1Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av Dr Eneas de Carvalho Aguiar 44 - Cerqueira Cesar, São Paulo, SP CEP 05403-000 Brazil
| | - Whady Hueb
- 1Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av Dr Eneas de Carvalho Aguiar 44 - Cerqueira Cesar, São Paulo, SP CEP 05403-000 Brazil
| | - Edimar Alcides Bocchi
- 1Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av Dr Eneas de Carvalho Aguiar 44 - Cerqueira Cesar, São Paulo, SP CEP 05403-000 Brazil
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25
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Hueb W, Rezende PC, Gersh BJ, Soares PR, Favarato D, Lima EG, Garzillo CL, Jatene FB, Ramires JAF, Filho RK. Ten-Year Follow-Up of Off-Pump and On-Pump Multivessel Coronary Artery Bypass Grafting: MASS III. Angiology 2018; 70:337-344. [PMID: 30286625 DOI: 10.1177/0003319718804402] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
It was a randomized trial, and 308 patients undergoing revascularization were randomly assigned: 155 to off-pump coronary artery bypass (OPCAB) and 153 to on-pump coronary artery bypass (ONCAB). End points were freedom from death, myocardial infarction, revascularization, and cerebrovascular accidents. The rates for 10-year, event-free survival for ONCAB versus OPCAB were 69.6% and 64%, (hazard ratio [HR]: 0.88; 95% confidence interval [CI] 0.86-1.02; P = .41), respectively. Adjusted Cox proportional hazard ratio was similar (HR: 0.92; 95% CI 0.61-1.38, P = .68). A difference occurred between the duration of OPCAB and ONCAB, respectively (4.9 ± 1.5 vs 6.6 ± 1.1 h, P < .001). Statistical differences occurred between OPCAB and ONCAB in the length of intensive care unit (ICU) stay (20 ± 2.5 vs 48 ± 10 hours, P < .001), time to extubation (5.5 ± 4.2 vs 10.2 ± 3.5 hours, P < .001), hospital stay (6.7 ± 1.4 vs 9.2 ± 1.3 days, P < .001), higher incidence of atrial fibrillation (AF; 33 vs 5 patients, P < .001), and blood requirements (46 vs 64 patients, P < .001). Grafts per patient was higher in ONCAB (3.15 vs 2.55 grafts, P < .001). No difference existed between the groups in primary composite end points at 10-year follow-up. Although OPCAB surgery was related to a lower number of grafts and higher incidence of AF, it had no effects related to long-term outcomes.
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Affiliation(s)
- Whady Hueb
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Paulo Cury Rezende
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Paulo Rogério Soares
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Desidério Favarato
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Gomes Lima
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Cibele Larrosa Garzillo
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Fabio B Jatene
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - José Antonio Franchini Ramires
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Roberto Kalil Filho
- 1 Clinical Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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26
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Scudeler TL, Hueb W, De Soarez PC, Campolina AG, Hueb AC, Rezende PC, Lima EG, Garzillo CL, Ribas FF, Takiuti ME, Ramires JAF, Kalil Filho R. P2657Cost-effectiveness analysis of on-pump and off-pump coronary artery bypass grafting for patients with multivesselcoronary artery disease: a Markov model based on data from the MASS III trial. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- T L Scudeler
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - W Hueb
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | | | - A G Campolina
- University of Sao Paulo, Cancer Institute, Sao Paulo, Brazil
| | - A C Hueb
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - P C Rezende
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - E G Lima
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - C L Garzillo
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - F F Ribas
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - M E Takiuti
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - J A F Ramires
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - R Kalil Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
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27
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Batista DV, Hueb W, Linhares Filho JPP, Silva RR, Lima EG, Rezende PC, Martins EB, Garzillo CL, Azevedo DFC, Ramires JAF, Kalil Filho R. 2363Impact of chronic kidney disease on diabetic patients with stable coronary disease undergoing surgery, angioplasty or medical treatment in a ten-year follow-up. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.2363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- D V Batista
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - W Hueb
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - J P P Linhares Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - R R Silva
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - E G Lima
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - P C Rezende
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - E B Martins
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - C L Garzillo
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - D F C Azevedo
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - J A F Ramires
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - R Kalil Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
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28
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Lima EG, Hueb W, Linhares Filho JPP, Batista DV, Rezende PC, Martins EB, Azevedo DFC, Garzillo CL, Ramires JAF, Kalil Filho R. P3591Very long-term follow-up of diabetic patients with coronary artery disease undergoing angioplasty with conventional and drug-eluting stents. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- E G Lima
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - W Hueb
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - J P P Linhares Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - D V Batista
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - P C Rezende
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - E B Martins
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - D F C Azevedo
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - C L Garzillo
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - J A F Ramires
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - R Kalil Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
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29
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Martins EB, Hueb W, Silva RR, Linhares Filho JPP, Batista DV, Ribas FF, Rezende PC, Lima EG, Azevedo DFC, Ramires JAF, Kalil Filho R. P6361SYNTAX score and outcomes after coronary artery bypass grafting: a long-term follow-up analysis. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p6361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- E B Martins
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - W Hueb
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - R R Silva
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - J P P Linhares Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - D V Batista
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - F F Ribas
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - P C Rezende
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - E G Lima
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - D F C Azevedo
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - J A F Ramires
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - R Kalil Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
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30
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Silva RR, Lima EG, Batista DV, Linhares Filho JPP, Martins EB, Rezende PC, Garzillo CL, Ribas FF, Hueb W, Ramires JAF, Kalil Filho R. P2658Long-term analysis of ventricular functionin patients with stable coronary disease submitted to on-pump or off-pump coronary artery bypass graft in MASS III. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- R R Silva
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - E G Lima
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - D V Batista
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - J P P Linhares Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - E B Martins
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - P C Rezende
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - C L Garzillo
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - F F Ribas
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - W Hueb
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - J A F Ramires
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - R Kalil Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
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31
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Linhares Filho JPP, Hueb W, Batista DV, Silva RR, Lima EG, Rezende PC, Martins EB, Garzillo CL, Azevedo DFC, Ramires JAF, Kalil Filho R. P2265Impact of glycated hemoglobin in diabetic patients with coronary artery disease undergoing surgery, angioplasty or clinical treatment in a very long-term follow-up. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J P P Linhares Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - W Hueb
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - D V Batista
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - R R Silva
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - E G Lima
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - P C Rezende
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - E B Martins
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - C L Garzillo
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - D F C Azevedo
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - J A F Ramires
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - R Kalil Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
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32
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Linhares Filho JPP, Hueb W, Batista DV, Silva RR, Lima EG, Rezende PC, Martins EB, Garzillo CL, Azevedo DFC, Ramires JAF, Kalil Filho R. 3270Prognostic evaluation of elevation of cardiac biomarkers after myocardial revascularization. Long-term follow-up of MASS-V trial. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.3270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J P P Linhares Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - W Hueb
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - D V Batista
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - R R Silva
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - E G Lima
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - P C Rezende
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - E B Martins
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - C L Garzillo
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - D F C Azevedo
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - J A F Ramires
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - R Kalil Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
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Ribas FF, Rezende PC, Boros GAB, Dallazen AR, Nomura CH, Rochitte CE, Morais T, Villa AV, Garzillo CL, Hueb W, Ramires JAF, Kalil Filho R. P3705Role of myocardial edema assessed by cardiac magnetic resonance after revascularization procedures. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- F F Ribas
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - P C Rezende
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - G A B Boros
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - A R Dallazen
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - C H Nomura
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - C E Rochitte
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - T Morais
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - A V Villa
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - C L Garzillo
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - W Hueb
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - J A F Ramires
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
| | - R Kalil Filho
- Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao Paulo, Brazil
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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: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- Fernando Teiichi Costa Oikawa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Whady Hueb
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Cesar Higa Nomura
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alexandre Ciappina Hueb
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alexandre Volney Villa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Leandro Menezes Alves da Costa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Rodrigo Morel Vieira de Melo
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Paulo Cury Rezende
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Carlos Alexandre Wainrober Segre
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Cibele Larrosa Garzillo
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Eduardo Gomes Lima
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Jose Antonio Franchini Ramires
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Roberto Kalil Filho
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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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] [What about the content of this article? (0)] [Affiliation(s)] [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]
Affiliation(s)
| | - Whady Hueb
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
| | - Cesar Higa Nomura
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
| | | | - Alexandre Volney Villa
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
| | | | | | - Paulo Cury Rezende
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
| | - Cibele Larrosa Garzillo
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
| | - Eduardo Gomes Lima
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
| | | | - Roberto Kalil Filho
- Department of Atherosclerosis; Heart Institute (InCor) of the University of São Paulo; São Paulo SP Brazil
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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] [What about the content of this article? (0)] [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, 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- Paulo Cury Rezende
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Whady Hueb
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Rosa Maria Rahmi
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Thiago Luis Scudeler
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Diogo Freitas Cardoso de Azevedo
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Cibele Larrosa Garzillo
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Carlos Alexandre Wainrober Segre
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Jose Antonio Franchini Ramires
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
| | - Roberto Kalil Filho
- Heart Institute (InCor) of the University of São Paulo, Avenida Dr. Eneas de Carvalho Aguiar, 44, AB sala 114, Cerqueira César, São Paulo, SP CEP 05403-900 Brazil
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Rezende PC, de Azevedo DFC, Hueb W. Interventional therapies in ischemic ventricular dysfunction: facts and versions! Ann Transl Med 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] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, SP, Brazil
| | | | - Whady Hueb
- Department of Atherosclerosis, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, SP, Brazil
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Affiliation(s)
- Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute of the University of São Paulo, School of Medicine, São Paulo, Brazil
| | - Whady Hueb
- Department of Atherosclerosis, Heart Institute of the University of São Paulo, School of Medicine, São Paulo, Brazil
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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] [What about the content of this article? (0)] [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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- Whady Hueb
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil.
| | | | | | | | | | - Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Cibele Larrosa Garzillo
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Eduardo Gomes Lima
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Cesar Higa Nomura
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Alexandre Volney Villa
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Alexandre Ciappina Hueb
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Celia Maria Cassaro Strunz
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Desiderio Favarato
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Myrthes Emy Takiuti
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Cicero Piva de Albuquerque
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | | | | | - Roberto Kalil Filho
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
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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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Affiliation(s)
- Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute of the University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Rosa Maria Rahmi
- Department of Atherosclerosis, Heart Institute of the University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Whady Hueb
- Department of Atherosclerosis, Heart Institute of the University of São Paulo Medical School, São Paulo, SP, Brazil
- *Whady Hueb:
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- Carlos Alexandre Wainrober Segre
- Department of Clinical Cardiology, Heart Institute (InCor) University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, BL I, Sala 114, Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
| | - Whady Hueb
- Department of Clinical Cardiology, Heart Institute (InCor) University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, BL I, Sala 114, Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
| | - Rosa Maria Rahmi Garcia
- Department of Clinical Cardiology, Heart Institute (InCor) University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, BL I, Sala 114, Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
| | - Paulo Cury Rezende
- Department of Clinical Cardiology, Heart Institute (InCor) University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, BL I, Sala 114, Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
| | - Desiderio Favarato
- Department of Clinical Cardiology, Heart Institute (InCor) University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, BL I, Sala 114, Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
| | - Celia Maria Cassaro Strunz
- Department of Clinical Cardiology, Heart Institute (InCor) University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, BL I, Sala 114, Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
| | - Marília da Costa Oliveira Sprandel
- Department of Clinical Cardiology, Heart Institute (InCor) University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, BL I, Sala 114, Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
| | - Alessandra Roggério
- Department of Clinical Cardiology, Heart Institute (InCor) University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, BL I, Sala 114, Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
| | - Ana Luiza de Oliveira Carvalho
- Department of Clinical Cardiology, Heart Institute (InCor) University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, BL I, Sala 114, Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
| | - Raul Cavalcante Maranhão
- Department of Clinical Cardiology, Heart Institute (InCor) University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, BL I, Sala 114, Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
| | - José Antonio Franchini Ramires
- Department of Clinical Cardiology, Heart Institute (InCor) University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, BL I, Sala 114, Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
| | - Roberto Kalil Filho
- Department of Clinical Cardiology, Heart Institute (InCor) University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, BL I, Sala 114, Cerqueira César, Sao Paulo, SP, 05403-000, Brazil.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Rosa Maria Rahmi
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Augusto Hiroshi Uchida
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Leandro Menezes Alves da Costa
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Thiago Luis Scudeler
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Cibele Larrosa Garzillo
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Eduardo Gomes Lima
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Carlos Alexandre Wainrober Segre
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Priscyla Girardi
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Myrthes Takiuti
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Marcela Francisca Silva
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Whady Hueb
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Jose Antonio Franchini Ramires
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Roberto Kalil Filho
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | | | - Thiago Luis Scudeler
- Department of Atherosclerosis, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | - Debora Nakamura
- Department of Atherosclerosis, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | | | - Whady Hueb
- Department of Atherosclerosis, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil.
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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] [What about the content of this article? (0)] [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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Scudeler TL, Rezende PC, Oikawa FTC, da Costa LMA, Hueb AC, Hueb W. A case of mid-apical obstructive hypertrophic cardiomyopathy treated with a transapical myectomy approach: a case report. J Med Case Rep 2014; 8:364. [PMID: 25384531 PMCID: PMC4232228 DOI: 10.1186/1752-1947-8-364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 08/27/2014] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Hypertrophic cardiomyopathy is a genetic cardiac disease characterized by marked variability in morphological expression and natural history. The hypertrophic myocardium is often confined to the septum or lateral wall of the left ventricle, but it can also be encountered in the middle or apical segments of the myocardium. Treatment is based on medical therapy. Others therapies, such as embolization of the septal artery or ventriculomyectomy, are indicated in special situations. Surgery is the standard treatment, and it is classically done via a transaortic approach; however, in cases in which the hypertrophic myocardium is confined to mid-apical segments, a transapical approach is an option. Only a few cases of mid-apical obstructive hypertrophic cardiomyopathy treated with a myectomy using a transapical approach have been reported in the English-language literature. In this report, we present a case of a patient with mid-apical obstructive hypertrophic cardiomyopathy treated using this new approach. CASE PRESENTATION A 63-year-old Caucasian woman presented with a history of chest pain and shortness of breath causing significant limitations on her daily life activities. She had a history of coronary artery disease. Her physical examination was unremarkable. Transthoracic echocardiography revealed normal systolic function and significant concentric left ventricular hypertrophy that was greater in the mid-apical region. Nuclear magnetic resonance imaging confirmed significant hypertrophy of the median segments of the left ventricle. The patient had persistent symptoms despite receiving optimized medical treatment, and a surgical approach was indicated. As a myectomy using transaortic technique was thought to be difficult to perform in her case, a transapical approach was used. No complications occurred, and her symptoms resolved. CONCLUSION A transapical myectomy should be taken into consideration for patients with mid-apical obstructive hypertrophic cardiomyopathy that is refractory to medical treatment.
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Affiliation(s)
| | | | | | | | | | - Whady Hueb
- Department of Atherosclerosis, Heart Institute (InCor), University of São Paulo, Avenida Doutor Enéas de Carvalho Aguiar 44, AB, Sala 114, Cerqueira César, 05403-000 São Paulo, SP, Brazil.
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Vieira de Melo RM, Hueb W, Rezende PC, Lima EG, Hueb AC, Ramires JAF, Kalil Filho R. On-pump versus off-pump coronary artery bypass surgery in patients older than 60 years: five-year follow-up of MASS III trial. J Cardiothorac Surg 2014; 9:127. [PMID: 25096030 PMCID: PMC4304776 DOI: 10.1186/1749-8090-9-136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 06/16/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aim to evaluate in-hospital events and long-term clinical outcomes in patients over 60 years of age with stable coronary artery disease and preserved left ventricular ejection fraction undergoing off-pump or on-pump coronary artery bypass grafting. METHODS The MASS III was a single-center randomized trial that evaluate 308 patients with stable coronary artery disease and preserved ventricular function assigned for: 155 to off-pump and 153 to on-pump CABG. Of this, 176 (58.3%) patients were 60 years or older at the time of randomization (90 of-pump and 86 on-pump). The primary short-term end point was a composite of myocardial infarction, stroke, and overall mortality occurring within 30 days after surgery or before discharge, whichever was later. The primary long-term end point was death from any cause within 5 years, non-fatal myocardial infarction between 30 days and 5 years, or additional revascularization between 30 days and 5 years. RESULTS On-pump CABG had a higher incidence of 30-day composite outcome than off-pump CABG (15,1% and 5.6%, respectively; P = 0.036). However, after the multivariate analysis, this association lost statistical significance, P = 0.05. After 5-year follow-up, there were no significant differences between both strategies of CABG in the composite end points 16.7% and 15.1%; Hazard Ratio 1.07; CI 0.41 - 1.82; P = 0.71, for off-pump and on-pump CABG respectively. CONCLUSIONS On-pump and off-pump CABG achieved similar results of combined events at short-term and 5-year follow-up. TRIAL REGISTRATION Clinical Trial Registration Information-URL: http://www.controlled-trials.com. REGISTRATION NUMBER ISRCTN59539154.
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Affiliation(s)
| | - Whady Hueb
- Heart Institute (InCor) University of Sao Paulo, Sao Paulo, Brazil.
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