Effect of continuous and interval exercise training on the PETCO2 response during a graded exercise test in patients with coronary artery disease

OBJECTIVE: The purpose of this study was to evaluate the following: 1) the effects of continuous exercise training and interval exercise training on the end-tidal carbon dioxide pressure (PETCO2) response during a graded exercise test in patients with coronary artery disease; and 2) the effects of exercise training modalities on the association between PETCO2 at the ventilatory anaerobic threshold (VAT) and indicators of ventilatory efficiency and cardiorespiratory fitness in patients with coronary artery disease. METHODS: Thirty-seven patients (59.7 +/- 1.7 years) with coronary artery disease were randomly divided into two groups: continuous exercise training (n = 20) and interval exercise training (n = 17). All patients performed a graded exercise test with respiratory gas analysis before and after three months of the exercise training program to determine the VAT, respiratory compensation point (RCP) and peak oxygen consumption. RESULTS: After the interventions, both groups exhibited increased cardiorespiratory fitness. Indeed, the continuous exercise and interval exercise training groups demonstrated increases in both ventilatory efficiency and PETCO2 values at VAT, RCP, and peak of exercise. Significant associations were observed in both groups: 1) continuous exercise training (PETCO(2)VAT and cardiorespiratory fitness r = 0.49; PETCO(2)VAT and ventilatory efficiency r = -0.80) and 2) interval exercise training (PETCO(2)VAT and cardiorespiratory fitness r = 0.39; PETCO(2)VAT and ventilatory efficiency r = -0.45). CONCLUSIONS: Both exercise training modalities showed similar increases in PETCO2 levels during a graded exercise test in patients with coronary artery disease, which may be associated with an improvement in ventilatory efficiency and cardiorespiratory fitness.

Phosphorus Is Associated with Coronary Artery Disease in Patients with Preserved Renal Function

High serum phosphorus levels have been associated with mortality and cardiovascular events in patients with chronic kidney disease and in the general population. In addition, high phosphorus levels have been shown to induce vascular calcification and endothelial dysfunction in vitro. The aim of this study was to evaluate the relation of phosphorus and coronary calcification and atherosclerosis in the setting of normal renal function. This was a cross-sectional study involving 290 patients with suspected coronary artery disease and undergoing elective coronary angiography, with a creatinine clearance >60 ml/min/1.73 m(2). Coronary artery obstruction was assessed by the Friesinger score and coronary artery calcification by multislice computed tomography. Serum phosphorus was higher in patients with an Agatston score >10 than in those with an Agatston score <= 10 (3.63 +/- 0.55 versus 3.49 +/- 0.52 mg/dl; p = 0.02). In the patients with Friesinger scores >4, serum phosphorus was higher (3.6 +/- 0.5 versus 3.5 +/- 0.6 mg/dl, p = 0.04) and median intact fibroblast growth factor 23 was lower (40.3 pg/ml versus 45.7 pg/ml, p = 0.01). Each 0.1-mg/dl higher serum phosphate was associated with a 7.4% higher odds of having a Friesinger score >4 (p = 0.03) and a 6.1% greater risk of having an Agatston score >10 (p = 0.01). Fibroblast growth factor 23 was a negative predictor of Friesinger score ( p = 0.002). In conclusion, phosphorus is positively associated with coronary artery calcification and obstruction in patients with suspected coronary artery disease and preserved renal function.

The association between coronary artery calcification progression and loss of bone density in non-dialyzed CKD patients

Background: Coronary artery calcification (CAC) and low bone density are coexisting deleterious conditions commonly shared by chronic kidney disease (CKD) patients. In the present study, we aimed to investigate whether the progression of CAC was associated with overtime reduction in bone density in non-dialyzed CKD patients. Methods: This is a prospective study of 24 months including 72 non-dialyzed CKD patients Stages 2 - 4 (age 57.6 +/- 10.3 years, 62% male, 22% diabetics). CAC and vertebral bone density (VBD) were measured by computed tomography. Results: At baseline, 46% of the patients had CAC (calcified group) and calcification was not identified in 54% of the patients (non-calcified group). The calcified group was older, predominantly male, and had lower VBD in comparison to non-calcified group. CAC progression was observed only in the calcified group (91% of the patients increased calcium score). The multiple regression analysis revealed loss of VBD as the independent determinant of CAC progression in these patients. Conclusion: CAC progression was associated with loss of VBD in non-dialyzed CKD patients.

Echocardiographic and hemodynamic determinants of right coronary artery flow reserve and phasic flow pattern in advanced non-ischemic cardiomyopathy

Abstract Background In patients with advanced non-ischemic cardiomyopathy (NIC), right-sided cardiac disturbances has prognostic implications. Right coronary artery (RCA) flow pattern and flow reserve (CFR) are not well known in this setting. The purpose of this study was to assess, in human advanced NIC, the RCA phasic flow pattern and CFR, also under right-sided cardiac disturbances, and compare with left coronary circulation. As well as to investigate any correlation between the cardiac structural, mechanical and hemodynamic parameters with RCA phasic flow pattern or CFR. Methods Twenty four patients with dilated severe NIC were evaluated non-invasively, even by echocardiography, and also by cardiac catheterization, inclusive with Swan-Ganz catheter. Intracoronary Doppler (Flowire) data was obtained in RCA and left anterior descendent coronary artery (LAD) before and after adenosine. Resting RCA phasic pattern (diastolic/systolic) was compared between subgroups with and without pulmonary hypertension, and with and without right ventricular (RV) dysfunction; and also with LAD. RCA-CFR was compared with LAD, as well as in those subgroups. Pearson's correlation analysis was accomplished among echocardiographic (including LV fractional shortening, mass index, end systolic wall stress) more hemodynamic parameters with RCA phasic flow pattern or RCA-CFR. Results LV fractional shortening and end diastolic diameter were 15.3 ± 3.5 % and 69.4 ± 12.2 mm. Resting RCA phasic pattern had no difference comparing subgroups with vs. without pulmonary hypertension (1.45 vs. 1.29, p = NS) either with vs. without RV dysfunction (1.47 vs. 1.23, p = NS); RCA vs. LAD was 1.35 vs. 2.85 (p < 0.001). It had no significant correlation among any cardiac mechanical or hemodynamic parameter with RCA-CFR or RCA flow pattern. RCA-CFR had no difference compared with LAD (3.38 vs. 3.34, p = NS), as well as in pulmonary hypertension (3.09 vs. 3.10, p = NS) either in RV dysfunction (3.06 vs. 3.22, p = NS) subgroups. Conclusion In patients with chronic advanced NIC, RCA phasic flow pattern has a mild diastolic predominance, less marked than in LAD, with no effects from pulmonary artery hypertension or RV dysfunction. There is no significant correlation between any cardiac mechanical-structural or hemodynamic parameter with RCA-CFR or RCA phasic flow pattern. RCA flow reserve is still similar to LAD, independently of those right-sided cardiac disturbances.

Diagnosis and treatment of coronary artery disease in hemodialysis patients evaluated for transplant

We present a review of current strategies for the diagnosis and treatment of coronary artery disease (CAD) in patients with advanced chronic kidney disease who are on the waiting list for transplants, based on data from the literature and originated from a single-center cohort of 1,250 patients with maximum follow-up of 12 years. We discuss the best way to select patients to be tested for CAD, how to choose the more adequate screening test for CAD and cardiovascular disease, how to select patients for invasive treatment studies and how to treat patients with significant CAD. We also suggest new research avenues to be explored to resolve some problems in this area.

Clinical evolution of patients hospitalized due to the first episode of Acute Coronary Syndrome

AIM: to assess the clinical evolution of patients hospitalized due to the first episode of Acute Coronary Syndrome (ACS) according to its clinical manifestation. METHODS: data were collected from 234 patients, hospitalized between May 2006 and July 2009 due to the first episode of an ACS, by consulting their medical records. RESULTS: 234 patients were hospitalized, 140 (59.8%) due to Acute Myocardial Infarction (AMI). In the group with AMI, 19.3% presented complications, against 12.8% in the group with Unstable Angina (UA) (p=0.19). Angioplasty levels were higher among patients with AMI than with UA (p=0.02) and coronary artery bypass graft surgery was more frequent among UA patients (p=0.03). The majority (227; 97%) survived after the coronary event. Among the seven patients who died during the hospitalization, four had AMI (2.9%) and three UA (3.2%). CONCLUSIONS: A larger number of complications were found among infarction victims and the accomplishment of coronary artery bypass graft surgery differed between the groups.

Adaptive immunity is related to coronary artery disease severity after acute coronary syndrome in subjects with metabolic syndrome

Metabolic syndrome (MetS) is an inflammatory state associated with high coronary disease risk. Inflammation and adaptive immunity modulate atherosclerosis and plaque instability. We examined early changes in anti-oxidized lowdensity lipoprotein (LDL) (anti-oxLDL) autoantibodies (Abs) in patients with MetS after an acute coronary syndrome (ACS). Patients of both genders (n=116) with MetS were prospectively included after an acute yocardial infarction (MI) or hospitalization due to unstable angina. Anti-oxLDL Abs (IgG class) were assayed at baseline, three and six weeks after ACS. The severity of coronary disease was evaluated by the Gensini score. We observed a decrease in anti-oxLDL Abs titers (p<0.002 vs. baseline), mainly in males (p=0.01), in those under 65 y (p=0.03), and in subjects with Gensini score above median (p=0.04). In conclusion, early decrease in circulating anti-oxLDL Abs is associated with coronary disease severity among subjects with MetS.

The Future REvascularization Evaluation in patients with Diabetes mellitus: Optimal management of Multivessel disease (FREEDOM) trial: Clinical and angiographic profile at study entry

Background The optimal revascularization strategy for diabetic patients with multivessel coronary artery disease (MVD) remains uncertain for lack of an adequately powered, randomized trial. The FREEDOM trial was designed to compare contemporary coronary artery bypass grafting (CABG) to percutaneous coronary intervention (PCI) with drug-eluting stents in diabetic patients with MVD against a background of optimal medical therapy. Methods A total of 1,900 diabetic participants with MVD were randomized to PCI or CABG worldwide from April 2005 to March 2010. FREEDOM is a superiority trial with a mean follow-up of 4.37 years (minimum 2 years) and 80% power to detect a 27.0% relative reduction. We present the baseline characteristics of patients screened and randomized, and provide a comparison with other MVD trials involving diabetic patients. Results The randomized cohort was 63.1 +/- 9.1 years old and 29% female, with a median diabetes duration of 10.2 +/- 8.9 years. Most (83%) had 3-vessel disease and on average took 5.5 +/- 1.7 vascular medications, with 32% on insulin therapy. Nearly all had hypertension and/or dyslipidemia, and 26% had a prior myocardial infarction. Mean hemoglobin A1c was 7.8 +/- 1.7 mg/dL, 29% had low-density lipoprotein <70 mg/dL, and mean systolic blood pressure was 134 +/- 20 mm Hg. The mean SYNTAX score was 26.2 with a symmetric distribution. FREEDOM trial participants have baseline characteristics similar to those of contemporary multivessel and diabetes trial cohorts. Conclusions The FREEDOM trial has successfully recruited a high-risk diabetic MVD cohort. Follow-up efforts include aggressive monitoring to optimize background risk factor control. FREEDOM will contribute significantly to the PCI versus CABG debate in diabetic patients with MVD. (Am Heart J 2012;164:591-9.)

Fatores de risco pré-operatórios para mediastinite após cirurgia cardíaca: análise de 2768 pacientes

INTRODUÇÃO: A esternotomia mediana longitudinal é a via de acesso mais utilizada no tratamento das doenças cardíacas. As infecções profundas da ferida operatória no pós-operatório das cirurgias cardiovasculares são uma complicação séria, com alto custo durante o tratamento. Diferentes estudos têm encontrado fatores de risco para o desenvolvimento de mediastinite e as variáveis pré-operatórias têm tido especial destaque. OBJETIVO: O objetivo deste estudo é identificar fatores de risco pré-operatórios para o desenvolvimento de mediastinite em pacientes submetidos a revascularização do miocárdio e a substituição valvar. MÉTODOS: Este estudo observacional representa uma coorte de 2768 pacientes operados consecutivamente. O período considerado para análise foi de maio de 2007 a maio de 2009 e não houve critérios de exclusão. Foi realizada análise univariada e multivariada pelo modelo de regressão logística das 38 variáveis pré-operatórias eleitas. RESULTADOS: Nesta série, 35 (1,3%) pacientes evoluíram com mediastinite e 19 (0,7%) com osteomielite associada. A idade média dos pacientes foi de 59,9 ± 13,5 anos e o EuroSCORE de 4,5 ± 3,6. A mortalidade hospitalar foi de 42,8%. Na análise multivariada, foram identificadas três variáveis como preditoras independentes de mediastinite: balão intra-aórtico (OR 5,41, 95% IC [1,83 -16,01], P=0,002), hemodiálise (OR 4,87, 95% IC [1,41 - 16,86], P=0,012) e intervenção vascular extracardíaca (OR 4,39, 95% IC [1,64 - 11,76], P=0,003). CONCLUSÃO: O presente estudo demonstrou que necessidade do suporte hemodinâmico pré-operatório com balão intra-aórtico, hemodiálise e intervenção vascular extracardíaca são fatores de risco para o desenvolvimento de mediastinite após cirurgia cardíaca.

Strategies for Multivessel Revascularization in Patients with Diabetes

BACKGROUND In some randomized trials comparing revascularization strategies for patients with diabetes, coronary-artery bypass grafting (CABG) has had a better outcome than percutaneous coronary intervention (PCI). We sought to discover whether aggressive medical therapy and the use of drug-eluting stents could alter the revascularization approach for patients with diabetes and multivessel coronary artery disease. METHODS In this randomized trial, we assigned patients with diabetes and multivessel coronary artery disease to undergo either PCI with drug-eluting stents or CABG. The patients were followed for a minimum of 2 years (median among survivors, 3.8 years). All patients were prescribed currently recommended medical therapies for the control of low-density lipoprotein cholesterol, systolic blood pressure, and glycated hemoglobin. The primary outcome measure was a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke. RESULTS From 2005 through 2010, we enrolled 1900 patients at 140 international centers. The patients' mean age was 63.1 +/- 9.1 years, 29% were women, and 83% had three-vessel disease. The primary outcome occurred more frequently in the PCI group (P=0.005), with 5-year rates of 26.6% in the PCI group and 18.7% in the CABG group. The benefit of CABG was driven by differences in rates of both myocardial infarction (P<0.001) and death from any cause (P=0.049). Stroke was more frequent in the CABG group, with 5-year rates of 2.4% in the PCI group and 5.2% in the CABG group (P=0.03). CONCLUSIONS For patients with diabetes and advanced coronary artery disease, CABG was superior to PCI in that it significantly reduced rates of death and myocardial infarction, with a higher rate of stroke. (Funded by the National Heart, Lung, and Blood Institute and others; FREEDOM ClinicalTrials.gov number, NCT00086450.)

Alveolar recruitment maneuver in refractory hypoxemia and lobar atelectasis after cardiac surgery: A case report

Abstract Objective This case report describes an unusual presentation of right upper lobe atelectasis associated with refractory hypoxemia to conventional alveolar recruitment maneuvers in a patient soon after coronary artery bypass grafting surgery. Method Results The alveolar recruitment with PEEP = 40cmH2O improved the patient’s atelectasis and hypoxemia. Conclusion In the present report, the unusual alveolar recruitment maneuver with PEEP 40cmH2O showed to be safe and efficient to reverse refractory hypoxemia and uncommon atelectasis in a patient after cardiac surgery.

Influência da posição do dreno pleural na função pulmonar de pacientes submetidos à revascularização do miocárdio

JUSTIFICATIVA E OBJETIVOS: Estudo longitudinal, prospectivo, aleatório e encoberto para avaliar a influência do local de inserção do dreno pleural, de PVC atóxico, na função pulmonar e na dor pós-operatória dos pacientes submetidos à revascularização do miocárdio nos três primeiros dias pós-cirúrgicos e logo após a retirada do dreno. PACIENTES E MÉTODOS: Trinta e seis pacientes escalados para cirurgia eletiva de revascularização do miocárdio, com uso de circulação extracorpórea (CEC), em dois grupos: grupo SX (dreno subxifoide) e grupo IC (dreno intercostal). Feitos registros espirométricos, da gasometria arterial e da dor. RESULTADOS: Trinta e um pacientes analisados, 16 no grupo SX e 15 no grupo IC. O grupo SX apresentou valores espirométricos maiores do que o grupo IC (p < 0,05) no pós-operatório (PO), denotando menor influência do local do dreno na respiração. A PaO2 arterial no segundo PO aumentou significantemente no grupo SX quando comparada com o grupo IC (p < 0,0188). A intensidade da dor no grupo SX, antes e após a espirometria, era menor do que no grupo IC (p < 0,005). Houve aumento significativo dos valores espirométricos em ambos os grupos após a retirada do dreno pleural. CONCLUSÃO: A inserção do dreno na região subxifoide altera menos a função pulmonar, provoca menos desconforto e possibilita uma melhor recuperação dos parâmetros respiratórios.

Intervenção Coronariana Percutânea prévia como fator de risco para Revascularização Miocárdica

FUNDAMENTO: A Intervenção Coronariana Percutânea (ICP) vem aumentando na doença arterial coronariana crônica. Consequentemente, cada vez mais pacientes submetidos a Cirurgia de Revascularização Miocárdica (CRM) apresentam stent coronariano. OBJETIVO: Avaliar a influência do antecedente de stent coronariano na mortalidade hospitalar após CRM. MÉTODOS: Análise prospectiva com 1.099 pacientes consecutivos submetidos a CRM com circulação extracorpórea, entre maio/2007 e junho/2009. Pacientes sem ICP prévia (n = 938; 85,3%) foram comparados com pacientes com ICP prévia (n = 161; 14,6%), utilizando modelos de regressão logística e análise de pareamento de amostras. RESULTADOS: Ambos os grupos apresentavam semelhança em relação aos fatores de risco, exceto pela maior presença de pacientes com angina instável no grupo com ICP prévia (16,1% vs. 9,9%; p = 0,019). A mortalidade hospitalar após CRM foi maior entre os pacientes com ICP prévia (9,3% vs. 5,1%, p = 0,034), e foi semelhante à esperada em relação ao EuroSCORE e ao 2000 Bernstein-Parsonnet score. Na análise com regressão logística multivariada a ICP prévia emergiu como fator de risco independente para mortalidade hospitalar pós-operatória (odds ratio 1,94; IC 95% 1,02-3,68; p = 0,044) tão forte quanto diabetes (odds ratio 1,86; IC 95% 1,07-3,24; p = 0,028). Após o pareamento dos grupos, a mortalidade hospitalar continuou sendo maior entre os pacientes com ICP prévia, com odds ratio 3,46 ; IC 95% 1,10-10,93; p = 0,034. CONCLUSÃO: A ICP prévia em pacientes com doença coronariana multiarterial é fator de risco independente para mortalidade hospitalar após CRM. Tal fato deve ser considerado quando a ICP for indicada como alternativa inicial em pacientes com doença arterial coronariana mais avançada. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)