Can patients with left main coronary artery disease wait for myocardial revascularization surgery?

OBJECTIVE: To assess the occurrence of cardiac events in patients diagnosed with left main coronary artery disease on diagnostic cardiac catheterization and waiting for myocardial revascularization surgery. METHODS: All patients diagnosed with left main coronary artery disease (stenosis > or = 50%) consecutively identified on diagnostic cardiac catheterization during an 8-month period were selected for the study. The group comprised 56 patients (40 males and 16 females) with a mean age of 61±10 years. The cardiac events included death, nonfatal acute myocardial infarction, acute left ventricular failure, unstable angina, and emergency surgery. RESULTS: While waiting for surgery, patients experienced the following cardiac events: 7 acute myocardial infarctions and 1 death. All events occurred within the first 60 days after the diagnostic cardiac catheterization. More patients, whose indication for diagnostic cardiac catheterization was unstable angina, experienced events as compared with those with other indications [p=0.03, relative risk (RR) = 5.25, 95% confidence interval = 1.47 - 18.7]. In the multivariate analysis of logistic regression, unstable angina was also the only factor that independently contributed to a greater number of events (p = 0.02, OR = 8.43, 95% CI =1.37 - 51.7). CONCLUSION: Unstable angina in patients with left main coronary artery disease acts as a high risk factor for cardiac events, emergency surgery being recommended in these cases.

Dual anterior descending coronary artery associated with coronary artery disease

The patient is a male with risk factors for coronary artery disease, who was referred for cardiac catheterization after acute myocardial infarction in the inferior wall. The patient underwent transluminal coronary angioplasty in the right coronary artery with successful stent implantation.

Coronary heart disease clinical manifestation and risk factors in Japanese immigrants and their descendents in the city of São Paulo

OBJECTIVE: To assess whether a difference exists in coronary heart disease clinical manifestations and the prevalence of risk factors between Japanese immigrants and their descendents in the city of São Paulo. METHODS: Retrospective analysis of coronary artery disease clinical manifestations and the prevalence of risk factors, comparing 128 Japanese immigrants (Japanese group) with 304 Japanese descendents (Nisei group). RESULTS: The initial manifestation of the disease was earlier in the Nisei group (mean = 53 years), a difference of 12 years when compared with that in the Japanese group (mean = 65 years) (P<0.001). Myocardial infarction was the first manifestation in both groups (P = 0.83). The following parameters were independently associated with early coronary events: smoking (OR = 2.25; 95% CI = 1.35-3.77; P<0.002); Nisei group (OR = 10.22; 95% CI = 5.64-18.5; P<0.001); and female sex (OR = 5.04; 95% CI = 2.66-9.52; P<0.001). CONCLUSION: The clinical presentation of coronary heart disease in the Japanese and their descendents in the city of São Paulo was similar, but coronary heart disease onset occurred approximately 12 years earlier in the Nisei group than in the Japanese group.

Kawasaki disease: involution of giant coronary aneurysms after prolonged anti-inflammatory treatment

The patient is a 5-year-old male with Kawasaki disease, whose involution of giant aneurysms of the left coronary arteries was surprising after a prolonged period of treatment, which lasted 80 uninterrupted days and comprised anti-inflammatory drugs associated with anticoagulation agents. The distal diameters of the anterior interventricular, the diagonal, and the circumflex arteries normalized by the end of the treatment. A residual giant aneurysm localized at the beginning of the anterior interventricular artery did not cause ischemia. Continuation of the medication for a prolonged period was recommended.

Comparison of immediate results and follow-up of patients with single-vessel and multivessel coronary artery disease younger than 50 years of age undergoing coronary stent implantation

OBJECTIVE: To assess the in-hospital results and clinical follow-up of young patients (< 50 years) with multivessel coronary artery disease undergoing stent implantation in native coronary arteries and to compare their results with those of patients with single-vessel coronary artery disease. METHODS: We retrospectively studied 462 patients undergoing coronary stent implantation. Patients were divided into 2 groups: group I (G-I) - 388 (84%) patients with single-vessel coronary artery disease; and group II (G-II) - 74 (16%) patients with multivessel coronary artery disease. RESULTS: The mean age of the patients was 45±4.9 years, and the clinical findings at presentation and demographic data were similar in both groups. The rate of clinical success was 95% in G-I and 95.8% in G-II (P=0.96), with no difference in regard to in-hospital evolution between the groups. Death, acute myocardial infarction, and the need for myocardial revascularization during clinical follow-up occurred in 10.1% and 11.2% (P=0.92) in G-I and G-II, respectively. By the end of 24 months, the actuarial analysis showed an event-free survival of 84.6 % in G-I and 81.1% in G-II (P=0.57). CONCLUSION: Percutaneous treatment with coronary stent implantation in young patients with multivessel disease may be safe with a high rate of clinical success, a low incidence of in-hospital complications, and a favorable evolution in clinical follow-up.

Quantifying the risk of coronary artery disease in a community: The Bambuí Project

OBJECTIVE: To determine the coronary risk profile in adults and elderly in a community. METHODS: The study comprised a sample of adults (30-59 years, n=547) and the entire elderly population (60-74 years, n=1165) residing in Bambuí town, Brazil. The Framingham score based on sex, age, smoking, diabetes mellitus, systolic and diastolic blood pressure, total cholesterol, and HDL-C was used. The score based on age and sex was defined as "expected" and compared with the mean score obtained by the sum of all risk factors in each age group and sex (score "observed"). RESULTS: The difference between the scores "observed" and "expected" increased with aging in both sexes. Smoking increased the difference from 30 years of age onwards, in both sexes, and hypertension was important in men above the age of 30 years and in women above the age of 50 years. Diabetes and elevated total cholesterol increased the risk of the disease above the age of 50 years in both sexes. A higher level of HDL-C reduced the risk among men above the age of 30 years, with no significant difference among women. Less schooling (< 4 years versus ³ 4 years) was associated with a higher score in adults of both sexes, but not among the elderly. CONCLUSION: Based on these results, in the community studied, the risk of coronary artery disease may be reduced up to 44% in men and 38% in women.

Tai Chi Chuan for Cardiac Rehabilitation in Patients with Coronary Arterial Disease

Background:Several studies have shown that Tai Chi Chuan can improve cardiac function in patients with heart disease.Objective:To conduct a systematic review of the literature to assess the effects of Tai Chi Chuan on cardiac rehabilitation for patients with coronary artery disease.Methods:We performed a search for studies published in English, Portuguese and Spanish in the following databases: MEDLINE, EMBASE, LILACS and Cochrane Register of Controlled Trials. Data were extracted in a standardized manner by three independent investigators, who were responsible for assessing the methodological quality of the manuscripts.Results:The initial search found 201 studies that, after review of titles and abstracts, resulted in a selection of 12 manuscripts. They were fully analyzed and of these, nine were excluded. As a final result, three randomized controlled trials remained. The studies analyzed in this systematic review included patients with a confirmed diagnosis of coronary artery disease, all were clinically stable and able to exercise. The three experiments had a control group that practiced structured exercise training or received counseling for exercise. Follow-up ranged from 2 to 12 months.Conclusion:Preliminary evidence suggests that Tai Chi Chuan can be an unconventional form of cardiac rehabilitation, being an adjunctive therapy in the treatment of patients with stable coronary artery disease. However, the methodological quality of the included articles and the small sample sizes clearly indicate that new randomized controlled trials are needed in this regard.

Association of Aortic Valve Sclerosis with Previous Coronary Artery Disease and Risk Factors

Background: Aortic valve sclerosis (AVS) is characterized by increased thickness, calcification and stiffness of the aortic leaflets without fusion of the commissures. Several studies show an association between AVS and presence of coronary artery disease. Objective: The aim of this study is to investigate the association between presence of AVS with occurrence of previous coronary artery disease and classical risk factors. Methods: The sample was composed of 2,493 individuals who underwent transthoracic echocardiography between August 2011 and December 2012. The mean age of the cohort was 67.5 ± 15.9 years, and 50.7% were female. Results: The most frequent clinical indication for Doppler echocardiography was the presence of stroke (28.8%), and the most common risk factor was hypertension (60.8%). The most prevalent pathological findings on Doppler echocardiography were mitral valve sclerosis (37.1%) and AVS (36.7%). There was a statistically significant association between AVS with hypertension (p < 0.001), myocardial infarction (p = 0.007), diabetes (p = 0.006) and compromised left ventricular systolic function (p < 0.001). Conclusion: Patients with AVS have higher prevalences of hypertension, stroke, hypercholesterolemia, myocardial infarction, diabetes and compromised left ventricular systolic function when compared with patients without AVS. We conclude that there is an association between presence of AVS with previous coronary artery disease and classical risk factors.

Biomarkers in Cardiology - Part 2: In Coronary Heart Disease, Valve Disease and Special Situations

Cardiovascular diseases are the main causes of mortality and morbidity in Brazil. Their primary and secondary preventions are a priority for the health system and require multiple approaches for increased effectiveness. Biomarkers are tools used to identify with greater accuracy high-risk individuals, establish a faster diagnosis, guide treatment, and determine prognosis. This review aims to highlight the importance of biomarkers in clinical cardiology practice and raise relevant points regarding their application and perspectives for the next few years. This document was divided into two parts. This second part addresses the application of biomarkers in coronary heart disease, valvular diseases, cardio-oncology, pulmonary embolism, and cardiorenal syndrome.

HFE gene mutations in coronary atherothrombotic disease

Although iron can catalyze the production of free radicals involved in LDL lipid peroxidation, the contribution of iron overload to atherosclerosis remains controversial. The description of two mutations in the HFE gene (Cys282Tyr and His63Asp) related to hereditary hemochromatosis provides an opportunity to address the question of the association between iron overload and atherosclerosis. We investigated the prevalence of HFE mutations in 160 survivors of myocardial infarction with angiographically demonstrated severe coronary atherosclerotic disease, and in 160 age-, gender- and race-matched healthy control subjects. PCR amplification of genomic DNA followed by RsaI and BclI restriction enzyme digestion was used to determine the genotypes. The frequency of the mutant Cys282Tyr allele was identical among patients and controls (0.022; carrier frequency, 4.4%), whereas the mutant His63Asp allele had a frequency of 0.143 (carrier frequency, 27.5%) in controls and of 0.134 (carrier frequency, 24.5%) in patients. Compound heterozygotes were found in 2 of 160 (1.2%) controls and in 1 of 160 (0.6%) patients. The finding of a similar prevalence of Cys282Tyr and His63Asp mutations in the HFE gene among controls and patients with coronary atherothrombotic disease, indirectly questions the possibility of an association between hereditary hemochromatosis and atherosclerosis.

Prevalence of peripheral arterial occlusive disease in patients referred to a tertiary care hospital in Salvador, Bahia, Brazil, for coronary angiography

The presence of peripheral arterial occlusive disease increases the morbidity and mortality of patients with coronary artery disease. The objective of the present study was to calculate the prevalence of peripheral arterial occlusive disease in patients referred for coronary angiography. This prevalence study was carried out at the Hemodynamics Unit of Hospital Santa Isabel, Salvador, Brazil, from December 2004 to April 2005. After approval by the Ethics Committee of the hospital, 397 patients with angiographic signs of coronary artery disease were enrolled. Diagnosis of peripheral arterial occlusive disease was made using the ankle-brachial blood pressure index (£0.90). Statistical analyses were performed using the z test and a level of significance of a = 5%, 95%CI, the chi-square test and t-test, and multiple logistic regression analysis. The prevalence of peripheral arterial occlusive disease was 34.3% (95%CI: 29.4-38.9). Mean age was 65.7 ± 9.4 years for patients with peripheral arterial occlusive disease, and 60.3 ± 9.8 years for patients without peripheral arterial occlusive disease (P = 0.0000003). The prevalence of peripheral arterial occlusive disease was 1.57 times greater in patients with hypertension (P = 0.007) and 2.91 times greater in patients with coronary stenosis ³50% (P = 0.002). Illiterate patients and those with little education had a 44% higher chance of presenting peripheral arterial occlusive disease probably as a result of public health prevention policies of limited effectiveness. The prevalence of peripheral arterial occlusive disease in patients referred to a tertiary care hospital in Salvador, Bahia, for coronary angiography, was 34.3%.