Angina Pectoris – ABC CARDIOL

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Original Article

Five-Year Mortality among Survivors of Coronary Artery Bypass Graft Surgery: A Retrospective Study from a Tertiary Center

Eduardo Martelli Moreira et al. Bernadette Cunha Waldvogel Eduardo Bello Martins Desiderio Favarato … Eduardo Gomes Lima Fabio Grunspun Pitta Fabiana Hanna Rached Henrique Trombini Pinesi Omar Asdrúbal Vilca Mejia Carlos Vicente Serrano Jr

Background

Long-term outcome data following Coronary Artery Bypass Graft (CABG) surgery in Brazil remain limited, yet are essential for informing public health policies and guiding clinical practice.

Objectives

To estimate five-year all-cause and cause-specific mortality rates in patients undergoing CABG and to identify associated risk factors.

Methods

A retrospective analysis of 6,933 patients who underwent CABG at the Heart Institute, Faculty of Medicine, University of São Paulo, between 2007 and 2018. Mortality data up to 2018 were retrieved from government databases. A significance level of 5% was adopted.

Results

The study cohort included 4,854 men (72%) with a median age of 63 years (IQR: 57–70). Diabetes mellitus was present in 2,984 patients (43%), and 1,918 (29%) had chronic kidney disease. During follow-up, 1,075 deaths occurred, of which 506 (47.1%) were attributed to cardiovascular causes. The 5-year all-cause mortality rate was 12.9% (95% CI: 11.9–13.9), and the cardiovascular mortality rate was 5.7% (95% CI: 5.1–6.4). The leading cause of cardiovascular death was ischemic heart disease (290 deaths, 57.3%), followed by cerebrovascular disease (84 deaths, 16.6%). Factors significantly associated with all-cause mortality included older age, diabetes mellitus, glomerular filtration rate, HDL-cholesterol, left ventricular ejection fraction, left atrial and left ventricular diastolic dimensions, urgent hospitalization, on-pump surgery, and length of hospital stay.

Conclusion

Patients undergoing CABG at a tertiary care center exhibited moderate 5-year all-cause and cardiovascular mortality rates. These findings highlight key prognostic factors that may support risk stratification and guide postoperative management strategies.

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Review Article

Coronary Sinus Reduction for the Treatment of Refractory Angina: What Have We Learned after 70 Years of the Beck Surgery?

Sara Del Vecchio Ziotti et al. Luciana Oliveira Cascaes Dourado Ranil de Silva Rasha Al-Lamee … Timothy D. Henry Luiz Antonio Machado Cesar Carlos Vicente Serrano Jr. Alexandre Antonio Cunha Abizaid Luis Henrique Wolff Gowdak

Abstract

With the increasing prevalence of chronic coronary syndromes, many patients with extensive atherosclerosis experience uncontrolled angina, even while receiving optimal medical therapy. This is especially true for patients who are not suitable candidates for surgical or percutaneous revascularization. Numerous treatments have been investigated for managing angina pectoris, and in this context, the coronary sinus reducer has emerged as a promising therapeutic option. Since the 1950s, beginning with Beck’s surgery, the coronary venous sinus has been a focal point of research in anti-ischemic therapies.

Significant scientific advances have been made in narrowing the venous sinus in the past two decades. Thanks to technological improvements in minimally invasive procedures and better methods for assessing myocardial blood flow, a new therapeutic option has become available for patients suffering from refractory angina and, possibly, for microvascular dysfunction.

In this review, we aim to examine key concepts related to angina pectoris and myocardial ischemia, highlighting the historical background, pathophysiological rationale, and technical aspects of coronary sinus reduction as a therapy for refractory angina. Additionally, we will explore the scientific evidence from recent decades, as well as identify existing gaps and outline future research directions concerning this emerging treatment.

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Original Article

Allopurinol versus Trimetazidine for the Treatment of Angina: A Randomized Clinical Trial

Tainá Viana et al. Rodrigo Morel Vieira de Melo Diogo Freitas Cardoso Azevedo Clara Salles Figueiredo … Gustavo Santana Luanna Mota Damasceno Luisa Latado Ludmila Tambuque Raissa Barreto Luiz Carlos Santana Passos

Abstract

Background

Recently, it was demonstrated that allopurinol, a xanthine oxidase inhibitor, has cardiovascular and anti-ischaemic properties and may be a metabolic antianginal agent option.Objective: The objective of this study was to evaluate the antianginal effect of allopurinol as a third drug for patients with stable coronary artery disease (CAD).

Methods

This was a randomized clinical trial between 2018 and 2020 including patients with CAD who maintained angina despite initial optimization with beta-blockers and calcium channel blockers. The individuals were randomized 1:1 to 300 mg of allopurinol twice daily or 35 mg of trimetazidine twice daily. The main outcome was the difference in the angina frequency domain of the Seattle Angina Questionnaire (SAQ-AF). A probability (p) value < 0.05 was considered statistically significant.

Results

A hundred and eight patients were included in the randomization phase, with 54 (50%) in the allopurinol group and 54 (50%) in the trimetazidine group. Six (5.6%) individuals, 3 from each group, were lost to follow-up for the primary outcome. In the allopurinol and trimetazidine groups, the median SAQ-AF scores were 50 (30.0 to 70.0) and 50 (21.3 to 78.3), respectively. In both groups, the SAQ-AF score improved, but the median of the difference compared to baseline was lower in the allopurinol group (10 [0 to 30] versus 20 [10 to 40]; p < 0.001), as was the mean of the difference in the total SAQ score (12.8 ± 17.8 versus 21.2 ± 15.9; p = 0.014).

Conclusion

Both allopurinol and trimetazidine improved the control of angina symptoms; however, trimetazidine presented a greater gain compared to baseline. Brazilian Registry of Clinical Trials – Registration Number RBR-5kh98y

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Viewpoint

Angina Pectoris and Orbita 2 Trial: Reflections on the Future of Angina Treatment

Eduardo Bello Martins et al. Eduardo Gomes Lima Jaime Paula Pessoa Linhares Filho Henrique Trombini Pinesi … Fabio Grunspun Pitta Carlos Vicente Serrano Júnior

The ORBITA trial

Although the above-mentioned studies have demonstrated some improvement in angina after myocardial revascularization, one of their major limitations is the open nature and a possible placebo effect. In this regard, the ORBITA study showed no benefit of PCI versus a placebo procedure on the primary end-point of an increase in exercise time. ORBITA was a well conducted study that demonstrated the possibility of a placebo component and lack of symptom improvement by PCI. However, several limitations could have influenced these results and have been discussed in the literature, such as the fact that it included patients with non-limiting symptoms, no ischemia in almost a quarter of the participants and short follow-up.

In 2023, the ORBITA 2 trial was finally published in NEJM and addressed for the first time the PCI as a monotherapy for angina relief at a placebo-controlled trial. It provides another piece of the puzzle of angina control and overcomes some of the first ORBITA limitations. ORBITA 2 was an investigator-initiated, multicenter, double-blind, randomized, placebo-controlled trial that was conducted at 14 sites in the United Kingdom and included 301 participants. Patients enrolled had angina or equivalent symptoms, anatomic evidence of severe coronary stenosis and objective evidence of ischemia based on noninvasive imaging or invasive coronary physiology testing. First, antianginal medications were discontinued (median number of antianginal drugs was only 1) and the participants were instructed to use a dedicated smartphone application to report the presence or absence of angina and the number of angina episodes daily. Patients also completed validated questionnaires on symptoms and quality of life. The Canadian Cardiovascular Society (CCS) functional classification was assessed, treadmill exercise test and dobutamine stress echocardiography were also performed. The patients then entered a two-week pre-randomization period during which they reported the number of episodes of angina daily, through the smartphone application. Patients were eligible to proceed to randomization if they reported at least one episode of angina during the symptom assessment phase.

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Viewpoint

Coronary Artery Microfistulas: Historical Description and Contemporary Clinical Relevance

Stans Murad Netto et al. Rachel Vianna O'Neill de Souza Victor Murad Evandro Tinoco Mesquita

Introduction

Coronary microfistula was initially described as an anatomical finding in the late 1960s by Murad and colleagues, and it was later recognized as a morphofunctional abnormality of the coronary arteries capable of causing clinical findings (). This often asymptomatic entity is still poorly recognized in clinical practice, although it can be readily identified in the catheterization laboratory, cineangiography studies, and more recently by coronary CT angiography.

Initially, this condition was not taken into consideration, and it was justified as a possible “error” in cineangiography technique. Different studies have demonstrated its existence and its potential as a nosological entity responsible for myocardial ischemia, cardiac chamber overload, arrhythmias, and even heart failure.^,

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Original Article

Two-Year Follow-Up of Chronic Ischemic Heart Disease Patients in a Specialized Center in Brazil

Eduardo Martelli Moreira et al. Henrique Trombini Pinesi Eduardo Bello Martins Fábio Grunspun Pitta … Paula Mathias Paulino Bolta Carlos Alexandre Wainrober Segre Desiderio Favarato Fabiana Hanna Rached Whady Armindo Hueb Eduardo Gomes Lima Roberto Kalil Filho Cibele Larrosa Garzillo Carlos Vicente Serrano Jr

Abstract

Background

The incidence of cardiovascular events in patients with chronic ischemic heart disease (CIHD) may vary significantly among countries. Although populous, Brazil is often underrepresented in international records.

Objectives

This study aimed to describe the quality of care and the two-year incidence of cardiovascular events and associated prognostic factors in CIHD patients in a tertiary public health care center in Brazil.

Methods

Patients with CIHD who reported for clinical evaluation at Instituto do Coração (São Paulo, Brazil) were registered and followed for two years. The primary endpoint was a composite of myocardial infarction (MI), stroke, or death. A significance level of 0.05 was adopted.

Results

From January 2016 to December 2018, 625 participants were included in the study. Baseline characteristics show that 33.1% were women, median age 66.1 [59.6 – 71.9], 48.6% had diabetes, 83.1% had hypertension, 62.6% had previous MI, and 70.4% went through some revascularization procedure. At a median follow-up (FU) of 881 days, we noted 37 (7.05%) primary endpoints. After adjustments, age, previous stroke, and LDL-cholesterol were independently associated with the primary endpoint. Comparing baseline versus FU, participants experienced relief of angina based on the Canadian Cardiovascular Society (CCS) scale according to the following percentages: 65.7% vs. 81.7% were asymptomatic and 4.2% vs. 2.9% CCS 3 or 4 (p < 0.001). They also experienced better quality of medication prescription: 65.8% vs. 73.6% (p < 0.001). However, there was no improvement in LDL-cholesterol or blood pressure control.

Conclusion

This study shows that CIHD patients had a two-year incidence of the primary composite endpoint of 7.05%, and the reduction of LDL-cholesterol was the only modifiable risk factor associated with prognosis.

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Research Letter

In the Cardiac Rehabilitation Era, is There a “No-Option” Refractory Angina Patient?: A Case Report

Luciana Oliveira Cascaes Dourado et al. Camila Paixão Jordão Camila Regina Alves Assumpção Luciana Diniz Nagem Janot de Matos

Abstract

Exercise-based cardiac rehabilitation, an effective and safe adjuvant treatment recommended to patients with coronary artery disease, is scarcely applied to patients with refractory angina (RA) due to difficulties related to safety, trainning prescription and their clinical management. This case report presents an instance of a “no-option” patient with RA, who was included in a 12-week exercise program, in sessions consisted of 40 minutes of treadmill aerobic exercise, three times a week, and intensity prescribed between ischemic/angina threshold and ventilatory threshold 1, obtained in the cardiopulmonary exercise test; mild to moderate angina was allowed during training. Furthermore, 15 minutes of moderate-intensity resistance training (large group muscle exercises, two sets of 8 to 12 repetitions) was performed. At the end of the protocol, the patient presented an important improvement in functional performance (VO ₂ peak 17.0 ml/kg/min to 27.3 ml/kg/min), angina threshold (HR 68 bpm to 95 bpm), and intensity chest pain (levels 7 to 5) with no clinical adverse events during the period. Exercise-based cardiac rehabilitation was safe, even in the occurrence of angina/ischemia during training, according to tolerability to symptoms and other warning clinical signs.

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Editorial

Myocardial Bridge: Friend, Enemy, or Frenemy?

Biljana Parapid et al. Vladimir I. Kanjuh

First mentioned in 1737 by Reyman as an autopsy finding, described in 1922 by Crainicianu, named by Polacek in 1956, and angiographically shown by Portmann and Iwig in 1960, myocardial bridging encompasses the tunneled portion of a coronary artery, while the muscle band enveloping it is termed the myocardial bridge (MB). A myocardial bridge may remain silent lifelong or cause a myriad of clinical symptoms – from angina and ischemia, via syncope with arrhythmia^, and heart failure up to sudden death^, – however, not even children are spared irrelevant of the setting of the hypertrophic cardiomyopathy (HCMP).^,

From the mainly pathoanatomical standpoint, three main questions remain unanswered: (1) do ethnic differences render some corners of the world more susceptible to being born with this congenital coronary artery anomaly? (2) what are the implications of single or multiple MBs of single or multiple vessels even in the absence of HCMP? Furthermore, (3) what is the real atherosclerotic burden of the tunneled and peri-bridged segment?

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Original Article

Does Myocardial Injury Occur After an Acute Aerobic Exercise Session in Patients with Refractory Angina?

Carla Giuliano de Sá Pinto Montenegro et al. Luciana Oliveira Cascaes Dourado Camila Paixão Jordão Marcelo Luiz Campos Vieira … Camila Regina Alves Assumpção Luis Henrique Wolff Gowdak Alexandre da Costa Pereira Carlos Eduardo Negrão Luciana Diniz Nagem Janot de Matos

Abstract

Background

It is unclear whether exercise is safe in patients with more advanced forms of coronary artery disease, such as those with refractory angina (RA).

Objective

We aimed to determine the effect of an acute aerobic exercise session (AAES) on high-sensitivity cardiac troponin T (hs-cTnT) levels in patients with RA.

Methods

This was a longitudinal, non-randomized, and non-controlled clinical study. Participants were recruited from April 2015 to January 2019. On a visual pain scale from 0 to 10, pain rated up to 3 was considered as the top level allowed to continue exercising. We assessed hs-cTnT at baseline and 3 hours after the AAES. The protocol consisted of 5 minutes of warm-up, 30 minutes of continuous aerobic exercise at heart rate corresponding to the anaerobic threshold or angina threshold obtained in the cardiopulmonary exercise testing, and 5 minutes of cooling down. P values less than 0.05 were considered statistically significant.

Results

Thirty-two patients with RA were included (61 ± 9 years, 59.4% male). The baseline hs-cTnT concentration was 10.9 ng/L (95% confidence interval: 9.1 to 13.0 ng/L). The hs-cTnT collected 3 hours after the AAES was 11.1 ng/L (95% confidence interval: 9.1 to 13.5 ng/L). No difference occurred in hs-cTnT before and after AAES (p = 0.657).

Conclusions

A single AAES performed at the angina threshold with corresponding visual pain scale did not alter hs-cTnT in patients with RA, suggesting that no significant myocardial injury was elicited by exercising and that this exercise protocol can be considered safe.

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Original Article

Pharmaco-invasive Strategy in Myocardial Infarction: Descriptive Analysis, Presentation of Ischemic Symptoms and Mortality Predictors

Henrique Tria Bianco et al. Rui Povoa Maria Cristina Izar Claudia Maria Rodrigues Alves … Adriano Henrique Pereira Barbosa Maria Teresa Nogueira Bombig Iran Gonçalves Jr Bráulio Luna Filho Ana Caroline Aguirre Pedro Ivo de Marqui Moraes Dirceu Almeida Flávio Tocci Moreira Fernando Focaccia Povoa Edson Stefanini Adriano Mendes Caixeta Amanda S. Bacchin Valdir Ambrósio Moisés Francisco A.H. Fonseca

Abstract

Background

ST-segment elevation myocardial infarction (STEMI) is defined by symptoms accompanied by typical electrocardiogram changes. However, the characterization of ischemic symptoms is unclear, especially in subgroups such as women and the elderly.

Objectives

To analyze the typification of ischemic symptoms, temporal metrics and observe the occurrence of in-hospital outcomes, in the analysis of predictive scores, in patients with STEMI, in a drug-invasive strategy.

Methods

Study involving 2,290 patients. Types of predefined clinical presentations: typical pain, atypical pain, dyspnea, syncope. We measured the time between the onset of symptoms and demand for care and the interval between arrival at the medical unit and thrombolysis. Odds-ratios (OR; CI-95%) were estimated in a regression model. ROC curves were constructed for mortality predictors. The adopted significance level (alpha) was 5%.

Results

Women had a high prevalence of atypical symptoms; longer time between the onset of symptoms and seeking care; delay between arrival at the emergency room and fibrinolysis. Hospital mortality was 5.6%. Risk prediction by Killip-Kimball classification: AUC: [0.77 (0.73-0.81)] in class ≥II. Subgroups studied [OR (CI-95%)]: women [2.06 (1.42-2.99); p=0.01]; chronic renal failure [3.39 (2.13-5.42); p<0.001]; elderly [2.09 (1.37-3.19) p<0.001]; diabetics [1.55 (1.04-2.29); p=0.02]; obese 1.56 [(1.01-2.40); p=0.04]: previous stroke [2.01 (1.02-3.96); p=0.04] correlated with higher mortality rates.

Conclusion

Despite higher mortality rates in some subgroups, significant disparity persists in women, with delays in symptom recognition and prompt thrombolysis. We highlight the applicability of the Killip-Kimball score in prediction, regardless of the clinical presentation.

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Case Report

Exercise-Induced Bronchoconstriction: A Frequent, but Neglected Cause of Chest Pain

Renata Rodrigues Teixeira de Castro et al. João Giffoni Silveira Neto Adalgiza Mafra Moreno Marco Orsini

Introduction

Chest pain is one of the most common complaints in emergency departments, and internal medicine and cardiology clinics. Patients’ comorbidities and the clinical characterization of chest pain are cornerstones to guide symptom differentiation. Information about pain intensity, duration, localization, changes with posture/movement, and its reaction to nitroglycerin helps diagnose cardiac chest pain. Typical angina pectoris is the presence of substernal chest pain or discomfort provoked by exertion or emotional stress, and is relieved by rest and nitroglycerin. Angina pectoris is attributed to myocardial ischemia due to the unbalance between myocardial oxygen supply and myocardial oxygen demand elicited during exercise or emotional stress.

The diagnosis and treatment workup in patients with moderate to high cardiovascular risk presenting angina pectoris is quite straight-forward. Nevertheless, exertional chest pain in a young man can be challenging and yield a common but overlooked diagnosis, as in the present case report.

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Case Report

Single Coronary Artery in Transplanted Heart: An Unusual Association

Thaís Rossana Cruz de Souza et al. Arthur Luiz Norte Gomes Pereira Araruna Cláudia do Nascimento Silva Fernandes Roberto Moreno Mendonça … Epitácio de Oliveira Belém Neto Robson Macedo

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Editorial

Precordial Pain and Infarction in the Elderly. It´S no so Elementary, My Dear Watson!

Ricardo Wang et al. José Carlos da Costa Zanon Fernando Carvalho Neuschwander

In Medical School, we learn the traditional way to conduct the investigative process in order to reach a diagnosis. This process is traditionally based on the collection of anamnesis and clinical exams, clinical reasoning, the generation of a hypothesis, and tests with complementary exams. In general, we follow the the Occam’s razor principle: “the simplest answer is usually the correct answer,” or as William Osler’s aphorism: “Where you hear hoofs, you don´t think of zebras”. However, in this investigative process, the clinical reasoning is challenged in an elderly population over 80 years of age, and not always is the simplest answer the most correct. In this age group, the presence of comorbidities is quite common and can interfere, changing the perception of cardiovascular symptoms (depression, dementia, medications that interfere in the central nervous system, diabetes, analgesics, etc.), or even modify the symptomatology. The presence of atypical symptoms, such as dyspnea, sudoresis, vomiting, diarrhea, epigastric pain, and mental confusion can all mask the cardiovascular pathology.^,

Many studies have shown the difficulty in diagnosing acute myocardial infarction (AMI) in this population, which clearly entails delays in or the lack of treatment. Even when the diagnosis and early treatment of AMI is established, the mortality rate remains high in this population. The under-treatment or lack of treatment contribute to the increase in mortality in this age group.^– Understanding the factors that make the diagnosis difficult is of utmost importance in establishing protocols directed toward the older age elderly patient.

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Original Article

Association Between Serum Elabela Levels and Chronic Totally Occlusion in Patients with Stable Angina Pectoris

Fethi Yavuz et al. Mehmet Kaplan

Abstract

Background:

The beneficial effects of Elabela on the cardiovascular system have been shown in studies.

Objective:

To compare serum Elabela levels of chronic total occlusion (CTO) patients with control patients with normal coronary arteries, and to investigate whether there is a correlation with collateral development.

Methods:

The study was planned cross-sectionally and prospectively. Fifty patients (28.0% female, mean age 61.6±7.3years) with CTO in at least one coronary vessel and 50 patients (38% female, mean age 60,7±6.38 years) with normal coronary arteries were included in the study. Patients in the CTO group were divided into two groups as Rentrop 0-1, those with weak collateral development, and Rentrop 2-3 with good collateral development. In addition to the age, sex, demographic characteristics and routine laboratory tests of the patients, Elabela levels were measured.

Results:

Demographic characteristics and laboratory values were similar in both groups. While the mean NT-proBNP and troponin were higher in the CTO group, the Elabela mean was lower (p <0.05 for all). In the multivariate regression analysis, NT-proBNP and Elabela levels were found to be independent predictors for CTO. Also, Elabela level was found to be statistically higher in Rentrop class 2-3 patients compared to Rentrop class 0-1 patients (p<0.05).

Conclusion:

In our study, we showed that the average Elabela level was low in CTO patients compared to normal patients. In addition, we found the level of Elabela to be lower in patients with weak collateral development compared to patients with good collateral development. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

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Research Letter

The Evolution of Percutaneous Coronary Intervention in Latin America

Costantino Roberto Costantini et al. Rafael Michel de Macedo Marcos Antônio Denk Sergio Gustavo Tarbine … Lazaro Garcia Mario Fernando Camargo Maranhão Costantino Ortiz Costantini

In August 1979, two years and one month after the first percutaneous coronary intervention (PCI) was performed in the world by Andreas Grüntzig, we received at Santa Casa de Misericordia in Curitiba (SCMC) a 55-year-old male patient (A.S.O.) with Canadian Cardiovascular Society (CCS) class 2 stable angina. Coronary angiography showed a severe (75-80 DS%) lesion in the middle segment of the Right Coronary Artery (RCA). The left coronary artery system did not have any significant atherosclerotic lesion and the left ventriculogram showed mild inferior wall hypokinesia with competent mitral and aortic valves.

That was the opportunity to put into practice the technique described by Gruntzig et al. for the first time in Latin America. The clinical presentation and the angiographic characteristics of the lesion met all the criteria described by Gruntzig: Single lesion, short length (<10mm), proximal arterial segment, without vasospasm, concentric, non-calcified and feasible for CABG. Thus, after discussing it with the clinical and cardiovascular surgery staff, it was decided to propose the dilation of the RCA obstruction to the patient as an attempt to treat his coronary disease.

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Original Article

Complete Revascularization Versus Treatment of the Culprit Artery Only in ST Elevation Myocardial Infarction: A Multicenter Registry

Julia Cremona Cadore et al. Mariana Vargas Furtado Rogério Tadeu Tumelero Alexandre Pereira Tognon … Ana Maria Krepsky Denis Cadore Karen Brasil Ruschel Julia Caldas Bedin Thais Conte Carisi Anne Polanczyk

Abstract

Background

Data on the management and prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease are limited in Brazil, showing that the available revascularization strategies should be investigated

Objective

To assess the outcomes of complete revascularization versus treatment of the culprit artery only in patients with STEMI and multivessel disease.

Methods

A prospective cohort study was conducted at two medical centers in southern Brazil with a 1-year follow-up after the index procedure. The primary outcome was a composite of cardiac death, reinfarction, or recurrent angina, while the secondary outcome was stroke, nonfatal cardiac arrest, major bleeding, or need for reintervention. The probability of outcomes occurring was compared between the groups using binary logistic regression. A p-value < 0.05 was considered statistically significant.

Results

Eighty-five patients were included. Their mean age was 62±12 years, and 61 (71.8%) were male. Fifty-eight (68.2%) were treated with complete revascularization and 27 (31.8%) with incomplete revascularization. The chance of both the primary and secondary outcomes occurring was significantly greater among patients treated with incomplete revascularization when compared to those treated with complete revascularization (odds ratio [OR] 5.1, 95% confidence interval [CI] 1.6-16.1 vs. OR 5.2, 95% CI 1.2-22.9, respectively), as well as cardiac death (OR 6.4, 95% CI 1.2-35.3).

Conclusion

Registry data from two centers in southern Brazil demonstrate that the complete revascularization strategy is associated with a significant reduction in primary and secondary outcomes in a 1-year follow-up when compared to the incomplete revascularization strategy (Arq Bras Cardiol. 2020; 115(2):229-237)

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Case Report

Asymptomatic Coronary Spasm Due to Polytraumatism

Maria Cruz Aguilera et al. Jorge Restrepo Fernando Rivero Teresa Bastante … Rio Aguilar Fernando Alfonso

Introduction

Variant angina is a form of angina pectoris caused by vasospasm of an epicardic coronary artery that results in myocardial ischemia that might be manifested by transient ST segment elevation on the electrocardiogram. Although it usually presents with chest pain, asymptomatic episodes are not rare.^, We report a case of an incidental diagnosis of asymptomatic coronary vasospam in a patient with polytrauma.

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Case Report

Severe Coronary Vasospasm Complicated with Ventricular Tachycardia

Göksel Acar et al. Serdar Fidan Servet İzci Anıl Avcı

Introduction

Variant form of angina was first described by Prinzmetal as transient and recurrent coronary spasm leading to recurrent episodes of myocardial ischemia. Although so many factors can trigger or aggravate coronary vasospasm; endothelial dysfunction was considered as an important mechanism underlying this situation. The location and extent of vasospasm determine the seriousness of the clinical picture, which can include myocardial infarction severe arrhythmias, cardiogenic shock and even death.

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Viewpoint

Atypical Manifestation of Myocardial Ischemia in the Elderly

Marcelo E. Ochiai et al. Neusa Helena Lopes Carolina Giusti Buzo Humberto Pierri

Often, elderly patients have atypical clinical picture for myocardial ischemia, or are asymptomatic. This review intends to re-examine the pathophysiology of atypical manifestation in elderly persons, its prognostic and therapeutic implications.

The coronary atherosclerotic disease is an increasing public health problem, of particular importance in higher age groups. Its prevalence increases significantly at the sixth decade of life, becoming the leading cause of death in older people, as well as the greatest responsible for hospitalization and invasive procedures.

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Atualização

Platelet antiaggregants in primary and secondary prevention of atherothrombotic events

Marcos Vinícius Ferreira Silva et al. Luci Maria SantAna Dusse Lauro Mello Vieira Maria das Graças Carvalho

Atherothrombosis and its complications are currently the leading cause of worldwide mortality and its incidence is increasing . Platelets play an essential role in the pathogenesis of atherothrombotic events, justifying the use of antiplatelet agents in their prevention. Thus, it is essential to know the efficacy and safety profile of these drugs in primary and secondary prevention of atherothrombotic events. In this context, this review was performed with the aim of describing and summarizing the outcomes of the main trials involving the use of antiplatelet agents in the two levels of prevention, and evaluating the effectiveness and major adverse events related to therapy.

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Brief Communication

Validation of the short-version of Rose angina questionnaire in Brazil

Maria-Socorro Bastos et al. Paulo A. Lotufo Aristarcho L. Whitaker Isabela M. Bensenor

BACKGROUND: Stable angina pectoris is a serious condition with few epidemiological studies in Brazil. OBJECTIVE: To validate the short-version of the Rose angina questionnaire in Brazilian Portuguese for its implementation in surveys and longitudinal studies. METHODS: A total of 116 consecutive patients from an outpatient clinic without prior myocardial infarction and/or coronary revascularization were enrolled for application of three questions of the Rose angina questionnaire addressing chest pain after exertion. We used the treadmill test as the gold standard with the Ellestad protocol. RESULTS: The short-version of the Rose angina questionnaire of the 116 subjects submitted to the exercise treadmill test disclosed 89.7% of accuracy, 25% of sensitivity, 92.0% of specificity, 10.0% of positive predictive value, 97.2% of negative predictive value, and 3.1 of positive likelihood ratio and 0.82 of negative likelihood ratio. CONCLUSION: The Portuguese version with three items of the Rose angina questionnaire is suitable for epidemiological purposes.

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Artigo Original

NT-Pro-BNP levels and their response to exercise in patients with slow coronary flow

Mustafa Yurtdaş et al. İsmail Türkay Özcan Ahmet Çamsar Dilek Çiçek … Lülüfer Tamer Veli Gökhan Cin Oben Döven Ali Sabri Seyis Mehmet Necdet Akkuş

BACKGROUND: Natriuretic peptides are released by the heart in response to wall stress. OBJECTIVE: The NT-Pro-BNP concentrations in slow coronary flow (SCF) patients were assessed before and after the exercise test and compared with the values of healthy controls. METHODS: The study population was 34 patients with SCF [22 males (64.7%), aged 51.0±6.2 years], and 34 normal subjects with normal coronary arteries [21 males (61.8%), aged 53.2±6.6 years]. Coronary flow rates of all patients and control subjects were documented as Thrombolysis in Myocardial Infarction (TIMI) frame count. Blood samples were drawn at rest and after the exercise testing. RESULTS: The baseline NT-Pro-BNP concentrations of the SCF patients were higher than those of the control subjects (NT-Pro-BNP: 49.7±14.2 pg/mL vs. 25.3±4.6 pg/mL p<0.0001, respectively), and this difference increased after exercise test between the groups (NT-Pro-BNP: 69.5±18.6 pg/mL vs. 30.9±6.4 pg/mL p<0.0001). In SCF group after exercise, NT-Pro-BNP concentration in 15 patients with angina was higher than those without angina (76.8 ± 17.8 pg/mL vs. 63.8±17.5 pg/mL p=0.041). NT-Pro-BNP concentration in 11 patients with ST depression was also higher than those without ST depression (82.4 ± 17.3 pg/mL vs. 63.3 ± 16.1 pg/mL p=0.004). Median post-exercise increases in NT-Pro-BNP (Δ NT-Pro-BNP) were higher in the SCF group than in the control group (Δ NT-Pro-BNP: 19.8±7.7 pg/mL vs. 5.7±4.5 pg/mL p<0.0001). CONCLUSION: The results of this study suggest that there may be an important pathophysiologic link between the severity of SCF (microvascular or epicardial coronary artery dysfunction) and the level of circulating NT-Pro-BNP in SCF patients.

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Artigo Original

New prognostic score for stable coronary disease evaluation

Fernanda Coutinho Storti et al. Paulo Jorge Moffa Augusto H. Uchida Whady Armindo Hueb … Luiz Antônio Machado César Beatriz Moreira Ayub Ferreira Paulo Augusto de Camargo Jr William Azem Chalela

BACKGROUND: The need to improve the exercise testing accuracy, pushed the development of scores, whose applicability was already broadly recognized. OBJECTIVE: Prognostic evaluation of stable coronary disease through a new simplified score. METHODS: A new score was applied in 372 multivessel coronary patients with preserved ventricular function, 71.8% male, age: 59.5 (± 9.07) years old, randomized to medical treatment, surgery (CABG) or angioplasty (PTCA), with 5 years of follow-up. Cardiovascular death was considered the primary endpoint. Non-fatal myocardial infarction, death and re-intervention were considered for a combined secondary endpoint. The score was based on an equation previously validated, resulting from a sum of one point for: male gender, infarction history, angina, diabetes, insulin use and one point for each decade of life after 40 years old. Positive exercise testing summed one additional point. RESULTS: Thirty six deaths was observed (10 in group PTCA, 15 in CABG and 11 in the clinical group), p = 0.61. We observed 93 combined events: 37 in PTCA group, 23 in CABG and 33 in the clinical group (p = 0.058). 247 patients presented clinical score > 5 points and 216 > 6 points. The cutoff point > 5 or > 6 points identified higher risk, p = 0.015 and p = 0.012, respectively. The survival curve showed a different death incidence after the randomization when score reached 06 points or more (p = 0.07), and a distinct incidence of combined events between the patients with score 6 points (p = 0.02). CONCLUSION: The new score was consistent for multiarterial stable coronary disease risk stratification.

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Percutaneous coronary intervention in Brazil: results from the Brazilian Public Health System

Leopoldo Soares Piegas et al. Nagib Haddad

BACKGROUND: The Brazilian Public Health System (SUS) holds approximately 80% of percutaneous coronary interventions (PCI) in Brazil. Being aware of these data will enable to design a proper plan for the treatment of coronary artery disease (CAD). OBJECTIVE: To review and discuss the results of PCIs performed by the SUS. METHODS: We reviewed data from SIH/DATASUS available for public consultation. RESULTS: From 2005 to 2008, 166,514 procedures were performed in 180 hospitals. Average hospital mortality was 2.33%, ranging from 0% to 11.35%, being lower in the Southeast, 2.03% and higher in the northern region, 3.64% (p 0.05). Mortality was higher in females (p 65 to = (p < 0.001). In the diagnosis of angina (79,324, 47.64%) mortality was 1.03%, and AMI (33,286, 32.30%) 6.35% (p < 0.0000001). In the single stent implantation, the most common (102,165, 61.36%), mortality was 1.20%, and primary PCI (27,125, 16.29%), 6.96%. CONCLUSION: Although it is growing, the number of PCIs in Brazil is still low. High-volume hospitals, in smaller numbers, accounted for most procedures. Single stent implantation through hospital admission was reported to be most commonly used procedure. Mortality rates were highly variable among the hospitals. Primary PCI was responsible for the highest mortality rate.

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