coronary arteriosclerosis – ABC CARDIOL

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Artigo Original

Interleukin-1 receptor antagonist gene VNTR polymorphism is associated with coronary artery disease

Ahmet Arman et al. Ozer Soylu Ahmet Yildirim Andrzej Furman … Nesrin Ercelen Hakki Aydogan Ajda Coker Tuna Tezel

BACKGROUND: Coronary Artery Disease (CAD) is the atherosclerosis of coronary arteries that carry blood to the heart muscle. Atherosclerosis is an inflammatory disease. Cytokine gene variations such as those associated with the IL1 family are involved in the pathogenesis of atherosclerosis. OBJECTIVE: The purpose of this study was to determine the relationship between IL1 family polymorphisms (IL1RN VNTR, IL1B positions -511 and +3953) and CAD in Turkish population. METHODS: 427 individuals were submitted to coronary angiography and were grouped as 170 control subjects and 257 CAD patients. The CAD subjects were divided into two subgroups: 91 Single Vessel Disease (SVD) and 166 Multiple Vessel Disease (MVD) subjects. The genotypes of IL1RN and of IL1B (-511, +3953) were determined by polymerase chain reaction (PCR) followed by restriction digestion analysis. RESULTS: No significant difference was found in IL1RN and IL1B (-511 and +3953) genotype distributions between CAD and control subjects or MVD and control subjects. However, significant association was seen in IL1RN 2/2 genotype between SVD and control subjects (P= 0.016, x2: 10.289, OR: 2.94, 95% CI: 1.183-7.229). Similarly, no statistically significant difference was found in IL1RN and IL1B (-511 and +3953) allele frequencies between CAD and control subjects, MVD and control subjects or SVD and control subjects. CONCLUSION: No association was found in either allele frequency or genotype distribution of IL1RN and IL1B polymorphisms between CAD and the control groups. However; IL1RN 2/2 genotype may be a risk factor for SVD in the Turkish population.

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Comparative costs between myocardial revascularization with or without extracorporeal circulation

Priscyla B. M. A. Girardi et al. Whady Hueb Célia R. S. R. Nogueira Myrthes E. Takiuti … Teryo Nakano Cibele Larrosa Garzillo Felipe da S. Paulitsch Aécio F. T. Góis Neuza H. M. Lopes Noedir A. Stolf

BACKGROUND: Surgical techniques of myocardial revascularization without the use of extracorporeal circulation (ECC) have raised hopes of attaining operative results with less systemic damage, lower occurrence of clinical complications and shorter hospital stay duration, generating expectations of lower hospital costs. OBJECTIVE: To evaluate the hospital costs in patients submitted to myocardial revascularization with and without ECC and in those with stable multiarterial coronary disease with preserved ventricular function. METHODS: The hospital costs were based on the existing governmental reimbursement. The costs included that of ortheses and prostheses and clinical complications. The time and costs of ICU stay and hospital stay duration were considered. RESULTS: Between January 2002 and August 2006, 131 patients were randomized to surgery with ECC (SECC), whereas 128 were randomized to surgery without ECC (WECC). The basal characteristics were similar for both groups. The costs of surgical complications were significantly lower (p < 0.001) in patients from the WECC when compared to the SECC group (606.00 ± 525.00 vs. 945.90 ± 440.00), as well as ICU costs: 432.20 ± 391.70 vs. 717.70 ± 257.70, respectively. The duration of the operating room stay were 4.9 ± 1.1 h vs. 3.9 ± 1.0 h, p < 0.001; at the ICU it was 48.2 ± 17.2 h vs. 29.2 ± 26.1h) (p < 0.001), with intubation time of 9.2 ± 4.5 h vs. 6.4 ± 5.1h, p < 0.001 for patients from the group with and without ECC, respectively. CONCLUSION: The present study allowed us to conclude that the myocardial revascularization surgery without extracorporeal circulation results in the decrease of operational costs and duration of the stay in each section related to the surgical treatment.

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Artigo Original

Quality of life after on-pump and off-pump coronary artery bypass grafting surgery

Celia R. S. R. Nogueira et al. Whady Hueb Myrthes E. Takiuti Priscyla B. M. A. Girardi … Teryo Nakano Fábio Fernandes Felipe da S. Paulitsch Aécio F. T. Góis Neuza H. M. Lopes Noedir A. Stolf

BACKGROUND: Coronary artery bypass grafting techniques without using cardiopulmonary bypass (off-pump CABG) result in less systemic damage, less clinical complications, less time spent in the intensive care unit, and shorter hospital stays, thereby raising the perspective of improved quality of life (QOL) for patients. OBJECTIVE: To assess quality of life in patients who underwent on-pump and off-pump CABG. METHODS: The Short-Form Health Survey (SF-36) Questionnaire was administered to patients with stable multivessel coronary artery disease (CAD) and preserved ventricular function before and at six and 12 months after surgery. RESULTS: Between January 2002 and December 2006, a total of 202 patients were randomized to either on-pump or off-pump CABG. Demographic, clinical, laboratory, and angiographic characteristics were similar in both groups. One hundred and five patients underwent off-pump CABG and 97 underwent on-pump CABG. In the postoperative course, 22 patients had myocardial infarction, 29 reported angina, one was reoperated, and three experienced stroke. No patient died. Quality of life, as measured by the SF-36 questionnaire, was shown to be similar in both groups regarding physical and mental components. However, male patients showed a significant improvement in physical functioning and role limitations due to physical problems. Also, a large number of patients in both groups returned to work. CONCLUSION: Progressive enhancement in quality of life and early return to work were observed for all patients, regardless of the surgical technique used. Save for a greater improvement in physical functioning and role limitations due to physical problems experienced by male patients, no statistically significant differences were found in the other domains between groups.

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Predictors of quality of life change after an acute coronary event

Emiliane N. Souza et al. Alexandre S. Quadros Rúbia Maestri Camila Albarrán Rogério Sarmento-Leite

BACKGROUND: The assessment of quality of life (QOL), identifying functional capacity and frequency of angina and other cardiac symptoms, are key issues in the treatment of chronic patients or in those with disease instability. OBJECTIVE: To identify predictors of quality of life (QOL) improvement in patients with non-ST segment elevation acute coronary syndrome (NSTEACS). METHODS: Patients hospitalized in a cardiology reference hospital were assessed with the Seattle Angina Questionnaire (SAQ) at the time of admission and after 6 months. The analyzed outcome was the variation of the QOL score, resulting from the difference between the score after six months and the score at the time of admission. Differences between patients with or without 6-month QOL improvements regarding the demographic, clinical and therapeutic characteristics were assessed by univariate and multivariate analysis. RESULTS: Hypertensive patients presented lower improvement in QOL scores when compared to non-hypertensive ones [8,3(0-25) vs. 16,6(0-33,3); P=0,05], as well as patients with dyslipidemia, when compared to non-dyslipidemic ones [8,3(0-25) vs. 16,6(0-33,3); P=0,02]. Patients with unstable angina presented greater improvements in QOL in relation to those with NSTE myocardial infarction [16.6(0-33.3) vs. 8.3(-8,3-25); P=0,03]. By multivariate analysis, myocardial revascularization in the first 30-days was associated with the greater improvement in the QOL score (8.47 points; P=0,005). On the other side, the presence of dyslipidemia at the baseline evaluation was an independent predictor of worse QOL scores (-7.2 points; P=0.01). CONCLUSION: Myocardial revascularization was associated with improvement in the 6-month QOL scores, while dyslipidemia was associated with worse scores.

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Prevalence of coronary artery disease and preoperative assessment in patients with valvopathy

Roney Orismar Sampaio et al. Vívian Masutti Jonke João L. Falcão Sandra Falcão … Guilherme S. Spina Flávio Tarasoutchi Max Grinberg

BACKGROUND: Coronary angiography has been indicated in the preoperative phase for patients with valvopathy over 35 years of age. However, the actual prevalence of obstructive coronary artery disease (CAD) in this population has been little studied. OBJECTIVE: To assess the prevalence of and the risk factors for CAD in candidates for valve surgery in Brazil. METHODS: Coronary angiography was performed in 3,736 patients who were candidates for valve surgery; prevalence of and risk factors for CAD associated with valvopathy were assessed. RESULTS: CAD was associated with valvopathy in 121 patients (prevalence of 3.42%). In 79 patients (68.1%), CAD was diagnosed by means of preoperative coronary angiography. Of these 79 patients, 50 (63.3%) had isolated aortic valvopathy or aortic valvopathy associated with mitral valvopathy. Smoking habit was observed in 54 patients (68.3%), hypertension in four (43%), family history in 24 (30.3%), diabetes mellitus in 15 (18.9%), and obesity in eight (10.1%). Of the 121 patients, 95.7% were over 50 years of age. Only five (4.3% of the patients with CAD) were below 50 years of age, and all of them had at least one risk factor for CAD. CONCLUSION: CAD prevalence was low in the patients studied. Aortic valvopathy was the most frequent valvopathy associated with CAD, and most patients were over 50 years of age. The ideal age for routine preoperative coronary angiography in patients with valvopathy should be reassessed.

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Clinical Update

Myeloperoxidase and coronary arterial disease: from research to clinical practice

Raquel Melchior Roman et al. Andrea Elisabet Wendland Carisi Anne Polanczyk

Myeloperoxidase (MPO) is an enzyme derived of leukocytes that catalyze formation of numerous reactive oxidant species. Besides members of the innate host defense, evidences have been proving the contribution of these oxidants to tissue injury during inflammation. MPO participates in proatherogenic biological activities related to the evolution of cardiovascular disease, including initiation, propagation and acute complications of atherosclerotic process. Thereby, MPO and its inflammatory cascade represents an attractive target for prognostical investigation and therapeutics in atherosclerotic cardiovascular disease. In this review, we present the state of the art in the understanding of biological actions to clinical evidences of the relationship between MPO and coronary arterial disease. Several studies point to the independent effect of MPO levels in the evolution of disease and incidence of events in patients with acute coronary syndrome. However, the additional predictive value of MPO levels in the cardiovascular risk assessment, to incorporate it to the clinical practice as marker of plaque vulnerability, is still not consistent. Additional studies are necessary to confirm its role in the different forms of presentation of ischemic disease, besides the standardization of the assay, fundamental point for transition of this marker from research atmosphere to use in clinical routine: : from laboratory to clinical practice.

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Review Article

Risk factors for the development of atherosclerosis in childhood and adolescence

Maria Gisele dos Santos et al. Marina Pegoraro Fabiano Sandrini Emílio César Macuco

Cardiovascular diseases (CVD) are a major cause of death in developed countries as well as in developing countries. In general, the clinical manifestations of CVD, such as myocardial infarction, stroke and peripheral vascular disease, are caused by an atherosclerotic process with onset as from the middle age. However, current studies indicate that the atherosclerotic process starts to develop in childhood. The pathogenesis of atherosclerosis has been studied as to its inflammatory aspect. Among the inflammatory markers, C-reactive protein (CRP) has been extensively studied in individuals with CVD, including those apparently healthy. High CRP levels have been related to risk factors for atherosclerosis: family history of coronary artery disease (CAD), dyslipidemia, hypertension, diabetes mellitus, obesity, smoking and sedentary lifestyle. A great part of these risk factors may be influenced by lifestyle modifications, such as changes in eating habits and engagement in physical activities. The effects of physical activity on CRP levels in adulthood are documented in the literature, however little is known on the influence of an active or sedentary lifestyle of children and adolescents on CRP levels. Thus, the objective of this study is to review the impact of physical activity of children and adolescents on CRP levels and the risk factors for the development of CVD.

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Artigo Original

Serum levels of interleukin-6 (Il-6), interleukin-18 (Il-18) and C-reactive protein (CRP) in patients with type-2 diabetes and acute coronary syndrome without ST-segment elevation

José Roberto Matos Souza et al. Romulo Tadeu Oliveira Maria Heloisa S. L. Blotta Otávio Rizzi Coelho

BACKGROUND: Atherosclerosis is an inflammatory disease, and serum levels of inflammatory markers such as interleukin 6 (IL-6), interleukin 18 (IL-18) and C-reactive protein (CRP) are used to evaluate patients with coronary artery disease. In patients with type-2 diabetes, atherosclerosis is related to a larger number of events such as myocardial infarction and death, when compared with patients without diabetes. OBJECTIVE: To evaluate the inflammatory response in patients with diabetes and acute events of coronary instability. METHODS: Two groups of patients were primarily selected. The first group was comprised of diabetic outpatients with stable angina (D-CCS) and presence of coronary artery disease on coronary angiography (n=36). The second group was comprised of diabetic patients seen in the emergency room with acute coronary syndrome (D-ACS) without ST-segment elevation (n=38). Non-diabetic patients with ACS (n=22) and CCS (n=16) comprised the control group. Serum levels of CRP, IL-6 and IL-18 were determined using nephelometry (CRP) and ELISA (IL-6 and IL-18) techniques. RESULTS: Higher serum IL-6 levels were found in diabetic or non-diabetic patients with ACS than in the group with CCS. On the other hand, diabetic patients with ACS had higher CRP levels in comparison with the other groups. Serum IL-18 levels were not significantly different among the patients studied. CONCLUSION: our findings suggest a more intense inflammatory activity in patients with coronary instability. This inflammatory activity, as measured by CRP, seems to be even more intense in diabetic patients.

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Use of drug-eluting stents in Brazil: the CENIC (National Registry of Cardiovascular Interventions) registry

Cristiano O. Cardoso et al. Alexandre S. de Quadros Luiz A. Mattos Carlos A. Gottschall … Rogério E. Sarmento-Leite José A. Marin-Neto

BACKGROUND: Drug-eluting stents (DES) represent a major advance in the management of ischemic heart disease, but the extrapolation of favorable results from clinical trials to the real-world practice has been criticized. OBJECTIVE: To assess the use of DES in Brazil between 2000 and 2005. METHODS: Using the database of the National Registry of Cardiovascular Interventions (CENIC – Central Nacional de Intervenções Cardiovasculares) of the Brazilian Society of Hemodynamics and Interventional Cardiology (SBHCI – Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista), all PCI procedures with DES implantation performed between 2000 and 2005 were analyzed. The groups were divided into the following biennia: 2000-2001(A), 2002-2003 (B), and 2004-2005 (C), and patient’s clinical and angiographic characteristics were compared, as well as their short-term clinical outcome. Statistical analyses were performed using the chi-square test or ANOVA, and p values of less than 0.05 were considered to be statistically significant. RESULTS: A total of 154,406 PCI procedures were studied, and DES was used in 10,426 (7%) interventions. A progressive and statistically significant increase was found in the use of DES during the period studied: 0.14% from 2000 to 2001, 5% from 2002 to 2003, and 14% from 2004 to 2005 (p < 0.0001). After 2001, there was an increase in success rates (96.58% in 2000-2001 (A), 99.69% in 2002-2003 (B), and 99.56% in 2004-2005 (C), A x B with p < 0.001; B x C with p = 0.015) and a decrease in hospital mortality rates (1.59% in group A, 0.38% in group B, and 0.66% in group C, with p = 0.59 for A x B and p < 0.0001 for B x C). CONCLUSION: In Brazil, the use of drug-eluting stents increased significantly during recent years, resulting in higher success rates and lower hospital mortality.

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Artigo Original

Coronary artery disease in patients with rheumatic and non-rheumatic valvular heart disease treated at a public hospital in Rio de Janeiro

Dany David Kruczan et al. Nelson Albuquerque de Souza e Silva Basílio de Bragança Pereira Vítor André Romão … Wilson Braz Correa Filho Fidel Ernesto Castro Morales

OBJECTIVE: to estimate the prevalence of coronary artery disease (CAD) in valvular heart disease of rheumatic (RVHD) and non-rheumatic (NVHD) etiology, assessing possible predictive factors for the presence of CAD. METHODS: This is a cross-sectional study of a series of cases obtained from a pre-defined population, wherein 1,412 patients referred for heart surgery of any etiology were evaluated. Of these, 294 primary heart disease patients aged >40 submitted to cinecoronary arteriography (CA) were identified and studied. RESULTS: patients with RVHD presented lower prevalence of CAD (4%) when compared to NVHD (33.61%), p55, SAH, TACP, diabetes and dyslipidemia were all related directly to CAD, with the latter three being the most important variables for the disease. CONCLUSION: the prevalence of CAD among RVHD patients is low, whereas it is high among NVHD patients; the rheumatic etiology does not seem to have any beneficial effects on the prevalence of CAD; gender, age, SAH, TACP, dyslipidemia and diabetes were identified as being strongly associated with the presence of CAD. It is possible to define the criteria that indicate the need for pre-surgical CA in heart valve replacements, so that the standard indication after the age of 40 years can be avoided.

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Prognostic value of Tc-99m tetrofosmin myocardial perfusion gated SPECT in patients with diabetes mellitus and suspected coronary artery disease

Márcia Maria Sales dos Santos et al. Mauricio da Rocha Pantoja Eduardo Cwajg

BACKGROUND: The cardiovascular disease is the main cause of death among diabetic patients, which makes it crucial to identify the individuals at higher risk of cardiovascular events. OBJECTIVE: To evaluate the prognostic value of scintigraphy with gated single photon emission computed tomography (SPECT) in patients with diabetes mellitus (DM) and suspected coronary artery disease. METHODS: Retrospective study with 232 diabetic patients submitted to scintigraphy with gated SPECT. Perfusion Gated SPECT (scores and number of altered segments) as well as ventricular function parameters (ejection fraction, left ventricle (LV) volume and contractility) were evaluated. Cardiac death, acute ischemic coronary syndrome, revascularization procedures or encephalic vascular accident were considered future cardiovascular events. The uni- and multivariate analyses were carried out by the multiple logistic regression model (p< 0.05). RESULTS: At the univariate analysis, age (p=0.02), chest angina (p=0.01), insulin therapy (p=0.02), myocardial perfusion abnormalities (p<0.0001), the number of segments involved (p=0.0001), the perfusion scores (p=0.0001), the ejection fraction (p=0.004), the final systolic volume (p=0.03) and the finding of segmental alteration at the left ventricle contractility (p 3 (p=0.0001) and the number of altered segments > 3 (p=0.0001) were predictors of cardiovascular events. CONCLUSION: The myocardial scintigraphy with gated SPECT adds independent information to the stratification of the risk of future cardiovascular events in patients with DM and suspected coronary artery disease.

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An assessment of neutrophils/lymphocytes ratio in patients suspected of acute coronary syndrome

Ana Denise Zazula et al. Daniel Précoma-Neto Aline Maria Gomes Heidi Kruklis … Giovano Franco Barbieri Rafael Yared Forte André Ribeiro Langowiski Giuseppe Facin Luiz Cesar Guarita de Souza José Rocha Faria Neto

BACKGROUND: Leukocytes total count is an independent risk marker for cardiovascular events. The ratio between neutrophils and lymphocytes (N/L) count has been investigated as a new predictor for cardiovascular risk, although its diagnostic role when assessing patients suspected of an acute coronary syndrome (ACS) condition is not yet known. OBJECTIVE: To evaluate the diagnostic power of N/L ratio in patients who have been admitted at a Chest Pain Unit (CPU) with the suspicion of ACS. METHODS: Evaluation was conducted in 178 patients admitted with chest pain. Diagnostic flowchart including clinical, electrocardiographic, and laboratory data. Diagnosis obtained was: acute myocardial infarction (AMI) with (AMI-STE) and with no segment T elevation (AMI-NSTE), unstable angina (UA ) and non-cardiac pain (NC). Total and differential leukocyte count was conducted in peripheral blood sample collected at admission. RESULTS: Patients diagnosed with non-cardiac pain reported the lowest N/L ratio (n=45; 3.0 ± 1.6), followed by UA (n=65; 3.6 ± 2.9), AMI-NSTE (n=33; 4.8 ± 3.7) and AMI-STE (n=35; 6.9 ± 5.7); p < 0.0001. N/L ratio above 5.7 (highest quartile) reported 91.1% specificity, 4.51 odds ratio (CI 95% 1.51 to 13.45) for the final diagnosis of ACS when compared to the groups at lower quartiles. CONCLUSION: The N/L ratio presents correlation with final diagnosis of patients with suspicion of ACS at admission. Considering this is a low cost, good reproductibility test, new studies should ellucidate whether the ratio may be of relevance for diagnosis flowcharts currently in use.

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Coronary artery disease in asymptomatic type-2 diabetic women: a comparative study between exercise test, cardiopulmonary exercise test, and dipyridamole myocardial perfusion scintigraphy in the identification of ischemia

Paola Emanuela Poggio Smanio et al. Antonio Carlos Carvalho Antonio Sergio Tebexreni Anneliese Thom … Filadelfo Rodrigues Romeu Meneghelo Luiz Mastrocolla Alexandre Alves Leopoldo Soares Piegas Angelo Amato de Paola

BACKGROUND: Cardiovascular disease is the leading cause of morbidity and mortality among diabetic individuals. Myocardial ischemia is frequently asymptomatic, thus leading to a late diagnosis and worse prognosis. Diabetic women are known to have a cardiovascular death risk higher than that in men. OBJECTIVE: To assess the prevalence of coronary artery disease (CAD) in asymptomatic diabetic women. To compare the results of exercise test (ET), cardiopulmonary exercise test (CPET), and dipyridamole myocardial perfusion scintigraphy (MPS) with the findings of coronary angiography, (ANGI) in order of identify the most accurate method in the detection of significant CAD. METHODS: A total of 104 diabetic women were assessed with ET, CPET and MPS in the period within two months from the ANGI. MIBI-99mTc scintigraphy was performed using the gated-SPECT technique. Pearson’s chi-square, Student’s t tests were used for the statistical analysis and also the logistic regression analysis. RESULTS: The prevalence of CAD in the group studied was 32.7%. For the ET, an effective test (p=0.045), the chronotropic incompetence (p=0.031), and the exercise time performed (p=0.022) showed a significant association with DAC. For CPET, peak VO2 and HR achieved were associated with CAD (p=0.004 and p=0.025, respectively). Most of the MPS variables showed a significant association with CAD (p=0.001, for all). CONCLUSION: The results obtained may suggest a high prevalence of CAD in diabetic women. Thus, this population should be investigated from the cardiovascular point of view even without cardiac symptom. Of the noninvasive diagnostic methods used, dipyridamole MPS was the one that showed the highest discrimination power in relation to diabetic women with CAD.

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Ultrasonic tissue characterization in acute coronary syndromes

Antonio Pazin-Filho et al. Gustavo Jardim Volpe Minna Moreira Dias Romano Gerson Antonio Tavares Júnior … André Schmidt Benedito Carlos Maciel

BACKGROUND: Ultrasonic tissue characterization (UTC), as evaluated through integrated backscatter, has the potential to detect precocious structural damage to myocardial tissue. In acute coronary syndromes (ACS) this technique is attracting attention due to its potential to evaluate myocardial viability. OBJECTIVE: To evaluate the role of UTC in the emergency department. METHODS: We studied 28 individuals, classified in three groups: Group I (13; 52.2±15.5 years) with patients admitted with chest pain who have negative evaluation for acute coronary syndrome; Group II (9; 54.2±10.0 years) with acute myocardial infarction in right coronary artery territory; and Group III (6; 62.1±9.1 years) with acute myocardial infarction in the anterior descendent branch territory. For each individual, we analyzed four segments in the short axis view at the papillary muscle level (1 – anterior; 2 – anterior-lateral; 3 – inferior e 4 – septal), for the following parameters: corrected coefficient, amplitude, delay index and IBS pattern. RESULTS: The acute myocardial isquemic process in its initial phase was not detected by the corrected coefficient or by the IBS amplitude. The sincronicity parameters (delay index and IBS pattern), more sensible, were partially able to identify changes in more extension regions of myocardial infarction. CONCLUSION: More studies should be conducted to evaluate these parameters in the early phase of acute coronary syndromes.

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Effects of epinephrine in local dental anesthesia in patients with coronary artery disease

Ricardo Simões Neves et al. Itamara Lucia Itagiba Neves Dante Marcelo Artigas Giorgi Cesar José Grupi … Luís Antonio Machado César Whady Hueb Max Grinberg

BACKGROUND: The use of vasoconstrictors for local anesthesia in patients with coronary heart disease is controversial in the literature, and there is concern regarding risk of cardiac decompensation. OBJECTIVE: To evaluate electrocardiographic and blood pressure parameters during restorative dental procedure under local anesthesia with and without a vasoconstrictor in patients with coronary artery disease. METHODS: Sixty-two patients were included in the study, ages ranging from 39 to 80 (mean 58.7 ± 8.8), 51 (83.2%) of whom were male. Thirty patients were randomly assigned to receive 2% lidocaine with epinephrine (epinephrine group), and the remaining patients, 2% lidocaine without epinephrine (non-epinephrine group) for local anesthesia. All patients underwent 24-hour ambulatory blood pressure monitoring and dynamic electrocardiography. Three periods were considered in the study: 1) baseline – recordings obtained during the 60 minutes prior to the procedure; 2) procedure – recordings obtained from the beginning of anesthesia to the end of the procedure and 3) 24 hours. RESULTS: There was an increase in blood pressure in both groups during the procedure, compared with baseline values; but when the two groups were compared no significant difference was detected between them. Heart rate remained unchanged in both groups. No ST-segment depression > 1 mm occurred either at baseline or during the procedure. Seven patients (12.5%) experienced more than ten arrhythmia episodes per hour during the procedure, four (13.8%) in the non-epinephrine group and three (11.1%) in the epinephrine group. CONCLUSION: No difference was observed in blood pressure, heart rate, or evidence of ischemia and arrhythmias in either group. The use of vasoconstrictor has proved to be safe within the range of the present study.

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Cardiovascular effects of local anesthesia with vasoconstrictor during dental extraction in coronary patients

Valeria C. L. S. Conrado et al. Januário de Andrade Gabriella A. M. C. de Angelis Ana Carolina P. de Andrade … Lilia Timerman Mercedes M. Andrade Dalmo R. Moreira Amanda G. M. R. Sousa J. Eduardo M. R. Sousa Leopoldo S. Piegas

OBJECTIVE: To evaluate the occurrence of variables detecting myocardial ischemia during or after dental treatment under anesthesia with vasoconstrictor (epinephrine). METHODS: A total of 54 coronary patients undergoing dental extraction under local anesthesia with or without vasoconstrictor were included. They were divided into two groups (by drawing envelopes): group I (27 patients) using anesthetics with vasoconstrictor, and group II (27 cases) without vasoconstrictor. 24-hour Holter monitoring, Doppler-echocardiogram before and after dental intervention, and determination of biochemical markers (CK-MB mass, CK-MB activity, and troponin T) before and 24 hours after dental extraction were performed in all patients. Heart rate and blood pressure were also measured in the pre, post-anesthesia and post-dental extraction phases. Doppler echocardiography assessed left ventricular segmental contractility and the occasional occurrence of mitral regurgitation. The usual pharmaceutical treatment prescribed by the cardiologist was maintained in all cases. RESULTS: Three patients in group I presented ST-segment depression (1.0 mm) during administration of anesthesia; two other patients in group I had CK-MB mass elevation, and ischemia was not observed in any other case, as assessed by the other methods. No chest pain, arrhythmias, occurrence or worsening of left ventricular segmental hypocontractility or mitral regurgitation were observed in the study. CONCLUSION: Dental extraction performed under anesthesia with 1:100,000 epinephrine does not imply additional ischemic risks, as long as performed with good anesthetic technique and maintenance of the pharmacological treatment prescribed by the cardiologist.

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Case Report

Coronary artery bypass surgery in patients with anomalous circumflex artery

Walter J. Gomes et al. Rodrigo P. Paez Francisco A. Alves

The anomalous origin of the circumflex artery (Cx) is uncommon and presents course variations that might make the coronary artery bypass surgery (CABG) difficult. Two patients presenting unstable angina were submitted to coronary angiography that disclosed tri-vessel disease and presence of Cx with an anomalous origin and retroaortic course with severe stenosis. Both patients underwent CABG with use of bilateral internal thoracic artery (ITA) grafts. Therefore, CABG with bilateral ITA use is feasible in cases of an anomalous origin of the Cx artery. However, this finding may constitute an additional technical setback.

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Intima-media thickness in the origin of right subclavian artery as an early marker of cardiovascular risk

Carlos Alberto Engelhorn et al. Ana Luiza Engelhorn Maria Fernanda Cassou Cassiana Casagrande Zanoni … Carlos José Gosalan Emerson Ribas Adriana Pacholok Marcela de Fátima Koehler

OBJECTIVE: Common carotid artery intima-media thickness (IMT) is considered a factor of cardiovascular risk and an early marker of coronary artery disease. This study aimed to investigate the existence of a correlation between IMT in the carotid arteries and at the origin of the right subclavian artery, as well as to evaluate IMT in the subclavian artery as an earlier marker of cardiovascular risk. METHODS: One hundred and six consecutive patients, 52 males and 54 females, average age 51 years, underwent color Doppler ultrasonography to evaluate carotid and right subclavian arteries. The relationship between carotid IMT and right subclavian IMT was assessed using the Pearson’s correlation coefficient analysis and a 95% confidence interval. Reliability of right subclavian artery IMT measurement for the diagnosis of early thickening (considering a > 0.8 mm carotid thickness as reference) was described as to sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Cut-off values for the right subclavian IMT were indicated by the ROC curve, and p values 0.8 mm. The mean IMT value for the carotid artery was 0.87 mm (SD = 0.23) and for the subclavian artery, 1.17 mm (SD = 0.46), with a 0.31 correlation coefficient (95% CI: 0.12; 0.47). The ROC curve analysis indicated a cut-off value of 0.7 mm for the right subclavian artery IMT, using as reference a 0.8 mm cut-off value for the carotid artery (91% sensitivity, 27% specificity, 66% PPV, 65% NPV, and 66% accuracy). CONCLUSION: Our study showed that carotid artery IMT correlates well with right subclavian artery IMT. With a 0.7 mm cut-off value, it is possible to detect IMT in the right subclavian artery earlier than in the carotid arteries. The IMT at the origin of the right subclavian artery can be considered an earlier marker for the assessment of cardiovascular risk.

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