Arcada coronária – uma anomalia rara da circulação coronária

Intercoronary communication or ‘coronary arcade’ is a rare congenital coronary anomaly. We present the case of a 65‐year‐old man with atypical chest pain for four months. The 12‐lead ECG and echocardiogram were normal. Treadmill exercise testing was interrupted at peak exercise due to consecutive salvos of ventricular premature beats, without significant ST‐T changes. Coronary angiography showed no significant coronary stenosis, but a connection between the right coronary and circumflex arteries was observed, consistent with coronary arcade. The functional importance of this variant is not clear, but it may cause myocardial ischemia by coronary steal or function as a natural bypass, in which case it may play a protective role in the myocardium if significant atherosclerosis develops.     

Cirurgia de revascularização coronária após doença de Kawasaki

Kawasaki disease (KD) is a systemic vasculitis of unknown etiology, which is the main cause of acquired heart disease in children in developed countries. The main complications result from the development of coronary aneurysms which can lead to ischemic heart disease.We present the case of a teenage boy with a diagnosis of KD at the age of seven. He was treated with gammaglobulin and aspirin and echocardiographic evaluation in the acute phase was apparently normal. At the age of eleven, he developed chest pain and exertional dyspnea. Nuclear perfusion scans with exercise revealed hypoperfusion of the left anterior descending (LAD) and right coronary (RC) artery territories. Cardiac catheterization showed occlusion of the proximal segments of both arteries. He underwent coronary artery bypass graft surgery (internal mammary artery bypass graft to the LAD artery and saphenous vein graft to the RC artery), with a good clinical result.This case report highlights the importance of early diagnosis and treatment of KD and regular cardiological follow-up, bearing in mind the potential late complications of this pediatric disease.     

Revascularização multivaso versus revascularização da artéria culprit em pacientes com síndrome coronária aguda sem supradesnivelamento do segmento ST e doença coronária multivaso

Introduction

There have been no prospective randomized trials that enable the best strategy and timing to be determined for revascularization in patients with non‐ST‐segment elevation acute coronary syndrome (NSTE‐ACS) and multivessel coronary artery disease (CAD).

Proteína C reativa de alta sensibilidade como biomarcador de risco na doença coronária

Vascular inflammation plays a crucial role in the pathogenesis of atherosclerosis and mediates various stages of atherosclerotic plaque development, from lipid streak formation to the plaque rupture and destabilization that precedes the clinical syndromes of cardiovascular disease. Inflammatory biomarkers constitute valuable tools to study this process, enabling the effects of different therapeutic interventions to be assessed. Currently, C-reactive protein (CRP) determined by high-sensitivity methods (hs-CRP) is the most extensively studied biomarker. Data regarding hs-CRP and cardiovascular risk, though largely consistent, are of unclear clinical relevance. This article provides a comprehensive review of current knowledge concerning cardiovascular risk and hs-CRP, and concludes with an evidence-based analysis of the current role of hs-CRP in cardiovascular risk assessment.     

Progressão ultrarrápida de doença coronária ou placa instável não detetada?

Coronary artery disease rarely manifests itself in the first decades of life, which explains why this population is underrepresented in clinical studies. The mechanisms and natural history of the disease seem to differ between this population and older patients. Recent studies suggest a more rapid disease progression in youth, presenting more unstable atherosclerotic plaques, although this correlation has yet to be proven. In this paper, we present the case of a 41‐year‐old man who presented with a non‐ST elevation myocardial infarction, with percutaneous coronary intervention of the culprit lesion (70–90% lesion at bifurcation of the circumflex artery with the first marginal obtuse artery and a sub‐occlusive lesion of the ramus intermedius). There was also a non‐significant lesion (estimated at 30%) located in the left anterior descending coronary artery. Ten days after discharge, the patient suffered another non‐ST elevation myocardial infarction. The coronary angiography revealed a surprising sub‐occlusive lesion of the left anterior descending coronary artery. Regarding this case, the authors reviewed the literature on the pathophysiology of rapidly progressive coronary artery disease and the approach for non‐significant lesions in patients with acute coronary syndrome, especially in the younger population.     

Seguimento clínico a longo prazo de doentes com intervenção coronária diferida guiada pela medição da fração de fluxo de reserva coronária

Introduction and aimsThe functional significance of coronary lesions can be assessed in the cardiac catheterization laboratory by determination of fractional flow reserve (FFR), thus overcoming one of the major limitations of conventional angiography. The aim of this study was to analyze the long-term clinical course of patients with intermediate coronary stenosis (50-70%) deferred for intervention based on FFR <0.80.MethodsBetween May 1999 and December 2009, 300 lesions in 231 patients (mean age 65±10 years, 68% male and 75.3% with multivessel disease) were studied by FFR. Intervention was deferred in 282 (94%) lesions and 18 were treated based on FFR <0.80. We assessed the occurrence of major adverse cardiovascular events (MACE), defined as cardiovascular death, non-fatal acute coronary syndrome and target lesion revascularization (TLR).ResultsDuring a median follow-up of 637 days (interquartile range 455-1160), there were 15 (6.5%) MACE in the subgroup of patients with target lesion intervention deferred based on FFR: one cardiovascular death, four hospitalizations for acute coronary syndrome and 14 TLR (12 patients were treated percutaneously and two underwent coronary artery bypass grafting). MACE-free survival at one year follow-up was 97.8%.ConclusionThese results, in a real-world population, support the current trend to base the decision to treat on functional rather than purely anatomical criteria, in order to improve safety and efficiency.     

Probabilidade teórica de doença coronária pré- e pós-teste em duas estratégias diagnósticas – Contributo relativo da prova de esforço e da angio-TC cardíaca

IntroductionThe purpose of this study was to assess the change in theoretical probability of coronary artery disease (CAD) in patients with suspected CAD undergoing coronary CT angiography (CCTA) as first line test vs. patients who underwent CCTA after an exercise ECG.MethodsPre- and post-test probabilities of CAD were assessed in 158 patients with suspected CAD undergoing dual-source CCTA as the first-line test (Group A) and in 134 in whom CCTA was performed after an exercise ECG (Group B). Pre-test probabilities were calculated based on age, gender and type of chest pain. Post-test probabilities were calculated according to Bayes’ theorem.ResultsThere were no significant differences between the groups regarding pre-test probability (median 23.5% [13.3-37.8] in group A vs. 20.5% [13.4-34.5] in group B; p=0,479). In group A, the percentage of patients with intermediate likelihood of disease (10-90%) was 90% before testing and 15% after CCTA (p<0,001), while in group B, it was 95% before testing, 87% after exercise ECG (p=NS), and 17% after CCTA (p<0,001).ConclusionUnlike exercise testing, CCTA is able to reclassify the risk in the majority of patients with an intermediate probability of obstructive CAD. The use of CCTA as a first-line diagnostic test for CAD may be beneficial in this setting.     

Documento de Consenso sobre Estratificação de Risco Cardiovascular e estudo da doença coronária em Portugal: a posição dos Grupos de Estudo de Cardiologia Nuclear,Ressonância Magnética e Tomografia Computorizada Cardíaca,de Ecocardiografia e de Fisiopatologia do Esforço e Reabilitação Cardíaca

Despite constant medical evolution, the reimbursement policy of Portuguese National Health Service (NHS) for the study and risk stratification of coronary heart disease has remained unchanged for several decades. Lack of adjustment to contemporary clinical practice has long been evident. However, the recent publication of the European Guidelines for diagnosis and treatment of chronic coronary syndromes further highlighted this gap and the urgent need for a change. Prompted by these Guidelines, the Working Group on Nuclear Cardiology, Cardiac Magnetic Resonance and Cardiac CT, the Working Group on Echocardiography and the Working Group on Stress Pathophysiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology, began a process of joint reflection on the current limitations and how these recommendations could be applied in Portugal. To this end, the authors suggest that the new imaging methods (stress echocardiogram, cardiac computed tomography and cardiac magnetic resonance), should be added to exercise treadmill stress test and myocardial perfusion scintigraphy in the available exam portfolio within the Portuguese NHS. This change would allow full adoption of European guidelines and a better use of tests, according to clinical context, availability and local specificities. The adoption of clinical guidance standards, based on these assumptions, would translate into a qualitative improvement in the management of these patients and would promote an effective use of the available resources, with potential health and financial gains.     

Exercício físico na diabetes: missão impossível ou uma questão de motivação?

Pulling from self-determination theory (SDT) and motivational interviewing (MI), this article sought to present contemporary frameworks for understanding and promoting human motivation as useful tools for health professionals aiming to facilitate adoption and adherence to physical activity, presenting empirical evidence for its use. Practical strategies that may be used by a health professional to create an autonomy-supportive, well-structured, and interpersonally involved exercise counseling environment, more likely to support selfdetermined motivation, also are presented.Combining the strong theoretical underpinnings of SDT and the strong clinical base of MI should allow for much progress in developing the kind of motivation required to initiate and maintain exercise behaviors over the long term. These relatively simple and straightforward principles can be incorporated into existing approaches currently used by professionals who desire to improve their effectiveness, enhancing positive outcomes in terms of exercise adoption, adherence, and well-being;     

Qual o verdadeiro impacto da intervenção coronária percutânea on‐site? Análise de score de propensão de doentes admitidos por síndrome coronária aguda

IntroductionIn an era in which coronary heart disease is one of the leading causes of death worldwide, several studies report the persistence of obstacles to accessing revascularization, and percutaneous coronary intervention in particular, which may be associated with worse outcomes.ObjectivesTo compare cardiovascular outcomes in patients admitted to hospitals with and without on‐site percutaneous coronary intervention (PCI) capabilities.Material and MethodsA retrospective study based on the National Registry of Acute Coronary Syndromes (ACS) ‐ with data collection from 2010 to 2018. Division of the patients into two groups: with and without ST‐elevation. Two subgroups were subsequently created according to the presence/absence of on‐site PCI. A propensity score was performed to standardize the results. Patients without information about hospital admission (with/without PCI) were excluded.Results6008 patients were included after exclusion criteria and propensity score were applied. We found that patients admitted for ACS with ST‐elevation (STE‐ACS) had more episodes of sustained ventricular tachycardia (OR 2.14; CI (1.26‐3.61); p=0.004) in hospitals without on‐site PCI. Regarding ACS without ST elevation (NSTE‐ACS), there were more cases of congestive heart failure (OR 0.79; CI (0.65‐0.98)) in hospitals with on‐site PCI.ConclusionThe incidence of a greater number of major adverse events in hospitalizations without on‐site PCI, particularly in the case of STE‐ACS, is a consequence of the delay before revascularization. National and local strategies must be established to reduce the negative impact of the absence of on‐site PCI and the resulting time before revascularization.     

Comentário a «Aplicações da ecocardiografia de sobrecarga para além da doença coronária»

Stress echocardiography is an established method for the diagnosis and prognostic stratification of coronary artery disease. In the last few years, the tremendous technological and conceptual versatility of this technique has been increasingly applied in challenging diagnostic fields. Today, in the echocardiography laboratory we can detect not only ischaemia from coronary artery stenosis, but can also recognize abnormalities of the coronary microvessels, myocardium, heart valves, pulmonary circulation, alveolar‐capillary barrier, and right ventricle. Therefore, we evaluate coronary arteries as well as coronary microvascular disease (associated with diabetes and hypertension), suspected or overt dilated cardiomyopathy, systolic and diastolic heart failure, hypertrophic cardiomyopathy, athletes’ hearts, valvular heart disease, congenital heart disease, incipient or overt pulmonary hypertension, and heart transplant patients for early detection of chronic or acute rejection as well as potential donors for better selection of suitable donor hearts. From a stress echo era with a one‐fits‐all approach (wall motion by 2D‐echo in the patient with known or suspected coronary artery disease) now we have moved on to an omnivorous, next‐generation laboratory employing a variety of technologies (from M‐Mode to 2 D and pulsed, continuous and colour Doppler, to lung ultrasound and real‐time 3 D echo, 2 D speckle tracking and myocardial contrast echo) on patients covering the entire spectrum of severity (from elite athletes to patients with end‐stage heart failure) and ages (from children with congenital heart disease to the elderly with low‐flow, low‐gradient aortic stenosis). For each patient, we can tailor a dedicated stress protocol with a specific method to address a particular diagnostic question. Provided that the acoustic window is acceptable and the necessary expertise available, stress echocardiography is useful and convenient in many situations, from valvular to congenital heart disease, and whenever there is a mismatch between symptoms during tress and findings at rest. Increasing societal concern regarding cost, environment and radiation risks of medical imaging will lead to a preferential application of ultrasound over competing techniques, due to its unsurpassed versatility, portability, absence of radiation, and low cost.

Comentário

O artigo publicado no número de Outubro da revista da Sociedade Europeia de Cardiologia aborda, de uma forma geral, a aplicação da ecocardiografia de sobrecarga a todas as áreas da cardiologia, para além da doença coronária. Trata‐se de um artigo de revisão, escrito por duas personalidades bem conhecidas do panorama clínico e ecocardiográfico mundial, uma da Europa, Eugenio Picano, do Instituto de Fisiologia Clínica da Universidade de Pisa, a outra dos EUA, Patricia Pellikka, da Clínica Mayo, Rochester, onde é revista importância da ecocardiografia de sobrecarga em outros cenários clínicos que não o da doença coronária.A ecocardiografia de sobrecarga propicia uma avaliação dinâmica da estrutura e função miocárdicas sob um cenário de stresse físico ou farmacológico. Poderá, assim, ser desmascarado um defeito estrutural que, ainda que oculto durante o repouso, se torne evidente em condições de carga diferentes.Nesse sentido, o seu valor no contexto da doença coronária conhecida ou suspeita encontra‐se bem descrito e discutido1, 2, 3.Contudo, atualmente, além da motilidade segmentar, a ecocardiografia de sobrecarga permite avaliar uma enorme panóplia de parâmetros sob o stresse induzido. Entre estes, incluem‐se o fluxo de reserva coronário, a função diastólica, os gradientes valvulares, os fluxos regurgitantes, a hipertensão pulmonar, etc.Recentemente, diversos estudos comprovaram o papel diagnóstico e prognóstico crucial noutras patologias.A revisão em questão reúne as principais evidências nesta área e aponta o interesse da técnica no estudo de diferentes patologias.Começa por descrever o valor da ecocardiografia de sobrecarga na avaliação da doença microvascular, apontando para o seu papel na definição de angina microvascular.É posteriormente apontado o papel da técnica na miocardiopatia dilatada de causa não isquémica, ressaltando a sua aplicação em fases iniciais no decurso da doença, mas também em fases avançadas com disfunção ventricular esquerda grave, na tentativa de detetar miocárdio viável (reserva contrátil)⁴. Por outro lado, na miocardiopatia hipertrófica, o exame pode ser efetuado com o objetivo de detetar gradientes dinâmicos, sobretudo se em repouso os gradientes se aproximarem de 50 mmHg⁵.O principal core do artigo centra‐se no papel da ecocardiografia de sobrecarga na avaliação da patologia valvular. As dificuldades na definição do timing cirúrgico no contexto de patologia é um problema bem reconhecido, sobretudo nos cenários clínicos extremos do doente assintomático com lesão valvular grave e do doente sintomático com lesão de grau apenas ligeiro a moderado. De uma forma global, neste contexto, a técnica possibilita a identificação dos doentes falsamente assintomáticos, que desenvolvem sintomas com baixa carga de «esforço», bem como permite reclassificar a gravidade de doenças valvulares menos graves no repouso, mas que revelando o seu caráter dinâmico se agravam com o stresse. No artigo citado, é referido em pormenor o papel da ecocardiografia de sobrecarga em cada uma das patologias valvulares mais comuns, interpretado à luz da evidência. Em particular, é referido o seu valor na estenose aórtica low‐flow low‐gradient com fração de ejeção diminuída em que o exame sob baixa dose de dobutamina permite distinguir a verdadeira estenose aórtica grave da «pseudoestenose» aórtica grave⁶. Por outro lado, encontra‐se também descrito o papel da ecocardiografia de exercício na identificação de candidatos a cirurgia precoce no contexto da regurgitação mitral⁶.Adicionalmente é também apontado o papel da técnica na deteção e follow up de doentes com hipertensão pulmonar suspeita ou conhecida, respetivamente.Relativamente à disfunção diastólica, é relembrada a recomendação da Sociedade Europeia de Cardiologia, de 2012, para a realização de teste de exercício perante o doente com suspeita de insuficiência cardíaca e fração de ejeção conservada, que durante a sua atividade diária apresenta sintomas e cujo estudo da função diastólica em repouso é inconclusivo⁴. Neste cenário clínico, a ecocardiografia de sobrecarga poderá permitir a confirmação do diagnóstico de insuficiência cardíaca com função sistólica preservada.Outros temas abordados no artigo são o interesse desta técnica nos doentes com cardiopatias congénitas⁷, nos doentes submetidos a transplantes cardíacos⁸ e nos atletas⁹.Em jeito de resumo, todas as indicações da técnica e suas bases científicas encontram‐se resumidas numa ilustrativa tabela, de fácil consulta.Finalmente, os autores elaboram as limitações os pitfalls inerentes à técnica, destacando‐se a subjetividade e operador dependência da mesma e a dificuldade da aquisição de informação fluxos Doppler no pico do esforço. São ainda apontados os desafios e inovações em desenvolvimento, particularmente no que se refere à análise de deformação miocárdica e à ecocardiografia tridimensional.Em suma, considera‐se o artigo recomendado de particular interesse na medida em que contemporiza as novas indicações da ecocardiografia de sobrecarga, uma técnica com longa história, mas cujo desenvolvimento continua em ebulição, possibilitando um alargamento franco do seu campo de aplicação.

Conflito de interesses

Os autores declaram não haver conflito de interesses.     

Os custos da insuficiência cardíaca em Portugal e a sua evolução previsível com o envelhecimento da população

Introduction and ObjectivesHeart failure (HF) is a growing public health problem. This study estimates the current and future costs of HF in mainland Portugal.MethodsCosts were estimated based on prevalence and from a societal perspective. The annual costs of HF included direct costs (resource consumption) and indirect costs (productivity losses). Estimates were mostly based on data from the Diagnosis‐Related Groups database, real‐world data from primary care, and the opinions of an expert panel. Costs were estimated for 2014 and, taking population aging into account, changes were forecast up to 2036.ResultsDirect costs in 2014 were €299 million (39% for hospitalizations, 24% for medicines, 17% for exams and tests, 16% for consultations, and the rest for other needs, including emergencies and long‐term care). Indirect costs were €106 million (16% for absenteeism and 84% for reduced employment). Between 2014 and 2036, due to demographic dynamics, total costs will increase from €405 to €503 million. Per capita costs are estimated to rise by 34%, which is higher than the increase in total costs (+24%), due to the expected reduction in the resident population.ConclusionsHF currently has a significant economic impact, representing around 2.6% of total public health expenditure, and this is expected to increase in the future. This should be taken into account by health policy makers, alerting them to the need for resource management in order to mitigate the impact of this disease.