Comparação entre Dois Escores de Risco quanto à Predição de Obstrução Microvascular Coronariana durante a Intervenção Percutânea Primária

Background:For patients with ST-segment elevation myocardial infarction (STEMI) that are suffering from subsequent coronary microvascular functional and structural obstruction (CMVO), no specific and definitive therapeutic approaches of attenuation have been proven valid in up-to-date large-scale tests, which highlights the urge to address its early recognition.Objectives:This study aimed to compare the performance of two clinical risk scores with an objective measurement of CMVO during percutaneous coronary intervention (PCI) with STEMI.Methods:The Index of Microcirculatory Resistance (IMR) measurement was conducted and the baseline clinical and angiographic parameters were also recorded. The patients were divided into MO (Microvascular obstruction) or NMO (Non-microvascular obstruction) groups according to the post-procedure IMR value. The CMVO risk was evaluated for all participants by SAK and ATI predictive scores, respectively. Each system was calculated by summing the scores of all variables. The receiver operator characteristic (ROC) curves and the area under the curve (AUC) of two risk models were used to evaluate the discriminatory performance. An echocardiography was performed seven days after the procedure to evaluate left ventricular ejection fraction (LVEF). A two-sided P-value of <0.05 was considered statistically significant.Results:Among the 65 eligible STEMI patients, 48 patients were allocated in the NMO group and 17 in the MO group, with a CMVO incidence of 26.15%. There was no significant difference in the AUC between both scores. The LVEF evaluated for the NMO group was higher than that of MO group.Conclusion:Both SAK and ATI scores performed well in estimating CMVO risk after primary PCI for STEMI patients.     

Relação entre Norepinefrina Urinária,Fibrose e Arritmias na Cardiopatia Chagásica Crônica com Fração de Ejeção Preservada ou Minimamente Reduzida

Background:In Chronic Chagas Cardiomyopathy (CCC), studies are needed to identify arrhythmogenic risk factors in patients in which moderate to severe ventricular dysfunction is not present.Objective:To verify the correlation between frequent ventricular arrhythmias (PVC), left ventricular ejection fraction (LVEF), extension of fibrosis by cardiac magnetic resonance (CMR), and urinary norepinephrine measurement (NOREPI) in CCC with preserved or mildly compromised LVEF.Methods:The presence of ventricular extrasystoles > 30/h was analyzed on Holter. At CMR, LVEF and quantification of fibrosis mass were evaluated. The dosage of NOREPI was performed using the Muskiet method. The correlation coefficient matrix was calculated to measure the predictive ability of the variables to predict another variable, with p < 0.05 being considered significant.Results:A total of 59 patients were included. The mean age was 57.9 + 10.94 years. PVC was detected in 28 patients. The fibrosis variable was inversely proportional to LVEF (R of −0.61) and NOREPI (R of −0.68). Also, the variable PVC was inversely proportional to LVEF (R of −0.33) and NOREPI (R of −0.27). On the other hand, LVEF was directly proportional to NOREPI (R of 0.83).Conclusion:In this sample, in patients with CCC with preserved or slightly reduced LVEF, integrity of the autonomic nervous system is observed in hearts with little fibrosis and higher LVEF despite the presence of traditional risk factors for sudden cardiac death. There is correlation between the levels of NOREPI, LVEF, and myocardial fibrosis, but not with PVC.     

Influência de um Protocolo de Mobilização Precoce no comportamento autonômico de pacientes submetidos a Angioplastia Coronária Transluminal Percutânea

Background:Recurrence Plots (RP) enable a nonlinear analysis of Heart Rate Variability (HRV) and provide information on the Autonomic Nervous System (ANS).Objectives:To evaluate whether early ambulation in patients undergoing Percutaneous Transluminal Coronary Angioplasty (PTCA) influences the quantitative and qualitative components of RP.Methods:A total of 32 participants who underwent PTCA were divided into a Control Group (CG - no physical exercises) and an Early Ambulation Group (EAG – with physical exercises). Beat-to-beat heart rate was recorded using a heart rate monitor in both groups upon admission and discharge. The linear indices in the time and frequency domains were analyzed, and nonlinear indices were obtained through RP. The Early Ambulation Physical Therapy Protocol began 12-18 hours after PTCA. A two-tailed unpaired t-test was used for comparisons, and p-values < 0.05 were accepted as significant.Results:When comparing both groups, upon discharge, EAG showed an increase in SDNN (23.55 ± 12.05 to 37.29 ± 16.25; p=0.042), Triangular Index (8.99 ± 3.03 to 9.66 ± 3.07; p=0.014), and VLF (694.20 ± 468.20 to 848.37 ± 526.51; p=0.004), but without significant changes in the nonlinear evaluation. In addition, in the qualitative analysis of RP, a more diffuse and less geometric pattern was observed in EAG, indicating greater variability, while in CG, an altered and more geometric pattern was noted.Conclusion:The Early Ambulation Protocol promotes an improvement in autonomic behavior as evaluated by HRV and by RP, which can thus be considered a useful procedure for better recovery of patients undergoing PTCA.     

Lesão Miocárdica após Cirurgia Não Cardíaca – Estado da Arte

Approximately 300 million non-cardiac surgeries are performed annually worldwide and adverse cardiovascular events are the main cause of morbidity and mortality in the peri- and postoperative period. Myocardial injury after non-cardiac surgery (MINS) is a new clinical entity associated with adverse cardiovascular outcomes. MINS is defined as myocardial injury that can result in necrosis due to ischemia, marked by increase in biomarker levels. It has prognostic relevance and occurs within up to 30 days after non-cardiac surgery. The diagnostic criteria for MINS are an elevated postoperative measure of troponin judged as secondary to myocardial ischemia, i.e., with no evidence of a non-ischemic etiology, during or within 30 days after non-cardiac surgery, and without the requirement of an ischemic symptom or electrocardiographic finding of ischemia. Recently, patients at higher risk for MINS have been recognized using clinical variables and biomarkers and established protocols for greater surveillance in relation to electrocardiographic monitoring and cardiac troponin dosage. Elderly patients with previous atherosclerotic disease need to measure troponin daily in the postoperative period. The aim of the present work is to describe this new public health problem, its clinical impact and contemporary therapeutic approach.     

Associação entre Escores de Risco Clínico (HEART,GRACE e TIMI) e Complexidade Angiográfica na Síndrome Coronária Aguda sem Elevação do Segmento ST

Background:GRACE, TIMI and HEART scores have been previously validated to predict serious untoward events among patients with non-ST elevation acute coronary syndrome (Non-ST ACS). However, the ability of these scores to discriminate the angiographic complexity of coronary artery disease has not been clearly established.Objectives:We sought to evaluate the correlation between clinical scores (TIMI, GRACE and HEART) and the anatomical complexity assessed by SYNTAX score, among non-ST ACS patients undergoing cinecoronariography.Methods:Transversal cohort encompassing patients with diagnosis of Non-ST ACS referred to invasive stratification in our single center, between July 2018 and February 2019. Association between the scores was established by the Pearson''s linear correlation test while the accuracy of the clinical scores versus SYNTAX score was determined with the ROC curve.Results:A total of 138 patients were enrolled. Median GRACE, TIMI and HEART scores were 97, 3 and 5, respectively, whereas the median SYNTAX was 8. There was a positive correlation between the SYNTAX and the HEART (ρ =0.29; p<0.01) and GRACE (ρ =0.18; p<0.01) scores, but the correlation with TIMI reached no statistical significance (ρ =0.15; p=0.08). The HEART score was also the one with the highest area under the curve to predict a SYNTAX ≥32 [HEART = 0.81 (IC95% 0.7-0.91). HEART> 4 presented 100% sensitivity, with 50% specificity; and GRACE> 139 showed 55% sensitivity and 97% specificity for high SYNTAX.Conclusion:The clinical scores presented a positive, although modest, association with the SYNTAX score. The combined use of HEART and GRACE offers good accuracy for detecting angiographic complexity.     

Estratégias de Revascularização em Doentes com Infarto Agudo do Miocárdio em Choque Cardiogênico – Resultados do Registo Português de Síndromes Coronárias Agudas

Background:In patients with acute myocardial infarction (MI), cardiogenic shock (CS), and multivessel disease (MVD) questions remain unanswered when it comes to intervention on non-culprit arteries.Objective:This article aims to 1) characterize patients with MI, CS and MVD included in the Portuguese Registry on Acute Coronary Syndromes (ProACS); 2) compare different revascularization strategies in the sample; 3) identify predictors of in-hospital mortality among these patients.Methods:Observational retrospective study of patients with MI, CS and MVD included in the ProACS between 2010 and 2018. Two revascularization strategies were compared: complete during the index procedure (group 1); and complete or incomplete during the index hospitalization (groups 2-3). The primary endpoint was a composite of in-hospital death or MI. Statistical significance was defined by a p-value <0.05.Results:We identified 127 patients with MI, CS, and MVD (18.1% in group 1, and 81.9% in groups 2-3), with a mean age of 7012 years, and 92.9% of the sample being diagnosed with ST-segment elevation MI (STEMI). The primary endpoint occurred in 47.8% of the patients in group 1 and 37.5% in group 2-3 (p = 0.359). The rates of in-hospital death, recurrent MI, stroke, and major bleeding were also similar. The predictors of in-hospital death in this sample were the presence of left ventricle systolic dysfunction on admission (OR 16.8), right bundle branch block (OR 7.6), and anemia (OR 5.2) (p ≤ 0.02 for both).Conclusions:Among patients with MI, CS, and MVD included in the ProACS, there was no significant difference between complete and incomplete revascularization during the index hospitalization regarding the occurrence of in-hospital death or MI. (Arq Bras Cardiol. 2021; 116(5):867-876)     

Troponina I por Percentil 99 da Definição Universal de Infarto do Miocárdio versus Ponto de Corte de Melhor Acurácia em Síndromes Coronárias Agudas

Background Contemporary diagnosis of ACS and risk stratification are essential for appropriate management and reduction of mortality and recurrent ischemic events, in the acute phase of disease and after hospitalization. The Universal Definition of Myocardial Infarction recommends the detection of troponin levels above the 99^th percentile.Objectives To evaluate the occurrence of early death and acute myocardial infarction (AMI) in patients without elevation of troponin (<0.034 ng/mL), patients with mild elevation (above the 99^th percentile [>0.034 ng/mL and <0.12 ng/mL)], and patients with significant elevation of troponin (above the diagnostic cutoff for AMI defined by the troponin kit (≥0.12 ng/mL)]; and to analyze the impact of troponin on the indication for invasive strategy and myocardial revascularization.Methods Cross-sectional cohort study of patients with ACS with assessment of peak troponin I, risk score, prospective analysis of 30-day clinical outcomes and two-sided statistical tests, with statistical significance set at p<0.05.Results A total of 494 patients with ACS were evaluated. Troponin > 99^th percentile and below the cutoff point, as well as values above the cutoff, were associated with higher incidence of composite endpoint (p<0.01) and higher rates of percutaneous or surgical revascularization procedures (p<0.01), without significative difference in 30-day mortality.Conclusions Troponin levels above the 99^th percentile defined by the universal definition of AMI play a prognostic role and add useful information to the clinical diagnosis and risk scores by identifying those patients who would most benefit from invasive risk stratification and coronary revascularization procedures.