Visceral fat index: a novel predictor for coronary collateral circulation

ABSTRACT Objective This study was designed to investigate the role of visceral adiposity along with other clinical parameters in predicting poor coronary collateral circulation (CCC) among patients with severe obstructive coronary artery disease (CAD). Subjects and methods A total of 135 patients with severe obstructive CAD and good (n = 70) or poor (n = 65) CCC were included. Data on angiographically detected CCC, the quality criteria for CCC (Rentrop scores) and visceral fat index (VFI) obtained via bioelectrical impedance were compared between good and poor CCC groups. Independent predictors of poor CCC, the correlation between VFI and Rentrop score and the role of VFI in the identification of CCC were analyzed. Results A significant negative correlation was noted between VFI and Rentrop scores (r = -0.668, < 0.001). The presence of hypertension (OR 4.244, 95% CI 1.184 to 15.211, p = 0.026) and higher VFI (OR 1.955, 95% CI 1.342 to 2.848, p < 0.001) were shown to be independent predictors of an increased risk for poor CCC. ROC analysis revealed a VFI > 9 (AUC [area under the curve] (95% CI): 0.898 (0.834-0.943), p < 0.0001) to be a potential predictor of poor CCC with a sensitivity of 95.38% and specificity of 85.71%. Conclusion In conclusion, our findings revealed comorbid hypertension and higher VFI to significantly predict the risk of poor CCC in patients with severe obstructive CAD.

Association between Hemogram Parameters and Coronary Collateral Development in Subjects with Non-ST-Elevation Myocardial Infarction

SUMMARY OBJECTIVE Coronary collateral development (CCD) predicts the severity of coronary heart disease. Hemogram parameters, such as mean platelet volume (MPV), eosinophil, red cell distribution width, and platelet distribution width (PDW), are supposed novel inflammatory markers. We aimed to compare hemogram parameter values in patients presenting with non-ST-elevation myocardial infarction (NSTEMI) with adequate or inadequate CCD. METHODS A total of 177 patients with NSTEMI undergoing coronary arteriography were enrolled and divided into two groups based on the development of CCD: one group with adequate CCD (n=88) and the other with impaired CCD (n=89). RESULTS Baseline demographics and clinical risk factors were similar between the groups. Hemogram parameters were not significantly different between the two groups. However, compared to the inadequate CCD group, the median PDW was significantly higher in the adequate CCD group, 17.6 (1.4) vs. 17.8 (1.6) p=0.004. In a multivariate analysis, PDW (p=0.001, 95% CI for OR: 0.489(0,319-0,750) was found to be significantly different in the adequate CCD group compared to the inadequate CCD group. Pearson's correlation analysis revealed that PDW was significantly correlated with the Rentrop score (r=0.26, p<0.001). CONCLUSIONS We suggest that since PDW is an index that is inexpensive and easy to assess, it could serve as a marker of CCD in patients with NSTEMI.

RESUMO OBJETIVO O desenvolvimento colateral coronariano (CCD) prediz a gravidade da doença coronariana. Parâmetros de hemograma como volume plaquetário médio (VPM), eosinófilo, largura de distribuição de glóbulos vermelhos e largura de distribuição de plaquetas (PDW) são supostos novos marcadores inflamatórios. Nosso objetivo foi comparar os valores do parâmetro hemograma em pacientes com infarto do miocárdio sem supradesnivelamento do segmento ST (IAMSSST) com DCC adequado ou inadequado. MÉTODOS Um total de 177 pacientes com NSTEMI submetidos à arteriografia coronariana foram incluídos e divididos, com base no desenvolvimento de CCD, em dois grupos: grupo com CCD adequado (n = 88) e grupo com CCD alterado (n = 89). RESULTADOS Os dados demográficos e os fatores de risco clínicos basais foram semelhantes entre os grupos. Os parâmetros do hemograma não foram significativamente diferentes entre os dois grupos. Mas, em comparação com a mediana inadequada do grupo CCD, o PDW foi significativamente maior em CCD adequado de 17,6 (1,4) vs. 17,8 (1,6) p = 0,004. Na análise multivariada, PDW (p = 0,001, IC 95% para OR: 0,489 (0,319-0,750) foi significativamente diferente no grupo CCD adequado em comparação com o grupo CCD inadequado. A análise de correlação de Pearson revelou que PDW foi significativamente correlacionado com escore de aluguel (r = 0,26, p <0,001). CONCLUSÃO Sugerimos que, uma vez que a PDW é um índice barato e de fácil avaliação, pode servir como um marcador de DCC em pacientes com IAMSSST.

Acute Physical Stress Preconditions the Heart Against Ischemia/Reperfusion Injury Through Activation of Sympathetic Nervous System / Estresse Físico Agudo Precondiciona o Coração Contra a Injúria por Isquemia/Reperfusão Através da Ativação do Sistema Nervoso Simpático

Abstract Background: Stress is defined as a complicated state that related to homeostasis disturbances, over-activity of the sympathetic nervous system and hypothalamus-pituitary-adrenal axis responses. Cardiac preconditioning reduces myocardial damages. Objective: This study was designed to assess the cardioprotective effects of acute physical stress against ischemia/reperfusion (I/R) injury through the activation of the sympathetic nervous system. Methods: Thirty-two male Wistar rats were divided into four groups; (1) IR (n = 8): rats underwent I/R, (2) Acute stress (St+IR) (n = 8): physical stress induced 1-hour before I/R, (3) Sympathectomy (Symp+IR) (n = 8): chemical sympathectomy was done 24-hours before I/R and (4) Sympathectomy- physical stress (Symp+St+IR) (n = 8): chemical sympathectomy induced before physical stress and I/R. Chemical sympathectomy was performed using 6-hydroxydopamine (100 mg/kg, sc). Then, the hearts isolated and located in the Langendorff apparatus to induce 30 minutes ischemia followed by 120 minutes reperfusion. The coronary flows, hemodynamic parameters, infarct size, corticosterone level in serum were investigated. P < 0.05 demonstrated significance. Results: Physical stress prior to I/R could improve left ventricular developed pressure (LVDP) and rate product pressure (RPP) of the heart respectively, (63 ± 2 versus 42 ± 1.2, p < 0.05, 70 ± 2 versus 43 ± 2.6, p < 0.05) and reduces infarct size (22.16 ± 1.3 versus 32 ± 1.4, p < 0.05) when compared with the I/R alone. Chemical sympathectomy before physical stress eliminated the protective effect of physical stress on I/R-induced cardiac damages (RPP: 21 ± 6.6 versus 63 ± 2, p < 0.01) (LVDP: 38 ± 4.5 versus 43 ± 2.6, p < 0.01) (infarct size: 35 ± 3.1 versus 22.16 ± 1.3, p < 0.01). Conclusion: Findings indicate that acute physical stress can act as a preconditional stimulator and probably, the presence of sympathetic nervous system is necessary.

Resumo Fundamento: O estresse é definido como um estado complicado de distúrbios da homeostase, hiperatividade do sistema nervoso simpático e das respostas do eixo hipotálamo-hipófise-adrenal. O pré-condicionamento cardíaco diminui os danos do miocárdio. Objetivo: Esse estudo avaliou os efeitos cardioprotetores do estresse físico agudo contra a lesão por isquemia-reperfusão (I/R) através da ativação do sistema nervoso simpático. Métodos: Trinta e dois ratos machos Wistar foram divididos em quatro grupos; (1) IR (n = 8): ratos submetidos a I/R, (2) Estresse agudo (St+IR) (n = 8): estresse físico induzido 1 hora antes da I/R, (3) Simpatectomia (Symp+IR) (n = 8): a simpatectomia química foi realizada 24 horas antes da I/R e (4) Simpatectomia-estresse físico (Symp+St+IR) (n = 8): simpatectomia induzida antes do estresse físico e da I/R. A simpatectomia química foi realizada com 6-hidroxidopamina (100 mg/kg, SC). Em seguida, os corações foram isolados e colocados em aparato de Lagendorff por 30 minutos para induzir isquemia, seguida de reperfusão por 120 minutos. Os fluxos coronarianos, os parâmetros hemodinâmicos, o tamanho do infarto e os níveis de corticosterona plasmática foram investigados. Valores de p < 0,05 foram considerados significativos. Resultados: O estresse físico anterior à I/R pode melhorar a pressão desenvolvida no ventrículo esquerdo (PDVE) e duplo produto (DP), respectivamente, (63 ± 2 versus 42 ± 1,2, p < 0,05, 70 ± 2 versus 43 ± 2,6, p < 0,05) e reduzir o tamanho do infarto (22,16 ± 1,3 versus 32±1,4, p < 0,05) quando comparado com a I/R isoladamente. A simpatectomia química antes do estresse físico eliminou o efeito protetor do estresse físico sobre os danos cardíacos induzidos pela I/R (DP: 21 ± 6,6 versus 63 ± 2, p < 0,01) (PDVE: 38 ± 4,5 versus 43 ± 2,6, p < 0,01) (tamanho do infarto: 35 ± 3,1 versus 22,16 ± 1,3, p < 0,01). Conclusão: Os achados indicam que o estresse físico agudo pode funcionar como um estimulador pré-condicional e, provavelmente, a presença do sistema nervoso simpático é necessária.

Coronary Flow Reserve in Non-Infarcted Myocardium Predicts Long-Term Clinical Outcomes in Patients Undergoing Percutaneous Coronary Intervention

PURPOSE: Coronary flow reserve (CFR) is recognized as an indicator of myocardial perfusion. The aim of this study was to assess the relationship between CFR in the non-infarcted myocardium and the incidence of major adverse cardiac events (MACEs). MATERIALS AND METHODS: 100 consecutive patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) were enrolled in the present study, and divided into MACE and non-MACE groups according to the incidence of 12-month MACEs. Left ventricular function and CFR were analyzed using two-dimensional echocardiography and myocardial contrast echocardiography at one week after PCI. Cardiac troponin I levels were assayed to estimate peak concentrations thereof. RESULTS: The MACE group was associated with lower CFR, compared to the non-MACE group (2.41 vs. 2.77, p < 0.001). In the multivariable model, CFR in the non-infarcted myocardium was an independent predictor of 12-month MACE (hazard ratio: 0.093, 95% confidence interval: 0.020–0.426, p=0.002) after adjustment for baseline demographic and clinical characteristics. CONCLUSION: CFR in the non-infarcted myocardium is a useful marker for predicting 12-month MACEs in patients with AMI undergoing primary PCI.

Association of Inflammation and Endothelial Dysfunction with Coronary Microvascular Resistance in Patients with Cardiac Syndrome X / Associação de Inflamação e Disfunção Endotelial com Resistência Microvascular Coronariana em Pacientes com Síndrome Cardíaca X

Abstract Background: Although a proportion of CSX patients have impaired brachial artery flow-mediated dilatation (FMD) in response to hyperemia, suggesting that endothelial dysfunction in these patients may be systemic and not just confined to the coronary circulation; the underlying mechanisms triggering endothelial dysfunction in these patients are still incompletely understood. Objectives: To assess the association of the index of Microcirculatory Resistance (IMR) with endothelial dysfunction and inflammation in patients with CSX. Methods: We studied 20 CSX patients and 20 age and gender-matched control subjects. Thermodilution-derived coronary flow reserve (CFR) and IMR were measured using a pressure-temperature sensor-tipped guidewire. Brachial artery FMD was measured using high-resolution, two-dimensional ultrasound images obtained with a Doppler ultrasound device (HDI-ATL 5000, USA) with a 5 MHz to 12 MHz linear-array transducer. Results: Compared with in control subjects, CFR was significantly lower (2.42 ± 0.78 vs. 3.59 ± 0.79, p < 0.001); IMR was higher (32.2 ± 8.0 vs. 19.5 ± 5.5, p < 0.001); the concentration of hs-CRP and FMD was higher (4.75 ± 1.62 vs. 2.75 ± 1.50; 5.24 ± 2.41 vs. 8.57 ± 2.46, p < 0.001) in CSX patients. The Duke treadmill score (DTS) was correlated positively to CFR and FMD (0.489 and 0.661, p < 0.001), it was negative to IMR and hsCRP (-0.761 and -0.087, p < 0.001) in CSX patients. Conclusions: The main finding in this study is that the DTS measured in patients with CSX was associated to hsCRP and FMD. Moreover, the independent effects of exercise tolerance can significantly impair FMD and hsCRP in CSX patients; especially it is particularly important to whom where FMD was associated negatively with IMR.

Resumo Fundamentos: Embora uma proporção de pacientes com SCX tenha dilatação mediada por fluxo da artéria braquial (DMF) prejudicada em resposta à hiperemia, sugerindo que a disfunção endotelial nestes pacientes pode ser sistémica e não limitar-se à circulação coronariana, os mecanismos subjacentes que desencadeiam a disfunção endotelial nestes pacientes ainda não são completamente compreendidos. Objetivos: Avaliar a associação do índice de resistência microcirculatória (IMR) com a disfunção endotelial e a inflamação em pacientes com SCX. Métodos: Estudaram-se 20 pacientes com SCX e 20 sujeitos de controle emparelhados em idade e género. A reserva de fluxo coronariano derivada da termodiluição (RFC) e a IMR forma medidas usando um fio guia com ponta de sensor de temperatura e pressão. A DMF da artéria braquial foi medida utilizando imagens ultrassónicas bidimensionais de alta resolução obtidas com um aparelho de ultrassom Doppler (HDI-ATL 5000, EE.UU.) com transdutor linear de 5 MHz a 12 MHz. Resultados: Em comparação com os sujeitos de controle, a RFC foi significativamente menor (2,42 ± 0,78 vs 3,59 ± 0,79, p < 0,001); o IMR foi maior (32,2 ± 8,0 frente a 19,5 ± 5,5, p < 0,001); a concentração de PCR-as e DMF foi maior (4,75 ± 1,62 frente a 2,75 ± 1,50, 5,24 ± 2,41 diante de 8,57 ± 2,46, p < 0,001) em pacientes com SCX. A escore de Duke (ED) se correlacionou positivamente com RFC e DMF (0,489 e 0,661, p < 0,001), foi negativa para IMR e PCR-as (-0,761 e -0,087, p < 0,001) em pacientes com SCX. Conclusões: O principal achado neste estudo é que o ED medido em pacientes com SCX esteve associado a PCR-as e DMF. Por outra parte, os efeitos independentes da tolerância ao exercício podem piorar significativamente a DMF e a PCR-as em pacientes com SCX especialmente, é particularmente importante que a DMF se associou negativamente com a RIM.

Coronary perfusion pressure during antegrade cardioplegia in on-pump CABG patients

Abstract Objective: The aim of this study was to investigate whether aortic tension estimated by palpation and cardioplegia infusion line pressure provide results equivalent to those obtained with direct aortic intraluminal pressure measurement. Methods: Sixty consecutive patients who underwent coronary artery bypass graft surgeries with extracorporeal circulation were analyzed. Sanguineous cardioplegic solution in a ratio of 4:1 was administered using a triple lumen antegrade cannula. After crossclamping, cardioplegia was infused and aortic root pressure was recorded by surgeon (A) considering the aortic tension he felt in his fingertips. At the same time, another surgeon (B) recorded his results for the same measurement. Concomitantly, the anesthesiologist recorded intraluminal pressure in the aortic root and the perfusionist recorded delta pressure in cardioplegia infusion line. None of the participants involved in these measurements was allowed to be informed about the values provided by the other examiners. Results: The Bland-Altman test showed that a considerable variation between aortic wall tension was found as measured by palpation and by intraluminal pressure, with a bias of -9.911±18.75% (95% limits of agreement: -46.7 to 26.9). No strong correlation was observed between intraluminal pressure and cardioplegia line pressure (Spearman's r=0.61, 95% confidence interval 0.5-0.7; P<0.0001). Conclusion: These findings reinforce that cardioplegia infusion should be controlled by measuring intraluminal pressure, and that palpation and cardioplegia line pressure are inaccurate methods, the latter should always be used to complement intraluminal measurement to ensure greater safety in handling the cardioplegia circuit.

Which Coronary Lesions Are More Prone to Cause Acute Myocardial Infarction? / Quais Lesões Coronarianas São Mais Propensas a Causar Infarto Agudo do Miocárdio?

Abstract Background: According to common belief, most myocardial infarctions (MIs) are due to the rupture of nonsevere, vulnerable plaques with < 70% obstruction. Data from recent trials challenge this belief, suggesting that the risk of coronary occlusion is, in fact, much higher after severe stenosis. The aim of this study was to investigate whether or not acute ST-elevation MIs result from high-grade stenoses by evaluating the presence of coronary collateral circulation (CCC). Methods: We retrospectively included 207 consecutive patients who had undergone primary percutaneous coronary intervention for acute ST-elevation MI. Collateral blood flow distal to the culprit lesion was assessed by two investigators using the Rentrop scoring system. Results: Out of the 207 patients included in the study, 153 (73.9%) had coronary collateral vessels (Rentrop 1-3). The Rentrop scores were 0, 1, 2, and 3 in 54 (26.1%), 50 (24.2%), 51 (24.6%), and 52 (25.1%) patients, respectively. Triglycerides, mean platelet volume (MPV), white cell (WBC) count, and neutrophil count were significantly lower in the group with good collateral vessels (p = 0.013, p = 0.002, p = 0.003, and p = 0.021, respectively). Conclusion: More than 70% of the patients with acute MI had CCC with Rentrop scores of 1-3 during primary coronary angiography. This shows that most cases of acute MI in our study originated from underlying high-grade stenoses, challenging the common believe. Higher serum triglycerides levels, greater MPV, and increased WBC and neutrophil counts were independently associated with impaired development of collateral vessels.

Resumo Fundamento: Há uma crença geral de que a maioria dos infartos agudos do miocárdio (IAM) ocorrem devido à ruptura de placas vulneráveis, não graves, com obstrução < 70%. Dados de ensaios recentes desafiam esta crença, sugerindo que o risco de oclusão coronariana é, na realidade, muito maior após estenose grave. O objetivo deste estudo foi investigar se a presença ou não de IAM com supradesnível do segmento ST resulta de estenoses de alto grau através da avaliação da presença de circulação colateral coronariana (CCC). Métodos: Nós incluímos retrospectivamente 207 pacientes consecutivos submetidos à intervenção coronariana percutânea primária devido à ocorrência de IAM com supradesnível do segmento ST. O fluxo sanguíneo colateral distal à lesão culpada foi avaliado por dois investigadores com utilização do sistema de escores de Rentrop. Resultados: Dos 207 pacientes incluídos no estudo, 153 (73,9%) apresentavam vasos coronarianos colaterais (Rentrop 1-3). Os escores Rentrop foram de 0, 1, 2 e 3 em 54 (26,1%), 50 (24,2%), 51 (24,6%) e 52 (25,1%) pacientes, respectivamente. Triglicérides, volume plaquetário médio (VPM), contagem de células brancas (CCB) e contagem de neutrófilos estiveram significativamente mais baixos no grupo com bons vasos colaterais (p = 0,013, p = 0,002, p = 0,003 e p = 0,021, respectivamente). Conclusão: Mais de 70% dos pacientes com IAM apresentaram CCC com escores de Rentrop de 1-3 durante angiografia coronariana primária. Isto demonstra que a maioria dos casos de IAM em nosso estudo originou a partir de estenoses subjacentes de alto grau, contrariamente à sabedoria comum. Níveis séricos mais elevados de triglicérides, maior VPM e elevação na CCB e na contagem de neutrófilos estiveram independentemente associados com comprometimento no desenvolvimento de vasos colaterais.

Lipoprotein(a) as a predictor of poor collateral circulation in patients with chronic stable coronary heart disease

As a mechanism compensating for obstructive coronary artery disease, coronary collateral circulation (CCC) has attracted cardiologists for a long time to explore its potential impact. In the present study, Chinese patients suffering from ≥95% coronary stenosis, as diagnosed by angiography, have been investigated for the correlation between CCC and lipoprotein(a) [Lp(a)] levels. A cohort of 654 patients was divided into four categories according to Rentrop grades 0, 1, 2, and 3. Lp(a) levels were divided into model 1, discretized with critical values of 33 and 66%, and model 2, discretized with a cutoff value of 30.0 mg/dL. Furthermore, we evaluated the correlation between CCC and serum Lp(a) levels. The four groups had significantly different Lp(a) levels (25.80±24.72, 18.99±17.83, 15.39±15.80, and 8.40±7.75 mg/dL; P<0.001). In model 1, concerning R0, the risk in the third Lp (a) tertile (OR=3.34, 95%CI=2.32-4.83) was greater than that in the first tertile. In model 2, concerning R0, the risk in Lp(a) >30.0 group (OR=6.77, 95%CI=4.44-10.4) was greater than that of Lp(a) <30.0 mg/dL. The worst condition of CCC can be predicted independently by Lp(a) levels. In addition to clinical usage, Lp(a) levels can also be utilized as biological markers.

Patterns of arterial vascularization in swine hearts / Padrões de vascularização arterial em corações de suínos

This study aimed to characterize the patterns of arterial vascularization in swine hearts. Ninety swine hearts were submitted to the Spalteholz diaphanization technique in order to dissect the coronary arteries. Three types of arterial vascularization patterns were characterized through the behaviorof the rami circumflexus and interventricularis, namely: balanced, right and left types. The balanced pattern was the most frequently (42.2%); in this case, the rami circumflexus and interventricularis occupied their respective sulci. The right type (40%) was further categorized into three vascularization subtypes. In the first, ramus circumflexus dexter branched from the ramus interventricularis subsinuosus. In the second, the arteria coronaria dextra branched from ramus interventricularis subsinuosus and ramus circumflexus. In the third model, arteria coronaria sinister branched from ramus interventricularis paraconalis. The left type (17.7%) exhibited two subtypes. In the first, ramus interventricularis paraconalis ran through the entire corresponding sulcus and the ventral third of sulcus interventricularis subsinuosus, and ramus interventricularis subsinuosus occupied the dorsal and middle third of its respective sulcus. In the second, ramus interventricularis subsinuosus branched from arteria coronaria dextra and ran through the dorsal and medium thirds of its respective sulcus, and the ventral third was occupied by the collateral branch of ramus circumflexus sinister. Our results reinforce the thesis that the blood distribution system through the coronary artery in swine is similar to human, not only in qualitative but also by a quantitative comparison.

Este estudo teve como objetivo caracterizar os padrões de vascularização arterial em corações de suínos. Para tanto, 90 corações de suínos foram submetidos à técnica de diafanização de Spalteholz com a finalidade de dissecar as artérias coronárias. Através do comportamento dos rami circumflexus e interventricularis caracterizou-se três modalidades de vascularização arterial do coração de suínos, sendo eles os tipos equilibrado, direito e esquerdo. O equilibrado foi observado com maior frequência (42,2%), neste caso os rami circumflexus e interventricularis das artérias coronárias ocupavam seus respectivos sulcos. O tipo direito (40%) apresentou três subtipos de vascularização. No primeiro o ramus circumflexus dexter ramificava-se formando o ramus interventricularis subsinuosus. No segundo, a arteria coronaria dextra emitia o ramus interventricularis subsinuosus e ramus circunflexus. E no terceiro modelo, da arteria coronaria sinistra emergia o ramus interventricularis paraconalis. O tipo esquerdo (17,7%) apresentou dois subtipos. No primeiro, o ramus interventricularis paraconalis percorria todo o sulco correspondente e o terço ventral do sulcus interventricularis subsinuosus, o ramus interventricularis subsinuosus ocupava os terços dorsal e médio do seu respectivo sulco. No segundo, o ramus interventricularis subsinuosus oriundo da arteria coronaria dextra percorria apenas os terços dorsal e médio do seu respectivo sulco, ficando o terço ventral ocupado por colateral do ramus circumflexus sinister. Nossos resultados reforçam a tese de que a distribuição do suprimento sanguíneo pela artéria coronária em suínos é semelhante ao humano, não apenas de maneira qualitativa, mas também do ponto de vista quantitativo.

Myocardial blood flow assessment with 82rubidium-PET imaging in patients with left bundle branch block

OBJECTIVES: Perfusion abnormalities are frequently seen in Single Photon Emission Computed Tomography (SPECT) when a left bundle branch block is present. A few studies have shown decreased coronary flow reserve in the left anterior descending territory, regardless of the presence of coronary artery disease. OBJECTIVE: We sought to investigate rubidium-82 (82Rb) positron emission tomography imaging in the assessment of myocardial blood flow and coronary flow reserve in patients with left bundle branch block. METHODS: Thirty-eight patients with left bundle branch block (GI), median age 63.5 years, 22 (58%) female, 12 with coronary artery disease (≥70%; GI-A) and 26 with no evidence of significant coronary artery disease (GI-B), underwent rest-dipyridamole stress 82Rb-positron emission tomography with absolute quantitative flow measurements using Cedars-Sinai software (mL/min/g). The relative myocardial perfusion and left ventricular ejection fraction were assessed in 17 segments. These parameters were compared with those obtained from 30 patients with normal 82Rb-positron emission tomography studies and without left bundle branch block (GII). RESULTS: Stress myocardial blood flow and coronary flow reserve were significantly lower in GI than in GII (p<0.05). The comparison of coronary flow reserve between GI-A and GI-B showed that it was different from the global coronary flow reserve (p<0.05) and the stress flow was significantly lower in the anterior than in the septal wall for both groups. Perfusion abnormalities were more prevalent in GI-A (p=0.06) and the left ventricular ejection fraction was not different between GI-A and GI-B, whereas it was lower in GI than in GII (p<0.001). CONCLUSION: The data confirm that patients with left bundle branch block had decreased myocardial blood flow and coronary flow reserve and coronary flow reserve assessed by 82Rb-positron emission tomography imaging may be useful in identifying coronary artery disease in patients with left bundle branch block.

Anxiety, Depression, and General Psychological Distress in Patients with Coronary Slow Flow / Ansiedade, Depressão e Distúrbios Psicológicos Gerais em Pacientes com Fluxo Coronariano Lento

AbstractBackground:The relationship between psychiatric illness and heart disease has been frequently discussed in the literature. The aim of the present study was to investigate the relationship between anxiety, depression and overall psychological distress, and coronary slow flow (CSF).Methods:In total, 44 patients with CSF and a control group of 50 patients with normal coronary arteries (NCA) were prospectively recruited. Clinical data, admission laboratory parameters, and echocardiographic and angiographic characteristics were recorded. Symptom Checklist 90 Revised (SCL-90-R), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) scales were administered to each patient.Results:The groups were comparable with respect to age, sex, and atherosclerotic risk factors. In the CSF group, BAI score, BDI score, and general symptom index were significantly higher than controls (13 [18.7] vs. 7.5 [7], p = 0.01; 11 [14.7] vs. 6.5 [7], p = 0.01; 1.76 [0.81] vs. 1.1[0.24], p = 0.01; respectively). Patients with CSF in more than one vessel had the highest test scores. In univariate correlation analysis, mean thrombolysis in myocardial infarction (TIMI) frame counts were positively correlated with BAI (r = 0.56, p = 0.01), BDI (r = 0.47, p = 0.01), and general symptom index (r = 0.65, p = 0.01). The psychiatric tests were not correlated with risk factors for atherosclerosis.Conclusion:Our study revealed higher rates of depression, anxiety, and overall psychological distress in patients with CSF. This conclusion warrants further studies.

ResumoFundamento:A investigação da relação entre doença psiquiátrica e doença cardíaca sempre foi um tema de interesse na literatura médica.Objetivo:Investigar a relação entre ansiedade, depressão e distúrbios psicológicos gerais e fluxo coronariano lento (FCL).Métodos:Quarenta e quatro pacientes com FCL e 50 pacientes com fluxo coronariano normal (FCN) foram recrutados prospectivamente. Foram registrados: dados clínicos, parâmetros laboratoriais à admissão e características ecocardiográficas e angiográficas. Escalas de avaliação da Lista de Verificação de Sintomas-90 Revisada (SCL-90-R), do Inventário Beck de Depressão (IBD) e do Inventário Beck de Ansiedade (IBA) foram determinadas para cada paciente.Resultados:O grupo FCL incluiu 44 indivíduos e o grupo controle 50 indivíduos. Os grupos foram comparados quanto à idade, sexo e fatores de risco para aterosclerose. No grupo FCL, os escores do IBA, do IBD e do índice geral de sintomas foram significativamente mais altos que no grupo controle (13 [18,7] vs. 7,5 [7], p = 0,01; 11 [14,7] vs. 6,5 [7], p = 0,01; 1,76 [0,81] vs. 1,1[0,24], p = 0,01; respectivamente). Pacientes com FCL em mais de um vaso apresentaram os escores mais elevados. Na análise de correlação univariada, a média das contagens de quadros TIMI foi correlacionada positivamente com o IBA (r = 0,56, p = 0,01), com o IBD (r = 0,47, p = 0,01) e com o Índice Geral de Sintomas (r = 0,65, p = 0,01). Os testes psiquiátricos não tiveram correlação com fatores de risco para aterosclerose.Conclusão:Nosso estudo revelou taxas de depressão, ansiedade e distúrbios psicológicos gerais mais elevadas em pacientes com FCL. Esta conclusão justifica novos estudos.

Evaluation of coronary dominance in pigs; a comparative study with findings in human hearts / Avaliação da dominância coronária em suínos. Estudo comparativo com os achados em corações humanos

Coronary dominance in swine has been poorly evaluated. The frequencies of each type of dominance have been described, but few details have been given as to the different expressions of each one. The aim of this study was to characterize coronary dominance in commercial breed swine. One hundred and fifty eight pig hearts were evaluated. The coronary arteries (CA) were infused with synthetic resin (Palatal 85% and Styrene15%) through the ostia after channeling. The coronary artery that gives origin to the posterior interventricular artery (PIA), and the site of termination of both the circumflex arteries (CXA), and left retroventricular branch (LRVB) were determined in order to establish the coronary dominance pattern. Right coronary dominance was found in 105 hearts (66.5%), and a balanced circulation in 53 specimens (33.5%). No dominance was observed for the left coronary artery in the hearts studied. The CXA ended on the posterior aspect of the left ventricle in 101 samples (64%) and on the crux cordis in 55 specimens (34.8%). In two specimens (1.3%) it ended as a left marginal artery. In all cases the PIA was a branch of the RCA, and was long in 105 hearts (66%), 55% of which corresponded to males and 45% to females, but this difference was not statistically significant (p=0.77). The AIA ended on the apex in 126 specimens (80%), 71 of which (56%) corresponded to males and 55 (44%) to females (p=0.74)...

A dominância coronária em suínos tem sido pouco avaliada. Descreveram-se as frequências de cada um dos tipos, mas não detalharam as diferentes expressões de cada um deles. O objetivo deste estudo foi caracterizar a dominância coronária em suínos de raças comerciais. Avaliaram-se 158 corações de suínos. As artérias coronárias (AC) foram infundidas através da canalização dos seus ostium com resina sintética (Palatal 85% e Estireno15%). Para estabelecer o tipo de dominância coronária, determinou-se de qual coronária desprendia-se a artéria interventricular posterior (AIP) e o lugar de finalização das artérias circunflexa (ACX) e do ramo retro ventricular esquerdo (RRVI). Encontrou-se dominância coronária direita em 105 corações (66%) e circulação balanceada em 53 exemplares (34%). Não foi observada a dominância coronária esquerda nos corações estudados. O calibre proximal e médio da ACD nos casos de dominância coronária direita foi de 3,84 ± 0,80 mm. Por outro lado, encontrou-se que este mesmo calibre nos corações com dominância coronária balanceada foi de 3,97 + 0,79 mm. (p=0,88). A ACX finalizou-se na face posterior do ventrículo esquerdo em 101 amostras (64%) e na crux cordis em 55 exemplares (34,8%). A AIP emergiu em todos os casos da ACD sendo comprida em 105 corações (66%) dos quais 55% correspondia a machos e 45% a fêmeas, sem que esta diferença fosse estatisticamente significativa (p=0,77). A AIA finalizou-se no ápice em 126 exemplares (80%), dos quais 71 (56%) corresponderam a machos e 55 (44%) a fêmeas (p=0,74)...

Increased neutrophil-to-lymphocyte ratio predicts persistent coronary no-flow after wire insertion in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

OBJECTIVES: Acute ST-segment elevation myocardial infarction patients presenting persistent no-flow after wire insertion have a lower survival rate despite successful mechanical intervention. The neutrophil-to-lymphocyte ratio has been associated with increased mortality and worse clinical outcomes in ST-segment elevation myocardial infarction. We hypothesized that an elevated neutrophil-to-lymphocyte ratio would also be associated with a persistent Thrombolysis In Myocardial Infarction flow grade of 0 after wire insertion in patients undergoing primary percutaneous coronary intervention. METHODS: A total of 644 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention within 12 hours of symptom onset were included in our study. Blood samples were drawn immediately upon hospital admission. The patients were divided into 3 groups according to their Thrombolysis In Myocardial Infarction flow grade: Thrombolysis In Myocardial Infarction flow grade 0 after wire insertion, Thrombolysis In Myocardial Infarction flow grade 1-3 after wire insertion and Thrombolysis In Myocardial Infarction flow grade 1-3 at baseline. RESULTS: The neutrophil-to-lymphocyte ratio was significantly higher in the group with Thrombolysis In Myocardial Infarction flow grade 0 after wire insertion compared with the group with Thrombolysis In Myocardial Infarction flow grade 1-3 after wire insertion and the group with Thrombolysis In Myocardial Infarction flow grade 1-3 at baseline. The group with Thrombolysis In Myocardial Infarction flow grade 0 after wire insertion also had a significantly higher in-hospital mortality rate. Persistent coronary no-flow after wire insertion was independently associated with the neutrophil-to-lymphocyte ratio. CONCLUSIONS: An increased neutrophil-to-lymphocyte ratio on admission is significantly associated with persistent coronary no-flow after wire insertion in patients with ST-segment ...

Reserva de Velocidade de Fluxo Coronariano durante o Ecocardiograma sob Estresse com Dobutamina / Coronary Flow Velocity Reserve during Dobutamine Stress Echocardiography

Fundamento: A reserva de velocidade de fluxo coronariano (RVFC) ≥ 2 é adequada para inferir bom prognóstico ou ausência de coronariopatia importante. Objetivo: Identificar parâmetros relevantes na obtenção da RVFC (adequada ou inadequada) na descendente anterior (ADA), durante o ecocardiograma sob estresse com dobutamina (EED). Métodos: Avaliação de 100 pacientes encaminhados para pesquisa de isquemia miocárdica através do EED, orientados para suspender o betabloqueador 72 horas antes do exame. Calculou-se a RVFC pela divisão do pico de velocidade (cm/s) diastólica (PVD) verificado no EED (PVD-EED) pelo de repouso (PVD-REP). No grupo I, a RVFC < 2 e no grupo II a RVFC ≥ 2. Foram utilizados o teste t de Student e o exato de Fisher. Significância estatística quando p < 0,05. Resultados: Em repouso, o tempo (segundos) para obter o Doppler na ADA nos grupos I e II não diferiu (53 ± 31 vs. 45 ± 32; p = 0,23). No EED, registrou-se a ADA em 92 pacientes. O grupo I evidenciou pacientes mais velhos (65,9 ± 9,3 vs. 61,2 ± 10,8 anos; p = 0,04), menor fração de ejeção (61 ± 10 vs. 66 ± 6%; p = 0,005), maior PVD-REP (36,81 ± 08 vs. 25,63 ± 06 cm/s; p < 0,0001) e menor RVFC (1,67 ± 0,24 vs. 2,53 ± 0,57; p < 0,0001), entretanto o PVD-EED não diferiu (61,40 ± 16 vs. 64,23 ± 16 cm/s; p = 0,42). A suspensão do betabloqueador associou-se à chance 4 vezes maior de ocorrer RVFC < 2 (OR = 4; 95% IC [1,171 - 13,63], p = 0,027). Conclusão: O PVD-REP foi o principal parâmetro para determinar uma RVFC adequada. A suspensão do betabloqueador associou-se significativamente com RVFC inadequada. A elevada exequibilidade e o tempo para registro da ADA favorecem a utilização dessa metodologia. .

Background: A coronary flow velocity reserve (CFVR) ≥ 2 is adequate to infer a favorable prognosis or the absence of significant coronary artery disease. Objective: To identify parameters which are relevant to obtain CFVR (adequate or inadequate) in the left anterior descending coronary artery (LAD) during dobutamine stress echocardiography (DSE). Methods: 100 patients referred for detection of myocardial ischemia by DSE were evaluated; they were instructed to discontinue the use of β-blockers 72 hours prior to the test. CFVR was calculated as a ratio of the diastolic peak velocity (cm/s) (DPV) on DSE (DPV-DSE) to baseline DPV at rest (DPV-Rest). In group I, CFVR was < 2 and, in group II, CFVR was ≥ 2. The Fisher's exact test and Student's t test were used for the statistical analyses. P values < 0.05 were considered statistically significant. Results: At rest, the time (in seconds) to obtain Doppler in LAD in groups I and II was not different (53±31 vs. 45±32; p=0.23). During DSE, LAD was recorded in 92 patients. Group I patients were older (65.9±9.3 vs. 61.2±10.8 years; p=0.04), had lower ejection fraction (61±10 vs. 66±6%; p=0.005), higher DPV-Rest (36.81±08 vs. 25.63 ± 06cm/s; p<0.0001) and lower CFVR (1.67 ± 0.24 vs. 2.53 ± 0.57; p<0.0001), but no difference was observed regarding DPVDSE (61.40±16 vs. 64.23±16cm/s; p=0.42). β-blocker discontinuation was associated with a 4-fold higher chance of a CFVR < 2 (OR= 4; 95% CI [1.171-13.63], p=0.027). Conclusion: DPV-Rest was the main parameter to determine an adequate CFVR. β-blocker discontinuation was significantly associated with inadequate CFVR. The high feasibility and the time to record the LAD corroborate the use of this methodology. .

Nitroprusiato: una droga confiable para la estimación de la reserva de flujo fraccional coronario / Nitroprusside: a reliable drug for fractional flow reserve assessment

La angiografía coronaria permanece como "gold standard" para el diagnóstico y toma de decisiones en la enfermedad coronaria. Sin embargo, la significación de lesiones con estenosis de 50-70 por ciento es difícil. La medición de la reserva de flujo fraccional (FFR) es una herramienta útil para dilucidar esta interrogante. Generalmente se usa adenosina (A) en bolo intracoronario para inducir máxima vasodilatación y hay poca evidencia para drogas alternativas con este objeto. En este estudio evaluamos el uso de nitroprusiato (N) como droga alternativa. Métodos y Resultados: Se efectuó un estudio clínico aleatorizado. A (120 ug IC) y posteriormente N (50 ug IC), o vice-versa, se usaron para evaluar cada lesión. Se evaluaron 60 lesiones en 44 pacientes (24 hombres) de 63.5 +/- 9.6 años, con masa corporal 28.95 +/- 3.32 kg/m2. Las lesiones se localizaron en arteria descendente anterior en 46.7 por ciento, coronaria derecha en 26.7 por ciento, circunfleja en 11.7 por ciento y 13.9 por ciento en las otras arterias. La estenosis coronaria promedio evaluada por angiografía cuantitativa fue 49.5 por ciento (95 por ciento CI: 46.5 - 52.5 por ciento). La presión arterial media (PAM) basal fue similar en ambos grupos (pre - A: 106.5 +/- 18.2 mmHg, pre - N: 105.6 +/- 18.8 mmHg, NS) o después de A, pero se observó un descenso transitorio después de NP (descenso promedio de 12.5 mmHg, 95 por ciento CI: 9.2 a15.7 mmHg, 2p < 0.001). Este efecto estaba asociado a la hiperemia prolongada lograda con N. (duración de hiperemia con N: 39.2 +/- 8.7 s., y con A of 15.3 +/- 3.2 s. 2p < 0.001). Hubo excelente correlación entre los resultados de A y de N respecto de FFR (r 0.986)...

Abstract: Coronary angiography remains the gold standard for diagnosing coronary artery disease and making therapeutic decisions. However the significance of intermediate lesions (between 50-70%) is difficult to evaluate. Fractional flow reserve (FFR) measurement is an important tool for the evaluation of these lesions. To achieve maximum vasodilatation, Intracoronary (IC) bolus or a continuous intravenous infusion of (A) is usually used. There is very little data for an alternative drug. The aim of this study was to evaluate Sodium nitroprusside (N) 50 IC bolus as an alternative to A for to determine FFR.Method and Results: A multicentric, randomized clinical trial was conducted. A, (120 IC) and subsequently N (50 IC) or vice versa was used for every lesion. 60 coronary lesions were evaluated in 44 patients (24 men and 20 women), mean age 63.5 ± 9.6 years and BMI 28.95 ± 3.32 kg/m2. The lesions were located in the left anterior descending artery in 46.7% of patients, the right coronary in 26.7%, the circumflex in 11.7% and others in 13.9%. Mean coronary artery stenosis as assessed by quantitative coronary angiography (QCA) was 49.5% (95% CI: 46.5 - 52.5%).The mean arterial pressure (MAP) was similar in groups at baseline.(pre - A: 106.5 ± 18.2 mmHg, pre - N: 105.6 ± 18.8 mmHg, NS), or after A, but there was a transient decrease in MAP when N was administered (average decline of MAP: 12.5 mmHg, (95% CI: 9.2 to 15.7 mmHg, 2p < 0.001). This effect was due to the prolonged hypere-mia time achieved with the drug (hyperemia duration with nitroprusside 39.2 ± 8.7 sec. and with adenosine of 15.3 ± 3.2 sec. 2p < 0.001). We could demonstrate an excellent correlation between IC nitroprusside and IC adenosine with regard to FFR measurement, (correlation coefficient = 0.986, p < 0.001)...

Coronary Flow Reserve in the Remote Myocardium Predicts Left Ventricular Remodeling Following Acute Myocardial Infarction

PURPOSE: Coronary flow reserve (CFR) in the non-infarcted myocardium is often impaired following acute myocardial infarction (AMI). However, the clinical significance of CFR in the non-infarcted myocardium is not fully understood. The objective of the present study was to assess whether a relationship exists between CFR and left ventricular remodeling following AMI. MATERIALS AND METHODS: We enrolled 18 consecutive patients undergoing coronary intervention. Heart function was analyzed using real-time myocardial contrast echocardiography at one week and six months after coronary angioplasty. Ten subjects were enrolled as the control group and were examined using the same method at the same time to assess CFR. Cardiac troponin I (cTnI) levels were routinely analyzed to estimate peak concentration. RESULTS: CFR was 1.55+/-0.11 in the infarcted zone and 2.05+/-0.31 in the remote zone (p2.05). The levels of cTnI were higher in Group I compared to Group II on admission (36.40 vs. 21.38, p<0.05). Furthermore, left ventricular end diastolic volume was higher in Group I compared to Group II at six months following coronary angioplasty. CONCLUSION: Microvascular dysfunction is commonly observed in the remote myocardium. The CFR value accurately predicts adverse ventricular remodeling following AMI.

Coronary Flow Reserve in the Remote Myocardium Predicts Left Ventricular Remodeling Following Acute Myocardial Infarction

PURPOSE: Coronary flow reserve (CFR) in the non-infarcted myocardium is often impaired following acute myocardial infarction (AMI). However, the clinical significance of CFR in the non-infarcted myocardium is not fully understood. The objective of the present study was to assess whether a relationship exists between CFR and left ventricular remodeling following AMI. MATERIALS AND METHODS: We enrolled 18 consecutive patients undergoing coronary intervention. Heart function was analyzed using real-time myocardial contrast echocardiography at one week and six months after coronary angioplasty. Ten subjects were enrolled as the control group and were examined using the same method at the same time to assess CFR. Cardiac troponin I (cTnI) levels were routinely analyzed to estimate peak concentration. RESULTS: CFR was 1.55+/-0.11 in the infarcted zone and 2.05+/-0.31 in the remote zone (p2.05). The levels of cTnI were higher in Group I compared to Group II on admission (36.40 vs. 21.38, p<0.05). Furthermore, left ventricular end diastolic volume was higher in Group I compared to Group II at six months following coronary angioplasty. CONCLUSION: Microvascular dysfunction is commonly observed in the remote myocardium. The CFR value accurately predicts adverse ventricular remodeling following AMI.

Impaired Coronary Flow Reserve Is the Most Important Marker of Viable Myocardium in the Myocardial Segment-Based Analysis of Dual-Isotope Gated Myocardial Perfusion Single-Photon Emission Computed Tomography

OBJECTIVE: The aim of this study was to investigate the most robust predictor of myocardial viability among stress/rest reversibility (coronary flow reserve [CFR] impairment), 201Tl perfusion status at rest, 201Tl 24 hours redistribution and systolic wall thickening of 99mTc-methoxyisobutylisonitrile using a dual isotope gated myocardial perfusion single-photon emission computed tomography (SPECT) in patients with coronary artery disease (CAD) who were re-vascularized with a coronary artery bypass graft (CABG) surgery. MATERIALS AND METHODS: A total of 39 patients with CAD was enrolled (34 men and 5 women), aged between 36 and 72 years (mean 58 +/- 8 standard in years) who underwent both pre- and 3 months post-CABG myocardial SPECT. We analyzed 17 myocardial segments per patient. Perfusion status and wall motion were semi-quantitatively evaluated using a 4-point grading system. Viable myocardium was defined as dysfunctional myocardium which showed wall motion improvement after CABG. RESULTS: The left ventricular ejection fraction (LVEF) significantly increased from 37.8 +/- 9.0% to 45.5 +/- 12.3% (p < 0.001) in 22 patients who had a pre-CABG LVEF lower than 50%. Among 590 myocardial segments in the re-vascularized area, 115 showed abnormal wall motion before CABG and 73.9% (85 of 115) had wall motion improvement after CABG. In the univariate analysis (n = 115 segments), stress/rest reversibility (p < 0.001) and 201Tl rest perfusion status (p = 0.024) were significant predictors of wall motion improvement. However, in multiple logistic regression analysis, stress/rest reversibility alone was a significant predictor for post-CABG wall motion improvement (p < 0.001). CONCLUSION: Stress/rest reversibility (impaired CFR) during dual-isotope gated myocardial perfusion SPECT was the single most important predictor of wall motion improvement after CABG.