Myocardial microstructure assessed by T1 mapping after on-pump and off-pump coronary artery bypass grafting.

Background: The correlation between the release of cardiac biomarkers after revascularization, in the absence of late gadolinium enhancement (LGE) or myocardial edema, and the development of myocardial tissue damage remains unclear. This study sought to identify whether the release of biomarkers is associated with cardiac damage by assessing myocardial microstructure on T1 mapping after on-pump (ONCAB) and off-pump coronary artery bypass grafting (OPCAB). Methods: Seventy-six patients with stable multivessel coronary artery disease (CAD) and preserved systolic ventricular function were included. T1 mapping, high-sensitive cardiac troponin I (cTnI), creatine kinase myocardial band (CK-MB) mass, and ventricular dimensions and function were measured before and after procedures. Results: Of the 76 patients, 44 underwent OPCAB, and 32 ONCAB; 52 were men (68.4%), and the mean age was 63±8.5 years. In both OPCAB and ONCAB the native T1 values were similar before and after surgeries. An increase in extracellular volume (ECV) values after the procedures was observed, due to the decrease in hematocrit levels during the second cardiac resonance. However, the lambda partition coefficient showed no significant difference after the surgeries. The median peak release of cTnI and CK-MB were higher after ONCAB than after OPCAB [3.55 (2.12-4.9) vs. 2.19 (0.69-3.4) ng/mL, P=0.009 and 28.7 (18.2-55.4) vs. 14.3 (9.3-29.2) ng/mL, P=0.009, respectively]. Left ventricular ejection fraction (LVEF) was similar in both groups before and after surgery. Conclusions: In the absence of documented myocardial infarction, T1 mapping did not identify structural tissue damage after surgical revascularization with or without cardiopulmonary bypass (CPB), despite the excessive release of cardiac biomarkers.

Myocardial tissue microstructure with and without stress-induced ischemia assessed by T1 mapping in patients with stable coronary artery disease.

BACKGROUND: Stress-induced myocardial ischemia seems not to be associated with cardiovascular events. However, its effects on myocardial tissue characteristics remain under debate. Thus, we sought to assess whether documented stress-induced ischemia is associated with changes in myocardial microstructure evaluated by magnetic resonance native T1 map and extracellular volume fraction (ECV). METHODS: This is a single-center, analysis of the previously published MASS V Trial. Multivessel patients with a formal indication for myocardial revascularization and with documented stress-induced ischemia were included in this study. Native T1 and ECV values evaluated by cardiac magnetic resonance imaging of ischemic and nonischemic myocardial segments at rest and after stress were compared. Myocardial ischemia was detected by either nuclear scintigraphy or stress magnetic cardiac resonance protocol. RESULTS: Between May 2012 and March 2014, 326 prospective patients were eligible for isolated CABG or PCI and 219 were included in the MASS V trial. All patients underwent resting cardiac magnetic resonance imaging. Of a total of 840 myocardial segments, 654 were nonischemic segments and 186 were ischemic segments. Native T1 and ECV values of ischemic segments were not significantly different from nonischemic segments, both at rest and after stress induction. In addition, native T1 and ECV values of myocardial segments supplied by vessels with obstructive lesions were similar to those supplied by nonobstructive ones. CONCLUSION AND RELEVANCE: In this study, cardiac magnetic resonance identified similar T1 mapping values between ischemic and nonischemic myocardial segments. This finding suggests integrity and stability of myocardial tissue in the presence of stress-induced ischemia.

BRASH Syndrome: A Case Report.

BACKGROUND BRASH syndrome is a newly recognized clinical entity characterized by bradycardia, renal failure, atrioventricular blockade, shock, and hyperkalemia. Patients with BRASH syndrome often have severe bradycardia that is refractory to antidotes and chronotropic medications. In these situations, transvenous pacemaker and renal replacement therapy may be necessary. Therefore, rapid diagnosis and correct management of this entity are crucial to reduce mortality. We report a case and the management of BRASH syndrome in the Emergency Department. CASE REPORT A 76-year-old man with chronic kidney disease stage 3, essential hypertension and psoriasis, and receiving atenolol presented to the Emergency Department with lethargy and weakness that started 3 days ago, with rapid deterioration into shock. His initial laboratory tests revealed hyperkalemia, metabolic acidosis, and acute kidney injury. His initial electrocardiogram was remarkable for sinus bradycardia with junctional escape rhythm with ventricular rate of 26 bpm. A chest X-ray was normal. Transthoracic echocardiogram showed normal systolic and diastolic function. Atenolol was immediately held. He was treated with potassium-lowering agents and vasoactive drugs. Due to the persistence of bradycardia, even after reversal of hyperkalemia, a temporary transvenous pacemaker was placed. Renal replacement therapy was not required. Renal function improved and heart rate stabilized at 80 bpm. The patient was discharged and advised to avoid atrioventricular-blocking agents, with Cardiology follow-up. CONCLUSIONS BRASH syndrome is a serious complication due to a combination of hyperkalemia, hypotension, and bradycardia in the setting of kidney dysfunction and medications that block the atrioventricular node. Hemodynamic support and temporary pacemaker use may be needed to manage this entity.

Diagnostic Management and Surgical Treatment of Isolated Tricuspid Regurgitation.

Severe tricuspid regurgitation is especially caused by pulmonary hypertension. Primary tricuspid regurgitation in the absence of pulmonary hypertension and of unknown etiology is a very rare condition with scarce data about its diagnosis, treatment, and follow-up. The particularities of surgery indication and outcomes are still not clearly known. A 72-year-old woman with a medical history of coronary artery bypass grafting three years ago presented with shortness of breath and low limb edema. Physical examination revealed a prominent bilateral jugular turgescence, hepatomegaly, peripheral edema, and a left midsternal border holosystolic murmur, suggestive of tricuspid regurgitation. The echocardiogram confirmed the diagnosis and showed preserved right and left ventricular dimensions and function. Coronary angiography showed no new obstructive lesions and patent surgical grafts. Right cardiac catheterization revealed mild pulmonary hypertension and increased right atrium pressure. Cardiac magnetic resonance showed mild right ventricular dilation with normal systolic function and normal left chambers. No late gadolinium enhancement was detected. Because of persistent symptoms, even after optimization of medical therapy, the patient was submitted to tricuspid valve replacement surgery. Immediately after the surgery, the patient developed significant right ventricular dysfunction, with the need of continuous hemodynamic support. She had progressive clinical recovery that was confirmed by serial echocardiograms that showed improvement in right ventricular volume and function. The patient was discharged with no signs or symptoms of right heart failure. The histopathological examination showed significant and diffuse myxomatous degeneration of the leaflets. No signs of infection or vegetation nor disruption of strands were observed. This report illustrates a very rare case of symptomatic primary isolated severe tricuspid regurgitation caused by myxomatous degeneration of the leaflets. The thoroughly diagnostic workup is presented, and only the histopathological analysis of the leaflets revealed the etiologic process. Surgical treatment indicated before the onset of right ventricular failure was essential to patient's full recovery.

Association of Longitudinal Values of Glycated Hemoglobin With Cardiovascular Events in Patients With Type 2 Diabetes and Multivessel Coronary Artery Disease.

Importance: Glycated hemoglobin (HbA1c) values are used to guide glycemic control, but in patients with type 2 diabetes and multivessel coronary artery disease (CAD), the association of the longitudinal values of HbA1c with cardiovascular outcomes is unclear. Objective: To assess whether longitudinal variation of HbA1c is associated with cardiovascular events in long-term follow-up among patients with diabetes and multivessel CAD. Design, Setting, and Participants: This cohort study included 888 patients with type 2 diabetes and multivessel CAD in the Medicine, Angioplasty, or Surgery Study (MASS) Registry of the Heart Institute of the University of São Paulo from January 2003 to December 2007. Data were analyzed from January 15, 2018, to October 15, 2019. Exposure: Longitudinal HbA1c values. Main Outcomes and Measures: The combined outcome of all-cause mortality, myocardial infarction, and ischemic stroke. Results: Of 888 patients with type 2 diabetes and multivessel CAD, 725 (81.6%; median [range] age, 62.4 [55.7-68.0] years; 467 [64.4%] men) had complete clinical and HbA1c information during a median (interquartile range) follow-up period of 10.0 (8.0-12.3) years, with a mean (SD) of 9.5 (3.8) HbA1c values for each patient. The composite end point of death, myocardial infarction, or ischemic stroke occurred in 262 patients (36.1%). A 1-point increase in the longitudinal value of HbA1c was significantly associated with a 14% higher risk of the combined end point of all-cause mortality, myocardial infarction, and ischemic stroke (hazard ratio, 1.14; 95% CI, 1.04-1.24; P = .002) in the unadjusted analysis. After adjusting for baseline factors (ie, age, sex, 2-vessel or 3-vessel CAD, initial CAD treatments, ejection fraction, and creatinine and low-density lipoprotein cholesterol levels), a 1-point increase in the longitudinal value of HbA1c was associated with a 22% higher risk of the combined end point (hazard ratio, 1.22; 95% CI, 1.12-1.35; P < .001). Conclusions and Relevance: Longitudinal increase of HbA1c was independently associated with higher rates of cardiovascular events in patients with type 2 diabetes and multivessel CAD.

Angina instável e infarto agudo do miocárdio sem supradesnivelamento de ST: tratamento e prognóstico / Unstable angina and non-ST elevation myocardial infarction: treatmemt and prognosis

Objetivo: As doenças cardiovasculares são responsáveis pela principal causa de óbitos na população adulta mundial, sendo a síndrome coronariana aguda (SCA) a mais prevalente entre elas. Resultados: Sabemos que hoje, do ponto de vista epidemiológico, a coronariopatia aguda sem supradesnivelamento de ST tornou-se a forma mais frequente de apresentação clínica da SCA, aproximadamente, em 62% dos casos. Nos últimos anos, houve importantes avanços em relação à terapêutica antiplaquetária e anticoagu-lante capazes de reduzir a mortalidade associada à doença coronariana. Além disso, a estratificação invasiva precoce teve papel fundamental nesse incremento de prognóstico. Conclusão:Dessa forma, atualmente, a escolha terapêutica e de estratificação devem ser avaliadas individual

Cardiovascular diseases are the main cause of death in the adult population worldwide, with acute coronary syndrome (ACS) being the most prevalent. We know that, presently, from an epidemiological point of view, non-ST elevation ACS is the most frequent form of clinical presentation of ACS, in about 62% of cases. Recently, important advances regarding antiplatelet and anticoagulant therapy exist, capable of reducing mortality associated with coronary heart disease. Moreover, early invasive stratification has played a key role in the improvement in prognosis. Thus, the choice of therapy and stratification should be evaluated individually and can modify short- and long-term outcome

Manuseio de emergências cardiológicas em hospitais gerais do estado do Paraná / Management of cardiologic emergencies in general hospitals in the state of Paraná

JUSTIFICATIVA E OBJETIVOS: As diretrizes sobre as condutas em reanimação cardiopulmonar (RCP) foram baseadas na grande evolução dos estudos nessa área, sendo atualizadas em certos períodos de tempo. É por isso que o manuseio correto de uma parada cardíaca depende apenas da atualização do profissional que a atende. O objetivo deste estudo foi avaliar a condutados profissionais responsáveis pelo primeiro atendimento frente a emergências cardiológicas em alguns serviços hospitalares. MÉTODO: Foram avaliados 80 médicos de hospitais gerais, tomando-se como padrão as normas do Advanced Cardiologic Life Support (ACLS) e comparando o índice de acertos em um questionário com alguns quesitos de formação e trabalho do profissional. Os profissionais foram identificados com idade, sexo, estado civil, tempo de formação e local de trabalho, e em seguida responderam a seis questões referentes às condutas utilizadas. RESULTADOS: O índice de acertos foi tabulado e comparado, apresentando uma média de acertos de 3,5 questões. O mínimo de acertos foi zero, e o máximo foram seis questões. Houve correlação inversa significativa entre a idade e o número de acertos, ou seja, médicos mais jovens acertaram mais questões que os médicos de mais idade. Não houve associação significativa entre sexo, estado civil, tempo de formação e local de trabalho em relação ao número de acertos. CONCLUSÃO: Portanto, há a necessidade de atualizações entre os profissionais, buscando o melhor atendimento emergencial.

BACKGROUND AND OBJECTIVES: The cardiopulmonary resuscitation (CPR) guidelines were based on the large evolution of the studies in this area, being updated in certain periods of time. That is why the correct management of a cardiac arrest only depends on the professionals updating. The goal of the study was to evaluate the behavior of professionals responsible for primary care when they are faced with cardiologic emergencies in some hospitals. METHOD: Eighty physicians of general hospitals were evaluated, taking as base the Advance Cardiologic Life Support (ACLS) guidelines and comparing the rates of correct answers in a questionnaire with questions about professional training and work. The professionals were identified by age, gender, civil state, time of training and work place, and then they answered six questions about the procedures undertaken. RESULTS: The correct answers were tabulated and compared, demonstrating an average number of right answers of 3.5. The minimum was zero right answers and the maximum, six. There was a significant inverse correlation between the age and the number of correct answers, i.e., younger physicians had more correct answers than older ones. There were not significant relations among gender, civil state, time of training, and work place and number of correct answers. CONCLUSION: Therefore, professionals should keep themselves updated in order to deliver better emergency care.