Auricular Vagal Neuromodulation and its Application in Patients with Heart Failure and Reduced Ejection Fraction. / Neuromodulação Vagal Auricular e sua Aplicabilidade em Pacientes com Insuficiência Cardíaca e Fração de Ejeção Reduzida.

BACKGROUND: The autonomic nervous system (ANS) imbalance in heart failure (HF) creates a vicious cycle, excess sympathetic activity, and decreased vagal activity contributing to the worsening of HF. Low-intensity transcutaneous electrical stimulation of the auricular branch of the vagus nerve (taVNS) is well tolerated and opens new therapeutic possibilities. OBJECTIVES: To hypothesize the applicability and benefit of taVNS in HF through intergroup comparison of echocardiography parameters, 6-minute walk test, Holter heart rate variability (SDNN and rMSSD), Minnesota quality of life questionnaire, and functional class by the New York Heart Association. In comparisons, p values <0.05 were considered significant. METHODS: Prospective, double-blind, randomized clinical study with sham methodology, unicentric. Forty-three patients were evaluated and divided into 2 groups: Group 1 received taVNS (frequencies 2/15 Hz), and Group 2 received sham. In comparisons, p values <0.05 were considered significant. RESULTS: In the post-intervention phase, it was observed that Group 1 had better rMSSD (31 x 21; p = 0.046) and achieved better SDNN (110 vs. 84, p = 0.033). When comparing intragroup parameters before and after the intervention, it was observed that all of them improved significantly in group 1, and there were no differences in group 2. CONCLUSION: taVNS is a safe to perform and easy intervention and suggests a probable benefit in HF by improving heart rate variability, which indicates better autonomic balance. New studies with more patients are needed to answer the questions raised by this study.

FUNDAMENTO: O desequilíbrio do sistema nervoso autônomo (SNA) na insuficiência cardíaca (IC) cria um ciclo vicioso, o excesso de atividade simpática e a diminuição da atividade vagal contribuindo para a piora da IC. A estimulação elétrica transcutânea de baixa intensidade do ramo auricular do nervo vago (taVNS) é bem tolerada e abre novas possibilidades terapêuticas. OBJETIVOS: Gerar hipótese da aplicabilidade e benefício da taVNS na IC através da comparação intergrupos de parâmetros ecocardiográficos, teste de caminhada de 6 min, variabilidade da frequência cardíaca pelo Holter (SDNN e rMSSD), questionário de qualidade de vida de Minnesota e classe funcional pela New York Heart Association. MÉTODOS: Estudo clínico prospectivo, duplo cego, randomizado com metodologia sham, unicêntrico. Avaliados 43 pacientes e alocados em 2 grupos: o Grupo 1 recebeu taVNS (frequências 2/15 Hz) e Grupo 2 recebeu sham. Nas comparações, valores de p<0,05 foram considerados significativos. RESULTADOS: Na fase pós-intervenção, observou-se que o Grupo 1 se manteve com melhor rMSSD (31 x 21; p = 0,046) e atingiu melhor SDNN (110 vs. 84, p = 0,033). Ao compararmos os parâmetros intragrupos, antes e após intervenção, observou-se que todos melhoraram significativamente no grupo 1 e não houve diferenças no grupo 2. CONCLUSÃO: A taVNS é uma intervenção segura, de fácil execução e que sugere provável benefício na IC pela melhora na variabilidade da frequência cardíaca, o que indica melhor equilíbrio autonômico. Novos estudos com maior número de pacientes são necessários para responder às questões levantadas por esse estudo.

Índices fisiológicos não hiperêmicos ­ base teórica, aplicações clínicas e limitações / Non-hyperemic pressure ratios ­ theoretical basis, clinical applications, and limitations

A fisiologia coronariana tornou-se o padrão de tratamento para avaliar o significado funcional da doença aterosclerótica coronariana. Ela permite identificar isquemia miocárdica em nível de vaso, discriminar os padrões funcionais da doença aterosclerótica e orientar a necessidade de revascularização; complementar o planejamento da intervenção coronária percutânea e confirmar o sucesso funcional dessa última. Em uma edição anterior do Journal of Transcatheter Interventions, apresentamos uma revisão abrangente sobre o fluxo fracionado de reserva do miocárdio. Apesar do robusto corpo de evidências que apoiam seu uso, a aceitação clínica do fluxo fracionado de reserva é variável e excessivamente baixa em muitas áreas do mundo. O aumento percebido no tempo do procedimento, o uso de agentes hiperêmicos com seus correspondentes custos e desconforto do paciente, e a dificuldade de interpretação dos resultados em determinadas situações anatômicas contribuíram para a adoção limitada do método. A introdução do índice de fluxo instantâneo no período livre de ondas superou a maioria dessas limitações. Apoiada por uma validação técnica sólida e dados de desfechos clínicos, o índice de fluxo instantâneo no período livre de ondas recebeu as mesmas indicações clínicas que o fluxo fracionado de reserva nas recomendações mais recentes das diretrizes. Isso foi seguido pela introdução de outros índices pressóricos não hiperêmicos, já comercialmente disponíveis. Neste artigo, revisamos as bases fisiológicas que justificam o uso de índices pressóricos não hiperêmicos, sua validação técnica e clínica e dados de desfechos clínicos, além de discutirmos suas aplicações em situações anatômicas específicas, com exemplos de casos dos autores, sempre que aplicável.

Coronary physiology has become the standard of care to assess the functional significance of coronary atherosclerotic disease. It allows for identification of myocardial ischemia on a vessel level, discrimination of the functional patterns of atherosclerotic disease, guidance for the need of revascularization, complements the planning of percutaneous coronary intervention and verification of the functional success of percutaneous coronary intervention. On a previous issue of the Journal of Transcatheter Interventions, we presented a comprehensive review about fractional flow reserve. Despite the robust body of evidence supporting its use, the clinical use of fractional flow reserve is variable, and unreasonably low in many areas around the globe. The perceived increase in procedure time, the use of hyperemic agents with its related costs and patient discomfort, and difficulty in interpreting results in certain anatomical scenarios have contributed to the limited adoption of fractional flow reserve. The introduction of instantaneous wave-free ratio overcame most of these limitations. Supported by sound technical validation, and clinical outcomes data, instantaneous wave-free ratio received the same clinical indications as fractional flow reserve in the most recent guidelines recommendations. This was followed by the introduction of other non- hyperemic pressure ratios for commercial use. In the current manuscript we review the physiological basis that supports the use of non-hyperemic pressure ratios, their technical and clinical validation, clinical outcomes data, and discuss its applications on specific anatomic scenarios, with examples of cases from the authors, whenever applicable.

Angiography quantitative flow ratio: a systematic review and analysis of diagnostic accuracy

INTRODUCTION: Fractional flow reserve (FFR) is the gold standard to evaluate severity of coronary stenosis. Quantitative flow ratio (QFR) is a new angiography-based method used to infer FFR. Studies have shown >90% agreement between QFR and FFR. OBJECTIVE: To conduct a systematic review and diagnostic accuracy analysis of QFR using individual vessel data. METHODS: This review follows PRISMA guidelines. MEDLINE, EMBASE and Cochrane Library of Clinical Trials were searched for QFR accuracy studies published until Oct 2020. Inclusion criteria: (a) QFR vs FFR; (b) QFR diagnostic capacity; (c) agreement data between QFR/FFR expressed as dot plots or individual data tables. Graphic data were digitized using a semiautomatic software. QFR/FFR values were dichotomized using cutoff values of ≤ 0.80 for ischemia. QFR diagnostic accuracy was assessed by two logistic regressions superimposed on the same graph to ensure the probability of agreement between QFR and FFR for any QFR value. FFR was the reference standard. RESULTS: 20 studies comprising 5,318 vessels from 4,429 patients were included. Most patients were male (64%) at an age of 66.8 ± 5.2 years. Figure 1A shows FFR distribution and QFR diagnostic accuracy for different QFR ranges. QFR overall accuracy, sensitivity, specificity, PPV and NPV are displayed in Figure 1B. A diagnostic accuracy of 87% was reached for QFR cutoff values 0.86, and 95% or 98% with cutoffs 0.91 and 0.94, respectively (Figure 1B). CONCLUSIONS: A very good diagnostic accuracy of QFR measures was observed using individual vessel data. QFR can be used to evaluate the severity of coronary stenosis. At less accurate values addition of FFR can improve precision.

Fluxo fracionado de reserva do miocárdio: bases fisiológicas, aplicações clínicas e limitações / Fractional flow reserve: physiological bases, clinical applications and limitations

A avaliação fisiológica invasiva da circulação coronariana emergiu nos últimos anos como uma abordagem diagnóstica valiosa no manejo de pacientes com síndrome coronariana crônica, contornando limitações importantes como avaliar função a partir da anatomia e a baixa resolução espacial associada à angiografia ou testes não invasivos. O valor das medidas de fluxo hiperêmico para estimar a relevância funcional das estenoses coronárias é suportado por um grande número de estudos. O objetivo do presente artigo é rever as principais bases fisiológicas, aplicações clínicas e limitações do fluxo fracionado de reserva do miocárdio, o principal índice utilizado na avaliação funcional invasiva da circulação coronariana.

Invasive physiological assessment of the coronary circulation has emerged in recent years as a valuable diagnostic approach in the management of patients with chronic coronary syndrome, overcoming important limitations such as evaluating function from the anatomy and the low spatial resolution associated with angiography or non-invasive tests. The value of hyperemic flow measurements to estimate the functional relevance of coronary stenoses is supported by many studies. The aim of this paper is to review the physiological bases, clinical applications and limitations of myocardial fractional flow reserve, the main index used in the invasive functional assessment of the coronary circulation.

Vagal Neuromodulation in Chronic Heart Failure With Reduced Ejection Fraction: A Systematic Review and Meta-Analysis.

Objectives: The aim of this study was to evaluate the effects of invasive vagal nerve stimulation (VNS) in patients with chronic heart failure (HF) and reduced ejection fraction (HFrEF). Background: Heart failure is characterized by autonomic nervous system imbalance and electrical events that can lead to sudden death. The effects of parasympathetic (vagal) stimulation in patients with HF are not well-established. Methods: From May 1994 to July 2020, a systematic review was performed using PubMed, Embase, and Cochrane Library for clinical trials, comparing VNS with medical therapy for the management of chronic HFrEF (EF ≤ 40%). A meta-analysis of several outcomes and adverse effects was completed, and GRADE was used to assess the level of evidence. Results: Four randomized controlled trials (RCT) and three prospective studies, totalizing 1,263 patients were identified; 756 treated with VNS and 507 with medical therapy. RCT data were included in the meta-analysis (fixed-effect distribution). Adverse effects related to VNS were observed in only 11% of patients. VNS was associated with significant improvement (GRADE = High) in the New York Heart Association (NYHA) functional class (OR, 2.72, 95% CI: 2.07-3.57, p < 0.0001), quality of life (MD -14.18, 95% CI: -18.09 to -10.28, p < 0.0001), a 6-min walk test (MD, 55.46, 95% CI: 39.11-71.81, p < 0.0001) and NT-proBNP levels (MD -144.25, 95% CI: -238.31 to -50.18, p = 0.003). There was no difference in mortality (OR, 1.24; 95% CI: 0.82-1.89, p = 0.43). Conclusions: A high grade of evidence demonstrated that vagal nerve stimulation improves NYHA functional class, a 6-min walk test, quality of life, and NT-proBNP levels in patients with chronic HFrEF, with no differences in mortality.

Auriculotherapy for Chronic Cervical Pain.

Objective: Chronic cervical pain is a common and recurrent complaint. Auriculotherapy (AT) or ear acupuncture is an effective complementary method used for pain control, but only a few studies have evaluated this treatment for chronic cervical pain. Thus, the aim of this study was to analyze the effectiveness of AT to control chronic cervical pain and improve functional capacity. Materials and Methods: This study involved patients with at least 2 years of cervical pain and a neck disability index score (NDI) >5. AT was performed at detectable points once per week over 6 weeks. Patients were evaluated with the NDI and a visual analogue scale (VAS) for pain before and at 1 and 4 months after the final treatments. An analysis of variance test for repeated measures was used for comparisons. Results: During the study, 19 patients, with a mean (± SD) age of 44.5 ± 15.2 years, were enrolled. The majority of the patients were right-handed (89%) and female (79%). The median (interquartile range) disease duration was 48 months (range: 24-66 months ). An average of 4 ear points were used per session; the most frequent points used were: Shen men, Posterior Wall, Zero, and C1. Statistically significant decreases in NDI (15.58 ± 5.93) and VAS (4.76 ± 2.37) scores were observed at 1 and 4 months (8.84 ± 5.59; P < 0.0001 and 3.21 ± 2.12; P = 0.003, respectively) after AT treatment. Conclusions: AT can be used successfully as a complementary method to treat chronic cervical pain.

Clinical Outcomes and Cost-Effectiveness Analysis of FFR Compared with Angiography in Multivessel Disease Patient / Impacto Clínico e Custo-Efetividade da FFR em Comparação à Angiografia em Pacientes com Doenças Multiarteriais Submetidos à ICP

Abstract Background: In multivessel disease patients with moderate stenosis, fractional flow reserve (FFR) allows the analysis of the lesions and guides treatment, and could contribute to the cost-effectiveness (CE) of non-pharmacological stents (NPS). Objectives: To evaluate CE and clinical impact of FFR-guided versus angiography-guided angioplasty (ANGIO) in multivessel patients using NPS. Methods: Multivessel disease patients were prospectively randomized to FFR or ANGIO groups during a 5 year-period and followed for < 12 months. Outcomes measures were major adverse cardiac events (MACE), restenosis and CE. Results: We studied 69 patients, 47 (68.1%) men, aged 62.0 ± 9.0 years, 34 (49.2%) in FFR group and 53 (50.7%) in ANGIO group, with stable angina or acute coronary syndrome. In FFR, there were 26 patients with biarterial disease (76.5%) and 8 (23.5%) with triarterial disease, and in ANGIO, 24 (68.6%) with biarterial and 11 (31.4%) with triarterial disease. Twelve MACEs were observed - 3 deaths: 2 (5.8%) in FFR and 1 (2.8%) in ANGIO, 9 (13.0%) angina: 4(11.7%) in FFR and 5(14.2%) in ANGIO, 6 restenosis: 2(5.8%) in FFR and 4 (11.4%) in ANGIO. Angiography detected 87(53.0%) lesions in FFR, 39(23.7%) with PCI and 48(29.3%) with medical treatment; and 77 (47.0%) lesions in ANGIO, all treated with angioplasty. Thirty-nine (33.3%) stents were registered in FFR (0.45 ± 0.50 stents/lesion) and 78 (1.05 ± 0.22 stents/lesion) in ANGIO (p = 0.0001), 51.4% greater in ANGIO than FFR. CE analysis revealed a cost of BRL 5,045.97 BRL 5,430.60 in ANGIO and FFR, respectively. The difference of effectiveness was of 1.82%. Conclusion: FFR reduced the number of lesions treated and stents, and the need for target-lesion revascularization, with a CE comparable with that of angiography.

Resumo Fundamentos: Em pacientes multiarteriais e lesões moderadas, a reserva de fluxo fracionada (FFR) avalia cada lesão e direciona o tratamento, podendo ser útil no custo-efetividade (CE) de implante de stents não farmacológicos (SNF). Objetivos: Avaliar CE e impacto clínico da angioplastia + FFR versus angioplastia + angiografia (ANGIO), em multiarteriais, utilizando SNF. Métodos: pacientes com doença multiarteriais foram randomizados prospectivamente durante ±5 anos para FFR ou ANGIO, e acompanhados por até 12 meses. Foram avaliados eventos cardíacos maiores (ECAM), reestenose e CE. Resultados: foram incluídos 69 pacientes, 47(68,1%) homens, 34(49,2%) no FFR e 35(50,7%) no ANGIO, idade 62,0 ± 9,0 anos, com angina estável e Síndrome Coronariana Aguda estabilizada. No FFR, havia 26 com doença (76,5%) biarterial e 8 (23,5%) triarterial, e no grupo ANGIO, 24(68,6%) biarteriais e 11(31,4%) triarteriais. Ocorreram 12(17,3%) ECAM - 3(4,3%) óbitos: 2(5,8%) no FFR e 1(2,8%) no ANGIO, 9(13,0%) anginas, 4(11,7%) no FFR e 5(14,2%) no ANGIO, 6 reestenoses: 2(5,8%) no FFR e 4 (11,4%) no ANGIO. Angiografia detectou 87(53,0%) lesões no FFR, 39(23,7%) com ICP e 48(29,3%) com tratamento clínico; e 77(47,0%) lesões no ANGIO, todas submetidas à angioplastia. Quanto aos stents, registrou-se 39(33,3%) (0,45 ± 0,50 stents/lesão) no FFR e 78(66,6%) (1,05 ± 0,22 stents/lesão) no ANGIO (p = 0,0001); ANGIO utilizou 51,4% a mais que o FFR. Análise de CE revelou um custo de R$5045,97 e R$5.430,60 nos grupos ANGIO e FFR, respectivamente. A diferença de efetividade foi 1,82%. Conclusões: FFR diminuiu o número de lesões tratadas e de stents e necessidade de revascularização do vaso-alvo, com CE comparável ao da angiografia.

Clinical Outcomes and Cost-Effectiveness Analysis of FFR Compared with Angiography in Multivessel Disease Patient.

BACKGROUND: In multivessel disease patients with moderate stenosis, fractional flow reserve (FFR) allows the analysis of the lesions and guides treatment, and could contribute to the cost-effectiveness (CE) of non-pharmacological stents (NPS). OBJECTIVES: To evaluate CE and clinical impact of FFR-guided versus angiography-guided angioplasty (ANGIO) in multivessel patients using NPS. METHODS: Multivessel disease patients were prospectively randomized to FFR or ANGIO groups during a 5 year-period and followed for < 12 months. Outcomes measures were major adverse cardiac events (MACE), restenosis and CE. RESULTS: We studied 69 patients, 47 (68.1%) men, aged 62.0 ± 9.0 years, 34 (49.2%) in FFR group and 53 (50.7%) in ANGIO group, with stable angina or acute coronary syndrome. In FFR, there were 26 patients with biarterial disease (76.5%) and 8 (23.5%) with triarterial disease, and in ANGIO, 24 (68.6%) with biarterial and 11 (31.4%) with triarterial disease. Twelve MACEs were observed - 3 deaths: 2 (5.8%) in FFR and 1 (2.8%) in ANGIO, 9 (13.0%) angina: 4(11.7%) in FFR and 5(14.2%) in ANGIO, 6 restenosis: 2(5.8%) in FFR and 4 (11.4%) in ANGIO. Angiography detected 87(53.0%) lesions in FFR, 39(23.7%) with PCI and 48(29.3%) with medical treatment; and 77 (47.0%) lesions in ANGIO, all treated with angioplasty. Thirty-nine (33.3%) stents were registered in FFR (0.45 ± 0.50 stents/lesion) and 78 (1.05 ± 0.22 stents/lesion) in ANGIO (p = 0.0001), 51.4% greater in ANGIO than FFR. CE analysis revealed a cost of BRL 5,045.97 BRL 5,430.60 in ANGIO and FFR, respectively. The difference of effectiveness was of 1.82%. CONCLUSION: FFR reduced the number of lesions treated and stents, and the need for target-lesion revascularization, with a CE comparable with that of angiography.

Utilização do fluxo fracionado de reserva do miocárdio para identificar variáveis preditoras de pior prognóstico após intervenções coronárias percutâneas / Use of myocardial fractional flow reserve to identify predictors of poor prognosis after percutaneous coronary interventions

INTRODUÇÃO: Vários estudos foram realizados para definir preditores de eventos adversos pós-intervenção coronária percutânea (ICP). Pacientes cujo fluxo fracionado de reserva do miocárdio (FFR) pós-procedimento é < 0,90 apresentam índice de eventos cardíacos adversos maiores em 6 meses pelo menos 3 vezes maior do que aqueles cujo FFR é ≥ 0,90. Este estudo teve por objetivo identificar fatores clínicos, angiográficos e do procedimento associados a FFR pós-ICP < 0,90. MÉTODOS: Foram incluídos 193 pacientes (256 lesões) tratados entre 2004 e 2005, e o FFR foi medido antes e depois da ICP em todos os vasos tratados. Os pacientes foram divididos nos grupos FFR < 0,90 e FFR ≥ 0,90. Análise multivariada por regressão logística foi utilizada para determinar as razões de chances (odds ratio - OR) ajustadas. RESULTADOS: Foi possível obter o FFR em todas as lesões. Não se observou diferença nos parâmetros clínicos entre os dois grupos de pacientes. Houve diferença em alguns parâmetros angiográficos e do procedimento, porém, ao aplicarmos o modelo de regressão logística, a única variável que se associou com FFR pós-ICP < 0,90 foi o tratamento da artéria descendente anterior (OR = 12,1; IC 95% 6,4-22,9; P < 0,01). CONCLUSÕES: A única variável preditora de FFR pós-ICP < 0,90 foi o tratamento da artéria descendente anterior.

BACKGROUND: Several studies were performed to define predictors of adverse events after percutaneous coronary intervention (PCI). Patients whose post-procedure myocardial fractional flow of reserve (FFR) is < 0.90 have an incidence of major cardiac events at 6 months at least 3 times higher than those whose FFR is ≥ 0.90. The aim of this study was to identify clinical, angiographic and procedure-related factors associated with a post-PCI FFR < 0.90. METHODS: One hundred and ninety-three patients (256 lesions) treated between 2004 and 2005 were included, and FFR was measured before and after PCI in all of the treated vessels. Patients were divided into groups with FFR < 0.90 and FFR ≥ 0.90. Logistic regression multivariate analysis was used to determine the adjusted odds ratio (OR). RESULTS: FFR was measured in all lesions. No difference was observed in clinical parameters between groups. There were differences in angiographic and procedure-related parameters, however, when the logistic regression model was used, the only variable associated to post-PCI FFR < 0.90 was the treatment of the left anterior descending artery (OR, 12.1; 95% CI, 6.4-22.9; P < 0.01). CONCLUSIONS: The only predictor of a FFR < 0.90 after PCI was the treatment of the left anterior descending artery.

Desfechos hospitalares em pacientes submetidos a intervenção coronária percutânea na vigência de síndromes coronárias agudas atendidos em unidades de pronto atendimento (UPAs) - Resultados de um centro de cardiologia terciário / In-hospital outcomes in patients with acute coronary syndromes undergoing coronary percutaneous intervention primarily assisted in the Emergency Care Units (ECUs): results from a Tertiary Cardiology Center

INTRODUÇÃO: A criação das Unidade de Pronto Atendimento (UPAs) veio atender a uma necessidade urgente do governo brasileiro em melhorar o atendimento à população carente. Rapidamente as UPAs se tornaram centros de referência para tratamento da dor torácica nessa população, em decorrência da agilidade do atendimento, da disponibilidade de medicamentos de última geração e da existência de pessoal treinado. Este estudo visa a descrever o perfil e a evolução hospitalar de pacientes com sindrome coronária aguda atendidos nessas unidades e posteriormente encaminhados a um hospital terciário, onde foram tratados por angioplastia com implante de stent. Método: No período de julho a dezembro de 2009, 300 pacientes foram encaminhados das UPAs para o hospital Santa Helena (Cabo Frio, RJ). Desses pacientes, 164 (2002 lesões) foram submetidos a implante de stent e divididos em dois grupos: grupo I, formado por 86 pacientes com síndrome coronária aguda...

BACKGROUND: Emergency Care Units (ECUs) were created to meet an urgent need of the Brazilian government to improve health care to low-income population. ECUs quickly became reference centers to treat chest pain in this population, due to their ability to provide prompt medical care, availability of last generation drugs and well trained staff. This study is aimed at describing the profile and inhospital follow-up of patients with acute coronary syndromes seen in these units and later referred to a tertiary hospital, where they were treated by percutaneous coronary intervention with stent implantation. METHOD: Three hundred patients were referred from ECUs to Santa Helena Hospital (Cabo Frio, RJ) from July to December, 2009. One hundred and sixty four patients (202 lesions) were treated by percutaneous intervention with stent and were divided in two groups: group I included 86 patients with acute coronary syndromes with ST segment elevation and group II included 78 patients with acute coronary syndromes without ST segment elevation. Clinical and angiographic characteristics and in-hospital major adverse cardiac events were compared between the two groups. RESULTS: Clinical and angiographic characteristics were similar in both groups except for smoking. Angiographic success was obtained in 99% of the procedures. Mean hospitalization time (ECU + tertiary hospital) was 6 days. There were 6 in-hospital major adverse cardiac events, 5 in group I and 1 in group II (5.8% vs. 1.3%; P = 0.60). CONCLUSION: Late percutaneous revascularization of patients with acute coronary syndromes seen at ECUs is a safe and effective procedure, with high success and low complication rates.

Estudo randomizado e comparativo da intervenção coronária percutânea com stents recobertos por titânio-óxido nítrico ou de aço inoxidável em pacientes com doença arterial coronária: estudo RIO / Randomized comparison of percutaneous coronary intervention with titanium-nitride-oxide-coated stents versus stainless steel stents in patients with coronary artery disease: RIO trial

O stent recoberto por titânio-óxido nítrico (Titan) mostrou-se eficaz para redução da hiperplastia neointimal comparado ao stent convencional em animais e seres humanos. Foi elaborado um estudo clínico prospectivo e randomizado do stent Titan versus stent de aço inoxidável, cujo objetivo foi comparar o índice de eventos cardíacos adversos maiores (ECAM) após dois anos...

Background: Stent coating with titanium-nitride oxide (Titan) has been shown to reduce neointimal hyperplasia in both animals and humans. A prospective, randomized, clinical study was designed to compare the incidence of major adverse cardiac events (MACE) after two years in patients with the Titan stent versus the stainless steel stent...

What is the angiography error when defining myocardial ischemia during percutaneous coronary interventions?

BACKGROUND: The angiography has been used as a reference standard to define coronary artery disease (CAD), although its limitations are well-known. The significance of the myocardial fractional flow reserve (FFR) in the assessment of CAD is well established. OBJECTIVE: The aim of this study was to evaluate the accuracy of angiography when defining ischemic lesions and its correlation with FFR. METHODS: Two hundred and fifty consecutive patients (471 arteries) were included in this study. All stenoses >or= 50% at the angiography visual estimate (AVE) were assessed by FFR measurements. When FFR was < 0.75, stenting was performed; when FFR was >or= 0.75, no interventional treatment was carried out. Offline quantitative coronary angiography (QCA) was performed in all stenoses, which were divided in intermediate (< 70% - 327) and severe (125). The correlation coefficients between the diameter of the stenosis (%DS) and FFR and the accuracy of VA of the angiography when assessing ischemia were determined. RESULTS: FFR could be obtained in 452 lesions (96%). Mean %DS and FFR were 56 +/- 8% and 0.74 and 76 +/- 6% and 0.48 for moderate and severe stenoses, respectively. Concordance between QCA and FFR was poor, especially in intermediate stenoses (Spearman's rho = - 0.33, p<0.0001). Visual assessment resulted in an accuracy of 57% and 96% in intermediate and severe lesions, respectively. CONCLUSION: Neither the visual assessment of an angiogram nor QCA can accurately predict the significance of most intermediate coronary stenoses, which emphasizes the importance of associating it to a functional evaluation of the coronary circulation, resulting in an adequate treatment of these stenoses.