Revista da Sociedade de Cardiologia do Estado de São Paulo
The spectrum of clinical conditions associated with the presence of myocardial ischemia and relat... more The spectrum of clinical conditions associated with the presence of myocardial ischemia and related symptoms (angina pectoris or equivalent), regardless of the cau-sative mechanism (obstructive disease, microvascular dysfunction or coronary spasm) is called chronic coronary syndrome (CCS). Although the essence of the treatment of patients with SCC consists of changes in lifestyle and strict control of cardiovascular risk factors, in addition to antianginal therapy in maximally tolerated doses, surgical or percutaneous revascularization procedures are indicated when medical treatment fails to offer adequate symptoms control or in scenarios in which they provide a reduction in the risk of events compared to clinical therapy alone. Thus, patients with left main disease, multivessel disease (especially diabetics or those with high angiographic complexity), patients with HFrEF of ischemic etiology, and those with the last remaining patent vessel or proximal lesion of the anterior descend...
The incidence of myocardial infarction (MI) is elevated in patients receiving renal replacement t... more The incidence of myocardial infarction (MI) is elevated in patients receiving renal replacement therapy (RRT). We hypothesized that an invasive strategy of assessment of coronary artery disease (CAD) will identify patients more prone to developing MI. This was a single-center observational cohort study that included 1678 patients receiving RRT (hemodialysis and renal transplantation) assessed for CAD prospectively and analyzed retrospectively. Endpoints were the incidence of MI and death. The median follow-up was 43 months, and 180 patients experienced an MI with a mortality rate of 74%. Multivariate analysis showed that diabetes (HR 1.633; 95% CI 1.165–2.289), prior MI (HR 1.724; 95% CI 1.153–2.579), and CAD (HR 2.073; 95% CI 1.400–3.071) were predictors of MI. Altered myocardial scan did not correlate with MI. At the discretion of the attending physicians, 20/180 patients (11%) underwent coronary intervention that was associated with a higher cumulative survival (Log-rank 0.007). Patients with CAD suffered an MI more frequently, independently of symptoms and risk factors for MI, including noninvasive testing. Because of the elevated rate of the lethality of MI, invasive coronary studies may be indicated in select patients on RRT. Once an MI occurs, our data suggest that an invasive therapeutic approach is warranted.
AimsLeft ventricular diastolic dysfunction (LVDD) and LV systolic dysfunction (LVSD) are prevalen... more AimsLeft ventricular diastolic dysfunction (LVDD) and LV systolic dysfunction (LVSD) are prevalent in CKD, but their prognostic relevance is debatable.We intent to verify whether LVDD and LVSD are independently predictive of all‐cause mortality and if they have comparable or different effects on outcomes.MethodsA retrospective analysis was conducted of the echocardiographic data of 1285 haemodialysis patients followed up until death or transplantation. LVDD was classified into 4 grades of severity. Endpoint was all‐cause mortality.ResultsDuring a follow‐up of 30 months, 419/1285 (33%) patients died, 224 (53%) due to CV events. LVDD occurred in 75% of patients, grade 1 DD was the prevalent diastolic abnormality, and pseudonormal pattern was the predominant form of moderate–severe DD. Moderate–severe LVDD (HR 1.379, CI% 1.074–1.770) and LVSD (HR 1.814, CI% 1.265–2.576) independently predicted death; a graded, progressive association was found between LVDD categories and the risk of de...
Introduction: Obesity is not associated with CV events and death and may even be protective in pa... more Introduction: Obesity is not associated with CV events and death and may even be protective in patients on hemodialysis (HD), contrary to observations in the general population. The reason for this apparent paradox is unknown, but necessarily involves chronic uremia. Methods: We examined the impact of obesity (BMI > 30 Kg/m2) on prognosis in a cohort of 1696 HD patients on the waiting list for renal transplantation (TX) (54.4 ± 10.7 yo, 68% Whites, 61% males, 42% diabetics, 29% smokers, 33% dyslipidemic, 42% with associated CVD) before and after TX. TX was performed in 439 patients (26%). End-points were coronary events (MI, unstable angina and sudden death) and death by any cause. Results: There were 357 patients with obesity (21%). Mean BMI were 32.7 ± 2.6 and 23.8 ± 3.0 for obese and non-obese, respectively. Obese patients on HD were older (55.9 ± 9.2 v 54.2 ± 11) and had an increased prevalence of diabetes (54% v 40%), dyslipidemia (49% v 30%), altered myocardial scan (38% v ...
Ischemic heart disease (IHD) is a main determinant of global health and mortality. Despite signif... more Ischemic heart disease (IHD) is a main determinant of global health and mortality. Despite significant advances in therapeutic options, many patients complain with persistent symptoms and/or signs of myocardial ischemia (ie, refractory angina). Main therapeutic strategies used in angina patients aim at either reducing the effects of coronary stenosis on coronary blood flow or at removing the coronary stenosis itself. However, obstructive coronary artery disease is not synonymous with IHD. Indeed, a number of other factors can precipitate myocardial ischemia, including microvascular dysfunction, focal or diffuse spasm, and altered mitochondrial metabolism. It is therefore not surprising that therapeutic strategies that target epicardial coronary stenosis are not effective in all IHD patients. When approaching a patient with angina, the multiple pathophysiology model should be adopted at all levels, including diagnostic and treatment strategies. Angina should be considered refractory ...
In this issue of Heart & Metabolism, our attention is focused on the challenging clinical conditi... more In this issue of Heart & Metabolism, our attention is focused on the challenging clinical condition of refractory angina. William Heberden’s classic description of angina pectoris was first presented to the Royal College of Physicians in 1768 and a few years later published in the Medical Transactions of the College. Although receiving praise for his detailed description of the symptoms accompanying the natural history of patients with exertional angina, Heberden humbly acknowledged that “with respect to the treatment of this complaint, I have little or nothing to advance.” Exactly two and a half centuries later, we are awed by the great developments we have witnessed in the treatment of patients with stable angina, ranging from effective antianginal drugs to revascularization procedures (percutaneous or surgical). But despite all the advances, we are occasionally faced with a patient with disabling symptoms related to myocardial ischemia and who becomes unresponsive after an initia...
Background: The role of N-acetylcysteine (NAC) for the prevention of renal damage in experimental... more Background: The role of N-acetylcysteine (NAC) for the prevention of renal damage in experimental models and in diverse clinical settings is controversial. Disparate results may be caused by differ...
Background In patients eligible for coronary artery bypass grafting, no data assess the importanc... more Background In patients eligible for coronary artery bypass grafting, no data assess the importance of the Heart Team in programming the best surgical strategy for patients with diffuse coronary artery disease (CAD). This study aims to determine the contribution of the Heart Team in predicting the feasibility of coronary artery bypass graft and angiographic surgical success in these patients based on visual angiographic analysis. Methods Patients with diffuse and severe CAD undergoing incomplete coronary artery bypass graft surgery were prospectively included. One-year postoperative coronary angiograms were obtained to evaluate graft occlusion. Two clinical cardiologists, two cardiovascular surgeons, and one interventional cardiologist retrospectively analyzed preoperative angiograms. A subjective scale was applied at a single moment to quantify the chance of successful coronary artery bypass grafting for each coronary territory with anatomical indication for revascularization. Based...
BACKGROUND Refractory angina is a chronic condition that implies significant impairment in qualit... more BACKGROUND Refractory angina is a chronic condition that implies significant impairment in quality of life; its management is a challenge. Current therapies are limited, and new approaches to treatment are needed that target symptoms and quality of life. Evidence is lacking regarding exercise-based cardiac rehabilitation safety and beneficial effects in patients with refractory angina. OBJECTIVE The aim of the present study is to evaluate the safety and feasibility of exercise-based cardiac rehabilitation in patients with refractory angina, and its effects on angina symptoms, functional capacity, and ischemic burden. METHODS This study is an ongoing prospective randomized controlled trial enrolling 52 patients with refractory angina randomized into 2 groups: optimal medical treatment (MT) or MT + exercise-based cardiac rehabilitation (CR) over 12 weeks (36 exercise sessions). Clinical evaluation, cardiopulmonary exercise testing, laboratory tests, and exercise echocardiography are p...
Introduction Refractory angina (RA) implies important impairment of quality of life. Cardiac reha... more Introduction Refractory angina (RA) implies important impairment of quality of life. Cardiac rehabilitation (CR) is still not recommended by guidelines due to few evidence regarding its effects in this population. This study evaluated the impact of CR on physical performance and on angina/ischemia threshold. Methods 36 RA patients undergoing optimal medical therapy were randomly assigned to a 12-week exercise based CR program or stablished clinical follow-up (CF). Clinical evaluation, exercise bicycle stress echocardiography (SE) and cardiopulmonary exercise testing (CP) were performed before and after the protocol. CR group performed in-hospital exercise sessions, and the aerobic training prescription was based on CP parameters or ischemia/ angina threshold. Each CR class was 60 min in duration (5min warm-up, 30min aerobic and 5min cooldown, 15min low load resistance training and 5min stretching). Bonferroni multiple comparison and t test were used in statistical analysis. Results ...
BackgroundCardiovascular mortality is increased in chronic kidney disease, a condition with a hig... more BackgroundCardiovascular mortality is increased in chronic kidney disease, a condition with a high prevalence of periodontal disease. Whether periodontitis treatment improves prognosis is unknown.MethodsThe effect of periodontal treatment on the incidence of cardiovascular events and death in 206 waitlist hemodialysis subjects was compared with that in 203 historical controls who did not undergo treatment. Patients were followed up for 24 months or until death or transplantation.ResultsThe prevalence of moderate/severe periodontitis was 74%. Coronary artery disease correlated with the severity of periodontal disease (P = .02). Survival free of cardiovascular events (94% vs 83%, log‐rank 0.009), coronary events (97% vs 89%, log‐rank = 0.009), and cardiovascular death (96% vs 87%, log‐rank = 0.037) was higher in the evaluated group. Death by any cause did not differ between groups. Multivariate analysis showed that treatment was associated with reduction in cardiovascular events (HR 0...
Despite the indisputable advances in medical treatment and revascularization procedures (percutan... more Despite the indisputable advances in medical treatment and revascularization procedures (percutaneous and surgical), many patients present debilitating symptoms related to myocardial ischemia which cannot be controlled by a combination of antianginal drugs due to progression of disease with arterial occlusion and diffuse involvement of previous grafts or post-angioplasty restenosis, preventing new attempts of myocardial revascularization. This condition is defined as refractory angina, which greatly impairs the quality of life of the affected. Recently, new therapeutic strategies are being either developed or already applied for the treatment of patients with refractory angina, including gene therapy, stem cell therapy, transmyocardial laser revascularization, enhanced external counterpulsation, spinal cord stimulation, and extracorporeal shockwave myocardial revascularization. However, many of the above techniques are still surrounded by a shadow of controversy, conflicting results between the basic science and clinical application, mixed feelings from the scientific community regarding their usefulness (beyond the placebo effect), and the appropriateness of the conducted clinical trials in which they have been tested. Common challenges in the field are, for example, the fact that there is no experimental model that exactly mimics the condition seen in patients with diffuse CAD; many promising new therapies, i.e. gene therapy, have succeeded in animal models of myocardial ischemia only to fail when rigorously tested in double-blind, placebo controlled trials. Finally, the scientific community should truly be committed regarding the rigor with which data are obtained and presented, so that science may steadily advance towards finding better, proven treatment options for patients with refractory angina.
Revista da Sociedade de Cardiologia do Estado de São Paulo
The spectrum of clinical conditions associated with the presence of myocardial ischemia and relat... more The spectrum of clinical conditions associated with the presence of myocardial ischemia and related symptoms (angina pectoris or equivalent), regardless of the cau-sative mechanism (obstructive disease, microvascular dysfunction or coronary spasm) is called chronic coronary syndrome (CCS). Although the essence of the treatment of patients with SCC consists of changes in lifestyle and strict control of cardiovascular risk factors, in addition to antianginal therapy in maximally tolerated doses, surgical or percutaneous revascularization procedures are indicated when medical treatment fails to offer adequate symptoms control or in scenarios in which they provide a reduction in the risk of events compared to clinical therapy alone. Thus, patients with left main disease, multivessel disease (especially diabetics or those with high angiographic complexity), patients with HFrEF of ischemic etiology, and those with the last remaining patent vessel or proximal lesion of the anterior descend...
The incidence of myocardial infarction (MI) is elevated in patients receiving renal replacement t... more The incidence of myocardial infarction (MI) is elevated in patients receiving renal replacement therapy (RRT). We hypothesized that an invasive strategy of assessment of coronary artery disease (CAD) will identify patients more prone to developing MI. This was a single-center observational cohort study that included 1678 patients receiving RRT (hemodialysis and renal transplantation) assessed for CAD prospectively and analyzed retrospectively. Endpoints were the incidence of MI and death. The median follow-up was 43 months, and 180 patients experienced an MI with a mortality rate of 74%. Multivariate analysis showed that diabetes (HR 1.633; 95% CI 1.165–2.289), prior MI (HR 1.724; 95% CI 1.153–2.579), and CAD (HR 2.073; 95% CI 1.400–3.071) were predictors of MI. Altered myocardial scan did not correlate with MI. At the discretion of the attending physicians, 20/180 patients (11%) underwent coronary intervention that was associated with a higher cumulative survival (Log-rank 0.007). Patients with CAD suffered an MI more frequently, independently of symptoms and risk factors for MI, including noninvasive testing. Because of the elevated rate of the lethality of MI, invasive coronary studies may be indicated in select patients on RRT. Once an MI occurs, our data suggest that an invasive therapeutic approach is warranted.
AimsLeft ventricular diastolic dysfunction (LVDD) and LV systolic dysfunction (LVSD) are prevalen... more AimsLeft ventricular diastolic dysfunction (LVDD) and LV systolic dysfunction (LVSD) are prevalent in CKD, but their prognostic relevance is debatable.We intent to verify whether LVDD and LVSD are independently predictive of all‐cause mortality and if they have comparable or different effects on outcomes.MethodsA retrospective analysis was conducted of the echocardiographic data of 1285 haemodialysis patients followed up until death or transplantation. LVDD was classified into 4 grades of severity. Endpoint was all‐cause mortality.ResultsDuring a follow‐up of 30 months, 419/1285 (33%) patients died, 224 (53%) due to CV events. LVDD occurred in 75% of patients, grade 1 DD was the prevalent diastolic abnormality, and pseudonormal pattern was the predominant form of moderate–severe DD. Moderate–severe LVDD (HR 1.379, CI% 1.074–1.770) and LVSD (HR 1.814, CI% 1.265–2.576) independently predicted death; a graded, progressive association was found between LVDD categories and the risk of de...
Introduction: Obesity is not associated with CV events and death and may even be protective in pa... more Introduction: Obesity is not associated with CV events and death and may even be protective in patients on hemodialysis (HD), contrary to observations in the general population. The reason for this apparent paradox is unknown, but necessarily involves chronic uremia. Methods: We examined the impact of obesity (BMI > 30 Kg/m2) on prognosis in a cohort of 1696 HD patients on the waiting list for renal transplantation (TX) (54.4 ± 10.7 yo, 68% Whites, 61% males, 42% diabetics, 29% smokers, 33% dyslipidemic, 42% with associated CVD) before and after TX. TX was performed in 439 patients (26%). End-points were coronary events (MI, unstable angina and sudden death) and death by any cause. Results: There were 357 patients with obesity (21%). Mean BMI were 32.7 ± 2.6 and 23.8 ± 3.0 for obese and non-obese, respectively. Obese patients on HD were older (55.9 ± 9.2 v 54.2 ± 11) and had an increased prevalence of diabetes (54% v 40%), dyslipidemia (49% v 30%), altered myocardial scan (38% v ...
Ischemic heart disease (IHD) is a main determinant of global health and mortality. Despite signif... more Ischemic heart disease (IHD) is a main determinant of global health and mortality. Despite significant advances in therapeutic options, many patients complain with persistent symptoms and/or signs of myocardial ischemia (ie, refractory angina). Main therapeutic strategies used in angina patients aim at either reducing the effects of coronary stenosis on coronary blood flow or at removing the coronary stenosis itself. However, obstructive coronary artery disease is not synonymous with IHD. Indeed, a number of other factors can precipitate myocardial ischemia, including microvascular dysfunction, focal or diffuse spasm, and altered mitochondrial metabolism. It is therefore not surprising that therapeutic strategies that target epicardial coronary stenosis are not effective in all IHD patients. When approaching a patient with angina, the multiple pathophysiology model should be adopted at all levels, including diagnostic and treatment strategies. Angina should be considered refractory ...
In this issue of Heart & Metabolism, our attention is focused on the challenging clinical conditi... more In this issue of Heart & Metabolism, our attention is focused on the challenging clinical condition of refractory angina. William Heberden’s classic description of angina pectoris was first presented to the Royal College of Physicians in 1768 and a few years later published in the Medical Transactions of the College. Although receiving praise for his detailed description of the symptoms accompanying the natural history of patients with exertional angina, Heberden humbly acknowledged that “with respect to the treatment of this complaint, I have little or nothing to advance.” Exactly two and a half centuries later, we are awed by the great developments we have witnessed in the treatment of patients with stable angina, ranging from effective antianginal drugs to revascularization procedures (percutaneous or surgical). But despite all the advances, we are occasionally faced with a patient with disabling symptoms related to myocardial ischemia and who becomes unresponsive after an initia...
Background: The role of N-acetylcysteine (NAC) for the prevention of renal damage in experimental... more Background: The role of N-acetylcysteine (NAC) for the prevention of renal damage in experimental models and in diverse clinical settings is controversial. Disparate results may be caused by differ...
Background In patients eligible for coronary artery bypass grafting, no data assess the importanc... more Background In patients eligible for coronary artery bypass grafting, no data assess the importance of the Heart Team in programming the best surgical strategy for patients with diffuse coronary artery disease (CAD). This study aims to determine the contribution of the Heart Team in predicting the feasibility of coronary artery bypass graft and angiographic surgical success in these patients based on visual angiographic analysis. Methods Patients with diffuse and severe CAD undergoing incomplete coronary artery bypass graft surgery were prospectively included. One-year postoperative coronary angiograms were obtained to evaluate graft occlusion. Two clinical cardiologists, two cardiovascular surgeons, and one interventional cardiologist retrospectively analyzed preoperative angiograms. A subjective scale was applied at a single moment to quantify the chance of successful coronary artery bypass grafting for each coronary territory with anatomical indication for revascularization. Based...
BACKGROUND Refractory angina is a chronic condition that implies significant impairment in qualit... more BACKGROUND Refractory angina is a chronic condition that implies significant impairment in quality of life; its management is a challenge. Current therapies are limited, and new approaches to treatment are needed that target symptoms and quality of life. Evidence is lacking regarding exercise-based cardiac rehabilitation safety and beneficial effects in patients with refractory angina. OBJECTIVE The aim of the present study is to evaluate the safety and feasibility of exercise-based cardiac rehabilitation in patients with refractory angina, and its effects on angina symptoms, functional capacity, and ischemic burden. METHODS This study is an ongoing prospective randomized controlled trial enrolling 52 patients with refractory angina randomized into 2 groups: optimal medical treatment (MT) or MT + exercise-based cardiac rehabilitation (CR) over 12 weeks (36 exercise sessions). Clinical evaluation, cardiopulmonary exercise testing, laboratory tests, and exercise echocardiography are p...
Introduction Refractory angina (RA) implies important impairment of quality of life. Cardiac reha... more Introduction Refractory angina (RA) implies important impairment of quality of life. Cardiac rehabilitation (CR) is still not recommended by guidelines due to few evidence regarding its effects in this population. This study evaluated the impact of CR on physical performance and on angina/ischemia threshold. Methods 36 RA patients undergoing optimal medical therapy were randomly assigned to a 12-week exercise based CR program or stablished clinical follow-up (CF). Clinical evaluation, exercise bicycle stress echocardiography (SE) and cardiopulmonary exercise testing (CP) were performed before and after the protocol. CR group performed in-hospital exercise sessions, and the aerobic training prescription was based on CP parameters or ischemia/ angina threshold. Each CR class was 60 min in duration (5min warm-up, 30min aerobic and 5min cooldown, 15min low load resistance training and 5min stretching). Bonferroni multiple comparison and t test were used in statistical analysis. Results ...
BackgroundCardiovascular mortality is increased in chronic kidney disease, a condition with a hig... more BackgroundCardiovascular mortality is increased in chronic kidney disease, a condition with a high prevalence of periodontal disease. Whether periodontitis treatment improves prognosis is unknown.MethodsThe effect of periodontal treatment on the incidence of cardiovascular events and death in 206 waitlist hemodialysis subjects was compared with that in 203 historical controls who did not undergo treatment. Patients were followed up for 24 months or until death or transplantation.ResultsThe prevalence of moderate/severe periodontitis was 74%. Coronary artery disease correlated with the severity of periodontal disease (P = .02). Survival free of cardiovascular events (94% vs 83%, log‐rank 0.009), coronary events (97% vs 89%, log‐rank = 0.009), and cardiovascular death (96% vs 87%, log‐rank = 0.037) was higher in the evaluated group. Death by any cause did not differ between groups. Multivariate analysis showed that treatment was associated with reduction in cardiovascular events (HR 0...
Despite the indisputable advances in medical treatment and revascularization procedures (percutan... more Despite the indisputable advances in medical treatment and revascularization procedures (percutaneous and surgical), many patients present debilitating symptoms related to myocardial ischemia which cannot be controlled by a combination of antianginal drugs due to progression of disease with arterial occlusion and diffuse involvement of previous grafts or post-angioplasty restenosis, preventing new attempts of myocardial revascularization. This condition is defined as refractory angina, which greatly impairs the quality of life of the affected. Recently, new therapeutic strategies are being either developed or already applied for the treatment of patients with refractory angina, including gene therapy, stem cell therapy, transmyocardial laser revascularization, enhanced external counterpulsation, spinal cord stimulation, and extracorporeal shockwave myocardial revascularization. However, many of the above techniques are still surrounded by a shadow of controversy, conflicting results between the basic science and clinical application, mixed feelings from the scientific community regarding their usefulness (beyond the placebo effect), and the appropriateness of the conducted clinical trials in which they have been tested. Common challenges in the field are, for example, the fact that there is no experimental model that exactly mimics the condition seen in patients with diffuse CAD; many promising new therapies, i.e. gene therapy, have succeeded in animal models of myocardial ischemia only to fail when rigorously tested in double-blind, placebo controlled trials. Finally, the scientific community should truly be committed regarding the rigor with which data are obtained and presented, so that science may steadily advance towards finding better, proven treatment options for patients with refractory angina.
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Papers by Luís Henrique W. Gowdak