[Show abstract][Hide abstract] ABSTRACT: Ischemic preconditioning is a powerful mechanism of myocardial protection and in humans it can be evaluated by sequential exercise tests. Coronary Artery Disease in the presence of diabetes mellitus may be associated with worse outcomes. In addition, some studies have shown that diabetes interferes negatively with the development of ischemic preconditioning. However, it is still unknown whether diabetes may influence the expression of ischemic preconditioning in patients with stable multivessel coronary artery disease.
This study will include 140 diabetic and non-diabetic patients with chronic, stable coronary artery disease and preserved left ventricular systolic function. The patients will be submitted to two sequential exercise tests with 30-minutes interval between them. Ischemic parameters will be compared between diabetic and non-diabetic patients. Ischemic preconditioning will be considered present when time to 1.0 mm ST-segment deviation is greater in the second of two sequential exercise tests. Exercise tests will be analyzed by two independent cardiologists.
Ischemic preconditioning was first demonstrated by Murry et al. in dog's hearts. Its work was reproduced by other authors, clearly demonstrating that brief periods of myocardial ischemia followed by reperfusion triggers cardioprotective mechanisms against subsequent and severe ischemia. On the other hand, the demonstration of ischemic preconditioning in humans requires the presence of clinical symptoms or physiological changes difficult to be measured. One methodology largely accepted are the sequential exercise tests, in which, the improvement in the time to 1.0 mm ST depression in the second of two sequential tests is considered manifestation of ischemic preconditioning.Diabetes is an important and independent determinant of clinical prognosis. It's a major risk factor for coronary artery disease. Furthermore, the association of diabetes with stable coronary artery disease imposes worse prognosis, irrespective of treatment strategy. It's still not clearly known the mechanisms responsible by these worse outcomes. Impairment in the mechanisms of ischemic preconditioning may be one major cause of this worse prognosis, but, in the clinical setting, this is not known.The present study aims to evaluate how diabetes mellitus interferes with ischemic preconditioning in patients with stable, multivessel coronary artery disease and preserved systolic ventricular function.
[Show abstract][Hide abstract] ABSTRACT: Diabetes mellitus is a major cause of coronary artery disease (CAD). Despite improvement in the management of patients with stable CAD, diabetes remains a major cause of increased morbidity and mortality. There is no conclusive evidence that either modality is better than medical therapy alone for the treatment of stable multivessel CAD in patients with diabetes in a very long-term follow-up. Our aim was to compare 3 therapeutic strategies for stable multivessel CAD in a diabetic population and non-diabetic population.
It was compared medical therapy (MT), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in 232 diabetic patients and 379 nondiabetic patients with multivessel CAD. Endpoints evaluated were overall and cardiac mortality.
Patients (n = 611) were randomized to CABG (n = 203), PCI (n = 205), or MT (n = 203). In a 10-year follow-up, more deaths occurred among patients with diabetes than among patients without diabetes (P = .001) for overall mortality. In this follow-up, 10-year mortality rates were 32.3% and 23.2% for diabetics and non-diabetics respectively (P = .024). Regarding cardiac mortality, 10-year cardiac mortality rates were 19.4% and 12.7% respectively (P = .031).Considering only diabetic patients and stratifying this population by treatment option, we found mortality rates of 31.3% for PCI, 27.5% for CABG and 37.5% for MT (P = .015 for CABG vs MT) and cardiac mortality rates of 18.8%, 12.5% and 26.1% respectively (P = .005 for CABG vs MT).
Among patients with stable multivessel CAD and preserved left ventricular ejection fraction, the 3 therapeutic regimens had high rates of overall and cardiac-related deaths among diabetic compared with non-diabetic patients. Moreover, better outcomes were observed in diabetic patients undergoing CABG compared to MT in relation to overall and cardiac mortality in a 10-year follow-up.
American heart journal 08/2013; 166(2):250-7. · 4.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE
To assess the effect of two hypoglycemic drugs on ischemic preconditioning (IPC) patients with type 2 diabetes and coronary artery disease (CAD).RESEARCH DESIGN AND METHODS
We performed a prospective study of 96 consecutive patients allocated into two groups: 42 to group repaglinide (R) and 54 to group vilgagliptin (V). All patients underwent two consecutive exercise tests (ET1 and ET2) in phase 1 without drugs. In phase 2, 1 day after ET1 and -2, 2 mg repaglinide three times daily or 50 mg vildagliptin twice daily was given orally to patients in the respective group for 6 days. On the seventh day, 60 min after 6 mg repaglinide or 100 mg vildagliptin, all patients underwent two consecutive exercise tests (ET3 and ET4).RESULTSIn phase 1, IPC was demonstrated by improvement in the time to 1.0 mm ST-segment depression and rate pressure product (RPP). All patients developed ischemia in ET3; however, 83.3% of patients in group R experienced ischemia earlier in ET4, without significant improvement in RPP, indicating the cessation of IPC (P < 0.0001). In group V, only 28% of patients demonstrated IPC cessation, with 72% still having the protective effect (P < 0.0069).CONCLUSIONS
Repaglinide eliminated myocardial IPC, probably by its effect on the K(ATP) channel. Vilgagliptin did not damage this protective mechanism in a relevant way in patients with type 2 diabetes and CAD, suggesting a good alternative treatment in this population.
[Show abstract][Hide abstract] ABSTRACT: Surgical techniques of myocardial revascularization without the use of extracorporeal circulation (ECC) have raised hopes of attaining operative results with less systemic damage, lower occurrence of clinical complications and shorter hospital stay duration, generating expectations of lower hospital costs.
To evaluate the hospital costs in patients submitted to myocardial revascularization with and without ECC and in those with stable multiarterial coronary disease with preserved ventricular function.
The hospital costs were based on the existing governmental reimbursement. The costs included that of ortheses and prostheses and clinical complications. The time and costs of ICU stay and hospital stay duration were considered.
Between January 2002 and August 2006, 131 patients were randomized to surgery with ECC (SECC), whereas 128 were randomized to surgery without ECC (WECC). The basal characteristics were similar for both groups. The costs of surgical complications were significantly lower (p < 0.001) in patients from the WECC when compared to the SECC group (606.00 +/- 525.00 vs. 945.90 +/- 440.00), as well as ICU costs: 432.20 +/- 391.70 vs. 717.70 +/- 257.70, respectively. The duration of the operating room stay were 4.9 +/- 1.1 h vs. 3.9 +/- 1.0 h, p < 0.001; at the ICU it was 48.2 +/- 17.2 h vs. 29.2 +/- 26.1h) (p < 0.001), with intubation time of 9.2 +/- 4.5 h vs. 6.4 +/- 5.1h, p < 0.001 for patients from the group with and without ECC, respectively.
The present study allowed us to conclude that the myocardial revascularization surgery without extracorporeal circulation results in the decrease of operational costs and duration of the stay in each section related to the surgical treatment.
Arquivos brasileiros de cardiologia 12/2008; 91(6):340-6. · 1.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Coronary artery bypass grafting techniques without using cardiopulmonary bypass (off-pump CABG) result in less systemic damage, less clinical complications, less time spent in the intensive care unit, and shorter hospital stays, thereby raising the perspective of improved quality of life (QOL) for patients.
To assess quality of life in patients who underwent on-pump and off-pump CABG.
The Short-Form Health Survey (SF-36) Questionnaire was administered to patients with stable multivessel coronary artery disease (CAD) and preserved ventricular function before and at six and 12 months after surgery.
Between January 2002 and December 2006, a total of 202 patients were randomized to either on-pump or off-pump CABG. Demographic, clinical, laboratory, and angiographic characteristics were similar in both groups. One hundred and five patients underwent off-pump CABG and 97 underwent on-pump CABG. In the postoperative course, 22 patients had myocardial infarction, 29 reported angina, one was reoperated, and three experienced stroke. No patient died. Quality of life, as measured by the SF-36 questionnaire, was shown to be similar in both groups regarding physical and mental components. However, male patients showed a significant improvement in physical functioning and role limitations due to physical problems. Also, a large number of patients in both groups returned to work.
Progressive enhancement in quality of life and early return to work were observed for all patients, regardless of the surgical technique used. Save for a greater improvement in physical functioning and role limitations due to physical problems experienced by male patients, no statistically significant differences were found in the other domains between groups.
[Show abstract][Hide abstract] ABSTRACT: Although the clinical benefits of coronary interventions seem to be confirmed, their effects on quality of life (QoL) are still scarcely studied.
To assess the QoL in multivessel coronary disease in patients randomly undergoing surgery, angioplasty or medical treatment.
The Short-Form Health Survey (SF-36) questionnaire was answered by 483 patients. Of these, 161 underwent surgical revascularization, 166 underwent angioplasty, and 153 were medically treated.
At baseline, 86% of the patients referred angina, 34% referred infarction, and 32% were smokers. Medical Treatment: 12 patients (7.7%) had AMI, 24 (15.3%) underwent surgery, and 19 (12.1%) died. In addition, 5 (3.2%) had stroke, and 40 (25.6%) had angina. As regards the mental component, 64.1% and 30.8% had their condition improved and worsened, respectively. As regards the physical component, 70.5% and 27.6% had their condition improved and worsened, respectively. Surgery: 13 patients (8.1%) had AMI, 2 (1.2%) underwent surgery, and 12(7.4%) died. Also, 9 (5.6%) had stroke and 30 (18.6%) had angina. As regards the mental component, 72.7 % and 25.5% had their condition improved and worsened, respectively. As regards the physical component, 82.6% and 16.1% had their condition improved and worsened, respectively. Angioplasty: 18 patients (10.9%) had AMI, 51 (30.7%) underwent interventions, and 18 (19.9%) died. Additionally, six (3.6%) presented stroke and 35 (21%) reported angina. As regards the mental component, 66.9% and 26.5% had their condition improved and worsened, respectively. As regards the physical component, 77.1% and 20.5% had their condition improved and worsened, respectively.
Improvement was observed in all domains and in the three therapeutic modalities. Comparatively, surgery had provided a better quality of life after a four-year follow-up.
Arquivos brasileiros de cardiologia 06/2007; 88(5):537-44. · 1.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We evaluated the impact of Coronary Artery Bypass Graft Surgery (CABG), Percutaneous Coronary Intervention (PCI) or Medical Therapy (MT) on self-perceived quality of life among patients with stable Coronary Artery Disease (CAD).
The Medicine, Angioplasty and Surgery Study (MASS-II) implemented initial policies of CABG, PCI or continued medical treatment in patients who allow assessment of mid-term health consequences.
A total of 542 patients were randomly assigned to CABG (175), to PCI (180) and to MT (187). The short form 36 (SF-36) self-administered quality of life (QoL) questionnaires were applied at baseline, 6 months and 12 months later.
All the three therapeutic strategies presented significant improvement in all dimensions of the SF-36 during the follow-up (p<0.0001). However, the CABG group was the one that had significantly greater improvement in physical and social functioning, vitality and general health when compared to MT and PCI. Also, men had the best QoL at the beginning of the treatment when compared to women, with a progressive improvement after 6 and 12 months.
The quality of life was better in both CABG and PCI groups compared to MT after 1 year of follow-up. However, the patients submitted to CABG were the ones that presented the greater and progressive improvement of QoL. Also, men presented better QoL at the beginning and after treatment when compared to women.
International journal of cardiology 05/2007; 116(3):364-70. · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aplicou-se o Medical Outcome Study Short Form-36(SF-36) questionnaire na avaliação da qualidade de vida (QV) de portadores de doença coronariana submetidos randomicamente aos três tipos de tratamentos convencionais. Na admissão, os 471 pacientes apresentavam angina estável e função ventricular preservada. O questionário incluiu avaliação física e mental com 36 itens. Após seguimento, observou-se melhora em todos os domínios para todos os tratamentos aplicados. Contudo, o tratamento cirúrgico foi o que melhor QV ofereceu aos pacientes. Tese (Doutorado).