Browsing by Author "Baptista, R"
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- Abordagem Invasiva versus Conservadora nas Síndromes Coronárias Agudas sem Supradesnivelamento do Segmento ST – Contributo para o Conhecimento e Avaliação da Realidade NacionalPublication . Teixeira, R; Lourenço, C; Baptista, R; Jorge, E; António, N; Monteiro, S; Gonçalves, F; Monteiro, P; Freitas, M; Providência, LABACKGROUND: In addition to medical therapy, revascularization plays an important role in determining prognosis in the acute setting of unstable angina (UA) or non-ST elevation myocardial infarction (NSTEMI). OBJECTIVE: To compare in-hospital and medium-term outcome of an invasive versus a conservative strategy in the setting of UA/ NSTEMI. METHODS: We carried out a prospective study of 802 consecutive patients admitted to a single coronary unit between May 2004 and December 2006 with UA/NSTEMI. Patients were divided into two groups: A (n=418)--invasive strategy; B (n=384)--conservative strategy. All-cause mortality and major adverse cardiovascular events (MACE) were assessed at one year. RESULTS: Group B patients were older (73.0 [29-93] vs. 64.0 [27-86] years, p < 0.001), more frequently female and diabetic (35.9 vs. 26.0%, p = 0.002), and were more likely to have a history of myocardial infarction and heart failure. They also presented with worse renal function, lower hemoglobin levels and lower left ventricular ejection fraction (53.0 [45-59] vs. 57.0% [50-60]%, p < 0.001). In hospital mortality was significantly higher for this group (5.7 vs. 1.9%, p = 0.004). Group A had more smokers, more frequent history of percutaneous coronary intervention, higher total and LDL cholesterol, lower Killip class on admission and lower TIMI scores. They were more frequently treated with anti-platelet therapy and at discharge were more often under beta-blocker and dual anti-platelet therapy. Female gender (adjusted OR 0.46; 95% CI 0.27-0.78) and older age (adjusted OR 0.55; 95% CI 0.31-0.99), were independent predictors for a conservative strategy during hospital stay. One-year survival was higher for the invasive strategy patients (95.9% vs. 86.2%, log rank p < 0.001), as was one-year MACE-free survival (88.3% vs. 75.7%, log rank p < 0.001). According to two multivariate Cox regression analyses, opting for an invasive strategy during hospital stay conferred a 57% reduction in relative risk of death (HR 0.43; 95% CI 0.20-0.94), and a 56% reduction in relative risk of MACE (HR 0.44; 95% CI 0.26-0.77) at one year. CONCLUSIONS: Despite some imbalances between the groups, in our population an invasive strategy during hospital stay independently predicted a favorable one-year outcome.
- An unusual cause of acute cardiogenic shock in the operating roomPublication . Baptista, R; Fonseca, J; Marconi, L; Furriel, F; Prieto, D; Bento, C; Antines, MJ; Figueiredo, AA 51-year-old man with a renal carcinoma with inferior vena cava (IVC) invasion was referred to our hospital for the performance of a radical nephrectomy with IVC thrombus excision. To prevent embolism, an IVC filter was implanted the day before surgery below the suprahepatic veins. On nephrectomy completion, the clinical status of the patient started to deteriorate and an unsuccessful attempt was made to excise the IVC thrombus. The patient developed profound refractory hypotension without significant bleeding and worsening splanchnic stasis was noted. A transesophageal echocardiogram was immediately performed in the operating room, revealing a hemispheric mass protruding from the IVC ostium to the right atrium, completely blocking all venous return. Volume depletion was evident by low left and right atrial volumes and increased septum mobility. No other abnormalities were found that could explain the shock, namely ventricular dysfunction or valvular disease. Cardiac surgery consultation was immediately obtained, ultimately deciding to perform a median sternotomy with direct exploration of right atrium. Under cardiopulmonary bypass, a 6-cm long thrombotic mass was identified, involving the IVC filter, blocking all lower body venous return; the removal of the mass reversed the shock. The patient had an uneventful recovery. Adverse outcomes associated with IVC filters are common. Our case highlights the importance of a team approach to rapid changes in hemodynamic status in the operating room, including the surgeon, the anesthesiologist, and the cardiologist. It also emphasizes the pivotal role of transesophageal echocardiogram in the clinical evaluation of severely unstable patient
- Apolipoprotein E epsilon-4 polymorphism is associated with younger age at referral to a lipidology clinic and a poorer response to lipid-lowering therapyPublication . Baptista, R; Rebelo, M; Decq-Mota, J; Dias, P; Monteiro, P; Providência, LA; Silva, JMThe risk of coronary heart disease (CHD) is related to environmental factors and genetic variants. Apolipoprotein E (apoE) polymorphisms are heritable determinants of total and low-density lipoprotein cholesterol, with some authors suggesting an association between the ε4 allele and CHD. We investigated the relationship between apoE genotype and age at referral to a specialized lipid clinic by the primary care physician and whether the benefits of treatment with statin differed between genotypes. METHODS: We assessed individual apoE genotypes and lipid blood profile in a total of 463 patients followed at a specialized lipid clinic due to dyslipidemia, with a 3-year median follow-up time. The primary care physician at the time of the referral had no access to the apoE genotyping results. Carriers of apoE ε4/ε2 genotype were excluded. RESULTS: The frequencies of ε2, ε3 and ε4 alleles were 7.8, 78.9 and 13.3%, respectively. There were no significant differences between genders. Although with similar lipid profiles and antidyslipidemic drug usage at baseline, ε4-carriers were referred to the clinic at a younger age (44.2 ± 14.7 years) compared with non-ε4 carriers (50.6 ± 13.8 years) (p < 0.001), with a substantially younger age of referral for homozygous E4/4 and for all genotypes with at least one copy of the ε4 allele (p < 0.001 for trend). Although both ε4 and non-ε4 carriers achieved significant reductions in total cholesterol during follow-up (p < 0.001 vs. baseline), the mean relative decrease in total cholesterol levels was higher in non-ε4 carriers (-19.9 ± 2.3%) compared with ε4 carriers (-11.8 ± 2.3%), p = 0.003. CONCLUSION: Our findings support the concept that there is a reduced response to anti-dyslipidemic treatment in ε4 carriers; this can be a contributing factor for the earlier referral of these patients to our specialized lipid clinic and reinforces the usefulness of apoE genotyping in predicting patients response to lipid lowering therapies.
- Can we improve outcomes in patients with previous coronary artery bypass surgery admitted for acute coronary syndrome?Publication . Teixeira, R; Lourenço, C; António, N; Jorge, E; Baptista, R; Saraiva, F; Mendes, P; Monteiro, S; Gonçalves, F; Monteiro, P; Freitas, M; Providência, LAINTRODUCTION AND OBJECTIVES: Prognosis and in-hospital management of patients with acute coronary syndrome (ACS) and a history of coronary artery bypass graft (CABG) surgery are still debated. The objective of this study was to characterize ACS patients with a CABG and to compare their in-hospital and postdischarge outcomes with those of patients without a CABG. METHODS: This ongoing prospective observational study included 1,495 consecutive patients admitted for ACS to a coronary care unit and followed up for a mean of 19 months. There were two groups: group A (n=73), with CABGs; and group B (n=1,223), without CABGs. RESULTS: Group A patients were more often male (86.3% versus 69.1%; P=.002), and more frequently had a history of diabetes, myocardial infarction and heart failure. Group B patients more frequently had ST-elevation myocardial infarction, and had a higher median ejection fraction (53% [interquartile range, 47%-60%] vs. 50% [42%-55%]; P< .01) and peak troponin-I concentration. There was no difference in the use of invasive techniques. Regarding medication, Group B patients were more likely to receive dual antiplatelet therapy at discharge. No significant difference was observed in in-hospital mortality (9.5% versus 5.9%; P=.2) or mortality at 1 month, 6 months or 1 year (9.8% versus 9.1%; log-rank test, P=.87) and the cumulative major adverse cardiac event rate was equally low in both groups. The presence of a CABG was associated with more readmissions for unstable angina (11.3% vs. 3.1%; P< .01). CONCLUSIONS: In our ACS patients, the presence of a CABG had no significant influence on short- or medium-term outcomes, such as all-cause mortality and adverse cardiac events.
- Circumferential vascular strain rate to estimate vascular load in aortic stenosis: a speckle tracking echocardiography studyPublication . Teixeira, R; Monteiro, R; Baptista, R; Barbosa, A; Leite, L; Ribeiro, M; Martins, R; Cardim, N; Gonçalves, LEvaluation of vascular mechanics through two-dimensional speckle-tracking (2D-ST) echocardiography is a feasible and accurate approach for assessing vascular stiffening. Degenerative aortic stenosis (AS) is currently considered a systemic vascular disease where rigidity of arterial walls increases. To assess the circumferential ascending aorta strain rate (CAASR) in thoracic aortas of patients with AS, applying 2D-ST technology. 45 patients with indexed aortic valve areas (iAVA) ≤0.85 cm(2)/m(2) were studied. Global CAASR served to assess vascular deformation. Clinical, echocardiographic, and non-invasive hemodynamic data were collected. A follow up (955 days) was also performed. Average age of the cohort was 76. ± 10.3 years, with gender balance. Mean iAVA was 0.43 ± 0.15 cm(2)/m(2). Waveforms adequate for determining CAASR were found in 246 (91 %) of the 270 aortic segments evaluated, for a mean global CAASR of 0.74 ± 0.26 s(-1). Both intra- and inter-observer variability of global CAASR were deemed appropriate. CAASR correlated significantly with age (r = -0.49, p < 0.01), the stiffness index (r = -0.59, p < 0.01), systemic arterial compliance and total vascular resistance. There was a significant positive correlation between CAASR, body surface area (BSA), iAVA, and a negative relationship with valvulo-arterial impedance and E/e' ratio (r = -0.37, p = 0.01). The stiffness index was (β = -0.41, p < 0.01) independently associated with CAASR, in a model adjusted for age, BSA, iAVA and E/e'. Patients with a baseline CAASR ≤0.66 s(-1) had a worse long-term outcome (survival 52.4 vs. 83.3 %, Log Rank p = 0.04). CAASR is a promising echocardiographic tool for studying the vascular loading component of patients with AS.
- Deveremos seguir as guidelines após uma síndrome coronária aguda?Publication . Baptista, R
- Exercise echocardiography for the assessment of pulmonary hypertension in systemic sclerosis: a systematic reviewPublication . Baptista, R; Serra, S; Martins, R; Teixeira, R; Castro, G; Salvador, MJ; Pereira da Silva, JA; Santos, L; Monteiro, P; Pêgo, MBACKGROUND: Pulmonary arterial hypertension (PAH) complicates the course of systemic sclerosis (SSc) and is associated with poor prognosis. The elevation of systolic pulmonary arterial pressure (sPAP) during exercise in patients with SSc with normal resting haemodynamics may anticipate the development of PAH. Exercise echocardiography (ExEcho) has been proposed as a useful technique to identify exercise-induced increases in sPAP, but it is unclear how to clinically interpret these findings. In this systematic review, we summarize the available evidence on the role of exercise echocardiography to estimate exercise-induced elevations in pulmonary and left heart filling pressures in patients with systemic sclerosis. METHODS: We conducted a systematic review of the literature using MEDLINE, Cochrane Library and Web of Knowledge, using the vocabulary terms: ('systemic sclerosis' OR 'scleroderma') AND ('exercise echocardiography') AND ('pulmonary hypertension'). Studies including patients with SSc without a prior diagnosis of PAH, and subjected to exercise echocardiography were included. All searches were limited to English and were augmented by review of bibliographic references from the included studies. The quality of evidence was assessed by the Effective Public Health Practice Project system. RESULTS: We identified 15 studies enrolling 1242 patients, who were mostly middle-aged and female. Several exercise methods were used (cycloergometer, treadmill and Master's two step), with different protocols and positions (supine, semi-supine, upright); definition of a positive test also varied widely. Resting estimated sPAP levels varied from 18 to 35 mm Hg, all in the normal range. The weighted means for estimated sPAP were 22.2 ± 2.9 mmHg at rest and 43.0 ± 4.3 mmHg on exercise; more than half of the studies reported mean exercise sPAP ≥40 mmHg. The assessment of left ventricular diastolic function on peak exercise was reported in a minority of studies; however, when assessed, surrogate variables of left ventricular (LV) diastolic dysfunction were associated with higher sPAP on exercise. CONCLUSIONS: We found very high heterogeneity in the methods, the protocols and the estimated sPAP response to exercise. LV diastolic dysfunction was common and was associated with greater elevation of sPAP on exercise.
- Exercise-induced pulmonary hypertension in scleroderma patients: a common finding but with elusive pathophysiologyPublication . Baptista, R; Serra, S; Martins, R; Salvador, MJ; Castro, G; Gomes, M; Santos, L; Monteiro, P; Pereira da Silva, JA; Pêgo, MBACKGROUND: The etiology of exercise-induced pulmonary hypertension (exPH) in systemic sclerosis (SSc) remains a complex task, as both left ventricle (LV) diastolic dysfunction and pulmonary vascular disease can contribute to its development. We determined the incidence of exPH in SSc and examined the association between pulmonary artery systolic pressure (PASP) and tissue Doppler-derived indexes of pulmonary capillary wedge pressure (PCWP). METHODS: Thirty-eight patients with SSc were studied, using a cycloergometer protocol; 10 were excluded due to resting PH or absence of tricuspid regurgitation (TR); TR and mitral E-wave velocities, LV outflow tract time-velocity integral and LV septal E'-wave were measured before and in peak exercise to calculate cardiac output (CO), PCWP and pulmonary vascular resistance (PVR). RESULTS: Mean age of diagnosis was 57.9 ± 8.9 years. At a mean workload of 64 ± 29 Watts, 48% of patients increased PASP ≥ 50 mmHg. PCWP, assessed by the E/e' ratio, did not change significantly during exercise (10.2 ± 3.1-10.0 ± 5.1; P = NS). Only 3 patients had elevations of the E/e' ratio ≥ 13 during exercise; 2 of them had an exercise PASP ≥ 50 mmHg, yielding a proportion of exPH due to elevated LV filling pressures of 2/11 (18%). Patients with exPH had lower DLCO and had more frequently the diffuse SSc. CONCLUSION: The elevation of PASP during exercise in most patients of this cohort seems to be related to a reduced pulmonary vascular reserve, and not to an increase in PCWP. Further studies are warranted to determine the therapeutic, as well as prognostic implications of these findings.
- Going beyond classic echo in aortic stenosis: left atrial mechanics, a new marker of severityPublication . Marques-Alves, P; Marinho, AV; Teixeira, R; Baptista, R; Castro, G; Martins, R; Gonçalves, LBACKGROUND: There is limited information regarding left atrial (LA) mechanics in aortic valve stenosis (AS). We assessed LA mechanics in AS through speckle-tracking echocardiography (STE) according to severity and prognosis. METHODS: We included 102 patients diagnosed with severe AS (sAS) and 80 patients with moderate AS (mAS), all with preserved ejection fraction and no coronary artery disease. LA mechanics and left ventricular global longitudinal strain (LV-GLS) were assessed by STE. The cohort was followed-up for a median of 30 (IQR 12.6-50) months, and outcomes were determined (combined outcome of HF, death, and aortic valve replacement). RESULTS: In our sample set, values of LV-GLS (- 18.5% vs - 17.1, p = 0.025), E/e' ratio (15.8 vs 18.4, p = 0.03), and global LA mechanics (LA ɛsys, 23% vs 13.8%, p < 0.001) were worse for sAS compared to those for mAS. However, LA ɛsys (AUC 0.85, 95% CI 0.78-0.90, p < 0.001), ɛe (AUC 0.83, 95% CI 0.75-0.88, p < 0.001), and ɛa (AUC 0.80, 95% CI 0.70-0.84, p < 0.001) were the best discriminators of sAS, with sensitivities higher than 85%. LA ɛsys showed a stronger correlation with both aortic valve area (r2 = 0.6, p < 0.001) and mean LV/aortic gradient (r2 = 0.55, p < 0.001) than LV-GLS (r2 = 0.3 and r2 = 0.25, p = 0.01). Either LV-GLS or LA ɛsys, but not the E/e' ratio, TAPSE, or RV/RA gradient, were a significant predictors of the combined outcome. CONCLUSIONS: LA global strain was the best discriminator of severity, surpassing E/e' ratio and LV-GLS, and a significant predictor of prognosis in AS.
- Impacto da função renal na mortalidade e incidência de eventos cardiovasculares adversos major em doentes com síndromes coronárias agudasPublication . Lourenço, C; Teixeira, R; António, N; Monteiro, S; Baptista, R; Jorge, E; Gonçalves, F; Monteiro, P; Gonçalves, L; Freitas, M; Providência, LABACKGROUND: Renal failure patients have a dismal prognosis in the setting of acute coronary syndromes (ACS). Several studies have shown that this population is undertreated, benefiting less frequently from cardiovascular agents and interventions. The aim of our study was to evaluate patients hospitalized for ACS who also presented renal dysfunction, identifying baseline clinical characteristics, treatment options and prognosis. We also assessed whether renal failure was an independent predictor of mortality and cardiovascular events. METHODS: We performed an observational, longitudinal, prospective and continuous study, including 1039 consecutive patients hospitalized in a single center for ACS. Two groups were compared according to estimated glomerular filtration rate (eGFR): eGFR > or = 60 ml/min (group A) and eGFR < 60 ml/min (group B). The mean follow-up was twelve months after discharge. Multivariate analysis was used to identify predictors of mortality and major adverse cardiovascular events (MACE) in this population. RESULTS: Group B patients were older and more frequently female, and presented a higher prevalence of cardiovascular risk factors and previous cardiovascular disease, and more severe coronary artery disease. Group B also had more cases of non-ST-elevation acute myocardial infarction, as well as higher blood glucose, higher heart rate on admission, and lower left ventricular ejection fraction. Patients in group B were less frequently treated with the main cardiovascular drugs or by an invasive strategy; this group also presented higher in-hospital mortality (9.1 vs. 2.5%, p < 0.001). During clinical follow-up, survival and MACE-free rates were significantly lower in group B patients (86.6 vs. 93.6%, p < 0.001, and 76.2 vs. 86.2%, p < 0.001, respectively). Multivariate analysis showed that eGFR of < 30 ml/min was an independent predictor of in-hospital mortality (OR 6.92; C statistic = 0.87) and that eGFR of < 60 ml/min was an independent predictor of MACE during follow-up (OR 2.19; C statistic = 0.71). CONCLUSION: We found that moderate to severe renal dysfunction is common in ACS patients, and this variable was an independent predictor of mortality and MACE. However, we also found that these patients are undertreated, which may contribute to their poor prognosis. Early identification of these high-risk patients is important so that the procedures recommended in the international guidelines can be more consistently implemented.