Arquivos brasileiros de cardiologia最新文献

With the increasing prevalence of chronic coronary syndromes, many patients with extensive atherosclerosis experience uncontrolled angina, even while receiving optimal medical therapy. This is especially true for patients who are not suitable candidates for surgical or percutaneous revascularization. Numerous treatments have been investigated for managing angina pectoris, and in this context, the coronary sinus reducer has emerged as a promising therapeutic option. Since the 1950s, beginning with Beck's surgery, the coronary venous sinus has been a focal point of research in anti-ischemic therapies. Significant scientific advances have been made in narrowing the venous sinus in the past two decades. Thanks to technological improvements in minimally invasive procedures and better methods for assessing myocardial blood flow, a new therapeutic option has become available for patients suffering from refractory angina and, possibly, for microvascular dysfunction. In this review, we aim to examine key concepts related to angina pectoris and myocardial ischemia, highlighting the historical background, pathophysiological rationale, and technical aspects of coronary sinus reduction as a therapy for refractory angina. Additionally, we will explore the scientific evidence from recent decades, as well as identify existing gaps and outline future research directions concerning this emerging treatment.

Percutaneous coronary intervention (PCI) is the most widely used coronary revascularization method worldwide, even in cases of high anatomical complexity. However, this increasing complexity has increased the risks associated with the procedure. Mechanical circulatory assist devices (MCADs), such as the iVAC 2L, have been used for hemodynamic support in high-risk PCIs. We describe the first case in Brazil of PCI performed with the support of the iVAC 2L, a pulsatile MCAD. The patient, an 81-year-old man, had functional class III angina and severe lesions in the left main coronary artery (LMCA), left anterior descending artery (LAD), and circumflex artery (CX), associated with extensive calcification. The procedure was performed with the support of the iVAC 2L, and PCI was performed with stenting of the LMCA, LAD, and CX. The entire procedure was performed without the need for vasoactive drugs, and the device was removed without vascular complications. High-risk PCI has become increasingly common, often requiring ventricular mechanical support. The iVAC 2L offers advantages such as pulsatile flow and ease of implantation, making it an alternative to the intra-aortic balloon pump and Impella. This report highlights the potential use of the iVAC 2L in Brazil, expanding therapeutic options for high-risk patients.

Background: Sleep blood pressure (BP) fall is a prognostic marker. Few studies have evaluated whether systolic BP (SBP) or diastolic BP (DBP) dipping more accurately predicts clinical outcomes.

Objective: To determine which type of BP dipping has greater predictive value for clinical outcomes.

Methods: This retrospective cohort evaluated patients who underwent ambulatory blood pressure monitoring (ABPM) between January 27, 2004, and February 16,2012. Patients were followed until the occurrence of the primary outcome (death from any cause), or until the end of follow-up period (February 01, 2022). Cox survival curves were constructed to assess which dipping classification - SBP or DBP - better distinguished the occurrence of outcomes. Dipping was defined as a nocturnal BP reduction of 10-20%. Absent and attenuated dipping were defined as reductions of ≤ 0% and 0-10%, respectively. Statistical significance was set at p < 0.05.

Results: A total of 756 patients were included, with a mean age of 54±16.4 years; 42% were male. In predicting the primary outcome (all-cause mortality), the absence of DBP dipping, adjusted for 24-hour SBP, was associated with a hazard-ratio (HR) of 2.051 (95% confidence interval [95%CI]: 1.147 - 3.670 (p=0.015). For the secondary outcome (cardiovascular mortality), the absence of DBP dipping, also adjusted for 24-hour SBP, showed a HR of 3.329 (95%CI: 1.317-8.412; p=0.011). In contrast, the absence of SBP dipping, when adjusted for 24-hour SBP, was not significantly associated with either outcome. In the fully adjusted model, which included age, diabetes, smoking, atherosclerotic vascular disease and chronic kidney disease, both SBP and DBP dipping lost statistically significant associations.

Conclusion: DBP dipping demonstrates superior predictive power for outcomes compared to SBP dipping, and adds to the prognostic value of mean 24-hour SBP. (Central Illustration).