CARLOS ALEXANDRE WAINROBER SEGRE
Projetos de Pesquisa
Unidades Organizacionais
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina - Médico
11 resultados
Resultados de Busca
Agora exibindo 1 - 10 de 11
- Myocardial injury in diabetic patients with multivessel coronary artery disease after revascularization interventions(2017) REZENDE, Paulo Cury; HUEB, Whady; RAHMI, Rosa Maria; SCUDELER, Thiago Luis; AZEVEDO, Diogo Freitas Cardoso de; GARZILLO, Cibele Larrosa; SEGRE, Carlos Alexandre Wainrober; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoBackground: Diabetic patients may be more susceptible to myocardial injury after coronary interventions. Thus, the aim of this study was to assess the release of cardiac biomarkers, CK-MB and troponin, and the findings of new late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) in patients with type 2 diabetes mellitus after elective revascularization procedures for multivessel coronary artery disease (CAD). Methods: Patients with multivessel CAD and preserved systolic ventricular function underwent either elective percutaneous coronary intervention (PCI), off-pump or on-pump bypass surgery (CABG). Troponin and CK-MB were systematically collected at baseline, 6, 12, 24, 36, 48 and 72 h after the procedures. CMR with LGE was performed before and after the interventions. Patients were stratified according to diabetes status at study entry. Biomarkers and CMR results were compared between diabetic and nondiabetics patients. Analyses of correlation were also performed among glycemic and glycated hemoglobin (A1c) levels and troponin and CK-MB peak levels. Patients were also stratified into tertiles of fasting glycemia and A1c levels and were compared in terms of periprocedural myocardial infarction (PMI) on CMR. Results: Ninety (44.5%) of the 202 patients had diabetes mellitus at study entry. After interventions, median peak troponin was 2.18 (0.47, 5.14) and 2.24 (0.69, 5.42) ng/mL (P = 0.81), and median peak CK-MB was 14.1 (6.8, 31.7) and 14.0 (4.2, 29.8) ng/mL (P = 0.43), in diabetic and nondiabetic patients, respectively. The release of troponin and CK-MB over time was statistically similar in both groups and in the three treatments, besides PCI. New LGE on CMR indicated that new myocardial fibrosis was present in 18.9 and 17.3% (P = 0.91), and myocardial edema in 15.5 and 22.9% (P = 0.39) in diabetic and nondiabetic patients, respectively. The incidence of PMI in the glycemia tertiles was 17.9% versus 19.3% versus 18.7% (P = 0.98), and in the A1c tertiles was 19.1% versus 13.3% versus 22.2% (P = 0.88). Conclusions: In this study, diabetes mellitus did not add risk of myocardial injury after revascularization interventions in patients with multivessel coronary artery disease.
- Type 2 diabetes mellitus and myocardial ischemic preconditioning in symptomatic coronary artery disease patients(2015) REZENDE, Paulo Cury; RAHMI, Rosa Maria; UCHIDA, Augusto Hiroshi; COSTA, Leandro Menezes Alves da; SCUDELER, Thiago Luis; GARZILLO, Cibele Larrosa; LIMA, Eduardo Gomes; SEGRE, Carlos Alexandre Wainrober; GIRARDI, Priscyla; TAKIUTI, Myrthes; SILVA, Marcela Francisca; HUEB, Whady; RAMIRES, Jose Antonio Franchini; FILHO, Roberto KalilBackground: The influence of diabetes mellitus on myocardial ischemic preconditioning is not clearly defined. Experimental studies are conflicting and human studies are scarce and inconclusive. Objectives: Identify whether diabetes mellitus intervenes on ischemic preconditioning in symptomatic coronary artery disease patients. Methods: Symptomatic multivessel coronary artery disease patients with preserved systolic ventricular function and a positive exercise test underwent two sequential exercise tests to demonstrate ischemic preconditioning. Ischemic parameters were compared among patients with and without type 2 diabetes mellitus. Ischemic preconditioning was considered present when the time to 1.0 mm ST deviation and rate pressure-product were greater in the second of 2 exercise tests. Sequential exercise tests were analyzed by 2 independent cardiologists. Results: Of the 2,140 consecutive coronary artery disease patients screened, 361 met inclusion criteria, and 174 patients (64.2 +/- 7.6 years) completed the study protocol. Of these, 86 had the diagnosis of type 2 diabetes. Among diabetic patients, 62 (72%) manifested an improvement in ischemic parameters consistent with ischemic preconditioning, whereas among nondiabetic patients, 60 (68%) manifested ischemic preconditioning (p = 0.62). The analysis of patients who demonstrated ischemic preconditioning showed similar improvement in the time to 1.0 mm ST deviation between diabetic and nondiabetic groups (79.4 +/- 47.6 vs 65.5 +/- 36.4 s, respectively, p = 0.12). Regarding rate pressure-product, the improvement was greater in diabetic compared to nondiabetic patients (3011 +/- 2430 vs 2081 +/- 2139 bpm x mmHg, respectively, p = 0.01). Conclusions: In this study, diabetes mellitus was not associated with impairment in ischemic preconditioning in symptomatic coronary artery disease patients. Furthermore, diabetic patients experienced an improvement in this significant mechanism of myocardial protection.
- Hypotheses, rationale, design, and methods for evaluation of ischemic preconditioning assessed by sequential exercise tests in diabetic and non-diabetic patients with stable coronary artery disease - a prospective study(2013) REZENDE, Paulo Cury; GARCIA, Rosa Maria Rahmi; UCHIDA, Augusto Hiroshi; COSTA, Leandro Menezes Alves; SCUDELER, Thiago Luis; MELO, Rodrigo Morel Vieira; OIKAWA, Fernando Teiichi Costa; GARZILLO, Cibele Larrosa; LIMA, Eduardo Gomes; SEGRE, Carlos Alexandre Wainrober; FAVARATO, Desiderio; GIRARDI, Priscyla; TAKIUTI, Myrthes; STRUNZ, Celia Cassaro; HUEB, Whady; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoBackground: 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. Methods/Design: 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. Discussion: 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.
- Chronic troponin elevation assessed by myocardial T1 mapping in patients with stable coronary artery disease(2023) SEGRE, Carlos Alexandre W.; LEMOS, James A. de; ASSUNCAO, Antonildes Nascimento; NOMURA, Cesar Higa; FAVARATO, Desiderio; STRUNZ, Celia Maria Cassaro; VILLA, Alexandre Volney; PARGA FILHO, Jose Rodrigues; REZENDE, Paulo Cury; HUEB, Whady; RAMIRES, Jose Antonio Franchini; KALIL FILHO, Roberto; SERRANO, Carlos VicenteBackground:Cardiac troponin detected with sensitive assays can be chronically elevated, in the absence of unstable coronary syndromes. In patients with chronic coronary artery disease, clinically silent ischemic episodes may cause chronic troponin release. T1 mapping is a cardiovascular magnetic resonance technique useful in quantitative cardiac tissue characterization. We selected patients with anatomically and functionally normal hearts to investigate associations between chronic troponin release and myocardial tissue characteristics assessed by T1 mapping. Methods:We investigated the relationship between cardiac troponin I concentrations and cardiovascular magnetic resonance T1 mapping parameters in patients with stable coronary artery disease enrolled in MASS V study before elective revascularization. Participants had no previous myocardial infarction, negative late gadolinium enhancement, normal left ventricular function, chamber dimensions and wall thickness. Results:A total of 56 patients were analyzed in troponin tertiles: nativeT1 and extracellular volume (ECV) values (expressed as means +/- standard deviations) increased across tertiles: nativeT1 (1006 +/- 27 ms vs 1016 +/- 27 ms vs 1034 +/- 37 ms, ptrend = 0.006) and ECV (22 +/- 3% vs 23 +/- 1.9% vs 25 +/- 3%, ptrend = 0.007). Cardiac troponin I concentrations correlated with native T1(R = 0.33, P = .012) and ECV (R = 0.3, P = .025), and were independently associated with nativeT1 (P = .049) and ventricular mass index (P = .041) in multivariable analysis. Conclusion:In patients with chronic coronary artery disease and structurally normal hearts, troponin I concentrations correlated with T1 mapping parameters, suggesting that diffuse edema or fibrosis scattered in normal myocardium might be associated with chronic troponin release.
- Alterations in lipid transfers to HDL associated with the presence of coronary artery disease in patients with type 2 diabetes mellitus(2015) SPRANDEL, Marilia C. O.; HUEB, Whady A.; SEGRE, Alexandre; RAMIRES, Jose A. F.; KALIL-FILHO, Roberto; MARANHAO, Raul C.Background: We previously showed that unesterified-cholesterol transfer to high-density lipoprotein ( HDL), a crucial step in cholesterol esterification and role in reverse cholesterol transport, was diminished in non-diabetic patients with coronary artery disease ( CAD). The aim was to investigate whether, in patients with type 2 diabetes mellitus ( T2DM), the occurrence of CAD was also associated with alterations in lipid transfers and other parameters of plasma lipid metabolism. Methods: Seventy-nine T2DM with CAD and 76 T2DM without CAD, confirmed by cineangiography, paired for sex, age ( 40-80 years), BMI and without statin use, were studied. In vitro transfer of four lipids to HDL was performed by incubating plasma of each patient with a donor emulsion containing radioactive lipids during 1 h at 37 degrees C. Lipids transferred to HDL were measured after chemical precipitation of non-HDL fractions and the emulsion. Results are expressed as % of total radioactivity of each lipid in HDL. Results: In T2DM + CAD, LDL-cholesterol and apo B were higher than in T2DM. T2DM + CAD also showed diminished transfer to HDL of unesterified cholesterol ( T2DM + CAD = 7.6 +/- 1.2; T2DM = 8.2 +/- 1.5 %, p < 0.01) and of cholesteryl-esters ( 4.0 +/- 0.6 vs 4.3 +/- 0.7, p < 0.01). Unesterified cholesterol in the non-HDL serum fraction was higher in T2DM + CAD ( 0.93 +/- 0.20 vs 0.85 +/- 0.15, p = 0.02) and CETP concentration was diminished ( 2.1 +/- 1.0 vs 2.5 +/- 1.1, p = 0.02). Lecithin-cholesterol acyltransferase activity, HDL size and lipid composition were equal. Conclusion: Reduction in T2DM + CAD of cholesterol transfer to HDL may impair cholesterol esterification and reverse cholesterol transport and altogether with simultaneous increased plasma unesterified cholesterol may facilitate CAD development in T2DM.
- Troponin in diabetic patients with and without chronic coronary artery disease(2015) SEGRE, Carlos Alexandre Wainrober; HUEB, Whady; GARCIA, Rosa Maria Rahmi; REZENDE, Paulo Cury; FAVARATO, Desiderio; STRUNZ, Celia Maria Cassaro; SPRANDEL, Marilia da Costa Oliveira; ROGGERIO, Alessandra; CARVALHO, Ana Luiza de Oliveira; MARANHAO, Raul Cavalcante; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoBackground: Cardiac-specific troponin detected with the new high-sensitivity assays can be chronically elevated in response to cardiovascular comorbidities and confer important prognostic information, in the absence of unstable coronary syndromes. Both diabetes mellitus and coronary artery disease are known predictors of troponin elevation. It is not known whether diabetic patients with coronary artery disease have different levels of troponin compared with diabetic patients with normal coronary arteries. To investigate this question, we determined the concentrations of a level 1 troponin assay in two groups of diabetic patients: those with multivessel coronary artery disease and those with angiographically normal coronary arteries. Methods: We studied 95 diabetic patients and compared troponin in serum samples from 50 patients with coronary artery disease (mean age = 63.7, 58 % male) with 45 controls with angiographically normal coronary arteries. Brain natriuretic peptide and the oxidative stress biomarkers myeloperoxidase, nitrotyrosine and oxidized LDL were also determined. Results: Diabetic patients with coronary artery disease had higher levels of troponin than did controls (median values, 12.0 pg/mL (95 % CI:10-16) vs 7.0 pg/mL (95 % CI: 5.9-8.5), respectively; p = 0.0001). The area under the ROC curve for the diagnosis of CAD was 0.712 with a sensitivity of 70 % and a specificity of 66 %. Plasma BNP levels and oxidative stress variables (myeloperoxidase, nitrotyrosine, and oxidized LDL) were not different between the two groups. In a multivariate analysis, gender (p = 0.04), serum glucose (0.03) and Troponin I (p = 0.01) had independent statistical significance. Conclusion: Troponin elevation is related to the presence of chronic coronary artery disease in diabetic patients with multiple associated cardiovascular risk factors. Troponin may serve as a biomarker in this high-risk population.
- Significant elevation of biomarkers of myocardial necrosis after coronary artery bypass grafting without myocardial infarction established assessed by cardiac magnetic resonance(2017) COSTA, Leandro Menezes Alves da; HUEB, Whady; NOMURA, Cesar Higa; HUEB, Alexandre Ciappina; VILLA, Alexandre Volney; OIKAWA, Fernando Teiichi Costa; MELO, Rodrigo Morel Vieira de; REZENDE, Paulo Cury; SEGRE, Carlos Alexandre Wainrober; GARZILLO, Cibele Larrosa; LIMA, Eduardo Gomes; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoThe release of myocardial necrosis biomarkers after off-pump coronary artery bypass grafting (OPCAB) frequently occurs. However, the correlation between biomarker release and the diagnosis of procedure-related myocardial infarction (MI) (type 5) has been controversial. This study aimed to evaluate the amount and pattern of cardiac biomarker release after elective OPCAB in patients without evidence of a new MI on cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE). Patients with normal baseline cardiac biomarkers referred for elective OPCAB were prospectively included. CMR with LGE was performed in all patients before and after interventions. Measurements of troponin I (cTnI) and creatine kinase MB fraction (CK-MB) were systematically performed before and after the procedure. Patients with new LGE on the postprocedure CMR were excluded. All of the 53 patients without CMR evidence of a procedure-related MI after OPCAB exhibited a cTnI elevation peak above the 99th percentile. In 48 (91%), the peak value was > 10 times this threshold. However, 41 (77%) had a CK-MB peak above the limit of the 99th percentile, and this peak was > 10 times the 99th percentile in only 7 patients (13%). The median peak release of cTnI was 0.290 (0.8-3.7) ng/mL, which is 50-fold higher than the 99th percentile. In contrast with CK-MB, considerable cTnI release often occurs after an elective OPCAB procedure, despite the absence of new LGE on CMR.
- Two-Year Follow-Up of Chronic Ischemic Heart Disease Patients in a Specialized Center in Brazil(2023) MOREIRA, Eduardo Martelli; PINESI, Henrique Trombini; MARTINS, Eduardo Bello; PITTA, Fabio Grunspun; BOLTA, Paula Mathias Paulino; SEGRE, Carlos Alexandre Wainrober; FAVARATO, Desiderio; RACHED, Fabiana Hanna; HUEB, Whady Armindo; LIMA, Eduardo Gomes; FILHO, Roberto Kalil; GARZILLO, Cibele Larrosa; JR, Carlos Vicente SerranoBackground: The incidence of cardiovascular events in patients with chronic ischemic heart disease (CIHD) may vary significantly among countries. Although populous, Brazil is often underrepresented in international records.Objectives: This study aimed to describe the quality of care and the two-year incidence of cardiovascular events and associated prognostic factors in CIHD patients in a tertiary public health care center in Brazil.Methods: Patients with CIHD who reported for clinical evaluation at Instituto do Coracao (Sao Paulo, Brazil) were registered and followed for two years. The primary endpoint was a composite of myocardial infarction (MI), stroke, or death. A significance level of 0.05 was adopted.Results: From January 2016 to December 2018, 625 participants were included in the study. Baseline characteristics show that 33.1% were women, median age 66.1 [59.6 - 71.9], 48.6% had diabetes, 83.1% had hypertension, 62.6% had previous MI, and 70.4% went through some revascularization procedure. At a median follow-up (FU) of 881 days, we noted 37 (7.05%) primary endpoints. After adjustments, age, previous stroke, and LDL-cholesterol were independently associated with the primary endpoint. Comparing baseline versus FU, participants experienced relief of angina based on the Canadian Cardiovascular Society (CCS) scale according to the following percentages: 65.7% vs. 81.7% were asymptomatic and 4.2% vs. 2.9% CCS 3 or 4 (p < 0.001). They also experienced better quality of medication prescription: 65.8% vs. 73.6% (p < 0.001). However, there was no improvement in LDL-cholesterol or blood pressure control. Conclusion: This study shows that CIHD patients had a two-year incidence of the primary composite endpoint of 7.05%, and the reduction of LDL-cholesterol was the only modifiable risk factor associated with prognosis.
- Hypotheses, rationale, design, and methods for prognostic evaluation of cardiac biomarker elevation after percutaneous and surgical revascularization in the absence of manifest myocardial infarction. A comparative analysis of biomarkers and cardiac magnetic resonance. The MASS-V Trial(2012) HUEB, Whady; GERSH, Bernard J.; REZENDE, Paulo Cury; GARZILLO, Cibele Larrosa; LIMA, Eduardo Gomes; VIEIRA, Ricardo D'Oliveira; GARCIA, Rosa Maria Rahmi; FAVARATO, Desiderio; SEGRE, Carlos Alexandre W.; PEREIRA, Alexandre Costa; SOARES, Paulo Rogerio; RIBEIRO, Expedito; LEMOS, Pedro; PERIN, Marco A.; STRUNZ, Celia Cassaro; DALLAN, Luis A. O.; JATENE, Fabio B.; STOLF, Noedir A. G.; HUEB, Alexandre Ciappina; DIAS, Ricardo; GAIOTTO, Fabio A.; COSTA, Leandro Menezes Alves da; OIKAWA, Fernando Teiichi Costa; MELO, Rodrigo Morel Vieira de; SERRANO JUNIOR, Carlos Vicente; AVILA, Luiz Francisco Rodrigues de; VILLA, Alexandre Volney; PARGA FILHO, Jose Rodrigues; NOMURA, Cesar; RAMIRES, Jose A. F.; KALIL FILHO, RobertoBackground: Although the release of cardiac biomarkers after percutaneous (PCI) or surgical revascularization (CABG) is common, its prognostic significance is not known. Questions remain about the mechanisms and degree of correlation between the release, the volume of myocardial tissue loss, and the long-term significance. Delayed-enhancement of cardiac magnetic resonance (CMR) consistently quantifies areas of irreversible myocardial injury. To investigate the quantitative relationship between irreversible injury and cardiac biomarkers, we will evaluate the extent of irreversible injury in patients undergoing PCI and CABG and relate it to postprocedural modifications in cardiac biomarkers and long-term prognosis. Methods/Design: The study will include 150 patients with multivessel coronary artery disease (CAD) with left ventricle ejection fraction (LVEF) and a formal indication for CABG; 50 patients will undergo CABG with cardiopulmonary bypass (CPB); 50 patients with the same arterial and ventricular condition indicated for myocardial revascularization will undergo CABG without CPB; and another 50 patients with CAD and preserved ventricular function will undergo PCI using stents. All patients will undergo CMR before and after surgery or PCI. We will also evaluate the release of cardiac markers of necrosis immediately before and after each procedure. Primary outcome considered is overall death in a 5-year follow-up. Secondary outcomes are levels of CK-MB isoenzyme and I-Troponin in association with presence of myocardial fibrosis and systolic left ventricle dysfunction assessed by CMR. Discussion: The MASS-V Trial aims to establish reliable values for parameters of enzyme markers of myocardial necrosis in the absence of manifest myocardial infarction after mechanical interventions. The establishments of these indices have diagnostic value and clinical prognosis and therefore require relevant and different therapeutic measures. In daily practice, the inappropriate use of these necrosis markers has led to misdiagnosis and therefore wrong treatment. The appearance of a more sensitive tool such as CMR provides an unprecedented diagnostic accuracy of myocardial damage when correlated with necrosis enzyme markers. We aim to correlate laboratory data with imaging, thereby establishing more refined data on the presence or absence of irreversible myocardial injury after the procedure, either percutaneous or surgical, and this, with or without the use of cardiopulmonary bypass.
- Resolution of coronary arteritis following tuberculosis treatment(2022) BARRETO-NETO, Nestor; SEGRE, Alexandre W.; GUEDES, Lissiane K. N.; SEGURO, Luciana P. C.; PEREIRA, Rosa M. R.Background: Coronary artery aneurysm (CAA) in an uncommon condition usually associated with atherosclerosis, but systemic vasculitides constitute important differential diagnoses. A less recognized cause of CAA, tuberculosis (TB) has also been noted to occur simultaneously in patients with such vascular abnormalities. Case report: A 60-year-old female presented to the Emergency Department with a non-ST segment elevation myocardial infarction. Angiography demonstrated segmental aneurysms of the left anterior descending coronary artery. Shortly after, she was also diagnosed with cutaneous TB, and treatment was promptly initiated. Reevaluation conducted several months later demonstrated that levels of inflammation markers had significantly decreased. New catheterization of coronary arteries evidenced complete resolution of coronary aneurysm images. Conclusion: Due to the clinical and radiologic resolution with only TB treatment, as well as lack of evidence supporting atherosclerotic or vasculitic etiologies, TB can be considered a possible contributor to aneurysm formation in this case. Prospective studies are necessary to reliably demonstrate causality between TB infection and CAA.