MARCIO SOMMER BITTENCOURT
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- Recurrent pulmonary edema caused by chronic left main coronary artery occlusion(2012) BITTENCOURT, M. S.; OLIVEIRA, A. L. V. De; GOWDAK, L. H. W.; CESAR, L. A. M.
conferenceObject Design and baseline characteristics of a coronary heart disease prospective cohort: 2-year experience from the strategy of registry of acute coronary syndrome study (ERICO study)(2012) SANTOS, Itamar S.; GOULART, Alessandra C.; SITNIK, Debora; STANIAK, Henrique L.; FEDELI, Ligia G.; BITTENCOURT, Marcio S.; PEREIRA, Alexandre C.; BENSENOR, Isabela M.; LOTUFO, Paulo A.Introduction: Acute coronary syndrome (ACS) is an important cause of hospitalization. Although most patients are treated at local hospitals, the vast majority of registry studies are set in tertiary facilities. The ERICO study (Strategy of Registry of Acute Coronary Syndrome) was created to verify the frequency of ACS and its subtypes, the role of known or potential risk factors and long-term event rate in a community teaching hospital in the southeastern region of Brazil. Objectives: To describe the design and baseline characteristics during the two initial years of ERICO enrollment. Methods: The ERICO study is an ongoing prospective cohort. It is conducted at a secondary general hospital in Sao Paulo, Brazil. All consecutive patients, 35 years-old or older, with a diagnosis of ACS who agree to participate are enrolled in the study. Sociodemographics, medical history, clinical exam and information about hospital treatment are obtained. A brief depression questionnaire is also applied for an ancillary study. Blood samples are drawn at admission and stored. In 30-day follow-up visit, data on medical history and occurence of depressive symptoms are updated and additional blood and urinary samples are collected. Retinography, carotid intima-media thickness, heart rate variability and pulse wave velocity are performed. Questionnaires about food frequency, physical activity and sleep apnea are applied. At six months, and annually after acute event, participants are followed by phone. Results: From February 2009 to January 2011, 570 patients were enrolled. Of these, 156 (27.4%) had ST-elevation myocardial infarction (STEMI), 233 (40.9%) non ST-elevation myocardial infarction (NSTEMI) and 181 (31.7%) unstable angina (UA). Median age was 62 (interquartile interval: 54–73) years. 332 (58.2%) were men and 451 (79.1%) had 8 years or less of education. Most common primary cardiovascular risk factors were hypertension and sedentarism. Among 455 individuals who could adequately inform about previous coronary disease, only 126 (27.7%) had a prior positive history. Compared to the subgroup with STEMI, individuals with UA and NSTEMI had a higher frequency of known hypertension (p<0.01), dyslipidemia (p=0.01), sedentarism (p=0.01), prior coronary heart disease (CHD, p heart failure (p<0.01). Conclusion: In contrast to studies performed in tertiary hospitals, this community-hospital based sample has a less frequent prior history of CHD, which possibly reflects more closely a community-based setting.- Left ventricular thrombus attenuation characterization in cardiac computed tomography angiography(2012) BITTENCOURT, Marcio Sommer; ACHENBACH, Stephan; MARWAN, Mohamed; SELTMANN, Martin; MUSCHIOL, Gerd; ROPERS, Dieter; DANIEL, Werner G.; PFLEDERER, TobiasBACKGROUND: Because of their similar visual appearance, differentiation of left ventricular thrombotic material and myocardial wall can be difficult in contrast-enhanced coronary computed tomography (CT) angiography. OBJECTIVE: We identified typical thrombi attenuation of left ventricular thrombi with the use of CT measurement. METHODS: Over a time period of 6 years; we retrospectively identified 31 patients who showed a left ventricular thrombus in CT angiography datasets. Patients underwent routine contrast cardiac CT to investigate coronary artery disease. CT attenuation of each thrombus was assessed in the 4-chamber view. CT densities were also determined in the ascending aorta, left ventricle, and myocardial wall both in the mid-septal and mid-lateral segments. The mean CT attenuation of thrombi and the difference between attenuation in thrombi, left ventricular cavity, and myocardial wall were determined. The ratio of attenuation values in thrombus versus aorta and myocardium versus aorta were also determined. RESULTS: Mean (+/- SD) CT attenuation of all left ventricular thrombi in 31 patients was 43.2 +/- 15.3 HU (range, 25-80 HU). Mean CT densities of septal and lateral myocardial wall were 102.9 +/- 23.1 HU (range, 63-155 HU) and 99.3 +/- 28.7 HU (range, 72-191 HU), respectively, and were thus significantly higher than the CT attenuation of thrombi (P < 0.001). A threshold of 65 HU yielded a sensitivity, specificity, and positive and negative predictive values of 94%, 97%, 94%, and 97%, respectively, to differentiate thrombus from the myocardial wall. The mean ratio between CT attenuation of thrombus and CT attenuation within the ascending aorta was 0.11 +/- 0.05 (range, 0.04-0.23), which was significantly lower compared with the mean ratio between CT attenuation of the myocardial wall and the CT attenuation within the ascending aorta. CONCLUSION: CT attenuation within left ventricular thrombi was significantly lower than myocardial attenuation in CT angiography datasets. Assessment of CT attenuation may contribute to the differentiation of thrombi.
- Transient acute lateral wall ST elevation myocardial infarction caused by 'benign' circunflex coronary artery anomaly originating from the right coronary artery(2012) PROTASIO, B. M.; GUABIRU, A. T.; DORNELAS, G. De Oliveira; STANIAK, H. Lane; SHAROVSKY, R.; LOTUFO, P. A.; BITTENCOURT, M. S.
conferenceObject Uncovering the meaning of the Canadian Cardiovascular Society classification in patients with stable angina(2012) DOURADO, Luciana O. C.; POPPI, Nilson T.; BITTENCOURT, Marcio S.; PEREIRA, Alexandre C.; CESAR, Luiz Antonio M.; GOWDAK, Luis HenriqueIntroduction: Angina is the hallmark of coronary artery disease (CAD). More than 30 years ago, the Canadian Cardiovascular Society (CCS) proposed a classification regarding the functional impairment imposed by angina pectoris. There is, however, a major caveat with that classification that might lead to an underestimation of the extension of CAD: either patients (pt) become self-limited as a strategy to avoid exertional pain or they very often depend on the use of nitrates to tolerate different levels of exercise. Objectives: To determine the relationship between CCS classification and the frequency of angina attacks and the consumption of sublingual, short-acting nitrates tablets. Methods: 72 pt (60 men,59±13 years) with stable angina due to CAD were included. All pt had to fulfill an angina diary during a 4-week period, in which they recorded the number of daily episodes of angina and the number of short-acting nitrates taken. Investigators also recorded the functional class according to the CCS classification (I to IV). Continuous data were expressed as mean SD and ordinal variables, as percentage. Spearman’s rank correlation coefficient was applied to determine correlation between variables. Results: The distribution (n, %) of pt according to the CCS was CCS I (9, 12.5%), CCS II (41, 57%), CCS III (7, 9.5%), and CCS IV (15, 21%). The mean number of angina attacks per week and the mean number of sublingual nitrates tablets taken per week were, respectively,3.0±3.0 and 1.2±1.4 (CCS I), 2.7±3.6 and 1.5±1.9 (CCS II), 7.8±4.6 and 1.6±2.3 (CCSIII), and 5.5±3.7 and 2.1±3.3 (CCS IV). We found a strong, positive association between angina episodes and sublingual nitrates tablets per week (r=0.511; P<0.0001), a positive association between CCS and angina episodes per week (r=0.34; P=0.003), but no association between CCS and sublingual nitrates tablets per week (r=0.103; P=0.38).Conclusion: The CCS functional classification is a valid tool to predict the intensity of exercise level that evokes angina. However, it fails in estimating the frequency of the angina attacks. So, the true impairment in quality of life in patients with CAD (which depends not only on exercise tolerance [intensity] but also on angina frequency) may be underestimated by the CCS classification. More likely, pt may avoid certain activities previously known to them to provoke angina or use short-acting nitrates before angina actually occurs. This information must be carefully obtained by a detailed medical history.conferenceObject Association of depression and coronary heart disease in the participants from the strategy of registry in acute coronary syndrome study (the ERICO study)(2012) GOULART, Alessandra C.; SANTOS, Itamar S.; SITNIK, Debora; STANIAK, Henrique L.; BITTENCOURT, Marcio S.; FEDELI, Ligia G.; BENSENOR, Isabela M.; LOTUFO, Paulo A.Introduction: Depression is 3 times more common in patients after acute coronary syndrome (ACS). Further, depressive symptoms and clinical depression have an unfavorable impact on mortality in these patients. The Patient Health Questtionaire-9 (PHQ-9) is a brief depression screening instrument that has been shown reasonable sensitivity and specificity in this group. Objectives: To evaluate the baseline frequency of mild-moderate depressive symptoms, major depression and, their associations to ACS among participants from the ERICO study(Strategy of Registry of Acute Coronary Syndrome). Methods: This is an ancillary study of the ERICO study, an ongoing cohort study held at the University Hospital of the Universityof São Paulo, a teaching public hospital located in São Paulo, Brazil. The ERICO study aims to verify the frequency of ACS and its subtypes, the role of potential risk factors and the long-term event rate. Besides the cardiovascular evaluation, participants are invited to answer PHQ-9 (score range 0 –27 points). The presence of mild to moderate depressive symptoms was defined as a score from 1 to 9 points. Major depression (MD) was defined as a score of 10 or more points. Results: From September 2009 to January 2011, 452 patients ( 35 years) were diagnosed as having SCA. From 218 patients (mean age 62 years) who answered PHQ-9, 130 (59%) were male. 65 (29.8%) were diagnosed as having unstable angina, 94 (43.1%) as non-ST elevation myocardial infaction (MI) and 59 (27.1%) as ST-elevation MI. Almost 90% had at least one depressive symptom and, the most common complaint was “felling tired or having little energy”. Major depression was present in 77 (35.3%) ACS patients. MD was more frequent in women than in men (59.7% vs. 40.3%, p<0.001). Almost 50% of married patients had MD (p=0.02). Other sociodemographics factors had no association with clinical depression. ACS subtypes did no nfluency the frequency of depressive symptoms or MD. Conclusion: Compared to previous studies, we found a higher frequency of MD, regardless of ACS subtypes. Follow-up study will address the impact of depressive symptoms and MD in long-term outcomes.conferenceObject Zero calcium scores is not reliable to rule out coronary artery disease in the emergency room(2012) STANIAK, Henrique L.; BITTENCOURT, Marcio S.; SHAROVSKY, Rodolfo; BENSENOR, Isabela; GOULART, Alessandra; CASTRO, Claudio C.; SANTOS, Itamar; OLMOS, Rodrigo; LOTUFO, PauloIntroduction: Several diagnostic tools have been proposed to investigate patients with acute chest pain in the emergency room. Recently, coronary computed angiotomography (CTA) has been studied for this purpose. Since CTA has some limitations including the use of ionizing radiation, iodine contrast and the need of drugs such as beta blockers and nitrates to achieve good image quality some authors have suggested that a negative calcium score would yield those patients with very low risk in which CTA could be safely avoided. Objectives: Evaluate the diagnostic accuracy of a negative calcium score when compared with CTA in the acute setting and subsequent downstream evaluation Methods: 65 patients (32 female) with acute chest pain, normal eletrocardiogram and cardiac biomarkers who underwent calcium score and CTA which had a negative calcium score were included. The exams were performed in a 64 detectors CT device with standard settings, and the CTA was performed using prospective acquisition, after beta blocker and nitrate unless contraindicated. The calcium score exams were compared to the CTA results. The CTA was considered positive if any lesion 50% was identified. Results: 65 patients were evaluated from February to August 2011. The mean age was 53.8 14.7 years and mean heart rate was 62 bpm. 2 of these zero calcium scores had non obstructive disease (50%), 3 of these zero calcium scores had obstructive disease and 1 patient had an invaluable CTA due to motion artifacts. These last 4 patients were furtherstratified with invasive coronary angiography and all 4 underwent coronary angioplasty. Conclusion: 8.2% of the patients with coronary artery disease would be misdiagnosed if coronary calcium score was used as the sole imaging strategy in this sample. Not only that, 4 patients which had an intervention performed would remain untreated.