JOSE ANTONIO FRANCHINI RAMIRES
Projetos de Pesquisa
Unidades Organizacionais
Departamento de Cardio-Pneumologia, Faculdade de Medicina - Docente
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina
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- Role of Trimetazidine in Ischemic Preconditioning in Patients With Symptomatic Coronary Artery Disease(2015) COSTA, Leandro M. A.; REZENDE, Paulo C.; GARCIA, Rosa M. R.; UCHIDA, Augusto H.; SEGURO, Luis Fernando B. C.; SCUDELER, Thiago L.; BOCCHI, Edimar A.; KRIEGER, Jose E.; HUEB, Whady; RAMIRES, Jose Antonio F.; KALIL FILHO, RobertoIschemic preconditioning (IP) is a powerful cardioprotective cellular mechanism that has been related to the warm-up phenomenon or walk-through angina, and has been documented through the use of sequential exercise tests (ETs). It is known that several drugs, for example, cromokalim, pinacidil, adenosine, and nicorandil, can interfere with the cellular pathways of IP. The purpose of this article is to report the effect of the anti-ischemic agent trimetazidine (TMZ) on IP in symptomatic coronary artery disease (CAD) patients.We conducted a prospective study evaluating IP by the analysis of ischemic parameters in 2 sequential ETs. In phase I, without TMZ, patients underwent ET1 and ET2 with a 30-minute interval between them. In phase II, after 1 week of TMZ 35mg twice daily, all patients underwent 2 consecutive ETs (ET3 and ET4). IP was considered present when the time to 1.0-mm segment ST on electrocardiogram deviation (T-1.0mm) and rate pressure product (RPP) were greater in the second of 2 tests. The improvement in T-1.0mm and RPP were compared in the 2 phases: without TMZ and after 1-week TMZ to assess the action of such drug in myocardial protective mechanisms. ETs were analyzed by 2 independent cardiologists.From 135 CAD patients screened, 96 met inclusion criteria and 62 completed the study protocol. Forty patients manifested IP by demonstrating an improvement in T-1.0mm in ET2 compared with ET1, without the use of any drugs (phase I). In phase II, after 1-week TMZ, 26 patients (65%) did not show any incremental result in ischemic parameters in ET4 compared with ET3. Furthermore, of these patients, 8 (20%) had IP blockage.In this study, TMZ did not add any benefit to IP in patients with stable symptomatic CAD.
- On-pump versus off-pump coronary artery bypass surgery in patients older than 60 years: five-year follow-up of MASS III trial(2014) MELO, Rodrigo Morel Vieira de; HUEB, Whady; REZENDE, Paulo Cury; LIMA, Eduardo Gomes; HUEB, Alexandre Ciappina; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoBackground: We aim to evaluate in-hospital events and long-term clinical outcomes in patients over 60 years of age with stable coronary artery disease and preserved left ventricular ejection fraction undergoing off-pump or on-pump coronary artery bypass grafting. Methods: The MASS III was a single-center randomized trial that evaluate 308 patients with stable coronary artery disease and preserved ventricular function assigned for: 155 to off-pump and 153 to on-pump CABG. Of this, 176 (58.3%) patients were 60 years or older at the time of randomization (90 of-pump and 86 on-pump). The primary short-term end point was a composite of myocardial infarction, stroke, and overall mortality occurring within 30 days after surgery or before discharge, whichever was later. The primary long-term end point was death from any cause within 5 years, non-fatal myocardial infarction between 30 days and 5 years, or additional revascularization between 30 days and 5 years. Results: On-pump CABG had a higher incidence of 30-day composite outcome than off-pump CABG (15,1% and 5.6%, respectively; P = 0.036). However, after the multivariate analysis, this association lost statistical significance, P = 0.05. After 5-year follow-up, there were no significant differences between both strategies of CABG in the composite end points 16.7% and 15.1%; Hazard Ratio 1.07; CI 0.41 - 1.82; P = 0.71, for off-pump and on-pump CABG respectively. Conclusions: On-pump and off-pump CABG achieved similar results of combined events at short-term and 5-year follow-up.
- 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.
- Ten-year outcomes of patients randomized to surgery, angioplasty, or medical treatment for stable multivessel coronary disease: Effect of age in the Medicine, Angioplasty, or Surgery Study II trial(2013) REZENDE, Paulo Cury; HUEB, Whady; GARZILLO, Cibele Larrosa; LIMA, Eduardo Gomes; HUEB, Alexandre Ciappina; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoObjective: With progressive aging, coronary artery disease has been diagnosed at more advanced ages. Although patients aged 65 years or more have been referred to surgical or percutaneous coronary interventions, the best option for coronary artery disease treatment remains uncertain. The current study compared the 3 treatment options for coronary artery disease in patients aged 65 years or more and analyzed the impact of age in treatment options. Methods: Patients were separated according to age: 65 years or more (n = 200) and less than 65 years (n = 411). All patients were followed for 10 years. The rates of overall mortality, acute myocardial infarction, and new revascularizations were analyzed. Results: Of 200 patients aged 65 years or more, 68 were randomized to medical therapy, 68 were randomized to percutaneous coronary intervention, and 64 were randomized to coronary artery bypass grafting. At 10 years, overall survival was 63% (medical therapy), 69% (percutaneous coronary intervention), and 66% (coronary artery bypass grafting) (P = .93). The survival free of combined events was 43% (medical therapy), 38% (percutaneous coronary intervention), and 66% (coronary artery bypass grafting) (P = .007). The survival free of myocardial infarction was 82% (medical therapy), 77% (percutaneous coronary intervention), and 90%(coronary artery bypass grafting) (P = .17), and survival free of new revascularizations was 59% (medical therapy), 58% (percutaneous coronary intervention), and 91% (coronary artery bypass grafting) (P = .0003). When the 2 age groups were compared, survival free of myocardial infarction for patients treated by percutaneous coronary intervention was 77% (older patients) and 92% (younger patients) (P = .004). Conclusions: In this analysis, treatment options for patients aged 65 years or more who have coronary artery disease yield similar overall survival. However, coronary artery bypass grafting was associated with fewer coronary events, and percutaneous coronary intervention was associated with a higher incidence of myocardial infarction.
- Brazilian Cardio-oncology Guideline-2020(2020) HAJJAR, Ludhmila Abrahao; COSTA, Isabela Bispo Santos da Silva da; LOPES, Marcelo Antonio Cartaxo Queiroga; HOFF, Paulo Marcelo Gehm; DIZ, Maria Del Pilar Estevez; FONSECA, Silvia Moulin Ribeiro; BITTAR, Cristina Salvadori; REHDER, Marilia Harumi Higuchi dos Santos; RIZK, Stephanie Itala; ALMEIDA, Dirceu Rodrigues; FERNANDES, Gustavo S. Santos; BECK-DA-SILVA, Luis; CAMPOS, Carlos Augusto Homem de Magalhaes; MONTERA, Marcelo Westerlund; ALVES, Silvia Marinho Martins; FUKUSHIMA, Julia Tizue; SANTOS, Maria Veronica Camara dos; NEGRAO, Carlos Eduardo; SILVA, Thiago Liguori Feliciano da; FERREIRA, Silvia Moreira Ayub; MALACHIAS, Marcus Vinicius Bolivar; MOREIRA, Maria da Consolacao Vieira; VALENTE NETO, Manuel Maria Ramos; FONSECA, Veronica Cristina Quiroga; SOEIRO, Maria da Carolina Feres de Almeida; ALVES, Juliana Barbosa Sobral; SILVA, Carolina Maria Pinto Domingues Carvalho; SBANO, Joao; PAVANELLO, Ricardo; PINTO, Ibraim Masciarelli F.; SIMAO, Antonio Felipe; DRACOULAKIS, Marianna Deway Andrade; HOFF, Ana Oliveira; ASSUNCAO, Bruna Morhy Borges Leal; NOVIS, Yana; TESTA, Laura; ALENCAR FILHO, Aristoteles Comte de; CRUZ, Cecilia Beatriz Bittencourt Viana; PEREIRA, Juliana; GARCIA, Diego Ribeiro; NOMURA, Cesar Higa; ROCHITTE, Carlos Eduardo; MACEDO, Ariane Vieira Scarlatelli; MARCATTI, Patricia Tavares Felipe; MATHIAS JUNIOR, Wilson; WIERMANN, Evanius Garcia; VAL, Renata do; FREITAS, Helano; COUTINHO, Anelisa; MATHIAS, Clarissa Maria de Cerqueira; VIEIRA, Fernando Meton de Alencar Camara; SASSE, Andre Deeke; ROCHA, Vanderson; RAMIRES, Jose Antonio Franchini; KALIL FILHO, Roberto
conferenceObject The Release of Cardiac Necrosis Biomarkers in Patients Without Myocardial Infarction After On-Pump Surgical Revascularization. A Study of Cardiac Magnetic Resonance Imaging(2016) OIKAWA, Fernando T.; HUEB, Whady; COSTA, Leandro M.; MELO, Rodrigo M. Vieira de; REZENDE, Paulo C.; GARZILLO, Cibele L.; LIMA, Eduardo G.; NOMURA, Cesar H.; VILLA, Alexandre V.; HUEB, Alexandre C.; RAMIRES, Jose A.; KALIL FILHO, Roberto- Long-Term Follow-Up of Implantable Cardioverter-Defibrillator for Secondary Prevention in Chagas' Heart Disease(2012) MARTINELLI, Martino; SIQUEIRA, Sergio Freitas de; STERNICK, Eduardo Back; RASSI JR., Anis; COSTA, Roberto; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoAssessing the efficacy of implantable cardioverter-defibrillators (ICD) in patients with Chagas' heart disease (ChHD) and identifying the clinical predictors of mortality and ICD shock during long-term follow-up. ChHD is associated with ventricular tachyarrhythmias and an increased risk of sudden cardiac death. Although ChHD is a common form of cardiomyopathy in Latin American ICD users, little is known about its efficacy in the treatment of this population. The study cohort included 116 consecutive patients with ChHD and an ICD implanted for secondary prevention. Of the 116 patients, 83 (72%) were men; the mean age was 54 +/- 10.7 years. Several clinical variables were tested in a multivariate Cox model for predicting long-term mortality. The average follow-up was 45 +/- 32 months. New York Heart Association class I-II developed in 83% of patients. The mean left ventricular ejection fraction was 42 +/- 16% at implantation. Of the 116 patients, 58 (50%) had appropriate shocks and 13 (11%) had inappropriate therapy. A total of 31 patients died (7.1% annual mortality rate). New York Heart Association class III (hazard ratio [HR] 3.09, 95% confidence interval 1.37 to 6.96, p = 0.0064) was a predictor of a worse prognosis. The left ventricular ejection fraction (HR 0.972, 95% confidence interval 0.94 to 0.99, p = 0.0442) and low cumulative right ventricular pacing (HR 0.23, 95% confidence interval 0.11 to 0.49, p = 0.0001) were predictors of better survival. The left ventricular diastolic diameter was an independent predictor of appropriate shock (I-ER 1.032, 95% confidence interval 1.004 to 1.060, p = 0.025). In conclusion, in a long-term follow-up, ICD efficacy for secondary sudden cardiac death prevention in patients with ChHD was marked by a favorable annual rate of all-cause mortality (7.1%); 50% of the cohort received appropriate shock therapy. New York Heart Association class III and left ventricular ejection fraction were independent predictors of worse prognosis, and low cumulative right ventricular pacing defined better survival.
- Prognostic Value of Coronary and Microvascular Flow Reserve in Patients with Nonischemic Dilated Cardiomyopathy(2013) LIMA, Marta F.; MATHIAS JR., Wilson; SBANO, Joao C. N.; CRUZ, Victoria Yezinia de la; ABDUCH, Maria Cristina; LIMA, Marcio S. M.; BOCCHI, Edmar A.; HAJJAR, Ludhmila A.; RAMIRES, Jose A. F.; KALIL FILHO, Roberto; TSUTSUI, Jeane M.Background: Coronary and microvascular blood flow reserve have been established as important predictors of prognosis in patients with cardiovascular disease. The aim of this study was to assess the value of coronary flow velocity reserve (CFVR) and real-time myocardial perfusion echocardiography (RTMPE) for predicting events in patients with nonischemic dilated cardiomyopathy. Methods: One hundred ninety-five patients (mean age 54 +/- 12 years; 66% men) with dilated cardiomyopathy (left ventricular ejection fraction < 35% and no obstructive coronary disease on invasive angiography or multi-detector computed tomography) who underwent dipyridamole stress (0.84 mg/kg over 10 min) RTMPE were prospectively studied. CFVR was calculated as the ratio of hyperemic to baseline peak diastolic velocities in the distal left anterior coronary artery. The replenishment velocity (beta), plateau of acoustic intensity (A(N)), and myocardial blood flow reserve were obtained from RTMPE. Results: Mean CFVR was 2.07 +/- 0.52, mean A(N) reserve was 1.05 +/- 0.09, mean beta reserve was 2.05 +/- 0.39, and mean myocardial blood flow reserve (A(N) x beta) was 2.15 +/- 0.48. During a median follow-up period of 29 months, 45 patients had events (43 deaths and two urgent transplantations). Independent predictors of events were left atrial diameter (relative risk, 1.16; 95% confidence interval, 1.08-1.26; P < .001) and beta reserve <= 2.0 (relative risk, 3.22; 95% confidence interval, 1.18-8.79; P < .001). After adjustment for beta reserve, CFVR and myocardial blood flow reserve no longer had predictive value. Left atrial diameter added prognostic value over clinical factors and left ventricular ejection fraction (chi(2) = 36.8-58.5, P < .001). Beta reserve added additional power to the model (chi(2) = 70.2, P < .001). Conclusions: Increased left atrial diameter and depressed beta reserve were independent predictors of cardiac death and transplantation in patients with nonischemic dilated cardiomyopathy. Beta reserve by RTMPE provided incremental predictive value beyond that provided by current known prognostic clinical and echocardiographic factors. (J Am Soc Echocardiogr 2013;26:278-87.)
- Cost-Effectiveness Analysis for Surgical, Angioplasty, or Medical Therapeutics for Coronary Artery Disease 5-Year Follow-Up of Medicine, Angioplasty, or Surgery Study (MASS) II Trial(2012) VIEIRA, Ricardo D'Oliveira; HUEB, Whady; HLATKY, Mark; FAVARATO, Desiderio; REZENDE, Paulo Cury; GARZILLO, Cibele Larrosa; LIMA, Eduardo Gomes; SOARES, Paulo Rogerio; HUEB, Alexandre Ciappina; PEREIRA, Alexandre Costa; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoBackground-The Second Medicine, Angioplasty, or Surgery Study (MASS II) included patients with multivessel coronary artery disease and normal systolic ventricular function. Patients underwent coronary artery bypass graft surgery (CABG, n = 203), percutaneous coronary intervention (PCI, n = 205), or medical treatment alone (MT, n = 203). This investigation compares the economic outcome at 5-year follow-up of the 3 therapeutic strategies. Methods and Results-We analyzed cumulative costs during a 5-year follow-up period. To analyze the cost-effectiveness, adjustment was made on the cumulative costs for average event-free time and angina-free proportion. Respectively, for event-free survival and event plus angina-free survival, MT presented 3.79 quality-adjusted life-years and 2.07 quality-adjusted life-years; PCI presented 3.59 and 2.77 quality-adjusted life-years; and CABG demonstrated 4.4 and 2.81 quality-adjusted life-years. The event-free costs were $9071.00 for MT; $19 967.00 for PCI; and $18 263.00 for CABG. The paired comparison of the event-free costs showed that there was a significant difference favoring MT versus PCI (P<0.01) and versus CABG (P<0.01) and CABG versus PCI (P<0.01). The event-free plus angina-free costs were $16 553.00, $25 831.00, and $24 614.00, respectively. The paired comparison of the event-free plus angina-free costs showed that there was a significant difference favoring MT versus PCI (P=0.04), and versus CABG (P<0.001); there was no difference between CABG and PCI (P>0.05). Conclusions-In the long-term economic analysis, for the prevention of a composite primary end point, MT was more cost effective than CABG, and CABG was more cost-effective than PCI.
conferenceObject EFFECT OF TICAGRELOR AND CLOPIDOGREL ON CORONARY MICROCIRCULATION IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION(2019) SCANAVINI FILHO, Marco Antonio; BERWANGER, Otavio; MATHIAS JUNIOR, Wilson; AGUIAR, Miguel Osman; CHIANG, Hsu Po; BARACIOLI, Luciano Moreira; LIMA, Felipe Gallego; MENEZES, Fernando Reis; DALCOQUIO, Talia; FURTADO, Remo Holanda M.; LUCA, Fabio Augusto De; UEZATO, Delcio; RAMIRES, Jose Antonio Franchini; KALIL FILHO, Roberto; NICOLAU, Jose Carlos