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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article 2 Citação(ões) na Scopus Optimized Approach in Cardiocerebral Resuscitation(2011) KERN, Karl B.; TIMERMAN, Sergio; GONZALEZ, Maria Margarita; RAMIRES, Jose AntonioCardiocerebral Resuscitation (CCR) is a new approach to the resuscitation of patients with out-of-hospital cardiac arrest (OHCA). The first major component of CCR is continuous chest compressions (also referred to as chest compressiononly CPR or ""hands-only CPR"") advocated as part of CCR for all bystanders who witness a sudden collapse of presumed cardiac origin. The second component of CCR is a new ACLS treatment algorithm for Emergency Medical Services. This algorithm emphasizes uninterrupted chest compressions regardless of other ongoing assignments as part of the rescue effort. A third component has recently been added to CCR, namely aggressive post-resuscitation care. Cardiocerebral resuscitation has increased bystander participation and has improved survival rates in a number of communities. Now is the time for other communities to re-examine their own outcomes with cardiac arrest and consider joining those cities and communities that have doubled and even tripled their survival from OHCA.- Unexplained sudden death in patients on the waiting list for renal transplantation(2011) LIMA, Jose Jayme Galvao De; GOWDAK, Luis Henrique Wolff; PAULA, Flavio Jota de; ARANTES, Rodolfo Leite; CESAR, Luiz Antonio Machado; RAMIRES, Jose Antonio Franchini; KRIEGER, Eduardo M.Background. The incidence of unexplained sudden death (SD) and the factors involved in its occurrence in patients with chronic kidney disease are not well known. Methods. We investigated the incidence and the role of co-morbidities in unexplained SD in 1139 haemodialysis patients on the renal transplant waiting list. Results. Forty-four patients died from SD of undetermined causes (20% of all deaths; 3.9 deaths/1000 patients per year), while 178 died from other causes and 917 survived. SD patients were older and likely to have diabetes, hypertension, past/present cardiovascular disease, higher left ventricular mass index, and lower ejection fraction. Multivariate analysis showed that cardiovascular disease of any type was the only independent predictor of SD (P = 0.0001, HR = 2.13, 95% CI 1.46-3.22). Alterations closely associated with ischaemic heart disease like angina, previous myocardial infarction and altered myocardial scan were not independent predictors of SD. The incidence of unexplained SD in these haemodialysis patients is high and probably a consequence of pre-existing cardiovascular disease. Conclusions. Factors influencing SD in dialysis patients are not substantially different from factors in the general population. The role played by ischaemic heart disease in this context needs further evaluation.
- Most of the patients presenting myocardial infarction would not be eligible for intensive lipid-lowering based on clinical algorithms or plasma C-reactive protein(2011) SPOSITO, Andrei C.; ALVARENGA, Bruno Farah; ALEXANDRE, Alison S.; ARAUJO, Ana Laura Ribeiro; SANTOS, Simone N.; ANDRADE, Joalbo M.; RAMIRES, Jose A. F.; SILVA, Jose C. Quinaglia e; COELHO, Otavio RizziObjective: The study we assessed how often patients who are manifesting a myocardial infarction (MI) would not be considered candidates for intensive lipid-lowering therapy based on the current guidelines. Methods: In 355 consecutive patients manifesting ST elevation MI (STEMI), admission plasma C-reactive protein (CRP) was measured and Framingham risk score (FRS), PROCAM risk score, Reynolds risk score, ASSIGN risk score, QRISK, and SCORE algorithms were applied. Cardiac computed tomography and carotid ultrasound were performed to assess the coronary artery calcium score (CAC), carotid intima-media thickness (cIMT) and the presence of carotid plaques. Results: Less than 50% of STEMI patients would be identified as having high risk before the event by any of these algorithms. With the exception of FRS (9%), all other algorithms would assign low risk to about half of the enrolled patients. Plasma CRP was <1.0 mg/L in 70% and >2 mg/L in 14% of the patients. The average cIMT was 0.8 +/- 0.2 mm and only in 24% of patients was >= 1.0 mm. Carotid plaques were found in 74% of patients. CAC > 100 was found in 66% of patients. Adding CAC >100 plus the presence of carotid plaque, a high-risk condition would be identified in 100% of the patients using any of the above mentioned algorithms. Conclusion: More than half of patients manifesting STEMI would not be considered as candidates for intensive preventive therapy by the current clinical algorithms. The addition of anatomical parameters such as CAC and the presence of carotid plaques can substantially reduce the CVD risk underestimation.
- Qualitative and Quantitative Real Time Myocardial Contrast Echocardiography for Detecting Hibernating Myocardium(2011) FERNANDES, Daniela Ribeiro Aleixo; TSUTSUI, Jeane Mike; BOCCHI, Edimar Alcides; CESAR, Luiz Antonio Machado; SBANO, Joao Cesar Nunes; RAMIRES, Jose Antonio Franchini; MATHIAS JR., WilsonBackground: Real time myocardial contrast echocardiography (RTMCE) is an emerging imaging modality for assessing myocardial perfusion that allows for noninvasive quantification of regional myocardial blood flow (MBF). Aim: We sought to assess the value of qualitative analysis of myocardial perfusion and quantitative assessment of myocardial blood flow (MBF) by RTMCE for predicting regional function recovery in patients with ischemic heart disease who underwent coronary artery bypass grafting (CABG). Methods: Twenty-four patients with coronary disease and left ventricular systolic dysfunction (ejection fraction < 45%) underwent RTMCE before and 3 months after CABG. RTMCE was performed using continuous intravenous infusion of commercially available contrast agent with low mechanical index power modulation imaging. Viability was defined by qualitative assessment of myocardial perfusion as homogenous opacification at rest in >= 2 segments of anterior or >= 1 segment of posterior territory. Viability by quantitative assessment of MBF was determined by receiver-operating characteristics curve analysis. Results: Regional function recovery was observed in 74% of territories considered viable by qualitative analysis of myocardial perfusion and 40% of nonviable (P = 0.03). Sensitivity, specificity, positive and negative predictive values of qualitative RTMCE for detecting regional function recovery were 74%, 60%, 77%, and 56%, respectively. Cutoff value of MBF for predicting regional function recovery was 1.76 (AUC = 0.77; 95% CI = 0.62-0.92). MBF obtained by RTMCE had sensitivity of 91%, specificity of 50%, positive predictive value of 75%, and negative predictive value of 78%. Conclusion: Qualitative and quantitative RTMCE provide good accuracy for predicting regional function recovery after CABG. Determination of MBF increases the sensitivity for detecting hibernating myocardium. (Echocardiography 2011;28:342-349).
- Preoperative B-type natriuretic peptide, and not the inflammation status, predicts an adverse outcome for patients undergoing heart surgery(2011) GANEM, Fernando; SERRANO JR., Carlos V.; FERNANDES, Juliano L.; BLOTTA, Maria Heloisa S. L.; SOUZA, Juliana A.; NICOLAU, Jose C.; RAMIRES, Jose A. F.; HUEB, Whady A.Objectives: B-type natriuretic peptide (BNP) and inflammatory markers are implicated in the pathophysiology of both ischemic cardiomyopathy and complications after cardiac surgery with cardiopulmonary bypass (CPB). The purpose of this study was to assess preoperative and postoperative levels of BNP, interleukin-6 (IL-6), interleukin-8 (IL-8), P-selectin, intercellular adhesion molecule (ICAM), C-reactive protein (CRP) in patients undergoing cardiac surgery with CPB and investigate their variation and ability to correlate with immediate outcome. Methods: Plasma levels of these markers were measured preoperatively, 6 and 24 h after CBP in 62 patients. Main endpoints were requirements for intra-aortic balloon pump, intensive care unit (ICU) stay longer than five days, ventilator dependence >24 h, requirement for dobutamine, hospital stay >10 days, clinical complications (infection, myocardial infarction, renal failure, stroke and ventricular arrhythmias) and in-hospital mortality. Results: Preoperative BNP levels correlate with longer ICU stay (P=0.003), longer ventilator use (P=0.018) and duration of dobutamine use (P<0.001). The receiver-operating characteristic curve demonstrated BNP levels >190 pg/ml as predictor of ICU >5 days and BNP levels >20.5 pg/ml correlated with dobutamine use, with areas under the curve of 0.712 and 0.842, respectively. Preoperative levels of ICAM-1 were associated with in-hospital mortality (P=0.042). In the postoperative period, was found association between CRP, IL-6 and P-selectin with ventilation duration (P=0.013, P=0.006, P<0.001, respectively) and P-selectin with ICU stay (P=0.009). Conclusions: BNP correlates with clinical endpoints more than inflammatory markers and can be used as a predictor of early outcome after heart surgery.
- Timing and Dose of Statin Therapy Define Its Impact on Inflammatory and Endothelial Responses During Myocardial Infarction(2011) SPOSITO, Andrei C.; SANTOS, Simone N.; FARIA, Eliana Cotta de; ABDALLA, Dulcineia S. P.; SILVA, Luiza P. da; SOARES, Alexandre A. Sousa; JAPIASSU, Andre V. T.; SILVA, Jose C. Quinaglia e; RAMIRES, Jose A. F.; COELHO, Otavio RizziObjective-Clinical trials of statins during myocardial infarction (MI) have differed in their therapeutic regimes and generated conflicting results. This study evaluated the role of the timing and potency of statin therapy on its potential mechanisms of benefit during MI. Methods and Results-ST-elevation MI patients (n = 125) were allocated into 5 groups: no statin; 20, 40, or 80 mg/day simvastatin starting at admission; or 80 mg/day simvastatin 48 hours after admission. After 7 days, all patients switched their treatment to 20 mg/day simvastatin for an additional 3 weeks and then underwent flow-mediated dilation in the brachial artery. As of the second day, C-reactive protein (CRP) differed between non-statin users (12.0 +/- 4.1 mg/L) and patients treated with 20 (8.5 +/- 4.0 mg/L), 40 (3.8 +/- 2.5 mg/L), and 80 mg/day (1.4 +/- 1.5 mg/L), and the daily differences remained significant until the seventh day (P < 0.0001). The higher the statin dose, the lower the elevation of interleukin-2 and tumor necrosis factor-alpha, the greater the reduction of 8-isoprostane and low-density lipoprotein(-), and the greater the increase in nitrate/nitrite levels during the first 5 days (P < 0.001). Later initiation of statin was less effective than its early introduction in relation to attenuation of CRP, interleukin-2, tumor necrosis factor-alpha, 8-isoprostane, and low-density lipoprotein(-), as well as in increase in nitrate/nitrite levels (P < 0.0001). At the 30th day, there was no longer a difference in lipid profile or CRP between groups; the flow-mediated dilation, however, was proportional to the initial statin dose and was higher for those who started the treatment early (P = 0.001). Conclusion-This study demonstrates that the timing and potency of statin treatment during MI are key elements for their main mechanisms of benefit.
- Dynamic Changes in Microcirculatory Blood Flow during Dobutamine Stress Assessed by Quantitative Myocardial Contrast Echocardiography(2011) MATHIAS JR., Wilson; KOWATSCH, Ingrid; SAROUTE, Ally Nader; OSORIO, Altamiro Filho Ferraz; SBANO, Joao Cesar Nunes; DOURADO, Paulo Magno Martins; RAMIRES, Jose Antonio Franchini; TSUTSUI, Jeane MikeBackground: Although dobutamine-atropine stress echocardiography (DASE) has been widely used for evaluating patients with coronary artery disease (CAD), dynamic changes that occur at microcirculatory level during each stage of stress have not been demonstrated in humans. Aim: We sought to determine variations in myocardial blood flow (MBF) during DASE using quantitative real time myocardial contrast echocardiography (RTMCE). Methods: We studied 45 patients who underwent coronary angiography and RTMCE. Replenishment velocity of microbubbles in the myocardium (beta) and MBF reserves were obtained at baseline, intermediate stage (70% of maximal predicted heart rate), peak stress, and recovery phase. Results: beta and MBF reserves were lower in patients with than without CAD at intermediate (1.65 vs. 2.10; P = 0.001 and 2.44 vs. 3.23; P = 0.004) and peak (1.63 vs. 3.00; P < 0.001 and 2.14 vs. 3.98; P < 0.001, respectively). In patients without CAD, beta, and MBF reserves increased from intermediate to peak and decreased at recovery, while in those without CAD reserves did not change significantly. Optimal cutoff values of beta reserve at intermediate, peak, and recovery were 1.78, 2.09, and 1.70, with areas under the curves of 0.80 (95%CI = 0.67-0.94), 0.89 (95%CI = 0.79-0.99), and 0.69 (95%CI = 0.53-0.85). Sensitivity, specificity and accuracy for detecting CAD at intermediate stage were 68% (95%CI = 48-89), 85% (95%CI = 71-98), and 78% (95%CI = 66-90), at peak stress were 79% (95%CI = 61-97), 96% (95%CI = 89-100), and 89% (95%CI = 80-98), and at recovery were 74% (95%CI = 54-93), 65% (95%CI = 47-84), and 69% (95%CI = 55-82), respectively. Conclusion: RTMCE allows for quantification of dynamic changes in microcirculatory blood flow at each stage of DASE. The best parameter for detecting CAD in all stages was beta reserve. (Echocardiography 2011;28:993-1001)
- B-type natriuretic peptide as a predictor of anterior wall location in patients with non-ST-elevation myocardial infarction(2011) RAMOS, Rogerio Bicudo; STRUNZ, Celia M.; AVAKIAN, Solange Desiree; RAMIRES, Jose Antonio; MANSUR, Antonio de PaduaOBJECTIVE: Involvement of the left ventricular anterior wall in ST-elevation myocardial infarction has a worse prognosis compared with other regions. In non-ST-elevation myocardial infarction, noninvasive methods of locating the ischemic myocardial territory have been limited. The objective of this report is therefore to determine what factors are predictive of the anterior location of the ischemic myocardial territory. METHODS: This study included 170 patients with non-ST-elevation myocardial infarction. Clinical, echocardiographic, and laboratory characteristics, including B-type natriuretic peptide measured within 24 hours of hospitalization, and coronary angiographic features were analyzed. RESULTS: The mean age was 64.5 +/- 12.3 years, and 112 of the patients were male (66%). The median follow-up was 23 months. The territory involved, as determined from the angiogram, was divided into anterior [n = 80 (47%)] regions and inferior and lateral [n = 90 (53%)] regions. Multivariate analysis showed that B-type natriuretic peptide was the only independent predictor of an anterior wall infarct [OR = 3.70 (95% CI: 1.61 - 8.53); P = 0.002] in non-ST-elevation myocardial infarction patients. Multivariate analysis also showed that B-type natriuretic peptide was an independent predictor of in-hospital cardiac events during index admission [OR = 5.05 (95% CI: 1.49 - 17.12); P = 0.009] and of cardiac events occurring during follow-up [HR = 1.79 (95% CI: 1.05 - 3.04); P = 0.032]. CONCLUSIONS: B-type natriuretic peptide was the only factor independently associated with anterior wall involvement in non-ST-elevation myocardial infarction, and the peptide levels upon admission predicted in-hospital and subsequent cardiac events.