EDUARDO GOMES LIMA
Projetos de Pesquisa
Unidades Organizacionais
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/11 - Laboratório de Cirurgia Cardiovascular e Fisiopatologia da Circulação, Hospital das Clínicas, Faculdade de Medicina
LIM/11 - Laboratório de Cirurgia Cardiovascular e Fisiopatologia da Circulação, Hospital das Clínicas, Faculdade de Medicina
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- 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 Evolution of ventricular function in patients with stable coronary artery disease submitted to on-pump or off-pump coronary artery bypass graft in MASS III trial(2012) STASZKO, K. F.; HUEB, W.; LIMA, E. G.; BISELLI, B.; GARZILLO, C. L.; PEREIRA, A. C.; HUEB, A. C.; REZENDE, P. C.; RAMIRES, J. A. F.; KALIL FILHO, R.Purpose: Ventricular function is a major determinant of prognosis in patients with coronary artery disease (CAD). Few data are available to assess the evolution of ventricular function among patients submitted to off-pump coronary artery bypas graft surgery (OPCAB). To compare the evolution of ventricular function in a long-term follow-up among patients with stable CAD submitted to OPCAB or On-Pump coronary artery bypass graft (ONCAB) Methods: Patients with stable CAD and preserved systolic left ventricular function were randomized to OPCAB or ONCAB and followed for 5 years. Patients who undergone a new evaluation of ventricular function in this follow-up were studied. Left ventricular ejection fraction (LVEF) was assessed by echocardiogram. Results: Of 308 patients randomized to OPCAB (n=155) or ONCAB (n=153), 91 had a new assessment of ventricular function by echocardiogram in a 5-year follow-up: 49 in ONCAB group and 42 in OPCAB group. In ONCAB group the initial and final mean of LVEF was respectively 59.85% and 56.16% (p=0.10). In OPCAB group the initial and final mean of LVEF was respectively 59.18% and 56.07 (p=0.17). Conclusion: There was no difference in the evolution of LVEF among patients with stable CAD randomized to ONCAB or OPCAB in a 5-year follow-up.conferenceObject EVOLUTION OF VENTRICULAR FUNCTION IN PATIENTS WITH STABLE CORONARY ARTERY DISEASE SUBMITTED TO ON-PUMP OR OFF-PUMP CORONARY ARTERY BYPASS GRAFT IN MASS III TRIAL(2012) STASZKO, Kamila F.; HUEB, Whady; LIMA, Eduardo; BISELLI, Bruno; GARCIA, Rosa Maria Rahmi; VIEIRA, Ricardo D. O.; GARZILLO, Cibele Larrosa; PEREIRA, Alexandre Costa; HUEB, Alexandre Ciappina; REZENDE, Paulo Cury; CASELLA-FILHO, Antonio; RAMIRES, Jose; KALIL-FILHO, RobertoBackground Ventricular function is a major determinant of prognosis in patients with coronary artery disease (CAD). Few data are available to assess the evolution of ventricular function among patients submitted to off-pump coronary artery bypass graft surgery (OPCAB). Purpose To compare the evolution of ventricular function in a long-term follow-up among patients with stable CAD submitted to OPCAB or On-Pump coronary artery bypass graft (ONCAB) Methods Patients with stable CAD and preserved systolic left ventricular function were randomized to OPCAB or ONCAB and followed for 5 years. Patients who undergone a new evaluation of ventricular function in this follow-up were studied. Left ventricular ejection fraction (LVEF) was assessed by echocardiogram. Results Of 308 patients randomized to OPCAB (n=155) or ONCAB (n=153), 91 had a new assessment of ventricular function by echocardiogram in a 5-year follow-up: 49 in ONCAB group and 42 in OPCAB group. In ONCAB group the initial and final mean of LVEF was respectively 59.85% and 56.16% (p=0.10). In OPCAB group the initial and final mean of LVEF was respectively 59.18 % and 56.07 (p=0.17). Conclusion There was no difference in the evolution of LVEF among patients with stable CAD randomized to ONCAB or OPCAB in a 5-year follow-up. ACC Moderated Poster Contributions McCormick Place South, Hall A Monday, March 26, 2012, 9:30 a.m.-10:30 a.m. Session Title: Fresh CABG: Good for SIHD? Abstract Category: 3. Chronic CAD/Stable Ischemic Heart Disease: Therapy Presentation Number: 1208-409conferenceObject DIRECT COMPARISON BETWEEN TWO HYPOGLYCEMIC AGENTS: EFFECTS ON MYOCARDIAL ISCHEMIC PRECONDITIONING IN DIABETIC PATIENTS WITH SYMPTOMATIC CORONARY DISEASE(2012) GARCIA, Rosa Maria Rahmi; HUEB, Whady; UCHIDA, Augusto; REZENDE, Paulo Cury; MOFFA, Paulo Jorge; GARZILLO, Cibele Larrosa; LIMA, Eduardo; SOARES, Paulo; RAMIRES, Jose; KALIL-FILHO, RobertoIntroduction It is well known that hypoglycemic agents (sulfonylureas and Glinides) can have direct effects on ischemic preconditioning (IPC) because of the effect on the extrapancreatic ATP-dependent K+ channels. Some hypoglycemic drugs can abolish the IPC, affecting the infarct size and contractile function contributing to a worse prognosis. The Vildagliptin's mode of action is distinct from established antidiabetic medications. This study was performed to compare the effects of 2 hypoglycemic agents on myocardial IPC in patients with type 2 diabetes and multivessel coronary disease. Methods We evaluated 81 patients with type 2 diabetes, a positive exercise test and double and triple-vessel coronary disease confirmed by coronary angiography. Forty-two of these patients received repaglinide 2 mg, and 38 patients received Vildagliptin 100 mg (groups A and B, respectively). In phase I, all patients underwent 2 consecutive treadmill exercise tests (T1 and T2). The patients received hypoglycemic drugs for one week and underwent 2 more sequential tests (T3 and T4) during phase 2. The time interval between the exercise tests was 30 minutes. Results In phase 1, IPC was demonstrated by improvement in the time to 1 mm of ST segment depression (T-1.0mm). All patients developed myocardial ischemia in T3; however, 83.3% of patients in group A experienced myocardial ischemia earlier in T4, indicating the cessation of IPC (p<0.0001). In group B, only 28% of patients demonstrated IPC atenuation, with 72% still preserving the protective effect (p<0.0069). Conclusions These results show that Vildagliptin maintains myocardial IPC, while Repaglinide might be able to prevent it. This is of particular interest because we could demonstrate the safety of this new class of oral antidiabetic agents known as dipeptidyl peptidase IV inhibitors with respect to cardiovascular side effects ACC Moderated Poster Contributions McCormick Place South, Hall A Monday, March 26, 2012, 11:00 a.m.-Noon Session Title: Lipids, Hypertension, Hyperglycemia: New Tricks for Old Targets Abstract Category: 2. Chronic CAD/Stable Ischemic Heart Disease: Clinical Presentation Number: 1202-228conferenceObject Five year follow-up of on-pump versus off pump coronary artery bypass surgery in elderly patients - the MASS III trial(2012) MELO, R. M. Vieira De; REZENDE, P. C.; GARZILLO, C. L.; LIMA, E. G.; SEGRE, C. A. W.; COSTA, L. M. A.; OIKAWA, F. T.; HUEB, W.; RAMIRES, J. A. F.; KALIL FILHO, R.Purpose: Advanced age is associated with increased mortality and morbidity in patients undergoing coronary artery bypass grafting (CABG), which may be a consequence of cardiopulmonary bypass. Thus, off-pump surgery may have an increased benefit in elderly patients. We aim to evaluate cardiac events and long-term clinical outcomes in elderly patients with stable coronary artery disease and preserved left ventricular ejection fraction undergoing off-pump and on-pump CABG. 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 off-pump (n=155) or on-pump (n=153) CABG. Of this, 176 (58,3%) patients had 60 years or older at the time of randomization (of-pump=90 and on-pump=86). Primary composite end points were death, myocardial infarction, further revascularization (surgery or angioplasty), or stroke. Results: The two randomized groups were well-matched for baseline demographic, clinical, and angiographic characteristics. The mean age was 67,2 ( ± 5,0) years. After 5-year follow-up, there were no significant differences between on- pump and off-pump groups in the composite end points: 27,9% vs 21,1% (hazard ratio 1.17, 95% CI 0.87 to 1.59; P=0.29) Figure 1. Six patients (7.0%) died in the on-pump group compared with 10 (11.1%) in the of-pump group (hazard ratio 0.78, 95% CI 0.47 to 1.29; p=0.33). On-pump patients had a higher incidence of postoperative stroke or myocardial infarction: 13 (15.1%) vs 5 (5,6%); p=0,036. Conclusions: Patients undergoing off-pump surgery had a lower incidence of in hospital stroke or myocardial infarction. This finding did not add benefit in clinical outcomes at 5-years follow-up.conferenceObject Role of Hypoglycemic Agents on Ischemic Preconditioning in Diabetic Patients with Stable Multivessel Coronary Artery Disease(2012) GARCIA, Rosa M.; HUEB, Whady; UCHIDA, Augusto H.; REZENDE, Paulo C.; LIMA, Eduardo G.; GARZILLO, Cibele L.; SEGRE, Carlos A.; FAVARATO, Desiderio; RAMIRES, Jose A.; KALIL FILHO, RobertoconferenceObject Five years follow-up of on-pump versus off pump coronary artery bypass surgery in diabetic patients of the MASS III Trial(2012) COSTA, L. M. A.; GARZILLO, C. L.; REZENDE, P. C.; LIMA, E. G.; FAVARATO, D.; MELO, R. M. Vieira De; OIKAWA, F. T.; HUEB, W.; RAMIRES, J. A. F.; KALIL FILHO, R.Purpose: Diabetic patients represent one-third of coronary artery disease (CAD) patients, many of whom are treated with revascularization procedures. They are at increased risk, including long-term mortality, compared with non-diabetic patients. Few data are available on the effects of off-pump coronary artery bypass graft surgery (OPCAB) on cardiac events and long-term clinical outcomes in this population. Methods: MASS III is a single-center randomized trial that evaluate 308 patients with stable coronary artery disease and preserved ventricular function assigned for off-pump (n=155) or on-pump (n=153) CABG. The subgroup of 110 diabetic patients were randomly assigned to off pump CAB (n=56) and on-pump CAB (n=54). Primary composite end points were death, myocardial infarction, further revascularization (surgery or angioplasty), or stroke. Results: The two randomized groups were well-matched for major baseline demographic, clinical, and angiographic characteristics. After 5-year follow-up, the primary composite end point was not different between groups (event-free survival 83.7% x 93.7%, p= 0.15). Conclusions:In this analysis, off pump diabetic patients presented the same incidence of composite end-points compared with on-pump CABG.conferenceObject PERFORMANCE OF LEFT VENTRICULAR EJECTION FRACTION ON PATIENTS WITH STABLE MULTIVESSEL CORONARY DISEASE SUBMITTED TO MEDICINE, ANGIOPLASTY OR SURGERY: 10 YEARS FOLLOW-UPFROM MASS II TRIAL(2012) GARZILLO, Cibele L.; HUEB, Whady; LIMA, Eduardo Gomes; REZENDE, Paulo Cury; FAVARATO, Desiderio; SOARES, Paulo; HUEB, Alexandre Ciappina; STOLF, Noedir A. G.; RAMIRES, Jose; KALIL-FILHO, RobertoBackground Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) are assumed as effective therapeutic options for the protection of the ischemic myocardium. However, it is not established if those procedures are effective for left ventricular ejection fraction (LVEF) preservation. In this setting, we evaluated the evolution of LVEF in patients with stable multivessel coronary disease, submitted to CABG, PCI or medical treatment (MT) alone, after ten years of follow-up. Methods Echocardiography was performed on patients participants of MASS II trial, previously to randomization for CABG, PCI or MT, and after 10 years. LVEF was measured by the biplane method (Simpson), when regional wall-motion abnormalities were present, or by the Teichholz method. Results After a follow-up of 10.32 (±1.43) years, 350 patients had LVEF reassessed: 108 patients on MT, 111 on CABG and 131 on PCI group. Main baseline characteristics and the occurrence of AMI were similar among the three groups. There was no difference of LVEF either at the beginning (0.61 + 0.07, 0.61 + 0.08 e 0.61 + 0.09 respectively for PCI, CABG and MT, p=0.675) and the end of follow up (0.56 + 0.11, 0.55 + 0.11 e 0.55 + 0.12 respectively for PCI, CABG and MT, p=0.675). The impact of other variables over LVEF evolution, such as gender, age, diabetes and arterial pattern, were also analyzed, and no relevance was demonstrated. However, the presence of previous AMI (OR 2.50, 95% CI 1.40-4.45; p= 0.0007) and the occurrence of AMI during follow up (OR 2.73, 95% IC 1.25-5.92; p=0.005) were associated with an increased risk of developing LVEF < 45%. Also, AMI during follow-up was responsible for a greater reduction of LVEF (reduction delta of 18.29 ± 21.22% and 6.63 ± 18.91%, respectively for patients with and without AMI, p=0.001). Conclusion Thus, compared with PCI or CABG patients, patients in the medical group with unprotected coronary artery disease by mechanical revascularization without adverse cardiac events showed no differences in the left ventricular function after 10 years of follow up. Moreover, whatever of interventional therapeutic strategies applied, the left ventricular function remained unchanged in absence of MACE. ACC Moderated Poster Contributions McCormick Place South, Hall A Monday, March 26, 2012, 9:30 a.m.-10:30 a.m. Session Title: Fresh CABG: Good for SIHD? Abstract Category: 3. Chronic CAD/Stable Ischemic Heart Disease: Therapy Presentation Number: 1208-410- Effect of Complete Revascularization on 10-Year Survival of Patients With Stable Multivessel Coronary Artery Disease MASS II Trial(2012) VIEIRA, Ricardo D'Oliveira; HUEB, Whady; GERSH, Bernard J.; LIMA, Eduardo Gomes; PEREIRA, Alexandre Costa; REZENDE, Paulo Cury; GARZILLO, Cibele Larrosa; HUEB, Alexandre Ciappina; FAVARATO, Desiderio; SOARES, Paulo Rogerio; RAMIRES, Jose Antonio Franchini; KALIL FILHO, RobertoBackground-The importance of complete revascularization remains unclear and contradictory. This current investigation compares the effect of complete revascularization on 10-year survival of patients with stable multivessel coronary artery disease (CAD) who were randomly assigned to percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). Methods and Results-This is a post hoc analysis of the Second Medicine, Angioplasty, or Surgery Study (MASS II), which is a randomized trial comparing treatments in patients with stable multivessel CAD, and preserved systolic ventricular function. We analyzed patients who underwent surgery (CABG) or stent angioplasty (PCI). The survival free of overall mortality of patients who underwent complete (CR) or incomplete revascularization (IR) was compared. Of the 408 patients randomly assigned to mechanical revascularization, 390 patients (95.6%) underwent the assigned treatment; complete revascularization was achieved in 224 patients (57.4%), 63.8% of those in the CABG group and 36.2% in the PCI group (P = 0.001). The IR group had more prior myocardial infarction than the CR group (56.2% X 39.2%, P = 0.01). During a 10-year follow-up, the survival free of cardiovascular mortality was significantly different among patients in the 2 groups (CR, 90.6% versus IR, 84.4%; P = 0.04). This was mainly driven by an increased cardiovascular specific mortality in individuals with incomplete revascularization submitted to PCI (P = 0.05). Conclusions-Our study suggests that in 10-year follow-up, CR compared with IR was associated with reduced cardiovascular mortality, especially due to a higher increase in cardiovascular-specific mortality in individuals submitted to PCI.
conferenceObject IMPACT OF METABOLIC SYNDROME ON THE OUTCOME OF PATIENTS WITH STABLE CORONARY ARTERY DISEASE SUBMITTED TO DIFFERENT TYPES OF TREATMENT: 10-YEAR FOLLOW-UP OF THE MASS II STUDY(2012) LIMA, Eduardo Gomes; HUEB, Whady; GARCIA, Rosa Maria Rahmi; VIEIRA, Ricardo D. O.; GARZILLO, Cibele Larrosa; PEREIRA, Alexandre Costa; HUEB, Alexandre Ciappina; REZENDE, Paulo Cury; CASELLA-FILHO, Antonio; RAMIRES, Jose; KALIL-FILHO, RobertoBackground Metabolic syndrome (MetS) is understood as a condition that promotes atherosclerosis and confers an additional risk of adverse cardiovascular events in patients with coronary artery disease. The prognosis of this syndrome in this subset of patients in a long term follow up is inconclusive. Objective Evaluate the impact of metabolic syndrome on cardiac death in patients with symptomatic chronic multivessel coronary artery disease. Methods Patients randomized in MASS II study submitted to coronary artery bypass graft (CABG), angioplasty (PCI) or medical treatment (MT) were evaluated for the presence of MetS and followed prospectively for 10 years. We evaluated the incidence of overall and cardiac death in this period. Results Criteria for MetS were fulfilled in 283 patients of 583 (54%) randomized to three therapeutic strategies. The presence of MetS, was associated with an increased cardiac related death in studied population. During a 10-year follow-up, the probability cardiac mortality free survival was significantly different among patients in the 2 groups (MetS = 81,6% × non-MetS = 91,3% P=0.004). Stratifying patients with MetS by therapeutic approach we identify a statistical difference in cardiac death free survival comparing interventional approaches (CABG and PCI) to MT: 82,4% for CABG; 86,2% for PCI and 75,9% for MT (P=0,003). Besides, there is a group with best prognosis: patients without MetS submitted to CABG presenting 98,7% of patients free of cardiac death in a 10-year follow-up. Conclusion MetS confers high rates of cardiac death in patients with stable coronary artery disease irrespective of therapeutic strategy used. In patients with MetS, interventional approaches (PCI or CABG) seem to confer more protection against cardiac death in a 10-year follow-up. ACC Moderated Poster Contributions McCormick Place South, Hall A Monday, March 26, 2012, 11:00 a.m.-Noon Session Title: DES and Drugs: Decisions in Diabetics Abstract Category: 3. Chronic CAD/Stable Ischemic Heart Disease: Therapy Presentation Number: 1209-477