LUIS HENRIQUE WOLFF GOWDAK
Projetos de Pesquisa
Unidades Organizacionais
Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/13 - Laboratório de Genética e Cardiologia Molecular, Hospital das Clínicas, Faculdade de Medicina
LIM/13 - Laboratório de Genética e Cardiologia Molecular, Hospital das Clínicas, Faculdade de Medicina
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conferenceObject Cardiac scintigraphy fails to identify patients with single-vessel coronary artery disease and end-stage renal disease: potential impact on cardiovascular morbidity(2012) GOWDAK, Luis Henrique W.; PAULA, Flavio J. de; CESAR, Luiz Antonio M.; LIMA, Jose Jayme G. deIntroduction: Patients (pt) with end-stage renal disease (ESRD) are at increased risk for CAD and major adverse cardiovascular events. Cardiac scintigraphy is regarded as a non-invasive, useful screening tool for risk stratification and to exclude significant CAD in the general population; invasive coronary angiography is usually performed following a positive result in the non-invasive assessment. Objectives: To determine the accuracy of such approach in pt with ESRD being considered as renal transplant candidates. Methods: 482 pt with ESRD (56 ±9 years; 69% men) underwent cardiac scintigraphy (99mTc MIBI-SPECT with dipyridamole) and coronary angiography, regardless of symptoms. Myocardial perfusion scans were categorized as normal or abnormal (fixed and/or transient perfusion defects); significant CAD was defined by luminal stenosis ≥70%. The sensitivity (Sen), specificity (Spe), positive (PPV) and negative (NPV) predictive values were calculated for pt with 1-, 2- or 3-vessel CAD. Kaplan-Meier curves were constructed for the probability of survival free of fatal/non-fatal MACE during a 5-year follow-up based on the results of angiography. Results: 240 pt (50%) had perfusion defects; 237 pt (49%) had significant CAD, of which 89 (38%), 70 (29%), and 78 (33%) had 1-, 2-, and 3-vessel disease, respectively. Figure 1 shows that pt with any degree of significant CAD had a worse-long term prognosis than pt with no CAD. Figure 2 shows that abnormal myocardial scans were more likely to be found in pt with 2- (69%) or 3-vessel CAD (76%), whereas in pt with no CAD, 64% of them had a normal perfusion scan (P<0.0001). However, in pt with 1-vessel CAD, the occurrence of normal and abnormal scans was almost identical (48 vs. 52%). A myocardial perfusion defect yielded a Sen=52%, 69% and 76%, a Spe=28%, 37% and 41%, a PPV=30%, 31% and 39%, and a NPV = 49%, 74% and 77% for the diagnosis of 1-, 2- and 3-vessel CAD, respectively. Conclusion: In pt with ESRD: 1) the prevalence of significant CAD is high, and this imposes a worse long-term prognosis independently of the number of affected vessels; 2) myocardial perfusion assessment by SPECT has a low sensitivity to detect 1-vessel CAD; 3) as a consequence, many pt with 1-vessel CAD could be mistakenly deemed to be free of CAD and, therefore, not treated accordingly, although their long-term prognosis seemed to be no different of that from pt with 2- or 3-vessel disease.conferenceObject Clinical impact of medical intensive treatment on functional class in patients initially diagnosed as refractory angina(2012) DOURADO, Luciana O. C.; POPPI, Nilson T.; PEREIRA, Alexandre C.; CESAR, Luiz Antonio M.; GOWDAK, Luis Henrique W.Introduction: Refractory angina is a major clinical challenge. Patients (pt) usually have significant functional impairment due to disabling symptoms, which greatly adversely impact their quality of life. Many pt may be erroneously diagnosed as refractory angina, if not on intensive medical therapy. Objectives: To evaluate the impact of intensive medical treatment on angina functional class in pt initially diagnosed as refractory angina. Methods: 45 pt (31 men, 59±13 years) were included based on the following criteria: 1) disabling symptoms; 2) objectively documented myocardial ischemia; 3) coronary anatomy unsuitable for myocardial revascularization procedures. Medical visits were scheduled every 4 weeks during a 3-month period (Vo to V3). Angina functional class was recorded in each visit as proposed by the Canadian Cardiovascular Society (CCS). Medical therapy was strongly encouraged to be optimized based on patient’s tolerance. Statistical analysis included the Student s t-test (continuous variables), the chi-square test (categorical variables), and the Wilcoxon test (changes in functional class). Results: There was an overall improvement in CCS class between V0 to V3 (p,<0,001), with 30 pt (66.7%) improving at least 1 class. In 14 pt (31.1%) there was no difference and in only 1 pt (2.2%) there was worsening of CCS class. In V0 and V3, anti-ischemic drugs were used as follows (%), respectively: beta-blockers (96 vs. 96), calcium channel blockers (78 vs. 84), long-acting nitrates (96 vs. 100), and trimetazidine (38 vs. 93). Mean daily dosages (mg)of selected drugs were: atenolol 105±49 to 113±59 (P=0.16); carvedilol 44±16 to 55±20 (P=0.06); amlodipine 7±3 to 8±3(P=0.12); isossorbide 95±28 to 106±24(P=0.09). There was a non-significant 4.4% decrease in the mean heart rate (bpm) from 66±11 to 63±9(P=0.10), and a non-significant 4% reduction in mean systolic (SBP) and diastolic (DBP) blood pressure: SBP - 128±23 to 123±23mmHg (P=0.10), and DBP -75±11 to 72±14mmHg (P=0.11). Conclusion: Pt enrolled in this clinical program, although initially diagnosed as refractory angina, experienced a significant improvement in their functional class. This could not be attributed to an increase in anti-ischemic drugs or to an hemodynamic effect. We believe that the regular visits at shorter intervals may have led to a better treatment adherence, emotional easiness and self-confidence. This study exemplifies how complex is the relationship between extensiveness of the disease and functional impairment.conferenceObject Incremental Prognostic Value of Coronary Artery Disease and Renal Function on the Prediction of Cardiovascular Events of Patients Evaluated by Coronary Computed Tomography: The Partners Registry(2013) BITTENCOURT, Marcio S.; HULTEN, Edward; ABBARA, Suhny; GHOSHHAJRA, Brian; MURTHY, Venkatesh L.; TRUONG, Ouynh A.; GOWDAK, Luis Henrique W.; RIELLA, Leonardo V.; DICARLI, Marcelo; HOFFMANN, Udo; BLANKSTEIN, RonconferenceObject 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 The Effectiveness of Intensive Medical Treatment of Patients Initially Referred as Refractory Angina: Preliminary Results(2012) DOURADO, Luciana O.; POPPI, Nilson T.; PEREIRA, Alexandre C.; CESAR, Luiz Antonio M.; KRIEGER, Jose Eduardo; GOWDAK, Luis Henrique W.conferenceObject Double-Blind, Placebo-Controlled, Randomized Trial of Stem Cell Therapy Combined With Bypass Surgery - The MiHeart Trial(2018) GOWDAK, Luis Henrique W.; SCHETTERT, Isolmar T.; MENEGHETTI, Jose Claudio; ROCHITTE, Carlos Eduardo; DALLAN, Luis Alberto O.; GUARITA-SOUZA, Luiz Cesar; BRITO, Jose Oscar R.; CESAR, Luiz Antonio M.; OLIVEIRA, Sergio A. de; CARVALHO, Antonio Carlos C. de; KRIEGER, Jose Eduardo