Whady Hueb

Background: Treatment strategies for coronary artery disease (CAD), namely coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI) and optimized medical therapy (OMT), have well established cardiovascular outcomes, but their long-term effects on renal function remain underexplored. Patients with chronic kidney disease (CKD) are frequently underrepresented in large trials, and renal endpoints are usually treated as markers of cardiovascular risk rather than as outcomes in their own right. This article reports the rationale and design of a study evaluating the long-term renal impact of these strategies. Methods: Single-centre, registry-based cohort study using the Medicine, Angioplasty or Surgery Study (MASS) registry, reported per the STROBE Statement. Eligible patients have stable multivessel CAD, preserved left ventricular function and annual serum creatinine over more than five years, and received OMT, CABG or PCI. The primary outcome is the longitudinal change in estimated glomerular filtration rate (eGFR) over five years; secondary outcomes are new-onset CKD, advanced CKD, renal replacement therapy and mortality. Renal-function trajectories will be modelled with generalized additive models for location, scale and shape (GAMLSS) including a random intercept per patient; time-to-event outcomes with Cox models adjusted for age, sex, diabetes, hypertension and baseline renal function. The cohort has been assembled and the vital-status update completed; outcome analyses are ongoing and will be reported separately. Conclusions: By positioning renal function as a primary outcome, this study may generate evidence to integrate cardiovascular and renal risk into treatment selection for stable multivessel CAD. Trial Registration: The study is registered at ClinicalTrials.gov (NCT07195747).

The long-term impact of metabolic control on cardiovascular outcomes in patients with type 2 diabetes mellitus and stable coronary artery disease remains u

Background: Evaluation of percutaneous coronary intervention (PCI) effectiveness typically focuses on overall coronary events, often overlooking the specific location of these events within the coronary vasculature. This study aimed to evaluate the incidence of coronary events in patients treated with PCI and to investigate the correlation between these events, the location of the event within the treated site, and the type of stent used. Methods: This study determined the proportion of coronary events occurring after percutaneous coronary intervention (PCI) and investigated the association between these events and the location of the previous treatment site. A retrospective cohort analysis was conducted on patients with stable coronary artery disease (CAD) who underwent PCI using either conventional or drug‐eluting stents. Data was obtained from the MASS Clinical Research Unit database. The location of the coronary event was determined by angiography. Results: Five hundred and sixty two patients were included, with 232 (41.3%) experiencing coronary events. 55.8% of the events occurred at the treated site, while the remaining 44.2% were unrelated to the treated site. Of the events related to the treated site, 54.1% occurred in the conventional stent group and 61.1% in the drug‐eluting stent group. No statistically significant association was found between the event in the treated site and the type of stent used ( p = 0.363). Conclusions: A significant proportion of coronary events occurred in untreated sites. Our results suggest that isolated evaluation of the treated site may provide a more accurate estimate of the effectiveness of stents.

Aims: The impact of longitudinal fluctuations in triglyceride levels on clinical outcomes in stable coronary artery disease (CAD) is yet to be clarified. This study aims to assess the association between increased upward variability in longitudinal fasting triglyceride levels and the incidence of cardiovascular events during long-term follow-up in patients with multivessel CAD. Methods and results: This cohort study included 1020 patients with multivessel CAD in the Medicine, Angioplasty, or Surgery Study Registry of the Heart Institute, University of São Paulo, from June 1995 to March 2010. Of 1020 patients with multivessel CAD, 886 had complete clinical and fasting triglyceride levels information during a mean follow-up period of 10.0 years, with a mean of 9.2 triglyceride measurements for each patient. The composite endpoint of death, myocardial infarction, ischaemic stroke, or unplanned myocardial revascularization occurred in 357 patients. A 100 mg/dL increase in the longitudinal triglyceride levels was significantly associated with a 19% higher risk of the combined endpoint [hazard ratio (HR), 1.19 (95% confidence interval (CI), 1.05–1.34); P = 0.008] in the unadjusted analysis. After multivariable adjustment for key baseline factors, this elevation in longitudinal triglyceride levels was associated with a 26% greater risk of the composite endpoint [HR, 1.26 (95% CI, 1.10–1.41); P < 0.001]. Triglyceride variability was also assessed according to baseline triglyceride levels (<150 and ≥ 150 mg/dL). These analyses showed that 100 mg/dL increase in the < 150 mg/dL group was associated with higher cardiovascular risk—HR 1.49 (95% CI, 1.00–1.93, P = 0.029)—compared with the ≥ 150 mg/dL group, HR 1.15 (95% CI, 0.99–1.39, P = 0.214)—both after multivariable analyses. Conclusion: Increased upward variation of longitudinal fasting triglyceride levels was independently associated with higher rates of cardiovascular outcomes in patients with multivessel CAD. This association was especially observed in individuals with previously controlled triglyceride levels but not in those with elevated baseline levels. Lay summary: Triglycerides are intricately associated with metabolic disorders that contribute to atherosclerotic events; however, the relationship between individual triglyceride trajectories and adverse cardiovascular outcomes in individuals with stable coronary artery disease (CAD) remains unclear. Using a cohort of 1020 patients with chronic CAD under long-term follow-up, we observed that greater triglyceride variability was associated with an increased cardiovascular risk, and this risk remained significant in individuals who previously had controlled triglyceride levels compared with those with persistently altered levels since baseline.

Cardiac biomarkers are frequently released after revascularization. Incomplete revascularization may be a potential mechanism of action. This study aimed to investigate the relationship between the completeness of revascularization, quantified by the residual SYNTAX score (rSS), and myocardial injury, infarction, and cardiac events after coronary artery bypass grafting. This study included patients with stable coronary artery disease who underwent surgery. Troponin levels, cardiac magnetic resonance, and late gadolinium enhancement were assessed before and after the procedure. The baseline SYNTAX score was determined from the angiograms, and the rSS was measured based on the operative report for each patient after the procedure. Of the 136 surgical patients studied, no significant correlations were found between the rSS and median peak troponin level (R = 0.06, P = .47). The rSS was not a predictor of myocardial infarction, as assessed by late gadolinium enhancement (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.86–1.03; P = .51) and release of troponin higher than the median (OR 1.00, 95% CI 0.92–1.08; P = .93). After multivariate analysis in a model including variables, only cardiopulmonary bypass time was a significant predictor of troponin peak release, which was higher than the median (OR 1.01, 95% CI 1.002–1.019; P = .01). During the 5-year follow-up, the incomplete revascularization group had more major cardiovascular events than the complete revascularization group (rSS = 0) (P log-rank = .006, adjusted hazard ratio = 11.32; P = .001). Myocardial injury and infarction were not significantly associated with the completeness of revascularization. However, the rSS had a prognostic impact during follow-up for cardiovascular events.

Background: The objective of this article is to clinically compare the inducing drugs ketamine and etomidate during the orotracheal intubation procedure in critically ill patients, aiming to reduce early mortality and other important complications involved in this act. Methods: This study is compliant to the PRISMA guidelines for systematic review and meta-analysis. A sensitive search was conducted using the databases PubMed (MEDLINE), Scopus, Lilacs (BVS), and Cochrane Library (Central). Our protocol included only randomized clinical trials, from the inception of the databases up to June 2024. Studies were selected if they compared ketamine to etomidate specifically for rapid sequence induction and intubation in critically ill patients. The outcomes assessed were: (1) all-cause mortality; (2) post-intubation arterial hypotension; (3) use of vasoactive drugs post-intubation; and (4) the incidence of adrenal insufficiency in the patient groups. Results: With the sensitive search strategy in question, we have identified 956 studies. Among these, 10 randomized clinical trials met the inclusion criteria, collectively involving a total of 2862 patients. Ketamine demonstrated comparable effectiveness to etomidate in preventing all-cause mortality (odds ratio [OR] = 0.8; 95% confidence interval [CI]: 0.65–1.21; P = .06). The rates of arterial hypotension post-intubation were also similar between the groups (OR = 1.28; 95% CI: 0.96–1.7; P = .34) and the same could be found when comparing the use of vasoactive drugs post-intubation (OR = 0.68; 95% CI: 0.36–1.27; P = .001). However, ketamine was less associated with adrenal insufficiency (OR = 0.35; 95% CI: 0.15–0.86; P = .008). Conclusion: Ketamine and etomidate demonstrated comparable effectiveness for rapid sequence intubation in terms of mortality and post-intubation hypotension. However, ketamine was associated with a lower risk of adrenal insufficiency, suggesting it may be a preferable option when patients are at high risk for adrenal suppression.

Background: This study investigates myocardial structural changes in stable coronary artery disease (CAD) patients with type 2 diabetes (T2D) using cardiac magnetic resonance (CMR) strain and T1 mapping. Methods: A total of 155 stable CAD patients underwent CMR examination, including left ventricular (LV) morphology and function assessment, late gadolinium enhancement (LGE), and feature tracking (CMR-FT) for LV global longitudinal, circumferential, and radial strain. T1 mapping with extracellular volume (ECV) evaluation was also performed. Results: Among the enrolled patients, 67 had T2D. Diabetic patients exhibited impaired LV strain and higher ECV compared to non-diabetics. Multivariate analysis identified T2D as an independent predictor of increased ECV and decreased strain. Conclusions: CMR-based strain and T1 mapping highlighted impaired myocardial contractility, elevated ECV, and potential interstitial fibrosis in diabetic patients with stable CAD. This suggests a significant impact of diabetes on myocardial health beyond CAD, emphasizing the importance of a comprehensive assessment in these individuals. Trial registration: http://www.controlled-trials.com/ISRCTN09454308

Introduction Plaque rupture and erosion are the most common immediate pathologies associated with acute myocardial infarction. However, other mechanisms must be considered. The reported case occurred at a time when percutaneous or pharmacological coronary revascularization were not the standard treatment, which sparked discussion about these other mechanisms, as well as the possible advantages associated with the myocardial revascularization procedures. […] Interpreting Acute Myocardial Infarction 40 Years Later. Evolution of Knowledge: What is the Best Explanation? Introduction Plaque rupture and erosion are the most common immediate pathologies associated with acute myocardial infarction. However, other mechanisms must be considered. The reported case occurred at a time when percutaneous or pharmacological coronary revascularization were not the standard treatment, which sparked discussion about these other mechanisms, as well as the possible advantages associated with the myocardial revascularization procedures. […] Interpreting Acute Myocardial Infarction 40 Years Later. Evolution of Knowledge: What is the Best Explanation?