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Papers by Paulo Rezende

Case Reports in Cardiology, 2021

Severe tricuspid regurgitation is especially caused by pulmonary hypertension. Primary tricuspid ... more Severe tricuspid regurgitation is especially caused by pulmonary hypertension. Primary tricuspid regurgitation in the absence of pulmonary hypertension and of unknown etiology is a very rare condition with scarce data about its diagnosis, treatment, and follow-up. The particularities of surgery indication and outcomes are still not clearly known. A 72-year-old woman with a medical history of coronary artery bypass grafting three years ago presented with shortness of breath and low limb edema. Physical examination revealed a prominent bilateral jugular turgescence, hepatomegaly, peripheral edema, and a left midsternal border holosystolic murmur, suggestive of tricuspid regurgitation. The echocardiogram confirmed the diagnosis and showed preserved right and left ventricular dimensions and function. Coronary angiography showed no new obstructive lesions and patent surgical grafts. Right cardiac catheterization revealed mild pulmonary hypertension and increased right atrium pressure. Ca...

Journal of the American College of Cardiology, Jan 9, 2018

Diabetic medications can cause hypoglycemia, which may lead to myocardial damage. This study soug... more Diabetic medications can cause hypoglycemia, which may lead to myocardial damage. This study sought to determine whether hypoglycemia is associated with higher levels of high-sensitivity cardiac troponin T (hsTnT). The BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial randomized patients with type 2 diabetes mellitus and stable coronary artery disease, and closely followed them for hypoglycemia over the first year. Hypoglycemia was classified by maximum severity and frequency. hsTnT was measured at baseline and 1 year, and analyzed using multivariable regression. Of 1,984 patients, follow-up hypoglycemia was absent in 1,026 (52%) patients, mild in 875 (44%), and severe in 83 (4%), and occurred less than weekly in 561 (28%) and greater than or equal to weekly in 397 (20%). hsTnT levels were associated with hypoglycemia: a median of 11.4 ng/l (interquartile range [IQR]: 8.1 to 17.3 ng/l) for none, 12.5 ng/l (IQR: 8.3 to 19.3 ng/l) for mild, and 13.7 ng/l (I...

Arquivos Brasileiros De Cardiologia, Apr 1, 2011

pressure 70/40 mm Hg. Heart and lung semiology was considered normal. Abdominal examination was n... more pressure 70/40 mm Hg. Heart and lung semiology was considered normal. Abdominal examination was normal and had no lower limb edema. Electrocardiogram (March 4) showed sinus rhythm, heart rate 75 bpm, PR 160 ms interval, QRS 80 ms duration, SÂQRS +30° backwards and abnormalities in ventricular repolarization (fig. 1). Laboratory tests (March 4) revealed hemoglobin 11.3 g/ dl, hematocrit 35%, mean corpuscular volume 85 fL, platelet 281,000/mm³, leukocytes 14,400/mm (neutrophils 81%, eosinophils 1%, lymphocytes 11% and monocytes 7%), creatinine 0.93 mg/dl, urea 42 mg/dl, sodium 145 mEq/l, potassium 3.4 mEq/l, C-reactive Protein 172 mg/l, troponin I < 0.20 ng/ml, CKMB 2,17 ng/ml, prothrombin time (INR) 1.2 and activated partial thromboplastin time ratio 0.89. Echocardiography (March 4) revealed preserved biventricular function, left ventricular hypertrophy in appearance, moderate to severe pericardial effusion, with no signs of restriction to ventricular filling.

Medicine, 2015

Ischemic preconditioning (IP) is a powerful cardioprotective cellular mechanism that has been rel... more Ischemic 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 35 mg 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-1.0 mm) and rate pressure product (RPP) were greater in the second of 2 tests. The improvement in T-1.0 mm 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-1.0 mm 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.

BMC cardiovascular disorders, Jan 21, 2015

Cardiac-specific troponin detected with the new high-sensitivity assays can be chronically elevat... more Cardiac-specific troponin detected with the new high-sensitivity assays can be chronically elevated in response to cardiovascular comorbidities and confer important prognostic information, in the absence of unstable coronary syndromes. Both diabetes mellitus and coronary artery disease are known predictors of troponin elevation. It is not known whether diabetic patients with coronary artery disease have different levels of troponin compared with diabetic patients with normal coronary arteries. To investigate this question, we determined the concentrations of a level 1 troponin assay in two groups of diabetic patients: those with multivessel coronary artery disease and those with angiographically normal coronary arteries. We studied 95 diabetic patients and compared troponin in serum samples from 50 patients with coronary artery disease (mean age = 63.7, 58 % male) with 45 controls with angiographically normal coronary arteries. Brain natriuretic peptide and the oxidative stress biom...

Cardiovascular Diabetology, 2015

Background: The influence of diabetes mellitus on myocardial ischemic preconditioning is not clea... more Background: The influence of diabetes mellitus on myocardial ischemic preconditioning is not clearly defined. Experimental studies are conflicting and human studies are scarce and inconclusive. Objectives: Identify whether diabetes mellitus intervenes on ischemic preconditioning in symptomatic coronary artery disease patients. Methods: Symptomatic multivessel coronary artery disease patients with preserved systolic ventricular function and a positive exercise test underwent two sequential exercise tests to demonstrate ischemic preconditioning. Ischemic parameters were compared among patients with and without type 2 diabetes mellitus. Ischemic preconditioning was considered present when the time to 1.0 mm ST deviation and rate pressure-product were greater in the second of 2 exercise tests. Sequential exercise tests were analyzed by 2 independent cardiologists. Results: Of the 2,140 consecutive coronary artery disease patients screened, 361 met inclusion criteria, and 174 patients (64.2 ± 7.6 years) completed the study protocol. Of these, 86 had the diagnosis of type 2 diabetes. Among diabetic patients, 62 (72 %) manifested an improvement in ischemic parameters consistent with ischemic preconditioning, whereas among nondiabetic patients, 60 (68 %) manifested ischemic preconditioning (p = 0.62). The analysis of patients who demonstrated ischemic preconditioning showed similar improvement in the time to 1.0 mm ST deviation between diabetic and nondiabetic groups (79.4 ± 47.6 vs 65.5 ± 36.4 s, respectively, p = 0.12). Regarding rate pressure-product, the improvement was greater in diabetic compared to nondiabetic patients (3011 ± 2430 vs 2081 ± 2139 bpm x mmHg, respectively, p = 0.01). Conclusions: In this study, diabetes mellitus was not associated with impairment in ischemic preconditioning in symptomatic coronary artery disease patients. Furthermore, diabetic patients experienced an improvement in this significant mechanism of myocardial protection.

Journal of Medical Cases, 2014

The standard treatment of calcific aortic stenosis (AS) is aortic valve replacement (AVR). Howeve... more The standard treatment of calcific aortic stenosis (AS) is aortic valve replacement (AVR). However, as population has become older, the number of patients who have prohibitive surgical risk is increasing. Although transcatheter aortic valve implantation (TAVI) has been indicated to some of these high-risk patients, its indication is limited because of anatomical contraindications, unstable clinical situations and financial problems. Thus, in experienced hands, the option for balloon aortic valvoplasty (BAV) should be considered, as it may be a good alternative to selected patients to ameliorate symptoms and prolong survival. In this report, we describe the case of an old patient with severe AS who evolved with cardiogenic shock and had contraindications to surgery and transcatheter valve implantation and who was successfully treated by BAV.

Journal of the American College of Cardiology, 2015

high sensitivitY cArdiAc troPonin i chAnges relAted With t1 mAPPing in PAtients With chronic isch... more high sensitivitY cArdiAc troPonin i chAnges relAted With t1 mAPPing in PAtients With chronic ischAemic heArt diseAse Without lAte enhAncement gAdolinium BY crm

World journal of clinical cases, Jan 16, 2015

Patients with coronary artery disease vary widely in terms of prognosis, which is mainly dependen... more Patients with coronary artery disease vary widely in terms of prognosis, which is mainly dependent on ventricular function. In relation to the major outcomes of death and myocardial infarction, it is not clear in the literature if an invasive strategy of myocardial revascularization is superior to a conservative strategy of optimized medical therapy. Moreover, with the exception of patients with left main coronary disease, this similarity in prognosis also occurs in different subgroups of patients.

Journal of Medical Case Reports, 2014

Introduction: Hypertrophic cardiomyopathy is a genetic cardiac disease characterized by marked va... more Introduction: Hypertrophic cardiomyopathy is a genetic cardiac disease characterized by marked variability in morphological expression and natural history. The hypertrophic myocardium is often confined to the septum or lateral wall of the left ventricle, but it can also be encountered in the middle or apical segments of the myocardium. Treatment is based on medical therapy. Others therapies, such as embolization of the septal artery or ventriculomyectomy, are indicated in special situations. Surgery is the standard treatment, and it is classically done via a transaortic approach; however, in cases in which the hypertrophic myocardium is confined to mid-apical segments, a transapical approach is an option. Only a few cases of mid-apical obstructive hypertrophic cardiomyopathy treated with a myectomy using a transapical approach have been reported in the English-language literature. In this report, we present a case of a patient with mid-apical obstructive hypertrophic cardiomyopathy treated using this new approach. Case presentation: A 63-year-old Caucasian woman presented with a history of chest pain and shortness of breath causing significant limitations on her daily life activities. She had a history of coronary artery disease. Her physical examination was unremarkable. Transthoracic echocardiography revealed normal systolic function and significant concentric left ventricular hypertrophy that was greater in the mid-apical region. Nuclear magnetic resonance imaging confirmed significant hypertrophy of the median segments of the left ventricle. The patient had persistent symptoms despite receiving optimized medical treatment, and a surgical approach was indicated. As a myectomy using transaortic technique was thought to be difficult to perform in her case, a transapical approach was used. No complications occurred, and her symptoms resolved. Conclusion: A transapical myectomy should be taken into consideration for patients with mid-apical obstructive hypertrophic cardiomyopathy that is refractory to medical treatment.

European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, Jan 22, 2014

The technical difficulty in the revascularization of the circumflex artery territory with off-pum... more The technical difficulty in the revascularization of the circumflex artery territory with off-pump surgery may compromise the outcome of this method in clinical follow-up. We aimed to evaluate cardiac events in patients with stable coronary artery disease and severe obstruction of the circumflex system, undergoing coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass. MASS III was a single-centre study that evaluated 308 patients with multivessel coronary artery disease randomized to on-pump (153) or off-pump (155) CABG. Of this total, 260 (84.4%) patients had, on coronary angiography, at least one 70% obstruction in the circumflex territory (141 on-pump and 119 off-pump). The combined outcome was death, myocardial infarction, target vessel revascularization (angioplasty or surgery) or hospitalization for cardiac causes. Variables with possible associations (P < 0.1) were included in the multivariate analysis. The two groups were well matched for demograph...

Arquivos Brasileiros de Cardiologia, 2014

Os anúncios veiculados nesta edição são de exclusiva responsabilidade dos anunciantes, assim co... more Os anúncios veiculados nesta edição são de exclusiva responsabilidade dos anunciantes, assim como os conceitos emitidos em artigos assinados são de exclusiva responsabilidade de seus autores, não refletindo necessariamente a opinião da SBC. Material de distribuição exclusiva à classe médica. Os Arquivos Brasileiros de Cardiologia não se responsabilizam pelo acesso indevido a seu conteúdo e que contrarie a determinação em atendimento à Resolução da Diretoria Colegiada (RDC) nº 96/08 da Agência Nacional de Vigilância Sanitária (Anvisa), que atualiza o regulamento técnico sobre Propaganda, Publicidade, Promoção e informação de Medicamentos. Segundo o artigo 27 da insígnia, "a propaganda ou publicidade de medicamentos de venda sob prescrição deve ser restrita, única e exclusivamente, aos profissionais de saúde habilitados a prescrever ou dispensar tais produtos (...)". Garantindo o acesso universal, o conteúdo científico do periódico continua disponível para acesso gratuito e integral a todos os interessados no endereço: www.arquivosonline.com.br.

Revista da Associação Médica Brasileira, 2010

World Journal of Diabetes, 2014

Murry et al in 1986 discovered the intrinsic mechanism of profound protection called ischemic pre... more Murry et al in 1986 discovered the intrinsic mechanism of profound protection called ischemic preconditioning. The complex cellular signaling cascades underlying this phenomenon remain controversial and are only partially understood. However, evidence suggests that adenosine, released during the initial ischemic insult, activates a variety of G protein-coupled agonists, such as opioids, bradykinin, and catecholamines, resulting in the activation of protein kinases, especially protein kinase C (PKC). This leads to the translocation of PKC from the cytoplasm to the sarcolemma, where it stimulates the opening of the ATP-sensitive K + channel, which confers resistance to ischemia. It is known that a range of different hypoglycemic agents that activate the same signaling cascades at various cellular levels can interfere with protection from ischemic preconditioning. This review examines the effects of several hypoglycemic agents on myocardial ischemic preconditioning in animal studies and clinical trials.

The Journal of Thoracic and Cardiovascular Surgery, 2013

Objective: With progressive aging, coronary artery disease has been diagnosed at more advanced ag... more Objective: 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 ¼ 200) and less than 65 years (n ¼ 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 ¼ .93). The survival free of combined events was 43% (medical therapy), 38% (percutaneous coronary intervention), and 66% (coronary artery bypass grafting) (P ¼ .007). The survival free of myocardial infarction was 82% (medical therapy), 77% (percutaneous coronary intervention), and 90% (coronary artery bypass grafting) (P ¼ .17), and survival free of new revascularizations was 59% (medical therapy), 58% (percutaneous coronary intervention), and 91% (coronary artery bypass grafting) (P ¼ .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 ¼ .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.

Journal of the American College of Cardiology, 2012

Introduction: It is well known that hypoglycemic agents (sulfonylureas and Glinides) can have dir... more Introduction: 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.

Journal of the American College of Cardiology, 2012

Background: Patients with coronary artery disease (CAD) and previous ischemic cerebrovascular eve... more Background: Patients with coronary artery disease (CAD) and previous ischemic cerebrovascular events (ICVE, ischemic stroke, or transitory ischemic attack) constitute a high-risk subgroup for cardiovascular outcomes. High-density lipoprotein cholesterol (HDL-C) levels are correlated with cardiovascular events. Lipid transfer to HDL affects structure size and HDL subclass profile. Impairment of this transfer could influence ischemic risk seen in patients with CAD + ICVE. The objective was to evaluate the HDL ability to receive the lipids in patients with CAD with or without ICVE. Methods: Patients with CAD + ICVE (n = 60) and patients with CAD only (n = 60) were matched by age, sex, acute coronary syndromes (ACS) event type, and time elapsed between the ACS event and inclusion in the study. Lipid transfer to HDL was evaluated by incubating donor lipid nanoparticles labeled with radioactive unesterified cholesterol (UC) and esterified cholesterol (EC), phospholipid (PL), and triglyceride (TG) with whole plasma. After the chemical precipitation of non-HDL fractions and nanoparticles, the supernatant was counted for HDL radioactivity.

$Research paper thumbnail of Long-term analysis of left ventricular ejection fraction in patients with stable multivessel coronary disease undergoing medicine, angioplasty or surgery: 10-year follow-up of the MASS II trial$

European Heart Journal, 2013

Background Assuming that coronary interventions, both coronary bypass surgery (CABG) and percutan... more Background Assuming that coronary interventions, both coronary bypass surgery (CABG) and percutaneous coronary intervention (PCI), are directed to preserve left ventricular function, it is not known whether medical therapy alone (MT) can achieve this protection. Thus, we evaluated the evolution of LV ejection fraction (LVEF) in patients with stable coronary artery disease (CAD) treated by CABG, PCI, or MT as a post hoc analysis of a randomized controlled trial with a follow-up of 10 years. Methods Left ventricle ejection fraction was assessed with transthoracic echocardiography in patients with multivessel CAD, participants of the MASS II trial before randomization to CABG, PCI, or MT, and re-evaluated after 10 years of follow-up. Results Of the 611 patients, 422 were alive after 10.32 + 1.43 years. Three hundred and fifty had LVEF reassessed: 108 patients from MT, 111 from CABG, and 131 from PCI. There was no difference in LVEF at the beginning (0.61 + 0.07, 0.61 + 0.08, 0.61 + 0.09, respectively, for PCI, CABG, and MT, P ¼ 0.675) or at the end of follow-up (0.56 + 0.11, 0.55 + 0.11, 0.55 + 0.12, P ¼ 0.675), or in the decline of LVEF (reduction delta of 27.2 + 17.13, 29.08 + 18.77, and 27.54 + 22.74). Acute myocardial infarction (AMI) during the follow-up was associated with greater reduction in LVEF. The presence of previous AMI (OR: 2.50, 95% CI: 1.40-4.45; P ¼ 0.0007) and during the follow-up (OR: 2.73, 95% CI: 1.25-5.92; P ¼ 0.005) was associated with development of LVEF ,45%. Conclusion Regardless of the therapeutic option applied, LVEF remains preserved in the absence of a major adverse cardiac event after 10 years of follow-up. Clinical Trial Registration URL: http://www.controlled-trials.com. Registration number ISRCTN66068876.

Diabetes Care, 2012

OBJECTIVE To assess the effect of two hypoglycemic drugs on ischemic preconditioning (IPC) patien... more OBJECTIVE To assess the effect of two hypoglycemic drugs on ischemic preconditioning (IPC) patients with type 2 diabetes and coronary artery disease (CAD). RESEARCH DESIGN AND METHODS We performed a prospective study of 96 consecutive patients allocated into two groups: 42 to group repaglinide (R) and 54 to group vildagliptin (V). All patients underwent two consecutive exercise tests (ET1 and ET2) in phase 1 without drugs. In phase 2, 1 day after ET1 and -2, 2 mg repaglinide three times daily or 50 mg vildagliptin twice daily was given orally to patients in the respective group for 6 days. On the seventh day, 60 min after 6 mg repaglinide or 100 mg vildagliptin, all patients underwent two consecutive exercise tests (ET3 and ET4). RESULTS In phase 1, IPC was demonstrated by improvement in the time to 1.0 mm ST-segment depression and rate pressure product (RPP). All patients developed ischemia in ET3; however, 83.3% of patients in group R experienced ischemia earlier in ET4, without s...

Circulation, 2012

Background— The Second Medicine, Angioplasty, or Surgery Study (MASS II) included patients with m... more Background— 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 9071.00forMT;9071.00 for MT; 9071.00forMT;19 967.00 for PCI;...

Case Reports in Cardiology, 2021

Journal of the American College of Cardiology, Jan 9, 2018

Arquivos Brasileiros De Cardiologia, Apr 1, 2011

Medicine, 2015

BMC cardiovascular disorders, Jan 21, 2015

Cardiovascular Diabetology, 2015

Journal of Medical Cases, 2014

Journal of the American College of Cardiology, 2015

World journal of clinical cases, Jan 16, 2015

Journal of Medical Case Reports, 2014

European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, Jan 22, 2014

Arquivos Brasileiros de Cardiologia, 2014

Revista da Associação Médica Brasileira, 2010

World Journal of Diabetes, 2014

The Journal of Thoracic and Cardiovascular Surgery, 2013

Journal of the American College of Cardiology, 2012

European Heart Journal, 2013

Diabetes Care, 2012

Circulation, 2012