INTRODUÇÃO: Estudos prévios comparando stents farmacológicos (SFs) e stents não-farmacológicos sugerem eficácia e segurança dos SFs no tratamento de pacientes com infarto agudo do miocárdio (IAM). No entanto, a evolução tardia de pacientes com IAM tratados com SFs na prática diária permanece desconhecida. Este estudo teve como objetivo investigar o seguimento tardio de pacientes com IAM recente tratados com SFs na prática diária do mundo real. MÉTODOS: Entre maio de 2002 e junho de 2009, 3.018 pacientes não-selecionados com indicação de intervenção percutânea eletiva ou de emergência foram consecutivamente tratados com SFs em uma instituição clínica. O seguimento tardio de até sete anos foi realizado em 98%, com mediana de 3,4 anos. Os pacientes foram divididos em dois grupos: pacientes com IAM recente (< 30 dias) e pacientes sem IAM recente. RESULTADOS: Os pacientes com IAM recente tinham menos comorbidades e mais doença multiarterial (68,1% vs. 60,7%; P < 0,001), lesões com trombo (13,6% vs. 1,3%; P < 0,001), fluxo TIMI 0/1 (8,3% vs. 1,1%; P < 0,001) e disfunção moderada/grave do ventrículo esquerdo (23,2% vs. 10,9%; P < 0,001), comparativamente aos pacientes sem IAM recente. O grupo IAM recente recebeu 1,6 ± 0,8 stent/ paciente e mais inibidores da glicoproteína IIb/IIIa (19,6% vs. 2%; P < 0,001), mas o sucesso angiográfico foi similar nos dois grupos (> 99%). No seguimento tardio, a incidência de óbito cardíaco (6,4% vs. 2,7%; P < 0,001) e de trombose de stent (3,6% vs. 1,3%; P < 0,001) foi significativamente maior no grupo IAM recente. O IAM recente permaneceu como preditor independente de trombose de stent na análise multivariada (RR 2,96, IC 95% 1,62-5,41; P < 0,001). CONCLUSÕES: Pacientes com IAM < 30 dias tratados com SFs apresentaram pior prognóstico quando comparados aos pacientes sem IAM recente, incluindo aumento significativo do óbito cardíaco até sete anos de acompanhamento, e ocorrência 2,5 vezes maior das taxas de trombose de stent.

BACKGROUND: Previous studies comparing drug-eluting stents (DES) and bare-metal stents suggest efficacy and safety of the DES in the treatment of patients with myocardial infarction (MI). However, the late evolution of patients with MI treated with DES in the daily practice remains unknown. Our goal was to investigate the late follow-up of patients with MI recently treated with DES in the real world. METHODS: Between May 2002 and June 2009, 3,018 non-selected patients with indication for elective or urgent percutaneous coronary intervention have been consecutively treated with DES in a clinical institution. The 7-year follow-up was performed in 98% of these patients, with a median of 3.4 years. The patients were divided in two groups: patients with recent MI (< 30 days) and patients without recent MI. RESULTS: Patients with recent MI had less co-morbidities, but more multiarterial disease (68.1% vs. 60.7%; P < 0.001), lesions with thrombus (13.6% vs. 1.3%; P < 0.001), TIMI flow 0/1 (8.3% vs. 1.1%; P < 0.001), and moderate/severe LV dysfunction (23.2% vs. 10.9%; P < 0.001) when compared with patients without MI. The recent MI group received 1.6 ± 0.8 stents/patient and more glycoprotein IIb/IIIa inhibitors (19.6% vs. 2%; P < 0.001), but the angiographic success (> 99%) was similar between groups. In the late follow-up, the incidence of cardiac death (6.4% vs. 2.7%; P < 0.001) and stent thrombosis (3.6% vs. 1.3%; P < 0.001) was significantly greater in the recent MI group. Recent MI remained an independent predictor of stent thrombosis in multivariate analysis (HR 2.96, 95% CI 1.62-5.41; P < 0,001). CONCLUSIONS: Patients with MI < 30 days treated with DES had a worse prognosis when compared with patients without recent MI, including a higher incidence of cardiac death and a 2.5 times greater occurrence of stent thrombosis rate up to 7-year follow-up.

FUNDAMENTOS: Reportamos a incidência e os preditores de trombose de stent numa grande coorte de pacientes complexos tratados com stents farmacológicos (SF) no "mundo-real". MÉTODO: Entre maio de 2002 e janeiro de 2008, 2.365 pacientes não-selecionados com > 1 lesão coronária com estenose > 50% foram tratados com SF. O seguimento clínico até cinco anos (média 2,2 ± 1,5 anos) foi completado em 98,3%. RESULTADOS: Entre os pacientes avaliados, 29% tinham diabetes, 60% eram portadores de doença multiarterial e 40% apresentavam síndrome coronária aguda (15%, infarto agudo do miocárdio [IAM]). A artéria descendente anterior foi o vaso-alvo mais freqüentemente tratado (35,8%), e 67% das lesões eram de alta complexidade (tipo B2/C). No total, 3.634 SF foram implantados e 40% dos pacientes receberam múltiplos stents. A trombose de stent (classificação Academic Research Consortium) incidiu em 1,6% (n = 38), 60,5% com confirmação angiográfica, 42% ocorreram entre 1 e 12 meses e 47% dos eventos tiveram desfecho fatal. Os preditores independentes de trombose de stent foram: tabagismo atual (razão de risco [RR] 2,59; intervalo de confiança [IC] 95% 1,18-5,67; p = 0,018), intervenção coronária percutânea (ICP) no IAM (RR 3,50; IC 95% 1,31-9,40; p = 0,013), calcificação moderada/grave (RR 2,38; IC 95% 1,34-4,23; p = 0,003), lesão excêntrica (RR 1,86; IC 95% 1,03-3,34; p = 0,039), > 1 SF implantado por território miocárdico (RR 1,81; IC 95% 1,09-3,02; p = 0,023), pósdilatação (RR 0,50; IC 95% 0,29-0,90; p = 0,020) e estenose residual intra-stent (RR 1,04 [por aumento de unidade %]; IC 95% 1,01-1,06; p = 0,003). CONCLUSÕES: Nesse registro prospectivo do "mundo-real", a incidência cumulativa de trombose de stent até cinco anos de seguimento foi rara (1,6%), e foi associada a tabagismo, ICP no IAM, morfologia complexa da lesão, múltiplos stents implantados por território miocárdico e subexpansão do stent.

BACKGROUND: We report the incidence of stent thrombosis (ST) predictors in a large cohort of complex patients treated with drug eluting stents (DES) in the real world. METHODS: From May 2002 until January 2008, 2,365 non-selected patients with > 1 coronary lesion with stenosis of > 50% were treated with DES. The clinical follow-up up to five years (mean time 2.2 ± 1.5 years) was completed in 98.3%. RESULTS: Twenty nine percent of patients had diabetes and 60% multi-vessel disease, 40% presented acute coronary syndrome (15%, acute myocardial infarction [AMI]). The anterior descending artery was the target vessel most frequently treated (35.8%), and 67% were complex lesions (Type B2/C). In all, 3,634 DES were implanted and 40% received multiple stents. Stent thrombosis (classification of the Academic Research Consortium) occurred in 1.6% (n = 38), 60.5% with angiographic confirmation, 42% occurred between 1 and 12 months and 47% of the events had a fatal outcome. The independent predictors of ST were: current smoking [relative risk (RR) 2.59; 95% confidence interval (CI) 1.18-5.67; p = 0.018], AMI intervention (RR 3.50; 95% CI 1.31-9.40; p = 0.013), moderate to severe calcification (RR 2.38; 95% CI 1.34-4.23; p = 0.003), excentric lesion (RR 1.86; 95% CI 1.03-3.34; p = 0.039), > 1 DES implanted per myocardial territory (RR 1.81; 95% CI 1.09-3.02; p = 0.023), post-dilatation (RR 0.50; 95% CI 0.29-0.90; p = 0.020) and intra-stent residual stenosis [RR 1.04 (per % unit increase); 95% CI 1.01-1.06; p = 0.003]. CONCLUSIONS: In this real world prospective registry, the cumulative incidence of stent thrombosis up to 5 year follow-up was rare (1.6%), and associated to smoking, PCI in the AMI, complex lesion morphology, multiple stents implanted per myocardial territory and subexpantion of the stent.

FUNDAMENTO: O diabetes melito está relacionado à ocorrência de desfechos desfavoráveis após intervenções coronárias percutâneas. Os stents farmacológicos podem conferir melhor evolução tardia a esse subgrupo de pacientes. O objetivo deste estudo foi avaliar o desempenho desses instrumentais em pacientes diabéticos. MÉTODO: O DESIRE é um registro unicêntrico, prospectivo, que incluiu 2.365 pacientes tratados consecutivamente com stents farmacológicos, entre maio de 2002 e janeiro de 2008. Para a presente análise foram excluídos pacientes com diagnóstico de infarto do miocárdio, aqueles com lesão tratada em ponte de safena e os com período de evolução inferior a 6 meses. RESULTADOS: Assim, 1.705 pacientes foram divididos em dois grupos: não-diabéticos (n = 1.211 pacientes, 71,1%) e diabéticos (n = 494 pacientes, 28,9%), sendo 109 (6,4%) pacientes em uso de insulina. Dentre os diabéticos, havia mais idosos (64,8 ± 9,8 anos vs. 63,4 ± 11,7 anos; p = 0,025), mulheres (28,9% vs. 22,5%; p = 0,005), obesos (35,2% vs. 23,5%; p < 0,001), hipertensos (86,6% vs. 73,7%; p < 0,001), multiarteriais (63,4% vs. 54,4%; p = 0,001), vasos finos (2,70 ± 0,51 mm vs. 2,75 ± 0,42 mm; p < 0,001) e calcificação na lesão tratada (32,3% vs. 27,1%; p = 0,009). No seguimento clínico tardio (2,2 ± 1,1 anos), os eventos cardíacos combinados ocorreram mais freqüentemente no grupo dos pacientes diabéticos (9,8% vs. 7,0%; p = 0,048). A análise multivariada mostrou que o diabetes melito (odds ratio [OR] = 1,45; intervalo de confiança de 95% [IC 95%] = 1,0 a 2,1) e a presença de calcificação na lesão tratada (OR = 3,06; IC 95% = 1,47 a 6,34) foram preditores independentes de eventos cardíacos maiores. CONCLUSÃO: O uso dos stents farmacológicos em diabéticos mostrou ser uma abordagem segura e eficiente. Os eventos cardíacos maiores combinados, embora em taxas muito baixas, ocorreram mais freqüentemente no grupo dos diabéticos.

BACKGROUND: Diabetes mellitus is related to the occurrence of unfavorable outcomes after percutaneous coronary interventions. Drug-eluting stents can confer a better late evolution to this subgroup. The aim of this study was to assess the performance of these devices in diabetic patients. METHODS: The DESIRE is a single-center, prospective registry that included 2,365 consecutive patients treated with drug-eluting stents between May 2002 and January 2008. For the present analysis, patients with a diagnosis of acute myocardial infarction, those with saphenous vein grafts lesions and those within 6 months of the index procedure, were excluded. RESULTS: Therefore, 1,705 patients were divided into two groups: non-diabetics (n = 1,211 P/71.1%) and diabetics (n = 494 P/28.9%), of which 109 P (6.4%) were insulin-dependent. Among the diabetics there was a higher number of older people (64.8 ± 9.8 years old vs. 63.4 ± 11.7 years old; p = 0.025), females (28.9 vs. 22.5%; p = 0.005), patients with obesity (35.2 vs. 23.5%; p < 0.001), hypertension (86.6 vs. 73.7%; p < 0.001), multi-vessel disease (63.4 vs. 54.4%; p = 0.001), small-vessel disease (2.70 ± 0.51 mm vs. 2.75 ± 0.42 mm; p < 0.001) and calcified lesions (32.3 vs. 27.1%; p = 0.009). In the late clinical follow up (2.2 ± 1.1 years), the combined cardiac events occurred more frequently in the diabetic patients (9.8 vs. 7.0%; p = 0.048). The multivariate analysis showed that diabetes mellitus (OR = 1.45; 95% confidence interval 1.0 to 2.1) and the presence of a calcified lesion (OR = 3.06; 95% CI 1.47 to 6.34) were independent predictors of major adverse cardiac events. CONCLUSION: The use of drug-eluting stents in diabetics showed to be a safe and efficient approach. The major adverse cardiac events, although in very low rates, occurred more frequently in the diabetics.

OBJECTIVE: To identify risk factors for acute myocardial infarction during the postoperative period after myocardial revascularization. METHODS: This was a case-control study paired for sex, age, number, type of graft used, coronary endarterectomy, type of myocardial protection, and use of extracorporeal circulation. We assessed 178 patients (89 patients in each group) undergoing myocardial revascularization, and the following variables were considered: dyslipidemia, systemic hypertension, smoking, diabetes mellitus, previous myocardial revascularization surgery, previous coronary angioplasty, and acute myocardial infarction. RESULTS: Baseline clinical characteristics did not differ in the groups, except for previous myocardial revascularization surgery, prevalent in the case group (34 patients vs. 12 patients; p = 0.0002). This was the only independent predictor of risk for acute myocardial infarction in the postoperative period, based on a multivariate logistic regression analysis (p=0.0001). Mortality and the time of hospital stay of the case group were significantly higher (19.1% vs. 1.1%; p<0.001 and 15.7 days vs. 10.6 days; p<0.05 respectively) than those of the control. CONCLUSION: Only previous myocardial revascularization was an independent predictor of acute myocardial infarction in the postoperative period, based on multivariate logistic regression analysis.