Delays in the treatment of acute coronary syndromeStill a contrast between pathophysiology and reality

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The copper archaeometallurgy at Monte Novo dos Albardeiros (Reguengos de Monsaraz, Évora)

The site of Monte Novo dos Albardeiros is located near the village of Campinho (Reguengos de Monsaraz, Évora). A small tell situated next to the magazine of a farmstead was partially excavated, revealing several phases of occupation. The know phases of occupation are: a third millennium fortified farmstead; a funerary structure of tholos type, datable to the second half of the third millennium; and above the collapsed structure of the latter, two funerary deposits of the Early Bronze Age. Metal arrefacts were recovered from all of these phases, including traces of local copper metallurgy from the two earliest phases of occupation of the site. Through the EDXRF method, the composition of two awls, an axe and an alène, all manufactured from copper, was analysed. A brief technico-cultural study is also presented, stressing the «arehaeometallurgic continuity» of the site and the question of arsenical copper.info:eu-repo/semantics/publishedVersio

An adverse effect of intense exercise?

Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.Regular physical exercise is responsible for various health benefits, and is recommended for primary and secondary cardiovascular (CV) prevention. Despite these recognized benefits, various clinical events can occur in athletes, including acute myocardial infarction and sudden cardiac death (SCD); the main cause of SCD in veteran athletes is coronary artery disease (CAD). The relationship between intense exercise training and CAD is controversial, and a U-shaped association has been hypothesized. If this is the case, screening for subclinical CAD in older athletes may be justified, and various different methodologies have been proposed. However, the methodology for screening veteran athletes is not consensual, and several markers of CAD, in addition to clinical CV risk factors, could improve risk stratification in this population. In the present paper we review the published data on CAD in athletes, focusing on the relationship between the dose of exercise and CAD, as well as the implications for pre-participation screening of veteran athletes.publishersversionpublishe

Utilidade da tomografia computorizada cardíaca na avaliação da doença coronária

RESUMO: Apesar de toda a evolução farmacológica e de meios complementares de diagnóstico possível nos últimos anos, o enfarte agudo do miocárdio e a morte súbita continuam a ser a primeira manifestação da aterosclerose coronária para muitos doentes, que estavam previamente assintomáticos. Os exames complementares de diagnóstico tradicionalmente usados para avaliar a presença de doença coronária, baseiam‐se na documentação de isquémia do miocárdio e por este motivo a sua positividade depende da presença de lesões coronárias obstrutivas. As lesões coronárias não obstrutivas estão também frequentemente implicadas no desenvolvimento de eventos coronários. Apesar de o risco absoluto de instabilização por placa ser superior para as lesões mais volumosas e obstrutivas, estas são menos prevalentes do que as placas não obstrutivas e assim, por questões probabilísticas, os eventos coronários resultam com frequência da rotura ou erosão destas últimas. Estudos recentes de imagiologia intracoronária avançada forneceram evidência de que apesar de ser possível identificar algumas características de vulnerabilidade em placas associadas ao desenvolvimento subsequente de eventos coronários, a sua sensibilidade e especificidade é muito baixa para aplicação clínica. Mais do que o risco associado a uma placa em particular, para o doente poderá ser mais importante o risco global da sua árvore coronária reflexo da soma das probabilidade de todas as suas lesões, sendo que quanto maior for a carga aterosclerótica maior será o seu risco. A angio TC cardíaca é a mais recente técnica de imagem não invasiva para o estudo da doença coronária e surgiu nos últimos anos fruto de importantes avanços na tecnologia de TC multidetectores. Estes avanços, permitiram uma progressiva melhoria da resolução espacial e temporal, contribuindo para a melhoria da qualidade dos exames, bem como uma significativa redução da dose de radiação. A par desta evolução tecnológica, foi aumentando a experiência e gerada mais evidência científica, tornando a angio TC cardíaca cada vez mais robusta na avaliação da doença coronária e aumentando a sua aplicabilidade clínica. Mais recentemente apareceram vários trabalhos que validaram o seu valor prognóstico, assinalando a sua chegada à idade adulta. Para além de permitir excluir a presença de doença coronária e de identificar a presença de estenoses significativas, a angio TC cardíaca permite identificar a presença de lesões coronárias não obstrutivas, característica impar desta técnica como modalidade de imagem não invasiva. Ao permitir identificar a totalidade das lesões ateroscleróticas (obstrutivas e não obstrutivas), a 18 angio TC cardíaca poderá fornecer uma quantificação da carga aterosclerótica coronária total, podendo essa identificação ser útil na estratificação dos indivíduos em risco de eventos coronários. Neste trabalho foi possível identificar preditores demográficos e clínicos de uma elevada carga aterosclerótica coronária documentada pela angioTC cardíaca, embora o seu poder discriminativo tenha sido relativamente modesto, mesmo quando agrupados em scores clínicos. Entre os vários scores, o desempenho foi um pouco melhor para o score de risco cardiovascular Heartscore. Estas limitações espelham a dificuldade de prever apenas com base em variáveis clínicas, mesmo quando agrupadas em scores, a presença e extensão da doença coronária. Um dos factores de risco clássicos, a obesidade, parece ter uma relação paradoxal com a carga aterosclerótica, o que pode justificar algumas limitações da estimativa com base em scores clínicos. A diabetes mellitus, por outro lado, foi um dos preditores clínicos mais importantes, funcionando como modelo de doença coronária mais avançada, útil para avaliar o desempenho dos diferentes índices de carga aterosclerótica. Dada a elevada prevalência de placas ateroscleróticas identificáveis por angio TC na árvore coronária, torna-‐se importante desenvolver ferramentas que permitam quantificar a carga aterosclerótica e assim identificar os indivíduos que poderão eventualmente beneficiar de medidas de prevenção mais intensivas. Com este objectivo, foi desenvolvido um índice de carga aterosclerótica que reúne a informação global acerca da localização, do grau de estenose e do tipo de placa, obtida pela angio TC cardíaca, o CT--‐LeSc. Este score poderá vir a ser uma ferramenta útil para quantificação da carga aterosclerótica coronária, sendo de esperar que possa traduzir a informação prognóstica da angio TC cardíaca. Por fim, o conceito de árvore coronária vulnerável poderá ser mais importante do que o da placa vulnerável e a sua identificação pela angio TC cardíaca poderá ser importante numa estratégia de prevenção mais avançada. Esta poderá permitir personalizar as medidas de prevenção primária, doseando melhor a sua intensidade em função da carga aterosclerótica, podendo esta vir a constituir uma das mais importantes indicações da angio TC cardíaca no futuro.---------------- ABSTRACT Despite the significant advances made possible in recent years in the field of pharmacology and diagnostic tests, acute yocardial infarction and sudden cardiac death remain the first manifestation of coronary atherosclerosis in a significant proportion of patients, as many were previously asymptomatic. Traditionally, the diagnostic exams employed for the evaluation of possible coronary artery disease are based on the documentation of myocardial ischemia and, in this way, they are linked to the presence of obstructive coronary stenosis. Nonobstructive coronary lesions are also frequently involved in the development of coronary events. Although the absolute risk of becoming unstable per plaque is higher for more obstructive and higher burden plaques, these are much less frequent than nonobstructive lesions and therefore, in terms of probability for the patient, coronary events are often the result of rupture or erosion of the latter ones. Recent advanced intracoronary imaging studies provided evidence that although it is possible to identify some features of vulnerability in plaques associated with subsequente development of coronary events, the sensitivity and sensibility are very limited for clinical application. More important than the individual risk associated with a certain plaque, for the patient it might be more important the global risk of the total coronary tree, as reflected by the sum of the diferent probabilities of all the lesions, since the higher the coronary Atherosclerotic burden, the higher the risk for the patient. Cardiac CT or Coronary CT angiography is still a young modality. It is the most recente noninvasive imaging modality in the study of coronary artery disease and its development was possible due to important advances in multidetector CT technology. These allowed significant improvements in temporal and spatial resolution, leading to better image quality and also some impressive reductions in radiation dose. At the same time, the increasing experience with this technique lead to a growing body of scientific evidence, making cardiac CT a robust imaging tool for the evaluation of coronary artery disease and increased its clinical indications. More recently, several publications documented its prognostic value, marking the transition of cardiac CT to adulthood. Besides being able to exclude the presence of coronary artery disease and of obstructive lesions, Cardiac CT allows also the identification of nonobstructive lesions, making this a unique tool in the field of noninvasive imaging modalities. By evaluating both obstructive and nonobstructive lesions, cardiac CT can provide for the quantification of total coronary atherosclerotic burden, and this can be useful to stratify the risk of future coronary events. In the present work, it was possible to identify significant demographic and clinical predictors of a high coronary atherosclerotic burden as assessed by cardiac CT, but with modest odds ratios, even when the individual variables were gathered in clinical scores. Among these diferent clinical scores, the performance was better for the Heartscore, a cardiovascular risk score. This modest performance underline the limitations on predicting the presence and severity of coronary disease based only on clinical variables, even when optimized together in risk scores, One of the classical risk factors, obesity, had in fact a paradoxical relation with coronary atherosclerotic burden and might explain some of the limitations of the clinical models. On the opposite, diabetes mellitus was one of the strongest clinical predictors, and was considered to be a model of more advanced coronary disease, useful to evaluate the performance of diferent plaque burden scores. In face of the high prevalence of plaques that can be identified in the coronary tree of patients undergoing cardiac CT, it is of utmost importance to develop tools to quantify the total coronary atherosclerotic burden providing the identification of patients that could eventually benefit from more intensive preventive measures. This was the rational for the development of a coronary atherosclerotic burden score, reflecting the comprehensive information on localization, degree of stenosis and plaque composition provided by cardiac CT – the CT-LeSc. This score may become a useful tool to quantify total coronary atherosclerotic burden and is expected to convey the strong prognostic information of cardiac CT. Lastly, the concept of vulnerable coronary tree might become more important than the concept of the vulnerable plaque and his assessment by cardiac CT Might become important in a more advance primary prevention strategy. This Could lead to a more custom-made primary prevention, tailoring the intensity of preventive measures to the atherosclerotic burden and this might become one of the most important indications of cardiac CT In the near future

a mid-term follow-up of 28 cases

Anomalous origin of the right coronary artery from the opposite sinus (right-ACAOS) with interarterial course (IAC) has been associated with increased risk of sudden cardiac death (SCD). Widespread use of coronary computed tomography angiography (CCTA) has led to increased recognition of this condition, even among healthy individuals. Our study sought to examine the prevalence, anatomical characteristics, and outcomes of right-ACAOS with IAC in patients undergoing CCTA for suspected coronary artery disease (CAD). We conducted a retrospective analysis of consecutive patients referred for CCTA at one tertiary hospital from January 2012 to December 2020. Patients exhibiting right-ACAOS with IAC were analyzed for cardiac symptoms and mid-term occurrence of first MACE (cardiac death, SCD, non-fatal myocardial infarction (MI) or revascularization of the anomalous vessel). CCTAs were reviewed for anatomical high-risk features and concomitant CAD. Among 10,928 patients referred for CCTA, 28 patients with right-ACAOS with IAC were identified. Mean age was 55 ± 17 years, 64% were male and 11 (39.3%) presented stable cardiac symptoms. Most patients had at least one high risk anatomical feature. During follow-up, there were no cardiac deaths or aborted SCD episodes and only 1 patient underwent surgical revascularization of the anomalous vessel. Right-ACAOS with IAC is an uncommon finding (prevalence of 0.26%). In a contemporary population of predominantly asymptomatic patients who survived this condition well into adulthood, most patients were managed conservatively with a low event rate. Additional studies are needed to support medical follow-up as the preferred option in this setting.publishersversionpublishe

A case report

Background Minimally invasive alternatives to surgical closure of cardiac perforations are a recognized need, especially in critically ill patients in whom predicted surgical mortality is prohibitive. To the best of our knowledge, this is the first reported case of an iatrogenic left atrium (LA) puncture closed with a plug-based vascular closure device (VCD). Case summary During a palliative right-sided thoracentesis on a 73-year-old woman, with end-stage heart failure due to rheumatic valvular heart disease, an accidental puncture and insertion of a central venous catheter into an aneurysmatic LA occurred. This complication was successfully managed percutaneously, under transthoracic echocardiographic guidance, after cardiac computed tomography planning, using a plug-based VCD. Discussion This case demonstrates the possible utility of plug-based devices for iatrogenic LA perforation closure, when surgical risk is deemed prohibitive.publishersversionpublishe

Colonialidade do poder e os desafios da integração regional na América Latina

Os processos de integração regional em curso hoje na América Latina têm sido marcados por uma lógica territorial que tem concebido grandes áreas do espaço geográfico latino-americano como “vazios demográficos” ou “terras disponíveis”. Essa forma de conceber o espaço geográfico latino-americano remonta ao legado colonial que atravessa a formação sócio-espacial da região e a própria posição que o continente americano ocupou no processo de formação do sistema-mundo moderno-colonial, a partir de 1492. Este artigo tem por objetivo problematizar os processos de integração física em curso atualmente no continente, especificamente a Iniciativa para Integração da Infra-estrutura Regional Sul-Americana (IIRSA), buscando evidenciar a reprodução da lógica da colonialidade do poder e do saber constituintes de seu modelo de desenvolvimento regional.Les processus d’intégration régionale en cours de nos jours en Amérique latine ont été marqué par une logique territoriale qui a conçu de grandes aires géographiques en Amérique latine comme des “vides démographiques” ou “terres disponibles”. Cette manière de concevoir l’espace géographique latino-américain trouve ses origines dans l’héritage colonial qui traverse la formation socio-spatiale de la région et la propre position que le continent américain occupa dans le processus de formation du système-monde moderno-colonial, à partir de 1492. Cet article vise à problématiser les processus d’intégration physique en cours sur le continent, et plus particulièrement l’Initiative pour l’Intégration de l’Infrastructure Régionale Sud-Américaine (IIRSA) afin de mettre en évidence la reproduction de la logique de la colonialité du pouvoir et du savoir propre à son modèle de développement régional.Los procesos de integración regional en curso hoy en América Latina han estado marcados por una lógica territorial que ha concebido grandes áreas de espacio geográfico en América Latina como “vacíos demográficos” o “tierras disponibles”. Esta forma de concebir el espacio geográfico latinoamericano se remonta a la herencia colonial que atraviesa la formación socio-espacial de la región y la propia posición que el continente americano ocupó en el proceso de formación del sistema-mundo moderno-colonial, a partir de 1492. Este artículo tiene como objetivo problematizar los procesos de integración física en curso en el continente, en particular la Iniciativa para la Integración de la Infraestructura Regional Suramericana (IIRSA) a fin de poner en evidencia la reproducción de la lógica de la colonialidad del poder y del saber constituyente de su modelo de desarrollo regional.The regional integration processes under way in Latin America today have been marked by a territorial logic that has conceived large areas of geographic territory in Latin America as “demographic emptiness” or as “available land.” This way of conceiving the geographical space in Latin America, dates back to the colonial legacy that accompanies the region´s socio-spatial formation and the place that the American continent fulfilled in the process of formation of the modern-colonial world system, since 1492. This article aims to discuss the physical integration processes currently under way on the continent, specifically the Initiative for Integration of Regional Infrastructure in South America (IIRSA), in an attempt to show the reproduction of the coloniality logic of power and knowledge, that constitutes  its regional development model

OS CONSELHOS MUNICIPAIS NO EXERCÍCIO DO CONTROLE SOCIAL: UMA ANÁLISE DO CONSELHO MUNICIPAL DE SAÚDE DIANTE DO ATO DE CONTROLAR AS AÇÕES DO SISTEMA ÚNICO DE SAÚDE (SUS) NO MUNICÍPIO DE CASTRO ALVES (BA) ENTRE OS ANOS 2010-2011

Este trabalho aborda os níveis de capacitação e apoio que o Conselho Municipal de Saúde (CMS) possui para executar suas atribuições pertinentes ao Controle Social nas ações do Sistema Único de Saúde (SUS) no município de Castro Alves (BA); visando à mobilização do Conselho e da sociedade local na criação de  artifícios que proporcionem qualidade na fiscalização e no controle dos serviços públicos de saúde. O tema proposto tem relevância no sentido de motivar a criação de políticas públicas que valorizem o Controle Social nos serviços públicos municipais. Este estudo propõe-se a desencadear, na administração pública, a participação popular nas ações de saúde nos municípios. Com isso, a Gestão do Sistema Único de Saúde (SUS) recebe o fortalecimento e a ênfase de promover o bem-estar social. Constatou-se que os níveis de capacitação e de apoio que o CMS possui para executar suas atribuições pertinentes ao Controle Social nas ações do SUS, no município de Castro Alves (BA), são considerados  insatisfatórios para manter o bom funcionamento do referido Conselho.Palavras-chave: Controle social. Conselho Municipal de Saúde. Sistema Únicode Saúde. Participação popular. Gestão pública

Computed tomography angiography for the interventional cardiologist

WOS:000339902400002In recent years, coronary CT angiography (CCTA) has become a widely adopted technique, not only due to its high diagnostic accuracy, but also to the fact that CCTA provides a comprehensive evaluation of the total (obstructive and non-obstructive) coronary atherosclerotic burden. More recently, this technique has become mature, with a large body of evidence addressing its prognostic validation. In addition, CT angiography has moved from the field of `imagers' and clinicians and entered the interventional cardiology arena, aiding in the planning of both coronary and structural heart interventions, being transcatheter aortic valve implantation one of its most successful examples. It is therefore of utmost importance that interventional cardiologists become familiar with image interpretation and up-to-date regarding several CTA features, taking advantage of this information in planning the procedure, ultimately leading to improvement in patient outcomes. On the other hand, the increasing use of CCTA as a gatekeeper for invasive coronary angiography is expected to lead to an increase in the ratio of interventional to diagnostic procedures and significant changes in the daily cath-lab routine. In a foreseeable future, cath-labs will probably offer an invasive procedure only to patients expected to undergo an intervention, perhaps becoming in this change true interventional-labs.publishersversionpublishe

Performance of traditional risk factors in identifying a higher than expected coronary atherosclerotic burden

Abstract Objective To evaluate the performance of traditional cardiovascular (CV) risk factors in identifying a higher than expected coronary atherosclerotic burden. Methods We assessed 2069 patients undergoing coronary CT angiography, with assessment of calcium score (CS), for suspected coronary artery disease. A higher than expected atherosclerotic burden was defined as CS >75th percentile (CS >P75) according to age and gender-adjusted monograms. The ability of traditional CV risk factors to predict a CS >P75 was assessed in a customized logistic regression model ("Clinical Score") and by the calculation of SCORE (Systemic Coronary Risk Evaluation). The population attributable risk (PAR) of risk factors for CS >P75 was calculated. Results The median CS was 3.0 (IQR 0.0-98.0); 362 patients had CS >P75. The median SCORE was 3.0 (IQR 1.0-4.0). With the exception of hypertension, all traditional CV risk factors were independent predictors of CS >P75: diabetes, dyslipidemia, smoking and family history (OR 1.3-2.2, p≤0.026). The areas under the ROC curves for CS >P75 were 0.64 for the Clinical Score (95% CI 0.61-0.67, pP75 were in the two lower quartiles of the Clinical Score. Altogether, the traditional risk factors explain 56% of the prevalence of CS >P75 (adjusted PAR 0.56). Conclusion Despite the association of CV risk factors with a higher than expected atherosclerotic burden, they appear to explain only half of its prevalence. Even when integrated in scores, the predictive power of these risk factors was modest, exposing the limitations of risk stratification based solely on demographic and clinical risk factors.publishersversionpublishe