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BACKGROUND: The management of unstable angina (UA) presents a challenge due to its subjective diagnosis and limited representation in randomized clinical trials that inform current practices. OBJECTIVES: This study aims to identify key factors associated with the indication for invasive versus non-invasive stratification in this population and to evaluate factors associated with stratification test results. METHODS: This retrospective cohort study included patients hospitalized with UA over a consecutive 20-month period. To assess factors associated with stratification strategies, patients were divided into invasive stratification (coronary angiography) and non-invasive stratification (other methods) groups. For the analysis of factors related to changes in stratification tests, patients were categorized into groups with or without obstructive coronary artery disease (CAD) or ischemia, as per the results of the requested tests. Comparisons between groups and multiple logistic regression analyses were performed, with statistical significance set at a 5% level. RESULTS: A total of 729 patients were included, with a median age of 63 years and a predominance of males (64.6%). Factors associated with invasive stratification included smoking (p = 0.001); type of chest pain (p < 0.001); "crescendo" pain (p = 0.006); TIMI score (p = 0.006); HEART score (p = 0.011). In multivariate analysis, current smokers (OR 2.23, 95% CI 1.13-4.8), former smokers (OR 2.19, 95% CI 1.39-3.53), and type A chest pain (OR 3.39, 95% CI 1.93-6.66) were independently associated. Factors associated with obstructive CAD or ischemia included length of hospital stay (p < 0.001); male gender (p = 0.032); effort-induced pain (p = 0.037); Diamond-Forrester score (p = 0.026); TIMI score (p = 0.001). In multivariate analysis, only chest pain (type B chest pain: OR 0.6, 95% CI 0.38-0.93, p = 0.026) and previous CAD (OR 1.42, 95% CI 1.01-2.0, p = 0.048) were independently associated. CONCLUSION: The type of chest pain plays a crucial role not only in the diagnosis of UA but also in determining the appropriate treatment. Our results highlight the importance of incorporating pain characteristics into prognostic scores endorsed by guidelines to optimize UA management.

FUNDAMENTO: O manejo da angina instável (AI) é um desafio devido ao seu diagnóstico subjetivo e à sua escassa representação em ensaios clínicos randomizados que determinem as práticas atuais. OBJETIVOS: O objetivo deste estudo é identificar os principais fatores associados à indicação de estratificação invasiva ou não nessa população e avaliar os fatores associados às alterações nos exames de estratificação. MÉTODOS: Coorte retrospectiva de pacientes internados por AI, em um período de 20 meses consecutivos. Para avaliar os fatores associados à estratégia de estratificação, os pacientes foram divididos em estratificação invasiva (cinecoronariografia) e não invasiva (demais métodos). Para análise de fatores relacionados às alterações nos exames de estratificação, os pacientes foram divididos em grupos com ou sem doença arterial coronariana (DAC) obstrutiva ou isquemia, conforme resultados dos exames solicitados. Foram realizadas comparações entre grupos e análise de regressão logística múltipla, com significância estatística definida em um nível de 5%. RESULTADOS: 729 pacientes foram incluídos, com mediana de idade de 63 anos e predomínio do sexo masculino (64,6%). Estiveram associados à estratificação invasiva: tabagismo (p = 0,001); tipo de dor torácica (p < 0,001); dor "em crescendo" (p = 0,006); escore TIMI (p = 0,006); escore HEART (p = 0,011). Na análise multivariada, tabagistas (OR 2,23, IC 95% 1,13-4,8), ex-tabagistas (OR 2,19, IC 1,39-3,53) e dor torácica tipo A (OR 3,39, IC 95% 1,93-6,66) estiveram associados de forma independente. Estiveram associados à DAC obstrutiva ou isquemia: tempo de internação hospitalar (p < 0,001); sexo masculino (p = 0,032); dor desencadeada por esforço (p = 0,037); Diamond-Forrester (p = 0,026); escore TIMI (p = 0,001). Na análise multivariada, apenas dor torácica (dor torácica tipo B: OR 0,6, IC 95% 0,38-0,93, p = 0,026) e DAC prévia (OR 1,42, IC 95% 1,01-2,0, p = 0,048) estiveram associadas de maneira independente. CONCLUSÕES: O tipo de dor torácica desempenha um papel crucial não apenas no diagnóstico da AI, mas também na definição do tratamento adequado. Nossos resultados destacam a importância de incorporar características da dor aos escores prognósticos endossados pelas diretrizes, para otimização do manejo da AI.

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The precise mechanisms underlying the cardiovascular complications due to acute kidney injury (AKI) and the retention of uremic toxins like p-cresyl sulfate (PCS) remain incompletely understood. The objective of this study was to evaluate the renocardiac effects of PCS administration in animals subjected to AKI induced by ischemia and reperfusion (IR) injury. C57BL6 mice were subjected to distinct protocols: (i) administration with PCS (20, 40, or 60 mg/L/day) for 15 days and (ii) AKI due to unilateral IR injury associated with PCS administration for 15 days. The 20 mg/L dose of PCS led to a decrease in renal mass, an increase in the gene expression of Cystatin C and kidney injury molecule 1 (KIM-1), and a decrease in the α-actin in the heart. During AKI, PCS increased the renal injury biomarkers compared to control; however, it did not exacerbate these markers. Furthermore, PCS did not enhance the cardiac hypertrophy observed after 15 days of IR. An increase, but not potentialized, in the cardiac levels of interleukin (IL)-1ß and IL-6 in the IR group treated with PCS, as well as in the injured kidney, was also noticed. In short, PCS administration did not intensify kidney injury, inflammation, and cardiac outcomes after AKI.

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Ovarian torsion can be defined as the bending of the ovaries on the supporting ligament, disrupting both venous and arterial blood circulation. Insufficient blood flow causes ovarian tissue hypoxia and leads to ischemia. This study aimed to investigate whether tocilizumab has a protective effect on ischemia-reperfusion injury due to ovarian torsion in rats. Eighteen female Wistar albino rats were divided into three equal groups (Sham (SG), ischemia-reperfusion (OIR), and ischemia-reperfusion+tocilizumab (OIRT)). Degeneration, necrosis, vascular dilatation/congestion, interstitial edema, hemorrhage, and polymorphonuclear lymphocyte (PMNL) infiltration scores were significantly different between the groups (p=0.001 for all parameters). Moreover, the OIRT group had a significant improvement in these criteria compared to the OIR group (p<0.05). Additionally, there was a considerable difference between OIRT and OIR groups in the number of primordial, developing, and atretic follicles groups (p<0.05), while there was no difference in the number of corpus luteum (p=0.052). Stress markers or cytokines, such as MDA, tGSH, NF-κB, TNF-α, IL-1ß, and IL-6, were significantly different between groups (p<0.05). Furthermore, a significant improvement was found in the measured variables when the OIRT group was compared with the OIR group (p<0.05). Tocilizumab may be an alternative option for treating ischemia-reperfusion injury due to ovarian torsion.

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Spinal cord infarction is an uncommon phenomenon, which can be caused by different etiologies, constituting a real diagnostic challenge which can lead to devastating consequences. General anesthesia in beach chair positioning with intraoperative hypotension in order to avoid surgical bleeding are associated with hypoperfusion and potential neurological ischemia-related complications. We present a case of spinal cord ischemia in the context of shoulder surgery in a beach chair position.

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Objective: Associating comorbidities and cardiac symptoms that alter myocardial mechanical function could help clinicians to correctly identify at-risk population. Methods: We conducted a functional open population cross-sectional study of patients referred to a positron emission computed tomography/computed tomography unit in Mexico City for evaluation of myocardial function, perfusion, and coronary circulation. Ischemia was defined as a sum difference score (SDS) > 2. Association between comorbidities and cardiac symptoms was tested using logistic regression models and trend analysis. We performed an interaction analysis to evaluate the addition of any accompanying symptoms to comorbid conditions on impairment of myocardial function. Results: One thousand two hundred and seventy-three patients were enrolled, 66.1% male, with a mean age of 62.4 (± 12.7) years, 360 (28.7%) with ischemia, 925 (72.7%) with at least one comorbidity, and 676 (53.1%) had at least one associated cardiac symptom. Patients without ischemia, type 2 diabetes, arterial hypertension, and adverse cardiac symptoms were associated with adverse function, perfusion, and coronary flow parameters. We observed a trend of a cumulative number of comorbidities and cardiac symptoms with increased ischemia and decreased coronary flow. Only in decreased LVEF, we demonstrated an interaction effect between increased comorbidities and adverse symptoms. Conclusions: The high burden of comorbidities and symptoms in our population alter myocardial function regardless of the level of ischemia.

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Abstract Spinal cord infarction is an uncommon phenomenon, which can be caused by different etiologies, constituting a real diagnostic challenge which can lead to devastating consequences. General anesthesia in beach chair positioning with intraoperative hypotension in order to avoid surgical bleeding are associated with hypoperfusion and potential neurological ischemia-related complications. We present a case of spinal cord ischemia in the context of shoulder surgery in a beach chair position.

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Preconditioning episodes of ischemia/reperfusion (IR) induce protection against acute kidney injury (AKI), however their long-term effect still unknown. We evaluated AKI to chronic kidney disease (CKD) transition, after three-mild or three-severe episodes of IR. AKI was induced by single bilateral IR (1IR), or three episodes of IR separated by 10-day intervals (3IR) of mild (20 min) or severe (45 min) ischemia. Sham-operated rats served as controls. During 9-months, the 1IR group (20 or 45 min) developed CKD evidenced by progressive proteinuria and renal fibrosis. In contrast, the long-term adverse effects of AKI were markedly ameliorated in the 3IR group. The acute response in 3IR, contrasted with the 1IR group, that was characterized by an increment in heme oxygenase-1 (HO-1) and an anti-inflammatory response mediated by a NFkB-p65 phosphorylation and IL-6 decrease, together with an increase in TGF-ß, and IL-10 expression, as well as in M2-macrophages. In addition, three episodes of IR downregulated endoplasmic reticulum (ER) stress markers expression, CHOP and BiP. Thus, repeated episodes of IR with 10-day intervals induced long-term renal protection accompanied with HO-1 overexpression and M2-macrophages increase.

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Liver ischemia-reperfusion (IR) injury is associated with poor outcome after liver transplantation and liver resections. Hexafluoroisopropanol (HFIP) is a tri-fluorinated metabolites of volatile anesthetics and has modulatory effects on inflammation that have been observed mainly in cell culture experiments. In this survey, we investigated the effects of HFIP in a rat model of normothermic hepatic ischemia-reperfusion injury. Twenty-four male Wistar rats were randomized into three groups: (1) control in which animals were submitted to 30 min of partial liver ischemia with resection of non-ischemic liver lobes immediate after reperfusion, (2) pre-ischemia (PI) group in which animals received intravenous HFIP (67 mg/kg) 5 min before liver ischemia, and (3) pre-reperfusion (PR) group in which animals received intravenous HFIP (67 mg/kg) 5 min before reperfusion. Four hours after reperfusion, all animals were euthanized for sample collection. Aspartate and alanine transaminases, glucose, and high mobility group box-1 (HMGB-1) protein concentrations showed a significant decreased, and malondialdehyde was increased in the PR group compared with control and PI groups. Interleukin 6 (IL-6) was increased in the PI group compared with control and PR groups. IL-10 and -12 were increased in the PR and PI groups, respectively, when compared with the control group. Glucose decreased in the PR when compared with the control group. Post-conditioning with HFIP led to a decrease in hepatocellular injury and was associated with a downregulation of HMGB-1. The HFIP resulted in a better control of inflammatory response to ischemia-reperfusion even without causing a reduction in oxidative stress.

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BACKGROUND: Coronary arteries tend to be more tortuous than other arteries and follow the repeated flexion and relaxation movements that occur during the cardiac cycle. Coronary tortuosity (CorT) leads to changes in coronary flow with a reduction in distal perfusion pressure, which could cause myocardial ischemia. OBJECTIVE: To assess the association between CorT and myocardial ischemia. METHODS: Between January 2015 and December 2017, 57 patients with angina and nonobstructive coronary artery disease detected by invasive coronary angiography (ICA) were retrospectively enrolled. Angiographic variables were analyzed to assess the presence and degree of tortuosity and correlated with their respective vascular territories on stress myocardial perfusion imaging (MPI). CorT was defined as coronary arteries with three or more bend angles ≤90°, measured during diastole. Statistical significance was determined at the 5% level. RESULTS: A total of 17 men and 40 women were enrolled (mean age 58.3 years). CorT was observed in 16 patients (28%) and in 24 of 171 arteries. There was a significant association between CorT and ischemia when analyzed per artery (p<0.0001). The angiographic factor most associated with ischemia was the number of bend angles in an epicardial artery measured at systole (p=0.021). CONCLUSION: This study showed an association of CorT and myocardial ischemia in patients with unobstructed coronary arteries and angina. An increased number of coronary bend angles measured by angiography during systole was related to ischemia.

FUNDAMENTO: As artérias coronárias tendem a ser mais tortuosas que outras artérias e acompanham os movimentos repetidos de flexão e relaxamento que ocorrem durante o ciclo cardíaco. A Tortuosidade das artérias Coronárias (TCor) causa alterações no fluxo coronariano, com uma redução na pressão de perfusão distal, o que pode levar à isquemia miocárdica. OBJETIVO: Avaliar a associação entre TCor e isquemia miocárdica. MÉTODOS: Entre janeiro de 2015 e dezembro de 2017, 57 pacientes com angina e doença arterial coronariana não obstrutiva pela angiografia coronária invasiva (ACI) foram incluídos retrospectivamente. Variáveis angiográficas foram analisadas para avaliar a presença e grau de tortuosidade e correlacionadas com seus respectivos territórios vasculares na cintilografia de perfusão miocárdica com estresse. A TCor foi definida como artérias coronárias com três ou mais curvaturas com ângulos ≤ 90o, medidos durante diástole. Um nível de 5% foi estabelecido como estatisticamente significativo. Um nível de 5% foi definido como estatisticamente significativo. RESULTADOS: Um total de 17 homens e 40 mulheres foram incluídos (idade média de 58,3 anos). A TCor foi observada em 16 pacientes (28%) e em 24 das 171 artérias. Observou-se uma associação significativa entre TCor e isquemia na análise por artéria (p<0,0001). O fator angiográfico mais associado com isquemia foi o número de curvaturas em uma artéria epicárdica medido na sístole (p=0,021). CONCLUSÃO: Este estudo mostrou uma associação da TCor com isquemia miocárdica em pacientes com artérias coronárias não obstruídas e angina. Observou-se uma relação entre número aumentado de curvaturas na artéria coronária medido por angiografia durante sístole e isquemia.

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OBJECTIVE: to evaluate the renal toxicity caused by tacrolimus and mycophenolate mofetil (MMF) in a single kidney ischemia and reperfusion model. METHOD: experimental study using Wistar rats, submitted to right nephrectomy and left renal ischemia for 20 minutes, separated into groups in the postoperative period (PO): 1) Control (nonoperated); 2) Sham (operated, without PO drug); 3) TAC0.1, TAC1 and TAC10, tacrolimus administered PO at doses of 0.1mg/kg, 1mg/kg and 10mg/kg via gavage, respectively; 4) MMF, administered mycophenolate mofetil 20mg/kg; 5) MMF/TAC1 and MMF/TAC0.5, with an association of mycophenolate mofetil 20mg/kg and tacrolimus 1mg/kg and 0.5mg/kg, respectively. They were killed on the 14th PO and the kidney was removed for tissue oxidative stress analysis, by the dosage of reduced glutathione (GSH), lipoperoxidation (LPO) and protein carbonylation (PCO), and histological analysis by glomerular stereology (Glomerular volume density, Numerical density glomerular and mean glomerular volume). Renal function was evaluated by the measurement of serum creatinine and urea. RESULTS: both drugs caused alterations in renal function, and the toxicity of tacrolimus was dose-dependent. Subacute toxicity did not show significant glomerular histological changes, and there was renal and compensatory glomerular hypertrophy in all groups except TAC10. CONCLUSION: Both drugs cause changes in renal function. Glomerular morphometry and stereology showed negative interference of immunosuppressants during compensatory glomerular hypertrophy.

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