Outcomes of Percutaneous Interventions in Diabetics Treated with

Rev Bras Cardiol Invas 2006; 14(2): 109-114.
Chaves ÁJ, et al. Outcomes of Percutaneous Interventions in Diabetics Treated with Drug Eluting Stents or Bare Metal Stents: The
SOLACI Registry Results. Rev Bras Cardiol Invas 2006; 14(2): 109-114.
Artigo Original
Outcomes of Percutaneous Interventions in Diabetics
Treated with Drug Eluting Stents or Bare Metal Stents:
The SOLACI Registry Results
Áurea J. Chaves1, Amanda G. M. R. Sousa1, Daniel Berrocal2, Alexandre Abizaid1, Ernesto Ban Hayashi3,
Fausto Buitrón4, Irving Peña5, Eugenio Marchant6, Expedito E. Ribeiro7, Jorge A. Belardi8,
Hugo F. Londero9, J. Eduardo Sousa1, on behalf of SOLACI Registry Participants
RESUMO
SUMMARY
Evolução de Pacientes Diabéticos Tratados por Intervenções
Percutâneas com Stents Farmacológicos ou Stents
Metálicos não Recobertos: Resultados do Registro SOLACI
Background: Randomized trials helped clarify the value of
drug-eluting stents (DES) in selected diabetic subgroups, but
little is known if those results can be generalized to everyday practice. We report the contemporary Latin American
experience with coronary DES implantation in diabetics,
using the 2003 SOLACI Registry databank. Method and
Results: Data were collected on 5,509 diabetics who underwent coronary stent implantation at 67 medical centers in
9 countries. From those, 4,724 (85.8%) patients received
bare metal stents (BMS), 440 (8.0%) sirolimus-eluting stents
(SES) and 345 (6.3%) paclitaxel-eluting stents (PES). Mean
age was 62.1 years; 62.6% were males. Approximately
50% of the patients underwent PCI for unstable coronary
syndromes (45.2% with unstable angina and 9.7% with
acute myocardial infarction). Average reference diameter
was 2.97 mm, and mean lesion length was 17.4 mm. Patients
treated with DES had more complex lesions (B2/C), smaller
vessels and longer lesions when compared to those treated
with BMS. No clinically significant differences were observed
in one-year mortality (0.9% SES vs. 0.3% PES vs. 1.2%
BMS) or myocardial infarction rates (0.9% SES vs. 0.9%
PES vs. 3.7% BMS). Target vessel revascularization, however,
was much improved in the DES groups. TVR was reduced
due to a decrease in both the need for percutaneous intervention (1.8% SES vs. 2.3% PES vs. 8.3% BMS) and bypass
surgery (0.9% SES vs. 0.6% PES vs. 3.4% BMS). Conclusions:
This large, Latin American, contemporary database revealed
that routine utilization of DES for diabetic patients is safe
and improves the 1-year clinical outcome compared to
BMS, reducing the need for TVR. These results are similar
to those observed in contemporary clinical registries and
provide a framework for improved treatment strategies for
diabetics with coronary artery disease.
Fundamentos: Estudos randomizados ajudaram a elucidar o
valor dos stents com eluição de fármacos (SEF) em subgrupos selecionados de pacientes diabéticos, mas pouco se sabe
se estes resultados podem ser generalizados para a prática
clínica cotidiana. Nós relatamos a experiência latino-americana
contemporânea com o implante de SEF em diabéticos, utilizando o banco de dados do Registro SOLACI do ano de 2003.
Método e Resultados: Dados foram coletados de 5.509 diabéticos que se submeteram ao implante de stents coronários, em
67 centros médicos de nove países. Destes, 4.724 (85,8%)
receberam stents metálicos não recobertos (SM), 440 (8,0%)
stents com eluição de sirolimus (SES) e 345 (6,3%) stents com
eluição de paclitaxel (SEP). A média das idades foi de 62,1
anos e 62,6% eram do sexo masculino. Aproximadamente
metade dos pacientes submeteu-se à intervenção coronária
percutânea para tratar síndrome coronária aguda (45,2%
com angina instável e 9,7% com infarto agudo do miocárdio).
A média dos diâmetros de referência foi de 2,97 mm e a
média das extensões da lesão, 17,4 mm. Pacientes tratados
com SEF apresentaram lesões mais complexas (B2/C), vasos
de menor calibre e lesões mais longas que os tratados com
SM. Não foram observadas diferenças clínicas significantes
nas taxas de mortalidade (0,9% SES vs. 0,3% SEP vs. 1,2%
SM) e infarto do miocárdio (0,9% SES vs. 0,9% SEP vs. 3,7%
SM), em um ano. As taxas de revascularização do vaso-alvo
(RVA), entretanto, foram menores nos grupos que utilizaram
os SEF. A RVA foi reduzida devido à diminuição da necessidade de nova intervenção percutânea (1,8% SES vs. 2,3%
SEP vs. 8,3% SM) e cirurgia de revascularização miocárdica
(0,9% SES vs. 0,6% SEP vs. 3,4% SM). Conclusões: Este
grande banco de dados latino-americano mostrou que a
utilização de rotina dos SEF em diabéticos é segura e melhora
a evolução clínica em um ano, reduzindo a necessidade de
RVA. Estes resultados são similares aos observados em registros clínicos contemporâneos e estabelecem uma plataforma
para melhorar as estratégias de tratamento de diabéticos
com doença arterial coronária.
DESCRITORES: Diabetes mellitus. Stents farmacológicos.
Angioplastia transluminal coronária.
DESCRIPTORS: Diabetes mellitus, Stents, Percutaneous
Coronary Intervention.
1
8
2
9
Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil.
Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
3
Instituto Nacional de Cardiologia Ignacio Chávez, Mexico City, México.
4
Asociación Española Primera de Socorros Mutuos, Montevideo, Uruguay.
5
Policlínica Metropolitana, Caracas, Venezuela.
6
Pontificia Universidad Catolica de Chile, Santiago, Chile.
7
Heart Institute (InCor), São Paulo, Brazil.
Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina.
Sanatorio Allende, Córdoba, Argentina.
Correspondência: Áurea J. Chaves. Invasive Cardiology Section, Instituto Dante Pazzanese de Cardiologia. Av. Dr. Dante Pazzanese, 500.
São Paulo, SP, Brazil. CEP 04012 -180. Tel: (55 11) 5085-4215
Fax: (55 11) 5549-7807 • e-mail: [email protected]
Recebido em: 30/05/2006 • Aceito em: 19/06/2006
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Chaves ÁJ, et al. Outcomes of Percutaneous Interventions in Diabetics Treated with Drug Eluting Stents or Bare Metal Stents: The
SOLACI Registry Results. Rev Bras Cardiol Invas 2006; 14(2): 109-114.
P
atients with diabetes mellitus have higher rates of
adverse outcomes after percutaneous coronary interventions. Recently, drug-eluting stent implantation
(DES) markedly reduced the incidence of angiographic
restenosis and repeat revascularizations in diabetic
patients1-5. Although randomized trials have helped to
clarify the value of DES in selected diabetic subgroups,
little is known about the extent of their use in global
clinical practice or whether those results can be generalized to everyday practice. In this publication, we are
reporting the contemporary Latin American experience
with coronary DES implantation in diabetic patients,
by means of a survey involving catheterization laboratories from countries registered in the Sociedad Latinoamericana de Cardiologia Intervencionista (SOLACI)
Registry databank.
METHOD
Study Population and Data Collection
The SOLACI Registry was developed to gather data
on the management and hospital outcome of patients
submitted to cardiac diagnostic and therapeutic procedures in Latin American centers (Table 1). This report
focuses on 2003 experience with coronary DES procedures in diabetic patients. At that time, only nine of
the Latin American countries had DES for clinical use
and contributed patients to this study.
For this purpose a specific questionnaire was mailed
to participating institutions. Patient data included demographics (eg, age, gender), cardiovascular risk factors
(eg, history of diabetes mellitus, hypertension, hyperlipidemia, and smoking), comorbidities (eg, history of
myocardial infarction, coronary artery bypass graft surgery
or PCI) and clinical presentation (eg, silent ischemia,
stable angina, unstable angina, myocardial infarction).
Angiographic and procedural data were also available
(eg, multivessel disease, left ventricular function, target
vessel, ACC/AHA lesion type, reference diameter, lesion
length, procedural success and complications).
History of diabetes was obtained through patient
self-report. Baseline treatment status (insulin or hypoglycemic agent versus diet control) was not recorded
by site coordinators. For the 1-year follow-up data, an
additional questionnaire was sent to the participating
catheterization laboratories and the information was
entered into a central database and subsequently analyzed at the SOLACI Registry Coordinating Center at the
Instituto Dante Pazzanese de Cardiologia. Data were
reported only in aggregate format. Consequently, registry
entries contemplated individual center results, not individual patients.
Interventions, Adjunctive Drug Therapy and
Angiographic Analyses
PCI patient eligibility was site-specific, as was periprocedural adjunctive therapy. The available stents
included bare metal stents, sirolimus-eluting stents and
paclitaxel-eluting stents. All interventions were performed
according to current standard guidelines, and the final
interventional strategy was entirely left to the discretion
of the operator. Core laboratory quantitative coronary
angiographic analysis was not available, although onsite analysis was usually performed. The physicians in
charge of the patients took care of them according to
their usual practice and independently from the study.
Endpoints and Definitions
Endpoints included hospital and the 1-year major
adverse cardiac events, defined as (1) death from any
cause, (2) nonfatal myocardial infarction, or (3) target
vessel revascularization (coronary bypass surgery or
percutaneous intervention). All adverse events were
investigator-reported. Myocardial infarction was defined
as clinical signs and symptoms of infarction confirmed
by new ECG changes or (re)elevation of cardiac enzymes.
TABLE 1
Cath labs and interventionalists registered at the SOLACI Database
Country
Argentina
Bolivia
Brazil
Colombia
Costa Rica
Cuba
Chile
Dominican Rep.
Ecuador
San Salvador
Cath Labs
(n=618)
Interventionalists
(n=1278)
Country
Cath Labs
(n=618)
Interventionalists
(n=1278)
138
004
267
029
006
006
019
008
010
002
263
007
572
053
005
027
050
013
011
004
Guatemala
Honduras
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Uruguay
Venezuela
002
002
069
001
005
005
018
005
007
015
004
003
134
001
006
009
040
008
021
047
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Chaves ÁJ, et al. Outcomes of Percutaneous Interventions in Diabetics Treated with Drug Eluting Stents or Bare Metal Stents: The
SOLACI Registry Results. Rev Bras Cardiol Invas 2006; 14(2): 109-114.
Stent thrombosis was considered when the patient had
acute myocardial infarction in the distribution of the
treated vessel or had sudden death, within 30 days of
index procedure. The SOLACI review board approved
of the use of these data for this study.
cant. Death occurred in 0.8% (0% SES vs. 0% PES vs.
1.0% BMS); myocardial infarction in 2.5% (0.5% SES
vs. 0.3% PES vs. 2.8% BMS) and urgent revascularization
in 0.6% (0.5% SES vs. 0% PES vs. 0.6% BMS). Stent
thrombosis was observed in 0.9%, 0.6% and 2.9% of
diabetics, respectively (Table 6).
RESULTS
Overall 5,509 diabetics with 7,812 lesions in 6,975
vessels from 67 catheterization laboratories were identified (Table 2). Of these, 4,724 (85.8%) patients received
bare metal stents, 440 (8.0%) sirolimus-eluting stents
and 345 (6.3%) paclitaxel-eluting stents.
Drug-eluting stent implantations varied widely across
countries, as manifested by coefficients of variation
(SD/mean) >0.3% for all stent groups (Table 3).
Demographics, Clinical and
Procedural Characteristics
The majority of diabetics were males; mean age of
62.1 years. Approximately half of the patients underwent
PCI for unstable coronary syndromes (45.2% with unstable angina and 9.7% with acute myocardial infarction).
Other high-risk features included multivessel coronary
artery disease (35.5%) and impaired left ventricular
function (25.1%) - Tables 4 and 5.
Treated lesions were class B2 or C in 51.9% according to the American College of Cardiology/American
Heart Association classification; the average reference
diameter was 2.97 mm, and mean lesion length was
17.4 mm. Patients treated with DES had more complex
lesions (B2/C), smaller vessels and longer lesions than
those treated with BMS. The angiographic success rate
was >97% and similar among groups (Table 5).
Thirty-Day Outcomes
Thirty-day event rates were low and the differences
among groups were not deemed to be clinically signifi-
TABLE 2
Number of diabetic patients treated with
coronary drug-eluting stents per country
in 2003 (SOLACI Database)
Country
Brazil
Argentina
Colombia
Uruguay
Mexico
Honduras
Chile
Venezuela
Peru
Total
SES
248
94
25
6
35
5
2
6
19
440
PES
187
57
74
13
6
2
0
6
0
345
BMS
2471
1030
777
278
67
52
41
8
0
4724
Total
2906
1181
876
297
108
59
43
20
19
5509
TABLE 3
Rates of DES and bare metal stents utilization
in diabetic patients (SOLACI Database 2003)
Mean (%)
Standard deviation (%)
Minimum (%)
Maximum (%)
Coefficient of variation
SES
PES
BMS
21.9
31.4
2.0
100.0
1.43
7.0
9.1
0
30.0
1.29
71.1
32.1
0
95.3
0.45
TABLE 4
Clinical characteristics of diabetic patients
treated with stents registered at the SOLACI Database (2003)
Characteristics
Age (y)
Female sex (%)
Hypertension (%)
Hypercholesterolemia (%)
Smokers (%)
Previous MI (%)
CABG (%)
PCI (%)
Stable angina/Silent ischemia (%)
Unstable angina (%)
Myocardial infarction (%)
SES (n=440)
PES (n=345)
BMS (n=4.724)
62.1
35.2
59.1
38.4
23.6
18.6
13.9
21.8
42.3
40.7
05.7
63.6
33.3
53.0
46.7
36.5
26.4
15.1
21.7
53.6
54.8
04.9
63.0
37.9
56.5
45.7
38.2
25.2
11.8
18.7
50.0
44.9
10.4
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Chaves ÁJ, et al. Outcomes of Percutaneous Interventions in Diabetics Treated with Drug Eluting Stents or Bare Metal Stents: The
SOLACI Registry Results. Rev Bras Cardiol Invas 2006; 14(2): 109-114.
TABLE 5
Angiographic and procedural data
Characteristics
Multivessel disease (%)
Impaired LV function (%)
Target vessel, n (%)
LAD
RCA
LCX
SVG/LIMA
LM
Target lesion, n (%)
A
B1
B2
C
Reference vessel diameter (mm)
Lesion length (mm)
Procedural success (%)
SES (n=440)
PES (n=345)
BMS (n=4.724)
40.9
21.6
33.6
32.2
35.2
24.9
235 (44.9)
145 (27.7)
108 (20.7)
27 (5.2)
8 (1.5)
239 (43.6)
158 (28.8)
120 (21.9)
22 (4.0)
9 (1.6)
2,651 (44.9)
1,591 (26.9)
1,331 (22.5)
239 (4.0)
92 (1.6)
83 (14.3)
133 (23.0)
265 (45.8)
98 (16.9)
2.73
20.3
98.2
94 (13.8)
162 (23.8)
318 (46.8)
106 (15.6)
2.82
19.1
99.7
1,297 (19.8)
1,988 (30.3)
2,389 (36.5)
879 (13.4)
3.00
17.1
97.5
TABLE 6
Clinical events at the follow-up
Events
30-Day events (%)
Death
MI
Urgent revascularization
Stent thrombosis
1-Year events (%)
Death
MI
TVR
PCI
CABG
SES n=440 (%)
PES n=345 (%)
BMS n=4,724 (%)
0
2 (0.5)
2 (0.5)
4 (0.9)
0
1 (0.3)
0
2 (0.6)
46 (1.0)
132 (2.8)
29 (0.6)
136 (2.9)
4 (0.9)
4 (0.9)
12 (2.7)
8 (1.8)
4 (0.9)
1(0.3)
3 (0.9)
10 (2.9)
8 (2.3)
2 (0.6)
58 (1.2)
173 (3.7)
553 (11.7)
392 (8.3)
161 (3.4)
1-Year Follow-Up
Although no relevant differences in mortality (0.9%
SES vs. 0.3% PES vs. 1.2% BMS) or myocardial infarction
rates (0.9% SES vs. 0.9% PES vs. 3.7% BMS) were
observed, the need for target vessel revascularization
was much improved in the DES groups (2.7% SES vs.
2.9% PES vs. 11.7% BMS). TVR was reduced due to
a decrease in both the need for percutaneous intervention and bypass surgery (Table 6).
DISCUSSION
The SOLACI Registry allows a contemporary overview of the current treatment patterns and 1-year outcomes for diabetic patients suitable for coronary stent
intervention in Latin American countries, providing key
information on how innovations are actually used and
how they impact clinical practice. This registry has
unique strengths including geographic and institutional
diversity and a large sample size over a relatively short,
contemporary time frame.
Little information is available with regard to how
drug-eluting stents are actually being implemented for
patients in Latin America and, to our knowledge, there
has been no report demonstrating the patterns of utilization and the assessment of the effectiveness of sirolimus
and paclitaxel-eluting stents in diabetics in those countries.
Overall, 14.3% of the diabetics included in the
registry in calendar year 2003 had been treated with
a sirolimus or a paclitaxel-eluting stent. The main result
of this strategy was a marked reduction in the rates of
repeat revascularization at 1 year with the 2 drugeluting stents when compared with bare metal stents.
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Chaves ÁJ, et al. Outcomes of Percutaneous Interventions in Diabetics Treated with Drug Eluting Stents or Bare Metal Stents: The
SOLACI Registry Results. Rev Bras Cardiol Invas 2006; 14(2): 109-114.
No clinically relevant differences in the rates of death
or MI among the groups were observed.
The new stents were used for indications where
randomized trials are still needed to achieve higher
levels of evidence about safety and efficacy6 (7.9% of
myocardial infarctions, 17% of bypass grafts and 15.6%
of the left main stenoses).
The 1-year death and MI frequency in our patients
treated with the sirolimus and paclitaxel eluting stents
(0.6% and 0.9%, respectively) lay between the 0.4%4.8% and 0-4.1% ranges reported for diabetics in the
drug-eluting arms of recent trials1-5,7-10. One-year target
vessel revascularization was lower than values recorded
in previously randomized studies, but similar to “realworld” registries. In our patients, we found an incidence
of target vessel revascularization of 2.7% in the sirolimus
stent group and 2.9% in the paclitaxel stent group. In
randomized trials, target vessel revascularizations were
in the 6.3%-9.9% range for diabetics treated with sirolimus stent2,4,5 and 11.3%-12.0% for those treated with
the paclitaxel stent3,4. In contrast, the figures were 2.1%8.8% and 3.4%-5.7%, respectively, in registries focusing
diabetic patients7-10. A mechanism that could explain
higher TVR in those randomized trials is the use of
mandated angiographic follow-up, elevating TVR by
increasing the likelihood of revascularization for patients
with moderate angiographic lesions.
Concerns have been brought up with the comparison between the SES and PES because it is suggested
that there may be differences between the 2 drug-eluting
stents regarding prevention of recurrences in patients
with diabetes. Evaluation of the results achieved with
these 2 drug-eluting stents indicates distinct restenosis
rates favoring the sirolimus stent. TLR, on the other
hand, was no different between groups4 - a finding
concordant with our data.
Similar to the comparable antirestenotic efficacy
of the two DES, no difference was observed with regard
to the safety of these devices. Thirty-day stent thromboses
were 0.9% for SES and 0.6% for PES, consistent with
the 0.5-2.8% range reported for diabetics in DES registries7,8,10. Observations beyond 1 month were not
available, and no conclusions could be drawn regarding
ultimate long-term behavior related to stent thromboses.
In this multicenter registry of DES implantation in
diabetics, all restrictions inherent to this particular study
design are relevant. Nevertheless, given the broad inclusion criteria, this cohort of patients precisely reflects
the daily practice in the “real world” of interventional
cardiology and, in our view the results could be extended
to virtually all patients with diabetes.
CONCLUSION
This large, Latin American, contemporary database
reveals that routine utilization of drug-eluting stents for
diabetic patients reduced importantly the rate of TVR
at 1-year compared to bare metal stents. No relevant
differences were found in the rates of death or MI
among the groups. These results are similar to that
observed in contemporary clinical registries and provide
a framework for improved treatment strategies for diabetics with coronary artery disease.
SOLACI REGISTRY PARTICIPANTS
Argentina: Adrian Rossini, Alberto A. Cristino, Alberto Licheri, Alberto Sampaolesi, Alberto Villegas, Alejandro
D. Fernández, Alejandro Daniel Mesples, Alejandro
Goldsmit, Alejandro Martorina, Alfedo Bravo, Alfredo
Eduardo Rodríguez, Amalia M.E. Descalzo, Andrin Oberdan, Anibal de Sanctis, Anibal Gentiletti, Carlos Alejandro
Álvarez Iorio, Carlos E. Mauvecin, Carlos J. Álvarez
Iorio, Carlos Rojas Matas, Daniel Berrocal, Eduardo D.
Paris, Eduardo Magariños, Eduardo R. Novero, Elisabet
Marsiglio, Fabio Säger, Fernando F. Ordóñez, Fernando
Tau, Francisco Vrsalovic, Gonzalo Calvo, Guillermo
Mulinaris, Guillermo Pacheco, Gustavo Bonzón, Gustavo
Caballero, Jaime Poch, Jorge Bordagaray, Jorge Iravedra,
Jorge Thomas, Jorge Wisner, José Luis Lazarte, José M.
Gabay, José Oscar Gómez Moreno, José Pereyra, José
Vaccaro, José Vicario, Juan Carlos Dalmaroni, Juan
José Lloberas, Julio A. Pascua, Liliana Grinfeld, Liliana
Rojo, Luis Gerardo, Manuel Sanjurjo, Marcelo E. Halac,
Marcelo Notrica, Marcelo Pettinari, Mario Daniel Pieroni,
Mario Montoya, Nicolas Nitti, Orlando Lepori, Osvaldo Laudano, Osvaldo Navarro, Pablo Luna, Raúl Bretal,
Ricardo Arce Cano, Roberto Diaz, Roberto Fernández
Viña, Sandra Reyes, Sebastián Araujo, Silvio Martínez,
Vasco Galvez; Brasil: Adnan Ali Salman, Alaor Queiroz
Araujo Filho, Alexandre A.C. Abizaid, Alexandre Manoel
Varela, Alfredo Nunes Ferreira Filho, Anderson Jorge
Lima Nascimento, André Cambra, André Labrunie, Antenório Aiolfi, Antonio Forte, Antonio José Muniz, Antonio José Neri Souza, Ari Mandil, Bruno Moulin Machado,
Carlos Augusto Arêas, Carlos Eduardo Domingues,
Décio Salvadori Jr., Dinaldo Cavalcanti, Edson Alcides
Bocchi, Fabio Prudente, Fausto Feres, Flavio A. Aranha Japyassú, Flavio Braga Mota, Flavio Roberto de
Oliveira Andrade, Galo A. Maldonado, George Meirelles,
Gustavo de Moraes Ramalho, Hélio Roque Figueira,
Henrique Ebaid, J. Eduardo M.R. Sousa, Jamil Abdalla
Saad, João Baptista Oliveira, João Batista Lopes Loures,
Jorge Hayashi, Jorge Roberto Büchler, José Airton de
Arruda, José Antonio de Souza Vieira, José Armando
Mangione, José Ary Boechat e Salles, José Del Carmen
Solano Aliaga, José Henrique Cavalcanti Mota, Júlio
Andréa, Leônidas Alvarenga Henriques, Luciano Abreu,
Luiz Alberto P. Mattos, Luiz Antonio Gubolino, Maéve
de Barros Correia, Manuel Nicolas Cano, Luiz Augusto
Lavalle, Marcos César V. de Almeida, Marcos Sumita,
Milton Macedo Soares Neto, Mônica Buchalla, Murillo
Kenji Furukawa, Norberto Toazza Duda, Pablo Tomé
Teixeirense, Roberto Abdalla Filho, Rodolfo Staico,
Rogério de Castro Pimentel, Rogério Tadeu Tumelero,
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Chaves ÁJ, et al. Outcomes of Percutaneous Interventions in Diabetics Treated with Drug Eluting Stents or Bare Metal Stents: The
SOLACI Registry Results. Rev Bras Cardiol Invas 2006; 14(2): 109-114.
Rogerio Tiossi, Salvador André B. Cristovão, Sérgio
Luiz N. Braga, Tiago Di Tucchi, Ulises Acuña Solorzano,
Virgilio Franco Jr., Vitor Gomes Barreto, Walasse Rocha
Vieira, Wilson Albino Pimentel Filho; Chile: Carlos
Caorsi, Darío Martínez Ojeda, Ivan Luksic Sandoval,
Juan Delgado, Lucio León, Marcelo Lindh Ibáñez, Misael
Lopetegui Aburto; Colombia: Alberto Suárez Nitola,
Carlos Andrés Carvajal, Darío Echeverri, Ebalo Real,
Edgar Hurtado, Germán Gómez, Héctor Hernández
Gallo, Jorge Villegas, Luis Calderón, Manuel Llevano
Triana, Manuel R. Téllez, Mauricio Pineda, Orlando
Corzo, Oscar Fernández Gómez, Pablo Castro, Rafael
Gonzalez Nino; Honduras: Francisco R. Somoza Alvarenga, Rene Echeverria Romero; Mexico: Carlos Humberto Wabi Dogre, Manuel de los Reyes Barrera Bustillos,
Joaquín Jiménez Noh; Peru: Alfredo Gama Medrano,
Grace Rojas Pareja, Roberto Kenny Santos Becerra;
Uruguay: Alberto Firszt, Alejandro Cuesta, Alfredo Fiandra, Ariel Durán, Bernardo Erramún, Carolina Artucio,
César Pardiñas, Daniel Fiandra, Daniel Mallo, Francisco Urrutia, Jorge Musetti, Juan Gaspar, Laura Cáceres,
Ricardo Lluberas, Silvia López; Venezuela: Carlos Vásquez Quintero, Freddy García Heres, Gerardo Alvarez,
Miguel López Hidalgo, Norberto Deibis, Ramón Cedeño
Ecarri, Yourki Tairouz.
3.
4.
5.
6.
7.
8.
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Disponível em: http://www.theheart.org/article/674081.do.
Acessado em: 30/04/2006.
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