Impact of cardiology referral: clinical outcomes and factors associated with physicians' adherence to recommendations

OBJECTIVES: Cardiology referral is common for patients admitted for non-cardiac diseases. Recommendations from cardiologists may involve complex and aggressive treatments that could be ignored or denied by other physicians. The purpose of this study was to compare the outcomes of patients who were given recommendations during cardiology referrals and to examine the clinical outcomes of patients who did not follow the recommendations. METHODS: We enrolled 589 consecutive patients who received in-hospital cardiology consultations. Data on recommendations, implementation of suggestions and outcomes were collected. RESULTS: Regarding adherence of the referring service to the recommendations, 77% of patients were classified in the adherence group and 23% were classified in the non-adherence group. Membership in the non-adherence group (p<0.001; odds ratio: 10.25; 95% CI: 4.45-23.62) and advanced age (p = 0.017; OR: 1.04; 95% CI: 1.01-1.07) were associated with unfavorable outcomes. Multivariate analysis identified four independent predictors of adherence to recommendations: follow-up notes in the medical chart (p<0.001; OR: 2.43; 95% CI: 1.48-4.01); verbal reinforcement (p = 0.001; OR: 1.86; 95% CI: 1.23-2.81); a small number of recommendation (p = 0.001; OR: 0.87; 95% CI: 0.80-0.94); and a younger patient age (p = 0.002; OR: 0.98; 95% CI: 0.96-0.99). CONCLUSIONS: Poor adherence to cardiology referral recommendations was associated with unfavorable clinical outcomes. Follow-up notes in the medical chart, verbal reinforcement, a limited number of recommendations and a patient age were associated with greater adherence to recommendations. .

Perioperative cardiovascular evaluation: heads or tails?

When dealing with surgical patients, a perioperative evaluation is essential to anticipate complications and institute measures to reduce the risks. Several algorithms and exams have been used to identify postoperative cardiovascular events, which account for more than 50% of perioperative mortality. However, they are far from ideal. Some of these algorithms and exams were proposed before important advances in cardiology, at a time when pharmacological risk reduction strategies for surgical patients were not available. New biomarkers and exams, such as C-reactive protein, brain natriuretic peptide, and multislice computed tomography have been used in cardiology and have provided important prognostic information. The ankle-brachial index is another significant marker of atherosclerosis. However, specific information regarding the perioperative context of all these methods is still needed. The objective of this article is to evaluate cardiovascular risk prediction models after noncardiac surgery.

Complicações cardiopulmonares das doenças falciformes / Cardiopulmonary complications of sickle cell disease

O pulmão é um dos principais alvos de complicações agudas e crônicas nas doenças falciformes (DF). A síndrome torácica aguda é a segunda causa de internação hospitalar apresentando considerável morbimortalidade. O suporte clínico de alta qualidade é a base do tratamento bem sucedido. A administração adequada de fluidos, a analgesia, a oxigenioterapia, a fisioterapia respiratória ativa e o uso criterioso de transfusões sanguíneas são elementos essenciais do tratamento. A hipertensão pulmonar (HP), por sua vez, tem sido recentemente reconhecida como uma das complicações mais graves e freqüentes destes pacientes. A pressão de artéria pulmonar deve ser medida periodicamente por meio de ecocardiografia. Se o diagnóstico de HP for confirmado, o uso de hidroxiuréia, anticoagulação, transfusões e oxigênio deveriam ser considerados. As manifestações cardíacas nas DF incluem cardiomegalia, isquemia miocárdica, disfunção ventricular e cor pulmonale. O tratamento destas complicações deve seguir as recomendações das diretrizes atuais.

The lung is a major target organ for acute and chronic complications in sickle cell disease. Acute chest syndrome is the second most common cause of hospital admission resulting in considerable morbidity and mortality. The mainstay of successful treatment remains high quality supportive care. Fluid management, analgesia, oxygenation, bronchodilators, incentive spirometry and judicious use of transfusion therapy are essential elements of supportive care management. Pulmonary hypertension (PHT) has emerged as one of the most frequent and serious complications in these patients. The pulmonary artery pressure should be evaluated periodically by echocardiography. If the PHT diagnosis is positive the use of hydroxiurea, anticoagulation, transfusions and oxygen therapy should be considered. Cardiac manifestations are common including enlargement of the heart, myocardial ischaemia, ventricular dysfunction and cor pulmonale. The management of these complications follows the current guidelines.

Multicenter study of perioperative evaluation for noncardiac surgeries in Brazil (EMAPO)

INTRODUCTION: The accuracy of perioperative evaluation methods available is better than chance, but their performance is not ideal. OBJECTIVES: To compare a new evaluation method (EMAPO) to the American College of Physicians method for determining the risk of cardiovascular complications in noncardiac surgeries and to look for new influencing variables. METHODS: Evaluations through EMAPO and the American College of Physicians method were employed for 700 patients. Cardiac events and deaths were recorded, the risk variables related to the occurrence of complications were verified, and the models were compared by analyzing the areas under the receiver operating characteristic curves. RESULTS: Mortality rate was 3.4 percent, and the incidence of cardiovascular complications was 5.3 percent. Renal failure (P = 0.01), major surgery (P = 0.004), and emergency surgery (P = 0.003) were independently related to the occurrence of cardiovascular complications. The two methods produced similar results. CONCLUSION: EMAPO is as good as the American College of Physicians method in determining the risk of cardiovascular complications in noncardiac surgeries. New variables related to surgical risk were identified.

INTRODUÇÃO: A precisão dos métodos de avaliação perioperatória disponíveis é melhor que o acaso, porém está longe do ideal. OBJETIVOS: Comparar um novo método de avaliação perioperatória (EMAPO) ao método do American College of Physicians para determinar o risco cardíaco em cirurgias não cardíacas e buscar novas variáveis envolvidas na determinação deste risco. MÉTODOS: O EMAPO e o método do American College of Physicians foram aplicados em 700 pacientes. A ocorrência de eventos cardíacos e de mortes foi documentada, a relação entre as variáveis de risco e as complicações foi estabelecida e os métodos foram comparados analisando as áreas sob a curva ROC. RESULTADOS: A mortalidade foi 3.4 por cento e a incidência de complicações cardiovasculares 5.3 por cento. A presença de insuficiência renal (p=0.01), cirurgia de grande porte (p=0.004) e cirurgia de emergência (p=0.003) se correlacionaram com a ocorrência de complicações cardiovasculares na análise multivariada. Não houve diferença entre os dois métodos. CONCLUSÕES: O EMAPO é tão eficaz quanto o método do American College of Physicians para determinar o risco de complicações cardiovasculares em cirurgias não cardíacas. Novas variáveis relacionadas com o risco perioperatório foram encontradas.