The impact of diabetes and subclinical hypothyroidism association with coronary artery calcium: results from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

ABSTRACT Objective: We aimed to analyze the association of diabetes and subclinical hypothyroidism with subclinical atherosclerosis measured by coronary artery calcium (CAC) in the baseline of the ELSA-Brasil study. Materials and methods: CAC was measured using a 64-detector computed tomographic scanner. The association of CAC > 0 was presented as an odds ratio (OR) and 95% confidence intervals (95%CI) in logistic models and as β (95%CI) in linear models after multivariable adjustment for confounders. Results: We analyzed 3,809 participants (mean-age (SD) 50.5 (8.8); 51.7% women). In the main analysis, we did not find an association of diabetes and subclinical hypothyroidism with CAC. However, in stratified analysis according to age strata, we found no significative interaction terms, an important heterogeneity between the groups, with the younger age strata showing an association of the group with both diseases and CAC > 0 (OR 7.16; 95%CI, 1.14; 44.89) with a wide but significative 95%CI, suggesting that the smaller number of participants in the younger group may influence the results. Our findings also showed an association of CAC > 0 and log (CAC+1) with diabetes in logistic (OR, 1.31; 95%CI, 1.05-1.63) and linear models (β, 0.24, 0.16, 0.40), respectively. Diabetes was independently associated with CAC > 0 in linear models. Discussion: In conclusion, our results showed a great heterogeneity in stratified analysis based on age in the younger age strata. Although we found no significant interaction factors, the smaller sample size for the analysis may influence the negative findings.

Prognóstico Relacionado à Terapia de Reperfusão Pós-Síndrome Coronariana Aguda na Atenção Secundária: Análise de Sobrevida em Longo Prazo na Estratégia ERICO / Prognosis Related to Reperfusion Therapy Post-Acute Coronary Syndrome in Secondary Care: Long-Term Survival Analysis in the ERICO Study

Resumo Fundamento A relação entre terapia de reperfusão após a síndrome coronariana aguda (SCA) e mortalidade na atenção secundária não é bem conhecida. Objetivos Avaliar o impacto de três estratégias terapêuticas: (1) terapia medicamentosa exclusiva, (2) Angioplastia Transluminal percutânea coronaria (ATPC) e (3) revascularização do miocárdio (RM) na sobrevida em longo prazo de participantes da Estratégia de Registro de Insuficiência Coronariana Aguda (ERICO). Métodos Análises de sobrevida para mortalidade por todas as causas, mortalidade por doença cardiovascular (DCV) e mortalidade por doença arterial coronariana (DAC) foram realizadas de acordo com três estratégias terapêuticas (tratamento clínico exclusivo, ATPC ou RM). Modelos de regressão de Cox foram usados para estimar o hazard ratio (HR) com intervalo de confiança de 95% (IC95%) de 180 dias a quatro anos de acompanhamento após a SCA. Os modelos são apresentados como modelo sem ajuste ou ajustado quanto à idade, sexo e DAC prévia, tipo de SCA, tabagismo, hipertensão, dislipidemia, fração de ejeção do ventrículo esquerdo e de acordo com o número de artérias coronárias principais obstruídas (≥50%). Resultados Entre os 800 participantes, as piores taxas de sobrevida (mortalidade por todas as causas e DCV) foram detectadas entre os indivíduos que se submeteram a RM. Houve correlação entre RM e DAC [HR: 2,19 (IC95% 1,05-4,55)], mas o risco perdeu significância no modelo multivariado. A ATPC foi associada a uma menor probabilidade de eventos fatais durante os quatro anos de acompanhamento: mortalidade por todas as causas [HR, análise multivariada: 0,42 (IC95% 0,26-0,70)], por DCV [HR: 0,39 (95% CI: 0,20-0,73)] e DAC [HR, análise multivariada: 0,24 (IC95% 0,09-0,63)] em comparação aos submetidos ao tratamento clínico exclusivo. Conclusão No ERICO, a ATPC após a SCA foi associada a um melhor prognóstico, principalmente sobrevida por DAC.

Abstract Background Relationship between reperfusion therapy post-acute coronary syndrome (ACS) and mortality in secondary care is not well-known. Objectives To evaluate the impact of three therapeutic strategies: (1) exclusive medical therapy, (2) percutaneous coronary intervention (PCI) and (3) coronary artery bypass grafting (CABG) on long-term survival of participants in the Strategy of Registry of Acute Coronary Syndrome (ERICO) study. Methods Survival analyses for all-cause, cardiovascular (CVD) and coronary artery disease (CAD) mortality were performed according to three therapeutic strategies (exclusive medical therapy, PCI or CABG). Cox regression models were used to estimate the hazard ratio (HR) with respective 95% confidence interval (95%CI) from 180 days to four years of follow-up after ACS. Models are presented as crude, age-sex adjusted and further adjusted for previous CAD, ACS subtype, smoking, hypertension, dyslipidemia, left ventricular ejection fraction and according to the number of obstructed (≥ 50%) major coronary arteries. Results Among 800 participants, the lowest crude survival rates were detected among individuals who underwent CABG (all-cause and CVD). CABG was correlated to CAD (HR: 2.19 [95% CI: 1.05-4.55]). However, this risk lost significance in the full model. PCI was associated to lower probability of fatal events during four-year follow-up: all-cause [multivariate HR: 0.42 (95% CI: 0.26-0.70)], CVD [HR: 0.39 (95% CI: 0.20-0.73)] and CAD [multivariate HR: 0.24 (95% CI: 0.09-0.63)] compared to those submitted to exclusive medical therapy. Conclusion In the ERICO study, PCI after ACS was associated to better prognosis, particularly CAD survival.

The association of diabetes, subclinical hypothyroidism and carotid intima-media thickness: results from the Brazilian Longitudinal Study of Adult Health (ELSA-Brazil)

Abstract Introduction: The association of diabetes with subclinical thyroid diseases may increase the risk of cardiovascular diseases. We analyzed the association of subclinical hypothyroidism, diabetes, and both diseases with carotid Intima-Media Thickness (cIMT) as a surrogate maker for early cardiovascular disease in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Methods: Cross-sectional analysis with data from the 3rd visit (2017‒2019). Linear regression models were used to evaluate the association of subclinical hypothyroidism, diabetes and of both diseases with a cIMT presented as Beta (95% Confidence Interval - 95% CI) without adjustment, with adjustment for sociodemographic variables (Model 1) and multivariable adjustment (Model 1 more cardiovascular risk factors). We also used logistic regression models to analyze the Odds Ratio (OR) and 95% CI for the association of both diseases using cIMT > P75%. Results: After the exclusion of patients with previous cardiovascular disease, 5,077 participants with no diseases, 1578 with diabetes, 662 with subclinical hypothyroidism, and 234 with both diseases were included in the analysis. Linear regression models showed an association of cIMT with only diabetes (β = 0.019; 95% CI 0.012 to 0.027; p < 0.0001) and subclinical hypothyroidism more diabetes (β = 0.03; 95% CI 0.010‒0.047, p < 0.0001). The logistic regression model reported an association between diabetes and CIMT higher than P75% (OR = 1.49, 95% CI 1.30‒1.71). No interaction between diabetes and subclinical hypothyroidism was detected using cIMT respectively as a continuous (p = 0.29) or as a categorical variable (p = 0.92). Discussion: Diabetes was associated with higher cIMT values. However, no additive effect of subclinical hypothyroidism associated with diabetes over cIMT was detected.

Association between psoriasis and thyroid function: results from the Brazilian Longitudinal Study of Adults Health (ELSA-Brasil)

ABSTRACT Objective: To determine the relationship between psoriasis, thyroid-stimulating hormone (TSH), free thyroxine (FT4), free triodothyronine (FT3), thyroid peroxidase antibodies (TPOAb), and subclinical thyroid dysfunctions in middle-aged and older adults. Materials and methods: Cross-sectional analyses included a self-reported medical diagnosis of psoriasis and thyroid function from the 3rd visit (2017-2019) of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). TSH, FT4, and FT3 levels were analyzed as continuous variables and quintiles, and TPOAb positivity and subclinical hypothyroidism as a yes/no variable. Logistic regression models were built as crude and adjusted by main confounders (age, sex, education level, race/ethnicity, and smoking). Results: From 9,649 participants (52.3% women; 59.2 ± 8.7 years old), the prevalence of psoriasis was 2.8% (n = 270). TSH, FT4, TPOAb positivity, and subclinical hypothyroidism were not associated with psoriasis in the main analyses. In the stratified analysis, our findings showed positive associations of the lowest (OR = 2.01; 95% CI 1.05-3.84; p = 0.036) and the highest (OR = 2.13; 95% CI 1.12-4.05; p = 0.022) quintiles of FT4 and a protective association of TPOAb positivity (OR = 0.43; 95% CI 0.19-0.98; p = 0.046) with prevalent psoriasis in women. In the logistic regression for FT3, participants in the 1st quintile showed a statistically significant association with psoriasis for the whole sample (OR = 1.66; 95% CI 1.11-2.46; p = 0.013) and for men (OR = 2.25; 95% CI 1.25-4.04; p = 0.007) in the sex-stratified analysis. Conclusions: The present study showed that the association of FT4 levels with psoriasis are different according to sex, with a possible U-shaped curve in women but not in men. Although there were some associations of FT3 with psoriasis, they may be a consequence of non-thyroidal illness syndrome. Further prospective data may clarify the association of thyroid function and psoriasis.

Saúde Cardiovascular e Fibrilação ou Flutter Atrial: Um Estudo Transversal do ELSA-Brasil / Cardiovascular Health and Atrial Fibrillation or Flutter: A Cross-Sectional Study from ELSA-Brasil

Resumo Fundamento A associação entre o status de saúde cardiovascular ideal ( ideal cardiovascular health ( ICVH) e diagnóstico de fibrilação ou flutter atrial (FFA) foi menos estudado em comparação a outras doenças cardiovasculares. Objetivos Analisar a associação entre o diagnóstico de FFA e métricas e escores de ICVH no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). Métodos Este estudo analisou dados de 13141 participantes com dados completos. Os traçados eletrocardiográficos foram codificados de acordo com o Sistema de Minnesota, em um centro de leitura centralizado. As métricas do ICVH (dieta, atividade física, índice de massa corporal, tabagismo, glicemia de jeju, e colesterol total) e escores do ICVH foram calculados conforme proposto pela American Heart Association . Modelos de regressão logística bruta e ajustada foram construídos para analisar associações de métricas e escores do ICVH com diagnóstico de FFA. O nível de significância foi estabelecido em 0,05. Resultados A idade mediana da amostra foi de 55 anos, e 54,4% eram mulheres. Nos modelos ajustados, os escores de ICVH não apresentaram associação significativa com diagnóstico de FFA prevalente [odds ratio (OR):0,96; intervalo de confiança de 95% (IC95%):0,80-1,16; p=0,70). Perfis de pressão arterial ideal (OR:0,33; IC95%:0,1-0,74; p=0,007) e colesterol total ideal (OR:1,88; IC95%:1,19-2,98; p=0,007) foram significativamente associados com o diagnóstico de FFA. Conclusões Não foram identificadas associações significativas entre escores de ICVH global e diagnóstico de FFA após ajuste multivariado em nossas análises, devido, ao menos em parte, às associações antagônicas da FFA com métricas de pressão arterial e de colesterol total do ICVH. Nossos resultados sugerem que estimar a prevenção da FFA por meio de escore de ICVH global pode não ser adequado, e as métricas do ICVH devem ser consideradas separadamente.

Abstract Background The association between ideal cardiovascular health (ICVH) status and atrial fibrillation or flutter (AFF) diagnosis has been less studied compared to other cardiovascular diseases. Objective To analyze the association between AFF diagnosis and ICVH metrics and scores in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Methods This study analyzed data from 13,141 participants with complete data. Electrocardiographic tracings were coded according to the Minnesota Coding System, in a centralized reading center. ICVH metrics (diet, physical activity, body mass index, smoking, blood pressure, fasting plasma glucose, and total cholesterol) and scores were calculated as proposed by the American Heart Association. Crude and adjusted binary logistic regression models were built to analyze the association of ICVH metrics and scores with AFF diagnosis. Significance level was set at 0.05. Results The sample had a median age of 55 years and 54.4% were women. In adjusted models, ICVH scores were not significantly associated with prevalent AFF diagnosis (odds ratio [OR]:0.96; 95% confidence interval [95% CI]:0.80-1.16; p=0.70). Ideal blood pressure (OR:0.33; 95% CI:0.15-0.74; p=0.007) and total cholesterol (OR:1.88; 95% CI:1.19-2.98; p=0.007) profiles were significantly associated with AFF diagnosis. Conclusions No significant associations were identified between global ICVH scores and AFF diagnosis after multivariable adjustment in our analyses, at least partially due to the antagonistic associations of AFF with blood pressure and total cholesterol ICVH metrics. Our results suggest that estimating the prevention of AFF burden using global ICVH scores may not be adequate, and ICVH metrics should be considered in separate.

Chronic inflammatory diseases, subclinical atherosclerosis, and cardiovascular diseases: Design, objectives, and baseline characteristics of a prospective case-cohort study ‒ ELSA-Brasil

Abstract Objectives This analysis describes the protocol of a study with a case-cohort to design to prospectively evaluate the incidence of subclinical atherosclerosis and Cardiovascular Disease (CVD) in Chronic Inflammatory Disease (CID) participants compared to non-diseased ones. Methods A high-risk group for CID was defined based on data collected in all visits on self-reported medical diagnosis, use of medicines, and levels of high-sensitivity C-Reactive Protein >10 mg/L. The comparison group is the Aleatory Cohort Sample (ACS): a group with 10% of participants selected at baseline who represent the entire cohort. In both groups, specific biomarkers for DIC, markers of subclinical atherosclerosis, and CVD morbimortality will be tested using weighted Cox. Results The high-risk group (n = 2,949; aged 53.6 ± 9.2; 65.5% women) and the ACS (n=1543; 52.2±8.8; 54.1% women) were identified. Beyond being older and mostly women, participants in the high-risk group present low average income (29.1% vs. 24.8%, p < 0.0001), higher BMI (Kg/m2) (28.1 vs. 26.9, p < 0.0001), higher waist circumference (cm) (93.3 vs. 91, p < 0.0001), higher frequencies of hypertension (40.2% vs. 34.5%, p < 0.0001), diabetes (20.7% vs. 17%, p = 0.003) depression (5.8% vs. 3.9%, p = 0.007) and higher levels of GlycA a new inflammatory marker (p < 0.0001) compared to the ACS. Conclusions The high-risk group selected mostly women, older, lower-income/education, higher BMI, waist circumference, and of hypertension, diabetes, depression, and higher levels of GlycA when compared to the ACS. The strategy chosen to define the high-risk group seems adequate given that multiple sociodemographic and clinical characteristics are compatible with CID.

Incidence of TPOAb over a 4-year follow-up period: results from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

ABSTRACT Objective: Although some previous data have suggested a high iodine intake in Brazil, the prevalence of antithyroperoxidase antibodies (TPOAb) in the country is compatible with rates from countries with adequate iodine intake. This observation emphasizes the importance of knowing the incidence of TPOAb in Brazil. Materials and methods: This prospective analysis included euthyroid participants with negative TPOAb at baseline and a thyroid function assessment at a 4-year follow-up. TPOAb was measured by electrochemiluminescence and considered positive when titers were ≥34 IU/mL. TSH and free T4 (FT4) levels were determined by a third-generation immunoenzymatic assay. The incidence of TPOAb is expressed in percentage per year or as a cumulative incidence within the 4-year follow-up period. Results: Of 8,922 euthyroid participants (mean age 51.1 years; 50.9% women) with a negative TPOAb test at baseline, 130 presented incident TPOAb at the 4-year follow-up, yielding an annual incidence of TPOAb of 0.38%/year (95% confidence interval [95% CI], 0.37-0.39%/year) and a cumulative incidence over 4 years of 1.46% (95% CI, 1.21-1.71%). In men, the annual incidence was 0.32% (95% CI, 0.31-0.33%), and the cumulative incidence over 4 years was 1.23% (95% CI, 0.90-1.56%). In women, the annual incidence was 0.43%/year (95% CI, 0.42-0.44%/year) and the cumulative incidence over 4 years was 1.67% (95% CI, 1.30-2.04%). The only factor associated with incident TPOAb was the occurrence of thyroid diseases at follow-up. No differences in TPOAb incidence were detected across ELSA-Brasil research centers. Conclusion: Based on the results of this study, the incidence of TPOAb per year and at a 4-year follow-up period are compatible with those of a country with adequate iodine intake.

Incidence of thyroid diseases: Results from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

ABSTRACT Objective: To evaluate incidence of subclinical and overt hyperthyroidism and hypothyroidism. Subjects and methods: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is a prospective cohort study of 15,105 civil servants, examined at baseline and over a 4-year follow-up. This analysis included 9,705 participants with normal thyroid function at baseline, follow-up information about thyroid function and with no report of using drugs that may interfere in the thyroid function. Thyroid function was defined by TSH/FT4 levels or routine use of thyroid hormones/anti-thyroid medications. Annual and cumulative (over 4-year) incidence rates were presented as percentages (95% Confidence Intervals). Results: The incidence of all overt and subclinical thyroid disease was 6.7% (1.73%/year): 0.19% for overt hyperthyroidism (0.048%/year), 0.54% for subclinical hyperthyroidism (0.14%/year), 1.98% for overt hypothyroidism (0.51%/year), and 3.99% for subclinical hypothyroidism (1.03%/year). The incidence of all thyroid diseases was higher in women, when compared to men, with a low women:men ratio (1.36). For Blacks the highest incidence was for overt hyperthyroidism, while for Whites, the highest incidence was for overt hypothyroidism. However, the highest incidence of overt hyperthyroidism was detected in Asian descendants. The presence of antithyroperoxidase antibodies at baseline was associated with higher incidence of overt thyroid diseases. Conclusion: These results showed a high incidence of hypothyroidism, which is compatible with a country with a more-than-adequate iodine intake. The low women:men ratio of the incidence of thyroid dysfunction highlights the importance of the diagnosis of thyroid diseases among men in Brazil.

Frequência e Motivos para a não Administração e Suspensão de Medicamentos durante um Evento de Síndrome Coronariana Aguda. Estudo ERICO / Frequency and Reasons for Non-Administration and Suspension of Drugs During an Acute Coronary Syndrome Event. The ERICO Study

Resumo Fundamentos: Poucos estudos discutiram causas para o subtratamento medicamentoso na SCA. Objetivos: Avaliar a não-administração e suspensão de medicamentos durante o tratamento intra-hospitalar da SCA na Estratégia de Registro de Síndrome Coronariana Aguda (estudo ERICO). Métodos: Analisamos prontuários de 563 participantes ERICO para avaliar a frequência e motivos da não administração e/ou suspensão de medicamentos. Construímos modelos de regressão logística para avaliar se sexo, idade ≥65 anos, nível educacional ou subtipo de SCA estavam associados com (a) não administração de ≥1 medicamentos; e (b) não administração ou suspensão de ≥1 medicamentos. O nível de significância foi 5%. Resultados: A amostra é composta por 58,1% de homens e com idade mediana de 62 anos. Em 183 (32,5%) participantes ≥1 medicamentos não foram administrados e 288 (51,2%) apresentaram ≥1 medicamentos não administrados ou suspensos. As causas mais frequentes foram risco de sangramento (aspirina, clopidogrel e heparina), insuficiência cardíaca (betabloqueadores) e hipotensão (inibidores da enzima conversora da angiotensina e bloqueadores dos receptores da angiotensina). Indivíduos com idade ≥65 anos (razão de chances [RC]:1,51; intervalo de confiança de 95% [IC95%]:1,05-2,19) e com angina instável (RC:1,72; IC95%:1,07-2,75) tiveram maior chance de não-administração. Considerando apenas pacientes com infarto do miocárdio, idade ≥65 anos foi associada tanto à não administração quanto à não administração ou suspensão. Conclusões: A não administração ou suspensão de ≥1 medicamento não foi rara no estudo ERICO. Indivíduos com idade ≥65 anos ou com angina instável tiveram maior chance de não administração e podem ser subtratados nesse cenário.

Abstract Background: Few studies have discussed the reasons for pharmacological undertreatment of Acute Coronary Syndrome (ACS). Objectives: To determine the frequency and reasons for the non-administration and suspension of medications during in-hospital treatments of ACS in the Strategy of Registry of Acute Coronary Syndrome (ERICO) study. Methods: The present study analyzed the medical charts of the 563 participants in the ERICO study to evaluate the frequency and reasons for the non-administration and/or suspension of medications. Logistic regression models were built to analyze if sex, age ≥65 years of age, educational level, or ACS subtype were associated with (a) the non-administration of ≥1 medications; and (b) the non-administration or suspension of ≥1 medications. The significance level was set at 5%. Results: This study's sample included 58.1% males, with a median of 62 years of age. In 183 (32.5%) participants, ≥1 medications were not administered, while in 288 (51.2%), ≥1 medications were not administered or were suspended. The most common reasons were the risk of bleeding (aspirin, clopidogrel, and heparin), heart failure (beta blockers), and hypotension (angiotensin-converting enzyme inhibitors and angiotensin receptor blockers). Individuals aged ≥65 (odds ratio [OR]:1.51; 95% confidence interval [95% CI]:1.05-2.19) and those with unstable angina (OR:1.72; 95% CI:1.07-2.75) showed a higher probability for the non-administration of ≥1 medication. Considering only patients with myocardial infarction, being ≥65 years of age was associated with both the non-administration and the non-administration or suspension of ≥1 medication. Conclusions: Non-administration or suspension of ≥1 medication proved to be common in this ERICO study. Individuals of ≥65 years of age or with unstable angina showed a higher probability of the non-administration of ≥1 medication and may be undertreated in this scenario. (Arq Bras Cardiol. 2020; 115(5):830-839)

Prevalence of antithyroperoxidase antibodies in a multiethnic Brazilian population: The ELSA-Brasil Study

ABSTRACT Objective In this study, we aimed to describe the prevalence and distribution of positive antithyroperoxidase antibodies (TPOAb) according to sex, age strata, and presence of thyroid dysfunction using baseline data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Materials and methods Thyroid hormone tests were obtained from each study participant at baseline. Levels of thyroid-stimulating hormone (TSH) and free thyroxine (FT4) were measured using a third-generation immunoenzymatic assay. Antithyroperoxidase antibodies were measured by electrochemiluminescence and were considered to be positive when ≥ 34 IU/mL. Results The prevalence of TPOAb among 13,503 study participants was 12%. Of participants with positive TPOAb, 69% were women. Almost 60% of the individuals with positive TPOAb were white. The presence of positive TPOAb was associated with the entire spectrum of thyroid diseases among women, but only with overt hyperthyroidism and overt hypothyroidism in men. Conclusion The distribution of positive TPOAb across sex, race, age, and thyroid function in the ELSA-Brasil study is aligned with the worldwide prevalence of positive TPOAb reported in iodine-sufficient areas. In women, the presence of TPOAb was related to the entire spectrum of thyroid dysfunction, while in men, it was only related to the occurrence of overt thyroid disease.

Elevated High-Sensitivity Troponin I in the Stabilized Phase after an Acute Coronary Syndrome Predicts All-Cause and Cardiovascular Mortality in a Highly Admixed Population: A 7-Year Cohort / A Troponina I de Alta Sensibilidade Elevada na Fase Estabilizada após Síndrome Coronariana Aguda Prevê Mortalidade por Todas as Causas e Mortalidade Cardiovascular em uma População Altamente Miscigenada: Uma Coorte de 7 Anos

Abstract Background: High-sensitivity cardiac troponin I (hs-cTnI) has played an important role in the risk stratification of patients during the in-hospital phase of acute coronary syndrome (ACS), but few studies have determined its role as a long-term prognostic marker in the outpatient setting. Objective: To investigate the association between levels of hs-cTnI measured in the subacute phase after an ACS event and long-term prognosis in a highly admixed population. Methods: We measured levels of hs-cTnI in 525 patients 25 to 90 days after admission for an ACS event; these patients were then divided into tertiles according to hs-cTnI levels and followed for up to 7 years. We compared all-cause and cardiovascular mortality using Cox proportional hazards models and adopting a significance level of 5%. Results: After a median follow-up of 51 months, patients in the highest tertile had a greater hazard ratio (HR) for all-cause mortality after adjustment for age, sex, known cardiovascular risk factors, medication use, and demographic factors (HR: 3.84, 95% CI: 1.92-8.12). These findings persisted after further adjustment for estimated glomerular filtration rate < 60 ml/min/1.73 m2 and left ventricular ejection fraction < 0.40 (HR: 6.53, 95% CI: 2.12-20.14). Cardiovascular mortality was significantly higher in the highest tertile after adjustment for age and sex (HR: 5.65, 95% CI: 1.94-16.47) and both in the first (HR: 4.90, 95% CI: 1.35-17.82) and second models of multivariate adjustment (HR: 5.89, 95% CI: 1.08-32.27). Conclusions: Elevated hs-cTnI levels measured in the stabilized phase after an ACS event are independent predictors of all-cause and cardiovascular mortality in a highly admixed population.

Resumo Fundamento: A troponina cardíaca de alta sensibilidade I (TnI-as) tem desempenhado um papel importante na estratificação de risco dos pacientes durante a fase intra-hospitalar da síndrome coronariana aguda (SCA), mas poucos estudos determinaram seu papel como marcador prognóstico de longo prazo no ambiente ambulatorial. Objetivo: Investigar a associação entre os níveis de TnI-as medidos na fase subaguda após um evento de SCA e o prognóstico a longo prazo, em uma população altamente miscigenada. Métodos: Medimos os níveis de TnI-as em 525 pacientes em um período de 25 a 90 dias após a entrada em hospital por um evento de SCA; esses pacientes foram então divididos em tercis conforme os níveis de TnI-as, e acompanhados por até 7 anos. Comparamos as mortalidades por todas as causas e cardiovascular através de modelos de riscos proporcionais de Cox e adotando um nível de significância de 5%. Resultados: Após um acompanhamento médio de 51 meses, os pacientes no tercil mais alto apresentaram uma taxa de risco (HR) maior para mortalidade por todas as causas, após ajustes para idade, sexo, fatores de risco cardiovascular conhecidos, uso de medicação e fatores demográficos (HR: 3,84 IC 95%: 1,92-8,12). Esses achados persistiram após um ajuste adicional para uma taxa de filtração glomerular (TFG) estimada < 60 ml/min/1,73 m2 e uma fração de ejeção do ventrículo esquerdo < 0,40 (HR: 6,53; IC95%: 2,12-20,14). A mortalidade cardiovascular foi significativamente maior no tercil mais alto, após ajustes para idade e sexo (RR: 5,65; IC95%: 1,94-16,47) e tanto no primeiro modelo de ajuste multivariado (HR: 4,90; IC 95%: 1,35-17,82) quanto no segundo (HR: 5,89; IC95%: 1,08-32,27). Conclusões: Níveis elevados de TnI-as, medidos na fase estabilizada após um evento de SCA, são preditores independentes de mortalidade por todas as causas e de mortalidade cardiovascular em uma população altamente miscigenada.

Impact of High Risk for Obstructive Sleep Apnea on Survival after Acute Coronary Syndrome: Insights from the ERICO Registry / Impacto do Alto Risco para Apneia Obstrutiva do Sono na Sobrevida após Síndrome Coronariana Aguda: Achados do Registro ERICO

Abstract Background: Obstructive sleep apnea (OSA) is a very often clinical condition that can be associated with high mortality risk, particularly in coronary heart disease (CHD). The diagnosis of OSA is not always accessible via the gold-standard method polysomnography. Objective: To evaluate long-term influence of the high risk for OSA on fatal and non-fatal outcomes after acute coronary syndrome (ACS) in the Acute Coronary Syndrome Registry Strategy (ERICO) Study using the Berlin questionnaire as a surrogate. Methods: Berlin questionnaire, a screening questionnaire for OSA, was applied in 639 cases of ACS 30 days after the index event. Cox regression proportional-hazards model was used to calculate the hazard ratio (HR) of all-cause, cardiovascular and CHD (myocardial infarction) mortality, as well as, the combined endpoint of fatal or recurrent non-fatal CHD. Results: The high-risk group for OSA had higher frequencies of previous personal/family history of CHD and diabetes, in addition to a poorer event-free survival, as compared to the low-risk group (p-log-rank=0.03). The HR for fatal or recurrent non-fatal CHD was 4.26 (95% confidence interval, 1.18 - 15.36) in patients at high risk for OSA compared to those at low risk for OSA after a 2.6-year mean follow-up. Conclusions: Using Berlin questionnaire, we were able to identify high risk for OSA as an independent predictor of non-fatal reinfarction or CHD mortality in post-ACS individuals in a long-term follow-up.

Resumo Fundamento: Apneia obstrutiva do sono (AOS) é uma condição clínica muito frequente, que pode estar associada a alto risco de mortalidade, particularmente em doença arterial coronariana (DAC). Nem sempre o diagnóstico de AOS acha-se disponível por polissonografia, o método padrão-ouro. Objetivo: Avaliar, usando o Questionário de Berlim como substituto, a influência a longo prazo do alto risco para AOS nos desfechos fatal e não fatal após síndrome coronariana aguda (SCA) na Estratégia de Registro de Insuficiência Coronariana (estudo ERICO). Métodos: O Questionário de Berlim, para triagem de AOS, foi aplicado a 639 casos de SCA 30 dias após o evento índice. Usou-se o modelo de riscos proporcionais de Cox para calcular a razão de risco (HR) para mortalidade por todas as causas, por doença cardiovascular e por IAM (infarto agudo do miocárdio), assim como os desfecho combinado infarto do miocárdio fatal e recorrente não fatal. Resultados: O grupo de alto risco para AOS apresentou maior frequência de história pessoal/familiar de DAC e diabetes, assim como pior sobrevida livre de evento, quando comparado ao de baixo risco (p-log-rank = 0,03). A HR para IAM fatal e recorrente não fatal foi 4,26 (intervalo de confiança 95%: 1,18-15,36) para os pacientes de alto risco para AOS em comparação àqueles de baixo risco após seguimento médio de 2,6 anos. Conclusões: Usando o Questionário de Berlim, conseguimos identificar alto risco para AOS como fator preditivo independente de reinfarto não fatal ou mortalidade por IAM após SCA em seguimento em longo prazo.

Prevalence of stroke and associated disability in Brazil: National Health Survey - 2013 / Prevalência de acidente vascular cerebral e de incapacidade associada no Brasil: Pesquisa Nacional de Saúde - 2013

There is scarce data about prevalence of stroke in Brazil. The National Health Survey (PNS) is a community-based epidemiological survey, with a nationally representative sample to assess the absolute numbers with respective prevalence rates of stroke and post-stroke disabilities. It was estimated 2,231.000 stroke and 568,000 stroke cases with severe disabilities. The point prevalences was 1.6% and 1.4% in men and women, respectively. The prevalences of post-stroke disabilities were 29.5% for men and 21.5% for women. Stroke prevalence rates increased with aging, low education level, among people living in urban areas with no difference according to self-reported skin color. The degree of post-stroke disability was not statistically different according to sex, race, education level or living area. This new data from PNS show high stroke prevalence rates especially in older individuals without formal education and urban dweller, but the degree of stroke disability was not determined by the sociodemographic characteristics of the Brazilian population.

Há poucos dados sobre prevalência de acidente vascular cerebral (AVC) no Brasil. A Pesquisa Nacional de Saúde (PNS), um inquérito epidemiológico de base domiciliar, com amostra representativa nacional avaliou a prevalência de AVC no Brasil calculou o número absoluto estimado de pessoas com AVC e incapacidade por AVC e respectivas prevalências. Estimou-se 2.231.000 pessoas com AVC e 568.000 com incapacidade grave. A prevalência pontual foi 1,6% em homens e 1,4% em mulheres, e a de incapacidade 29,5% em homens e de 21,5% em mulheres. A prevalência aumentou com a idade, nos menos escolarizados, residentes da zona urbana sem diferenças pela cor da pele auto-declarada. O grau de incapacidade pós-AVC não foi estatisticamente diferente segundo sexo, raça, nível de educação ou área de moradia. Os dados inéditos da PNS mostram altas taxas de prevalências de AVC principalmente em indivíduos mais idosos, sem educação formal, moradores de centros urbanos porém o grau de incapacidade pelo ACV não foi determinado pelas características sociodemográficas da população brasileira.

Post-Acute Coronary Syndrome Alcohol Abuse: Prospective Evaluation in the ERICO Study / Abuso de Álcool após Síndrome Coronariana Aguda: Avaliação Prospectiva no Estudo ERICO

Background: Some studies have indicated alcohol abuse as one of the contributors to the development of cardiovascular disease, particularly coronary heart disease. However, this relationship is controversial. Objective: To investigate the relationship between post-acute coronary syndrome (ACS) alcohol abuse in the Acute Coronary Syndrome Registry Strategy (ERICO Study). Methods: 146 participants from the ERICO Study answered structured questionnaires and underwent laboratory evaluations at baseline, 30 days and 180 days after ACS. The Alcohol Use Disorders Identification Test (AUDIT) was applied to assess harmful alcohol consumption in the 12 months preceding ACS (30 day-interview) and six months after that. Results: The frequencies of alcohol abuse were 24.7% and 21.1% in the 12 months preceding ACS and six months after that, respectively. The most significant cardiovascular risk factors associated with high-risk for alcohol abuse 30 days after the acute event were: male sex (88.9%), current smoking (52.8%) and hypertension (58.3%). Six months after the acute event, the most significant results were replicated in our logistic regression, for the association between alcohol abuse among younger individuals [35-44 year-old multivariate OR: 38.30 (95% CI: 1.44-1012.56) and 45-54 year-old multivariate OR: 10.10 (95% CI: 1.06-96.46)] and for smokers [current smokers multivariate OR: 51.09 (95% CI: 3.49-748.01) and past smokers multivariate OR: 40.29 (95% CI: 2.37-685.93)]. Conclusion: Individuals younger than 54 years and smokers showed a significant relation with harmful alcohol consumption, regardless of the ACS subtype. .

Fundamento: Alguns estudos identificaram que o abuso de álcool contribui para o desenvolvimento de doença cardiovascular, em particular doença arterial coronariana. Tal relação, no entanto, é controversa. Objetivo: Investigar a relação entre abuso de álcool após síndrome coronariana aguda (SCA) na Estratégia de Registro de Insuficiência Coronariana (ERICO). Métodos: 146 participantes do ERICO responderam questionários estruturados e foram submetidos a avaliações laboratoriais nas condições basais e 30 dias e 180 dias após SCA. Aplicou-se o Questionário AUDIT (Alcohol Use Disorders Identification Test) para avaliar o consumo prejudicial de álcool nos 12 meses anteriores à SCA (entrevista 30 dias após a SCA) e seis meses após a SCA. Resultados: As frequências de abuso de álcool foram 24,7% e 21,1% nos 12 meses anteriores à SCA e seis meses após, respectivamente. Os fatores de risco cardiovascular mais significativos associados com alto risco de abuso de álcool 30 dias após o evento agudo foram: sexo masculino (88,9%), tabagismo atual (52,8%) e hipertensão (58,3%). Seis meses após o evento agudo, os resultados mais significativos foram replicados em regressão logística para a associação de abuso de álcool e indivíduos mais jovens [35-44 anos, RC multivariada: 38,30 (IC 95%: 1,44-1012,56); e 45-54 anos, RC multivariada: 10,10 (IC 95%: 1,06-96,46)] e fumantes [fumantes atuais, RC multivariada: 51,09 (IC 95%: 3,49-748,01); e ex-fumantes, RC multivariada: 40,29 (IC 95%: 2,37-685,93)]. Conclusão: Indivíduos com menos de 54 anos e fumantes apresentaram uma significativa relação com consumo prejudicial de álcool, a despeito do subtipo de SCA. .

Design and baseline characteristics of a coronary heart disease prospective cohort: two-year experience from the strategy of registry of acute coronary syndrome study (ERICO study)

OBJECTIVES: To describe the ERICO study (Strategy of Registry of Acute Coronary Syndrome), a prospective cohort to investigate the epidemiology of acute coronary syndrome. METHODS: The ERICO study, which is being performed at a secondary general hospital in São Paulo, Brazil, is enrolling consecutive acute coronary syndrome patients who are 35 years old or older. The sociodemographic information, medical assessments, treatment data and blood samples are collected at admission. After 30 days, the medical history is updated, and additional blood and urinary samples are collected. In addition, a retinography, carotid intima-media thickness, heart rate variability and pulse-wave velocity are performed. Questionnaires about food frequency, physical activity, sleep apnea and depression are also applied. At six months and annually after an acute event, information is collected by telephone. RESULTS: From February 2009 to September 2011, 738 patients with a diagnosis of an acute coronary syndrome were enrolled. Of these, 208 (28.2%) had ST-elevation myocardial infarction (STEMI), 288 (39.0%) had non-ST-elevation myocardial infarction (NSTEMI) and 242 (32.8%) had unstable angina (UA). The mean age was 62.7 years, 58.5% were men and 77.4% had 8 years or less of education. The most common cardiovascular risk factors were hypertension (76%) and sedentarism (73.4%). Only 29.2% had a prior history of coronary heart disease. Compared with the ST-elevation myocardial infarction subgroup, the unstable angina and non-ST-elevation myocardial infarction patients had higher frequencies of hypertension, diabetes, prior coronary heart disease (p<0.001) and dyslipidemia (p = 0.03). Smoking was more frequent in the ST-elevation myocardial infarction patients (p = 0.006). CONCLUSIONS: Compared with other hospital registries, our findings revealed a higher burden of CV risk factors and less frequent prior CHD history.

Early stroke case-fatality rates in three hospital registries in the Northeast and Southeast of Brazil / Taxas de letalidade precoce por acidente vascular cerebral em três registros hospitalares no nordeste e sudeste do Brasil

Few studies have addressed early cerebrovascular lethality in Brazil. OBJECTIVE: To evaluate 10 and 28-day stroke case-fatality rates in three hospitals in three Brazilian cities. METHODS: We described the stroke registries in São Paulo, João Pessoa, and Natal. RESULTS: Out of a total of 962 first-ever events (mean age, 68.1 years-old; 53% men), 83.6% (804 cases) were classified as ischemic and 16.4% (158) as hemorrhagic stroke. Overall, the case-fatality rates and 95% confidence intervals (95%CI) for hemorrhagic stroke events were higher than for ischemic events, both at 10 (12.3%; 95%CI 7.2-17.4 versus 7.0%; 95%CI 5.3-8.8) and at 28 days (19.8%; 95%CI 13.6-26.0 versus 11.1%; 95%CI 8.9-13.3). CONCLUSIONS: We did not find any substantial differences in early case-fatality rates according to stroke subtypes, when comparing the three centers.

Poucos estudos abordaram a letalidade cerebrovascular precoce no Brasil. OBJETIVO: Avaliar taxas de letalidade por acidente vascular cerebral (AVC) em 10 e 28 dias após evento em três hospitais em três cidades brasileiras. MÉTODOS: Foram descritos os registros de AVC em São Paulo, João Pessoa e Natal. RESULTADOS: De um total de 962 primeiros eventos (idade média de 68,1 anos; 53% homens), 83,6% (804 casos) foram classificados como AVC isquêmico e 16,4% (158) como hemorrágico. As taxas de letalidade e intervalos de confiança de 95% (IC95%) para eventos de AVC hemorrágico foram maiores que para os isquêmicos em: 10 (12,3%; IC95% 7,2-17,4 versus 7,0%; IC95% 5,3-8,8) e 28 dias (19,8%; IC95% 13,6-26,0 versus 11,1%; IC95% 8,9-13,3). CONCLUSÕES: Não foram encontradas diferenças substanciais nas taxas de letalidade precoce por subtipo de AVC ao comparar os três centros estudados.

Educational levels and the functional dependence of ischemic stroke survivors / Nível de escolaridade e dependência funcional em sobreviventes de acidente vascular cerebral isquêmico

We evaluated the functional dependence of stroke survivors from the Study of Stroke Mortality and Morbidity, using the Rankin Scale. Out of 355 ischemic stroke survivors (with a mean age of 67.9 years), 40% had some functional dependence at 28 days and 34.4% had some functional dependence at 6 months. Most predictors of physical dependence were identified at 28 days. These predictors were: low levels of education [illiterate vs. > 8 years of education, multivariate odds ratio (OR) = 3.7; 95% confidence interval (95%CI): 1.60-8.54] and anatomical stroke location (total anterior circulation infarct, OR = 16.9; 95%CI: 2.93-97.49). Low levels of education and ischemic brain injury influenced functional dependence in these stroke survivors. Our findings reinforce the necessity of developing strategies for the rehabilitation of stroke patients, more especially in formulating specific strategies for care and treatment of stroke survivors with low socioeconomic status.

Foi avaliada a dependência funcional em sobreviventes de acidente vascular cerebral (AVC) do Estudo da Mortalidade e Morbidade do Acidente Vascular Cerebral, utilizando a Escala de Rankin. De 355 sobreviventes com AVC isquêmico (idade média de 67,9 anos), 40% tinham dependência funcional em 28 dias e 34,4% em 6 meses. Os principais indicadores de dependência física foram identificados em 28 dias, e eram: baixa escolaridade (analfabetos vs. > 8 anos de educação, RC = 3,7; IC95%: 1,60-8,54) e localização do AVC (infarto circulação total anterior, RC = 16,9; IC95%: 2,93-97,49). Baixo nível educacional e insulto cerebral isquêmico influenciaram o grau de dependência funcional nesses sobreviventes de AVC. Nossos achados reforçam a necessidade de desenvolvimento de estratégias para reabilitação de pacientes com AVC e formulação de estratégias específicas de atenção e tratamento para essas pessoas, especialmente na população com baixo nível socioeconômico.

Race, gender and stroke subtypes mortality in São Paulo, Brazil

Stroke mortality rates have a discrepant distribution according to socioeconomic variables as social exclusion in Brazil. Recently, data from race has been available from the official health statistics considering five categories: White, Mixed, Black, Asian and Native. We addressed in the city of São Paulo, Brazil, an analysis of cerebrovascular mortality according to race (excluding Asian and Native due to small number of events) and gender during 1999-2001 for people aged 30 to 79 years-old. For all cerebrovascular diseases, age-adjusted mortality rates (x 100,000) for men were higher for Black (150.2), intermediate for Mixed (124.2) and lower for White (104.5) people. These gradient patterns were similar for all stroke subtypes, except for subarachnoideal hemorrhage in which no differences were detected. For women, the rates were lower compared to men and the same pattern was observed among Black (125.4), Mixed (88.5) and White (64.1) women. Compared to White men, the risk ratio of Black men was 1.4. However, compared to White women, the risk ratio for Black women was 2.0. Concluding, there is a significant gradient of stroke mortality according to race, mainly among women.

As taxas de mortalidade pela doença cerebrovascular apresentam distribuição diferenciada de acordo com variáveis socioeconômicas. Informação sobre raça é nova no sistema de informação de mortalidade do Ministério da Saúde. Na cidade de São Paulo foi verificada entre três categoria de raça - branca, parda e negra - a taxa específica de mortalidade nos anos de 1999-2001 para pessoas entre 30 e 79 anos. Para o conjunto das doenças cerebrovasculares as taxas de mortalidade ajustadas para idade (x 100.000) para homens foram maiores entre os negros (150,2), intermediária para os pardos (124,2) e menor para brancos (104,5). Esse gradiente foi o mesmo para todos os subtipos, excluindo a hemorragia subaracnoídea. Para as mulheres, as taxas foram menores quando comparada aos homens e, o mesmo padrão foi observado para negras (125,4), pardas (88,5) e brancas (64,1). A razão de risco para homens negros quando comparado aos brancos foi 1.4, mas entre as mulheres negras e as brancas foi o dobro. Concluindo, houve um gradiente significativo da mortalidade cerebrovascular de acordo com raça, principalmente entre mulheres.