Validation of the Grace Risk Score to Predict In-Hospital and 6-Month Post-Discharge Mortality in Patients with Acute Coronary Syndrome

Abstract Background The wide range of clinical presentations of acute coronary syndrome (ACS) makes it indispensible to use tools for risk stratification and for appropriate risks management; thus, the use of prognosis scores is recommended in the immediat clinical decision-making. Objective To validate the Global Registry of Acute Coronary Events (GRACE) score as a predictor of in-hospital and 6-month post-discharge mortality in a population diagnosed with ACS. Methods This is a prospective cohort study of consecutive patients diagnosed with ACS between May and December 2018. GRACE scores were calculated, as well as their predictive value for in-hospital and 6-month post-discharge mortality. The validity of the model was assessed by two techniques: discriminative power using the area under the receiver operating characteristic curve (AUC) and goodness-of-fit, using the Hosmer-Lemeshow (HL) test, at the 5% level of significance. Results A total of 160 patients were included, mean age 64 (±10.9) years; of which 60% were men. The risk model showed to have satisfactory ability to predict both in-hospital mortality, with an area under the curve (AUC) of 0.76 (95% confidence interval [CI], 0.57-0.95; p = 0.014), and 6-month post-discharge mortality, with AUC of 0.78 (95%CI, 0.62-0.94), p = 0.002. The HL test indicated good-fit for both models of the GRACE score. Conclusion In this study, the GRACE risk score for predicting mortality was appropriately validated in patients with ACS, with good discriminative power and goodness-of-fit. The results suggest that the GRACE score is appropriate for clinical use in our setting.

Acute Myocardial Infarction with Non-Obstructive Coronary Arteries - Stratifying the Risk of a "new" Clinical Entity using an "Old" Tool

Abstract Background Some of the patients admitted for acute myocardial infarction have non-obstructive coronary artery disease (MINOCA). Their prognosis is not always benign, making it necessary the development of tools for risk stratification of these patients. Objectives To describe the characteristics of a sample of patients admitted for suspected MINOCA and to evaluate the prognostic value of GRACE score in this population. Methods This was a retrospective, observational, single-center, cohort study involving 56 consecutive patients with MINOCA. During one-year follow-up, patients were assessed for mortality and major adverse cardiovascular events (MACE) - a composite of all-cause mortality and hospitalization due to acute myocardial infarction, heart failure, ischemic stroke, and acute limb ischemia. Statistical analysis was performed using a non-parametric approach, with the Mann-Whitney U test for quantitative variables and ROC curves for assessing the discriminatory power of the Grace score in predicting cardiovascular events. The level of significance was set at 5%. Results Of the 56 MINOCA patients included in the study (median age 67 years), 55.4% were female. During the one-year follow-up, mortality rate was 5.5% and 9.1% of patients had MACE. A higher GRACE score was associated with mortality (p = 0.019; AUC 0.907; 95%CI 0.812-1.000; cut off 138) and MACE (p =0.034; AUC 0.790; 95%CI 0.632-0.948; cutoff 114). Conclusion The definition of MINOCA includes various diagnoses and prognoses, and the GRACE score is useful for risk stratification of patients with this condition.

Treatment of individual predictors with neural network algorithms improves Global Registry of Acute Coronary Events score discrimination / El tratamiento con redes neuronales de las variables del Global Registry of Acute Coronary mejora la discriminación del score

Abstract Objective: The aim of this study was to develop, train, and test different neural network (NN) algorithm-based models to improve the Global Registry of Acute Coronary Events (GRACE) score performance to predict in-hospital mortality after an acute coronary syndrome. Methods: We analyzed a prospective database, including 40 admission variables of 1255 patients admitted with the acute coronary syndrome in a community hospital. Individual predictors included in GRACE score were used to train and test three NN algorithm-based models (guided models), namely: one- and two-hidden layer multilayer perceptron and a radial basis function network. Three extra NNs were built using the 40 admission variables of the entire database (unguided models). Expected mortality according to GRACE score was calculated using the logistic regression equation. Results: In terms of receiver operating characteristic area and negative predictive value (NPV), almost all NN algorithms outperformed logistic regression. Only radial basis function models obtained a better accuracy level based on NPV improvement, at the expense of positive predictive value (PPV) reduction. The independent normalized importance of variables for the best unguided NN was: creatinine 100%, Killip class 61%, ejection fraction 52%, age 44%, maximum creatine-kinase level 41%, glycemia 40%, left bundle branch block 35%, and weight 33%, among the top 8 predictors. Conclusions: Treatment of individual predictors of GRACE score with NN algorithms improved accuracy and discrimination power in all models with respect to the traditional logistic regression approach; nevertheless, PPV was only marginally enhanced. Unguided variable selection would be able to achieve better results in PPV terms.

Resumen Objetivo: El objetivo fue desarrollar, entrenar y probar diferentes modelos basados en algoritmos de redes neuronales (RN) para mejorar el rendimiento del score del Registro Global de Eventos Coronarios Agudos (GRACE) para predecir la mortalidad hospitalaria después de un síndrome coronario agudo. Métodos: Analizamos una base de datos prospectiva que incluía 40 variables de ingreso de 1255 pacientes con síndrome coronario agudo en un hospital comunitario. Las variables incluidas en la puntuación GRACE se usaron para entrenar y probar tres algoritmos basados en RN (modelos guiados), a saber: perceptrones multicapa de una y dos capas ocultas y una red de función de base radial. Se construyeron tres RN adicionales utilizando las 40 variables de admisión de toda la base de datos (modelos no guiados). La mortalidad esperada según el GRACE se calculó usando la ecuación de regresión logística. Resultados: En términos del área ROC y valor predictivo negativo (VPN), casi todos los algoritmos RN superaron la regresión logística. Solo los modelos de función de base radial obtuvieron un mejor nivel de precisión basado en la mejora del VPN, pero a expensas de la reducción del valor predictivo positivo (VPP). La importancia normalizada de las variables incluidas en la mejor RN no guiada fue: creatinina 100%, clase Killip 61%, fracción de eyección 52%, edad 44%, nivel máximo de creatina quinasa 41%, glucemia 40%, bloqueo de rama izquierda 35%, y peso 33%, entre los 8 predictores principales. Conclusiones: El tratamiento de las variables del score GRACE mediante algoritmos de RN mejoró la precisión y la discriminación en todos los modelos con respecto al enfoque tradicional de regresión logística; sin embargo, el VPP solo mejoró marginalmente. La selección no guiada de variables podría mejorar los resultados en términos de PPV.

Practical Approach to Acute Coronary Syndrome in Patients with COVID-19

Abstract Acute cardiac injury is associated with higher mortality in patients with the novel coronavirus disease-2019 (COVID-19) and the exact etiology can be challenging to diagnose in the emergency setting during the pandemic. From a pathophysiological perspective, SARS-CoV-2 infection is characterized by an overproduction of inflammatory cytokines (IL-6, TNF-alpha) that leads to systemic inflammation and consequent increased risk of acute myocardial infarction (AMI) caused by atheromatous plaque rupture and significant myocardial oxygen supply-demand imbalance. Moreover, SARS-CoV-2 tropism to the renin-angiotensin-aldosterone system through the ACE2 receptor induces myocarditis that may rapidly progress to left ventricular dysfunction and hemodynamic instability. Myocardial inflammation with pericardial involvement, i.e. , myopericarditis, can progress to cardiac tamponade and obstructive shock. These cardiovascular complications, which are associated with a worse prognosis and higher mortality, can be associated with clinical manifestations, electrocardiographic changes, and troponin values similar to AMI. Thus, the diagnosis and treatment of patients with acute chest pain and dyspnea admitted to the emergency department is a significant challenge during the COVID-19 pandemic. Here, we provide a review of the literature focusing on a practical approach to acute coronary syndrome patients with confirmed or suspected COVID-19.

Diferencias en el tratamiento antitrombótico y pronóstico en función del sexo en pacientes con síndrome coronario agudo tratados con stent / Sex-specific differences in antithrombotic therapy and prognosis in patients with acute coronary syndrome treated with stent

Resumen Antecedentes y objetivo: El interés sobre la influencia del sexo en pacientes con síndrome coronario agudo (SCA) tratados con stent y nuevos antiagregantes inhibidores de P2Y12 en la práctica clínica es creciente. Se analizan las diferencias en función del sexo en el tratamiento con doble antiagregación plaquetaria (DAPT) y los eventos adversos isquémicos y hemorrágicos Materiales y métodos: Estudio prospectivo de pacientes consecutivos con diagnóstico de SCA tratados con stent coronario desde julio de 2015 hasta enero de 2016. Resultados: De un total de 283 pacientes incluidos, 75 (26.5%) correspondió a mujeres y 208 (73.5%) a hombres. La edad media fue de 71 ± 13 y 66.5 ± 13 años, respectivamente. Un 44% de mujeres se presentó como SCA con elevación del segmento ST contra un 52.4 de los hombres, p = 0.21. Las mujeres mostraron un mayor riesgo de sangrado (CRUSADE), sin diferencias en el riesgo isquémico (GRACE y TIMI). Se usaron stents farmacoactivos con más frecuencia en mujeres (88.9 vs. 75.5%, p = 0.04). Se observó una tendencia de menor prescripción del ticagrelor en mujeres (42.6 vs. 50.9%, p = 0.29) en favor de un mayor uso del clopidogrel. No se identificaron diferencias en cuanto a la prescripción del prasugrel. Las mujeres presentaron al año una menor mortalidad (1.4 vs. 6.7%, p = 0.19), aunque mayor sangrado (23.3 vs. 17.4%, p = 0.27). Conclusiones: En este estudio de pacientes consecutivos con SCA tratados con stent se registró una mayor prescripción de clopidogrel en las mujeres que en los hombres. Las mujeres presentaron una menor incidencia anual de mortalidad, pero mayor sangrado en comparación con los hombres, no significativo.

Abstract Aims and objective: Impact of sex-related differences in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention and treated with new P2Y12 inhibitors is not adequately characterised. We aimed to analyse gender-based differences in dual antiplatelet therapy, and adverse cardiovascular events and bleeding. Materials and methods: Prospective-observational study of the consecutive ACS patients treated with stent from July 2016 to January 2016, with a follow-up of 1 year. Results: We examined 283 patients, 75 (26.5%) women and 208 (73.5%) men. Women were older than men (71 ± 13 vs. 66,5 ± 13 years). There were 44% of women and 52% of men presenting with ST-elevation ACS (p = 0.21). Women had a higher bleeding risk (CRUSADE), without differences in the ischaemic risk (GRACE and TIMI). More women were treated with drug-eluting stent (88.9 vs. 75.5%, p = 0.04). There was a lower rate of ticagrelor prescription in women (42.6 vs. 50.9%, p = 0.29), in favour of clopidogrel. No differences were observed in prasugrel prescription. No significant differences were observed after a year of follow up, but women had a tendency towards lower mortality (1.4 vs. 6.7%, p = 0.19) and higher bleeding rates (23.3 vs. 17.4%, p = 0.27). Conclusions: In our study of patients presenting with ACS treated with stent, clopidogrel was preferred in women, whereas ticagrelor was the most frequent prescription in men. No significant differences were noted in clinical outcomes, but women experienced a tendency towards less mortality and more bleeding events.

Performance of cardiovascular risk scores in mortality prediction ten years after Acute Coronary Syndromes

SUMMARY BACKGROUND The objective of this study was to evaluate the performance of the Framingham risk score (FRS) and risk score by the American College of Cardiology/American Heart Association (SR ACC/AHA) in predicting mortality of patients ten years after acute coronary syndrome (ACS). METHODS This is a retrospective cohort study that included patients aged ≥ 18 years with ACS who were hospitalized at the Coronary Intensive Care Unit (ICU) of the Botucatu Medical School Hospital from January 2005 to December of 2006. RESULTS A total of 447 patients were evaluated. Of these, 118 were excluded because the mortality in 10 years was not obtained. Thus, 329 patients aged 62.9 ± 13.0 years were studied. Among them, 58.4% were men, and 44.4% died within ten years of hospitalization. The median FRS was 16 (14-18) %, and the ACC/AHA RS was 18.5 (9.1-31.6). Patients who died had higher values of both scores. However, when we classified patients at high cardiovascular risk, only the ACC/AHA RS was associated with mortality (p <0.001). In the logistic regression analysis, both scores were associated with mortality at ten years (p <0.001). CONCLUSIONS Both FRS and SR ACC/AHA were associated with mortality. However, for patients classified as high risk, only the ACC/AHA RS was associated with mortality within ten years.

RESUMO OBJETIVO Avaliar a performance do escore de risco de Framingham (ERF) e do escore proposto pela American College of Cardiology/American Heart Association (ER ACC/AHA) em predizer a mortalidade em pacientes dez anos após síndrome coronariana aguda (SCA). MÉTODOS Trata-se de um estudo de coorte retrospectivo que incluiu pacientes com idade ≥18 anos, com SCA, que estiveram internados na Unidade de Terapia Intensiva Coronariana (UTI) do Hospital das Clínicas de Botucatu, no período de janeiro de 2005 a dezembro de 2006. RESULTADOS Foram avaliados 447 pacientes. Destes, 118 foram excluídos, pois a mortalidade em dez anos não foi obtida. Logo, 329 pacientes com idade de 62,9±13,0 anos foram estudados. Dentre eles, 58,4% eram homens e 44,4% morreram no período de dez anos após a internação. A mediana do ERF foi de 16 (14-18)%, e do ER ACC/AHA foi 18,5 (9,1-31,6)%. Os pacientes que evoluíram a óbito apresentaram maiores valores dos escores. No entanto, quando classificamos os pacientes em alto risco cardiovascular, apenas o ER ACC/AHA foi associado com a mortalidade (p<0,001). Na análise de regressão logística, ambos os escores foram associados com a mortalidade em dez anos (p<0,001). CONCLUSÕES Tanto o ERF quanto o ER ACC/AHA foram associados com a mortalidade. No entanto, para os pacientes classificados como alto risco, apenas o ER ACC/AHA foi associado com a mortalidade em dez anos.

Application of Risks Scores in Acute Coronary Syndromes. How Does ProACS Hold Up Against Other Risks Scores? / Aplicação de Escores de Risco em Síndromes Coronárias Agudas: Como o ProACS se Comporta Diante de Outros Escores de Risco?

Abstract Background: Multiple risk scores (RS) are approved in the prediction of worse prognosis in acute coronary syndromes (ACS). Recently, the Portuguese Journal of Cardiology has proposed the ProACS RS. Objective: Application of several validated RS, as well as ProACS in patients, admitted for ACS. Evaluation of each RS's performance in predicting in-hospital mortality and the occurrence of all-cause mortality or non-fatal ACS at one-year follow-up and compare them to the ProACS RS. Methods: A retrospective study of ACS was performed. The following RS were applied: GRACE, ACTION Registry-GWTG, PURSUIT, TIMI, EMMACE, SRI, CHA2DS2-VASc-HS, C-ACS and ProACS. ROC Curves were created to determine the predictive power for each RS and then were directly compared to ProACS. Results: The ProACS, ACTION Registry-GWTG and GRACE showed a c-statistics of 0.908, 0.904 and 0.890 for predicting in-hospital mortality, respectively, performing better in ST-segment elevation myocardial infarction patients. The other RS performed satisfactorily, with c-statistics over 0.750, apart from the CHA2DS2-VASc-HS and C-ACS which underperformed. All RS underperformed in predicting worse long-term prognosis revealing c-statistics under 0.700. Conclusion: ProACS is an easily obtained risk score for early stratification of in-hospital mortality. When evaluating all RS, the ProACS, ACTION Registry-GWTG and GRACE RS showed the best performance, demonstrating high capability of predicting a worse prognosis. ProACS was able to demonstrate statistically significant superiority when compared to almost all RS. Thus, the ProACS has showed that it is able to combine simplicity in the calculation of the score with good performance in predicting a worse prognosis.

Resumo Fundamento: Existem muitos escores de risco (ERs) aprovados na predição de um pior prognóstico em síndromes coronárias agudas (SCAs). Recentemente, a Revista Portuguesa de Cardiologia propôs o ER ProACS. Objetivo: Aplicar vários ERs validados, bem como o ProACS em pacientes internados por SCA. Avaliar o desempenho de cada ER em predizer mortalidade hospitalar e a ocorrência de mortalidade por todas as causas ou SCA não fatal em um ano de acompanhamento e compará-los com o ProACS. Métodos: Estudo retrospectivo de SCA. Os seguintes ERs foram aplicados: GRACE, ACTION Registry-GWTG, PURSUIT, TIMI, EMMACE, SRI, CHA2DS2-VASc-HS, C-ACS e ProACS. Curvas ROC foram criadas para determinar o poder preditivo de cada ER e diretamente comparadas com a do ProACS. Resultados: Os escores ProACS, ACTION Registry-GWTG e GRACE mostraram estatística-C de 0,908, 0,904 e 0,890, respectivamente, em predizer mortalidade hospitalar, mostrando melhor desempenho em pacientes com infarto do miocárdio com elevação do segmento ST. Os demais ERs mostraram desempenho satisfatório, com estatística-C acima de 0,750, com exceção de CHA2DS2-VASc-HS e C-ACS, que mostraram baixa performance. Todos os ERs apresentaram baixo desempenho em predizer um pior prognóstico em longo prazo, com estatística-C abaixo de 0,700. Conclusão: O ProACS é um escore de risco facilmente obtido para estratificação precoce de mortalidade intra-hospitalar. Ao avaliar todos os ERs, ProACS, ACTION Registry-GWTG e GRACE mostraram o melhor desempenho, com alta capacidade de predizer um pior prognóstico. O ProACS mostrou superioridade estatisticamente significativa em comparação aos outros ERs. Portanto, o ProACS mostrou-se capaz de combinar simplicidade no cálculo do escore com bom desempenho em predizer um pior prognóstico.

Readmission of Patients with Acute Coronary Syndrome and Determinants / Reinternação de Pacientes com Síndrome Coronariana Aguda e seus Determinantes

Abstract Background: Acute coronary syndrome (ACS) is responsible for high rates of hospital admission and readmission, which are associated with increased costs for the patient and the health system, and increased in-hospital mortality rates. Objective: To evaluate readmission in patients with ACS and its determinants. Methods: This was a retrospective cohort study of adult and elderly patients with ACS, readmitted to public and private referral cardiology hospitals within one year after the first hospitalization for ACS. The occurrence of readmissions, the time elapsed from the first to the second admission, and the use of medications at admission were collected from the medical records. Associations between categorical variables were evaluated by the chi-square test or the Fisher's exact test. Multiple logistic regression was used to evaluate predictors for readmissions. A p < 0.05 was set as statistically significant. Results: Readmission rate was 21.5% (n = 115) and mean time between admissions was 122.7 ± 112.1 days. The patients were mostly men (64.0%), mean age of 63.15 ± 12.3 years. Among readmitted patients, 7% had a prognosis of "death", and 68.7% were readmitted more than once within a one-year period. The main reasons of readmission were cardiovascular diseases including ACS. Private health care and the diagnosis of congestive heart failure were associated with multiple logistic regression. Conclusion: ACS was the main cause of readmission, with higher prevalence among users of supplemental health care. Readmissions were associated with previous diagnosis of congestive heart failure and the type of health care provided.

Resumo Fundamento: A síndrome coronariana aguda (SCA) é responsável por elevados números de admissões e readmissões hospitalares, os quais estão associados ao aumento dos custos para o paciente e para o sistema de saúde, bem como à elevação nas taxas de mortalidade hospitalar. Objetivo: Investigar a reinternação entre pacientes com SCA e seus determinantes. Métodos: Trata-se de uma coorte retrospectiva de pacientes de ambos os sexos, adultos e idosos, diagnosticados com SCA. Foram avaliados, a partir dos registros dos hospitais locais públicos e privados de referência em cardiologia, a ocorrência de reinternação em até 1 ano após internação por SCA, o tempo entre as admissões e o uso de medicamentos no momento da reinternação. As variáveis categóricas foram associadas por meio do teste qui-quadrado, ou pelo teste exato de Fisher. Regressão logística múltipla foi utilizada para avaliar as variáveis preditoras da reinternação. Adotou-se como critério de significância estatística um valor de p < 0,05. Resultados: A ocorrência de reinternações foi de 21,46% (n = 115), e o período médio entre as internações foi de 122,74 (DP 112,14) dias. Os pacientes avaliados eram, em sua maioria, do sexo masculino (64,0%), com média de idade de 63,15 anos (DP 12,26). Sete por cento apresentaram óbito como prognóstico da reinternação, e 68,7% tiveram mais de uma reinternação em 1 ano. As causas cardiovasculares, entre elas a recorrência da SCA, foram as mais prevalentes entre as reinternações hospitalares. A assistência privada e o diagnóstico de insuficiência cardíaca congestiva (ICC) foram associados a reinternação após a regressão logística múltipla. Conclusão: Conclui-se que a SCA foi a principal causa de reinternação, sendo mais prevalente entre os usuários da rede suplementar de saúde. As reinternações associaram-se ao diagnóstico prévio de ICC e ao tipo de assitência à saúde.

Implementation of an Acute Coronary Syndrome Simulation Training Strategy for Emergency Healthcare Professionals

The knowledge on the management of patients with acute coronary syndrome (ACS) is essential to reduce the gap between evidence and practice. Objective: To describe a simulation training strategy for emergency healthcare professionals and provide preliminary data on knowledge acquisition, learners' confidence and prescription of medications after training. Methods: The training was part of the implementation of two myocardial infarction systems of care. It comprehended lectures and simulation-based learning using high and low-fidelity mannequins and actors. It was tested in two phases: the first one in Belo Horizonte and the second one in Montes Claros, both in the state of Minas Gerais. A test was applied before and after training to assess knowledge acquisition. Confidence to perform thrombolysis in ST-elevation myocardial infarction (STEMI) patients was assessed using a questionnaire, and the impact on medication prescription analyzed STEMI patients admitted to hospitals in Montes Claros. Results: In the first phase, 156 professionals answered both tests: 70% of them improved their results and the median number of right answers increased (6, interquartile range [IQR] 5-7; vs 7 ([IQR] 6-9; p < 0.05). In the second phase, 242 professionals answered both tests: 58% of the physicians and 83% of the nurses obtained better test scores. Participants referred a positive impact on their clinical practice, 95% reported feeling very secure when perform fibrinolysis after the training, and there was also an impact on medication prescription. Conclusions: There was an impact on the learners' knowledge acquisition and confidence using our two-phase training model, with evidence of impact on performance

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 periodontal disease on late morbimortality (10 years) of pacientes with acute coronary syndrome / Impacto da doença periodontal na morbimortalidade tardia (10 anos) de pacientes com síndrome coronariana aguda

Background: It is known that predisposing factors for periodontal disease (PD) and cardiovascular diseases are similar, just as dissemination of oral flora pathogens can induce the development of cardiovascular diseases, which play a direct role on the morbimortality of patients. Objective: To assess the impact of periodontal disease in the presence of acute coronary syndrome on late morbimortality after long-term follow-up of patients (10 years). Methods: The historical prospective study of continuous assessment was based on the evaluation of 345 medical records of patients hospitalized for acute coronary syndrome, divided into 3 groups: edentulous, with periodontal disease and without periodontal disease. The patients studied were in the ICU, in 2006, with a clinical picture of acute coronary syndrome submitted to invasive stratification with coronary angiography on the basis of clinical indication and were reassessed over the next 10 years. The qualitative variables were compared using the Chi-square test. Long-term mortality was assessed using the Kaplan-Meier curves, quantified with the hazard ratio (HR) and a confidence interval of 95% and compared through Cox regression. P values of less than or equal to 0.05 were regarded as statistically significant. Results: Of the 345 patients, 233 had at least one coronary obstruction greater than or equal to 50%, being the main group for comparison according to the different status of periodontal disease (without periodontal disease, with periodontal disease and edentulous). In his cardiovascular condition, we found a difference in mortality among edentulous patients compared to those free of periodontal disease, with a p = 0.004 and a hazard ratio of 10.496 (95% CI: 4.988-22.089). A is ignificant difference was also noted between edentulous patients and patients with periodontal disease, with a p = 0.0017 and a hazard ratio of 2.512 (95% CI: 1.491-4.234). Conclusion: A significant increase in mortality was found according with the progression of periodontal disease, which justifies its classification as an important risk factor for the development of cardiovascular diseases, as well as the need for prevention and treatment of oral diseases

Fractional Flow Reserve-Guided Strategy in Acute Coronary Syndrome. A Systematic Review and Meta-Analysis / Estratégia Guiada por Reserva de Fluxo Fracionada na Síndrome Coronária Aguda: Revisão Sistemática Metanálise

Abstract Background: There are limited data on the prognosis of deferral of lesion treatment in patients with acute coronary syndrome (ACS) based on fractional flow reserve (FFR). Objectives: To provide a systematic review of the current evidence on the prognosis of deferred lesions in ACS patients compared with deferred lesions in non-ACS patients, on the basis of FFR. Methods: We searched Medline, EMBASE, and the Cochrane Library for studies published between January 2000 and September 2017 that compared prognosis of deferred revascularization of lesions on the basis of FFR in ACS patients compared with non-ACS patients. We conducted a pooled relative risk meta-analysis of four primary outcomes: mortality, cardiovascular (CV) mortality, myocardial infarction (MI) and target-vessel revascularization (TVR). Results: We identified 7 studies that included a total of 5,107 patients. A pooled meta-analysis showed no significant difference in mortality (relative risk [RR] = 1.44; 95% CI, 0.9-2.4), CV mortality (RR = 1.29; 95% CI = 0.4-4.3) and TVR (RR = 1.46; 95% CI = 0.9-2.3) after deferral of revascularization based on FFR between ACS and non-ACS patients. Such deferral was associated with significant additional risk of MI (RR = 1.83; 95% CI = 1.4-2.4) in ACS patients. Conclusion: The prognostic value of FFR in ACS setting is not as good as in stable patients. The results demonstrate an increased risk of MI but not of mortality, CV mortality, and TVR in ACS patients.

Resumo Fundamento: Existem dados limitados sobre o prognóstico do adiamento do tratamento das lesões em pacientes com síndrome coronária com base na reserva de fluxo fracionada (FFR). Objetivos: Realizar uma revisão sistemática da evidência atual sobre o prognóstico do adiamento do tratamento de lesões em pacientes com SCA com base na FFR, comparando-o com o prognóstico em pacientes sem SCA. Métodos: Pesquisamos as bases de dados do Medline, EMBASE, e Cochrane Library por estudos publicados entre janeiro de 2000 e setembro de 2017 que compararam o prognóstico do adiamento da revascularização das lesões com base na FFR em pacientes com SCA em comparação a pacientes sem SCA. Conduzimos uma metanálise do risco relativo de quatro desfechos primários: mortalidade, mortalidade cardiovascular, infarto do miocárdio (IM) e revascularização do vaso-alvo (TVR). Resultados: Identificamos sete estudos que incluíram um total de 5107 pacientes. A metanálise mostrou que não houve diferença quanto à mortalidade [risco relativo (RR) = 1,44; IC95%, 0,9-2,4), mortalidade cardiovascular (RR = 1,29; IC95% = 0,4-4,3) e TVR (RR = 1,46; IC95% = 0,9-2,3) após adiamento da revascularização com base na FFR entre pacientes com SCA e pacientes sem SCA. Tal adiamento foi associado com risco adicional de IM (RR = 1,83; IC95% = 1,4-2,4) em pacientes com SCA. Conclusão: O valor prognóstico da FFR na SCA não é tão bom como em pacientes estáveis. Os resultados mostram um risco aumentado de IM, mas não de mortalidade, mortalidade cardiovascular, e TVR em pacientes com SCA.

Gerenciamento do protocolo de dor torácica no setor de emergência / Management of the toracic pain protocol in the emergency department

OBJETIVO: Avaliar a adesão dos plantonistas da emergência na aplicação de um protocolo de dor torácica e o impacto no índice de mortalidade por infarto agudo do miocárdio. MÉ- TODOS: Estudo retrospectivo, realizado de maio de 2016 até maio de 2017. Os dados foram obtidos por relatórios do sistema TASY e mostram todas as admissões por queixa de dor torácica, segundo a CID10. Estas admissões foram tabuladas em planilha Excel. RESULTADOS: Dos 1.657 pacientes com entrada na emergência clínica por queixa de dor torácica, 471 apresentavam síndrome coronariana. Na amostra, 67,39% dos pacientes eram do sexo masculino, com média de idade de 59,72 anos. Destes, 92 (19,96%) foram diagnosticados com infarto agudo do miocárdio, 30 (28,26%) apresentavam supradesnivelamento do segmento ST e 62 (71,74%) foram diagnosticados como infarto agudo do miocárdio sem supradesnivelamento do segmento ST. Todos os casos que necessitaram de angioplastia tiveram o procedimento executado dentro do prazo estabelecido pelas diretrizes internacionais. Receberam aspirina profilática 469 (99,57%) pacientes. A mortalidade dos pacientes internados com infarto agudo do miocárdio foi de 2,17%. CONCLUSÃO: O gerenciamento deste protocolo permite mapear o processo, bem como verificar eficácia, pontos fortes e fracos, e os riscos.(AU)

OBJECTIVE: To evaluate the adherence of emergency doctors to the application of the chest pain protocol, and the impact on mortality rate from acute myocardial infarction. METHODS: This is a retrospective study performed from May 2016 to May 2017. Data were obtained from TASY reports and show all admissions for chest pain complaints (ICD-10). These admissions were tabulated in Excel spreadsheet. RESULTS: Of the 1.657 patients admitted to the clinical emergency due to a complaint of chest pain, 471 had a coronary syndrome. In the sample, 67.39% of patients were male, with a mean age of 59.72 years. Of these, 92 (19.96%) were diagnosed with acute myocardial infarction, 30 (28.26%) presented ST segment elevation, and 62 (71.74%) were diagnosed as acute myocardial infarction without ST segment elevation. All cases requiring angioplasty had the procedure performed within the period established by the international guidelines. Of the patients, 469 (99.57%) received prophylactic aspirin. The mortality of patients hospitalized with acute myocardial infarction was 2.17%. CONCLUSION: The management of this protocol allows mapping the process, checking efficacy, strengths, weaknesses, and risks.(AU)

Prognostic Impact of Iron Metabolism Changes in Patients with Acute Coronary Syndrome / Impacto Prognóstico das Alterações do Metabolismo do Ferro em doentes com Síndrome Coronária Aguda

Abstract Background: Iron metabolism disorders have been associated with an increased risk of cardiovascular events. However, the prognostic impact on patients (pts) with acute coronary syndrome (ACS) has yet to be clarified. Objective: To determine the prognostic value of serum iron and ferritin levels in pts with ACS in the short and long-term. Methods: Consecutive pts admitted to a coronary care unit with a diagnosis of ACS, for a period of 2 years, were evaluated. The population was divided into tertiles of serum iron and ferritin distribution. The primary adverse events were the occurrence of in-hospital death or heart failure (HF) and death or HF at 1 year of follow-up. Results: We studied 280 pts (73% males; mean age 68 ± 13 years). The mean levels of serum iron and ferritin were 59 ± 34 mcg/dL and 205 ± 185 ng/mL, respectively. Patients included in the 1st tertile of serum iron (≤ 40 mcg/dL) had a higher rate of adverse events, in-hospital and after 1 year. Lower and higher levels of ferritin (1st and 3rd tertiles, ≤ 110; >219 ng/ml, respectively) were associated with a higher incidence of HF during hospitalization and death at 1 year. A ferritin value >316 ng /mL was an independent risk factor for death at 1 year (adjusted OR: 14; 95%CI: 2.6 to 75.9). Conclusion: In this population, iron metabolism alterations were associated with a higher rate of adverse events and higher ferritin levels constituted an independent mortality predictor in the long-term.

Resumo Fundamento: Alterações do metabolismo do ferro têm sido associadas a um aumento do risco de eventos cardiovasculares. No entanto, o impacto prognóstico em doentes (dts) com síndrome coronária aguda (SCA) encontra-se ainda pouco esclarecido. Objetivo: Determinar o valor prognóstico a curto e longo prazo dos níveis séricos do ferro e ferritina em dts com SCA. Métodos: Foram avaliados doentes consecutivos admitidos numa Unidade Coronária com o diagnóstico de SCA no período de 2 anos. A população foi agrupada segundo os tercis de distribuição de ferro e ferritina. Os eventos adversos primários foram a ocorrência de morte intrahospitalar e a 1 ano, bem como, insuficiência cardíaca (IC) intrahospitalar e a 1 ano de follow-up. Resultados: Estudaram-se 280 dts (73% sexo masculino; idade média de 68 ± 13 anos). O nível médio de ferro sérico e de ferritina foi 59 ± 34 mcg/dl e 205 ± 185 ng/ml, respetivamente. Os doentes incluídos no 1º tercil (≤ 40 mcg/dl) de ferro sérico apresentaram maior percentagem de eventos adversos intrahospitalares e a 1 ano. Níveis mais baixos e mais elevados de ferritina (1º e 3º tercil, respetivamente, ≤ 110; > 219 ng/ml) estiveram associados a uma maior ocorrência de IC em internamento e de morte a 1 ano. Um valor de ferritina > 316 ng/mL constituiu fator de risco independente de morte a 1 ano (OR ajustado 14 IC 95% 2,6-75,9). Conclusão: Nesta população alterações do metabolismo do ferro estiveram associadas a uma maior ocorrência de eventos adversos e níveis elevados de ferritina constituíram preditor independente de mortalidade a longo prazo.

Registro de síndrome coronariana aguda na enfermaria do Hospital Governador Flávio Ribeiro Coutinho em Santa Rita-PB / Record of Acute Coronary Syndrome in the infirmary at Governador Hospital Flávio Ribeiro Coutinho in Santa Rita-PB

Observamos que no nosso serviço, o uso de AAS e clopidogrel na emergência, a positividade da CKMB e um maior período de internamento estiveram associados a uma maior associação com pontuação intermediária no escore de risco TIMI

Is There Any Relationship between TSH Levels and Prognosis in Acute Coronary Syndrome? / Existe Alguma Relação entre Níveis de TSH e Prognóstico em Síndrome Coronariana Aguda?

Abstract Background: Some small studies have related higher levels of thyrotropin (TSH) to potentially worse prognosis in acute coronary syndromes. However, this relationship remains uncertain. Objective: To analyze the outcomes of patients with acute coronary syndromes in relation to the value of TSH at admission. Methods: Observational and retrospective study with 505 patients (446 in group I [TSH ≤ 4 mIU/L] and 59 in group II [TSH > 4 mIU/L]) with acute coronary syndromes between May 2010 and May 2014. We obtained data about comorbidities and the medications used at the hospital. The primary endpoint was in-hospital all-cause death. The secondary endpoint included combined events (death, non-fatal unstable angina or myocardial infarction, cardiogenic shock, bleeding and stroke). Comparisons between groups were made by one-way ANOVA and chi-square test. Multivariate analysis was determined by logistic regression. Analyses were considered significant when p < 0.05. Results: Significant differences between groups I and II were observed regarding the use of enoxaparin (75.2% vs. 57.63%, p = 0.02) and statins (84.08% vs. 71.19%, p < 0.0001), previous stroke (5.83% vs. 15.25%, p = 0.007), combined events (14.80% vs. 27.12%, OR = 3.05, p = 0.004), cardiogenic shock (4.77% vs. 6.05%, OR = 4.77, p = 0.02) and bleeding (12.09% vs. 15.25%, OR = 3.36, p = 0.012). Conclusions: In patients with acute coronary syndromes and TSH > 4 mIU/L at admission, worse prognosis was observed, with higher incidences of in-hospital combined events, cardiogenic shock and bleeding.

Resumo Fundamento: Estudos pequenos têm relacionado níveis mais elevados de hormônio tireoestimulante (TSH) a pior prognóstico em pacientes com síndrome coronariana aguda (SCA). Tal relação, no entanto, permanece incerta. Objetivo: Analisar os desfechos de pacientes com SCA, relacionando-os aos níveis de TSH medidos no setor de emergência. Métodos: Estudo retrospectivo observacional incluindo 505 pacientes com SCA (446 no grupo I: TSH ± 4 mUI/L; 59 no grupo II: TSH > 4 mUI/L) entre maio de 2010 e maio de 2014. Dados sobre comorbidades e medicamentos usados foram obtidos. O desfecho primário foi mortalidade intra-hospitalar por todas as causas. O desfecho secundário incluiu eventos combinados (morte, angina instável não fatal ou infarto do miocárdio, choque cardiogênico, sangramento e acidente vascular encefálico). A comparação entre grupos foi realizada através de ANOVA de uma via e teste do qui-quadrado. A análise multivariada foi realizada por regressão logística, adotando-se o nível de significância de p < 0,05. Resultados: Diferenças significativas foram observadas entre os grupos I e II relacionadas ao uso de enoxaparina (75,2% vs. 57,63%; p = 0,02) e estatinas (84,08% vs. 71,19%; p < 0,0001), acidente vascular encefálico prévio (5,83% vs. 15,25%; p = 0,007), eventos combinados (14,80% vs. 27,12%, OR = 3,05; p = 0,004), choque cardiogênico (4,77% vs. 6,05%, OR = 4,77; p = 0,02) e sangramento (12,09% vs. 15,25%, OR = 3,36; p = 0,012). Conclusão: Em pacientes com SCA e TSH > 4 mUI/L à admissão hospitalar, observou-se pior prognóstico associado à maior incidência de eventos combinados intra-hospitalares, choque cardiogênico e sangramentos.

Prognostic Accuracy of the GRACE Score in Octogenarians and Nonagenarians with Acute Coronary Syndromes / Acurácia Prognóstica do Escore GRACE em Octogenários e Nonagenários com Síndromes Coronarianas Agudas

Abstract Background: The GRACE Score was derived and validated from a cohort in which octogenarians and nonagenarians were poorly represented. Objective: To test the accuracy of the GRACE score in predicting in-hospital mortality of very elderly individuals with acute coronary syndromes (ACS). Methods: Prospective observational study conducted in the intensive coronary care unit of a tertiary center from September 2011 to August 2016. Patients consecutively admitted due to ACS were selected, and the very elderly group was defined by age ≥ 80 years. The GRACE Score was based on admission data and its accuracy was tested regarding prediction of in-hospital death. Statistical significance was defined by p value < 0,05. Results: A total of 994 individuals was studied, 57% male, 77% with non-ST elevation myocardial infarction and 173 (17%) very elderly patients. The mean age of the sample was 65 ± 13 years, and the mean age of very elderly patients subgroup was 85 ± 3.7 years. The C-statistics of the GRACE Score in very elderly patients was 0.86 (95% CI = 0.78 - 0.93), with no difference when compared to the value for younger individuals 0.83 (95% CI = 0.75 - 0.91), with p = 0.69. The calibration of the score in very elderly patients was described by χ2 test of Hosmer-Lemeshow = 2.2 (p = 0.98), while the remaining patients presented χ2 = 9.0 (p = 0.35). Logistic regression analysis for death prediction did not show interaction between GRACE Score and variable of very elderly patients (p = 0.25). Conclusion: The GRACE Score in very elderly patients is accurate in predicting in-hospital ACS mortality, similarly to younger patients.

Resumo Fundamento: O Escore GRACE foi derivado e validado por coorte de questionável representatividade de indivíduos octogenários e nonagenários. Objetivo: Testar a acurácia do Escore GRACE na predição de óbito hospitalar em indivíduos muito idosos com síndromes coronarianas agudas (SCAs). Métodos: Coleta prospectiva realizada em unidade coronariana de hospital terciário, durante o período de setembro de 2011 a agosto de 2016. Indivíduos consecutivamente internados com SCA foram selecionados e o grupo muito idoso definido por idade ≥ 80 anos. A acurácia do Escore GRACE foi testada quanto à predição de óbito hospitalar. A significância estatística foi definida por valor p < 0,05. Resultados: Foram estudados 994 indivíduos, sendo 57% do sexo masculino, 77% com SCA sem supradesnível do segmento ST e 173 pacientes muito idosos. A média geral de idade foi 65 ± 13 anos, e a média de idade dos pacientes muito idosos, 85 ± 3,7 anos. A estatística-C do Escore GRACE em indivíduos muito idosos foi de 0,86 (95% IC = 0,78 - 0,93), sem diferença em relação aos indivíduos mais jovens (0,83; 95% IC = 0,75 - 0,91), com p = 0,69. A calibração do escore em muito idosos foi descrita por Teste χ2 de Hosmer-Lemeshow = 2,2 (p = 0,98), enquanto os demais pacientes apresentaram χ2 = 9,0 (p = 0,35). A análise de regressão logística para predição de óbito não revelou interação entre Escore GRACE e a variável muito idoso (p = 0,25). Conclusão: O Escore GRACE em indivíduos muito idosos é acurado para predição de mortalidade hospitalar em SCA, semelhante para indivíduos mais jovens.

Incremental Prognostic Value of the Incorporation of Clinical Data Into Coronary Anatomy Data in Acute Coronary Syndromes: SYNTAX-GRACE Score / Valor Prognóstico Incremental da Incorporação de Dados Clínicos à Anatomia Coronária em Síndromes Coronarianas Agudas: Escore SYNTAX-GRACE

Abstract Background: When performing coronary angiography in patients with acute coronary syndrome (ACS), the anatomical extent of coronary disease usually prevails in the prognostic reasoning. It has not yet been proven if clinical data should be accounted for in risk stratification together with anatomical data. Objective: To test the hypothesis that clinical data increment the prognostic value of anatomical data in patients with ACS. Methods: Patients admitted with objective criteria for ACS and who underwent angiography during hospitalization were included. Primary outcome was defined as in-hospital cardiovascular death, and the prognostic value of the SYNTAX Score (anatomical data) was compared to that of the SYNTAX-GRACE Score, which resulted from the incorporation of the GRACE Score into the SYNTAX score. The Integrated Discrimination Improvement (IDI) was calculated to evaluate the SYNTAX-GRACE Score ability to correctly reclassify information from the traditional SYNTAX model. Results: This study assessed 365 patients (mean age, 64 ± 14 years; 58% male). In-hospital cardiovascular mortality was 4.4%, and the SYNTAX Score was a predictor of that outcome with a C-statistic of 0.81 (95% CI: 0.70 - 0.92; p < 0.001). The GRACE Score was a predictor of in-hospital cardiac death independently of the SYNTAX Score (p < 0.001, logistic regression). After incorporation into the predictive model, the GRACE Score increased the discrimination capacity of the SYNTAX Score from 0.81 to 0.92 (95% CI: 0.87 - 0.96; p = 0.04). Conclusion: In patients with ACS, clinical data complement the prognostic value of coronary anatomy. Risk stratification should be based on the clinical-anatomical paradigm, rather than on angiographic data only.

Resumo Fundamento: Uma vez realizada a coronariografia em pacientes com síndrome coronariana aguda (SCA), a extensão anatômica da doença coronária prevalece no raciocínio prognóstico. Não está estabelecido se dados clínicos devem também ser contabilizados na estimativa de risco, uma vez que se tenha conhecimento da anatomia coronária. Objetivo: Testar a hipótese de que dados clínicos incrementam o valor prognóstico da avaliação anatômica em pacientes com SCA. Métodos: Indivíduos admitidos com critérios objetivos de SCA e que realizaram coronariografia durante o internamento foram incluídos no estudo. Desfecho primário foi definido como óbito cardiovascular hospitalar, sendo comparado o valor prognóstico do Escore SYNTAX (anatomia) com o do escore SYNTAX-GRACE, resultante da incorporação do Escore GRACE ao Escore SYNTAX. O cálculo do Integrated Discrimination Improvement (IDI) foi realizado para avaliar a capacidade do modelo SYNTAX-GRACE para reclassificar corretamente a informação do modelo SYNTAX tradicional. Resultados: Foram estudados 365 pacientes, idade 64±14 anos, 58% masculinos. A mortalidade cardiovascular durante hospitalização foi de 4,4% e o Escore SYNTAX foi preditor desse desfecho com estatística-C de 0,81 (IC 95% = 0,70 - 0,92; p < 0,001). O Escore GRACE mostrou-se preditor de óbito cardiovascular intra-hospitalar, independente do Escore SYNTAX (p < 0,001 por regressão logística). Ao ser incorporado ao modelo preditor, o Escore GRACE incrementou a capacidade discriminatória do SYNTAX de 0,81 para 0,92 (IC 95% = 0,87 - 0,96; p = 0,04). Conclusão: Em pacientes com SCA, dados clínicos complementam o valor prognóstico da anatomia coronária, devendo a estratificação de risco ser baseada no paradigma clínico-anatômico e não apenas em dados angiográficos.