Clinical Course of Patients Undergoing Myocardial Revascularization Surgery in a Public Cardiology Referral Hospital in Pará, Brazil

Myocardial revascularization surgery (MRS) is the most frequently performed cardiac surgery in Brazil. However, data on mortality rates among patients undergoing MRS in hospitals other than the main referral centers in the northern Brazil are scarce. Objective: To describe the clinical course of patients that submitted to MRS in the major public cardiology referral hospital in the Brazilian Amazon. Methods: Retrospective cohort analysis, by review of medical records of patients who had undergone MRS at Hospital das Clínicas Gaspar Vianna (FHCGV) from January 2013 to June 2014. Results: A total of 179 patients were evaluated. Mortality rate was 11.7% until 30 days after surgery. Waiting time for surgery ≥ 30 days (OR 2.59, 95%CI 1.02 - 6.56, p = 0.039), infection during hospitalization (OR 3.28, 95%CI 1.15 - 9.39, p = 0.021) and need for hemodialysis after surgery (OR 9.06 95%CI 2.07 - 39.54, p = 0.001) were predictors of mortality after CABG. Conclusion: A high mortality rate in the study population was found, higher than that reported in the literature and in other regions of Brazil

Dor torácica na sala de emergência: quem fica e quem pode ser liberado? / Chest pain in the emergency room: who is left and who can be released?

A dor torácica aguda é um sintoma muito frequente nas unidades de emergência, constituindo-se em um possível sinal de alerta para as doenças com risco iminente de morte. Como a maioria desses pacientes é internada para avaliação de uma possível síndrome coronariana aguda, isso gera um custo hospitalar muito alto por paciente. Por conta dessa possibilidade diagnóstica, muitos emergencistas internam a maioria dos pacientes. Por outro lado, a liberação inapropriada daqueles com infarto agudo do miocárdio representa um risco para o médico e, especialmente, para o paciente. Outro ponto importante é a demora para o atendimento, em que há a influência de fatores relacionados ao paciente, assim como, pontos negativos na logística de atendimento dos serviços de emergência em nosso país. Para excelência no atendimento, é importante uma anamnese detalhada adicionada ao exame físico, a qual permite a elaboração das hipóteses diagnósticas. E para auxiliar os médicos na escolha da hipótese diagnóstica e na tomada rápida de decisão, escores de risco são disponibilizados, os quais, facilmente, identificam a probabilidade de eventos adversos. A conduta imediata de casos com risco de morte imediata tem como principal objetivo reduzir a morbidade e a mortalidade, aumentando, consequentemente, a segurança do profissional da emergência. Sugestões de fluxogramas e algoritmos para o atendimento desses pacientes na sala de emergência definem, de forma objetiva, quem fica e quem pode ser liberado

Acute chest pain is a frequent symptom in emergency units, being a possible war-ning sign of diseases with an imminent risk of death. Since most of these patients are hospitalized to evaluate possible acute coronary syndrome, this generates a very high hospital cost per patient. Because of this diagnostic possibility, emergency professionals admit most patients. In contrast, the inappropriate release of those with acute myocardial infarction poses a risk to the physician and, especially, the patient. Another important point is the delay in care, where there is an influence of patient-related factors, as well as negative points in the logistics of care in the emergency services in our country. For excellence in care, a detailed anamnesis added to the examination is important, allowing the elaboration of diagnostic hypotheses. Moreover, to assist physicians in selecting the diagnostic hypothesis and making fast decisions, there are risk scores that easily identify the likelihood of adverse events. The immediate management of cases with an imminent risk of death is the main objective to reduce morbidity and mortality and, consequently, increase the safety of emergency professionals. Flowcharts and algorithm suggestions targeting patients in the emergency room objectively define who stays and who can be released

Severity of erectile dysfunction is highly correlated with the syntax score in patients undergoing coronariography

ABSTRACT Objective To investigate the association between the severity of erectile dysfunction (ED) and coronary artery disease (CAD) in men undergoing coronary angiography for angina or acute myocardial infarct (AMI). Material and Methods We studied 132 males who underwent coronary angiography for first time between January and November 2010. ED severity was assessed by the international index of erectile function (IIEF-5) and CAD severity was assessed by the Syntax score. Patients with CAD (cases) and without CAD (controls) had their IIEF-5 compared. In the group with CAD, their IIEF-5 scores were compared to their Syntax score results. Results We identified 86 patients with and 46 without CAD. The IIEF-5 score of the group without CAD (22.6±0.8) was significantly higher than the group with CAD (12.5±0.5; p<0.0001). In patients without ED, the Syntax score average was 6.3±3.5, while those with moderate or severe ED had a mean Syntax score of 39.0±11.1. After adjustment, ED was independently associated to CAD, with an odds ratio of 40.6 (CI 95%, 14.3-115.3, p<0.0001). The accuracy of the logistic model to correctly identify presence or absence of CAD was 87%, with 92% sensitivity and 78% specificity. The average time that ED was present in patients with CAD was 38.8±2.3 months before coronary symptoms, about twice as high as patients without CAD (18.0±5.1 months). Conclusions ED severity is strongly and independently correlated with CAD complexity, as assessed by the Syntax score in patients undergoing coronariography for evaluation of new onset coronary symptoms.

Angioplastia no tronco calcificado com suporte biorreabsorvível por limitação para antiagregação / Bioresorbable device implantation in left main in patients with limitation for long-term using of dual

Homem com angina instável e lesão grave, calcificada no tronco de coronária esquerda (TCE). Antecedentes:revascularização e anemia. A intenção de tratamento era angioplastia com stent farmacológico (SF) no TCE.Apresentou hemorragia digestiva e piora da anemia, que foram tratadas. Angina refratária à terapêutica clínica. Devido à limitação para antiagregação foi implantado o dispositivo biorreabsorvível (BVS) no TCE. Este relato discute o uso do BVS em lesão complexa, proporcionando absorção do dispositivo, possibilitando melhor manuseio da antiagregação e o seguimento futuro da obstrução tratada, através de métodos de imagem não invasivos.

Male patient with unstable angina and critical calcified lesion in the left main coronary artery (LMCA). Background: coronary artery bypass grafting and anemia. The intention to treat was angioplasty with drug-eluting stents (DES) in the LMCA. The patientpresented gastrointestinal bleeding and worsening of anemia, which were treated. Angina was refractory to medical therapy. Because of antiplatelet therapy limitation, bioresorbable vascular support (BVS) was implanted in the LMCA. This case report discusses theuse of BVS in complex lesion, enabling absorption of the device and better management of antiplatelet therapy and future follow-up of the obstruction treated using by non-invasive imaging methods.

Comparison of ACUITY and CRUSADE Scores in Predicting Major Bleeding during Acute Coronary Syndrome / Comparação entre os Escores ACUITY e CRUSADE para Predição de Sangramento Maior na Síndrome Coronariana Aguda

The ACUITY and CRUSADE scores are validated models for prediction of major bleeding events in acute coronary syndrome (ACS). However, the comparative performances of these scores are not known.

Os escores ACUITY e CRUSADE são modelos validados para a predição de eventos de sangramento maior na síndrome coronariana aguda (SCA). Os desempenhos comparativos desses escores, entretanto, são desconhecidos.

Anticoagulação na síndrome coronária aguda / Anticoagulation in acute coronary syndrome

As síndromes coronárias agudas geralmente resultam da instabilização de uma placa aterosclerótica, com subsequente ativação plaquetária e de diversos fatores de coagulação.O tratamento visa aliviar a dor isquêmica, limitar o dano miocárdico e diminuir a mortalidade. Diversos agentes anticoagulantes provaram sua utilidade e novas drogas passarama compor o arsenal terapêutico atual, buscando maior eficácia anti-isquêmica e menores índices de sangramento. Apesar dos avanços, as taxas de mortalidade, reinfarto e reinternação ainda permanecem elevadas. Nessa revisão, sintetizamos as características e aplicabilidade dos anticoagulantes aprovados para o tratamento das síndromes coronárias agudas.

Acute coronary syndromes usually are the result of thedestabilization of atherosclerotic plaque with subsequent plateletand various coagulation factors activation. Treatment aims torelieve ischemic pain, limit myocardial damage and decreasemortality. Several anticoagulants have proven their usefulnessand new drugs compose the therapeutic arsenal, seekinggreater anti-ischemic efficacy and lower rates of bleeding.Despite advances, mortality rates, infarction and hospitalreadmission still remains high. In this review we summarizedthe characteristics and applicability of the anticoagulants thatare approved for the treatment of acute coronary syndromes.

Angina instável não aumenta mortalidade em cirurgia de revascularização miocárdica / Unstable angina does not increase mortality in coronary artery bypass graft surgery

INTRODUÇÃO: A cirurgia de revascularização do miocárdio muitas vezes é o tratamento de escolha de pacientes que sofrem angina instável. Não sabemos se essa condição acresce morbimortalidade nesse cenário. OBJETIVO: Comparar os desfechos dos pacientes submetidos a cirurgia de revascularização do miocárdio com quadro de angina instável com os pacientes submetidos a cirurgia de revascularização do miocárdio que não apresentaram angina instável. MÉTODOS: Coorte retrospectiva. A angina instável foi definida como síndrome coronariana aguda sem supradesnivelamento de ST e sem alteração enzimática e/ou angina classe IV. RESULTADOS: No período entre fevereiro de 1996 a julho de 2010, de 2.818 a cirurgia de revascularização do miocárdio isoladas realizadas, 1.016 (36,1%) pacientes apresentaram angina instável. A análise multivariada demonstrou que os pacientes com angina instável no pré-operatório utilizaram mais medicações como ácido acetilsalicílico, betabloqueador, heparina (anticoagulação plena), nitrato e menor necessidade de diureticoterapia, do que pacientes sem angina instável. Pacientes com angina instável utilizaram maior monitorização com Swan-Ganz e suporte com balão intra-aórtico do que os pacientes estáveis. Sobre os desfechos, necessitaram de maior tempo de internação (P=0,030) e apresentaram menor taxa de óbito (P=0,018) no pós-operatório de cirurgia de revascularização do miocárdio isolada. CONCLUSÃO: Submeter pacientes a cirurgia de revascularização do miocárdio isolada na vigência de síndrome coronariana aguda como angina instável não elevou a taxa de mortalidade.

INTRODUCTION: Coronary artery bypass graft is often the treatment of choice for patients who suffer from unstable angina. We do not know whether this condition adds morbidity in this scenario. OBJECTIVE: To compare the outcomes of patients undergoing coronary artery bypass graft with unstable angina framework with patients who underwent coronary artery bypass graft showed no unstable angina. METHODS: Retrospective cohort study. Unstable angina was defined as acute coronary syndrome without ST elevation and without enzymatic alteration and/or class IV angina. RESULTS: Between February 1996 and July 2010, to 2,818 isolated coronary artery bypass graft performed, 1,016 (36.1%) patients had unstable angina. Multivariate analysis showed that patients with preoperative unstable angina used more medications such as acetylsalicylic acid, beta-blocker, heparin (anticoagulation), nitrate and less need for diuretics than patients without unstable angina. Patients with unstable angina used increased monitoring with Swan-Ganz and support with intra-aortic balloon than stable patients. On outcomes, required longer hospitalization (P=0.030) and had a lower death rate (P=0.018) in the post-coronary artery bypass graft alone. CONCLUSION: Submit patients to coronary artery bypass graft in the presence of acute coronary syndrome such as unstable angina did not increase the mortality rate.

Resistência à insulina e indicadores antropométricos em pacientes com sindrome coronariana aguda / Insulin resistance and anthropometric indexes among patients with acute coronary syndrome

Fundamentos: Prevalências de resistência à insulina (RI) são elevadas em pacientes com síndrome coronariana aguda (SCA); entretanto sua associação com indicadores antropométricos específicos e a identificação do melhor parâmetro para detecção de RI nesses pacientes ainda não estão estabelecidos. Objetivos: Determinar a prevalência de RI através de diversos indicadores e correlacioná-los com parâmetros antropométricos em pacientes com SCA. Métodos: Estudo transversal incluindo 28 pacientes. Aferiu-se peso (kg), estatura (m), circunferências da cintura e do quadril e foram calculados índice de massa corporal (IMC), circunferência da cintura (CC), razão cintura-quadril (RCQ), razão cintura-estatura (RCEst) e body adiposity index (BAI). Exames bioquímicos foram obtidos através de prontuário médico e resistência à insulina foi determinada por razão glicose-insulina (RGI), índice HOMA-IR e critério clínico de Stern. Regressão linear múltipla e modelos lineares generalizados foram utilizados para associações. Resultados: As prevalências de resistência à insulina de acordo com os diferentes critérios foram: HOMA-IR 67,9 %; critério clínico 57,1 % e RGI 43,4 %. RCEst, CC e BAI se correlacionaram significativamente com HOMA e RGI. Em relação ao critério clínico de S t e r n , a p e n a s a C C a p r e s e n t o u m é d i a s significativamente diferentes, sendo inferior nos indivíduos classificados com não RI (95,8±9,9 vs. 106,4±12,5, p=0,02). Todos os índices antropométricos se associaram com RI após ajuste para idade, sexo e diagnóstico médico prévio de diabetes mellitus. Conclusões: As prevalências de RI são elevadas em pacientes com SCA independente do critério utilizado; entretanto HOMA-IR parece ser o melhor preditor. Indicadores de obesidade central, assim como BAI, apresentam melhor associação com RI.

Background: The prevalence of insulin resistance (IR) is high among patients with acute coronary syndrome (ACS); its association with specific anthropometric indicators has not been established, nor has the best parameter been identified for detecting IR among these patients. Objectives: To detect the prevalence of IR through assorted indicators and correlate them with anthropometric parameters for patients with ACS. Methods: Cross-sectional study of 28 patients, measuring their weight (kg), height (m), waist (WC) and hip circumferences and calculating their Body Mass Index (BMI), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR) and Body Adiposity Index (BAI). Biochemical data were obtained from their medical records and IR was detected by the glucose-insulin ratio (GIR), HOMA-IR index and the Stern clinical criterion. Multiple linear regression and generalized linear models were used for associations. Results: The prevalence of IR based on different criteria was: HOMA-IR 67.9 %; GIR 57.1 % and clinical criteria 43.4 %. The WHtR, WC, and BAI were significantly correlated with HOMA and GIR. With regard to the Stern criterion, only the WC presented significantly different measurements, being lower among individuals classified as non-IR (95.8±9.9 vs. 106.4±12.5, p=0.02). All the anthropometric indexes were associated with IR after adjustments for age, gender and previous medical diagnosis of diabetes mellitus. Conclusions: The prevalence of insulin resistance is high among patients with ACS, regardless of the criteria used; however, HOMA-IR seems to be the best predictor. The central obesity and BAI indicators presented a better association with IR.

Escore de risco Dante Pazzanese na predição de eventos adversos intra-hospitalares em pacientes com síndromes coronarianas agudas sem supradesnivelamento do segmento ST / Dante Pazzanese Ris k Score at the prediction of in-hospital adverse events in patients with non-ST-segment elevation acute coronary syndromes

No contexto das síndromes coronarianas agudas, a estratificaçãodo risco se constitui em ferramenta útil na determinação mais acurada do prognóstico e na seleção da melhor estratégia terapêutica. Foi objetivo, deste estudo, avaliar a capacidade do escore de risco Dante Pazzanese na predição de eventos intra-hospitalares em uma coorte externa de pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST. Aplicou-se o escore de risco Dante Pazzanese a 306 pacientes com diagnóstico de síndrome coronariana aguda sem supradesnivelamento do segmento ST, admitidos em um centro brasileiro terciário de cardiologia. O desfecho do estudo foi composto de óbito por todas as causas ou reinfarto, ocorrendo durante a internação hospitalar. A distribuição do escore de risco Dante Pazzanese entre os participantes do estudo foi: muito baixo risco (30,1%); baixo risco (48,4%);risco intermediário (17,3%); alto risco (4,2%). Ocorreu pelo menos um evento adverso, durante o período de internação,em 14 (4,5%) pacientes, sendo seis (1,9%) reinfartos e oito(2,6%) óbitos. Houve incremento estatisticamente significativo dos óbitos (p = 0,0073) e do desfecho combinado - óbito e/ou reinfarto (p = 0,0015), proporcionalmente ao aumento da pontuação do escore de risco. De forma simples, o escore de risco Dante Pazzanese foi capaz de predizer a ocorrência intra--hospitalar de morte e/ou reinfarto em pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST.

Risk stratification presents as a useful tool to prognostication and selection of the best therapeutic strategy in acute coronary syndromes. This study aimed to evaluate the capacity of Dante Pazzanese Risk Score to predict in-hospital adverse events in an external cohort of patients with non-ST-segment elevation acute coronary syndromes. Dante Pazzanese risk score was applied to 306 patients with non-ST-segment elevation acute coronary syndromes, admitted at a cardiology center in Brazil. The outcome of the study was all cause mortality or re-infarction, occurring during the internment. Distribution of Dante Pazzanese risk score among the participants of the study was: very low risk (30.1%), low risk(48.4%), intermediate risk (17.3%), high risk (4.2%). During the internment period 14 (4.5%) patients suffered at least one adverse event, with six (1.9%) re-infarction and eight(2.6%) deaths. There was a statistical significant incrementof deaths (p = 0.0073) and of combined event – death and/or re-infarction (p = 0.0015), proportionally to the increaseof the risk score. Simply and easily, such score was ableto determine the probability of occurrence of in-hospital death and/or re-infarction in patients with non-ST-segment elevation acute coronary syndromes.

Association between diabetic retinopathy and left ventricular dysfunction in diabetic patients with unstable angina

Diabetes mellitus [DM] is associated with serious complications including macro- and microvascular problems such as diabetic retinopathy. Coronary involvement in diabetic patients is believed to be a consequence of microvascular complications. However, the available data are inconclusive and scarce. This study aimed to evaluate the probable association between diabetic retinopathy and left ventricular dysfunction in diabetic patients with unstable angina [UA]. In this cross-sectional study, 200 diabetic patients with UA [100 cases with diabetic retinopathy and 100 cases without diabetic retinopathy] were enrolled in a teaching hospital. Left ventricular ejection fraction [LVEF] as well as the frequency of cases with left ventricular dysfunction [LVEF<50%] were compared between the two groups and different degrees of diabetic retinopathy [proliferative and non-proliferative]. Patients' demographic variables were comparable between the two groups. Mean diagnosis time of DM was significantly higher in the patients with diabetic retinopathy [8.40 +/- 6.60 vs. 3.81 +/- 3.58 years; P=0.001]. Mean LVEF was significantly lower in the retinopathy group [50.50 +/- 6.91% vs. 53.07 +/- 4.87%; P=0.003]. Frequency of cases with left ventricular dysfunction was significantly higher in the group with diabetic retinopathy [31% vs. 12%; P=0.001, OR=3.33, 95%CI: 1.58-7.14]. The frequency of cases with left ventricular dysfunction was significantly yet independently higher in patients with proliferative vs. non-proliferative diabetic retinopathy. Left ventricular dysfunction is more common in diabetic patients with unstable angina and diabetic retinopathy compared with their counterparts without diabetic retinopathy

Intervalo QT corregido en relación con las complicaciones y la mortalidad del síndrome coronario agudo / Corrected QT interval in relation to complications and mortality of acute coronary syndrome

Se realizó un estudio descriptivo, observacional, transversal, con 102 pacientes afectados por síndrome coronario agudo atendidos en la sala de emergencias del Hospital General Docente Leopoldito Martínez de San José de las Lajas, provincia Mayabeque, en el período comprendido desde enero de 2007 hasta diciembre de 2008. Fue medido el intervalo QT en el primer electrocardiograma, se calculó el intervalo QT corregido por la fórmula de Bazett y este fue relacionado con las siguientes variables: sexo, tipo de síndrome coronario agudo, presencia de complicaciones y mortalidad general. Predominaron los pacientes con infarto agudo del miocardio con onda Q mayores de 60 años y del sexo masculino. El intervalo QT corregido máximo estuvo más prolongado en mujeres con infarto agudo del miocardio con onda Q y el QT corregido medio tuvo mayor duración en mujeres con infarto agudo del miocardio sin onda Q. Fueron más frecuentes los pacientes con síndrome coronario agudo que no se complicaron. Entre los que si tuvieron complicaciones predominó el infarto agudo del miocardio con onda Q. El intervalo QT corregido máximo y medio tuvieron una mayor duración en el infarto agudo del miocardio con onda Q sin complicaciones. Predominaron los pacientes con síndrome coronario agudo que no fallecieron. El infarto agudo del miocardio con onda Q tuvo la mayor mortalidad. El QT corregido máximo tuvo mayor duración en pacientes con infarto agudo del miocardio con onda Q que no fallecieron. El valor medio de QT corregido estuvo más prolongado en afectados por infarto agudo del miocardio sin onda Q que no fallecieron. Según la prueba de comparación de medias, no existieron diferencias estadísticamente significativas (p > 0,05; IC: 95 per cent) de los valores medios del QT corregido en relación con el tipo de síndrome coronario agudo, el sexo, las complicaciones y la mortalidad

It was performed a descriptive, transversal study, with 102 patients with acute coronary syndrome (ACS), assisted in the emergency room of the Leopoldito Martínez Teaching Hospital in San José de las Lajas, Mayabeque Province, since january 2007 until december 2008. It was measured the QT interval in the first electrocardiogram, it was calculated QT corrected interval through the Bazett´s formula and it was related with the following variables: age, sex, type of ACS, frequency of complications and overall mortality. There was a predominance of patients with acute myocardial infarction (AMI) with Q wave older than 60 years and male sex. Maximum QTc interval was more elongated in women with Q wave AMI and the average QTc lasted more in women with non-Q wave AMI. ACS Patients without complications were more frequents. It was prevalent the Q wave AMI in complicated patients. Maximum and average QTc intervals lasted more in patients with Q wave AMI without complications. ACS patients who did not decease were more frequent. Mortality was higher in Q wave AMI patients. The maximum QTc interval lasted more in Q wave AMI patients who survived. The average QTc value was more elongated in non-Q wave AMI patients who did not decease. Based on the average comparison test, there was not statistically significant differences (p > 0,05; IC: 95 per cent) between the average values of the QTc interval related to the type of ACS, sex, complications and mortality

Endothelial Dysfunction and Increased Carotid Intima-Media Thickness in the Patients with Slow Coronary Flow

Flow mediated brachial dilatation (FMD) and carotid intima-media thickness (IMT) have been a surrogate for early atherosclerosis. Slow coronary flow in a normal coronary angiogram is not a rare condition, but its pathogenesis remains unclear. A total of 85 patients with angina were evaluated of their brachial artery FMD, carotid IMT and conventional coronary angiography. Coronary flow was quantified using the corrected thrombosis in myocardial infarction (TIMI) frame count method. Group I was a control with normal coronary angiography (n = 41, 56.1 +/- 8.0 yr) and group II was no significant coronary stenosis with slow flow (n = 44, 56.3 +/- 10.0 yr). Diabetes was rare but dyslipidemia and family history were frequent in group II. Heart rate was higher in group II than in group I. White blood cells, especially monocytes and homocysteine were higher in group II. The FMD was significantly lower in group II than in group I. Elevated heart rate, dyslipidemia and low FMD were independently related with slow coronary flow in regression analysis. Therefore, endothelial dysfunction may be an earlier vascular phenomenon than increased carotid IMT in the patients with slow coronary flow.

A Significância da valiação intra-hospitalar da capacidade funcionalna síndrome coronariana aguda / Significance of in-hospital evaluation of functional capacity in acute coronary syndrome

Fundamentos: A avaliação da capacidade funcional (CF) pode ser realizada através do teste de caminhada de 6minutos (TC6), porém habitualmente não é aplicado em pacientes com síndrome coronariana aguda (SCA) pré-alta hospitalar. Objetivo: Avaliar a significância da capacidade funcional(CF) através do teste de caminhada de 6 minutos (TC6) em pacientes com síndrome coronariana aguda (SCA) naunidade coronariana (UCO). Métodos: Estudo experimental, transversal, com 23 pacientes apresentando SCA estável, sendo 14 homens e 9 mulheres, com idade média de 57 anos. Todos foramsubmetidos ao TC6 para avaliação da CF, antes da alta hospitalar (4º ao 6º dia), no corredor da unidade. Mensurou-se a distância percorrida e, antes e após o teste: escala de Borg, frequência respiratória, frequência cardíaca, pressão arterial sistólica, diastólica e média, assim como saturação de oxigênio. Resultados: A aplicação do TC6 demonstrou, com exceção da variável pressão arterial média (PAM), que todas as demais variáveis apresentaram diferença significativa (p<0,05). Na comparação entre a distância percorrida pela amostra e a preditiva, o teste t pareado revelou uma diferença significativa (p=0,0001), mas quando comparado à preditiva baseada no limite inferior não revelou diferença significativa (p=0,085). Conclusão: Os resultados encontrados apontam para uma redução da capacidade funcional de indivíduos com SCA.

Angina instável pós-infarto aumenta o risco de complicações na cirurgia de revascularização miocárdica? / Does post-infarction unstable angina increase the risk of coronary artery bypass graft surgery?

Fundamentos : Admite-se que os riscos de complicações pós-operatórias sejam maiores na angina instável pós-infarto.Objetivo: Verificar se a angina instável (AI) pósinfarto (classe C de Braunwald) aumenta o risco de eventos cardiovasculares maiores (ECMA) nacirurgia de revascularização miocárdica (CRVM) em comparação às síndromes coronarianas estáveis. Métodos: Em pacientes submetidos consecutivamenteà CRVM isolada, durante um período de dois anos, comparou-se a incidência de ECMA [morte, infarto agudo do miocárdio com onda Q (IAM) e acidentevascular encefálico (AVE)] entre aqueles com síndromes coronarianas estáveis (G1) e aqueles com AI classe B (G2) e AI classe C (G3) de Braunwald.Resultados: De 333 pacientes operados no período, 238 (71,0%) compunham o G1, 56 (17,0%) o G2 e 39 (12,0%) o G3. Mais pacientes dos G2 e G3apresentavam DPOC (12,5% e 10,0% vs 2,9%, p=0,005) e necessidade de cirurgia de urgência/emergência (18,0% e 33% vs 0,4%; p=0,0001) do que o G1. Não houve diferença significativa na morte hospitalar (4,6%, 8,9% e 5,1%; p=0,45), IAMQ (2,9%,3,6% e 5,1%; p=0,69) e AVE (5,5%, 0%, e 5,1%; p=0,17) ou ECMA (10,9%, 12,5% e 12,8%; p=0,85) entre osG1, G2 e G3, respectivamente.Conclusão: Este estudo sugere que a angina instável pós-IAM não aumenta o risco de eventos cardiovasculares maiores na CRVM em comparaçãoàs síndromes coronarianas estáveis.

Background: It is assumed that post-infarction unstable angina increases the risk of post-operative complications.Objective: To ascertain whether post-infarction unstable angina (Braunwald class C) increases the risk of major cardiovascular events (MACE) for coronary artery bypass surgery (CABG) in comparison to stable coronary syndromes. Methods: In patients undergoing individual CABGconsecutively for a period of two years, the incidence of MACE (hospital mortality, non-fatal Q-wave myocardial infarction [AMI], and stroke) wascompared for patients with stable coronary syndromes (G1) and patients with class B unstable angina (G2),and patients with Braunwald class C unstable angina (G3). Results: Among 333 patients operated during thatperiod, 238 (71%) belonged to G1, 56 (17%) to G2, and 39 (12%) to G3. More G2 and G3 patients presentedCOPD (12.5% and 10.0% vs 2.9%, p=0.005), and the need for emergency / urgent surgery (18.0% and 33.0%vs 0.4%; p=0.0001) than in G1. No significant difference appeared in hospital mortality (4.6%, 8.9%, and 5.1%; p=0.45), non-fatal AMI (2.9%, 3.6%, and 5.1%; p=0.69), and stroke (5.5%, 0%, and 5.1%; p=0.17) or MACE(10.9%, 12.5%, and 12.8%; p=0.85) among G1, G2, and G3 respectively.Conclusion: This study suggests that post-infarction unstable angina did not increase the risk of MACE in CABG compared to stable coronary syndromes.

Congenital hypopituitarism: Monitoring after coronary artery bypass grafting.

Cardiovascular disease in patients with congenital hypopituitarism is not rare; however, there is a lack of reports referring to cardiac interventions in such patients. We present a 76-year-old man with complete pituitary hormone deficiency, who presented with recurrent events of unstable angina. He had a significant stenosis of the left anterior descending artery and he underwent off-pump coronary artery bypass. Our aim is to present the successful management of this patient with congenital hypopituitarism who underwent cardiac surgery and to review the relevant literature.

Heparinas nas síndromes isquêmicas miocárdicas instáveis com e sem supradesnível do segmento ST / Heparin in acute coronary syndromes

A erosão ou a rotura da placa aterosclerótica são os mecanismos essenciais que disparam os eventos fisiopatológicos que se exteriorizam clinicamente como angina instável e infarto agudo do miocárdio com ou sem supradesnível do segmento ST. Os elementos figurados do sangue bem como os fatores de coagulação são expostos ao contato com o material subendotelial. Isso leva à ativação, à adesão e à agregação plaquetária, e à geração acelerada de trombina, como mecanismos essenciais de trombose subsequente. É, assim, bastante justificável a utilização de fármaco antitrombótico padrão (heparina não-fracionada) em concomitância à terapêutica antiplaquetária para o tratamento rotineiro de pacientes com as diversas modalidades de síndrome coronária aguda. Embora por mecanismo indireto, o principal efeito anticoagulante da heparina depende de sua ligação específica à antitrombina. Ajusta-se o regime de heparinização para valores de tempo de tromboplastina parcial ativada entre 50 segundos e 70 segundos . Da heparina não-fracionada surgiram as heparinas de baixo peso molecular, que têm como característica comum, embora em grau variável, a capacidade de se ligar preferencialmente ao fator Xa (e menos ao fator IIa), inativando-o. As heparinas de baixo peso molecular...

Ruptured or eroded atherosclerotic plaques are essential mechanisms which trigger pathophysiological events clinically manifested as unstable angina and ST-segment and non-ST-segment elevation acute myocardial infarction. Blood elements as well as coagulation factors are exposed to sub-endothelial material leading to platelet adhesion and aggregation and accelerated thrombin generation, as essential mechanisms of subsequent thrombosis. Therefore, the use of standard antithrombotic agents (unfractionated heparin) in combination with antiplatelet therapy is justifiable in the routine treatment of patients with different modalities of acute coronary syndrome. Although it has an indirect mechanism, the main anticoagulation effect of heparin depends on its specific binding to antithrombin. The heparinization regimen is adjusted for activated partial thromboplastin time (aPTT) values of 50 to 70 s. Low-molecular-weight heparins were obtained from unfractionated heparin, whose common characteristic is the ability to bind to factor Xa (and somewhat less to factor IIa), inactivating it...

Síndrome coronária aguda - do pré-hospitalar à sala de emergência / Acute coronary syndrome - from pre-hospital care to the emergency room

O infarto do miocárdio configura-se como uma das maiores causas de morte no mundo ocidental. Nas últimas décadas, o uso da terapia trombolítica modificou drasticamente o prognóstico dos pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST. Esse fato decorreu principalmente da redução significante da mortalidade e da disfunção ventricular proporcionadas pela terapia trombolítica A arritmia mais frequentemente relacionada à parada cardiorrespiratória nas primeiras horas de infarto é a fibrilação ventricular, e sua abordagem precoce e adequada é de extrema relevância, sendo até mesmo mais eficaz que a terapia trombolítica no salvamento de vidas. Cada vez mais tem sido salientada a importância da identificação rápida e eficiente de pacientes com isquemia miocárdica aguda nos serviços de emergência. O exame eletrocardiográfico deve ser realizado idealmente em menos de 10 minutos da apresentação à emergência e é o centro do processo decisório inicial em pacientes com suspeita de infarto agudo do miocárdio. É importante que seja feita a estratificação de risco inicial de acordo com a probabilidade de o doente desenvolver eventos e complicações cardíacas isquêmicas no futuro para que a estratégia de tratamento mais adequada possa ser instituída, objetivando uma terapêutica mais potente e precoce quando se identificam os riscos intermediários e alto, com a intenção de reduzir eventos...

Acute myocardial infarction is one of the major causes of death in the Western world. In recent decades, the use of thrombolytic therapy dramatically changed the prognosis of patients with ST segment elevation acute myocardial infarction. This occurred mainly due to a significant reduction of mortality and ventricular dysfunction provided by thrombolytic therapy. Ventricular fibrillation is the type of arrhythmia most frequently related to cardiopulmonary arrest in the early hours of infarction, and an early and appropriate approach is extremely important and even more effective than thrombolytic therapy in saving lives. The importance of a prompt and efficient identification of patients with acute myocardial ischemia has been increasingly highlighted. Electrocardiographic examination must be carried out within less than 10 minutes of presentation to the emergency room and is the core of the early decision-making process in patients with suspected acute myocardial infarction. Risk stratification should be done as soon as possible according to the probability of developing ischemic cardiac events and complications in the future so that the most appropriate treatment strategy is established, aiming at a more potent and early therapy when intermediate and high risk groups are identified, aiming at reducing adverse events such as (re)infarction or death. Currently, the use of troponins T and I and CK-MB mass is suggested as markers of myocardial injury. CK-MB activity measurement should be replaced as soon as possible. In large centers, the use of fibrinolytics combined with other drugs reduced hospital mortality rates to below 6.5%. However there has been little progress in understanding the epidemiology and treatment in the prehospital phase.