Predominance of STEMI and severity of coronary artery disease in a cohort of patients hospitalized with acute coronary syndrome: a report from ABC Medical School / Predomínio de infarto agudo do miocárdio com supra ST e gravidade da doença arterial coronariana em uma coorte de pacientes internados com síndrome coronariana aguda: relato da Faculdade de Medicina do ABC.

Summary Introduction: acute coronary syndromes (ACS) represent a widely prevalent health issue with high mortality in Brazil and worldwide. The severity of ACS is not known in patients in the city of São Bernardo do Campo a municipality contiguous and adjacent to the city of São Paulo. Objectives: to study the profile of coronary disease in patients hospitalized with ACS who underwent coronary angiography in the emergency room between 2012 and 2013. Methods: this is an observational study that included consecutive patients with ACS admitted to the emergency room of a hospital. Data collection was performed using medical records with the following variables: sex, age, risk factors for cardiovascular disease, coronary angiography. Results: the sample in this period included 131 patients, of which 64.8% were men. The most prevalent diagnosis was ST-elevation myocardial infarction (STEMI) (57.2%) followed by non-ST-elevation myocardial infarction (NSTEMI) (22.1%) and unstable angina (UA) (20.6%). There were no significant differences in the epidemiology and risk factors between the diagnoses, except that heart failure was more prevalent in patients with UA. Discussion: there were no differences between groups regarding the coronaries involved; however, STEMI patients showed similar numbers of multi- and singlevessel lesions, NSTEMI patients showed more multivessel lesions, and UA patients showed more multivessel lesions or lesion-free arteries. Although multivessel lesions were prevalent in all groups, STEMI patients showed a significantly higher number of single-vessel lesions compared with the other acute coronary syndromes. Conclusion: the study demonstrated a predominance of STEMI in the studied population, which differs from the usual results in ACS. .

Resumo Introdução: a síndrome coronariana aguda (SCA) é uma das principais causas de morbidade e mortalidade no Brasil e no mundo. A gravidade da coronariopatia em pacientes atendidos na cidade de São Bernardo do Campo não é conhecida. Objetivo: estudar o perfil da doença coronariana em pacientes internados com SCA e submetidos à cineangiocoronariografia entre 2012 e 2013. Métodos trata-se de estudo descritivo no qual se incluíram pacientes com SCA admitidos no setor de emergência do hospital. Houve consulta aos prontuários das seguintes variáveis: sexo, idade, fatores de risco para doença cardiovascular, diagnóstico e lesões coronárias. O erro alfa estabelecido foi de 5%. Resultados: a amostra neste período foi de 131 pacientes, sendo 64,8% homens. O diagnóstico mais prevalente foi o infarto agudo do miocárdio com supradesnível do segmento ST (IAMCST) (57,2%), seguido de infarto agudo do miocárdio sem supradesnível do segmento ST (IAMSST) (22,1%) e angina instável (AI) (20,6%). Não houve diferenças significativas quanto ao perfil epidemiológico e a fatores de risco entre os diagnósticos, com exceção da presença de insuficiência cardíaca, mais prevalente nos pacientes com AI. Discussão: as coronárias acometidas não diferiram entre os grupos; porém, enquanto o grupo IAMCST apresentou proporção de lesões multi e uniarteriais similares, o grupo IAMSST apresentou mais lesões multiarteriais, e o grupo AI, mais lesões multiarteriais ou artérias livres de lesões. Apesar das lesões multiarteriais serem prevalentes em todos os grupos, os pacientes com IAMCST apresentaram um número significativamente maior de lesões uniarteriais em comparação a pacientes com outras síndromes coronárias agudas. Conclusão: o estudo demonstrou um predomínio de IAMCST na população estudada, o que difere dos resultados habituais na SCA. .

Hora da admissão na unidade de emergência e mortalidade hospitalar na síndrome coronária aguda / Emergency service admission time and in-hospital mortality in acute coronary syndrome

FUNDAMENTO: Há controvérsias sobre a hora da admissão e os desfechos hospitalares da síndrome coronária aguda (SCA). A admissão em horários não regulares seria associada ao pior prognóstico dos pacientes. OBJETIVO: Analisar a influência da hora da admissão na internação prolongada e na mortalidade de pacientes com SCA, segundo os períodos diurno (das 7h às 19h) e noturno (das 19h às 7h). MÉTODOS: Foram avaliados, prospectivamente, 1.104 pacientes consecutivos com SCA. O óbito intra-hospitalar e a internação igual ou superior a cinco dias foram os desfechos analisados. RESULTADOS: A admissão no período diurno foi maior em comparação ao noturno (63 por cento vs. 37 por cento; p < 0,001). A angina instável foi mais prevalente no período diurno (43 por cento vs. 32 por cento; p < 0,001) e o infarto sem supradesnivelamento do segmento ST (IAMssST) no noturno (33 por cento vs. 43 por cento; p = 0,001). Não se observaram diferenças na mortalidade e no tempo de internação nos períodos estudados. Os fatores de predição de internação igual ou superior a cinco dias foram: idade [OR 1,042 (IC 95 por cento 1,025 - 1,058), p < 0,001]; fração de ejeção (FE) [OR 0,977 (IC 95 por cento 0,966 - 0,988), p < 0,001]; IAMssST [OR 1,699 (IC 95 por cento 1,221 - 2,366), p = 0,001]; e tabagismo [OR 1,723 (IC 95 por cento 1,113 - 2,668), p = 0,014]. Para o óbito intra-hospitalar, foram: idade [OR 1,090 (IC 95 por cento 1,047 - 1,134), p < 0,001]; FE [OR 0,936 (IC 95 por cento 0,909 - 0,964), p < 0,001]; e tratamento cirúrgico [OR 3,781 (IC 95 por cento 1,374 - 10,409), p = 0,01]. CONCLUSÃO: A internação prolongada e óbito intra-hospitalar em pacientes com SCA independem do horário de admissão.

BACKGROUND: The relationship between admission time to an emergency service and in-hospital outcomes in acute coronary syndrome (ACS) is controversial. Admission during off-hours would be associated with worse prognosis. OBJECTIVE: To assess the influence of admission time on prolonged hospitalization and mortality for ACS patients, regarding regular hours (7AM-7PM) and off-hours (7PM-7AM). METHODS: The study assessed prospectively 1,104 consecutive ACS patients. In-hospital mortality and length of hospital stay > 5 days were the outcomes analyzed. RESULTS: Admission during regular hours was greater as compared with that during off-hours (63 percent vs. 37 percent; p < 0.001). Unstable angina was more prevalent during regular hours (43 percent vs. 32 percent; p < 0.001), while non-ST-segment elevation myocardial infarction (NSTEMI) was during off-hours (33 percent vs. 43 percent; p = 0.001). Differences in neither mortality nor length of hospital stay were observed in the time periods studied. Predictive factors for length of hospital stay > 5 days were as follows: age [OR 1.042 (95 percentCI: 1.025 - 1.058), p < 0.001]; ejection fraction (EF) [OR 0.977 (95 percentCI: 0.966 - 0.988), p < 0.001]; NSTEMI [OR 1.699 (95 percentCI: 1.221 - 2.366), p = 0.001]; and smoking [OR 1.723 (95 percentCI: 1.113 - 2.668), p = 0.014]. Predictive factors for in-hospital mortality were as follows: age [OR 1.090 (95 percentCI: 1.047 - 1.134), p < 0.001]; EF [OR 0.936 (95 percentCI: 0.909 - 0.964), p < 0.001]; and surgical treatment [OR 3.781 (95 percentCI: 1.374 - 10.409), p = 0.01]. CONCLUSION: Prolonged length of hospital stay and in-hospital mortality in ACS patients do not depend on admission time.

Influence of folic acid on plasma homocysteine levels & arterial endothelial function in patients with unstable angina.

Background & objectives: High plasma homocysteine (Hcy) levels are known to be associated with coronary artery disease, but the precise level associated with an increased risk is yet controversial. Whether the beneficial effects of folic acid on arterial endothelial function persist over longer periods is not known. This study was carried out to assess whether folic acid supplementation could produce improvements in Hcy levels and arterial endothelial function in the patients with unstable angina (UA) and hyperhomocysteinaemia. Methods: The plasma Hcy levels of 52 cases with UA and 30 control subjects were measured by using high-performance liquid chromatography (HPLC) with fluorescence detection, plasma folic acid and vitamin B12 levels were also measured. The patients with hyperhomocysteinaemia were treated with 5 mg of folic acid for 8 wk, and then rechecked the plasma levels of Hcy, folic acid and vitamin B12 at the end of 4th and 8th wk. Arterial endothelial function was measured as flow-mediated dilation of the brachial artery using high-resolution B-mode ultrasound in 22 cases with UA and hyperhomocysteinaemia before and after folic acid treatment. Results: The plasma Hcy level was significant higher in the patients with UA than in the controls (19.2 ± 4.9 vs 10.7 ± 5.3 μmol/l, P<0.01). The plasma levels of folic acid and vitamin B12 were significant lower in the patients with UA than in the controls. There were 22(42.3%) patients with hyperhomocysteinaemia in UA group. After 4 and 8 wk of administration of folic acid, the Hcy level reduced by 20.3 and 55.3 per cent in the UA patients with hyperhomocysteinaemia, respectively. Flow-mediated dilation also improved significantly, from 6.4 ± 1.9 to 9.0 ± 1.2 per cent (P<0.05) after 8 wk treatment with folic acid. Interpretation & conclusions: Plasma Hcy level was elevated in patients with UA. Folic acid can reduce the plasma Hcy levels and improve arterial endothelial function in the UA patients with hyperhomocysteinaemia.

Does the circadian pattern for acute cardiac events presentation vary with fasting?

BACKGROUND: Over one billion Muslims fast worldwide during the month of Ramadan. The impact of fasting on circadian presentation with acute cardiac events is unknown. AIM: To determine if fasting has any effect on the circadian presentation of acute cardiac events. SETTING AND DESIGN: A prospective study in a general hospital. MATERIALS AND METHODS: Patients with acute coronary events were divided into two groups based on the history of fasting. Information about age, gender, cardiovascular risk factor profiles and outcome was collected. The relationship of time of presentation of initial symptoms with fasting was evaluated using Student's t-test, Mann-Whitney U-test and chi2 analysis. RESULTS: Of the 1019 patients hospitalized during the study period, 162 were fasting. Although, fasting patients were more likely to present to the emergency department in the time periods 5-6 AM (10.5% vs 6.3%) and 11 PM (11.1% vs 7.1%) and were less likely to present in the time periods 1-2 PM (3.7% vs 7.2%) and 5-6 PM (3.7% vs 7.0%); these differences were not statistically significant. Fasting patients were less likely to have their symptoms start between 5 and 8 AM (11.1% vs 19.4%) and more likely to have symptoms between 5 and 6 PM (11.1% vs 6.0%) and 3 and 4 AM (11.1% vs 6.9%). These differences for time of initial symptoms were statistically significant (P=0.002). CONCLUSION: Exogenous factors associated with fasting, namely, the changes in food intake and/or sleep timings, affect the circadian rhythm and influence the timing of presentation of acute coronary events.

Avaliação das pressões sistólica, diastólica e pressão de pulso como fator de risco para doença aterosclerótica coronariana grave em mulheres com angina instável ou infarto agudo do miocárdio sem supradesnivelamento do segmento ST / Evaluation of systolic, diastolic, and pulse pressure as risk factors for severe coronary arteriosclerotic disease in women with unstable angina non-ST-elevation acute myocardial infarction

OBJETIVO: Avaliar se as pressões, medidas na raiz da aorta, são fatores de risco para doença aterosclerótica coronariana grave em mulheres com angina instável ou infarto agudo do miocárdio sem supradesnivelamento do segmento ST (AI/IAMSS). MÉTODO:As pressões, assim como os fatores de risco para doença arterial coronariana (DAC) foram prospectivamente coletados de março/1993 a agosto/2001 em 593 mulheres com diagnóstico de AI/IAMSS submetidas à cinecoronariografia. Lesões coronarianas definidas como graves estenoses > 70 por cento. RESULTADOS: Idade média de 59,2±11,2 anos, significantemente mais alta nas pacientes com DAC: 61,9 ± 10,8 anos vs 56.4 ± 10,8 anos; tabagismo, diabetes e climatério foram mais freqüentes nas pacientes com DAC. As médias das pressões sistólica e arterial média foram iguais nos dois grupos, entretanto as médias das pressões diastólicas do ventrículo esquerdo (17.6 ± 8.7 x 15.1 ± 8.1, p=0.001) e da pressão de pulso aórtica foram significantemente maiores nas pacientes com DAC (75.5 ± 22 x 70 ± 19, p=0.002), enquanto a média da pressão diastólica aórtica foi significantemente mais alta nas pacientes sem DAC (75.3 ± 17.5 x 79.8 ± 16, p=0.003). Na análise multivariada a pressão de pulso > 80 mmHg e pressão sistólica > 165 foram independentemente associadas a DAC com razão de chance de 2.12 e 2.09, p<0.05, respectivamente. CONCLUSAO: A doença arterial coronariana está associada à pressão de pulso mais elevada e pressão diastólica mais baixa em mulheres com AI/IAMSS. Embora a média da pressão sistólica não tenha se associado com DAC, valores dicotomisados de pressão de pulso > 80 mmHg e pressão sistólica > 165 mmHg determinaram risco duas vezes maior de lesão coronariana grave.

A novel trigger for acute coronary syndromes: the effect of lunar cycles on the incidence and in-hospital prognosis of acute coronary syndromes--a 3-year retrospective study.

Circadian variations in the incidence of hypertension and coronary events are well known with early morning surges. Effect of lunar cycles on various medical illnesses like seizures and psychiatric disturbances are documented. However, the effect of lunar cycles on coronary events has been sparsely documented. The authors studied the incidence of acute coronary events and admission patterns in the departments of emergency medicine and cardiology. Inclusion criteria included unstable angina, non-ST elevation myocardial infarction (MI) and ST elevation MI. Exclusion criteria included chest pain syndromes which were subsequently deemed non-cardiac by invasive or non-invasive investigations. Data from 1999 to 2001 were analysed. Admissions on full moon days were compared with those on new moon days. There were 30 full moon days and 30 new moon days and 223 admissions on full moon days and 266 on new moon days. This difference was statistically significant [p = .005]. Sixty-seven per cent were males and the rest were females. Subgroup analysis of mortality, postinfarction angina, effect on diabetics and hypertensives were done which showed an increased trend in new moon days. It is concluded that there is increased incidence of acute coronary events associated with new moon days.

Diferença de letalidade hospitalar da angina instável entre homens e mulheres / Difference in the in-hospital mortality of unstable angina pectoris between men women

Objetivo - Avaliar possíveis diferenças na letalidade hospitalar (LH) de angina intável (AI) entre homens e mulheres, considerando a influência da idade, infradesnivelamento do segmento ST, história prévia de infarto agudo do miocárdio (IAM) e fatores de risco coronariano. Métodos - Foram selecionados 261 pacientes com AI, entre outubro/96 e março/98. Modelos de regressão logística foram desenvolvidos para ajustar a associação entre sexo e LH para possíveis influências das co-variáveis; hipertensão arterial, diabetes mellitus, dislipidemia, sedentarismo, tabagismo e história familiar de doença coronariana precoce. Resultados - A LH da AI foi aproximadamente 3 vezes maior nas mulheres (9,3 por cento; 12/129) do que nos homens (3,0 por cento; 4/132), correspondendo a um risco relativo de 3,07; intervalo de confiança (IC) de 95 por cento=1,02-9,27. Nos modelos de regressão logística, a associação entre sexo e morte não foi alterada de forma importante ao se levar em consideração a idade, presença de infradesnível do segmento ST, história de IAM prévio e fatores de risco coronariano; a odds ratio (OR) não ajustada e a OR ajustada para as diversas co-variáveis foram 3,28 (IC 95 por cento = 1,03-10,45) e 3,14 (IC 95 por cento = 0,88-11,20), respectivamente. Conclusão - Conforme o observado no IAM, a LH da AI é maior nas mulheres do que nos homens. A idade, fatores de risco coronariano e a presença de infradensível ST no eletrocardiograma da admissão não influenciaram de forma importante a associação entre sexo e morte.

Influencia de factores de riesgo y terapia farmacológica en la mortalidad de hipertensos esenciales / Influence of pharmacological treatment and risk factors on mortality of hypertensive patients

Background: The V JNC consensus stated that although new antihypertensive agents, such as angiotensin converting enzyme inhibitors and calcium channel blockers, are considered safer drugs, there is no firm evidence from large controlled trials that these drugs are associated with a lower cardiovascular mortality. Aim: To study the association between cardiovascular risk factors, blood pressure levels, pharmacological treatment and mortality in a group of hypertensive patients followed at an hypertension outpatient clinic. Patients and methods: Patients with essential hypertension were treated with different antihypertensive medications, according to physicians criteria, and controlled until death or loss from follow up. Causes of death were obtained from hospital records and death certificates. Survival was analyzed using life tables, comparisons between groups of patients were done using chi square or a Cox's proportional hazards model. Results: Three hundred thirty nine hypertensive patients aged 33 to 80 years old were followed for a mean period of 9.8 ñ 4.9 years. Eighty six were treated with beta blockers, 64 with diuretics, 133 with calcium antagonists and 56 with ACE inhibitors. Blood pressure dropped similarly with all medications. During follow up, 79 patients died. Life table analysis showed that patients with a history of angina, diabetes or myocardial infarction had higher mortality rates. Similarly, patients treated with beta blockers and diuretics had higher mortality than patients treated with calcium antagonists or angiotensin converting enzyme inhibitors. The proportional hazards model showed that the effect of treatment modality persisted after correction for the other risk factors for mortality. Conclusions: In this series of hypertensive patients, those treated with beta blockers or diuretics had higher mortality rates than those receiving calcium channel antagonists or angiotensin converting enzyme inhibitors

Angina inestable: modalidad evolutiva intrahospitalaria / Unstable angina: intrahospitable evolutive peculiarity

Para proveer un perfil epidemiológico y determinar el valor pronóstico de variables clínicas de pacientes con angina inestable, evaluamos el curso hospitalario de 193 pacientes admitidos, en la Unidad Coronaria del Hospital Escuela de Corrientes. Se confeccionaron registros de las variables clínicas y adjuntaron los electrocardiogramas de ingreso y en los episodios anginosos durante la internación. De acuerdo con la presentación clínica se consideraron los siguientes grupos: Angina Progresiva, de Reciente Comienzo, Primaria y Secundaria (con factores desencadenantes). Recurrencia de angina: fue diagnosticada si se presentaba un episodio anginoso después de la veinticuatro horas. Un subgrupo fue identificado para los que permanecieron sintomáticos más allá de 48 horas. La recurrencia de Angina después de 48 hs, Infarto y Muerte fueron considerados eventos mayores y constituyen el punto final combinado para el análisis de las variables pronósticas. La edad, sexo, hipertensión arterial, tabaquismo, diabetes, presencia de cambios electrocardiográficos, tipo de angina, infarto de miocardio previo y recurrencia de angina fueron las variables seleccionadas. La prevalencia de angina inestable como causa de internación fué de 25 por ciento. El promedio de edad de 58 años. El 60 por ciento eran del sexo masculino. La recurrencia de angina, infarto agudo de miocardio o muerte ocurrieron en el: 14 por ciento, 2,5 por ciento y 1,5 por ciento. Los pacientes con cambios electrocardiográficos se presentaron en un 52,5 por ciento de los casos. La presencia de cambios electrocardiográficos se asoció a una incidencia estadísticamente significativa de eventos mayores (p = 0,01). Los pacientes con factores desencadenantes (angina secundaria), presentaron un 7 por ciento de eventos mayores en contraste con el 20 por ciento de aquellos que no (angina primaria)

Percutaneous transluminal coronary angioplasty (PTCA) in unstable angina.

We performed percutaneous transluminal coronary angioplasty in 33 highly selected patients of unstable angina, a majority of whom were initially stabilized by medical therapy. All these patients had single vessel disease with type A lesion. The initial success rate was 91% with recurrence of 17% at the end of 1 year.

Angioplastia coronária em octogenários / Coronary angioplasty in octogenarians

Objetivo - Avaliar e discutir as indicações, resultados e evolução de pacientes com idade ≥ 80 anos submetidos a angioplastia coronária.Métodos - No período de junho de 1987 a julhode 1990, 36 pacientes com idade maior ou igual a 80 anos, realizaram angioplastia coronária como método terapêutico alternativo. A idade variou de 80 a 85 (média = 83) anos, sendo 25 do sexo masculino. Considerou-se a obstrução significativa quando a estenose fosse maior ou igual a 70% do diâmetro da artéria. Resultado satisfatório, após a realização do procedimento, foi considerado quando houvesse redução da obstrução a valores menores ou iguais a 50%. Resultados - O sucesso inicial da angioplastia coronária foi observado em 34/36 (94,4%) pacientes. Dos 46 vasos abordados, obteve-se sucesso em 44 (95,6%). Em apenas um paciente foi observada oclusão coronária aguda seguida de infarto agudo do miocárdio, tratado clinicamente. Não houve cirurgia de emergência ou óbitos imediatos nesta série. Quinze dos 34 pacientes, que obtiveram sucesso inicial, puderam ser acompanhados na evolução clínica; 4/15 (26,6%) foram reestudados - (1, 3,6 e 12 meses pós-angioplastia), devido ao reaparecimento de angina; 2 evidenciaram reestenose sendo redilatados com sucesso. Na evolução clínica desses 15 pacientes, num período de 1 a 21 (média = 9,6) meses, incluindo os pacientes redilatados, observaram-se os seguintes fatos: 2 (13,3%) pacientes apresentaram infarto agudo do miocárdio, sendo tratados clinicamente; óbito tardio ocorreu em 3 (20%) pacientes, 1 de natureza cardíaca. A sobrevivência, no período observado, foi 12/15 (80%) pacientes pacientes octogenários, nesta série, mostrou ser um procedimento intervencionista alternativo, seguro e eficaz no tratamento deste subgrupo de pacientes Conclusão - A angioplastia coronária em pacientes octogenários, nesta série, mostrou ser um procedimento intervencionista alternativo, seguro e eficaz notratamento deste subgrupo de pacientes

Purpose - To evaluate the indications, results and follow - up of patients with 80 years old and over, who had undergone percutaneous transluminal coronary angioplasty (PTCA). Methods - From July 1987 through July 1990,36 patients, 80 years of age and over, had PTCA as an alternative method to treat coronary artery disease. Their age ranged from 80 to 85 (mean = 83) years. Twenty five were male. Significative obstrution was considered when 70% or more of the internal diameter was stenosed. Satisfactory results were achieved when reduction of 50% or more of the coronary artery obstruction was obtained. Results - In 34 of 36 patients (94.4%), PTCA was successfully performed. Forty four of 46 coronary arteries were successfully dilated. One patient had acute coronary occlusion with acute myocardial infarction treated clinically. There were no emergency surgeries or early deaths. Clinical follow-up was obtained in 15 of the 34 patients. Four had repeated coronary arteriography (at 1, 3, 6 and 12 months after primary PTCA) due to angina. Two of them had restenosis and were successfully redilated (the patients restudied at 3 and 6 months, respectively). Within a mean clinical follow-up period of9.6 (ranging from 1 from 21) months the following features were observed: two of 15 patients (13.3%) had acute myocardial infarction and were clinically followed; late death occured in 3 patients (20%) with only one related to cardiac events. Survival has been observed in 12 of these 15 patients (80%). Conclusion - PTCA represents an alternative, safe and effective invasive procedure to treat octogenarians with coronary artery disease

Isquemia silenciosa del miocardio: importancia clinica y pronostico / Silent myocardial ischemia: clinical importance and prognosis

El mecanismo preciso responsable de la isquemia silenciosa del miocardio no se ha establecido, pero los datos disponibles sugieren que tanto un aumento en la demanda de oxigeno como una disminucion en el flujo sanguineo coronario pueden ser los causantes. Los estudios indican que mas de 60 minutos de isquemia silenciosa durante un control, electrocardiografico ambulatorio se correlaciona con un incremento en la frecuencia de infarto del miocardio, muerte de origen cardiaco y sintomas recurrentes que requieren revascularizacion coronaria. Aun en pacientes con episodios mas cortos y repetidos de isquemia silenciosa es posible el desarrollo de pequenas areas de necrosis subendocardica, que terminan eventualmente en una disfuncion progresiva del ventriculo izquierdo, lo cual aumenta el riesgo subsiguiente de mortalidad. La terapia antianginosa, aunque sea efectiva en el control de sintomas, no elimina la isquemia sileciosa. Se requieren estudios adicionales de la patogenesis de la isquemia sileciosa antes de poder establecer un plan efectivo de tratamiento