Angioplastia primaria en Argentina. Registro ARGEN-IAM-ST (relevamiento nacional del infarto agudo de miocardio con elevación del segmento ST) / Primary angioplasty in Argentina. Results from ARGEN-IAM-ST registr

Se evaluaron las características clínicas, demoras, resultados y morbimortalidad de 1142 pacientes tratados con angioplastia primaria (AP) dentro de las 36 horas del infarto, incluidos en el registro ARGEN-IAM-ST, de carácter prospectivo, transversal, multicéntrico y de alcance nacional. Edades: 61.2 ± 12 años, 88% varones, 20% diabéticos y 58% hipertensos; 77.6% en Killip y Kimball I y 6.2% en shock cardiogénico. El tiempo desde el inicio del dolor hasta el ingreso fue de 153 (75-316) minutos, y puerta-balón de 91 (60-150) minutos. Los casos derivados (17%) tuvieron mayor demora de ingreso, 200 minutos (195-420; p = 0.0001) y mayor tiempo puerta-balón, 113 minutos (55-207); p = 0.099. En 47.6% de los casos la AP se hizo en arteria descendente anterior, en 36.4% a coronaria derecha, en 14.8% a circunfleja y en 1.2% al tronco de coronaria izquierda; en 95% con stent (29% farmacológico). El 95% fue exitoso. El 1.3% presentó angina post-infarto (APIAM), 1.3% re-infarto, 8.8% shock y 3.2% sangrado. Se asociaron a mayor mortalidad edad > 64 años (OR 6.2 (IC 95%: 3.2-12), p < 0.001), diabetes (OR 2.5, IC 95% 1.6-3.9, p < 0.001), re-infarto o APIAM (OR 3.3, IC 95% 1.3-8.3, p = 0.011) y shock (OR 29.2 (15.6-54.8), p < 0.001). La mortalidad hospitalaria del infarto agudo de miocardio con elevación del segmento ST tratado con AP fue de 7.6%. La derivación se asoció a demora de tratamiento. El shock cardiogénico y la isquemia post-infarto se asociaron a alta mortalidad. No hubo variables del procedimiento asociadas a mortalidad.

Our objective was to evaluate clinical characteristics, results and morbi-mortality in primary angioplasty (PA), of patients treated with PA within 36 hours of a myocardial infarction (MI), included in a prospective, transversal, multicenter and national survey (ARGEN-IAM-ST). A total of 1142 patients treated with PA were registered, 61.2 ± 12 years old, 88% male, 20% diabetics and 58% with hypertension; 77.6% in Killip Kimball I and 6.2% in cardiogenic shock. The time from the onset of pain until admission was 153 (75-316) minutes, and door-balloon of 91 (60-150) minutes. The transferred patients (17%) showed longer delay to admission, 200 minutes (195-420; p = 0.0001) and door-to-balloon 113.5 minutes (55-207); p = 0.099. In 47.6% of the cases, the PA was made in the anterior descending artery, in 36.4% in the right coronary artery, in 14.8% in the circumflex artery and in 1.2% in the left coronary artery; in 95% with stent (29% pharmacological); 95% was successful, 1.3% presented post-infarct angina (APIAM), 1.3% re-infarct, 8.8% shock and 3.2% bleeding. Age > 64 years (OR 6.2 (95% CI: 3.2-12), p <0.001), diabetes (OR 2.5, 95% CI 1.6-3.9, p < 0.001), re-infarction or APIAM (OR 3.3, 95% CI 1.3-8.3, p = 0.011) and shock (OR 29.2 (15.6-54.8), p < 0.001) were independently associated with higher mortality. In-hospital mortality of acute myocardial infarction with ST-segment elevation treated with PA was 7.6%. Transference from other center was associated with delay in the admission and treatment. Cardiogenic shock and post-infarct ischemia were associated with high mortality. There were no procedural variables associated with mortality.

Exceso de mortalidad no cardíaca en pacientes sometidos a angioplastía de puentes coronarios / Excess non cardiac mortality in patients undergoing PCI of venous coronary bypass grafts

Resumen: Introducción Las fallas de los puentes venosos pueden llegar casi al 50% a 10 años y la angioplastía percutánea es el tratamiento de elección. Estos pacientes constituyen un grupo de muy alto riesgo cardiovascular con tasas de mortalidad cercanas al 30% en el mediano plazo. Objetivo Caracterizar a la población sometida a angioplastia de puentes coronarios (APC) y comparar su mortalidad con un grupo pareado de pacientes intervenidos con Infarto agudo al miocardio con elevación del segmento ST (IAMCEST). Métodos Estudio retrospectivo de tipo Caso-Control que incluyó a pacientes con APC entre los años 2010-2016 comparados con igual número de controles con IAMCEST pareados por edad y sexo. Se analizaron características clínicas del procedimiento y mortalidad, tanto global como de causa cardiaca usando T Student, Chi2 y curvas de Kaplan Meier. Resultados Se identificaron 63 pacientes sometidos a APC (total 76 procedimientos). Los puentes más comúnmente intervenidos fueron a la arteria circunfleja 48,7%. Hubo 18 (28,5%) pacientes fallecidos en el grupo APC y 6 (9,5%) pacientes en el grupo con IAM-CEST, lo que resultó en un exceso de mortalidad global en pacientes con APC (HR 3,02; IC 95% 1,11 - 8,22, p=0,02). Esta diferencia se debió a una mayor mortalidad de causa no cardiaca en el grupo APC (12,7% (n=8) vs 3,2% (n= 2) [p=0,04]). Conclusión Los pacientes sometidos a APC presentan una mortalidad 3 veces mayor que aquellos pacientes con IAMCEST, principalmente derivada de una mayor mortalidad no cardíaca.

Abstract: Background Failure rates of saphenous vein grafts can reach almost 50% at 10 years and percutaneous angioplasty is the treatment of choice. This is a group with a very high cardiovascular risk, with mid-term mortality rates close to 30%. Aim To describe the population undergoing coronary bypass angioplasty (CBA) and compare their mortality with an age and gender matched group of patients with acute myocardial infarction with ST segment elevation (STEMI) Methods This was a retrospective case-control study including patients with CBA between 2010-2016. This group was compared with the same number of controls with STEMI matched by age and sex. Clinical characteristics, procedure variables and overall mortality as well as cardiac mortality were analyzed using Student's T test, Chi squared test and Kaplan Meier curves (significance set at p <0.05). Results: We identified 63 patients undergoing CBA (76 procedures). The most commonly intervened bypasses were to the circumflex artery (48.7%). There were 18 (28.5%) patients who died in the CBA group and 6 (9.5%) patients in the STEMI group, which resulted in an excess of global mortality risk in patients with CBA (HR 3.02, 95% CI 1.11 - 8.22, p = 0.02). This difference was driven by a higher non-cardiac mortality in the CBA group (12.7% (n = 8) vs 3.2% (n = 2) [p = 0.04]) Conclusion Patients undergoing CBA have a mortality rate more than three times that of the STEMI patients, mainly due to a higher non-cardiac mortality.

Potential Utility of the SYNTAX Score 2 in Patients Undergoing Left Main Angioplasty / Utilidade Potencial do SYNTAX Score 2 em Pacientes Submetidos a Angioplastia do Tronco Comum

Abstract Background: The revascularization strategy of the left main disease is determinant for clinical outcomes. Objective: We sought to 1) validate and compare the performance of the SYNTAX Score 1 and 2 for predicting major cardiovascular events at 4 years in patients who underwent unprotected left main angioplasty and 2) evaluate the long-term outcome according to the SYNTAX score 2-recommended revascularization strategy. Methods: We retrospectively studied 132 patients from a single-centre registry who underwent unprotected left main angioplasty between March 1999 and December 2010. Discrimination and calibration of both models were assessed by ROC curve analysis, calibration curves and the Hosmer-Lemeshow test. Results: Total event rate was 26.5% at 4 years.The AUC for the SYNTAX Score 1 and SYNTAX Score 2 for percutaneous coronary intervention, was 0.61 (95% CI: 0.49-0.73) and 0.67 (95% CI: 0.57-0.78), respectively. Despite a good overall adjustment for both models, the SYNTAX Score 2 tended to underpredict risk. In the 47 patients (36%) who should have undergone surgery according to the SYNTAX Score 2, event rate was numerically higher (30% vs. 25%; p=0.54), and for those with a higher difference between the two SYNTAX Score 2 scores (Percutaneous coronary intervention vs. Coronary artery by-pass graft risk estimation greater than 5.7%), event rate was almost double (40% vs. 22%; p=0.2). Conclusion: The SYNTAX Score 2 may allow a better and individualized risk stratification of patients who need revascularization of an unprotected left main coronary artery. Prospective studies are needed for further validation.

Resumo Fundamento: A estratégia de revascularização na doença do tronco comum é determinante para os resultados clínicos. Objetivo: Procurou-se: 1) validar e comparar o desempenho do SYNTAX Score 1 e 2 na predição de eventos cardiovasculares aos 4 anos, em pacientes submetidos a angioplastia do tronco comum não protegido e 2) avaliar os resultados a longo prazo de acordo com a estratégia de revascularização recomendada pelo SYNTAX Score. Métodos: Estudo retrospectivo de centro único de 132 pacientes consecutivos submetidos a angioplastia do tronco comum não protegido entre março de 1999 e dezembro de 2010. A discriminação e calibração de ambos os modelos foram avaliadas por análise de curva ROC, curvas de calibração e teste de Hosmer-Lemeshow. Resultados: A taxa de eventos aos 4 anos foi de 26,5%. A AUC para o SYNTAX Score 1 e 2 foi de 0,61 (IC 95% 0,49-0,73) e 0,67 (IC 95% 0,57-0,78), respectivamente. Apesar de uma calibração global boa, o SYNTAX Score 2 tende a subestimar o risco. Nos 47 pacientes (36%) que deveriam ter sido submetidos a cirurgia de revascularização de acordo com o SYNTAX Score 2, a taxa de eventos foi numericamente superior (30% vs. 25%; p=0,54) e para os que tinham uma diferença superior entre as estimativas do SYNTAX Score 2 (>5,7%), a taxa de eventos foi quase o dobro (40% vs. 22%; p=0,2). Conclusão: O SYNTAX Score 2 permite uma estratificação de risco individualizada e melhor em pacientes que requerem revascularização do tronco comum não protegido. São necessários estudos prospectivos para validação adicional.

Procedural outcome of primary PCI inst-segment elevation myocardial infarction at Afic and Nihd Rawalpindi - Pakistan

To determine the procedural outcome of primary percutaneous coronary interventions [PCI] in ST segment elevation myocardial infarction. A quasi-experimental study. Armed Forces Institute of Cardiology and National Institute of Heart Diseases, a tertiary care cardiac institute from November 2011 to September 2013. Total 228 patients who underwent primary percutaneous intervention [primary PCI] were included in this study. A pre designed performa was prospectively filled which included demographic and procedural variables. Procedural success and in hospital mortality were recorded. The mean age was 59 +/- 10.88 years. There were 205 [89.9%] males, 80 [35.1%] patients were found to be diabetic, 47 [20.6%] hypertensive, and 90 [39.5%] patients were smokers. Family history of ischemic heart disease was positive in 51 [22.4] patients. Anterior, inferior and lateral myocardial infarction were present in 137 [60.1%], 90 [39.5%] and 1 [0.4%] patients respectively. The Median time from the onset of symptoms to the arrival in the hospital was 122.5 +/- 142.57 and median door to balloon time was 60 +/- 22.88 min. Left anterior descending [LAD] was the commonest infarct related artery accounting for culprit artery in 138 [60.5%] followed by right coronary artery [RCA] and left circumflex artery [LCX] in 72 [31.6%] and 18 [7.9%] cases respectively. Procedural success was achieved in 222 [97.4%] patients. Six [2.6%] patients died in the hospital. High success rate with low mortality rates can be achieved in our set up. However more studies and long term follow up is required to validate our results

Características clínicas, predictores de mortalidad y resultados inmediatos y a largo plazo en el tratamiento con angioplastía primaria del infarto agudo al miocardio con supradesnivel del ST complicado con shock cardiogénico / Clinical characteristics and predictors of early and global mortality in patients with ST segment elevation myocardial infarction and cardiogenic shock undergoing primary angioplasty

Introducción: El shock cardiogénico (SC) es la complicación más grave del infarto agudo al miocardio (IAM). La mortalidad del SC varía entre un 40-60%. Con el acceso a la angioplastía primaria, el pronóstico del SC ha mejorado en los últimos años, aunque la mortalidad permanece elevada. Nuestro objetivo fue analizar las características clínicas, predictores de mortalidad intrahospitalaria y a largo plazo de los pacientes con IAM complicados con SC en 3 centros hospitalarios con disponibilidad de hemodinamia de urgencia las 24 horas del día.Métodos y Resultados. Estudio analítico observacional. Se incluyeron pacientes entre Enero 2009 y Agosto 2013. La mortalidad se confirmó por certificado de defunción emitido por el registro civil. En el período estudiado se encontraron 101 pacientes con IAM con SC, con una mortalidad intrahospitalaria de 40.8% y global de 53.5% con un seguimiento medio de 1.6 años. No hubo deiferencias significativas entre vivos y fallecidos, respecto de la edad de presentación, antecedentes CV, enfermedad renal, PCR al momento de presentación, tiempo transcurrido desde la presentación del SC, trombo-aspiración, uso de balón de contrapulsación intraórtico (BCIAo), ni resultado angiográfico final. El grupo de mortalidad presentaba mayor número de vasos enfermos (83.3% vs 63.2%; p:0.012), peor fracción de eyección (Fe<30% 66.7% vs 22.5%; p<0,001). Los predictores ajustados de mortalidad intrahospitalaria fueron la presencia de 2 o más vasos enfermos OR 2.9 (IC 95% 1.19-7,1; p= 0.012), y la FE < 30% (OR 6.8, IC 95% 2.23 - 21.27; p=0.001)...

Background. Cardiogenic shock in acute myocardial infarction (AMI) is associated with a high mortality rate (40-60%). An improvement in this prognosis has followed the introduction of primary angioplasty. The aim of this study was to analyze the clinical and angiographic characteristics as well as to determine the early and late mortality in patients with St elevation AMI and cardiogenic shock undergoing primary angioplasty in 3 hospital centers where this procedure was available on a 24hr basis.Methods and Results. We analyzed the clinical an angiographic data of patients treated with primary PTCA for AMI and cardiogenic shock from January 2009 to August 2013. Mortality was confirmed by the data from a National Statistics Office. 101 patients were included and followed for an average of 1.6 years after primary PTCA. Early and total mortality rates were 40.8% and 53.5%, respectively. No differences were found between survivors and non survivors regarding age, risk factors, previous cardiovascular disease, renal failure, CRP and time to PTCA. Intracoronary thrombus aspiration, use of intra-aortic balloon pumping or final angiographic findings were also similar between groups. Compared to survivors, deceased patients had more vessels involved (>= 2 vessels in 83.3% vs 63.2%, respectively, p=0.012) and lower EF (under 30% in 66.7% vs 22.5%, respectively, p<0.001). Predictors of hospital mortality were the presence of >= 2 vessel disease (OR 2.9, 95% C.I. 1.19 - 7.1, p=0.012) and EF under 30% (OR 6.8, C.I. 2.23 - 21.27, p= 0.001)...

Comparison of Coronary Artery Bypass Grafting with Percutaneous Coronary Intervention for Unprotected Left Main Coronary Artery Disease

PURPOSE: Coronary artery bypass grafting (CABG) is the optimal treatment option for left main coronary artery disease (LMCAD). However, LMCAD remains a constant topic of discussion between cardiac surgeons and interventional cardiologists. The aim of this study was to assess the efficacy of LMCAD treatments by comparing the mid-term outcomes of CABG and percutaneous coronary intervention (PCI) using bare metal stents or drug-eluting stents (DESs). MATERIALS AND METHODS: The study population was comprised of 199 consecutive patients admitted with unprotected LMCAD. All of the patients were assigned to PCI (88 patients) or CABG (111 patients). The primary clinical end point indicated death, stroke of acute coronary syndrome (ACS). RESULTS: Patients assigned to PCI were at higher operative risk than patients scheduled for CABG (6.49+/-4.09 vs. 4.81+/-2.67, p=0.0032). Comparison of the group that received DESs with the CABG group did not reveal any differences in major adverse cardio-cerebral events (MACCE) occurrence (21% vs. 16%, p=NS). Patients in the CABG and PCI groups died with similar frequency (11% vs. 16%, p=NS). The mortality rate in the CABG group was higher than among those treated with DES (11% vs. 3%, p=0.049). The rate of ACS was higher in the PCI group than in the CABG group (13% vs. 4%, p=0.016). CONCLUSION: Despite the fact that patients treated with PCI were at higher operative risk, PCI with DES was shown to be comparable to CABG in terms of mortality, stroke and ACS. However, the frequency of repeat revascularizations remains a constant concern with PCI.

Desempenho e gastos do SUS com revascularizações do miocárdio no Estado do Rio de Janeiro, de 1999 a 2008 / Coronary artery bypass graft surgery performance and costs by the Brazilian Public Health System (SUS) in the State of Rio de Janeiro, from 1999 to 2008

FUNDAMENTO: Os gastos com cirurgia de revascularização do miocárdio (RVM) e angioplastia coronariana (AC), representaram importante ônus para o SUS. OBJETIVO: Analisar gastos do SUS com RVM e AC e sua performance nos hospitais do Estado do Rio de Janeiro (ERJ), de 1999 a 2008. MÉTODOS: As informações provieram das AIH pagas dos hospitais com mais de 100 revascularizações. As taxas de letalidade foram ajustadas por modelos Poisson (covariáveis idade, dias de permanência no hospital e gasto em UTI). Foram construídos índices de gasto médio relativo, dividindo-se o valor médio da fração de gasto em cada hospital pelo gasto médio no ERJ, em dólares. Para análise estatística empregou-se o Stata. RESULTADOS: Foram pagas 10.983 RVM e 19.661 AC em 20 hospitais nos 10 anos, com valores médios de US$ 3.088,12 e 2.183,93, respectivamente. A taxa de letalidade nas RVM flutuou de 9,2 por cento-1999 para 7,7 por cento-2008, com valores extremos de 5,0 por cento-9,2 por cento e nas AC de 1,6 por cento-1999 para 1,5 por cento-2008, com valores extremos de 0,9 por cento-2,3 por cento. Os hospitais diminuíram a realização de RVM e duplicaram a de AC. Idade, tempo de internação e gastos em UTI correlacionaram-se significativamente com a letalidade nas RVM e AC pagas no ERJ. Em média, os gastos com os serviços hospitalares representaram 41 por cento do total das RVM e 18 por cento das AC, e os com as órteses e próteses, 55 por cento das AC e 28 por cento nas RVM. CONCLUSÃO: Evidencia-se necessidade de melhorar a qualidade do atendimento das instituições que realizam RVM e AC pagas pelo SUS.

BACKGROUND: Expenses with coronary artery bypass grafting (CABG) surgery and coronary angioplasty (CA) represented a significant cost to SUS. OBJECTIVE: To analyze SUS expenses with CABG and CA and their performance in hospitals in the state of Rio de Janeiro (SRJ), from 1999 to 2008. METHODS: The information came from paid HAA in hospitals with more than 100 revascularization procedures. Mortality rates were adjusted by Poisson (with covariates age, length of hospital stay and ICU expenses). Mean relative cost indices were calculated by dividing the mean value of the cost fraction spent in each hospital by the mean expense in the SRJ in U.S. dollars. Stata software was used for statistical analysis. RESULTS: A total of 10,983 CABG and 19,661 CA were paid by SUS in 20 hospitals during the 10 years, with mean values of US$ 3,088.12 and 2,183.93, respectively. The mortality rate in CABG varied from 9.2 percent-1999 to 7.7 percent-2008, with ranges of 5.0 percent-9.2 percent and in CA, from 1.6 percent-1999 to 1.5 percent-2008, with ranges of 0.9 percent-2.3 percent. The hospitals decreased the number of CABG procedures and doubled CA procedures. Age, time of hospital stay and ICU costs significantly correlated with lethality in CABG and CA paid by SUS in the SRJ. On average, hospital service costs represented 41 percent of the total cost of CABG and 18 percent of CA, and with ortheses and prostheses, 55 percent in CA and 28 percent in CABG. CONCLUSION: It is clear the need to improve the quality of healthcare service in institutions that perform CABG and CA paid by SUS.

Angioplastia coronariana versus cirurgia de revascularização: revisão de estudos randomizados / Coronary angioplasty versus CABG: review of randomized

Realizamos uma revisão com agregação de resultados dos ensaios randomizados que compararam intervenção coronariana percutânea (ICP) com cirurgia de revascularização miocárdica (CRM). Os 25 ensaios selecionados envolveram 12.305 pacientes dos quais 11.103 pertenciam a estudos em multiarteriais e 1.212 pertenciam a estudos em lesão única de descendente anterior (DA). Nos estudos em multiarteriais a ICP mostrou uma tendência a menor mortalidade precoce (1,2 por cento versus 2 por cento) e menor incidência de acidente vascular cerebral (AVC): 0,7 por cento versus 1,65 por cento. Não houve diferença na mortalidade intermediária (3,8 por cento versus 3,8 por cento). Houve tendência à superioridade da CRM na mortalidade tardia (10,5 por cento versus 9,6 por cento). A diferença deveu-se exclusivamente aos estudos da era balão, tendendo a inverter-se na era stent (9,6 por cento versus 9,9 por cento). Nos estudos de lesão única de DA não houve diferença significativa em nenhum desfecho. A agregação de resultados de nove estudos que avaliaram a mortalidade tardia em diabéticos mostrou diferença favorável à cirurgia (21,3 por cento versus 15,9 por cento). Dois estudos que avaliaram lesão de tronco não mostraram diferença significativa na mortalidade em um ano (3,9 por cento versus 4,7 por cento). A incidência de nova revascularização foi consistentemente maior na ICP, apesar de progressiva melhora dos resultados na era stent.

We carried out a review that included results of randomized trials that made a comparison between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). The 25 selected trials involved 12,305 patients, 11,103 of whom were from studies in patients with multi-vessel disease and 1,212 were from studies in patients with single lesion of the left anterior descending (LAD). In the studies of multi-vessel disease patients, the PCI showed a trend towards lower early mortality (1.2 percent versus 2 percent) and lower incidence of stroke: 0.7 percent versus 1.65 percent. There was no difference in the intermediate mortality (3.8 percent versus 3.8 percent). There was a trend towards the superiority of CABG in late mortality (10.5 percent versus 9.6 percent). The difference was exclusively due to "balloon era" studies, with a trend towards an inversion in the "stent era" (9.6 percent versus 9.9 percent). In studies of single lesion of LAD, there was no significant difference in any endpoint. The aggregation of results from nine studies that assessed late mortality in diabetic patients showed a difference in favor of surgery (21.3 percent versus 15.9 percent). Two studies that evaluated main coronary artery disease did not show a significant difference in mortality at one year (3.9 percent versus 4.7 percent). The incidence of repeat revascularization was consistently higher in PCI, despite the progressive improvement in results in the stent era.

Avaliação prognóstica da doença coronária estável através de um novo escore / New prognostic score for stable coronary disease evaluation / Evaluación pronóstica de la enfermedad coronaria estable a través de un nuevo score

FUNDAMENTO: A necessidade de melhorar a acurácia do teste de esforço, determinou o desenvolvimento de escores, cuja aplicabilidade já foi amplamente reconhecida. OBJETIVO: Avaliação prognóstica do coronariopata estável através de um novo escore simplificado. MÉTODOS: Um novo escore foi aplicado em 372 coronariopatas multiarteriais e função ventricular preservada, 71,8 por cento homens, idade média 59,5 (± 9,07) anos, randomizados para angioplastia, revascularização cirúrgica e tratamento clínico, acompanhados por 5 anos. Óbito cardiovascular foi o desfecho primário. Infarto do miocárdio não-fatal, óbito e re-intervenção formaram o desfecho combinado secundário. O escore baseou-se numa equação previamente validada resultante da soma de 1 ponto para: sexo masculino, história de infarto, angina, diabete, uso de insulina e ainda 1 ponto para cada década de vida a partir dos 40 anos. Teste positivo adicionou 1 ponto. RESULTADOS: Ocorreram 36 óbitos (10 no grupo angioplastia, 15 no grupo revascularização e 11 no grupo clínico), p = 0,61. Observou-se 93 eventos combinados: 37 no grupo angioplastia, 23 no grupo revascularização e 33 no grupo clínico (p = 0,058). 247 pacientes apresentaram escore clínico > 5 pontos e 216 > 6 pontos. O valor de corte > 5 ou > 6 pontos identificou maior risco, com p = 0,015 e p = 0,012, respectivamente. A curva de sobrevida mostrou uma incidência de óbito após a randomização diferente naqueles com escore > 6 pontos (p = 0,07), e uma incidência de eventos combinados diferente entre pacientes com escore < 6 e > 6 pontos (p = 0,02). CONCLUSÃO: O novo escore demonstrou consistência na avaliação prognóstica do coronariopata estável multiarterial.

BACKGROUND: The need to improve the exercise testing accuracy, pushed the development of scores, whose applicability was already broadly recognized. OBJECTIVE: Prognostic evaluation of stable coronary disease through a new simplified score. METHODS: A new score was applied in 372 multivessel coronary patients with preserved ventricular function, 71.8 percent male, age: 59.5 (± 9.07) years old, randomized to medical treatment, surgery (CABG) or angioplasty (PTCA), with 5 years of follow-up. Cardiovascular death was considered the primary endpoint. Non-fatal myocardial infarction, death and re-intervention were considered for a combined secondary endpoint. The score was based on an equation previously validated, resulting from a sum of one point for: male gender, infarction history, angina, diabetes, insulin use and one point for each decade of life after 40 years old. Positive exercise testing summed one additional point. RESULTS: Thirty six deaths was observed (10 in group PTCA, 15 in CABG and 11 in the clinical group), p = 0.61. We observed 93 combined events: 37 in PTCA group, 23 in CABG and 33 in the clinical group (p = 0.058). 247 patients presented clinical score > 5 points and 216 > 6 points. The cutoff point > 5 or > 6 points identified higher risk, p = 0.015 and p = 0.012, respectively. The survival curve showed a different death incidence after the randomization when score reached 06 points or more (p = 0.07), and a distinct incidence of combined events between the patients with score < 6 and > 6 points (p = 0.02). CONCLUSION: The new score was consistent for multiarterial stable coronary disease risk stratification.

FUNDAMENTO: La necesidad de mejorar la exactitud de las pruebas de estrés, determinó el desarrollo de los puntajes, cuya aplicación fue ampliamente reconocida. OBJETIVO: La evaluación pronóstica del coronariópata estable a través de un nuevo score simplificado. MÉTODOS: Un nuevo score se aplicó en 372 coronariópatas multiarteriales y función ventricular preservada, el 71,8 por ciento varones, edad media de 59,5 (± 9,07) años, randomizados para angioplastia, revascularización quirúrgica y tratamiento clínico, seguidos de cinco años. Muerte cardiovascular fue el resultado primario. El infarto de miocardio no fatal, la muerte y la re-intervención formaron el desenlace combinado secundario. El score se basó en una ecuación previamente validada resultante de la suma de 1 punto a: sexo masculino, antecedentes de infarto, angina, diabetes, uso de insulina y todavía un punto por cada década de vida después de 40 años. Prueba positiva añadida 1 punto. RESULTADOS: Hubo 36 muertes (10 en el grupo de angioplastia, 15 en el grupo de revascularización y 11 en el grupo clínico), p = 0,61. Se observó 93 eventos combinados: 37 en el grupo angioplastia, 23 en el grupo revascularización y 33 en el grupo clínico (p = 0,058). Presentaron score clínico > 5 puntos y 216 > 6 puntos 247 pacientes. El valor de corte > 5 o > 6 puntos identificó un mayor riesgo, con p = 0,015 y p = 0,012, respectivamente. La curva de sobrevida mostró una incidencia de muerte después de la aleatorización que aquellos con score > 6 puntos (p = 0,07), y una incidencia de eventos combinados diferentes entre los pacientes con score < 6 y > 6 puntos (p = 0,02). CONCLUSIÓN: El nuevo score demostró consistencia en la evaluación pronóstica del coronariópata estable multiarterial. (Arq Bras Cardiol 2011;96(5):411-419).

Intervenção coronariana percutânea no Brasil: resultados do Sistema Único de Saúde / Percutaneous coronary intervention in Brazil: results from the Brazilian Public Health System / Intervención coronaria percutánea en el Brasil: Resultados del Sistema Único de Salud

FUNDAMENTO: O Sistema Único de Saúde (SUS) realiza aproximadamente 80 por cento das intervenções coronarianas percutâneas (ICP) no Brasil. O conhecimento desses dados permitirá planejar adequadamente o tratamento da doença arterial coronariana (DAC). OBJETIVO: Analisar e discutir os resultados das ICP realizadas pelo SUS. MÉTODOS: Foram avaliados os dados do SIH/DATASUS disponibilizados para consulta pública. RESULTADOS: Entre os anos de 2005 a 2008 foram realizados 166.514 procedimentos em 180 hospitais. A mortalidade hospitalar média foi de 2,33 por cento, variando de 0 por cento a 11,35 por cento, sendo mais baixa no Sudeste, 2,03 por cento e mais alta na região Norte, 3,64 por cento (p < 0,001). A mortalidade foi de 2,33 por cento nos 45 (25 por cento) hospitais de maior volume, responsáveis por 101.218 (60,8 por cento) das ICP, 2,29 por cento nos 90 (50 por cento) de médio volume com 50.067 (34,9 por cento) ICP e 2,52 por cento nos 45 (25 por cento) de pequeno volume com 7.229 (4,3 por cento) ICP (p > 0,05). A mortalidade foi maior no gênero feminino (p < 0,0001), e nas idades > 65 a (p < 0,001). No diagnóstico de angina (79.324, 47,64 por cento) a mortalidade foi de 1,03 por cento e no de IAM (33.286, 32,30 por cento) 6,35 por cento (p < 0,0000001). No implante único de stent, o mais frequente (102.165, 61,36 por cento), a mortalidade foi de 1,20 por cento, e na ICP primária (27.125, 16,29 por cento), 6,96 por cento. CONCLUSÃO: Embora crescente, ainda é baixo o número de ICP no país. Os hospitais de grande volume, em menor número, foram responsáveis pela maior parte dos procedimentos. O implante único de stent por internação foi o procedimento reportado mais empregado. As mortalidades tiveram grande variabilidade entre os hospitais. A ICP primária foi a responsável pela maior taxa de mortalidade.

BACKGROUND: The Brazilian Public Health System (SUS) holds approximately 80 percent of percutaneous coronary interventions (PCI) in Brazil. Being aware of these data will enable to design a proper plan for the treatment of coronary artery disease (CAD). OBJECTIVE: To review and discuss the results of PCIs performed by the SUS. METHODS: We reviewed data from SIH/DATASUS available for public consultation. RESULTS: From 2005 to 2008, 166,514 procedures were performed in 180 hospitals. Average hospital mortality was 2.33 percent, ranging from 0 percent to 11.35 percent, being lower in the Southeast, 2.03 percent and higher in the northern region, 3.64 percent (p < 0.001). The mortality rate was 2.33 percent in 45 (25 percent) higher-volume hospitals, accounting for 101,218 (60.8 percent) of the PCIs, 2.29 percent in 90 (50 percent) medium-volume hospitals with 50,067 (34.9 percent) PCIs and 2.52 percent in 45 (25 percent) small-volume hospitals with 7,229 (4.3 percent) PCIs (p > 0.05). Mortality was higher in females (p < 0.0001) and at ages > 65 to = (p < 0.001). In the diagnosis of angina (79,324, 47.64 percent) mortality was 1.03 percent, and AMI (33,286, 32.30 percent) 6.35 percent (p < 0.0000001). In the single stent implantation, the most common (102,165, 61.36 percent), mortality was 1.20 percent, and primary PCI (27,125, 16.29 percent), 6.96 percent. CONCLUSION: Although it is growing, the number of PCIs in Brazil is still low. High-volume hospitals, in smaller numbers, accounted for most procedures. Single stent implantation through hospital admission was reported to be most commonly used procedure. Mortality rates were highly variable among the hospitals. Primary PCI was responsible for the highest mortality rate.

FUNDAMENTO: El Sistema Único de Salud (SUS) realiza aproximadamente 80 por ciento de las intervenciones coronarias percutáneas (ICP) en el Brasil. El conocimiento de esos datos permitirá planear adecuadamente el tratamiento de la enfermedad arterial coronaria (EAC). OBJETIVO: Analizar y discutir los resultados de las ICP realizadas por el SUS. MÉTODOS:Fueron evaluados los datos del SIH/DATASUS disponibles para la consulta pública. RESULTADOS: Entre los años 2005 a 2008 fueron realizados 166.514 procedimientos en 180 hospitales. La mortalidad hospitalaria media fue de 2,33 por ciento, variando de 0 por ciento a 11,35 por ciento, siendo más baja en el Sudeste, 2,03 por ciento y más alta en la región Norte, 3,64 por ciento (p < 0,001). La mortalidad fue de 2,33 por ciento en los 45 (25 por ciento) hospitales de mayor volumen, responsables por 101.218 (60,8 por ciento) de las ICP, 2,29 por ciento en los 90 (50 por ciento) de medio volumen con 50.067 (34,9 por ciento) ICP y 2,52 por ciento en los 45 (25 por ciento) de pequeño volumen con 7.229 (4,3 por ciento) ICP (p > 0,05). La mortalidad fue mayor en el género femenino (p < 0,0001), y en las edades > 65 a (p < 0,001). En el diagnóstico de angina (79.324, 47,64 por ciento) la mortalidad fue de 1,03 por ciento y en el de IAM (33.286, 32,30 por ciento) 6,35 por ciento (p < 0,0000001). En el implante único de stent, el más frecuente (102.165, 61,36 por ciento), la mortalidad fue de 1,20 por ciento, y en la ICP primaria (27.125, 16,29 por ciento), 6,96 por ciento. CONCLUSIÓN:Aunque creciente, aun es bajo el número de ICP en el país. Los hospitales de gran volumen, en menor número, fueron responsables por la mayor parte de los procedimientos. El implante único de stent por internación fue el procedimiento reportado como más empleado. Las mortalidades tuvieron gran variabilidad entre los hospitales. La ICP primaria fue la responsable por la mayor tasa de mortalidad.

Perfil clínico-angiográfico na doença arterial coronariana: desfecho hospitalar com ênfase nos muito idosos / Clinical and angiographic profile in coronary artery disease: hospital outcome with emphasis on the very elderly / Perfil clínico-angiográfico en la enfermedad arterial coronaria: desenlace hospitalario con énfasis en los muy añosos

FUNDAMENTO: Conhecer fatores de risco e manifestações clínicas da doença arterial coronariana (DAC) permite-nos intervir de maneira mais eficaz junto a uma determinada população. OBJETIVO: Identificar perfis clínicos e angiográficos dos pacientes submetidos a cateterismo cardíaco, atendidos em um hospital terciário e tratados por meio de intervenções coronarianas percutâneas (ICP). MÉTODOS: Casuística de 1.282 pacientes submetidos a 1.410 cateterismos cardíacos, selecionados de mar/2007-mai/2008 em um banco de dados de um hospital geral para diagnóstico de doença arterial coronariana (DAC). Fatores de risco, indicação do exame, detalhes técnicos da ICP e desfechos intra-hospitalares foram prospectivamente coletados. RESULTADOS: Foram 688 (54,0 por cento) pacientes do sexo masculino, com média de idade de 65,4 ± 10,9 anos, sendo 20,0 por cento acima dos 75 anos. O quadro clínico confirmado com mais frequência foi o de síndrome coronariana aguda (SCA) sem supradesnivelamento do segmento ST (SST) (38,7 por cento). A DAC multiarterial ocorreu em 46,4 por cento, foi indicada ICP em 464 pacientes, sendo tratadas 547 lesões-alvo (tipo B2 ou C, em 86,0 por cento), sendo destas, 14,0 por cento tratadas com stent farmacológico. Dentre os IAM com SST, ICP primária foi realizada em 19,0 por cento dos pacientes, sendo que, destes, 77,0 por cento foram transferidos dos hospitais de origem tardiamente (ICP tardia) e não receberam trombolítico prévio, e 4,0 por cento realizaram ICP de resgate. Foi obtido sucesso angiográfico em 94,2 por cento das ICPs. Aconteceu óbito em 5,6 por cento dos pacientes, tendo estes uma média de idade de 75,2 ± 10,2 anos. CONCLUSÃO: Observamos predomínio de idosos (estando 20,1 por cento > 75 anos) e do sexo masculino. Dos fatores de risco para DAC, os mais frequentes foram hipertensão arterial sistêmica e dislipidemia. Ocorreu predomínio da SCA. A idade > 75 anos, DAC multiarterial e a insuficiência renal crônica foram os preditores de óbito intra-hospitalar.

BACKGROUND: Knowing the risk factors and clinical manifestations of coronary artery disease (CAD) allows us to intervene more effectively with a particular population. OBJECTIVE: To identify clinical and angiographic profiles of patients undergoing cardiac catheterization, treated at a tertiary hospital and treated by percutaneous coronary interventions (PCI). METHODS: The study of 1,282 patients who underwent 1,410 cardiac catheterizations, selected from March/2007 to May/2008 from a database in a general hospital for diagnosis of coronary artery disease (CAD). Risk factors, indication for examination, technical details of PCI and in-hospital outcomes were prospectively collected. RESULTS: There were 688 (54.0 percent) males, mean age 65.4 ± 10.9 years and 20.0 percent above 75 years age. The most frequent clinical condition was acute coronary syndrome (ACS) without ST-segment elevation (STS) (38.7 percent). The multi artery CAD occurred in 46.4 percent, PCI was indicated in 464 patients, 547 target lesions were treated (type B2 or C, 86.0 percent), and of these, 14.0 percent treated with drug eluting stents. Among those with AMI with STS, primary PCI was performed in 19.0 percent of the patients, from these, 77.0 percent were transferred from the origin hospitals late (late PCI) and had not received prior thrombolytic, and 4.0 percent had PCI rescue. Angiographic success was achieved in 94.2 percent of PCIs. Death occurred in 5.6 percent of patients, with average age of 75.2 ± 10.2 years. CONCLUSION: The prevalence of elderly (20.1 percent being > 75 years) and male was observed. From the risk factors for CAD, the most common were systemic hypertension and dyslipidemia. There was a predominance of ACS. Age > 75 years old, multiarterial CAD and chronic renal failure were predictors of in-hospital deaths.

FUNDAMENTO: Conocer factores de riesgo y manifestaciones clínicas de la enfermedad arterial coronaria (EAC) nos permite intervenir de manera más eficaz en una determinada población. OBJETIVO: Identificar perfiles clínicos y angiográficos de los pacientes sometidos a cateterismo cardíaco, atendidos en un hospital terciario y tratados por medio de intervenciones coronarias percutáneas (ICP). MÉTODOS: Casuística de 1.282 pacientes sometidos a 1.410 cateterismos cardíacos, seleccionados de mar/2007-may/2008 en un banco de datos de un hospital general para diagnóstico de enfermedad arterial coronaria (EAC). Factores de riesgo, indicación del examen, detalles técnicos de la ICP y desenlaces intrahospitalarios fueron prospectivamente colectados. RESULTADOS: Fueron 688 (54,0 por ciento) pacientes del sexo masculino, con media de edad de 65,4 ± 10,9 años, siendo 20,0 por ciento encima de los 75 años. El cuadro clínico confirmado con más frecuencia fue el de síndrome coronario agudo (SCA) sin supradesnivel del segmento ST (SST) (38,7 por ciento). La EAC multiarterial ocurrió en 46,4 por ciento, fue indicada ICP en 464 pacientes, siendo tratadas 547 lesiones-blanco (tipo B2 o C, en 86,0 por ciento), siendo de éstas, 14,0 por ciento tratadas con stent farmacológico. Entre los IAM con SST, ICP primaria fue realizada en 19,0 por ciento de los pacientes, siendo que, de éstos, 77,0 por ciento fueron transferidos de los hospitales de origen tardíamente (ICP tardía) y no recibieron trombolítico previo, y 4,0 por ciento realizaron ICP de rescate. Fue obtenido éxito angiográfico en 94,2 por ciento de las ICPs. Sucedió óbito en 5,6 por ciento de los pacientes, teniendo éstos una media de edad de 75,2 ± 10,2 años. CONCLUSIÓN: Observamos predominio de añosos (siendo 20,1 por ciento > 75 años) y del sexo masculino. De los factores de riesgo para EAC, los más frecuentes fueron hipertensión arterial sistémica y dislipidemia. Ocurrió predominio de la SCA. La edad > 75 años, EAC multiarterial y la insuficiencia renal crónica fueron los predictores de óbito intrahospitalario.

Letalidade e complicações de angioplastias em hospitais públicos no Rio de Janeiro, RJ / In-hospital mortality and complications after coronary angioplasty, City of Rio de Janeiro, Southeastern Brazil

OBJETIVO: Estimar a prevalência de letalidade e de complicações decorrentes de angioplastia coronariana em hospitais públicos. MÉTODOS: Foram analisados dados obtidos no Sistema de Autorização Hospitalar do Sistema Único de Saúde referentes aos 2.913 procedimentos de angioplastia coronariana realizados no município do Rio de Janeiro, RJ, de 1999 a 2003. Após amostragem aleatória simples e ponderação de dados, foram analisados 529 prontuários de pacientes, incluindo todos os óbitos, submetidos à angioplastia coronariana em quatro hospitais públicos: federal de ensino, estadual de ensino, federal de referência e estadual de referência. Os testes de comparação entre as letalidades segundo características dos pacientes, co-morbidades, complicações, tipos e indicações de angioplastia coronariana foram feitas com modelos de regressão de Poisson. RESULTADOS: A letalidade cardíaca geral foi de 1,6 por cento, variando de 0,9 por cento a 6,8 por cento. De acordo com grupo etário, a letalidade foi: 0,2 por cento em pacientes com idade inferior a 50 anos; 1,6 por cento entre 50 e 69; e 2,7 por cento acima de 69 anos. A letalidade na angioplastia coronariana primária e de resgate foram elevadas, 17,4 por cento e 13,1 por cento, respectivamente; nas angioplastias eletivas foi de 0,8 por cento. As principais complicações foram dissecção (5 por cento dos pacientes, letalidade cardíaca = 11,5 por cento) e oclusão do vaso (2,6 por cento; letalidade cardíaca = 21,8 por cento). Sangramento ocorreu em 5,9 por cento dos pacientes (letalidade = 5,6 por cento) e em 3,0 por cento houve necessidade de transfusão (letalidade = 12,0 por cento). Infarto agudo aconteceu em 1,1 por cento com letalidade de 38 por cento e o acidente vascular encefálico indicou uma letalidade de 17,5 por cento. CONCLUSÕES: A letalidade foi elevada para as angioplastias primárias e de resgate nos quatro hospitais públicos estudados no período de 1999-2003. As angioplastias coronarianas ...

OBJECTIVE: To estimate in-hospital mortality and prevalence of complications of percutaneous transluminal coronary angioplasty (PTCA) in public hospitals. METHODS: Data for 2,913 PTCA were obtained from the Brazilian National Health System (SUS) Hospital Authorization Database in the city of Rio de Janeiro, Southeastern Brazil, between 1999 and 2003. After simple random sampling and data weighting, 529 medical records of patients undergoing PTCA, including all deaths, in four public hospitals (federal and state university, and federal and state reference hospitals) were studied. Comparison tests of mortality according to patient characteristics, comorbidities, complications, types of PTCA procedures, and indications for PTCA were performed using Poisson's regression models. RESULTS: The overall in-hospital mortality was 1.6 percent (range: 0.9-6.8 percent). The age distribution of mortality was as follows: 0.2 percent in patients younger than 50; 1.6 percent in those 50-69; and 2.7 percent in those older than 69. High mortality was seen in primary and rescue PTCAs: 17.4 percent and 13.1 percent, respectively; and mortality in elective PTCA was 0.8 percent. The main complications during PTCA were dissection (5 percent; mortality: 11.5 percent) and artery occlusion (2.6 percent; mortality: 21.8 percent). Bleeding was seen in 5.9 percent of the patients (mortality: 5.6 percent) and 3.0 percent required blood transfusion (mortality: 12.0 percent). The complication of acute myocardial infarction was seen in 1.1 percent of patients (mortality: 38 percent) and stroke was associated with a mortality of 17.5 percent. CONCLUSIONS: The cardiac in-hospital mortality was high when PTCA was performed for a patient with ST elevation acute myocardial infaction. Elective PTCA had mortality and complications levels above the expected in four public hospitals in the main city of Rio de Janeiro

The role of invasive therapies in elderly patients with acute myocardial infarction

INTRODUCTION: In elderly patients with acute myocardial infarction, very little is known about the role of surgical myocardial revascularization and percutaneous coronary intervention (invasive therapies - IT), especially in the context of long-term outcomes after hospital discharge. METHODS: We analyzed 1588 patients with MI who had been included prospectively in a databank and followed for up to 7.5 years. In this population, 548 patients were ¡Ý70 years old (elderly group - EG), and 1040 were <70 years of age (younger group - YG); 1088 underwent IT during hospitalization, and the remaining 500 were treated medically (conservative therapy - CT). Patients were monitored either by visit or by phone at least once a year. A standard questionnaire was administered to all patients. The impact of IT was analyzed with both non-adjusted and adjusted models. RESULTS: By the end of the follow-up period, the survival rates for the IT and CT groups were, respectively, 71.9% versus 47.2% in the global population (hazard ratio=0.55, P<0.001), 81.5% versus 66.6% in the YG (hazard ratio=0.68, P=0.018) and 48.8% versus 20.3% in the EG (hazard ratio=0.58, P<0.001). In the adjusted models, the hazard ratios were 0.62 (P<0.001) in the global population, 0.74 in the YG (P=0.073) and 0.64 (P=0.001) in the EG. CONCLUSION: Long-term follow-up of patients with myocardial infarction revealed that IT during the in-hospital phase was at least as effective in elderly patients as in younger patients.

Incidência, preditores e impacto clínico dos sangramentos maiores associados à intervenção coronária percutânea / Incidence, predictors and clinical impact of major bleeding after percutaneous coronary intervention

Introdução: O sangramento associado ao periprocedimento é uma das complicações mais freqüentes da intervenção coronária percutânea (ICP). O objetivo deste estudo foi avaliar a incidência, os preditores de sangramento maior e o impacto deste nos eventos adversos após ICP. Método: Realizada análise retrospectiva de 8.739 pacientes consecutivos submetidos a ICP eletiva no período de junho de 1997 a fevereiro de 2008. Comparamos os pacientes que apresentaram ou não sangramento maior (grupos SM e NSM, respectivamente) em relação às características clínicas e angiográficas e do procedimento, e a evolução intra-hospitalar e tardia. Resultados: Sangramento maior ocorreu em 1,6% dos pacientes. O modelo de regressão logística múltipla identificou como fatores preditores independentes de sangramento maior associado à ICP: sexo feminino, idade, cirurgia de revascularização miocárdica prévia e uso dos inibidores da glicoproteína IIb/IIIa. O sangramento maior periprocedimento foi preditor independente de insuficiência renal aguda, infarto agudo do miocárdio (IAM) e óbito na fase hospitalar e de IAM na fase tardia. Conclusão: Este estudo demonstra que o sangramento maior associado periprocedimento é preditor independente de eventos adversos nas fases precoce e tardia pós-ICP.

Background: Bleeding is one of the most frequent complications of percutaneous coronary intervention (PCI). The objective of this study was to evaluate the incidence and predictors of major bleeding and the impact of this complication on adverse events after PCI. Method: A retrospective analysis of 8,739 consecutive patients who were submitted to elective PCI from June/1997 to February/ 2008 was carried out. We compared patients with or without major bleeding in relation to pre-procedure clinic and angiographic characteristics and in-hospital and late outcomes. Results: Major bleeding was identified in 1.6% of the patients. A multiple logistic regression model identified as independent predictors of major bleeding: female sex, age, previous coronary bypass surgery and use of glycoprotein IIb/IIIa inhibitors. Major bleeding was an independent predictor of in-hospital acute renal failure, myocardial infarction and death and of myocardial infarction in the late follow-up. Conclusion: Our study demonstrates that procedure-related major bleeding is an independent predictor of acute and late adverse events post-PCI.

Muito baixo peso ponderal em pacientes tratados com angioplastia coronária: impacto na mortalidade precoce e tardia / Very low ponderal weight in patients treated with coronary angioplasty: impact on early and late mortality

Fundamentos: Pacientes de muito baixo peso tratados com intervenção coronária percutânea têm maior risco de complicações durante a internação. Até o momento, não existem estudos para avaliar o efeito a longo prazo do baixo peso após angioplastia coronária na população brasileira. Método: Um total de 3.687 pacientes foi separado em dois grupos, de acordo com o índice de massa corporal (IMC), calculado como peso (em quilogramas) dividido pela altura (em metros) ao quadrado: grupo baixo peso (IMC ≤ 20 kg/m²; 125 pacientes) e grupo não-baixo peso (IMC > 20 kg/m², 3.562 pacientes). A mortalidade intrahospitalar foi avaliada prospectivamente durante a internação inicial. Após a alta, a ocorrência de óbito foi acessada por meio da revisão dos registros hospitalares e contato telefônico. Resultados: Pacientes com IMC ≤ 20 kg/m² apresentavam peso, altura e IMC médios de 49,4 ± 7,1 kg, 1,62 ± 0,10 m, e 18,7 ± 1,1 kg/m², respectivamente. O peso, a altura e o IMC de pacientes com IMC > 20 kg/m² foram de 74,4 ± 13,8 kg, 1,64 ± 0,09 m, e 27,3 ± 4,3 kg/m², respectivamente (p < 0,01 para todas as características). Pacientes do grupo baixo peso apresentaram mortalidade significativamente maior que pacientes com IMC > 20 kg/m² após 2,5 anos da angioplastia (19,4% vs. 6,9%, respectivamente; hazard ratio [HR]: 2,51, intervalo de confiança de 95% [IC 95%]: 1,61-3,91; p < 0,01). Após o ajuste multivariado para a presença de outros fatores de risco, a presença de IMC ≤ 20 kg/m² persistiu como fator independente associado a aumento da mortalidade (HR: 2,04; IC 95%: 1,28-3,25; p < 0,01)...

Background: Patients with very low weight treated with percutaneous coronary intervention have a greater risk of complications during hospitalization. So far, there have been no studies to evaluate the long-term effect of low weight after coronary angioplasty in the Brazilian population. Methods: A total of 3,687 patients were divided into two groups according to their body mass index (BMI), calculated by dividing the weight in kilograms by the height in metres squared: low-weight group (BMI < 20 kg/m²; 125 patients), and non-low-weight group (BMI > 20 kg/m²; 3,562 patients). The in-hospital mortality was evaluated prospectively during first admission. After discharge, death occurrence was assessed by reviewing hospital records and through telephone contact. Results: Patients with BMI ≤ 20 kg/m² presented weight, height, and BMI averages of 49.4 ± 7.1 kg, 1.62 ± 0.10 m, and 18.7 ± 1.1 kg/m², respectively. The weight, height and BMI of patients with BMI > 20 kg/m² was 74.4 ± 13.8 kg, 1.64 ± 0.09 m, and 27.3 ± 4.3 kg/m², respectively (p < 0.01 for all characteristics). Patients from the low-weight group showed significantly higher mortality than patients with BMI > 20 kg/m² 2.5 years after angioplasty (19.4% vs. 6.9%, respectively; hazard ratio [HR]: 2.51; 95% confidence interval [95% CI]: 1.61-3.91; p < 0.01). After multivariate adjustment for other risk factors, the presence of BMI ≤ 20 kg/m² persisted as an independent factor associated to increased mortality (HR: 2.04; 95% CI: 1.28-3.25; p < 0.01)...

Mortalidad intrahospitalaria en hombres y mujeres según terapias de reperfusión en infarto agudo del miocardio con supradesnivel del ST / ln-hospital mortality after ST-segment elevation myocardial infarction according to reperiusion therapy

Primary angioplasty is considered the best reperiusion therapy in the treatment of ST-segment elevation myocardial infarction (STEMI). However, thrombolysis is the reperiusion method most commonly used, due to its wide availability, reduced costs and ease of administration. Aim: To compare inhospital mortality in STEMI patients according to reperiusion therapy. Material and Methods: Patients admitted to Chilean hospitals participating in the GEMI network, from 2001 to 2005, with STEMI were included. They were divided in three groups: a) treated with thrombolytics, b) treated with primary angioplasty, c) without reperiusion procedure. Inhospital mortality according to gender, was analized in each group, using a logistic regression method, to assess risk factors associated with mortality. Results: We included 3,255 patients. Global mortality was 9.9 percent (7.5 percent in men and 16.7 percent in women, p <0.001). Mortality in patients treated with thrombolytics, was 10.2 percent (7.6 percent in men and 18.7 percent in women, p <0.01). The figure for patients treated with primary angioplasty, was 4.7 percent (2.5 percent in men and 13 percent in women, p <0.01), and in patients without reperiusion, was 11.6 percent (9.8 percent in men and in 15.4 percent women, p <0.01). In each group women were older, had a higher prevalence of hypertension and a higher percentage of Killip 3-4 infarctions. Logistic regression showed that angioplasty, compared with no reperiusion, was associated with a reduced mortality only in men. The use oí thrombolytics in women was associated with a higher mortality. Conclusions: Primary angioplasty was the reperiusion therapy associated to the lower mortality in STEMI. Use of thrombolytics in women was associated with a higher mortality rate than in non reperfused women.

The Impact of Initial Treatment Delay Using Primary Angioplasty on Mortality among Patients with Acute Myocardial Infarction: from the Korea Acute Myocardial Infarction Registry

The impact of treatment delays to reperfusion on patient mortality after primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) is controversial. We analyzed 5,069 patients included in the Korea Acute Myocardial Infarction Registry (KAMIR) between November 2005 and January 2007. We selected 1,416 patients who presented within 12 hr of symptom onset and who were treated with primary PCI. The overall mortality at one month was 4.4%. The medians of door-to-balloon time, symptom onset-to-balloon time, and symptom onset-to-door time were 90 (interquartile range, 65-136), 274 (185-442), and 163 min (90-285), respectively. One-month mortality was not increased significantly with any increasing delay in door-to-balloon time (4.3% for 90 min; p=0.94), symptom onset-to-balloon time (3.9% for 240 min; p=0.41), and symptom onset-to-door time (3.3% for 120 min; p=0.13). These time variables had no impact on one-month mortality in any subgroup. Thus, this first nationwide registry data in Korea showed a good result of primary PCI, and the patient prognosis may not depend on the initial treatment delay using the current protocols.

Predictors of mortality and adverse outcome in elderly high-risk patients undergoing percutaneous coronary intervention / Predictores de mortalidad y mal pronóstico en pacientes ancianos y de alto riesgo que van a ser sometidos a intervención coronaria percutánea

OBJECTIVES: We sought to identify predictors of in-hospital and long-term (> 1 year) mortality and major adverse cardiac events (MACE) in elderly patients referred for percutaneous coronary intervention (PCI). METHODS: Seventy-three patients (> or = 80 years) were included. Clinical and interventional characteristics were collected retrospectively. Primary end points were in-hospital and long-term mortality, and a composite of non-fatal myocardial infarction, target vessel revascularization, urgent coronary artery bypass graft surgery, and death (MACE). RESULTS: Eighty-three percent of the patients had acute coronary syndromes, 43% three-vessel disease, and 42% heart failure. In-hospital mortality and MACE were 16.4% and 19%, respectively. Long-term mortality and MACE were 11.3% and 16.4%, respectively. Univariate characteristics associated with in-hospital mortality and MACE were: Killip Class III-IV, heart failure, cardiogenic shock, TIMI 0-2 flow prior and after intervention, diabetes mellitus, contrast nephropathy, and presence of A-V block or atrial fibrillation (AF). Long term predictors for mortality were the presence of heart failure, cardiogenic shock, diabetes mellitus, TIMI flow 0-2 before and after intervention, and A-V block or AF. CONCLUSION: The identification of the factors previously mentioned may help to predict complications in elderly patients.