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

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

Early Use of Handgrip Exercise Associated with Dobutamine Stress Echocardiography in Women

Abstract Background Coronary artery disease (CAD) is an important cause of morbidity and mortality in women and requires early diagnosis for defining the appropriate treatment. Objective To identify the positive predictive value (PPV) and safety of the early use of handgrip exercise in pharmacological stress echocardiography using dobutamine (early-ECHO) in women. Methods Positive ischemic early-ECHO records from 111 women were evaluated from January 2012 to March 2018. Subsequently, the hospital medical records were verified to locate patients who underwent conventional coronary angiography (CCA), and we analyzed the medical conduct adopted for these patients. Statistical analyses were performed using SPSS employing one-way analysis of variance (ANOVA), Fisher's exact test, or Pearson's chi-square test. The level of statistical significance was set at p < 0.05 for all analyses. Results Four patients (4.4%) presented serious complications during the examination. Out of 90 patients who underwent CCA, 71 (78.9%) had CAD. Among these 71 patients, 58 (81.7%) had severe lesions and 13 (18.3%) presented moderate CAD. Moreover, CCA did not demonstrate relevant coronary lesions in 19 of the 90 patients (21.1%). Among patients with severe CAD, 16 (27.6%) underwent myocardial revascularization surgery; 34 (58.6%) underwent percutaneous coronary angioplasty; and 08 (13.7%) had their clinical treatments intensified. The PPV for early-ECHO was 78.9%. Conclusions Early-ECHO showed a high PPV for diagnosing myocardial ischemia in women. It presented a low complication rate and provided rapid disease identification, allowing the early treatment of injuries and potentially preventing CAD complications.

Does cha2ds2-vasc score predict mace in patients undergoing isolated coronary artery bypass grafting surgery?

Abstract Objective: To evaluate the prognostic value of CHA2DS2-VASc score in individuals undergoing isolated coronary artery bypass grafting (CABG) surgery. Methods: Records of consecutive 464 patients who underwent elective isolated CABG, between January 2015 and August 2017, were retrospectively reviewed. A major adverse cardiac event (MACE) was the primary outcome of this study. MACE in patients with low (L) (<2, n: 238) and high (H) (≤2, n: 226) CHA2DS2-VASc scores were compared. Univariate logistic regression analysis identified preditors of MACE. Results: Hypertension, diabetes mellitus, and peripheral vascular disease were more frequent in the H group than in the L group. European System for Cardiac Operative Risk Evaluation (EuroSCORE) I and SYNTAX I scores were similar in both groups while SYNTAX II-CABG score was significantly higher in the H group than in the L group. Postoperative myocardial infarction, need for intra-aortic balloon pump, acute renal failure, and mediastinitis were more frequent in the H group than in the L group. The H group had significantly higher in-hospital mortality and MACE rates than the L group (P<0.01). EuroSCORE I, SYNTAX II-CABG, and CHA2DS2-VASc scores were predictors for MACE. SYNTAX II-CABG > 25.1 had 68.4% sensitivity and 52.7% specificity (area under the curve [AUC]: 0.653, P=0.04, 95% confidence interval [CI]: 0.607-0.696) and CHA2DS2-VASc > 2 had 52.6% sensitivity and 84.1% specificity (AUC: 0.752, P<0.01, 95% CI: 0.710-0.790) to predict MACE. Pairwise comparison of receiver-operating characteristic curves revealed similar accuracy for both scoring systems. Conclusion: CHA2DS2-VASc score may predict MACE in patients undergoing isolated CABG.

Single-center study comparing short and mid-term results of evar in old and young populations

Abstract Objective: The purpose of this study was to compare the operative mortality rate and outcomes of endovascular aneurysm repair (EVAR) between young and geriatric people in a single center. Methods: Eighty-five patients with abdominal aortic aneurysms who underwent EVAR between January 2012 and September 2016 were included. Outcomes were compared between two groups: the young (aged < 65 years) and the geriatric (aged ≥ 65 years). The primary study outcome was technical success; the secondary endpoints were mortality and secondary interventions. The mean follow-up time was 36 months (3-60 months). Results: The study included 72 males and 13 females with a mean age of 71.08±8.6 years (range 49-85 years). Of the 85 patients analyzed, 18 (21.2%) were under 65 years old and 67 patients (78.8%) were over 65 years old. There was no statistically significant correlation between chronic disease and age. We found no statistically significant difference between aneurysm diameter, neck angle, neck length, or right and left iliac angles. The secondary intervention rate was 7% (six patients). The conversion to open surgery was necessary for only one patient and only three deaths were reported (3.5%). There was no statistically significant difference in the mortality and reintervention rates between the age groups. The three deaths occurred only in the geriatric group and two died secondary to rupture. Kidney failure was observed in three patients in the geriatric group (4.5%). Conclusion: Our single-center experience shows that EVAR can be used safely in both young and geriatric patients.

Association between Smoking and Alcohol Consumption and the Severity of Coronary Artery Injuries in Patients with AMI

Smoking is the most important risk factor for coronary heart disease (CHD) and ischemic events; alcohol consumption, on the other hand, appears to have a protective role. Objective: Assess the association between smoking and alcohol consumption with the severity of coronary artery injuries in patients with acute myocardial infarction (AMI). Methods: Cross-sectional study, performed in Santa Catarina. Variables were evaluated using the Chi-squared T/Fisher's exact test, Kendall's correlation coefficient, Student's t test or Mann-Whitney U test. Values of p < 0.05 were considered significant. Results: Between August 2016 to June 2017, 226 patients were evaluated with first episode of AMI. There was a difference in sex distribution, showing that 59.7% of men and 85.4% of women were not alcoholic (p < 0.001). There was a higher prevalence of non-hypertensive patients who consumed alcohol than hypertensive ones (40.7% vs. 24.4% and p = 0.010) and patients without diabetes who had drinking habits than those diabetic (36.4% vs. 12.0% and p = 0.001). There was also a higher prevalence of non-diabetic patients who smoked than diabetic ones (38.1% vs. 22.0% and p = 0.035). A weak and negative correlation was found between the number of cigarettes per day and the pack-year with the TIMI frame count (r = -0.174 and p = 0.041 and r = -0.192 and p = 0.027, respectively). The other associations did not show statistical significance. Conclusion: The study showed that the number of cigarettes consumed per day and the pack-year is related to a smaller TIMI frame count, i.e., to a better coronary flow, which may be related to the Smoker's Paradox. There was no correlation between the beverage type and quantity with the SYNTAX score, Ejection fraction and TIMI frame count

An overview of care change in the last 6 year in primary PCI in ST-elevation myocardial infarction in a Tertiary University Brazilian Hospital / Panorama da mudança do cuidado nos últimos 6 anos na ICP primária em infarto agudo do miocárdio com supradesnivelamento do segmento ST em hospital universitário de nível terciário

Background: Although new studies and guidelines can be considered useful tools, it does not necessarily mean they are put into clinical practice. Objective: The aim of the current analysis was to assess the changes in primary percutaneous coronary intervention (PCI) and mortality in a tertiary university hospital in southern Brazil during a six-year period .Methods: We have included consecutive patients with ST-elevation myocardial infarction (STEMI) who underwent primary PCI between March 2011 and February 2017. Previous clinical history, characteristics of the procedure, and reperfusion strategies were collected. In-hospital, short and long-term mortalities were also evaluated. The significance level adopted for all tests was 5%. Results: There was an increase in the use of radial access in patients from 20.0% in 2011 to 62.7% in 2016 (ptrend < 0.0001). Moreover, thrombus aspiration decreased significantly from 66.7% in 2011 to less than 3.0% in 2016 (ptrend < 0.0001). In-hospital, short and long-term mortalities remained reasonably stable from 2011 to 2016 (ptrend > 0.05). However, a lower in-hospital mortality was observed in patients treated through radial access (p < 0.001). Cardiogenic shock occurred in 11.1%, without statistical differences in the period (ptrend = 0.39), while long-term mortality rate decreased from 80.0% in 2011 to 27.3% in 2016 in this patient group (ptrend = 0.29). Conclusions: During a 6-year follow-up period, primary PCI characteristics underwent important modifications. Radial access became widely used, with a decrease in mortality with the use of this route, while aspiration thrombectomy became a rare procedure. The incidence of cardiogenic shock remained stable, but has shown a reduction in its mortality

Cirugía coronaria: resultados inmediatos y alejados de la cirugía de revascularización miocárdica en enfermedad coronaria / Early and late results of coronary artery bypass grafting in coronary artery disease in Concepcion, Chile

Background: Coronary artery bypass grafting (CABG) is the best treatment for a large group of patients with coronary artery disease. Aim: To describe early and late results of patients treated with CABG at our Center. Patients and Methods: Revision of data bases, surgical protocols and clinical registers of patients operated between January 2006 and December 2008. Results: Of 1.003 cardiac surgeries performed during the period, 658 corresponded to isolated CABG (78% in men). The median age of patients was 62 years. Left common coronary artery lesions was found in 135 cases (20%), 555 patients (84%) had hypertension and 231 (35%) were diabetics. Four-hundred thirty (65%) had stable angina and 211 (32%) had a recent myocardial infarction. Twenty-two had left ventricular ejection fraction < 30%. In 248 (38%), a low Additive EuroSCORE risk was found. Emergency surgery was required in 36 (6%) patients. Use of extracorporeal circulation was required in 466 patients (71%). Within 30 days of surgery, complications were recorded in 105 patients (16%) (15 (2%) stroke, 14 (2%) myocardial infarction, 7 (1%) mediastinitis, and in 14 (2%) a reoperation for bleeding). Thirteen patients died (2%). Among the 303 patients with stable angina and preserved left ventricular function, two died (0,7%). Survival at 1, 3 and 5 years was 97,4%, 93,8% y 90,9% respectively. Major adverse cardiac and cerebrovascular events at five years occurred in 20%, stroke in 4%, myocardial infarction in 3% and reintervention in 2%. Seven percent of patients had recurrence of angina. Conclusions: We describe a heterogeneous series of patients. The immediate and late results are comparable with international communications.

The Prognostic Value and Clinical Use of Myocardial Perfusion Scintigraphy in Asymptomatic Patients after Percutaneous Coronary Intervention / O Valor Prognóstico e o uso Clínico da Cintilografia de Perfusão Miocárdica em Pacientes Assintomáticos após Intervenção Coronariana Percutânea

Abstract Background: The role of myocardial perfusion scintigraphy (MPS) in the follow-up of asymptomatic patients after percutaneous coronary intervention (PCI) is not established. Objectives: To evaluate the prognostic value and clinical use of MPS in asymptomatic patients after PCI. Methods: Patients who underwent MPS consecutively between 2008 and 2012 after PCI were selected. The MPS were classified as normal and abnormal, the perfusion scores, summed stress score (SSS), and summed difference score (SDS) were calculated and converted into percentage of total perfusion defect and ischemic defect. The follow-up was undertaken through telephone interviews and consultation with the Mortality Information System. Primary endpoints were death, cardiovascular death, and nonfatal acute myocardial infarction (AMI), and secondary endpoint was revascularization. Logistic regression and COX method were used to identify the predictors of events, and the value of p < 0.05 was considered statistically significant. Results: A total of 647 patients were followed for 5.2 ± 1.6 years. 47% of MPS were normal, 30% were abnormal with ischemia, and 23% were abnormal without ischemia. There were 61 deaths, 27 being cardiovascular, 19 non-fatal AMI, and 139 revascularizations. The annual death rate was higher in those with abnormal perfusion without ischemia compared to the groups with ischemia and normal perfusion (3.3% × 2% × 1.2%, p = 0.021). The annual revascularization rate was 10.3% in the ischemia group, 3.7% in those with normal MPS, and 3% in those with abnormal MPS without ischemia. The independent predictors of mortality and revascularization were, respectively, total perfusion defect greater than 6%, and ischemic defect greater than 3%. Forty-two percent of the patients underwent MPS less than 2 years after PCI, and no significant differences were observed in relation to those who underwent it after that period. Conclusion: Although this information is not contemplated in guidelines, in this study MPS was able to predict events in asymptomatic after PCI patients, regardless of when they were performed.

Resumo Fundamentos: O papel da cintilografia de perfusão miocárdica (CPM) no seguimento de pacientes assintomáticos após intervenção coronariana percutânea (ICP) não está estabelecido. Objetivos. Avaliar o valor prognóstico e o uso clínico da CPM em pacientes assintomáticos após ICP. Métodos: Foram selecionados pacientes que realizaram CPM consecutivamente entre 2008 e 2012 após ICP. As CPM foram classificadas em normais e anormais, os escores de perfusão, escore somado do estresse (SSS) e escore somado da diferença (SDS) foram calculados e convertidos em porcentagem de defeito perfusional total e de defeito isquêmico. O seguimento foi por meio de entrevistas telefônicas e consulta ao Sistema de Informação de Mortalidade. Desfechos primários foram morte, morte cardiovascular e infarto agudo do miocárdio (IAM) não fatal e desfecho secundário foi revascularização. Regressão logística e método de COX foram utilizados para identificar os preditores de eventos e o valor de p < 0,05 foi considerado estatisticamente significativo. Resultados: 647 pacientes foram acompanhados por 5,2 ± 1,6 anos. 47% das CPM foram normais, 30% anormais com isquemia e 23% anormais sem isquemia. Ocorreram 61 mortes, 27 cardiovasculares, 19 IAM não fatais e 139 revascularizações. A taxa anual de óbitos foi superior naqueles com perfusão anormal sem isquemia comparada aos grupos com isquemia e perfusão normal (3,3% × 2% × 1,2%, p = 0,021). A taxa anual de revascularização foi 10,3% no grupo com isquemia, 3,7% naqueles com CPM normal e 3% naqueles com CPM anormal sem isquemia. Foram preditores independentes de mortalidade e revascularização, respectivamente, defeito perfusional total maior que 6% e defeito isquêmico maior que 3%. Quarenta e dois por cento dos pacientes realizaram CPM menos de 2 anos após ICP e não foram observadas diferenças relevantes em relação aos que realizaram após esse período. Conclusão: Embora esta informação não esteja contemplada em diretrizes, neste estudo a CPM foi capaz de predizer eventos em pacientes assintomáticos após ICP, independente do momento de realização.

Anger and Coronary Artery Disease in Women Submitted to Coronary Angiography: A 48-Month Follow-Up / Raiva e Doença Arterial Coronariana em Mulheres Submetidas a Angiografia Coronariana: Acompanhamento de 48 Meses

Abstract Background: Anger control was significantly lower in patients with coronary artery disease (CAD), regardless of traditionally known risk factors, occurrence of prior events or other anger aspects in a previous study of our research group. Objective: To assess the association between anger and CAD, its clinical course and predictors of low anger control in women submitted to coronary angiography. Methods: This is a cohort prospective study. Anger was assessed by use of Spielberger's State-Trait Anger Expression Inventory (STAXI). Women were consecutively scheduled to undergo coronary angiography, considering CAD definition as ≥ 50% stenosis of one epicardial coronary artery. Results: During the study, 255 women were included, being divided into two groups according to their anger control average (26.99). Those with anger control below average were younger and had a family history of CAD. Patients were followed up for 48 months to verify the occurrence of major cardiovascular events. Conclusion: Women with CAD undergoing coronary angiography had lower anger control, which was associated with age and CAD family history. On clinical follow-up, event-free survival did not significantly differ between patients with anger control above or below average.

Resumo Fundamento: O controle da raiva mostrou-se significativamente mais baixo em pacientes com doença arterial coronariana (DAC), independentemente dos fatores de risco tradicionais conhecidos, da ocorrência de eventos prévios, ou de outros aspectos da raiva em estudo prévio do nosso grupo. Objetivo: Avaliar a associação entre raiva e DAC, sua evolução clínica e preditores de baixo controle de raiva em mulheres submetidas a coronariografia. Métodos: Trata-se de estudo de coorte prospectivo. Avaliou-se raiva com o Inventário de Expressão de Raiva como Estado e Traço de Spielberger (STAXI). Todas as mulheres agendadas para realização de angiografia coronariana durante o período de estudo foram abordadas consecutivamente. Definiu-se DAC como estenose de uma artéria coronária epicárdica ≥ 50%. Resultados: Este estudo incluiu 255 mulheres, que foram divididas em dois grupos, acima e abaixo da média do controle de raiva (26,99). Aquelas com controle abaixo da média eram mais jovens e tinham história familiar de DAC. As pacientes foram seguidas por 48 meses para verificar a ocorrência de eventos cardiovasculares maiores. Conclusão: As mulheres com DAC submetidas a coronariografia apresentaram menor controle de raiva, que se associou com idade e história familiar de DAC. No seguimento clínico, a sobrevida livre de evento não diferiu significativamente entre pacientes com controle de raiva acima da média e aquelas com controle abaixo.

Consumo leve a moderado de álcool e isquemia miocárdica à ecocardiografia sob estresse físico / Low to moderate alcohol consuption and myocardial ischemia on exercise stress echocardiography

Fundamento: O impacto do consumo de álcool na evolução da isquemia miocárdica permanece incerto. Os estudos divergem quanto a um eventual efeito cardioprotetor ou a um fator de risco cardiovascular desse consumo de maneira leve a moderada. Objetivo: Estudar a relação do consumo leve a moderado de álcool com a isquemia miocárdica à ecocardiografia sob estresse físico (EEF). Métodos: Estudo transversal composto por 6632 pacientes submetidos à EEF, de janeiro de 2000 a dezembro de 2015. Dividiram-se dois grupos: G1 - composto por 2130 (32,1%) pacientes com relato de consumo médio igual ou inferior a 1 dose de bebida alcoólica por dia para mulheres ou de 2 doses para homens; e G2 - formado por 4502 (67,9%) indivíduos que negaram consumo de álcool. A comparação entre os grupos foi feita mediante teste t de Student para variáveis quantitativas, e teste qui-quadrado ou teste de Fisher para as variáveis categóricas. Foram considerados significativos os valores de p < 0,05. Realizou-se, também, regressão logística para identificação de fatores de risco independentes para isquemia miocárdica. Resultados: G1 apresentou maior frequência de indivíduos do sexo masculino (77,1%; p < 0,001), menor idade média (54,8 ± 10,3 anos; p < 0,001) e maior frequência de isquemia miocárdica à EEF (p = 0,014). Idade, sexo masculino, dislipidemia, hipertensão arterial sistêmica, diabete melito, tabagismo e história familiar positiva apresentaram-se independentemente associados à presença de isquemia miocárdica à EEF. Não foi observada associação independente entre etilismo leve a moderado e isquemia miocárdica (OR 0,96; IC 95%: 0,83-1,11). No entanto, observou-se associação entre idade, sexo masculino, tabagismo e dislipidemia com o consumo de álcool. Conclusão: Etilismo leve a moderado não se apresentou como preditor independente de presença de isquemia miocárdica à EEF. Observou-se, no grupo dos etilistas, um predomínio de homens, dislipidêmicos e tabagistas, importantes variáveis preditoras de isquemia miocárdica

Background: The impact of alcohol consumption on the development of myocardial ischemia remains uncertain. Studies diverge whether low to moderate alcohol consumption provides cardioprotection or whether it is a risk factor for myocardial ischemia. Objective: To study the relationship between low to moderate alcohol consumption and myocardial ischemia on exercise stress echocardiography (ESE). Methods: Cross-sectional study with 6632 patients with known or suspected coronary artery disease undergoing ESE between January/2000 and December/2015. The patients were divided into two groups: G1, composed of 2130 (32.1%) patients whose report showed maximal consumption of 1 drink per day on average for women or of 2 drinks per day for men; G2, composed of individuals denying any alcohol consumption. For comparing between the groups, Student t test was used for quantitative variables, and chi-square test or Fisher exact test, for categorical variables. The significance level adopted was p < 0.05. Logistic regression was also used to evaluate independent risk factors for myocardial ischemia. Results: G1 had a higher number of men (77.1%; p < 0.001), lower mean age (54.8 ± 10.3 years old; p < 0.001) and higher frequency of myocardial ischemia on ESE (p = 0.014). Age, male sex, dyslipidemia, systemic arterial hypertension, diabetes mellitus, smoking and family history were independently associated with myocardial ischemia on ESE. Independent association between low to moderate alcohol consumption and myocardial ischemia on ESE (OR 0.96; 95%CI: 0.83 to 1.11) was not observed. However, age, male sex, smoking and dyslipidemia were associated with alcohol consumption. Conclusion: Low to moderate alcohol consumption was not an independent predictor of myocardial ischemia on ESE. Nevertheless, we observed a predominance of the male sex, dyslipidemia and smoking habit, important predictors of myocardial ischemia, in the group of alcohol consumers

Impacto dos fatores de risco para doença arterial coronatriana nos gastos hospitalares dos pacientes submetidos à cirurgia de revascularização do miocárdio no SUS / Impact of risk factors for coronary artery disease on hospital costs of patients undergoing myocardial revascularization surgery in the Brazilian Unified Health System (SUS)

Background: Cardiovascular diseases are a major cause of mortality and morbidity. Myocardial revascularization surgery may be indicated for the relief of symptoms and to reduce mortality. However, surgery is a costly procedure and the impact of the number of cardiovascular risk factors on the cost of the procedure has not been established. Objectives: To identify the impact of risk factors for coronary artery disease on myocardial revascularization surgery cost. Methods: We selected 239 patients undergoing myocardial revascularization surgery at the National Institute of Cardiology in the period from 01 January to 31 December 2013. We included patients aged over 30 years, with indication for the procedure. Patients undergoing combined procedures were excluded. Results: Seven patients had only one risk factor, 32 patients had two risk factors, 75 patients had 3 risk factors, 78 patients had four risk factors, 36 patients had 5 risk factors and 11 patients presented 6 risk factors. The total costs, on average, was R$ 14,143.22 in the group with 1 risk factor, R$ 18,380.40 in the group with 2 risk factors, R$ 21,229.51 in the group with 3 risk factors, R$ 24,620.86 in the group with 4 risk factors, R$ 21,337.92 in the group with 5 risk factors and R$ 36,098,35 in the group with 6 risk factors (p = 0.441). Conclusion: This study demonstrates that, in a public referral center for highly complex cardiology procedures, there was no significant correlation between the number of cardiovascular risk factors and hospitalization costs

Fundamentos: As doenças cardiovasculares representam uma importante causa de mortalidade e morbidade. A cirurgia de revascularização do miocárdio pode ser indicada para o alívio dos sintomas e para diminuir a mortalidade. Entretanto, a cirurgia é um procedimento de custo elevado e não está estabelecido o impacto do número de fatores de risco cardiovasculares nos gastos do procedimento. Objetivos: Identificar o impacto dos fatores de risco para a doença arterial coronariana nos gastos com a cirurgia de revascularização do miocárdio. Métodos: Foram selecionados 239 pacientes submetidos à cirurgia de revascularização do miocárdio isolada no Instituto Nacional de Cardiologia no período entre 01 de Janeiro a 31 de Dezembro de 2013. Foram incluídos pacientes com idade superior a 30 anos e indicação de revascularização cirúrgica do miocárdio. Foram excluídos os pacientes submetidos a procedimentos combinados. Resultados: Sete pacientes apresentaram apenas 1 fator de risco, 32 pacientes apresentaram 2 fatores de risco, 75 pacientes apresentaram 3 fatores de risco, 78 pacientes apresentaram 4 fatores de risco, 36 pacientes apresentaram 5 fatores de risco e 11 pacientes apresentaram 6 fatores de risco. O total dos gastos, em média, foi de R$ 14 143,22 no grupo com 1 fator de risco, R$ 18 380,40 no grupo com 2 fatores de risco, R$ 21 229,51 no grupo com 3 fatores de risco, R$ 24 620,86 no grupo com 4 fatores de risco, R$ 21 337,92 no grupo com 5 fatores de risco e R$ 36 098,35 no grupo com 6 fatores de risco (p = 0,441). Conclusão: Este trabalho demonstra que, em uma unidade pública de referência para a realização de procedimentos cardiológicos de alta complexidade, não houve uma correlação significativa entre o número de fatores de risco cardiovascular e os custos da internação

Avaliação da relação do índice tornozelo-braquial com a gravidade da doença arterial coronáriana / Assessment of the relationship of ankle-brachial index with coronary artery disease severity

Fundamento: A Doença Arterial Periférica (DAP) está associada a eventos cardiovasculares, podendo ser diagnosticada e estimada através do Índice Tornozelo-Braquial (ITB). Está bem estabelecido que o ITB é fator agravante na estratificação de risco cardiovascular, mas sua contribuição para definir a gravidade do acometimento arterial coronariano não está bem estabelecida. Objetivos: Estudo testou o valor do ITB com a gravidade da doença aterosclerótica coronariana pelo Escore de Syntax (ES) em pacientes com Síndrome Coronariana Aguda (SCA). Métodos: Estudo prospectivo com medida do ITB de todos os pacientes internados com SCA no Hospital São Lucas da PUCRS, consecutivamente, de maio a setembro de 2016, e comparação de seu valor com o ES e tipos de SCA desses pacientes. As análises foram realizadas considerando-se o nível de confiança de 95% ( α = 5%). Resultados: 101 pacientes, com média de idade de 62,6±12,0 anos, 58 (57,4%) masculinos, 74 (82,2%) hipertensos, 33 (45,8%) diabéticos e 46 (45,5%) com infarto agudo do miocárdio com supradesnivelamento do ST (IAMCSST). A gravidade da DAP não teve relação com a gravidade anatômica da doença arterial coronariana (DAC). Encontramos uma associação significativa de ES intermediário com infarto agudo do miocárdio sem supradesnivelamento do ST (IAMSSST) e de ES baixo com angina instável (AI) [OR (IC95%): 1,11 (1,03-1,20); p = 0,004], que se manteve após análise multivariada, ajustada para idade, tabagismo, história familiar de DAC e DAC prévia [OR (IC95%): 1,13 (1,02-1,25); p = 0,019]. Conclusões: Analisando nossos resultados, encontramos que pacientes com ITB < 0,9 não apresentaram associação com maior complexidade determinada pelo ES em pacientes com SCA. Os pacientes com IAMSSST estiveram mais associados com ES intermediário

DOI: 10.5935/2359-4802.20170094 47 International Journal of Cardiovascular Sciences. 2018;31(1)47-55 ARTIGO ORIGINAL Correspondência: Andrea Mabilde Petracco Av. Ipiranga, 7464, sala 524. CEP: 91530-000, Jardim Botânico, Porto Alegre, RS ­ Brasil. E-mail: apetracco@terra.com.br; apetracco@cardiol.br Avaliação da Relação do Índice Tornozelo-Braquial com a Gravidade da Doença Arterial Coronária Assessment of the Relationship of Ankle-Brachial Index With Coronary Artery Disease Severity Andrea Mabilde Petracco, Luiz Carlos Bodanese, Gustavo Farias Porciúncula, Gabriel Santos Teixeira, Denise de Oliveira Pellegrini, Luiz Claudio Danzmann, Ricardo Medeiros Pianta, João Batista Petracco Hospital São Lucas, da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS ­ Brasil Artigo recebido em 28/02/2017; revisado em 12/08/2017; aceito em 21/08/2017 Resumo Fundamento: A Doença Arterial Periférica (DAP) está associada a eventos cardiovasculares, podendo ser diagnosticada e estimada através do Índice Tornozelo-Braquial (ITB). Está bem estabelecido que o ITB é fator agravante na estratificação de risco cardiovascular, mas sua contribuição para definir a gravidade do acometimento arterial coronariano não está bem estabelecida. Objetivos: Estudo testou o valor do ITB com a gravidade da doença aterosclerótica coronariana pelo Escore de Syntax (ES) em pacientes com Síndrome Coronariana Aguda (SCA). Métodos: Estudo prospectivo com medida do ITB de todos os pacientes internados com SCA no Hospital São Lucas da PUCRS, consecutivamente, de maio a setembro de 2016, e comparação de seu valor com o ES e tipos de SCA desses pacientes. As análises foram realizadas considerando-se o nível de confiança de 95% ( α = 5%). Resultados: 101 pacientes, com média de idade de 62,6±12,0 anos, 58 (57,4%) masculinos, 74 (82,2%) hipertensos, 33 (45,8%) diabéticos e 46 (45,5%) com infarto agudo do miocárdio com supradesnivelamento do ST (IAMCSST). A gravidade da DAP não teve relação com a gravidade anatômica da doença arterial coronariana (DAC). Encontramos uma associação significativa de ES intermediário com infarto agudo do miocárdio sem supradesnivelamento do ST (IAMSSST) e de ES baixo com angina instável (AI) [OR (IC95%): 1,11 (1,03-1,20); p = 0,004], que se manteve após análise multivariada, ajustada para idade, tabagismo, história familiar de DAC e DAC prévia [OR (IC95%): 1,13 (1,02-1,25); p = 0,019]. Conclusões: Analisando nossos resultados, encontramos que pacientes com ITB < 0,9 não apresentaram associação com maior complexidade determinada pelo ES em pacientes com SCA. Os pacientes com IAMSSST estiveram mais associados com ES intermediário. (Int J Cardiovasc Sci. 2018;31(1)47-55) Palavras-chave: Índice Tornozelo-Braço, Síndrome Coronariana Aguda, Doença da Artéria Coronariana, Índice de Severidade da Doença, Aterosclerose, Doença Arterial Periférica. Abstract Background: Peripheral Artery Disease (PAD) is associated with cardiovascular events and can be diagnosed and estimated by use of the Ankle-Brachial Index (ABI). ABI is a worsening factor in the stratification of cardiovascular risk, but its contribution to define the severity of coronary artery disease has not been well established. Objectives: To compare the ABI value with the coronary atherosclerotic disease severity by use of the Syntax Score (SS) in patients with Acute Coronary Syndrome (ACS). Methods: This prospective study measured the ABI of all patients with ACS consecutively admitted to the São Lucas Hospital of PUCRS from May to September 2016, and compared the ABI values with the SS and ACS types of those patients. The analyzes were performed considering the 95%confidence interval ( α = 5%). Results: This study assessed 101 patients [mean age, 62.6 ± 12.0 years; 58 men (57.4%)], 74 (82.2%) were hypertensive, 33 (45.8%) had diabetes and 46 (45,5%) had ST-elevation acute myocardial infarction (STEMI). The PAD severity was not related to the anatomical severity of the coronary artery disease (CAD). We found a significant association of intermediate SS with non-ST-elevation acute myocardial infarction (NSTEMI), and of low SS with unstable angina (UA) [OR (95% CI): 1.11 (1.03-1.20) (p = 0.004)], which remained after multivariate analysis adjusted to age, smoking, family history of CAD and previous CAD [(OR 95%): 1.13 (1.02-1.25) (p = 0.019)]. Conclusions: Patients with ABI < 0.9 showed no association with higher disease complexity determined by the SS in patients with ACS. Patients with NSTEMI were more associated with an intermediate risk on the SS

Como melhorar as práticas de medicina nuclear em cardiologia nas economias emergentes: papel da Agência Internacional de Energia atômica / Improving nuclear medicine practices in cardiology in the emerging economies: role of the International Atomic Energy Agency

As doenças cardiovasculares (DCVs) representam 38% do total das doenças não transmissíveis (DNTs), seguidas de câncer com 27%. Os países de baixa e média renda (PBMRs) são particularmente afetados pelas DCVs, já que mais de 75% de todas as mortes por DCV ocorrem nesses países. Os dados prognósticos globais são alarmantes, pois estima-se que 23,6 milhões de pessoas morrerão por ano devido a DCVs até 2030. Por esse motivo, a Agenda de Desenvolvimento Sustentável das Nações Unidas, com seus Objetivos de Desenvolvimento Sustentável (ODSs), visa a reduzir a mortalidade precoce por DNT em 30% até 2030. Dentro da família das Nações Unidas, a Agência Internacional de Energia Atômica (AIEA) está encarregada de promover o uso seguro e pacífico das tecnologias nucleares. A AIEA está fortemente melhorando a qualidade da prática clínica, estabelecendo sistemas de gerenciamento de qualidade e aconselhando sobre como cumprir os padrões internacionais, além de usar a tecnologia de forma adequada e segura. Esta revisão abrangerá as atividades da AIEA para promover, implementar e apoiar aplicações nucleares em cardiologia em PBMRs empenhada em realizar a Agenda das Nações Unidas de 2030 e, através da Divisão de Saúde Humana, contribuir para o sucesso dos ODSs. Um dos principais objetivos da Divisão de Saúde Humana é apoiar os Estados Membros para enfrentar o ônus das DCVs através do seu subprograma de Medicina Nuclear e Diagnóstico por Imagem. Isto é conseguido apoiando o estabelecimento e o fortalecimento das capacidades dos Estados Membros para oferecer o uso apropriado e seguro de aplicações clínicas de cardiologia nuclear. O apoio consiste em ajudar os países nos estágios de planejamento e implementação, fornecendo treinamento, mantendo e

Percutaneous Intervention in ST-Elevation Myocardial Infarction: Culprit-only or Complete Revascularization? / Intervenção Percutânea no Infarto com Supradesnivelamento do Segmento ST: Revascularização Completa ou Tratamento apenas da Artéria Culpada?

Abstract The best approach of multivessel coronary artery disease in the context of acute myocardial infarction with ST segment elevation and primary percutaneous coronary intervention is one of the main reasons for controversy in cardiology. Although the main global guidelines do not recommend routine complete revascularization in these patients, recent randomized clinical trials have demonstrated benefit of this approach in reducing cardiovascular outcomes. For this reason, an adequate review of this evidence is essential in order to establish scientifically based strategy and achieve better outcomes for these patients who present with acute myocardial infarction. This review aims to present objectively the most recent evidence available on this topic.

Resumo O adequado manejo da doença arterial coronariana (DAC) multivascular, no contexto do infarto agudo do miocárdio com supradesnivelamento do segmento ST e da intervenção coronariana percutânea primária, é um dos grandes motivos de controvérsia em Cardiologia. Embora as principais diretrizes mundiais não recomendem a revascularização completa de forma rotineira nesses pacientes, recentes ensaios clínicos randomizados (ECRs) têm demonstrado benefício dessa abordagem na redução de desfechos cardiovasculares. Por esse motivo, torna-se imprescindível uma adequada revisão dessas evidências, a fim de que se possa estabelecer uma conduta cientificamente embasada e capaz de trazer benefícios aos pacientes que se apresentam no contexto agudo do infarto do miocárdio. Esta revisão objetivou apresentar de forma objetiva as evidências mais recentes disponíveis a respeito desse tema.

Comparison of Secondary Prevention Status between Percutaneous Coronary Intervention and Coronary Artery Bypass Patients / Comparação de Prevenção Secundária em Intervenção Coronária Percutânea e Cirurgia de Revascularização Miocárdica

Abstract Background: Data are scarce regarding disparities in cardiovascular risk factor management between patients treated with percutaneous coronary intervention (PCI) and those treated with coronary artery bypass grafting (CABG). Objective: Whether the goal achievement rates of cardiovascular risk factors were different between PCI and CABG patients. Methods: We retrospectively reviewed the data retrieved from a clinical record database of patients admitted to Beijing Anzhen Hospital between January 1, 2014, and December 31, 2014, who underwent PCI or CABG. Results: Compared with the CABG group, low-density lipoprotein cholesterol (LDL-C) < 1.8 mmol/L (28.6% vs. 24.7%; p < 0.01), LDL-C < 2.07 mmol/L (43.5% vs. 39.4%; p < 0.01) and blood pressure (BP) < 140/90 mm Hg (85.6% vs. 77.7%; p < 0.01) goal achievement rates were significantly higher in the PCI group. Compared with patients ≥ 60 years old: patients < 60 years old had better BP < 140/90 mm Hg goal achievement rates (87.7% vs. 84.4%; p < 0.01) in the PCI group, and better fasting blood-glucose (FBG) < 7 mmol/L (79.4% vs.72.0%; p < 0.01) and HbA1c < 7% (79.4% vs. 70.1%; p < 0.01) goal achievement rates in the CABG group. Compared with females: males had better LDL-C < 2.07 mmol/L (24.7% vs. 28.5%; p < 0.01), FBG < 7 mmol/L (71.8% vs.75.2%; p < 0.01) and HbA1c < 7% (70.4% vs. 74.1%; p < 0.01) goal achievement rates in the PCI group. Conclusion: Patients in the PCI group were generally more likely than those in the CABG group to achieve LDL-C < 1.8 mmol/L and BP goals. The control of cardiovascular risk factors differed between patients ≥ 60 years old and < 60 years old. Female patients were less likely to achieve LDL-C, FBG and HbA1c goals.

Resumo Fundamento: Há poucos dados referentes às disparidades no manejo de fatores de risco cardiovascular entre pacientes tratados com intervenção coronária percutânea (ICP) e aqueles tratados com cirurgia de revascularização miocárdica (CRM). Objetivo: Avaliar se as taxas de cumprimento de metas de fatores de risco cardiovascular diferiram entre pacientes submetidos a ICP ou a CRM. Métodos: Revisão retrospectiva de banco de dados de prontuários médicos de pacientes admitidos no Hospital Beijing Anzhen entre 1 de janeiro de 2014 e 31 de dezembro de 2014, submetidos a ICP ou a CRM. Resultados: Comparado ao grupo CRM, o grupo ICP apresentou taxas significativamente maiores de cumprimento de meta de colesterol da lipoproteína de baixa densidade (LDL-C) < 1,8 mmol/L (28,6% vs. 24,7%; p < 0,01), LDL-C < 2,07 mmol/L (43,5% vs. 39,4%; p < 0,01) e pressão arterial (PA) <140/90 mmHg (85,6% vs. 77,7%; p < 0,01). Comparados aos pacientes ≥ 60 anos de idade, aqueles < 60 anos de idade apresentaram melhor taxa de cumprimento de meta de PA < 140/90 mmHg (87,7% vs. 84,4%; p < 0,01) no grupo ICP, e melhores taxas de cumprimento de meta de glicemia de jejum (GJ) < 7 mmol/L (79.4% vs.72.0%; p < 0.01) e HbA1c < 7% (79.4% vs. 70.1%; p < 0.01) no grupo CRM. Comparados às mulheres, os homens apresentaram melhores taxas de cumprimento de meta de LDL-C < 2,07 mmol/L (24,7% vs. 28,5%; p < 0,01), GJ < 7 mmol/L (71,8% vs. 75,2%; p < 0,01) e HbA1c < 7% (70,4% vs. 74,1%; p < 0,01) no grupo ICP. Conclusão: Em geral, o grupo ICP apresentou maior probabilidade do que o grupo CRM de cumprir as metas de LDL-C < 1,8 mmol/L e PA. O controle dos fatores de risco cardiovascular diferiu entre pacientes ≥ 60 e < 60 anos de idade. As mulheres apresentaram menor probabilidade de cumprir as metas de LDL-C, GJ e HbA1c.

Efetividade da Terapia Medicamentosa e dos Procedimentos de Revascularização como Estratégia Inicial na Doença Arterial Coronariana Estável: Estudo de Coorte / Effectiveness of Medical and Revascularization Procedures as the Initial Strategy in Stable Coronary Artery Disease: A Cohort Study

Fundamento: A cirurgia de revascularização miocárdica (CRM) e a intervenção coronária percutânea (ICP) são estratégias amplamente utilizadas no manejo da doença arterial coronariana (DAC) estável. Objetivo: Avaliar o prognóstico de pacientes com DAC estável inicialmente tratada com terapia médica (TM), em comparação com os pacientes submetidos a procedimentos de revascularização. Métodos: Estudo prospectivo de coorte com 560 pacientes ambulatoriais de um hospital terciário com seguimento médio de 5 anos. Os pacientes foram classificados nos grupos TM (n = 288), ICP (n = 159) e CRM (n = 113) de acordo com sua estratégia inicial de tratamento. Os desfechos primários foram mortalidade global e eventos combinados de morte, síndrome coronária aguda e AVC. Resultados: Durante o seguimento, as taxas de mortalidade foram de 11,1% em TM, 11,9% em ICP e 15,9% em pacientes submetidos à CRM, sem diferença estatística (Hazard Ratio [HR] para ICP, 1,05; Intervalo de Confiança de 95% [IC95%], 0,59 a 1,84; e HR para CRM, 1,20; IC95%, 0,68 a 2,15). Os desfechos combinados ocorreram com maior frequência entre os pacientes inicialmente submetidos à ICP em relação à TM (HR 1,50, IC 95% 1,05 a 2,14) e não diferiram entre TM e CRM (HR 1,24, IC95% 0,84 a 1,83). Entre os pacientes com diabetes (n = 198), a ICP foi a única estratégia terapêutica preditiva de desfechos combinados (HR 2,14; IC 95%: 1,25 a 3,63). Conclusão: Neste estudo observacional de doença arterial coronariana estável, não houve diferença na mortalidade global entre as estratégias iniciais de terapia médico ou de cirurgia de revascularização. Os pacientes inicialmente tratados com ICP tiveram maior chance de desenvolver eventos cardiovasculares maiores combinados

Background: Coronary artery bypass grafting surgery (CABG) and percutaneous coronary intervention (PCI) are widely-used strategies in the management of stable coronary artery disease (CAD). Objective: To evaluate the prognosis of patients with stable CAD initially treated by medical therapy (MT), compared to the patients who were submitted to revascularization procedures. Methods: We conducted a prospective cohort study of 560 patients from an outpatient clinic in a tertiary hospital, with a mean follow-up of 5 years. Patients were classified into MT (n = 288), PCI (n = 159) and CABG (n=113) groups according to their initial treatment strategy. Primary endpoints were overall mortality and combined events of death, acute coronary syndrome, and stroke. Results: During follow-up, death rates were 11.1% in MT, 11.9% in PCI and 15.9% in CABG patients, with no statistical difference (hazard ratio [HR] for PCI, 1.05; 95% confidence interval [95%CI], 0.59 to 1.84; and HR for CABG, 1.20; 95% CI: 0.68 to 2.15). Combined outcomes occurred more often among patients initially submitted to PCI compared to MT (HR 1.50, 95% CI 1.05 to 2.14), and did not differ between MT and CABG patients (HR 1.24, 95% CI 0.84 to 1.83). Among patients with diabetes (n=198), PCI was the only therapeutic strategy predictive of combined outcomes (HR 2.14; 95% CI 1.25 to 3.63). Conclusion: In this observational study of stable coronary artery disease, there was no difference in overall mortality between initial medical therapy or revascularization surgery strategies. Patients initially treated with PCI had greater chance to develop combined major cardiovascular events

Diagnóstico de necrosis tubular aguda en pacientes egresados fallecidos / Diagnosis of acute tubular necrosis in deceased patients

Introducción: el diagnóstico histopatológico de necrosis tubular aguda, generalmente de causa isquémica o nefrotóxica, se encuentra muy relacionado con el desarrollo de insuficiencia renal aguda. Objetivo: analizar la presencia de diagnóstico histopatológico de necrosis tubular aguda en los egresados fallecidos autopsiados y explorar la relación con posibles factores favorecedores. Métodos: estudio retrospectivo, observacional de las autopsias en el Hospital Militar Central Dr. Luis Díaz Soto, en el período 1962 al 2015. Se estableció en ellas el diagnóstico histopatológico de necrosis tubular aguda y se analizó el comportamiento de variables demográficas, clínicas y anatomopatológicas. Resultados: se registraron 843 341 egresados, de ellos 25 213 fallecidos (índice de mortalidad 3,0), se realizaron 18 630 autopsias (índice autopsia 75,3 por ciento), en estas se estableció diagnóstico de necrosis tubular aguda en 6.264 (33,6 por ciento). Predominaron los pacientes masculinos y los mayores de 45 años de edad. El shock (22,3 por ciento), la bronconeumonía (16,3 por ciento), la aterosclerosis coronaria(18,5 por ciento) y el edema pulmonar (11,3 por ciento) constituyeron las principales causas directas de muerte. La aterosclerosis coronaria (18,5 por ciento) fue la principal causa básica de muerte. Conclusiones: se registró un incremento sostenido de egresos, de fallecidos y de autopsias practicadas, así como del diagnóstico histopatológico de necrosis tubular aguda. Predominaron los pacientes del sexo masculino y aquellos mayores de 45 años de edad. Las principales causas directas de muerte en estos fueron el shock, la bronconeumonía y el edema pulmonar. La aterosclerosis fue la principal causa básica de muerte(AU)

Introduction: The histopathological diagnosis of acute tubular necrosis, usually of ischemic or nephrotoxic cause, is closely related to the development of acute renal failure. Objective: To analyze the presence of histopathological diganosis of acute tubular necrosis in deceased autopsied and to explore the relationship with possible favoring factors. Method: Retrospective, observational study, with descriptive statistical study of the autopsies at the Central Military Hospital Dr. Luis Díaz Soto in the period from 1962 to 2015. The histopathological diagnosis of acute tubular necrosis was done and demographic, clinical and anatomopathological variables were analyzed. Results: 843 341 discharged from hospital were recorded, of which 25 213 died (mortality rate 3.0), 18 630 autopsies were performed (autopsy rate 75.3 percent). In these cases a diagnosis of acute tubular necrosis was done in 6 264 (33.6 percent). Male patients and those over 45 years of age predominated. Shock (22.3 percent), bronchopneumonia (16.3 percent), coronary atherosclerosis (18.5 percent) and pulmonary edema (11.3 percent) were the main direct causes of death. Coronary atherosclerosis (18.5 percent) was the main underlying cause of death. Conclusions: There was a sustained increase in discharged patients, deaths and autopsies, as well as the histopathological diagnosis of acute tubular necrosis. Male patients predominated and those older than 45 years of age. The main direct causes of death in these were shock, bronchopneumonia and pulmonary edema. Atherosclerosis was the leading cause of death(AU)