El puntaje de Framingham ayudaría en la estratificación del riesgo de pacientes con ergometría positiva y SPECT normal / The Framingham score could help in risk stratification of patients with positive ergometry and normal SPECT

Antecedentes. El valor pronóstico de una ergometría positiva en el contexto de imágenes tomográficas de perfusión miocárdica de estrés y reposo (SPECT) normales no está bien establecido. Objetivos. Documentar la incidencia de infarto, muerte y revascularización coronaria en pacientes con una ergometría positiva de riesgo intermedio e imágenes de perfusión SPECT normales, y explorar el potencial valor del puntaje de riesgo de Framingham en la estratificación pronóstica de estos pacientes. Métodos. Cohorte retrospectiva integrada por pacientes que habían presentado síntomas o hallazgos electrocardiográficos compatibles con enfermedad arterial coronaria durante la prueba de esfuerzo, con criterios de riesgo intermedio en la puntuación de Duke y perfusión miocárdica SPECT normal. Fueron identificados a partir de la base de datos del laboratorio de cardiología nuclear del Instituto de Cardiología y Cirugía Cardiovascular de la ciudad de Posadas, Argentina. Resultados. Fueron elegibles 217 pacientes. El seguimiento fue de 3 1,5 años. La sobrevida libre de eventos (muerte,infarto de miocardio no fatal, angioplastia coronaria o cirugía de bypass de arteria coronaria) a uno, tres y cinco años fue significativamente menor (Log-rank test, p= 0,001) en el grupo con puntaje de Framingham alto o muy alto (77, 71y 59 %, respectivamente) que en el grupo de puntaje bajo o intermedio (89, 87 y 83 %). Tomando como referencia a los pacientes con riesgo bajo en el puntaje de Framingham, luego de ajustar por edad, sexo y puntaje de Duke, los pacientes categorizados en los estratos alto y muy alto riesgo del puntaje de Framingham presentaron una incidencia del evento combinado cercana al triple (hazard ratio [HR] 2,81; intervalo de confianza [IC] del 95 % 0,91 a 8,72; p= 0,07 y HR 3,61;IC 95 % 1,23 a 10,56; p= 0,019 respectivamente). Conclusiones. La estimación de riesgo con el puntaje de Framingham sería de ayuda en la estratificación pronóstica de los pacientes con ergometría positiva y SPECT normal. (AU)

Background. The prognostic value of positive exercise testing with normal SPECT myocardial perfusion imaging is not well established. Objectives. To document the incidence of infarction, death, and coronary revascularization in patients with a positive intermediate-risk exercise test and normal SPECT perfusion images and to explore the potential value of the Framingham Risk Score in the prognostic stratification of these patients. Methods. A retrospective cohort comprised patients who presented symptoms or electrocardiographic findings compatible with coronary artery disease during the stress test, with intermediate risk criteria in the Duke score and normal SPECT myocardial perfusion. They were identified from the database of the nuclear cardiology laboratory of the Instituto de Cardiología y Cirugía Cardiovascular of Posadas, Argentina. Results. 217 patients were eligible. Follow-up was 3 1.5 years. Event-free survival (death, non-fatal myocardial infarction, coronary angioplasty, or coronary artery bypass surgery) at one, three, and five years was significantly lower (Log-ranktest, p: 0.001) in the group with a score of Framingham high or very high (77, 71 and 59 %, respectively) than in the lowor intermediate score group (89, 87 and 83 %). Taking as reference the low-risk patients in the Framingham score, after adjusting for age, sex, and Duke score, the patients categorized in the high-risk and very high-risk strata showed about three times higher incidence of the combined event (hazard ratio [HR] 2.81; 95 % confidence interval [CI] 0.91 to 8.72;p=0.07 and HR 3.61; 95 % CI 1.23 to 10.56; p=0.019 respectively). Conclusions. Risk estimation with the Framingham score would be helpful in the prognostic stratification of patients with positive exercise testing and normal SPECT. (AU)

Association between Periodontitis and Myocardial Infarction: Systematic Review and Meta-Analysis

Abstract The association between periodontitis and myocardial infarction remains unclear in the literature. Few studies have addressed periodontitis exposure as a predisposing factor for the development of myocardial infarction. Therefore, the present systematic review aims to analyze the association between periodontitis and myocardial infarction. This meta-analysis systematically searched MEDLINE, EMBASE, The Cochrane Controlled Trials Register, SCIELO, LILACS, CINAHL, Scopus, Web of Science and grey literature for studies estimating the association between periodontitis and myocardial infarction. Quality of evidence was assessed for all studies. The meta-analysis was conducted using random-effects models. Four of the six studies selected were included in the meta-analysis, including 1,035,703 subjects. The association between periodontitis and myocardial infarction was: RR: 5.99 (95% CI: 1.17-30.68), but with high heterogeneity (I2 = 100%; p <0.01). The results including only the highest quality articles, was lower: RR: 2.62 (95% CI: 1.47-4.70 3.83), but with lower heterogeneity (I2 = 85.5%; p < 0.01).The present systematic review with meta-analysis showed an association between periodontitis and acute myocardial infarction, but with a high level of heterogeneity.

Óbitos intra e extra-hospitalares por infarto agudo do miocárdio nas capitais brasileiras / In- and out-of-hospital deaths by acute myocardial infarction in brazilian state capitals

Resumo Fundamento: O infarto agudo do miocárdio (IAM) é a principal causa de óbito no Brasil e no mundo. Aproximadamente metade dos óbitos ocorrem fora do ambiente hospitalar. Objetivos: Analisar a distribuição, a evolução temporal e as características sociodemográficas (CSD) dos óbitos intra e extra-hospitalares por IAM nas capitais brasileiras e a sua relação com indicadores municipais de desenvolvimento (IMD). Métodos: Estudo ecológico com contagem anual dos óbitos por IAM nas 27 capitais brasileiras de 2007 a 2016, os quais foram divididos em dois grupos, intra-hospitalar (H) e extra-hospitalar (EH). Avaliou-se a evolução temporal das taxas de mortalidade em cada grupo e as diferenças das CSD. Modelos de regressão binominal negativa compararam temporalmente a contagem de óbitos em cada grupo com as seguintes variáveis: residir nas regiões Sul e Sudeste (S/SE), índice de desenvolvimento humano municipal (IDHM), índice de Gini e expectativa de anos de estudo (EAE). Considerou-se estatisticamente valores significativos de p < 0,05. Resultados: A taxa de mortalidade EH para o conjunto das capitais aumentou ao longo do tempo. Todas as CSD pesquisadas foram difententes entre os grupos (p < 0,001). No grupo EH prevaleceram os óbitos em homens, em pacientes ≥ 80 anos e em solteiros. O S/SE elevou a incidência de óbitos extra-hospitalares (IRR = 2,84; IC 95% = 1,67-4,85), enquanto o maior EAE registrou queda (IRR = 0,86; IC 95% = 0,77-0,97). Para o grupo H, o maior IDHM reduziu a incidência de óbitos (IRR = 0,44; IC 95% = 0,33-0,58), enquanto o maior EAE apresentou crescimento (IRR = 1,09; IC 95% = 1,03-1,15). Conclusão: Os óbitos intra e extra-hospitalares por IAM nas capitais apresentam diferenças sociodemográficas, incidência influenciada por IMD e progressivo aumento da ocorrência extra-hospitalar.

Abstract Background: Acute myocardial infarction (AMI) is the main cause of death in Brazil and the world. Approximately half of these deaths occur outside the hospital. Objectives: To analyze the distribution, temporal evolution, and sociodemographic characteristics (SDC) of in- and out-of-hospital deaths by AMI in Brazilian state capitals and their relationship with municipal development indicators (MDI). Methods: This is an ecological study of the number of deaths due to AMI reported annually by the 27 Brazilian state capitals from 2007 to 2016; these were divided into 2 groups: in-hospital (H) and out-of-hospital (OH). We evaluated the temporal evolution of mortality rates in each group and differences in SDC. Negative binomial regression models were used to compare the temporal evolution of the number of deaths in each group with the following variables: residing in the South/Southeast regions (S/SE), municipal human development index (MHDI), Gini coefficient, and expected years of schooling (EYS). We considered p-values<0.05 as statisticallysignificant. Results: The OH mortality rate increased with time for all state capitals. All studied SDC were different between groups (p<0.001). In the OH group, most deaths were of men and patients aged 80 years or older and not married. S/SE increased the incidence of OH deaths (incidence rate ratio [IRR]=2.84; 95% confidence interval [CI]=1.67-4.85), while higher EYS reduced it (IRR=0.86; 95% CI=0.77-0.97). In the H group, higher MHDI reduced the incidence of deaths (IRR=0.44; 95% CI=0.33-0.58), while higher EYS increased it (IRR=1.09; 95% CI=1.03-1.15). Conclusions: In- and out-of-hospital deaths due to AMI in Brazilian state capitals were influenced by MDI, presented sociodemographic differences and a progressive increase in out-of-hospital occurrences.

Factores predictores de mortalidad hospitalaria en pacientes con infarto agudo del miocardio / Predictor factors of hospital mortality in patients with acute myocardial infarction / Fatores preditivos de mortalidade hospitalar em pacientes com infarto agudo do miocárdio

RESUMEN Introducción: Las enfermedades cardiovasculares representan la principal causa de muerte de la población mundial. Objetivo: Identificar los factores predictores de mortalidad hospitalaria en pacientes con infarto agudo del miocardio en el Hospital General Docente "Dr. Agostinho Neto", durante el año 2017. Método: Se realizó un estudio retrospectivo analítico de tipo caso y control, en una población conformada por 90 pacientes con infarto. En el grupo caso se encontraron todos los pacientes fallecidos durante el ingreso (n=30) que cumplieron los criterios de inclusión y exclusión, mientras que el grupo control estuvo constituido por 60 pacientes que egresaron vivos, seleccionados al azar mediante un muestreo aleatorio simple. Resultados: La media de la edad fue mayor en el grupo de los casos 74,06 respecto a los controles, (p=0,021). El 86,6 % de los casos no recibió trombolisis y el 6,6 % tuvo algún criterio de reperfusión pos-estreptoquinasa (p=0,00). El 36,6 % de los casos presentó choque cardiogénico (p=0,003), ruptura cardíaca (30 %) (p=0,03), y taponamiento (23,3 %) (p=0,01). Conclusiones: Los factores predictores de mortalidad hospitalaria en pacientes con infarto agudo del miocardio son: la edad avanzada, el tiempo prolongado entre el inicio de los síntomas y la asistencia médica, la existencia de las complicaciones, tales como el choque cardiogénico, el taponamiento cardíaco y la ruptura cardíaca, así como la no administración de tratamiento trombolítico y la ausencia de reperfusión.

ABSTRACT Introduction: Cardiovascular disease is the main cause of death worldwide. Objective: To identify the predictor factors of hospital mortality in patients with acute myocardial infarction at the Hospital General Docente "Dr. Agostinho Neto" in 2017. Method: A retrospective analytical case-control study was performed in a population of 90 patients with myocardial infarction. The case-cohort study included all patients who died during admission (n=30) and met the inclusion and exclusion criteria, while the case-control study included 60 patients who were discharged alive, randomly selected by simple random sampling. Results: The mean age was higher in the case-cohort studied (74.06 years) than the case-control (p=0.021). The 86,6% of cases did not receive thrombolysis and 6.6% had some reperfusion criteria after the streptokinase (p=0.00). Cardiogenic shock (p=0.003), cardiac rupture (30%) (p=0.03), and cardiac tamponade (23.3%) (p=0.01) were present in 36.6% of cases. Conclusions: The predictor factors of hospital mortality in patients with acute myocardial infarction are as follows: age, the prolonged time between the onset of symptoms and medical attention, presence of complications such as cardiogenic shock, cardiac tamponade and cardiac rupture, as well as the non-administration of thrombolytic treatment and the absence of reperfusion.

RESUMO Introdução: As doenças cardiovasculares representam a principal causa de morte da população mundial. Objetivo: Identificar os fatores preditivos de mortalidade hospitalar em pacientes com infarto agudo do miocárdio no Hospital Geral Universitário "Dr. Agostinho Neto", durante 2017. Método: Foi realizado um estudo retrospectivo analítico caso-controle em uma população de 90 pacientes com infarto. No grupo caso, foram encontrados todos os pacientes que morreram na admissão (n=30) que atenderam aos critérios de inclusão e exclusão, enquanto o grupo controle foi composto por 60 pacientes que receberam alta com vida, selecionados aleatoriamente por amostragem aleatória simples. Resultados: A média de idade foi maior no grupo de casos 74,06 em relação aos controles (p=0,021). 86,6% dos casos não receberam trombólise e 6,6% tinham algum critério para reperfusão pós-estreptoquinase (p=0,00). 36,6% dos casos apresentaram choque cardiogênico (p=0,003), ruptura cardíaca (30%) (p=0,03) e tamponamento (23,3%) (p=0,01). Conclusões: Os fatores preditivos de mortalidade hospitalar em pacientes com infarto agudo do miocárdio são: idade avançada, longo tempo entre o início dos sintomas e o atendimento médico, a existência de complicações, como choque cardiogênico, tamponamento cardíaco e ruptura cardíaca, bem como a não administração de tratamento trombolítico e a ausência de reperfusão.

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

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

Perfil de riesgo en fallecidos por infarto agudo de miocardio en atención pre- hospitalaria: 2017-2019 / Risk profile of deaths from acute myocardial infarction in pre-hospital care: 2017-2019

Antecedente: El infarto miocárdico es un problema de salud global. El conocimiento del perfil de riesgo podría con- tribuir a planificar intervenciones sobre todo en la atención prima- ria. Objetivo: Describir el perfil de riesgo en fallecidos por infarto miocárdico en la atención pre-hospitalaria en Florida, Cuba entre 2017 y 2019. Métodos: Se realizó un estudio descriptivo retros- pectivo de los 53 fallecidos por infarto miocárdico en la atención pre-hospitalaria en el municipio Florida. Los datos se obtuvieron del registro de fallecidos, historias clínicas, y de la autopsia verbal realizada a familiares. Resultados: Predominaron los hombres con 67.9% (36), el color de piel blanca 35.8% (19) y el grupo de edad entre 60 a 69 años 30.2% (16). El edema agudo del pulmón representado por 37.8% y la insuficiencia cardiaca 24.3%, fueron las complicaciones más frecuentes. La mayoría de los pacientes fallecieron en domicilio 35.9% (19) y el 22.6% (12) fallecieron en traslado no sanitario hacia hospitales. Procedían de áreas urba- nas 56.6%. La hipertensión arterial 73.6%, el tabaquismo 66.0%, y obesidad 52.8% fueron los factores de riesgo modificables más identificados. Tener más de 3 factores de riesgo y mayor demora en ser admitido influyó negativamente en la sobrevida. La morta- lidad fue significativamente mayor en los pacientes con elevación del segmento ST en 74.2%. Discusión: Existió un comportamien- to similar al revisado en la literatura en cuanto a riesgos y tiempo en llegar al hospital. La atención pre-hospitalaria al IAM es el punto más crítico en el abordaje de esta entidad...(AU)

Giant cell arteritis: a diagnostic challenge in an older adult / Arterite de células gigantes: um desafio diagnóstico em um idoso

Giant cell arteritis is a large-vessel vasculitis usually seen in older adults. The inflammatory process results in systemic, ophthalmic, and neurological lesions. It is difficult to diagnose in older adults and may present as a medical emergency. Here, we report the case of an 83-year-old woman who presented with bitemporal headache, jaw claudication, glossodynia, failure to thrive, and amaurosis fugax. The findings supported the hypothesis of giant cell arteritis. Despite receiving treatment, the patient died of an acute myocardial infarction. Headache in older adults raises the possibility of giant cell arteritis, especially when combined with an ophthalmic emergency. Many symptoms indicate the condition, but the diagnosis may be challenging, especially for the generalist physician.

A arterite de células gigantes é uma vasculite de grandes vasos geralmente observada em adultos mais velhos. O processo inflamatório resulta em lesões sistêmicas, oftalmológicas e neurológicas. É de difícil diagnose em adultos mais velhos e pode se apresentar como uma emergência médica. Apresentamos o caso de uma mulher de 83 anos que apresentou cefaleia bitemporal, claudicação da mandíbula, glossodinia, incapacidade de prosperar e amaurose fugaz. Os resultados apoiaram a hipótese de arterite de células gigantes. Apesar de receber tratamento, o paciente morreu por infarto agudo do miocárdio. Dor de cabeça em idosos aumenta a possibilidade de arterite de células gigantes, especialmente quando combinada com uma emergência oftalmológica. Muitos sintomas indicam a condição, mas o diagnóstico pode ser desafiador, especialmente para o médico generalista.

Muerte súbita intrahospitalaria luego de infarto agudo de miocardio en Cuba en los últimos tres años. Análisis de registros institucionales / Sudden intra-hospital death after acute myocardial infarction in Cuba in the last three years. Analysis of institutional records

Resumen Objetivo: Analizar el comportamiento de posibles causas predisponentes de muerte súbita (MS) intrahospitalaria luego de un infarto agudo de miocardio (IMA) en registros cubanos. Material y método: Se realizó una búsqueda de registros clínicos de pacientes con IMA en Cuba en las bases de datos de revistas nacionales, Scientific Library On-line (ScieLO) y Medline. Se priorizaron los artículos publicados desde 2016 para ser incluidos. Se definió como muerte súbita aquélla secundaria a arritmias ventriculares malignas (TV y FV), así como los pacientes con rotura cardíaca y actividad eléctrica sin pulso o asistolia como forma de presentación. Con posterioridad se evaluó la relación de este parámetro con la aparición de muerte súbita en 710 pacientes del Registro de Síndromes Coronarios Agudos (RESCUE). Resultados: En el contexto extrahospitalario, más de la mitad de las muertes súbitas cardíacas son secundarias a un infarto agudo de miocardio. En el hospital, la mortalidad en Cuba por IMA es homogénea. Sólo los centros con intervencionismo coronario escapan a este fenómeno. Aunque no del todo letales, las arritmias ventriculares malignas se relacionan con un peor pronóstico y su prevalencia no es homogénea en los registros revisados. Conclusiones: La muerte súbita luego de infarto agudo de miocardio será aún en Cuba una de las principales causas de muerte en los pacientes de fase aguda.

Abstract Objective: To analyze possible predisposing causes of in hospital sudden cardiac death (SCD) after an acute myocardial infarction (IMA) in Cuban registries. Material and methods: A search of clinical records of patients with IMA in Cuba was performed in the databases of national journals, Scientific Library On-line and Medline. Those articles published since 2016 were prioritized for inclusion. Sudden death is defined as that secondary to malignant ventricular arrhythmias (ventricular tachycardia, ventricular fibrillation) as well as patients with cardiac rupture with pulseless electrical activity or asystole as a form of presentation. Subsequently, the relationship of this parameter with the occurrence of sudden death was evaluated in 710 patients from the Registry of Acute Coronary Syndromes (RESCUE). Results: In the out-of-hospital setting, more than half of SCD are secondary to an IMA. Once in the hospital, mortality in Cuba from IMA is homogeneous. Only centers with coronary interventionism escape this phenomenon. Although not totally lethal, the presence of malignant ventricular arrhythmias is associated with a worse prognosis and its prevalence is not homogeneous in the reviewed records. Conclusions: Sudden death after IMA will continue to be one of the main causes of death of patients in the acute phase in Cuba.

Score Cadillac como predictor de muerte en pacientes con infarto agudo de miocardio sometidos a angioplastia / CADILLAC Risk Score as a Death Predictor in Patients with Acute Myocardial Infraction and Who Received Angioplasty

Introducción: El infarto de miocardio es una de las enfermedades que causa más muertes en el mundo. Estudios demuestran que, en pacientes con infarto agudo de miocardio, la reperfusión percutánea temprana (angioplastia) tiene mejores resultados que el tratamiento médico aislado en la función ventricular, la clase funcional y la mortalidad temprana y tardía. Objetivo: Predecir la muerte a corto plazo en pacientes con infarto agudo de miocardio sometidos a angioplastia. Métodos: Investigación retrospectiva de corte transversal, cuyos datos fueron recolectados de las historias clínicas en un Centro Cardiológico de Ecuador. La muestra estuvo conformada por 50 pacientes que reunieron los criterios de inclusión, cuyos datos fueron valorados por la escala Score Cadillac, utilizada como instrumento, tomando en cuenta la supervivencia a los treinta días posteriores al procedimiento. Resultados: La tasa de mortalidad a los 30 días fue del 22 por ciento, de los cuales el 32,3 por ciento pertenecieron al grupo de edad mayor a 65 años, los predictores de mortalidad que más influyeron fueron: la fracción de eyección del ventrículo izquierdo (FEVI) ; 40 por ciento (73,3 por ciento), el flujo final de trombólisis en infarto de miocardio (TIMI) < 2 (46,1 por ciento), la anemia (66,6 por ciento) y la presencia de insuficiencia cardiaca (42,3 por ciento). Conclusión: El Score Cadillac es un importante predictor de mortalidad. La anemia deberá ser tomada en cuenta como predictor de mortalidad(AU)

Introduction: Myocardial infarction is one of the diseases that cause the most deaths worldwide. Studies show that, in patients with acute myocardial infarction, early percutaneous reperfusion (angioplasty) has better outcomes than isolated medical treatment in ventricular function, functional class, and early and late mortality. Objective: To predict short-term death in patients with acute myocardial infarction who have been received angioplasty. Methods: Retrospective and cross-sectional research, whose data was collected from medical records at a cardiology center in Ecuador. The sample consisted of 50 patients who met the inclusion criteria, whose data were assessed according the CADILLAC risk score, used as an instrument, taking into account survival at thirty days after the procedure. Results: The mortality rate at 30 days was 22 percent, of which 32.3 percent belonged to the age group over 65 years. The most influential mortality predictors were left ventricular ejection fraction (LVEF) under 40 percent (73.3 percent), final flow of thrombolysis in myocardial infarction (TIMI) under grade 2 (46.1 percent), anemia (66.6 percent), and the presence of heart failure (42,3 percent). Conclusion: The CADILLAC risk score is an important predictor for mortality. Anemia should be taken into account as a mortality predictor(AU)

Performance of a Hematological Scoring System in Predicting All-Cause Mortality in Patients with Acute Myocardial Infarction

Abstract Background: The presence of nucleated red blood cells (NRBCs) and increases in mean platelet volume (MPV) and neutrophil to lymphocyte ratio (NLR) in peripheral circulation are associated with poorer prognosis in patients with acute coronary disease. Objective: We developed a scoring system for in-hospital surveillance of all-cause mortality using hematological laboratory parameters in patients with acute myocardial infarction (AMI). Methods: Patients admitted for AMI were recruited in this prospective study. Exclusion criteria were age younger than 18 years, glucocorticoid therapy, cancer or hematological diseases and readmissions. NRBCs, MPV and NLR were measured during hospitalization. The scoring system was developed in three steps: first, the magnitude of the association of clinical and laboratory parameters with in-hospital mortality was measured by odds ratio (OR), second, a multivariate logistic regression model was conducted with all variables significantly (p < 0.05) associated with the outcome, and third, a β-coefficient was estimated by multivariate logistic regression with hematological parameters with a p < 0.05. Results: A total of 466 patients (mean age were 64.2 ± 12.8 years, 61.6% male) were included in this study. A hematological scoring system ranging from 0 to 49, where higher values were associated with higher risk of in-hospital death. The best performance was registered for a cut-off value of 26 with sensitivity of 89.1% and specificity of 67.2%, positive predictive value of 26.8% (95% CI: 0.204 - 0.332) and negative predictive value of 97.9% (95% CI: 0.962 - 0.996). The area under the curve for the scoring system was 0.868 (95% CI: 0.818 - 0.918). Conclusions: Here we propose a hematological scoring system for surveillance tool during hospitalization of patients with acute myocardial infarction. Based on total blood count parameters, the instrument can evaluate inflammation and hypoxemia due to in-hospital complications and, consequently, predict in-hospital mortality.

Association Between Chocolate Consumption and Severity of First Infarction

Abstract Background: Cardiovascular diseases, such as acute myocardial infarction, are the main causes of death in the world. The flavonoids present in chocolate can have benefits for people who have risk factors to the development of cardiovascular diseases and have a coadjuvant effect on known therapies. Objective: To analyze the association between chocolate consumption, severity of coronary lesions, risk factors and severity of the first infarction in patients attended at the Cardiology Institute of Santa Catarina and other hospitals in the State of Santa Catarina. Methods: Subanalysis of the Catarina Heart Study cohort, evaluated 350 patients with first myocardial infarction. We evaluated clinical, echocardiographic, hemodynamic laboratorial variables. We used chi square test to evaluate qualitative variables, t student test in the case of parametric variables and U Mann Whitney test in non-parametric variables. We considered significant p < 0,05. Results: Lower prevalence of hypertension (43.2% % vs. 62.3% p = 0.003), diabetes mellitus (13.5% vs. 25.7%, p = 0.027) and smoking (24.3% vs. 37.7%, p = 0.032) among those who consume chocolate. Higher use of alcohol (40.5% vs. 26.4%, p = 0.018) and drugs (9.5% vs. 3.3%, p = 0.023) among those who consumed chocolate. Among the patients who consumed chocolate, there was a negative correlation between amount consumed and Syntax (r = -0.296, p = 0.019). Conclusion: There was association between chocolate consumption and lower prevalence of hypertension, diabetes and smoking. There was no association between amount of chocolate consumed and post-infarction ventricular function and TIMI frame count. Higher prevalence of alcohol and drug use among those who consume chocolate. Negative correlation between Syntax and the amount of chocolate consumed.

C-reactive Protein is a predictor of mortality in ST-segment elevation acute myocardial infarction / Proteína C-reativa é um preditor de mortalidade no infarto agudo do miocárdio com elevação do segmento ST

Background: Inflammation is a major component of the response to tissue injury caused by myocardial infarction. High-sensitivity C-reactive protein (hs-CRP) levels might be a simple marker of the severity of this inflammatory response, providing prognostic information. Objective: To associate hs-CRP level on admission and other clinical characteristics with in-hospital mortality of patients with acute ST-segment elevation myocardial infarction (STEMI). Methods: A retrospective cohort study of patients admitted with STEMI was carried out. Patients were analyzed regarding clinical characteristics, reperfusion therapy, hs-CRP on admission and outcomes. Continuous variables were analyzed by non-parametric Mann-Whitney U test and categorical variables by chi-square test. A p value of < 0.05 was considered statistically significant. Results: Of the 118 patients analyzed, 20 died during hospitalization. Higher levels of hs-CRP (p = 0.001) and older ages (p = 0.003) were observed among those patients who died. Logistic regression showed that a one unit increase in hs-CRP increased the risk of death by 15% (p = 0.0017), after adjustment for established risk factors. Similarly, each one-year increase in age increases the risk of death by 6.6% (p = 0.003). Conclusion: Our results demonstrate a strong association between hs-CRP obtained on admission and in-hospital mortality after STEMI. It suggests that hs-CRP can be a marker of inflammatory response to myocardial ischemia, providing prognostic information regarding the risk of death

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

Risk factor differences in acute myocardial infarction between young and older people: a systematic review and meta-analysis / Diferenças de fatores de risco no infarto agudo do miocárdio entre jovens e idosos: uma revisão sistemática e metanálise

Acute myocardial infarction (AMI) is less frequent in young individuals (≤ 45 years) than in older ones (> 45 years). Young AMI patients differ from older AMI patients in different ways. This article aims to assess the differences between young and older AMI patients. A search was made in the database of Cochrane Library, PubMed, BioMed Central and Embase, sence their establishment to December 2016, using the key words: risk factors, clinical characteristics, acute myocardial infarction and young. Meta-analysis was performed by using the Review Manager 5.3 software, pooled odds ratios and 95% confidence intervals were used to assess the strength of differences. Eight studies with fairly quality, enrolling 13,358 patients in the analysis. Compared with older AMI patients, young AMI patients had a higher rate of smoking and obesity (OR = 2.71,95%CI:1.87 to 3.92; OR = 1.76,95%CI:1.13 to 2.74), higher rate of family history of coronary artery disease and alcohol consumption (OR = 2.36,95%CI:1.22 to 4.59; OR = 1.76,95%CI:1.04 to 2.97). Moreover, Young AMI patients had a lower rate of hypertension and diabetes mellitus (OR = 0.52,95%CI:0.37 to 0.73; OR = 0.58,95%CI:0.50 to 0.67). No significant differences were observed in hyperlipidemia, a subgroup data-analysis showed a higher total cholesterol, triglyceride lipase, and low-density lipoprotein levels (p < 0.05), and lower levels of high-density lipoprotein (p < 0.01) in young AMI patients. Smoking, family history of coronary artery disease, obesity and alcohol consumption are the most main risk factors of AMI among young individuals, and young AMI patients have better prognosis than older ones

Intensive treatment of hyperglycemia in the acute phase of myocardial infarction: the tenuous balance between effectiveness and safety - a systematic review and meta-analysis of randomized clinical trials

SUMMARY INTRODUCTION In acute myocardial infarction (AMI), each 18 mg/dl (1 mmol/L) increment is associated with a 3% increase in mortality rates. All strategies applied for reducing blood glucose to this date, however, have not presented encouraging results. METHODOLOGY We searched the Medline (PubMed) and Cochrane Library databases for randomized clinical trials (RCTs) from 1995 to 2017 that used the intensive strategy or GIK therapy for blood glucose control during the acute stage of the AMI. We included eight studies. In order to identify the effects of GIK or insulin therapy, we calculated a overall risk ratio (RR) with meta-analysis of fixed and random effects models. A two-tail p-value of < 0.05 was considered statistically significant. RESULTS A total of 28,151 patients were included: 1,379 intensively treated with insulin, 13,031 in GIK group, and 13,741 in the control group. The total mortality was 10.5% (n=2,961) and the RR of 1.03 [95%CI 0.96-1.10]; I2 = 31%; p = 0.41 for the combined intensive insulin plus GIK groups in comparison with the control group. In meta-regression analyses, intense reductions in blood glucose (> 36 mg/dL) in relation to the estimated average blood glucose (estimated by HbA1c) were associated with higher mortality, whereas lower reductions in blood glucose (< 36 mg/dL) were not associated with mortality. The lowering of blood glucose in the acute phase of MI compared with the average blood glucose was more effective around 18 mg/dL. CONCLUSION This meta-analysis suggests that there may be a tenuous line between the effectiveness and safety of reducing blood glucose in the acute phase of MI. The targets must not exceed a reduction greater than 36 mg/dL in relation to estimated average blood glucose.

RESUMO INTRODUÇÃO No infarto agudo do miocárdio (IAM), cada incremento de 18 mg/dl (1 mmol/L) se associa a um aumento de 3% na mortalidade. As estratégias de redução da glicemia tentadas até o momento, entretanto, não trouxeram resultados animadores. METODOLOGIA Foram pesquisadas nas bases de dados Medline (PubMed) e Cochrane Library os ensaios clínicos randomizados (ECRs) de 1995 a 2017 que utilizaram estratégia intensiva ou a terapia GIK no controle glicêmico durante a fase aguda do IAM. Foram incluídos oito estudos. Para identificar os efeitos da insulinoterapia ou da terapia GIK, calculamos um risco relativo geral (RR) com meta-análises de modelos de efeitos fixos e aleatórios. Um valor de p-bicaudal < 0,05 foi considerado estatisticamente significativo. RESULTADOS Foram incluídos 28.151 pacientes, sendo 1.379 no grupo de tratamento intensivo da glicemia, 13.031 no GIK e 13.741 no controle. A mortalidade total foi de 2.961 (10,5%), computando um risco relativo de 1,03 [95%CI 0,96-1,10]; I 2 = 31%; p = 0,41 para o grupo intensivo ou GIK contra o grupo conservador. Reduções intensas (> 36 mg/dL) em relação à glicemia estimada média se associaram à maior mortalidade, enquanto reduções menores não se associaram com seu incremento ou redução. A redução glicêmica na fase aguda em relação à glicemia estimada média foi mais efetiva e segura na faixa em torno de 18 mg/dL. CONCLUSÃO Esta meta-análise levanta a hipótese de haver um limite tênue entre efetividade e segurança para a redução glicêmica na fase aguda, sendo que os alvos não devem exceder uma redução maior do que 36 mg/dL de glicemia.

Factores pronósticos de morbimortalidad cardiovascular en pacientes egresados con infarto agudo al miocardio seguidos por un año / Prognostic factors of cardiovascular morbidity and mortality in patients with acute myocardial infarction followed for one year

Acute myocardial infarction is one of the main causes of death in the world, this occurs in the in-hospital period as well as in the follow-up. It has been much studied what occurs in the in-hospital period, but much less what occurs in the follow-up of patients with this pathology. The objective of this study was to follow patients discharged after myocardial infarction for 1 year and analyze predictors of cardiovascular events. 1174 patients were followed for 1 year, of which 17% presented some serious cardiovascular event, associated with the presence of male sex, older age, arterial hypertension, previous history of angina, hospital treatment only pharmacological, inclusion of positive inotropes in the initial treatment and use of calcium channel blockers, factors already shown by international literature but less analyzed in our country, and furthermore, the demonstration that invasive management with coronary angioplasty or bypass surgery are protective factors of the occurrence of events in this period, which reinforces the idea of a more intensive and invasive management in patients with this pathology. (AU)