The lack of knowledge on acute stroke in Brazil: A cross-sectional study with children, adolescents, and adults from public schools

Abstract Objective: Stroke is an important cause of disability and death in adults worldwide. However, it is preventable in most cases and treatable as long as patients recognize it and reach capable medical facilities in time. This community-based study investigated students' stroke knowledge, Emergency Medical Services (EMS) activation, associated risk factors, warning signs and symptoms, and prior experience from different educational levels in the KIDS SAVE LIVES BRAZIL project. Methods: The authors conducted the survey with a structured questionnaire in 2019‒2020. Results: Students from the elementary-school (n = 1187, ~13 y.o., prior experience: 14%, 51% women), high-school (n = 806, ~17 y.o., prior experience: 13%, 47% women) and University (n = 1961, ~22 y.o., prior experience: 9%, 66% women) completed the survey. Among the students, the awareness of stroke general knowledge, associated risk factors, and warning signs and symptoms varied between 42%‒66%. When stimulated, less than 52% of the students associated stroke with hypercholesterolemia, smoking, diabetes, and hypertension. When stimulated, 62%‒65% of students recognized arm weakness, facial drooping, and speech difficulty; only fewer identified acute headache (43%). Interestingly, 67% knew the EMS number; 81% wanted to have stroke education at school, and ~75% wanted it mandatory. Women, higher education, and prior experience were associated with higher scores of knowing risk factors (OR = 1.28, 95% CI: 1.10‒1.48; OR = 2.12, 95% CI: 1.87‒2.40; OR = 1.46, 95% CI: 1.16‒1.83; respectively), and warning signs- symptoms (OR = 2.22, 95% CI: 1.89‒2.60; OR = 3.30, 95% CI: 2.81‒3.87; OR = 2.04, 95% CI: 1.58‒2.63; respectively). Conclusion: Having higher education, prior experience, and being a woman increases stroke-associated risk factors, and warning signs and symptoms identification. Schoolchildren and adolescents should be the main target population for stroke awareness. HIGHLIGHTS Higher education, prior experience, and being women improved the odds of identifying stroke warning signs and symptoms as associated risk factors Improving knowledge, skills, and attitude on acute stroke in the school community may represent a significant advance in public health management Future stroke awareness campaigns and educational efforts should focus on schoolchildren and adolescents, especially in low-income countries

The involvement of multiple thrombogenic and atherogenic markers in premature coronary artery disease

OBJECTIVE: To examine the association of atherogenic and thrombogenic markers and lymphotoxin-alfa gene mutations with the risk of premature coronary disease. METHODS: This cross-sectional, case-control, age-adjusted study was conducted in 336 patients with premature coronary disease (<50 years old) and 189 healthy controls. The control subjects had normal clinical, resting, and exercise stress electrocardiographic assessments. The coronary disease group patients had either angiographically documented disease (>50% luminal reduction) or a previous myocardial infarction. The laboratory data evaluated included thrombogenic factors (fibrinogen, protein C, protein S, and antithrombin III), atherogenic factors (glucose and lipid profiles, lipoprotein(a), and apolipoproteins AI and B), and lymphotoxin-alfa mutations. Genetic variability of lymphotoxin-alfa was determined by polymerase chain reaction analysis. RESULTS: Coronary disease patients exhibited lower concentrations of HDL-cholesterol and higher levels of glucose, lipoprotein(a), and protein S. The frequencies of AA, AG, and GG lymphotoxin-alfa mutation genotypes were 55.0%, 37.6%, and 7.4% for controls and 42.7%, 46.0%, and 11.3% for coronary disease patients (p = 0.02), respectively. Smoking, dyslipidemia, family history, and lipoprotein(a) and lymphotoxin-alfa mutations in men were independent variables associated with coronary disease. The area under the curve (C-statistic) increased from 0.779 to 0.802 (p<0.05) with the inclusion of lipoprotein(a) and lymphotoxin-alfa mutations in the set of conventional risk factors. CONCLUSIONS: The inclusion of lipoprotein(a) and lymphotoxin-alfa mutations in the set of conventional risk factors showed an additive but small increase in the risk prediction of premature coronary disease. .

Isquemia silenciosa na doença coronariana estável em vigência de tratamento medicamentoso / Silent myocardial ischemia in patients with stable coronary artery disease receiving conventional antianginal drug therapy

FUNDAMENTO: Existem poucos dados sobre comportamento da isquemia miocárdica às atividades habituais na vigência da medicação em pacientes com doença coronariana. OBJETIVO: Estudar mecanismo gerador da isquemia miocárdica avaliando-se o comportamento da pressão arterial e da freqüência cardíaca em pacientes com doença aterosclerótica estável, medicados e com evidência de isquemia. MÉTODOS: Cinqüenta pacientes (40 homens) realizaram ambulatorialmente por 24 horas a monitorização eletrocardiográfica sincronizada com a monitorização da pressão arterial. RESULTADOS: Em 17 pacientes detectaram-se 35 episódios de isquemia miocárdica, com duração total de 146,3 minutos, ocorrendo relato de angina em cinco casos. Houve 29 episódios (100,3 minutos) durante o período de vigília, com 11 episódios (35,3+3,7 min) no período das 11 às 15 horas. A avaliação da pressão arterial e freqüência cardíaca nos três intervalos de 10 minutos posteriores ao momento de isquemia mostrou diferença estatisticamente significante (p<0,05), o que não ocorreu nos três intervalos anteriores. Entretanto, durante o momento isquêmico, percebeu-se elevação maior que 10 mmHg da pressão arterial e de cinco batimentos por minuto da freqüência cardíaca quando comparado ao intervalo de tempo entre 20 e 10 minutos anterior. A freqüência cardíaca média no início da isquemia durante teste ergométrico prévio ao estudo foi de 118,2+14,0, e de 81,1+20,8 batimentos por minuto na eletrocardiografia de 24 horas (p<0,001). CONCLUSÃO: A incidência de isquemia silenciosa é freqüente na doença coronária estável, relacionando-se com alterações da pressão arterial e da freqüência cardíaca, com diferentes limiares de isquemia para o mesmo paciente.

BACKGROUND: Few data are available on the behavior of myocardial ischemia during daily activities in patients with coronary artery disease receiving antianginal drug therapy. OBJECTIVE: To study the mechanism generating myocardial ischemia by evaluating blood pressure and heart rate changes in patients with stable atherosclerotic disease receiving drug therapy and with evidence of myocardial ischemia. METHODS: Fifty non-hospitalized patients (40 males) underwent 24-hour electrocardiographic monitoring synchronized with blood pressured monitoring. RESULTS: Thirty five episodes of myocardial ischemia were detected in 17 patients, with a total duration of 146.3 minutes; angina was reported in five cases. Twenty nine episodes (100.3 minutes) occurred during wakefulness, with 11 episodes (35.3 + 3.7 min) in the period from 11 a.m. to 3 p.m. Blood pressure and heart rate evaluation in the three ten-minute intervals following the ischemic episodes showed a statistically significant difference (p< 0.05), unlike that shown for the three intervals preceding the episodes. However, during the ischemic episode, a higher than 10-mmHg elevation in blood pressure and 5 beats per minute in heart rate were observed when compared with the time interval between 20 and 10 minutes before the episode. The mean heart rate at the onset of ischemia during the exercise test performed before the study was 118.2 + 14.0, and 81.1 + 20.8 beats per minute on the 24-hour electrocardiogram (p < 0.001). CONCLUSION: The incidence of silent myocardial ischemia is high in stable coronary artery disease and is related to alterations in blood pressure and heart rate, with different thresholds for ischemia for the same patient.

Polimorfismo S447X da lipase lipoprotéica: influência sobre a incidência de doença arterial coronariana prematura e sobre os lípides plasmáticos / The S447X polymorphism of lipoprotein lipase: effect on the incidence of premature coronary disease and on plasma lipids

OBJETIVO: O objetivo deste estudo foi avaliar o efeito do polimorfismo S447X sobre os lípides plasmáticos em pacientes com doença arterial coronariana (DAC) prematura. MÉTODOS: Os lípides plasmáticos e a genotipagem foram determinados em 2 grupos: 313 pacientes com DAC prematura (<55 anos) e 150 controles sem DAC. RESULTADOS: A freqüência do polimorfismo S447X foi de 18 por cento nos pacientes com DAC e de 23 por cento no grupo controle. O polimorfismo S447X da lipase lipoprotéica está relacionado com diminuição das concentrações plasmática de triglicérides nos pacientes do sexo masculino com DAC, não havendo essa relação no sexo feminino. CONCLUSÃO: A presença do polimorfismo S447X da lípase lipoprotéica não foi associada à incidência de DAC.

OBJECTIVE: The objective of this study was to evaluate the effect of polymorphism S447X on plasma lipids of patients with premature coronary artery disease (CAD). METHODS: Plasma lipids and genotypes were determined in 2 groups: 313 patients with premature CAD (<55 years of age) and 150 controls without CAD. RESULTS: Frequency of the S447X polymorphism was 18 percent in patients with CAD and 23 percent in the control group. The S447X polymorphism of lipoprotein lipase is related to a decrease in plasma triglyceride concentrations in male patients with CAD, but this correlation is not observed in female patients. CONCLUSION: The presence of the S447X lipoprotein lipase polymorphism was not associated with the incidence of CAD.

Elective vs non-elective radial artery grafts: comparing midterm results through 64-Slice computed tomography

BACKGROUND: Left internal thoracic artery to left anterior descending artery (LITA-LADA) grafting has become a fundamental part of the coronary artery bypass graft procedure (CABG). This grafting in turn has led to an increased use of other arterial conduits, of which the radial artery (RA) is most popular. Whether RA grafting can be used in the emergency patient is controversial. METHODS: 47 patients with critical stenosis (>70 percent) in all target vessels underwent CABG with LITA and RA grafts from 1996 to 2003. Patients were divided into elective (23 patients) and non-elective groups (24 patients) with LITA and RA grafts per patient being similar in both groups. Of these 47 patients, 5 died from non-cardiac complications and 12 were unavailable. Thus, 30 patients (71 percent of survivors) were studied by multidetector computed tomography. A total of 36 LITA and 64 RA grafts were studied. RESULTS: The RA patency rate for elective and non-elective grafts were 82 percent (31/38) and 85 percent (22/26), respectively (p=0.75). The RA had a similar patency rate for all target vessels ranging from 73 percent to 100 percent. Only one patient had a redo CABG and 29 (97 percent) are free from angina or re-intervention. LITA-LADA had a 92 percent (11/12) and 100 percent (10/10) patency rate for elective and non-elective groups, respectively (p=0.37). The sequential LITA-diagonal-LADA in the elective group had a 50 percent (03/06) patency rate, which was significantly lower than the 100 percent (08/08) patency rate of the non-elective group (p=0.02). CONCLUSION: Radial Artery grafts can be used in both elective and non-elective patients with excellent results.

INTRODUÇÃO: A anastomose da artéria torácica interna esquerda com a artéria descendente anterior (ATIE-DA) se tornou parte fundamental da cirurgia de revascularização do miocárdio (RM). Esta técnica levou ao aumento de utilização de outros enxertos arteriais, entre os quais, a artéria radial (AR) é muito usasa. Na literatura há controvérsia se a AR pode ser usada em pacientes em RM de emergência. MÉTODOS: 47 pacientes com lesões críticas (>70 por cento) em todas as artérias alvo foram submetidos à RM com ATIE e a AR entre 1996 e 2003. Os pacientes foram agrupados em eletivos (23 pacientes) e não eletivos (24 pacientes) sendo similares para número de enxertos de ATIE e AR por paciente. Dos 47 pacientes, 5 morreram de complicações não cardíacas e 12 não estavam disponíveis. Portanto, 30 pacientes (71 por cento dos sobreviventes) foram estudados com tomografia computadorizada. Um total de 36 ATIE e 64 AR foram analisadas. RESULTADOS: a perviabilidade da AR nos grupos eletivo e não eletivo foram respectivamente 82 por cento (31/38) e 85 por cento (22/26) (p=0,75). A AR teve perviabilidade semelhante para todas as artérias alvo variando de 73 por cento a 100 por cento. Apenas um paciente foi submetido à nova RM e 29 (97 por cento) estão livres de angina ou nova re-intervenção. ATIE-DA teve perviabilidade de 92 por cento (11/12) e 100 por cento (10/10) respectivamente nos grupos eletivo e não-eletivo (p=0,37). ATIE-Diagonal-DA seqüencial obteve perviabilidade de 50 por cento (03/06) no grupo eletivo que foi significativamente menor que a perviabilidade de 100 por cento (08/08) do não-eletivo (p=0,02). CONCLUSÃO: A AR pode ser utilizada nos pacientes eletivos e não eletivos com excelentes resultados.

Prescriçäo e aderência das estatinas em pacientes com doença arterial coronariana e hipercolesterolemia / Prescription and adherence to statins of patients with coronary artery disease and hypercholesterolemia

OBJECTIVE: Statins have proved to be safe and effective in the secondary prevention of coronary artery disease, but the level of prescription and the reasons for nonadherence to treatment in many coronariopathy treatment centers has not been determined. The purpose of this study was to identify reasons for nonadherence to statin therapy. METHODS: We analyzed 207 consecutive patients with coronary artery disease and hypercholesterolemia (total cholesterol > or = 200mg/dL or LDL - cholesterol > or = 130mg/dL). Patients' average age was 61.7 + or - 10 year; 111 (53.6 percent) male were and 94 (46.6 percent) were female. We analyzed the level of prescription and adherence to treatment with statins. RESULTS: Statins were prescribed for 139 (67 percent) patients, but only 85 (41 percent) used the drug. In spite of being indicated, statins were not prescribed in 68 (33 percent) patients. Of 54 (26 percent) patients, nonadherent to statins, 67 percent did not use the drug due to its high cost, 31 percent due to the lack of instruction, and only 2 percent due to side effects. Total cholesterol (260.3Ý42.2 vs 226.4 + or -51.9; p<0.0001) and LDL cholesterol (174.6 + or -38.1 vs 149.6 + or - 36.1; p<0.0001) were lower in patients on medication. HDL-cholesterol increased from 37.6 + or -9.6 to 41.5 + or -12.9mg/dL (p=0.02), and triglycerides were not modified in patients using statins. CONCLUSION: The prescription of statins in patients with coronary artery disease and dyslipidemia is high; however, its adherence is far from satisfactory, due to the high cost of the medication. Reduction in total cholesterol and LDL cholesterol levels did not reach the targets recommended by the Brazilian Consensus on Dyslipidemia

O gemfibrozil reduz níveis elevados de lipoproteína (a) em pacientes hipercolesterolêmicos / Gemfibrozil reduces elevated lipoprotein (a) levels in hypercholesterolemic patients

PURPOSE: To compare the effects of gemfibrozil and lovastatin in patients with hypercholesterolemia and increased lipoprotein(a) [Lp(a)] levels. METHODS: Twenty-seven subjects with total cholesterol (TC) > 240 mg/dL, LDL-C > 160 mg/dL and Lp(a) > 25 mg/dL were studied. Patients were randomized to receive gemfibrozil 1200 mg/day, (n = 14, 54 +/- 7 years) or lovastatin 40-80 mg at night (n = 13, 55 +/- 9 years) for 12 weeks. Lipid profile and Lp(a) were determined at 4 and 12 weeks of treatment. RESULTS: Gemfibrozil reduced TC (-21), LDL-C (-26), triglycerides (TG)(-48) and Lp(a) (-25), increased HDL-C (+48)(p < 0.001). Lovastatin reduced TC (-29), LDL-C (-37) and TG (-25) (p < 0.001) however, it did not affect Lp(a). CONCLUSION: Besides reducing plasma LDL-C, TG and increasing HDL-C, gemfibrozil effectively lowers Lp(a) levels. Lovastatin did not affect Lp(a) levels.

Estudo comparativo do gemfibrozil versus pravastatina no tratamento de portadores de doença arterial coronária e níveis reduzidos de HDL-colesterol / Comparative study of gemfibrozil versus pravastatin in the treatment of patients with coronary artery disease and low HDL cholesterol levels

PURPOSE--To evaluate the effects of gemfibrozil and pravastatin in coronary artery disease patients with HDL-cholesterol (HDL-C) < 35 mg/dl). METHODS--Twenty-nine patients (20 males, 60 +/- 9) were divided in a gemfibrozil group (G) (1200 mg/day n = 15) and a pravastatin group (P) (10 or 20 mg n = 10 and 4, respectively). The plasma lipid profile (LP) e.g. total cholesterol (TC), fractions and triglycerides (TG) was determined at 4 and 12 weeks of treatment. RESULTS--HDL-C was not affected in P, TC and LDL-cholesterol (LDL-C) reductions were superior to those in G (31.3 vs 13.4 and 38.7 and 11.5, p < 0.05 and < 0.01 respectively). In G HDL-C raised by 50 (12th week p < 0.01). Gemfibrozil reduced TG levels in 44.7 while in P it varied -32.2 (12th week p < 0.01 and < 0.05 respectively). CONCLUSION--Gemfibrozil is more effective in reducing TG and raising HDL-C than pravastatin. On the other hand, pravastatin was more potent in reducing LDL-C levels.

Objetivo - Comparar os efeitos do gemfibrozil e pravastatina no perfil lipídico (PL) de pacientes coronarianos com HDL-colesterol (HDL-C) <35 mg/dl Métodos - Vinte e nove pacientes (20 homens, 60 9 anos) divididos em grupo gemfibrozil (G) (1200mg/dia n=15) e grupo pravastatina (P) (10mg e 20mg, 10 e 4 pacientes, respectivamente). O perfil lipídico plasmático [colesterol total (CT), frações e triglicérides (TG)] foi avaliado a 4 e 12 semanas de tratamento. Resultados - Em P, o HDL-C não se alterou, as reduções de CT e LDL-colesterol (LDL-C) foram superiores às de G (31,3% vs 13,4% e 38,7 e 11,5%, respectivamente p<0,05 e <0,01). Em G. o HDL-C elevou-se em até 50% (12º semana, p<0,01). O gemfibrozil reduziu os TG em 44,7% (p<0,01) enquanto que em P, a variação foi de -32,2% na 12º semana (p<0,05). Conclusão - O gemfibrozil é mais eficaz que a pravastatina para reduzir os TG e elevar o HDL-C, porém a pravastatina é um redutor mais potente do LDLC

Nitroglicerina transdérmica em portadores de angina estável / Nitroglycerin patches in patients with stable angina

Objetivo - Avaliar os efeitos clínicos da nitroglicerina transdérmica em portadores de angina estável. Métodos - Quinhentos e trinta e cinco especialistas avaliaram mil quinhentos e trinta e nove pacientes com angina estável, idade média de 61,0 ñ 10,3 anos, sendo 891 (57,97%) do sexo masculino. O estudo multicêntrico prospectivo consistiu na aplicaçäo inicial de 5 mg e, após duas semanas, caso persistisse quadro de angina ou infradesnivelamanto de ST, a dose era aumentada para 10 mg de nitroglicerina transdérmica, a cada 12-14 horas, por 12 semanas. Foram realizadas avaliaçöes clínicas no período inicial e nas semanas 2, 4, 8 e 12, e eletrocardiograma e eletrocardiograma de esforço (ECGE), no início e na 12ª semana. Resultados - Observou-se reduçäo estatisticamente significante (p < 0,005) no número de crises anginosas, no consumo de nitratos sublingual, na pressäo arterial e na porcentagem de pacientes com ECGE isquêmico. A frequência cardíaca e a dose de nitroglicerina transdérmica utilizada näo tiveram alteraçöes significativas. A tolerabilidade desta via de administraçäo foi considerada muito boa e boa em 92,2% dos pacientes. Conclusäo - A utilizaçäo da nitroglicerina transdérmica mostrou-se eficaz no tratamento da angina estável, com excelente tolerabilidade pelo paciente

Purpose - To evaluate the nitroglycerin patches efficacy and tolerability in patients with stable angina pectoris. Methods - One thousand and five hundred and thirty nine patients with stable angina pectoris, mean age 61.0 + 10.3, 891 men and 648 women were prospectively evaluated by five hundred and thirty five specialists after 5 mg or, posteriorly, if clinical necessary, 10 mg of nitroglycerin patches during 12 weeks. Clinical evaluation, electrocardiogram (ECG) and treadmill exercise were obtained on study entry and at weeks 2, 4, 8 and 12 for clinical evaluation, and at week 12 for ECG and treatmill exercise. Results - A significative reduction was observed in the number of angina crisis, sublingual nitrates consumption, arterial blood pressure and on the percentage of positive treadmill exercise tests. The heart rate and nitroglycerin patches dose did not show statistical differences. The compliance of transdermal administration was excellent. Conclusion - The nitroglycerin patches administration was effective for stable angina pectoris with excellent patient's compliance

Septicemia apos injeçao intracavernosa de papaverina / Septicaemia after intracavernous papaverine injection for impotence

Os autores descrevem um caso de septicemia por Staphilococcus epidermidis apos injeçao intracavernosa de papaverina como metodo propedeutico para avaliaçao de impotencia. O tratamento antibiotico foi instituido, obtendo-se bom resultado e alta hospitalar apos 25 dias

Acute myocardial infarction in chronic chagas' cardiomyopathy: report of two cases with no obstructive coronary artery lesions

Säo relatados dois pacientes com doença de Chagas, foram cardíacas crônica, que desenvolveram Infarto Agudo do Miocárdio (IAM). Ambos apresentaram dor precordial súbita em opressäo, sem fatores precipitantes. No primeiro o pico de CKMB foi 65 U após 22 horas do início da dor e no segundo foi de 77U após 18 horas. O ECG em ambos evidenciou apenas alteraçöes sugerindo IAM näo transmural. A cintilografia miocárdica com 99mTc-PYP foi positiva no primeiro caso. 1 coronariografia realizada respectivamente no 16§ e 9§ dia näo evidenciou lesöes obstrutivas. Säo discutidos os possíveis mecanismos de IAM com coronárias sem lesöes obstrutivas na doença de Chagas tais como: eventos embolíticos, trombóticos e espásticos