Impact of cardiology referral: clinical outcomes and factors associated with physicians' adherence to recommendations

OBJECTIVES: Cardiology referral is common for patients admitted for non-cardiac diseases. Recommendations from cardiologists may involve complex and aggressive treatments that could be ignored or denied by other physicians. The purpose of this study was to compare the outcomes of patients who were given recommendations during cardiology referrals and to examine the clinical outcomes of patients who did not follow the recommendations. METHODS: We enrolled 589 consecutive patients who received in-hospital cardiology consultations. Data on recommendations, implementation of suggestions and outcomes were collected. RESULTS: Regarding adherence of the referring service to the recommendations, 77% of patients were classified in the adherence group and 23% were classified in the non-adherence group. Membership in the non-adherence group (p<0.001; odds ratio: 10.25; 95% CI: 4.45-23.62) and advanced age (p = 0.017; OR: 1.04; 95% CI: 1.01-1.07) were associated with unfavorable outcomes. Multivariate analysis identified four independent predictors of adherence to recommendations: follow-up notes in the medical chart (p<0.001; OR: 2.43; 95% CI: 1.48-4.01); verbal reinforcement (p = 0.001; OR: 1.86; 95% CI: 1.23-2.81); a small number of recommendation (p = 0.001; OR: 0.87; 95% CI: 0.80-0.94); and a younger patient age (p = 0.002; OR: 0.98; 95% CI: 0.96-0.99). CONCLUSIONS: Poor adherence to cardiology referral recommendations was associated with unfavorable clinical outcomes. Follow-up notes in the medical chart, verbal reinforcement, a limited number of recommendations and a patient age were associated with greater adherence to recommendations. .

Improving cardiovascular prevention through patient awareness / Melhora da prevenção cardiovascular pelo conhecimento do paciente

OBJECTIVE: Patients with peripheral artery disease (PAD) or coronary artery disease (CAD) must have their risk factors rigorously controlled, but there is a gap between practice and ideal. This study aimed to demonstrate how cardiovascular prevention is performed for these patients in a Brazilian university hospital, and to identify predictors of good practice. METHODS: 192 patients with CAD or PAD were included in this transversal study. Six prevention goals were analyzed: 1) systolic blood pressure < 140 mmHg; 2) diastolic blood pressure < 90 mmHg; 3) LDL < 100 mg/dL; 4) HDL > 40 mg/dL for men/ > 50 mg/dL for women; 5) not smoking; 6) regular practice of aerobic exercise. RESULTS: The mean age of the patients was 65.7 years, and 60% were men. The percentage of patients that achieved goals 1 to 6 was 57.3%, 67.2%, 40.1%, 27.6%, 88.5%, and 25%, respectively. The average number of goals achieved by patients was 3.06 ± 1.31. When asked about the reason for being treated, 182(94.8%) patients claimed to know about their disease, but when the diagnosis reported by the patients with the physician's diagnosis were compared, it was discordant in 12% of cases. The average number of goals achieved by patients was 2.67 and 3.46 for the PAD and the CAD group, respectively. The independent predictors of a higher number of goals/patient were: male gender (p = 0.011), hospitalization (p < 0.0001), CAD diagnosis (p = 0.011), knowing the reason for treatment (p = 0.028), and receiving prescription of β -blocker (p = 0.011). CONCLUSION: Even in an university hospital, prevention is far from ideal. Efforts to increase patients' awareness should be stimulated, and can possibly improve the effectiveness of preventive measures.

OBJETIVO: Pacientes com doença arterial periférica (DAP) ou doença arterial coronariana (DAC) necessitam de um controle rigoroso dos seus fatores de risco, mas essa prática ainda está muito aquém da ideal. O objetivo deste estudo foi verificar como é feita a prevenção cardiovascular nesses pacientes em um hospital universitário no Brasil e identificar os preditores de melhor prevenção secundária. MÉTODOS: Trata-se de estudo transversal, com 192 pacientes portadores de DAC ou DAP. Foram analisadas seis metas a serem atingidas: 1) pressão arterial sistólica < 140 mmHg; 2) pressão arterial diastólica < 90 mmHg; 3) LDL < 100 mg/dL; 4) HDL > 40 mg/dL para homens/> 50 mg/dL para mulheres; 5) não fumar; 6) prática de exercício físico aeróbico regular. RESULTADOS: A idade média dos pacientes é 65,7 anos e 60% são do sexo masculino. A porcentagem dos pacientes que atingiram de 1 a 6 metas foi 57,3%; 67,2%; 40,1%; 27,6%; 88,5% e 25%, respectivamente. O número médio de metas atingidas por paciente foi 2,67 e 3,46 para os pacientes com DAP e DAC, respectivamente. Os preditores independentes de maior número de metas/paciente foram: sexo masculino (p = 0,011), estar internado (p < 0,001), diagnóstico de DAC (p = 0,011), saber o motivo do tratamento (p = 0,028) e receber prescrição de β-bloqueador (p = 0,011). CONCLUSÃO: Mesmo em um hospital universitário, a prevenção encontra-se longe da ideal. Esforços para aumentar a conscientização do paciente devem ser estimulados e podem possivelmente melhorar a efetividade das medidas preventivas.

Perioperative cardiovascular evaluation: heads or tails?

When dealing with surgical patients, a perioperative evaluation is essential to anticipate complications and institute measures to reduce the risks. Several algorithms and exams have been used to identify postoperative cardiovascular events, which account for more than 50% of perioperative mortality. However, they are far from ideal. Some of these algorithms and exams were proposed before important advances in cardiology, at a time when pharmacological risk reduction strategies for surgical patients were not available. New biomarkers and exams, such as C-reactive protein, brain natriuretic peptide, and multislice computed tomography have been used in cardiology and have provided important prognostic information. The ankle-brachial index is another significant marker of atherosclerosis. However, specific information regarding the perioperative context of all these methods is still needed. The objective of this article is to evaluate cardiovascular risk prediction models after noncardiac surgery.