The Renin Angiotensin System and Bipolar Disorder: A Systematic Review.

Bipolar Disorder (BD) is a chronic a multifactorial psychiatric illness that affects mood, cognition, and functioning. BD is associated with several psychiatric conditions as well clinical comorbidities, particularly cardiovascular diseases. The neurobiology of BD is complex and multifactorial and several systems have been implicated. Considering that the Renin Angiotensin System (RAS) plays an important role in cardiovascular diseases and that recently evidence has suggested its role in psychiatric disorders, the aim of the present study is to summarize and to discuss recent findings related to the modulation of RAS components in BD. A systematic search of the literature using the electronic databases MEDLINE and LILACS was conducted through March 2019. The search terms were: "Bipolar Disorder"; "Renin Angiotensin System"; "Angiotensin 2"; "Angiotensin receptors"; "Angiotensin 1-7"; "ACE"; "ACE2"; "Mas Receptor". We included original studies assessing RAS in BD patients. Two hundred twenty-two citations were initially retrieved. Eleven studies were included in our systematic review. In the majority of studies (6 of 8), the ACE insertion/deletion (I/D) polymorphism did not differ between BD patients and controls. BD patients presented higher plasma renin activity in comparison with controls. The studies evaluating the RAS molecules in BD are very scarce and heterogeneous. The literature suggests a potential role of RAS in BD. Further studies are necessary to investigate this relationship.

Impact of telemedicine interventions on mortality in patients with acute myocardial infarction: a systematic review and meta-analysis.

BACKGROUND: Despite the promise of telemedicine to improve care for ischaemic heart disease, there are significant obstacles to implementation. Demonstrating improvement in patient-centred outcomes is important to support development of these innovative strategies. OBJECTIVE: To assess the impact of telemedicine interventions on mortality after acute myocardial infarction (AMI). METHODS: Articles were searched in MEDLINE, Cochrane Central Register of Controlled Trials, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Base de Dados de Enfermagem (BDENF), Indice Bibliográfico Español en Ciencias de la Salud (IBECs), Web of Science, Scopus and Google Scholar, from January 2004 to January 2018. Study selection and data extraction were performed by two independent reviewers. In-hospital mortality (primary outcome), and door-to-balloon (DTB) time, 30-day mortality and long-term mortality (secondary outcomes) were assessed. Random effects models were applied to estimate pooled results. RESULTS: Thirty non-randomised controlled and seven quasi-experimental studies were included (16 960 patients). They were classified as moderate or serious risk of bias by ROBINS-I (Risk Of Bias In Non-randomized Studies-of Interventions tool). In 31 studies, the intervention was prehospital ECG transmission. Telemedicine was associated with reduced in-hospital mortality compared with usual care (relative risk (RR) 0.63(95% confidence interval[CI] 0.55 to 0.72); I2 <0.001%). DTB time was consistently reduced (mean difference -28 (95% CI -35 to -20) min), but showed large heterogeneity (I2=94%). Thirty-day mortality (RR 0.62;95% CI 0.43 to 0.85) and long-term mortality (RR 0.61(95% CI 0.40 to 0.92)) were also reduced, with moderate heterogeneity (I2=52%). CONCLUSIONS: There is moderate-quality evidence that telemedicine strategies, in particular ECG transmission, combined with the usual care for AMI are associated with reduced in-hospital mortality and very-low quality evidence that they reduce DTB time, 30-day mortality and long-term mortality.

Cardiovascular emergencies in primary care: an observational retrospective study of a large-scale telecardiology service

ABSTRACT BACKGROUND: Electrocardiograms (ECGs) are an essential examination for identification and management of cardiovascular emergencies.The aim of this study was to report on the frequency and recognition of cardiovascular emergencies in primary care units. DESIGN AND SETTING: Observational retrospective study assessing consecutive patients whose digital ECGs were sent for analysis to the team of the Telehealth Network of Minas Gerais. METHODS: Data from patients diagnosed with cardiological emergencies in the primary care setting of 750 municipalities in Minas Gerais, Brazil, between March and September 2015, were collected via telephone contact with the healthcare practitioner who performed the ECG. After collection, the data were subjected to statistical analysis. RESULTS: Over the study period, 304 patients with cardiovascular emergencies were diagnosed within primary care. Only 73.4% of these were recognized by the local physicians. Overall, the most frequent ECG abnormalities were acute ischemic patterns (44.7%) and the frequency of such patterns was higher among the ECGs assigned as emergency priority (P = 0.03). It was possible to obtain complete information on 231 patients (75.9%). Among these, the mean age was 65 ± 14.4 years, 57.1% were men and the most prevalent comorbidity was hypertension (68.4%). In total, 77.9% were referred to a unit caring for cases of higher complexity and 11.7% of the patients died. CONCLUSION: In this study, cardiovascular emergencies were misdiagnosed in primary care settings, acute myocardial ischemia was the most frequent emergency and the mortality rate was high.