Fondaparinux versus Enoxaparin in the Treatment of Obese Patients with Acute Coronary Syndrome. / Fondaparinux versus Enoxaparina no Tratamento de Pacientes Obesos com Síndrome Coronariana Aguda.

BACKGROUND: Fondaparinux is an effective and safe anticoagulant in the treatment of acute coronary syndromes (ACS). However, due to the low representation of obese individuals in clinical trials, the effects of applying the results of this drug to this population remain uncertain. OBJECTIVES: To compare Fondaparinux to Enoxaparin in the treatment of obese patients with ACS. METHODS: This is a retrospective cohort study, including obese individuals (BMI ≥ 30 Kg/m2) admitted with non-ST-segment elevation myocardial infarction (NSTEMI) or unstable angina (UA) and treated with Fondaparinux or Enoxaparin between 2010 and 2020. The Fondaparinux and Enoxaparin groups were compared for their clinical and laboratory characteristics using chi-square and Mann-Whitney tests, as appropriate. The incidence of primary outcomes (death, reinfarction, stroke, major bleeding) was compared between groups. P-value < 0.05 was considered significant for all analyses. RESULTS: A total of 367 obese patients with NSTEMI or UA were included, of whom 258 used Fondaparinux and 109 used Enoxaparin. Mean age was 64 ± 12 years, and 52.9% were male. The prevalence of diabetes, hypertension, dyslipidemia, prior coronary artery disease, prior stroke, and implementation of invasive strategy was similar between groups. The incidence of the primary outcome was 4.7% in the Fondaparinux group and 5.5% in the Enoxaparin group (p = 0.729). There was no difference between groups when analyzing the components of the primary outcome separately. CONCLUSION: In a sample of obese patients with NSTEMI or UA, there was no difference in the occurrence of the composite outcome (death, stroke, reinfarction, major bleeding) between patients who used Fondaparinux or Enoxaparin.

FUNDAMENTO: O fondaparinux é um anticoagulante eficaz e seguro usado no tratamento de síndromes coronarianas agudas (SCAs). No entanto, devido à baixa representatividade de indivíduos obesos em ensaios clínicos, os efeitos de se aplicar os resultados desse medicamento nesta população continuam incertos. OBJETIVOS: Comparar o fondaparinux à enoxaparina no tratamento de obesos com SCA. MÉTODOS: Este é um estudo do tipo coorte retrospectivo, incluindo indivíduos obesos (IMC ≥ 30 Kg/m2) internados com Infarto do Miocárdio sem Elevação do Segmento ST (IAMSSST) ou Angina Instável (AI) e tratados com fondaparinux ou enoxaparina entre 2010 e 2020. Os grupos que receberam fondaparinux e enoxaparina foram comparados quanto suas características clínicas e laboratoriais usando o teste do qui-quadrado e o teste de Mann-Whitney, conforme apropriado. A incidência dos desfechos primários (morte, reinfarto, acidente vascular cerebral, sangramento maior) foi comparada entre os grupos. Um p<0,05 foi considerado estatisticamente significativo em todas as análises. RESULTADOS: Um total de 367 pacientes obesos com IAMSSST ou AI foi incluído, dos quais 258 usaram fondaparinux e 109 usaram enoxaparina. A idade média foi 64 ± 12 anos, 52,9% eram do sexo masculino. A prevalência e diabetes, hipertensão, dislipidemia, doença arterial coronariana prévia, acidente vascular cerebral prévio, e implementação de estratégia invasiva foi similar entre os grupos. A incidência do desfecho primário foi 4,7% no grupo fondaparinux e 5,5% no grupo enoxaparina (p = 0,729). Não houve diferença entre os grupos quando os componentes do desfecho primário foram analisados separadamente. CONCLUSÃO: Em uma amostra de pacientes obesos com IAMSSST ou AI, não houve diferença na ocorrência do desfecho composto (morte, acidente vascular cerebral, reinfarto, sangramento maior) entre os pacientes que utilizaram fondaparinux ou enoxaparina.

Gene expression patterns of Sirtuin family members (SIRT1 TO SIRT7): Insights into pathogenesis and prognostic of Myelodysplastic neoplasm.

To assess and validate the gene expression profile of SIRTs (SIRT1, SIRT2, SIRT3, SIRT4, SIRT5, SIRT6, and SIRT7) in relation to the pathogenesis and prognostic progression of Myelodysplastic neoplasm (MDS). Eighty bone marrow samples of patients with de novo MDS were diagnosed according to WHO 2022 and IPSS-R criteria. Ten bone marrow samples were obtained from elderly healthy volunteers and used as control samples. Gene expression levels of all SIRTs were assessed using RT-qPCR assays. Downregulation of SIRT2 (p = 0.009), SIRT3 (p = 0.048), SIRT4 (p = 0.049), SIRT5 (p = 0.046), SIRT6 (p = 0.043), and SIRT7 (p = 0.047) was identified in MDS patients compared to control individuals. Also, we identified that while SIRT2-7 genes are typically down-regulated in MDS patients compared to normal controls, there are relative expression variations among MDS patient subgroups. Specifically, SIRT4 (p = 0.029) showed increased expression in patients aged 60 or above, and both SIRT2 (p = 0.016) and SIRT3 (p = 0.036) were upregulated in patients with hemoglobin levels below 8 g/dL. SIRT2 (p = 0.045) and SIRT3 (p = 0.033) were highly expressed in patients with chromosomal abnormalities. Different SIRTs exhibited altered expression patterns concerning specific MDS clinical and prognostic characteristics. The downregulation in SIRTs genes (e.g., SIRT2 to SIRT7) expression in Brazilian MDS patients highlights their role in the disease's development. The upregulation of SIRT2 and SIRT3 in severe anemia patients suggests a potential link to manage iron overload-related complications in transfusion-dependent patients. Moreover, the association of SIRT2/SIRT3 with genomic instability and their role in MDS progression signify promising areas for future research and therapeutic targets. These findings underscore the importance of SIRT family in understanding and addressing MDS, offering novel clinical, prognostic, and therapeutic insights for patients with this condition.

Purification and use of crude green glycerol from the transesterification of triglycerides in the formulation of an alcohol gel hand sanitizer.

The aim of this study was to produce an alcohol gel hand sanitizer containing green glycerol. Crude glycerol was purified using chemical and physical treatments. The sanitizer was prepared using 71.100 g of 99.3° GL ethanol, 28.0 g H2O, 0.5 g of Carboxypolymethylene [Carbopol 940® or Carbomer], 5 drops of triethanolamine (pH 5-7), and glycerol (1.5% w/w). The thermal behavior of the ethanol, carbopol, triethanolamine, glycerol, and alcohol gels were evaluated using Thermogravimetry and Differential Thermal Analysis. The apparent viscosity was obtained using a rotary viscometer. The determination of in vitro spreadability was achieved by an adaptation of the Knorst method. The ethanol content was measured by headspace gas chromatography using a flame ionization detector. The thermal behavior of the gels was influenced by the presence of glycerol, which confirms the possible network interactions formed. The relative densities of the samples were between 0.887 and 0.890 g/cm3. No alteration of the pH of the formulation resulted from the incorporation of glycerol. The apparent viscosities of the alcohol gels were greater than 20,000 cP. No alteration in the in vitro spreadability of the gel alcohol (530.6 mm2) resulted from the addition of glycerol. Hand sanitizer was produced using glycerol from a transesterification reaction. It represents an alternative use for the glycerol being produced in biodiesel processes. The product satisfied the requirements of WHO that preconize a formulation containing 1.45% glycerol as an humectant to protect skin against dryness and dermatitis.

High PD-L1 expression is associated with unfavorable clinical features in myelodysplastic neoplasms

ABSTRACT Introduction: Immune checkpoints are regulators of the immune system response that allow self-tolerance. Molecules such as Programmed Cell Death Protein 1 (PD-1) and its Ligand (PD-L1) participate in the immune checkpoint by signaling co-inhibition of lymphocyte responses. In cancers, PD-L1 expression is associated with the immune evasion mechanism, which favors tumor growth. The use of anti-PD-1/PD-L1 drugs is already well described in solid tumors, but still not fully understood in hematologic malignancies. Myelodysplastic neoplasms (MDSs) are heterogeneous bone marrow disorders with an increased risk of progression to Acute Myeloid Leukemia (AML). The MDS affects hematopoietic stem cells and its pathogenesis is linked to genetic and epigenetic defects, in addition to immune dysregulation. The influence of the PD-L1 on the MDS remains unknown. Methods: In this study, we evaluated the mRNA expression of the PD-L1 in 53 patients with MDS, classified according to the WHO 2016 Classification. Results: Patients with dyserythropoiesis presented significantly higher PD-L1 expression than patients without dyserythropoiesis (p = 0.050). Patients classified as having MDS with an excess of blasts 2 (MDS-EB2) presented a significant upregulation in the mRNA expression of the PD-L1 compared to the MDS with an excess of blasts 1 (MDS-EB1) (p = 0.050). Furthermore, we detected three patients with very high levels of PD-L1 expression, being statistically classified as outliers. Conclusion: We suggested that the high expression of the PD-L1 is associated with a worse prognosis in the MDS and functional studies are necessary to evaluate the possible use of anti-PD-L1 therapies for high-risk MDS, such as the MDS-EBs.

High PD-L1 expression is associated with unfavorable clinical features in myelodysplastic neoplasms.

INTRODUCTION: Immune checkpoints are regulators of the immune system response that allow self-tolerance. Molecules such as Programmed Cell Death Protein 1 (PD-1) and its Ligand (PD-L1) participate in the immune checkpoint by signaling co-inhibition of lymphocyte responses. In cancers, PD-L1 expression is associated with the immune evasion mechanism, which favors tumor growth. The use of anti-PD-1/PD-L1 drugs is already well described in solid tumors, but still not fully understood in hematologic malignancies. Myelodysplastic neoplasms (MDSs) are heterogeneous bone marrow disorders with an increased risk of progression to Acute Myeloid Leukemia (AML). The MDS affects hematopoietic stem cells and its pathogenesis is linked to genetic and epigenetic defects, in addition to immune dysregulation. The influence of the PD-L1 on the MDS remains unknown. METHODS: In this study, we evaluated the mRNA expression of the PD-L1 in 53 patients with MDS, classified according to the WHO 2016 Classification. RESULTS: Patients with dyserythropoiesis presented significantly higher PD-L1 expression than patients without dyserythropoiesis (p = 0.050). Patients classified as having MDS with an excess of blasts 2 (MDS-EB2) presented a significant upregulation in the mRNA expression of the PD-L1 compared to the MDS with an excess of blasts 1 (MDS-EB1) (p = 0.050). Furthermore, we detected three patients with very high levels of PD-L1 expression, being statistically classified as outliers. CONCLUSION: We suggested that the high expression of the PD-L1 is associated with a worse prognosis in the MDS and functional studies are necessary to evaluate the possible use of anti-PD-L1 therapies for high-risk MDS, such as the MDS-EBs.

Promising strategies for improving oral bioavailability of poor water-soluble drugs.

INTRODUCTION: Oral administration of poorly water-soluble drugs (PWSDs) is generally related to low bioavailability, leading to high drug doses, multiple side effects, and low patient compliance. Thus, different strategies have been developed to increase drug solubility and dissolution in the gastrointestinal tract, opening new venues for these drugs. AREAS COVERED: This review outlines the current challenges in PWSD formulation development and the strategies to overcome the oral barriers and increase their solubility and bioavailability. Conventional strategies include altering crystalline and molecular structures and modifying oral solid dosage forms. In contrast, novel strategies comprise micro- and nanostructured systems. Recent representative studies involving how these strategies have improved the oral bioavailability of PWSDs were also reviewed and reported. EXPERT OPINION: New approaches to enhance PWSD bioavailability have sought to improve water solubility and dissolution rates, drug protection by overcoming biological barriers, and increased absorption. Still, only a handful of studies have focused on quantifying the increase in bioavailability. Improving the oral bioavailability of PWSDs remains an exciting unexplored field of research and has become an important issue for successfully developing pharmaceutical products.

Underuse of Catheter Ablation as First-Line Therapy for Supraventricular Tachycardia.

Background Catheter ablation (CA) is a safe, effective, cost-effective technique and may be considered a first-line strategy for the treatment of symptomatic supraventricular tachycardias (SVT). Despite the high prospect of cure and the recommendations of international guidelines in considering CA as a first-line treatment strategy, the average time between diagnosis and the procedure may be long. The present study aims to evaluate predictors related to non-referral for CA as first-line treatment in patients with SVT. Methods and Results The model was derived from a retrospective cohort of patients with SVT or ventricular pre-excitation referred for CA in a tertiary center. Clinical and demographical features were used as independent variables and non-referral for CA as first-line treatment the dependent variable in a stepwise logistic regression analysis. Among 20 clinical-demographic variables from 350 patients, 10 were included in initial logistic regression analysis: age, women, presence of pre-excitation on ECG, palpitation, dyspnea and chest discomfort, number of antiarrhythmic drugs before ablation, number of concomitant symptoms, symptoms' duration and evaluations in the emergency room due to SVT. After multivariable adjusted analysis, age (odds ratio [OR], 1.2; 95% CI 1.01-1.32; P=0.04), chest discomfort during supraventricular tachycardia (OR, 2.7; CI 1.6-4.7; P<0.001) and number of antiarrhythmic drugs before ablation (OR, 1.8; CI 1.4-2.3; P<0.001) showed a positive independent association for non-referral for CA as SVT first-line treatment. Conclusions The independent predictors of non-referral for CA as first-line treatment in our logistic regression analysis indicate the existence of biases in the decision-making process in the referral process of patients who would benefit the most from catheter ablation. They very likely suggest a skewed medical decision-making process leading to catheter ablation underuse.

Reflexões sobre o acolhimento de profissionais de saúde na pandemia / Reflections about the psychological attention of health workers in the pandemic / Reflexiones sobre la acogida de trabajadores sanitarios en la pandemia

O presente artigo tem como objetivo, por meio de um relato de experiência, compartilhar reflexõesa respeito das ações de um projeto de extensão realizado em 2020 com o intuito de fortalecer trabalhadores de saúde durante a pandemia da Covid-19. Estudantes de psicologia, psicólogos residentes e uma docente participaram da experiência,oferecendo acolhimento psicológico a treze trabalhadoras de instituições públicas de saúde, em sua maioria profissionais da enfermagem, que buscaram o projeto por demanda espontânea. Durante os encontros, estimulou-se a análise do cotidiano do trabalho e dos mecanismos de enfrentamento individuais e coletivos, metodologia baseada na Ergologia. Os temas convergentes nos acolhimentos foram: senso de responsabilidade, sentimento deculpa e sofrimento no trabalho; risco de contaminação, distanciamento social e estigmas; gestão do trabalho e humanização do cuidado. Por fim, considera-se a importância do projeto para o suporte e reflexão crítica das trabalhadoras sobre os processos de trabalho. (AU)

This article aims, through an experience report, at sharing reflections on the actions that were part of an extra-curricular project carried out in 2020 with the goal of strengthening health workers during the Covid-19 pandemic. Psychology students, resident psychologists and a professor took part in the experience, offering psychological care to thirteen workers from public health institutions, mostly nursing professionals, who sought the project on a spontaneous demand. During the sessions, the analysis of the day-to-day work and of individual and collective coping mechanisms was stimulated, a methodology based on Ergology. The converging themes that emerged in the sessions were: sense of responsibility, feeling of guilt and suffering at work; risk of contamination, social distance, and stigmas; work management and humanization of care. Finally, the importance of the project is considered both for the psychological attention and critical reflection of the workers about the labor processes. (AU)

Este artículo tiene como objetivo compartir reflexiones, a través de un relato de experiencia, sobre las acciones de un proyecto de extensión realizado en 2020 con la finalidad de fortalecer a los trabajadores de la salud durante la pandemia Covid-19. Participaron estudiantes de psicología, psicólogas residentes y una profesora, que ofrecieron atención psicológica a trece trabajadoras de instituciones públicas de salud, en su mayoría profesionales de enfermería, que buscaron el proyecto por demanda espontánea. Durante los encuentros se incentivó el análisis del trabajo diario y los mecanismos de afrontamiento individuales y colectivos, metodología basada en la Ergología. Los temas convergentes fueron: sentido de responsabilidad, sentimiento de culpa y sufrimiento en el trabajo; riesgo de contaminación, distancia social y estigmas; y gestión del trabajo y humanización del cuidado. Finalmente, se considera la importancia del proyecto para la recepción y reflexión crítica de las trabajadoras sobre los procesos de trabajo. (AU)

Prognostic Contrast between Anatomical and Clinical Models Regarding Fatal and Non-Fatal Outcomes in Acute Coronary Syndromes. / Competência Prognóstica Distinta entre Modelo Clínico e Anatômico em Síndromes Coronarianas Agudas: Comparação por Tipo de Desfecho.

BACKGROUND: Recurrent ischemic events are mediated by atherosclerotic plaque instability, whereas death after an ischemic event results from gravity of insult and ability of the organism to adapt. The distinct nature of those types of events may respond for different prediction properties of clinical and anatomical information regarding type of outcome. OBJECTIVE: To identify prognostic properties of clinical and anatomical data in respect of fatal and non-fatal outcomes of patients hospitalized with acute coronary syndromes (ACS). METHODS: Patients consecutively admitted with ACS who underwent coronary angiography were recruited. The SYNTAX score was utilized as an anatomic model and the GRACE score as a clinical model. The predictive capacity of those scores was separately evaluated for prediction of non-fatal ischemic outcomes (infarction and refractory angina) and cardiovascular death during hospitalization. It was considered as significant a p-value <0,05. RESULTS: EAmong 365 people, cardiovascular death was observed in 4,4% and incidence of non-fatal ischemic outcomes in 11%. For cardiovascular death, SYNTAX and GRACE score presented similar C-statistic of 0,80 (95% IC: 0,70 - 0,92) and 0,89 (95% IC 0,81 - 0,96), respectively - p = 0,19. As for non-fatal ischemic outcomes, the SYNTAX score presented a moderate predictive value (C-statistic = 0,64; 95%IC 0,55 - 0,73), whereas the GRACE score did not presented association with this type of outcome (C-statistic = 0,50; 95%IC 0,40-0,61) - p = 0,027. CONCLUSION: Clinical and anatomic models similarly predict cardiovascular death in ACS. However, recurrence of coronary instability is better predicted by anatomic variables than clinical data. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

FUNDAMENTO: Eventos isquêmicos recorrentes decorrem de instabilidade de placa aterosclerótica, enquanto morte após um evento isquêmico decorre da gravidade do insulto. A natureza diversa desses tipos de eventos pode fazer com que dados clínicos e anatômicos tenham diferentes capacidades prognósticas a depender do tipo de desfecho. OBJETIVO: Identificar as predileções prognósticas de dados clínicos e dados anatômicos em relação a desfechos coronários fatais e não fatais durante hospitalização de pacientes com síndromes coronarianas agudas (SCA). MÉTODOS: Pacientes consecutivamente admitidos por SCA que realizaram coronariografia foram recrutados. O escore SYNTAX foi utilizado como modelo anatômico e o escore GRACE como modelo clínico. A capacidade preditora desses escores foi comparada quando à predição de desfechos isquêmicos não fatais (infarto ou angina refratária) e de morte cardiovascular durante hospitalização. Significância estatística foi definida por p < 0,05. RESULTADOS: Entre 365 indivíduos, 4,4% foi a incidência de óbito hospitalar e 11% de desfechos isquêmicos não fatais. Para morte cardiovascular, ambos os escores ­ SYNTAX e GRACE ­ apresentaram capacidade discriminatória, com estatísticas-C similares: 0,80 (95%IC: 0,70­0,92) e 0,89 (95%IC 0,81­0,96), respectivamente ­ p=0,19. Quantos aos desfechos isquêmicos não fatais, o escore SYNTAX apresentou valor preditor (estatística-C = 0,64; 95%IC 0,55­0,73), porém o escore GRACE não mostrou associação com esse tipo de desfecho (estatística-C = 0,50; 95%IC: 0,40­0,61) ­ p=0,027. CONCLUSÃO: Os modelos clínico e anatômico predizem satisfatoriamente morte cardiovascular em SCA, enquanto a recorrência de instabilidade coronária é melhor prevista por características anatômicas do que por dados clínicos. (Arq Bras Cardiol. 2020; 115(2):219-225).

Competência Prognóstica Distinta entre Modelo Clínico e Anatômico em Síndromes Coronarianas Agudas: Comparação por Tipo de Desfecho / Prognostic Contrast between Anatomical and Clinical Models Regarding Fatal and Non-Fatal Outcomes in Acute Coronary Syndromes

Resumo Fundamento Eventos isquêmicos recorrentes decorrem de instabilidade de placa aterosclerótica, enquanto morte após um evento isquêmico decorre da gravidade do insulto. A natureza diversa desses tipos de eventos pode fazer com que dados clínicos e anatômicos tenham diferentes capacidades prognósticas a depender do tipo de desfecho. Objetivo Identificar as predileções prognósticas de dados clínicos e dados anatômicos em relação a desfechos coronários fatais e não fatais durante hospitalização de pacientes com síndromes coronarianas agudas (SCA). Métodos Pacientes consecutivamente admitidos por SCA que realizaram coronariografia foram recrutados. O escore SYNTAX foi utilizado como modelo anatômico e o escore GRACE como modelo clínico. A capacidade preditora desses escores foi comparada quando à predição de desfechos isquêmicos não fatais (infarto ou angina refratária) e de morte cardiovascular durante hospitalização. Significância estatística foi definida por p < 0,05. Resultados Entre 365 indivíduos, 4,4% foi a incidência de óbito hospitalar e 11% de desfechos isquêmicos não fatais. Para morte cardiovascular, ambos os escores — SYNTAX e GRACE — apresentaram capacidade discriminatória, com estatísticas-C similares: 0,80 (95%IC: 0,70-0,92) e 0,89 (95%IC 0,81-0,96), respectivamente — p=0,19. Quantos aos desfechos isquêmicos não fatais, o escore SYNTAX apresentou valor preditor (estatística-C = 0,64; 95%IC 0,55-0,73), porém o escore GRACE não mostrou associação com esse tipo de desfecho (estatística-C = 0,50; 95%IC: 0,40-0,61) — p=0,027. Conclusão Os modelos clínico e anatômico predizem satisfatoriamente morte cardiovascular em SCA, enquanto a recorrência de instabilidade coronária é melhor prevista por características anatômicas do que por dados clínicos. (Arq Bras Cardiol. 2020; 115(2):219-225)

Abstract Background Recurrent ischemic events are mediated by atherosclerotic plaque instability, whereas death after an ischemic event results from gravity of insult and ability of the organism to adapt. The distinct nature of those types of events may respond for different prediction properties of clinical and anatomical information regarding type of outcome. Objective To identify prognostic properties of clinical and anatomical data in respect of fatal and non-fatal outcomes of patients hospitalized with acute coronary syndromes (ACS). Methods Patients consecutively admitted with ACS who underwent coronary angiography were recruited. The SYNTAX score was utilized as an anatomic model and the GRACE score as a clinical model. The predictive capacity of those scores was separately evaluated for prediction of non-fatal ischemic outcomes (infarction and refractory angina) and cardiovascular death during hospitalization. It was considered as significant a p-value <0,05. Results EAmong 365 people, cardiovascular death was observed in 4,4% and incidence of non-fatal ischemic outcomes in 11%. For cardiovascular death, SYNTAX and GRACE score presented similar C-statistic of 0,80 (95% IC: 0,70 - 0,92) and 0,89 (95% IC 0,81 - 0,96), respectively - p = 0,19. As for non-fatal ischemic outcomes, the SYNTAX score presented a moderate predictive value (C-statistic = 0,64; 95%IC 0,55 - 0,73), whereas the GRACE score did not presented association with this type of outcome (C-statistic = 0,50; 95%IC 0,40-0,61) - p = 0,027. Conclusion Clinical and anatomic models similarly predict cardiovascular death in ACS. However, recurrence of coronary instability is better predicted by anatomic variables than clinical data. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Option for the radial versus femoral access in coronary intervention in acute coronary syndromes: a risk-treatment paradox / Opção para o acesso radial versus femoral na intervenção coronária em síndromes coronárias agudas: um paradoxo de tratamento de risco

Background: In coronary procedures, although the radial approach protects patients from hemorrhagic complications, it is technically more complex than the femoral approach. Objectives: To test the hypothesis that the radial approach is the procedure of choice in ACS patients due to the high risk of bleeding; and to identify independent predictors of the choice for radial access. Methods: Patients admitted for ACS who underwent invasive coronary procedure were included. We registered the type of access (femoral or radial) chosen by the physician for the first angiography; the investigators did not interfere with this choosing process. Student's t-test was used for comparisons between the CRUSADE and ACUITY scores. Predictors of radial access were compared between the groups. Statistical significance was defined by p < 0,05.Results: Radial access was chosen in 67% of 347 consecutive patients. Patients who underwent radial approach had lower risk of bleeding determined by CRUSADE (30 ± 14 vs. 37 ± 15; p < 0.001) as compared with femoral access. In multivariate analysis, four variables were identified as independent predictors negatively associated with radial access ­ age (OR = 0.98; 95%CI = 0.96 ­ 0.99), creatinine (OR = 0.54; 95%CI = 0.3 ­ 0.98), signs of left ventricular failure (OR = 0.45; 95% CI = 0.22 ­ 0.92) and previous CABG (OR = 0.022; 95%CI = 0.003 ­ 0.166). Conclusion: The propensity to choose radial over femoral access in coronary intervention was not primarily influenced by patients' bleeding risk. Predictors of this decision, identified in the study, indicated less complex patients, suggesting that the difficulty in performing the technique was a stronger determinant than its potential antihemorrhagic effect

Incremental Prognostic Value of the Incorporation of Clinical Data Into Coronary Anatomy Data in Acute Coronary Syndromes: SYNTAX-GRACE Score / Valor Prognóstico Incremental da Incorporação de Dados Clínicos à Anatomia Coronária em Síndromes Coronarianas Agudas: Escore SYNTAX-GRACE

Abstract Background: When performing coronary angiography in patients with acute coronary syndrome (ACS), the anatomical extent of coronary disease usually prevails in the prognostic reasoning. It has not yet been proven if clinical data should be accounted for in risk stratification together with anatomical data. Objective: To test the hypothesis that clinical data increment the prognostic value of anatomical data in patients with ACS. Methods: Patients admitted with objective criteria for ACS and who underwent angiography during hospitalization were included. Primary outcome was defined as in-hospital cardiovascular death, and the prognostic value of the SYNTAX Score (anatomical data) was compared to that of the SYNTAX-GRACE Score, which resulted from the incorporation of the GRACE Score into the SYNTAX score. The Integrated Discrimination Improvement (IDI) was calculated to evaluate the SYNTAX-GRACE Score ability to correctly reclassify information from the traditional SYNTAX model. Results: This study assessed 365 patients (mean age, 64 ± 14 years; 58% male). In-hospital cardiovascular mortality was 4.4%, and the SYNTAX Score was a predictor of that outcome with a C-statistic of 0.81 (95% CI: 0.70 - 0.92; p < 0.001). The GRACE Score was a predictor of in-hospital cardiac death independently of the SYNTAX Score (p < 0.001, logistic regression). After incorporation into the predictive model, the GRACE Score increased the discrimination capacity of the SYNTAX Score from 0.81 to 0.92 (95% CI: 0.87 - 0.96; p = 0.04). Conclusion: In patients with ACS, clinical data complement the prognostic value of coronary anatomy. Risk stratification should be based on the clinical-anatomical paradigm, rather than on angiographic data only.

Resumo Fundamento: Uma vez realizada a coronariografia em pacientes com síndrome coronariana aguda (SCA), a extensão anatômica da doença coronária prevalece no raciocínio prognóstico. Não está estabelecido se dados clínicos devem também ser contabilizados na estimativa de risco, uma vez que se tenha conhecimento da anatomia coronária. Objetivo: Testar a hipótese de que dados clínicos incrementam o valor prognóstico da avaliação anatômica em pacientes com SCA. Métodos: Indivíduos admitidos com critérios objetivos de SCA e que realizaram coronariografia durante o internamento foram incluídos no estudo. Desfecho primário foi definido como óbito cardiovascular hospitalar, sendo comparado o valor prognóstico do Escore SYNTAX (anatomia) com o do escore SYNTAX-GRACE, resultante da incorporação do Escore GRACE ao Escore SYNTAX. O cálculo do Integrated Discrimination Improvement (IDI) foi realizado para avaliar a capacidade do modelo SYNTAX-GRACE para reclassificar corretamente a informação do modelo SYNTAX tradicional. Resultados: Foram estudados 365 pacientes, idade 64±14 anos, 58% masculinos. A mortalidade cardiovascular durante hospitalização foi de 4,4% e o Escore SYNTAX foi preditor desse desfecho com estatística-C de 0,81 (IC 95% = 0,70 - 0,92; p < 0,001). O Escore GRACE mostrou-se preditor de óbito cardiovascular intra-hospitalar, independente do Escore SYNTAX (p < 0,001 por regressão logística). Ao ser incorporado ao modelo preditor, o Escore GRACE incrementou a capacidade discriminatória do SYNTAX de 0,81 para 0,92 (IC 95% = 0,87 - 0,96; p = 0,04). Conclusão: Em pacientes com SCA, dados clínicos complementam o valor prognóstico da anatomia coronária, devendo a estratificação de risco ser baseada no paradigma clínico-anatômico e não apenas em dados angiográficos.

Incremental Prognostic Value of the Incorporation of Clinical Data Into Coronary Anatomy Data in Acute Coronary Syndromes: SYNTAX-GRACE Score.

BACKGROUND: When performing coronary angiography in patients with acute coronary syndrome (ACS), the anatomical extent of coronary disease usually prevails in the prognostic reasoning. It has not yet been proven if clinical data should be accounted for in risk stratification together with anatomical data. OBJECTIVE: To test the hypothesis that clinical data increment the prognostic value of anatomical data in patients with ACS. METHODS: Patients admitted with objective criteria for ACS and who underwent angiography during hospitalization were included. Primary outcome was defined as in-hospital cardiovascular death, and the prognostic value of the SYNTAX Score (anatomical data) was compared to that of the SYNTAX-GRACE Score, which resulted from the incorporation of the GRACE Score into the SYNTAX score. The Integrated Discrimination Improvement (IDI) was calculated to evaluate the SYNTAX-GRACE Score ability to correctly reclassify information from the traditional SYNTAX model. RESULTS: This study assessed 365 patients (mean age, 64 ± 14 years; 58% male). In-hospital cardiovascular mortality was 4.4%, and the SYNTAX Score was a predictor of that outcome with a C-statistic of 0.81 (95% CI: 0.70 - 0.92; p < 0.001). The GRACE Score was a predictor of in-hospital cardiac death independently of the SYNTAX Score (p < 0.001, logistic regression). After incorporation into the predictive model, the GRACE Score increased the discrimination capacity of the SYNTAX Score from 0.81 to 0.92 (95% CI: 0.87 - 0.96; p = 0.04). CONCLUSION: In patients with ACS, clinical data complement the prognostic value of coronary anatomy. Risk stratification should be based on the clinical-anatomical paradigm, rather than on angiographic data only.

Accuracy of the GRACE and TIMI scores in predicting the angiographic severity of acute coronary syndrome.

BACKGROUND: The accuracy of the GRACE and TIMI scores in predicting coronary disease extension in patients with non-ST-elevation acute coronary syndromes (ACS) has not been established. OBJECTIVE: To assess the hypothesis that the GRACE and TIMI risk scores satisfactorily predict coronary disease extension in patients withnon-ST-elevation ACS undergoing coronary angiography. METHODS: Individuals meeting the objective criteria for ACS and undergoing coronary angiography during hospitalization were consecutively assessed. Angiographic coronary disease was described as follows: quantification of coronary disease extension by using Gensini score; presence of any coronary artery obstruction (> 70% or > 50% when affecting left main coronary artery); and presence of severe disease (three-vessel disease or affecting the left main coronary artery). RESULTS: Of 112 patients assessed, a positive correlation of the Gensini score was observed with the GRACE (p = 0.017) and TIMI (p = 0.02) scores, but that association was weak (r = 0.23 and r = 0.27; respectively). The GRACE score could predict neither obstructive coronary disease (area under the ROC curve = 0.57; 95% CI = 0.46 - 0.69), nor severe coronary disease (ROC = 0.59; 95% CI = 0.48 - 0.70). The TIMI score proved to be a modest predictor of coronary disease (ROC = 0.65; 95% CI = 0.55 - 0.76) and of severe coronary disease (ROC = 0.66; 95% CI = 0.56 - 0.76). CONCLUSION: (1) There is a positive association between the values of the TIMI or GRACE scores and the extension of coronary artery disease in patients with ACS; (2) however, the degree of that association is not sufficient to make those scores accurate predictors of coronary angiography results.

Acurácia dos escores GRACE e TIMI na predição da gravidade angiográfica da síndrome coronariana aguda / Accuracy of the GRACE and TIMI scores in predicting the angiographic severity of acute coronary syndrome

FUNDAMENTO: A acurácia dos escores GRACE e TIMI em predizer a extensão da doença coronariana em pacientes com síndromes coronarianas agudas sem supradesnivelamento do segmento ST (SCA) não está estabelecida. OBJETIVO: Testar a hipótese de que os escores de risco GRACE e TIMI predizem satisfatoriamente a extensão da doença coronariana, em pacientes com SCA submetidos a coronariografia. MÉTODOS: Indivíduos admitidos com critérios objetivos de SCA e que realizaram coronariografia durante o internamento foram consecutivamente analisados. A doença coronariana angiográfica foi descrita de três formas: quantificação da extensão da doença coronariana pelo escore de Gensini; presença de qualquer obstrução coronariana (> 70% ou > 50% quando tronco de coronária esquerda); presença de doença severa (triarterial ou tronco de coronária esquerda). RESULTADOS: Em 112 pacientes avaliados, observou-se correlação positiva do escore de Gensini com os escores GRACE (p = 0,017) e TIMI (p = 0,02), porém essa associação foi de fraca magnitude (r = 0,23 e r = 0,27; respectivamente). O escore GRACE não foi capaz de predizer doença coronariana obstrutiva (área abaixo da curva ROC = 0,57; 95%IC = 0,46 - 0,69), nem doença coronariana severa (ROC = 0,59; 95%IC = 0,48 -0,70). O Escore TIMI se mostrou modesto preditor em relação à presença de doença coronariana (ROC = 0,65; 95%IC = 0,55 - 0,76) e presença de doença severa (ROC = 0,66; 95%IC = 0,56 - 0,76). CONCLUSÃO: (1) Existe associação positiva entre o valor dos escores TIMI ou GRACE e a extensão da doença coronária em pacientes com SCA; (2) No entanto, o grau dessa associação não é suficiente para que esses escores sejam preditores acurados dos resultados da coronariografia.

BACKGROUND: The accuracy of the GRACE and TIMI scores in predicting coronary disease extension in patients with non-ST-elevation acute coronary syndromes (ACS) has not been established. OBJECTIVE: To assess the hypothesis that the GRACE and TIMI risk scores satisfactorily predict coronary disease extension in patients withnon-ST-elevation ACS undergoing coronary angiography. METHODS: Individuals meeting the objective criteria for ACS and undergoing coronary angiography during hospitalization were consecutively assessed. Angiographic coronary disease was described as follows: quantification of coronary disease extension by using Gensini score; presence of any coronary artery obstruction (> 70% or > 50% when affecting left main coronary artery); and presence of severe disease (three-vessel disease or affecting the left main coronary artery). RESULTS: Of 112 patients assessed, a positive correlation of the Gensini score was observed with the GRACE (p = 0.017) and TIMI (p = 0.02) scores, but that association was weak (r = 0.23 and r = 0.27; respectively). The GRACE score could predict neither obstructive coronary disease (area under the ROC curve = 0.57; 95% CI = 0.46 - 0.69), nor severe coronary disease (ROC = 0.59; 95% CI = 0.48 - 0.70). The TIMI score proved to be a modest predictor of coronary disease (ROC = 0.65; 95% CI = 0.55 - 0.76) and of severe coronary disease (ROC = 0.66; 95% CI = 0.56 - 0.76). CONCLUSION: (1) There is a positive association between the values of the TIMI or GRACE scores and the extension of coronary artery disease in patients with ACS; (2) however, the degree of that association is not sufficient to make those scores accurate predictors of coronary angiography results.

Análise de causalidade da relação entre sangramento e letalidade de Síndromes Coronarianas Agudas / Causality analysis of the relationship between bleeding and lethality in Acute Coronary Syndromes

FUNDAMENTO: Eventos hemorrágicos em Síndromes Coronarianas Agudas (SCA) apresentam associação independente com óbito em registros multicêntricos internacionais. No entanto, essa associação não foi testada em nosso meio e a verdadeira relação causal entre sangramento e óbito não está plenamente demonstrada. OBJETIVO: Testar as hipóteses de que: (1) sangramento maior é preditor independente de óbito hospitalar em SCA; (2) a relação entre esses dois desfechos é causal. MÉTODOS: Incluídos pacientes com critérios pré-definidos de angina instável, infarto sem supradesnivelamento do ST ou infarto com supradesnivelamento do ST. Sangramento maior durante o internamento foi definido de acordo com os tipos 3 ou 5 da Classificação Universal de Sangramento. Regressão logística e análise da sequência de eventos foram utilizadas para avaliar a associação entre sangramento e óbito. RESULTADOS: Dentre 455 pacientes estudados, 29 desenvolveram sangramento maior (6,4%; 95%IC = 4,3-9,0%). Esses indivíduos apresentaram mortalidade hospitalar de 21%, comparados a 5,6% nos pacientes sem sangramento (RR = 4,0; 95%IC = 1,8-9,1; P = 0,001). Após ajuste para escore de propensão, sangramento maior permaneceu preditor de óbito hospitalar (OR = 3,34; 95%IC = 1,2-9,5; P = 0,02). Houve 6 óbitos dentre 29 pacientes que sangraram. No entanto, análise detalhada da sequência de eventos demonstrou relação causal em apenas um caso. CONCLUSÃO: (1) Sangramento maior é preditor independente de óbito hospitalar em SCA; (2) O papel do sangramento como marcador de risco predomina sobre seu papel de fator de risco para óbito. Essa conclusão deve ser vista como geradora de hipótese a ser confirmada por estudos de maior tamanho amostral. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).

BACKGROUND: Hemorrhagic events in Acute Coronary Syndromes (ACS) have been independently associated with death in international multicenter registries. However, that association has not been tested in Brazil and the true causal relationship between bleeding and death has not been completely shown. OBJECTIVE: To test the following hypotheses: (1) major bleeding is an independent predictor of in-hospital death in ACS; (2) the relationship between those two endpoints is causal. METHODS: This study included patients meeting predefined criteria of unstable angina, non-ST-segment elevation myocardial infarction or ST-segment elevation myocardial infarction. Major bleeding during hospitalization was defined according to the Bleeding Academic Research Consortium (types 3 or 5). Logistic regression and analysis of the sequence of events were used to assess the association between bleeding and death. RESULTS: Of the 455 patients studied, 29 experienced major bleeding (6.4%; 95% CI = 4.3-9.0%). They had in-hospital mortality of 21%, as compared with 5.6% of those not experiencing bleeding (RR = 4.0; 95% CI = 1.8-9.1; P = 0.001). After adjusting for the propensity score, major bleeding remained as a predictor of in-hospital death (OR = 3.34; 95% CI = 1.2-9.5; P = 0.02). Of the 29 patients who experienced bleeding, six died. However, the detailed analysis of the sequence of events showed causal relationship only in one case. CONCLUSION: (1) Major bleeding is an independent predictor of in-hospital death in ACS; (2) the role of bleeding as a risk marker overcomes that as a risk factor for death. This conclusion should be seen as a hypothesis generator to be confirmed by larger-sample studies. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).