Results of primary angioplasty in a reference center: in-hospital outcomes.

INTRODUCTION: Primary angioplasty is accepted as the preferred treatment for acute myocardial infarction in the first 12 hours. However, outcomes depend to a large extent on the volume of activity and experience of the center. Continuous monitoring of methods and results obtained is therefore crucial to quality control. OBJECTIVE: To describe the demographic, clinical and angiographic characteristics as well as in-hospital outcomes of patients undergoing primary PCI in a high-volume Portuguese center. We also aimed to identify variables associated with in-hospital mortality in this population. METHODS: This was a retrospective registry of consecutive primary PCIs performed at Santa Marta Hospital between January 2001 and August 2007. Demographic, clinical, and angiographic characteristics and in-hospital outcomes were analyzed. Independent predictors of in-hospital mortality were identified by multivariate logistic regression analysis. RESULTS: A total of 1157 patients were identified, mean age 61+/-12 years, 76% male. Mean pain-to-balloon time was 7.6 hours and primary angiographic success was 88%. Overall in-hospital mortality was 6.9%, or 5.5% if patients presenting in cardiogenic shock were excluded from the analysis. Previous history of heart failure, cardiogenic shock on admission, invasive ventilatory support, major hemorrhage, and age over 75 years were found to be associated with increased risk of in-hospital death. CONCLUSIONS: In this center primary PCI is effective and safe. Angiographic success rates and in-hospital mortality and morbidity are similar to other international registries. Patients at increased risk for adverse outcome can be identified by simple clinical characteristics such as advanced age, cardiogenic shock on admission, mechanical ventilation and major hemorrhage during hospitalization.

Differences in outcome in primary angioplasty in women.

BACKGROUND: In acute myocardial infarction (AMI), primary percutaneous transluminal coronary angioplasty (PTCA) has proved to be the best therapeutic approach. Several factors have been associated with worse outcome in AMI in females. Are there differences in outcome in women undergoing PTCA for AMI? AIM: To evaluate gender influence on clinical outcome and in-hospital mortality in patients with AMI who undergo primary percutaneous interventions. METHODS: We studied 245 consecutive patients (72 women, 29.4 %), who underwent primary PTCA between January 2000 and December 2001. The following parameters were analyzed: risk factors for coronary artery disease including hypertension, diabetes, smoking, hypercholesterolemia and family history, previous AMI, PTCA or angina, pain-to-balloon time, extent of coronary disease and outcome. RESULTS: Female patients were older (67.9+/-11.6 vs. 59.6+/-13; p < 0.001) with a higher prevalence of hypertension (65.3 % vs. 47.4 %; p < 0.05) and angina (29.0 % vs. 16.0 %; p < 0.05) and lower prevalence of smoking (27.8 % vs. 54.3 %; p < 0.001). Pain-to-balloon time was longer in women (6.8+/-4.1 vs. 5.4+/-3.7 hours; p < 0.05). Extent of coronary disease was similar in both groups. Glycoprotein IIb/IIIa inhibitors were used in 84.7 % of women and 90.8 % of men. The frequency of hemorrhagic complications (5.6 % vs. 5.2 %) and arrhythmias (15.3 % vs. 10.4%) and in-hospital mortality (9.7 6.4 %) were higher in females, although without statistical significance (p = NS). Hospitalization time was similar in both groups. CONCLUSIONS: Despite the growing awareness of a gender bias in therapeutic approaches to AMI, there are still some differences in outcome, with a trend towards higher mortality rates in women. Older age and longer pain-to-balloon time could account for this.

Primary coronary angioplasty in the elderly.

BACKGROUND: Primary coronary angioplasty is the best therapeutic approach in acute myocardial infarction (AMI), and more so in the population aged over 75 years, in whom the hemorrhagic risk of thrombolysis becomes almost unacceptable. AIM: To evaluate age-related influences on clinical evolution and in-hospital mortality in patients with AMI who undergo primary percutaneous coronary interventions (PCI). METHODS: We studied 245 consecutive patients (aged between 31 and 90, 63+/-13), who underwent primary PCI between January 2000 and December 2001. Forty-six patients (18.8%) aged over 75 years were compared with the rest. The following parameters were analyzed: risk factors for coronary artery disease including hypertension, diabetes, smoking, hypercholesterolemia and family history, previous AMI, PCI or angina, extent of coronary disease, angiographic results and in-hospital mortality. RESULTS: Female gender was more frequent in older patients (56.5% vs. 23.1%; p<0.001) and smoking was more prevalent in the younger group (54.3% vs. 13.0%; p<0.001), as was previous AMI (p<0.05). PCI success was high in both groups (93.5% in the older population and 96.7% in the rest; p=NS), multivessel coronary disease was significantly more frequent in the elderly group (41.3% vs. 26.2%; p<0.05), and glycoprotein IIb/IIIa inhibitors were used less (80.4% vs. 91%; p<0.05). Killip class evolution was more favorable in the younger group (class I in 88.4% vs. 69.8% in older patients; p<0.001). The number of hemorrhagic complications and in-hospital mortality were higher in elderly patients (3.5% vs. 13.0%; p<0.05 and 4.5% vs. 19.6%; p<0.001, respectively). CONCLUSIONS: Primary PCI has a similarly high success rate in elderly patients, although this age-group still has higher mortality. The increased rate of hemorrhagic complications in this population should lead to greater caution in the use of adjuvant antithrombotic drugs.

A systematic invasive strategy in non-ST elevation acute coronary syndromes: is age a limiting factor?

INTRODUCTION: A systematic invasive therapeutic strategy for acute coronary syndromes (ACS) is currently accepted as safe and effective and evidence is growing for its superiority compared to a conservative attitude. Elderly patients, given their greater susceptibility, are frequently excluded from this approach, and this may limit the potential benefits. OBJECTIVE: To evaluate the influence of age on the characteristics and clinical evolution of patients with ACS treated by an invasive strategy and to determine whether this in itself limits its adoption. METHODS: We retrospectively studied 203 patients admitted for ACS (consecutive and non-selected). considered of medium to high risk after evaluation and treated with glycoprotein IIb/IIIa receptor inhibitors. Of these, 45 patients were aged > or =75 years and they constituted the Elderly group, the remainder constituting the Non-elderly group. Their baseline characteristics, treatment and clinical evolution were analyzed and compared. RESULTS: The Elderly group had more women, although the difference was not statistically significant. Of the other characteristics studied, family history of coronary disease and smoking presented significant differences, both being less frequent among the elderly. There was a non-significant tendency to perform less catheterization in the elderly, the two groups being similar regarding the revascularization therapy chosen. Overall, hemorrhagic complications were more frequent in the Elderly group, but the difference regarding significant hemorrhages did not reach statistical significance. In-hospital mortality was higher in the elderly, but diminished and did not reach statistical significance when only patients in whom catheterization was performed were considered. CONCLUSION: In this population the elderly had more non-significant hemorrhagic complications but their higher in-hospital mortality was not associated with the adoption of an invasive approach. We therefore suggest that age by itself does not limit the adoption of a systematic invasive strategy.

Importance of complex additional stenosis after primary angioplasty for acute myocardial infarction in medium-term prognosis.

BACKGROUND: There is some controversy about the ideal type of revascularization in the context of primary angioplasty (percutaneous coronary intervention--PCI) for acute myocardial infarction (AMI). The presence of additional stenosis, especially if complex, can have an impact on prognosis. OBJECTIVES: To evaluate medium-term (1-year) prognosis according to the presence of complex additional stenosis after primary PCI. POPULATION AND METHODS: A retrospective study of 138 consecutive patients admitted to our unit for ST-segment elevation AMI who underwent primary PCI. Patients were followed up for 1 year and divided in 2 groups: without complex additional stenosis (n = 69, 61 +/- 14 years, 62% males) and with complex additional stenosis (n = 69, 65 +/- 13 years, 73% males, p = NS). We evaluated demographic characteristics, risk factors for coronary artery disease, previous cardiac history and signs of heart failure on admission. Angiographic characteristics, medication and PCI outcome were also evaluated. The impact of these variables on the combined end-point of death, reinfarction, and myocardial revascularization at 1 year was assessed. RESULTS: The angiographic success rate was 96.4%. Twenty-four percent of patients were aged 75 years or over and 4.3% of the total population were in Killip class IV on admission. Anterior AMI was slightly more common in the non-complex additional stenosis group (60% vs. 44%, p = 0.06), and inferior AMI in the complex additional stenosis group (26% vs. 42%, p = 0.07). One-vessel disease was more prevalent in the group without complex additional stenosis, as expected (86% vs. 11%, p < 0.001) and stent implantation was also more frequent in this group (96% vs. 86%, p = 0.08). There were no differences in other variables. Death/reinfarction/revascularization was more frequent in the group with complex additional stenosis (13% vs. 32%, p = 0.014). Sixty-seven per cent of the events occurred in the first 30 days of follow-up. At 1 year, univariate predictors of outcome were Killip class > or = 2, TIMI flow < 3 in the infarct-related vessel after PCI, non-use of glycoprotein IIb/IIIa receptor antagonists, beta-blockers or statins, multivessel disease, and the presence of complex additional stenosis (log rank, p = 0.003). Using multivariate regression analysis, the independent predictors of outcome at 1 year were Killip class > or = 2 (OR 0.28; 95% CI 0.08-0.93, p = 0.037) and the presence of complex additional stenosis (OR 0.32; 95% CI 0.12-0.84, p = 0.020). CONCLUSIONS: The presence of complex additional stenosis after primary PCI had a worse prognosis at 1 year, suggesting the need for further interventions to stabilize the plaque, particularly in the first 30 days after AMI.

Prognostic value of neutrophil response in the era of acute myocardial infarction mechanical reperfusion.

BACKGROUND: In ST-segment elevation myocardial infarction (STEMI) patients treated with primary angioplasty, neutrophil response and its prognostic significance are not entirely understood. METHODS: We retrospectively studied 305 consecutive and non-selected STEMI patients. They were divided into three groups according to the maximum neutrophil percentage in the first 48 hours. We compared baseline demographic characteristics, coronary disease risk factors, cardiac history, clinical presentation, therapeutics administered and clinical evolution. We then assessed survival in the three groups and determined predictors of 30-day mortality. Group 1 (G1) had a mean age of 57 +/- 14 years and showed mean neutrophilia of 73.3%, Group 2 (G2) 61 +/- 13 years and 79.9%, and Group 3 (G3) 66 +/- 13 years and 84.2%. We compared outcomes and 30-day mortality between the groups. RESULTS: Mean age rose with increased neutrophil response. There were no statistically significant baseline differences between the groups except for more smokers in Groups 1 and 2, and more patients presenting with Killip class > or = 2 and fewer with uncomplicated evolution in Group 3. During 30-day follow-up there were 19 deaths (G1=1, G2=3 and G3=15). In univariate analysis mortality predictors were age > or = 75 years, anterior STEMI, maximum creatinine kinase > or = 2500 UI/L, culprit lesion in proximal anterior descending artery, incomplete revascularization, Killip > or = 2 at presentation, and being in G3. After multivariate regression analysis independent predictors were age > or = 75 years, incomplete revascularization and being in G3. CONCLUSION: In myocardial infarction patients undergoing mechanical revascularization, an intense neutrophil response (routinely, easily and inexpensively assessed) is related to worse short-term prognosis.

Estudo prospectivo e randomizado do uso de antimicrobiano profilático em cesarianas / Prospective and randomized trial of the use of antibiotics as prophylatic in cesarean section

Este estudo prospectivo e randomizado foi realizado com o objetivo de comparar as taxas de infecçoes hospitalares de dois grupos, do total de 200 pacientes, submetidos à cesariana. Cem pacientes usaram cefalotina (IBA) 1g. EV após a ligadura do cordao umbilical e 100 pacientes nao usaram o antimicrobiano.Foi estabelecido um protocolo visando a correlaçao das infecçoes hospitalares com diversos fatores de risco para infecçoes puerperais. Submetido ao tratamento estatístico, o estudo nao demonstrou diferença significativa entre a incidência de infecçoes nos dois grupos, exceto no estudo dos fatores sociais, onde o grupo pertencente às classes DE, nao submetido a antibiótico-profilaxia, apresentou uma incidência de infecçoes hospitalares mais elevada do que o grupo das camadas sociais ABC.A taxa global de infecçoes hospitalares foi de 7,0 por cento. Sendo 4 por cento no grupo que usou antimicrobiano e 10 por cento no grupo que nao usou. A análise destes dados demonstrou que nao estamos autorizados a recomendar ou nao o uso de antimicrobianos (Cefalotina) profilático nas cesarianas.

Reflexos econômicos das infecçöes hospitalares / Economic reflex of the cross infections

Este trabalho tem como objetivo demonstrar que as dificuldades financeiras que atualmente os hospitais filantrópicos privados enfrentam, a exemplo da Santa Casa da Misericórdia de Cachoeiro de Itapemirim (SCMCI), Espírito Santo, instituiçäo considerada pelo Ministério da Saúde em 1991 como padräo pelo seu desempenho nas atividades de controle das infecçöes hospitalares, ocasionam visivelmente uma queda na qualidade do atendimento médico-hospitalar e, consequëntemente, elevaçäo das incidências das infecçöes hospitalares que, fechando um círculo vicioso, elevam os custos das internaçöes hospitalares.

Indices de infecçöes hospitalares em cirurgia / Indices of hospital infectious in surgery

Divulgam-se os índices de infecçöes hospitalares em cirurgia analisados através de estudo prospectivo de 1970 fichas de pacientes de especialidades cirúrgicas diversas, no período de outubro de 1985 a setembro de 1986. Mostra-se o perfil de uso profilático de antimicrobianos entre as especialidades e faz-se uma análise comparativa dos índices de infecçöes de cada cirurgiäo, pesquisados na Santa Casa de Misericórdia de Cachoeiro de Itapemirim