Correlation between Very Short and Short-Term Blood Pressure Variability in Diabetic-Hypertensive and Healthy Subjects.

BACKGROUND: Blood pressure (BP) variability can be evaluated by 24-hour ambulatory BP monitoring (24h-ABPM), but its concordance with results from finger BP measurement (FBPM) has not been established yet. OBJECTIVE: The aim of this study was to compare parameters of short-term (24h-ABPM) with very short-term BP variability (FBPM) in healthy (C) and diabetic-hypertensive (DH) subjects. METHODS: Cross-sectional study with 51 DH subjects and 12 C subjects who underwent 24h-ABPM [extracting time-rate, standard deviation (SD), coefficient of variation (CV)] and short-term beat-to-beat recording at rest and after standing-up maneuvers [FBPM, extracting BP and heart rate (HR) variability parameters in the frequency domain, autoregressive spectral analysis]. Spearman correlation coefficient was used to correlate BP and HR variability parameters obtained from both FBPM and 24h-ABPM (divided into daytime, nighttime, and total). Statistical significance was set at p < 0.05. RESULTS: There was a circadian variation of BP levels in C and DH groups; systolic BP and time-rate were higher in DH subjects in all periods evaluated. In C subjects, high positive correlations were shown between time-rate index (24h-ABPM) and LF component of short-term variability (FBPM, total, R = 0.591, p = 0.043); standard deviation (24h-ABPM) with LF component BPV (FBPM, total, R = 0.608, p = 0.036), coefficient of variation (24h-ABPM) with total BPV (FBPM, daytime, -0.585, p = 0.046) and alpha index (FBPM, daytime, -0.592, p = 0.043), time rate (24h-ABPM) and delta LF/HF (FBPM, total, R = 0.636, p = 0.026; daytime R = 0,857, p < 0.001). Records obtained from DH showed weak positive correlations. CONCLUSIONS: Indices obtained from 24h-ABPM (total, daytime) reflect BP and HR variability evaluated by FBPM in healthy individuals. This does not apply for DH subjects.

Correlation between Very Short and Short-Term Blood Pressure Variability in Diabetic-Hypertensive and Healthy Subjects / Correlação entre a Variabilidade da Pressão Arterial de Muito Curto Prazo e Curto Prazo em Indivíduos Diabéticos-Hipertensos e Saudáveis

Abstract Background: Blood pressure (BP) variability can be evaluated by 24-hour ambulatory BP monitoring (24h-ABPM), but its concordance with results from finger BP measurement (FBPM) has not been established yet. Objective: The aim of this study was to compare parameters of short-term (24h-ABPM) with very short-term BP variability (FBPM) in healthy (C) and diabetic-hypertensive (DH) subjects. Methods: Cross-sectional study with 51 DH subjects and 12 C subjects who underwent 24h-ABPM [extracting time-rate, standard deviation (SD), coefficient of variation (CV)] and short-term beat-to-beat recording at rest and after standing-up maneuvers [FBPM, extracting BP and heart rate (HR) variability parameters in the frequency domain, autoregressive spectral analysis]. Spearman correlation coefficient was used to correlate BP and HR variability parameters obtained from both FBPM and 24h-ABPM (divided into daytime, nighttime, and total). Statistical significance was set at p < 0.05. Results: There was a circadian variation of BP levels in C and DH groups; systolic BP and time-rate were higher in DH subjects in all periods evaluated. In C subjects, high positive correlations were shown between time-rate index (24h-ABPM) and LF component of short-term variability (FBPM, total, R = 0.591, p = 0.043); standard deviation (24h-ABPM) with LF component BPV (FBPM, total, R = 0.608, p = 0.036), coefficient of variation (24h-ABPM) with total BPV (FBPM, daytime, -0.585, p = 0.046) and alpha index (FBPM, daytime, -0.592, p = 0.043), time rate (24h-ABPM) and delta LF/HF (FBPM, total, R = 0.636, p = 0.026; daytime R = 0,857, p < 0.001). Records obtained from DH showed weak positive correlations. Conclusions: Indices obtained from 24h-ABPM (total, daytime) reflect BP and HR variability evaluated by FBPM in healthy individuals. This does not apply for DH subjects.

Resumo Fundamento: A variabilidade da pressão arterial (PA) pode ser avaliada por meio da monitorização ambulatorial da PA em 24 horas (MAPA-24h), mas sua concordância com os resultados da medição da PA digital (MPAD) ainda não foi estabelecida. Objetivo: O objetivo deste estudo foi comparar os parâmetros da variabilidade a curto prazo (MAPA-24h) com a variabilidade da PA a muito curto prazo (MPAD) em sujeitos saudáveis (C) e diabéticos-hipertensos (DH). Métodos: Estudo transversal com 51 sujeitos DH e 12 sujeitos C que se submeteram a MAPA-24h [extraindo time rate, desvio padrão (SD) e coeficiente de variação (CV)] e registro batimento-a-batimento em repouso e após manobra de manobra de ortostatismo ativo [MPAD, extraindo parâmetros de variabilidade da PA e da frequência cardíaca (FC) no domínio da frequência, análise espectral por modelagem autoregressiva]. O coeficiente de correlação de postos de Spearman foi utilizado para correlacionar os parâmetros de variabilidade de PA e FC obtidos tanto da MPAD quanto da MAPA-24h (dividida em dia, noite e total). A significância estatística foi estabelecida em p < 0.05. Resultados: Houve uma variação circadiana dos níveis de PA nos grupos C e DH; A PA sistólica e a taxa de tempo foram maiores em indivíduos DH em todos os períodos avaliados. Em indivíduos C, foram apresentadas altas correlações positivas entre o índice de taxa de tempo (MAPA-24h) e o componente de baixa frequência (LF, do inglês low frequency) da variabilidade de curto prazo (MPAD, total, R = 0,591, p = 0,043); desvio padrão (MAPA-24h) com o componente de LF VPA (MPAD, total, R = 0,608, p = 0,036), coeficiente de variação (24h-ABPM) com VPA total (MPAD, dia, -0,585, p = 0,046) e índice alfa (MPAD, dia, -0,592, p = 0,043), taxa de tempo (MAPA-24h) e delta LF/HF (MPAD, total, R = 0,636, p = 0,026; dia R = 0,857, p < 0,001). Os registros obtidos dos pacientes DH apresentaram correlações positivas fracas. Conclusões: Os índices obtidos a partir da MAPA-24h (total, durante o dia) refletem a variabilidade da PA e da FC avaliada pela MPAD em indivíduos saudáveis, o que não se aplica a indivíduos DH.

Diabetes and cardiovascular events in high-risk patients: Insights from a multicenter registry in a middle-income country.

AIMS: The aim of this study was to determine the rate of major clinical events and its determinants in patients with previous cardiovascular event or not, and with or without diabetes from a middle-income country. METHODS: REACT study is a multicenter registry conducted between July 2010 and May 2013 in Brazil. Patients were eligible if they were over 45years old and high cardiovascular risk. Patients were followed for 12months; data were collected regarding adherence to evidence-based therapies and occurrence of clinical events (all-cause mortality, non-fatal cardiac arrest, myocardial infarction, or stroke). RESULTS: A total of 5006 subjects was included and analyzed in four groups: No diabetes and no previous cardiovascular event, n=430; diabetes and no previous cardiovascular event, n=1138; no diabetes and previous cardiovascular event, n=1747; and diabetes and previous cardiovascular event, n=1691. Major clinical events in one-year follow-up occurred in 332 patients. A previous cardiovascular event was associated with a higher risk of having another event in the follow-up (HR 2.31 95% CI 1.74-3.05, p<0.001), as did the presence of diabetes (HR 1.28 95% CI 1.10-1.73, p=0.005). In patients with diabetes,failure to reach HbA1c targetswas related topoorer event-free survival compared to patients with good metabolic control (HR 1.70 95% CI 1.01-2.84, p=0.044). CONCLUSIONS: In Brazil, diabetes confers high risk for major clinical events, but this condition is not equivalent to having a previous cardiovascular event. Moreover, not so strict targets for HbA1c in patients with diabetes and previous cardiovascular events might be considered.

Diabetes and cardiovascular events in high-risk patients: Insights from a multicenter registry in a middle-income country

AIMS:The aim of this study was to determine the rate of major clinical events and its determinants in patients with previous cardiovascular event or not, and with or without diabetes from a middle-income country.METHODS:REACT study is a multicenter registry conducted between July 2010 and May 2013 in Brazil. Patients were eligible if they were over 45years old and high cardiovascular risk. Patients were followed for 12months; data were collected regarding adherence to evidence-based therapies and occurrence of clinical events (all-cause mortality, non-fatal cardiac arrest, myocardial infarction, or stroke).

Blood pressure variability and its association with echocardiographic parameters in hypertensive diabetic patients.

BACKGROUND: Blood pressure (BP) variability is associated with target organ damage in hypertension and diabetes. The 24 h ambulatory blood pressure monitoring (24 h-ABPM) has been proposed as an evaluation for BP variability using several indexes [standard deviation (SD) of mean BP, coefficient of variation (CV), BP variation over time (time-rate index)]. METHODS: We evaluated the association between BP variability measured by 24 h-ABPM indexes and echocardiographic variables in a cross-sectional study in 305 diabetic-hypertensive patients. RESULTS: Two groups were defined by the median (0.55 mmHg/min) of time-rate systolic BP (SBP) index and classified as low or high variability. Age was 57.3 ± 6.2 years, 196 (64.3%) were female. Diabetes duration was 10.0 (5.0-16.2) years, HbA1c was 8.2 ± 1.9%. Baseline clinical characteristics were similar between low (n = 148) and high (n = 157) variability groups. Office SBP and systolic 24 h-ABPM were higher in the high variability group (139.9 mmHg vs 146.0 mmHg, P = 0.006; 128.3 mmHg vs 132.9 mmHg, P = 0.019, respectively). Time-rate index, SD and CV of SBP, were higher in high variability group (P < 0.001; P < 0.001 and P = 0.003, respectively). Time-rate index was not independently associated with the echocardiography's variables in multiple linear model when adjusting for age, 24 h-ABPM, diabetes duration and HbA1c. The multiple linear regression model revealed that the significant and independent determinants for septum thickness, relative wall thickness and posterior wall thickness (parameters of left ventricular hypertrophy) were: age (p = 0.025; p = 0.010; p = 0.032, respectively) and 24 h-SBP (p < 0.001 in the three parameters). CONCLUSION: BP variability estimated by 24 h-ABPM is not independently associated with echocardiographic parameters in diabetic-hypertensive patients.

White coat effect and masked uncontrolled hypertension in treated hypertensive-diabetic patients: Prevalence and target organ damage.

BACKGROUND: The association between hypertensive phenotypes of controlled hypertension (CH), white-coat effect (WCE), masked uncontrolled hypertension (MUH) and sustained hypertension (SH) with target organ damage have not been clearly established in diabetic hypertensive treated patients. The present study aims to evaluate the prevalence of the four phenotypes considering the current cut-off points for office and 24 h-ambulatory blood pressure monitoring (ABPM) and the association with left ventricle hypertrophy (LVH), diastolic function and nephropathy. METHODS: Cross-sectional study with 304 patients on anti-hypertensive treatment aged 57.6 ± 6.1 years, who were submitted to ABPM and echocardiography. They were classified into CH (normal office BP and ABPM), WCE (high office BP and normal ABPM), MUH (normal office BP and high ABPM), and SH (high office BP and ABPM). RESULTS: Median HbA1c and diabetes duration were 7.9% (6.8-9.2), and 10 years (5-16), respectively. Prevalences of CH, WCE, MUH and SH were 27.3%, 17.1%, 18.8%, and 36.8%. MUH prevalence was higher than previously described. There was a significant increasing trend across the four groups in variables related to LVH (P < 0.001 for trend). There was not a clear "dose-response" relationship of the four hypertensive phenotypes with nephropathy and diastolic function. CONCLUSION: The use of ABPM beyond the traditional cardiovascular risk stratification tools has limitations, but is still useful in high-risk patients. Longitudinal studies could better evaluate the role of the use of ABPM in this scenario. Cut-off points for normality of office and ABPM influence the prevalences of WCH and MUH.

Vitamin D insufficiency is associated with lower physical function in patients with heart failure and diabetes.

Vitamin D deficiency is frequent among patients with heart failure (HF) and diabetes, disorders associated with exercise intolerance and muscle weakness. This study aims to search for associations between vitamin D sufficiency and physical function indexes in patients with HF and diabetes. A cross-sectional study of 146 HF patients, 39.7% with diabetes, at a Brazilian tertiary outpatient clinic was performed. Patients underwent clinical evaluation, 6-minute walk test (6 MWT), handgrip strength, physical activity level (IPAQ), and biochemical evaluations including serum 25-hydroxyvitamin D. Classification was done according to vitamin D status (≥ 30 ng/dL, sufficient) and presence/absence of diabetes in vitamin sufficient, no diabetes (DS-C, n = 25), vitamin sufficient, diabetes (DS-DM, n = 18), vitamin deficient, no diabetes (DD-C, n = 63), and vitamin deficient, diabetes (DD-DM, n = 40). Patients age was 55.4 ± 8 yrs; 70.5% had vitamin D deficiency. Clinical characteristics were similar among groups. Total time expended in physical activity was similar among groups (P = 0.26). DS-C covered higher distances in the 6 MWT (392 ± 60 m) versus DD-DM (309 ± 116 m); P = 0.024. Handgrip strength was similar among groups but tended to lower levels in DD-DM (P = 0.074) even after being adjusted to physical activity (P = 0.069). Vitamin D deficiency can influence physical function in HF diabetic patients.

Efficacy and Safety of Drug-Eluting Stents in the Real World: 8-Year Follow-Up / Eficácia e Segurança de Stents Eluidores de Drogas no Mundo Real: Acompanhamento de 8 Anos

Background: Drug-eluting stents have been used in daily practice since 2002, with the clear advantages of reducing the risk of target vessel revascularization and an impressive reduction in restenosis rate by 50%-70%. However, the occurrence of a late thrombosis can compromise long-term results, particularly if the risks of this event were sustained. In this context, a registry of clinical cases gains special value. Objective: To evaluate the efficacy and safety of drug-eluting stents in the real world. Methods: We report on the clinical findings and 8-year follow-up parameters of all patients that underwent percutaneous coronary intervention with a drug-eluting stent from January 2002 to April 2007. Drug-eluting stents were used in accordance with the clinical and interventional cardiologist decision and availability of the stent. Results: A total of 611 patients were included, and clinical follow-up of up to 8 years was obtained for 96.2% of the patients. Total mortality was 8.7% and nonfatal infarctions occurred in 4.3% of the cases. Target vessel revascularization occurred in 12.4% of the cases, and target lesion revascularization occurred in 8% of the cases. The rate of stent thrombosis was 2.1%. There were no new episodes of stent thrombosis after the fifth year of follow-up. Comparative subanalysis showed no outcome differences between the different types of stents used, including Cypher®, Taxus®, and Endeavor®. Conclusion: These findings indicate that drug-eluting stents remain safe and effective at very long-term follow-up. Patients in the "real world" may benefit from drug-eluting stenting with excellent, long-term results. .

Fundamento: Stents eluidores de drogas têm sido utilizados na prática médica desde 2002, e apresentam grande eficácia na redução do risco de revascularização do vaso-alvo, e notável redução da taxa de reestenose de 50%-70%. No entanto, a ocorrência de trombose tardia pode comprometer os resultados a longo prazo, especialmente se o risco de trombose for mantido ao longo dos anos. Neste contexto, o registro da prática clínica assume grande importância. Objetivo: Avaliar a eficácia e segurança de stents eluidores de drogas no mundo real. Métodos: Relatamos os resultados de todos os pacientes que foram submetidos à intervenção coronária percutânea com stent eluidor de drogas no período entre janeiro de 2002 a abril de 2007, e que foram acompanhados por 8 anos. Os stents eluidores de drogas foram utilizados de acordo com as recomendações clínicas do cardiologista intervencionista e a disponibilidade do stent. Resultados: Um total de 611 pacientes foram avaliados, com acompanhamento clínico de 96,2% destes pacientes por até 8 anos. A mortalidade total foi de 8,7%. Infarto não-fatal ocorreu em 4,3% dos casos. A taxa de revascularização do vaso-alvo foi de 12,4% e a da lesão-alvo foi de 8,0%. A taxa de trombose de stent foi de 2,1%. Não houve novos episódios de trombose de stent após o quinto ano de acompanhamento. Uma subanálise comparativa indicou não haver diferenças nos desfechos clínicos apos a utilização dos stents Cypher, Taxus e Endeavor. Conclusão: Estes resultados indicam que stents eluidores de drogas são seguros e eficazes em acompanhamentos de longo prazo, e que pacientes no mundo real podem beneficiar destes stents, com excelentes resultados a longo prazo. .

Efficacy and safety of drug-eluting stents in the real world: 8-year follow-up.

BACKGROUND: Drug-eluting stents have been used in daily practice since 2002, with the clear advantages of reducing the risk of target vessel revascularization and an impressive reduction in restenosis rate by 50%-70%. However, the occurrence of a late thrombosis can compromise long-term results, particularly if the risks of this event were sustained. In this context, a registry of clinical cases gains special value. OBJECTIVE: To evaluate the efficacy and safety of drug-eluting stents in the real world. METHODS: We report on the clinical findings and 8-year follow-up parameters of all patients that underwent percutaneous coronary intervention with a drug-eluting stent from January 2002 to April 2007. Drug-eluting stents were used in accordance with the clinical and interventional cardiologist decision and availability of the stent. RESULTS: A total of 611 patients were included, and clinical follow-up of up to 8 years was obtained for 96.2% of the patients. Total mortality was 8.7% and nonfatal infarctions occurred in 4.3% of the cases. Target vessel revascularization occurred in 12.4% of the cases, and target lesion revascularization occurred in 8% of the cases. The rate of stent thrombosis was 2.1%. There were no new episodes of stent thrombosis after the fifth year of follow-up. Comparative subanalysis showed no outcome differences between the different types of stents used, including Cypher®, Taxus®, and Endeavor®. CONCLUSION: These findings indicate that drug-eluting stents remain safe and effective at very long-term follow-up. Patients in the "real world" may benefit from drug-eluting stenting with excellent, long-term results.

Association between erectile dysfunction and echocardiographic variables of ventricular hypertrophy and diastolic function in hypertensive patients with type 2 diabetes mellitus: a cross-sectional study.

BACKGROUND: This study was conducted among individuals with diabetes and hypertension in order to assess the prevalence of erectile dysfunction (ED) and the association between ED and cardiovascular risk variables such as echocardiographic changes. METHODS: We evaluated 114 men with type 2 diabetes mellitus and hypertension. ED was assessed by International Index of Erectile Function (IIEF-5) score. Clinical and laboratory variables were evaluated, including C-reactive protein (CRP), ambulatory blood pressure monitoring (ABPM), ankle brachial index (ABI) and transthoracic echocardiography. Comparisons between patients with ED (IIEF-5 < 22) and without ED (IIEF-5 ≥ 22) were performed. RESULTS: Patients were 56.8 ± 5.7 years-old, systolic and diastolic blood pressure were 150.7 ± 19.5 mmHg and 85.4 ± 11.4 mmHg, respectively, and HbA1c was 8.0 ± 1.7%. The majority (74.6%) of patients had ED. Levels of CRP, ABPM values and ABI were similar between men with and without ED. Echocardiography variables related to cardiac chamber diameters, left ventricular hypertrophy and diastolic function were similar between groups, except there was a slight lower left ventricular ejection fraction in men with ED (64.9 ± 7.3 vs 68.1 ± 3.9%, P = 0.004). CONCLUSIONS: In high cardiovascular risk hypertensive individuals with type 2 diabetes, ED is highly prevalent as expected, but its presence is associated with neither echocardiographic variables, nor other cardiovascular risk factors.

Controle glicêmico em pacientes com diabetes mellitus e doença cardiovascular acompanhados em ambulatório de referência / Glycemic control in patients with diabetes mellitus and cardiovascular disease monitored at a reference outpatient clinic

INTRODUÇÃO: O controle da hiperglicemia característica do diabetes mellitus é parte importante do seu tratamento, e se associa, em longo prazo, à redução de complicações crônicas da doença. No entanto, atingir bom controle glicêmico não é tarefa fácil; múltiplas abordagens têm sido buscadas com este intuito. Nosso objetivo foi descrever o controle glicêmico de uma amostra de pacientes atendidos em nível terciário e analisar possíveis preditores de alcance de bom controle glicêmico no seguimento. MÉTODOS: Estudo observacional, coletados dados de pacientes com diabetes tipo 2 em acompanhamento ambulatorial, através de dados do prontuário eletrônico. Coletadas variáveis demográficas, clínicas e laboratoriais (glicemia, hemoglobina glicada (HbA1c), lipídios, creatinina e microalbuminúria). RESULTADOS: Foram incluídos 57 pacientes; 61,4% alcançaram HbA1c ≤8% (grupo Diabetes Mellitus controlado, DMC) e 22 (38,6%) não atingiram este valor (grupo Diabetes Mellitus não controlado, DMNC) em 1 ano. A maioria dos pacientes do grupo DMNC eram homens (p = 0,030); idade, associação com outras comorbidades, escolaridade, tempo de diabetes não foram diferentes entre os grupos. Número de consultas marcadas foi semelhante entre os grupos, mas o de consultas realizadas foi maior no grupo DMNC. O controle glicêmico inicial era pior no grupo DMNC (HbA1c 9,2 ±1,4 vs.11,0 ±1,5%, p < 0,001). Alta ambulatorial foi mais frequente no grupo DMC (p = 0,01). CONCLUSÃO: A intensificação do cuidado ao diabetes por equipe especializada em nível terciário é capaz de trazer melhor controle glicêmico para a maioria destes pacientes, especialmente quando encaminhados ainda com HbA1c não muito elevada

INTRODUCTION: Controlling hyperglycemia in diabetes mellitus is an important part of the treatment and is associated with long-term reduction of chronic complications. However, it is difficult to achieve, and different approaches to glycemic control are being investigated. We aimed to analyze glycemic control in a sample of patients treated at a tertiary hospital, as well as to analyze possible predictors of good glycemic control during follow-up. METHODS: In this observational study, we collected data from the electronic medical records of patients with type 2 diabetes treated at a reference outpatient clinic. We analyzed demographic, clinical and laboratory variables (blood glucose, glycosylated hemoglobin (HbA1c), lipids, creatinine and microalbuminuria). RESULTS: Out of 57 patients, 61.4% had HbA1c levels ≤8% (controlled diabetes mellitus group, CDM), and 38.6% (n = 22) did not reach this value (uncontrolled diabetes mellitus group, UDM) in 1 year. Most patients in the UDM group were men (p = 0.030). Age, association with other comorbidities, educational attainment, and duration of diabetes were not different between groups. The number of scheduled appointments was similar between groups, but the number of attended appointments was higher in the UDM group. Initial glycemic control was worse in the UDM group (HbA1c 9.2 ±1.4 vs. 11.0 ±1.5%, p < 0.001). Outpatient discharge was more frequent in the CDM group (p = 0.01). CONCLUSION: Intensifying diabetes care by a specialized team at tertiary centers can improve metabolic control for the majority of these patients, especially for those with a lower HbA1c at the time of referral

Associação entre diabetes mellitus e gravidade da doença arterial coronariana em pacientes submetidos à intervenção coronária percutânea / Association between diabetes mellitus and severity of coronary artery disease in patients undergoing percutaneous coronary intervention

Objetivos: Avaliar a prevalência de diabetes mellitus buscando associação com a gravidade da doença arterial coronária em pacientes submetidos à intervenção coronária percutânea em centro de referência no sul do Brasil.Métodos: Estudo transversal. Foram avaliados todos os pacientes submetidos à intervenção coronária percutânea eletiva entre novembro/2006 e dezembro/2007 em hospital de referência. Aplicou-se questionário previamente ao procedimento e realizou-se glicemia capilar em jejum.Resultados: Foram realizadas 617 intervenções coronárias percutâneas e implantados 718 stents em 569 indivíduos (1,32 stents por intervenção).Destes, 177 pacientes (32,2%) foram considerados diabéticos. Característicasdemográficas, fatores de risco para doença arterial coronária, vaso alvo, diâmetro do vaso e extensão da lesão foram semelhantes entre os grupos. Doença arterial coronária grave, categorias III e IV, foi encontrada em 51,2% dos pacientes com diabetes, comparados com 37,6% dos sem diabetes (p<0,001). Houve correlação significativa entre os níveis de glicemia e a gravidade da doença arterial coronária(p<0,05).Conclusões: Existe associação entre a presença de diabetes e a gravidade angiográfica da doença arterial coronária em pacientes submetidos à intervenção coronária percutânea, o que sugere que essa maior gravidade possa contribuir para os desfechos adversos nesses pacientes.

Aim: To evaluate the prevalence of diabetes mellitus by searching for an association between severe coronary artery disease (CAD) in patients undergoing percutaneous coronary intervention (PCI) in a reference center in southern Brazil. Methods: This was a cross-sectional study. Data were derived from patients undergoing PCI from November, 2006 to December, 2007 in a Brazilian reference center. A questionnaire was administered as well as a capillary blood glucose test before the procedure.Results: In all, 617 PCIs were performed with 718 stents implanted in 569 patients (1.32 stent/PCI).Diabetes was present in 177 patients (32%). Baseline demographics and angiographic characteristics(including CAD risk factors, target-vessels, vessel diameters, and lesion extensions) were similar between the two groups. Severe CAD (levels III and IV) was found in 51.2% of diabetic patients as compared to 37.6% of non-diabetic patients (p<0.001). Coronary artery disease was significantly less severe in non-diabetic subjects as compared to diabetic patients, with the presence of 1-vessel disease respectively in 38.5 vs. 27.9% (p<0.001). There was a significant correlation between bloodglucose levels and CAD severity (p<0.05).Conclusion: There is a significant correlation between the presence of diabetes and the severity of CAD in patients submitted for PCI, thereby suggesting that this more intense atherosclerotic process might contribute to the adverse cardiovascular events seen in diabetic patients.

Predictors of infection in post-coronary artery bypass graft surgery.

BACKGROUND: Although coronary artery bypass grafting (CABG) is a good alternative therapy in severe arterial disease, it may evolve with complications, especially infections. OBJECTIVES: To determine the incidence of infection in post-CABG and its clinical predictors in a cardiology reference center in Brazil. METHODS: Cohort study. Data were collected from all patients undergoing CABG between January/2004 and February/2006, excluding emergency surgery, absent record of glucose blood levels preoperatively and infection prior to surgery. STATISTICAL ANALYSIS: Student's t test, chi square, logistic regression. RESULTS: We evaluated 717 patients, 61.9 ± 11 years old, 67.1% were men, 29.6% with diabetes, of whom 137 (19.1%) developed infection (62% respiratory, 25% superficial wound, 9.5% urinary, 3.6% deep wound). Diabetes was more prevalent in those who developed infection, as well as prolonged time of indwelling central venous catheter (79.3 ± 40.5 vs. 61.0 ± 19.3 hours, P<0.001). After multivariate analysis (model adjusted for dyslipidemia, hypertension, smoking and leukocytes), both diabetes (OR 4.18 [2.60-6.74]), prolonged central venous line (OR 1.019 [1.00-1.02] and cardiac catheterism (OR 2.03 [1.14-3.60] remained predictors of infection. While diabetes is associated with a higher percentage of infections (P <0.001), preoperative serum glucose was not associated with increased risk of infection. CONCLUSIONS: Diabetes and permanence of central venous catheters were associated with development of infection in post-CABG. The preoperative blood glucose was not a predictor of risk of infection. It is probably necessary to study with greater detail glycemic control trans- and post-operatively.

Preditores de infecção no pós-operatório de cirurgia de revascularização miocárdica / Predictors of infection in post-coronary artery bypass graft surgery

INTRODUÇÃO: Embora a cirurgia de revascularização miocárdica (CRM) seja uma boa alternativa terapêutica na doença arterial grave, pode evoluir com complicações, especialmente infecções. OBJETIVOS: Determinar a incidência de infecção no pós-operatório de CRM e seus preditores clínicos em um centro de referência cardiológico brasileiro. MÉTODOS: Estudo de coorte. Foram coletados dados de todos os pacientes submetidos à CRM entre janeiro/2004 e fevereiro/2006, excluindo-se cirurgias de urgência, sem glicemia pré-operatória e com infecção prévia à cirurgia. Análise estatística: teste t-Student, qui quadrado e regressão logística. RESULTADOS: Foram avaliados 717 pacientes, 61,9 ± 11 anos, 67,1 por cento homens, 29,6 por cento com diabetes, dos quais 137 (19,1 por cento) desenvolveram infecção (62 por cento respiratória, 25 por cento superficial de ferida operatória, 9,5 por cento urinária, 3,6 por cento profunda de ferida operatória). Diabetes foi mais prevalente naqueles que desenvolveram infecção, assim como maior tempo de permanência do cateter venoso central (79,3 ± 40,5 vs. 61,0 ± 19,3 h, P<0,001). Após análise multivariada (modelo ajustado para dislipidemia, hipertensão, tabagismo e leucócitos), tanto diabetes (OR 4,18 [2,60-6,74]), quanto tempo de permanência do cateter venoso central (OR 1,019 [1,00-1,02]) e cateterismo cardíaco durante a internação (OR 2,03 [1,14-3,60] mantiveram-se preditores do desfecho infecção (P<0,001). Apesar do diabetes estar associado a maior percentual de infecções (P<0,001), glicemia do pré-operatório não se associou a maior risco de infecção. CONCLUSÕES: Diabetes e tempo de permanência do cateter venoso central se associaram ao desenvolvimento de infecção no pós-operatório de CRM. A glicemia pré-operatória não foi preditora de risco de infecção, provavelmente havendo necessidade de caracterização mais detalhada do controle glicêmico trans e pós-operatório imediato.

BACKGROUND: Although coronary artery bypass grafting (CABG) is a good alternative therapy in severe arterial disease, it may evolve with complications, especially infections. OBJECTIVES: To determine the incidence of infection in post-CABG and its clinical predictors in a cardiology reference center in Brazil. METHODS: Cohort study. Data were collected from all patients undergoing CABG between January/2004 and February/2006, excluding emergency surgery, absent record of glucose blood levels preoperatively and infection prior to surgery. Statistical analysis: Student's t test, chi square, logistic regression. RESULTS: We evaluated 717 patients, 61.9 ± 11 years old, 67.1 percent were men, 29.6 percent with diabetes, of whom 137 (19.1 percent) developed infection (62 percent respiratory, 25 percent superficial wound, 9.5 percent urinary, 3.6 percent deep wound). Diabetes was more prevalent in those who developed infection, as well as prolonged time of indwelling central venous catheter (79.3 ± 40.5 vs. 61.0 ± 19.3 hours, P<0.001). After multivariate analysis (model adjusted for dyslipidemia, hypertension, smoking and leukocytes), both diabetes (OR 4.18 [2.60-6.74]), prolonged central venous line (OR 1.019 [1.00-1.02] and cardiac catheterism (OR 2.03 [1.14-3.60] remained predictors of infection. While diabetes is associated with a higher percentage of infections (P <0.001), preoperative serum glucose was not associated with increased risk of infection. CONCLUSIONS: Diabetes and permanence of central venous catheters were associated with development of infection in post-CABG. The preoperative blood glucose was not a predictor of risk of infection. It is probably necessary to study with greater detail glycemic control trans- and post-operatively.

Clinical features and outcomes in patients with diabetes mellitus undergoing coronary artery bypass graft in a reference center in southern Brazil.

OBJECTIVE: To describe clinical/laboratory features of patients undergoing coronary artery bypass graft (CABG) in a cardiology reference center. METHODS: Cohort study; data from patients undergoing CABG (January 2004 to February 2006, n = 717) were evaluated for clinical/laboratory features before, during and after surgery (infections, duration of hospital stay, deaths). RESULTS: Patients were 61.9 ± 11 years old, 67.1% males, 29.6% diabetics. Intraoperatively, diabetics had a central venous catheter placed for a longer period (p < 0.001), but extracorporeal circulation, aortic clamping and total surgery times were similar to those for non-diabetics. Infection occurred in 19.1% of patients (40.1% diabetics vs. 10.3% non-diabetics, p < 0.001). The duration of hospital stay was longer for patients with diabetes vs. non-diabetic patients, but there was no difference in deaths between the two groups (p = 0.797). CONCLUSION: Patients with diabetes undergoing CABG develop more infectious diseases and stay longer in hospital than non-diabetics.

Perfil e evolução dos pacientes com diabetesmellitus submetidos à cirurgia de revascularização miocárdica em serviço de referência no sul do Brasil / Clinical features and outcomes in patients with diabetes mellitus undergoing coronary artery bypass graft in a reference center in southern Brazil

OBJETIVO: Descrever perfil/evolução de pacientes submetidos à cirurgia de revascularização miocárdica (CRM) em centro de referência cardiológico. MÉTODOS: Estudo de coorte; avaliados todos os pacientes submetidos à CRM (janeiro/2004 e fevereiro/2006, n = 717) quanto às características clínicas/laboratoriais antes, durante e após a cirurgia (infecções, tempo de internação, óbitos). RESULTADOS: Os pacientes tinham 61,9 ± 11 anos, 67,1 por cento homens, 29,6 por cento diabéticos. No transoperatório, aqueles com diabetes usaram cateter venoso central por mais tempo (p < 0,001), mas tempo de circulação extra- corpórea, de clampeamento da aorta e cirúrgico foi semelhante versus os sem diabetes. Infecção ocorreu em 19,1 por cento dos pacientes (40,1 por cento vs. 10,3 por cento nos com e sem diabetes, p < 0,001). Tempo de permanência no hospital foi maior nos pacientes com diabetes versus pacientes sem diabetes, mas não houve diferença no número de óbitos ocorridos entre os grupos (p = 0,797). CONCLUSÃO: Pacientes com diabetes submetidos a CRM desenvolvem mais infecções e permanecem mais tempo internados do que aqueles sem diabetes.

OBJECTIVE: To describe clinical/laboratory features of patients undergoing coronary artery bypass graft (CABG) in a cardiology reference center. METHODS: Cohort study; data from patients undergoing CABG (January 2004 to February 2006, n = 717) were evaluated for clinical/laboratory features before, during and after surgery (infections, duration of hospital stay, deaths). RESULTS: Patients were 61.9 ± 11 years old, 67.1 percent males, 29.6 percent diabetics. Intraoperatively, diabetics had a central venous catheter placed for a longer period (p < 0.001), but extracorporeal circulation, aortic clamping and total surgery times were similar to those for non-diabetics. Infection occurred in 19.1 percent of patients (40.1 percent diabetics vs. 10.3 percent non-diabetics, p < 0.001). The duration of hospital stay was longer for patients with diabetes vs. non-diabetic patients, but there was no difference in deaths between the two groups (p = 0.797). CONCLUSION: Patients with diabetes undergoing CABG develop more infectious diseases and stay longer in hospital than non-diabetics.

Inflammatory and oxidative stress markers after intravenous insulin in percutaneous coronary intervention with stent in type 2 diabetes mellitus: a randomized controlled trial.

CONTEXT/OBJECTIVE: The objective of the study was to evaluate the effects of normalizing glycemia through iv insulin per 24 h on markers of oxidative stress and inflammation in patients with diabetes submitted to percutaneous coronary intervention (PCI) with stent. PATIENTS/METHODS: This was a prospective, open-label, randomized controlled trial, comparing continuous iv insulin per 24 h targeting glycemia less than 110 mg/dl iv insulin treatment (IIT; n = 35) to standard treatment (ST; n = 35, regular insulin if glycemia was greater than 200 mg/dl). Blood samples for glycemia, glycated hemoglobin, lipids, inflammatory markers [C-reactive protein (CRP), soluble CD40 ligand, IL-6, and endothelin 1 (ET-1)] and oxidative stress (total antioxidant status, carbonyl) were collected immediately after and 24 h after PCI. RESULTS: Seventy patients were included. Mean age was 60.5 ± 10 yr, 60% were men, glycated hemoglobin was 8.1 ± 1.8 (IIT) vs. 7.6 ± 1.6% (ST) (P = 0.39). The intensive insulin group had lower glycemia (P = 0.006) and higher insulinemia (P < 0.001). Insulin did not change CRP [4.5 (2.1-11.7) vs. 6.8 (2.4-10.3), P = 0.35], soluble CD40 ligand [402 (191-843) vs. 610 (230-1200), P = 0.68], IL-6 [6.21 (3.1.-10.4) vs. 10.37 (5.9-15.3), P = 0.09], and ET-1 [1.02 (0.7-1.8) vs. 1.10 (0.7-1.9), P = 0.657]. CRP, IL-6, and ET-1 increased after PCI in both groups (P < 0.05). No change was observed on protein oxidation (carbonyl, P = 0.70; total antioxidant status, P = 0.33). There was a positive correlation between CRP and glycemia (r = 0.29, P = 0.002). CONCLUSIONS: Continuous iv insulin for 24 h increased insulin levels and prevented hyperglycemia. Insulin infusion did not prevent the rise in inflammatory and oxidative stress markers, and no differences were observed between IIT and ST after PCI with a stent.