Mortality in Women with Coronary Artery Disease in Paraná State, Brazil: A Bayesian Spatiotemporal Analysis.

Background: Mortality resulting from coronary artery disease (CAD) among women is a complex issue influenced by many factors that encompass not only biological distinctions but also sociocultural, economic, and healthcare-related components. Understanding these factors is crucial to enhance healthcare provisions. Therefore, this study seeks to identify the social and clinical variables related to the risk of mortality caused by CAD in women aged 50 to 79 years old in Paraná state, Brazil, between 2010 and 2019. Methods: This is an ecological study based on secondary data sourced from E-Gestor, IPARDES, and DATASUS. We developed a model that integrates both raw and standardized coronary artery disease (CAD) mortality rates, along with sociodemographic and healthcare service variables. We employed Bayesian spatiotemporal analysis with Markov Chain Monte Carlo simulations to assess the relative risk of CAD mortality, focusing specifically on women across the state of Paraná. Results: A total of 14,603 deaths from CAD occurred between 2010 and 2019. Overall, temporal analysis indicates that the risk of CAD mortality decreased by around 22.6% between 2010 (RR of 1.06) and 2019 (RR of 0.82). This decline was most prominent after 2014. The exercise stress testing rate, accessibility of cardiology centers, and IPARDES municipal performance index contributed to the reduction of CAD mortality by approximately 4%, 8%, and 34%, respectively. However, locally, regions in the Central-West, Central-South, Central-East, and Southern regions of the Central-North parts of the state exhibited risks higher-than-expected. Conclusion: In the last decade, CAD-related deaths among women in Paraná state decreased. This was influenced by more exercise stress testing, better access to cardiology centers, improved municipal performance index. Yet, elevated risks of deaths persist in certain regions due to medical disparities and varying municipal development. Therefore, prioritizing strategies to enhance women's access to cardiovascular healthcare in less developed regions is crucial.

A prevalência do transtorno depressivo em pacientes com doença arterial coronária submetidos à intervenção coronariana percutânea / The prevalence of depressive disorder in patients with coronary artery disease undergoing percutaneous coronary intervention

A Doença Arterial Coronariana (DAC) é a maior causa global de morte. No Brasil, em 2011, 8,8% dos óbitos cardiovasculares ocorreram devido à DAC. Os estudos indicam que 20-40% dos pacientes com DAC apresentam transtorno depressivo e, nesses casos, sua mortalidade é aumentada em 1,6 vezes. Atualmente, a Intervenção Coronariana Percutânea (ICP) é a modalidade terapêutica mais utilizada para DAC. OBJETIVO: Avaliar a prevalência da depressão e intenção suicida nos pacientes portadores de DAC submetidos à ICP, correlacionando-a às suas características biopsicossociais e à dosagem de mediadores neuroendócrinos. MÉTODO: Estudo retrospectivo, com inclusão consecutiva de pacientes com DAC submetidos a ICP eletiva no Instituto Dante Pazzanese de Cardiologia entre Maio e Dezembro de 2013. Para detectar e classificar o transtorno depressivo, aplicouse o Questionário de Saúde do Paciente (PHQ-9) e Questionário de Beck (BDI). RESULTADOS: Foram incluídos 206 pacientes. Destes, 59,7% apresentaram depressão, de acordo com o PHQ-9. Utilizando o BDI, foi detectado o transtorno em 37,4% dos casos. 6,8% reportaram intenção suicida. A Tabela 1 demonstra as características físicas e dosagem sérica de mediadores neuroendócrinos de pacientes com e sem depressão. A divergência entre os resultados obtidos pelo BDI e PHQ-9 é uma das limitações do estudo, possivelmente ocorrida devido à diferente classificação do transtorno em cada questionário. Ainda, o desenho retrospectivo do estudo não permite saber a ordem de aplicação dos questionários, o que pode interferir no resultado. CONCLUSÃO: A depressão e a DAC apresentam evidente associação. Seu reconhecimento precoce, além da maior interação entre cardiologistas e psiquiatras, pode ser benéfica e impactar positivamente na morbimortalidade destes agravos. (AU)

Efficacy of Patient Selection for Diagnostic Coronary Angiography in Suspected Coronary Artery Disease / Eficácia da Seleção de Pacientes para Cateterismo Coronário por Suspeita de Doença Arterial Coronariana

AbstractBackground:Guidelines recommend that in suspected stable coronary artery disease (CAD), a clinical (non-invasive) evaluation should be performed before coronary angiography.Objective:We assessed the efficacy of patient selection for coronary angiography in suspected stable CAD.Methods:We prospectively selected consecutive patients without known CAD, referred to a high-volume tertiary center. Demographic characteristics, risk factors, symptoms and non-invasive test results were correlated to the presence of obstructive CAD. We estimated the CAD probability based on available clinical data and the incremental diagnostic value of previous non-invasive tests.Results:A total of 830 patients were included; median age was 61 years, 49.3% were males, 81% had hypertension and 35.5% were diabetics. Non-invasive tests were performed in 64.8% of the patients. At coronary angiography, 23.8% of the patients had obstructive CAD. The independent predictors for obstructive CAD were: male gender (odds ratio [OR], 3.95; confidence interval [CI] 95%, 2.70 - 5.77), age (OR for 5 years increment, 1.15; CI 95%, 1.06 - 1.26), diabetes (OR, 2.01; CI 95%, 1.40 - 2.90), dyslipidemia (OR, 2.02; CI 95%, 1.32 - 3.07), typical angina (OR, 2.92; CI 95%, 1.77 - 4.83) and previous non-invasive test (OR 1.54; CI 95% 1.05 - 2.27).Conclusions:In this study, less than a quarter of the patients referred for coronary angiography with suspected CAD had the diagnosis confirmed. A better clinical and non-invasive assessment is necessary, to improve the efficacy of patient selection for coronary angiography.

ResumoFundamento:Diretrizes recomendam que na suspeita de doença arterial coronariana (DAC) estável, uma avaliação clínica (não-invasiva) deve ser realizada antes da realização da coronariografia.Objetivo:Avaliar a eficácia da seleção de pacientes à coronariografia invasiva na suspeita de DAC estável.Métodos:Prospectivamente, selecionamos pacientes sem diagnóstico prévio de DAC referenciados a um centro terciário de grande volume. Características demográficas, fatores de risco, sintomatologia e resultados de exames não-invasivos foram correlacionados com a presença de DAC obstrutiva. Estimamos a probabilidade de DAC com base nos dados clínicos disponíveis e no valor incremental diagnóstico dos exames não-invasivos.Resultados:Um total de 830 pacientes foi incluído, mediana de idade de 61 anos, 49,3% homens, 81% hipertensos e 35,5% de diabéticos. Exames não-invasivos foram realizados em 64,8% dos pacientes. Na coronariografia, 23,8% dos pacientes tinham DAC obstrutiva. Os preditores independentes para DAC obstrutiva foram: sexo masculino (odds ratio [OR], 3,95; intervalo de confiança [IC] de 95%, 2,70 – 5,77), idade (OR por incremento de 5 anos, 1,15; IC 95%, 1,06 – 1,26), diabetes (OR, 2,01; IC 95%, 1,40 – 2,90), dislipidemia (OR, 2,02; IC 95%, 1,32 – 3,07), angina típica (OR, 2,92; IC 95%, 1,77 – 4,83) e teste não-invasivo prévio (OR 1,54; IC 95% 1,05 – 2,27).Conclusão:Nesse estudo, menos de um quarto dos pacientes referenciados a um centro terciário para a realização de coronariografia por suspeita de DAC estável teve o diagnóstico confirmado. Uma melhor avaliação clínica e maior acesso a exames não-invasivos são necessários para aumentar a eficácia da seleção de pacientes para coronariografia invasiva.

Efficacy of Patient Selection for Diagnostic Coronary Angiography in Suspected Coronary Artery Disease.

BACKGROUND: Guidelines recommend that in suspected stable coronary artery disease (CAD), a clinical (non-invasive) evaluation should be performed before coronary angiography. OBJECTIVE: We assessed the efficacy of patient selection for coronary angiography in suspected stable CAD. METHODS: We prospectively selected consecutive patients without known CAD, referred to a high-volume tertiary center. Demographic characteristics, risk factors, symptoms and non-invasive test results were correlated to the presence of obstructive CAD. We estimated the CAD probability based on available clinical data and the incremental diagnostic value of previous non-invasive tests. RESULTS: A total of 830 patients were included; median age was 61 years, 49.3% were males, 81% had hypertension and 35.5% were diabetics. Non-invasive tests were performed in 64.8% of the patients. At coronary angiography, 23.8% of the patients had obstructive CAD. The independent predictors for obstructive CAD were: male gender (odds ratio [OR], 3.95; confidence interval [CI] 95%, 2.70 - 5.77), age (OR for 5 years increment, 1.15; CI 95%, 1.06 - 1.26), diabetes (OR, 2.01; CI 95%, 1.40 - 2.90), dyslipidemia (OR, 2.02; CI 95%, 1.32 - 3.07), typical angina (OR, 2.92; CI 95%, 1.77 - 4.83) and previous non-invasive test (OR 1.54; CI 95% 1.05 - 2.27). CONCLUSIONS: In this study, less than a quarter of the patients referred for coronary angiography with suspected CAD had the diagnosis confirmed. A better clinical and non-invasive assessment is necessary, to improve the efficacy of patient selection for coronary angiography.

The usefulness of T-wave peak to T-wave end interval in identifying malignant arrhythmias in patients with Chagas disease.

INTRODUCTION: Abnormal ventricular repolarization has been proposed as a marker of arrhythmogenesis, and cardiovascular morbidity and mortality. However, little is known about the influence of the interval between the peak and the end of the T wave (Tp-Te) on the inducibility of sustained ventricular arrhythmias (VA) in patients with Chagas disease (CD). METHODS: Using a case-control design, chagasics undergoing electrophysiological study (EPS) in the last three years were matched by age and sex. Cases represented those with positive EPS and controls those with no inducible VA. Tp-Te>100 ms was considered abnormal. Logistic regression analysis was performed to assess the association between Tp-Te and a positive EPS, after adjusting for confounders. RESULTS: A total of 105 patients (mean age 56 years, 52.4% male) were included: 41 (39%) had a positive EPS; 85.4% with inducible VA (n=35) had non-sustained ventricular tachycardia on the Holter monitoring, compared to 62.5% with negative EPS (n=40, p<0.001). While ventricular aneurysm (adjusted OR=5.3, 95% CI: 1.11-24.96, p=0.03) and coronary artery disease (adjusted OR=8.8, 95% CI: 1.45-53.15, p=0.01) were associated with an increased risk of malignant arrhythmias, a greater ejection fraction (adjusted OR=0.96, 95% CI: 0.93-0.99, p<0.01) was associated with a lower risk of VA. Prolonged Tp-Te trended to be associated with an increased risk of induced VA (p=0.07). CONCLUSIONS: Ventricular aneurysm, coronary artery disease, and ejection fraction are associated with inducible VA. Prolonged TP-Te may have a modest role in the identification of patients with CD who are at high risk for VA. Further studies are warranted to validate our results and to correlate them with clinical outcomes.

Tratamento com a técnica de duplo cateter-guia de perfuração coronária tipo III / Treatment with the double guiding catheter technique for type III coronary perforation

A perfuração coronária é uma complicação rara da intervenção coronária percutânea e potencialmente catastrófica. Pode levar ao derrame pericárdico, com ou sem tamponamento cardíaco, e, se não diagnosticada com precocidade e tratada adequadamente, pode levar ao óbito. Relatamos o caso de uma intervenção coronária percutânea complicada com perfuração coronária, rapidamente tratada com reversão da anticoagulação, insuflação prolongada com balão e implante de stent recoberto pela técnica do duplo cateter-guia.

Coronary perforation is a rare complication of percutaneous coronary intervention and is potentially catastrophic. Coronary perforation may lead to pericardial effusion with or without cardiac tamponade and if not diagnosed early on and treated properly it is life-threatening. We present a case of percutaneous coronary intervention complicated by coronary perforation, which was quickly treated by the reversal of anticoagulation, prolonged balloon inflation and a covered-stent, using the double guiding catheter technique.

Estratégias populacionais em promoção de saúde cardiovascular / Population strategies in promoting cardiovascular health

De acordo com a Organização Mundial de Saúde, "saúde é um estado de completo bem-estar físico, mental e social, e não apenas a ausência de doenças". Tendo em vista este ideal, a saúde é mantida e melhorada, não só por meio da promoção e aplicação da Medicina, mas também pela melhoria da qualidade de vida do indivíduo e da sociedade. Um terço de todos os óbitos mundiais é resultado das doenças cardiovasculares, colocando-as como a principal causa de morte, afetando principalmente a faixa etária mais produtiva de uma nação, prejudicando o desenvolvimento socioeconômico e familiar de todo um país. A piora dos hábitos alimentares, o aumento do nível de sedentarismo e do tabagismo incrementou a ocorrência destas doenças. O monitoramento da prevalência dos fatores de risco para DCV, no âmbito epidemiológico, permite, por meio das evidências científicas observadas, a implementação de ações preventivas com melhor custo-efetividade. No entanto, uma mudança no padrão comportamental e nos hábitos de vida de uma população, está estreitamente relacionada com padrões culturais, sociais, do modismo, do consumo, da oferta e demandas estabelecidas pela sociedade que a compõem. Desta forma além de prevenção primária, a promoção da saúde tem-se demonstrado uma alternativa teórica e prática para a resolução integral dos fatores que constituem o quadro epidemiológico das DCVs. O envolvimento de organizações comunitárias promove estratégias que visam mudança de comportamento de risco e de sua sustentabilidade, com base na prevenção primária dos fatores de risco e na promoção da saúde por meio da mobilização comunitária, de comunicação de massa e interação individual, identificação populacional e intervenções que visam a mudanças ambientais. Algumas experiências comunitárias realizadas desde os meados do último século comprovaram a importância de uma ação global e abrangente. Muitos estudos populacionais demonstraram que é possível mudar o rumo da incidência das doença...

According to the World Helth Orgazination, "Health s a state of complete physical, mental and social well-being, and not merely the absence of disease". In view of this ideal, healt is maintained and improved, not only by promoting and applying the Medicine, but also by improving the quality of life of the individual and of society. A third of all global deaths result from cardiovascular disease placing them as the leading cause of death mainly affecting the most productive age group harming the socioeconomic and family development of na entire nation. The worsening dietary habits, na increase in the level of physical inactivity and smoking increased the occurence of these disease. The monitoring of the prevalence of CVD risk factors in the epidemiological scope allows, by means of scientific evidence observed, the implementation of preventive actions with better cost effectiveness, However a change in ehavioral pattern and life habits of a population is closely related to culture, social standard, fad, consuptiom, supply and demands laid down by the society. In this way, in addition to the primary prevention, health promotion has been shown to be a theoretical and practical alternative to the full resolution of the factors that constitute the framework of epidemiological CVDs. The envolvement of community organizations will promote strategies aimed at changing risky behavior and its sustainability, based on the primary prevention and risk factors in health promotion through community mobilization, mass media and individual interaction, population identification and interventions aimed at enviromental changes. Some community experiences carried out since the middle of last century have proved the importance of a global and comprehensive action. Many population studies have shown that it is possible to change the direction of incidence of cardiovascular diseases...

The usefulness of T-wave peak to T-wave endInterval in identifying malignant arrhythmias in patients with chagas disease

Introduction: Abnormal ventricular repolarization has been proposed as a marker of arrhythmogenesis, andcardiovascular morbidity and mortality. However, little is known about the influence of the interval betweenthe peak and the end of the T wave (Tp-Te) on the inducibility of sustained ventricular arrhythmias (VA) inpatients with Chagas disease (CD).Methods: Using a case-control design, chagasics undergoing electrophysiological study (EPS) in the lastthree years were matched by age and sex. Cases represented those with positive EPS and controls thosewith no inducible VA. Tp-Te>100 ms was considered abnormal. Logistic regression analysis was performedto assess the association between Tp-Te and a positive EPS, after adjusting for confounders.Results: A total of 105 patients (mean age 56 years, 52.4% male) were included: 41 (39%) had a positiveEPS; 85.4% with inducible VA (n=35) had non-sustained ventricular tachycardia on the Holter monitoring,compared to 62.5% with negative EPS (n=40, p<0.001). While ventricular aneurysm (adjustedOR=5.3, 95% CI: 1.11-24.96, p=0.03) and coronary artery disease (adjusted OR=8.8, 95% CI: 1.45-53.15, p=0.01) were associated with an increased risk of malignant arrhythmias, a greater ejection fraction(adjusted OR=0.96, 95% CI: 0.93-0.99, p<0.01) was associated with a lower risk of VA. Prolonged Tp-Tetrended to be associated with an increased risk of induced VA (p=0.07).Conclusions: Ventricular aneurysm, coronary artery disease, and ejection fraction are associated with inducibleVA. Prolonged TP-Te may have a modest role in the identification of patients with CD who are at highrisk for VA. Further studies are warranted to validate our results and to correlate them with clinical outcomes.

Gastroesophageal reflux and atrial fibrillation: is there any correlation?

Atrial fibrillation (AF), gastroesophageal reflux disease (GERD) and hiatal hernias are commonly seen in clinical practice. GERD and hiatal hernias have been proposed to be a possible cause of AF. In this paper, we will briefly review GERD, AF and hiatal hernias, consider the available literature covering the association between these diseases and provide further insight into the topic in general.

Papel dos métodos diagnósticos não invasivos na avaliação dos pacientes multiarteriais coronarianos / Papel dos métodos diagnósticos não invasivos na avaliação dos pacientes multiarteriais coronarianos

As doenças cardiovasculares ainda são a primeira causade morte no Brasil. A avaliação precoce eficaz destes indivíduos pelos métodos não-invasivos pode auxiliar no manuseio clínico adequado diminuindo o risco de eventos adversos. Nessa monografia revisaremos o papel dos métodos diagnósticos não invasivos na doença multiarterial coronariana. Tentaremos, ainda, modificar o conceito da limitação da cintilografia de perfusão miocárdica no paciente multiarterial.A doença arterial coronariana (DAC) é considerda basicamente uma doença inflamatória e com sua evolução crônica , vários graus de obstruçãoe restrição do fluxocoronariano podem ocorrer. A metodologia do Escore de Cálcio (EC) vai demonstrar alterações muto precoces nessa evolução: depósitos de cálcio na coronária...

The dual effect of isoproterenol on insulin release is suppressed in pancreatic islets from hypothalamic obese rats.

Hyperinsulinemia in obesity has been attributed to insulin oversecretion by pancreatic beta-cells. Beta-cells are equipped with cholinergic and adrenergic receptors; whereas overall acetylcholine action is to potentiate, catecholamines' effect is to inhibit glucose-induced insulin release (GIIR) via alpha2-adrenoceptor. However, it has been shown that beta-adrenergic agonists potentiate glucose response. GIIR was studied in pancreatic islets from hyperinsulinemic adult obese rats, obtained by L-glutamate monosodium (MSG) neonatal treatment. Islets from MSG-rats were more glucose responsive than control ones. Isoproterenol, a beta-adrenergic agonist, inhibited the GIIR in islets from MSG-obese rats. Results indicate that MSG treatment causes alteration on function of beta-cell adrenoceptors.