Adriana Belo

Prevalence of anaemia and iron deficiency in Portugal: the EMPIRE Study

Anaemia and iron deficiency are major public health problems with great implications on quality of life.

Association of metabolic risk factors with uncontrolled hypertension: comparison of the several definitions of metabolic syndrome

Aims: To evaluate the influence of metabolic syndrome in the effectiveness of antihypertensive treatment and to compare it using the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) (2001 and 2004), International Diabetes Federation (IDF) and American Heart Association/National Heart, Lung and Blood Institute (AHA-NHLBI) definitions. Methods: The VALSIM (Estudo de Prevalência da Síndrome Metabólica) survey was designed as an observational cross-sectional study performed in a primary healthcare setting in Portugal. The first two adult patients scheduled for an appointment on a given day were invited to participate. The treatment effectiveness was evaluated by the occurrence of uncontrolled hypertension (≥140/90 mmHg) in patients taking antihypertensive drugs. Logistic regression analysis was used to determine the association between uncontrolled hypertension and metabolic risk factors, with adjustments for age, sex, and pattern of antihypertensive treatment. Results: Among the 16 856 individuals evaluated, 8925-treated hypertensive patients were identified. Only 35.8% of them had controlled hypertension. The risk of poor blood pressure control increased with age, waist circumference, serum levels of triglycerides and HDL-cholesterol. Among treatable risk factors, metabolic syndrome as defined by NCEP-ATP III 2001 diagnostic criteria was the strongest independent predictor of uncontrolled hypertension (odds ratio: 1.23; 95% CI: 1.08–1.41; P = 0.002). In opposition, the IDF or AHA-NHLBI definitions of metabolic syndrome failed to identify patients at risk of poor blood pressure control. Conclusion: Metabolic syndrome is associated with lower effectiveness of antihypertensive therapy and the NCEP-ATP III 2001 definition of metabolic syndrome is the one that better identifies patients at risk of poor blood pressure control.

ProACS risk score: An early and simple score for risk stratification of patients with acute coronary syndromes

INTRODUCTION There are barriers to proper implementation of risk stratification scores in patients with acute coronary syndromes (ACS), including their complexity. Our objective was to develop a simple score for risk stratification of all-cause in-hospital mortality in a population of patients with ACS. METHODS The score was developed from a nationwide ACS registry. The development and internal validation cohorts were obtained from the first 31829 patients, randomly separated (60% and 40%, respectively). The external validation cohort consisted of the last 8586 patients included in the registry. This cohort is significantly different from the other cohorts in terms of baseline characteristics, treatment and mortality. Multivariate logistic regression analysis was used to select four variables with the highest predictive potential. A score was allocated to each parameter based on the regression coefficient of each variable in the logistic regression model: 1 point for systolic blood pressure ≤116 mmHg, Killip class 2 or 3, and ST-segment elevation; 2 points for age ≥72 years; and 3 points for Killip class 4. RESULTS The new score had good discriminative ability in the development cohort (area under the curve [AUC] 0.796), and it was similar in the internal validation cohort (AUC 0.785, p=0.333). In the external validation cohort, there was also excellent discriminative ability (AUC 0.815), with an adequate fit. CONCLUSIONS The ProACS risk score enables easy and simple risk stratification of patients with ACS for in-hospital mortality that can be used at the first medical contact, with excellent predictive ability in a contemporary population.

Role of intra-aortic balloon pump counterpulsation in the treatment of acute myocardial infarction complicated by cardiogenic shock: Evidence from the Portuguese nationwide registry.

Background: In previous guidelines, intra-aortic balloon pump (IABP) use was strongly recommended in the treatment of cardiogenic shock in the context of acute myocardial infarction. The recent IABP-SHOCK II trial demonstrated no benefit in short- and medium-term mortality with the use of IABP. It was our objective to evaluate in a real life nationwide population of patients with acute myocardial infarction the impact of IABP in short- and medium-term mortality. Methods: We included patients admitted with acute myocardial infarction in Killip class IV in the first 24 hours, all submitted to urgent coronary angiography. Our study objective was the occurrence of hospital and six-month all-cause mortality. Results: From the 33,300 patients included in the registry, 4.2% presented with Killip class IV in the first 24 hours and 646 (43.6%) were submitted to urgent coronary angiography. IABP was implanted in 19.8% of these patients. The IABP group was younger, had higher admission heart rate, more multivessel disease and more left main disease. There were 260 hospital deaths (40.2%), similar between groups (46.1% vs. 38.8%, p=0.132). IABP use was associated with a deleterious effect in patients with previous MI and beneficial effect in patients with mechanical complications. IABP use had a neutral effect on mortality (hazard ratio 1.14, 95% confidence interval 0.84–1.56). This was further confirmed in a propensity score matching analysis. Conclusions: In a real life population of patients with acute myocardial infarction, the use of IABP for the treatment of cardiogenic shock was associated with a neutral effect.

Validação externa do score de risco ProACS para estratificação de risco de doentes com síndrome coronária aguda

INTRODUCTION The ProACS risk score is an early and simple risk stratification score developed for all-cause in-hospital mortality in acute coronary syndromes (ACS) from a Portuguese nationwide ACS registry. Our center only recently participated in the registry and was not included in the cohort used for developing the score. Our objective was to perform an external validation of this risk score for short- and long-term follow-up. METHODS Consecutive patients admitted to our center with ACS were included. Demographic and admission characteristics, as well as treatment and outcome data were collected. The ProACS risk score variables are age (≥72 years), systolic blood pressure (≤116 mmHg), Killip class (2/3 or 4) and ST-segment elevation. We calculated ProACS, Global Registry of Acute Coronary Events (GRACE) and Canada Acute Coronary Syndrome risk score (C-ACS) risk scores for each patient. RESULTS A total of 3170 patients were included, with a mean age of 64±13 years, 62% with ST-segment elevation myocardial infarction. All-cause in-hospital mortality was 5.7% and 10.3% at one-year follow-up. The ProACS risk score showed good discriminative ability for all considered outcomes (area under the receiver operating characteristic curve >0.75) and a good fit, similar to C-ACS, but lower than the GRACE risk score and slightly lower than in the original development cohort. The ProACS risk score provided good differentiation between patients at low, intermediate and high mortality risk in both short- and long-term follow-up (p<0.001 for all comparisons). CONCLUSIONS The ProACS score is valid in external cohorts for risk stratification for ACS. It can be applied very early, at the first medical contact, but should subsequently be complemented by the GRACE risk score.

Progress in Identifying High Nature Value Montados: Impacts of Grazing on Hardwood Rangeland Biodiversity

ABSTRACT Due to their complex structure and traditional low-intensity management, Portuguese oak woodland rangelands known as montados are often considered high nature value (HNV) farming systems, and as such, they may be deemed eligible for subsidies and incentives by governmental and nongovernmental agencies. Too little is known about how the HNV concept might be applied to conserve complex silvopastoral systems. These systems, due to their structural and functional complexity at multiple scales, tend to support high levels of biodiversity. Montados are in sharp decline as a result of the rapid specialization of land management that, through simplification, undermines multifunctionality. Understanding how changes in management influence these systems and their biodiversity is needed for prioritizing conservation efforts and for ensuring they remain HNV systems. On the basis of a field survey in 58 plots distributed among 29 paddocks on 17 farms, we conducted an integrated analysis of the relationship between grazing intensity and biodiversity in montados of similar biophysical and structural characteristics. Data on management were obtained through interviews, and biodiversity data (vegetation, macrofungi, birds, herpetofauna) were obtained through specific field protocols. Additional spatial data, such as soil characteristics, slope, land cover, and linear landscape elements, were also analyzed. The results show no overall biodiversity variation as a result of different management practices. However, different groups of species react differently to specific management practices, and within a pasture, grazing impacts are heterogenous. In low grazing intensity plots, macrofungi species richness was found to be higher, while bird species richness was lower. Using tree regeneration as proxy for montado sustainability, results show less tree regeneration in areas with higher forage quality and more intense grazing. Pathways for future progress are proposed, including creating areas within a paddock that attract grazing away from where regeneration is desired.

Acute kidney injury in acute coronary syndromes – An important multifactorial consequence

INTRODUCTION Acute kidney injury (AKI) is a pathological phenomenon with a negative impact on outcomes in different clinical scenarios. Its mechanism in acute coronary syndrome (ACS) is not completely understood, and measures to prevent it are not uniform. We set out to study the incidence, clinical relevance, predictors and possible implications for patient management of AKI in ACS. METHODS Using data from a multicenter national registry on ACS, we retrospectively analyzed predictors of AKI and its impact on outcomes (in-hospital complications and one-year mortality). All ACS types were included. AKI was defined as an increase in serum creatinine of ≥0.3 mg/dl (≥26.4 μmol/l) and/or by ≥1.5 times baseline. RESULTS A total of 7808 ACS patients were included in the analysis, 1369 (17.5%) of whom developed AKI. AKI was shown to be an independent predictor of in-hospital major bleeding (odds ratio [OR] 2.09; 95% confidence interval [CI] 1.19-3.64; p=0.01), mortality (OR 4.72; 95% CI 2.94-7.56; p<0.001) and one-year mortality (hazard ratio 2.01; 95% CI 1.51-2.68; p<0.001). The incidence of AKI was associated with older age, history of hypertension, renal failure and stroke/transient ischemic attack, Killip class >1 on admission and left ventricular ejection fraction <50%. Performance of coronary angiography or angioplasty were not associated with AKI. Diuretics during admission were predictors of AKI only in patients in Killip class 1. CONCLUSIONS AKI is an important finding in ACS, with a significant impact on hard clinical endpoints such as in-hospital and one-year mortality. It is associated with easily identifiable clinical factors and an invasive strategy does not increase its incidence.

Disfunção sistólica ventricular esquerda detetada por speckle tracking em hipertensos com fração de ejeção preservada

INTRODUCTION The spectrum of hypertensive heart disease is wide, and can include left ventricular dysfunction. The development of echocardiographic parameters to improve patient stratification and to identify early adverse changes could be clinically useful. Aim To identify subclinical left ventricular dysfunction in hypertensive subjects with preserved ejection fraction (>55%), identified by global parameters of myocardial strain on speckle tracking imaging. METHODS This was a comparative observational study of two groups of individuals: normotensive (n=20, age 59 ± 7 years, 55% male) and hypertensive (n=229, age 62 ± 12 years, 57% male). Left ventricular function was assessed by various conventional clinical and echocardiographic parameters and global longitudinal and circumferential myocardial strain. Cut-off values to detect subclinical left ventricular dysfunction were established and applied in the hypertensive group. The Students t test, Mann-Whitney test and chi-square test were used for the comparative statistical analysis. RESULTS Most hypertensive subjects (53.7%) had grade I hypertension; blood pressure was controlled in 64.9%, and 54.8% showed left ventricular structural changes. Comparison between the normotensive and hypertensive groups showed no significant differences in parameters of global longitudinal or circumferential systolic strain. Application of the cut-offs to the hypertensive group identified 35 individuals (15.3%) as having subclinical left ventricular systolic dysfunction as assessed by global longitudinal myocardial strain parameters. CONCLUSIONS In this group of hypertensive patients, global myocardial strain parameters identified a group of individuals with subclinical left ventricular systolic dysfunction despite preserved ejection fraction. The clinical relevance of these findings needs to be assessed in long-term follow-up studies.

Caracterização do perfil lipídico nos utentes dos cuidados de saúde primários em Portugal

AIM To characterize the distribution of total cholesterol (TC), LDL cholesterol (LDL-C), HDL cholesterol (HDL-C) and triglycerides in primary health care users. METHODS We performed a cross-sectional study in a primary care setting, involving 719 general practitioners based on stratified distribution proportional to the population density of each region of Portugal. The first two adult patients scheduled for an appointment on a given day were invited to participate. A questionnaire was applied to assess sociodemographic, clinical and laboratory data including lipid profile. RESULTS The study included 16 856 individuals (mean age 58.1±15.1 years; 61.6% women). Data on TC, LDL-C, HDL-C and triglycerides were available for 95.9% (n=16 159), 59.1% (n=9956), 95.4% (n=16 074) and 97.9% (n=16 494) of the population, respectively. Hypercholesterolemia (TC ≥200 mg/dl) was detected in 47%, and 38.4% had high levels of LDL-C (≥130 mg/dl). Hypertriglyceridemia (≥200 mg/dl) and low HDL-C (<40 mg/dl) were less prevalent, affecting roughly 13% of the population. Dyslipidemia was more common in middle-aged men and in post-menopausal women. Of the population aged over 40, 54.1% met eligibility criteria for lipid-lowering therapy and 44.7% were medicated with statins, but only 16.0% of these had TC ≤175 mg/dl. CONCLUSIONS Dyslipidemia is highly prevalent in primary health care users in Portugal. It is particularly common in middle-aged men and post-menopausal women, who should be considered target groups for preventive public health measures.

COMPARISON OF DEFINITIONS OF METABOLIC SYNDROME IN RELATION TO THE RISK OF CORONARY HEART DISEASE AND STROKE: PP.34.360

Aims: To compare definitions of metabolic syndrome (MS) with regard to their association with coronary artery disease (CAD) and stroke. Methods: Cross-sectional study performed in a primary care setting, involving 719 general practitioners pursuant to stratified distribution proportional to the population density. The first 2 adult patients scheduled for an appointment on a given day were invited to participate, irrespective of the reason for the consultation. A questionnaire for social-demographic, clinical and laboratory data was applied. MS diagnosis was defined according to NCEP-ATP III 2001, NCEP-ATP III 2004, IDF and AHA/NHLBI criteria. Multivariate logistic regression analysis was used to assess the risk of CAD and stroke according to sex, age, body mass index, waist circumference, HDL-cholesterol, triglycerides, hypertension (HT), diabetes and MS according to each definition. Results: The study included 16,856 individuals (58.1 ± 15.1 years). The prevalence of MS adjusted to sex, age and size of the regions by NCEP-ATP III 2001, 2004, IDF and AHA/NHLBI definitions was 28.4%, 32.8%, 65.5% and 69.4%, respectively. The degrees of agreement according to the k statistics were modest and only 60.3% simultaneously fulfilled the criteria of all definitions. HT was the treatable risk factor most strongly associated to CAD and stroke. Only the IDF and AHA/NHLBI definitions of MS were independently associated to CAD (OR: 1.74 and 2.26, respectively). Regarding to stroke, only AHA/NHLBI criteria provided statistically significant association (OR: 1.85). Conclusions: The definition of MS according to the AHA/NHLBI criteria appears to be a better predictor of CAD and stroke in the Portuguese population. MS as defined by AHA/NHLBI criteria remains an independent risk factor for CAD and stroke after adjustment to its individual components. Figure 1. No caption available.