André Coelho Marques

Coronary plaque rupture in patients with myocardial infarction after noncardiac surgery: Frequent and dangerous

PURPOSE The pathophysiology of acute coronary syndromes (ACS) after noncardiac surgery is not established yet. Thrombosis over a vulnerable plaque or decreased oxygen supply secondary to anemia or hypotension may be involved. The purpose of this study was to investigate the pathophysiology of ACS complicating noncardiac surgery. METHODS Clinical and angiographic data were prospectively recorded into a database for 120 consecutive patients that had an ACS after noncardiac surgery (PACS), for 120 patients with spontaneous ACS (SACS), and 240 patients with stable coronary artery disease (CAD). Coronary lesions with obstructions greater than 50% were classified based on two criteria: Ambroses classification and complex morphology. The presence of Ambroses type II or complex lesions were compared between the three groups. RESULTS We analyzed 1470 lesions in 480 patients. In PACS group, 45% of patients had Ambroses type II lesions vs. 56.7% in SACS group and 16.4% in stable CAD group (P<0.001). Both PACS and SACS patients had more complex lesions than patients in stable CAD group (56.7% vs. 79.2% vs. 31.8%, respectively; P<0.001). Overall, the independent predictors of plaque rupture were being in the group PACS (P<0.001, OR 2.86; CI, 1.82-4.52 for complex lesions and P<0.001, OR 3.43; CI, 2.1-5.6 for Ambroses type II lesions) or SACS (P<0.001, OR 8.71; CI, 5.15-14.73 for complex lesions and P<0.001, OR 5.99; CI, 3.66-9.81 for Ambroses type II lesions). CONCLUSIONS Nearly 50% of patients with perioperative ACS have evidence of coronary plaque rupture, characterizing a type 1 myocardial infarction.

Cardiovascular prevention in HIV patients: Results from a successful intervention program

OBJECTIVES To analyze the effect of a prevention program on the estimated cardiovascular risk calculated by three risk scores. METHODS We prospectively evaluated 87 HIV+patients with elevated cardiovascular risk estimation. Framingham (FRS), PROCAM and National Cholesterol Education Program (ATP-III) were applied. Cardiovascular risk was defined as elevated if >10%. All patients received non-pharmacological (diet, exercise, smoking cessation) and, when appropriate, pharmacological therapy. RESULTS Mean age was 52 years, 92% were male, 39.1% were smokers, 70.1% had hypertension, 18.4% had diabetes. All patients were under HAART, 56.3% were receiving protease inhibitors (PI). After 6 months, intervention was associated to significant changes on triglycerides (298+/-242 and 206+/-135 mg/dL, p<0.05), total-cholesterol (224+/-47 and 189+/-38 mg/dL, p<0.001), LDL-cholesterol (129+/-44 and 109+/-30 mg/dL, p<0.001). Frequencies of patients with elevated cardiac risk before and 6 months after intervention were 92% x 27.6% (p<0.0001), 80.5% x 50.6% (p<0.0002), and 25.3% x 14.9% (p=0.12), for FRS, ATP III and PROCAM, respectively. CONCLUSIONS An intervention program focused on reduction of traditional risk factors was able to decrease the frequency of patients with HIV infection and elevated cardiovascular risk estimation. FRS showed greater sensitivity than the other scores.

Non-cardiac surgery in developing countries: epidemiological aspects and economical opportunities--the case of Brazil.

Background Worldwide distribution of surgical interventions is unequal. Developed countries account for the majority of surgeries and information about non-cardiac operations in developing countries is scarce. The purpose of our study was to describe the epidemiological data of non-cardiac surgeries performed in Brazil in the last years. Methods and Findings This is a retrospective cohort study that investigated the time window from 1995 to 2007. We collected information from DATASUS, a national public health system database. The following variables were studied: number of surgeries, in-hospital expenses, blood transfusion related costs, length of stay and case fatality rates. The results were presented as sum, average and percentage. The trend analysis was performed by linear regression model. There were 32,659,513 non-cardiac surgeries performed in Brazil in thirteen years. An increment of 20.42% was observed in the number of surgeries in this period and nowadays nearly 3 million operations are performed annually. The cost of these procedures has increased tremendously in the last years. The increment of surgical cost was almost 200%. The total expenses related to surgical hospitalizations were more than

Reactive Hyperemia Revisited

10 billion in all these years. The yearly cost of surgical procedures to public health system was more than

The Ankle-Brachial Index is Associated With Cardiovascular Complications After Noncardiac Surgery

1.27 billion for all surgical hospitalizations, and in average, U

Perioperative cardiovascular evaluation: heads or tails?

445.24 per surgical procedure. The total cost of blood transfusion was near

Perioperative myocardial infarction has been forgotten.

98 million in all years and annually approximately

Prediction of major cardiac events after vascular surgery

10 million were spent in perioperative transfusion. The surgical mortality had an increment of 31.11% in the period. Actually, in 2007, the surgical mortality in Brazil was 1.77%. All the variables had a significant increment along the studied period: r square (r2) = 0.447 for the number of surgeries (P = 0.012), r2 = 0.439 for in-hospital expenses (P = 0.014) and r2 = 0.907 for surgical mortality (P = 0.0055). Conclusion The volume of surgical procedures has increased substantially in Brazil through the past years. The expenditure related to these procedures and its mortality has also increased as the number of operations. Better planning of public health resource and strategies of investment are needed to supply the crescent demand of surgery in Brazil.

Impact of cardiology referral: clinical outcomes and factors associated with physicians' adherence to recommendations

To the Editor: We read with great interest Dr Huang’s study, published in Arteriosclerosis, Thrombosis, and Vascular Biology .1 We are in total agreement with the authors about the clinical relevance in the perioperative setting of the hyperemic flow velocity, measured by brachial artery Doppler ultrasound. Dr Huang suggests that reactive hyperemia increases the accuracy of the noninvasive vascular reactivity test, namely the brachial artery flow-mediated dilation, in predicting cardiovascular events after major vascular surgery, even though in his patients the strongest isolated predictor was flow-mediated dilation. In a population of 96 vascular surgical patients, we assessed brachial artery flow-mediated dilation and reactive hyperemia with the same technique as Dr Huang’s before major vascular surgery was performed, with a Siemens ultrasound system ( Sequoia ), equipped with a 7.5-mHz vascular transducer. The brachial artery ultrasound was always performed in the morning, after a 6-hour fast and at least 12 hours without smoking. Patients received all medications, including statins, and remained resting in supine position 15 minutes before the beginning until the end of the examination. We acquired 2-dimensional ultrasound …

Transient global amnesia as a manifestation of acute myocardial infarction: A case of missed sudden cardiac death?

Carmo et al in their article ‘‘The Ankle-Brachial Index is Associated With Cardiovascular Complications After Noncardiac Surgery?’’ investigated the association between the anklebrachial index (ABI) and cardiovascular (CV) complications after noncardiac surgery. Those with abnormal ABI had increased CV complications. Cardiovascular disease (CVD) is a common cause of hospitalization and mortality worldwide. Therefore, clinicians have searched for predictors of CVD. Arterial stiffness (AS) is a noninvasive method to assess subclinical atherosclerosis, and it is also associated with coronary artery disease, hypertension, diabetes mellitus, stroke, and peripheral arterial disease. Pulse wave analysis (PWA) includes pulse wave velocity (PWV), augmentation index, and central aortic pressure. Other studies have reported abnormal PWA in patients with CVD, renal failure, and chronic inflammatory disease. Measurement of PWA is considered relatively simple, reproducible, and cost effective for CV risk estimation. The European Network for Non-invasive Investigation of Large Artery consensus for the assessment of AS considered PWV as the gold standard for the measurement of AS. Carmo et al used the ABI for CV risk estimation. Increased PWV and a low ABI are accepted as a marker of CVD and increased total CV risk. In this context, it would have been useful if authors had also measured PWV to assess AS. The authors reported that isolated troponin elevation was observed in 24.2% of the patients, and CV complication event rate was 6.4%. They suggest that physicians should perform troponin analysis after surgery in all patients. However, we could not determine whether there was any significant difference for troponin analysis between the 2 groups studied. More information could provide clearer information regarding the role of troponin in relation to CV complications after noncardiac surgery.