Bernardo Rangel Tura

B-type natriuretic peptide: a strong predictor of early and late mortality in patients with acute chest pain without ST-segment elevation in the emergency department.

BackgroundThe prognostic importance of early measurement of B-type natriuretic peptide (BNP) in patients with acute chest pain while the diagnosis is still uncertain is unknown. We determined the prognostic value of BNP in these patients immediately after presenting to the emergency department. MethodsSeven hundred and twenty-three consecutive individuals with suspicious ischemic acute chest pain and no ST-segment elevation were prospectively evaluated using a systematic diagnostic strategy and followed for 1 year. Acute coronary syndrome was diagnosed in 326 patients during their hospital stay. ResultsIn the follow-up, 15 (2.1%) patients of the whole cohort died of cardiac cause at 1 month and 51 (7.1%) at 1 year. Patients who died had significantly higher admission BNP levels than survivors and this correlation proved linear according to quartile levels. Patients with BNP greater than 101 pg/ml had 13 times higher rate of 1-month mortality (P<0.0001) and 5.3 times higher rate of 1-year mortality (P<0.0001) than patients with BNP of 101 pg/ml or less. Multiple logistic regression analysis disclosed BNP as a strong independent predictor of 1-month and 1-year mortality adding significant prognostic information over traditional risk markers. ConclusionAdmission BNP is an independent and powerful marker of early and late cardiac mortality in patients with acute chest pain without ST-segment elevation. These results suggest that BNP should be measured upon arrival at the emergency department for risk stratification in all these patients.

Risk of coronary artery disease in individuals infected with human immunodeficiency virus

UNLABELLED Current treatment for human immunodeficiency virus (HIV) infection has improved survival and allowed infected patients to develop atherosclerotic coronary artery disease (CAD). Specific strategies to reduce cardiovascular risk in the infected population have not been developed. It is necessary to know the magnitude of cardiovascular risk in this population. OBJECTIVES This study aimed to assess cardiovascular risk using a well-known clinical score and to investigate coronary artery calcium scoring (CACS) in this population. METHODS This was a cross-sectional study. Adults with HIV infection were studied. Demographic, clinical and anthropometric data, serum glucose and lipids were obtained. Cardiovascular risk was calculated through Framingham risk score (FRS) and CACS. Categorical variables were compared by Chi-square or Fishers exact test, and continuous variables were analyzed by Student t test or Mann-Whitney test. An analysis of concordance between FRS and CACS was performed using kappa statistic. RESULTS Forty patients, aged 45.9 ± 8.1 years, were studied. Age of risk for CAD were found in 30.0%, hypertension in 55.0%, diabetes in 10.0%, smoking in 35.0%, dyslipidemia in 67.5% and family history of CAD in 57.5%. Altered levels of total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides were found in 30.0%, 25.0% and 82.5%, respectively. HDL-cholesterol and triglycerides were altered more frequently among protease inhibitors users. The FRS classified the risk as low for 72.5%, moderate for 25.0%, and high for 2.5%. CACS > 0 was found in 32.5% of the patients, in 67.5% the score was low, in 17.5% moderate, and in 15.0% high. Concordance between FRS and CACS showed a kappa = 0.435. CONCLUSIONS There is a high prevalence of risk factors for CAD in the studied population, with dyslipidemia being the most frequent. HDL-cholesterol and triglycerides were the most frequently altered factors and were associated with the use of protease inhibitors. Risk assessed by the FRS was low in most cases. CACS > 0 was found in 32.5%, demonstrating the need to re-evaluate the strategies for assessing cardiovascular risk in the HIV-infected population.

Importância da proteína C-reativa no diagnóstico e no prognóstico intra-hospitalar em pacientes com dor torácica na sala de emergência

OBJECTIVE To test immediate diagnostic and prognostic values of C-reactive protein (CRP) in patients admitted to the emergency room (ER) with chest pain (CP) without ST-segment elevation on the electrocardiogram (ECG). METHODS From January 2002 to December 2003, 980 patients were consecutively seen in the ER with CP suggestive of acute coronary syndrome (ACS) (age = 64.9 +/- 14.3, men = 55%, diabetic = 18%, normal ECG = 84%). Serial CRP, creatine kinase MB mass (CKMB-mass) and troponin I determinations were performed on admission, in addition to serial ECG. CRP measurements were standardized (s-CRP) by the upper limit of normal (ULN) of the test used (3.0 mg/L for high-sensitivity C-reactive protein [hs-CRP] and 0.1 mg/dL for titrated CRP [t-CRP]). RESULTS One hundred and twenty-five patients were diagnosed with acute myocardial infarction (AMI), and their s-CRP values were 1.31 +/- 2.90 (median = 0.47) compared to 0.79 +/- 1.39 (0.30) in no-AMI patients (p = 0.031). The s-CRP > 1.0 showed 30% sensitivity and 80% specificity, plus negative and positive predictive values of 6.1% and 96.7%, respectively, for AMI diagnosis. There were forty in-hospital cardiac events (16 deaths, 22 urgent revascularizations, and 2 acute myocardial infarction). In the first quartile of the s-CRP (< 0.10), three events were recorded, while in the fourth quartile (> 0.93) 15 events (p = 0.003) occurred. In the logistic regression model, masculine gender and s-CRP > 0.32 (odds ratio 7.6, 2.8 and 2.2, respectively) were independent predictors of cardiac events and left ventricular failure. CONCLUSION In patients with chest pain presenting at the emergency room, s-CRP was not a good marker of AMI, although this diagnosis is virtually excluded by a normal value; in addition, values one-third above the upper limit of normal (>1 mg/L for hs-CRP or >0.33 mg/dL for t-CRP) were predictive of in-hospital adverse cardiac events.

Tendência temporal de letalidade hospitalar por infarto agudo do miocárdio: 1994-2003

OBJECTIVE To analyze the temporal tendency of lethality due to acute myocardial infarction (AMI) and if the change in behavior directly interfered in such lethality. METHODS 1055 non-selected patients, who were hospitalized in coronary unit from 1994 to 2003, were assessed. Clinical and therapeutic profile-related variables were analyzed. The statistic analysis used the exponential damping of temporal series and other techniques, such as the logistic linear regression. RESULTS The average lethality was 10.8%, being 12% in 1994 and 7% in 2002 (p=0.000), a relative reduction of 58%. There was no significant variation in the risk profile of the patients. There were 67.4% of men and 32.4% of women, with an average age of 60.93 and 64.84 years old, respectively. It was observed a significant increase in the percentage of cardiac catheterization (from 14% to 51%), in the angioplasty carried out 24 hours after the infarction (from 2% to 33%), in the surgery for myocardial revascularization (from 4% to 7%) and in the primary angioplasty (from 4% to 11%) with p=0.000, p=0.021, p=0.000 and p=0.000, respectively, for linear tendency. In the first 24 hours there was an increase of the use of aspirin and beta-blockers, from 78% to 100% and, from 33% to 76% (p=0.003 and p=0.004, respectively) along the years. After the analysis, the myocardial reperfusion therapy, the use of aspirin and beta-blocker in the first 24 hours of the AMI (p=0.010, p=0.024 and p=0.035, respectively) kept on being lethality determiners. CONCLUSION There was a decrease in lethality and the change of behavior in the treatment of AMI along the years was responsible for the reduction of lethality in that temporal series.

Impact of Complications of Myocardial Revascularization Surgery on Expenses During Hospital Stay

Mailing Address: João Luis Barbosa Av. Embaixador Abelardo Bueno, 3250/BL 2/603. Postal Code: 22775-040, Barra da Tijuca, Rio de Janeiro Brazil. E-mail: joaoluis@cardiol.br Impact of Complications of Myocardial Revascularization Surgery on Expenses During Hospital Stay João Luís Barbosa,1,2,4 Clarissa Antunes Thiers,1 Anderson Ferreira Rolim da Silva,2 Marcos Maia Vianna,2 Paulo Otávio de Paula Ravaglia Gedeon,2 Lauro Martins Neto,2 Marina Brunner Uchôa Dantas Moreira,2 Luiz Felipe Faria,2 Bernardo Rangel Tura1 Instituto Nacional de Cardiologia (INC),1 RJ Brazil Universidade Estácio de Sá,2 RJ Brazil Universidade Fluminense Federal (UFF),3 Niterói, RJ Brazil Universidade Federal do Rio de Janeiro (UFRJ),4 RJ Brazil

Performance of Diagnostic Tests for Intermediate Probabilities of Coronary Heart Disease: A Decision Making Analysis

Pacientes com probabilidade intermediaria de doenca coronariana sao um desafio diagnostico e e justamente nessa populacao onde o grau de incerteza e maior que os testes diagnosticos tem sua maior aplicabilidade. Entretanto, de acordo com a definicao vigente, submeter uma populacao com probabilidade de doenca entre 10 e 90% pode gerar exames desnecessarios e resultados equivocados. Conhecer as caracteristicas de cada teste, assim como riscos e beneficios do tratamento medicamentoso para doenca coronariana e conjugar essas informacoes atraves dos limiares de diagnostico trazem uma nova perspectiva a tomada de decisao. Objetivos: Revisar a origem dos conceitos atualmente preconizados de probabilidade intermediaria e determinar os limiares de diagnostico e tratamento dos testes nao invasivos e, com base neles, propor um novo conceito de probabilidade intermediaria de doenca coronariana. Atraves da revisao bibliografica foram extraidas metanalises nas quais dados de sensibilidade, especificidade, razao de verossimilhanca positiva e negativa, riscos e beneficios dos testes e tratamento foram fornecidos. Utilizando-se algoritmo desenvolvido por Pauker e colaboradores foi possivel obter os limiares de diagnostico e tratamento ajustados para cada exame em questao. O conceito de probabilidade intermediaria de doenca coronariana e bastante amplo, variando, conforme os autores, entre 10 e 90%, 1 e 92%, 15 e 85%, com racionalidade distinta. Contemplando-se o poder discriminatorio de cada exame, riscos dos testes, riscos e beneficios do tratamento, os limiares de diagnostico e tratamento foram definidos para teste ergometrico (22-58%), eco-stress (10-72), cintilografia miocardica (12-80%), ressonância nuclear magnetica (16-80%) e angiotomografia de coronarias (6,7-81%). A decisao quanto a submissao aos testes diagnosticos deve ser individualizada, levando-se em consideracao os limiares de diagnostico e tratamento de cada metodo em questao.

Impact of Risk Factors for Coronary Artery Disease on Hospital Costs of Patients Undergoing Myocardial Revascularization Surgery in the Brazilian Unified Health System (SUS)

Background: Cardiovascular diseases are a major cause of mortality and morbidity. Myocardial revascularization surgery may be indicated for the relief of symptoms and to reduce mortality. However, surgery is a costly procedure and the impact of the number of cardiovascular risk factors on the cost of the procedure has not been established. Objectives: To identify the impact of risk factors for coronary artery disease on myocardial revascularization surgery cost. Methods: We selected 239 patients undergoing myocardial revascularization surgery at the National Institute of Cardiology in the period from 01 January to 31 December 2013. We included patients aged over 30 years, with indication for the procedure. Patients undergoing combined procedures were excluded. Results: Seven patients had only one risk factor, 32 patients had two risk factors, 75 patients had 3 risk factors, 78 patients had four risk factors, 36 patients had 5 risk factors and 11 patients presented 6 risk factors. The total costs, on average, was R

Mortality from coronary artery disease during dengue epidemics

14,143.22 in the group with 1 risk factor, R

B-type natriuretic peptide: a novel early blood marker of acute myocardial infarction in patients with chest pain and no ST-segment elevation

18,380.40 in the group with 2 risk factors, R

Sintomas depressivos e óbito em síndromes coronarianas isquêmicas agudas

21,229.51 in the group with 3 risk factors, R