Carisi Anne Polanczyk
Universidade Federal do Rio Grande do Sul
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Circulation | 1999
Thomas H. Lee; Edward R. Marcantonio; Carol M. Mangione; Eric J. Thomas; Carisi Anne Polanczyk; E. Francis Cook; David J. Sugarbaker; Magruder C. Donaldson; Robert Poss; Kalon K.L. Ho; Lynn E. Ludwig; Alex Pedan; Lee Goldman
BACKGROUND Cardiac complications are important causes of morbidity after noncardiac surgery. The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications. METHODS AND RESULTS We studied 4315 patients aged > or = 50 years undergoing elective major noncardiac procedures in a tertiary-care teaching hospital. The main outcome measures were major cardiac complications. Major cardiac complications occurred in 56 (2%) of 2893 patients assigned to the derivation cohort. Six independent predictors of complications were identified and included in a Revised Cardiac Risk Index: high-risk type of surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum creatinine >2.0 mg/dL. Rates of major cardiac complication with 0, 1, 2, or > or = 3 of these factors were 0.5%, 1.3%, 4%, and 9%, respectively, in the derivation cohort and 0.4%, 0.9%, 7%, and 11%, respectively, among 1422 patients in the validation cohort. Receiver operating characteristic curve analysis in the validation cohort indicated that the diagnostic performance of the Revised Cardiac Risk Index was superior to other published risk-prediction indexes. CONCLUSIONS In stable patients undergoing nonurgent major noncardiac surgery, this index can identify patients at higher risk for complications. This index may be useful for identification of candidates for further risk stratification with noninvasive technologies or other management strategies, as well as low-risk patients in whom additional evaluation is unlikely to be helpful.
Annals of Internal Medicine | 2001
Carisi Anne Polanczyk; Edward R. Marcantonio; Lee Goldman; Luis Eduardo Paim Rohde; John Orav; Carol M. Mangione; Thomas H. Lee
As the U.S. population ages, major surgical procedures are being performed in elderly patients with increasing frequency (1), but few data are available to guide preoperative risk stratification. Several studies have described correlates of cardiac morbidity and mortality in patients undergoing noncardiac surgery (2-8), but the number of elderly patients in most series has been small. Furthermore, few data are available on noncardiac complications, the overall complication rate, and length of stay. We describe the influence of age on perioperative complication and mortality rates in a large cohort of patients undergoing noncardiac surgery. As discussed elsewhere, age was not an independent correlate of major cardiac complications in this cohort (7). This analysis tests the hypothesis that advanced age is a correlate of the overall rate of complications, after adjustment for functional status. Methods Patients All patients 50 years of age or older who underwent major nonemergent noncardiac procedures at Brigham and Womens Hospital, Boston, Massachusetts, from 18 July 1989 to 28 February 1994 were eligible for the study. Major noncardiac procedures were defined as those with an expected length of stay of 2 or more days. Procedures were electively scheduled or were performed nonemergently during inpatient admissions. Eligibility criteria included the ability to speak English and adequate cognitive function to give informed consent. The enrollment and clinical data collection protocols were approved by the institutional review board of Brigham and Womens Hospital. The full study protocol included preoperative interviews by clinical study personnel (physicians or research nurses). Of the 4315 patients who provided informed consent to participate, 621 (14.4%) did not provide consent before surgery for the serial interview portion of the study, which included interviews 1 and 6 months after surgery. Patients who were not interviewed before surgery were not excluded on the basis of age or clinical status, but solely according to the availability of study personnel. Data Collection The data collection protocol is described elsewhere (7, 9, 10). In brief, patients who provided informed consent to the full study protocol underwent preoperative evaluation by clinical investigators (physicians or research nurses) using a structured data form. These evaluations included detailed medical histories, physical examinations, and laboratory tests. For patients who did not undergo this evaluation because they could not be approached or because they declined participation in the interview portion of the study, we obtained clinical data from the structured evaluation by the anesthesiologist found in the medical record. This data source was also used to obtain American Society of Anesthesiologists classification for all patients. Hence, prospectively recorded clinical data were available for all patients. Consenting patients agreed to postoperative sampling of creatine kinase and, if total creatine kinase levels were elevated, measurement of creatine kinaseMB immediately after surgery, at 8 p.m. on the evening of surgery, and on the next two mornings. In all other enrolled patients, creatine kinaseMB was measured according to the physicians orders. Among all participants, the mean (SD) number of cardiac enzyme samples obtained was 4.0 2.2. Electrocardiography was performed in the recovery room and on the first, third, and fifth postoperative days if the patient remained hospitalized. The Charlson Comorbidity Index, a weighted comorbidity score based on the number and the severity of 16 selected medical diseases, was used to quantify the burden of medical comorbid conditions (11). The mean number of other common comorbid conditions in this population was calculated for all patients. Preoperative functional status was assessed in 3890 patients by performing structured interviews using the Specific Activity Scale, an ordinally scaled, four-class instrument based on metabolic expenditure in various personal care, housework, occupational, and recreational activities (12, 13). This group included 196 patients who consented to preoperative interviews but did not consent to the full study protocol, including long-term follow-up. Classification of Outcomes The occurrence of major cardiac events postoperatively was classified by a single reviewer who was blinded to preoperative clinical data and who evaluated only postoperative clinical information, including cardiac enzyme measurements, electrocardiograms, and clinical events. Myocardial infarction was diagnosed on the basis of creatine kinaseMB levels and electrocardiographic findings (10). Major cardiac complications were unstable angina (postoperative typical chest pain associated with ischemic electrocardiographic changes), myocardial infarction, cardiogenic pulmonary edema, documented ventricular tachycardia, ventricular fibrillation or primary cardiac arrest, and sustained complete heart block requiring pacemaker. Major noncardiac events were pulmonary embolism documented by autopsy, angiography, or a high-probability ventilationperfusion scan; respiratory failure requiring intubation for more than 2 days or reintubation; noncardiogenic pulmonary edema; lobar pneumonia confirmed by chest radiography and requiring antibiotic therapy; acute renal failure requiring dialysis; or cerebrovascular accident with new neurologic deficit. In-hospital mortality was also recorded, and the combined end point of major cardiac or noncardiac complications or death was used in these analyses. Statistical Analysis To evaluate the impact of age on postoperative complications, we performed analyses in which age was considered as a continuous variable and as four categories (50 to 59 years, 60 to 69 years, 70 to 79 years, and 80 years). Because age was not linearly associated with the risk for outcomes, categorized age variables are used throughout this report. Univariate correlations between clinical characteristics and age category were analyzed by using the chi-square test and the Fisher exact test for categorical variables and a t-test or Wilcoxon test for continuous variables. Because several clinical and laboratory variables are associated with age and because it is difficult to exclude the association of age with the event of interest, we included all relevant clinical variables in the multivariate analysis. Logistic regression analysis was used to determine the independent association of age with postoperative complications while controlling for the presence of comorbid conditions, sex, ethnicity, functional status as measured by Specific Activity Scale class, type of procedure, and preoperative laboratory data. Patients for whom data on selected variables were missing were excluded from the model. Clinically relevant variables from the regression model were analyzed for potential interactions, and potentially significant interaction terms were considered in the regression models. A two-sided P value less than 0.05 was considered statistically significant in all analyses. Linear regression models were used to estimate the independent variation in length of stay attributable to age, controlling for sex, ethnicity, preoperative clinical characteristics, American Society of Anesthesiologists classification, type of procedure, postoperative events, and in-hospital mortality. The logarithmic transformation of length of stay was used because of the non-normal distribution of this variable. The percentage change in the geometric mean of length of stay in the final model was used to estimate the numbers of adjusted hospital days attributable to age groups. All analyses were performed by using SAS statistical software for Windows, version 6.12 (SAS Institute, Inc., Cary, North Carolina). Role of the Funding Source The funding source had no role in data collection and analysis or in subsequent decisions about publication of manuscripts. Results Patients The study sample constituted 4315 patients who had a mean age of 67 9 years; 2096 patients (48%) were male and 3903 (90%) were white. Twenty-four percent (1015 patients) were younger than 59 years, 38% (1646 patients) were 60 to 69 years of age, 31% (1341 patients) were 70 to 79 years of age, and 7% (313 patients) were older than 80 years of age. These patients undergoing elective surgery had a low prevalence of comorbid conditions, and 3187 (74%) patients had Charlson Comorbidity Index scores of 0 through 2. The types of procedures performed were orthopedic (35%), intrathoracic (12%), abdominal (12%), abdominal aortic aneurysm (5%), other vascular (17%), and other general surgical procedures (33%). In the oldest age group, significantly fewer patients were male and nonwhite compared with the younger age groups (Table 1). The number of comorbid conditions and the average Charlson Comorbidity Index scores increased with increasing age. The distribution of Specific Activity Scale class and American Society of Anesthesiology class was also significantly worse in the older age groups; a greater proportion of patients 70 to 79 years of age and 80 years of age was classified as class 3 or 4. As expected, the type of surgical procedure performed varied among age groups. Higher percentages of older patients underwent orthopedic procedures, aortic aneurysm repair, and other vascular surgeries (Table 1). Table 1. Patient Characteristics Perioperative Complications Major or fatal perioperative complications occurred in 44 (4.3%) patients younger than 59 years of age, 93 (5.7%) patients 60 to 69 years of age, 129 (9.6%) patients 70 to 79 years of age, and 39 (12.5%) patients 80 years of age or older (P<0.001) (Figure). Age was significantly associated with a higher risk for cardiogenic pulmonary edema, myocardial infarction, ventricular arrhythmias, bacterial pneumonia, respiratory failure requiring intubation, and in-hospital mortality. All other major complications e
Anesthesiology | 2014
Fernando Botto; P. Alonso-Coello; Matthew T. V. Chan; Juan Carlos Villar; D. Xavier; Sadeesh Srinathan; G Guyatt; P. Cruz; Michelle M. Graham; C. Y. Wang; O. Berwanger; Rupert M Pearse; B. M. Biccard; Valsa Abraham; G. Malaga; Graham S. Hillis; Reitze N. Rodseth; Deborah J. Cook; Carisi Anne Polanczyk; Wojciech Szczeklik; D. I. Sessler; Tej Sheth; Gareth L. Ackland
Background:Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study’s four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods:In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated “abnormal” laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results:An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors’ diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6–41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion:Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.
Journal of the American College of Cardiology | 1998
Carisi Anne Polanczyk; Thomas H. Lee; E. Francis Cook; Ron M. Walls; Donald R. Wybenga; Gail Printy-Klein; Lynn E. Ludwig; Gretchen Guldbrandsen; Paula A. Johnson
OBJECTIVES We sought to evaluate the diagnostic and prognostic value of cardiac troponin I (cTnI) in emergency department (ED) patients with chest pain. BACKGROUND Although cTnI has been shown to correlate with an increased risk for complications in patients with unstable angina, the prognostic significance of this assay in the heterogeneous population of patients who present to the ED with chest pain is unclear. METHODS cTnI and creatine kinase-MB fraction (CK-MB) mass concentration were collected serially during the first 48 h from onset of symptoms in 1,047 patients > or =30 years old admitted for acute chest pain. Sensitivity, specificity and receiver operating characteristic curves were calculated for cTnI and CK-MB collected in the first 24 h. RESULTS The sensitivity, specificity and positive predictive value of cTnI for major cardiac events were 47%, 80% and 19%, respectively. Among patients were who ruled out for myocardial infarction, cTnI was elevated in 26% who had major cardiac complications compared with 5% for CK-MB; the positive predictive value for an abnormal cTnI result was 8%. Elevated cTnI in the presence of ischemia on the electrocardiogram was associated with an adjusted odds ratio of 1.8 (95% confidence interval 1.1 to 2.9) for major cardiac events within 72 h. Among patients without a myocardial infarction or unstable angina, cTnI was not an independent correlate of complications. CONCLUSIONS In patients presenting to the ED with acute chest pain, cTnI was an independent predictor of major cardiac events, However, the positive predictive value of an abnormal assay result was not high in this heterogeneous cohort.
American Journal of Cardiology | 2001
Luis Eduardo Paim Rohde; Carisi Anne Polanczyk; Lee Goldman; E. Francis Cook; Richard T. Lee; Thomas H. Lee
Transthoracic echocardiography (TTE) is frequently ordered before noncardiac surgery, although its ability to predict perioperative cardiac complications is uncertain. To evaluate the incremental information provided by TTE after consideration of clinical data for prediction of cardiac complications after noncardiac surgery, 570 patients who underwent TTE before major noncardiac surgery at a university hospital were studied. Preoperative clinical data and clinical outcomes were collected prospectively according to a structured protocol. TTE data included left ventricular (LV) function, hypertrophy indexes, and Doppler-derived measurements. In univariate analyses, preoperative systolic dysfunction was associated with postoperative myocardial infarction (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.1 to 7.0), cardiogenic pulmonary edema (OR 3.2, 95% CI 1.4 to 7.0), and major cardiac complications (OR 2.4, 95% Cl 1.3 to 4.5). Moderate to severe LV hypertrophy, moderate to severe mitral regurgitation, and increased aortic valve gradient were also associated with major cardiac events (OR 2.3, 95% CI 1.2 to 4.6; OR 2.2, 95% CI 1.1 to 4.3; OR 2.1, 95% CI 1.0 to 4.5, respectively). In logistic regression analysis, models with echocardiographic variables predicted major cardiac complications significantly better than those that included only clinical variables (c statistic 0.73 vs 0.68; p <0.05). Echocardiographic data added significant information for patients at increased risk for cardiac complications by clinical criteria, but not in otherwise low-risk patients. In conclusion, preoperative TTE before noncardiac surgery can provide independent information about the risk of postoperative cardiac complications in selected patients.
Revista De Saude Publica | 1993
Bruce Bartholow Duncan; Maria Inês Schmidt; Carisi Anne Polanczyk; Roger dos Santos Rosa; Aloyzio Cechella Achutti
Tres quartos da mortalidade no Estado do Rio Grande do Sul (Brasil) ocorrem por doencas nao-transmissiveis. Dentre elas as doencas cardiovasculares, por si so, correspondem a 35% das causas de morte. Para avaliar a prevalencia de fatores de risco para essas doencas, foi realizado inquerito domiciliar no periodo de 1986/87. Foram entrevistados 1.157 individuos entre 15-64 anos, residentes em setores censitarios de 4 areas docente-assistenciais do Municipio de Porto Alegre, RS. A prevalencia padronizada de tabagismo foi de 40%, hipertensao 14%, obesidade 18%, sedentarismo geral 47% e consumo excessivo de alcool, 7%. Trinta e nove por cento da amostra acumulavam dois ou mais desses cinco fatores de risco, somente 22% de homens e 21% de mulheres nao apresentaram esses fatores de risco. As elevadas frequencias e concomitâncias desses fatores de risco alertam para sua importância em programas que visam a prevencao das doencas nao-transmissiveis.
American Journal of Cardiology | 1998
Carisi Anne Polanczyk; Paula A. Johnson; L. Howard Hartley; Ron M. Walls; Shimon Shaykevich; Thomas H. Lee
An exercise tolerance test (ETT) is often performed to identify patients for early discharge after observation for acute chest pain, but the safety of this strategy is unproven. We prospectively studied 276 low-risk patients who underwent an ETT within 48 hours after presentation to the emergency department with acute chest pain. The ETT was considered negative if subjects achieved at least stage I of the Bruce protocol and the electrocardiogram showed no evidence of ischemia. There were no complications associated with ETT performance. The ETT was negative in 195 patients (71%); there was no identifiable subsets of patients at very low probability of an abnormal test. During the 6-month follow-up, patients with a negative ETT had fewer additional visits to the emergency department (17% vs 21%, respectively; p < 0.05) and fewer readmissions to the hospital (12% vs 17%; p < 0.01) than those with positive or inconclusive ETTs. No patient with a negative ETT died and only 4 patients with a negative ETT experienced a major cardiac event (myocardial infarction, coronary angioplasty, or bypass) within 6 months. Among these 4 patients, only 1 had an event within 4 months. In conclusion, our results suggest that ETT can be safely used to identify patients at low risk of subsequent events. Patients without a clearly negative test are at increased risk for readmission and cardiac events, and should be reevaluated either during the same admission or shortly after discharge.
The American Journal of Medicine | 2002
Carisi Anne Polanczyk; Anthereca Lane; Michelle Coburn; Edward F. Philbin; G. William Dec; Thomas G. DiSalvo
PURPOSE The possible benefit that hospital teaching status may confer in the care of patients with cardiovascular disease is unknown. Our purpose was to determine the effect of hospital teaching status on in-hospital mortality, use of invasive procedures, length of stay, and charges in patients with myocardial infarction, heart failure, or stroke. SUBJECTS AND METHODS We analyzed a New York State hospital administrative database containing information on 388 964 consecutive patients who had been admitted with heart failure (n = 173 799), myocardial infarction (n = 121 209), or stroke (n = 93 956) from 1993 to 1995. We classified the 248 participating acute care hospitals by teaching status (major, minor, nonteaching). The primary outcomes were standardized in-hospital mortality ratios, defined as the ratio of observed to predicted mortality. RESULTS Standardized in-hospital mortality ratios were significantly lower in major teaching hospitals (0.976 for heart failure, 0.945 for myocardial infarction, 0.958 for stroke) than in nonteaching hospitals (1.01 for heart failure, 1.01 for myocardial infarction, 0.995 for stroke). Standardized in-hospital mortality ratios were significantly higher for patients with stroke (1.06) but not heart failure (1.0) or myocardial infarction (1.06) in minor teaching hospitals than in nonteaching hospitals. Compared with nonteaching hospitals, use of invasive cardiac procedures and adjusted hospital charges were significantly greater in major and minor teaching hospitals for all three conditions. The adjusted length of stay was also shorter for myocardial infarction in major teaching hospitals and longer for stroke in minor teaching hospitals. CONCLUSION Major teaching hospital status was an important determinant of outcomes in patients hospitalized with myocardial infarction, heart failure, or stroke in New York State.
Revista De Saude Publica | 1993
Maria Inês Schmidt; Bruce Bartholow Duncan; Mário Tavares; Carisi Anne Polanczyk; Lucia Campos Pellanda; Paulo M Zimmer
In order to evaluate the validity of self-reported weight for use in obesity prevalence surveys, self-reported weight was compared to measured weight for 659 adults living in the Porto Alegre county, RS Brazil in 1986-87, both weights being obtained by a technician in the individuals home on the same visit. The mean difference between self-reported and measured weight was small (-0.06 +/- 3.16 kg; mean +/- standard deviation), and the correlation between reported and measured weight was high (r = 0.97). Sixty-two percent of participants reported their weight with an error of < 2 kg, 87% with an error of < 4 kg, and 95% with an error of < 6 kg. Underweight individuals overestimated their weight, while obese individuals underestimated theirs (p < 0.05). Men tended to overestimate their weight and women underestimate theirs, this difference between sexes being statistically significant (p = 0.04). The overall prevalence of underweight (body mass index < 20) by reported weight was 11%, by measured weight 13%; the overall prevalence of obesity (body mass index > or = 30) by reported weight was 10%, by measured weight 11%. Thus, the validity of reported weight is acceptable for surveys of the prevalence of ponderosity in similar settings.
Arquivos Brasileiros De Cardiologia | 2005
Rodrigo Antonini Ribeiro; Renato Gorga Bandeira de Mello; Raquel Melchior; Juliana de Castro Dill; Clarissa Barlem Hohmann; Angélica M. Lucchese; Ricardo Stein; Jorge Pinto Ribeiro; Carisi Anne Polanczyk
OBJECTIVE To estimate the annual cost of coronary artery disease (CAD) management in Public Health Care System (SUS) and HMOs values in Brazil. METHODS Cohort study, including ambulatory patients with proven CAD. Clinic visits, exams, procedures, hospitalizations and medications were considered to estimate direct costs. Values of appointments and exams were obtained from the SUS and the Medical Procedure List (LPM 1999) reimbursement tables. Costs of cardiovascular events were obtained from admissions in public and private hospitals with similar diagnoses-related group classifications in 2002. The price of medications used was the lowest found in the market. RESULTS The 147 patients (65 +/- 12 years old, 63% men, 69% hypertensive, 35% diabetic and 59% with previous AMI) had an average follow-up of 24 +/- 8 months. The average estimated annual cost per patient was R
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Luciane Maria Fabian Restelatto
Universidade Federal do Rio Grande do Sul
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