Carolina Lourenço

Can We Improve Outcomes in Patients With Previous Coronary Artery Bypass Surgery Admitted for Acute Coronary Syndrome

INTRODUCTION AND OBJECTIVES Prognosis and in-hospital management of patients with acute coronary syndrome (ACS) and a history of coronary artery bypass graft (CABG) surgery are still debated. The objective of this study was to characterize ACS patients with a CABG and to compare their in-hospital and postdischarge outcomes with those of patients without a CABG. METHODS This ongoing prospective observational study included 1,495 consecutive patients admitted for ACS to a coronary care unit and followed up for a mean of 19 months. There were two groups: group A (n=73), with CABGs; and group B (n=1,223), without CABGs. RESULTS Group A patients were more often male (86.3% versus 69.1%; P=.002), and more frequently had a history of diabetes, myocardial infarction and heart failure. Group B patients more frequently had ST-elevation myocardial infarction, and had a higher median ejection fraction (53% [interquartile range, 47%-60%] vs. 50% [42%-55%]; P< .01) and peak troponin-I concentration. There was no difference in the use of invasive techniques. Regarding medication, Group B patients were more likely to receive dual antiplatelet therapy at discharge. No significant difference was observed in in-hospital mortality (9.5% versus 5.9%; P=.2) or mortality at 1 month, 6 months or 1 year (9.8% versus 9.1%; log-rank test, P=.87) and the cumulative major adverse cardiac event rate was equally low in both groups. The presence of a CABG was associated with more readmissions for unstable angina (11.3% vs. 3.1%; P< .01). CONCLUSIONS In our ACS patients, the presence of a CABG had no significant influence on short- or medium-term outcomes, such as all-cause mortality and adverse cardiac events.

Left ventricular end diastolic pressure and acute coronary syndromes

BACKGROUND Data is lacking in the literature regarding the prognostic impact of left ventricular-end diastolic pressure (LVEDP) across acute coronary syndromes (ACS). OBJECTIVE To assess LVEDP and its prognostic implications in ACS patients. METHODS Prospective, longitudinal and continuous study of 1329 ACS patients from a single center between 2004 and 2006. Diastolic function was determined by LVEDP. Population was divided in two groups: A - LVEDP < 26.5 mmHg (n = 449); group B - LVEDP ≥ 26.5 mmHg (n = 226). RESULTS There were no significant differences between groups with respect to risk factors for cardiovascular disease, medical history and medical therapy during admission. In group A, patients with non-ST elevation ACS were more frequent, as well as normal coronary angiograms. In-hospital mortality was similar between groups, but one-year survival was higher in group A patients (96.9 vs 91.2%, log rank p = 0.002). On a multivariate Cox regression model, a LVEDP ≥ 26.5 mmHg (HR 2.45, 95%CI 1.05 - 5.74) remained an independent predictor for one-year mortality, when adjusted for age, LV systolic ejection fraction, ST elevation ACS, peak troponin, admission glycemia, and diuretics at 24 hours. Also, a LVEDP ≥ 26.5 mmHg was an independent predictor for a future readmission due to congestive HF (HR 6.65 95%CI 1.74 - 25.5). CONCLUSION In our selected population, LVEDP had a significant prognostic influence.FUNDAMENTO: Ha falta de dados sobre o impacto prognostico da pressao diastolica final do ventriculo esquerdo (PDFVE) sobre as sindromes coronarianas agudas (SCA). OBJETIVO: Avaliar a PDFVE e suas implicacoes prognosticas em pacientes com SCA. METODOS: Estudo prospectivo, longitudinal e continuo de 1.329 pacientes com SCA de um unico centro, realizado entre 2004 e 2006. A funcao diastolica foi determinada atraves da PDFVE. A populacao foi dividida em dois grupos: Grupo A - PDFVE 26,5 mmHg (n = 226). RESULTADOS: Nao houve diferencas significantes entre os grupos em relacao aos fatores de risco para doenca cardiovascular, historico medico e terapia medica durante a admissao. Nos pacientes do grupo A, a SCA sem elevacao do segmento ST foi mais frequente, bem como angiogramas coronarios normais. A mortalidade hospitalar foi similar entre os grupos, mas a sobrevida de um ano foi maior entre os pacientes do grupo A (96,9 vs 91,2%, log rank p = 0,002). Em um modelo multivariado de regressao de Cox, uma PDFVE > 26,5 mmHg (RR 2,45, IC95% 1,05 - 5,74) permaneceu um preditor independente para mortalidade de um ano, quando ajustado para idade, fracao de ejecao sistolica do VE, SCA com elevacao do segmento ST, pico da troponina, glicemia na admissao hospitalar e diureticos apos 24 horas. Alem disso, uma PDFVE > 26,5 mmHg foi um preditor independente de uma futura rehospitalizacao por IC congestiva (RR 6,65 IC95% 1,74 - 25,5). CONCLUSAO: Em nossa populacao selecionada, a PDFVE apresentou uma influencia prognostica significante.

Impact of previous insulin therapy on the prognosis of diabetic patients with acute coronary syndromes

OBJECTIVE To determine whether previous insulin treatment independently influences subsequent outcomes in diabetic patients with ACS (acute coronary syndromes). SUBJECTS AND METHODS 375 diabetic patients with ACS, divided in 2 groups: Group A (n = 69)--previous insulin and Group B (n = 306)--without previous insulin. Predictors of 1-year mortality and major adverse cardiac events (MACE) were analyzed by Cox regression analysis. RESULTS Group A had more previous stroke (17.4% vs. 9.2%, p = 0.047) and peripheral artery disease (13.0% vs. 3.6%, p = 0.005). They had significantly higher admission glycemia and lower LDL cholesterol. There were no significant differences in the type of ACS, in 1-year mortality (18.2% vs. 10.4%, p = 0.103) or MACE (32.1% vs. 23.0%, p = 0.146) between groups. In multivariate analysis, insulin treatment was neither an independent predictor of 1-year mortality nor of MACE. CONCLUSION Despite the more advanced atherosclerotic disease, diabetics under insulin had similar outcomes to those without insulin. Insulin may protect diabetics from the expected poor adverse outcome of an advanced atherosclerotic disease.

Pressão diastólica final do ventrículo esquerdo e síndromes coronarianas agudas

BACKGROUND Data is lacking in the literature regarding the prognostic impact of left ventricular-end diastolic pressure (LVEDP) across acute coronary syndromes (ACS). OBJECTIVE To assess LVEDP and its prognostic implications in ACS patients. METHODS Prospective, longitudinal and continuous study of 1329 ACS patients from a single center between 2004 and 2006. Diastolic function was determined by LVEDP. Population was divided in two groups: A - LVEDP < 26.5 mmHg (n = 449); group B - LVEDP ≥ 26.5 mmHg (n = 226). RESULTS There were no significant differences between groups with respect to risk factors for cardiovascular disease, medical history and medical therapy during admission. In group A, patients with non-ST elevation ACS were more frequent, as well as normal coronary angiograms. In-hospital mortality was similar between groups, but one-year survival was higher in group A patients (96.9 vs 91.2%, log rank p = 0.002). On a multivariate Cox regression model, a LVEDP ≥ 26.5 mmHg (HR 2.45, 95%CI 1.05 - 5.74) remained an independent predictor for one-year mortality, when adjusted for age, LV systolic ejection fraction, ST elevation ACS, peak troponin, admission glycemia, and diuretics at 24 hours. Also, a LVEDP ≥ 26.5 mmHg was an independent predictor for a future readmission due to congestive HF (HR 6.65 95%CI 1.74 - 25.5). CONCLUSION In our selected population, LVEDP had a significant prognostic influence.FUNDAMENTO: Ha falta de dados sobre o impacto prognostico da pressao diastolica final do ventriculo esquerdo (PDFVE) sobre as sindromes coronarianas agudas (SCA). OBJETIVO: Avaliar a PDFVE e suas implicacoes prognosticas em pacientes com SCA. METODOS: Estudo prospectivo, longitudinal e continuo de 1.329 pacientes com SCA de um unico centro, realizado entre 2004 e 2006. A funcao diastolica foi determinada atraves da PDFVE. A populacao foi dividida em dois grupos: Grupo A - PDFVE 26,5 mmHg (n = 226). RESULTADOS: Nao houve diferencas significantes entre os grupos em relacao aos fatores de risco para doenca cardiovascular, historico medico e terapia medica durante a admissao. Nos pacientes do grupo A, a SCA sem elevacao do segmento ST foi mais frequente, bem como angiogramas coronarios normais. A mortalidade hospitalar foi similar entre os grupos, mas a sobrevida de um ano foi maior entre os pacientes do grupo A (96,9 vs 91,2%, log rank p = 0,002). Em um modelo multivariado de regressao de Cox, uma PDFVE > 26,5 mmHg (RR 2,45, IC95% 1,05 - 5,74) permaneceu um preditor independente para mortalidade de um ano, quando ajustado para idade, fracao de ejecao sistolica do VE, SCA com elevacao do segmento ST, pico da troponina, glicemia na admissao hospitalar e diureticos apos 24 horas. Alem disso, uma PDFVE > 26,5 mmHg foi um preditor independente de uma futura rehospitalizacao por IC congestiva (RR 6,65 IC95% 1,74 - 25,5). CONCLUSAO: Em nossa populacao selecionada, a PDFVE apresentou uma influencia prognostica significante.

A importância de um EGC normal em síndromes coronarianas agudas sem supradesnivelamento do segmento ST

FUNDAMENTO: El electrocardiograma (ECG) de ingreso tiene un gran impacto en el diagnostico y tratamiento de sindromes coronarios agudos (SCA) sin supradesnivel del segmento ST. OBJETIVO: Evaluar el impacto del ECG de ingreso en el pronostico del SCA sin supradesnivel de ST. METODOS: Poblacion: estudio prospectivo, continuo, observacional, de 802 pacientes con SCA sin supradesnivel de ST de un unico centro. Los pacientes se dividieron en 2 grupos: A (n=538) - ECG Anormal y B (n=264) - ECG Normal. ECG Normal era sinonimo de ritmo sinusal sin alteraciones isquemicas agudas. Se realizo un seguimiento clinico de un ano teniendo como objetivo todas las causas de mortalidad y la tasa de eventos cardiacos adversos mayores (MACE). RESULTADOS: Los pacientes del Grupo A eran mas viejos (68,7±11,7 vs 63,4±12,7 anos, p<0,001), presentaban clases Killip mas altas y picos mas altos de biomarcadores de necrosis miocardica. Ademas de ello, presentaban menor fraccion de eyeccion del ventriculo izquierdo (FEVI) (52,01±10,55 vs 55,34± 9,51%, p<0,001), tasa de filtrado glomerular, hemoglobina inicial, y niveles de colesterol total. Los pacientes del Grupo B fueron sometidos mas frecuentemente a estrategias invasivas (63,6 vs 46,5%, p<0,001) y tratados con aspirina, clopidogrel, betabloqueantes y estatinas. Estos tambien presentaban mas frecuentemente una anatomia coronaria normal (26,2 vs 18,0%, p=0,45). Se observo una tendencia a la mayor mortalidad hospitalaria en el grupo A (4,6 vs 1,9%, p=0,054). El analisis de Kaplan-Meyer mostro que la sobrevida de 1 mes y un ano (95,1 vs 89. 5%, p=0.012) era mas alta en el grupo B y el resultado se mantuvo significativo en un modelo de regresion de Cox (ECG normal HR 0,45 (0,21 - 0,97). No hubo diferencias con relacion a la tasa de MACE. CONCLUSION: En nuestra poblacion de pacientes son SCA sin supradesnivel de ST, un ECG normal fue un marcador inicial para un buen pronostico.BACKGROUND Admission ECG has a major impact on the diagnosis and management of non-ST elevation acute coronary syndromes (ACS). OBJECTIVE To assess the impact of the admission ECG on prognosis over non-ST ACS. POPULATION prospective, continuous, observational study of 802 non-ST ACS patients from a single center. METHODS Patients were divided in 2 groups: A (n=538) - Abnormal ECG and B (n=264) - Normal ECG. Normal ECG was synonymous of sinus rhythm and no acute ischemic changes. A one-year clinical follow up was performed targeting all causes of mortality and the MACE rate. RESULTS Group A patients were older (68.7+/-11.7 vs. 63.4+/-12.7Y, p<0.001), had higher Killip classes and peak myocardial necrosis biomarkers. Furthermore, they had lower left ventricular ejection fraction (LVEF) (52.01+/-10.55 vs. 55.34+/- 9.51%, p<0.001), glomerular filtration rate, initial hemoglobin, and total cholesterol levels. Group B patients were more frequently submitted to invasive strategy (63.6 vs. 46.5%, p<0.001) and treated with aspirin, clopidogrel, beta blockers and statins. They also more often presented normal coronary anatomy (26.2 vs. 18.0%, p=0.45). There was a trend to higher in-hospital mortality in group A (4.6 vs. 1.9%, p=0.054). Kaplan-Meyer analysis showed that at one month and one year (95.1 vs. 89.5%, p=0.012) survival was higher in group B and the result remained significant on a Cox regression model (normal ECG HR 0.45 (0.21 - 0.97). There were no differences regarding the MACE rate. CONCLUSION In our non-ST elevation ACS population, a normal ECG was an early marker for good prognosis.

Transcatheter Closure of a Traumatic VSD with an ASD Occluder

Traumatic ventricular septal defects (VSD) are exceptionally rare. They can be a consequence of either blunt or penetrating trauma. It is believed that most patients die before reaching the hospital, which makes this condition even more challenging. Percutaneous closure of traumatic VSD has been presented as an alternative to open conventional surgery.1 Transcatheter intervention may have some benefits. The objective of this case report is to present a situation where the defect was closed using an Amplatzer septal occluder. Case Report A 23-year-old man was admitted in the emergency department after a frontal car collision. He had suffered severe blunt trauma, which included cervical subcutaneous emphysema, bilateral pulmonary contusion, left hemothorax, pneumomediastinum and complex fractures of both femurs. He was in hemorrhagic shock and was immediately taken to the operatory room. After external fixation of both femurs and reaching hemodynamic stability, he was transferred to the Intensive Care Unit. The following morning the presence of a loud holosystolic murmur was noted. The 12-lead electrocardiogram showed only sinus tachycardia. A transthoracic and later a transesophageal echocardiogram (TEE) were performed and both demonstrated a large muscular ventricular septal defect, located in the mid anteroseptal segment with signs of dissection through the basal septum (Figure 1). It measured 19 mm on the left ventricular (LV) side and 7 mm on the right ventricular (RV) side. The peak left to right shunt gradient was estimated in 84 mmHg and the Qp/Qs ratio was estimated in 1.8/1.0. Cardiac catheterization showed limited hemodynamic repercussion (systolic pulmonary artery pressure of 35 mmHg and a Qp/Qs ratio of 1.9/1.0) and the patient remained clinically stable, so a conservative strategy was decided at that time to allow the edges to heal and create a more delimited defect. Open in a separate window Figure 1 Echocardiographic images of the VSD. Panel A: VSD located in the mid anteroseptal segment. Panel B: VSD measuring 19 mm on the LV side and 7 mm on the RV side. Panel C: continuous wave Doppler estimating peak gradient at 84 mmHg.

Eosinophilic Myocarditis: Clinical Case and Literature Review

Eosinophilic myocarditis is a rare and potentially lethal disease characterized by eosinophil infiltration of the myocardium.1 The association between eosinophilia and myocardial injury is well established and may present several etiologies, from hypersensitivity and autoimmune diseases to neoplasias and infections.1,2 In some cases the etiology remains unknown, and it is denominated idiopathic hypereosinophilic syndrome. Clinical manifestations present a wide spectrum, ranging from mild symptomatology to severe symptoms such as retrosternal pain, rhythm disturbances, and sudden death.2,3 The definitive diagnosis is made through endomyocardial biopsy.1 Cardiac magnetic resonance imaging is a valid alternative, identifying the main structural changes caused by myocarditis.4 Treatment includes neurohumoral therapy, management of cardiac complications, and in cases selected, systemic corticosteroid therapy.5 Next, we present the case of a patient with symptomatology suggestive of myocardial infarction, but who in the course of the investigation had the diagnosis of eosinophilic myocarditis.

Anabolic drugs and myocardial infarction - a clinical case report.

In most cases of myocardial infarction (MI) in young people, traditional cardiovascular risk factors continue to be of utmost importance; but at this age, other causes should also be considered, such as drug abuse. Anabolic steroids are synthetic derivatives of testosterone and are often illegally used by athletes to increase their physical performance. There is a correlation between the use of these drugs and increased cardiovascular risk1. Human growth hormone (hGH) has also been used to increase physical performance, despite the risk of cardiovascular complications2. Clenbuterol is a potent β2-agonist that also has anabolic effects. However, at present, little is known about its potential cardiovascular risk3. Despite reports of MI associated with the use of anabolic steroids, no previous studies have reported the simultaneous use of these three types of medications.

Presión diastólica final del ventrículo izquierdo y síndromes coronarios agudos

BACKGROUND Data is lacking in the literature regarding the prognostic impact of left ventricular-end diastolic pressure (LVEDP) across acute coronary syndromes (ACS). OBJECTIVE To assess LVEDP and its prognostic implications in ACS patients. METHODS Prospective, longitudinal and continuous study of 1329 ACS patients from a single center between 2004 and 2006. Diastolic function was determined by LVEDP. Population was divided in two groups: A - LVEDP < 26.5 mmHg (n = 449); group B - LVEDP ≥ 26.5 mmHg (n = 226). RESULTS There were no significant differences between groups with respect to risk factors for cardiovascular disease, medical history and medical therapy during admission. In group A, patients with non-ST elevation ACS were more frequent, as well as normal coronary angiograms. In-hospital mortality was similar between groups, but one-year survival was higher in group A patients (96.9 vs 91.2%, log rank p = 0.002). On a multivariate Cox regression model, a LVEDP ≥ 26.5 mmHg (HR 2.45, 95%CI 1.05 - 5.74) remained an independent predictor for one-year mortality, when adjusted for age, LV systolic ejection fraction, ST elevation ACS, peak troponin, admission glycemia, and diuretics at 24 hours. Also, a LVEDP ≥ 26.5 mmHg was an independent predictor for a future readmission due to congestive HF (HR 6.65 95%CI 1.74 - 25.5). CONCLUSION In our selected population, LVEDP had a significant prognostic influence.FUNDAMENTO: Ha falta de dados sobre o impacto prognostico da pressao diastolica final do ventriculo esquerdo (PDFVE) sobre as sindromes coronarianas agudas (SCA). OBJETIVO: Avaliar a PDFVE e suas implicacoes prognosticas em pacientes com SCA. METODOS: Estudo prospectivo, longitudinal e continuo de 1.329 pacientes com SCA de um unico centro, realizado entre 2004 e 2006. A funcao diastolica foi determinada atraves da PDFVE. A populacao foi dividida em dois grupos: Grupo A - PDFVE 26,5 mmHg (n = 226). RESULTADOS: Nao houve diferencas significantes entre os grupos em relacao aos fatores de risco para doenca cardiovascular, historico medico e terapia medica durante a admissao. Nos pacientes do grupo A, a SCA sem elevacao do segmento ST foi mais frequente, bem como angiogramas coronarios normais. A mortalidade hospitalar foi similar entre os grupos, mas a sobrevida de um ano foi maior entre os pacientes do grupo A (96,9 vs 91,2%, log rank p = 0,002). Em um modelo multivariado de regressao de Cox, uma PDFVE > 26,5 mmHg (RR 2,45, IC95% 1,05 - 5,74) permaneceu um preditor independente para mortalidade de um ano, quando ajustado para idade, fracao de ejecao sistolica do VE, SCA com elevacao do segmento ST, pico da troponina, glicemia na admissao hospitalar e diureticos apos 24 horas. Alem disso, uma PDFVE > 26,5 mmHg foi um preditor independente de uma futura rehospitalizacao por IC congestiva (RR 6,65 IC95% 1,74 - 25,5). CONCLUSAO: Em nossa populacao selecionada, a PDFVE apresentou uma influencia prognostica significante.

La importancia de un ECG normal en síndromes coronarios agudos sin supradesnivel del segmento ST

FUNDAMENTO: El electrocardiograma (ECG) de ingreso tiene un gran impacto en el diagnostico y tratamiento de sindromes coronarios agudos (SCA) sin supradesnivel del segmento ST. OBJETIVO: Evaluar el impacto del ECG de ingreso en el pronostico del SCA sin supradesnivel de ST. METODOS: Poblacion: estudio prospectivo, continuo, observacional, de 802 pacientes con SCA sin supradesnivel de ST de un unico centro. Los pacientes se dividieron en 2 grupos: A (n=538) - ECG Anormal y B (n=264) - ECG Normal. ECG Normal era sinonimo de ritmo sinusal sin alteraciones isquemicas agudas. Se realizo un seguimiento clinico de un ano teniendo como objetivo todas las causas de mortalidad y la tasa de eventos cardiacos adversos mayores (MACE). RESULTADOS: Los pacientes del Grupo A eran mas viejos (68,7±11,7 vs 63,4±12,7 anos, p<0,001), presentaban clases Killip mas altas y picos mas altos de biomarcadores de necrosis miocardica. Ademas de ello, presentaban menor fraccion de eyeccion del ventriculo izquierdo (FEVI) (52,01±10,55 vs 55,34± 9,51%, p<0,001), tasa de filtrado glomerular, hemoglobina inicial, y niveles de colesterol total. Los pacientes del Grupo B fueron sometidos mas frecuentemente a estrategias invasivas (63,6 vs 46,5%, p<0,001) y tratados con aspirina, clopidogrel, betabloqueantes y estatinas. Estos tambien presentaban mas frecuentemente una anatomia coronaria normal (26,2 vs 18,0%, p=0,45). Se observo una tendencia a la mayor mortalidad hospitalaria en el grupo A (4,6 vs 1,9%, p=0,054). El analisis de Kaplan-Meyer mostro que la sobrevida de 1 mes y un ano (95,1 vs 89. 5%, p=0.012) era mas alta en el grupo B y el resultado se mantuvo significativo en un modelo de regresion de Cox (ECG normal HR 0,45 (0,21 - 0,97). No hubo diferencias con relacion a la tasa de MACE. CONCLUSION: En nuestra poblacion de pacientes son SCA sin supradesnivel de ST, un ECG normal fue un marcador inicial para un buen pronostico.BACKGROUND Admission ECG has a major impact on the diagnosis and management of non-ST elevation acute coronary syndromes (ACS). OBJECTIVE To assess the impact of the admission ECG on prognosis over non-ST ACS. POPULATION prospective, continuous, observational study of 802 non-ST ACS patients from a single center. METHODS Patients were divided in 2 groups: A (n=538) - Abnormal ECG and B (n=264) - Normal ECG. Normal ECG was synonymous of sinus rhythm and no acute ischemic changes. A one-year clinical follow up was performed targeting all causes of mortality and the MACE rate. RESULTS Group A patients were older (68.7+/-11.7 vs. 63.4+/-12.7Y, p<0.001), had higher Killip classes and peak myocardial necrosis biomarkers. Furthermore, they had lower left ventricular ejection fraction (LVEF) (52.01+/-10.55 vs. 55.34+/- 9.51%, p<0.001), glomerular filtration rate, initial hemoglobin, and total cholesterol levels. Group B patients were more frequently submitted to invasive strategy (63.6 vs. 46.5%, p<0.001) and treated with aspirin, clopidogrel, beta blockers and statins. They also more often presented normal coronary anatomy (26.2 vs. 18.0%, p=0.45). There was a trend to higher in-hospital mortality in group A (4.6 vs. 1.9%, p=0.054). Kaplan-Meyer analysis showed that at one month and one year (95.1 vs. 89.5%, p=0.012) survival was higher in group B and the result remained significant on a Cox regression model (normal ECG HR 0.45 (0.21 - 0.97). There were no differences regarding the MACE rate. CONCLUSION In our non-ST elevation ACS population, a normal ECG was an early marker for good prognosis.