Edson Stefanini

Use of demonstrably effective therapies in the treatment of acute coronary syndromes: comparison between different Brazilian regions. Analysis of the Brazilian Registry on Acute Coronary Syndromes (BRACE).

BACKGROUND: Little is known in our country about regional differences in the treatment of acute coronary disease. OBJECTIVE: To analyze the behavior regarding the use of demonstrably effective regional therapies in acute coronary disease. METHODS: A total of 71 hospitals were randomly selected, respecting the proportionality of the country in relation to geographic location, among other criteria. In the overall population was regionally analyzed the use of aspirin, clopidogrel, ACE inhibitors / AT1 blocker, beta-blockers and statins, separately and grouped by individual score ranging from 0 (no drug used) to 100 (all drugs used). In myocardial infarction with ST elevation (STEMI) regional differences were analyzed regarding the use of therapeutic recanalization (fibrinolytics and primary angioplasty). RESULTS: In the overall population, within the first 24 hours of hospitalization, the mean score in the North-Northeast (70.5 ± 22.1) was lower (p <0.05) than in the Southeast (77.7 ± 29.5), Midwest (82 ± 22.1) and South (82.4 ± 21) regions. At hospital discharge, the score of the North-Northeast region (61.4 ± 32.9) was lower (p <0.05) than in the Southeast (69.2 ± 31.6), Midwest (65.3 ± 33.6) and South (73.7 ± 28.1) regions; additionally, the score of the Midwest was lower (p <0.05) than the South region. In STEMI, the use of recanalization therapies was highest in the Southeast (75.4%, p = 0.001 compared to the rest of the country), and lowest in the North-Northeast (52.5%, p <0.001 compared to the rest of the country). CONCLUSION: The use of demonstrably effective therapies in the treatment of acute coronary disease is much to be desired in the country, with important regional differences.BACKGROUND Little is known in our country about regional differences in the treatment of acute coronary disease. OBJECTIVE To analyze the behavior regarding the use of demonstrably effective regional therapies in acute coronary disease. METHODS A total of 71 hospitals were randomly selected, respecting the proportionality of the country in relation to geographic location, among other criteria. In the overall population was regionally analyzed the use of aspirin, clopidogrel, ACE inhibitors / AT1 blocker, beta-blockers and statins, separately and grouped by individual score ranging from 0 (no drug used) to 100 (all drugs used). In myocardial infarction with ST elevation (STEMI) regional differences were analyzed regarding the use of therapeutic recanalization (fibrinolytics and primary angioplasty). RESULTS In the overall population, within the first 24 hours of hospitalization, the mean score in the North-Northeast (70.5 ± 22.1) was lower (p <0.05) than in the Southeast (77.7 ± 29.5), Midwest (82 ± 22.1) and South (82.4 ± 21) regions. At hospital discharge, the score of the North-Northeast region (61.4 ± 32.9) was lower (p <0.05) than in the Southeast (69.2 ± 31.6), Midwest (65.3 ± 33.6) and South (73.7 ± 28.1) regions; additionally, the score of the Midwest was lower (p <0.05) than the South region. In STEMI, the use of recanalization therapies was highest in the Southeast (75.4%, p = 0.001 compared to the rest of the country), and lowest in the North-Northeast (52.5%, p <0.001 compared to the rest of the country). CONCLUSION The use of demonstrably effective therapies in the treatment of acute coronary disease is much to be desired in the country, with important regional differences.

Predictors of in-hospital mortality in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive treatment

OBJECTIVES: To identify predictors of in-hospital mortality in patients with acute myocardial infarction undergoing pharmacoinvasive treatment. METHODS: This was an observational, prospective study that included 398 patients admitted to a tertiary center for percutaneous coronary intervention within 3 to 24 hours after thrombolysis with tenecteplase. ClinicalTrials.gov: NCT01791764 RESULTS: The overall in-hospital mortality rate was 5.8%. Compared with patients who survived, patients who died were more likely to be older, have higher rates of diabetes and chronic renal failure, have a lower left ventricular ejection fraction, and demonstrate more evidence of heart failure (Killip class III or IV). Patients who died had significantly lower rates of successful thrombolysis (39% vs. 68%; p = 0.005) and final myocardial blush grade 3 (13.0% vs. 61.9%; p<0.0001). Based on the multivariate analysis, the Global Registry of Acute Coronary Events score (odds ratio 1.05, 95% confidence interval (CI) 1.02-1.09; p = 0.001), left ventricular ejection fraction (odds ratio 0.9, 95% CI 0.89-0.97; p = 0.001), and final myocardial blush grade of 0-2 (odds ratio 8.85, 95% CI 1.34-58.57; p = 0.02) were independent predictors of mortality. CONCLUSIONS: In this prospective study that evaluated patients with ST-segment elevation myocardial infarction treated by a pharmacoinvasive strategy, the in-hospital mortality rate was 5.8%. The Global Registry of Acute Coronary Events score, left ventricular ejection fraction, and myocardial blush were independent predictors of mortality in this high-risk group of acute coronary syndrome patients.

Analysis of Plasma Homocysteine Levels in Patients with Unstable Angina

OBJECTIVE To determine the prevalence of hyperhomocystinemia in patients with acute ischemic syndrome of the unstable angina type. METHODS We prospectively studied 46 patients (24 females) with unstable angina and 46 control patients (19 males), paired by sex and age, blinded to the laboratory data. Details of diets, smoking habits, medication used, body mass index, and the presence of hypertension and diabetes were recorded, as were plasma lipid and glucose levels, C-reactive protein, and lipoperoxidation in all participants. Patients with renal disease were excluded. Plasma homocysteine was estimated using high-pressure liquid chromatography. RESULTS Plasma homocysteine levels were significantly higher in the group of patients with unstable angina (12.7+/-6.7 micromol/L) than in the control group (8.7+/-4.4 micromol/L) (p<0.05). Among males, homocystinemia was higher in the group with unstable angina than in the control group, but this difference was not statistically significant (14.1+/-5.9 micromol/L versus 11.9+/-4.2 micromol/L). Among females, however, a statistically significant difference was observed between the 2 groups: 11.0+/-7.4 micromol/L versus 6.4+/-2.9 micromol/L (p<0.05) in the unstable angina and control groups, respectively. Approximately 24% of the patients had unstable angina at homocysteine levels above 15 micromol/L. CONCLUSION High homocysteine levels seem to be a relevant prevalent factor in the population with unstable angina, particularly among females.

Utilização de terapêuticas comprovadamente úteis no tratamento da coronariopatia aguda: comparação entre diferentes regiões brasileiras. Análise do Registro Brasileiro de Síndromes Coronarianas Agudas (BRACE - Brazilian Registry on Acute Coronary Syndromes)

BACKGROUND: Little is known in our country about regional differences in the treatment of acute coronary disease. OBJECTIVE: To analyze the behavior regarding the use of demonstrably effective regional therapies in acute coronary disease. METHODS: A total of 71 hospitals were randomly selected, respecting the proportionality of the country in relation to geographic location, among other criteria. In the overall population was regionally analyzed the use of aspirin, clopidogrel, ACE inhibitors / AT1 blocker, beta-blockers and statins, separately and grouped by individual score ranging from 0 (no drug used) to 100 (all drugs used). In myocardial infarction with ST elevation (STEMI) regional differences were analyzed regarding the use of therapeutic recanalization (fibrinolytics and primary angioplasty). RESULTS: In the overall population, within the first 24 hours of hospitalization, the mean score in the North-Northeast (70.5 ± 22.1) was lower (p <0.05) than in the Southeast (77.7 ± 29.5), Midwest (82 ± 22.1) and South (82.4 ± 21) regions. At hospital discharge, the score of the North-Northeast region (61.4 ± 32.9) was lower (p <0.05) than in the Southeast (69.2 ± 31.6), Midwest (65.3 ± 33.6) and South (73.7 ± 28.1) regions; additionally, the score of the Midwest was lower (p <0.05) than the South region. In STEMI, the use of recanalization therapies was highest in the Southeast (75.4%, p = 0.001 compared to the rest of the country), and lowest in the North-Northeast (52.5%, p <0.001 compared to the rest of the country). CONCLUSION: The use of demonstrably effective therapies in the treatment of acute coronary disease is much to be desired in the country, with important regional differences.BACKGROUND Little is known in our country about regional differences in the treatment of acute coronary disease. OBJECTIVE To analyze the behavior regarding the use of demonstrably effective regional therapies in acute coronary disease. METHODS A total of 71 hospitals were randomly selected, respecting the proportionality of the country in relation to geographic location, among other criteria. In the overall population was regionally analyzed the use of aspirin, clopidogrel, ACE inhibitors / AT1 blocker, beta-blockers and statins, separately and grouped by individual score ranging from 0 (no drug used) to 100 (all drugs used). In myocardial infarction with ST elevation (STEMI) regional differences were analyzed regarding the use of therapeutic recanalization (fibrinolytics and primary angioplasty). RESULTS In the overall population, within the first 24 hours of hospitalization, the mean score in the North-Northeast (70.5 ± 22.1) was lower (p <0.05) than in the Southeast (77.7 ± 29.5), Midwest (82 ± 22.1) and South (82.4 ± 21) regions. At hospital discharge, the score of the North-Northeast region (61.4 ± 32.9) was lower (p <0.05) than in the Southeast (69.2 ± 31.6), Midwest (65.3 ± 33.6) and South (73.7 ± 28.1) regions; additionally, the score of the Midwest was lower (p <0.05) than the South region. In STEMI, the use of recanalization therapies was highest in the Southeast (75.4%, p = 0.001 compared to the rest of the country), and lowest in the North-Northeast (52.5%, p <0.001 compared to the rest of the country). CONCLUSION The use of demonstrably effective therapies in the treatment of acute coronary disease is much to be desired in the country, with important regional differences.

Sumário de atualização da II Diretriz Brasileira de Insuficiência Cardíaca Aguda 2009/2011

In the past two years we observed several changes in the diagnostic and therapeutic approach of patients with acute heart failure (acute HF), which led us to the need of performing a summary update of the II Brazilian Guidelines on Acute Heart Failure 2009. In the diagnostic evaluation, the diagnostic flowchart was simplified and the role of clinical assessment and echocardiography was enhanced. In the clinical-hemodynamic evaluation on admission, the hemodynamic echocardiography gained prominence as an aid to define this condition in patients with acute HF in the emergency room. In the prognostic evaluation, the role of biomarkers was better established and the criteria and prognostic value of the cardiorenal syndrome was better defined. The therapeutic approach flowcharts were revised, and are now simpler and more objective. Among the advances in drug therapy, the safety and importance of the maintenance or introduction of beta-blockers in the admission treatment are highlighted. Anticoagulation, according to new evidence, gained a wider range of indications. The presentation hemodynamic models of acute pulmonary edema were well established, with their different therapeutic approaches, as well as new levels of indication and evidence. In the surgical treatment of acute HF, CABG, the approach to mechanical lesions and heart transplantation were reviewed and updated. This update strengthens the II Brazilian Guidelines on Acute Heart Failure to keep it updated and refreshed. All clinical cardiologists who deal with patients with acute HF will find, in the guidelines and its summary, important tools to help them with the clinical practice for better diagnosis and treatment of their patients.

Exercise may cause myocardial ischemia at the anaerobic threshold in cardiac rehabilitation programs

Myocardial ischemia may occur during an exercise session in cardiac rehabilitation programs. However, it has not been established whether it is elicited when exercise prescription is based on heart rate corresponding to the anaerobic threshold as measured by cardiopulmonary exercise testing. Our objective was to determine the incidence of myocardial ischemia in cardiac rehabilitation programs according to myocardial perfusion SPECT in exercise programs based on the anaerobic threshold. Thirty-nine patients (35 men and 4 women) diagnosed with coronary artery disease by coronary angiography and stress technetium-99m-sestamibi gated SPECT associated with a baseline cardiopulmonary exercise test were assessed. Ages ranged from 45 to 75 years. A second cardiopulmonary exercise test determined training intensity at the anaerobic threshold. Repeat gated-SPECT was obtained after a third cardiopulmonary exercise test at the prescribed workload and heart rate. Myocardial perfusion images were analyzed using a score system of 6.4 at rest, 13.9 at peak stress, and 10.7 during the prescribed exercise (P < 0.05). The presence of myocardial ischemia during exercise was defined as a difference > or = 2 between the summed stress score and summed rest score. Accordingly, 25 (64%) patients were classified as ischemic and 14 (36%) as nonischemic. MIBI-SPECT showed myocardial ischemia during exercise within the anaerobic threshold. The 64% prevalence of ischemia observed in the study should not be looked on as representative of the whole population of patients undergoing exercise programs. Changes in patient care and exercise programs were implemented as a result of our finding of ischemia during the prescribed exercise.

Transitory myocardial ischemia in patients with vascular lower limb amputation: relationship with long-term atherothrombotic events.

Ingham SJM, Chamlian TR, de Souza JM, Stefanini E, Azevedo R, Mussi A, Carvalho AC: Transitory myocardial ischemia in patients with vascular lower limb amputation: Relationship with long-term atherothrombotic events. Objective:To evaluate the prevalence of asymptomatic transitory myocardial ischemia during scintigraphy among amputees of vascular etiology as well as to ascertain correlation with atherothrombotic events during long-term follow-up. Design:A cohort, mean follow-up of 2.1 yrs study was performed in an outpatient rehabilitation clinic with 58 lower limb vascular amputees who were referred for rehabilitation, asymptomatic for coronary heart disease. Patients were evaluated for myocardial ischemia by dipyridamole scintigraphy, and occurrence of severe cardiovascular events (death, acute myocardial infarction, stroke, and peripheral ischemia with hospitalization) was assessed. Results:Of the 58 patients, 26 (44.8%) had positive dipyridamole myocardial scintigraphy for transitory myocardial ischemia. During follow-up, 12 subjects (20.7%), mainly diabetic patients (83%), registered a serious cardiovascular event, with 9 of 12 events having occurred in those who had tested positive for transitory ischemia on scintigraphy (P < 0.025). There were five deaths (19.2%) in those with a positive scintigraphy and a single death (3.1%) in those with a negative dipyridamole test, although the Kaplan-Meier survival curve and Cox regression were not significant (P = 0.09 and 0.1, respectively). Conclusions:We found that 44.8% of patients with vascular lower limb amputation, asymptomatic for coronary disease, tested positive on myocardial scintigraphy for transitory myocardial ischemia. In a mean follow-up of 2.1 yrs, there was 10.3% of atherothrombotic events/year, with a higher death toll in those patients with positive scintigraphy.

Mortality after myocardial infarction: the role of renal function and systolic and diastolic functions of the left ventricle.

BACKGROUND The relationship between renal dysfunction and mortality after myocardial infarction (MI) has been demonstrated in patients with reduced ejection fraction. The importance of diastolic dysfunction in this scenario is unknown. METHODS We studied 749 patients with acute MI who were evaluated within 24 hours of symptom onset. The Modification of Diet in Renal Disease equation was used to calculate the estimated glomerular filtration rate (eGFR). Preserved and depressed renal functions were defined as eGFR >60 and <60 mL/min, respectively. Diastolic function was determined by echocardiography and classified as normal or mildly, moderately or severely reduced. The left ventricular systolic function (cutoff of 0.55) was assessed by echocardiography. RESULTS The mean age of the cohort was 62 years (±13 years); 61.3% were male, 70.2% were hypertensive, 32% were diabetic and 34.8% had hyperlipidemia. Seventy-eight patients died in hospital (10.4%), and 319 (42.6%) had an eGFR <60 mL/min. Diastolic dysfunction was present in 520 (69.4%) patients. Renal function was independently associated with worse in-hospital mortality (adjusted odds ratio 3.12, 95% confidence interval 1.71-5.69, per 10 mL/min 
decrease in eGFR <60 mL/min). For patients with normal-to-moderate diastolic dysfunction, normal renal function was not associated with increased in-hospital mortality (p-interaction = 0.01). CONCLUSIONS Impaired renal function and both systolic and diastolic dysfunctions were associated with worse in-hospital mortality. However, normal-to-moderate diastolic dysfunction in the presence of normal renal function was not associated with worse outcome. 
Efforts to preserve renal function in patients with acute myocardial infarction should be made, particularly 
in those with diastolic dysfunction.

Utilización de terapéuticas comprobadamente útiles en el tratamiento de la coronariopatía aguda: comparación entre diferentes regiones brasileñas. Análisis del Registro Brasileño de Síndromes Coronarios Agudos (BRACE - Brazilian Registry on Acute Coronary Syndromes)

BACKGROUND: Little is known in our country about regional differences in the treatment of acute coronary disease. OBJECTIVE: To analyze the behavior regarding the use of demonstrably effective regional therapies in acute coronary disease. METHODS: A total of 71 hospitals were randomly selected, respecting the proportionality of the country in relation to geographic location, among other criteria. In the overall population was regionally analyzed the use of aspirin, clopidogrel, ACE inhibitors / AT1 blocker, beta-blockers and statins, separately and grouped by individual score ranging from 0 (no drug used) to 100 (all drugs used). In myocardial infarction with ST elevation (STEMI) regional differences were analyzed regarding the use of therapeutic recanalization (fibrinolytics and primary angioplasty). RESULTS: In the overall population, within the first 24 hours of hospitalization, the mean score in the North-Northeast (70.5 ± 22.1) was lower (p <0.05) than in the Southeast (77.7 ± 29.5), Midwest (82 ± 22.1) and South (82.4 ± 21) regions. At hospital discharge, the score of the North-Northeast region (61.4 ± 32.9) was lower (p <0.05) than in the Southeast (69.2 ± 31.6), Midwest (65.3 ± 33.6) and South (73.7 ± 28.1) regions; additionally, the score of the Midwest was lower (p <0.05) than the South region. In STEMI, the use of recanalization therapies was highest in the Southeast (75.4%, p = 0.001 compared to the rest of the country), and lowest in the North-Northeast (52.5%, p <0.001 compared to the rest of the country). CONCLUSION: The use of demonstrably effective therapies in the treatment of acute coronary disease is much to be desired in the country, with important regional differences.BACKGROUND Little is known in our country about regional differences in the treatment of acute coronary disease. OBJECTIVE To analyze the behavior regarding the use of demonstrably effective regional therapies in acute coronary disease. METHODS A total of 71 hospitals were randomly selected, respecting the proportionality of the country in relation to geographic location, among other criteria. In the overall population was regionally analyzed the use of aspirin, clopidogrel, ACE inhibitors / AT1 blocker, beta-blockers and statins, separately and grouped by individual score ranging from 0 (no drug used) to 100 (all drugs used). In myocardial infarction with ST elevation (STEMI) regional differences were analyzed regarding the use of therapeutic recanalization (fibrinolytics and primary angioplasty). RESULTS In the overall population, within the first 24 hours of hospitalization, the mean score in the North-Northeast (70.5 ± 22.1) was lower (p <0.05) than in the Southeast (77.7 ± 29.5), Midwest (82 ± 22.1) and South (82.4 ± 21) regions. At hospital discharge, the score of the North-Northeast region (61.4 ± 32.9) was lower (p <0.05) than in the Southeast (69.2 ± 31.6), Midwest (65.3 ± 33.6) and South (73.7 ± 28.1) regions; additionally, the score of the Midwest was lower (p <0.05) than the South region. In STEMI, the use of recanalization therapies was highest in the Southeast (75.4%, p = 0.001 compared to the rest of the country), and lowest in the North-Northeast (52.5%, p <0.001 compared to the rest of the country). CONCLUSION The use of demonstrably effective therapies in the treatment of acute coronary disease is much to be desired in the country, with important regional differences.