Fernando Ganem

Preoperative B-type natriuretic peptide, and not the inflammation status, predicts an adverse outcome for patients undergoing heart surgery

OBJECTIVES B-type natriuretic peptide (BNP) and inflammatory markers are implicated in the pathophysiology of both ischemic cardiomyopathy and complications after cardiac surgery with cardiopulmonary bypass (CPB). The purpose of this study was to assess preoperative and postoperative levels of BNP, interleukin-6 (IL-6), interleukin-8 (IL-8), P-selectin, intercellular adhesion molecule (ICAM), C-reactive protein (CRP) in patients undergoing cardiac surgery with CPB and investigate their variation and ability to correlate with immediate outcome. METHODS Plasma levels of these markers were measured preoperatively, 6 and 24 h after CBP in 62 patients. Main endpoints were requirements for intra-aortic balloon pump, intensive care unit (ICU) stay longer than five days, ventilator dependence >24 h, requirement for dobutamine, hospital stay >10 days, clinical complications (infection, myocardial infarction, renal failure, stroke and ventricular arrhythmias) and in-hospital mortality. RESULTS Preoperative BNP levels correlate with longer ICU stay (P = 0.003), longer ventilator use (P = 0.018) and duration of dobutamine use (P < 0.001). The receiver-operating characteristic curve demonstrated BNP levels >190 pg/ml as predictor of ICU >5 days and BNP levels >20.5 pg/ml correlated with dobutamine use, with areas under the curve of 0.712 and 0.842, respectively. Preoperative levels of ICAM-1 were associated with in-hospital mortality (P = 0.042). In the postoperative period, was found association between CRP, IL-6 and P-selectin with ventilation duration (P = 0.013, P = 0.006, P < 0.001, respectively) and P-selectin with ICU stay (P = 0.009). CONCLUSIONS BNP correlates with clinical endpoints more than inflammatory markers and can be used as a predictor of early outcome after heart surgery.

The bleeding risk score as a mortality predictor in patients with acute coronary syndrome

Background It is well known that the occurrence of bleeding increases in-hospital mortality in patients with acute coronary syndromes (ACS), and there is a good correlation between bleeding risk scores and bleeding incidence. However, the role of bleeding risk score as mortality predictor is poorly studied. Objective The main purpose of this paper was to analyze the role of bleeding risk score as in-hospital mortality predictor in a cohort of patients with ACS treated in a single cardiology tertiary center. Methods Out of 1,655 patients with ACS (547 with ST-elevation ACS and 1,118 with non-ST-elevation ACS), we calculated the ACUITY/HORIZONS bleeding score prospectively in 249 patients and retrospectively in the remaining 1,416. Mortality information and hemorrhagic complications were also obtained. Results Among the mean age of 64.3 ± 12.6 years, the mean bleeding score was 18 ± 7.7. The correlation between bleeding and mortality was highly significant (p < 0.001, OR = 5.296), as well as the correlation between bleeding score and in-hospital bleeding (p < 0.001, OR = 1.058), and between bleeding score and in-hospital mortality (adjusted OR = 1.121, p < 0.001, area under the ROC curve 0.753, p < 0.001). The adjusted OR and area under the ROC curve for the population with ST-elevation ACS were, respectively, 1.046 (p = 0.046) and 0.686 ± 0.040 (p < 0.001); for non-ST-elevation ACS the figures were, respectively, 1.150 (p < 0.001) and 0.769 ± 0.036 (p < 0.001). Conclusions Bleeding risk score is a very useful and highly reliable predictor of in-hospital mortality in a wide range of patients with acute coronary syndromes, especially in those with unstable angina or non-ST-elevation acute myocardial infarction.

Manifestação rara de edema agudo de pulmão associado à miocardite lúpica aguda

Systemic Lupus Erythematosus (SLE) is the most common systemic autoimmune disease, occurring more frequently in women, usually aged between 16 and 55 years 1, 2. Although classically the kidneys are the organs most affected in SLE, cardiopulmonary circulation and the heart may also be affected significantly 3. In this context, the occurrence of acute pulmonary edema associated with lupus myocarditis is rare and specific immunosuppressive therapy remains unclear.

THE PROGNOSTIC VALUE OF DIABETES AND OF ACUTE HYPERGLYCEMIA IS DIFFERENT DURING THE IN-HOSPITAL AND CHRONIC PHASES AFTER MYOCARDIAL INFARCTION

THE PROGNOSTIC VALUE OF DIABETES AND OF ACUTE HYPERGLYCEMIA IS DIFFERENT DURING THE IN-HOSPITAL AND CHRONIC PHASES AFTER MYOCARDIAL INFARCTION José C. Nicolau, Felipe G. Lima, Marcelo Franken, Carlos V. Serrano Jr., Roberto R. Giraldez, Luciano M. Baracioli, Fernando Ganem, Caio F. Fernandes, Karin D. Campos, Thiago F. Pinto, José A.F. Ramires Background: Diabetes (DM) and hyperglycemia are both powerful risk factors for pts with acute myocardial infarction (AMI). However, the relationship between them and their individual role during the in-hospital phase and in the long-term after hospital discharge are not clearly understood. Methods: We analyzed retrospectively 1429 pts with AMI (mean age 64.5 + 0.34 y.o., 72.5% men) treated in a single tertiary institution, included prospectively in a dedicated databank and followed for up to 11.7 years (mean survival time=8.7 years). Correlations with mortality were carried out utilizing the Chi-square/log-rank tests and logistical/Cox stepwise regression models as indicated. Results: (1) In-hospital phase: Death rates for diabetics and nondiabetics were, respectively, 12.7% and 9.6% (P=0.08); by univariate logistic regression, glucose level (as continuous variable) at hospital arrival was highly correlated with mortality (P<0.001); putting together both variables in a multivariate model, the figures were P=0.74 for DM and P<0.001 for glucose level (GL); in the adjusted model with 15 baseline variables included, GL remained correlating significantly with mortality (P<0.001), along with age (P<0.001), ST-elevation AMI (P=0.03), and history of heart failure (P<0.001) and hypertension (P=0.005). (2) Long-term outcome: The mean survival time for nondiabetics and diabetics were, respectively, 9.02 and 7.88 years (P<0.001); GL showed a borderline correlation with mortality (P=0.046); with both variables in the same model, the figures were P= 0.001 for DM and P=0.75 for GL; in the multivariate model with all 15 variables included, history of DM remained correlating significantly with mortality (P=0.022), along with age (P<0.001) and history of previous AMI (P<0.001), heart failure (P=0.01) and stroke (P=0.013). In a multivariate model excluding in-hospital deaths, DM remained correlating significantly with mortality (P=0.041). Conclusions: During the in-hospital phase the glucose level at hospital arrival is a better mortality predictor than DM; on the other hand, DM is a good mortality predictor in the long-term follow up after AMI, contrary to glucose level.

Características clínicas, angiográficas e evolução a longo prazo em pacientes com arterite de Takayasu e síndrome coronária aguda

INTRODUCTION Monitoring of disease activity and the best therapeutic approach are a challenge in Takayasu arteritis (TA). When associated with acute coronary syndromes (ACS), the best interventional treatment has not been established. The objective of this study was to describe the baseline characteristics, clinical manifestations, treatment and long-term outcome of patients with TA and ACS. METHODS We retrospectively analyzed eight patients between 2004 and 2010. The following data were obtained: age, gender, clinical and electrocardiographic manifestations, Killip class, risk factors for ACS, markers of myocardial necrosis (CK-MB and troponin), creatinine clearance, left ventricular ejection fraction, inflammatory markers (C-reactive protein and erythrocyte sedimentation rate [ESR]), medication during hospital stay, angiographic findings, treatment (medical, percutaneous or surgical) and long-term outcome. Statistical data were expressed as percentages and absolute values. RESULTS All eight patients were women, median age 49 years. Typical chest pain was present in 37.5%. Elevated ESR was observed in 85.7%. Three patients underwent coronary artery bypass grafting, three underwent percutaneous coronary angioplasty (two with bare-metal stents and one with a drug-eluting stent) and two were treated medically. In-hospital mortality was 25%. There were no deaths during a mean follow-up of 30 months. CONCLUSIONS In our study, patients who were discharged home had good outcomes in long-term follow-up with medical, percutaneous or surgical treatment. ESR appears to be associated with ACS in TA.