Jorge Mimoso

Implementation of a pre-hospital network favoring primary angioplasty in STEMI to reduce mortality: The Algarve Project

OBJECTIVE To analyze the impact of reperfusion by either primary percutaneous coronary intervention (PPCI) or fibrinolysis, and mortality rates of a pre-hospital fast-track network for treating patients with ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS A pre-hospital network for STEMI patients, designated the Green Lane for Acute Myocardial Infarction (GL-AMI), has been implemented in the southern region of Portugal --the Algarve Project. We performed an observational study based on a prospective registry of 1338 patients admitted to Faro Hospital between 2004 and 2009, classified in two groups according to the method of admission: emergency department group (EDG) and GL-AMI group (GLG). More patients from GLG were reperfused (p < 0.0001). PPCI was the preferred method of reperfusion, 73.1% in GLG and 45.3% in EDG. Time delays were significantly shorter in GLG, except for pre-hospital delay: pre-hospital delay (p = 0.11); door-to-needle (p < 0.0001); door-to-balloon (p < 0.0001); and delay between symptoms and reperfusion (p < 0.0001). In-hospital mortality (4.3% vs 9.2%, p = 0.0007) and 6-month mortality (6.3% vs 13.8%, p < 0.0001) were significantly lower in GLG. CONCLUSIONS The Algarve Project significantly reduced the time delay between onset of symptoms and reperfusion, significantly increased the rate of reperfusion, and significantly reduced in-hospital and six-month mortality.

Alteração nas redes de referenciação de doentes para cirurgia cardiotorácica: as razões económicas serão destituídas de custos?

INTRODUCTION AND OBJECTIVES The aim of this study was to determine whether changes to referral protocols for cardiac surgery have had an impact on waiting times, hospitalizations and mortality during the waiting period and during the first year of follow-up after surgery. METHODS In this retrospective study of patients referred for cardiac surgery between January 1, 2008 and September 30, 2014, the study population was divided into two groups: those referred before (group A, January 1, 2008 to August 31, 2011) and after (group B, September 1, 2011 to September 30, 2014) the change in referral protocols. A telephone follow-up was conducted. RESULTS There were 864 patients referred for cardiac surgery, 557 in group A and 307 in group B. Patient characteristics were similar between groups. The mean waiting time for surgery was 10.6±18.5 days and 55.7±79.9 days in groups A and B, respectively (p=0.00). During the waiting period two patients (0.4%) were hospitalized in group A and 28 (9.1%) in group B (p=0:00); mortality was, respectively, 0% and 2.3% (p=0.00). During one-year follow-up 12.8% of group A patients and 16% of group B patients were hospitalized. Cardiovascular mortality in this period was around 5% in both groups (p>0.05). CONCLUSION Changes to referral protocols for cardiac surgery had an impact on waiting times, on the number of hospitalizations and on mortality in this period.

Compliance of pharmacological treatment for non-ST-elevation acute coronary syndromes with contemporary guidelines: influence on outcomes.

BACKGROUND Although the proven efficacy of evidence-based therapy in patients with cardiovascular diseases, the recommendations are not always instituted. We aimed to analyse the compliance of non-ST-elevation acute coronary syndrome (NSTE-ACS) patients with treatment guidelines and to assess the impact of these measures in hospital death during the index hospitalization. POPULATION AND METHODS All consecutive patients (pts) included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between January 1, 2002 and August 31, 2011 were analysed. Compliance with Guidelines for the management of NSTE-ACS was evaluated with a 6-point therapeutic score (ThSc), comprising the treatment with: aspirin, clopidogrel, heparin, beta-blocker, angiotensin-converting enzyme inhibitor and statin. One point was assigned for each drug prescribed and zero if not given. The total therapeutic compliance was defined as ThSc =6 points. RESULTS The final analysis comprised 14,276 pts (67.1% male; mean age 67.6±12.3 years), most of them admitted with non-ST elevation myocardial infarction (77.4%). The mean value of ThSc was 4.9±1.1 and total compliance occurred in 36.7% pts. Centres with percutaneous coronary intervention (PCI) capacity had a statistically significant higher ThSc (5.0±1.0 vs. 4.8±1.1, P<0.001) and were associated with higher total compliance [OR 1.53, 95% confidence intervals (CI), 1.42-1.65, P<0.001]. In-hospital mortality was 2.4% (354 deaths). Compared to pts who died, the survivors had a higher ThSc (4.9±1.1 vs. 4.2±1.3, P<0.001) and this score was independently associated with lower risk of in-hospital mortality (OR 0.70, 95% CI, 0.64-0.77, P<0.001). Receiver operating characteristics curve analysis showed a good accuracy of ThSc for the occurrence of in-hospital mortality with the area under the curve (AUC) 0.82 (95% CI, 0.80-0.84, P<0.001), sensitivity 71.6% and specificity 78.0%. Age, peripheral artery disease, Killip-Kimball class >I, electrocardiogram (ECG) with ST-segment depression and positive troponin were other independent predictors of in-hospital mortality. CONCLUSIONS In the present study, patients with NSTE-ACS who received medications recommended by guidelines had better in-hospital outcomes. These findings highlight the need to clarify the clinical recommendations and to develop approaches for quality improvement in this subset of patients.

Choque cardiogénico – fármacos inotrópicos e vasopressores

Cardiogenic shock is characterized by a decrease in myocardial contractility, and presents a high mortality rate. Inotropic and vasopressor agents have been recommended and used for several years in the treatment of patients in shock, but they remain controversial. Despite its beneficial effect on myocardial contractility, the side effects of inotropic therapy (arrhythmias and increased myocardial oxygen consumption) may be associated with increased mortality. The pharmacodynamics of different inotropic agents suggest benefits in specific situations, but these differences have not been reflected in reduced mortality in most studies, making it difficult to formulate recommendations. This review integrates data from different studies on the use of inotropes and vasopressors in patients with cardiogenic shock, proposing a therapeutic scheme for the pharmacological treatment of patients in cardiogenic shock according to the patients hemodynamic profile.

Registo Nacional de Síndromes Coronárias Agudas: 15 anos de um registo prospetivo contínuo

The Portuguese Registry of Acute Coronary Syndromes (ProACS) has completed 15 years of continuous and prospective activity. We present an overall picture of the data from this powerful tool. Up to 2016, 45 141 records were included, mostly male (71%), and with a mean age of 66 years. Baseline characteristics remained stable over the years. Of the overall population, 44% of cases were ST-elevation myocardial infarction (STEMI). Over the years there was a significant improvement in compliance with international guidelines, in terms of both diagnostic and therapeutic procedures, as well as for medication. In particular, the rate of reperfusion in STEMI increased to 84%, mainly by primary percutaneous coronary intervention (only 5.2% were treated by thrombolysis in 2016). By contrast, timings in STEMI did not change significantly. Improvements in treatment were accompanied by a reduction in in-hospital mortality from 6.7% in 2002 to 2.5% in 2016 in the overall population. This registry enables analysis of the management and results of acute coronary syndromes over time in Portugal, and hence assessment of improvements in quality of care.

Original articleImplementation of a pre-hospital network favoring primary angioplasty in STEMI to reduce mortality: The Algarve ProjectImplementação de uma rede pré-hospitalar privilegiando a angioplastia primária no enfarte agudo do miocárdio com elevação do segmento ST, para reduzir a mortalidade: O Projeto Algarve

Objective To analyze the impact of reperfusion by either primary percutaneous coronary inter-vention (PPCI) or fibrinolysis, and mortality rates of a pre-hospital fast-track network for treating patients with ST-elevation myocardial infarction (STEMI).

Impacto da via verde coronária e da angioplastia primária na redução da mortalidade associada ao enfarte com elevação do segmento ST anterior. A experiência algarvia

INTRODUCTION There are few published data on mortality in anterior ST-segment elevation myocardial infarction (STEMI) in Portugal, particularly in centers with direct access to primary angioplasty. We present the experience of a center with direct access to primary angioplasty in the management of patients admitted with anterior STEMI. METHODS We performed a retrospective study of 120 patients admitted with anterior STEMI in 2008 to Faro Hospital (Algarve region, Portugal). RESULTS Significant coronary artery stenosis was found in 99 patients (82.5%). These patients were predominantly male (79%), and had a mean age of 63 years. Primary angioplasty was performed in the majority of patients within 6 hours of symptom onset and median ECG-to-balloon time was 89 minutes. Primary angioplasty was successful in 98% of patients and complete revascularization was achieved in 83%. Radial access was used in 82% of cases. In-hospital and 30-day mortality was 3%. CONCLUSION Direct access to primary angioplasty was associated with low mortality in patients admitted with anterior STEMI.

Miocardite fulminante – a propósito de um caso clínico

A 46-year-old woman was admitted due to diplopia because of ophthalmoplegia, which improved with corticosteroid therapy. Eight days later, she was admitted with fulminant myocarditis in cardiogenic shock, with severe left ventricular dysfunction and frequent episodes of nonsustained ventricular tachycardia. As there was no clinical improvement, an endomyocardial biopsy was performed that revealed inflammatory infiltrate, vasculitis, and PCR positive for cytomegalovirus, Epstein-Barr virus, parvovirus B19 and enterovirus. Left ventricular function recovered with heart failure treatment and corticosteroids. Three months later, after progressive withdrawal of prednisolone, there was recurrence of myocarditis and left ventricular dysfunction, which was successfully treated by restarting corticosteroid therapy. One month later she was readmitted with fulminant myocarditis which again responded to steroids. She intermittently presented cutaneous purpura lesions. At this time the provisional diagnosis was vasculitis and she started monthly cycles of cyclophosphamide. Before the second cycle she was admitted with pneumonia and ventricular dysfunction and died.

Comment on «Duration of treatment with nonsteroidal anti-inflammatory drugs and impact on risk of death and recurrent myocardial infarction in patients with prior myocardial infarction. A Nationwide Cohort Study»

BACKGROUND: Despite the fact that nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated among patients with established cardiovascular disease, many receive NSAID treatment for a short period of time. However, little is known about the association between NSAID treatment duration and risk of cardiovascular disease. We therefore studied the duration of NSAID treatment and cardiovascular risk in a nationwide cohort of patients with prior myocardial infarction (MI). METHODS AND RESULTS: Patients ≥30 years of age who were admitted with first-time MI during 1997 to 2006 and their subsequent NSAID use were identified by individual-level linkage of nationwide registries of hospitalization and drug dispensing from pharmacies in Denmark. Risk of death and recurrent MI according to duration of NSAID treatment was analyzed by multivariable time-stratified Cox proportional-hazard models and by incidence rates per 1000 person-years. Of the 83 677 patients included, 42.3% received NSAIDs during follow-up. There were 35 257 deaths/recurrent MIs. Overall, NSAID treatment was significantly associated with an increased risk of death/recurrent MI (hazard ratio, 1.45; 95% confidence interval, 1.29 to 1.62) at the beginning of the treatment, and the risk persisted throughout the treatment course (hazard ratio, 1.55; 95% confidence interval, 1.46 to 1.64 after 90 days). Analyses of individual NSAIDs showed that the traditional NSAID diclofenac was associated with the highest risk (hazard ratio, 3.26; 95% confidence interval, 2.57 to 3.86 for death/MI at day 1 to 7 of treatment). CONCLUSIONS: Even short-term treatment with most NSAIDs was associated with increased risk of death and recurrent MIin patients with prior MI. Neither short- nor long-term treatment with NSAIDs is advised in this population, and any NSAID use should be limited from a cardiovascular safety point of view.