José Alberto Oliveira

Histamine release induced by glucose (mannose)-specific lectins isolated from Brazilian beans. Comparison with concanavalin A

The histamine releasing properties of glucose (mannose)-specific lectins isolated from Brazilian beans was examined. TheCanavalia brasiliensis, Dioclea rostrata, andDioclea virgata lectins induced histamine release in rat peritoneal mast cells similar to concanavalin A. Less potency and efficacy was observed forCanavalia maritima, Dioclea guianensis, andDioclea violacea while very low activities were seen for the lectins fromDioclea grandiflora, Canavalia bonariensis, andCratylia floribunda.The histamine releasing effect was quenched by higher doses ofD. virgata lectin similar to what was reported for concanavalin A. This effect was abrogated by increasing the concentration of calcium in the incubating medium. As these above proteins have sites that bind calcium, higher doses of the lectins might withdraw the calcium which is essential for the mast cell secretion.

Is it possible to simplify risk stratification scores for patients with ST-segment elevation myocardial infarction undergoing primary angioplasty?

INTRODUCTION There are several risk scores for stratification of patients with ST-segment elevation myocardial infarction (STEMI), the most widely used of which are the TIMI and GRACE scores. However, these are complex and require several variables. The aim of this study was to obtain a reduced model with fewer variables and similar predictive and discriminative ability. METHODS We studied 607 patients (age 62 years, SD=13; 76% male) who were admitted with STEMI and underwent successful primary angioplasty. Our endpoints were all-cause in-hospital and 30-day mortality. Considering all variables from the TIMI and GRACE risk scores, multivariate logistic regression models were fitted to the data to identify the variables that best predicted death. RESULTS Compared to the TIMI score, the GRACE score had better predictive and discriminative performance for in-hospital mortality, with similar results for 30-day mortality. After data modeling, the variables with highest predictive ability were age, serum creatinine, heart failure and the occurrence of cardiac arrest. The new predictive model was compared with the GRACE risk score, after internal validation using 10-fold cross validation. A similar discriminative performance was obtained and some improvement was achieved in estimates of probabilities of death (increased for patients who died and decreased for those who did not). CONCLUSION It is possible to simplify risk stratification scores for STEMI and primary angioplasty using only four variables (age, serum creatinine, heart failure and cardiac arrest). This simplified model maintained a good predictive and discriminative performance for short-term mortality.

Serum uric acid: a forgotten prognostic marker in acute coronary syndromes?

Background: Serum uric acid (UA) has been shown to be an independent predictor of outcome in the general population and in patients with heart failure. There are, however, limited data regarding the prognostic value of UA in the context of acute coronary syndromes (ACS) particularly in medium-term follow up and the available results are contradictory. Materials and methods: Study of consecutive patients admitted with an ACS (with and without ST-segment elevation) at a single-centre coronary care unit. Primary endpoint was all-cause mortality at 1-year follow up. We evaluated if serum UA is an independent predictor of outcome and if it has any added value on top of GRACE risk score for risk prediction. Results: We included 683 patients, mean age 64±13 years, 69% males. In-hospital and 1-year mortality were 4.5 and 7.6% respectively. The best cut-off of UA to predict 1-year mortality was 6.25 mg/dl (sensitivity 59%, specificity 72%) and 30.2% of the patients had an increased UA according to this cut off. Independent predictors of UA were male gender (β= 0.078), body mass index (β=0.163), diuretics before admission (β=0.142), and admission serum creatinine (β=0.403). One-year mortality was significantly higher in patients with increased UA (15.5 vs. 4.2%, p<0.001; log rank, p<0.001). After adjustment, both increased UA as a categorical variable (HR 2.25, 95% CI 1.23–4.13, p=0.008) and as a continuous variable (HR 1.26, 95% CI 1.13–1.41, p<0.001) are independent predictors of mortality. The AUC increases only slightly after inclusion of UA in the model with GRACE risk score (from 0.78 to 0.79, p=0.350). Both models had a good fit; however, model fit worsened after inclusion of UA. Overall, the inclusion of UA in the original was associated with an improvement in both the net reclassification improvement (continuous NRI=44%), and the integrated discrimination improvement (IDI=0.052) suggesting effective reclassification. Conclusions: Serum UA is an independent predictor of all-cause mortality in medium-term after the whole spectrum of ACS and has an added value for risk stratification.

Does admission NT-proBNP increase the prognostic accuracy of GRACE risk score in the prediction of short-term mortality after acute coronary syndromes?

Background: NT-proBNP has prognostic implications in heart failure. In acute coronary syndromes (ACS) setting, the prognostic significance of NT-proBNP is being sought. We studied short-term prognostic impact of admission NT-proBNP in patients admitted for ACS and in association with GRACE risk score (GRS). Methods and Results: We studied 1035 patients admitted with ACS. Patients were divided in quartiles according to NT-proBNP levels on admission: Q1 <180 pg/ml; Q2 180–691 pg/ml; Q3 696–2664 pg/ml; Q4 2698–35 000 pg/ml. Groups were compared in terms of short-term all-cause mortality. Patients with higher NT-proBNP had worst GRS on admission. They also received less aggressive treatment. In-hospital mortality was 0.8%, 3.0%, 5.8% and 12.8% (P<0.001) and 30-day mortality 1.6%, 4.6%, 6.5% and 16.7% (P<0.001) respectively. In multivariate logistic regression analysis, NT-proBNP is an independent predictor of in-hospital (OR 2.35; 95% CI: 1.12–4.93, P=0.022) and 30-day mortality (OR 2.20; 95% CI: 1.17–4.12, P=0.014). However, NT-proBNP does not add any incremental benefit to GRS for prediction of outcome by ROC curve analysis. Conclusions: NT-proBNP is an independent predictor of in-hospital and 30-day mortality after ACS, independently of left ventricular function, but does not increase the prognostic accuracy of GRS.

Impact of body mass index in the results after primary angioplasty in patients with ST segment elevation acute myocardial infarction

Introduction: Obese patients submitted to elective coronary angioplasty have a paradoxical reduction in hospital and long-term mortality. In primary angioplasty setting, the relation with Body Mass Index (BMI) is less studied. Objectives: To evaluate the impact of obesity in the results after ST-segment elevation acute myocardial infarction treated by primary angioplasty. Methods: Study of 539 consecutive patients with ST-segment elevation acute myocardial infarction (STEMI) submitted to primary angioplasty. We evaluated in-hospital, 30-day and one-year all-cause mortality according to BMI: ‘normal’, <25 kg/m2; ‘overweight’, 25–29.9 kg/m2 and ‘obese’, ≥ 30 kg/m2.Results: Obese patients were younger, had more hypertension and hyperlipidemia. There were no differences in previous cardiac history and hospital data. In-hospital mortality was 8.0% for patients with normal BMI, 4.4% for overweight patients and 5.9% for obese patients (P=0.296). At 30 days, 9.6%, 5.2% and 6.9% (P=0.212) and at first year, 11.2%, 5.2% and 6.9% (P=0.064), respectively. Overweight was the only group with decreased risk (OR: 0.44, 95% CI: 0.21–0.90, P=0.015), even after adjustment for confounding variables (OR: 0.37, 95% CI: 0.15–0.95, P=0.038). Conclusions: Overweight patients had a better prognosis after primary angioplasty for STEMI compared with other BMI groups.

Usefulness of right ventricular and right atrial two-dimensional speckle tracking strain to predict late arrhythmic events in adult patients with repaired Tetralogy of Fallot

OBJECTIVE To determine whether right ventricular and/or atrial speckle tracking strain is associated with previous arrhythmic events in patients with repaired tetralogy of Fallot. METHODS AND RESULTS We studied right ventricular and atrial strain in 100 consecutive patients with repaired tetralogy of Fallot referred for routine echocardiographic evaluation. Patients were divided into two groups, one with previous documentation of arrhythmias (n=26) and one without arrhythmias, in a median follow-up of 22 years. Patients with arrhythmias were older (p<0.001) and had surgical repair at an older age (p=0.001). They also had significantly reduced right ventricular strain (-14.7±5.5 vs. -16.9±4.0%, p=0.029) and right atrial strain (19.1±7.7% vs. 25.8±11.4%, p=0.001). Neither right ventricular nor right atrial strain were independent predictors of the presence of a history of documented arrhythmias, which was associated with age at correction and with the presence of residual defects. In a subanalysis after excluding 23 patients who had had more than one corrective surgery, right ventricular strain was an independent predictor of the presence of previous arrhythmic events (OR 1.19, 95% CI 1.02-1.38, p=0.025). Right atrial strain was also an independent predictor after adjustment (OR 0.93, 95% CI 0.87-0.99, p=0.029). The ideal cut-off for right ventricular strain was -15.3% and for right atrial strain 23.0%. CONCLUSIONS Compared with conventional echocardiographic parameters, strain measures of the right heart are associated with the presence of arrhythmic events, and may be useful for risk stratification of patients with repaired tetralogy of Fallot, although a prospective study is required.

Admission heart rate as a predictor of mortality in patients with acute coronary syndromes

Introduction: Heart rate (HR) is a prognostic factor in stable angina. However, in the context of acute coronary syndromes (ACS), it is less studied. Aims: To evaluate the influence of admission HR as a prognostic factor in patients with ACS. Methods: We evaluated in-hospital, 30-day and one-year mortality in patients with ACS, according to admission HR. Results: We analysed 1126 patients, 69% males, mean age 64 years, 59% with ST-segment elevation acute myocardial infarction and 15% on medication with a beta-blocker. On admission, 14% presented signs of heart failure. In 10%, left ventricular ejection fraction was <35%. In-hospital mortality was 7.1%, 30-day mortality 9.1% and one-year mortality 10.7%. The best cut-off of HR to predict mortality was 80 bpm (sensitivity 64–66% and specificity 54–55%). By multivariate analysis, a heart rate ≥80 bpm was an independent predictor of all-cause mortality (HR 1.50, 95% CI: 1.01–2.23, P=0.047). Conclusions: In a population with ACS, a higher admission HR is an independent predictor of short- and medium-term prognosis, which is also independent of left ventricular function.

Pode a presenca de anemia na admissão melhorar a capacidade preditiva do score GRACE para mortalidade a curto e médio prazo após síndrome coronária aguda

Introduction: In patients admitted for acute coronary syndrome (ACS), the presence of anemia is a predictor of prognosis. However, risk scores used for prognostic stratification do not include this variable. Objectives: To evaluate whether the presence of anemia on admission in patients with ACS has additional value over the GRACE risk score in the prediction of short-and medium-term mortality. Methods: Between January 2005 and December 2008, we assessed consecutive patients admitted to our intensive care unit for ACS and included in our single-center ACS registry. In all patients information was collected on demographic and anthropometric variables, risk factors for coronary artery disease, and clinical and laboratorial data on admission, including hemoglobin. Patients with anemia were identified (hemoglobin <12 g/dl for women and <13 g/dl for men). Patients were classified as low, intermediate or high risk on the GRACE risk score (<126, 126-154 and >154, respectively). In-hospital, 30-day and one-year mortality were analyzed. Results: The study population included 1423 patients with a mean age of 64 ± 13 years, 69% male, anemia on admission being present in 27.7%. These patients were older and more often female, with a higher proportion of hypertensives and diabetics, and more often had a history of myocardial infarction, worse Killip class on admission and higher GRACE risk score. On the other hand, fewer were smokers, fewer presented ST-segment elevation myocardial infarction and they were less often treated with beta-blockers, statins and coronary angioplasty. They had more bleeding complications during hospital stay. In-hospital (10% vs. 4%), 30-day (12% vs. 5%) and one-year mortality (15% vs. 6%) were higher in the anemia group (p < 0.001). In bivariate analysis, the presence of anemia was a predictor of in-hospital ଝ Please cite this article as: Timóteo, AT. Pode a presença de anemia na admissão melhorar a capacidade preditiva do score GRACE para mortalidade a curto e médio-prazo após síndrome coronária aguda? Any transmission of this document by any media or format is strictly prohibited. 280 A.T. Timóteo et al. no longer significant. When we analyzed the presence or absence of anemia for each GRACE risk score group, there was only a difference in one-year mortality, which was higher in both the intermediate-and high-risk GRACE score groups (6.7% vs. 2.3%, p = 0.024; 23.4% vs. 15.6%, p = 0.022, respectively), with a trend for higher 30-day mortality in the high-risk group (19.6% vs. 13.5%, p = 0.056). Conclusions: Our data …

Impacto da idade no tratamento e resultados após enfarte agudo do miocárdio em particular nos muito idosos

INTRODUCTION The elderly population admitted for acute myocardial infarction is increasing. This group is not well studied in international trials and is probably treated with a more conservative approach. OBJECTIVES To evaluate the presentation and treatment of myocardial infarction according to age, particularly in very elderly patients. METHODS We studied 1242 consecutive patients admitted with acute myocardial infarction, assessing in-hospital, 30-day and one-year mortality during follow-up for each age-group. Patients were divided into four groups according to age: <45 years (7.6%); 45-64 years (43.3%); 65-74 years (23.4%); and ≥75 years (25.7%). RESULTS Elderly patients had a worse risk profile (except for smoking), more previous history of coronary disease and a worse profile on admission, with the exception of lipid profile, which was more favorable. With regard to treatment of the elderly, although less optimized than in other age-groups, it was significantly better compared to other registries, including for percutaneous coronary angioplasty. Both complications and mortality were worse in the older groups. In elderly patients (≥75 years), adjusted risk of mortality was 4.9-6.3 times higher (p<0.001) than patients in the reference age-group (45-64 years). In these patients, the independent predictors of death were left ventricular function and renal function, use of beta-blockers being a predictor of survival. CONCLUSIONS Elderly patients represent a substantial proportion of the population admitted with myocardial infarction, and receive less evidenced-based therapy. Age is an independent predictor of short- and medium-term mortality.

Longitudinal strain by two-dimensional speckle tracking to assess ventricular function in adults with transposition of the great arteries: Can serial assessment be simplified?

INTRODUCTION Transposition of the great arteries (TGA) is a rare form of congenital heart disease in which most patients reach adulthood. Right ventricular dysfunction is the most severe residual complication in long-term follow-up, both in patients treated by atrial switch and in those with congenitally corrected TGA. New echocardiographic tools such as longitudinal strain by two-dimensional (2D) speckle tracking may improve assessment of ventricular function in these patients. METHODS AND RESULTS We performed a retrospective analysis of echocardiograms in adult patients with TGA (26 patients with dextro-TGA - 15 treated by atrial switch and six by arterial switch - and five with congenitally corrected TGA) and in a control group of 14 healthy individuals. Right ventricular strain was significantly worse (p<0.001), as was the corresponding annular plane systolic excursion (p=0.010) in atrial switch patients, in comparison to arterial switch patients, while no differences were found in left ventricular parameters. In the overall population, systemic right ventricular parameters were significantly less negative than pulmonary right ventricular parameters, and these were less negative than in controls. Left ventricular parameters were similar across groups, except for pulmonary left ventricular strain, which was worse than in controls (p=0.008) as well as pulmonary right ventricular strain. CONCLUSIONS Assessment of ventricular function in patients with TGA by 2D speckle tracking longitudinal strain is easy and feasible and may be a useful tool for serial follow-up. Of particular note, we found that there is also some degree of ventricular dysfunction even after re-establishment of normal connections.