José Péricles Esteves

Prognostic value of GRACE scores versus TIMI score in acute coronary syndromes

BACKGROUND Although the TIMI score is the one most frequently used in acute coronary syndromes (ACS) without ST-segment elevation, the GRACE score has potential prognostic superiority, as it was created based on an observational registry, part of the variables is treated in a semi-quantitative form and renal function is taken into account in its calculation. OBJECTIVE To test the hypothesis that the GRACE risk score has superior in-hospital prognostic value, when compared to the TIMI score in patients admitted with ACS. METHODS Individuals with unstable angina or myocardial infarction without ST-segment elevation, consecutively admitted at the Coronary Unit between August 2007 and January 2009, were included in the study. RESULTS A total of 154 patients aged 71 +/- 13 years, of which 56% were females, with a GRACE median of 117 and a TIMI median of 3 were studied. During the hospitalization period, the incidence of events was 8.4% (12 deaths and 1 non-fatal infarction). The Hosmer-Lemeshow test applied to the GRACE score presented an chi2 of 5.3 (P = 0.72), whereas the TIMI score presented an chi2 of 1.85 (P = 0.60). Therefore, both scores presented good calibration. As for the analysis of discrimination, the GRACE score presented a C-statistics of 0.91 (95%CI= 0.86 - 0.97), significantly superior to the C-statistics of 0.69 of the TIMI score (95%CI = 0.55 - 0.84) - P = 0.02 for the difference between the scores. CONCLUSION Regarding the prediction of hospital events in patients with ACS, the GRACE score has superior prognostic capacity when compared to the TIMI score.Resumen Fundamento: Aunque el Score de Riesgo TIMI sea el mas utilizado en sindromes coronarios agudos sin supradesnivel del segmento ST (SCA), el Score GRACE tiene potencial superioridad pronostica, pues fue creado a partir de un registro observacional, parte de las variables son tratadas de forma semicuantitativa y la funcion renal se computa en su calculo.Objetivo: Probar la hipotesis de que el Score de Riesgo GRACE tiene superior valor pronostico hospitalario, comparado con el Score TIMI en pacientes ingresados con SCA.Metodos: Fueron incluidos individuos con angina inestable o infarto de miocardio sin supradesnivel del segmento ST, consecutivamente internados en Unidad Coronaria entre agosto de 2007 y enero de 2009.Resultados: Fueron estudiados 154 pacientes, edad 71 ± 13 anos, el 56% del sexo femenino, mediana de GRACE de 117 y mediana de TIMI de 3. Durante el periodo de internacion, la incidencia de eventos fue del 8,4% (12 fallecimientos y 1 infarto no fatal). El test de Hosmer-Lemeshow aplicado al Score GRACE presento χ

Valor prognóstico do Escore de Risco GRACE versus Escore de Risco TIMI em síndromes coronarianas agudas

BACKGROUND Although the TIMI score is the one most frequently used in acute coronary syndromes (ACS) without ST-segment elevation, the GRACE score has potential prognostic superiority, as it was created based on an observational registry, part of the variables is treated in a semi-quantitative form and renal function is taken into account in its calculation. OBJECTIVE To test the hypothesis that the GRACE risk score has superior in-hospital prognostic value, when compared to the TIMI score in patients admitted with ACS. METHODS Individuals with unstable angina or myocardial infarction without ST-segment elevation, consecutively admitted at the Coronary Unit between August 2007 and January 2009, were included in the study. RESULTS A total of 154 patients aged 71 +/- 13 years, of which 56% were females, with a GRACE median of 117 and a TIMI median of 3 were studied. During the hospitalization period, the incidence of events was 8.4% (12 deaths and 1 non-fatal infarction). The Hosmer-Lemeshow test applied to the GRACE score presented an chi2 of 5.3 (P = 0.72), whereas the TIMI score presented an chi2 of 1.85 (P = 0.60). Therefore, both scores presented good calibration. As for the analysis of discrimination, the GRACE score presented a C-statistics of 0.91 (95%CI= 0.86 - 0.97), significantly superior to the C-statistics of 0.69 of the TIMI score (95%CI = 0.55 - 0.84) - P = 0.02 for the difference between the scores. CONCLUSION Regarding the prediction of hospital events in patients with ACS, the GRACE score has superior prognostic capacity when compared to the TIMI score.Resumen Fundamento: Aunque el Score de Riesgo TIMI sea el mas utilizado en sindromes coronarios agudos sin supradesnivel del segmento ST (SCA), el Score GRACE tiene potencial superioridad pronostica, pues fue creado a partir de un registro observacional, parte de las variables son tratadas de forma semicuantitativa y la funcion renal se computa en su calculo.Objetivo: Probar la hipotesis de que el Score de Riesgo GRACE tiene superior valor pronostico hospitalario, comparado con el Score TIMI en pacientes ingresados con SCA.Metodos: Fueron incluidos individuos con angina inestable o infarto de miocardio sin supradesnivel del segmento ST, consecutivamente internados en Unidad Coronaria entre agosto de 2007 y enero de 2009.Resultados: Fueron estudiados 154 pacientes, edad 71 ± 13 anos, el 56% del sexo femenino, mediana de GRACE de 117 y mediana de TIMI de 3. Durante el periodo de internacion, la incidencia de eventos fue del 8,4% (12 fallecimientos y 1 infarto no fatal). El test de Hosmer-Lemeshow aplicado al Score GRACE presento χ

Correlation between turbidimetric and nephelometric methods of measuring C-reactive protein in patients with unstable angina or non-ST elevation acute myocardial infarction

OBJECTIVE To evaluate the performance of the turbidimetric method of C-reactive protein (CRP) as a measure of low-grade inflammation in patients admitted with non-ST elevation acute coronary syndromes (ACS). METHODS Serum samples obtained at hospital arrival from 68 patients (66 11 years, 40 men), admitted with unstable angina or non-ST elevation acute myocardial infarction were used to measure CRP by the methods of nephelometry and turbidimetry. RESULTS The medians of C-reactive protein by the turbidimetric and nephelometric methods were 0.5 mg/dL and 0.47 mg/dL, respectively. A strong linear association existed between the 2 methods, according to the regression coefficient (b=0.75; 95% C.I.=0.70-0.80) and correlation coefficient (r=0.96; P<0.001). The mean difference between the nephelometric and turbidimetric CRP was 0.02 0.91 mg/dL, and 100% agreement between the methods in the detection of high CRP was observed. CONCLUSION In patients with non-ST elevation ACS, CRP values obtained by turbidimetry show a strong linear association with the method of nephelometry and perfect agreement in the detection of high CRP.

Preditores de mortalidade hospitalar em pacientes com embolia pulmonar estáveis hemodinamicamente

BACKGROUND Pulmonary embolism is associated with high mortality in patients with hypotension or circulatory shock. However, the association between some clinical variables and mortality is still unclear in hemodynamically stable patients. OBJECTIVES To derive an in-hospital mortality risk stratification model in hemodynamically stable patients with pulmonary embolism. METHODS This is a prospective multicenter cohort study of 582 consecutive patients admitted in emergency units or intensive care units with clinically suspected pulmonary embolism and whose diagnosis was confirmed by one or more of the following tests: pulmonary arteriography, spiral CT angiography, magnetic resonance angiography, Doppler echocardiography, pulmonary scintigraphy, or venous duplex scan. Data on demographics, comorbidities and clinical manifestations were collected and included in a logistic regression analysis so as to build the prediction model. RESULTS Overall mortality was 14.1%. The following parameters were identified as independent death risk variables: age > 65 years, bed rest > 72h, chronic cor pulmonale, sinus tachycardia, and tachypnea. After risk stratification, mortalities of 5.4%, 17.8%, and 31.3% were found in the low, moderate and high-risk subgroups, respectively. The model showed 65.5% sensitivity and 80% specificity, with a 0.77 area under the curve. CONCLUSION In hemodynamically stable patients with pulmonary embolism, age > 65 years, bed rest > 72h, chronic cor pulmonale, sinus tachycardia and tachypnea were independent predictors of in-hospital mortality. However, further validation of the prediction model in other populations is required so that it can be incorporated into the clinical practice.FUNDAMENTO: A embolia pulmonar apresenta alta mortalidade em pacientes com hipotensao arterial ou choque circulatorio. Entretanto, em pacientes hemodinamicamente estaveis, a associacao de algumas variaveis clinicas com a mortalidade ainda nao esta claramente estabelecida. OBJETIVOS: Derivar um modelo de estratificacao do risco de mortalidade intra-hospitalar em pacientes com embolia pulmonar hemodinamicamente estaveis. METODOS: Estudo de coorte multicentrico prospectivo de 582 pacientes consecutivos que foram admitidos em unidades de emergencia ou de terapia intensiva, com suspeita clinica de embolia pulmonar, e que tiveram o diagnostico confirmado por meio de um ou mais dos seguintes exames: arteriografia pulmonar, angiotomografia computadorizada helicoidal, angioressonância magnetica, ecodopplercardiograma, cintilografia pulmonar ou duplex-scan venoso. Os dados sobre caracteristicas demograficas, comorbidades e manifestacoes clinicas foram coletados e incluidos em uma analise de regressao logistica para compor o modelo de predicao. RESULTADOS: A mortalidade global foi de 14,1%. Foram identificadas como variaveis independentes de risco de obito: idade > 65 anos; repouso no leito > 72h; cor pulmonale cronico; taquicardia sinusal e taquipneia. Apos a estratificacao por faixas de risco, observaram-se mortalidades de 5,4%, 17,8% e 31,3%, respectivamente nos subgrupos de baixo, moderado e alto riscos. O modelo mostrou sensibilidade de 65,5% e especificidade de 80%, com uma area sob a curva de 0,77. CONCLUSAO: Em pacientes hemodinamicamente estaveis com embolia pulmonar, a idade > 65 anos, o repouso no leito > 72h, o cor pulmonale cronico, a taquicardia sinusal e a taquipneia foram preditores independentes da mortalidade intra-hospitalar. Entretanto o modelo de predicao necessita ser validado em outras populacoes para sua incorporacao a pratica clinica.

Predictors of hospital mortality in hemodynamically stable patients with pulmonary embolism.

BACKGROUND Pulmonary embolism is associated with high mortality in patients with hypotension or circulatory shock. However, the association between some clinical variables and mortality is still unclear in hemodynamically stable patients. OBJECTIVES To derive an in-hospital mortality risk stratification model in hemodynamically stable patients with pulmonary embolism. METHODS This is a prospective multicenter cohort study of 582 consecutive patients admitted in emergency units or intensive care units with clinically suspected pulmonary embolism and whose diagnosis was confirmed by one or more of the following tests: pulmonary arteriography, spiral CT angiography, magnetic resonance angiography, Doppler echocardiography, pulmonary scintigraphy, or venous duplex scan. Data on demographics, comorbidities and clinical manifestations were collected and included in a logistic regression analysis so as to build the prediction model. RESULTS Overall mortality was 14.1%. The following parameters were identified as independent death risk variables: age > 65 years, bed rest > 72h, chronic cor pulmonale, sinus tachycardia, and tachypnea. After risk stratification, mortalities of 5.4%, 17.8%, and 31.3% were found in the low, moderate and high-risk subgroups, respectively. The model showed 65.5% sensitivity and 80% specificity, with a 0.77 area under the curve. CONCLUSION In hemodynamically stable patients with pulmonary embolism, age > 65 years, bed rest > 72h, chronic cor pulmonale, sinus tachycardia and tachypnea were independent predictors of in-hospital mortality. However, further validation of the prediction model in other populations is required so that it can be incorporated into the clinical practice.FUNDAMENTO: A embolia pulmonar apresenta alta mortalidade em pacientes com hipotensao arterial ou choque circulatorio. Entretanto, em pacientes hemodinamicamente estaveis, a associacao de algumas variaveis clinicas com a mortalidade ainda nao esta claramente estabelecida. OBJETIVOS: Derivar um modelo de estratificacao do risco de mortalidade intra-hospitalar em pacientes com embolia pulmonar hemodinamicamente estaveis. METODOS: Estudo de coorte multicentrico prospectivo de 582 pacientes consecutivos que foram admitidos em unidades de emergencia ou de terapia intensiva, com suspeita clinica de embolia pulmonar, e que tiveram o diagnostico confirmado por meio de um ou mais dos seguintes exames: arteriografia pulmonar, angiotomografia computadorizada helicoidal, angioressonância magnetica, ecodopplercardiograma, cintilografia pulmonar ou duplex-scan venoso. Os dados sobre caracteristicas demograficas, comorbidades e manifestacoes clinicas foram coletados e incluidos em uma analise de regressao logistica para compor o modelo de predicao. RESULTADOS: A mortalidade global foi de 14,1%. Foram identificadas como variaveis independentes de risco de obito: idade > 65 anos; repouso no leito > 72h; cor pulmonale cronico; taquicardia sinusal e taquipneia. Apos a estratificacao por faixas de risco, observaram-se mortalidades de 5,4%, 17,8% e 31,3%, respectivamente nos subgrupos de baixo, moderado e alto riscos. O modelo mostrou sensibilidade de 65,5% e especificidade de 80%, com uma area sob a curva de 0,77. CONCLUSAO: Em pacientes hemodinamicamente estaveis com embolia pulmonar, a idade > 65 anos, o repouso no leito > 72h, o cor pulmonale cronico, a taquicardia sinusal e a taquipneia foram preditores independentes da mortalidade intra-hospitalar. Entretanto o modelo de predicao necessita ser validado em outras populacoes para sua incorporacao a pratica clinica.

Valor Pronóstico del Score de Riesgo GRACE versus Score de Riesgo TIMI en Síndromes Coronarios Agudos

BACKGROUND Although the TIMI score is the one most frequently used in acute coronary syndromes (ACS) without ST-segment elevation, the GRACE score has potential prognostic superiority, as it was created based on an observational registry, part of the variables is treated in a semi-quantitative form and renal function is taken into account in its calculation. OBJECTIVE To test the hypothesis that the GRACE risk score has superior in-hospital prognostic value, when compared to the TIMI score in patients admitted with ACS. METHODS Individuals with unstable angina or myocardial infarction without ST-segment elevation, consecutively admitted at the Coronary Unit between August 2007 and January 2009, were included in the study. RESULTS A total of 154 patients aged 71 +/- 13 years, of which 56% were females, with a GRACE median of 117 and a TIMI median of 3 were studied. During the hospitalization period, the incidence of events was 8.4% (12 deaths and 1 non-fatal infarction). The Hosmer-Lemeshow test applied to the GRACE score presented an chi2 of 5.3 (P = 0.72), whereas the TIMI score presented an chi2 of 1.85 (P = 0.60). Therefore, both scores presented good calibration. As for the analysis of discrimination, the GRACE score presented a C-statistics of 0.91 (95%CI= 0.86 - 0.97), significantly superior to the C-statistics of 0.69 of the TIMI score (95%CI = 0.55 - 0.84) - P = 0.02 for the difference between the scores. CONCLUSION Regarding the prediction of hospital events in patients with ACS, the GRACE score has superior prognostic capacity when compared to the TIMI score.Resumen Fundamento: Aunque el Score de Riesgo TIMI sea el mas utilizado en sindromes coronarios agudos sin supradesnivel del segmento ST (SCA), el Score GRACE tiene potencial superioridad pronostica, pues fue creado a partir de un registro observacional, parte de las variables son tratadas de forma semicuantitativa y la funcion renal se computa en su calculo.Objetivo: Probar la hipotesis de que el Score de Riesgo GRACE tiene superior valor pronostico hospitalario, comparado con el Score TIMI en pacientes ingresados con SCA.Metodos: Fueron incluidos individuos con angina inestable o infarto de miocardio sin supradesnivel del segmento ST, consecutivamente internados en Unidad Coronaria entre agosto de 2007 y enero de 2009.Resultados: Fueron estudiados 154 pacientes, edad 71 ± 13 anos, el 56% del sexo femenino, mediana de GRACE de 117 y mediana de TIMI de 3. Durante el periodo de internacion, la incidencia de eventos fue del 8,4% (12 fallecimientos y 1 infarto no fatal). El test de Hosmer-Lemeshow aplicado al Score GRACE presento χ

Influência do gênero no valor prognóstico da troponina I após angioplastia coronariana eletiva

OBJECTIVE To evaluate the association between troponin I concentrations (TnI) in patients submitted to elective percutaneous coronary interventions (PCI) and adverse coronary events (ACE) during a six month follow-up period. METHODS One hundred and eleven patients who had been submitted to an elective PCI were consecutively selected during a one year timeframe. The patients had stable angina (SA), unstable angina (UA) or silent ischemia (SI) and were asymptomatic for at least 72 hours before the procedure. TnI concentrations were measured between 8 and 24 hours after the PCI. Each patient was contacted by telephone six months later and interviewed regarding ACE which were defined as death, myocardial infarction, new revascularization and recurrent ischemia. RESULTS Twenty-four patients showed elevated concentrations of TnI (21.6%) after the PCI regardless of clinical characteristics or procedure complications. Those who presented elevated TnI concentrations had higher event rates: 66.7 vs. 42.5% (RR=1.57; CI 95%=1.08-2.28). This risk seems to be higher in the subgroups of females and patients with a previous diagnosis of unstable angina. Multivariate analysis confirmed that gender was the only effect modifying co-variable associated with ACE risk, which is higher for females with elevated TnI concentrations (OR=7.22; CI 95%=1.4 -36.9) and unaltered for males (OR=1.26; CI 95%=0.35-4.55). CONCLUSION Elevated TnI concentrations were a common occurrence after PCI and is a factor related to the development of ACE in the mid term. However, when adjusted for other variables, this effect is only maintained in female patients.

Predictores de mortalidad hospitalaria en pacientes con embolia pulmonar estables hemodinámicamente

BACKGROUND Pulmonary embolism is associated with high mortality in patients with hypotension or circulatory shock. However, the association between some clinical variables and mortality is still unclear in hemodynamically stable patients. OBJECTIVES To derive an in-hospital mortality risk stratification model in hemodynamically stable patients with pulmonary embolism. METHODS This is a prospective multicenter cohort study of 582 consecutive patients admitted in emergency units or intensive care units with clinically suspected pulmonary embolism and whose diagnosis was confirmed by one or more of the following tests: pulmonary arteriography, spiral CT angiography, magnetic resonance angiography, Doppler echocardiography, pulmonary scintigraphy, or venous duplex scan. Data on demographics, comorbidities and clinical manifestations were collected and included in a logistic regression analysis so as to build the prediction model. RESULTS Overall mortality was 14.1%. The following parameters were identified as independent death risk variables: age > 65 years, bed rest > 72h, chronic cor pulmonale, sinus tachycardia, and tachypnea. After risk stratification, mortalities of 5.4%, 17.8%, and 31.3% were found in the low, moderate and high-risk subgroups, respectively. The model showed 65.5% sensitivity and 80% specificity, with a 0.77 area under the curve. CONCLUSION In hemodynamically stable patients with pulmonary embolism, age > 65 years, bed rest > 72h, chronic cor pulmonale, sinus tachycardia and tachypnea were independent predictors of in-hospital mortality. However, further validation of the prediction model in other populations is required so that it can be incorporated into the clinical practice.FUNDAMENTO: A embolia pulmonar apresenta alta mortalidade em pacientes com hipotensao arterial ou choque circulatorio. Entretanto, em pacientes hemodinamicamente estaveis, a associacao de algumas variaveis clinicas com a mortalidade ainda nao esta claramente estabelecida. OBJETIVOS: Derivar um modelo de estratificacao do risco de mortalidade intra-hospitalar em pacientes com embolia pulmonar hemodinamicamente estaveis. METODOS: Estudo de coorte multicentrico prospectivo de 582 pacientes consecutivos que foram admitidos em unidades de emergencia ou de terapia intensiva, com suspeita clinica de embolia pulmonar, e que tiveram o diagnostico confirmado por meio de um ou mais dos seguintes exames: arteriografia pulmonar, angiotomografia computadorizada helicoidal, angioressonância magnetica, ecodopplercardiograma, cintilografia pulmonar ou duplex-scan venoso. Os dados sobre caracteristicas demograficas, comorbidades e manifestacoes clinicas foram coletados e incluidos em uma analise de regressao logistica para compor o modelo de predicao. RESULTADOS: A mortalidade global foi de 14,1%. Foram identificadas como variaveis independentes de risco de obito: idade > 65 anos; repouso no leito > 72h; cor pulmonale cronico; taquicardia sinusal e taquipneia. Apos a estratificacao por faixas de risco, observaram-se mortalidades de 5,4%, 17,8% e 31,3%, respectivamente nos subgrupos de baixo, moderado e alto riscos. O modelo mostrou sensibilidade de 65,5% e especificidade de 80%, com uma area sob a curva de 0,77. CONCLUSAO: Em pacientes hemodinamicamente estaveis com embolia pulmonar, a idade > 65 anos, o repouso no leito > 72h, o cor pulmonale cronico, a taquicardia sinusal e a taquipneia foram preditores independentes da mortalidade intra-hospitalar. Entretanto o modelo de predicao necessita ser validado em outras populacoes para sua incorporacao a pratica clinica.

Safety and efficacy of angioplasty with intracoronary stenting in patients with unstable coronary syndromes. Comparison with stable coronary syndromes

OBJECTIVE To assess safety and efficacy of coronary angioplasty with stent implantation in unstable coronary syndromes. METHODS Retrospective analysis of in-hospital and late evolution of 74 patients with unstable coronary syndromes (unstable angina or infarction without elevation of the ST segment) undergoing coronary angioplasty with stent placement. These 74 patients were compared with 31 patients with stable coronary syndromes (stable angina or stable silent ischemia) undergoing the same procedure. RESULTS No death and no need for revascularization of the culprit artery occurred in the in-hospital phase. The incidences of acute non-Q-wave myocardial infarction were 1.4% and 3.2% (p = 0.6) in the unstable and stable coronary syndrome groups, respectively. In the late follow-up (11.2 +/- 7.5 months), the incidences of these events combined were 5.7% in the unstable coronary syndrome group and 6.9% (p = 0.8) in the stable coronary syndrome group. In the multivariate analysis, the only variable with a tendency to significance as an event predictor was diabetes mellitus (p = 0.07; OR = 5.2; 95% CI = 0.9-29.9). CONCLUSION The in-hospital and late evolutions of patients with unstable coronary syndrome undergoing angioplasty with intracoronary stent implantation are similar to those of the stable coronary syndrome group, suggesting that this procedure is safe and efficacious when performed in unstable coronary syndrome patients.