Lilia Nigro Maia

Prognostic value of acute kidney injury after cardiac surgery according to kidney disease: improving global outcomes definition and staging (KDIGO) criteria.

Objectives The definition of acute renal failure has been recently reviewed, and the term acute kidney injury (AKI) was proposed to cover the entire spectrum of the syndrome, ranging from small changes in renal function markers to dialysis needs. This study was aimed to evaluate the incidence, morbidity and mortality associated with AKI (based on KDIGO criteria) in patients after cardiac surgery (coronary artery bypass grafting or cardiac valve surgery) and to determine the value of this feature as a predictor of hospital mortality (30 days). Methods From January 2003 to June 2013, a total of 2,804 patients underwent cardiac surgery in our service. Cox proportional hazard models were used to determine the association between the development of AKI and 30-day mortality. Results A total of 1,175 (42%) patients met the diagnostic criteria for AKI based on KDIGO classification during the first 7 postoperative days: 978 (35%) patients met the diagnostic criteria for stage 1 while 100 (4%) patients met the diagnostic criteria for stage 2 and 97 (3%) patients met the diagnostic criteria for stage 3. A total of 63 (2%) patients required dialysis treatment. Overall, the 30-day mortality was 7.1% (2.2%) for patients without AKI and 8.2%, 31% and 55% for patients with AKI at stages 1, 2 and 3, respectively. The KDIGO stage 3 patients who did not require dialysis had a mortality rate of 41%, while the mortality of dialysis patients was 62%. The adjusted Cox regression analysis revealed that AKI based on KDIGO criteria (stages 1–3) was an independent predictor of 30-day mortality (P<0.001 for all. Hazard ratio = 3.35, 11.94 and 24.85). Conclusion In the population evaluated in the present study, even slight changes in the renal function based on KDIGO criteria were considered as independent predictors of 30-day mortality after cardiac surgery.

Effects of the use of mechanical ventilation weaning protocol in the Coronary Care Unit: randomized study

OBJECTIVE To compare mechanical ventilation weaning based on a protocol using the spontaneous breathing trial against mechanical ventilation weaning without a standardized protocol in heart patients. METHODS Prospective, open, randomized study. In 2006, 36 patients undergoing mechanical ventilation for over 24 hours were randomized into two groups: control group - eighteen patients whose mechanical ventilation weaning was performed according to the different procedures adopted by the multidisciplinary team; and experimental group - eighteen patients weaned according to previously established protocol. RESULTS Control group patients started the weaning process sooner than experimental group patients (74.7 ± 14.7 hours vs. 185.7 ± 22.9 hours, P=0.0004). However, after the experimental group patients were ready for weaning, the extubation was carried out more rapidly than in the control group (149.1 ± 3.6 min vs. 4179.1 ± 927.8 min, P < 0.0001) with significantly lower reintubation rates (16.7% vs. 66.7%, P = 0.005). CONCLUSION The use of a specific protocol based on the spontaneous breathing trial for mechanical ventilation weaning in heart patients had better outcomes than weaning carried out without a standardized protocol, with shorter weaning times and lower reintubation rates.

Elevated Troponin Levels after Prolonged Supraventricular Tachycardia in Patient with Normal Coronary Angiography

The European Society of Cardiology and the American College of Cardiology redefined the concept of myocardial infarction in the presence of highly positive markers of myocardial injury associated with at least one of the following: ischemic symptoms; development of pathologic Q waves on the ECG or ECG changes indicative of ischemia (positive or negative deviation of the ST segment), making troponins one of the most important aspects in the evaluation and stratification of patients with chest pain in the emergency room. However, although troponin gives excellent accuracy in the identification of myocardial necrosis, it is known that it can also be elevated in a series of nonatherosclerotic heart diseases. We present the case of a 49-year-old female patient admitted to the Chest Pain Unit with a history of supraventricular tachycardia associated with chest discomfort, nausea and diaphoresis. During risk stratification, the patient presented with a high serum troponin T level (0.143 ng/ml) but with a normal coronary angiography.

Acute kidney injury after on-pump coronary artery bypass graft surgery.

FUNDAMENTO: Lesion renal aguda (LRA) es una compleja enfermedad, la que, actualmente, no tiene definicion patron acepta. AKIN (Acute Kidney Injury Network) representa una tentativa de estandardizacion de criterios para el diagnostico y estadiamiento de LRA basado en los criterios RIFLE (risk, injury, failure, loss, y end-stage kidney disease) publicados recientemente. OBJETIVO: Evaluar la incidencia y mortalidad asociada a LRA en pacientes sometidos a revascularizacion del miocardio (RM) con circulacion extracorporea (CEC). METODOS: El total de 817 pacientes fueron divididos en dos grupos: LRA negativa (-), con 421 pacientes (51,5%), y LRA positiva (+), con 396 pacientes (48,5%). LRA fue considerada la elevacion de creatinina en 0,3 mg/dl el aumento en 50% de creatinina en relacion a su valor basal. RESULTADOS: La mortalidad dentro de 30 dias de los pacientes con y sin LRA ha sido de 12,3 y 1,4%, respectivamente (p 14 dias), 14 versus 2%; p<0,0001. CONCLUSION: En la poblacion estudiada, mismo una discreta alteracion de la funcion renal basada en los criterios AKIN ha sido predictora independiente de obito, en 30 dias tras RM con CEC. (Registro ClinicalTrials.gov - NCT00780845).BACKGROUND The acute kidney injury (AKI) is a complex disease for which there is no accepted standard definition nowadays. The Acute Kidney Injury Network (AKIN) represents an attempt to standardize the criteria for diagnosis and staging of acute renal dysfunction based on recently published RIFLE criteria, that means, (Risk, Injury, Failure, Loss, and End-stage kidney disease). OBJECTIVES To evaluate the incidence and associated mortality of AKI in patients submitted to on-pump coronary artery bypass graft surgery (on-pump CABG). METHODS A total of 817 patients were divided into two groups: negative AKI (-), with 421 patients (51.5%), and positive AKI (+), with 396 patients (48.5%). Increase of 0.3 mg/dL in creatinine or of 50% in creatinines basal value was considered as AKI. RESULTS The rate of patients mortality with or without AKI within 30 days after cardiac surgery was 12.6% and 1.4%, respectively (p<0.0001). In a multivariate logistic regression model, AKI after on-pump CABG was an independent predictor of death within 30 days (OR=6.7; p=0.0002). This group of patients presented a longer period of permanency in intensive care unit (ICU) [median 2 days (2 to 3) versus 3 days (2 to 5); p=0.0001] and a bigger proportion of patients with prolonged permanence in intensive care (>14 days) (14 versus 2%; p=0.0001). CONCLUSION In the studied population, even a discrete alteration in renal function, based on AKIN criteria, was an independent predictor of death in 30 days after on-pump CABG.

Inflammatory markers of atherosclerotic plaque stabilization after acute coronary event - temporal trends

OBJECTIVE To evaluate the length of time required for atherosclerotic plaque stabilization in acute coronary syndromes (ACS), using inflammatory markers. METHODS In this prospective study, C-reactive protein (CRP), fibrinogen, factor VIIIc, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) levels were measured on admission, at discharge, and three and six months post-discharge in 40 patients with non-ST-segment elevation ACS (NSTE-ACS) and 40 healthy subjects. RESULTS C-reactive protein levels were significantly higher on admission and at discharge, but not at three and six months post-discharge, compared with the control group. Fibrinogen levels remained unchanged, except at six months, when they were significantly lower than in the control group. Factor VIII-c did not differ from that of the control group on admission, but it was significantly higher at discharge, with no differences at three and six months. Interleukin-6 levels were significantly higher than in the control group in all time points. However, they declined significantly between discharge and three months. In no time point was TNF-alpha significantly different from that of the control group. Only IL-6 correlated significantly and independently with future cardiovascular events. CONCLUSION With respect to CRP and factor VIIIc, plaque stabilization is suggested in up to three months; IL-6 analysis suggests stabilization as from the third month, although it remained higher than that of the control group for up to six months. Only IL-6 showed prognostic value for further events within a year.

ST-segment resolution and late (6-month) left ventricular remodeling after acute myocardial infarction

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Diltiazem improves left ventricular systolic function following acute myocardial infarction treated with streptokinase

The role of diltiazem on left ventricular systolic function was analyzed in 101 patients with acute myocardial infarction treated with streptokinase, being obtained, for the total of the population, higher LV global ejection fraction (p = 0.022), LV regional shortening (p = 0.046) and LV global shortening (p = 0.064) for the treated group, relative to the placebo group; the p values were, respectively, 0.005, 0.009, and 0.012, for patients that achieved TIMI-3 antegrade coronary flow. It is concluded that diltiazem is useful as adjuvant to streptokinase, especially when antegrade coronary blood flow TIMI-3 is obtained.

Acute Myocardial Infarction due to Coronary Artery Embolism in a Patient with Mechanical Aortic Valve Prosthesis

Previous cases of coronary embolism as a cause of myocardial infarction (MI) in association with prosthetic mechanical valves have been reported, but the fact that the patient was not aware of the importance of maintaining anticoagulation therapy is relevant in this case. A 16-year-old female was referred for primary coronary intervention due to subacute anterolateral ST elevation MI, after she decided to discontinue warfarin therapy three weeks before. Coronary angiography showed distal occlusion of the left anterior descending coronary artery with an image suggesting embolic material. Conventional echocardiography demonstrated akinesia of anteroseptal, inferior, and posterior segments of the left ventricle, with severe systolic dysfunction, beyond the intraventricular thrombus. The presence of mechanic aortic prosthesis and no anticoagulation therapy are highly suggestive of coronary embolism as the cause of MI. This case report confirms that patient education is vital in our struggle to prevent this complication in high-risk patients.

Evolução dos níveis de colesterol na população adulta de São José do Rio Preto (1991-1997)

PURPOSE: To develop a survey about risk factors for atherosclerosis in a ³20-year-old population from Sao Jose do Rio Preto, and compare the results with those obtained in a similar survey in 1991. METHODS: Quantitative survey with sample stratified by sex and age. The individuals (a total of 646, 303 men) where contacted in outpatient facilities from the Health Secretary and other populated sites, distributed by geographic zone and social class of different neighborhoods. The standard error of the survey was 4%, and the confidence interval was 95%. RESULTS: A) Mean HDL-cholesterol (only in 1997): male gender 43.7±15mg/dL, female gender 49.6±13.5mg/dL (p<0.001, 95% CI 3.7 a 8.1). B) Mean total cholesterol in 1991 vs 1997: for the global population 192.5±48.9mg/dL vs 190.5±42.5mg/dL (p=NS); for men 187.6±53.3mg/dL vs 190.5±42.5mg/dL (p=NS); for women 196.8±40mg/dL vs 187.6±37.8mg/dL (p=0.008, 95% CI 2.4 a 15.9). C) By regression analysis, the variables that correlated significantly with cholesterol levels, in both surveys, were: age (p<0.001), systolic (p<0.001) and diastolic (p<0.001) arterial pressure, diet (p<0.001). Female gender showed correlation only in the 1991 survey (p=0.011), and sedentarism only in 1997 (p=0.014). CONCLUSION: The mean cholesterol levels in the adult population of Sao Jose do Rio Preto are very favorable and, in female gender, showed a significant decrease in the 1997 survey, relatively to the 1991 survey.

Atorvastatin for high-risk statin-naïve patients undergoing noncardiac surgery: The Lowering the Risk of Operative Complications Using Atorvastatin Loading Dose (LOAD) randomized trial

Background Preliminary evidence suggests that statins may prevent major perioperative vascular complications. Methods We randomized 648 statin‐naïve patients who were scheduled for noncardiac surgery and were at risk for a major vascular complication. Patients were randomized to a loading dose of atorvastatin or placebo (80 mg anytime within 18 hours before surgery), followed by a maintenance dose of 40 mg (or placebo), started at least 12 hours after the surgery, and then 40 mg/d (or placebo) for 7 days. The primary outcome was a composite of all‐cause mortality, nonfatal myocardial injury after noncardiac surgery, and stroke at 30 days. Results The primary outcome was observed in 54 (16.6%) of 326 patients in the atorvastatin group and 59 (18.7%) of 316 patients in the placebo group (hazard ratio [HR] 0.87, 95% CI 0.60‐1.26, P = .46). No significant effect was observed on the 30‐day secondary outcomes of all‐cause mortality (4.3% vs 4.1%, respectively; HR 1.14, 95% CI 0.53‐2.47, P = .74), nonfatal myocardial infarction (3.4% vs 4.4%, respectively; HR 0.76, 95% CI 0.35‐1.68, P = .50), myocardial injury after noncardiac surgery (13.2% vs 16.5%; HR 0.79, 95% CI 0.53‐1.19, P = .26), and stroke (0.9% vs 0%, P = .25). Conclusion In contrast to the prior observational and trial data, the LOAD trial has neutral results and did not demonstrate a reduction in major cardiovascular complications after a short‐term perioperative course of statin in statin‐naïve patients undergoing noncardiac surgery. We demonstrated, however, that a large multicenter blinded perioperative statin trial for high‐risk statin‐naïve patients is feasible and should be done to definitely establish the efficacy and safety of statin in this patient population.