Luiz Carlos Santana Passos

Anti-inflammatory effect of atorvastatin (80 mg) in unstable angina pectoris and non–Q-wave acute myocardial infarction

In this randomized trial, C-reactive protein increased during the first 5 days of an acute coronary syndrome in patients treated with placebo, but this phenomenon was not observed in those randomized to atorvastatin 80 mg/day. This suggests that short-term statin therapy inhibits inflammation in patients with non-ST-elevation acute coronary syndromes.

Evaluation of the accuracy of anthropometric clinical indicators of visceral fat in adults and elderly.

Background Visceral obesity is associated with higher occurrence of cardiovascular events. There are few studies about the accuracy of anthropometric clinical indicators, using Computed Tomography (CT) as the gold standard. We aimed to determine the accuracy of anthropometric clinical indicators for discrimination of visceral obesity. Methods Cross-sectional study with 191 adults and elderly of both sexes. Variables: area of visceral adipose tissue (VAT) identified by CT, Waist-to-Height Ratio (WHtR), Conicity index (C index), Lipid Accumulation Product (LAP) and Visceral Adiposity Index (VAI). ROC analyzes. Results There were a strong correlation between adiposity indicators and VAT area. Higher accuracy of C index and WHtR (AUC≥0.81) than the LAP and the VAI was observed. The higher AUC of LAP and VAI were observed among elderly with areas of 0.88 (CI: 0.766–0.944) and 0.83 (CI: 0.705–0.955) in men and 0.80 (CI: 0.672–0.930) and 0.71 (CI: 0.566–0.856) in women, respectively. The cutoffs of C index were 1.30 in elderly, in both sexes, with sensitivity ≥92%, the LAP ranged from 26.4 to 37.4 in men and from 40.6 to 44.0 in women and the VAI was 1.24 to 1.45 (sens≥76.9%) in men and 1.46 to 1.84 in women. Conclusion Both the anthropometric indicators, C Index and WHtR, as well as LAP and VAI had high accuracy in visceral obesity discrimination. So, they are effective in cardiovascular risk assessment and in the follow-up for individual and collective clinical practice.

A comparison of the Beers and STOPP criteria for identifying the use of potentially inappropriate medications among elderly patients in primary care

RATIONALE, AIMS AND OBJECTIVES Explicit criteria for evaluating the appropriateness of medication use among the elderly have been extensively employed in several countries. The aim of the current study was to assess and characterize the prevalence of potentially inappropriate medications (PIMs) according to the Screening Tool of Older Peoples Prescriptions (STOPP) criteria and compare these data with the 2012 Beers criteria. METHODS A prospective survey of the medications used by elderly patients was performed. A total of 142 participants were randomly selected via systematic sampling. The Beers and STOPP criteria were applied to evaluate the use of PIMs among the sample. All of the medications included in these criteria were assessed for their availability in Brazil. The prevalence of PIMs was chosen as an occurrence measure and compared among the exposure group using the prevalence ratio (PR) as a measure of association. RESULTS The prevalence of PIM use in the sample was 33.8% according to the STOPP criteria and 51.8% using the 2012 Beers criteria. The most prevalent PIMs according to the Beers criteria were short-acting nifedipine (17.4%) and glyburide (11.9%); according to the STOPP criteria, they were acetylsalicylic acid (32.9%), clonazepam (10.1%) and diclofenac (6.3%). The use of four or more drugs (polypharmacy) was associated with a higher prevalence of PIM use (PR = 3.11, 95% CIs = 1.65-5.85). CONCLUSIONS The 2012 Beers criteria identified more PIMs than the STOPP criteria. This difference highlights the need to develop national criteria.

Entraves no acesso à atenção médica: vivências de pessoas com infarto agudo do miocárdio

OBJETIVO: Analisar o caminho percorrido por homens e mulheres que sofreram infarto agudo do miocardio ate conseguirem atencao medica. Conhecer essa trajetoria pode permitir a tomada de decisoes que resultem em atendimento precoce e eficiente nos primeiros minutos apos o inicio dos sintomas, reduzindo a morbi-mortalidade. METODOS: Foram entrevistadas 43 mulheres e 54 homens que sofreram infarto com dor. Os dados foram submetidos a analise de conteudo e inferencia estatistica. RESULTADOS:A mediana de idade para os homens foi 55,3 e para as mulheres 61,5 anos. Predominou para os sexos a baixa escolaridade, inatividade profissional e ocorrencia do infarto no domicilio. Os homens tinham renda familiar maior (p=0,005) e viviam mais em companhia de alguem (p=0,001). Somente 7% das mulheres utilizaram ambulância. Dois tercos da amostra procuraram o hospital como primeiro local de atendimento, mas apenas 33% conseguiram internacao. Assim, 67% dos sujeitos perambularam por ate cinco servicos ate conseguirem a hospitalizacao. As principais razoes para nao admissao hospitalar foram falta de recursos, negacao de atendimento e encaminhamento medico para casa. O local procurado para atendimento, numero de atendimentos recebidos ate a hospitalizacao e a acao medica nao foram associados ao sexo (p=NS). CONCLUSAO: Homens e mulheres optaram por meios de transporte e locais de atendimento inadequados e o sistema de saude nao parece preparado para atende-los. Estes achados convidam a reflexao sobre a importância e os alvos dos programas da educacao para saude e a qualidade da assistencia ao infarto.

Quality of Life analysis of patients in chronic use of oral anticoagulant: an observational study

BackgroundTreatment with oral anticoagulant may influence the quality of life perception as it promotes changes in the patients life, not offering an evident symptomatic relief and presenting well defined risks, such as bleeding. In this trial, the influence of chronic use of anticoagulants on the quality of life perception has been analyzed in patients assisted at the anticoagulation outpatient unit.MethodsThe health related quality of life was evaluated through a cross-section study with a sample composed of 72 patients seen from July 23, 2009 to September 2, 2010 at the Anticoagulation Outpatient Unit of the Federal University of Bahias University Hospital. The studys population was composed by patients with atrial fibrillation and mechanical heart valve. The patients were submitted to two quality of life evaluation questionnaires: a generic questionnaire - the Medical Outcomes Study SF-36 Health Survey (SF36) - and a specific questionnaire - the Duke Anticoagulation Satisfaction Scale (DASS).ResultsThe quality of life perception of the patients studied, based on both the DASS and the SF36, was positive regarding the treatment with oral anticoagulant. The SF36 presented an average score of 62.2 (± 20.0). Among the SF36 evaluated domains, the physical-emotional aspect was the most compromised one regarding life quality perception. The DASS presented an average score of 67.1 (± 18.2) and the domain presenting a greater compromise was the one related to the treatment inconveniences (annoyances, burdens and obligations). Previous hemorrhagic event, comorbidities, drug interactions with medicines that increase the anticoagulant effect, lower education level in the SF36 and younger age group influence a more negative perception of the quality of life, whereas lower education level in the DASS and the duration of treatment for more than 1 year offer a more positive perception.ConclusionPatients seen at the anticoagulation outpatient unit of the University Hospital of Federal University of Bahia/Brazil had a positive perception of the treatment. Factors such as hemorrhagic event, comorbidities, drug interactions, education level, age group and duration of treatment have an influence on the quality of life perception.

Preditores de letalidade hospitalar em pacientes com insuficiência cardíaca avançada

OBJECTIVE Describe the clinical characteristics and identify potential risk factors for in-hospital lethality in patients with decompensated heart failure admitted to an intensive care unit. METHODS Decompensated heart failure patients consecutively admitted to an intensive care unit between June 2001 and December 2003 were selected and followed during hospitalization until discharge or death. Clinical characteristics at admission were recorded and evaluated as independent risk predictors for in-hospital mortality by multiple logistic regression analysis. RESULTS A total of 299 patients (69+/-13 years of age and 54% men) were enrolled. Coronary artery disease was the main cause of heart failure in 49% of the cases. Diabetes mellitus and systemic arterial hypertension occurred in 37.5% and 78% of the patients, respectively. At admission, 22% of them had atrial fibrillation, 21.5% had renal dysfunction, and 48% anemia (16.5% with severe anemia). Severe systolic dysfunction (left ventricular ejection fraction <30%) affected 44% of the patients. In-hospital mortality was 17.4%. After the multivariate analysis had been performed, previous history of stroke, atrial fibrillation, renal failure, age > 70 years, and hyponatremia were independently associated with in-hospital mortality. CONCLUSION Patients admitted to an intensive care unit due to decompensated heart failure have high in-hospital lethality. In this study, variables recorded at admission, such as previous stroke, atrial fibrillation, hyponatremia, renal failure, and age > 70 years were predictors of in-hospital lethality.

Mortality Attributed to Myocardial Infarction in the Male and Female Population of Salvador, BA, between 1981 and 1996

OBJECTIVE To describe according to gender the trend in mortality attributed to myocardial infarction (MI) in the population of Salvador, Bahia between 1981 and 1996. METHODS This study was on mortality due to MI estimates by period and gender of the city of Salvador, Bahia. Data from 1981 to 1996 were stratified by quadrienia, and the percentage reduction in death rate due to MI relative to the preceding period (PRR) was determined. Comparisons between genders were expressed by the male/female death ratio (DR) based on the gender-related PPR. RESULTS An overall increase of approximately 8% was observed in the death rate attributed to MI for the period 1985-1988 (89.2/10 5 individuals / year) versus the period 1981-1984 (82.1/10(5)/ year). In the subsequent periods, overall reductions of 10% and 20.3% were observed for the periods 1989-1992 and 1993-1996, respectively. For men, the PPRs were 11.1 in the period 1989-1992 and 22.7% in the period 1993-1996. The PPRs in women were lower: 8.6% and 17.4% between 1989 and 1992, and 1993 and 1996, respectively. Death rate reduction was greater for men than women, then the male/female DR decreased from 1.66 in 1981-1984 to 1.35 in 1993-1996. CONCLUSION The results indicate a trend towards a reduction in the death rate attributed to myocardial infarction in the city of Salvador from the second half of the 1980s onwards, striking in men.

Discriminatory power of indicators predictors of visceral adiposity evaluated by computed tomography in adults and elderly individuals

INTRODUCTION Identifying anthropometric methods of abdominal adiposity, predictors of excess area of visceral adipose tissue (VAT) allows rapid and low cost evaluation for the risk of cardiovascular diseases in the elderly. OBJECTIVE To evaluate the discriminatory power of anthropometric indicators for detection of excess of the area of VAT. METHODS Cross-sectional study comprising 194 adults and elderly individuals for comparison of both sexes and age groups. Anthropometric variables: waist-to-height Ratio (WHtR), waist-tothigh Ratio (WTR), Abdominal Diameter Index (ADI) and Sagittal Abdominal Diameter Height Index (SAD/Height). The VAT area was identified by computed tomography (CT). Analysis with the ROC curve. RESULTS There was a high correlation between the VAT area and most of the anthropometric indicators (p ≤0.001). Among elderly men, WHtR showed areas under the ROC curve over 0.90 and cutoff of 0.55 (sens: 85.7%; spec: 82.4%, PPV: 99.9%). For older women, the WHtR cutoff was 0.58 (sens: 81.0%; spec: 78.6%). For the SAD/Height, the areas under the ROC curve were ≥0.83 (p ≤0.01), with cutoffs of 0.12 for men and 0.13 for women. CONCLUSION There was a strong discriminatory power of the anthropometric indicators abdominal visceral obesity. The WHtR and SAD/Height showed better performance to predict the VAT area of risk in elderly, without the need of measuring it by computed tomography.

Existe evidência para tratar insuficiência cardíaca baseada na raça ou etnia

OBJECTIVE To assess if there is evidence to support different interventions for treatment of heart failure based upon race/ethnicity. METHODS Systematic review of randomized clinical trials permitted comparisons between blacks and whites with systolic heart failure concerning the efficacy of angiotensin converting enzyme (ACE) inhibitors, beta blockers and a combination of hydralazine/ nitrate to reduce the risks of death and hospitalization. The literature search was based on articles published between 1980 and December 2006 cited in MEDLINE or LILACS. RESULTS Three studies fulfilled the criteria of the reiew. In SOLVD, enalapril was efficient in reducing the risks of death or hospitalization similarly in whites (relative risk reduction (RRR) =18%) and blacks (RRR=17%). In US Carvedilol, carvediol was also associated with significant reduction in the risk of death or hospitalization both in whites (RRR=49%) and blacks (RRR=43%). In V-HeFT II, enalapril was superior to the combination hydralazine with nitrate in reducing the death risk only in whites. CONCLUSION According to the data ACE inhibitors and beta blockers should be considered as the essential drugs to improve the prognosis of heart failure both in blacks and whites. The A-HeFT study was not included in the review because it was restricted to blacks; however, it should be viewed as evidence that the combination hydralazine/nitrate is beneficial to improve survival in patients with advanced heart failure. Data support development of a clinical trial especially designed to assess if the combination hydralazine/nitrate is also efficient in patients not classified as blacks, with advanced heart failure.OBJECTIVE: To assess if there is evidence to support different interventions for treatment of heart failure based upon race/ethnicity. METHODS: Systematic review of randomized clinical trials permitted comparisons between blacks and whites with systolic heart failure concerning the efficacy of angiotensin converting enzyme (ACE) inhibitors, beta blockers and a combination of hydralazine/ nitrate to reduce the risks of death and hospitalization. The literature search was based on articles published between 1980 and December 2006 cited in MEDLINE or LILACS. RESULTS: Three studies fulfilled the criteria of the reiew. In SOLVD, enalapril was efficient in reducing the risks of death or hospitalization similarly in whites (relative risk reduction (RRR) =18%) and blacks (RRR=17%). In US Carvedilol, carvediol was also associated with significant reduction in the risk of death or hospitalization both in whites (RRR=49%) and blacks (RRR=43%). In V-HeFT II, enalapril was superior to the combination hydralazine with nitrate in reducing the death risk only in whites. CONCLUSION: According to the data ACE inhibitors and beta blockers should be considered as the essential drugs to improve the prognosis of heart failure both in blacks and whites. The A-HeFT study was not included in the review because it was restricted to blacks; however, it should be viewed as evidence that the combination hydralazine/nitrate is beneficial to improve survival in patients with advanced heart failure. Data support development of a clinical trial especially designed to assess if the combination hydralazine/nitrate is also efficient in patients not classified as blacks, with advanced heart failure.

Effect of atorvastatin (80 mg) on recurrent ischemia in unstable angina pectoris or Non–ST-Elevation acute myocardial infarction

A body of evidence has suggested that many cellular actions of statin therapy may acutely improve endothelial function even before affecting the lipid profile.1 Statins can acutely enhance nitric oxide bioavailability via their lipid-independent actions by upregulating endothelial nitric oxide synthase.2 In this randomized clinical trial, we evaluated the effect of high-dose atorvastatin on myocardial ischemia measured by ST-segment monitoring during the first 2 days after an episode of unstable angina pectoris (UAP) or non–Q-wave acute myocardial infarction (AMI). • • • Patients admitted to the coronary care unit of Portuguese Hospital, Salvador, Brazil, due to UAP or non–Q-wave AMI from December 2000 to March 2002 were considered candidates for the study. Inclusion criteria were defined as onset of chest discomfort in the previous 48 hours in patients with electrocardiographic changes consisting of transient ST-segment depression ( 0.05 mV), T-wave inversion ( 0.1 mV) and/or positive troponin I ( 1.0 ng/dl). Patients with positive troponin results were defined as having AMI, otherwise they were characterized as UAP. Patients were excluded if they had left bundle branch block, any liver disease, history of statin intolerance, pregnancy, or lactation. The study was approved by the local ethic committee and all participants provided written informed consent. A first blood sample to measure plasma lipids was drawn before initiation of therapy. The enrolled patients were submitted to a randomized, double-blind, placebo-controlled program with either 80 mg of atorvastatin or placebo administered once a day. ST-segment recording (Holter) was performed during the first 2 days of therapy and treatment efficacy was primarily assessed by comparing the amount of ischemia measured by Holter in the 2 groups. After 5 days, experimental therapy was withdrawn and another blood sample was taken for evaluation of the drug effect on plasma lipids. Cardiovascular events during hospitalization, defined as the composite of death, nonfatal AMI, and recurrent UAP, were also recorded. No other type of lipid-lowering therapy was offered to the patients during the first 5 days. Continuous 2-channel electrocardiographic recordings was performed by a calibrated amplitude-modulated cassette recorder (Dynamis 3000, Sao Paulo, Brazil) to detect reversible ST-segment shifts compatible with ischemia, which was defined as a 0.1 mV ST-segment depression or elevation measured 80 ms after the J point, lasting 1 minute and separated by the last episode by 1 minute. Number of ischemic episodes and total ischemia duration was measured in each patient. Ischemic burden was defined as the product of ischemic duration in minutes by the ST-segment depression in millimeters.3 The time from the first episode of ischemia was also recorded. Commercial enzymatic methods were used for the determination of total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides (Dimension Clinical Chemistry System; Dade-Behring, Newark, Delaware).4 HDL cholesterol was determined by the same method used for total cholesterol after precipitation of apolipoprotein B containing lipoproteins with magnesium phosphotungstate. Low-density lipoprotein (LDL) cholesterol was calculated by Friedewald’s formula. Duration of ischemia, number of ischemic epidodes, ischemic burden, and time to the first ischemic episode in each patient were compared between the 2 groups by Wilcoxon’s rank-sum test. The prevalence of patients with ischemia and of patients with 60 minutes of ischemia were compared between the 2 groups by Fisher’s exact test. Baseline characteristics were compared by unpaired Student’s t test for continuous variables and by chi-square or Fisher’s exact tests for categorical variables. Wilcoxon’s sign-rank test was utilized for the paired analysis of plasma lipid changes after therapy in each group. Cardiovascular events were compared between the 2 groups by the chi-square test. Nonparametric tests were applied in most situations because Holter variables were not normally distributed. Analysis of variance and logistic regression were utilized to adjust Holter variables to baseline differences between the groups. We calculated a sample size of 50 patients per group, based on a 2-sided of 5% and a statistical power of 85%, assuming that a 50% reduction in duration of ischemia with atorvastatin would be clinically significant. We based this calculation on the previously described 11 9 minutes of ischemia per patient with UAP per 24 hours.5 One hundred patients were randomized (64 12 years; 51 men); 55 had AMI and 45 had UAP. Fifty From the School of Medicine, Federal University of Bahia, Salvador; Cardiology Division, Portuguese Hospital, Salvador; and Heart Institute (InCor), University of Sao Paulo Medicine School, Sao Paulo, Brazil. Dr. Correia’s address is: Rua do Taruma 90/1002, Salvador BA, Brazil 41.810-440. E-mail: lucorrei@terra.com.br. Manuscript received November 22, 2002; revised manuscript received and accepted February 24, 2003.