Márcia Noya-Rabelo

Relation of severe deficiency of vitamin D to cardiovascular mortality during acute coronary syndromes.

Vitamin D deficiency is associated with risk for a first cardiovascular event in the general population, possibly because of inflammation, insulin resistance, and neurohumoral activation. However, its relation with outcomes in acute coronary syndromes has not been reported. To test the hypothesis that severe deficiency of vitamin D is independently associated with cardiovascular mortality during ACS, 206 patients admitted for unstable angina, non-ST-segment elevation myocardial infarction, or ST-segment elevation acute myocardial infarction had 25-hydroxyvitamin D serum levels measured at admission. Severe vitamin D deficiency was defined a priori as a value ≤10 ng/ml. The average concentration of vitamin D was 20 ± 8.2 ng/ml, and 10% of patients were severely deficient (95% confidence interval 6.6% to 15%). Cardiovascular mortality during hospitalization took place in 14 patients, an incidence of 6.8%. Patients with severe vitamin D deficiency had in-hospital cardiovascular mortality of 24%, significantly higher than the 4.9% observed in the remaining patients (relative risk 4.3, 95% confidence interval 1.8 to 10, p = 0.001). After adjustment for Global Registry of Acute Coronary Events (GRACE) score, Gensini angiographic score, and potential confounding variables, severe deficiency of vitamin D remained an independent predictor of in-hospital cardiovascular mortality (odds ratio 14, 95% confidence interval 1.2 to 158, p = 0.03). In conclusion, severe vitamin D deficiency is independently associated with in-hospital cardiovascular mortality in patients with acute coronary syndromes.

Acurácia dos escores GRACE e TIMI na predição da gravidade angiográfica da síndrome coronariana aguda

FUNDAMENTO: A acuracia dos escores GRACE e TIMI em predizer a extensao da doenca coronariana em pacientes com sindromes coronarianas agudas sem supradesnivelamento do segmento ST (SCA) nao esta estabelecida. OBJETIVO: Testar a hipotese de que os escores de risco GRACE e TIMI predizem satisfatoriamente a extensao da doenca coronariana, em pacientes com SCA submetidos a coronariografia. METODOS: Individuos admitidos com criterios objetivos de SCA e que realizaram coronariografia durante o internamento foram consecutivamente analisados. A doenca coronariana angiografica foi descrita de tres formas: quantificacao da extensao da doenca coronariana pelo escore de Gensini; presenca de qualquer obstrucao coronariana (> 70% ou > 50% quando tronco de coronaria esquerda); presenca de doenca severa (triarterial ou tronco de coronaria esquerda). RESULTADOS: Em 112 pacientes avaliados, observou-se correlacao positiva do escore de Gensini com os escores GRACE (p = 0,017) e TIMI (p = 0,02), porem essa associacao foi de fraca magnitude (r = 0,23 e r = 0,27; respectivamente). O escore GRACE nao foi capaz de predizer doenca coronariana obstrutiva (area abaixo da curva ROC = 0,57; 95%IC = 0,46 - 0,69), nem doenca coronariana severa (ROC = 0,59; 95%IC = 0,48 -0,70). O Escore TIMI se mostrou modesto preditor em relacao a presenca de doenca coronariana (ROC = 0,65; 95%IC = 0,55 - 0,76) e presenca de doenca severa (ROC = 0,66; 95%IC = 0,56 - 0,76). CONCLUSAO: (1) Existe associacao positiva entre o valor dos escores TIMI ou GRACE e a extensao da doenca coronaria em pacientes com SCA; (2) No entanto, o grau dessa associacao nao e suficiente para que esses escores sejam preditores acurados dos resultados da coronariografia.

Effectiveness of a myocardial infarction protocol in reducing door-to-ballon time

Background An adequate door-to-balloon time (<120 minutes) is the necessary condition for the efficacy of primary angioplasty in infarction to translate into effectiveness. Objective To describe the effectiveness of a quality of care protocol in reducing the door-to-balloon time. Methods Between May 2010 and August 2012, all individuals undergoing primary angioplasty in our hospital were analyzed. The door time was electronically recorded at the moment the patient took a number to be evaluated in the emergency room, which occurred prior to filling the check-in forms and to the triage. The balloon time was defined as the beginning of artery opening (introduction of the first device). The first 5 months of monitoring corresponded to the period of pre-implementation of the protocol. The protocol comprised the definition of a flowchart of actions from patient arrival at the hospital, the teams awareness raising in relation to the prioritization of time, and provision of a periodic feedback on the results and possible inadequacies. Results A total of 50 individuals were assessed. They were divided into five groups of 10 sequential patients (one group pre-and four groups post-protocol). The door-to-balloon time regarding the 10 cases recorded before protocol implementation was 200 ± 77 minutes. After protocol implementation, there was a progressive reduction of the door-to-balloon time to 142 ± 78 minutes in the first 10 patients, then to 150 ± 50 minutes, 131 ± 37 minutes and, finally, 116 ± 29 minutes in the three sequential groups of 10 patients, respectively. Linear regression between sequential patients and the door-to-balloon time (r = - 0.41) showed a regression coefficient of - 1.74 minutes. Conclusion The protocol implementation proved effective in the reduction of the door-to-balloon time.

Prognostic Value of TIMI Score versus GRACE Score in ST-segment Elevation Myocardial Infarction

Background The TIMI Score for ST-segment elevation myocardial infarction (STEMI) was created and validated specifically for this clinical scenario, while the GRACE score is generic to any type of acute coronary syndrome. Objective Between TIMI and GRACE scores, identify the one of better prognostic performance in patients with STEMI. Methods We included 152 individuals consecutively admitted for STEMI. The TIMI and GRACE scores were tested for their discriminatory ability (C-statistics) and calibration (Hosmer-Lemeshow) in relation to hospital death. Results The TIMI score showed equal distribution of patients in the ranges of low, intermediate and high risk (39 %, 27 % and 34 %, respectively), as opposed to the GRACE Score that showed predominant distribution at low risk (80 %, 13 % and 7%, respectively). Case-fatality was 11%. The C-statistics of the TIMI score was 0.87 (95%CI = 0.76 to 0.98), similar to GRACE (0.87, 95%CI = 0.75 to 0.99) - p = 0.71. The TIMI score showed satisfactory calibration represented by χ2 = 1.4 (p = 0.92), well above the calibration of the GRACE score, which showed χ2 = 14 (p = 0.08). This calibration is reflected in the expected incidence ranges for low, intermediate and high risk, according to the TIMI score (0 %, 4.9 % and 25 %, respectively), differently to GRACE (2.4%, 25% and 73%), which featured middle range incidence inappropriately. Conclusion Although the scores show similar discriminatory capacity for hospital death, the TIMI score had better calibration than GRACE. These findings need to be validated populations of different risk profiles.

Evaluation of Galectin-3 as a Novel Biomarker for Chagas Cardiomyopathy

Objectives: Chagas cardiomyopathy has worse long-term outcomes than other cardiomyopathies. A biomarker strategy to refer subjects for noninvasive cardiac imaging may help in the early identification of cardiac damage in subjects with Chagas disease. Galectin-3 (Gal-3) is a mediator of cardiac fibrosis shown to be upregulated in animal models of decompensated heart failure. Here we assessed the correlation of Gal-3 with myocardial fibrosis in patients with Chagas disease. Methods: This study comprised 61 subjects with Chagas disease. All subjects underwent clinical assessments, Doppler echocardiography and magnetic resonance imaging. Plasmatic Gal-3 was determined by ELISA. Results: Delayed enhancement (DE) was identified in 37 of 61 subjects (64%). The total amount of myocardial fibrosis was 9.4% [interquartile interval (IQI): 2.4-18.4]. No differences were observed in Gal-3 concentration according to the presence or absence of myocardial fibrosis, with a median Gal-3 concentration of 11.7 ng/ml (IQI: 9.4-15) in subjects with DE versus 12.9 ng/ml (IQI: 9.2-14) in subjects without DE (p = 0.18). No correlation was found between myocardial fibrosis and Gal-3 concentration (r = 0.098; p = 0.47). Conclusions: There is no correlation between the degree of myocardial fibrosis and the concentration of Gal-3 in subjects with Chagas disease.

Hemoglobin Level Adds Prognostic Value to the Global Registry of Acute Coronary Events Score in Non-ST Elevation Acute Coronary Syndromes

Objective: We aimed to test the hypothesis that hemoglobin values add prognostic information to the Global Registry of Acute Coronary Events (GRACE) score at admission in patients with non-ST elevation acute coronary syndromes (ACS). Methods: A total of 225 consecutive patients with non-ST elevation ACS were studied. Hemoglobin was measured at admission, and its prognostic value was evaluated in relation to cardiovascular events during hospitalization, defined as the composite of death or myocardial infarction. Results: The incidence of major in-hospital events was 7% (10 deaths and 5 nonfatal myocardial infarctions). Hemoglobin significantly predicted events, with a C statistic of 0.67 [95% confidence interval (CI) 0.53–0.81; p = 0.03], with 12.1 g/dl as the cutoff point of best performance. After adjustment for the GRACE score, low hemoglobin (≤12.1 g/dl) remained an independent predictor of events (odds ratio 3.9, 95% CI 1.2–13; p = 0.028). The C statistic of the GRACE score for prediction of events improved from 0.80 to 0.84 after hemoglobin was taken into account. Finally, the addition of hemoglobin to the GRACE score promoted a net reclassification improvement of 16% in identifying high-risk patients (p = 0.025). Conclusions: The present study provides preliminary evidence that hemoglobin level independently predicts recurrent events during hospitalization and improves the prognostic performance of the GRACE score in patients with non-ST elevation ACS.

The D-dimer approach for troponin in the diagnosis of myocardial infarction: is it really useful?

We read with interest the paper by Body et al. ([1][1]). In a cohort of 703 individuals with acute chest pain, Body et al. demonstrated that the use of a high-sensitivity troponin assay coupled with a low cutoff point (any detectable level) yields 100% sensitivity for recognizing myocardial

Comparison of ACUITY and CRUSADE Scores in Predicting Major Bleeding during Acute Coronary Syndrome

Background The ACUITY and CRUSADE scores are validated models for prediction of major bleeding events in acute coronary syndrome (ACS). However, the comparative performances of these scores are not known. Objective To compare the accuracy of ACUITY and CRUSADE in predicting major bleeding events during ACS. Methods This study included 519 patients consecutively admitted for unstable angina, non-ST-elevation or ST-elevation myocardial infarction. The scores were calculated based on admission data. We considered major bleeding events during hospitalization and not related to cardiac surgery, according to the Bleeding Academic Research Consortium (BARC) criteria (type 3 or 5: hemodynamic instability, need for transfusion, drop in hemoglobin ≥ 3 g, and intracranial, intraocular or fatal bleeding). Results Major bleeding was observed in 31 patients (23 caused by femoral puncture, 5 digestive, 3 in other sites), an incidence of 6%. While both scores were associated with bleeding, ACUITY demonstrated better C-statistics (0.73, 95% CI = 0.63 - 0.82) as compared with CRUSADE (0.62, 95% CI = 0.53 - 0.71; p = 0.04). The best performance of ACUITY was also reflected by a net reclassification improvement of + 0.19 (p = 0.02) over CRUSADE’s definition of low or high risk. Exploratory analysis suggested that the presence of the variables ‘age’ and ‘type of ACS’ in ACUITY was the main reason for its superiority. Conclusion The ACUITY Score is a better predictor of major bleeding when compared with the CRUSADE Score in patients hospitalized for ACS.

Assessment of Galectin-3 Polymorphism in Subjects with Chronic Chagas Disease.

Background Galectin-3, a β-galactoside binding lectin, has been described as a mediator of cardiac fibrosis in experimental studies and as a risk factor associated with cardiovascular events in subjects with heart failure. Previous studies have evaluated the genetic susceptibility to Chagas disease in humans, including the polymorphisms of cytokine genes, demonstrating correlations between the genetic polymorphism and cardiomyopathy development in the chronic phase. However, the relationship between the galectin-3 single nucleotide polymorphism (SNP) and phenotypic variations in Chagas disease has not been evaluated. Objective The present study aimed to determine whether genetic polymorphisms of galectin-3 may predispose to the development of cardiac forms of Chagas disease. Methods Fifty-five subjects with Chagas disease were enrolled in this observational study. Real-time polymerase chain reaction (PCR) was used for genotyping the variants rs4644 and rs4652 of the galectin-3 gene. Results For the SNP rs4644, the relative risk for the cardiac form was not associated with the genotypes AA (OR = 0.79, p = 0.759), AC (OR = 4.38, p = 0.058), or CC (OR = 0.39, p = 0.127). Similarly, for the SNP rs4652, no association was found between the genotypes AA (OR = 0.64, p = 0.571), AC (OR = 2.85, p = 0.105), or CC (OR = 0.49, p = 0.227) and the cardiac form of the disease. Conclusion Our results showed no association between the different genotypes for both SNPs of the galectin-3 gene and the cardiac form of Chagas disease.

Lack of association between serum syndecan-4, myocardial fibrosis and ventricular dysfunction in subjects with chronic Chagas disease

Background Syndecan-4 is a transmembrane glycoprotein associated with inflammation and fibrosis. Increased syndecan-4 levels were previously detected after acute myocardial infarction and in subjects with heart failure. However, the levels of syndecan-4 in subjects with Chagas disease have not so far been investigated. The aim of this study was to investigate the potential role of serum sydencan-4 as a novel biomarker for myocardial fibrosis and cardiac dysfunction in subjects with Chagas disease. Methods This study comprised subjects with Chagas disease (n = 56), being 14 (25%) with the indeterminate form, 16 (29%) with the cardiac form without ventricular dysfunction, and 26 (46%) with the cardiac form with ventricular dysfunction. Results Syndecan-4 serum concentrations did not correlate with presence or absence of myocardial fibrosis (P = 0.386) nor disease severity in subjects with Chagas disease (P = 0.918). Additionally, no correlation was found either between the degree of myocardial fibrosis and serum syndecan-4 [r = 0.08; P = 0.567] or between left ventricular ejection fraction and syndecan-4 [r = 0.02; P = 0.864]. In contrast, NT-proBNP levels correlated with ejection fraction and myocardial fibrosis. Conclusions Our results demonstrate the lack of correlations between serum syndecan-4, myocardial fibrosis and cardiac dysfunction in subjects with Chagas disease. Further studies are required to show if syndecan-4 concentrations can be marker for prognosis assessment or disease progression.