De-escalação de inibidores dos receptores P2Y12 após intervenção coronária percutânea / P2Y12 inhibitor de-escalation after percutaneous coronary interventions

Em pacientes que apresentam síndromes coronárias agudas e são tratados com intervenção coronária percutânea, a prescrição do esquema antiplaquetário duplo, composto de ácido acetilsalicílico e um inibidor dos receptores P2Y12, é mandatória, contribuindo para a redução de eventos cardíacos maiores. No entanto, ao mesmo tempo em que previne eventos isquêmicos, essa associação pode precipitar complicações hemorrágicas maiores, o que é mais comumente observado quando são prescritos os medicamentos mais potentes, como o prasugrel ou o ticagrelor. Essas constatações levaram à procura de alternativas terapêuticas capazes de manter a proteção contra eventos isquêmicos e, ao mesmo tempo, prevenir a ocorrência de hemorragias. Uma das estratégias que está em estudo é a de-escalação dos inibidores P2Y12, que consiste no uso dos medicamentos mais potentes numa fase precoce após o procedimento, com substituição deles pelo clopidogrel, após um período de, em geral, 30 dias de evolução; outra possibilidade seria a simples redução da dose do fármaco de maior potência, algo que, até o momento, só pode ser cogitado com o prasugrel. A de-escalação pode ser feita de forma guiada, utilizando testes de mensuração objetiva da agregação plaquetária ou exames para avaliar o perfil genético dos pacientes, ou não guiada, na qual o cardiologista simplesmente faz a substituição ou redução da dose ao fim do período estipulado, sem o auxílio de exames complementares. A literatura contempla ensaios clínicos com essas duas opções de estratégia, os quais são discutidos nesta revisão. Até o momento, nenhuma diretriz médica recomenda de forma explícita o uso regular dessa alternativa terapêutica.

In patients who have acute coronary syndromes and are treated with percutaneous coronary intervention, the prescription of a dual antiplatelet regimen, consisting of acetylsalicylic acid and a P2Y12 receptor inhibitor, is mandatory, contributing to the reduction of major cardiac events. However, while preventing ischemic events, this association may precipitate major bleeding complications, which is more commonly seen when more potent drugs, such as prasugrel or ticagrelor, are prescribed. These findings led to the search for therapeutic alternatives that could maintain the protection against ischemic events and, at the same time, prevent the occurrence of hemorrhages. One of the strategies being studied is de-escalation of P2Y12 inhibitors, which consists of the use of more potent drugs in an early phase after the procedure, replacing them with clopidogrel, after a period of, in general, 30 days of clinical course. Another possibility would be to simply reduce the dose of the most potent drug, which so far can only be considered with prasugrel. De-escalation can be done in a guided way, using objective measuring tests of platelet aggregation or exams to assess the genetic profile of patients, or unguided, in which the cardiologist simply replaces or reduces the dose at the end of the stipulated period, with no ancillary tests. The literature includes clinical trials with these two strategy options, which are discussed in this review. So far, no medical guideline explicitly recommends the regular use of this therapeutic alternative.

Caracterización de los pacientes con diagnóstico de Síndrome Coronario Agudo ingresados en el Hospital Militar Central en el periodo comprendido de julio 2021 a septiembre 2022 / Characterization of patients diagnosed with Acute Coronary Syndrome admitted to the Central Military Hospital in the period from July 2021 to September 2022

En el presente trabajo se obtuvo la caracterización clínico epidemiológico de los pacientes que se hospitalizaron con diagnóstico de SCA en el Hospital Militar Central, se realizó un estudio retrospectivo, de tipo descriptivo con corte transversal; a través de revisión de expediente clínico en el periodo comprendido de julio de 2021 a septiembre de 2022. Se recolectaron datos de un total de 30 pacientes que cumplieron con los criterios de inclusión, se obtuvieron los siguientes resultados el grupo de mayores de 65 años obtuvo mayor prevalencia, el SCA fue más frecuente en el sexo masculino obteniendo 73% de prevalencia. El SCASEST que represente el 53% de los casos, el SCACEST represento el 47% del total de casos. La manifestaciones clínicas se obtuvo que el dolor retroesternal reportado en un 93% de la población en estudio, seguido por angustia 77% y diaforesis 67%. En las pruebas de laboratorio el valor de CPK total fue el dato mayor reportado en el 60% de los pacientes, seguido de CK-MB en el 50%, y la troponina I en el 37%. El área cardiaca mayor afectada fue anteroseptal en el 30% de los casos. Como hallazgos ecocardiográficos que se reporta con FEVI reducida al 33% de los casos. Los factores de riesgo asociado a mayor incidencia de SCA fueron Hipertensión Arterial 73% de los casos, seguido de Dislipidemia en el 67% y Diabetes Mellitus 50%. Del tratamiento administrado la anticoagulación, la terapia con doble antiagregante, y las estatinas fueron administradas en el 100% de los casos, betabloqueador e IECA/ARAII fueron administrados en el 80% y 77% respectivamente, La trombólisis con alteplase se indicó en el 40% de los casos. Se observó que el tiempo de hospitalización de los pacientes con SCA fue <5 días en el 30% de los casos, entre 5-6 días en el 37% y tiempo >7 días en el 33% de los casos. La condición de egresos vivos fue del 97% y mortalidad únicamente del 3%.

In the present work, the epidemiological clinical characterization of the patients who were hospitalized with a diagnosis of ACS at the Central Military Hospital was obtained. A retrospective, descriptive cross-sectional study was carried out; through review of the clinical file in the period from July 2021 to September 2022. Data was collected from a total of 30 patients who met the inclusion criteria, the patients with a diagnosis of ACS were found within the group over 65 years of age, this group being the most affected, ACS was more frequent in males, obtaining a 73% prevalence. NSTE-ACS represents 53% of cases, NSTE-ACS represents 47% of all cases. The clinical manifestations were obtained that retrosternal pain was reported in 93% of the study population, followed by anguish 77% and diaphoresis 67%. In laboratory tests, the total CPK value was the highest value reported in 60% of the patients, followed by CK-MB in 50%, and troponin I in 37%. The major cardiac area affected was anteroseptal in 30% of the cases. As an echocardiographic result that is reported with LVEF reduced to 33% of cases. The risk factors associated with a higher incidence of ACS were Arterial Hypertension in 73% of the cases, followed by Dyslipidemia in 67% and Diabetes Mellitus in 50%. Of the treatment administered, anticoagulation, dual antiplatelet therapy, and statins were administered in 100% of the cases, beta-blockers and ACEI/ARAII were administered in 80% and 77% respectively. Thrombolysis with alteplase was normalized in 40 % of the cases. It will be ruled out that the hospitalization time of patients with ACS was <5 days in 30% of the cases, between 5-6 days in 37% and time >7 days in 33% of the cases. The condition of discharges alive was 97% and mortality was only 3%.

Risco de mediastinite no pós-operatório de cirurgia de revascularização do miocárdio / Risk of mediastinitis in the postoperative period of myocardial revascularization surgery / Riesgo de mediastinitis en el postoperatorio de cirugía de revascularización miocárdica

Objetivo: classificar os pacientes segundo o risco de desenvolvimento de mediastinite no pós-operatório de cirurgia de revascularização do miocárdio. Método: estudo observacional, transversal, realizado na Unidade de Terapia Intensiva Pós-Operatória de um hospital universitário no interior paulista. Amostra consecutiva e não probabilística foi constituída por pacientes adultos, submetidos à revascularização do miocárdio. A coleta de dados foi realizada na alta da Terapia Intensiva, utilizando o Escore de Risco Multivariável para Mediastinite. Para a obtenção do escore foram realizadas análises estatística descritivas. Resultados: participaram do estudo 50 pacientes, 68% do sexo masculino, com média de idade de 62,7 anos. Nenhum paciente foi reoperado ou apresentava doença pulmonar obstrutiva crônica; 26,0% eram obesos; 12,0% apresentaram angina instável e 4,0% foram politransfundidos no pós-operatório. Segundo o escore, 58,0% apresentaram baixo e 42,0% médio risco de desenvolvimento de mediastinite. Conclusão: a maior parte dos pacientes apresentava baixo risco de desenvolvimento de mediastinite

Objective: to classify patients according to the risk of developing mediastinitis in the postoperative period of myocardial revascularization surgery. Method: observational, cross-sectional study, carried out in the Post-Operative Intensive Care Unit of a university hospital in the interior of São Paulo. Consecutive and non-probabilistic sample consisted of adult patients who underwent myocardial revascularization. Data collection was performed at discharge from the Intensive Care, using the Multivariable Risk Score for Mediastinitis. To obtain the score, descriptive statistical analyzes were performed. Results: the50 patients participated in the study, 68% were male, with a mean age of 62.7 years. No patient was reoperated or had chronic obstructive pulmonary disease; 26.0% were obese; 12.0% had unstable angina and 4.0% were transfused in the postoperative period. According to the score, 58.0% had a low and 42.0% medium risk of developing mediastinitis. Conclusion: most patients were at low risk of developing mediastinitis

Objetivo: clasificar a los pacientes según el riesgo de desarrollar mediastinitis en el postoperatorio de cirugía de revascularización miocárdica. Método: estudio observacional, transversal, realizado en la Unidad de Cuidados Intensivos Posoperatorios de un hospital universitario del interior de São Paulo. La muestra consecutiva y no probabilística estuvo constituida por pacientes adultos sometidos a revascularización miocárdica. La recolección de datos se realizó al alta de la Unidad de Cuidados Intensivos, utilizando el Multivariable Risk Score para Mediastinitis. Para obtener la puntuación se realizaron análisis estadísticos descriptivos. Resultados: participaron en el estudio 50 pacientes, el 68% eran varones, con una edad media de 62,7 años. Ningún paciente fue reintervenido ni presentó enfermedad pulmonar obstructiva crónica; El 26,0% eran obesos; El 12,0% presentó angina inestable y el 4,0% recibió transfusión en el postoperatorio. Según el puntaje, el 58.0% tenía un riesgo bajo y el 42.0% medio de desarrollar mediastinitis. Conclusión: la mayoría de los pacientes tenían un riesgo bajo de desarrollar mediastinitis

Estado periodontal de pacientes con cardiopatía isquémica / Periodontal state of patients with ischemic heart disease

Introducción: En numerosos estudios realizados en las últimas 3 décadas, se ha tratado de atribuir una relación causal a la enfermedad periodontal en la fisiopatología de la cardiopatía isquémica. Objetivo: Caracterizar el estado periodontal de pacientes con cardiopatía isquémica y algunos factores de riesgo cardiovascular. Métodos: Se realizó un estudio transversal de 50 pacientes, atendidos en la sala de cuidados coronarios del Hospital Provincial Vladimir Ilich Lenin de Holguín, desde septiembre de 2019 hasta enero de 2020. Se evaluó el estado periodontal mediante el Índice Periodontal de Russell simplificado. Se exploraron algunos factores de riesgo de la cardiopatía isquémica y se emplearon métodos teóricos, empíricos, así como la estadística descriptiva. Resultados: En la serie predominó el grupo de 60-69 años de edad (23 para 46,0 %); 56,0 % de los pacientes presentó infarto agudo de miocardio y 62,0 % periodontitis avanzada. Entre los factores de riesgo cardiovascular más frecuentes figuraron: hipertensión arterial (74,0 %) y tabaquismo (70,0 %). Conclusiones: En este estudio se halló, en gran medida, la periodontitis crónica en pacientes con cardiopatía isquémica, lo cual sirve de pauta para la toma de decisiones de médicos y estomatólogos.

Introduction: In numerous studies carried out in the last 3 decades, it has been tried to attribute a causal relationship to the periodontal disease in the pathophysiology of the ischemic heart disease. Objective: To characterize the periodontal state of patients with ischemic heart disease and some cardiovascular risk factors. Methods: A cross-sectional study of 50 patients, assisted in the Coronary Cares Service of Vladimir Ilich Lenin Provincial Hospital in Holguín, was carried out from September, 2019 to January, 2020. The periodontal state was evaluated by means of the Russell Periodontal Index simplified. Some risk factors of the ischemic heart disease were explored and theoretical, empiric methods were used, as well as the descriptive statistic. Results: In the series there was a prevalence of the 60-69 age group (23 for 46 %); 56.0 % of the patients presented acute myocardial infarction and 62.0 % presented advanced periodontitis. Among the most frequent cardiovascular risk factors we can mention: hypertension (74.0 %) and nicotine addiction (70.0 %). Conclusions: In this study it was found, in great measure, the chronic periodontitis in patients with ischemic heart disease, which serves as rule for the decisions making of doctors and dentists.

Prevalencia de la enfermedad periodontal en pacientes con antecedente de síndrome coronario agudo en un programa de rehabilitación cardiaca / Prevalence of periodontal disease in patients with a history of acute coronary syndrome in a cardiac rehabilitation programme

Resumen Objetivo: establecer la prevalencia y la gravedad de la enfermedad periodontal en pacientes con síndrome coronario agudo sin comorbilidades, que ingresan al programa de rehabilitación cardíaca en la Fundación Clínica Shaio. Métodos: se examinaron 83 pacientes con diagnóstico de síndrome coronario agudo sin comorbilidades y los siguientes diagnósticos: angina inestable (n = 27), infarto de miocardio con elevación del segmento ST (STEMI) (n = 34) e infarto de miocardio sin elevación del segmento ST (NSTEMI) (n = 22). La prevalencia y la gravedad de la enfermedad periodontal fueron evaluadas con el índice periodontal de los Centros para el Control y la Prevención de Enfermedades (CDC). Se compararon entre los grupos índice clínico, placa, cálculo, hemorragia gingival, profundidad de sondaje y nivel de inserción clínica. Resultados: la prevalencia de enfermedad periodontal fue del 97,6% y se observó periodontitis avanzada en el 38,3%. Los pacientes con STEMI mostraron la mayor gravedad de la periodontitis. Los índices clínicos inflamatorios de la enfermedad periodontal se elevaron en todos los grupos sin diferencias significativas. El nivel de inserción clínica no mostró diferencias significativas entre las condiciones cardíacas. Sin embargo, se observó mayor porcentaje de sitios con pérdida de inserción clínica (PIC) ≥ 6 mm, y sitios con una profundidad de bolsas > 6 mm, en pacientes con STEMI. Conclusión: los pacientes con síndrome coronario agudo sin comorbilidades, que ingresaron al programa de rehabilitación cardíaca para completar su tratamiento, tuvieron alta prevalencia y gravedad de la enfermedad periodontal. Es necesario hacer énfasis en el control de la enfermedad periodontal en pacientes con enfermedad coronaria.

Abstract Objective: To determine the prevalence and severity of periodontal disease in patients with acute coronary syndrome with no comorbidities admitted to a cardiac rehabilitation programme in the Clínica Shaio Foundation, Colombia. Methods: The study included a total of 83 patients diagnosed with acute coronary syndrome with no comorbidities and the following diagnoses: unstable angina (n = 27), ST-segment elevation myocardial infarction (STEMI) (n = 34), and non-ST-elevation myocardial infarction (NSTEMI) (n = 22). The prevalence and severity of periodontal disease were evaluated using the Periodontal Index of the Centres for the Control and Prevention of Diseases. A between-group comparison was made of the clinical index, plaque, calculi, gingival bleeding, probing depth, and level of clinical attachment. Results: The prevalence of periodontal disease was 97.6%, and advance periodontitis was observed in 38.3% of subjects. The patients with a STEMI showed more severe periodontitis. The inflammatory clinical indices of periodontal disease were increased in all groups, with no significant differences being observed. There were no significant differences between clinical attachment and heart conditions. However, it was observed that there was a higher percentage of locations with a loss of clinical attachment ≥ 6 mm, and locations with bag depths > 6 mm in patients with a STEMI. Conclusión: The patients with acute coronary syndrome with no comorbidities, and who entered the cardiac rehabilitation programme to complete their treatment, had a high prevalence and severity of periodontal disease. The control of periodontal disease should be emphasised in patients with coronary disease..

Circulating microrna expression profiles in patients with stable and unstable angina

OBJECTIVES: High incidence and case fatality of unstable angina (UA) is, to a large extent, a consequence of the lack of highly sensitive and specific non-invasive markers. Circulating microRNAs (miRNAs) have been widely recommended as potential biomarkers for numerous diseases. In the present study, we characterized distinctive miRNA expression profiles in patients with stable angina (SA), UA, and normal coronary arteries (NCA), and identified promising candidates for UA diagnosis. METHODS: Serum was collected from patients with SA, UA, and NCA who visited the Department of Cardiovascular Diseases of the Meizhou People's Hospital. Small RNA sequencing was carried out on an Illumina HiSeq 2500 platform. miRNA expression in different groups of patients was profiled and then confirmed based on that in an independent set of patients. Functions of differentially expressed miRNAs were predicted using gene ontology classification and Kyoto Encyclopedia of Genes and Genomes pathway analysis. RESULTS: Our results indicated that circulating miRNA expression profiles differed between SA, UA, and NCA patients. A total of 36 and 161 miRNAs were dysregulated in SA and UA patients, respectively. miRNA expression was validated by reverse transcription quantitative polymerase chain reaction. CONCLUSION: The results suggest that circulating miRNAs are potential biomarkers of UA.

Caracterización del síndrome de Wellens y su relación como predictor de obstrucción grave de la arteria descendente anterior. Unidad de Cuidados Coronarios Intensivos Hospital Manuel Fajardo 2016-2017 / Characterization of Wellens syndrome and its relationship as a predictor of severe obstruction of the left anterior descending artery. Intensive Coronary Care Unit Hospital Manuel Fajardo 2016-2017

RESUMEN Introducción: El síndrome de Wellens es un patrón electrocardiográfico que se ha sugerido desde la década del 80 como indicador de obstrucción grave de la arteria descendente anterior, a pesar de ello es poco conocido y no se encuentra en las principales guías de tratamiento de los síndromes coronarios agudos. Objetivo: Demostrar la utilidad del diagnóstico del síndrome de Wellens como predictor de obstrucción grave de la descendente anterior. Método: Se realizó un estudio transversal con componente analítico, que abarcó a los 40 pacientes ingresados en la Unidad de Cuidados Coronarios Intensivos del Hospital Manuel Fajardo, en el período enero de 2016 hasta diciembre de 2017, con diagnóstico de síndrome coronario agudo sin elevación del segmento ST, a los que se les realizó coronariografía. Resultados: Se encontró la presencia de síndrome de Wellens en un 13,5% de los pacientes ingresados con este tipo de síndrome coronario agudo. La edad, el sexo y la presencia de comorbilidades no se relacionaron significativamente con la presencia de este síndrome. El estudio angiográfico evidenció, en los pacientes con un síndrome de Wellens, un riesgo relativo 3,4 veces mayor que el resto, de presentar una obstrucción grave de la arteria descendente anterior. Conclusiones: La identificación oportuna del síndrome de Wellens y su relación con una obstrucción coronaria grave deben motivar una estrategia intervencionista precoz en estos casos.

ABSTRACT Introduction: Wellens syndrome is an electrocardiographic pattern that has been suggested, since the 1980s, as indicator of severe obstruction of the left anterior descending artery, although it is poorly understood and it is not found in the main treatment guidelines for acute coronary syndromes. Objective: To demonstrate the usefulness of the diagnosis of Wellens syndrome as a predictor of severe obstruction of the left anterior descending artery. Method: A cross-sectional study with an analytical component was carried out, covering the 40 patients admitted to the Intensive Coronary Care Unit of the Hospital Manuel Fajardo, in the period from January 2016 to December 2017, with a diagnosis of non-ST-segment elevation acute coronary syndrome, who underwent coronary angiography. Results: The presence of Wellens syndrome was found in 13.5% of the patients admitted with this type of acute coronary syndrome. Age, sex and the presence of comorbidities were not significantly related to the presence of this syndrome. The angiographic study showed, in patients with a Wellens syndrome, a relative risk -3.4 times greater than the rest- of presenting a severe obstruction of the left anterior descending artery. Conclusions: The timely identification of Wellens syndrome and its relationship with a severe coronary obstruction should motivate an early interventionist strategy in these cases.

Clinical Course of Patients Undergoing Myocardial Revascularization Surgery in a Public Cardiology Referral Hospital in Pará, Brazil

Myocardial revascularization surgery (MRS) is the most frequently performed cardiac surgery in Brazil. However, data on mortality rates among patients undergoing MRS in hospitals other than the main referral centers in the northern Brazil are scarce. Objective: To describe the clinical course of patients that submitted to MRS in the major public cardiology referral hospital in the Brazilian Amazon. Methods: Retrospective cohort analysis, by review of medical records of patients who had undergone MRS at Hospital das Clínicas Gaspar Vianna (FHCGV) from January 2013 to June 2014. Results: A total of 179 patients were evaluated. Mortality rate was 11.7% until 30 days after surgery. Waiting time for surgery ≥ 30 days (OR 2.59, 95%CI 1.02 - 6.56, p = 0.039), infection during hospitalization (OR 3.28, 95%CI 1.15 - 9.39, p = 0.021) and need for hemodialysis after surgery (OR 9.06 95%CI 2.07 - 39.54, p = 0.001) were predictors of mortality after CABG. Conclusion: A high mortality rate in the study population was found, higher than that reported in the literature and in other regions of Brazil

Option for the radial versus femoral access in coronary intervention in acute coronary syndromes: a risk-treatment paradox / Opção para o acesso radial versus femoral na intervenção coronária em síndromes coronárias agudas: um paradoxo de tratamento de risco

Background: In coronary procedures, although the radial approach protects patients from hemorrhagic complications, it is technically more complex than the femoral approach. Objectives: To test the hypothesis that the radial approach is the procedure of choice in ACS patients due to the high risk of bleeding; and to identify independent predictors of the choice for radial access. Methods: Patients admitted for ACS who underwent invasive coronary procedure were included. We registered the type of access (femoral or radial) chosen by the physician for the first angiography; the investigators did not interfere with this choosing process. Student's t-test was used for comparisons between the CRUSADE and ACUITY scores. Predictors of radial access were compared between the groups. Statistical significance was defined by p < 0,05.Results: Radial access was chosen in 67% of 347 consecutive patients. Patients who underwent radial approach had lower risk of bleeding determined by CRUSADE (30 ± 14 vs. 37 ± 15; p < 0.001) as compared with femoral access. In multivariate analysis, four variables were identified as independent predictors negatively associated with radial access ­ age (OR = 0.98; 95%CI = 0.96 ­ 0.99), creatinine (OR = 0.54; 95%CI = 0.3 ­ 0.98), signs of left ventricular failure (OR = 0.45; 95% CI = 0.22 ­ 0.92) and previous CABG (OR = 0.022; 95%CI = 0.003 ­ 0.166). Conclusion: The propensity to choose radial over femoral access in coronary intervention was not primarily influenced by patients' bleeding risk. Predictors of this decision, identified in the study, indicated less complex patients, suggesting that the difficulty in performing the technique was a stronger determinant than its potential antihemorrhagic effect

Angina instável e infarto agudo do miocárdio sem supradesnivelamento de ST: tratamento e prognóstico / Unstable angina and non-ST elevation myocardial infarction: treatmemt and prognosis

Objetivo: As doenças cardiovasculares são responsáveis pela principal causa de óbitos na população adulta mundial, sendo a síndrome coronariana aguda (SCA) a mais prevalente entre elas. Resultados: Sabemos que hoje, do ponto de vista epidemiológico, a coronariopatia aguda sem supradesnivelamento de ST tornou-se a forma mais frequente de apresentação clínica da SCA, aproximadamente, em 62% dos casos. Nos últimos anos, houve importantes avanços em relação à terapêutica antiplaquetária e anticoagu-lante capazes de reduzir a mortalidade associada à doença coronariana. Além disso, a estratificação invasiva precoce teve papel fundamental nesse incremento de prognóstico. Conclusão:Dessa forma, atualmente, a escolha terapêutica e de estratificação devem ser avaliadas individual

Cardiovascular diseases are the main cause of death in the adult population worldwide, with acute coronary syndrome (ACS) being the most prevalent. We know that, presently, from an epidemiological point of view, non-ST elevation ACS is the most frequent form of clinical presentation of ACS, in about 62% of cases. Recently, important advances regarding antiplatelet and anticoagulant therapy exist, capable of reducing mortality associated with coronary heart disease. Moreover, early invasive stratification has played a key role in the improvement in prognosis. Thus, the choice of therapy and stratification should be evaluated individually and can modify short- and long-term outcome

Dor torácica na sala de emergência: quem fica e quem pode ser liberado? / Chest pain in the emergency room: who is left and who can be released?

A dor torácica aguda é um sintoma muito frequente nas unidades de emergência, constituindo-se em um possível sinal de alerta para as doenças com risco iminente de morte. Como a maioria desses pacientes é internada para avaliação de uma possível síndrome coronariana aguda, isso gera um custo hospitalar muito alto por paciente. Por conta dessa possibilidade diagnóstica, muitos emergencistas internam a maioria dos pacientes. Por outro lado, a liberação inapropriada daqueles com infarto agudo do miocárdio representa um risco para o médico e, especialmente, para o paciente. Outro ponto importante é a demora para o atendimento, em que há a influência de fatores relacionados ao paciente, assim como, pontos negativos na logística de atendimento dos serviços de emergência em nosso país. Para excelência no atendimento, é importante uma anamnese detalhada adicionada ao exame físico, a qual permite a elaboração das hipóteses diagnósticas. E para auxiliar os médicos na escolha da hipótese diagnóstica e na tomada rápida de decisão, escores de risco são disponibilizados, os quais, facilmente, identificam a probabilidade de eventos adversos. A conduta imediata de casos com risco de morte imediata tem como principal objetivo reduzir a morbidade e a mortalidade, aumentando, consequentemente, a segurança do profissional da emergência. Sugestões de fluxogramas e algoritmos para o atendimento desses pacientes na sala de emergência definem, de forma objetiva, quem fica e quem pode ser liberado

Acute chest pain is a frequent symptom in emergency units, being a possible war-ning sign of diseases with an imminent risk of death. Since most of these patients are hospitalized to evaluate possible acute coronary syndrome, this generates a very high hospital cost per patient. Because of this diagnostic possibility, emergency professionals admit most patients. In contrast, the inappropriate release of those with acute myocardial infarction poses a risk to the physician and, especially, the patient. Another important point is the delay in care, where there is an influence of patient-related factors, as well as negative points in the logistics of care in the emergency services in our country. For excellence in care, a detailed anamnesis added to the examination is important, allowing the elaboration of diagnostic hypotheses. Moreover, to assist physicians in selecting the diagnostic hypothesis and making fast decisions, there are risk scores that easily identify the likelihood of adverse events. The immediate management of cases with an imminent risk of death is the main objective to reduce morbidity and mortality and, consequently, increase the safety of emergency professionals. Flowcharts and algorithm suggestions targeting patients in the emergency room objectively define who stays and who can be released

Correlação entre a complexidade das lesões coronarianas e os níveis de Troponina ultrassensível em pacientes com Síndrome Coronariana Aguda / Correlation between the complexity of coronary lesions and high-sensitivity Troponin levels in patients with Acute Coronary Syndrome

Fundamento: As doenças cardiovasculares são a principal causa de morte no Brasil. Marcadores bioquímicos possuem importância diagnóstica e prognóstica nas síndromes coronarianas agudas (SCAs), sendo a troponina o biomarcador preferido. Estudos já demonstram relação positiva entre elevação da troponina ultrassensível (TnUs) e prognóstico. Entretanto, poucos relacionam seus níveis com a complexidade das lesões coronárias. Objetivos: Comparar níveis de TnUs com a complexidade das lesões coronarianas pelo escore SYNTAX e relacionar os escores TIMI e GRACE com os níveis desse biomarcador em pacientes com SCA. Métodos: Estudo retrospectivo, transversal com 174 indivíduos com SCA. A correlação entre as variáveis foi avaliada pelo teste de correlação linear não paramétrico de Spearman e a análise estatística realizada pelo programa SPSS, com nível de significância de 5%. Resultados: A média de idade foi 63 anos, predominando o sexo feminino (52,9%). A maioria dos pacientes era hipertensa, não diabética e não tabagista. Dos pacientes avaliados, 19,0% apresentaram IAM com SST, 43,1% IAM sem SST e 36,8% angina instável. A maioria encontrava-se em Killip 1 (82,8%). A mediana de TnUs foi de 67pg/ml. As medianas dos escores de risco foram de 3, 121 e 3 pontos nas escalas TIMI, GRACE e SYNTAX, respectivamente. Houve correlação da taxa de TnUs com os escores SYNTAX (p < 0,001, r = 0,440), TIMI (p < 0,001, r = 0,267) e GRACE (p = 0,001, r = 0,261). Conclusão: Encontrada correlação linear positiva entre os níveis de TnUs e complexidade das lesões coronarianas, assim como entre esse biomarcador e os escores clínicos TIMI e GRACE

Background: Cardiovascular diseases are the leading cause of death in Brazil. Biochemical markers have diagnostic and prognostic importance in acute coronary syndromes (ACSs), with troponin as the preferred biomarker. Studies have already demonstrated a positive relationship between increased levels of high-sensitivity troponin (hsTn) and prognosis. However, few studies have correlated hsTn levels with the complexity of coronary lesions. Objectives: To compare hsTn levels with the complexity of coronary lesions according to the SYNTAX score, and to correlate the levels of this biomarker with the TIMI and GRACE scores in patients with ACS. Methods: Retrospective, cross-sectional study with 174 patients with ACS. The correlation between variables was assessed by the nonparametric Spearman's rank correlation, and statistical analysis was performed by the SPSS program, with a significance level of 5%. Results: Mean age was 63 years, and most patients were women (52.9%), hypertensive, non-diabetic and non-smokers. Nineteen percent of the patients had STEMI, 43.1% NSTEMI, and 36.8% unstable angina. Most were in Killip 1 (82.8%). Median hsTn was 67 pg/mL. Median risk scores were 3, 121 and 3 in the TIMI, GRACE and SYNTAX scores, respectively. There was a correlation of hsTn with SYNTAX (p <0.001, r = 0.440), TIMI (p < 0.001, r = 0.267) and GRACE (p = 0.001, r = 0.261) scores. Conclusion: A positive linear correlation was found of hsTn levels with the complexity of coronary lesions, and with the TIMI and GRACE

Applicability of Longitudinal Strain of Left Ventricle in Unstable Angina / Aplicabilidade do Strain Longitudinal do Ventrículo Esquerdo na Angina Instável

Abstract Background: Unstable angina (UA) is a common cause of hospital admission; risk stratification helps determine strategies for treatment. Objective: To determine the applicability of two-dimensional longitudinal strain (SL2D) for the identification of myocardial ischemia in patients with UA. Methods: Cross-sectional, descriptive, observational study lasting 60 days. The sample consisted of 78 patients, of which fifteen (19.2%) were eligible for longitudinal strain analysis. The value of p < 0.05 was considered significant. Results: The group of ineligible patients presented: a lower proportion of women, a higher prevalence of diabetes mellitus (DM), use of ASA, statins and beta-blockers and larger cavity diameters. The main causes of non-applicability were: presence of previous infarction (56.4%), previous CTA (22.1%), previous MRI (11.5%) or both (16.7%) and the presence of specific electrocardiographic abnormalities (12.8%). SL2D assessment revealed a lower global strain value in those with stenosis greater than 70% in some epicardial coronary arteries (17.1 [3.1] versus 20.2 [6.7], with p = 0.014). Segmental strain assessment showed an association between severe CX and RD lesions with longitudinal strain reduction of lateral and inferior walls basal segments; (14 [5] versus 21 [10], with p = 0.04) and (12.5 [6] versus 19 [8], respectively). Conclusion: There was very low SL2D applicability to assess ischemia in the studied population. However, the global strain showed a correlation with the presence of significant coronary lesion, which could be included in the UA diagnostic arsenal in the future.

Resumo Fundamento: A angina instável (AI) é uma causa comum de internação hospitalar, a estratificação de risco ajuda a determinar estratégias para o tratamento. Objetivo: Determinar a aplicabilidade do strain longitudinal bidimensional (SL2D) para identificação de isquemia miocárdica, em pacientes com AI. Métodos: Estudo observacional transversal, descritivo, com duração de 60 dias. A amostra foi composta por 78 pacientes, sendo quinze (19,2%) elegíveis para análise do strain longitudinal. O valor de p < 0.05 foi considerado significativo. Resultados: O grupo dos não elegíveis apresentou: menor proporção de mulheres, maior prevalência de diabetes mellitus (DM), do uso de AAS, estatinas e betabloqueadores e maiores diâmetros cavitários. As principais causas da não aplicabilidade foram: presença de infarto prévio (56,4%), ATC prévia (22,1%), RM prévia (11,5%) ou ambos (16,7%) e presença de alterações eletrocardiográficas específicas (12,8%). A avaliação do SL2D revelou um valor de strain global inferior naqueles com estenose maior que 70% em alguma coronária epicárdica (17,1 [3,1] versus 20,2 [6,7], com p = 0,014). A avaliação do strain segmentar demonstrou associação entre lesão grave nas coronárias CX e CD com redução do strain longitudinal dos segmentos basais das paredes lateral e inferior; (14 [5] versus 21 [10], com p = 0,04) e (12,5 [6] versus 19 [8], com p = 0,026), respectivamente. Conclusão: Houve aplicabilidade muito baixa do SL2D para avaliar isquemia na população estudada. Entretanto, o strain global apresentou correlação com presença de lesão coronária significativa, podendo, futuramente, ser incluído no arsenal diagnóstico da AI.

Factores de riesgo asociados al desarrollo de eventos cardiovasculares en pacientes postrasplante renal / Risk factors associated with cardiovascular events in kidney transplant patients

Resumen Objetivo: describir el comportamiento de los factores de riesgo cardiovascular en pacientes con trasplante renal y su relación con los desenlaces cardiovasculares a uno y cinco años luego del trasplante. Métodos: se realizó un estudio analítico de cohorte retrospectivo en los pacientes con trasplante renal del Hospital Universitario San Ignacio con seguimiento institucional por lo menos de un año. Se analizaron las variables demográficas, los factores de riesgo cardiovascular y los desenlaces cardiovasculares a uno y cinco años. Resultados: se incluyeron 166 pacientes con seguimiento a un año y 79 con seguimiento a cinco años postrasplante renal. En el primer año postrasplante hubo una reducción significativa del tabaquismo y la hipertensión arterial sin cambios en el control de la dislipidemia ni de la diabetes mellitus. Se presentaron 9 eventos en el primer año con 6 casos de angina inestable, 2 infartos de miocardio y un ataque cerebrovascular. En la evaluación al quinto año se mantuvo el cese del tabaquismo con aumento de los casos de hipertensión arterial. Se presentaron 8 casos de angina inestable, cifra que corresponde a un 10% de eventos cardiovasculares. Conclusiones: en el seguimiento a uno y cinco años postrasplante renal de los pacientes del Hospital Universitario San Ignacio se identificó una tasa baja de eventos cardiovasculares con una modificación en la prevalencia de algunos factores de riesgo cardiovascular.

Abstract Objective: To describe the behaviour of the cardiovascular risk factors in kidney transplant patients, and its relationship with the outcomes at 1 and 5 years after the transplant. Methods: A retrospective analytical cohort study was performed on patients with kidney transplant from the Hospital Universitario San Ignacio with a follow-up of at least 1 year. An analysis was carried out on the demographic variables, cardiovascular risk factors, and the cardiovascular outcomes at 1 and 5 years. Results: The study included 166 patients with a follow-up of 1 year, and 79 with a follow-up of 5 years post-kidney transplant. In the first year post-transplant there was a significant reduction in smoking, as well as in blood pressure, with no changes in the control of dyslipidaemia or in diabetes mellitus. There were 9 events in the first year, with 6 cases of unstable angina, 2 myocardial infarctions, and one stroke. In the evaluation at the fifth year the quitting smoking was maintained, with an increase in arterial hypertension. There were 8 cases of unstable angina, corresponding to 10% of the cardiovascular events. Conclusions: A low rate of cardiovascular events was identified in the one year and five year follow-up of post-kidney transplant patients from the Hospital Universitario San Ignacio, with a change in the prevalence of some of cardiovascular risk factors.

Diagnóstico automático del síndrome coronario agudo utilizando un sistema multiagente basado en redes neuronales / Automatic diagnosis of acute coronary syndrome using a multi-agent system based in neural networks

Resumen Introducción: Por tratarse de una tarea altamente compleja y de importancia clínica, el diagnóstico del síndrome coronario agudo se presta para su exploración por medio de modelado mediante sistemas inteligentes. Objetivo: desarrollar un sistema multiagente que ensamble las decisiones de varias redes neuronales para el diagnóstico del dolor torácico enfocado a los síndromes coronarios agudos. Metodología: estudio de pruebas diagnósticas en el que se entrenan un conjunto de redes neuronales con una precisión cercana al 70%, que luego son ensambladas mediante tres sistemas de votación para luego adicionar el resultado de redes especiales en poblaciones particulares y seleccionar la mejor configuración que hará parte de un sistema multiagente para el diagnóstico del dolor torácico. Resultados: Se generaron 84 redes con precisión promedio del 72% en pruebas; al ensamblarse aumentan dicha precisión hasta llegar a un máximo del 84% que tras la adición de los grupos especiales alcanza el 89%. Se escoge una conformación que brinda una sensibilidad del 96% con una especificidad del 77%, con valores predictivos positivo y negativo de 87 y 93% respectivamente para el diagnóstico de síndrome coronario agudo. Conclusiones: Es posible desarrollar una herramienta para el diagnóstico automático del síndrome coronario agudo a partir de un sistema multiagente que ensamble la disposición tomada por un conjunto de redes neuronales artificiales, cuyo rendimiento permite su consideración para su implementación dentro de un sistema de soporte a las decisiones clínicas.

Abstract Introduction: Because it is a highly complex task of a great clinical importance, the diagnosis of acute coronary syndromes allows for their analysis by means of intelligent system models. Motivation: To develop a multi-agent system that assembles the decisions of several neural networks for the diagnosis of chest pain with a focus on acute coronary syndromes. Methods: A study of diagnostic tests where a series of neural networks are trained with a precision close to 70%, and are later on assembled with three voting systems. Then the results of special networks on specific populations are added to select the best configuration that Will make part of a multi-agent system for diagnosing chest pain. Results: A total of 84 networks were generated, with an average precision of 72% during testing; once assembled this precision rises up to a maximum of 84%, which then reaches 89% when the special groups are included. A configuration that offers a sensitivity of 96% with a specificity of 77% and positive and negative predictive values of 87 and 93% respectively is chosen for the diagnosis of acute coronary syndrome. Conclusions: It is possible to develop a tool for the automatic diagnosis of acute coronary syndrome using a multi-agent system that assembles the dispositions taken by a set of artificial neural networks. Its performance allows taking it into consideration for implementing it within a clinical decision-making support system.

Impact of free thyroxine levels and other clinical factors on bare metal stent restenosis

ABSTRACT Objective Thyroid hormones have both direct and indirect effects on thermogenesis such as modulating vascular smooth muscle cell proliferation. However, the influence of more subtle changes in thyroid hormones on coronary atherosclerosis remains a matter of speculation. Smooth muscle cells play a crucial role in the pathogenesis of in-stent restenosis (ISR). However, the relationship between free thyroxine (fT4) and ISR has not been studied. In the present study, we aimed to assess the role of preprocedural serum fT4 level on the development of ISR in patients undergoing coronary bare metal stent (BMS) implantation. Materials and methods We enrolled and analyzed clinical, biochemical, and angiographic data from 705 consecutive patients without a history of primary thyroid disease [mean age 60.3 ± 9.3 years, 505 (72%) male]; all patients had undergone BMS implantation and further control coronary angiography owing to stable or unstable angina pectoris. Patients were divided into 3 tertiles based on preprocedural serum fT4 levels. Results ISR was observed in 53 (23%) patients in the lowest tertile, 82 (35%) patients in the second tertile, and 107 (46%) patients in the highest fT4 tertile (p < 0.001). Using multiple logistic regression analysis, five characteristics emerged as independent predictors of ISR: diabetes mellitus, smoking, HDL-cholesterol, stent length, and preprocedural serum fT4 level. In receiver operating characteristics curve analysis, fT4 level > 1.23 mg/dL had 70% sensitivity and 73% specificity (AUC: 0.75, p < 0.001) in predicting ISR. Conclusion Higher preprocedural serum fT4 is a powerful and independent predictor of BMS restenosis in patients with stable and unstable angina pectoris.