Primary Prevention of Cardiovascular Disease at Community Clinics in the State of Sao Paulo, Brazil: Results from the Epidemiological Information Study of Communities.

Background: Primary prevention of cardiovascular disease (CVD) remains a major challenge, especially in communities of low- and middle-income countries with poor medical assistance influenced by distinct local, financial, infrastructural, and resource-related factors. Objective: This a community-based study aimed to determine the proportion and prevalence of uncontrolled cardiovascular risk factors (CRF) in Brazilian communities. Methods: The EPICO study was an observational, cross-sectional, and community clinic-based study. Subjects were living in Brazilian communities and were of both sexes and ≥18 years old, without a history of a stroke or myocardial infarction but presenting at least one of the following cardiovascular risk factors: hypertension, diabetes mellitus and hypercholesterolemia. The study was carried out in Brazil, including 322 basic health units (BHU) in 32 cities. Results: A total of 7,724 subjects with at least one CRF were evaluated, and one clinical visit was performed. Mean age was 59.2 years-old (53.7% were >60 years old). A total of 66.7% were women. Of the total, 96.2% had hypertension, 78.8% had diabetes mellitus type II, 71.1% had dyslipidemia, and 76.6% of patients were overweight/obese. Controlled hypertension (defined by <130/80 mmHg or <140/90 mmHg) was observed in 34.9% and 55.5% patients among respective criteria, the rates of controlled blood glucose in patients taking antidiabetic medications was 29.5%, and among those with documented dyslipidemia who received any lipid-lowering medication, only 13.9% had LDL-c on target. For patients presenting three CRF less than 1.9% had LDL-c < 100 mg/dL once their BP and blood glucose were on target. High education level as associated with blood pressure (BP) target of less than 130 / 80mm Hg. The glucose and LDL-c levels on target were associated with the presence of hypertension and diabetes mellitus. Conclusion: In Brazilian community clinics, regarding most patients in primary prevention, the CRF such as BP, blood glucose, and lipid levels are poorly controlled, with a majority of patients not achieving guidelines/recommendations.

Mortality after discharge from a public tertiary cardiovascular referral hospital.

It is critically important for stakeholders with distinct foci of attention on healthcare to understand patient evolution in the presence of an established diagnosis or with a suspected diagnosis of various diseases, specially considering death as an outcome. To study the long-term mortality of patients at a cardiovascular referral hospital. Deterministic binding (selection of pairs of registers from the hospital electronic health records and the mortality records of São Paulo state) from 2002 to 2017 was performed. Studied variables were: age, sex, hospital treatment unit where the first visit occurred (Emergency Unit, Outpatient Unit, Hospital Admissions, Diagnostics Services), treatment type, elapsed time between the first visit and death, diagnosis at first and last visits and variables related to death. Statistical Methods: descriptive, survival (with Kaplan-Meier method), correspondence and competitive risks analyses; in case of nonoccurrence of death until the end of 2017, the patients were considered alive. Statistical significance was set at values of P < .05. Median age at the first visit to the Hospital was 51.9 years. Birth locations included 4496 cities, 17.33% in São Paulo, 0.41% in Rio de Janeiro, 0.40% in Osasco, 24.04% in other cities. Sex included females (46.7%), males (44.2%), not defined (6.3%), and other (2.8%). We observed an association between diseases in ICD-10 Chapter 16 (certain conditions originating in the perinatal period) and Chapter 17 (congenital malformations, deformations, and chromosomal abnormalities), both as diagnoses and underlying causes of death, as well as between neoplasms as diagnoses and as the underlying cause of death. In this sample, there was an association between admission diagnoses and underlying causes of death, such as neoplasms, cardiovascular diseases, and congenital heart malformations. Additionally, patients who underwent a cardiac intervention had a smaller less mortality rate than those who were not operated on. There were also differences in cardiovascular mortality between distinct treatment units of the hospital ((Emergency Unit, Outpatient Unit, Hospital Admissions, Diagnostic Services).

Adherence to the cardiac surgery checklist decreased mortality at a teaching hospital: A retrospective cohort study.

OBJECTIVE: To evaluate the impact of adherence to the cardiac surgical checklist on mortality at the teaching hospital. METHODS: A retrospective cohort study after the implementation of the cardiac surgical safety checklist in a reference hospital in Latin America. All patients undergoing coronary artery bypass surgery and/or heart valve surgery from 2013 to 2019 were analyzed. After the implementation of the project InCor-Checklist "Five steps to safe cardiac surgery" in 2015, the correlation between adherence and completeness of this instrument with surgical mortality was assessed. The EuroSCORE II was used as a reference to assess the risk of expected mortality for patients. Cross-sectional questionnaires were during the implementation of the InCor-Checklist. To perform the correlation, Pearson's coefficient was calculated using R software. RESULTS: Since 2013, data from 8139 patients have been analyzed. The average annual mortality was 5.98%. In 2015, the instrument was used in only 58% of patients; in contrast, it was used in 100% of patients in 2019. There was a decrease in surgical mortality from 8.22% to 3.13% for the same group of procedures. The results indicate that the greater the checklist use, the lower the surgical mortality (r = 88.9%). In addition, the greater the InCor-Checklist completeness, the lower the surgical mortality (r = 94.1%). CONCLUSION: In the formation of the surgical patient safety culture, the implementation and adherence to the InCor-Checklist "Five steps to safe cardiac surgery" was associated with decreased mortality after cardiac surgery.

Training Non-Cardiologists Could Improve the Treatment Results of ST Elevation Myocardial Infarction. / Treinamento de Não-Cardiologistas pode Melhorar os Resultados do Tratamento de Infarto Agudo do Miocárdio com Supra de ST.

BACKGROUND: According to the World Health Organization, emerging countries will have an enormous growth in the number of heart attacks and related deaths. The main medical issue in Brazil is mortality caused by acute ST elevation myocardial infarction (STEMI). The Society of Cardiology in the State of São Paulo has never trained non-cardiologists as emergency personnel. Patients usually seek help from emergency departments instead of calling for an ambulance. OBJECTIVES: We aimed at reducing in-hospital death rates from acute myocardial infarction by training emergency personnel in the city of Sao Paulo. METHODS: We used a training program for the personnel of five hospitals with >100 patients admitted with STEMI per year, and at least 15% in-hospital STEMI-associated mortality rate. We performed internet training, biannual-quarterly symposia for up to 400 participants, informative folders and handouts. Statistical analysis used the two proportion comparison test with p <0.05. RESULTS: Nearly 200 physicians and 350 nurses attended at least one training from May 2010 to December 2013. Initially, many emergency physicians could not recognize an acute myocardial infarction on the electrocardiogram, but tele-electrocardiography is used in some emergency departments to determine the diagnosis. The death rate in the five hospitals decreased from 25.6%, in 2009, to 18.2%, in 2010 (p=0.005). After the entire period of training, the STEMI-associated death rate in all public hospitals of São Paulo decreased from 14.31%, in 2009, to 11.25%, in 2014 (p<0.0001). CONCLUSION: Even simple training programs for emergency personnel can greatly reduce acute myocardial infarction death rates in undeveloped countries.

FUNDAMENTO: De acordo com a Organização Mundial da Saúde, países emergentes terão um crescimento considerável no número de ataques cardíacos e mortes relacionadas. Um dos principais problemas médicos no Brasil é a mortalidade causada por infarto agudo do miocárdio com supra de ST (IAMCSST). A Sociedade de Cardiologia do Estado de São Paulo nunca treinou não-cardiologistas para atendimentos de emergência. Os pacientes normalmente buscam ajuda em prontos-socorros, em vez de chamar a ambulância. OBJETIVO: Nosso objetivo foi reduzir as taxas de mortalidade hospitalar causada por infarto agudo do miocárdio ao treinar profissionais da emergência na cidade de São Paulo. MÉTODOS: Utilizamos um programa de treinamento para as equipes de cinco hospitais com > 100 pacientes internados com IAMCSST por ano, e pelo menos 15% de mortes hospitalares relacionadas ao IAMCSST. Realizamos treinamentos online, organizamos de dois a quatro eventos para até 400 participantes, fizemos folders e panfletos informativos. A análise estatística utilizou o teste para comparação de duas proporções, com p <0,05. RESULTADOS: Quase 200 médicos e 350 enfermeiros participaram de pelo menos um treinamento de maio de 2010 até dezembro de 2013. Inicialmente, muitos médicos da emergência não reconheciam um infarto agudo do miocárdio no eletrocardiograma, mas a tele-ecocardiografia é usada em alguns departamentos da emergência para determinar o diagnóstico. A taxa de mortalidade nos cinco hospitais caiu de 25,6%, em 2009, para 18,2%, em 2010 (p=0,005). Depois da conclusão do período de treinamento, as mortes relacionadas ao IAMCSST em todos os hospitais públicos de São Paulo diminuíram de 14,31%, em 2009, para 11,25%, em 2014 (p<0,0001). CONCLUSÃO: Mesmo programas simplificados de treinamento de pessoal da emergência pode reduzir muito as taxas de morte por infarto agudo do miocárdio em países em desenvolvimento.

Retention of Cardiopulmonary Resuscitation Skills in Medical Students. / Retenção das Habilidades de Ressuscitação Cardiopulmonar nos Estudantes de Medicina.

BACKGROUND: Reduction of mortality and sequelae of cardiac arrest depends on an effective and fast intervention, started as soon as possible. Basic life support involves a series of steps that may be initiated out of the hospital setting and taught to any person in specific courses. However, it is important that the rescuers retain the knowledge and skills to perform cardiopulmonary resuscitation (CPR), as one never knows when they will be required. Studies have shown that a loss of skills occurs as early as 30 days after the training course, with variations according to personal and professional characteristics. OBJECTIVES: to assess whether medical students are able to retain skills acquired in a BLS course for more than six months. METHODS: Prospective, case-control, observational study. Medical students attended a 40-hour course on sudden death and cardiac arrest. Skills acquired during the course were evaluated immediately after and six months after the course. Students' individual scores were compared between these time points, the percentage of correct answers was evaluated, and overall performance was rated as excellent, good, and poor. Observers and evaluation criteria were the same immediately after the course and six months later. Data were analyzed using the paired t-test and the McNemar test. The 95% confidence interval was established, and a p < 0.05 was set as statistically significant. RESULTS: Fifty students (27 female) in the first year of medical school aged from 18 to 24 years (mean of 21 years) attended the course. The number of steps successfully completed by the students at six months was significantly lower than immediately after the course (10.8 vs 12.5 p < 0.001). Neither sex nor age affected the results. Overall performance of 78% of the students was considered excellent immediately after the course, and this percentage was significantly higher than six months later (p < 0.01). After six months, the steps that the students failed to complete at six months were those related to practical skills (such as a correct hand positioning). CONCLUSION: A significant loss of skills was detected six months after the BLS course among medical students, compromising their overall performance.

FUNDAMENTO: A redução da mortalidade e das sequelas de uma vítima de parada cardíaca depende de um atendimento eficaz, rápido e iniciado o mais precocemente possível. O suporte básico de vida (SBV) compreende uma série de etapas que podem ser iniciadas fora do ambiente hospitalar, e ensinadas para qualquer pessoa em cursos específicos. Porém, é importante que o socorrista retenha o conhecimento e as habilidades, pois nunca se sabe quando será necessário realizar uma ressuscitação cardiopulmonar (RCP). Entretanto, estudos mostram que existe uma perda das habilidades em executar uma RCP já com 30 dias após o treinamento, com variações segundo algumas características das pessoas e da atividade profissional. OBJETIVO: Avaliar se os estudantes de medicina são capazes de reter as habilidades por mais de seis meses. MÉTODOS: Estudo prospectivo, caso controle, observacional. Estudantes de medicina realizaram um curso sobre morte súbita e parada cardíaca de 40 horas. A avaliação das habilidades foi realizada imediatamente após o curso e seis meses depois. Foram comparadas as notas individuais entre dois momentos, foi avaliada a porcentagem de acerto em cada etapa e uma análise global do atendimento foi classificado como ótimo, bom e ruim. Os avaliadores e critérios foram os mesmos nos dois momentos. Os dados foram analisados pelos teste-t pareado e teste de McNemar, onde para um nível de confiança de 95% o critério para significância foi p < 0,05. RESULTADOS: Cinquenta estudantes (27 do sexo feminino) do primeiro ano, com idade entre 18 e 24 anos (média 21), realizaram o curso. O número de etapas cumpridas de forma correta após seis meses foi significativamente menor que logo após o curso (10,8 vs 12,5 p < 0,001). O sexo e idade não interferiram nos resultados. A qualidade global foi considerada ótima em 78% dos atendimentos realizados logo após o curso, significativamente, maior que os 40% após seis meses (p < 0,01). Após seis meses, maior número de erros foi observado nas etapas relacionadas às habilidades mais práticas (como posicionamento das mãos). CONCLUSÃO: Seis meses após o curso observamos uma perda significativa das habilidades, entre estudantes de medicina, prejudicando a eficácia global do atendimento.

Adherence to the cardiac surgery checklist decreased mortality at a teaching hospital: A retrospective cohort study

Abstract Objectives To evaluate the impact of adherence to the cardiac surgical checklist on mortality at the teaching hospital. Methods A retrospective cohort study after the implementation of the cardiac surgical safety checklist in a reference hospital in Latin America. All patients undergoing coronary artery bypass surgery and/or heart valve surgery from 2013 to 2019 were analyzed. After the implementation of the project InCor-Checklist "Five steps to safe cardiac surgery" in 2015, the correlation between adherence and completeness of this instrument with surgical mortality was assessed. The EuroSCORE II was used as a reference to assess the risk of expected mortality for patients. Cross-sectional questionnaires were during the implementation of the InCor-Checklist. To perform the correlation, Pearson's coefficient was calculated using R software. Results Since 2013, data from 8139 patients have been analyzed. The average annual mortality was 5.98%. In 2015, the instrument was used in only 58% of patients; in contrast, it was used in 100% of patients in 2019. There was a decrease in surgical mortality from 8.22% to 3.13% for the same group of procedures. The results indicate that the greater the checklist use, the lower the surgical mortality (r = 88.9%). In addition, the greater the InCor-Checklist completeness, the lower the surgical mortality (r = 94.1%). Conclusion In the formation of the surgical patient safety culture, the implementation and adherence to the InCor-Checklist "Five steps to safe cardiac surgery" was associated with decreased mortality after cardiac surgery. HIGHLIGHTS Checklists avoid human errors and are commonly used in high-reliability industries. The "InCor Checklist" was associated with decreased mortality over time. Adherence, completeness, and sustainability within public policies are necessary.

Retenção das Habilidades de Ressuscitação Cardiopulmonar nos Estudantes de Medicina / Retention of Cardiopulmonary Resuscitation Skills in Medical Students

Resumo Fundamento A redução da mortalidade e das sequelas de uma vítima de parada cardíaca depende de um atendimento eficaz, rápido e iniciado o mais precocemente possível. O suporte básico de vida (SBV) compreende uma série de etapas que podem ser iniciadas fora do ambiente hospitalar, e ensinadas para qualquer pessoa em cursos específicos. Porém, é importante que o socorrista retenha o conhecimento e as habilidades, pois nunca se sabe quando será necessário realizar uma ressuscitação cardiopulmonar (RCP). Entretanto, estudos mostram que existe uma perda das habilidades em executar uma RCP já com 30 dias após o treinamento, com variações segundo algumas características das pessoas e da atividade profissional. Objetivo Avaliar se os estudantes de medicina são capazes de reter as habilidades por mais de seis meses. Métodos Estudo prospectivo, caso controle, observacional. Estudantes de medicina realizaram um curso sobre morte súbita e parada cardíaca de 40 horas. A avaliação das habilidades foi realizada imediatamente após o curso e seis meses depois. Foram comparadas as notas individuais entre dois momentos, foi avaliada a porcentagem de acerto em cada etapa e uma análise global do atendimento foi classificado como ótimo, bom e ruim. Os avaliadores e critérios foram os mesmos nos dois momentos. Os dados foram analisados pelos teste-t pareado e teste de McNemar, onde para um nível de confiança de 95% o critério para significância foi p < 0,05. Resultados Cinquenta estudantes (27 do sexo feminino) do primeiro ano, com idade entre 18 e 24 anos (média 21), realizaram o curso. O número de etapas cumpridas de forma correta após seis meses foi significativamente menor que logo após o curso (10,8 vs 12,5 p < 0,001). O sexo e idade não interferiram nos resultados. A qualidade global foi considerada ótima em 78% dos atendimentos realizados logo após o curso, significativamente, maior que os 40% após seis meses (p < 0,01). Após seis meses, maior número de erros foi observado nas etapas relacionadas às habilidades mais práticas (como posicionamento das mãos). Conclusão Seis meses após o curso observamos uma perda significativa das habilidades, entre estudantes de medicina, prejudicando a eficácia global do atendimento.

Abstract Background Reduction of mortality and sequelae of cardiac arrest depends on an effective and fast intervention, started as soon as possible. Basic life support involves a series of steps that may be initiated out of the hospital setting and taught to any person in specific courses. However, it is important that the rescuers retain the knowledge and skills to perform cardiopulmonary resuscitation (CPR), as one never knows when they will be required. Studies have shown that a loss of skills occurs as early as 30 days after the training course, with variations according to personal and professional characteristics. Objectives to assess whether medical students are able to retain skills acquired in a BLS course for more than six months. Methods Prospective, case-control, observational study. Medical students attended a 40-hour course on sudden death and cardiac arrest. Skills acquired during the course were evaluated immediately after and six months after the course. Students' individual scores were compared between these time points, the percentage of correct answers was evaluated, and overall performance was rated as excellent, good, and poor. Observers and evaluation criteria were the same immediately after the course and six months later. Data were analyzed using the paired t-test and the McNemar test. The 95% confidence interval was established, and a p < 0.05 was set as statistically significant. Results Fifty students (27 female) in the first year of medical school aged from 18 to 24 years (mean of 21 years) attended the course. The number of steps successfully completed by the students at six months was significantly lower than immediately after the course (10.8 vs 12.5 p < 0.001). Neither sex nor age affected the results. Overall performance of 78% of the students was considered excellent immediately after the course, and this percentage was significantly higher than six months later (p < 0.01). After six months, the steps that the students failed to complete at six months were those related to practical skills (such as a correct hand positioning). Conclusion A significant loss of skills was detected six months after the BLS course among medical students, compromising their overall performance.

Treinamento de Não-Cardiologistas pode Melhorar os Resultados do Tratamento de Infarto Agudo do Miocárdio com Supra de ST / Training Non-Cardiologists Could Improve the Treatment Results of ST Elevation Myocardial Infarction

Resumo Fundamento De acordo com a Organização Mundial da Saúde, países emergentes terão um crescimento considerável no número de ataques cardíacos e mortes relacionadas. Um dos principais problemas médicos no Brasil é a mortalidade causada por infarto agudo do miocárdio com supra de ST (IAMCSST). A Sociedade de Cardiologia do Estado de São Paulo nunca treinou não-cardiologistas para atendimentos de emergência. Os pacientes normalmente buscam ajuda em prontos-socorros, em vez de chamar a ambulância. Objetivo Nosso objetivo foi reduzir as taxas de mortalidade hospitalar causada por infarto agudo do miocárdio ao treinar profissionais da emergência na cidade de São Paulo. Métodos Utilizamos um programa de treinamento para as equipes de cinco hospitais com > 100 pacientes internados com IAMCSST por ano, e pelo menos 15% de mortes hospitalares relacionadas ao IAMCSST. Realizamos treinamentos online, organizamos de dois a quatro eventos para até 400 participantes, fizemos folders e panfletos informativos. A análise estatística utilizou o teste para comparação de duas proporções, com p <0,05. Resultados Quase 200 médicos e 350 enfermeiros participaram de pelo menos um treinamento de maio de 2010 até dezembro de 2013. Inicialmente, muitos médicos da emergência não reconheciam um infarto agudo do miocárdio no eletrocardiograma, mas a tele-ecocardiografia é usada em alguns departamentos da emergência para determinar o diagnóstico. A taxa de mortalidade nos cinco hospitais caiu de 25,6%, em 2009, para 18,2%, em 2010 (p=0,005). Depois da conclusão do período de treinamento, as mortes relacionadas ao IAMCSST em todos os hospitais públicos de São Paulo diminuíram de 14,31%, em 2009, para 11,25%, em 2014 (p<0,0001). Conclusão Mesmo programas simplificados de treinamento de pessoal da emergência pode reduzir muito as taxas de morte por infarto agudo do miocárdio em países em desenvolvimento.

Abstract Background According to the World Health Organization, emerging countries will have an enormous growth in the number of heart attacks and related deaths. The main medical issue in Brazil is mortality caused by acute ST elevation myocardial infarction (STEMI). The Society of Cardiology in the State of São Paulo has never trained non-cardiologists as emergency personnel. Patients usually seek help from emergency departments instead of calling for an ambulance. Objectives We aimed at reducing in-hospital death rates from acute myocardial infarction by training emergency personnel in the city of Sao Paulo. Methods We used a training program for the personnel of five hospitals with >100 patients admitted with STEMI per year, and at least 15% in-hospital STEMI-associated mortality rate. We performed internet training, biannual-quarterly symposia for up to 400 participants, informative folders and handouts. Statistical analysis used the two proportion comparison test with p <0.05. Results Nearly 200 physicians and 350 nurses attended at least one training from May 2010 to December 2013. Initially, many emergency physicians could not recognize an acute myocardial infarction on the electrocardiogram, but tele-electrocardiography is used in some emergency departments to determine the diagnosis. The death rate in the five hospitals decreased from 25.6%, in 2009, to 18.2%, in 2010 (p=0.005). After the entire period of training, the STEMI-associated death rate in all public hospitals of São Paulo decreased from 14.31%, in 2009, to 11.25%, in 2014 (p<0.0001). Conclusion Even simple training programs for emergency personnel can greatly reduce acute myocardial infarction death rates in undeveloped countries.

Fatores de risco cardiovascular: o diagnóstico e prevenção devem iniciar nas crianças e adolescentes / Cardiovascular risk factors: diagnosis and prevention muststart in children and adolescents

A infância e a adolescência são períodos que compreendem a transição para a vida adulta, no qual ocorrem mudanças no âmbito físico, psicológico, emocional e social. Nesse período tão crucial para o desenvolvimento, fatores ambientais e doenças aos quais os jovens estão expostos podem refletir na vida adulta, gerando maiores chances de desenvolvimento de doenças crônicas, incluindo a doença cardiovascular (DCV). A principal etiologia das doenças cardiovasculares é a aterosclerose, que tem seu início na infância. Dessa forma, é reconhecido atualmente que a prevenção cardiovascular primordial deve iniciar precocemente, na infância e adolescência, antes da instalação da doença de fato, de modo a diminuir a prevalência e incidência das DCV na idade adulta.

Childhood and adolescence constitute the transition to adult life, where changes occur in the physical, psychological, emotional and social spheres. In such a crucial period of deve-lopment, environmental factors and diseases to which young people are exposed may have repercussions in adulthood, increasing the chances of developing chronic diseases, including cardiovascular disease (CVD). The main etiology of cardiovascular diseases is atheroscle-rosis, which has its onset in childhood. Accordingly, it is currently recognized that primordial prevention of cardiovascular disease should begin early, i.e. in childhood and adolescence, prior to its actual onset, in order to reduce the prevalence and incidence of CVD in adulthood.

1st Guidelines of the Brazilian Society of Cardiology on processes and skills for education in cardiology in Brazil--executive summary.

This article summarizes the "1st Guidelines of the Brazilian Society of Cardiology on Processes and Skills for Education in Cardiology in Brazil," which can be found in full at: . The guideline establishes the education time required in Internal Medicine and Cardiology with Specialization through theoretical and practical training. These requirements must be available at the center forming Specialists in Cardiology and the Cardiology contents.

Eticidade do uso de placebo em pesquisa clínica: proposta de algoritmos decisórios / Ethics of the use of placebos in clinical research: a proposal for decision-making algorithms

O uso de placebo em pesquisa clínica tem sido motivo de debate nos últimos anos, sobretudo após a Associação Médica Mundial publicar, em 2002, nota de esclarecimento do parágrafo 29 da Declaração de Helsinki. O Brasil tem se destacado por sua posição firme e contrária ao uso flexível de placebo. Tanto o Conselho Federal de Medicina quanto o Conselho Nacional de Saúde editaram resoluções que normatizam seu uso no Brasil, de forma a não admiti-lo em caso da existência de um método terapêutico melhor. O presente artigo reforça essa posição e tem por objetivo descrever as diversas aplicações de placebo em pesquisa clínica, bem como trazer à luz a complexa decisão sobre a eticidade de seu uso. Além disso, os autores propõem uma reflexão acerca da utilização de placebo no âmbito da pesquisa, por meio de algoritmos decisórios baseados nas normativas éticas brasileiras...

The use of placebos in clinical research has been a matter of considerable debate in recent years, notably when the World Medical Association published, in 2002, a note of clarification for paragraph 29 of the Helsinki Declaration. Brazil is known for its strong opposition to the flexible use of placebos. Both the Federal Council of Medicine and the National Health Council have published resolutions regulating the use of placebos in Brazil, preventing their use if there is a more effective therapeutic method already in place. The present study reinforces that position and aims to describe the various uses of placebos in clinical research, as well as examining the complex decisions relating to the ethics of their use. Additionally, the authors propose a reflection on the use of placebos through decision-making algorithms based on Brazilian ethical standards...

El uso del placebo en la investigación clínica ha sido un tema de debate en los últimos años, sobre todo después de que la Asociación Médica Mundial publicara, en 2002, una nota aclaratoria del párrafo 29 de la Declaración de Helsinki. Brasil se ha destacado por su firme posición en contra de la utilización flexible del placebo. Tanto el Consejo Federal de Medicina como el Consejo Nacional de Salud editaron resoluciones que regulan el uso del placebo en Brasil, no admitiéndose su uso cuando existe un mejor método terapéutico. El presente artículo refuerza esa posición y tiene como objetivo describir diferentes usos del placebo en la investigación clínica, así como contribuir en la discusión sobre la ética de su uso. Además, los autores proponen una reflexión sobre el uso del placebo en la investigación a través de algoritmos para la toma de decisiones, los cuales se basan en las normativas éticas de Brasil...

Combination of amlodipine and enalapril in hypertensive patients with coronary disease.

BACKGROUND: Patients (pts) with stable coronary artery disease (CAD) can benefit from a decrease in the blood pressure (BP), according to recent studies. OBJECTIVE: To evaluate the efficacy and tolerability of the fixed combination: amlodipine + enalapril, when compared to amlodipine in the normalization of the diastolic arterial pressure (DAP) (<85 mmHg), in pts with CAD and systemic arterial hypertension (SAH). METHODS: Double-blind and randomized study, with two groups of pts with DAP > or =90 and <110 mmHg and CAD. Patients with left ventricular ejection fraction (LVEF) < 40%, symptoms of heart failure or angina class III and IV, severe diseases and DAP > or =110 mmHg during the four-week wash-out with atenolol treatment alone, were excluded. After the wash-out, pts were randomly distributed for the use of the combination (A) or amlodipine (B) and were followed every four weeks up to 98 days. The initial doses (in mg) were, respectively: A- 2.5/10 and B- 2.5; the doses were increased when DAP > 85mmHg, at the visits. Statistical analysis was carried out with chi2, Fischer and analysis of variance, for p< 0.05. RESULTS: Of the 110 selected pts, 72 (A= 32, B= 40) were randomized. The decreases in DAP and systolic arterial pressure (SAP) were significant (p< 0.01), but with no difference between the groups in mmHg: SAP, A (127.7 +/- 13.4) and B (125.3 +/- 12.6) (p= 0.45) and DAP, A (74.5 +/- 6.7 mmHg) and B (75.5 +/- 6.7 mmHg) (p= 0.32). Group A presented a lower incidence of lower-limb edema: (7.1% vs 30.6%, p=0.02) on the 98th day of follow-up. CONCLUSION: The fixed combination of enalapril and amlodipine, as well as isolated amlodipine, was effective in the normalization of BP in pts with CAD and SAH stages I and II, adding blockage of the renin-angiotensin system.

Silent myocardial ischemia in patients with stable coronary artery disease receiving conventional antianginal drug therapy.

BACKGROUND: Few data are available on the behavior of myocardial ischemia during daily activities in patients with coronary artery disease receiving antianginal drug therapy. OBJECTIVE: To study the mechanism generating myocardial ischemia by evaluating blood pressure and heart rate changes in patients with stable atherosclerotic disease receiving drug therapy and with evidence of myocardial ischemia. METHODS: Fifty non-hospitalized patients (40 males) underwent 24-hour electrocardiographic monitoring synchronized with blood pressured monitoring. RESULTS: Thirty five episodes of myocardial ischemia were detected in 17 patients, with a total duration of 146.3 minutes; angina was reported in five cases. Twenty nine episodes (100.3 minutes) occurred during wakefulness, with 11 episodes (35.3 + 3.7 min) in the period from 11 a.m. to 3 p.m. Blood pressure and heart rate evaluation in the three ten-minute intervals following the ischemic episodes showed a statistically significant difference (p< 0.05), unlike that shown for the three intervals preceding the episodes. However, during the ischemic episode, a higher than 10-mmHg elevation in blood pressure and 5 beats per minute in heart rate were observed when compared with the time interval between 20 and 10 minutes before the episode. The mean heart rate at the onset of ischemia during the exercise test performed before the study was 118.2 + 14.0, and 81.1 + 20.8 beats per minute on the 24-hour electrocardiogram (p < 0.001). CONCLUSION: The incidence of silent myocardial ischemia is high in stable coronary artery disease and is related to alterations in blood pressure and heart rate, with different thresholds for ischemia for the same patient.

I Diretriz da Sociedade Brasileira de Cardiologia sobre processos e competências para a formação em cardiologia no Brasil: resumo executivo / 1st Guidelines of the Brazilian Society of Cardiology on processes and skills for education in cardiology in Brazil: executive summary / I Directriz de la Sociedade Brasileira de Cardiologia sobre procesos y competencias para la formación en cardiología en el Brasil: resumen ejecutivo

Este artigo resume a "I Diretriz da Sociedade Brasileira de Cardiologia sobre Processos e Competências para a Formação em Cardiologia no Brasil", que pode ser encontrada na íntegra no seguinte endereço:

This article summarizes the "1st Guidelines of the Brazilian Society of Cardiology on Processes and Skills for Education in Cardiology in Brazil," which can be found in full at:

Este artículo resume la "I Directriz de la Sociedade Brasileira de Cardiologia sobre Procesos y Competencias para la Formación en Cardiología en el Brasil", que puede ser encontrada completa en la siguiente dirección:

Síndrome coronária aguda sem supradesnivelamento do segmento ST: estratificação de risco e tratamento. Parte 2: tratamento / Non-ST-segment elevation acute coronary syndrome: risk stratification and management. Part 2: management

A causa mais comum da síndrome coronária é a redução ou a perfusão miocárdica por um trombo sobre uma placa aterosclerótica instável, que leva à oclusão parcial ou total da artéria coronária. Na abordagem do paciente com suspeita de síndrome coronária aguda no pronto-socorro, tanto o diagnóstico como a estratificação de risco inicial baseiam-se em quatro elementos: história, exame físico, eletrocardiograma e marcadores bioquímicos de necrose miocárdica. Por meio desses quatro elementos, é possível definir rapidamente a forma de abordagem desses pacientes, classificando-os em classes de orientarão a escolha do local ao atendimento, do nível de monitorização e da terapêutica aplicada a cada paciente. O tratamento da síndrome coronaria aguda sem supradesnivelamento do segmento ST visa, fundamentalmente, à estabilização da placa aterosclerótica, ao alívio dos sintomas isquêmicos e à prevenção de eventos como arritmia, recorrência de isquemia, infarto, necessidade de revascularização...

Insuficiência coronariana crônica / Chronic coronary disease

A história clínica é o passo mais importante na avaliação de um paciente com dor torácica, que, associada à presença dos chamados fatores de risco para doença aterosclerótica, permite ao clínico estimar a probabilidade de ser doença coronária. Após o diagnóstico, a estratificação de risco é fundamental por sua implicação terapêutica. Na avaliação do paciente levamos em conta o tipo de angina, alterações ao ECG convencional, refratariedade à medicação, função ventricular esquerda e provas funcionais de isquemia. O tratamento tem os seguintes objetivos: alívio dos sintomas, redução de eventos mórbidos, tratar as condições que promovam angina, modificar os fatores de risco e mudança no estilo de vida.Com relação ao tratamento medicamentoso, há medicações que reduzem eventos (antiagregantes plaquetários, b-bloqueadores, inibidores da enzima conversora de angiotensina, ivabradina e estatinas) e medicações para alívio dos sintomas (nitratos, b-bloqueadores, bloqueadores de canal de cálcio e trimetazidina), o que leva a melhora na qualidade de vida destes pacientes 27. Com relação ao tratamento direcionado por métodos invasivos, tem importância a presença de: isquemia em provas funcionais, disfunção ventricular esquerda, lesão de tronco de artéria coronária esquerda, sintomas não controlados com o tratamento medicamentoso e muita limitação das atividades habituais, idade biológica do paciente e experiência dos hemodinamicistas e cirurgiões do local. Por fim, é importante salientar que o uso indiscriminado de exames de métodos diagnósticos gera mais procedimentos que não necessariamente melhoram a qualidade de vida e, principalmente, podem não oferecer maior tempo de vida aos pacientes.