Potential performance of a 0 h/1 h algorithm and a single cut-off measure of high-sensitivity troponin T in a diverse population: main results of the IN-HOPE study.

AIMS: Chest pain is a major cause of medical evaluation at emergency department (ED) and demands observation to exclude the diagnosis of acute myocardial infarction (AMI). High-sensitivity cardiac troponin assays used as isolated measure and by 0- and 1-h algorithms are accepted as a rule-in/rule-out strategy, but there is a lack of validation in specific populations. METHODS AND RESULTS: The IN-HOspital Program to systematizE Chest Pain Protocol (IN-HOPE study) is a multicentre study that prospectively included patients admitted to the ED due to suspected symptoms of AMI at 16 sites in Brazil. Medical decisions of all patients followed the standard approach of 0 h/3 h protocol, but, in addition, blood samples were also collected at 0 and 1 h and sent to a central laboratory (core lab) to measure high-sensitivity cardiac troponin T (hs-cTnT). To assess the theoretical performance of 0 h/1 h algorithm, troponin < 12 ng/L with a delta < 3 was considered rule-out while a value ≥ 52 or a delta ≥ 5 was considered a rule-in criterion (the remaining were considered as observation group). The main objective of the study was to assess, in a population managed by the 0 h/3 h protocol, the accuracy of 0 h/1 h algorithm overall and in groups with a higher probability of AMI. All patients were followed up for 30 days, and potential events were adjudicated. In addition to the prospective cohort, a retrospective analysis was performed assessing all patients with hs-cTnT measured during the year of 2021 but not included in the prospective cohort, regardless of the indication of the test. A total of 5.497 patients were included (583 in the prospective and 4.914 in the retrospective analysis). The prospective cohort had a mean age of 57.3 (± 14.8) and 45.6% of females with a mean HEART score of 4.0 ± 2.2. By the core lab analysis, 74.4% would be eligible for a rule-out approach (45.3% of them with a HEART score > 3) while 7.3% would fit the rule-in criteria. In this rule-out group, the negative predictive value for index AMI was 100% (99.1-100) overall and regardless of clinical scores. At 30 days, no death or AMI occurred in the rule-out group of both 0/1 and 0/3 h algorithms while 52.4% of the patients in the rule-in group (0 h/1 h) were considered as AMI by adjudication. In the observation group (grey zone) of 0 h/1 h algorithm, GRACE discriminated the risk of these patients better than HEART score. In the retrospective analysis, 1.091 patients had a troponin value of <5 ng/L and there were no cardiovascular deaths at 30 days in this group. Among all 4.914 patients, the 30-day risk of AMI or cardiovascular death increased according to the level of troponin: 0% in the group < 5 ng/L, 0.6% between 5 and 14 ng/L, 2.2% between 14 and 42 ng/L, 6.3% between 42 and 90 ng/L, and 7.7% in the level ≥ 90 ng/L. CONCLUSION: In this large multicentre study, a 0 h/1 h algorithm had the potential to classify as rule-in or rule-out in almost 80% of the patients. The rule-out protocol had high negative predictive value regardless of clinical risk scores. Categories of levels of hs-cTn T also showed good accuracy in discriminating risk of the patients with a very favourable prognosis for cardiovascular death in the group with value < 5 ng/L. CLINICALTRIALS.GOV: NCT04756362.

Potential performance of a 0 h/1 h algorithm and a single cut-off measure of high-sensitivity troponin T in a diverse population: main results of the IN-HOPE study

BACKGROUND: Chest pain is a major cause of medical evaluation at emergency department (ED) and demands observation to exclude the diagnosis of acute myocardial infarction (AMI). High-sensitivity cardiac troponin assays used as isolated measure and by 0 h and 1 h algorithms are accepted as a rule-in/rule-out strategy but there is a lack of validation in specific populations. METHODS: The IN-HOspital Program to systematizE chest pain protocol (In Hope study) is a multicentre study that prospectively included patients admitted to the ED due to suspected symptoms of AMI at 16 sites in Brazil. Medical decisions of all patients followed the standard approach of 0/3-h protocol but, in addition, blood samples were also collected at 0 and 1 hour and sent to a central laboratory (core lab) to measure high-sensitivity troponin T (hs-cTnT). To assess the theoretical performance of 0/1-h algorithm, troponin < 12 ng/L with a delta <--- 3 was considered rule out while a value ≥ 52 and/or a delta ≥ 5 was considered a rule in criteria (the remaining were considered as observation group). The main objective of the study was to assess, in a population managed by the 0/3-h protocol, the accuracy of 0/1-h algorithm overall and in groups with higher probability of AMI. All patients were followed for 30 days, and potential events were adjudicated. In addition to the prospective cohort, a retrospective analysis was performed assessing all patients with hs-cTnT measured during the year of 2021 but not included in the prospective cohort, regardless the indication of the test. RESULTS: A total of 5.497 patients were included (583 in the prospective and 4.914 in the retrospective analysis). The prospective cohort had a mean age of 57.3 (± 14.8) and 45.6% of females with a mean HEART score of 4.0 ± 2.2. By the core lab analysis, 74.4% would be eligible for a rule-out approach (45.3% of HEART score > 3) while 7.3% would fit the rule-in criteria. In this rule-out group, the negative predictive value for index AMI was 100% (99.1-100) overall and regardless clinical scores. At 30 days, no death or AMI occurred in the rule-out group of both 0/1 and 0/3-hour while 52.4% of the patients in the rule-in group (0/1-hour) were considered as AMI by adjudication. In the observation group (grey zone) of 0/1- hour algorithm, GRACE discriminated the risk of these patients better than HEART score. In the retrospective analysis, 1.091 patients had a troponin value < 5 ng/L and there were no cardiovascular deaths at 30 days in this group. Among all 4.914 patients, the 30-day risk of AMI or cardiovascular death increased according to the level of troponin: 0% in the group < 5 ng/L, 0.6% between 5 and 14 ng/L, 2.2% between 14 and 42 ng/L, 6.3% between 42 and 90 ng/L and 7.7% in the level ≥ 90 ng/L. CONCLUSIONS: In this large multicentre study, a 0/1-h algorithm had the potential to classify as rule in or out almost 80% of the patients. The rule-out protocol had high negative predictive value regardless of clinical risk scores. Categories of levels of hs-cTn T also showed good accuracy in discriminating risk of the patients with a very favourable prognosis for cardiovascular death in the group with values < 5 ng/L.

Fasting glucose of patients from public health care in the southern region of São Paulo: correlation with glycated hemoglobin and lipid levels. / Glicemia de jejum de pacientes da rede pública de saúde na região sul de São Paulo: correlação com hemoglobina glicada e níveis lipídicos.

INTRODUCTION: Fasting glucose is a test used for monitoring diabetes mellitus, as well as its screening and diagnosis. The objective of this study was to evaluate fasting glucose results and their correlation with glycated hemoglobin and lipids. METHODS: Cross-sectional study, involving 77,581 patients, attended in 2014. RESULTS: The majority of the patients are women (65%). The age of the patients ranged from 18 to 115 years (mean of 53 ± 15.5). The agreement between fasting glucose and glycated hemoglobin was moderate (kappa = 0.416); however, it was substantial for the levels used for the diagnosis of diabetes (kappa = 0.689) and poor for pre-diabetes (kappa = 0.188). Fasting glucose ≥ 100 mg/dL was observed in 41.1% of the patients and 61.5% present glycated hemoglobin ≥ 5.7%. Lipid abnormalities are likeliest in patients with elevated fasting glucose. From those 14,241 individuals that had fasting glucose ≥ 126 mg/dL, the microalbuminuria test was performed in only 883 (6.2%) patients, with abnormal results in 201 (22.8%). CONCLUSIONS: The high frequency of fasting glucose with abnormal results may reflect the high proportion of exams performed by individuals with diagnosis of diabetes, to evaluate their glycemic control. The low frequency of requests for microalbuminuria tests in those with probable diagnosis of diabetes reflects the little attention paid for the screening of chronic complications of diabetes. It calls attention the high frequency of dyslipidemia in those individuals, highlighting the fact that this is a population with high cardiovascular risk.

INTRODUÇÃO: A glicemia de jejum é um teste usado para o monitoramento do diabetes mellitus, bem como para seu rastreamento e diagnóstico. O objetivo do estudo foi analisar resultados de glicemia de jejum de pacientes da rede pública e sua correlação com hemoglobina glicada e lipídios. MÉTODOS: Estudo transversal, com 77.581 pacientes, atendidos em 2014. RESULTADOS: A maioria é do sexo feminino (65%), com idade entre 18 e 115 anos (53 ± 15,5 anos). A concordância entre glicemia de jejum e hemoglobina glicada foi moderada (Kappa = 0,416), entretanto foi substancial para níveis compatíveis com diabetes (Kappa = 0,689) e pobre para pré-diabetes (Kappa = 0,188). Glicemia de jejum ≥ 100 mg/dL foi encontrada em 41,1% dos pacientes e hemoglobina glicada ≥ 5,7% em 61,5%. As alterações lipídicas são mais frequentes nos indivíduos com alterações na glicemia. Dos 14.241 indivíduos com glicemia de jejum ≥ 126 mg/dL, a microalbuminúria foi pesquisada em apenas 883 (6,2%) indivíduos, com resultado alterado em 201 (22,8%). CONCLUSÕES: Nos indivíduos que realizaram mais de uma dosagem de glicemia de jejum, a maioria permaneceu com exames alterados, principalmente os que apresentavam valores compatíveis com o diagnóstico de diabetes, sugerindo que não conseguem um controle adequado. A baixa frequência de pesquisa de microalbuminúria em indivíduos com glicemia de jejum sugestiva de diabetes reflete a pequena preocupação com o rastreio de suas complicações crônicas. A elevada frequência de dislipidemia nesses indivíduos evidencia ser uma população de elevado risco cardiovascular.

Cardiovascular Risk in Xavante Indigenous Population.

BACKGROUND: The prevalence of cardiovascular risk factors is little known in Brazilian indigenous populations. In the last two decades, important changes have occurred in the lifestyle and epidemiological profile of the Xavante people. OBJECTIVE: to assess the prevalence of cardiovascular risk factors in Xavante adults in São Marcos and Sangradouro/Volta Grande reserves, in the state of Mato Grosso, Brazil. METHODS: Cross-sectional study carried out with 925 Xavante people aged ≥ 20 years between 2008 and 2012. The following indicators were assessed: triglycerides (TG), total, LDL and HDL-cholesterol, Castelli index I and II, TG/HDL-cholesterol ratio, apo B / Apo A1 ratio, Framingham risk score, C-reactive protein, body mass index (BMI), waist circumference (WC), hypertriglyceridemic waist (HW), glycemia and blood pressure. Kolmogorov-Smirnov, Student's t test and Chi-square test (χ2) were used for statistical analysis, and significance level was set at 5%. RESULTS: High prevalence of elevated cardiovascular risk was observed in men and women according to HDL-cholesterol (66.2% and 86.2%, respectively), TG (53.2% and 51.5%), TG/HDL-cholesterol ratio (60.0% and 49.1%), C-reactive protein (44.1% and 48.1%), BMI (81.3% and 81.7%), WC (59.1% and 96.2%), HW (38.0% and 50,6%) and glycemia (46.8% and 70.2%). Individuals aged 40 to 59 years had the highest cardiovascular risk. CONCLUSIONS: The Xavante have a high cardiovascular risk according to several indicators evaluated. The present analysis of cardiovascular risk factors provides support for the development of preventive measures and early treatment, in attempt to minimize the impact of cardiovascular diseases on this population.

Cardiovascular Risk in Xavante Indigenous Population / Risco Cardiovascular na População Indígena Xavante

Abstract Background: The prevalence of cardiovascular risk factors is little known in Brazilian indigenous populations. In the last two decades, important changes have occurred in the lifestyle and epidemiological profile of the Xavante people. Objective: to assess the prevalence of cardiovascular risk factors in Xavante adults in São Marcos and Sangradouro/Volta Grande reserves, in the state of Mato Grosso, Brazil. Methods: Cross-sectional study carried out with 925 Xavante people aged ≥ 20 years between 2008 and 2012. The following indicators were assessed: triglycerides (TG), total, LDL and HDL-cholesterol, Castelli index I and II, TG/HDL-cholesterol ratio, apo B / Apo A1 ratio, Framingham risk score, C-reactive protein, body mass index (BMI), waist circumference (WC), hypertriglyceridemic waist (HW), glycemia and blood pressure. Kolmogorov-Smirnov, Student's t test and Chi-square test (χ2) were used for statistical analysis, and significance level was set at 5%. Results: High prevalence of elevated cardiovascular risk was observed in men and women according to HDL-cholesterol (66.2% and 86.2%, respectively), TG (53.2% and 51.5%), TG/HDL-cholesterol ratio (60.0% and 49.1%), C-reactive protein (44.1% and 48.1%), BMI (81.3% and 81.7%), WC (59.1% and 96.2%), HW (38.0% and 50,6%) and glycemia (46.8% and 70.2%). Individuals aged 40 to 59 years had the highest cardiovascular risk. Conclusions: The Xavante have a high cardiovascular risk according to several indicators evaluated. The present analysis of cardiovascular risk factors provides support for the development of preventive measures and early treatment, in attempt to minimize the impact of cardiovascular diseases on this population.

Resumo Fundamento: A prevalência de fatores de risco cardiovascular ainda é pouco estudada em populações indígenas brasileiras. Nas duas últimas décadas, observaram- se importantes mudanças no estilo de vida e no perfil epidemiológico dos Xavante. Objetivo: Avaliar a prevalência de fatores de risco cardiovascular na população adulta Xavante das Reservas Indígenas de São Marcos e Sangradouro/Volta Grande - MT. Métodos: Estudo transversal realizado com 925 indígenas Xavante com 20 ou mais anos de idade, no período de 2008 a 2012. Foram considerados os indicadores: níveis séricos de triglicérides (TG), colesterol (total, LDL e HDL), Índices de Castelli I (CT/HDL-c) e II (LDL-c/HDL-c), razão TG/HDL-C, relação Apo B/Apo A1, escore de Framingham, proteína C reativa (PCR), Índice de Massa Corporal (IMC), circunferência da cintura (CC), cintura hipertrigliceridêmica (CH), glicemia e pressão arterial. Foram utilizados os testes Kolmogorov-Smirnov, t de Student e Qui quadrado (χ2), sendo considerado um nível de significância de 5%. Resultados: Verificaram-se altas prevalências de risco cardiovascular elevado, em homens e mulheres, respectivamente, segundo os indicadores HDL-colesterol (66,2% e 86,2%), TG (53,2% e 51,5%), razão TG/HDL-c (60,0% e 49,1%), PCR (44,1% e 48,1%), IMC (81,3% e 81,7%), CC (59,1% e 96,2%), CH (38,0% e 50,6%) e glicemia (46,8% e 70,2%). Os indivíduos de 40 a 59 anos foram os que apresentaram maior risco cardiovascular. Conclusões: Os Xavante apresentam elevado risco cardiovascular segundo vários indicadores avaliados. Este inquérito fornece subsídios para ações de prevenção e tratamento precoce, a fim de minimizar os potenciais danos causados por doenças cardiovasculares entre os Xavante.

Prevalence of metabolic syndrome in the Brazilian Xavante indigenous population.

BACKGROUND: The raising prevalence of weight excess and of non-communicable diseases in indigenous populations, as well as changes in food consumption and reduction in the frequency and intensity of physical activity, suggest that the prevalence of metabolic syndrome (MS) is also elevated. The objective of this study was to evaluate the prevalence of MS and the frequency of its components in the Xavante adult population living in the Indian reservations of São Marcos and Sangradouro/Volta Grande, in the state of Mato Grosso, Brazil. A cross-sectional study was carried out among 932 Xavante Indians aged 20 years or more, in the 2008-2012 period. The variables analysed were gender, age, weight, height, waist circumference, blood pressure, initial and 2-h capillary glycemia in a 75 g OGTT, levels of triglycerides and HDL-cholesterol. The diagnostic criteria for MS proposed by the IDF and AHA/NHLBI were used. RESULTS: The prevalence of MS was 66.1 % (95 % CI 63.0-69.2), being 76.2 % (95 % CI 72.4-80.0) in women and 55.6 % (95 % CI 51.0-60.2) in men. Women had higher prevalence of MS in all age groups. Elevated waist circumference and lower levels of HDL-cholesterol were the more frequent components in those with MS, and elevated blood pressure was the less frequent. CONCLUSIONS: The high prevalence of MS in the Xavante Indians is mainly due to the increased prevalence of weight excess that resulted from an intense change in their life-style, in a short period of time in a population with a genetic predisposition. These findings highlight the magnitude of this health problem and make an alert about the necessity to implement specific preventive interventions.