Comparison Between Treatment Strategies of Carotid Stenosis in Patients Undergoing Coronary Artery Bypass Grafting.

INTRODUCTION: In patients undergoing coronary artery bypass grafting (CABG), stroke is a major complication that increases morbidity and mortality. The presence of carotid stenosis (CS) increases risk of stroke, and the optimal treatment remains uncertain due to the lack of randomized clinical trials. The aim of this study is to compare three management approaches to CS in patients submitted to CABG. METHODS: From 2005 to 2015, 79 consecutive patients with significant CS submitted to CABG were retrospectively evaluated. Patients were divided in three groups, according to CS treatment: 17 underwent staged carotid endarterectomy (CEA)-CABG, 26 underwent synchronous CEA-CABG, and 36 underwent isolated CABG without carotid intervention. The primary outcomes were composed by 30-day postoperative acute myocardial infarction (MI), 30-day postoperative stroke, and death due to all causes during the follow-up. RESULTS: Patients were evaluated during an average 2.05 years (95% confidence interval = 1.51-2.60) of follow-up. Major adverse cardiac events, including death, postoperative MI, and postoperative stroke, occurred in 76.5% of the staged group, 34.6% of the synchronous group, and 33.3% of the isolated CABG group (P=0.007). As for MI, the rates were 29.4%, 3.85%, and 11.1% (P=0.045), respectively. There was no statistically significant difference in total mortality rates (35.3%, 30.8%, and 25.0%, respectively; P=0,72) and stroke (29.4%, 7.7%, and 8.3%, respectively; P=0,064) between groups. CONCLUSION: Staged CEA-CABG is associated with higher major adverse cardiac events and MI rate when compared to the strategy of synchronous and isolated CABG, but without statistically difference in total mortality during the entire follow-up.

Comparison Between Treatment Strategies of Carotid Stenosis in Patients Undergoing Coronary Artery Bypass Grafting

ABSTRACT Introduction: In patients undergoing coronary artery bypass grafting (CABG), stroke is a major complication that increases morbidity and mortality. The presence of carotid stenosis (CS) increases risk of stroke, and the optimal treatment remains uncertain due to the lack of randomized clinical trials. The aim of this study is to compare three management approaches to CS in patients submitted to CABG. Methods: From 2005 to 2015, 79 consecutive patients with significant CS submitted to CABG were retrospectively evaluated. Patients were divided in three groups, according to CS treatment: 17 underwent staged carotid endarterectomy (CEA)-CABG, 26 underwent synchronous CEA-CABG, and 36 underwent isolated CABG without carotid intervention. The primary outcomes were composed by 30-day postoperative acute myocardial infarction (MI), 30-day postoperative stroke, and death due to all causes during the follow-up. Results: Patients were evaluated during an average 2.05 years (95% confidence interval = 1.51-2.60) of follow-up. Major adverse cardiac events, including death, postoperative MI, and postoperative stroke, occurred in 76.5% of the staged group, 34.6% of the synchronous group, and 33.3% of the isolated CABG group (P=0.007). As for MI, the rates were 29.4%, 3.85%, and 11.1% (P=0.045), respectively. There was no statistically significant difference in total mortality rates (35.3%, 30.8%, and 25.0%, respectively; P=0,72) and stroke (29.4%, 7.7%, and 8.3%, respectively; P=0,064) between groups. Conclusion: Staged CEA-CABG is associated with higher major adverse cardiac events and MI rate when compared to the strategy of synchronous and isolated CABG, but without statistically difference in total mortality during the entire follow-up.

Very Long-Term Prognostic Role of Admission BNP in Non-ST Segment Elevation Acute Coronary Syndrome.

BACKGROUND: BNP has been extensively evaluated to determine short- and intermediate-term prognosis in patients with acute coronary syndrome, but its role in long-term mortality is not known. OBJECTIVE: To determine the very long-term prognostic role of B-type natriuretic peptide (BNP) for all-cause mortality in patients with non-ST segment elevation acute coronary syndrome (NSTEACS). METHODS: A cohort of 224 consecutive patients with NSTEACS, prospectively seen in the Emergency Department, had BNP measured on arrival to establish prognosis, and underwent a median 9.34-year follow-up for all-cause mortality. RESULTS: Unstable angina was diagnosed in 52.2%, and non-ST segment elevation myocardial infarction, in 47.8%. Median admission BNP was 81.9 pg/mL (IQ range = 22.2; 225) and mortality rate was correlated with increasing BNP quartiles: 14.3; 16.1; 48.2; and 73.2% (p < 0.0001). ROC curve disclosed 100 pg/mL as the best BNP cut-off value for mortality prediction (area under the curve = 0.789, 95% CI= 0.723-0.854), being a strong predictor of late mortality: BNP < 100 = 17.3% vs. BNP ≥ 100 = 65.0%, RR = 3.76 (95% CI = 2.49-5.63, p < 0.001). On logistic regression analysis, age >72 years (OR = 3.79, 95% CI = 1.62-8.86, p = 0.002), BNP ≥ 100 pg/mL (OR = 6.24, 95% CI = 2.95-13.23, p < 0.001) and estimated glomerular filtration rate (OR = 0.98, 95% CI = 0.97-0.99, p = 0.049) were independent late-mortality predictors. CONCLUSIONS: BNP measured at hospital admission in patients with NSTEACS is a strong, independent predictor of very long-term all-cause mortality. This study allows raising the hypothesis that BNP should be measured in all patients with NSTEACS at the index event for long-term risk stratification.

Chest pain units: a modern way of managing patients with chest pain in the emergency department.

It is estimated that 5 to 8 million individuals with chest pain or other symptoms suggestive of myocardial ischemia are seen each year in emergency departments (ED) in the United States 1,2, which corresponds to 5 to 10% of all visits 3,4. Most of these patients are hospitalized for evaluation of possible acute coronary syndrome (ACS). This generates an estimated cost of 3 - 6 thousand dollars per patient 5,6. From this evaluation process, about 1.2 million patients receive the diagnosis of acute myocardial infarction (AMI), and just about the same number have unstable angina. Therefore, about one half to two thirds of these patients with chest pain do not have a cardiac cause for their symptoms 2,3. Thus, the emergency physician is faced with the difficult challenge of identifying those with ACS - a life-threatening disease - to treat them properly, and to discharge the others to suitable outpatient investigation and management.

Safety, feasibility, and results of exercise testing for stratifying patients with chest pain in the emergency room.

OBJECTIVE: To assess safety, feasibility, and the results of early exercise testing in patients with chest pain admitted to the emergency room of the chest pain unit, in whom acute myocardial infarction and high-risk unstable angina had been ruled out. METHODS: A study including 1060 consecutive patients with chest pain admitted to the emergency room of the chest pain unit was carried out. Of them, 677 (64%) patients were eligible for exercise testing, but only 268 (40%) underwent the test. RESULTS: The mean age of the patients studied was 51.7 12.1 years, and 188 (70%) were males. Twenty-eight (10%) patients had a previous history of coronary artery disease, 244 (91%) had a normal or unspecific electrocardiogram, and 150 (56%) underwent exercise testing within a 12-hour interval. The results of the exercise test in the latter group were as follows: 34 (13%) were positive, 191 (71%) were negative, and 43 (16%) were inconclusive. In the group of patients with a positive exercise test, 21 (62%) underwent coronary angiography, 11 underwent angioplasty, and 2 underwent myocardial revascularization. In a univariate analysis, type A/B chest pain (definitely/probably anginal) (p<0.0001), previous coronary artery disease (p<0.0001), and route 2 (patients at higher risk) correlated with a positive or inconclusive test (p<0.0001). CONCLUSION: In patients with chest pain and in whom acute myocardial infarction and high-risk unstable angina had been ruled out, the exercise test proved to be feasible, safe, and well tolerated.

Very Long-Term Prognostic Role of Admission BNP in Non-ST Segment Elevation Acute Coronary Syndrome / Papel Prognóstico a Muito Longo Prazo do BNP de Admissão na Síndrome Coronariana Aguda sem Elevação do Segmento ST

Abstract Background: BNP has been extensively evaluated to determine short- and intermediate-term prognosis in patients with acute coronary syndrome, but its role in long-term mortality is not known. Objective: To determine the very long-term prognostic role of B-type natriuretic peptide (BNP) for all-cause mortality in patients with non-ST segment elevation acute coronary syndrome (NSTEACS). Methods: A cohort of 224 consecutive patients with NSTEACS, prospectively seen in the Emergency Department, had BNP measured on arrival to establish prognosis, and underwent a median 9.34-year follow-up for all-cause mortality. Results: Unstable angina was diagnosed in 52.2%, and non-ST segment elevation myocardial infarction, in 47.8%. Median admission BNP was 81.9 pg/mL (IQ range = 22.2; 225) and mortality rate was correlated with increasing BNP quartiles: 14.3; 16.1; 48.2; and 73.2% (p < 0.0001). ROC curve disclosed 100 pg/mL as the best BNP cut-off value for mortality prediction (area under the curve = 0.789, 95% CI= 0.723-0.854), being a strong predictor of late mortality: BNP < 100 = 17.3% vs. BNP ≥ 100 = 65.0%, RR = 3.76 (95% CI = 2.49-5.63, p < 0.001). On logistic regression analysis, age >72 years (OR = 3.79, 95% CI = 1.62-8.86, p = 0.002), BNP ≥ 100 pg/mL (OR = 6.24, 95% CI = 2.95-13.23, p < 0.001) and estimated glomerular filtration rate (OR = 0.98, 95% CI = 0.97-0.99, p = 0.049) were independent late-mortality predictors. Conclusions: BNP measured at hospital admission in patients with NSTEACS is a strong, independent predictor of very long-term all-cause mortality. This study allows raising the hypothesis that BNP should be measured in all patients with NSTEACS at the index event for long-term risk stratification.

Resumo Fundamento: O BNP foi exaustivamente avaliado para a determinação do prognóstico em curto e médio prazo em pacientes com síndrome coronariana aguda, mas o seu papel para a mortalidade a longo prazo é incerta. Objetivo: Determinar o papel prognóstico a muito longo prazo do peptídeo natriurético do tipo B (BNP) para a mortalidade por todas as causas em pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST (SCASSST). Métodos: Coorte de 224 pacientes consecutivos com SCASSST, prospectivamente atendidos no setor de emergência, em que se mediu o BNP na chegada para estabelecer o prognóstico ao longo do seguimento mediano de 9,34 anos para a mortalidade por todas as causas. Resultados: Diagnosticou-se angina instável em 52,2% e infarto do miocárdio sem supradesnivelamento do segmento ST em 47,8%. A mediana do BNP da admissão foi de 81,9 pg/mL (intervalo IQ = 22,2; 225) e a taxa de mortalidade correlacionou-se com quartis crescentes de BNP: 14,3; 16,1; 48,2; e 73,2% (p < 0,0001). A curva ROC revelou 100 pg/mL como o melhor ponto de corte de BNP para a predição de mortalidade (área sob a curva = 0,789, 95% CI = 0,723-0,854) sendo um forte preditor de mortalidade tardia: BNP < 100 = 17,3% vs. BNP ≥ 100 = 65,0%, RR = 3,76 (IC 95% = 2,49-5,63, p < 0,001). Na análise de regressão logística, idade>72 anos (OR = 3,79, IC 95% = 1,62-8,86, p = 0,002), BNP ≥ 100 pg/mL (OR = 6,24, IC 95% = 2,95-13,23, p < 0,001) e taxa de filtração glomerular estimada (OR = 0,98, IC 95% = 0,97-0,99, p = 0,049) foram preditores independentes de mortalidade tardia. Conclusões: O BNP medido na admissão hospitalar em pacientes com SCASSST é um forte preditor independente de mortalidade por todas as causas de muito longo prazo. Este estudo permite que se levante a hipótese de que o BNP deva ser medido em todos os pacientes com SCASSST no evento-índice para a estratificação de risco a longo prazo.

B-type natriuretic peptide: a strong predictor of early and late mortality in patients with acute chest pain without ST-segment elevation in the emergency department.

BACKGROUND: The prognostic importance of early measurement of B-type natriuretic peptide (BNP) in patients with acute chest pain while the diagnosis is still uncertain is unknown. We determined the prognostic value of BNP in these patients immediately after presenting to the emergency department. METHODS: Seven hundred and twenty-three consecutive individuals with suspicious ischemic acute chest pain and no ST-segment elevation were prospectively evaluated using a systematic diagnostic strategy and followed for 1 year. Acute coronary syndrome was diagnosed in 326 patients during their hospital stay. RESULTS: In the follow-up, 15 (2.1%) patients of the whole cohort died of cardiac cause at 1 month and 51 (7.1%) at 1 year. Patients who died had significantly higher admission BNP levels than survivors and this correlation proved linear according to quartile levels. Patients with BNP greater than 101 pg/ml had 13 times higher rate of 1-month mortality (P<0.0001) and 5.3 times higher rate of 1-year mortality (P<0.0001) than patients with BNP of 101 pg/ml or less. Multiple logistic regression analysis disclosed BNP as a strong independent predictor of 1-month and 1-year mortality adding significant prognostic information over traditional risk markers. CONCLUSION: Admission BNP is an independent and powerful marker of early and late cardiac mortality in patients with acute chest pain without ST-segment elevation. These results suggest that BNP should be measured upon arrival at the emergency department for risk stratification in all these patients.

Avaliação dos benefícios funcionais de um programa de reabilitação cardíaca / Evaluation of the functional benefits of a cardiac rehabilitation program

Fundamentos: Um grande número de estudos tem confirmado que o treinamento físico é um dos métodos mais eficazes para melhorar a capacidade funcional e o bem-estar dos pacientes cardiopatas. Objetivo: Avaliar os benefícios clínicos e funcionais do Programa de Reabilitação Cardíaca em pacientes encaminhados ao Centro de Cardiologia do Exercício do Instituto Estadual de Cardiologia Aloysio de Castro, Rio de Janeiro. Métodos: Foi realizado um estudo retrospectivo tipo coorte, comparativo antes e depois da participação no Programa de Reabilitação Cardíaca numa amostra de 88 indivíduos (60 homens e 28 mulheres) com idade entre37 anos e 81 anos. A maioria dos pacientes era portadora de doença coronariana estável. As principais variáveis analisadas dos testes ergométricos foram a duração doexercício, consumo de oxigênio do pico de exercício (VO2pico), o equivalente metabólico (MET), o déficit aeróbico funcional (FAI), o duplo-produto no pico do exercício(DP pico), a redução da frequência cardíaca no primeiro minuto da recuperação, a presença de isquemia, a classe funcional segundo a NYHA e a aptidão cardiorrespiratória (APCR) segundo a American Heart Association. Resultados: Houve melhora significativa da maioria das variáveis analisadas tais como da capacidade funcional,da duração do exercício, do VO2 pico, da quantidade deMET obtidos, do FAI, e da APCR (p<0,0001). Não foram observadas diferenças significativas em relação ao duplo produto(p=0,1359). Conclusão: O Programa de Reabilitação Cardíaca utilizado neste estudo proporcionou significativa melhora dos parâmetros fisiológicos, hemodinâmicos, funcionais e autonômicos dos pacientes e, consequentemente, no desempenho cardiovascular e metabólico no exercício.

Background: A great number of studies have confirmed that physical training is one of the most effective methods of improving functional capacity and well-being in patients with heart disease.Objective: To evaluate the clinical and functional benefits of the Cardiac Rehabilitation Program in patients referred to the Cardiac Exercise Center at the Aloysio de Castro State Institute of Cardiology in Rio de Janeiro, Brazil.Methods: A retrospective comparative cohort study was conducted of a sample of 88 individuals (60 men and 28 women) between 37 and 81 years old. Most of the patients had stable coronary artery disease. The main parameters analyzed for the treadmill tests wereexercise duration, peak oxygen consumption (peak VO2), metabolic equivalent (MET), functional aerobicimpairment (FAI), peak exercise double product (peak DP), reduction in heart rate for the first minute of recovery, presence of ischemia, NYHA functional class and American Heart Association cardiorespiratory fitness. Results: There was significant improvement in mostof the parameters analyzed, such as functional capacity, exercise duration, peak VO2, MET achieved, FAI and cardiorespiratory fitness (p<0.0001). There was no significant difference for the double product (p=0.1359). Conclusion: The Cardiac Rehabilitation Program used in this study provided significant improvements in the physiological, hemodynamic, functional and autonomic parameters of the patients and consequently their cardiovascular and metabolic exerciseperformance.

C-reactive protein diagnostic and prognostic value in patients presenting at the emergency room with chest pain.

OBJECTIVE: To test immediate diagnostic and prognostic values of C-reactive protein (CRP) in patients admitted to the emergency room (ER) with chest pain (CP) without ST-segment elevation on the electrocardiogram (ECG). METHODS: From January 2002 to December 2003, 980 patients were consecutively seen in the ER with CP suggestive of acute coronary syndrome (ACS) (age = 64.9 +/- 14.3, men = 55%, diabetic = 18%, normal ECG = 84%). Serial CRP, creatine kinase MB mass (CKMB-mass) and troponin I determinations were performed on admission, in addition to serial ECG. CRP measurements were standardized (s-CRP) by the upper limit of normal (ULN) of the test used (3.0 mg/L for high-sensitivity C-reactive protein [hs-CRP] and 0.1 mg/dL for titrated CRP [t-CRP]). RESULTS: One hundred and twenty-five patients were diagnosed with acute myocardial infarction (AMI), and their s-CRP values were 1.31 +/- 2.90 (median = 0.47) compared to 0.79 +/- 1.39 (0.30) in no-AMI patients (p = 0.031). The s-CRP > 1.0 showed 30% sensitivity and 80% specificity, plus negative and positive predictive values of 6.1% and 96.7%, respectively, for AMI diagnosis. There were forty in-hospital cardiac events (16 deaths, 22 urgent revascularizations, and 2 acute myocardial infarction). In the first quartile of the s-CRP (< 0.10), three events were recorded, while in the fourth quartile (> 0.93) 15 events (p = 0.003) occurred. In the logistic regression model, masculine gender and s-CRP > 0.32 (odds ratio 7.6, 2.8 and 2.2, respectively) were independent predictors of cardiac events and left ventricular failure. CONCLUSION: In patients with chest pain presenting at the emergency room, s-CRP was not a good marker of AMI, although this diagnosis is virtually excluded by a normal value; in addition, values one-third above the upper limit of normal (>1 mg/L for hs-CRP or >0.33 mg/dL for t-CRP) were predictive of in-hospital adverse cardiac events.

B-type natriuretic peptide: a novel early blood marker of acute myocardial infarction in patients with chest pain and no ST-segment elevation.

AIMS: This study was undertaken to determine the diagnostic value of admission B-type natriuretic peptide (BNP) for acute myocardial infarction (AMI) in patients with acute chest pain and no ST-segment elevation. METHODS AND RESULTS: A prospective study with 631 consecutive patients was conducted in the emergency department. Non-ST elevation AMI was present in 72 patients and their median admission BNP level was significantly higher than in unstable angina and non-acute coronary syndrome patients. Sensitivity of admission BNP for AMI (cut-off value of 100 pg/mL) was significantly higher than creatine kinase-MB (CKMB) and troponin-I on admission (70.8 vs. 45.8 vs. 50.7%, respectively, P<0.0001) and specificity was 68.9%. Simultaneous use of these markers significantly improved sensitivity to 87.3% and the negative predictive value to 97.3%. In multiple logistic regression analysis, admission BNP was a significant independent predictor of AMI, even when CKMB and troponin-I were present in the model. CONCLUSION: BNP is a useful adjunct to standard cardiac markers in patients presenting to the emergency department with chest pain and no ST-segment elevation, particularly if initial CKMB and/or troponin-I are non-diagnostic.

Accuracy of a neural diagnostic tree for the identification of acute coronary syndrome in patients with chest pain and no ST-segment elevation.

Identifying acute coronary syndrome is a difficult task in the emergency department because symptoms may be atypical and the electrocardiogram has low sensitivity. In this prospective cohort study done in a tertiary community emergency hospital, we developed and tested a neural diagnostic tree in 566 consecutive patients with chest pain and no ST-segment elevation for the diagnosis of acute coronary syndrome. Multivariate regression and recursive partitioning analysis allowed the construction of decision rules and of a neural tree for the diagnosis of acute myocardial infarction and acute coronary syndrome. Predictive variables of acute coronary syndrome were: age > or =60 years (odds ratio [OR] = 2.3; P = 0.0016), previous history of coronary artery disease (OR = 2.9; P = 0.0008), diabetes (OR = 2.8; P = 0.0240), definite/probable angina-type chest pain (OR = 17.3; P = 0.0000) and ischemic electrocardiogram (ECG) changes on admission (OR = 3.5; P = 0.0002). The receiver operating characteristic curve of possible diagnostic decision rules of the regression model disclosed a C-index of 0.904 (95% confidence interval = 0.878 to 0.930) for acute coronary syndrome and 0.803 (95% confidence interval 0.757 to 0.849) for acute myocardial infarction. For both disorders, sensitivities of the neural tree were 99% and 93%, respectively, and negative predictive values were both 98%. Negative likelihood ratios were 0.02 and 0.1, respectively. It is concluded that this simple and easy-to-use neural diagnostic tree was very accurate in the identification of non-ST segment elevation chest pain patients without acute coronary syndrome. Patients identified as low probability of disease could receive immediate stress testing and be discharged if the test is negative.

Probability stratification and systematic diagnostic approach for chest pain patients in the emergency department.

Management of chest pain patients in the emergency department has been a dilemma because of difficulty in identifying those who can be immediately discharged and those who need to be hospitalized. We assessed the efficacy of a probability stratification model and a systematic diagnostic strategy in 1003 consecutive chest pain patients prospectively evaluated and stratified for acute coronary syndromes according to chest pain characteristics and admission electrocardiogram. Patients with no suspicion of acute coronary syndromes (n = 224) were immediately discharged, whereas those with very-high probability (n =119) were admitted to the coronary care unit. Remaining patients were evaluated in a Chest Pain Unit and investigated during a 9-hour period (intermediate-probability, n = 433) (route 2) and a 6-hour period (low-probability, n = 277) (route 3). Sensitivity and negative predictive value of chest pain type for the diagnosis of acute myocardial infarction (94% and 97%, respectively) was much better than the admission electrocardiogram (49% and 86%, respectively) and admission creatine kinase-MB (46% and 86%, respectively). Serial creatine kinase-MB determinations ruled out acute myocardial infarction by the third-hour postadmission in all route 3 patients but only at the ninth-hour in route 2 patients. For patients with no ST-segment elevation, chest pain type was the strongest independent predictor of acute coronary syndromes. It is concluded that chest pain type is the best single diagnostic tool to rule in/out acute coronary syndromes on admission to the emergency department. Patients with suspicious chest pain must have serum creatine kinase-MB measurements up to 9 hours postadmission to rule out acute myocardial infarction.

Importância da proteína C-reativa no diagnóstico e no prognóstico intra-hospitalar em pacientes com dor torácica na sala de emergência / C-reactive protein diagnostic and prognostic value in patients presenting at the emergency room with chest pain / C-reactive protein diagnostic and prognostic value in patients presenting at the emergency room with chest pain

OBJETIVO: Testar os valores diagnóstico e prognóstico imediatos da proteína C-reativa (PCR) nos pacientes admitidos na sala de emergência (SE) com dor torácica (DT) e sem elevação do segmento ST no eletrocardiograma (ECG). MÉTODOS: De janeiro de 2002 a dezembro de 2003, 980 pacientes consecutivos foram atendidos com DT suspeita de síndrome coronariana aguda na SE (idade = 64,9 ± 14,3 anos, homens = 55 por cento, diabéticos = 18 por cento, ECG normal = 84 por cento). Dosou-se a PCR na admissão, a creatinofosfoquinase MB fração massa (CKMB) e a troponina I seriadas, além de se registrar ECG seriados. As medidas da PCR foram padronizadas (PCR-p) pelo valor do limite superior da normalidade (LSN) do teste utilizado (3,0 mg/L para a PCR de alta sensibilidade-PCR-AS e 0,1 mg/dl para PCR titulada-PCR-t). RESULTADOS: Foi diagnosticado infarto agudo do miocárdio (IAM) em 125 pacientes, e seus valores para a PCR-p foram 1,31 ± 2,90 (mediana = 0,47) versus 0,79 ± 1,39 (0,30) nos sem IAM (p = 0,031). A PCR-p > 1,0 apresentou sensibilidade de 30 por cento, especificidade de 80,4 por cento, valores preditivos positivo e negativo de 6,1 por cento e de 96,7 por cento, para o diagnóstico de IAM. Houve quarenta eventos cardíacos intra-hospitalares (óbitos = dezesseis, revascularizações de urgência = 22, IAM = dois). No 1° quartil da PCR-p (< 0,10) registraram-se três eventos, enquanto no 4° quartil (> 0,93) ocorreram quinze eventos (p = 0,003). Na regressão logística foram preditores independentes para eventos cardíacos a insuficiência ventricular esquerda, o sexo masculino e a PCR-p > 0,32, com razão de chances de 7,6, 2,8 e 2,2, respectivamente. CONCLUSÃO: Nos pacientes atendidos com DT na SE, a PCR-p: 1) Não foi um bom marcador de IAM, apesar de um valor normal praticamente afastar esse diagnóstico; 2) Um valor superior a um terço do seu limite superior da normalidade (LSN) (>1 mg/L da PCR-AS ou >0,33 mg/dl da PCR-t) foi preditor de eventos cardíacos adversos intra-hospitalares.

OBJECTIVE: To test immediate diagnostic and prognostic values of C-reactive protein (CRP) in patients admitted to the emergency room (ER) with chest pain (CP) without ST-segment elevation on the electrocardiogram (ECG). METHODS: From January 2002 to December 2003, 980 patients were consecutively seen in the ER with CP suggestive of acute coronary syndrome (ACS) (age = 64.9 ± 14.3, men = 55 percent, diabetic = 18 percent, normal ECG = 84 percent). Serial CRP, creatine kinase MB mass (CKMB-mass) and troponin I determinations were performed on admission, in addition to serial ECG. CRP measurements were standardized (s-CRP) by the upper limit of normal (ULN) of the test used (3.0 mg/L for high-sensitivity C-reactive protein [hs-CRP] and 0.1 mg/dL for titrated CRP [t-CRP]). RESULTS: One hundred and twenty-five patients were diagnosed with acute myocardial infarction (AMI), and their s-CRP values were 1.31 ± 2.90 (median = 0.47) compared to 0.79 ± 1.39 (0.30) in no-AMI patients (p = 0.031). The s-CRP > 1.0 showed 30 percent sensitivity and 80 percent specificity, plus negative and positive predictive values of 6.1 percent and 96.7 percent, respectively, for AMI diagnosis. There were forty in-hospital cardiac events (16 deaths, 22 urgent revascularizations, and 2 acute myocardial infarction). In the first quartile of the s-CRP (< 0.10), three events were recorded, while in the fourth quartile (> 0.93) 15 events (p = 0.003) occurred. In the logistic regression model, masculine gender and s-CRP > 0.32 (odds ratio 7.6, 2.8 and 2.2, respectively) were independent predictors of cardiac events and left ventricular failure. CONCLUSION: In patients with chest pain presenting at the emergency room, s-CRP was not a good marker of AMI, although this diagnosis is virtually excluded by a normal value; in addition, values one-third above the upper limit of normal (>1 mg/L for hs-CRP or >0.33 mg/dL for t-CRP) were predictive of in-hospital adverse cardiac events.

Unidades de dor torácica: uma forma moderna de manejo de pacientes com dor torácica na sala de emergência / Chest pain units: a modern way of managing patients with chest pain in the emergency department

It is estimated that 5 to 8 million individuals with chest pain or other symptoms suggestive of myocardial ischemia are seen each year in emergency departments (ED) in the United States 1,2, which corresponds to 5 to 10 percent of all visits 3,4. Most of these patients are hospitalized for evaluation of possible acute coronary syndrome (ACS). This generates an estimated cost of 3 - 6 thousand dollars per patient 5,6. From this evaluation process, about 1.2 million patients receive the diagnosis of acute myocardial infarction (AMI), and just about the same number have unstable angina. Therefore, about one half to two thirds of these patients with chest pain do not have a cardiac cause for their symptoms 2,3. Thus, the emergency physician is faced with the difficult challenge of identifying those with ACS - a life-threatening disease - to treat them properly, and to discharge the others to suitable outpatient investigation and management

É o sexo feminino um preditor independente de mortalidade hospitalar no infarto agudo do miocárdio? / Is female sex an independent predictor of in-hospital mortality in acute myocardial infarction?

OBJECTIVE: To assess whether female sex is a factor independently related to in-hospital mortality in acute myocardial infarction. METHODS: Of 600 consecutive patients (435 males and 165 females) with acute myocardial infarction, we studied 13 demographic and clinical variables obtained at the time of hospital admission through uni- and multivariate analysis, and analyzed their relation to in-hospital death. RESULTS: Females were older (p<0.001) and had a higher incidence of hypertension (p<0.001). Males were more frequently smokers (p<0.001). The remaining risk factors had a similar incidence among both sexes. All variables underwent uni- and multivariate analysis. Through univariate analysis, the following variables were found to be associated with in-hospital death: female sex (p<0.001), age >70 years (p<0.001), the presence of previous coronary artery disease (p=0.0004), previous myocardial infarction (p<0.001), infarction in the anterior wall (p=0.007), presence of left ventricular dysfunction (p<0.001), and the absence of thrombolytic therapy (p=0.04). Through the multivariate analysis of logistic regression, the following variables were associated with in-hospital mortality: female sex (p=0.001), age (p=0.008), the presence of previous myocardial infarction (p=0.02), and left ventricular dysfunction (p<0.001). CONCLUSION: After adjusting for all risk variables, female sex proved to be a variable independently related to in-hospital mortality in acute myocardial infarction

História natural de sobreviventes de infarto agudo do miocárdio: estudo prospectivo e correlaçäo ergométrica e angiográfica / Natural history of survivors of acute myocardial infarction: prospective study and ergometric and angiographic correlation

Cento e trinta e oito pacientes consecutivos e näo selecionados, com menos de 70 anos de idade, internados com diagnóstico clínico, eletrocardiográfico e enzímico de infarto agudo do miocárdio foram estudados para determinar a relaçäo entre os achados do teste ergométrico precoce e da cinecoronariografia com o seu seguimento após a alta hospitalar. Quarenta e dois pacientes foram excluídos por recusarem o estudo invansivo (suas características clínicas e eletrocardiográficas eram semelhantes às dos demais pacientes), sete perderam-se no seguimento (suas características clínicas, eletrocardiográficas, ergométricas e angiográficas eram semelhantes às dos demais pacientes). Os 89 pacientes restantes foram acompanhados por um período médio de 21,7 + ou - 11,0 meses. Obito cardíaco ocorreu em 5 casos (6%) três nos primeiros seis meses), angina pós-infarto em 14 casos (16%), insuficiência ventricular esquerda em 7 casos (8%) e reinfarto do miocárdio em 2 casos (2%). Cinqüenta e oito pacientes (65%) estavam assintomáticos. Em todos os casos de Obitos cardíacos havia doença coronária multivascular e em 79% dos sobreviventes; 40% dos Obitos e 13% dos sobreviventes tinham fraçäo de ejeçäo do ventrículo esquerdo menor que 30%. Em todos os falecidos, o teste ergométrico precoce era anormal assim como em 49% dos sobreviventes. Em relaçäo aos pacientes que desenvolveram algum evento cardíaco no seguimento, todos tinham doença coronária multivascular vs. 71% dos assintomáticos (p < 0,005). O teste ergométrico precoce foi anormal em 73% dos pacientes com eventos vs. 41% dos assintomáticos (p < 0,05). A associaçäo de doença multivascular e/ou fraçäo de ejeçäo < 50% e/ou teste ergométrico anormal foi encontrada em 93% dos pacientes com ...

E a cinecoronariografia mais acurada que o teste ergométrico precose na identificaçäo de sobreviventes de infarto agudo do miocárdio de alto risco? / Is coronary cineangiography more accurate than early bicycle ergometry test in the identification of high-risk acute myocardial infarction survivors?

Purpose­To determine if attenuated early treadmill stress testing is more or less accurate than cinecoronary arteriography in the identification of high-risk acute myocardial infarction (AMI) survivors. Patients and Methods­In a prospective study 96 non-selected and consecutive AMI survivors underwent cinecoronary arteriography in the 4th week of hospitalization and were followed up for a period of 3 to 39 (21.7 ± 11.0) months. One-half of the patients were randomly submitted to an attenuated heart rate-limited treadmill stress testing in the 3rd week. Seven patients were lost in the follow-up. Of the remaining 89 patients 5 died of cardiac causes. Cardiac events (death, reinfarction, angina and heart failure) ocurred in 26 patients. Multivessel coronary artery disease was found in 67 patients (75%) and mean left ventricular ejection fraction was 49.1 ± 15.6%. Positive treadmill stress testing for myocardial ischemia ocurred in 20 of 43 patients (46%). Results­All patients who died of cardiac causes or who had a cardiac event had multivessel coronary artery disease, the mean left ventricular ejection fraction was 38.6 ± 16.6% and 45.2 ± 16.4%, respectively, and two-thirds of patients had positive stress testing. For cardiac death, multivessel coronary artery disease had better sensitivity than positive stress testing and left ventricular ejection fraction less than 0.3 (100% vs 67% vs 20%, respectively) while ejection fraction had better specificity than stress testing and multivessel coronary artery disease (87% vs 55% vs 21%, respectively). Stress testing had a better positive predictive value...

Efeitos hemodinâmicos da desoprimida oral em pacientes com infarto do miocárdio / Hemodynamic effects of disopyramide by oral route in patients with acute myocardial infaction

Disopiramida, na dose de 200 mg a cada 8 h foi administrada por via oral a 18 pacientes nao selecionados na 2a. ou 3a. semana de infarto agudo do miocardio.As repercussoes hemodinamicas foram avaliadas atraves dos intervalos sistolicos do fonomecanocardiograma. Nove pacientes tinham infarto de parede anterior, 8 de parede inferior e 1 subendocardico. Realizou-se os fonomecardiograma antes e de 2 a 3 dias apos o uso da droga, comparando os intervalos sistolicos (corrigidos para a frequencia cardiaca), a duracao do QRS e a pressao arterial pre e pos-dispiramida. O Q-A2c, o tempo de ejecao do ventriculo esquerdo (TEVEc), o indice de Weissler (PPEAEVE), pressao arterial e frequencia cardiaca nao apresentaram modificacao significativa.Entretanto, o PPEc e o QRS aumentaram significativamente (de 138,0 +/- 14,9 para 145, 3 +/- 16,2 ms, e de 74,4 +/- 9,8 para 78,9 +/- 11,8 ms, respectivamente) ( p < 0,05).Concluiu-se que a disopiramida, na dose de 600 mg/dia, por via oral, pode ser administrada a pacientes na fase subaguda do infarto do miocardio causando somente um aumento de PPEc que provavelmente se deve a un aumento do tempo de ativacao eletrica ventricular (QRS), nao se detectando reducao da funcao sistolica mesmo nos pacientes com disfuncao ventricular esquerda previa

Anatomia coronaria e funçäo ventricular esquerda em pacientes sobreviventes de infarto aguda do miocárdio / Coronary anatomy and left ventricular function in patients surviving acute myocardial infarction

Cento e trinta e oito pacientes consecutivos e não selecionados, com menos de 70 anos de idade, sobreviventes da fase aguda de infarto do miocárdio (IM) entraram no estudo. Quarenta e dois (30%) desses recusaram estudos invasivos, restando 96 pacientes que se submeteram à cinecoronariografia na 4.ª semana de evolução. IM de parede inferior ocorreu em 44/96 (46%) pacientes, IM de parede anterior em 42/96 (44%), IM não-transmural em 9/90 (9%) e IM de localização indeterminada em 1 (1%). A idade dos pacientes variou de 30 a 69 (53,9 ± 9,6) anos e 82/96 (85%) eram do sexo masculino. Doença coronária de um vaso foi encontrada em 24/96 (25%) pacientes (12 tinham IM anterior, 10 tinham IM inferior, 1 tinha IM não-transmural). Doença coronária de 2 e 3 vasos foi encontrada em 31/96 (32%) e 41/96 (43%) pacientes, respectivamente. Lesão do tronco da artéria coronária esquerda foi vista em 11/96 (11%) pacientes (6 tinham IM inferior, 4 tinham IM anterior e 1 tinha IM não-transmural). A freqüência de lesão de 1, 2 ou 3 vasos ou de tronco nos IM anterior, inferior e subendocárdico não foi significativamente diferente. Pacientes com idade de 50 anos ou menos tinham menor freqüência de doença coronária multivascular que os mais idosos (67% vs. 81%, N.S.), o mesmo observandose em relação à lesão de tronco (0% vs. 19%, p < 0,01). A maioria dos pacientes tinha oclusão ou suboclusão de pelo menos um vaso e cerca de um quarto tinha oclusão de 2 vasos. Nenhum paciente tinha artérias coronárias normais. O volume diastólico final do ventrículo esquerdo variou de 24 a 171 ml/m2 (75,7 ± 23,8). O volume sistólico final variou de 8 a 134 ml/m2 (40,1 ± 21,2) e era significativamente maior nos pacientes com IM de parede anterior. A fração de ejeção ventricular esquerda variou de 16% a 86% (48,4 ± 15,6) e era significativamente menor nos pacientes com IM anterior; 14% dos pacientes tinham valor igual ou menor que 30%. A pressão diastólica final do ventrículo esquerdo variou de 3 a 37 mmHg (16,4 ± 7,6), e 30% dos pacientes tinham valores iguais ou maiores que 20 mmHg. Conclui-se que os pacientes que sobrevivem à fase aguda do IM têm alta prevalência de doença coronária multivascular, a qual é ainda maior nos indivíduos com mais de 50 anos de idade. Pacientes com IM de parede anterior têm função ventricular esquerda significativamente pior do que aqueles com IM inferior. A maioria dos pacientes com IM não-transmural tem função ventricular esquerda normal