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1.
Heart Lung Circ ; 17(1): 5-8, 2008 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-17419100

RESUMO

BACKGROUND: Thienopyridine use, in particular clopidogrel in acute coronary syndromes, has been associated with an improvement in outcome. However, little information is available regarding their bleeding risk when used in combination with other antithrombotic agents and revascularisation. METHODS: In a large, multinational, prospective registry, the Global Registry of Acute Coronary Events, the major bleeding rate (using GRACE criteria) of 27,358 patients with unstable angina or non-ST-elevation myocardial infarction was recorded during index admission. The interaction of thienopyridines on major bleeding with other antithrombotic agents and with revascularisation was analysed. RESULTS: The 11,478 patients who received thienopyridines during hospitalisation experienced a significant increase in major bleeding (2.8% with thienopyridines, 2.2% without thienopyridines; p=0.002). No significant interaction with glycoprotein IIb/IIIa inhibitors and thienopyridines was seen with regard to bleeding. Thienopyridines with unfractionated heparin did not alter bleeding risk, but thienopyridines with low molecular weight heparin was associated with a significant excess of bleeding (2.1% with thienopyridines, 1.3% without thienopyridines; p=0.004). There was no significant difference in major bleeding with thienopyridines in patients who did or did not undergo revascularisation. CONCLUSIONS: Major bleeding was increased in patients receiving thienopyridines. No increase in bleeding risk was seen in patients having revascularisation.


Assuntos
Angina Instável/tratamento farmacológico , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Infarto do Miocárdio/tratamento farmacológico , Piridinas/efeitos adversos , Tromboembolia/prevenção & controle , Angina Instável/diagnóstico , Angina Instável/mortalidade , Angina Instável/terapia , Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/métodos , Angiografia Coronária , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Eletrocardiografia , Feminino , Mortalidade Hospitalar/tendências , Humanos , Cooperação Internacional , Masculino , Estudos Multicêntricos como Assunto , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/métodos , Probabilidade , Prognóstico , Estudos Prospectivos , Piridinas/uso terapêutico , Sistema de Registros , Medição de Risco , Índice de Gravidade de Doença , Análise de Sobrevida
2.
Am Heart J ; 153(6): 960-9, 2007 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-17540196

RESUMO

OBJECTIVES: The purpose of this study is to evaluate hospital mortality and major bleeding rates among patients receiving low molecular weight heparin (LMWH), unfractionated heparin (UFH), or both, and to investigate whether concomitant glycoprotein (GP) IIb/IIIa antagonists and coronary intervention affect patterns of use and outcomes with different heparins. BACKGROUND: With widespread use of glycoprotein (GP) IIb/IIIa inhibitors and invasive treatments, patients with high-risk acute coronary syndrome (ACS) may have a greater bleeding risk and may not gain additional benefit from LMWHs. The purpose of this study is to evaluate hospital mortality and major bleeding rates among patients receiving LMWH, UFH, or both, and to investigate whether concomitant GP IIb/IIIa antagonists and coronary intervention affect patterns of use and outcomes with different heparins. METHODS: Data were analyzed from 28,445 patients with ACS; 21,287 had non-ST-segment elevation myocardial infarction or unstable angina and received LMWH or UFH. RESULTS: Fifty-one percent of patients received LMWH, 32% UFH, and 17% both. The lowest inhospital mortality and bleeding rates occurred with LMWH (2.7% and 1.8% vs UFH, 4.1% and 2.7%; all P < .0001). After multivariable analysis, LMWH was associated with lower inhospital mortality rates in patients not treated with GP IIb/IIIa antagonists, irrespective of whether they had a percutaneous coronary intervention (PCI) (odds ratio 0.77, 95% confidence interval 0.63-0.94 without PCI vs odds ratio 0.45, 95% confidence interval 0.21-0.98 with PCI). Excess bleeding occurred with PCI in LMWH-treated patients. Patients older than 75 years who received GP IIb/IIIa antagonists and any antithrombotic but not PCI had an increased risk of major bleeding (LMWH 14%, UFH 8.3%). CONCLUSIONS: In patients with non-ST-elevation ACS without GP IIb/IIIa antagonists, LMWH was associated with a lower mortality rate and more bleeding episodes in PCI-treated patients than UFH; no differences occurred with GP IIb/IIIa antagonists. Elderly patients managed medically with GP IIb/IIIa antagonists and either heparin had a very high major bleeding risk.


Assuntos
Doença das Coronárias/terapia , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Heparina/efeitos adversos , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Sistema de Registros , Adulto , Idoso , Angioplastia Coronária com Balão/estatística & dados numéricos , Comorbidade , Doença das Coronárias/epidemiologia , Interações Medicamentosas , Feminino , Heparina/análogos & derivados , Heparina de Baixo Peso Molecular/efeitos adversos , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Medição de Risco , Análise de Sobrevida , Taxa de Sobrevida , Varfarina/administração & dosagem
3.
Am Heart J ; 153(4): 493-9, 2007 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-17383284

RESUMO

BACKGROUND: Current guidelines advise the use of risk stratification to determine which patients should receive more aggressive antithrombotic and invasive therapies. Our objective was to evaluate the relationship between risk stratification and therapeutic decision making in patients with non-ST-segment elevation acute coronary syndromes. METHODS: We analyzed data from 15,026 patients with acute coronary syndrome who were enrolled into the GRACE registry between 1999 and 2003. We assessed the evidence-based use of antithrombotic therapy and early invasive strategy according to risk profile defined by baseline troponin elevation, presenting ST-segment depression, and GRACE risk score. Patients with possible contraindications were removed to define the use of therapies specifically among clearly eligible patients. RESULTS: Patients with elevated troponin were more likely to receive enoxaparin (60% vs 50.4%, respectively), GP IIb/IIIa inhibitors (32.8% vs 17.6%), and to undergo catheterization (66% vs 54%) and percutaneous coronary intervention (37.4% vs 25.6%; all P < .0001). Patients with ST depression received modestly more enoxaparin and GP IIb/IIIa than those without ST depression, but not more catheterization (P = .8) or percutaneous coronary intervention (P = .09). Highest risk patients were somewhat less likely to receive enoxaparin (P < .0001) and cardiac catheterization (P = .0002) according to GRACE risk deciles. CONCLUSIONS: In spite of current guidelines recommending the use of selected therapies in high-risk patients, there is no clear correlation of use of effective therapies with overall risk profile even among eligible patients. Thus, there is substantial opportunity to improve use of effective therapies, especially in high-risk populations.


Assuntos
Angina Instável/tratamento farmacológico , Angina Instável/cirurgia , Angioplastia Coronária com Balão , Cateterismo Cardíaco , Enoxaparina/uso terapêutico , Fibrinolíticos/uso terapêutico , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/cirurgia , Doença Aguda , Idoso , Medicina Baseada em Evidências , Humanos , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Sistema de Registros , Medição de Risco/métodos , Síndrome
4.
Circulation ; 111(24): 3242-7, 2005 Jun 21.
Artigo em Inglês | MEDLINE | ID: mdl-15956123

RESUMO

BACKGROUND: Stroke is a recognized complication after acute myocardial infarction, but few studies have investigated the incidence and outcome of stroke in patients with acute coronary syndrome (ACS). This study examined the incidence and outcomes of hemorrhagic and nonhemorrhagic stroke and risk factors associated with stroke in patients with ACS. METHODS AND RESULTS: Data were obtained from 35,233 patients enrolled in the Global Registry of Acute Coronary Events (GRACE) with an ACS. In-hospital strokes occurred in 310 patients (0.9%), of which 100 (32.6%) were fatal. The incidence of in-hospital stroke was significantly higher in patients with ST-segment-elevation myocardial infarction than in non-ST-segment myocardial infarction or unstable angina (1.3%, 0.9%, 0.5%, respectively; P<0.001). Overall, 35.5% of in-hospital strokes occurred within 6 days of hospitalization. The strongest risk factor for in-hospital nonhemorrhagic stroke was in-hospital CABG, followed by in-hospital atrial fibrillation, previous stroke, initial enzyme elevation, and advanced age. Prior statin use was a protective factor. After controlling for potential confounders, in-hospital mortality was significantly higher among patients who experienced an in-hospital stroke (adjusted odds ratio, 8.3; 95% CI, 6.0 to 11.4). A total of 269 additional strokes (1.1%) occurred within 6 months after discharge from hospital, of which 56 (20.9%) were fatal. The most important risk factor for postdischarge stroke was the occurrence of an in-hospital stroke. CONCLUSIONS: Stroke is an uncommon event in patients with ACS but is associated with high mortality. Despite current therapy, the incidence of postdischarge stroke is not low. New approaches are warranted to reduce the risk of stroke in patients with ACS.


Assuntos
Doença da Artéria Coronariana/complicações , Acidente Vascular Cerebral/etiologia , Doença Aguda , Idoso , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/terapia , Eletrocardiografia , Estudos Epidemiológicos , Feminino , Hemorragia , Mortalidade Hospitalar , Hospitalização , Humanos , Incidência , Masculino , Recidiva , Sistema de Registros , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/mortalidade , Resultado do Tratamento
5.
Am Heart J ; 152(6): 1015-21, 2006 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-17161045

RESUMO

BACKGROUND: Early beta-blocker (BB) therapy improves outcomes in ST-segment elevation myocardial infarction; however, limited data are available on its early use and its impact in non-ST-segment elevation myocardial infarction (NSTEMI). METHODS: We evaluated data from 7106 patients with NSTEMI, without contraindications to BBs, enrolled in the Global Registry of Acute Coronary Events between April 1999 and September 2004. Baseline characteristics, management, and outcomes were analyzed according to the use of oral (+/-intravenous) BB within 24 hours of presentation. Multivariable analysis was conducted adjusting for comorbidities using the Global Registry of Acute Coronary Events risk model (c statistic 0.83). RESULTS: Beta-blocker therapy was initiated within the first 24 hours in 76% of patients with NSTEMI (79% with Killip class I vs 62% with class II/III; P < .001). Failure to initiate BBs within the first 24 hours was associated with lower rates of subsequent BB therapy (P < .001) and other evidence-based therapies. Early BB therapy was correlated with lower hospital mortality for NSTEMI patients (OR 0.58, 95% CI 0.42-0.81) and for those with Killip class II/III (OR 0.39, 95% CI 0.23-0.68) with a trend toward lower mortality in the Killip class I group (OR 0.77, 95% CI 0.49-1.21). At 6 months postdischarge, early BB use was associated with lower mortality in NSTEMI patients (OR 0.75, 95% CI 0.56-0.997) with a trend toward lower mortality in patients with Killip class I or II/III. CONCLUSIONS: Many eligible patients do not receive early BB therapy. Treatment with early BBs may have a beneficial impact on hospital and 6-month mortality in all patients, including those presenting with heart failure.


Assuntos
Antagonistas Adrenérgicos beta/administração & dosagem , Insuficiência Cardíaca/etiologia , Infarto do Miocárdio/complicações , Infarto do Miocárdio/tratamento farmacológico , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Esquema de Medicação , Eletrocardiografia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Sistema de Registros , Resultado do Tratamento
6.
Neurosurg Focus ; 20(4): E16, 2006 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-16709021

RESUMO

OBJECT: In patients with glioma, image-guided surgery helps to define the radiographic limits of the tumor to maximize safety and the extent of resection while minimizing damage to eloquent brain tissue. The authors hypothesize that image-guided resection (IGR) techniques are associated with improved outcomes in patients with malignant glioma. METHODS: Data recorded in 486 patients enrolled in the Glioma Outcomes Project were analyzed in this study. Demographic data and outcomes in patients who underwent IGR were compared with those in patients who underwent resection without IGR. Univariate analysis performed with chi-square testing was used to compare patient presentation, tumor characteristics, and death rates. Multivariate logistic regression was used to predict various outcome parameters. Patients who underwent IGR were younger and had smaller, lower-grade tumors than those in whom IGR was not performed. They were more likely to present with seizure and normal consciousness. Unexpectedly, gross-total resection was performed in significantly fewer patients with IGR than in individuals without IGR. Patients with IGR were more likely to be discharged home with the ability to live independently, and they had a shorter duration of hospital stay than patients without IGR. Survival was significantly longer in patients who underwent IGR, but multivariate analysis showed that glioblastoma multiforme (GBM) and age accounted for these observations. CONCLUSIONS: Selection bias occurs regarding patients who receive IGR; these biases include younger age, presentation with seizure and normal level of consciousness, tumor diameter less than 4 cm, and non-GBM on histopathological studies. Outcome appears to be improved in patients who undergo IGRs of high-grade gliomas. It is unclear if these improved outcomes are due to the selection of a more favorable patient population or to the IGR techniques themselves. It is likely that the full potential of image guidance in glioma surgery will not be realized until it is applied to a wider range of patients.


Assuntos
Neoplasias Encefálicas/cirurgia , Glioma/cirurgia , Neuronavegação/métodos , Procedimentos Neurocirúrgicos/métodos , Avaliação de Resultados em Cuidados de Saúde , Seleção de Pacientes , Cirurgia Assistida por Computador/métodos , Atividades Cotidianas , Fatores Etários , Transtornos da Consciência/complicações , Transtornos da Consciência/etiologia , Progressão da Doença , Humanos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Estudos Longitudinais , Neuronavegação/efeitos adversos , Procedimentos Neurocirúrgicos/efeitos adversos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos , Convulsões/complicações , Convulsões/etiologia , Viés de Seleção , Inquéritos e Questionários , Taxa de Sobrevida/tendências
7.
Circulation ; 109(4): 494-9, 2004 Feb 03.
Artigo em Inglês | MEDLINE | ID: mdl-14744970

RESUMO

BACKGROUND: Few data are available on the impact of heart failure (HF) across all types of acute coronary syndromes (ACS). METHODS AND RESULTS: The Global Registry of Acute Coronary Events (GRACE) is a prospective study of patients hospitalized with ACS. Data from 16 166 patients were analyzed: 13 707 patients without prior HF or cardiogenic shock at presentation were identified. Of these, 1778 (13%) had an admission diagnosis of HF (Killip class II or III). HF on admission was associated with a marked increase in mortality rates during hospitalization (12.0% versus 2.9% [with versus without HF], P<0.0001) and at 6 months after discharge (8.5% versus 2.8%, P<0.0001). Of note, HF increased mortality rates in patients with unstable angina (defined as ACS with normal biochemical markers of necrosis; mortality rates: 6.7% with versus 1.6% without HF at admission, P<0.0001). By logistic regression analysis, admission HF was an independent predictor of hospital death (odds ratio, 2.2; P<0.0001). Admission HF was associated with longer hospital stay and higher readmission rates. Patients with HF had lower rates of catheterization and percutaneous cardiac intervention, and fewer received beta-blockers and statins. Hospital development of HF (versus HF on presentation) was associated with an even higher in-hospital mortality rate (17.8% versus 12.0%, P<0.0001). In patients with HF, in-hospital revascularization was associated with lower 6-month death rates (14.0% versus 23.7%, P<0.0001; adjusted hazard ratio, 0.5; 95% CI, 0.37 to 0.68, P<0.0001). CONCLUSIONS: In this observational registry, heart failure was associated with reduced hospital and 6-month survival across all ACS subsets, including patients with normal markers of necrosis. More aggressive treatment of these patients may be warranted to improve prognosis.


Assuntos
Angina Instável/complicações , Insuficiência Cardíaca/diagnóstico , Infarto do Miocárdio/complicações , Doença Aguda , Idoso , Angina Instável/diagnóstico , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/terapia , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Prognóstico , Estudos Prospectivos , Sistema de Registros , Síndrome , Fatores de Tempo
8.
Am J Med ; 118(8): 858-65, 2005 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-16084178

RESUMO

PURPOSE: To identify patient and health care factors which are related to the use of medical treatments that comprise quality measures and to assess the relation of these measures with mortality. METHODS: The study sample consisted of 20 140 patients with acute coronary syndromes from the international GRACE registry. Multivariable logistic regression modeling was used to determine predictors of quality performance. Quality indicators were use of aspirin and beta-blockers within 24 hours and at hospital discharge, use of angiotensin-converting enzyme (ACE) inhibitors at discharge, and in-hospital mortality. RESULTS: Use of medications in eligible patients at discharge ranged from 73% for ACE inhibitors to 93% for aspirin. High-risk features (eg, heart failure, older age) were related to failure to use aspirin and beta-blockers. Being at a teaching hospital and care by a cardiologist were associated with better use of aspirin and beta-blockers. Coronary artery bypass surgery was associated with failure to use ACE inhibitors and aspirin. When hospitals were divided into quartiles of quality performance, adjusted in-hospital mortality was 4.1% in the top versus 5.6% in the bottom quartile, representing a 27% (95% confidence interval: 11% to 42%) lower relative mortality. CONCLUSION: Identification of factors associated with failure to use proven treatments, including high-risk groups that would derive particular benefit from effective therapies, provides an opportunity to focus quality improvement interventions. The association of lower hospital mortality with better use of selected medical treatments supports their measurement to improve quality of care.


Assuntos
Angina Instável/tratamento farmacológico , Angina Instável/mortalidade , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/mortalidade , Garantia da Qualidade dos Cuidados de Saúde , Antagonistas Adrenérgicos beta/uso terapêutico , Fatores Etários , Idoso , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Aspirina/uso terapêutico , Austrália/epidemiologia , Serviço Hospitalar de Cardiologia , Ponte de Artéria Coronária , Europa (Continente)/epidemiologia , Feminino , Hospitais de Ensino , Humanos , Modelos Logísticos , Masculino , América do Norte/epidemiologia , Admissão do Paciente , Alta do Paciente , Inibidores da Agregação Plaquetária/uso terapêutico , Sistema de Registros , Fatores de Tempo , Disfunção Ventricular Esquerda/tratamento farmacológico , Disfunção Ventricular Esquerda/mortalidade
9.
Am J Cardiol ; 95(12): 1397-403, 2005 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-15950559

RESUMO

We assessed whether timing of catheterization is associated with the type of non-ST-segment elevation acute coronary syndrome and/or outcome in patients who were enrolled in the Global Registry of Acute Coronary Events. Overall, 8,853 patients who had unstable angina pectoris or non-ST-elevation myocardial infarction were categorized according to timing of catheterization: expeditive (<24 hours), early (24 to 48 hours), and delayed (>48 hours). Patients in the delayed group were older, more frequently had previous myocardial infarction or stroke, and had a higher risk score compared with those in the expeditive and early groups (all p < or =0.001). Killip class IV at admission, non-ST-elevation myocardial infarction, and Q waves after the index electrocardiogram were more common in the expeditive group (all p <0.0001). Patients in the expeditive and early groups were treated more aggressively with medications than were those in the delayed group. The in-hospital composite end point (death, stroke, or major bleed) occurred most frequently in the expeditive group (expeditive 6.6%, early 3.9%, delayed 5.1%, p = 0.0005), as did in-hospital death (expeditive 3.5%, early 1.4%, delayed 2.0%, p <0.0001). The highest incidence of death during follow-up occurred in the delayed group (3.8% delayed vs 2.8% expeditive/early, p = 0.0210). Multivariate regression analysis suggested that expeditive catheterization was related to in-hospital death and death from time of catheterization to 6 months. We conclude that expeditive catheterization is associated with unstable presenting features that contribute significantly to the higher risk of death and death or myocardial infarction in hospital compared with patients who undergo later catheterization.


Assuntos
Angina Instável/diagnóstico , Cateterismo Cardíaco , Eletrocardiografia , Infarto do Miocárdio/diagnóstico , Sistema de Registros , Distribuição por Idade , Angina Instável/mortalidade , Angina Instável/fisiopatologia , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Cooperação Internacional , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Distribuição por Sexo , Taxa de Sobrevida/tendências , Fatores de Tempo
10.
Am J Cardiol ; 96(7): 913-6, 2005 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-16188515

RESUMO

In the prospective, multicenter Canadian Acute Coronary Syndromes Registry, in-hospital revascularization was independently associated with better 1-year survival only among patients with high-risk non-ST-elevation acute coronary syndromes stratified by the Global Registry of Acute Coronary Events risk score; similar benefits were not observed in the low- and intermediate-risk groups. The Global Registry of Acute Coronary Events risk score appears to be a useful risk stratification tool that identifies high-risk patients for whom more aggressive treatment is warranted.


Assuntos
Angina Instável/terapia , Infarto do Miocárdio/terapia , Revascularização Miocárdica , Idoso , Angina Instável/mortalidade , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Revascularização Miocárdica/mortalidade , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento
11.
Am J Cardiol ; 96(7): 917-21, 2005 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-16188516

RESUMO

Few data exist on the use of aggressive combination therapy with thienopyridines and glycoprotein IIb/IIIa inhibitors in higher risk patients with an acute coronary syndrome (ACS). The aim of this study was to characterize the combined use of these agents and the associated hospital outcomes in patients with ACS enrolled in the multinational Global Registry of Acute Coronary Events. Data from 8,081 patients with non-ST-segment elevation myocardial infarction or unstable angina were analyzed. Of these patients, 5,070 (62.7%) received aspirin and a thienopyridine, and the remainder received aspirin, a thienopyridine, and a glycoprotein IIb/IIIa blocker. The presence of a non-ST-segment elevation myocardial infarction; a history of diabetes or coronary artery bypass surgery; performance of in-hospital catheterization, percutaneous coronary intervention, or coronary artery bypass grafting; and in-hospital use of heparin were independent predictors of the use of triple antiplatelet therapy with aspirin, thienopyridines, and glycoprotein IIb/IIIa blockers. Increased diastolic blood pressure and increased serum creatinine were associated with a failure to prescribe triple therapy. An increased risk of major bleeding during hospitalization was associated with the use of triple antiplatelet therapy (odds ratio 1.6, 95% confidence interval 1.2 to 2.2). Aggressive antiplatelet therapy was used in approximately 2 of every 5 patients presenting with an ACS. Triple therapy was associated with the performance of catheterization and/or percutaneous coronary intervention, as well as high-risk patient features. Although no differences in hospital death rates were evident in patients receiving triple therapy, this population was at significantly increased risk of major bleeding episodes during hospitalization.


Assuntos
Angina Instável/tratamento farmacológico , Infarto do Miocárdio/tratamento farmacológico , Inibidores da Agregação Plaquetária/administração & dosagem , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/administração & dosagem , Idoso , Angina Instável/diagnóstico , Angina Instável/mortalidade , Quimioterapia Combinada , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Inibidores da Agregação Plaquetária/efeitos adversos , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/efeitos adversos , Piridinas/administração & dosagem , Piridinas/efeitos adversos
12.
Am Heart J ; 147(1): 42-8, 2004 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-14691417

RESUMO

OBJECTIVE: To examine the association between elevated leukocyte count and hospital mortality and heart failure in patients enrolled in the multinational, observational Global Registry of Acute Coronary Events (GRACE). BACKGROUND: Elevated leukocyte count is associated with adverse hospital outcomes in patients presenting with acute myocardial infarction (AMI). The association of this prognostic factor with hospital mortality and heart failure in patients with other acute coronary syndromes (ACS) is unclear. METHODS: We examined the association between admission leukocyte count and hospital mortality and heart failure in 8269 patients presenting with an ACS. This association was examined separately in patients with ST-segment elevation AMI, non-ST-segment elevation AMI, and unstable angina. Leukocyte count was divided into 4 mutually exclusive groups (Q): Q1 <6000, Q2 = 6000-9999, Q3 = 10,000-11,999, Q4 >12,000. Multiple logistic regression analysis was performed to examine the association between elevated leukocyte count and hospital events while accounting for the simultaneous effect of several potentially confounding variables. RESULTS: Increasing leukocyte count was significantly associated with hospital death (adjusted odds ratio [OR] 2.8, 95% CI 2.1-3.6 for Q4 compared to Q2 [normal range]) and heart failure (OR 2.7, 95% CI 2.2-3.4) for patients presenting with ACS. This association was seen in patients with ST-segment elevation AMI (OR for hospital death 3.2, 95% CI 2.1-4.7; OR for heart failure 2.4, 95% CI 1.8-3.3), non-ST-segment elevation AMI (OR for hospital death 1.9, 95% CI 1.2-3.0; OR for heart failure 1.7, 95% CI 1.1-2.5), or unstable angina (OR for hospital death 2.8, 95% CI 1.4-5.5; OR for heart failure 2.0, 95% CI 0.9-4.4). CONCLUSION: In men and women of all ages with the spectrum of ACS, initial leukocyte count is an independent predictor of hospital death and the development of heart failure.


Assuntos
Angina Instável/mortalidade , Arritmias Cardíacas/mortalidade , Insuficiência Cardíaca/etiologia , Mortalidade Hospitalar , Contagem de Leucócitos , Infarto do Miocárdio/mortalidade , Adulto , Idoso , Análise de Variância , Angina Instável/sangue , Arritmias Cardíacas/sangue , Feminino , Insuficiência Cardíaca/sangue , Humanos , Inflamação/sangue , Inflamação/complicações , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Valor Preditivo dos Testes , Síndrome
13.
Am Heart J ; 146(6): 999-1006, 2003 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-14660991

RESUMO

BACKGROUND: Many agents are available to treat acute coronary syndromes (ACS), yet limited information is available about their use from a multinational perspective. The objective of this report was to describe patterns of use of antithrombotic and antiplatelet therapies in patients with the spectrum of ACS through the use of data from the Global Registry of Acute Coronary Events (GRACE). METHODS: Data from 12,665 patients with ACS were analyzed. Baseline characteristics, clinical presentation, and medication use were compared. Regional differences in the administration of antiplatelet and antithrombotic therapies were analyzed. Multivariable logistic regression was implemented to determine independent variables indicating the use of various hospital therapies. RESULTS: Overall, unfractionated heparin was used in 57% of patients and low-molecular-weight heparin in 47% (P <.0001). More than 90% of patients received aspirin, but approximately 13% were not discharged on aspirin. Overall, 30% of patients received thienopyridines (with percutaneous coronary intervention [PCI] in 79%). Of those who did not receive aspirin, 31% received thienopyridines. Intravenous glycoprotein inhibitors were given to 17% of patients. Among those treated with PCI, only 47% received glycoprotein inhibitors, and 21% of those given glycoprotein inhibitors did not undergo PCI. Significant geographic variation was apparent in the use of unfractionated heparin, low-molecular-weight heparin, thienopyridines, and glycoprotein inhibitors. CONCLUSIONS: Despite the availability of guidelines, striking geographic and practice variations are apparent in the use of antithrombotic and antiplatelet therapies. There remains significant room for improvement in the use of these therapies in patients with ACS, which should lead to improvement in care and outcomes.


Assuntos
Trombose Coronária/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Inibidores da Agregação Plaquetária/uso terapêutico , Doença Aguda , Idoso , Angioplastia Coronária com Balão , Biomarcadores/sangue , Feminino , Heparina/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Sistema de Registros , Análise de Regressão , Estatísticas não Paramétricas , Síndrome , Troponina/sangue
14.
Am J Cardiol ; 92(9): 1031-6, 2003 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-14583352

RESUMO

Preexisting or new-onset atrial fibrillation (AF) commonly occurs in patients with an acute coronary syndrome (ACS). However, it is currently unknown if previous or new-onset AF confers different risks in these patients. To determine the prognostic significance of new-onset and previous AF in patients with ACS, we evaluated all patients with ACS enrolled in the multinational Global Registry of Acute Coronary Events (GRACE) between April 1999 and September 2001. We compared clinical characteristics, management, and hospital outcomes in patients with ACS and new-onset and previous AF with those without AF. Of a total of 21,785 patients with ACS enrolled in GRACE, 1,700 (7.9%) had previous AF and 1,221 (6.2%) had new-onset AF. Patients with any AF were older, more likely to be women, had more co-morbid conditions, and worse hemodynamic status. Most in-hospital adverse events (reinfarction, shock, pulmonary edema, bleeding, stroke, and mortality) were significantly higher in patients with any AF than those without AF. Only new-onset AF (not previous AF) was an independent predictor of all adverse in-hospital outcomes. We conclude that compared with patients with ACS without any AF, previous and new-onset AF are associated with increased hospital morbidity and mortality. However, only new-onset AF is an independent predictor of in-hospital adverse events in patients with ACS.


Assuntos
Angina Instável/complicações , Angina Instável/terapia , Fibrilação Atrial/complicações , Infarto do Miocárdio/complicações , Infarto do Miocárdio/terapia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Angina Instável/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Síndrome , Resultado do Tratamento
15.
JAMA ; 291(22): 2727-33, 2004 Jun 09.
Artigo em Inglês | MEDLINE | ID: mdl-15187054

RESUMO

CONTEXT: Accurate estimation of risk for untoward outcomes after patients have been hospitalized for an acute coronary syndrome (ACS) may help clinicians guide the type and intensity of therapy. OBJECTIVE: To develop a simple decision tool for bedside risk estimation of 6-month mortality in patients surviving admission for an ACS. DESIGN, SETTING, AND PATIENTS: A multinational registry, involving 94 hospitals in 14 countries, that used data from the Global Registry of Acute Coronary Events (GRACE) to develop and validate a multivariable stepwise regression model for death during 6 months postdischarge. From 17,142 patients presenting with an ACS from April 1, 1999, to March 31, 2002, and discharged alive, 15,007 (87.5%) had complete 6-month follow-up and represented the development cohort for a model that was subsequently tested on a validation cohort of 7638 patients admitted from April 1, 2002, to December 31, 2003. MAIN OUTCOME MEASURE: All-cause mortality during 6 months postdischarge after admission for an ACS. RESULTS: The 6-month mortality rates were similar in the development (n = 717; 4.8%) and validation cohorts (n = 331; 4.7%). The risk-prediction tool for all forms of ACS identified 9 variables predictive of 6-month mortality: older age, history of myocardial infarction, history of heart failure, increased pulse rate at presentation, lower systolic blood pressure at presentation, elevated initial serum creatinine level, elevated initial serum cardiac biomarker levels, ST-segment depression on presenting electrocardiogram, and not having a percutaneous coronary intervention performed in hospital. The c statistics for the development and validation cohorts were 0.81 and 0.75, respectively. CONCLUSIONS: The GRACE 6-month postdischarge prediction model is a simple, robust tool for predicting mortality in patients with ACS. Clinicians may find it simple to use and applicable to clinical practice.


Assuntos
Angina Instável/mortalidade , Técnicas de Apoio para a Decisão , Isquemia Miocárdica/mortalidade , Medição de Risco , Idoso , Causas de Morte , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros
16.
Arch Intern Med ; 169(4): 402-9, 2009 Feb 23.
Artigo em Inglês | MEDLINE | ID: mdl-19237725

RESUMO

BACKGROUND: Elevated blood glucose level at admission is associated with worse outcome after a myocardial infarction. The impact of elevated glucose level, particularly fasting glucose, is less certain in non-ST-segment elevation acute coronary syndromes. We studied the relationship between elevated fasting blood glucose levels and outcome across the spectrum of ST-segment elevation and non-ST-segment elevation acute coronary syndromes in a large multicenter population broadly representative of clinical practice. METHODS: Fasting glucose levels were available for 13 526 patients in the Global Registry of Acute Coronary Events. A multivariate logistic regression analysis was used for assessing the association between admission or fasting glucose level and in-hospital or 6-month outcome, adjusted for the variables from the registry risk scores. RESULTS: Higher fasting glucose levels were associated with a graded increase in the risk of in-hospital death (odds ratios [95% confidence intervals] vs <100 mg/dL: 1.51 [1.12-2.04] for 100-125 mg/dL, 2.20 [1.64-2.60] for 126-199 mg/dL, 5.11 [3.52-7.43] for 200-299 mg/dL, and 8.00 [4.76-13.5] for > or =300 mg/dL). When taken as a continuous variable, higher fasting glucose level was related to a higher probability of in-hospital death, without detectable threshold and irrespective of whether patients had a history of diabetes mellitus. Higher fasting glucose levels were found to be associated with a higher risk of postdischarge death up to 6 months. The risk of postdischarge death at 6 months was significantly higher with fasting glucose levels between 126 and 199 mg/dL (1.71 [1.25-2.34]) and 300 mg/dL or greater (2.93 [1.33-6.43]), but not within the 200- to 299-mg/dL range (1.08 [0.60-1.95]). CONCLUSIONS: Short-term and 6-month mortality was increased significantly with higher fasting glucose levels in patients across the spectrum of acute coronary syndromes, thus extending this relation to patients with non-ST-segment elevation myocardial infarction. The relation between fasting glucose level and risk of adverse short-term outcomes is graded across different glucose levels with no detectable threshold for diabetic or nondiabetic patients.


Assuntos
Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/mortalidade , Glicemia/metabolismo , Síndrome Coronariana Aguda/fisiopatologia , Adulto , Idoso , Feminino , Saúde Global , Sistema de Condução Cardíaco/fisiopatologia , Mortalidade Hospitalar/tendências , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/mortalidade , Razão de Chances , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo
17.
Rev Esp Cardiol ; 62(5): 501-9, 2009 May.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-19406064

RESUMO

INTRODUCTION AND OBJECTIVES: To investigate how thienopyridine treatment, with or without associated fibrinolysis, affects the rates of major bleeding and inhospital death in patients with ST-elevation myocardial infarction (STEMI). METHODS: The rates of major bleeding and in-hospital death were studied in 14,259 consecutive patients with STEMI. During hospitalization, 5340 (38%) received thienopyridines, 3007 (21%) received fibrinolytic drugs, and 2044 (14%) received both. RESULTS: Major bleeding occurred more frequently in patients who received thienopyridines with or without fibrinolytics, in 4.6% and 4.1%, respectively, compared with 2.3% in those who received fibrinolytics alone and 2.8% in those who received neither (P< .001). Multivariate analysis, which included adjustments for risk factors for bleeding, percutaneous coronary intervention and cardiac catheterization, showed that thienopyridine treatment was an independent risk factor for bleeding (odds ratio=1.68; 95% confidence interval, 1.23-2.31). In-hospital mortality was lower in patients who received a thienopyridine, and such treatment was an independent predictor of lower mortality (odds ratio=0.50; 95% confidence interval, 0.39-0.60). CONCLUSIONS: Thienopyridine treatment was associated with an increased risk of major bleeding but also with a better in-hospital prognosis. These findings in unselected patients with STEMI, who are representative of those seen in daily clinical practice, complement, but do not replace, the data obtained in randomized clinical trails of selected patients.


Assuntos
Doença das Coronárias/epidemiologia , Fibrinolíticos/uso terapêutico , Infarto do Miocárdio/tratamento farmacológico , Piridinas/uso terapêutico , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Eletrocardiografia , Determinação de Ponto Final , Feminino , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia , Estudos Prospectivos , Piridinas/efeitos adversos , Sistema de Registros
18.
Int J Cardiol ; 119(1): 65-72, 2007 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-17045681

RESUMO

BACKGROUND: We evaluated the association between invasive and non-invasive management and hospital and 6-month outcomes in patients with a prior coronary artery bypass graft (CABG) who experienced an acute coronary syndrome. METHODS: Data were analysed from patients with a prior CABG who developed an acute coronary syndrome and were enrolled in the Global Registry of Acute Coronary Events. From 44,991 patients included in the study, 3853 fulfilled the inclusion criteria. Of these, 3356 received non-invasive treatment approaches while 497 underwent invasive treatment (percutaneous coronary intervention [PCI] within 48 h of admission). RESULTS: The primary composite endpoint of death, non-fatal myocardial infarction, and recurrent ischaemia during hospitalization was similar in patients in the non-invasive and invasive groups (31% vs 30%, respectively; P=0.53). The rates of hospital mortality (non-invasive 3.4% vs invasive 3.2%) and non-fatal myocardial infarction (3.4% vs 5.1%, respectively) were similar. At 6-month follow-up, the mortality rate was 6.5% in the non-invasive group vs 3.4% in the invasive group (P<0.02); the combined endpoint of death or myocardial infarction was lower in the invasive group (P<0.01). Multivariable analysis showed that, at 6-month follow-up, the combined endpoint of death, non-fatal myocardial infarction, and rehospitalization for heart disease was similar (P=0.10). A greater proportion of patients in the invasive group required unscheduled diagnostic and therapeutic invasive procedures compared with those in the non-invasive group (angiography 15.4% vs 8.1%; PCI 10% vs 5.0%; both P<0.001). CONCLUSIONS: The results from this observational study show no statistically significant differences in hospital outcomes between acute coronary syndrome patients with a prior CABG who undergo invasive or non-invasive treatment. Invasively treated patients experienced higher rates of readmission and additional cardiac procedures than non-invasively treated patients but a lower incidence of cardiovascular complications at 6 months.


Assuntos
Angioplastia Coronária com Balão/estatística & dados numéricos , Ponte de Artéria Coronária/estatística & dados numéricos , Infarto do Miocárdio/cirurgia , Infarto do Miocárdio/terapia , Doença Aguda , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Angina Pectoris/tratamento farmacológico , Angina Pectoris/mortalidade , Angina Pectoris/cirurgia , Angina Pectoris/terapia , Angioplastia Coronária com Balão/mortalidade , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anticoagulantes/uso terapêutico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Ponte de Artéria Coronária/mortalidade , Feminino , Seguimentos , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/mortalidade , Isquemia Miocárdica/tratamento farmacológico , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/cirurgia , Isquemia Miocárdica/terapia , Readmissão do Paciente/estatística & dados numéricos , Inibidores da Agregação Plaquetária/uso terapêutico , Valor Preditivo dos Testes , Recidiva , Sistema de Registros/estatística & dados numéricos , Fatores de Risco , Resultado do Tratamento
19.
BMJ ; 333(7578): 1091, 2006 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-17032691

RESUMO

OBJECTIVE: To develop a clinical risk prediction tool for estimating the cumulative six month risk of death and death or myocardial infarction to facilitate triage and management of patients with acute coronary syndrome. DESIGN: Prospective multinational observational study in which we used multivariable regression to develop a final predictive model, with prospective and external validation. SETTING: Ninety four hospitals in 14 countries in Europe, North and South America, Australia, and New Zealand. POPULATION: 43,810 patients (21,688 in derivation set; 22,122 in validation set) presenting with acute coronary syndrome with or without ST segment elevation enrolled in the global registry of acute coronary events (GRACE) study between April 1999 and September 2005. MAIN OUTCOME MEASURES: Death and myocardial infarction. RESULTS: 1989 patients died in hospital, 1466 died between discharge and six month follow-up, and 2793 sustained a new non-fatal myocardial infarction. Nine factors independently predicted death and the combined end point of death or myocardial infarction in the period from admission to six months after discharge: age, development (or history) of heart failure, peripheral vascular disease, systolic blood pressure, Killip class, initial serum creatinine concentration, elevated initial cardiac markers, cardiac arrest on admission, and ST segment deviation. The simplified model was robust, with prospectively validated C-statistics of 0.81 for predicting death and 0.73 for death or myocardial infarction from admission to six months after discharge. The external applicability of the model was validated in the dataset from GUSTO IIb (global use of strategies to open occluded coronary arteries). CONCLUSIONS: This risk prediction tool uses readily identifiable variables to provide robust prediction of the cumulative six month risk of death or myocardial infarction. It is a rapid and widely applicable method for assessing cardiovascular risk to complement clinical assessment and can guide patient triage and management across the spectrum of patients with acute coronary syndrome.


Assuntos
Isquemia Miocárdica/mortalidade , Métodos Epidemiológicos , Feminino , Humanos , Masculino , Infarto do Miocárdio/mortalidade , Isquemia Miocárdica/diagnóstico , Prognóstico , Índice de Gravidade de Doença , Síndrome , Triagem/métodos
20.
Eur Heart J ; 26(11): 1063-9, 2005 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-15716281

RESUMO

AIMS: To evaluate clinical outcomes associated with the combined use of clopidogrel and statins vs. clopidogrel alone on a background of aspirin therapy in patients with the spectrum of acute coronary syndromes (ACS). METHODS AND RESULTS: Utilizing data from the Global Registry of Acute Coronary Events, we studied 15 693 patients admitted with non-ST-segment elevation myocardial infarction (MI) or unstable angina, dividing them according to discharge medications: aspirin alone (group I); aspirin + clopidogrel (group II); aspirin + statin (group III); aspirin + clopidogrel + statin (group IV). Among the groups of patients in whom clopidogrel was used (groups II and IV), group II patients were older, more likely to have prior MI, but less likely to have a history of prior revascularization. In-hospital cardiac catheterization and revascularization rates were similar between groups II and IV. Importantly, Kaplan-Meier analysis showed that the 6 month mortality rate was lower in group IV (log-rank test 22.8, P<0.0001). The hazard ratio for the 6 month mortality rate was adjusted using the Cox proportional hazard model for confounding variables and for propensity score, and the 6 month mortality rate for patients in group IV remained lower compared with those in group II [0.59 (0.41-0.86), P<0.0001]. CONCLUSION: Our data suggest that the combination of clopidogrel with a statin has synergistic effects on the clinical outcomes of patients with non-ST-segment elevation ACS.


Assuntos
Angina Instável/tratamento farmacológico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Infarto do Miocárdio/tratamento farmacológico , Inibidores da Agregação Plaquetária/uso terapêutico , Ticlopidina/análogos & derivados , Adolescente , Adulto , Idoso , Angina Instável/mortalidade , Aspirina/uso terapêutico , Clopidogrel , Quimioterapia Combinada , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/mortalidade , Revascularização Miocárdica , Acidente Vascular Cerebral/etiologia , Ticlopidina/uso terapêutico , Resultado do Tratamento
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