Effect of a Strategy of Comprehensive Vasodilation vs Usual Care on Mortality and Heart Failure Rehospitalization Among Patients With Acute Heart Failure: The GALACTIC Randomized Clinical Trial.

Importance: Short-term infusions of single vasodilators, usually given in a fixed dose, have not improved outcomes in patients with acute heart failure (AHF). Objective: To evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation using individualized up-titrated doses of established vasodilators in patients with AHF. Design, Setting, and Participants: Randomized, open-label blinded-end-point trial enrolling 788 patients hospitalized for AHF with dyspnea, increased plasma concentrations of natriuretic peptides, systolic blood pressure of at least 100 mm Hg, and plan for treatment in a general ward in 10 tertiary and secondary hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Enrollment began in December 2007 and follow-up was completed in February 2019. Interventions: Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization (n = 386) or usual care (n = 402). Early intensive and sustained vasodilation was a comprehensive pragmatic approach of maximal and sustained vasodilation combining individualized doses of sublingual and transdermal nitrates, low-dose oral hydralazine for 48 hours, and rapid up-titration of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or sacubitril-valsartan. Main Outcomes and Measures: The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days. Results: Among 788 patients randomized, 781 (99.1%; median age, 78 years; 36.9% women) completed the trial and were eligible for primary end point analysis. Follow-up at 180 days was completed for 779 patients (99.7%). The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 117 patients (30.6%) in the intervention group (including 55 deaths [14.4%]) and in 111 patients (27.8%) in the usual care group (including 61 deaths [15.3%]) (absolute difference for the primary end point, 2.8% [95% CI, -3.7% to 9.3%]; adjusted hazard ratio, 1.07 [95% CI, 0.83-1.39]; P = .59). The most common clinically significant adverse events with early intensive and sustained vasodilation vs usual care were hypokalemia (23% vs 25%), worsening renal function (21% vs 20%), headache (26% vs 10%), dizziness (15% vs 10%), and hypotension (8% vs 2%). Conclusions and Relevance: Among patients with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, did not significantly improve a composite outcome of all-cause mortality and AHF rehospitalization at 180 days. Trial Registration: ClinicalTrials.gov Identifier: NCT00512759.

Comprehensive vasodilatation in women with acute heart failure: Novel insights from the GALACTIC randomized controlled trial.

AIMS: Sex-specific differences in acute heart failure (AHF) are both relevant and underappreciated. Therefore, it is crucial to evaluate the risk/benefit ratio and the implementation of novel AHF therapies in women and men separately. METHODS AND RESULTS: We performed a pre-defined sex-specific analysis in AHF patients randomized to a strategy of early intensive and sustained vasodilatation versus usual care in an international, multicentre, open-label, blinded endpoint trial. Inclusion criteria were AHF with increased plasma concentrations of natriuretic peptides, systolic blood pressure ≥100 mmHg, and plan for treatment in a general ward. Among 781 eligible patients, 288 (37%) were women. Women were older (median 83 vs. 76 years), had a lower body weight (median 64.5 vs. 77.6 kg) and lower estimated glomerular filtration rate (median 48 vs. 54 ml/min/1.73 m2 ). The primary endpoint, a composite of all-cause mortality or rehospitalization for AHF at 180 days, showed a significant interaction of treatment strategy and sex (p for interaction = 0.03; hazard ratio adjusted for female sex 1.62, 95% confidence interval 1.05-2.50; p = 0.03). The combined endpoint occurred in 53 women (38%) in the intervention group and in 35 (24%) in the usual care group. The implementation of rapid up-titration of renin-angiotensin-aldosterone system (RAAS) inhibitors was less successful in women versus men in the overall cohort and in patients with heart failure with reduced ejection fraction (median discharge % target dose in patients randomized to intervention: 50% in women vs. 75% in men). CONCLUSION: Rapid up-titration of RAAS inhibitors was less successfully implemented in women possibly explaining their higher rate of all-cause mortality and rehospitalization for AHF. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, unique identifier NCT00512759.

Effect of a strategy of comprehensive vasodilation versus usual care on health-related quality of life among patients with acute heart failure.

AIMS: We aimed to assess the long-term effect of a strategy of comprehensive vasodilation versus usual care on health-related quality of life (HRQL) among patients with acute heart failure (AHF). METHODS AND RESULTS: Health-related quality of life was prospectively assessed by the generic 3-levelled EQ-5D and the disease-specific Kansas City Cardiomyopathy Questionnaire (KCCQ) among adult AHF patients enrolled in an international, multicentre, randomised, open-label blinded-end-point trial of a strategy that emphasized early intensive and sustained vasodilation using maximally tolerated doses of established oral and transdermal vasodilators according to systolic blood pressure. Changes in EQ-5D and KCCQ from admission to 180 day follow-up were individually compared between the intensive vasodilatation and the usual care group. Among 666 patients eligible for 180 day follow-up, 284 (43%, median age 79 years, 35% women) and 198 (30%, median age 77 years, 35% women) had completed the EQ-5D and KCCQ at baseline and follow-up, respectively. There was a significant improvement in HRQL as quantified by both, EQ-5D and KCCQ, from hospitalization to 180 day follow-up, with no significant differences in the change of HRQL between both treatment strategies. For instance, 39 (26%) versus 33 (25%) patients had an improvement by at least one level in at least two categories in the EQ-5D. Median increase in KCCQ overall summary score (KCCQ-OSS) was 17.6 (IQR 2.0-42.6) in the intervention group versus 18.5 (IQR 3.9-39.3) in the usual care group (P < 0.001 vs. baseline, P = 0.945 between groups). CONCLUSIONS: Among patients with AHF, long-term HRQL quantified by EQ-5D and KCCQ improved substantially, with overall no significant differences between a strategy of comprehensive vasodilation versus usual care.

Biomarkers for prediction of mortality in left-sided infective endocarditis.

BACKGROUND: Evidence regarding biomarkers for risk prediction in patients with infective endocarditis (IE) is limited. We aimed to investigate the value of a panel of biomarkers for the prediction of in-hospital mortality in patients with IE. METHODS: Between 2016 and 2018, consecutive IE patients admitted to the emergency department were prospectively included. Blood concentrations of nine biomarkers were measured at admission (D0) and on the seventh day (D7) of antibiotic therapy: C-reactive protein (CRP), sensitive troponin I (s-cTnI), procalcitonin, B-type natriuretic peptide (BNP), neutrophil gelatinase-associated lipocalin (NGAL), interleukin 6 (IL6), tumor necrosis factor α (TNF-α), proadrenomedullin, alpha-1-acid glycoprotein, and galectin 3. The primary endpoint was in-hospital mortality. RESULTS: Among 97 patients, 56% underwent cardiac surgery, and in-hospital mortality was 27%. At admission, six biomarkers were independent predictors of in-hospital mortality: s-cTnI (OR 3.4; 95%CI 1.8-6.4; P<0.001), BNP (OR 2.7; 95%CI 1.4-5.1; P=0.002), IL-6 (OR 2.06; 95%CI 1.3-3.7; P=0.019), procalcitonin (OR 1.9; 95%CI 1.1-3.2; P=0.018), TNF-α (OR 1.8; 95%CI 1.1-2.9; P=0.019), and CRP (OR 1.8; 95%CI 1.0-3.3; P=0.037). At admission, S-cTnI provided the highest accuracy for predicting mortality (area under the ROC curve: s-cTnI 0.812, BNP 0.727, IL-6 0.734, procalcitonin 0.684, TNF-α 0.675, CRP 0.670). After 7 days of antibiotic therapy, BNP and inflammatory biomarkers improved their performance (s-cTnI 0.814, BNP 0.823, IL-6 0.695, procalcitonin 0.802, TNF-α 0.554, CRP 0.759). CONCLUSION: S-cTnI concentration measured at admission had the highest accuracy for mortality prediction in patients with IE.

Infection in Patients with Decompensated Heart Failure: In-Hospital Mortality and Outcome.

BACKGROUND: Heart failure (HF) is a syndrome, whose advanced forms have a poor prognosis, which is aggravated by the presence of comorbidities. OBJECTIVE: We assessed the impact of infection in patients with decompensated HF admitted to a tertiary university-affiliated hospital in the city of São Paulo. METHODS: This study assessed 260 patients consecutively admitted to our unit because of decompensated HF. The presence of infection and other morbidities was assessed, as were in-hospital mortality and outcome after discharge. The chance of death was estimated by univariate logistic regression analysis of the variables studied. The significance level adopted was P < 0.05. RESULTS: Of the patients studied, 54.2% were of the male sex, and the mean age ± SD was 66.1 ± 12.7 years. During hospitalization, 119 patients (45.8%) had infection: 88 (33.8%) being diagnosed with pulmonary infection and 39 patients (15.0%), with urinary infection. During hospitalization, 56 patients (21.5%) died, and, after discharge, 36 patients (17.6%). During hospitalization, 26.9% of the patients with infection died vs 17% of those without infection (p = 0.05). However, after discharge, mortality was lower in the group that had infection: 11.5% vs 22.2% (p = 0.046). CONCLUSIONS: Infection is a frequent morbidity among patients with HF admitted for compensation of the condition, and those with infection show higher in-hospital mortality. However, those patients who initially had infection and survived had a better outcome after discharge.

Sensitive Troponin I Assay in Patients with Chest Pain - Association with Significant Coronary Lesions with or Without Renal Failure.

INTRODUCTION: Despite having higher sensitivity as compared to conventional troponins, sensitive troponins have lower specificity, mainly in patients with renal failure. OBJECTIVE: Study aimed at assessing the sensitive troponin I levels in patients with chest pain, and relating them to the existence of significant coronary lesions. METHODS: Retrospective, single-center, observational. This study included 991 patients divided into two groups: with (N = 681) and without (N = 310) significant coronary lesion. For posterior analysis, the patients were divided into two other groups: with (N = 184) and without (N = 807) chronic renal failure. The commercial ADVIA Centaur® TnI-Ultra assay (Siemens Healthcare Diagnostics) was used. The ROC curve analysis was performed to identify the sensitivity and specificity of the best cutoff point of troponin as a discriminator of the probability of significant coronary lesion. The associations were considered significant when p < 0.05. RESULTS: The median age was 63 years, and 52% of the patients were of the male sex. The area under the ROC curve between the troponin levels and significant coronary lesions was 0.685 (95% CI: 0.65 - 0.72). In patients with or without renal failure, the areas under the ROC curve were 0.703 (95% CI: 0.66 - 0.74) and 0.608 (95% CI: 0.52 - 0.70), respectively. The best cutoff points to discriminate the presence of significant coronary lesion were: in the general population, 0.605 ng/dL (sensitivity, 63.4%; specificity, 67%); in patients without renal failure, 0.605 ng/dL (sensitivity, 62.7%; specificity, 71%); and in patients with chronic renal failure, 0.515 ng/dL (sensitivity, 80.6%; specificity, 42%). CONCLUSION: In patients with chest pain, sensitive troponin I showed a good correlation with significant coronary lesions when its level was greater than 0.605 ng/dL. In patients with chronic renal failure, a significant decrease in specificity was observed in the correlation of troponin levels and severe coronary lesions.

Is There Any Relationship between TSH Levels and Prognosis in Acute Coronary Syndrome?

BACKGROUND: Some small studies have related higher levels of thyrotropin (TSH) to potentially worse prognosis in acute coronary syndromes. However, this relationship remains uncertain. OBJECTIVE: To analyze the outcomes of patients with acute coronary syndromes in relation to the value of TSH at admission. METHODS: Observational and retrospective study with 505 patients (446 in group I [TSH ≤ 4 mIU/L] and 59 in group II [TSH > 4 mIU/L]) with acute coronary syndromes between May 2010 and May 2014. We obtained data about comorbidities and the medications used at the hospital. The primary endpoint was in-hospital all-cause death. The secondary endpoint included combined events (death, non-fatal unstable angina or myocardial infarction, cardiogenic shock, bleeding and stroke). Comparisons between groups were made by one-way ANOVA and chi-square test. Multivariate analysis was determined by logistic regression. Analyses were considered significant when p < 0.05. RESULTS: Significant differences between groups I and II were observed regarding the use of enoxaparin (75.2% vs. 57.63%, p = 0.02) and statins (84.08% vs. 71.19%, p < 0.0001), previous stroke (5.83% vs. 15.25%, p = 0.007), combined events (14.80% vs. 27.12%, OR = 3.05, p = 0.004), cardiogenic shock (4.77% vs. 6.05%, OR = 4.77, p = 0.02) and bleeding (12.09% vs. 15.25%, OR = 3.36, p = 0.012). CONCLUSIONS: In patients with acute coronary syndromes and TSH > 4 mIU/L at admission, worse prognosis was observed, with higher incidences of in-hospital combined events, cardiogenic shock and bleeding.

Supradesnivelamento do Segmento ST localizado como apresentação atípica de perimiocardite aguda / Located ST-Segment Elevation as atypical presentation of acute perimiocarditis

Relatamos o caso de um paciente jovem admitido no pronto-socorro com quadro de dor precordial. O eletrocardiograma de admissão identificou supradesnivelamento do segmento ST localizado em parede lateral associado à imagem em "espelho", com enzimas cardíacas altamente elevadas, o que sugere diagnóstico de síndrome coronariana com supradesnivelamento de ST. O ecocardiograma evidenciou derrame pericárdico com fração de ejeção preservada e ausência de alterações segmentares, sugerindo, assim, pericardite aguda, com comprometimento do miocárdio. Desta forma, foi realizada ressonância magnética cardíaca, que evidenciou presença de realce tardio não isquêmico, confirmando o diagnóstico de perimiocardite. Trata-se de situação pouco frequente na prática clínica e que merece maior compreensão e atenção por parte dos médicos que trabalham em prontos-socorros

Is There Safety in the Use of Clopidogrel Loading Dose in Patients Over 75 Years of Age with Acute Coronary Syndrome?

There is limited evidence in the literature regarding the administration of clopidogrel to acute coronary syndrome (ACS) in patients over 75 years of age. Most studies excluded this age group, making the subject controversial due to the increased risk of bleeding in this population. Objective: This is a retrospective, unicentric, and observational study aimed at assessing whether the administration of clopidogrel loading dose increases bleeding rates in patients over 75 years of age. Methods: Patients were divided into two groups: group I: 75 mg of clopidogrel; group II: 300-to 600-mg loading dose of clopidogrel. A total of 174 patients (129 in group I and 45 in group II) were included between May 2010 and May 2015. Statistical analysis: The primary outcome was bleeding (major and/or minor). The secondary outcome was combined events (cardiogenic shock, reinfarction, death, stroke and bleeding). The comparison between groups was performed through Q-square and T-test. The multivariate analysis was performed by logistic regression, being considered significant p < 0.05. Results: Comparisons between groups I and II showed differences in the prevalence of diabetes (46.5% vs. 24.4%, p = 0.01), arterial hypertension (90.7% vs. 75, p = 0.01), dyslipidemia (62% vs. 42.2%, p = 0.021), ST segment elevation (11.6% vs. 26.6%, p = 0.016) and coronary intervention percutaneous (16.5% vs. 62.2%, p < 0.0001), respectively. In the multivariate analysis, significant differences were observed between groups I and II in relation to the occurrence of bleeding (8.5% vs. 20%, OR = 0.173, 95% CI: 0.049 - 0.614, p = 0.007). Conclusion: A loading dose of 300 mg or more of clopidogrel

Infection in Patients with Decompensated Heart Failure: In-Hospital Mortality and Outcome / Infecção em Pacientes com Insuficiência Cardíaca Descompensada: Mortalidade Hospitalar e Evolução

Abstract Background: Heart failure (HF) is a syndrome, whose advanced forms have a poor prognosis, which is aggravated by the presence of comorbidities. Objective: We assessed the impact of infection in patients with decompensated HF admitted to a tertiary university-affiliated hospital in the city of São Paulo. Methods: This study assessed 260 patients consecutively admitted to our unit because of decompensated HF. The presence of infection and other morbidities was assessed, as were in-hospital mortality and outcome after discharge. The chance of death was estimated by univariate logistic regression analysis of the variables studied. The significance level adopted was P < 0.05. Results: Of the patients studied, 54.2% were of the male sex, and the mean age ± SD was 66.1 ± 12.7 years. During hospitalization, 119 patients (45.8%) had infection: 88 (33.8%) being diagnosed with pulmonary infection and 39 patients (15.0%), with urinary infection. During hospitalization, 56 patients (21.5%) died, and, after discharge, 36 patients (17.6%). During hospitalization, 26.9% of the patients with infection died vs 17% of those without infection (p = 0.05). However, after discharge, mortality was lower in the group that had infection: 11.5% vs 22.2% (p = 0.046). Conclusions: Infection is a frequent morbidity among patients with HF admitted for compensation of the condition, and those with infection show higher in-hospital mortality. However, those patients who initially had infection and survived had a better outcome after discharge.

Resumo Fundamento: A insuficiência cardíaca (IC) é uma síndrome cujas formas avançadas têm mau prognóstico, que é mais agravado pela presença de comorbidades. Objetivo: Avaliamos o impacto da infecção em pacientes com IC descompensada que internaram em hospital universitário terciário de São Paulo. Métodos: Estudamos 260 pacientes consecutivos que internaram em nossa unidade com IC descompensada. Avaliamos a presença de infecção e de outras morbidades. Avaliaram-se mortalidade hospitalar e evolução após a alta. A chance de óbito foi estimada pela análise de regressão logística univariada para as variáveis estudadas. Considerou-se P < 0,05 significativo. Resultados: Dos pacientes estudados, 54,2% eram homens, sendo a idade média ± DP de 66,1 ± 12,7 anos. Durante a internação, 119 pacientes (45,8%) apresentaram infecção: 88 (33,8%) tiveram diagnóstico de infecção pulmonar e 39 (15%), de infecção urinária. A mortalidade hospitalar ocorreu em 56 pacientes (21,5%) e, após a alta, 36 pacientes (17,6%) morreram no seguimento. Durante a internação, 26,9% do grupo com infecção morreu vs 17% do grupo sem infecção (p = 0,05). Entretanto, após a alta, a mortalidade foi menor no grupo com infecção: 11,5% vs 22,2% (p = 0,046). Conclusões: Infecção é uma comorbidade frequente entre os pacientes com IC internados para compensação, causando um aumento da mortalidade durante a hospitalização. Entretanto, após a alta, os pacientes inicialmente com infecção apresentaram melhor evolução.

Is There Any Relationship between TSH Levels and Prognosis in Acute Coronary Syndrome? / Existe Alguma Relação entre Níveis de TSH e Prognóstico em Síndrome Coronariana Aguda?

Abstract Background: Some small studies have related higher levels of thyrotropin (TSH) to potentially worse prognosis in acute coronary syndromes. However, this relationship remains uncertain. Objective: To analyze the outcomes of patients with acute coronary syndromes in relation to the value of TSH at admission. Methods: Observational and retrospective study with 505 patients (446 in group I [TSH ≤ 4 mIU/L] and 59 in group II [TSH > 4 mIU/L]) with acute coronary syndromes between May 2010 and May 2014. We obtained data about comorbidities and the medications used at the hospital. The primary endpoint was in-hospital all-cause death. The secondary endpoint included combined events (death, non-fatal unstable angina or myocardial infarction, cardiogenic shock, bleeding and stroke). Comparisons between groups were made by one-way ANOVA and chi-square test. Multivariate analysis was determined by logistic regression. Analyses were considered significant when p < 0.05. Results: Significant differences between groups I and II were observed regarding the use of enoxaparin (75.2% vs. 57.63%, p = 0.02) and statins (84.08% vs. 71.19%, p < 0.0001), previous stroke (5.83% vs. 15.25%, p = 0.007), combined events (14.80% vs. 27.12%, OR = 3.05, p = 0.004), cardiogenic shock (4.77% vs. 6.05%, OR = 4.77, p = 0.02) and bleeding (12.09% vs. 15.25%, OR = 3.36, p = 0.012). Conclusions: In patients with acute coronary syndromes and TSH > 4 mIU/L at admission, worse prognosis was observed, with higher incidences of in-hospital combined events, cardiogenic shock and bleeding.

Resumo Fundamento: Estudos pequenos têm relacionado níveis mais elevados de hormônio tireoestimulante (TSH) a pior prognóstico em pacientes com síndrome coronariana aguda (SCA). Tal relação, no entanto, permanece incerta. Objetivo: Analisar os desfechos de pacientes com SCA, relacionando-os aos níveis de TSH medidos no setor de emergência. Métodos: Estudo retrospectivo observacional incluindo 505 pacientes com SCA (446 no grupo I: TSH ± 4 mUI/L; 59 no grupo II: TSH > 4 mUI/L) entre maio de 2010 e maio de 2014. Dados sobre comorbidades e medicamentos usados foram obtidos. O desfecho primário foi mortalidade intra-hospitalar por todas as causas. O desfecho secundário incluiu eventos combinados (morte, angina instável não fatal ou infarto do miocárdio, choque cardiogênico, sangramento e acidente vascular encefálico). A comparação entre grupos foi realizada através de ANOVA de uma via e teste do qui-quadrado. A análise multivariada foi realizada por regressão logística, adotando-se o nível de significância de p < 0,05. Resultados: Diferenças significativas foram observadas entre os grupos I e II relacionadas ao uso de enoxaparina (75,2% vs. 57,63%; p = 0,02) e estatinas (84,08% vs. 71,19%; p < 0,0001), acidente vascular encefálico prévio (5,83% vs. 15,25%; p = 0,007), eventos combinados (14,80% vs. 27,12%, OR = 3,05; p = 0,004), choque cardiogênico (4,77% vs. 6,05%, OR = 4,77; p = 0,02) e sangramento (12,09% vs. 15,25%, OR = 3,36; p = 0,012). Conclusão: Em pacientes com SCA e TSH > 4 mUI/L à admissão hospitalar, observou-se pior prognóstico associado à maior incidência de eventos combinados intra-hospitalares, choque cardiogênico e sangramentos.

Sensitive Troponin I Assay in Patients with Chest Pain - Association with Significant Coronary Lesions with or Without Renal Failure / Troponinas I Sensíveis em Pacientes com Dor Torácica - Associação com Lesões Coronarianas Significativas e Variação em Insuficiência Renal Crônica

Abstract Introduction: Despite having higher sensitivity as compared to conventional troponins, sensitive troponins have lower specificity, mainly in patients with renal failure. Objective: Study aimed at assessing the sensitive troponin I levels in patients with chest pain, and relating them to the existence of significant coronary lesions. Methods: Retrospective, single-center, observational. This study included 991 patients divided into two groups: with (N = 681) and without (N = 310) significant coronary lesion. For posterior analysis, the patients were divided into two other groups: with (N = 184) and without (N = 807) chronic renal failure. The commercial ADVIA Centaur® TnI-Ultra assay (Siemens Healthcare Diagnostics) was used. The ROC curve analysis was performed to identify the sensitivity and specificity of the best cutoff point of troponin as a discriminator of the probability of significant coronary lesion. The associations were considered significant when p < 0.05. Results: The median age was 63 years, and 52% of the patients were of the male sex. The area under the ROC curve between the troponin levels and significant coronary lesions was 0.685 (95% CI: 0.65 - 0.72). In patients with or without renal failure, the areas under the ROC curve were 0.703 (95% CI: 0.66 - 0.74) and 0.608 (95% CI: 0.52 - 0.70), respectively. The best cutoff points to discriminate the presence of significant coronary lesion were: in the general population, 0.605 ng/dL (sensitivity, 63.4%; specificity, 67%); in patients without renal failure, 0.605 ng/dL (sensitivity, 62.7%; specificity, 71%); and in patients with chronic renal failure, 0.515 ng/dL (sensitivity, 80.6%; specificity, 42%). Conclusion: In patients with chest pain, sensitive troponin I showed a good correlation with significant coronary lesions when its level was greater than 0.605 ng/dL. In patients with chronic renal failure, a significant decrease in specificity was observed in the correlation of troponin levels and severe coronary lesions.

Resumo Fundamento: Apesar de apresentar maior sensibilidade em comparação às troponinas convencionais, as troponinas sensíveis apresentam menor especificidade, principalmente em pacientes com insuficiência renal. Objetivo: Avaliar os valores de troponina I sensível em pacientes com dor torácica, relacionando-os à presença de lesões coronarianas significativas. Métodos: Estudo retrospectivo, unicêntrico e observacional. Foram incluídos 991 pacientes, divididos em dois grupos: com (N = 681) ou sem lesão coronariana (N = 310). Para análise posterior, os pacientes foram separados em outros dois grupos: com (N = 184) ou sem insuficiência renal (N = 807). A troponina utilizada pertence ao kit comercial ADVIA Centaur® TnI-Ultra (Siemens Healthcare Diagnostics). A análise foi feita por curva ROC para identificar a sensibilidade e a especificidade do melhor ponto de corte da troponina como discriminador de probabilidade de lesão coronariana. As associações foram consideradas significativas quando p < 0,05. Resultados: Cerca de 52% dos pacientes eram do sexo masculino e a idade mediana da amostra foi de 63 anos. A área sob a curva ROC entre os valores de troponina e lesões coronarianas significativas foi de 0,685 (IC 95%: 0,65 - 0,72). Em pacientes sem e com insuficiência renal, as áreas sob a curva foram 0,703 (IC 95%: 0,66 - 0,74) e 0,608 (IC 95%: 0,52 - 0,70), respectivamente. Os melhores pontos de corte para discriminar a presença de lesão coronária significativa foram: 0,605 ng/dL (sensibilidade de 63,4%, especificidade de 67%) no grupo geral, 0,605 ng/dL (sensibilidade de 62,7% e especificidade de 71%) em pacientes sem insuficiência renal e 0,515 ng/dL (sensibilidade de 80,6% e especificidade de 42%) no grupo com insuficiência renal crônica. Conclusão: Na população avaliada de pacientes com dor torácica, a troponina I sensível apresentou boa correlação com lesões coronarianas significativas quando acima de 0,605 ng/dL. Em pacientes com insuficiência renal crônica, observamos uma queda importante de especificidade na correlação dos valores com lesões coronarianas graves.

Redução de Mortalidade em Longo Prazo Relacionada a Doses Mais Elevadas de Atorvastatina em Pacientes com Síndrome Coronariana Aguda / Reduction of in Long-Term Mortality Related to Higher Doses of Atorvastatin in Patients with Acute Coronary Syndromes

Fundamento: Diversos estudos experimentais têm mostrado redução de marcadores inflamatórios associados às doses mais elevadas de estatinas em pacientes com síndrome coronariana aguda (SCA). No entanto, a implicação clínica da dose de estatina na fase aguda da SCA ainda é incerta. Objetivo: Comparar desfechos em curto e longo prazo entre pacientes com SCA que receberam doses mais elevadas de atorvastatina versus baixas doses de atorvastatina iniciadas nas primeiras 24 horas da admissão hospitalar. Métodos: Para tal, os pacientes foram divididos em dois grupos: grupo I (N = 464): dose de atorvastatina 40 mg/dia. Foram obtidos dados demográficos, exames laboratoriais, medicações utilizadas e tratamento coronário adotado. Análise estatística: O desfecho primário foi mortalidade por todas as causas. A comparação entre grupos foi realizada através de Q-quadrado e teste T. A análise multivariada de desfechos intrahospitalares foi realizada por regressão logística, sendo considerado significativo p < 0,05. Em longo prazo foi avaliada a mortalidade e eventos combinados pelo método Kaplan-Meier com seguimento médio de 8,79 meses. Resultados: Na análise de desfechos intrahospitalares, não se observaram diferenças significativas entre os grupos I e II. Em longo prazo o grupo II apresentou menor mortalidade em relação ao grupo I (3,9% vs. 8,4%, p = 0,013), respectivamente. Conclusão: Diferenças favoráveis e significativas foram observadas em relação à mortalidade em longo prazo em pacientes com SCA que receberam desde a fase aguda doses elevadas de atorvastatina

Background: Recent experimental studies have described reduction in inflammatory markers related to higher doses of statins in patients with acute coronary syndromes (ACS). However, the clinical implication of the dose of statin in the acute phase of the ACS remains uncertain. Objective: To compare the outcomes in short and long terms among patients with acute coronary syndromes that received higher doses of atorvastatin versus low doses of atorvastatin started in the first 24 hours of hospital admission.Methods: For such, the patients were divided in two groups: group I (N = 464): atorvastatin dose: 40 mg/day. Demographic data, laboratory exams, medications used and coronary treatment adopted were obtained. Statistical analysis: The primary outcome was mortality from all causes. The comparison between groups was made by T-test and Q-square. Multivariative analysis of in-hospital outcomes were determined by logistic regression, considered significant when p < 0.05. In long-term, the mortality and combined events by the Kaplan-Meier method were assessed, with median follow-up of 8.79 months. Results: In the analysis of in-hospital outcomes, no significant differences were observed between groups I and II. In the long-term, group II presented lower mortality in comparison with group 9 (8.4% vs. 3.9%, p = 0.013). Conclusions: Favorable and significant differences were observed in relation to long-term mortality in patients with ACS that received high doses of atorvastatin since the acute phase