Ivabradine plus conventional treatment vs conventional treatment alone in reducing the mean heart rate in heart transplant recipients: A randomized clinical trial.

The absence of afferent nerves for heart rate (HR) regulation leaves the transplanted heart under the influence of its internal and hormonal control. The HR of heart transplantation (HTx) recipients varies from to 90-110 bpm, indicating a lack of vagal parasympathetic tone. We hypothesized that the reduction in mean HR using an If-channel antagonist (ivabradine) could be effective and safe in HTx recipients. The primary objective of this open-label randomized clinical trial was to compare the mean HR at 3, 6, 12, 18, 24, 30, and 36 months after randomization between an ivabradine plus conventional treatment group (IG) and conventional treatment alone group (CG). The secondary objectives were reduction in mortality, graft dysfunction, and ventricular mass. All patients were randomized between 1 and 12 months after HTx. Ivabradine started at randomization. Of the 35 patients, 54.28% were in the CG and 45.72% in the IG. There were no significant between-group differences in demographics. Over time, the HR differences between the groups became significant (P < .01). There were no significant between-group differences in mortality, graft dysfunction, and ventricular mass. We conclude that ivabradine could effectively and consistently reduce the HR in HTx recipients.

Endothelial Microparticles: Markers of Inflammatory Response After Sutureless Valve Implantation.

INTRODUCTION: Systemic inflammatory response syndrome (SIRS) is related to increased circulating endothelial microparticles (EMP). OBJECTIVE: The aim of this study was to compare the plasma concentration of EMP between patients undergoing aortic valve replacement with conventional bioprosthesis implantation and Perceval™ S (LivaNova) and to evaluate its impact on the inflammatory response in the short-term follow-up. METHODS: This is a randomized clinical trial with 24 patients submitted to isolated aortic valve replacement divided into two groups: Perceval™ S (Group P) and conventional bioprostheses (Group C). Incidence of severe SIRS (three or more criteria) in the first 48 hours postoperatively, EMP release profile, interleukins (IL) 6 and 8, C-reactive protein, and procalcitonin were analyzed preand postoperatively at 24 hours and three months. RESULTS: There were 24 patients (12 in each group), mean age was 69.92±5.17 years, 83.33% were female, the incidence of severe SIRS was 66.7% and 50% in groups C and P, respectively (P=0.68), and EMP showed a significant increase in the 24-hour postoperative period (P≤0.001) and subsequent decrease in the three-month postoperative period (P≤0.001), returning to baseline levels. For IL-6 and IL-8, there was a greater increase in group C at 24 hours postoperatively (P=.0.02 and P<0.001). CONCLUSION: The incidence of severe SIRS was similar in both groups, with significantly higher levels of IL-6 and IL-8, at the 24-hour postoperative period, in group C, however with higher levels of EMP in group P, and subsequent return to baseline levels at the three-month postoperative period in both groups.

Use of a Portable Mechanical Ventilator during Cardiopulmonary Resuscitation is Feasible, Improves Respiratory Parameters, and Prevents the Decrease of Dynamic Lung Compliance. / O Uso de um Ventilador Mecânico Portátil na Ressuscitação Cardiopulmonar é Viável, Melhora os Parâmetros Respiratórios e Previne a Redução da Complacência Pulmonar Dinâmica.

BACKGROUND: For practical and protective ventilation during cardiopulmonary resuscitation (CPR), a 150-grams mechanical ventilator (VLP2000E) that limits peak inspiratory pressure (PIP) during simultaneous ventilation with chest compressions was developed. OBJECTIVES: To evaluate the feasibility of VLP2000E ventilation during CPR and to compare monitored parameters versus bag-valve ventilation. METHODS: A randomized experimental study with 10 intubated pigs per group. After seven minutes of ventricular fibrillation, 2-minute CPR cycles were delivered. All animals were placed on VLP2000E after achieving return of spontaneous circulation (ROSC). RESULTS: Bag-valve and VLP2000E groups had similar ROSC rate (60% vs. 50%, respectively) and arterial oxygen saturation in most CPR cycles, different baseline tidal volume [0.764 (0.068) vs. 0.591 (0.123) L, p = 0.0309, respectively] and, in 14 cycles, different PIP [52 (9) vs. 39 (5) cm H2O, respectively], tidal volume [0.635 (0.172) vs. 0.306 (0.129) L], ETCO2[14 (8) vs. 27 (9) mm Hg], and peak inspiratory flow [0.878 (0.234) vs. 0.533 (0.105) L/s], all p < 0.0001. Dynamic lung compliance (≥ 0.025 L/cm H2O) decreased after ROSC in bag-valve group but was maintained in VLP2000E group [0.019 (0.006) vs. 0.024 (0.008) L/cm H2O, p = 0.0003]. CONCLUSIONS: VLP2000E ventilation during CPR is feasible and equivalent to bag-valve ventilation in ROSC rate and arterial oxygen saturation. It produces better respiratory parameters, with lower airway pressure and tidal volume. VLP2000E ventilation also prevents the significant decrease of dynamic lung compliance observed after bag-valve ventilation. Further preclinical studies confirming these findings would be interesting.

FUNDAMENTOS: Para ventilação prática e protetora durante a ressuscitação cardiopulmonar (RCP), desenvolveu-se um ventilador mecânico (VLP2000E) de 150 gramas que limita o pico de pressão inspiratória (PPI) durante ventilação e compressões torácicas simultâneas. OBJETIVOS: Avaliar a viabilidade da ventilação com VLP2000E durante RCP e comparar os parâmetros monitorados versus ventilação com bolsa-válvula. MÉTODOS: Estudo experimental randomizado com 10 porcos intubados por grupo. Após sete minutos de fibrilação ventricular, iniciaram-se ciclos de RCP de 2 minutos. Todos os animais foram ventilados com VLP2000E após o retorno da circulação espontânea (RCE). RESULTADOS: Os grupos bolsa-válvula e VLP2000E apresentaram taxa de RCE (60% vs. 50%, respectivamente) e saturação arterial de oxigênio similares na maioria dos ciclos de RCP, volume corrente basal diferente [0,764 (0,068) vs. 0,591 (0,123) L, p = 0,0309, respectivamente] e, em 14 ciclos, diferentes PPI [52 (9) vs. 39 (5) cm H2O, respectivamente], volume corrente [0,635 (0,172) vs. 0,306 (0,129) L], ETCO2 [14 (8) vs. 27 (9) mm Hg], e pico de fluxo inspiratório [0,878 (0,234) vs. 0,533 (0,105) L/s], todos p < 0,0001. A complacência pulmonar dinâmica (≥ 0,025 L/cm H2O) diminuiu após o RCE no grupo bolsa-válvula, mas se manteve no grupo VLP2000E [ 0,019 (0,006) vs. 0,024 (0,008) L/cm H2O, p = 0,0003]. CONCLUSÕES: Ventilação com VLP2000E durante RCP é viável e equivalente a ventilação com bolsa-válvula quanto à taxa de RCE e saturação arterial de oxigênio. Esse ventilador produz melhores parâmetros respiratórios, com pressão das vias aéreas e volume corrente menores. Ventilação com VLP2000E também previne a redução significante da complacência pulmonar dinâmica observada após ventilação com bolsa-válvula. Seria interessante realizar mais estudos pré-clínicos para confirmar esses resultados.

Association between Clinical Risk Score (Heart, Grace and TIMI) and Angiographic Complexity in Acute Coronary Syndrome without ST Segment Elevation. / Associação entre Escores de Risco Clínico (HEART, GRACE e TIMI) e Complexidade Angiográfica na Síndrome Coronária Aguda sem Elevação do Segmento ST.

BACKGROUND: GRACE, TIMI and HEART scores have been previously validated to predict serious untoward events among patients with non-ST elevation acute coronary syndrome (Non-ST ACS). However, the ability of these scores to discriminate the angiographic complexity of coronary artery disease has not been clearly established. OBJECTIVES: We sought to evaluate the correlation between clinical scores (TIMI, GRACE and HEART) and the anatomical complexity assessed by SYNTAX score, among non-ST ACS patients undergoing cinecoronariography. METHODS: Transversal cohort encompassing patients with diagnosis of Non-ST ACS referred to invasive stratification in our single center, between July 2018 and February 2019. Association between the scores was established by the Pearson's linear correlation test while the accuracy of the clinical scores versus SYNTAX score was determined with the ROC curve. RESULTS: A total of 138 patients were enrolled. Median GRACE, TIMI and HEART scores were 97, 3 and 5, respectively, whereas the median SYNTAX was 8. There was a positive correlation between the SYNTAX and the HEART (ρ =0.29; p<0.01) and GRACE (ρ =0.18; p<0.01) scores, but the correlation with TIMI reached no statistical significance (ρ =0.15; p=0.08). The HEART score was also the one with the highest area under the curve to predict a SYNTAX ≥32 [HEART = 0.81 (IC95% 0.7-0.91). HEART> 4 presented 100% sensitivity, with 50% specificity; and GRACE> 139 showed 55% sensitivity and 97% specificity for high SYNTAX. CONCLUSION: The clinical scores presented a positive, although modest, association with the SYNTAX score. The combined use of HEART and GRACE offers good accuracy for detecting angiographic complexity.

FUNDAMENTOS: Os escores GRACE, TIMI e HEART foram validados para avaliar desfechos clínicos desfavoráveis no contexto da suspeita de síndrome coronária aguda sem elevação do segmento ST (SCASSST). No entanto, a associação entre os escores clínicos e a complexidade angiográfica ainda não está bem estabelecida. OBJETIVOS: Descrever as características clínicas de pacientes com SCASSST admitidos em internação hospitalar para estratificação invasiva, a fim de avaliar a associação entre os escores clínicos (TIMI, GRACE e HEART) e a complexidade angiográfica, através do escore SYNTAX. MÉTODOS: Estudo observacional incluindo pacientes com diagnóstico de SCA e admitidos no Instituto Dante Pazzanese de Cardiologia entre os meses de julho de 2018 e fevereiro de 2019. A associação entre os escores foi avaliada por correlações bivariadas e a sua acurácia pela área sob a curva (ASC) ROC. A significância estatística foi estabelecida em 5% (p < 0,05). RESULTADOS: Um total de 138 pacientes foram diagnosticados com SCASSST. As medianas do GRACE, TIMI e HEART foram de 97, 3 e 5, respectivamente. A mediana do SYNTAX foi de 8. Foram observadas correlações positivas do SYNTAX com o HEART (ρ = 0,29; p < 0,01) e o GRACE (ρ = 0,18; p < 0,03). Em contrapartida, a correlação com o TIMI não atingiu significância estatística (ρ = 0,15; p = 0,08). O HEART foi o escore com a maior ASC para predizer SYNTAX > 32 [HEART = 0,81] (IC 95% 0,7-0,91). HEART > 4 apresentou sensibilidade de 100%, com especificidade de 50%, e GRACE > 139 sensibilidade de 55% e especificidade de 97% para SYNTAX alto. CONCLUSÃO: Os escores clínicos de risco apresentam associação modesta ao escore SYNTAX. O uso combinado do HEART e do GRACE, entretanto, oferece acurácia favorável para a detecção de complexidade angiográfica.

Endothelial Microparticles: Markers of Inflammatory Response After Sutureless Valve Implantation

ABSTRACT Introduction: Systemic inflammatory response syndrome (SIRS) is related to increased circulating endothelial microparticles (EMP). Objective: The aim of this study was to compare the plasma concentration of EMP between patients undergoing aortic valve replacement with conventional bioprosthesis implantation and Perceval™ S (LivaNova) and to evaluate its impact on the inflammatory response in the short-term follow-up. Methods: This is a randomized clinical trial with 24 patients submitted to isolated aortic valve replacement divided into two groups: Perceval™ S (Group P) and conventional bioprostheses (Group C). Incidence of severe SIRS (three or more criteria) in the first 48 hours postoperatively, EMP release profile, interleukins (IL) 6 and 8, C-reactive protein, and procalcitonin were analyzed preand postoperatively at 24 hours and three months. Results: There were 24 patients (12 in each group), mean age was 69.92±5.17 years, 83.33% were female, the incidence of severe SIRS was 66.7% and 50% in groups C and P, respectively (P=0.68), and EMP showed a significant increase in the 24-hour postoperative period (P≤0.001) and subsequent decrease in the three-month postoperative period (P≤0.001), returning to baseline levels. For IL-6 and IL-8, there was a greater increase in group C at 24 hours postoperatively (P=.0.02 and P<0.001). Conclusion: The incidence of severe SIRS was similar in both groups, with significantly higher levels of IL-6 and IL-8, at the 24-hour postoperative period, in group C, however with higher levels of EMP in group P, and subsequent return to baseline levels at the three-month postoperative period in both groups.

Association between left atrial strain and left ventricular diastolic function in patients with acute coronary syndrome.

BACKGROUND: Left ventricular diastolic function is an important prognostic marker in acute coronary syndrome. However, classification of the dysfunction grade using isolated echocardiographic parameters remains difficult. Therefore, it is necessary to combine multiple data in diagnostic algorithms. The purpose of this study was to evaluate the capacity of left atrial strain (LAS) components to classify left ventricular diastolic dysfunction (DD) grade. METHODS: Cross-sectional study with 109 consecutive patients admitted to the emergency room with acute coronary syndrome. Patients were referred for echocardiographic evaluation within 72 h. Mean values of LAS, corresponding to three phases of atrial function (reservoir, conduit and contraction), were obtained by speckle-tracking echocardiography. Patients were divided according to the diastolic dysfunction grade for later association with the LAS. RESULTS: The three LAS components showed moderate correlation with most diastolic variables (left atrial volume index, E/e' ratio and e' wave). In addition, there was related reduction of the LAS, which was inversely proportional to the DD grade (p < 0.05). LAS was effective for the identification of patients with DD grade III [area under the curve (AUC) for the reservoir = 0.99; conduit AUC = 0.89; contraction AUC = 0.99) and also those with DD grade II or III (reservoir AUC = 0.94; conduit AUC = 0.92; contraction AUC = 0.80]. CONCLUSIONS: LAS alone presented excellent capacity to classify DD in patients with acute coronary syndrome and may represent an additional tool for this purpose.

Independent predictors of effective blood pressure control in patients with hypertension on drug treatment in Brazil.

Population assessment of effective blood pressure (BP) control is fundamental for reducing the global burden of hypertension, especially in low- and middle-income countries. The authors evaluated the effectiveness of BP control and determined independent predictors associated with effective control among patients with hypertension on drug treatment in a large cross-sectional study performed in two metropolitan areas in Brazil's southeast region. A total of 43 647 patients taking antihypertensive treatment were identified. Less than half of the patients (40.9%) had controlled BP (systolic BP <140 mm Hg and diastolic BP <90 mm Hg). Independent predictors of BP control were age, eating fruit daily, physical activity, previous cardiovascular disease, male sex, diabetes mellitus, ethnicity, and obesity. Simple variables associated with BP control may be utilized for knowledge translation strategies aiming to reduce the burden of hypertension.

O Uso de um Ventilador Mecânico Portátil na Ressuscitação Cardiopulmonar é Viável, Melhora os Parâmetros Respiratórios e Previne a Redução da Complacência Pulmonar Dinâmica / Use of a Portable Mechanical Ventilator during Cardiopulmonary Resuscitation is Feasible, Improves Respiratory Parameters, and Prevents the Decrease of Dynamic Lung Compliance

Resumo Fundamentos Para ventilação prática e protetora durante a ressuscitação cardiopulmonar (RCP), desenvolveu-se um ventilador mecânico (VLP2000E) de 150 gramas que limita o pico de pressão inspiratória (PPI) durante ventilação e compressões torácicas simultâneas. Objetivos Avaliar a viabilidade da ventilação com VLP2000E durante RCP e comparar os parâmetros monitorados versus ventilação com bolsa-válvula. Métodos Estudo experimental randomizado com 10 porcos intubados por grupo. Após sete minutos de fibrilação ventricular, iniciaram-se ciclos de RCP de 2 minutos. Todos os animais foram ventilados com VLP2000E após o retorno da circulação espontânea (RCE). Resultados Os grupos bolsa-válvula e VLP2000E apresentaram taxa de RCE (60% vs. 50%, respectivamente) e saturação arterial de oxigênio similares na maioria dos ciclos de RCP, volume corrente basal diferente [0,764 (0,068) vs. 0,591 (0,123) L, p = 0,0309, respectivamente] e, em 14 ciclos, diferentes PPI [52 (9) vs. 39 (5) cm H2O, respectivamente], volume corrente [0,635 (0,172) vs. 0,306 (0,129) L], ETCO2 [14 (8) vs. 27 (9) mm Hg], e pico de fluxo inspiratório [0,878 (0,234) vs. 0,533 (0,105) L/s], todos p < 0,0001. A complacência pulmonar dinâmica (≥ 0,025 L/cm H2O) diminuiu após o RCE no grupo bolsa-válvula, mas se manteve no grupo VLP2000E [ 0,019 (0,006) vs. 0,024 (0,008) L/cm H2O, p = 0,0003]. Conclusões Ventilação com VLP2000E durante RCP é viável e equivalente a ventilação com bolsa-válvula quanto à taxa de RCE e saturação arterial de oxigênio. Esse ventilador produz melhores parâmetros respiratórios, com pressão das vias aéreas e volume corrente menores. Ventilação com VLP2000E também previne a redução significante da complacência pulmonar dinâmica observada após ventilação com bolsa-válvula. Seria interessante realizar mais estudos pré-clínicos para confirmar esses resultados.

Abstract Background For practical and protective ventilation during cardiopulmonary resuscitation (CPR), a 150-grams mechanical ventilator (VLP2000E) that limits peak inspiratory pressure (PIP) during simultaneous ventilation with chest compressions was developed. Objectives To evaluate the feasibility of VLP2000E ventilation during CPR and to compare monitored parameters versus bag-valve ventilation. Methods A randomized experimental study with 10 intubated pigs per group. After seven minutes of ventricular fibrillation, 2-minute CPR cycles were delivered. All animals were placed on VLP2000E after achieving return of spontaneous circulation (ROSC). Results Bag-valve and VLP2000E groups had similar ROSC rate (60% vs. 50%, respectively) and arterial oxygen saturation in most CPR cycles, different baseline tidal volume [0.764 (0.068) vs. 0.591 (0.123) L, p = 0.0309, respectively] and, in 14 cycles, different PIP [52 (9) vs. 39 (5) cm H2O, respectively], tidal volume [0.635 (0.172) vs. 0.306 (0.129) L], ETCO2[14 (8) vs. 27 (9) mm Hg], and peak inspiratory flow [0.878 (0.234) vs. 0.533 (0.105) L/s], all p < 0.0001. Dynamic lung compliance (≥ 0.025 L/cm H2O) decreased after ROSC in bag-valve group but was maintained in VLP2000E group [0.019 (0.006) vs. 0.024 (0.008) L/cm H2O, p = 0.0003]. Conclusions VLP2000E ventilation during CPR is feasible and equivalent to bag-valve ventilation in ROSC rate and arterial oxygen saturation. It produces better respiratory parameters, with lower airway pressure and tidal volume. VLP2000E ventilation also prevents the significant decrease of dynamic lung compliance observed after bag-valve ventilation. Further preclinical studies confirming these findings would be interesting.

[Renal function outcome in acute myocardial infarction as a prognostic factor of in-hospital events and at one-year follow-up]. / Evolução da função renal na fase aguda do infarto do miocárdio como fator prognóstico de eventos na fase intra-hospitalar e em um ano de seguimento.

OBJECTIVE: To analyze the role of renal dysfunction at admission or during hospitalization in patients with acute myocardial infarction (AMI). METHODS: Two hundred and seventy-four patients with AMI were assessed between January 2000 and December 2001. Renal function was monitored by serum creatinine (Cr) measurement at admission and peak level during hospitalization. Creatinine clearance (CrCl) was estimated by the Cockcroft-Gault formula. In-hospital and one-year morbidity and mortality were evaluated. RESULTS: Mean age of the population studied was 62.2 +/- 13.5, and 73% of the patients were male. Renal function was more reduced in male patients and in those with systemic arterial hypertension and prior CABG. Multivariate analysis showed higher hospital mortality rates associated with increased peak serum Cr levels (OR: 1.18 95% CI: 1.18-2.77 p = 0.006), decreased baseline CrCl (OR: 0.96 95% CI: 0.93-0.99 p = 0.025) and peak CrCl (OR: 0.96 95% CI: 0.92-0.99 p = 0.023). Percent difference between baseline CrCl and the lowest CrCl obtained during hospitalization also indicated higher mortality rates (OR: 1.04 95% CI: 1.00-1.07 p = 0.033). No change was observed in the one-year morbidity and mortality from worsening of renal function. CONCLUSION: Renal dysfunction at admission and its deterioration during hospitalization have proved to be a major prognostic marker for immediate poor outcome.

[Electrical cardioversion and myocardial injury: evaluation by new cardiac injury markers]. / Cardioversão elétrica e lesão miocárdica: avaliação pelos novos marcadores de injúria cardíaca.

OBJECTIVE: Evaluate, based on the evolution of new biochemical markers of cardiac damage, if electrical cardioversion (ECV) causes myocardial injury. METHODS: Seventy-six patients (P) submitted to elective ECV for atrial fibrillation or atrial flutter were evaluated. Creatine phosphokinase (CPK), CK-MB activity, CK-MB mass, myoglobin and cardiac troponin I (cTnI) were measured before, and 6 and 24 hours after ECV. RESULTS: ECV was successful in 58 P (76.3%). Cumulative energy (CE) was up to 350 joules (J) in 36 P, from 500 to 650 J in 20 P and from 900 to 960 J in 20 P; the mean energy delivered being 493 J (+/- 309). The levels of cTnI remained within normal limits in all 76 P. The increase of cumulative energy led to an elevation of CPK levels (> p value = 0.007), CK-MB activity (> p value = 0.002), CK-MB mass (> p value = 0.03), and myoglobin (> p value = 0.015). A positive correlation between the cumulative energy and CPK peaks was observed (r = 0.660; p < 0.001), CK-MB activity (r = 0.429; p < 0.0001), CK-MB mass (r = 0.265; p = 0.02), and myoglobin (r = 0.684; p < 0.0001), as well as between the number of shocks and the CPK peaks (r = 0.770; p < 0.001), CK-MB activity (r = 0.642; p < 0.0001), CK-MB mass (r = 0.430; p < 0.0001), and myoglobin (r = 0.745; p < 0.0001). CONCLUSION: ECV does not cause myocardial injury detectable by cTnI measurement. Elevations of CPK, CK-MB activity, CK-MB mass and myoglobin result from skeletal muscle injury and are positively correlated with the CE delivered or with the number of shocks.

Prospective evaluation of clinical outcomes after acute ST-elevation myocardial infarction in patients who are ineligible for reperfusion therapy: preliminary results from the TETAMI registry and randomized trial.

BACKGROUND: Treatment with lytics or primary percutaneous coronary interventions (PCI) reduces the mortality rate of patients with ST-elevation myocardial infarction (STEMI) presenting within 12 hours. Patients presenting >12 hours are generally considered to be ineligible for reperfusion therapy, and there are currently no specific treatment recommendations for this subgroup.Methods- All patients with STEMI <24 hours were included in the Treatment with Enoxaparin and Tirofiban in Acute Myocardial Infarction (TETAMI) randomized trial or registry. Those patients who were ineligible for acute reperfusion, had no cardiogenic shock, and were not planned for revascularization within 48 hours were randomized to 1 of 4 antithrombotic regimens involving enoxaparin or unfractionated heparin (UFH), in combination with tirofiban or placebo for 2 to 8 days. A concurrent registry tracked STEMI patients coming in within <12 hours, and who underwent reperfusion. This registry also tracked the remaining STEMI patients who neither received reperfusion nor were enrolled in the TETAMI randomized trial. The demographics and clinical outcomes of all three groups (received reperfusion therapy, too late for reperfusion and enrolled in the randomized trial, neither received reperfusion therapy nor were enrolled in the randomized trial) were prospectively tracked. RESULTS AND CONCLUSIONS: There were 2,737 patients who presented with STEMI or a new left branch bundle block (LBBB), of which 1,654 (60%) presented < or =12 hours. There were 1,196 (72%) of 1,654 patients who received reperfusion therapy. There were 458 (28%) of the 1,654 patients deemed "ineligible" for reperfusion, mostly because of a contraindication to lytics or for being "too old." In contrast, 1,083 (40%) of 2,737 patients presented >12 hours. Apart from 34 of these patients who had a stuttering infarction and were referred for reperfusion, the remaining patients did not receive reperfusion therapy. Registry patients who received reperfusion therapy, compared with TETAMI randomized patients (all of whom received antithrombotic therapy) and registry patients who did not receive reperfusion, were younger (61 years versus 63 years and 67 years), were more likely to be male (78% versus 73% and 63%), and had persistent ST-segment elevation as opposed to LBBB or Q waves. Registry patients who received reperfusion therapy had better clinical outcomes, even after adjusting for admission Killip class, compared with TETAMI randomized patients and registry patients who did not receive reperfusion therapy. TETAMI randomized patients had better outcomes than registry patients who did not receive reperfusion therapy. The major obstacle to expanding the delivery of reperfusion therapy to patients with STEMI is the large fraction of patients who present too late for reperfusion therapy. Examination of prospectively gathered data on STEMI patients who are ineligible for reperfusion may help optimize their treatment.

The safety and efficacy of subcutaneous enoxaparin versus intravenous unfractionated heparin and tirofiban versus placebo in the treatment of acute ST-segment elevation myocardial infarction patients ineligible for reperfusion (TETAMI): a randomized trial.

OBJECTIVES: The aims of the Safety and Efficacy of Subcutaneous Enoxaparin Versus Intravenous Unfractionated Heparin and Tirofiban Versus Placebo in the Treatment of Acute ST-Segment Elevation Myocardial Infarction Patients Ineligible for Reperfusion (TETAMI) study were to demonstrate that enoxaparin was superior to unfractionated heparin (UFH) and that tirofiban was better than placebo in patients with acute ST-segment elevation myocardial infarction (STEMI) who do not receive timely reperfusion. BACKGROUND: An optimal treatment strategy has not been identified for the many STEMI patients ineligible for acute reperfusion. METHODS: A total of 1224 patients were enrolled in 91 centers in 14 countries between July 1999 and July 2002. Patients with STEMI ineligible for reperfusion were randomized to enoxaparin, enoxaparin plus tirofiban, UFH, or UFH plus tirofiban. All patients received oral aspirin. The primary efficacy end point was the 30-day combined incidence of death, reinfarction, or recurrent angina; the primary analysis was the comparison of the pooled enoxaparin and UFH groups. RESULTS: The incidence of the primary efficacy end point was 15.7% enoxaparin versus 17.3% for UFH (odds ratio 0.89 [95% confidence interval CI = 0.66 to 1.21]) and 16.6% for tirofiban versus 16.4% for placebo (odds ratio 1.02 [95% CI 0.75 to 1.38]). The Thrombolysis In Myocardial Infarction (TIMI) major hemorrhage rate was 1.5% for enoxaparin versus 1.3% for UFH (odds ratio 1.16 [95% CI 0.44 to 3.02]) and 1.8% versus 1% for tirofiban versus placebo (odds ratio 1.82 [95% CI 0.67 to 4.95]). CONCLUSIONS: This study did not show that enoxaparin significantly reduced the 30-day incidence of death, reinfarction, and recurrent angina compared with UFH in non-reperfused STEMI patients. However, enoxaparin appears to have a similar safety and efficacy profile to UFH and may be an alternative treatment. Additional therapy with tirofiban did not appear beneficial.

[Prognostic factors of survival in post-cardiopulmonary-cerebral resuscitation in general hospital]. / Fatores prognósticos de sobrevida pós-reanimação cardiorrespiratória cerebral em hospital geral.

OBJECTIVE: To assess clinical and demographic characteristics of patients who had cardiopulmonary resuscitation and identify short- and long-term survival prognostic factors. METHODS: Four hundred and fifty-two (452) resuscitated patients in general hospitals from Salvador were prospectively assessed through bivariate and stratified analysis in associations between variables and survival curve for a nine-year evolution assessment. RESULTS: Age ranged from 14 to 93 years old, mean of 54.11 years old. Male gender patients prevailed and half of them had at least a base disease. Cardiovascular disease was the responsible etiology in 50% of cases. Cardiac arrest was observed in 77% of cases and only 69% of patients were immediately resuscitated. Initial cardiac rhythm was not diagnosed in 59% of patients. Asystole was the most frequent rhythm (42%), followed by ventricular arrhythmia (35%). Immediate survival was 24% and hospital discharge survival 5%. Cardiac arrest etiology, initial cardiac rhythm diagnosis, ventricular fibrillation or tachycardia as arrest mechanism, pre-resuscitation estimated time lower than or equal to 15 minutes and resuscitation time lower than or equal to 5 minutes were recognized as short-term prognostic factors. Non-administration of epinephrine, being resuscitated in private hospital and resuscitation time lower than or equal to 15 minutes were nine-year evolution survival prognostic factors. CONCLUSION: Data may help healthcare professionals decide when start or stop in-hospital resuscitation.

[Prospective risk analysis in patients submitted to myocardial revascularization surgery]. / Análise prospectiva de risco em pacientes submetidos à cirurgia de revascularização miocárdica.

OBJECTIVE: To perform a stratified risk analysis in Myocardial Revascularization Surgery (MRS). METHODS: 814 patients were prospectively studied by applying two prognostic indexes (PI): Parsonnet and Modified Higgins. The Higgins PI was modified by substituting the variable "cardiac index value" by "low cardiac output syndrome" at the Intensive Care Unit (ICU) admission. The discriminatory capacity for morbimortality of both indexes was analyzed by ROC (receiver operating characteristic) curve. Logistic reaction identified the associated factors, independently from the events. RESULTS: Mortality and morbidity rates were 5.9% and 35.5%, respectively. The Modified Higgins PI, which analyzes pre- and intra-operative and physiological variables at the ICU admission showed areas under the ROC curve of 77% for mortality and 67% for morbidity. The Parsonnet PI, which only analyzes pre-operative variables, showed areas of 62.2% and 62.4%, respectively. Twelve variables were characterized as independent prognostic factors: age, diabetes mellitus, low body surface, creatinine levels (>1.5 mg/dL), hypoalbuminemia, non-elective surgery, prolonged time of extracorporeal circulation (ECC), necessity of post-ECC intra-aortic balloon, low cardiac output syndrome at the ICU admission, elevated cardiac frequency, decrease in serum bicarbonate concentrations and increase of the alveolar-arterial oxygen gradient within this period. CONCLUSION: The Modified Higgins PI showed to be superior to the Parsonnet PI at the surgical risk stratification, showing the importance of the analysis of intraoperative events and physiological variables at the patient's ICU admission, when prognostic definition is achieved.

Echocardiography for prognostication during the resuscitation of intensive care unit patients with non-shockable rhythm cardiac arrest.

AIM: Transthoracic echocardiography (TTE) during cardiopulmonary arrest (CPA) has been studied in victims of cardiac arrests. Our objective was to evaluate the feasibility and usefulness of TTE in victims of cardiac arrest with non-shockable rhythms hospitalized in intensive care units (ICUs). METHODS: This prospective and observational cohort study evaluated ICU patients with CPA in asystole or pulseless electrical activity (PEA). Intensivists performed TTE during intervals of up to 10s as established in the treatment protocol. Myocardial contractility was defined as intrinsic movement of the myocardium coordinated with cardiac valve movement. PEA without contractility was classified as electromechanical dissociation (EMD), and with contractility as pseudo-EMD. The images, the rates of return of spontaneous circulation (ROSC) and the survival upon hospital discharge and after 180 days were evaluated. RESULTS: A total of 49 patients were included. Image quality was considered adequate in all cases and contributed to the diagnosis of CPA in 51.0% of the patients. Of the 49 patients included, 17 (34.7%) were in asystole and 32 (65.3%) in PEA, among which 5 (10.2%) were in EMD and 27 (55.1%) in pseudo-EMD. The rates of ROSC were 70.4% for those in pseudo-EMD, 20.0% for those in EMD, and 23.5% for those in asystole. Survival upon hospital discharge and after 180 days occurred only in patients in pseudo-EMD (22.2% and 14.8%, respectively). CONCLUSIONS: TTE conducted during cardiopulmonary resuscitation in ICU patients can be performed without interfering with care protocols and can contribute to the differential diagnosis of CPA and to the identification of a subgroup of patients with better prognosis.

Risk factors for myocardial infarction in Brazil.

BACKGROUND: Approximately three-quarters of cardiovascular disease deaths in the world come from developing countries, and acute myocardial infarction (AMI) is an important cause of death. Brazil is one of the largest countries in Latin America and the contemporary evaluation of risk factors for AMI is crucial for a more efficacious disease management. METHODS: The Acute Myocardial Infarction Risk Factor Assessment in Brazil (AFIRMAR) study is a case-control, hospital-based study involving 104 hospitals in 51 cities in Brazil, designed to evaluate risk factors for a first ST-segment elevation AMI. RESULTS: A total of 1279 pairs, matched by age (+/- 5 years) and sex, were enrolled. The conditional multivariable analysis of 33 variables showed the following independent risk factors for AMI: > or =5 cigarettes per day (odds ratio [OR] 4.90, P <.00001); glucose > or =126 mg/dL (OR 2.82, P <.00001); waist/hip ratio > or =0.94 (OR 2.45, P <.00001); family history of CAD (OR 2.29, P <.00001), low-density lipoprotein-cholesterol 100 to 120 mg/dL (OR 2.10, P <.00001); reported hypertension (OR 2.09, P <.00001); <5 cigarettes per day (OR 2.07, P =.0171); low-density lipoprotein-cholesterol >120 mg/dL (OR 1.75, P <.00001); reported diabetes mellitus (OR 1.70, P =.0069); waist/hip ratio 0.90 to 0.93 (OR 1.52, P =.0212); alcohol intake (up to 2 days/week) (OR 0.75, P <.0309); alcohol intake (3-7 days/week) (OR 0.60, P =.0085); family income R$600 to R$1200 and college education (OR 2.92, P =.0499); family income >R$1200 and college education (OR 0.68, P = 0.0239) CONCLUSIONS: The independent risk factors for AMI in Brazil showed a conventional distribution pattern (smoking, diabetes mellitus and central obesity among others) with different strengths of association; most of them being preventable by implementation of adequate policies.

Association between angiotensin-converting enzyme inhibitors and troponin in acute coronary syndrome.

BACKGROUND: Cardiovascular disease is the leading cause of mortality in the western world and its treatment should be optimized to decrease severe adverse events. OBJECTIVE: To determine the effect of previous use of angiotensin-converting enzyme inhibitors on cardiac troponin I measurement in patients with acute coronary syndrome without ST-segment elevation and evaluate clinical outcomes at 180 days. METHODS: Prospective, observational study, carried out in a tertiary center, in patients with acute coronary syndrome without ST-segment elevation. Clinical, electrocardiographic and laboratory variables were analyzed, with emphasis on previous use of angiotensin-converting enzyme inhibitors and cardiac troponin I. The Pearson chi-square tests (Pereira) or Fisher's exact test (Armitage) were used, as well as the non-parametric Mann-Whitney's test. Variables with significance levels of <10% were submitted to multiple logistic regression model. RESULTS: A total of 457 patients with a mean age of 62.1 years, of whom 63.7% were males, were included. Risk factors such as hypertension (85.3%) and dyslipidemia (75.9%) were the most prevalent, with 35% of diabetics. In the evaluation of events at 180 days, there were 28 deaths (6.2%). The statistical analysis showed that the variables that interfered with troponin elevation (> 0.5 ng / mL) were high blood glucose at admission (p = 0.0034) and ST-segment depression ≥ 0.5 mm in one or more leads (p = 0.0016). The use of angiotensin-converting inhibitors prior to hospitalization was associated with troponin ≤ 0.5 ng / mL (p = 0.0482). The C-statistics for this model was 0.77. CONCLUSION: This study showed a correlation between prior use of angiotensin-converting enzyme inhibitors and reduction in the myocardial necrosis marker troponin I in patients admitted for acute coronary syndrome without ST-segment elevation. However, there are no data available yet to state that this reduction could lead to fewer severe clinical events such as death and re-infarction at 180 days.