Prognostic value of perioperative high sensitivity troponin in patients undergoing hip and knee arthroplasty

Abstract The authors conducted a prospective observational study to investigate the prognostic value of high-sensitivity Troponin I (hs-TnI) in the short- and long-term periods after orthopedic surgery, including Total Hip and Knee Arthroplasty (THA and TKA, respectively), in a tertiary orthopedic center in Brazil. Perioperative Myocardial Injury (PMI) was defined as an absolute increase in hs-TnI of ≥ 26 ng/L above preoperative values. The primary endpoint was all-cause mortality assessed at 30 days and 18 months after surgery. The secondary endpoint consisted of a composite outcome: cardiovascular death, acute myocardial infarction, angina requiring revascularization, and/or stroke. The authors compared Relative Risks (RR) of all-cause mortality and composite outcomes in patients with or without PMI at 30 days and 18 months. A Cox proportional hazards model for long-term outcomes was calculated and adjusted for age > 70 years, gender, and Revised Cardiac Risk Index (RCRI) class ≥ 2. PMI occurred in 3.4 % of all surgeries. At 30-days, 6.6 % of patients with PMI had died versus none without PMI. At 18 months, 20.0 % of PMI versus 4.7 % without PMI had died (RR = 5.0; 95 % Confidence Interval [95 % CI 1.3-19.3]). Based on composite outcomes in short and long-term periods, the RRs were 16.2 (95 % CI 2.7-96.5) and 7.7 (95 % CI 2.2-26.6), respectively. PMI was associated with all-cause mortality after 18 months and increased risk for a composite outcome (Hazard Ratio [HR = 3.97], 95 % CI 1.13-13.89 and HR = 5.80, 95 % CI 1.93-17.45, respectively). Patients with PMI who underwent THA or TKA presented worse short- and long-term prognoses compared to those without PMI.

Programa de Residência Médica em Cardiologia de Adultos do InCor em 2022: 40 Anos Formando Cardiologistas para as Demandas do Brasil / Incor Residency Program in Adult Cardiology in 2022: 40 Years Preparing Cardiologists for the Demands in Brazil

Resumo Fundamento Diante de dados demográficos referentes às áreas de atuação dos cardiologistas no Brasil, a coordenação do Programa de Residência Médica em Cardiologia do Instituto do Coração (PRM INCOR) entendeu a necessidade de uma atualização de seu conteúdo programático, a fim de adaptar o processo de formação à realidade profissional do cardiologista. Objetivo O presente artigo tem como objetivo descrever à comunidade científica as atualizações recentemente implementadas no PRM INCOR. Métodos No artigo, descrevemos as atualizações recentes do PRM INCOR, comparando a grade teórica pregressa e a atual. Expomos também o racional por trás de tais mudanças com dados de literatura relacionados à atuação do médico cardiologista no mercado de trabalho. Resultado Houve uma redução da carga horária destinada a estágios de terapia intensiva, e um incremento nas atividades ambulatoriais relacionadas a medidas de prevenção primária e secundária. Além disso, o programa passou por uma reformulação de seu conteúdo didático, organizado agora por núcleos de competência. Conclusão A atualização da grade curricular decorre da necessidade de adequar o PRM INCOR à realidade atual do mercado de trabalho brasileiro. O grupo envolvido na atualização está ciente que se trata de um processo dinâmico e que pode exigir modificações no decorrer do tempo.

Abstract Background Considering demographic data related to the cardiologist's fields of work in Brazil, the administrative board of the InCor medical residency program decided for an update of its curriculum content, to adapt the educational process to the cardiologist's work reality. Objective This article aimed to describe the recent updates applied to the InCor medical residency program. Methods In the article, we described the recent updates on the InCor residency program, and compared the current curriculum track with the previous one. We also presented the rationale for these changes, based on the literature on the participation of cardiologists in the labor market. Results There was a reduction in the working hours of residents in training in the intensive care unit, and an increase in the outpatient activities of primary and secondary prevention. Also, the didactic content was reformulated and became organized by the corresponding division. Conclusion The update of the curriculum track of the InCor medical residency program was required in order to adapt it to the Brazilian labor market. The commission in charge of this update is aware that this is a dynamic process that may need changes over time.

Lifestyle, inadequate environments in childhood and their effects on adult cardiovascular health

Abstract Objectives: To discuss the associations between habits and environment in childhood and cardiovascular effects on adults. Source of data: Search in PubMed, Scielo and Science databases, cohort or case-control studies, and systematic or scope-based reviewson the causal relationship among exposures in the pediatric age group and cardiovascular effects in adults. Synthesis of data: The authors identified 41 eligible articles, which demonstrated an impact on cardiovascular health (characterized as surrogate events - structural or functional vascular alterations or left ventricular dysfunction - or clinical events - myocardial infarction, stroke or cardiovascular death) with environmental aspects (intrauterine or economically poor environment, violence, reduced life expectancy and serious infections) and habits (nutrition, physical activity and tobacco exposure). In addition to the direct and independent associations between exposures and outcomes, several traditional cardiovascular risk factors (CVRF) or family histories are also intermediate pathophysiological pathways in the described phenomena. Conclusions: There are direct relationships between lifestyle and inadequate environments in childhood and cardiovascular effects, although the observed associations showed divergences in terms of results and interpretation. In spite of these, it is recommended to encourage healthy lifestyles and protection against childhood adverse exposures, as habit formation occurs at this age, and its relationship with CVRF since childhood has already been well established. On the other hand, the format and intensity of the stimulus must respect the social, cultural and psychological aspects of each population, aiming to obtain the best and most lasting result without generating harmful consequences for the individuals.

Hemodynamic depression after carotid surgery: Incidence, risk factors and outcomes

Abstract Introduction: Hemodynamic Depression (HD) characterized by hypotension and bradycardia is a complication of carotid surgery due to direct autonomic stimulation in the carotid sinus. The authors believe the incidence of HD is high and possibly related to major cardiac complications. Methods: Analysis of patient records during admissions for carotid surgery between January 2014 and December 2018 in two hospitals. HD was defined as bradycardia or hypotension in the first 24 postoperative hours. Bradycardia was defined as heart rate < 50bpm; hypotension as systolic blood pressure < 90 mmHg, continuous use of vasopressors, or a drop in SBP > 20% compared to preoperative values. Myocardial infarction, stroke, and cardiovascular death were defined as adverse events. Results: Overall, 237 carotid surgeries (178 endarterectomies, 59 angioplasties) were studied, and the global incidence of HD was 54.4% (hypotension in 50.2%, bradycardia in 11.0%, and hypotension and bradycardia in 6.8%). The independent predictors of HD were asymptomatic carotid stenosis (OR = 1.824; 95% CI 1.014 −3.280; p = 0.045), endovascular surgery (OR = 3.319; 95% CI 1.675−6.576; p = 0.001) and intraoperative hypotension or bradycardia (OR = 2.144; 95% CI 1.222−3.762; p = 0.008). Hypotension requiring continuous vasopressor infusion was the only factor independently associated with adverse cardiovascular events (OR = 5.504; 95% CI 1.729-17.529; p = 0.004). Discussion/conclusion: Incidence of Hemodynamic Depression after carotid surgery is high and independently associated with surgical technique, symptomatic repercussion of the carotid stenosis, and intraoperative hypotension or bradycardia. Hypotension requiring the continuous infusion of vasopressors was independently associated with the occurrence of MACE.

High risk coronavirus disease 2019: The primary results of the CoronaHeart multi-center cohort study

BACKGROUND: Patients with Coronavirus Disease 2019 (COVID-19) may present high risk features during hospitalization, including cardiovascular manifestations. However, less is known about the factors that may further increase the risk of death in these patients. METHODS: We included patients with COVID-19 and high risk features according to clinical and/or laboratory criteria at 21 sites in Brazil from June 10th to October 23rd of 2020. All variables were collected until hospital discharge or in-hospital death. RESULTS: A total of 2546 participants were included (mean age 65 years; 60.3% male). Overall, 70.8% were admitted to intensive care units and 54.2% had elevated troponin levels. In-hospital mortality was 41.7%. An interaction among sex, age and mortality was found (p = 0.007). Younger women presented higher rates of death than men (30.0% vs 22.9%), while older men presented higher rates of death than women (57.6% vs 49.2%). The strongest factors associated with in-hospital mortality were need for mechanical ventilation (odds ratio [OR] 8.2, 95% confidence interval [CI] 5.4­12.7), elevated C-reactive protein (OR 2.3, 95% CI 1.7­2.9), cancer (OR 1.8, 95 %CI 1.2­2.9), and elevated troponin levels (OR 1.8, 95% CI 1.4­2.3). A risk score was developed for risk assessment of in-hospital mortality. CONCLUSIONS: This cohort showed that patients with COVID-19 and high risk features have an elevated rate of in-hospital mortality with differences according to age and sex. These results highlight unique aspects of this population and might help identifying patients who may benefit from more careful initial surveillance and potential subsequent interventional therapies

Patients with COVID-19 who experience a myocardial infarction have complex coronary morphology and high in-hospital mortality: Primary results of a nationwide angiographic study

OBJECTIVES: We aimed to explore angiographic patterns and in-hospital outcomes of patients with concomitant coronavirus disease-19 (COVID-19) and myocardial infarction (MI). BACKGROUND: Patients with COVID-19 may experience MI during the course of the viral infection. However, this association is currently poorly understood. METHODS: This is a multicenter prospective study of consecutive patients with concomitant COVID-19 and MI who underwent coronary angiography. Quantitative and qualitative coronary angiography were analyzed by two observers in an independent core lab. RESULTS: A total of 152 patients were included, of whom 142 (93.4%) had COVID-19 diagnosis confirmation. The median time between symptom onset and hospital admission was 5 (1­10) days. A total of 83 (54.6%) patients presented with ST elevation MI. The median angiographic Syntax score was 16 (9.0­25.3) and 69.0% had multi-vessel disease. At least one complex lesion was found in 73.0% of patients, 51.3% had a thrombus containing lesion, and 57.9% had myocardial blush grades 0/1. The overall in-hospital mortality was 23.7%. ST-segment elevation MI presentation and baseline myocardial blush grades 0 or 1 were independently associated with a higher risk of death (HR 2.75, 95%CI 1.30­5.80 and HR 3.73, 95%CI 1.61­8.61, respectively). CONCLUSIONS: Patients who have a MI in the context of ongoing COVID-19 mostly present complex coronary morphologies, implying a background of prior atherosclerotic disease superimposed on a thrombotic milieu. The in-hospital prognosis is poor with a markedly high mortality, prompting further investigation to better clarify this newly described condition.

Cardiology referral during the COVID-19 pandemic

OBJECTIVES: This study presents the cardiology referral model adopted at the University of São Paulo-Hospital das Clínicas complex during the initial period of the coronavirus disease (COVID-19) pandemic, main reasons for requesting a cardiologic evaluation, and clinical profile of and prognostic predictors in patients with COVID-19. METHODS: In this observational study, data of all cardiology referral requests between March 30, 2020 and July 6, 2020 were collected prospectively. A descriptive analysis of the reasons for cardiologic evaluation requests and the most common cardiologic diagnoses was performed. A multivariable model was used to identify independent predictors of in-hospital mortality among patients with COVID-19. RESULTS: Cardiologic evaluation was requested for 206 patients admitted to the ICHC-COVID. A diagnosis of COVID-19 was confirmed for 180 patients. Cardiologic complications occurred in 77.7% of the patients. Among these, decompensated heart failure was the most common complication (38.8%), followed by myocardial injury (35%), and arrhythmias, especially high ventricular response atrial fibrillation (17.7%). Advanced age, greater need of ventilatory support on admission, and pre-existing heart failure were independently associated with in-hospital mortality. CONCLUSIONS: A hybrid model combining in-person referral with remote discussion and teaching is a viable alternative to overcome COVID-19 limitations. Cardiologic evaluation remains important during the pandemic, as patients with COVID-19 frequently develop cardiovascular complications or decompensation of the underlying heart disease.

Medical students with performance difficulties need wide support: Initial results of an academic tutoring program

BACKGROUND: Even students with previous academic success may face challenges that affect their academic performance. Many medical schools offer programs to students at the risk of academic failure, to ensure that they succeed in the course. OBJECTIVE AND METHODS: In this report we describe a pioneering academic tutoring program developed at a Brazilian medical school and discuss the initial results of the program based on the feedback from tutors and data regarding the progression of students in the medical course. RESULTS: In 2018, 33 students enrolled into the program. Students' performance difficulties were mainly associated with mental health problems and socioeconomic vulnerability. Of the 33 students, 27 (81.8%) were assisted by the Mental Health Support Service and 16 (48.5%) were assisted by the Social Assistance Service. In addition to the planning academic activity class load, tutors were able to assist students in solving socioeconomic issues, carrying out personal support interventions with the promotion of self-esteem, and presenting suggestions for behavioral changes in their routine. For most students (72%), the action plan proposed by the tutors was successful. Eight of the 14 (57%) students in the fourth year progressed to the final two years of in-hospital practical training (internship). CONCLUSIONS: The Academic Tutoring Program showed positive results for most of the students. Close monitoring and tutor intervention allowed students with poor academic performance to overcome the low performance cycle. These important tasks demand time and energy from tutors, and institutional recognition of these professionals is essential for the successful maintenance of the program.

Children First Study II: an educational programme on cardiovascular prevention in public schools can reduce parents cardiovascular risk

SUMMARY OBJECTIVE: The aim of this study was to analyze whether the implementation of a multidisciplinary educational programme for cardiovascular prevention in public schools can contribute to reducing the Fram INGHAM CARDIOVASCULAR RISK SCORE OF THE CHILDREN'S PARENTS AFTER ONE YEAR. METHODS: This was a prospective, community-based, case-control study carried out in public schools in Sao Paulo, Brasil. Students were randomized to receive healthy lifestyle recommendations by two different approaches. The control group received written cardiovascular health educational brochures for their parents. The intervention group received the same brochures for the parents, and the children were exposed to a weekly educational programme on cardiovascular prevention with a multidisciplinary health team for one year. Clinical and laboratorial data were collected at the onset and end of the study. RESULTS: We studied 265 children and their 418 parents. At the baseline, the rate of parents with intermediate or high Framingham scores (risk of cardiovascular disease over the next 10 years greater than 10%) was 6.9% in the control group and 13.3% in the intervention group. After one year, the rate of parents with intermediate or high Framingham risk score was reduced by 22.2% in the intervention group and increased by 33.3% in the control group (p=0.031). The cardiovascular risk factors that improved in the intervention group were blood pressure, LDL-cholesterol (low-density lipoprotein cholesterol), and glucose levels. CONCLUSION: An educational programme on cardiovascular prevention for school-age children in public schools can reduce the cardiovascular risk of their parents.

RESUMO OBJETIVO: Analisar se a implementação de um programa educacional multidisciplinar para prevenção cardiovascular em escolas públicas durante um ano pode contribuir para reduzir o escore de risco cardiovascular de Framingham dos pais das crianças. MÉTODOS: Estudo prospectivo, de base comunitária, caso-controle em duas escolas públicas de São Paulo, Brasil. Os alunos foram randomizados para receber recomendações de estilo de vida saudável por duas abordagens diferentes. O grupo controle recebeu folhetos educacionais de saúde cardiovascular encaminhados para seus pais. O grupo intervenção recebeu os mesmos folhetos e as crianças foram expostas a um programa educacional semanal, durante um ano, com uma equipe multidisciplinar em prevenção cardiovascular. Dados clínicos e laboratoriais foram coletados no início e no final do estudo. RESULTADOS: Foram sujeitos do estudo 418 pais das crianças das escolas. No início da pesquisa, o total de pais com escore de Framingham intermediário ou alto (risco superior a 10% de doença cardiovascular nos próximos dez anos) foi de 6,9% no grupo controle e de 13,3% no grupo intervenção. Após um ano, dentre os pais com escore de risco de Framingham intermediário ou alto, foi observada redução de 22,2% no grupo intervenção e aumento de 33,3% no grupo controle (p=0,031). Os fatores de risco cardiovascular que melhoraram no grupo de intervenção foram pressão arterial, LDL-colesterol (lipoproteína de baixa densidade) e glicemia. CONCLUSÃO: Um programa educacional de prevenção cardiovascular para crianças em idade escolar, em escolas públicas, pode reduzir o risco cardiovascular de seus pais.

Anticoagulants and antiplatelet drugs during cataract surgery / Anticoagulantes e agentes antiaplaquetários na cirurgia de catarata

ABSTRACT Patients undergoing cataract surgery are generally elderly, and many take drugs with systemic effects. The surgeon must be aware of the risks of continuing or discontinuing such medications perioperatively. Antiplatelet drugs and anticoagulants, prescribed to reduce the incidence of thromboembolic events, are often used in this population. This paper aims to review the perioperative use of antiplatelet and anticoagulant drugs in the setting of cataract surgery. Topical or intracameral anesthesia is preferred over anesthesia injected with needles. Aspirin can be safely continued in patients undergoing cataract surgery. Warfarin has been extensively studied, and the risk of hemorrhage associated with cataract surgery is low if the international normalized ratio is in the therapeutic range. Only a few studies of direct oral anticoagulants are available, and therefore no definite recommendations regarding those agents can be made at this time. Anesthesia in cataract surgery carries a low risk, even for patients taking anticoagulant or antiplatelet drugs. The discontinuation of this class of drugs before cataract surgery may increase the risk of thromboembolism.

RESUMO Os pacientes submetidos à cirurgia de catarata são geralmente idosos e muitos deles usam drogas com efeitos sistêmicos. No entanto, o cirurgião deve estar ciente dos riscos em manter ou descontinuar medicamentos sistêmicos no pré-operatório da cirurgia de catarata, como os anticoagulantes e os antiplaquetários. Este artigo tem como objetivo revisar a classe de drogas antiplaquetárias e anticoagulantes e orientar o cirurgião de catarata. A classe de fármacos anticoagulantes e antiplaquetária reduz a incidência de eventos potencialmente tromboembólicos. A anestesia tópica ou intracameral nesses pacientes deve ser preferida em relação à anestesia com agulhas. Aspirina pode ser mantida com segurança nos pacientes submetidos à cirurgia de catarata. A varfarina foi amplamente estudada e os riscos na cirurgia de catarata são baixos, no entanto, o INR deve ser controlado. Mais estudos são necessários com anticoagulantes orais diretos. Anestesia na cirurgia de catarata tem baixo risco de complicações, mesmo em uso de anticoagulantes ou antiplaquetários sistêmicos. A descontinuação desta classe de medicamentos no pré-operatório da cirurgia de catarata pode aumentar os riscos sistêmicos tromboembólicos.