Cost modifications during the early years of the use of the national cardiovascular data registry for quality improvement

OBJECTIVES: Quality improvement (QI) initiatives based on data from international registries have been reported previously; however, there is a lack of information on the impact on the costs of medical care associated with the use of these tools. METHODS: Patients admitted due to myocardial infarction (MI), included in the ACTION Registry® and CathPCI Registry®, in a private Brazilian hospital (i.e., the reference hospital) were analyzed. The costs of care of these patients were compared to the costs of MI admissions in nine similar hospitals not included in the same QI program. Regression models were used to analyze the cost change over time between the two groups of hospitals. Readmission rates were compared using logistic regression, adjusting for the same variables as in the cost model. RESULTS: Overall, the annual medical cost inflation in Brazil was higher than the annual cost trend in the reference hospital during the period of analysis. Moreover, the annual in-hospital costs indicate that the reference hospital has a statistically significant 6% lower cost trend for patients with acute MI, compared to patients with the same diagnostic code in the comparison hospitals group, in an adjusted analysis (p-value=0.041). Using multivariable analysis, the readmission rates were also found to be significantly lower in the reference hospital than in the comparison hospitals, with an odds ratio of 0.68 (p-value=0.042). CONCLUSION: The use of the NCDR® as a benchmark to guide QI programs outside the United States was associated with the positive impact of bending the cost curve to below that of national medical inflation and the comparison hospitals' costs, with a lower incidence of hospital readmission.

Cardiomiopatia periparto associada à síndrome do QT longo e síncope por taquicardia ventricular polimórfica: relato de caso / Peripartum cardiomyopathy associated with long QT syndrome and polymorphic ventricular tachycardia syncope: a case report

A cardiomiopatia periparto é uma causa rara de insuficiência cardíaca no período entre o último mês de gestação e os cinco meses após o parto. A síndrome do QT longo caracteriza-se pelo atraso da repolarização ventricular e pode se manifestar com síncope e morte súbita devido a um tipo de taquicardia ventricular polimórfica conhecida como torsades de pointes. Descrição do caso: J.S., 26 anos, sexo feminino, natural e procedente de São Paulo. Paciente puérpera - 40º dia (G3P3A0), procurou o pronto-socorro com queixa de síncope durante amamentação e dispneia em moderados esforços. Durante a avaliação no PS, evoluiu para desconforto torácico e agitação psicomotora, sendo notada taquicardia ventricular não sustentada no monitor cardíaco ( torsades de pointes), que foi controlada com cardioversão elétrica e sulfato de magnésio intravenoso. O eletrocardiograma mostrou ritmo sinusal, alteração difusa da repolarização ventricular e intervalo QTc de 580 ms. O ecocardiograma mostrou disfunção sistólica moderada, com fração de ejeção do ventrículo esquerdo de 43% à custa de hipocinesia difusa. Após avaliação da equipe de arritmologia chegou-se ao diagnóstico de cardiomiopatia periparto associado à síndrome do QT longo. Foi iniciado tratamento otimizado para insuficiência cardíaca e implantado cardiodesfibrilador por causa de episódios recorrentes de arritmia durante a internação. Discussão: A cardiomiopatia periparto é uma doença rara, porém, tem taxa de mortalidade elevada, entre 18% e 56%. A paciente descrita satisfez os quatro critérios para o diagnóstico: sintomas de insuficiência cardíaca nos primeiros 5 meses depois do parto, ausência de cardiomiopatia prévia, etiologia desconhecida e disfunção sistólica com FEVE < 45%. A síndrome do QT longo é uma doença genética de apresentações variáveis. Os fatores que desencadeiam as taquiarritmias são situações de instabilidade elétrica por hiperatividade do sistema simpático e também situações raras, como a cardiomiopatia periparto. Em casos de arritmias ventriculares graves, o tratamento é o implante de cardiodesfibrilador. Conclusão: A associação da cardiomiopatia periparto com a síndrome do QT longo é rara. A gravidade associada a essas condições torna importante o diagnóstico precoce e tratamento imediato pelo potencial risco de morte associado a ambas as condições clínicas

Peripartum cardiomyopathy is a rare cause of heart failure during the period between the last month of pregnancy and five months after delivery. Long QT syndrome is characterized by a delay in ventricular repolarization and may manifest with syncope and sudden death due to a type of polymorphic ventricular tachycardia known as torsades de pointes. Case description: J.S., 26-years-old, female, born and residing in São Paulo, Puerperal - 40th day (G3C3A0), went to the emergency room complaining of syncope during breastfeeding and dyspnea on moderate exertion. During evaluation in the ER, the patient developed thoracic discomfort and psychomotor agitation, with non-sustained ventricular tachycardia on the cardiac monitor (torsades de pointes), which was controlled with electrical cardioversion and intravenous magnesium sulfate. The electrocardiogram showed sinus rhythm, diffuse alteration of ventricular repolarization and QTc interval of 580 ms. The echocardiogram showed moderate systolic dysfunction, with a left ventricular ejection fraction of 43% influenced by diffuse hypokinesia. After evaluation by the arrhythmology team, the diagnosis of peripartum cardiomyopathy associated with long QT syndrome was made. Optimized treatment for heart failure was initiated and a cardioverter-defibrillator was implanted due to recurrent episodes of arrhythmia during hospitalization. Discussion: Peripartum cardiomyopathy is a rare disease, but it has a high mortality rate, between 18% and 56%. The patient described met the 4 diagnostic criteria: symptoms of heart failure in the first 5 months after delivery, absence of prior cardiomyopathy, unknown etiology, and systolic dysfunction with LVEF<45%. Long QT syndrome is a genetic disease of varying presentations. The factors that trigger the tachyarrhythmias are situations of electrical instability due to sympathetic system hyperactivity and rare situations, such as peripartum cardiomyopathy. In cases of severe ventricular arrhythmias, the treatment is a cardioverter-defibrillator implant. Conclusion: The association of peripartum cardiomyopathy with long QT syndrome is rare. The severity associated with these conditions points out early diagnosis and immediate treatment important because of the potential risk of death associated with both clinical conditions

Atualização do diagnóstico e tratamento do tromboembolismo pulmo / Update on diagnosis and treatment of pulmonary thromboembolism

A embolia pulmonar e a trombose venosa profunda são doenças com mesma base fisiopatogênica, denominada tromboembolismo venoso. Em 90% dos casos, os trombos originam-se no sistema da veia cava inferior, especialmente acima dos joelhos e pelve, alojando-se em ramos principais e segmentares dos pulmões, geralmentenos lobos inferiores. Nos Estados Unidos, é a terceira causa de óbito cardiovascular (seguida do infarto do miocárdio e acidente vascular cerebral isquêmico), com incidência anual estimada de 500.000 casos e 100.000 óbitos. A mortalidade hospitalar varia de 1% a 30%, dependendo das repercussões hemodinâmicas e da condição clínica do paciente. O diagnóstico e tratamento precoce reduzem a mortalidade hospitalar (disfunção e falência do ventrículo direito/hipoxemia) bem como suas principais complicações tardias: hipertensão pulmonar crônica, síndrome pós-trombótica, flegmasia alba dolens e cerulea dolens. O prognóstico poderá ser modificado adotando-se medidas preventivas, identificação e tratamento em tempo hábil, além da anticoagulação oral por período adequado...

Pulmonary embolism and deep vein thrombosis are diseases with same physiopathogenic base, called venous thromboembolism. In 90% of cases, thrombi originate in the inferior vena cava system, especially above the knees and pelvis, lodging in the main and segmental branches of the lungs, usually in the lower lobes. In the United States, it is the third leading cause of cardiovascular death (followed by myocardial infarction and ischemic stroke), with estimated annual incidence of 500,000 cases and 100,000 deaths. The hospital mortality rate ranges from 1% to 30%, depending on the hemodynamic effects and clinical condition of the patient. Early diagnosis and treatment reduce hospital mortality (dysfunction and failure of the right ventricle/hypoxemia) and its main late complications: chronic pulmonary hypertension, post-thrombotic syndrome, phlegmasia alba dolens and cerulea dolens. The prognosis may be modified by adopting preventive measures, identification and treatment in a timely manner, as well as oral anticoagulation for an adequate period...

Splenic Rupture after Infective Endocarditis by Enterococcus faecalis: Case Report.

Aims: In patients with infective endocarditis, with risk of embolization, early identification of parenchymal changes may suggest the risk of splenic rupture. Presentation of Case: A 68-year-old male presented with a history of 2 months of fever and also left upper quadrant pain initiated 2 days before admission. Transesophageal echocardiogram demonstrated the presence of two mobile vegetations on the ventricular side of the aortic valve; the largest diameter being 2.1 cm. Enterococcus faecalis was isolated in blood culture after a diagnosis of subacute aortic valve infective endocarditis. He complained of abdominal pain. An abdominal computed tomography scan revealed infarction of the upper region of the spleen (septic embolism). Therapy with penicillin and gentamicin was initiated, but the patient developed symptoms of heart failure that led to a surgical treatment, and aortic bioprosthesis was implanted on day 14. On day 5 postoperatively, the patient developed sudden hemorrhagic shock signs due to splenic rupture and underwent emergency splenectomy. A pathological examination revealed areas of splenic laceration of the capsule, splenic infarction areas, and the absence of abscesses. Splenic rupture is a complication much rarely occurring due to infectious endocarditis caused by E. faecalis. Conclusion: This case highlights the importance of conducting serial imaging, particularly in symptomatic patients, for the early detection of parenchymal changes that may suggest the risk of rupture.

Improving Indicators in a Brazilian Hospital Through Quality-Improvement Programs Based on STS Database Reports

ABSTRACT OBJECTIVE: To report the initial changes after quality-improvement programs based on STS-database in a Brazilian hospital. METHODS: Since 2011 a Brazilian hospital has joined STS-Database and in 2012 multifaceted actions based on STS reports were implemented aiming reductions in the time of mechanical ventilation and in the intensive care stay and also improvements in evidence-based perioperative therapies among patients who underwent coronary artery bypass graft surgeries. RESULTS: All the 947 patients submitted to coronary artery bypass graft surgeries from July 2011 to June 2014 were analyzed and there was an improvement in all the three target endpoints after the implementation of the quality-improvement program but the reduction in time on mechanical ventilation was not statistically significant after adjusting for prognostic characteristics. CONCLUSION: The initial experience with STS registry in a Brazilian hospital was associated with improvement in most of targeted quality-indicators.

Segurança e preditores de sucesso da alta hospitalar no mesmo dia apósintervenção coronária percutânea eletiva / Safety and predictors of same day discharge after elective percutaneous coronary intervention

Apesar de a alta hospitalar no mesmo dia (AHMD) após intervenção coronária percutânea(ICP) eletiva não complicada ser adotada mundialmente, ela permanece pouco estudada em nosso meio.Objetivamos, assim, avaliar nossa experiência inicial com a AHMD após ICP eletiva, em relação à suas egurança e aos preditores de sucesso. Métodos: Foram incluídos 161 pacientes consecutivos para AHMD, de único centro, selecionados em ambulatório especializado. Para a identificação dos fatores associados ao sucesso da AHMD, foram ajustados modelos de regressão logística simples e múltipla. Resultados: A AHMD foi realizada com sucesso em 114 pacientes (70,8%), tendo os 47 pacientes restantes permanecido internados (45 com alta na manhã seguinte e 2 pacientes após 2 dias). Nenhum paciente com AHMD apresentou evento cardíaco adverso maior ou complicação vascular importante aos 30 dias e no seguimento mediano de 12 meses. No grupo internação, ocorreu apenas um caso de infarto agudo do miocárdio por oclusão de ramo lateral e dois hematomas > 5 cm relacionados ao sítio de punção. Os preditores de sucesso da AHMD foram: via de acesso radial (OR = 5,92; IC95% 1,73-20,21; p = 0,005), presença de lesões tipo A/B1 (OR = 14,09; IC95% 1,70-116,49; p = 0,01) e volume de contraste (OR = 0,76;IC95% 0,65-0,88; p < 0,001). Conclusões: A AHMD foi segura e pôde ser realizada com sucesso na maioria dos pacientes selecionados para ICP eletiva, sendo seus preditores de sucesso o acesso radial, as lesões menos complexas e um volume menor de contraste...

Background: Although same-day discharge (SDD) after elective uncomplicated percutaneous coronary intervention (PCI) be adopted worldwide, it remains poorly studied in our country. We aim to evaluate our initial experience with SDD after elective PCI, regarding its safety and predictors of success. Methods: A hundred and sixty-one single-center consecutive patients, selected in a specialized out patient clinic, were included for SDD. To identify the factors associated with SDD, single and multiple logistic regression models were adjusted. Results: SDD was successfully performed in 114 patients (70.8%) and the remaining 47 patients remained hospitalized (45 with discharge in the following morning and 2 patients after 2 days). No patient with SDD presented major adverse cardiac events or major vascular complications at 30 days or at a median follow-up of 12 months. In the inpatient group, there was only one case of acute myocardial infarction due to a lateral branch occlusion and two patients with > 5 cm hematoma related to the access site. The SDD predictors were radial access route (OR = 5.92; 95%CI 1.73-20.21; p = 0.005), presence of type A/B1 lesions(OR = 14.09; 95%CI 1.70-116.49%; p = 0.01) and contrast volume (OR = 0.76; 95%CI 0.65-0.88; p < 0.001). Conclusions: SDD was safe and could be successfully performed in most patients selected for elective PCI, and its predictors were the radial access, less complex coronary lesions and a and lower contrast volume...

The influence of aerobic fitness status on ventilatory efficiency in patients with coronary artery disease

OBJECTIVE: To test the hypotheses that 1) coronary artery disease patients with lower aerobic fitness exhibit a lower ventilatory efficiency and 2) coronary artery disease patients with lower initial aerobic fitness exhibit greater improvements in ventilatory efficiency with aerobic exercise training. METHOD: A total of 123 patients (61.0±0.7 years) with coronary artery disease were divided according to aerobic fitness status into 3 groups: group 1 (n = 34, peak VO2<17.5 ml/kg/min), group 2 (n = 67, peak VO2>17.5 and <24.5 ml/kg/min) and group 3 (n = 22, peak VO2>24.5 ml/kg/min). All patients performed a cardiorespiratory exercise test on a treadmill. Ventilatory efficiency was determined by the lowest VE/VCO2 ratio observed. The exercise training program comprised moderate-intensity aerobic exercise performed 3 times per week for 3 months. Clinicaltrials.gov: NCT02106533 RESULTS: Before intervention, group 1 exhibited both lower peak VO2 and lower ventilatory efficiency compared with the other 2 groups (p<0.05). After the exercise training program, group 1 exhibited greater improvements in aerobic fitness and ventilatory efficiency compared with the 2 other groups (group 1: ▵ = -2.5±0.5 units; group 2: ▵ = -0.8±0.3 units; and group 3: ▵ = -1.4±0.6 units, respectively; p<0.05). CONCLUSIONS: Coronary artery disease patients with lower aerobic fitness status exhibited lower ventilatory efficiency during a graded exercise test. In addition, after 3 months of aerobic exercise training, only the patients with initially lower levels of aerobic fitness exhibited greater improvements in ventilatory efficiency. .

Impacto inicial de uma clínica de insuficiência cardíaca em hospital cardiológico privado / Initial impact of a disease management program on heart failure in a private cardiology hospital

Fundamentos: A insuficiência cardíaca ainda leva a hospitalizações frequentes apesar dos notáveis avanços terapêuticos. Programas que monitoram e otimizam cuidados têm potencial para melhorar o controle desses pacientes apesar de evidências ainda controversas quanto ao seu real benefício. Objetivos: Caracterizar a população incluída em clínica de insuficiência cardíaca e avaliar a hipótese de benefícios a curto prazo (seis meses). Métodos: Estudo prospectivo que avaliou pacientes hospitalizados com insuficiência cardíaca em hospital privado cardiológico de janeiro a dezembro 2012. Os pacientes foram estratificados em: Grupo 1 – pacientes pré-Programa de cuidados (feito apenas registro de dados); Grupo 2 – pacientes pós-Programa (registro dos mesmos dados junto com intervenções educativas feitas pelo programa de cuidados da Clínica de Insuficiência Cardíaca). Analisadas características da população, indicadores de qualidade e desfechos clínicos. Resultados: Avaliados 762 pacientes, média de idade 70,4±11,0 anos, 56,0 % do sexo masculino. Fração de ejeção reduzida observada em 65,0 %, perfil hemodinâmico B em 66,0 %, etiologia isquêmica em 52,0 % e infecção como fator de descompensação em 29,0 % dos casos. Desfechos analisados nos Grupos 1 e 2, respectivamente: re-hospitalização em 30 dias (13,0 % vs. 9,0 %; p=0,10); tempo médio de hospitalização (9,0 dias vs. 8,4 dias; p=0,4); descompensação por má aderência (17,0 % vs. 10,0 %; p=0,004); mortalidade hospitalar (9,0 % vs. 8,0 %; p=0,7).

Background: Heart failure still leads to frequent hospitalizations despite notable therapeutic advances. Programs that monitor and optimize care have the potential to enhance control of these patients, although evidence of their real benefits is still controversial. Objectives: To describe the population with heart failure included in a Clinical Care Program, assessing the hypothesis of short-term benefits (6 months). Methods: Prospective study assessing heart failure patients in a private cardiology hospital from January to December 2012, divided into two groups: Group 1 – pre-Care Program patients with only data recorded; Group 2 – post-Care Program patients with the same data recorded, together with educational interventions through the Care Program run by the Heart Failure Clinic. The demographic characteristics of the population were analyzed, together with quality indicators and clinical outcomes. Results: Among the 762 patients assessed, the mean age was 70.4±11.0 years, with 56.0% male. Reduced ejection fraction was noted in 65.0%, hemodynamic profile B in 66.0%, ischemic etiology in 52.0% and infection as a decompensation factor in 29.0% of cases. The outcomes analyzed in Groups 1 and 2 were, respectively: hospital readmissions within 30 days (13.0% vs. 9.0%; p=0.1); average length of stay (9.0 days vs. 8.4 days, p=0.4); decompensation due to poor compliance (17.0% vs. 10.0%; p=0.004); and in-hospital mortality (9.0% vs. 8.0%; p=0.7).

Evaluation of the Society of Thoracic Surgeons score system for isolated coronary bypass graft surgery in a Brazilian population / Avaliação dos escores da Society of Thoracic Surgeons para cirurgia de revascularização miocárdica isolada em uma população brasileira

Objective: Report the experience with the Society of Thoracic Surgeons scoring system in a Brazilian population submitted to isolated coronary artery bypass graft surgery. Methods: Data were collected from January-2010 to December-2011, and analyzed to determine the performance of the Society of Thoracic Surgeons scoring system on the determination of postoperative mortality and morbidity, using the method of the receiver operating characteristic curve as well as the Hosmer-Lemeshow and the Chi-square goodness of fit tests. From the 1083 cardiac surgeries performed during the study period 659 represented coronary artery bypass graft procedures which are included in the present analysis. Mean age was 61.4 years and 77% were men. Results: Goodness of fit tests have shown good calibration indexes both for mortality (X2=6.78, P=0.56) and general morbidity (X2=6.69, P=0.57). Analysis of area under the ROC-curve (AUC) demonstrated a good performance to detect the risk of death (AUC 0.76; P<0.001), renal failure (AUC 0.79; P<0.001), prolonged ventilation (AUC 0.80; P<0.001), reoperation (AUC 0.76; P<0.001) and major morbidity (AUC 0.75; P<0.001) which represents the combination of the assessed postoperative complications. STS scoring system did not present comparable results for short term hospital stay, prolonged length of hospital stay and could not be properly tested for stroke and wound infection. Conclusion: Society of Thoracic Surgeons scoring system presented a good calibration and discrimination in our population to predict postoperative mortality and the majority of the harmful events following coronary artery bypass graft surgery. Analysis of larger samples might be needed to further validate the use of the score system in Brazilian populations. .

Objetivo: Relatar a experiência com o "Society of Thoracic Surgeons scoring system" em uma amostra de pacientes da população brasileira submetida a cirurgia de revascularização miocárdica isolada. Métodos: Foram coletados dados de janeiro de 2010 até dezembro de 2011 e analisados para determinar o desempenho do "Society of Thoracic Surgeons scoring system" na determinação de mortalidade e morbidade pós-operatória, utilizando o método da característica de operação do receptor (ROC-curve) e tes tes Chi-quadrado e Hosmer-Lemeshow para qualidade de ajus te. Das 1083 cirurgias cardíacas realizadas durante o período de estudo, 659 foram cirurgias de revascularização miocárdica que são aqui analisadas. A idade média foi de 61,4 anos e 77% dos pacientes eram homens. Resultados: Testes de bondade de ajustamento demonstraram boa calibração tanto para mortalidade (X2=6,78, P=0,56) quanto para morbidade geral (X2=6,69, P=0,57). A análise da área sob a curva ROC (AUC) demonstrou bom desempenho para detectar o risco de morte (AUC 0,76; P<0,001), insuficiência renal (AUC 0,79; P<0,001), ventilação prolongada (AUC 0,80; P<0,001), reoperação (AUC 0,76; P<0,001) e morbidade maior (AUC 0,75; P<0.001) que representa a combinação das complicações avaliadas. O escore Society of Thoracic Surgeons não apresentou resultados comparáveis para internação de curta duração, internação hospitalar prolongada e não pôde ser adequadamente testado para acidente vascular cerebral e infecção de ferida operatória. Conclusão: O sistema de escore Society of Thoracic Surgeons apresentou boa calibração e discriminação em nossa população para a predição de mortalidade p...

Implantação de protocolo institucional para o uso racional de hemoderivados e seu impacto no pós-operatório de cirurgias de revascularização miocárdica / Implementation of an institutional protocol for rational use of blood products and its impact on postoperative of coronary artery bypass graft surgery

OBJETIVO: Cirurgias cardíacas são, por vezes, acompanhadas de perdas sanguíneas significativas, e transfusões de sangue podem ser necessárias. No entanto, o uso indiscriminado de hemoderivados pode resultar em efeitos danosos para o paciente. Neste estudo, avaliamos os efeitos imediatos da implantação de um protocolo para o uso racional de hemoderivados no perioperatório de cirurgias de revascularização miocárdica. MÉTODOS: Entre os meses de abril e junho de 2011, foi implementado um protocolo institucional em um hospital privado especializado em cardiologia com a anuência e a colaboração de sete equipes de cirurgia cardíaca, visando ao uso racional de hemoderivados. Foram verificados dados clínicos e demográficos dos pacientes, e avaliados o uso de hemoderivados e os desfechos clínicos no período intra-hospitalar, antes e após a implantação do protocolo. O protocolo consistiu em uma campanha institucional junto às equipes cirúrgicas, de anestesiologia e intensivistas, para difundir a prática do uso de hemoderivados com base em critérios clínicos objetivos (anemia com repercussões hemodinâmicas e disfunção ventricular significativa), bem como tornar rotineira a prescrição de ácido epsilon-aminocaproico no intraoperatório, que é prática recomendada por diretrizes internacionais baseadas em evidência científica. RESULTADOS: Após os 3 meses de implantação do protocolo, houve aumento do uso de ácido epsilon-aminocaproico de 31% para 100%. Antes da implantação do protocolo, 67% das cirurgias utilizaram alguma transfusão sanguínea; após a implantação, 40% das cirurgias necessitaram de alguma transfusão sanguínea nos meses subsequentes do mesmo ano (p<0,001). Não houve diferença significativa nos desfechos clínicos avaliados antes e após implantação do protocolo. CONCLUSÃO: O uso racional de hemoderivados, associado à infusão do ácido epsilon-aminocaproico, tem o potencial de reduzir o número de hemotransfusões no perioperatório de cirurgias cardíacas...

OBJECTIVE: Cardiac surgeries are sometimes followed by significant blood loss, and blood transfusions may be necessary. However, indiscriminant use of blood components can result in detrimental effects for the patient. We evaluated the short-term effects of implementation of a protocol for the rational use of blood products in the perioperative period of cardiac surgery. METHODS: Between April and June 2011, an institutional protocol was implemented in a private hospital specializing in cardiology to encourage rational use of blood products, with the consent and collaboration of seven cardiac surgery teams. We collected clinical and demographic data on the patients. The use of blood products and clinical outcomes were analyzed during hospital stay before and after protocol implementation. The protocol consisted of an institutional campaign with an educational intervention to surgical and anesthesiology teams; the goal was to tailor blood transfusion practice according to clinical goals (anemia with hemodynamic changes and significant ventricular dysfunction) and to make routine the prescription of å-aminocaproic acid intraoperatively, which is recommended by international guidelines based on scientific evidence. RESULTS: After three months of protocol implementation, the use of å-aminocaproic acid increased from 31% to 100%. A total of 67% of surgeries before protocol implementation required any blood transfusion, compared with 40% that required any blood transfusion after protocol implementation in subsequent months of the same year (p<0.001). There was no significant difference in clinical outcomes assessed before and after implementation of the protocol. CONCLUSION: The rational use of blood products associated with infusion of å-aminocaproic acid has the potential to reduce the number of blood transfusions in perioperative of cardiac surgeries, but it can affect the risk of complications.

Effect of continuous and interval exercise training on the PETCO2 response during a graded exercise test in patients with coronary artery disease

OBJECTIVE: The purpose of this study was to evaluate the following: 1) the effects of continuous exercise training and interval exercise training on the end-tidal carbon dioxide pressure (PETCO2) response during a graded exercise test in patients with coronary artery disease; and 2) the effects of exercise training modalities on the association between PETCO2 at the ventilatory anaerobic threshold (VAT) and indicators of ventilatory efficiency and cardiorespiratory fitness in patients with coronary artery disease. METHODS: Thirty-seven patients (59.7 + 1.7 years) with coronary artery disease were randomly divided into two groups: continuous exercise training (n = 20) and interval exercise training (n = 17). All patients performed a graded exercise test with respiratory gas analysis before and after three months of the exercise training program to determine the VAT, respiratory compensation point (RCP) and peak oxygen consumption. RESULTS: After the interventions, both groups exhibited increased cardiorespiratory fitness. Indeed, the continuous exercise and interval exercise training groups demonstrated increases in both ventilatory efficiency and PETCO2 values at VAT, RCP, and peak of exercise. Significant associations were observed in both groups: 1) continuous exercise training (PETCO2VAT and cardiorespiratory fitness r = 0.49; PETCO2VAT and ventilatory efficiency r = -0.80) and 2) interval exercise training (PETCO2VAT and cardiorespiratory fitness r = 0.39; PETCO2VAT and ventilatory efficiency r = -0.45). CONCLUSIONS: Both exercise training modalities showed similar increases in PETCO2 levels during a graded exercise test in patients with coronary artery disease, which may be associated with an improvement in ventilatory efficiency and cardiorespiratory fitness.

Comparação das vias radial e femoral nas intervenções coronárias percutâneas: resultados do registro TotalCor / Comparison of radial vs. femoral access in percutaneous coronary interventions: outcomes of the TotalCor registry

Introdução: A intervenção coronária percutânea (ICP) por via radial ainda é pouco utilizada em nosso meio. O objetivo do presente estudo foi avaliar a prevalência e os resultados da ICP por via radial, comparada à via femoral, em uma população do mundo real. Métodos: Registro unicêntrico, com 507 pacientes consecutivos submetidos a ICP pelas vias radial (n = 121) e femoral (n = 386), de acordo com a escolha do operador. Resultados: Os pacientes que utilizaram a via radial (23,9%) eram mais frequentemente do sexo masculino (78,5% vs. 69,9%; P = 0,07) e tabagistas (19,8% vs. 11,7%; P = 0,02), com maior prevalência de lesões uniarteriais (59,5% vs. 46,4%), tipo A/B1 (39% vs. 28,4%) e com função ventricular preservada (87,1% vs. 73%; P < 0,01). Nesse grupo foram utilizados stents de maior diâmetro e menor comprimento. O sucesso do procedimento foi elevado (97,3% vs. 96,3%; P = 0,56) e a incidência de óbito foi baixa, não diferindo entre os grupos (0,8% vs. 0,8%; P = 0,96), assim como as taxas de infarto do miocárdio (2,5% vs. 2,1%; P = 0,73). Não ocorreram revascularizações do vaso-alvo de urgência. Os pacientes tratados pela via radial permaneceram menos tempo internados (1 dia vs. 2 dias; P = 0,02) e não apresentaram complicações vasculares (0 vs. 3,4%; P = 0,045). Conclusões: A utilização da ICP por via radial representa o dobro da média nacional na instituição em que o estudo foi realizado, e a escolha de pacientes para essa técnica trouxe resultados do procedimento equivalentes aos da via femoral, nenhuma complicação vascular, e reduziu à metade o tempo de internação hospitalar.

BACKGROUND: In our country radial access is still underused in percutaneous coronary interventions (PCI). The objective of this study was to evaluate the prevalence and compare radial to femoral vascular access for PCI in a real-world population. METHODS: Single center registry, with 507 consecutive patients undergoing PCI by radial (n = 121) and femoral (n = 386) access, according to the operator's choice. RESULTS: Patients using radial access (23.9%) were more often male (78.5% vs. 69.9%; P = 0.07) and smokers (19.8% vs. 11.7%; P = 0.02), had a higher prevalence of single-vessel disease (59.5% vs. 46.4%), type A/B1 (39% vs. 28.4%) lesions and had preserved ventricular function (87.1% vs. 73%; P < 0.01). Larger diameter and shorter stents were used in this group. Procedure success was high (97.3% vs. 96.3%; P = 0.56), the incidence of death was low and was not different between groups (0.8% vs. 0.8%; P = 0.96), as well as myocardial infarction rates (2.5% vs. 2.1%; P = 0.73). There were no urgent target-vessel revascularizations. Patients treated by the radial approach had a shorter hospitalization period (1 day vs. 2 days; P = 0.02) and did not have vascular complications (0 vs. 3.4%; P = 0.045). CONCLUSIONS: The use of radial access for PCI in our institution is twice the national average and the choice of patients for this technique provided similar results to those obtained by the femoral approach, no vascular complications and halved patients' average stay in hospital.