Revascularization strategies in STEMI and multivessel disease.

INTRODUCTION: The main treatment for ST-elevation myocardial infarction (STEMI) is the re-establishment of the coronary flow of infarct-related arteries. However, 50% of cases present multivessel disease (MVD), negatively affecting mortality. Complete revascularization (CR) is currently advocated since it reduces major adverse cardiovascular events (MACE). OBJECTIVE: Evaluation of the adopted revascularization strategy and its prognostic value in a Portuguese cohort of STEMI patients with MVD. MATERIAL AND METHODS: Retrospective analysis of patients admitted with STEMI included in the Portuguese Registry of Acute Coronary Syndromes between 2010 and 2019. Patients were divided in two groups regarding revascularization strategy (complete versus incomplete) and compared. Independent predictors of a composite of all-cause mortality and rehospitalization for cardiovascular causes were assessed by multivariate logistic regression. RESULTS: A total of 3500 patients were included. A CR strategy was performed in 21.8% of patients, who were younger and healthier. They also presented more hemodynamically stable and had less kidney dysfunction and anaemia. Their coronary anatomy was less complex, with a higher prevalence of 2-vessel and a lower proportion of chronic occlusions. In-hospital and 1-year adverse events were less frequent between patients with CR. CONCLUSION: In hemodynamically stable STEMI patients, CR substantially reduced in-hospital and 1-year all-cause mortality and MACE.

Acute coronary syndrome and stress: Is there a relationship?

INTRODUCTION: Acute coronary syndrome (ACS) is the result of a complex pathophysiological process with various dynamic factors. The 10-item Perceived Stress Scale (PSS-10) is a validated instrument for estimating stress levels in clinical practice and may be useful in the assessment of ACS. METHODS: We carried out a single-center prospective study engaging patients hospitalized with ACS between March 20, 2019 and March 3, 2020. The PSS-10 was completed during the hospitalization period. The ACS group was compared to a control group (the general Portuguese population), and a subanalysis in the stress group were then performed. RESULTS: A total of 171 patients with ACS were included, of whom 36.5% presented ST-elevation myocardial infarction (STEMI), 38.1% were female and the mean PSS score was 19.5±7.1. Females in the control group scored 16.6±6.3 on the PSS-10 and control males scored 13.4±6.5. The female population with ACS scored 22.8±9.8 on the PSS-10 (p<0.001). Similarly, ACS males scored a mean of 17.4±6.4 (p<0.001). Pathological stress levels were not a predictor of major adverse cardiovascular events or severity at admission. CONCLUSIONS: ACS patients had higher perceived stress levels compared to the control group. Perceived stress level was not associated with worse prognosis in ACS patients.

The National Response to Patients with Acute Coronary Syndrome during the First Wave of the COVID-19 Pandemic in Portugal.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led to changes in healthcare institutions and medical assistance. Non-SARS-CoV-2 related diseases were indirectly affected by the pandemic. Nonetheless, their treatment remains crucial. Cardiovascular conditions such as acute coronary syndrome (ACS) are common, and it was necessary to adjust medical assistance to these diseases during the pandemic. This study aimed to assess the national impact and healthcare system response during the first wave of the pandemic in patients admitted for ACS. MATERIAL AND METHODS: Multicenter retrospective study based on the Acute Coronary Syndrome Portuguese National Registry between the 1st January 2016 and the 28th February 2021. Two groups were defined: the previous year to the SARS-CoV-2 pandemic (March, April, May and June 2019) (952 patients) and the first wave of the pandemic (March, April, May and June 2020) (642 patients). Clinical course, time until reperfusion, in-hospital outcomes and follow-up at one year were compared between both periods. RESULTS: There was a lower incidence of ACS between March and June 2020 compared with the same period in 2019, with a reduction of 32.6%. There were no statistically significant differences between the two periods regarding patient demographic characteristics (except for a higher prevalence of familiar cardi vascular history and chronic obstructive pulmonary disease in 2020 and higher prevalence of diabetes in 2019), clinical features, clinical management, in-hospital major adverse cardiac events, mortality and readmission at one-year follow-up. There was a trend towards longer delays until reperfusion, yet without statistical significance. The patients that developed ACS during the first wave of the SARS-CoV-2 pandemic were less often referred to percutaneous coronary intervention centers (p = 0.034) and were more frequently transferred to another hospital (p < 0.001). CONCLUSION: During the first wave of the SARS-CoV-2 pandemic there was a nationwide reduction in demand of healthcare services due to ACS events. Even though the Portuguese healthcare system was under strain and forced to divert resources and medical assistance towards the pandemic management, it was capable of responding adequately to ACS.

Prognostic value of brain natriuretic peptide in ST-elevation myocardial infarction patients: A Portuguese registry.

INTRODUCTION: Brain natriuretic peptide (BNP) is a highly sensitive and specific biomarker for the extent of myocardial infarction that is strongly related to short- and long-term prognosis in patients with acute coronary syndromes. OBJECTIVE: To assess the prognostic value of BNP levels in a Portuguese cohort of ST-elevation myocardial infarction (STEMI) patients. METHODS: We performed a retrospective analysis of patients admitted with STEMI included in the Portuguese Registry of Acute Coronary Syndromes (ProACS) between 2010 and 2019. Patients were divided into three groups according to BNP level (<100 pg/ml, 100-399 pg/ml and ≥400 pg/ml) and compared. Independent predictors of a composite of all-cause mortality and rehospitalization for cardiovascular causes were assessed by multivariate logistic regression. For sample homogenization, propensity score matching and pairwise matching with a tolerance level of 0.005 were performed. RESULTS: A total of 1650 patients were included, of whom 21.5% presented high BNP levels (≥400 pg/ml). These were older and had more comorbidities, lower admission systolic blood pressure and hemoglobin, higher heart rate, Killip class and creatinine, worse left ventricular systolic function and severe coronary anatomy. Higher BNP was associated with more in-hospital complications, in-hospital mortality and adverse outcomes at one year. CONCLUSION: BNP levels during the index hospitalization were a powerful prognostic biomarker for all-cause mortality and major adverse cardiac events in patients admitted with STEMI to Portuguese hospitals.

Early and late new-onset of atrial fibrillation in acute coronary syndromes: Their differences in mortality and cardiac event.

Background: In a stressful situation like acute coronary syndrome (ACS), the occurrence of the first episode of atrial fibrillation is more frequent. The impact of the timing occurrence of AF new-onset (nAF) in the setting of ACS is still debatable. Methods: Multicenter retrospective study based on the Acute Coronary Syndrome Portuguese National Registry, including 29 851 patients admitted for ACS between 1/10/2010 and 4/09/2019. The group with early nAF - nAF in the first 48 h of hospitalization; and late nAF - patients with nAF after the first 48 h of in-hospital admission. Results: New-onset AF was identified in 1067 patients, nonetheless, just 38.1% had late nAF. The group with late nAF presented more cardiovascular comorbidities and worse left ventricular ejection fraction. Late nAF patients received more anti-arrhythmic therapy, and early nAF had a higher beta-block prescription. Early nAF had higher rates of in-hospital complications, on the other hand, late nAF group exhibited more mortality and readmission at one year follow-up. Multiple logistic regression revealed that symptoms onset to the first medical contact time, admission hemoglobin <12 g/dl, right bundle branch block at admission, and diuretic therapy during the hospitalization for ACS were predictors of late nAF in ACS. Conclusions: The ACS population could be divided by the timing of nAF occurrence into the two groups with different characteristics, therapeutic approaches, and outcomes. Late nAF patients had a worse prognosis at 1 year follow-up, however, the early nAF group had more major adverse cardiac events during the hospitalization for ACS.

A systemic review of endocardial left ventricular pacing.

BACKGROUND: Endocardial left ventricular pacing is an alternative technique used in cardiac resynchronization therapy (CRT), when placement of a left ventricular lead is not possible via the coronary sinus or in non-responders to conventional CRT. OBJECTIVES: To review the evidence regarding the efficacy and safety of endocardial left ventricular pacing. METHODS: Systematic research on Medline (PubMed), ClinicalTrials.gov and Embase with the terms "endocardial left ventricular pacing", "biventricular pacing" or "endocardial left pacing" was performed with the identification of 1038 results. Eleven studies with endocardial left ventricular pacing patients were included, independent of the technique being applied to naïve CRT patients or con non-responders to conventional CRT. The end-point of this analysis was the impact of endocardial left ventricular pacing techniques regarding New York Heart Association (NYHA) functional classification, left ventricular ejection fraction (LVEF) and QRS width, and the occurrence of complications Mean differences (MD) and confidence interval (CI) was used as a measurement of treatment. RESULTS: A total of 560 patients were included, with different techniques used (trans-atrial septal technique, trans-ventricular septal technique and transapical technique). Significant improvement was registered in NYHA class (MD 0.73, CI 0.48-0.98, p<0.00001, I2 = 87%), LVEF (MD -7.63, CI -9.93 - -5.33, p<0.00001, I2 = 69%) and QRS width (MD 29.25, CI 9.99-48.50, p<0.00001, I2 = 91%). Several complications were reported after the procedure, 11 pocket infections, 22 transient ischemic attacks, 18 ischemic strokes, 41 thromboembolic events, among other complications. The mortality rate during the follow-up was 20.54%. CONCLUSION: Left ventricular endocardial pacing is a feasible alternative to conventional CRT, with clinical, electrocardiographic and echocardiogrphic improvement. However, first data regarding this procedure was associated with significant complications rates.

High-grade atrioventricular block in acute coronary syndrome: Portuguese experience.

BACKGROUND: The high-grade atrioventricular block (HAVB) occurrence in acute coronary syndrome (ACS) is a potentially life-threatening complication, that demands a rapid and efficient response regarding reperfusion time and rhythm stabilization. This study aimed to analyse the rate, clinical features, therapeutic approach, complications, in-hospital mortality and follow-up of HAVB in the setting of ACS. METHODS: Multicenter retrospective study based on the Acute Coronary Syndrome Portuguese National Registry, including 32157 patients admitted for ACS between 1/10/2010-3/05/2020, classified according to the presence or absence of HAVB during the hospitalization for ACS. Comparison between the two groups was performed. Logistic regression was accomplished to assess predictors of HAVB in ACS patients. RESULTS: Patients with HAVB were older, and had higher rates of females, history of stroke and neoplasia. HAVB patients presented more frequently ST-segment elevation myocardial infarction, syncope as a major symptom, higher Killip-Kimball class and multivessel disease. Furthermore, HAVB patients had more major adverse cardiac events during the hospitalization for ACS, namely heart failure complication, cardiogenic shock complication, new-onset of atrial fibrillation, ACS mechanical complication, sustained ventricular tachycardia, cardiac arrest, stroke complication and in-hospital death. Logistic regression revealed that female gender, age ≥ 75 years old, heart rate < 60 and Killip-Kimball class > I were predictors of HAVB in ACS patients. Also, HAVB patients presented higher rates of all-causes of death at 1-year follow-up (p = 0.011). CONCLUSIONS: Using real-life data, patients with HAVB in the setting of ACS had a worse prognosis during hospitalization and in the short-term follow-up period.

An inappropriate shock after reprogramming tachycardia zones.

A patient with an implantable cardioverter-defibrillator (ICD) (Abbott®) had episodes of slow monomorphic ventricular tachycardia (VT) and his ICD was programmed with three tachycardia zones. During the follow-up, he received an inappropriate shock. Upon interrogation (of the device), trigeminal pattern binned as ventricular sensing (VS)-VS-ventricular fibrillation (VF) was detected. VF was assumed according to binning system. When VF is present, discrimination algorithms are not available and five consecutive sinus beats are necessary to reset binning system. Catheter ablation was performed to treat VT in order to reprogram tachycardia zones.

[Depression and suicidal ideation in elderly institutionalized and non-institutionalized in Portugal]. / Depressão e ideação suicida em idosos institucionalizados e não institucionalizados em Portugal.

INTRODUCTION/OBJECTIVES: Depression has shown as the more common mental disorder in elderly community and suicide is it worst consequence. In the Portuguese context suicide rates among the elderly take values higher than in other age groups. The present study aimed to compare elderly institutionalized and not institutionalized in terms of depression, suicidal ideation, dependency and leisure activities. MATERIAL AND METHODS: The sample was collected in Algarve, Alentejo and Lisbon, in 155 elderly, 85 institutionalized and 71 not institutionalized, with similar proportions between genders. The instruments were The Activity and Leisure Index (IAL), the Geriatric Depression Scale (GDS), The Barthel Index and the Beck Scale for Suicide Ideation (BSI). RESULTS: The results showed that the elderly institutionalized did not presented higher depression, loneliness, suicidal thoughts or lowest level of activity and leisure, but were less independent. The participants with highest suicidal thoughts had more depression. A self-perception of worse health and more loneliness were related with more depression. A higher activity and leisure was related with less suicidal ideation. CONCLUSIONS: The data seem to show that the institutionalization of elderly is not related negatively with depression and suicidal ideation.

Does orthostatic hypotension predict the occurrence of nocturnal arterial hypertension in the elderly patient?

OBJECTIVE: To determine whether the presence of orthostatic hypotension--which, in this age-group, could be due to varying degrees of autonomic dysfunction--is an indicator of nocturnal arterial hypertension. PATIENTS: Between 1999 and 2001 we prospectively and consecutively studied 93 elderly patients with untreated (office) arterial hypertension, 65 (70%) of whom were true hypertensives according to 24 h ambulatory blood pressure monitoring (ABPM). INTERVENTIONS: The patients were studied by clinical examination including blood pressure (BP) measurement in dorsal decubitus and orthostatic position, 24 h ABPM, evaluation of vascular distensibility by carotid-femoral pulse wave velocity (PWV) and Doppler echocardiography. For this study we analyzed especially the ambulatory behavior of BP, so we could relate the variation of systolic blood pressure (SBP) during orthostatism with non-dipper status for SBP and absolute nocturnal values of SBP. MEASUREMENTS AND RESULTS: The results indicated that a greater decrease of blood pressure with orthostatism corresponded to a greater probability of nocturnal hypertension (p = 0.005) and of non-dipper status (p = 0.02). These results are in agreement with those subsequently found by other authors (Kario et al., 2002). CONCLUSIONS: In this way, by means of a simple clinical maneuver that should always be performed in an elderly hypertensive patient, we can suspect the presence of nocturnal hypertension--which is a high-risk cardiovascular situation--and use this information to help select patients to undergo 24 hour-ABPM.

[Pulmonary hypertension. Topic review. 2 clinical cases]. / Hipertensão pulmonar. Revisão do tema. A propósito de dois casos clínicos.

The authors describe two cases of pulmonary hypertension (PHT). In the first case it is secondary to pulmonary thromboembolism, a frequent and serious occurrence, witch is well known as a cause of PHT. In the second case the PHT is probably secondary to infection by human immunodeficiency virus, also a serious and frequent condition in clinical practice but which was only recently identified as a cause of PHT. Formerly these patients were considered as suffering from primary PHT. The authors make a brief review of the literature on pulmonary hypertension.