Cardiovascular Statistics from the Good Practices in Cardiology Program - Data from a Brazilian Tertiary Public Hospital. / Estatísticas Cardiovasculares do Programa Boas Práticas em Cardiologia ­ Dados de um Hospital Público Terciário Brasileiro.

BACKGROUND: The Good Practices in Cardiology Program is an initiative created by the Brazilian Society of Cardiology (SBC) to improve the quality of care of cardiovascular disease patients in Brazilian public hospitals. OBJECTIVES: To characterize patients admitted to a tertiary public hospital with diagnosis of acute coronary syndrome (ACS) or heart failure (HF) and to evaluate performance indicators in both ACS and HF arms, with a pre-established target of 85% adherence to the SBC recommendations. METHODS: This was a descriptive cross-sectional study through data collection of patients hospitalized between May 2016 and September 2019. RESULTS: A total of 1,036 patients were included, 273 in the HF arm and 763 in the ACS arm. Mean age was 59.8 ± 12.0 years in the ACS and 57.0 ± 14.1 years in the HF, with a predominance of male patients in both groups. More than half of patients had some primary education and more than 90% reported a monthly income of less than five minimum wages. In ACS, the diagnosis of ACS with ST segment elevation was predominant (66.3%), and 2.9% of patients died. In HF, the most common etiology was Chagas disease (25.8%), and 17.9% died. Analysis of the performance indicators revealed an adherence rate higher than 85% to nine of the 12 indicators. CONCLUSION: Quality programs are essential for improvement of quality of care. Performance indicators pointed to a good adherence to the SBC guidelines, mainly in the ACS arm.

FUNDAMENTO: O Programa Boas Práticas em Cardiologia é uma iniciativa da Sociedade Brasileira de Cardiologia (SBC) destinada à melhoria do cuidado cardiovascular nos hospitais públicos brasileiros. OBJETIVOS: Descrever características dos pacientes internados com Síndrome Coronariana Aguda (SCA) e Insuficiência Cardíaca (IC) e avaliar os indicadores de desempenho alcançados nos braços (SCA e IC) em um hospital público terciário, com uma meta pré-estabelecida de 85% de aderência às recomendações da SBC. MÉTODOS: Estudo do tipo transversal descritivo realizado por meio da coleta de dados de pacientes que estiveram internados entre maio de 2016 e setembro de 2019. RESULTADOS: Foram incluídos 1036 pacientes, 273 pacientes no braço IC e 763 no braço SCA. A média de idade foi de 59,8 ± 12,0 anos na SCA e 57,0 ± 14,1 anos na IC, com predomínio do sexo masculino em ambos os grupos. Mais da metade dos pacientes não tinham ensino fundamental completo e mais de 90% declararam renda mensal inferior a cinco salários-mínimos. Na SCA, predominou o diagnóstico de SCA com supradesnivelamento do segmento ST (66,3%) e 2,9% dos pacientes foram a óbito. Na IC, a etiologia mais comum foi a Doença de Chagas (25,8%) e 17,9% dos pacientes foram a óbito. Na avaliação dos indicadores de desempenho, nove dos 12 indicadores tiveram taxas de aderência acima de 85%. CONCLUSÃO: Programas de qualidade são essenciais à melhoria do cuidado e os indicadores de desempenho do hospital apontam para uma boa adesão às diretrizes assistenciais da SBC, particularmente no braço da SCA.

Estatísticas Cardiovasculares do Programa Boas Práticas em Cardiologia - Dados de um Hospital Público Terciário Brasileiro / Cardiovascular Statistics from the Good Practices in Cardiology Program - Data from a Brazilian Tertiary Public Hospital

Resumo Fundamento O Programa Boas Práticas em Cardiologia é uma iniciativa da Sociedade Brasileira de Cardiologia (SBC) destinada à melhoria do cuidado cardiovascular nos hospitais públicos brasileiros. Objetivos Descrever características dos pacientes internados com Síndrome Coronariana Aguda (SCA) e Insuficiência Cardíaca (IC) e avaliar os indicadores de desempenho alcançados nos braços (SCA e IC) em um hospital público terciário, com uma meta pré-estabelecida de 85% de aderência às recomendações da SBC. Métodos Estudo do tipo transversal descritivo realizado por meio da coleta de dados de pacientes que estiveram internados entre maio de 2016 e setembro de 2019. Resultados Foram incluídos 1036 pacientes, 273 pacientes no braço IC e 763 no braço SCA. A média de idade foi de 59,8 ± 12,0 anos na SCA e 57,0 ± 14,1 anos na IC, com predomínio do sexo masculino em ambos os grupos. Mais da metade dos pacientes não tinham ensino fundamental completo e mais de 90% declararam renda mensal inferior a cinco salários-mínimos. Na SCA, predominou o diagnóstico de SCA com supradesnivelamento do segmento ST (66,3%) e 2,9% dos pacientes foram a óbito. Na IC, a etiologia mais comum foi a Doença de Chagas (25,8%) e 17,9% dos pacientes foram a óbito. Na avaliação dos indicadores de desempenho, nove dos 12 indicadores tiveram taxas de aderência acima de 85%. Conclusão Programas de qualidade são essenciais à melhoria do cuidado e os indicadores de desempenho do hospital apontam para uma boa adesão às diretrizes assistenciais da SBC, particularmente no braço da SCA.

Abstract Background The Good Practices in Cardiology Program is an initiative created by the Brazilian Society of Cardiology (SBC) to improve the quality of care of cardiovascular disease patients in Brazilian public hospitals. Objectives To characterize patients admitted to a tertiary public hospital with diagnosis of acute coronary syndrome (ACS) or heart failure (HF) and to evaluate performance indicators in both ACS and HF arms, with a pre-established target of 85% adherence to the SBC recommendations. Methods This was a descriptive cross-sectional study through data collection of patients hospitalized between May 2016 and September 2019. Results A total of 1,036 patients were included, 273 in the HF arm and 763 in the ACS arm. Mean age was 59.8 ± 12.0 years in the ACS and 57.0 ± 14.1 years in the HF, with a predominance of male patients in both groups. More than half of patients had some primary education and more than 90% reported a monthly income of less than five minimum wages. In ACS, the diagnosis of ACS with ST segment elevation was predominant (66.3%), and 2.9% of patients died. In HF, the most common etiology was Chagas disease (25.8%), and 17.9% died. Analysis of the performance indicators revealed an adherence rate higher than 85% to nine of the 12 indicators. Conclusion Quality programs are essential for improvement of quality of care. Performance indicators pointed to a good adherence to the SBC guidelines, mainly in the ACS arm.

Survival and Risk Factors Among Dialytic Acute Kidney Injury Patients After Cardiovascular Surgery.

OBJECTIVE: Acute kidney injury (AKI) is a frequent postoperative complication after cardiovascular surgery. It has been described as a predictor of decreased survival rates, but how dialysis decreases survival when initiated on the postoperative period has yet to be determined. To analyze the survival of patients who presented postoperative AKI requiring dialysis up to 30 days after cardiovascular surgery and its risk factors is the aim of this study. METHODS: Of the 5,189 cardiovascular surgeries performed in a 4-year period, 157 patients developed AKI requiring dialysis in the postoperative period. The Kaplan-Meier survival curve and log-rank test were used in the statistical analysis to compare the curves of categorical variables. P-value< 0.05 was considered significant. RESULTS: Patient average survival was 546 days and mortality was 70.7%. The need for dialysis on the postoperative period decreased late survival. Risk factors for decreased survival included age (P<0.001) and postoperative complications (P<0.0003). CONCLUSION: The average survival was approximately one year among dialytic patients. Age and postoperative complications were risk factors that determined decreased survival.

Survival and risk factors among dialytic acute kidney injury patients after cardiovascular surgery

Abstract Objective: Acute kidney injury (AKI) is a frequent postoperative complication after cardiovascular surgery. It has been described as a predictor of decreased survival rates, but how dialysis decreases survival when initiated on the postoperative period has yet to be determined. To analyze the survival of patients who presented postoperative AKI requiring dialysis up to 30 days after cardiovascular surgery and its risk factors is the aim of this study. Methods: Of the 5,189 cardiovascular surgeries performed in a 4-year period, 157 patients developed AKI requiring dialysis in the postoperative period. The Kaplan-Meier survival curve and log-rank test were used in the statistical analysis to compare the curves of categorical variables. P-value< 0.05 was considered significant. Results: Patient average survival was 546 days and mortality was 70.7%. The need for dialysis on the postoperative period decreased late survival. Risk factors for decreased survival included age (P<0.001) and postoperative complications (P<0.0003). Conclusion: The average survival was approximately one year among dialytic patients. Age and postoperative complications were risk factors that determined decreased survival.

Behavior of lyophilized biological valves in a chronic animal model.

Glutaraldehyde is used in order to improve the mechanical and immunogenic properties of biological tissues, such as bovine pericardium membranes, used to manufacture heart valve bioprostheses. Lyophilization, also known as freeze-drying, preserves biological material without damage by freezing the water content and removing ice by sublimation. Through this process, dehydrated products of high quality may be obtained; also, the material may be easily handled. The lyophilization process reduces aldehyde residues in biological tissue previously treated with glutaraldehyde, thus promoting reduction of cytotoxicity, increasing resistance to inflammation, and possibly decreasing the potential for tissue calcification. The objective of this study was to chronically evaluate the calcification of bovine pericardium heart valve prostheses, previously lyophilized or not, in an animal model. Six-month-old sheep received implants of lyophilized and unlyophilized heart valve prostheses in the pulmonary position with right bypass. The study followed 16 animals for a period of 90 days. Right ventricle-pulmonary artery (RV/PA) transvalvular pressure gradient was evaluated before and immediately after implantation and before explantation, as were tissue calcium, inflammation intensity, and thrombosis and pannus formation. The t-test was used for statistical analysis. Twelve animals survived to the end of the experiment, but one of the animals in the control group had endocarditis and was excluded from the data. Four animals died early. The mean RV/PA gradient on implantation was 2.0 ± 1.6 mm Hg in the control group and 6.2 ± 4.1 mm Hg in the lyophilized group (P = 0.064). This mean gradient increased at explantation to 7.7 ± 3.9 mm Hg and 8.6 ± 5.8 mm Hg, respectively (P = 0.777). The average calcium content in the tissue leaflets after 3 months was 21.6 ± 39.1 mg Ca(2+)/g dry weight in the control group, compared with an average content of 41.2 ± 46.9 mg Ca(2+)/g dry weight in the lyophilized group (P = 0.478). In this experimental study there was no reduction of calcification after lyophilization. However, histological analysis showed less inflammation over the lyophilized tissue when compared with the control.

In vitro and in vivo evaluation of lyophilized bioprosthetic valve.

Freeze-drying of biological tissues allows for dry storage and gamma ray sterilization, which may improve their use as a medical prosthesis. The objective of this study was to evaluate the rehydration characteristics and hydrodynamic performance of prosthetic valves before and after lyophilization. Two size 23 bovine pericardium aortic valve prostheses from different manufacturers were evaluated in a Shelhigh (Union, NJ, USA) pulse duplicator (80 ppm, 5 L/min) before and after lyophilization. Flow and transvalvular pressure gradient were registered in vitro and in vivo, and images of opening and closing of the prosthesis were obtained in the pulse duplicator in a digital camera. Rehydration was evaluated by comparison of dry valve weight with valve weight after 15 min, and 1, 24, 48, and 72 h in saline solution, inside the pulse duplicator. In vivo performance was assessed by surgical implantation in Santa Inês young male sheep in the pulmonary position after 30 min rehydration with 0.9% saline. Transvalvular pressure gradient and flow measurements were obtained immediately after implantation and 3 months after surgery when valves were explanted. Captured images showed a change in the profile opening and closing of valve prosthesis after lyophilization. The gradient measured (in vitro) in two valves was 17.08 ± 0.57 and 18.76 ± 0.70 mm Hg before lyophilization, and 34.24 ± 0.59 and 30.40 ± 0.97 mm Hg after lyophilization. Rehydration of both lyophilized valves was approximately 82%. Drying changed the profile of the opening and closing of valve prostheses, and increased on average by 83% the gradient in vitro tests. The result of the in vivo tests suggests maintaining pressure levels of the animal with the lyophilized prostheses within acceptable levels.

Effect of haematocrit on pump and kidney dysfunction after myocardial revascularization.

OBJECTIVE: Kidney dysfunction is a common complication after cardiac surgery. It occurs in 7 to 31% of the patients. The lowest haematocrit after cardiopulmonary bypass surgery (LHCT) has been identified as a risk factor for kidney dysfunction after cardiac surgery. The aim of this study is to determine whether different levels of haematocrit during cardiopulmonary bypass surgery are related to kidney dysfunction. METHODS AND RESULTS: A prospective study was conducted on consecutive adult patients undergoing myocardial revascularization. Preoperative renal function was assessed by baseline serum creatinine level (CrPre). Peak postoperative creatinine (CrPost) was defined as the highest daily in-hospital postoperative value. Peak fractional change in creatinine (% deltaCr) was defined as the difference between the CrPre and CrePost represented as a percentage of the preoperative value. The LHTC was defined as the lowest recorded haematocrit prior to weaning from the initial pump run. A category variable was created for haematocrit based on the distribution of values. The category variable had the following cut-off points: less than 23%, 23.1 to 28% and greater than 28.1%. Lowest haematocrit (26.62 +/- 4.15%), CPB (74.71 +/- 24.90 min), CrPre (1.23 +/- 0.37 mg/dl) and highest CrPost (1.52 +/- 0.47 mg/dl) data varied in near-normal fashion. Statistical significance has been observed in the < 23% lowest haematocrit group (Cr IPOD and Cr5POD; P = 0.006) and the 23.1-28% lowest haematocrit level group (CrPre and Cr2POD; P = 0.047). CrPre and Cr5POD did not differ between groups (P > 0.05). The multiple linear regression model confirmed that the determinants for higher % deltaCr were age, body surface area and preoperative serum creatinine level. CONCLUSION: The LHTC was not identified as a risk factor for kidney dysfunction after myocardial revascularization.

Insuficiência renal aguda no pós-operatório de cirurgia cardíaca / Acute renal failure following cardiac surgery

A insuficiência renal aguda (IRA) no pós-operatório de cirurgia cardíaca é causa de maior morbidade e mortalidade. A disfunção renal caracterizada peloaumento da creatinina sérica determina maior número de complicações operatórias e diminuição da sobrevida. Fatores de risco genéticos no pré-operatórioforam determinados, contudo a influência dos fatores de risco intra-operatórios, a circulação extracorpórea e suas variáveis também devem serconsideradas. A cirurgia de revascularização do miocárdio sem circulação extracorpórea tem sido utilizada por diminuir a morbidade. Os fatoresrelacionados à circulação extracorpórea devem ser monitorados no intra-operatório para diminuir o risco de IRA em cirurgia cardíaca. O objetivo destarevisão é avaliar os diferentes fatores de risco para desenvolver IRA no pós-operatório de cirurgia cardíaca, com enfâse naqueles relacionados à circulaçãoextracorpórea.

Acute renal failure after cardiovascular surgery is a risk factor for morbidity and mortality. An increase in serum creatinine is related to kidney dysfunctionwhich determines augmentation of post operative complications and affects long term-survival. Genetic and pre-operative risk factors have been identified,however, cardiopulmonary bypass and its variables might be considered. Myocardial revascularization without cardiopulmonary bypass is being used toattenuate morbidity. Variables related to cardiopulmonary bypass are easily monitored in the operating room and might be treated to attenuate kidneydysfunction. The objective of this review is to evaluate risk factors, especially those related to cardiopulmonary bypass.

Prognostic implications of myocardial creatine kinase and cardiac troponin in coronary artery bypass surgery

OBJETIVO: Avaliar a implicaçäo prognóstica da dosagem da creatino-quinase miocárdica (CKMB) e Troponina I (cTn I) em amostras no seio coronariano, na evoluçäo de pacientes submetidos a revascularizaçäo do miocárdio (RM), com e sem o pré-condicionamento isquêmico. MÉTODO: Entre outubro de 1998 e maio de 1999, 35 pacientes com insuficiência coronariana foram submetidos a RM foram estudados. No intra-operatório foram coletadas amostras do seio coronariano para dosagem de CKMB e cTn I. Os momentos de coleta foram: momento 1-no início da circulaçäo extracorpórea (CEC), momento 2- após a primeira anastomose e momento 3- no final da CEC. Em maio de 2002, 29 pacientes foram avaliados quanto aos sintomas para classe funcional de angina e de insuficiência cardíaca congestiva, número de internações hospitalares, ocorrência de infarto agudo do miocárdio e morte. Os 29 pacientes estavam distribuídos em dois grupos: 15 no grupo pré-condicionamento e 14 no grupo controle. Cada grupo também foi subdividido em: pacientes com sintomas cardiovasculares e assintomáticos. RESULTADOS: Os grupos controle e pré-condicionado näo apresentaram diferença estatística para a presença de sintomas cardiovasculares. Houve aumento progressivo nos valores de CKMB e cTn I nos diferentes momentos de coleta. A cTn I no grupo pré-condicionado foi de 1,21 ± 0,64 ng/ml e 3,19 ± 3,21 ng/ml no grupo controle (p<0,05). O grupo controle sintomático foi o que apresentou valor de cTn I mais elevado, de 5,07 ± 3,69 ng/ml, estaticamente maior dos outros grupos (p<0,05). CONCLUSÕES: Houve menor liberaçäo de c Tn I no grupo pré-condicionado. A cTn I pode ser um marcador de evoluçäo tardia em pacientes submetidos a RM.