Mortality after discharge from a public tertiary cardiovascular referral hospital.

It is critically important for stakeholders with distinct foci of attention on healthcare to understand patient evolution in the presence of an established diagnosis or with a suspected diagnosis of various diseases, specially considering death as an outcome. To study the long-term mortality of patients at a cardiovascular referral hospital. Deterministic binding (selection of pairs of registers from the hospital electronic health records and the mortality records of São Paulo state) from 2002 to 2017 was performed. Studied variables were: age, sex, hospital treatment unit where the first visit occurred (Emergency Unit, Outpatient Unit, Hospital Admissions, Diagnostics Services), treatment type, elapsed time between the first visit and death, diagnosis at first and last visits and variables related to death. Statistical Methods: descriptive, survival (with Kaplan-Meier method), correspondence and competitive risks analyses; in case of nonoccurrence of death until the end of 2017, the patients were considered alive. Statistical significance was set at values of P < .05. Median age at the first visit to the Hospital was 51.9 years. Birth locations included 4496 cities, 17.33% in São Paulo, 0.41% in Rio de Janeiro, 0.40% in Osasco, 24.04% in other cities. Sex included females (46.7%), males (44.2%), not defined (6.3%), and other (2.8%). We observed an association between diseases in ICD-10 Chapter 16 (certain conditions originating in the perinatal period) and Chapter 17 (congenital malformations, deformations, and chromosomal abnormalities), both as diagnoses and underlying causes of death, as well as between neoplasms as diagnoses and as the underlying cause of death. In this sample, there was an association between admission diagnoses and underlying causes of death, such as neoplasms, cardiovascular diseases, and congenital heart malformations. Additionally, patients who underwent a cardiac intervention had a smaller less mortality rate than those who were not operated on. There were also differences in cardiovascular mortality between distinct treatment units of the hospital ((Emergency Unit, Outpatient Unit, Hospital Admissions, Diagnostic Services).

Accuracy of Myocardial Biomarkers in the Diagnosis of Myocardial Infarction After Revascularization as Assessed by Cardiac Resonance: The Medicine, Angioplasty, Surgery Study V (MASS-V) Trial.

BACKGROUND: The lack of a correlation between myocardial necrosis biomarkers and electrocardiographic abnormalities after revascularization procedures has resulted in a change in the myocardial infarction (MI) definition. METHODS: Patients with stable multivessel disease who underwent percutaneous or surgical revascularization were included. Electrocardiograms and concentrations of high-sensitive cardiac troponin I (cTnI) and creatine kinase (CK)-MB were assessed before and after procedures. Cardiac magnetic resonance and late gadolinium enhancement were performed before and after procedures. MI was defined as more than five times the 99th percentile upper reference limit for cTnI and 10 times for CK-MB in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), respectively, and new late gadolinium enhancement for cardiac magnetic resonance. RESULTS: Of the 202 patients studied, 69 (34.1%) underwent on-pump CABG, 67 (33.2%) off-pump CABG, and 66 (32.7%) PCI. The receiver operating characteristic curve showed the accuracy of cTnI for on-pump CABG, off-pump CABG, and PCI patients was 21.7%, 28.3%, and 52.4% and for CK-MB was 72.5%, 81.2%, and 90.5%, respectively. The specificity of cTnI was 3.6%, 9.4%, and 42.1% and of CK-MB was 73.2%, 86.8%, and 96.4%, respectively. Sensitivity of cTnI was 100%, 100%, and 100% and of CK-MB was 69.2%, 64.3%, and 44.4%, respectively. The best cutoff of cTnI for on-pump CABG, off-pump CABG, and PCI was 6.5 ng/mL, 4.5 ng/mL, and 4.5 ng/mL (162.5, 112.5, and 112.5 times the 99th percentile upper reference limit) and of CK-MB was 37.5 ng/mL, 22.5 ng/mL, and 11.5 ng/mL (8.5, 5.1, and 2.6 times the 99th percentile upper reference limit), respectively. CONCLUSIONS: Compared with cardiac magnetic resonance, CK-MB was more accurate than cTnI for diagnosing MI. These data suggest a higher troponin cutoff for the diagnosis of procedure-related MI.

Mortality and embolic potential of cardiac tumors.

BACKGROUND: Cardiac tumors are rare, mostly benign with high embolic potential. OBJECTIVES: To correlate the histological type of cardiac masses with their embolic potential, implantation site and long term follow up in patients undergoing surgery. METHODS: Between January 1986 and December 2011, we retrospectively analyzed 185 consecutive patients who underwent excision of intracardiac mass (119 females, mean age 48±20 years). In 145 patients, the left atrium was the origin site. 72% were asymptomatic and prior embolization was often observed (19.8%). The diagnosis was established by echocardiography, magnetic resonance and histological examination. RESULTS: Most tumors were located in the left side of the heart. Myxoma was the most common (72.6%), followed by fibromas (6.9%), thrombi (6.4%) and sarcomas (6.4%). Ranging from 0.6cm to 15cm (mean 4.6 ± 2.5cm) 37 (19.8%) patients had prior embolization, stroke 10.2%, coronary 4.8%, peripheral 4.3% 5.4% of hospital death, with a predominance of malignant tumors (40% p < 0.0001). The histological type was a predictor of mortality (rhabdomyomas and sarcomas p = 0.002) and embolic event (sarcoma, lipoma and fibroelastoma p = 0.006), but not recurrence. Tumor size, atrial fibrillation, cavity and valve impairment were not associated with the embolic event. During follow-up (mean 80±63 months), there were 2 deaths (1.1%) and two recurrences 1 and 11 years after the operation, to the same cavity. CONCLUSION: Most tumors were located in the left side of the heart. The histological type was predictor of death and preoperative embolic event, while the implantation site carries no relation with mortality or to embolic event.

Mortality and Embolic Potential of Cardiac Tumors / Mortalidade e Potencial Embólico dos Tumores Cardíacos

Background: Cardiac tumors are rare, mostly benign with high embolic potential. Objectives: To correlate the histological type of cardiac masses with their embolic potential, implantation site and long term follow up in patients undergoing surgery. Methods: Between January 1986 and December 2011, we retrospectively analyzed 185 consecutive patients who underwent excision of intracardiac mass (119 females, mean age 48±20 years). In 145 patients, the left atrium was the origin site. 72% were asymptomatic and prior embolization was often observed (19.8%). The diagnosis was established by echocardiography, magnetic resonance and histological examination. Results: Most tumors were located in the left side of the heart. Myxoma was the most common (72.6%), followed by fibromas (6.9%), thrombi (6.4%) and sarcomas (6.4%). Ranging from 0.6cm to 15cm (mean 4.6 ± 2.5cm) 37 (19.8%) patients had prior embolization, stroke 10.2%, coronary 4.8%, peripheral 4.3% 5.4% of hospital death, with a predominance of malignant tumors (40% p < 0.0001). The histological type was a predictor of mortality (rhabdomyomas and sarcomas p = 0.002) and embolic event (sarcoma, lipoma and fibroelastoma p = 0.006), but not recurrence. Tumor size, atrial fibrillation, cavity and valve impairment were not associated with the embolic event. During follow-up (mean 80±63 months), there were 2 deaths (1.1%) and two recurrences 1 and 11 years after the operation, to the same cavity. Conclusion: Most tumors were located in the left side of the heart. The histological type was predictor of death and preoperative embolic event, while the implantation site carries no relation with mortality or to embolic event. .

Fundamento: Os tumores do coração são infrequentes, em sua maioria benignos e com alto potencial embólico. Objetivo: Correlacionar o tipo histológico do tumor cardíaco com seu potencial embólico, com o sítio de implantação e analisar a evolução tardia destes pacientes submetidos à cirurgia. Métodos: No período de dezembro de 1986 a setembro de 2011 foram retrospectivamente analisados 186 pacientes operados (119 do sexo feminino e idade média de 48 ± 20 anos). Foram 145 tumores de átrio esquerdo (77%), 72% dos pacientes assintomáticos e 19,8% com embolização prévia. O diagnóstico foi confirmado por ecocardiograma, ressonância magnética e exame histológico. Resultados: A maioria dos tumores situava-se nas câmaras esquerdas. O mixoma foi o mais frequente (72,6%), seguido dos fibromas (6,9%), trombos (6,4%) e sarcomas (6,4%). Seus tamanhos variaram de 0,6cm a 15 cm (média de 4,6 ± 2,5cm). Houve 37 embolizações prévias à operação (10,2% AVC, 4,8% IAM e 4,3% periférica). Foram 5,4% de óbito hospitalar, com predomínio nos tumores malignos (40% p < 0,0001). O tipo histológico foi preditor de mortalidade (rabdomioma e sarcomas p = 0,002) e de evento embólico (sarcomas, fibroelastoma e lipoma p = 0,006), porém não de recidiva. O tamanho tumoral, a fibrilação atrial, a cavidade e valva acometida não apresentaram relação com o evento embólico. Durante o seguimento (média de 80 ± 63 meses), houve 2 óbitos (1,1%) e duas recidivas tumorais 1 e 11 anos após a operação, ambas para a mesma cavidade. Conclusão: O tipo histológico foi preditor de óbito e de evento embólico pré-operatório, enquanto o sítio de implantação não. .

Effects of acute hormone therapy on recurrent ischemia in postmenopausal women with unstable angina.

OBJECTIVES: We tested whether acute hormone therapy reduces ambulatory electrocardiographic ischemia in postmenopausal (PMP) women with unstable angina (UA). BACKGROUND: Endothelial dysfunction contributes to the pathophysiology of UA. Acute estrogen administration improves endothelial function in PMP women with coronary artery disease and increases coronary artery blood flow. METHODS: Two hundred ninety-three PMP women with UA (mean age 69.7 years), treated with standard anti-ischemic therapy, were enrolled within 24 h of symptom onset. In a double-blind fashion, subjects were randomized to receive intravenous followed by oral conjugated estrogen for 21 days, intravenous estrogen followed by oral conjugated estrogen plus medroxyprogesterone for 21 days or placebo. The primary end point was the number of ambulatory electrocardiographic ischemic events over the first 48 h. Clinical events were also determined over six months of follow-up. RESULTS: Electrocardiographic ischemia did not differ among the three randomized groups. The mean number of ischemic events per patient over 48 h was 0.74 for estrogen, 0.86 for estrogen plus progesterone and 0.74 for the placebo groups (p = 0.87). The percentage of patients with ischemic events and the mean duration of ischemia did not differ between hormone- and placebo-treated patients. In-hospital and six-month rates of adverse clinical events were also similar among the three randomized groups. CONCLUSIONS: Acute hormone therapy does not reduce ischemia in PMP women with UA when added to standard anti-ischemic therapy.

Tendências das publicaçoes nas fases trimestral, bimestral e mensal das cinco décadas dos Arquivos Brasileiros de Cardiologia / Publication trends in the quartely, bimonthly and monthly cycles of publication in the Brazilian Archives of Cardiology over five decades

OBJETIVO: Estudar tendências das publicaçoes nos Arquivos Brasileiros de Cardiologia de março de 1948 a fevereiro de 1998, nas fases trimestral, bimestral e mensal de publicaçao. MÉTODOS: Foram sorteados aleatoriamente 25 por cento dos fascículos de cada fase e constituída amostra de 98 fascículos: 13 (11,5 por cento) da fase trimestral, 27 (23,5 por cento) da fase bimestral e 58 (65 por cento) da fase mensal. Foram estudados o tipo de texto, o número de autores, a procedência, o idioma, e as referências bibliográficas. RESULTADOS: Foram estudados 1.204 textos, 90 (7,5 por cento) da fase trimestral, 238 (19,8 por cento) da fase bimestral e 876 (72,8 por cento) da fase mensal. Os textos mais freqüentes foram artigos originais (353), revisoes de tema (350) e relatos de caso (205). Nas três fases de periodicidade: nao houve diferença significativa das proporçoes de artigos originais, revisoes e relatos de caso; houve maior número de autores na fase mensal; verificou-se concentraçao geográfica das contribuiçoes [864 de 1204 (72 por cento) de três Estados], diminuíram as contribuiçoes internacionais (20,8 por cento, 4,4 por cento e 4,9 por cento), houve reduçao de publicaçoes em outras línguas; a média de referências internacionais superou 16,7 e de nacionais foi inferior a 4,7. CONCLUSAO: A análise da tendência evolutiva em cinco décadas de publicaçao revelou hiatos que podem ser preenchidos pelos Arquivos Brasileiros de Cardiologia, para melhor acompanhar as tendências internacionais de editoraçao de periódicos médicos, das expectativas dos autores e dos leitores.

Papel do acometimento da artéria coronária circunflexa no infarto do miocárdio sem onda Q / The Role of Left Circunflex Coronary Artery Obstruction in Non-Q Ware Acute Myocardial Infarction

PURPOSE--To determine the patency and incidence rates of left circumflex coronary artery (LCX) as the infarct related artery (IRA) in Q-wave and non-Q wave acute myocardial infarction (AMI). METHODS--Two-hundreds and twenty one patients (172 men) with AMI were stratified in Q and non-Q waves groups. All patients were submitted to cinecoronary angiography 72 hours after the beginning of symptoms and the IRA and its patency were evaluated. RESULTS--In non-Q wave AMI, the LCX was considered to be the IRA in 35 of the patients. In Q wave AMI, this incidence was 8 (p < 0.001). Occlusion of LCX was seen in all non-Q wave AMI patients when it was the IRA. CONCLUSION--The incidence of LCX as IRA was significantly higher in non-Q wave AMI patients. This group did not have the previously expected greater patency rates, what could result in different clinical and evolutive characteristics.

Purpose - To determine the patency and incidencerates of left circunflex coronary artery (LCX) as the infarct related artery (IRA) in Q-wave and non-Q wave acute myocardial infarction (AMI). Methods - Two-hundreds and twenty one patients (172 men) with AMI were stratified in Q and non-Q waves groups. All patients were submitted to cinecoronary angiography 72 hours after the beginning of symptoms and the IRA and its patency were evaluated. Results -In non-Q wave AMI, the LCX was considered to be the IRA in 35% of the patients. In Q wave AMI, this incidence was 8% (p<0.001). Occlusion of LCX was seen in all non-Q wave AMI patients when it was the IRA. Conclusion - The incidence of LCX as IRA was significantly higher in non-Q wave AMI patients. This group did not have the previously expected greater patency rates, what could result in different clinical and evolutive characteristics

Evolução hospitalar de pacientes com infarto de ventrículo direito e a importância da perviabilidade da artéria coronária direita / In-Hospital Outcome of Patients with Righ Ventricular Infarction and the Role of Right Coronary Artery Patency

PURPOSE--To evaluate the importance of the right coronary artery (RCA) patency in patients with right ventricular infarction. METHODS--Fifty-two patients with inferior wall myocardial infarction and right ventricular involvement were studied and divided in two groups: group A (GA) included 35 patients in whom the RCA was patent at coronary angiography, and group B (GB), 17 who had an occluded RCA. They were prospectively evaluated for electrical and hemodynamic complications, as well as in-hospital mortality. RESULTS--The mortality in GA was 11 and 29 in GB, p = 0.13; electrical complications were 11 in GA and 35 in GB, p = 0.06; hemodynamic complications were 8 in GA and 41 in GB, p = 0.009. CONCLUSION--These findings suggest a trend towards reduction in mortality and electrical complications, and significant reduction of hemodynamic complications in patients with inferior wall myocardial infarction with involvement of the right ventricle who have the RCA patent. Thus, RCA patency appears to be important in determining in-hospital outcomes of these patients.

Magnetic resonance imaging in Chagas' heart disease

Many important aspects of Chagas' heart disease can be successfully assessed using magnetic resonance imaging of the heart. It is possible to obtain with great detail the anatomic characterization of the cardiac chambers as well as important information of the functional or metabolic status of the heart. Magnetic resonance imaging after gadolinium infusion seems also a promising technique to obtain a better regional characterization of myocardial tissue, and may be important in the non-invasive diagnosis of active myocarditis in patients with Chagas' heart disease.

Estado lítico sistêmico como marcador do sucesso terapêutico após rt-PA em bolo no infarto do miocárdio / lytic state as marker of therapeutic success after rt-PA in bolus in myocardial infarction

Avaliar o estado lítico sistêmico (ELS) através do nível de fibrinogênio sérico (FS) após tratamento com rt-PA em bolo no infarto do miocárdio (IM) e sua relaçäo com recanalizaçäo coronária. Cinqüenta e um pacientes (38 homens, média de idade de 53 ñ 9,8 anos) com IM submetidos a terapêutica com 70 mg de rt-PA em bolo por via venosa após demonstraçäo de oclusäo da artéria relacionada ao infarto (ARI). Foram feitas dosagens de FS pré-tratamento e após 90 minutos e comparados seus níveis no grupo de pacientes recanalizados (grupo 1) com os do grupo de pacientes com falha terapêutica (grupo 2). Todos os pacientes tinham níveis normais de FS e pré-tratamento. Após 90 minutos a média do FS diminuiu em 35,1% (276,8 ñ 55,5 mg/dl para 168,9 ñ 78,2 mg/dl). Os grupos 1 e 2 aos 90 minutos apresentaram níveis de FS semelhantes (145,1 ñ 96,7 mg/dl contra 187,0 + 53,7 mg/dl). A terapêutica com rt-PA em bolo no IM reduz de maneira significativa o FS, mas o ELS atingido foi semelhante nos grupos com ou sem recanalizaçäo da ARI

Purpose: Evaluate the lytic state (LS) expressed by the level of plasmatic fibrinogen (PF) after rt-PA in bolus tn,fusion for acute myocardial infarction (MI) and its relation to coronary reperfusion. Patients and methods: Fifty-one patients (38 men, mean age of 53.0 ± 9.8 years) with demonstrated occlusion of the infarct related artery (IRA) received an intravenous bolus infusion of 70 mg of rt-PA, PF was assessed before and 90 minutes after the treatment and the levels were compared in patients with (group 1) and without (group 2) reperfusion of the IRA. Results: Basal levels of PF were within the normal range in all patients. There was a decrement of 35.1% in the PF dosed at 90 minutes, from 276.8 ± 55.5 mg/al to 168.0 ± 68.2 mg/dl. Both groups were similar in the levels of PF 90 after treatment (145.1 ± 95.7 mg/dl in group I versus 187.0 ± 53.7 mg/dl in group 2). Conclusion: In bolus rt-PA treatment for MI significantly reduces the PF, but the LS obtained was similar in patients with or without reperfusion of the IRA.

Segmento ST como indicador de recanalizaçäo arterial após terapêutica trombolítica no infarto do miocárdio / ST segment as an arterial recanalization indicator after thrombolytic therapy in acute myocardial infarction

Objetivo: Avaliar a importância do segmento ST como indicador de recanalizaçäo da artéria em pacientes com infarto do miocárdio submetidos a terapêutica trombolítica por via venosa. Casuística e Métodos: Setenta e quatro pacientes (62 homens, média de idade 52,6 ñ 10 anos) com oclusäo da artéria relacionada ao infarto (ARI) antes da infusäo venosa "in bolus" de rt-PA em doses de 50, 60 e 70 mg. Após 90 minutos realizou-se nova angiografia e o estado da ARI foi relacionado ao comportamento do segmento ST antes e após o tratamento. Resultados: Cinqüenta e seis (75,6%) pacientes apresentaram normalizaçäo ou diminuiçäo do segmento ST (grupo I e II). Destes, em 47 notou-se recanalizaçäo da ARI. Dos demais 18 pacientes que näo apresentaram alteraçöes no segmento ST (grupo III), a ARI estava ocluída em 13 e recanalizada em cinco. O comportamento do segmento ST apresentou sensibilidade de 90,3% especificidade de 59,1%, valor preditivo positivo de 83,9% e valor preditivo negativo de 72,9%. Conclusäo: O segmento ST constitui importante indicador de recanalizaçäo ou näo da ARI após terapêutica trombolítica

Purpose: To evaluate the importance of the segment ST in the identification of coronary recanalization in patients submitted to intravenous thrombolysis during acute myocardial infarction (MI). Patients and Methods: Seventy four patients with MI, 62 male with mean age of 52.6 ± 10 years. All patients had angiographically demonstrated occlusion of the infarct-related artery (IRA) before the thrombolytic treatment with intravenous in bolus infusion of 50 mg, 60 mg and 70 mg of rt-PA. The recanalization of the IRA was assessed 90 minutes later. The real status of the IRA in the angiograms was compared with the ST segment changes between the ECGs obtained before and after the thrombolytic therapy. Results: Fifty six (75.6% ) patients presented a significant reduction in the ST segment elevation (groups I and II). Of these, 47 possessed an openned IRA. From the 18 patients who did not show ST segment decrement (group III),13 had an occluded IRA, and 5 an openned one. The method presented sensitivity of 90.3% and a specificity of 59.1%, positive predictive value of 83.9% and negative predictive value of 72.2%. Conclusions: The ST segment is an important marker of coronary recanalization or not following intravenous thrombolytic therapy.

Diagnóstico ecodopplercardiográfico de aneurisma aterosclerótico de artéria coronária / Doppler echocardiographic diagnosis of atherosclerotic aneurysm of the coronary artery

Homem de 74 anos com infarto do miocárdio submetido a terapêutica trombolítica realizou ecoDopplercardiograma que permitiu diagnosticar aneurisma aterosclerótico de artéria coronária direita. Este diagnóstico, raramente conseguido por exames näo invasivos, foi subseqüentemente confirmado por estudo cineangiográfico e biópsia transoperatória

A 74 year-old man with acute myocardial infarction submitted to thrombolytic therapy had the diagnosis of atherosclerotic aneurysm of the coronary artery attained with Doppler echocardiography. Subsequently diagnosis was confirmed by angiography and the atherosclerotic etiology identified in pathology.

Comportamento dos potenciais tardios em portadores de infarto do miocárdio submetidos à trombólise coronária / Late potentials in patients with myocardial infarction submitted to thrombolytic therapy

Objetivo­Analisar o comportamento dos potenciais tardios (Pr) em pacientes submetidos com sucesso a trombólise coronária. Casuística e Métodos­Trinta e cinco pacientes com infarto do miocárdio, 32 (91,4%) do sexo masculino com idades entre 33 e 68 (média de 52,6) anos. Trombólise coronária foi obtida durante estudo hemodinâmico através da infusão venosa, em bolo, de doses variáveis de 50,60 e 70mg de rt-PA, sucedida por nova dose de 30mg aos 60 minutos do procedimento. O exame angiocardiográfico foi repetido 12-48h após. O eletrocardiograma de alta resolução foi obtido, utilizando-se sistema ART modelo 1200 EPX, antes, a seguir e 72 horas após o término do estudo hemodinâmico. PT foram reconhecidos pela presença de ondas elétricas com amplitude inferior a 20 microvolts e duração maior que 35ms nos últimos 40ms do complexo QRS (duração total do QRS entre 110 e 114ms)...

Purpose­Analyse the behavior of the late potentials (LP) in patients submitted to thrombolysis with success. Material and Metllods­Thrty-five patients with acute myocardial infarction, 32 (91,4%) male with ages varying from 33 to 68 (mean 52.ó). Thrombolysis was obtained during cinecoronariography with intravenous infusion "in bolus" of d oses of 50mg, 60mg and 70mg of rt-PA, with a new bolus of 30mg at 60 minutes after the procedure. A new angiographic study was performed 12-48 hours late. The high resolution ECG was taken with the ART system model 1200 EPX. before, after and 72 hours later. The presence of electrical activity in the last 40ms of the QRS comple:£ with less than 20 uvolts in amplitude and more than 35ms in duration characterized the LP...