Effect of Loading Dose of Atorvastatin Prior to Planned Percutaneous Coronary Intervention on Major Adverse Cardiovascular Events in Acute Coronary Syndrome The SECURE-PCI Randomized Clinical Trial

IMPORTANCE The effects of loading doses of statins on clinical outcomes in patients with acute coronary syndrome (ACS) and planned invasive management remain uncertain. OBJECTIVE To determine if periprocedural loading doses of atorvastatin decrease 30-day major adverse cardiovascular events (MACE) in patients with ACS and planned invasive management. DESIGN, SETTING, AND PARTICIPANTS Multicenter, double-blind, placebo-controlled, randomized clinical trial conducted at 53 sites in Brazil among 4191 patients with ACS evaluated with coronary angiography to proceed with a percutaneous coronary intervention (PCI) if anatomically feasible. Enrollment occurred between April 18, 2012, and October 6, 2017. Final follow-up for 30-day outcomes was on November 6, 2017. INTERVENTIONS Patients were randomized to receive 2 loading doses of 80 mg of atorvastatin (n = 2087) or matching placebo (n = 2104) before and 24 hours after a planned PCI. All patients received 40 mg of atorvastatin for 30 days starting 24 hours after the second dose of study medication. MAIN OUTCOMES AND MEASURES The primary outcome was MACE, defined as a composite of all-cause mortality, myocardial infarction, stroke, and unplanned coronary revascularization through 30 days. RESULTS Among the 4191 patients (mean age, 61.8 [SD, 11.5] years; 1085 women [25.9%]) enrolled, 4163 (99.3%) completed 30-day follow-up. A total of 2710 (64.7%) underwent PCI, 333 (8%) underwent coronary artery bypass graft surgery, and 1144 (27.3%) had exclusively medical management. At 30 days, 130 patients in the atorvastatin group (6.2%) and 149 in the placebo group (7.1%) had a MACE (absolute difference, 0.85% [95% CI, −0.70% to 2.41%]; hazard ratio, 0.88; 95% CI, 0.69-1.11; P = .27). No cases of hepatic failure were reported; 3 cases of rhabdomyolysis were reported in the placebo group (0.1%) and 0 in the atorvastatin group. CONCLUSIONS AND RELEVANCE Among patients with ACS and planned invasive management with PCI, periprocedural loading doses of atorvastatin did not reduce the rate of MACE at 30 days. These findings do not support the routine use of loading doses of atorvastatin among unselected patients with ACS and intended invasive management.

Effect of Loading Dose of Atorvastatin Prior to Planned Percutaneous Coronary Intervention on Major Adverse Cardiovascular Events in Acute Coronary Syndrome: The SECURE-PCI Randomized Clinical Trial.

Importance: The effects of loading doses of statins on clinical outcomes in patients with acute coronary syndrome (ACS) and planned invasive management remain uncertain. Objective: To determine if periprocedural loading doses of atorvastatin decrease 30-day major adverse cardiovascular events (MACE) in patients with ACS and planned invasive management. Design, Setting, and Participants: Multicenter, double-blind, placebo-controlled, randomized clinical trial conducted at 53 sites in Brazil among 4191 patients with ACS evaluated with coronary angiography to proceed with a percutaneous coronary intervention (PCI) if anatomically feasible. Enrollment occurred between April 18, 2012, and October 6, 2017. Final follow-up for 30-day outcomes was on November 6, 2017. Interventions: Patients were randomized to receive 2 loading doses of 80 mg of atorvastatin (n = 2087) or matching placebo (n = 2104) before and 24 hours after a planned PCI. All patients received 40 mg of atorvastatin for 30 days starting 24 hours after the second dose of study medication. Main Outcomes and Measures: The primary outcome was MACE, defined as a composite of all-cause mortality, myocardial infarction, stroke, and unplanned coronary revascularization through 30 days. Results: Among the 4191 patients (mean age, 61.8 [SD, 11.5] years; 1085 women [25.9%]) enrolled, 4163 (99.3%) completed 30-day follow-up. A total of 2710 (64.7%) underwent PCI, 333 (8%) underwent coronary artery bypass graft surgery, and 1144 (27.3%) had exclusively medical management. At 30 days, 130 patients in the atorvastatin group (6.2%) and 149 in the placebo group (7.1%) had a MACE (absolute difference, 0.85% [95% CI, -0.70% to 2.41%]; hazard ratio, 0.88; 95% CI, 0.69-1.11; P = .27). No cases of hepatic failure were reported; 3 cases of rhabdomyolysis were reported in the placebo group (0.1%) and 0 in the atorvastatin group. Conclusions and Relevance: Among patients with ACS and planned invasive management with PCI, periprocedural loading doses of atorvastatin did not reduce the rate of MACE at 30 days. These findings do not support the routine use of loading doses of atorvastatin among unselected patients with ACS and intended invasive management. Trial Registration: clinicaltrials.gov Identifier: NCT01448642.

Reporting Clinical End Points and Safety Events in an Acute Coronary Syndrome Trial: Results With Integrated Collection.

BACKGROUND: End points and adverse events (AEs) are collected separately in clinical trials, yet regulatory requirements for serious AE reporting vary across regions, so classifying end points according to seriousness criteria can be useful in global trials. METHODS AND RESULTS: In the Apixaban for Prevention of Acute Ischemic Events 2 (APPRAISE-2) trial, patients with a recent acute coronary syndrome were randomized to apixaban or placebo for the prevention of recurrent ischemic events. Suspected end points (myocardial infarction, stroke, or bleeding) were adjudicated by an independent clinical events classification committee. Safety criteria were collected for suspected end points and AEs. Patient-level event rates per 100 patient-days of follow-up, modeled using Poisson regression, explored the influence of region and patient characteristics on event reporting. Overall, 13 909 events were reported by 858 sites in 39 countries; 8.4% (n=1166) were suspected end points, and 91.6% (n=12 743) were AEs. Overall, 66.0% of suspected end points were confirmed by the clinical events classification committee. Most clinical events classification committee-confirmed end points met criteria to be classified as serious (94.0%); many clinical events classification committee-negated end points also did (63.2%), but fewer AEs met seriousness criteria (17.9%). The most common seriousness criterion was hospitalization (79.9%, n=2594). Region explained 28.7% of end point- and 26.4% of serious AE-reporting variation, and patient characteristics explained an additional 25.4% of end point and 13.4% of serious AE variation. Nonserious AE-reporting variation was not explained by adjustment. CONCLUSIONS: An integrated collection of end points and serious AEs is feasible in a multinational trial and illustrates the shared characteristics of events. Tailoring event collection to fit the phase and purpose of the trial is achievable and informative. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00831441.

Do Diabetic Patients with Acute Coronary Syndromes Have a Higher Threshold for Ischemic Pain? / Pacientes Diabéticos com Síndromes Coronárias Agudas têm um Limiar Maior para a Dor Isquêmica?

Background: Data from over 4 decades have reported a higher incidence of silent infarction among patients with diabetes mellitus (DM), but recent publications have shown conflicting results regarding the correlation between DM and presence of pain in patients with acute coronary syndromes (ACS). Objective: Our primary objective was to analyze the association between DM and precordial pain at hospital arrival. Secondary analyses evaluated the association between hyperglycemia and precordial pain at presentation, and the subgroup of patients presenting within 6 hours of symptom onset. Methods: We analyzed a prospectively designed registry of 3,544 patients with ACS admitted to a Coronary Care Unit of a tertiary hospital. We developed multivariable models to adjust for potential confounders. Results: Patients with precordial pain were less likely to have DM (30.3%) than those without pain (34.0%; unadjusted p = 0.029), but this difference was not significant after multivariable adjustment, for the global population (p = 0.84), and for subset of patients that presented within 6 hours from symptom onset (p = 0.51). In contrast, precordial pain was more likely among patients with hyperglycemia (41.2% vs 37.0% without hyperglycemia, p = 0.035) in the overall population and also among those who presented within 6 hours (41.6% vs. 32.3%, p = 0.001). Adjusted models showed an independent association between hyperglycemia and pain at presentation, especially among patients who presented within 6 hours (OR = 1.41, p = 0.008). Conclusion: In this non-selected ACS population, there was no correlation between DM and hospital presentation without precordial pain. Moreover, hyperglycemia correlated significantly with pain at presentation, especially in the population that arrived within 6 hours from symptom onset. .

Fundamento: Dados de mais de 4 décadas relataram maior incidência de infarto silencioso entre os pacientes com diabetes mellitus (DM), mas publicações recentes mostraram resultados conflitantes quanto à correlação entre DM e presença de dor em pacientes com síndromes coronárias agudas (SCA). Objetivo: Nosso objetivo principal foi analisar a associação entre dor precordial e DM na chegada ao hospital. Análises secundárias avaliaram a associação entre hiperglicemia e dor precordial na apresentação, e o subgrupo de pacientes que se apresentaram em até 6 horas após o início dos sintomas. Métodos: Analisamos um registro prospectivo de 3.544 pacientes com SCA internados em unidade coronária de um hospital terciário. Desenvolvemos modelos multivariados para ajustar potenciais fatores de confusão. Resultados: Os pacientes com dor precordial eram menos propensos a ter DM (30,3%) do que aqueles sem dor (34,0 %, p não ajustado = 0,029), mas essa diferença não foi significativa após ajuste multivariado, para a população global (p = 0,84), e para o subgrupo de pacientes que se apresentaram dentro do período de 6 horas após o início dos sintomas (p = 0,51). Em contraste, a dor precordial era mais provável entre os pacientes com hiperglicemia (41,2% vs. 37,0% sem hiperglicemia, p = 0,035) na população total, e também entre aqueles que se apresentaram no período de 6 horas (41,6% vs. 32,3%, p = 0,001). Modelos ajustados mostraram uma associação independente entre hiperglicemia e dor na apresentação, especialmente entre os pacientes que se apresentaram no período de até 6 horas (OR = 1,41, p = 0,008). Conclusão: Nesta população não-selecionada com SCA, não houve correlação entre DM e a ...

Do diabetic patients with acute coronary syndromes have a higher threshold for ischemic pain?

BACKGROUND: Data from over 4 decades have reported a higher incidence of silent infarction among patients with diabetes mellitus (DM), but recent publications have shown conflicting results regarding the correlation between DM and presence of pain in patients with acute coronary syndromes (ACS). OBJECTIVE: Our primary objective was to analyze the association between DM and precordial pain at hospital arrival. Secondary analyses evaluated the association between hyperglycemia and precordial pain at presentation, and the subgroup of patients presenting within 6 hours of symptom onset. METHODS: We analyzed a prospectively designed registry of 3,544 patients with ACS admitted to a Coronary Care Unit of a tertiary hospital. We developed multivariable models to adjust for potential confounders. RESULTS: Patients with precordial pain were less likely to have DM (30.3%) than those without pain (34.0%; unadjusted p = 0.029), but this difference was not significant after multivariable adjustment, for the global population (p = 0.84), and for subset of patients that presented within 6 hours from symptom onset (p = 0.51). In contrast, precordial pain was more likely among patients with hyperglycemia (41.2% vs 37.0% without hyperglycemia, p = 0.035) in the overall population and also among those who presented within 6 hours (41.6% vs. 32.3%, p = 0.001). Adjusted models showed an independent association between hyperglycemia and pain at presentation, especially among patients who presented within 6 hours (OR = 1.41, p = 0.008). CONCLUSION: In this non-selected ACS population, there was no correlation between DM and hospital presentation without precordial pain. Moreover, hyperglycemia correlated significantly with pain at presentation, especially in the population that arrived within 6 hours from symptom onset.

O escore de risco de sangramento como preditor de mortalidade em pacientes com síndromes coronarianas agudas / The bleeding risk score as a mortality predictor in patients with acute coronary syndrome

FUNDAMENTO: A ocorrência de sangramento aumenta a mortalidade intra-hospitalar em pacientes com síndromes coronarianas agudas (SCAs), e há uma boa correlação entre os escores de risco de sangramento e a incidência de eventos hemorrágicos. No entanto, o papel dos escores de risco de sangramento como fatores preditivos de mortalidade é pouco estudado. OBJETIVO: Analisar o papel do escore de risco de sangramento como fator preditivo de mortalidade intra-hospitalar numa coorte de pacientes com SCA tratados num centro terciário de cardiologia. MÉTODOS: Dos 1.655 pacientes com SCA (547 com SCA com supra de ST e 1.118 com SCA sem supra de ST), calculou-se o escore de risco de sangramento ACUITY/HORIZONS prospectivamente em 249 pacientes e retrospectivamente nos demais 1.416. Informações sobre mortalidade e complicações hemorrágicas também foram obtidas. RESULTADOS: A idade média da população estudada foi 64,3 ± 12,6 anos e o escore de risco de sangramento médio foi 18 ± 7,7. A correlação entre sangramento e mortalidade foi altamente significativa (p < 0,001; OR = 5,29), assim como a correlação entre escore de sangramento e hemorragia intra-hospitalar (p < 0,001; OR = 1,058), e entre escore de sangramento e mortalidade intra-hospitalar (OR ajustado = 1,121, p < 0,001, área sob a curva ROC 0,753; p < 0,001). O OR ajustado e a área sob a curva ROC para a população com SCA com supra de ST foram 1,046 (p = 0,046) e 0,686 ± 0,040 (p < 0,001), respectivamente, e para SCA sem supra de ST foram 1,150 (p < 0,001) e 0,769 ± 0,036 (p < 0,001), respectivamente. CONCLUSÃO: O escore de risco de sangramento é um fator preditivo muito útil e altamente confiável para mortalidade intra-hospitalar em uma grande variedade de pacientes com SCAs, especialmente aqueles com angina instável ou infarto agudo do miocárdio sem supra de ST.

BACKGROUND: It is well known that the occurrence of bleeding increases in-hospital mortality in patients with acute coronary syndromes (ACS), and there is a good correlation between bleeding risk scores and bleeding incidence. However, the role of bleeding risk score as mortality predictor is poorly studied. OBJECTIVE: The main purpose of this paper was to analyze the role of bleeding risk score as in-hospital mortality predictor in a cohort of patients with ACS treated in a single cardiology tertiary center. METHODS: Out of 1655 patients with ACS (547 with ST-elevation ACS and 1118 with non-ST-elevation ACS), we calculated the ACUITY/HORIZONS bleeding score prospectively in 249 patients and retrospectively in the remaining 1416. Mortality information and hemorrhagic complications were also obtained. RESULTS: Among the mean age of 64.3 ± 12.6 years, the mean bleeding score was 18 ± 7.7. The correlation between bleeding and mortality was highly significant (p < 0.001, OR = 5.296), as well as the correlation between bleeding score and in-hospital bleeding (p < 0.001, OR = 1.058), and between bleeding score and in-hospital mortality (adjusted OR = 1.121, p < 0.001, area under the ROC curve 0.753, p < 0.001). The adjusted OR and area under the ROC curve for the population with ST-elevation ACS were, respectively, 1.046 (p = 0.046) and 0.686 ± 0.040 (p < 0.001); for non-ST-elevation ACS the figures were, respectively, 1.150 (p < 0.001) and 0.769 ± 0.036 (p < 0.001). CONCLUSIONS: Bleeding risk score is a very useful and highly reliable predictor of in-hospital mortality in a wide range of patients with acute coronary syndromes, especially in those with unstable angina or non-ST-elevation acute myocardial infarction.

The bleeding risk score as a mortality predictor in patients with acute coronary syndrome.

BACKGROUND: It is well known that the occurrence of bleeding increases in-hospital mortality in patients with acute coronary syndromes (ACS), and there is a good correlation between bleeding risk scores and bleeding incidence. However, the role of bleeding risk score as mortality predictor is poorly studied. OBJECTIVE: The main purpose of this paper was to analyze the role of bleeding risk score as in-hospital mortality predictor in a cohort of patients with ACS treated in a single cardiology tertiary center. METHODS: Out of 1655 patients with ACS (547 with ST-elevation ACS and 1118 with non-ST-elevation ACS), we calculated the ACUITY/HORIZONS bleeding score prospectively in 249 patients and retrospectively in the remaining 1416. Mortality information and hemorrhagic complications were also obtained. RESULTS: Among the mean age of 64.3 ± 12.6 years, the mean bleeding score was 18 ± 7.7. The correlation between bleeding and mortality was highly significant (p < 0.001, OR = 5.296), as well as the correlation between bleeding score and in-hospital bleeding (p < 0.001, OR = 1.058), and between bleeding score and in-hospital mortality (adjusted OR = 1.121, p < 0.001, area under the ROC curve 0.753, p < 0.001). The adjusted OR and area under the ROC curve for the population with ST-elevation ACS were, respectively, 1.046 (p = 0.046) and 0.686 ± 0.040 (p < 0.001); for non-ST-elevation ACS the figures were, respectively, 1.150 (p < 0.001) and 0.769 ± 0.036 (p < 0.001). CONCLUSIONS: Bleeding risk score is a very useful and highly reliable predictor of in-hospital mortality in a wide range of patients with acute coronary syndromes, especially in those with unstable angina or non-ST-elevation acute myocardial infarction.

In patients with acute myocardial infarction, the impact of hyperglycemia as a risk factor for mortality is not homogeneous across age-groups.

OBJECTIVE: To assess the impact of hyperglycemia in different age-groups of patients with acute myocardial infarction (AMI). RESEARCH DESIGN AND METHODS: A total of 2,027 patients with AMI were categorized into one of five age-groups: <50 years (n = 301), ≥50 and <60 (n = 477), ≥60 and <70 (n = 545), ≥70 and <80 (n = 495), and ≥80 years (n = 209). Hyperglycemia was defined as initial glucose ≥115 mg/dL. RESULTS: The adjusted odds ratios for hyperglycemia predicting hospital mortality in groups 1-5 were, respectively, 7.57 (P = 0.004), 3.21 (P = 0.046), 3.50 (P = 0.003), 3.20 (P < 0.001), and 2.16 (P = 0.021). The adjusted P values for correlation between glucose level (as a continuous variable) and mortality were 0.007, <0.001, 0.043, <0.001, and 0.064. The areas under the ROC curves (AUCs) were 0.785, 0.709, 0.657, 0.648, and 0.613. The AUC in group 1 was significantly higher than those in groups 3-5. CONCLUSIONS: The impact of hyperglycemia as a risk factor for hospital mortality in AMI is more pronounced in younger patients.

Effect of beta-blockers on the risk of atrial fibrillation in patients with acute myocardial infarction.

INTRODUCTION: Oral beta-blockers improve the prognosis of patients with acute myocardial infarction, while atrial fibrillation worsens the prognosis of this population. The reduction of atrial fibrillation incidence in patients treated with beta-blockers could at least in part explain the benefits of this drug. OBJECTIVE: To investigate the effect of beta-blockers on the incidence of atrial fibrillation in patients with acute myocardial infarction. METHODS: We analyzed 1401 patients with acute myocardial infarction and evaluated the occurrence or absence of atrial fibrillation, the use of oral beta-blockers and mortality during the first 24 hours. RESULTS: a) The use of beta-blockers was inversely correlated with the presence of atrial fibrillation (rho = 0.004; OR = 0.54). b) Correlations with mortality were as follows: 31.5% in patients with atrial fibrillation, 9.2% in those without atrial fibrillation (rho < 0.001; Odds Ratio = 4.52), and 17.5% in patients not treated with beta-blockers and 6.7% in those who received the drug (rho < 0.001; OR = 0.34). c) Adjusted Models: The presence of atrial fibrillation was independently correlated with mortality (OR = 2.48, rho = 0.002). The use of beta-blockers was inversely and independently correlated with mortality (OR = 0.53; rho = 0.002). The patients who used beta-blockers showed a lower risk of atrial fibrillation (OR = 0.59; rho = 0.029) in the adjusted model. CONCLUSION: The presence of atrial fibrillation and the absence of oral beta-blockers increased in-hospital mortality in patients with acute myocardial infarction. Oral beta-blockers reduced the incidence of atrial fibrillation, which might be at least partially responsible for the drug's benefit.

Effect of â-blockers on the risk of atrial fibrillation in patients with acute myocardial infarction

INTRODUCTION: Oral â-blockers improve the prognosis of patients with acute myocardial infarction, while atrial fibrillation worsens the prognosis of this population. The reduction of atrial fibrillation incidence in patients treated with â-blockers could at least in part explain the benefits of this drug. OBJECTIVE: To investigate the effect of â-blockers on the incidence of atrial fibrillation in patients with acute myocardial infarction. METHODS: We analyzed 1401 patients with acute myocardial infarction and evaluated the occurrence or absence of atrial fibrillation, the use of oral â-blockers and mortality during the first 24 hours. RESULTS: a) The use of â-blockers was inversely correlated with the presence of atrial fibrillation (ñ = 0.004; OR = 0.54). b) Correlations with mortality were as follows: 31.5 percent in patients with atrial fibrillation, 9.2 percent in those without atrial fibrillation (ñ < 0.001; Odds Ratio = 4.52), and 17.5 percent in patients not treated with â-blockers and 6.7 percent in those who received the drug (ñ < 0.001; OR = 0.34). c) Adjusted Models: The presence of atrial fibrillation was independently correlated with mortality (OR = 2.48, ñ = 0.002). The use of â-blockers was inversely and independently correlated with mortality (OR = 0.53; ñ = 0.002). The patients who used â-blockers showed a lower risk of atrial fibrillation (OR = 0.59; ñ = 0.029) in the adjusted model. CONCLUSION: The presence of atrial fibrillation and the absence of oral â-blockers increased in-hospital mortality in patients with acute myocardial infarction. Oral â-blockers reduced the incidence of atrial fibrillation, which might be at least partially responsible for the drug's benefit.

A influência do plano de saúde na evolução a longo prazo de pacientes com infarto agudo do miocárdio / The influence of health insurance plans on the long term outcome of patients with acute myocardial infarction

FUNDAMENTO: Pouco se sabe, principalmente em nosso meio, sobre a influência dos planos de saúde na evolução a longo prazo pós-infarto agudo do miocárdio (IAM). OBJETIVO: Avaliar a evolução de pacientes com IAM usuários do SUS ou de outros convênios. MÉTODOS: Foram analisados 1588 pacientes com IAM (idade média de 63,3 ± 12,9 anos, 71,7 por cento homens), incluídos de forma prospectiva em banco de dados específico, e seguidos por até 7,55 anos. Deste total, 1003 foram alocados no "grupo SUS" e 585 no "outros convênios". Qui-quadrado, log-rank e Cox ("stepwise") foram aplicados nas diferentes análises estatísticas. O modelo multivariado a longo prazo, com mortalidade como variável dependente, incluiu 18 variáveis independentes. RESULTADOS: As mortalidades hospitalares nos grupos "outros convênios" e "SUS" foram de 11,4 por cento e 10,3 por cento, respectivamente (P=0,5); a longo prazo, as chances de sobrevivência nos grupos foram, respectivamente, de 70,4 por cento ± 2,9 e 56,4 por cento ± 4,0 (P=0,001, "hazard-ratio"=1,43, ou 43 por cento a mais de chance de óbito no grupo "SUS"). No modelo ajustado, o grupo "SUS" permaneceu com probabilidade significativamente maior de óbito (36 por cento a mais de chance, P=0,005), demonstrando-se ainda que cirurgia de revascularização miocárdica e angioplastia melhoraram o prognóstico dos pacientes, ao passo que idade e história de infarto prévio, diabete ou insuficiência cardíaca, pioraram o prognóstico dos mesmos. CONCLUSÃO: Em relação a usuários de outros convênios, o usuário SUS apresenta mortalidade similar durante a fase hospitalar, porém tem pior prognóstico a longo prazo, reforçando a necessidade de esforços adicionais no sentido de melhorar o nível de atendimento destes pacientes após a alta hospitalar.

BACKGROUND: Little is known, especially in our country, about the influence of health insurance plans on the long term outcome of patients after acute myocardial infarction (AMI). OBJECTIVE: To assess the outcome of patients with AMI who are covered by the National Health System (SUS) or other health insurance plans. METHODS: We analyzed 1,588 patients with AMI (mean age of 63.3 + 12.9 years, 71.7 percent male) who were included prospectively into a specific database and followed up for up to 7.55 years. Of this total, 1,003 were placed in the "SUS" group and 585 in the "other insurance plans" group. We applied chi-square, log-rank and Cox (stepwise) to the different statistical analyses. The long term multivariate model with mortality as a dependent variable included 18 independent variables. RESULTS: In-hospital mortality rates in the "other insurance plans" and "SUS" groups were 11.4 percent and 10.3 percent, respectively (p = 0.5); in the long term, survival chances in the groups were respectively, 70.4 percent + 2.9 and 56.4 percent + 4.0 (p = 0.001, hazard-ratio = 1.43, or a 43 percent higher chance of death in the "SUS" group). In the adjusted model, the "SUS" group had a significantly higher chance of death (a 36 percent higher chance, p = 0.005). Surgical revascularization and angioplasty improved the prognosis of these patients, whereas age and previous history of infarction, diabetes or heart failure worsened the prognosis. CONCLUSIONS: Relative to patients with other insurance plans, SUS users present similar mortality rates during hospital stay, but their prognosis is worse in the long term, thus reinforcing the need for additional efforts to improve the care provided to these patients after hospital discharge.

The influence of health insurance plans on the long term outcome of patients with acute myocardial infarction.

BACKGROUND: Little is known, especially in our country, about the influence of health insurance plans on the long term outcome of patients after acute myocardial infarction (AMI). OBJECTIVE: To assess the outcome of patients with AMI who are covered by the National Health System (SUS) or other health insurance plans. METHODS: We analyzed 1,588 patients with AMI (mean age of 63.3 + 12.9 years, 71.7% male) who were included prospectively into a specific database and followed up for up to 7.55 years. Of this total, 1,003 were placed in the "SUS" group and 585 in the "other insurance plans" group. We applied chi-square, log-rank and Cox (stepwise) to the different statistical analyses. The long term multivariate model with mortality as a dependent variable included 18 independent variables. RESULTS: In-hospital mortality rates in the "other insurance plans" and "SUS" groups were 11.4% and 10.3%, respectively (p = 0.5); in the long term, survival chances in the groups were respectively, 70.4% + 2.9 and 56.4% + 4.0 (p = 0.001, hazard-ratio = 1.43, or a 43% higher chance of death in the "SUS" group). In the adjusted model, the 'SUS' group had a significantly higher chance of death (a 36% higher chance, p = 0.005). Surgical revascularization and angioplasty improved the prognosis of these patients, whereas age and previous history of infarction, diabetes or heart failure worsened the prognosis. CONCLUSIONS: Relative to patients with other insurance plans, SUS users present similar mortality rates during hospital stay, but their prognosis is worse in the long term, thus reinforcing the need for additional efforts to improve the care provided to these patients after hospital discharge.

Hematoma da aorta ascendente / Intramural hematoma of the ascending aorta

É relatado o caso de um paciente do sexo masculino com idade de 71 anos, dando entrada no pronto-atendimento com palidez cutaneomucosa, acompanhada de hipertensão arterial sistêmica e dor torácica. Na investigação diagnóstica não foi evidenciada alteração compatível com isquemia miocárdica aguda. A radiografia de tórax evidenciava alargamento importante do mediastino. Ao ecocardiograma, a aorta ascendente media 47 mm, no nível do tronco pulmonar. Um dia após o eco, o paciente foi submetido a exame de ressonância magnética (RNM), quando se evidenciou aorta ascendente de 62 mm, sem evidenciar fluxo em falsa luz ou "flap" intimal, mas mostrando hematoma intramural da aorta ascendente, estendendo-se da raiz da aorta até um terço proximal do arco aórtico. Procedeu-se a correção cirúrgica, sendo realizada substituição da aorta ascendente e parte do arco aórtico (hemiarco), com preservação da valva aórtica pela suspensão das comissuras. Paciente evolui bem sem intercorrência, recebendo alta no nono dia de pós-operatório. Enfatizamos nesse relato de caso a semelhança do quadro clínico do hematoma intramural da aorta com o quadro de dissecção da aorta, a importância de se estabelecer diagnóstico correto e o melhor tratamento.

It is reported the case of a 71 year old male patient admitted to the emergency service pale and with systemic arterial hypertension and thoracic pain. In the diagnostic investigation, there was no evidence of compatible with acute myocardial ischemia. The thorax x-ray showed important enlargement of the mediastinum. In the echocardiogram the ascending aorta measured 47mm, at the level of the pulmonary artery. One day after the echo, submitted to exam of magnetic resonance (RNM), the ascending aorta had a diameter of 62mm, without false lumen flow or intimal "flap", but showing intramural hematoma envolving the ascending aorta and the proximal portion of the aorta. It was submitted to the surgical correction, being accomplished by resection of the ascending aorta and part of the aortic arch (hemiarch), with preservation of the aortic valve with suspension of the comissures. The patient had ununventfull recovery, being discharged in the 9th postoperative day. We emphasized the similarity of the clinical presentation of the intramural hematoma of the aorta with that of aortic dissection, the importance of establishing correct diagnosis and the best treatment.