Carotid stenosis management: a review for the internist.

Stroke is one of the most important causes of mortality and morbidity worldwide and, for a long time, was the leading cause of death in developed countries. Atherothrombotic carotid stenosis is one of the most important etiologies behind this event. If properly recognized and treated, lives can be saved, as well as long-term disabilities prevented. With population aging and improvements in surgical and clinical care, patients with several comorbidities will be referred for revascularization procedures more frequently, posing a challenge for physicians. The purpose of this review is to provide internists and clinicians with information based on several studies so they can offer to their patients, the best evidence-based care, indicating appropriate medical therapy, as well as referral to a vascular surgeon, or what contraindicates endarterectomy or angioplasty, depending on individual characteristics.

Coronary plaque rupture in patients with myocardial infarction after noncardiac surgery: frequent and dangerous.

PURPOSE: The pathophysiology of acute coronary syndromes (ACS) after noncardiac surgery is not established yet. Thrombosis over a vulnerable plaque or decreased oxygen supply secondary to anemia or hypotension may be involved. The purpose of this study was to investigate the pathophysiology of ACS complicating noncardiac surgery. METHODS: Clinical and angiographic data were prospectively recorded into a database for 120 consecutive patients that had an ACS after noncardiac surgery (PACS), for 120 patients with spontaneous ACS (SACS), and 240 patients with stable coronary artery disease (CAD). Coronary lesions with obstructions greater than 50% were classified based on two criteria: Ambrose's classification and complex morphology. The presence of Ambrose's type II or complex lesions were compared between the three groups. RESULTS: We analyzed 1470 lesions in 480 patients. In PACS group, 45% of patients had Ambrose's type II lesions vs. 56.7% in SACS group and 16.4% in stable CAD group (P<0.001). Both PACS and SACS patients had more complex lesions than patients in stable CAD group (56.7% vs. 79.2% vs. 31.8%, respectively; P<0.001). Overall, the independent predictors of plaque rupture were being in the group PACS (P<0.001, OR 2.86; CI, 1.82-4.52 for complex lesions and P<0.001, OR 3.43; CI, 2.1-5.6 for Ambrose's type II lesions) or SACS (P<0.001, OR 8.71; CI, 5.15-14.73 for complex lesions and P<0.001, OR 5.99; CI, 3.66-9.81 for Ambrose's type II lesions). CONCLUSIONS: Nearly 50% of patients with perioperative ACS have evidence of coronary plaque rupture, characterizing a type 1 myocardial infarction.

Aspirina no perioperatório de cirurgias não cardíacas: o dilema entre manter ou suspender / Aspirin perioperatively in noncardiac surgery: the dilemma between keeping or suspend

JUSTIFICATIVA E OBJETIVOS: É crescente o número de pacientes em uso de aspirina que serão submetidos a procedimentos cirúrgicos, situação que contribui para o dilema entre suspensão ou manutenção da medicação. Se por um lado a manutenção da aspirina durante o perioperatório está associada a um aumento no número de complicações hemorrágicas, por outro a sua interrupção está associada a graves complicações trombóticas. O objetivo deste estudo foi revisar de forma não sistemática as bases de dados Medline, Cochrane, Google Scholar e LILACS quanto aos efeitos da suspensão ou manutenção da aspirina no perioperatório de operações não cardíacas.CONTEÚDO: Os pacientes em uso de aspirina devem ser avaliados individualmente e a antiga recomendação de suspender a medicação de 7 a 10 dias antes de todo procedimento cirúrgico deve ser revista em razão dos comprovados efeitos prejudiciais. A aspirina deve ser mantida naqueles pacientes em prevenção secundária na maioria das situações, com exceção das cirurgias em cavidades fechadas e da prostatectomia transuretral, onde os riscos associados ao sangramento mostraram-se elevados. Os pacientes com stent coronariano também devem manter o uso da aspirina indefinidamente e a realização de procedimentos cirúrgicos eletivos deve ser postergada enquanto o uso concomitante do clopidogrel estiver indicado. CONCLUSÃO: A decisão sobre a manutenção da aspirina no perioperatório deve levar em conta riscos aterotrombóticos associados à sua suspensão e riscos de sangramento inerentes ao procedimento cirúrgico proposto. As evidências disponíveis apontam a favor de uma relação risco-benefício favoráveis à manutenção da aspirina na maioria das situações, embora estudos mais definitivos sejam necessários.(AU)

BACKGROUND AND OBJECTIVES: The number of patients taking aspirin who will undergo invasive surgical procedures is increasing. This clinical situation contributes to the dilemma between maintaining or withdraws the medication. In one hand, the maintenance during the perioperative periodis associated with an increased number of bleeding complications;on the other its discontinuation is associated with severe thrombotic complications. The purpose of this article was a non-systematic review of databases Medline, Cochrane Library, Google Scholar and LILACS as to the effects of the suspension or maintenance of aspirin perioperatively in noncardiac operations. CONTENTS: Patients taking aspirin must be evaluated individually and the former recommendation to discontinue the medication 7-10 days prior to any procedure should be reviewed because of the proven harmful effects. Aspirin should be maintained in patients in secondary prevention in most situations, except in closed space surgeries and transurethral prostatectomy, situations where the risk of bleeding appeared to be high. Patients with coronary stenting should also keep aspirin indefinitely and the holding of elective surgeries must be postponed while the concomitant use of clopidogrel is indicated. CONCLUSION: The decision on the maintenance of aspirin in the perioperative period should consider the atherothrombotic risks associated with suspension and bleeding risks inherent of the proposed surgical procedure. The available evidence points in favor of a risk-benefit ratio favorable to the maintenance of aspirin in most situations, although more definitive studies are needed.(AU)

Impacto da interconsulta cardiológica na evolução clínica de pacientes hospitalizados / Impact of cardiology referral on clinical outcomes in hospitalized patients

A interconsulta cardiológica corresponde a uma parcela considerável das atividades assistenciais e de ensino do cardiologista, refletindo gasto extra de tempo e recursos. Apesar disso, essa atividade não tem recebido a devida atenção da literatura, com poucos estudos sobre o tema. O objetivo do presente estudo foi, primariamente, comparar a evolução clínica dos pacientes envolvidos na interconsulta cardiológica que tiveram as recomendações seguidas pela equipe médica solicitante (grupo ACEITADOR) com aqueles em que as recomendações não foram seguidas (grupo NÃO ACEITADOR). De forma secundária, procuramos identificar as variáveis determinantes da aceitação das sugestões da equipe cardiológica. Para isso, foi realizado um estudo observacional envolvendo pacientes internados no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, para os quais foram solicitadas interconsultas cardiológicas, no período de março a setembro de 2008. Os dados referentes às interconsultas foram coletados pelo investigador de maneira prospectiva a partir do prontuário dos pacientes. Dentre as 589 interconsultas selecionadas para o estudo, 271 consistiam em avaliações clínicas e 318 avaliações pré-operatórias. Em relação à taxa de aceitação das recomendações cardiológicas, 77% dos pacientes foram classificados no grupo ACEITADOR e 23% classificados no grupo NÃO ACEITADOR. A análise da evolução clínica demonstrou que, dentre os pacientes do grupo NÃO ACEITADOR, 38,8% evoluíram de forma desfavorável (piora clínica ou óbito) contra 5,4% dos pacientes do grupo ACEITADOR (P<0,0001). Após análise de regressão logística, pertencer ao grupo NÃO ACEITADOR (P<0,001; OR 10,25; IC 95% 4,45 - 23,62) e a idade dos pacientes (P=0,017; OR 1,04; IC 95% 1,01 1,07) estiveram associados de forma independente a uma evolução clínica desfavorável. Foram identificados quatro preditores independentes de aceitação das recomendações: a realização de visitas de seguimento...

Cardiology referral represents an important part of cardiologist activities, accounting for substantial workload and demanding extra time and resources. Despite the importance of these facts, it has received little attention in the medical literature in the last years. The purpose of this study was to compare the clinical outcome of patients involved in cardiology referral who had the cardiologic recommendations followed by the requesting service (ACCEPTING group) with those whose recommendations were not followed (NON-ACCEPTING group). Secondly, we aimed to determine which of the variables involved in cardiology referral were related to acceptance to consultants recommendations. An observational study was performed at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, involving cardiology consultations during the months of March 2008 through September 2008. Data regarding consultations were prospectively extracted from the medical records by a physician-researcher. Among the 589 cardiology consultations selected for the study, 271 were clinical evaluations and 318 were preoperative evaluations. Regarding compliance of the referring service in following the recommendations offered by cardiology team, 77% of patients were classified in the ACCEPTING group and 23% in the NON-ACCEPTING group. A clinical outcome analysis was performed and showed that 38,8% of patients allocated to NON-ACCEPTING group had evolved unfavorably (clinical deterioration or death) against 5,4% of patients allocated to accepting group (P<0.0001). After logistic regression analysis, belong to NON-ACCEPTING group (P<0.001; OR 10.25; CI 95% 4.45 23.62) and patients age (P=0.017; OR 1.04; CI 95% 1.01 1.07) were variables independently associated to an unfavorable clinical outcome. The multivariate analysis indentified 4 independent predictors of acceptance to consultants recommendations: follow-up notes in the chart (P<0.001; OR 2.43; CI 95% 1.48 4.01), personal...

Non-cardiac surgery in developing countries: epidemiological aspects and economical opportunities--the case of Brazil.

BACKGROUND: Worldwide distribution of surgical interventions is unequal. Developed countries account for the majority of surgeries and information about non-cardiac operations in developing countries is scarce. The purpose of our study was to describe the epidemiological data of non-cardiac surgeries performed in Brazil in the last years. METHODS AND FINDINGS: This is a retrospective cohort study that investigated the time window from 1995 to 2007. We collected information from DATASUS, a national public health system database. The following variables were studied: number of surgeries, in-hospital expenses, blood transfusion related costs, length of stay and case fatality rates. The results were presented as sum, average and percentage. The trend analysis was performed by linear regression model. There were 32,659,513 non-cardiac surgeries performed in Brazil in thirteen years. An increment of 20.42% was observed in the number of surgeries in this period and nowadays nearly 3 million operations are performed annually. The cost of these procedures has increased tremendously in the last years. The increment of surgical cost was almost 200%. The total expenses related to surgical hospitalizations were more than $10 billion in all these years. The yearly cost of surgical procedures to public health system was more than $1.27 billion for all surgical hospitalizations, and in average, U$445.24 per surgical procedure. The total cost of blood transfusion was near $98 million in all years and annually approximately $10 million were spent in perioperative transfusion. The surgical mortality had an increment of 31.11% in the period. Actually, in 2007, the surgical mortality in Brazil was 1.77%. All the variables had a significant increment along the studied period: r square (r(2)) = 0.447 for the number of surgeries (P = 0.012), r(2) = 0.439 for in-hospital expenses (P = 0.014) and r(2) = 0.907 for surgical mortality (P = 0.0055). CONCLUSION: The volume of surgical procedures has increased substantially in Brazil through the past years. The expenditure related to these procedures and its mortality has also increased as the number of operations. Better planning of public health resource and strategies of investment are needed to supply the crescent demand of surgery in Brazil.

Transient global amnesia as a manifestation of acute myocardial infarction: a case of missed sudden cardiac death?

Acute myocardial infarction may lead to several clinical manifestations and many times this diagnosis is missed. Transient global amnesia (TGA) is a well-defined clinical syndrome of unknown etiology. Several mechanisms have been proposed but only trigger events have been clearly associated with the attack. We describe a case of acute myocardial infarction manifestated by TGA.

Spondylodiscitis and infectious endocarditis: a round-trip to be considered

The association between spondylodiscitis and endocarditis was first reported in 1965 by de Sèze et al. The most common clinical picture of this association is musculoskeletal symptoms preceding endocarditis diagnosis, but we report here a case of spondylodiscitis complicating endocarditis in its late course. A 70-year-old man, with an established diagnosis of mitral valve endocarditis caused by Streptococcus intermedius, early submitted to surgical treatment because of heart failure, who had an uneventful recovery up to the 12th day of antibiotic therapy when he presented intensive backache, with tenderness in the two lower lumbar vertebras. Spondylodiscitis was confirmed by a magnetic resonance imaging and the treatment was non-esteroidal anti-inflamatory and analgetics drug, with good results, and prolongation of antibiotic treatment up to 3 months. Appropriate diagnosis of this association has important consequences, as the need of a longer antibiotic therapy course, which can range from 6 weeks to 3 months.

O ecocardiograma na avaliação do risco perioperatório / Echocardiogram in the operative setting

A estratificação pré-operatória de risco cardíaco, em pacientes submetidos a operações não cardíacas, tem como objetivo identificar aqueles com risco aumentado de eventos cardíacos que possam beneficiar-se de intervenções antes da operação. Várias informações podem ser utilizadas com esse propósito, incluíndo história clínica, exame físico, eletrocardiograma e exames laboratoriais. Nos últimos anos, numerosas publicações têm estudado a ecocardiografia como uma ferramenta segura, factível e determinante de informação prognóstica, nesse contexto. Este artigo discute os dados disponíveis, na literatura, sobre o valor adicional da ecocardiografia na avaliação de risco cardíaco, em operações não cardíacas, e descreve suas principis aplicações.

Spondylodiscitis and infectious endocarditis: a round-trip to be considered.

The association between spondylodiscitis and endocarditis was first reported in 1965 by de Sèze et al. The most common clinical picture of this association is musculoskeletal symptoms preceding endocarditis diagnosis, but we report here a case of spondylodiscitis complicating endocarditis in its late course. A 70-year-old man, with an established diagnosis of mitral valve endocarditis caused by Streptococcus intermedius, early submitted to surgical treatment because of heart failure, who had an uneventful recovery up to the 12th day of antibiotic therapy when he presented intensive backache, with tenderness in the two lower lumbar vertebras. Spondylodiscitis was confirmed by a magnetic resonance imaging and the treatment was non-esteroidal anti-inflammatory and analgetics drug, with good results, and prolongation of antibiotic treatment up to 3 months. Appropriate diagnosis of this association has important consequences, as the need of a longer antibiotic therapy course, which can range from 6 weeks to 3 months.