Implications for Clinical Practice from a Multicenter Survey of Heart Failure Management Centers.

OBJECTIVES: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil. METHODS: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment. RESULTS: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment. CONCLUSION: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

Implications for clinical practice from a multicenter survey of heart failure management centers

OBJECTIVES: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil. METHODS: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment. RESULTS: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment. CONCLUSION: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

Electrolyte changes related to muscle pain after resistance exercises / Alterações eletrolíticas relacionadas à dor muscular após exercícios resistidos / Alteraciones electrolíticas relacionadas al dolor muscular después de ejercicios resistidos

ABSTRACT Introduction Resistance exercises (RE) performed at high intensity cause an inflammatory response and electrolyte abnormalities in blood plasma. Objectives To study the plasma electrolyte changes resulting from a high-intensity session of RE in untrained volunteers, and to correlate these with delayed onset muscle soreness (DOMS). Methods Twenty volunteers, aged 26.9 (±4.4) years, underwent an RE session. The workout (leg extension, squat and leg press) consisted of four sets of 10 maximum repetitions. Electrolytes (Na+, K+, Ca2+ e Mg2+) were evaluated before the training (baseline), immediately (0 min), and 30 minutes after the RE. The DOMS was assessed 24 hours after the sessions. Results The Na+ increased immediately after the RE and returned to normal after 30 min (p<0.001). After 30 min, K+ increased compared to baseline levels and immediately after the RE (p<0.001). Ca2+ and Mg2+ levels did not change throughout the study. Changes in Na+ and K+ levels were correlated immediately (r=-0.511; p=0.021) and 30 min (r=-0.455; p=0.049) after RE. Plasma concentrations of Na+ 0 min were correlated (r=-0.520; p=0.018) with the DOMS. Conclusion High-intensity RE in untrained volunteers leads to changes in plasma concentrations of Na+ and K+. Na+ concentrations immediately after RE were related to DOMS; individuals that presented smaller alterations in this electrolyte reported more muscular pain. Level of evidence II; Diagnostic Studies - Development of diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).

RESUMO Introdução Os exercícios resistidos (ER) realizados em alta intensidade provocam uma resposta inflamatória e alterações eletrolíticas no plasma sanguíneo. Objetivo Estudar as alterações eletrolíticas plasmáticas resultantes de uma sessão de ER de alta intensidade em voluntários destreinados e correlacionar com a dor muscular de início tardio (DMIT). Métodos Vinte voluntários com 26,9 (±4,4) anos de idade foram submetidos à sessão de ER. A sessão de exercícios (cadeira extensora, agachamento e leg press) consistiu em quatro séries de 10 repetições máximas. Os eletrólitos (Na+, K+, Ca2+ e Mg2+) foram avaliados previamente (basal), imediatamente (0 min) e 30 minutos após os ER. A DMIT foi avaliada 24 horas após as sessões. Resultados O Na+ aumentou imediatamente após os ER e retornou ao normal após 30 min (p<0,001). Em 30 min, o K+ aumentou em relação aos valores basais e imediatamente após os ER (p<0,001). O Ca2+ e o Mg2+ não se modificaram ao longo do estudo. As alterações de Na+ e de K+ correlacionaram-se imediatamente (r=-0,511; p=0,021) e 30 min (r=-0,455; p=0,049) após os ER. As concentrações plasmáticas de Na+ 0 min correlacionam-se (r=-0,520; p=0,018) com a DMIT. Conclusão Os ER de alta intensidade em voluntários destreinados aumentaram as concentrações plasmáticas de Na+ e de K+. As concentrações de Na+ imediatamente após os ER correlacionaram-se com a DMIT, em que os indivíduos que apresentam menores alterações desse eletrólito sentem mais dor muscular. Nível de Evidência II; Estudos diagnósticos - Desenvolvimento de critérios diagnósticos em pacientes consecutivos (com padrão de referência "ouro" aplicado).

RESUMEN Introducción Los ejercicios resistidos (ER) realizados en alta intensidad provocan una respuesta inflamatoria y alteraciones electrolíticas en el plasma sanguíneo. Objetivo Estudiar las alteraciones electrolíticas plasmáticas resultantes de una sesión de ER de alta intensidad en voluntarios desentrenados y correlacionar con el dolor muscular de inicio tardío (DMIT). Métodos Veinte voluntarios con 26,9 (±4,4) años de edad fueron sometidos a la sesión de ER. La sesión de ejercicios (mesa extensora, sentadillas y leg press) consistió en cuatro series de 10 repeticiones máximas. Los electrólitos (Na+, K+, Ca2+ y Mg2+) fueron evaluados previamente (basal), inmediatamente (0 min) y 30 minutos después de los ER. La DMIT fue evaluada 24 horas después de las sesiones. Resultados El Na+ aumentó inmediatamente después de los ER y retornó a lo normal después de 30 min (p<0,001). En 30 min el K+ aumentó con relación a los valores basales e inmediatamente después de los ER (p<0,001). El Ca2+ y el Mg2+ no se modificaron a lo largo del estudio. Las alteraciones de Na+ y de K+ se correlacionaron inmediatamente (r=-0,511, p=0,021) y 30 min (r=-0,455, p=0,049) después de los ER. Las concentraciones plasmáticas de Na+ 0 min se correlacionan (r=-0,520, p=0,018) con la DMIT. Conclusión Los ER de alta intensidad en voluntarios desentrenados aumentaron las concentraciones plasmáticas de Na+ y de K+. Las concentraciones de Na+ inmediatamente después de los ER se correlacionaron con la DMIT, en que los individuos que presentan menores alteraciones de ese electrolito sienten más dolor muscular. Nivel de evidencia II; Estudios diagnósticos - Desarrollo de criterios diagnósticos en pacientes consecutivos (con estándar de referencia "oro" aplicado).

Continuous positive airway pressure for adults with obstructive sleep apnea and cardiovascular disease: a meta-analysis of randomized trials.

BACKGROUND: It remains uncertain whether continuous positive airway pressure (CPAP) therapy would significantly impact hard clinical outcomes in patients with obstructive sleep apnea (OSA). This meta-analysis aimed to assess the effects of CPAP in survival and secondary prevention of major cardiovascular events in patients with OSA and cardiovascular disease (CVD). METHODS: PubMed, Cochrane CENTRAL, LILACS, and SciElo databases (up to January 2018) were searched for randomized trials that compared CPAP with no active treatment in adults with OSA and CVD. The primary outcomes were all-cause death, cardiovascular death, acute myocardial infarction, stroke, and any major cardiovascular event. We used risk ratios (RR) and 95% confidence interval (CI) as the effect measures for dichotomous data, and weighted mean difference (WMD) and 95% CI for continuous variables. We used the random-effects method for meta-analysis. RESULTS: Nine trials involving 3314 patients contributed data for meta-analysis of at least one outcome. The duration (median) of CPAP treatment varied from one month to 56.9 months. The pooled RR (95% CI) was 0.86 (0.60-1.23, I2 = 0.0%) for all-cause death, 0.58 (0.19-1.74, I2 = 47%) for cardiovascular death, 1.11 (0.76-1.62, I2 = 0.0%) for myocardial infarction, 0.77 (0.46-1.28, I2 = 16%) for stroke, and 0.93 (0.70-1.24, I2 = 49%) for any major cardiovascular event. The quality of evidence for these outcomes was low. CONCLUSIONS: Low-quality evidence suggests that CPAP therapy does not significantly improve survival or prevent major cardiovascular events in adults with OSA and cardiovascular disease.

Cold water immersion and inflammatory response after resistance exercises / Imersão em água fria e resposta inflamatória após exercícios resistidos / Inmersión en agua fría en respuesta inflamatoria posterior a ejercicios resistidos

INTRODUCTION: High-intensity resistance exercises (RE) cause an inflammatory response that reduces functionality. OBJECTIVE: To evaluate the effects of Cold Water Immersion (CWI) on leukocytosis, oxidative stress parameters, inflammatory markers and delayed onset muscle soreness (DOMS) resulting from a RE session in untrained volunteers. METHODS: Thirteen volunteers (aged 26 ± 5 years) who do not engage in RE were randomized and underwent Control RE and RE with CWI sessions. Exercise sessions (leg extension machine, squats and leg presses) consisted of four sets of 10 maximum repetitions (one-week interval between the assessment and the sessions). CWI consisted of immersion in water (15°C) to the umbilicus for 10 minutes immediately after the exercise session. Complete blood count, CRP, creatine kinase (CK) and lipoperoxidation (LPO) were assessed previously (baseline) and immediately, 30 minutes and 2 hours after RE. DOMS was assessed 24 hours after the sessions. RESULTS: RE induced progressive leukocytosis (P<0.001). CRP was elevated 2 hours after exercise (P=0.008) only in the Control RE session. CK increased 30 minutes and 2 hours after exercise (P<0.001) in the Control session, whereas in the CWI session the increase was observed after 2 hours (P<0.001). LPO increased only in the Control session after 2 hours (P=0.025). CWI reduced DOMS by 57% (P<0.001). CONCLUSION: CWI slows the inflammatory response and reduces DOMS in untrained individuals undergoing RE. Level of Evidence I; Randomized Clinical Trial.

INTRODUÇÃO: Os exercícios resistidos (ER) de alta intensidade provocam resposta inflamatória que reduz a funcionalidade. OBJETIVO: Avaliar os efeitos da imersão em água fria (IAF) sobre leucocitose, parâmetros de estresse oxidativo, marcadores inflamatórios e dor muscular de início tardio (DMIT), resultantes de uma sessão ER em voluntários destreinados. MÉTODOS: Treze voluntários (26 ± 5 anos de idade) não praticantes de ER foram randomizados e submetidos a sessões de ER Controle (ERC) e ER com IAF (ER+IAF). As sessões de exercícios (cadeira extensora, agachamento e leg press) consistiram em quatro séries de 10 repetições máximas (intervalo de uma semana entre a avaliação e as sessões). A IAF consistiu em imersão em água (15 °C), no nível da região umbilical, durante 10 minutos, imediatamente após a sessão de exercícios. Hemograma completo, PCR, creatina quinase (CK) e lipoperoxidação (LPO) foram avaliados previamente (basal) e imediatamente, aos 30 minutos e 2 horas após os ER. A DMIT foi avaliada 24 horas após as sessões. RESULTADOS: Os ER induziram leucocitose progressiva (P < 0,001). A PCR foi elevada 2 horas após os exercícios (P = 0,008), apenas na sessão de ER Controle. A CK aumentou 30 minutos e 2 horas após os exercícios (P < 0,001) na sessão Controle, enquanto na sessão IAF o aumento foi observado após 2 horas (P < 0,001). A LPO aumentou somente na ERC depois de 2 horas (P = 0,025). A IAF reduziu em 57% a DMIT (P < 0,001). CONCLUSÃO: A IAF retarda a resposta inflamatória e reduz a DMIT em indivíduos destreinados submetidos a ER. Nível de Evidência I; Ensaio Clínico Randomizado.

INTRODUCCIÓN: Los ejercicios resistidos (ER) realizados en alta intensidad provocan una respuesta inflamatoria que reduce la funcionalidad. OBJETIVO: Evaluar los efectos de la inmersión en agua fría (IAF) sobre la leucocitosis, estrés oxidativo, marcadores inflamatorios y en el dolor muscular de inicio tardío (DMIT) resultantes de una sesión de ER en voluntarios no entrenados. MÉTODOS: Trece voluntarios (26 ± 5 años de edad) no practicantes de ER fueron aleatoriamente sometidos a sesiones de Control ER y ER con IAF. Las sesiones de ejercicios (silla extensora, sentadillas y leg press) consistieron en cuatro series de 10 repeticiones máximas (intervalo de una semana entre la evaluación y las sesiones). La IAF consistió en inmersión en agua (15°C) a nivel de la cicatriz umbilical, durante 10 minutos posteriores a la sesión de ejercicios. Se realizó un análisis completo de hemograma, PCR, creatina quinasa (CK) y lipoperoxidación (LPO), los cuales se evaluaron previa (basal), e inmediatamente después de 30 minutos y 2 horas después de los ER. La DMIT fue evaluada 24 horas después de las sesiones. RESULTADOS: Los ER indujeron a una progresiva leucocitosis (P<0,001). La PCR se elevó 2 horas luego de los ejercicios (P=0,008) apenas en la sesión de Control ER. La CK aumentó después de 30 minutos y 2 horas después de los ejercicios (P<0,001) en la sesión Control, mientras que en la sesión IAF el aumento se observó después de 2 horas (P<0,001). La LPO sólo aumentó en la sesión de Control en 2 horas (P=0,025). La IAF redujo en 57% el DMIT (P<0,001). CONCLUSIÓN: La IAF retarda la respuesta inflamatoria y reduce la DMIT en individuos no entrenados sometidos a ER. Nivel de Evidencia I, Ensayo Clínico Randomizado.

Use of sunscreen and risk of melanoma and non-melanoma skin cancer: a systematic review and meta-analysis.

The use of sunscreen is a key component of public health campaigns for skin cancer prevention, but epidemiological studies have raised doubts on its effectiveness in the general population. This systematic review and meta-analysis aimed to assess the association between risk of skin cancer and sunscreen use. We searched PubMed, BIREME and Google Scholar from inception to May 17, 2017, to identify observational studies and controlled trials. We used a random-effects model for conventional and cumulative meta-analyses. We included 29 studies (25 case-control, two cohort, one cross-sectional, and one controlled trial) involving 313,717 participants (10,670 cases). The overall meta-analysis did not show a significant association between skin cancer and sunscreen use (odds ratio (OR) = 1.08; 95% CI: 0.91-1.28, I2 = 89.4%). Neither melanoma (25 studies; 9,813 cases) nor non-melanoma skin cancer (five studies; 857 cases) were associated with sunscreen use, with a pooled OR (95% CI) of 1.10 (0.92-1.33) and 0.99 (0.62-1.57), respectively. The cumulative evidence before the 1980s showed a relatively strong positive association between melanoma and sunscreen use (cumulative OR: 2.35; 95% CI: 1.66-3.33). The strength of the association between risk of skin cancer and sunscreen use has constantly decreased since the early 1980s, and the association was no longer statistically significant from the early 1990s. While the current evidence suggests no increased risk of skin cancer related to sunscreen use, this systematic review does not confirm the expected protective benefits of sunscreen against skin cancer in the general population.

Different frequencies of transcutaneous electrical nerve stimulation on sympatho-vagal balance / Diferentes frequências da estimulação elétrica nervosa transcutânea no balanço simpato-vagal

This study aims to evaluate the effects of TENS at different frequencies on autonomic balance in healthy volunteers. It is a case-control study, and was composed of fourteen healthy volunteers (5 women) with 28 (3.9) years old who underwent low (10 Hz 200ms-1) and high (100 Hz 200ms-1) frequency TENS. The interventions were randomized and applied for 30 minutes in the trajectory brachial nerve plexus from non -dominant member. Intensities were adjusted every 5 minutes and maintained below motor threshold. The autonomic balance was assessed before and after interventions by heart rate variability (HRV). TENS 10 Hz increased 10% sympathetic activity and decreased 10% parasympathetic activity; however, TENS 100 Hz showed opposite effects (p < 0.05). The sympatho-vagal balance increased with low frequency TENS and decreased with high frequency (p < 0.05). It can be concluded that different frequencies of TENS applied in the trajectory brachial nerve plexus modify cardiovascular autonomic responses. High frequency TENS reduces sympathetic activity and increases the parasympathetic, which favors beneficial effects on autonomic balance in healthy volunteers.

Este estudo objetiva avaliar os efeitos de diferentes frequências da TENS sobre o balanço autonômico em voluntários saudáveis. Estudo caso-controle composto de quatorze voluntários saudáveis (5 mulheres), com 28 (3,9) anos de idade que foram submetidos a baixa (10 Hz 200 ms-1) e a alta (100 Hz 200 ms-1) frequências da TENS. As intervenções foram randomizadas e aplicadas por 30 minutos sobre a trajetória do plexo nervoso braquial do membro não dominante. As intensidades foram ajustadas a cada 5 minutos e mantidas abaixo do limiar motor. O balanço autonômico foi avaliado antes e após as intervenções pela variabilidade da frequência cardíaca (VFC). TENS a 10 Hz aumentou 10% da atividade simpática e diminui 10% a atividade parassimpática, mas a TENS a 100 Hz apresentou efeitos opostos (p < 0,05). O balanço simpato-vagal aumentou com a TENS de baixa frequência e diminuiu com a alta frequência (p < 0,05). Conclui-se que as diferentes frequências da TENS aplicadas sobre a trajetória do plexo nervoso braquial modificam as respostas autonômicas cardiovasculares. A alta frequência da TENS reduz a atividade simpática e aumenta a parassimpática, o que favorece aos efeitos benéficos sobre o balanço autonômico em voluntários saudáveis.

Effects of Different Therapeutic Ultrasound Waveforms on Endothelial Function in Healthy Volunteers: A Randomized Clinical Trial.

The purpose of this study was to determine the effects of different therapeutic 1-MHz ultrasound waveforms on endothelial function before and after cyclooxygenase (COX) inhibition. Forty-two healthy volunteers aged 27.2 ± 3.8 y underwent interventions and an evaluation for endothelial function (n = 15; with COX inhibition, n = 15; duration of the vasodilator effect, n = 12) by technique flow-mediated dilation. Continuous ultrasound therapy (0.4 W/cm(2 SATA)), pulsed ultrasound therapy (20% duty cycle, 0.08 W/cm(2 SATA)) or placebo (equipment power off) was randomly applied over the brachial artery for 5 min. COX inhibition (aspirin) was carried out 30 min before treatments. In relation to the placebo, flow-mediated dilation increased by 4.8% using continuous ultrasound and by 3.4% using pulsed ultrasound. After COX, flow-mediated dilation was enhanced by 2.1% by continuous ultrasound and 2.6% by pulsed ultrasound. This vasodilation persisted for 20 min. Continuous and pulsed therapeutic 1-MHz ultrasound waveforms improved endothelial function in humans, which provided them with anti-inflammatory vascular effects.

EFEITOS DO TREINAMENTO FÍSICO NO ENDOTÉLIO APÓS CIRURGIA DE REVASCULARIZAÇÃO / EFFECTS OF PHYSICAL TRAINING ON ENDOTHELIUM AFTER CORONARY ARTERY BYPASS GRAFT / EFECTOS DEL ENTRENAMIENTO FÍSICO EN EL ENDOTELIO DESPUÉS DE REVASCULARIZACIÓN

Introdução A cirurgia de revascularização do miocárdio (CRM) é uma das mais frequentes cirurgias realizadas em todo o mundo, muitos estudos vêm relatando os benefícios do treinamento físico para a melhora da capacidade funcional, porém há poucos estudos sobre os efeitos na função endotelial vascular. Objetivo Analisar os efeitos do treinamento físico sobre a função endotelial vascular em pacientes submetidos à CRM, isoladamente na fase tardia da reabilitação após seis meses de programa de reabilitação cardíaca (PCR). Métodos Foram incluídos pacientes que haviam sido submetidos à CRM no período máximo de um ano após a cirurgia. O PRC foi empregado durante seis meses consecutivos, com três sessões semanais. Todos os pacientes realizaram exames laboratoriais, teste de força muscular de uma repetição máxima (1-RM) para os membros superiores e inferiores, teste de caminhada de 6 min (TC6M) e avaliação da função endotelial através da técnica de vasodilatação mediada pelo fluxo. Resultados Onze pacientes iniciaram o PRC, porém nove pacientes o completaram. A média de idade foi de 66 anos (50 a 82 anos) e o sexo masculino foi predominante (55,6%). Houve mudanças significativas nos exames laboratoriais bioquímicos: aumento do colesterol total (Basal: 162 ± 31mg/dL vs. 195 ± 39mg/dL; P=0,012) e diminuição da hemoglobina glicada (Basal: 6,74 ± 1,64% vs. 6,26 ± 1,62%; P=0,028). A força muscular aumentou significativamente nos membros superiores e inferiores (P=0,030 e P=0,038, respectivamente); no TC6M observou-se um aumento significativo de 20% na distância percorrida (P=0,020) após seis meses consecutivos de treinamento e houve uma melhora na vasodilatação mediada pelo fluxo (Basal: 6,35 ± 3,92% vs. 6 meses: 9,90 ± 4,19%; P=0,026). Conclusão O treinamento combinado realizado em seis meses ajudou a melhorar a função endotelial e a capacidade funcional de pacientes sedentários que foram submetidos à CRM na fase tardia da reabilitação.

Introduction The coronary artery bypass graft surgery (CABG) is one of the most common surgeries performed worldwide, many studies have reported the benefits of physical training to improve functional capacity, however there are few studies about the effect of this training on vascular endothelial function. Objective To analyze the effects of physical training on vascular endothelial function in patients who underwent CABG surgery alone in the last phase of rehabilitation after six months of cardiac rehabilitation program (CRP). Methods Patients who underwent CABG surgery in a maximum period of one year after surgery were included in the study. The CRP was carried out during six consecutive months, with three sessions per week. All patients underwent biochemical blood tests, muscle strength testing of one repetition maximum (1-RM test) for upper and lower limbs, 6-minute walk test (6MWT), and evaluation of endothelial function through the flow-mediated vasodilation technique. Results Eleven patients started CRP, but only nine patients completed it. The mean age was 66 years old (50 to 82 years old), males being predominant (55.6%). There were significant changes in biochemical laboratory tests: increase on total cholesterol (Baseline: 162 ± 31mg/dL vs. 195 ± 39mg/dL; P=0.012), and decrease on glycated hemoglobin (Baseline: 6.74 ± 1.64% vs. 6.26 ± 1.62%; P=0.028). Muscle strength was significantly increased in upper and lower limbs (P=0.030, and P=0.038, respectively) and in 6MWT we observed a significant increase of 20% in distance traveled (P=0.020) after six consecutive months of training. There was also a flow-mediated vasodilation improvement (6.35 ± 3.92% vs. 9.90 ± 4.19%; P=0.026). Conclusion The combined training carried out in six months helped to improve endothelial function and functional capacity in sedentary patients submitted to CABG surgery in the last phase of cardiac rehabilitation.

Introducción La cirugía de revascularización miocárdica (CRM) es una de las cirugías más comunes que se realizan en todo el mundo, muchos estudios han reportado los beneficios del entrenamiento físico para mejorar la capacidad funcional, pero hay pocos estudios sobre el efecto en la función endotelial vascular. Objetivo Analizar los efectos del entrenamiento físico sobre la función endotelial vascular en los pacientes sometidos a CRM solo en la última fase de la rehabilitación después de seis meses del programa de rehabilitación cardíaca (PRC). Métodos Fueron incluidos los pacientes que habían sido sometidos a CRM con el período máximo de un año después de la cirugía. Los pacientes fueron sometidos a lo PRC por seis meses consecutivos, con tres sesiones semanales. Todos los pacientes realizaron pruebas de laboratorio, pruebas de fuerza muscular una repetición máxima (1-RM) para miembros superiores e inferiores, prueba de la marcha de 6 minutos (PM6M) y la evaluación de la función endotelial mediante la técnica de la vasodilatación mediada por flujo. Resultados Once pacientes iniciaron el PRC, pero nueve pacientes lo completaron. La edad promedio fue de 66 años (50-82 años) y los varones predominaron (55,6%). Hubo cambios significativos en las pruebas de laboratorio bioquímico: aumento en el colesterol total (basal: 162 ± 31 mg/dl vs. 195 ± 39 mg/dl; p = 0,012) y disminución de la hemoglobina glucosada (basal: 6,74 ± 1,64% % vs. 6,26 ± 1,62, p = 0,028). La fuerza muscular se incrementó significativamente en los miembros superiores e inferiores (P = 0,030 y P = 0,038, respectivamente) y en PM6M se observó un aumento significativo de 20% en la distancia cubierta (p = 0,020) después de seis meses consecutivos de entrenamiento y también la vasodilatación mediada por flujo ha mejorado (basal: 6,35 ± 3,92% vs. 9,90 ± 4,19%, p = 0,026). Conclusión El entrenamiento combinado realizado en seis meses ha mejorado la función endotelial y la capacidad funcional de los pacientes sedentarios sometidos a CRM en la última fase de la rehabilitación.

Inflammatory response after session of resistance exercises in untrained volunteers / Resposta inflamatória após sessão de exercícios resistidos em voluntários destreinados

The present study aimed to investigate the interaction between the blood cells, inflammatory markers, oxidative stress parameters and delayed onset muscle soreness (DOMS) after a session of resistance exercise (SRE). The sample consisted of sixteen untrained men (26.4±5 years; 25.9±3 kg m- 2). The SRE was composed of 4 sets of 10 repetitions maximum (extensor bench, squat and leg press) for each exercise. Complete blood cell count, C-reactive protein (CRP), creatine kinase (CK), lipid peroxidation and antioxidant capacity against peroxyl radicals were previously evaluated (baseline), and at 0, 30 and 120 min. after the SRE. DOMS was assessed 24 hours after the exercises. Immediately after the SRE, an increase of blood cell number was observed; returning to baseline after 30 min. However, after 120 min., neutrophils showed higher values than the baseline and 30 min. assessments. CK and CRP increased progressively throughout the experiment. LPO increased immediately and 120 min. after the SRE. Untrained volunteers presented an apparent biphasic inflammatory response after an acute SRE and the changes in oxidative stress, inflammatory markers and leukocytosis were best evidenced two hours after exercise.

O presente estudo investigou a interação entre as células sanguíneas, marcadores inflamatórios, parâmetros de estresse oxidativo e dor muscular de início tardio (DMIT) após uma sessão de exercícios de resistência (SER). A amostra compreendeu dezesseis voluntários destreinados (26.4±5 anos; 25.9±3 kg m-2). A SER consistiu em 4 séries de 10 repetições máximas (extensão do joelho, agachamento e leg press) para cada exercício. Hemograma completo, proteína C-reativa (PCR), creatina kinase (CK), lipoperoxidação e capacidade antioxidante contra o radical peroxil foram avaliados previamente (basal), 0, 30 e 120 min. após a SER. A DMIT foi avaliada 24h após os exercícios. Imediatamente após a SER ocorreu um aumento no número de células sanguíneas, retornando aos valores basais após 30 min. Entretanto, após 120 min. os neutrófilos apresentaram valores mais elevados que as avaliações basais e 30 min. A CK e a PCR aumentaram progressivamente ao longo do experimento. A liperoxidação aumentou imediatamente e 120 min. após a SER. Voluntários destreinados apresentam uma aparente resposta inflamatória bifásica após SER e as alterações dos parâmetros de estresse oxidativo, marcadores inflamatórios e leucocitose são melhor evidenciadas duas horas após os exercícios.

Reabilitacao cardiaca em pacientes submetidos a cirurgia de revascularizacao do miocardio / Cardiac rehabilitation in patients undergoing to coronary artery bypass graft / Rehabilitacion cardiaca en pacientes sometidos a cirugia de revascularizacion de miocardio

INTRODUÇÃO: Os programas de reabilitação cardíaca (PRC) vêm diminuindo a morbidade e a mortalidade em pacientes após cirurgias de revascularização do miocárdio (CRM). OBJETIVO: Observar a adesão de pacientes submetidos à CRM isoladamente na fase tardia a um PRC e analisar a qualidade de vida e capacidade funcional antes e após o treinamento físico de três meses de PRC. MÉTODOS: Foram contatados todos os pacientes submetidos à CRM isoladamente no período de um ano para participarem de um PRC com duração de três meses com três sessões semanais de uma hora de duração. Todos os pacientes realizaram exames bioquímicos de sangue, teste de força muscular de uma repetição máxima (1-RM) para membros superiores e inferiores, teste de caminhada dos 6 minutos (TC6) e responderam o questionário de qualidade de vida SF-36 antes e após o treinamento. RESULTADOS: De todos os 86 pacientes contatados, apenas 13% (n = 11) concluíram o PRC. A média de idade foi 67 ± 9 anos. O sexo masculino foi predominante, 73% (oito homens). Não houve alterações significativas nos exames bioquímicos laboratoriais. No TC6 houve um aumento significativo na distância percorrida (p = 0,014); quanto à força muscular houve um aumento significativo na carga para o teste em membros superiores (p = 0,043); e no questionário SF-36 não observamos diferenças significativas nos escores antes e depois dos três meses de PRC. CONCLUSÃO: A adesão ao PRC foi baixa, logo é de suma importância a divulgação da participação de pacientes que realizaram CRM nesses programas para proporcionar maior capacidade funcional. .

INTRODUCTION: The Cardiac Rehabilitation Programs (CRP) is decreasing the morbidity and mortality in patients after coronary artery bypass graft (CABG). OBJECTIVE: To observe the adherence of patients undergoing CABG alone in late phase to a PRC and analyze the quality of life and functional capacity before and after physical training in a period of three months. METHODS: We contacted all patients undergoing CABG alone in the period of one year to participate in a CRP lasting three months with three weekly sessions of one hour duration. All patients underwent biochemical blood tests, one-repetition maximum test (1RM) for the muscular strength in upper and lower limbs, 6-minute walk test (6MWT) and completed the quality of life questionnaire (SF-36) before and after training. RESULTS: In all 86 patients contacted, only 13% (n=11) patients completed the CRP. The mean age was 67 ± 9 years, predominantly male, 73% (8 men). There were no significant differences in the biochemical laboratory tests, however in 6MWT we observed significant increase in distance walked (p=0.014), a significant increase in muscle strength in the upper limbs (p=0.043), and in the SF-36, there were no significant differences in the scores before and after three months of CRP. CONCLUSION: Adherence to the CRP was low, so it is of paramount importance to disclose the participation of patients who underwent CABG in these programs to provide greater functional capacity. .

INTRODUCCIÓN: Los programas de rehabilitación cardíaca (PRC) vienen disminuyendo la morbidez y la mortalidad en pacientes después de cirugías de revascularización de miocardio (CRM). OBJETIVO: Observar la adhesión de pacientes sometidos a CRM aisladamente en la fase tardía a un PRC y analizar la calidad de vida y capacidad funcional antes y después del entrenamiento físico de tres meses de PRC. MÉTODOS: Fueron contactados todos los pacientes sometidos a CRM aisladamente en el período de un año para participar en un PRC con duración de tres meses con tres sesiones semanales de una hora de duración. Todos los pacientes realizaron exámenes bioquímicos de sangre, test de fuerza muscular de una repetición máxima (1-RM) para miembros superiores e inferiores, test de caminata de 6 minutos (TC6) y respondieron el cuestionario de calidad de vida SF-36 antes y después del entrenamiento. RESULTADOS: De los 86 pacientes contactados, solamente 13% (n = 11) concluyeron el PRC. El promedio de edad fue de 67 ± 9 años. El sexo masculino fue predominante, 73% (ocho hombres). No hubo alteraciones significativas en los exámenes bioquímicos de laboratorio. En el TC6 hubo un aumento significativo en la distancia recorrida (p = 0,014); cuanto a la fuerza muscular hubo un aumento significativo en la carga para el test en miembros superiores (p = 0,043); y en el cuestionario SF-36 no observamos diferencias significativas en los índices antes y después de los tres meses de PRC. CONCLUSIÓN: La adhesión al PRC fue baja, por lo tanto es de suma importancia la divulgación de la participación de pacientes que realizaron CRM en esos programas para proporcionar mayor capacidad funcional. .

Impact of coronary artery bypass grafting in elderly patients.

OBJECTIVE: To analyze the results of isolated on-pump coronary artery bypass graft surgery (CABG) in patients > 65 years-old. METHODS: Patients undergoing isolated on-pump CABG from December 1st 2010 to July 31th 2012 were divided in two groups: GE (elderly > 65 years-old, n=103) and GA (adults < 65 years-old, n=150). Preoperative data, intraoperative (as cardiopulmonar bypass time, aortic clamping time, time length of stay in mechanical ventilation--MV--and number of grafts), and postoperative variable (as morbidity, mortality and time length of stay in hospital) were analyzed during hospitalization. RESULTS: In GE, the morbidity rate was greater than in GA (30% vs. 14%, P=0.004), but there was no difference in the mortality rate (5.8% vs. 2.0%, P=0.165). In GA, there was higher prevalence DM (39.6% vs. 27%, P=0.043) and smoking (32.2% versus 19.8%, P=0.042); and in GE, higher prevalence of stroke (17% vs. 6.7%, P=0.013). There was no difference between the groups regarding intraoperative variables. After multivariate analysis, age > 65-year-old was associated with greater morbidity, but it was not independent predictive factor for in-hospital mortality. Considering in-hospital mortality, stay in ward time length (P=0.006), cardiac (P=0.011) and respiratory complications (P=0.026) were independent predictive factors. CONCLUSION: This study suggests that patients > 65-year old were at increased risk of postoperative complications when submitted to isolated on-pump CABG in comparison to patients < 65-year-old, but not under increased risk of death.

Impact of coronary artery bypass grafting in elderly patients / Impacto da cirurgia de revascularização do miocárdio em pacientes idosos

OBJECTIVE: To analyze the results of isolated on-pump coronary artery bypass graft surgery (CABG) in patients > 65 years-old. METHODS: Patients undergoing isolated on-pump CABG from December 1st 2010 to July 31th 2012 were divided in two groups: GE (elderly > 65 years-old, n=103) and GA (adults < 65 years-old, n=150). Preoperative data, intraoperative (as cardiopulmonar bypass time, aortic clamping time, time length of stay in mechanical ventilation - MV - and number of grafts), and postoperative variable (as morbidity, mortality and time length of stay in hospital) were analyzed during hospitalization. RESULTS: In GE, the morbidity rate was greater than in GA (30% vs. 14%, P=0.004), but there was no difference in the mortality rate (5.8% vs. 2.0%, P=0.165). In GA, there was higher prevalence DM (39.6% vs. 27%, P=0.043) and smoking (32.2% versus 19.8%, P=0.042); and in GE, higher prevalence of stroke (17% vs. 6.7%, P=0.013). There was no difference between the groups regarding intraoperative variables. After multivariate analysis, age > 65-year-old was associated with greater morbidity, but it was not independent predictive factor for in-hospital mortality. Considering in-hospital mortality, stay in ward time length (P=0.006), cardiac (P=0.011) and respiratory complications (P=0.026) were independent predictive factors. CONCLUSION: This study suggests that patients > 65-year old were at increased risk of postoperative complications when submitted to isolated on-pump CABG in comparison to patients < 65-year-old, but not under increased risk of death.

OBJETIVO: Analisar os desfechos da cirurgia de revascularização do miocárdio (CRM) isolada com circulação extracorpórea em pacientes com idade > 65 anos em comparação àqueles com < 65 anos. MÉTODOS: foram analisados 253 pacientes submetidos consecutivamente à CRM isolada entre 1º de dezembro de 2010 a 31 de julho de 2012. Os pacientes foram separados em dois grupos: GI (idosos > 65 anos) e GA (adultos < 65 anos). Foram analisadas variáveis pré-operatórias, intraoperatórias (tempo de CEC, tempo de pinçamento aórtico, tempo de submissão à VM e número de enxertos) e pós-operatórias (morbidade, mortalidade e tempo de internação). RESULTADOS: Dos 253 pacientes, 103 pertenciam ao GI (40,7%) e 150 ao GA (59,3%). A taxa de morbidade foi significativamente maior no GI quando comparada ao GA (30% vs. 14%, P=0,004), porém não houve diferença na taxa de mortalidade (5,8% vs. 2,0%, P=0,165). No GA havia maior prevalência DM (39,6% vs. 27%, P=0,043) e tabagismo (32,2% vs. 19,8%, P=0,042); e no GI, maior prevalência de acidente vascular encefálico prévio (17% vs. 6,7%, P=0,013). Não houve diferença entre os grupos quanto às variáveis intraoperatórias. Na análise multivariada: tempo de internação na enfermaria (P=0,006), complicações cardíacas (P=0,011) e complicações respiratórias (P=0,026) foram variáveis preditoras de risco para maior mortalidade intra-hospitalar. No entanto, a idade > 65 anos não foi um fator preditor de risco associada a variável óbito. CONCLUSÃO: Este estudo sugere que pacientes com idade igual ou superior a 65 anos possuem um maior risco de complicações intra-hospitalares no pós-operatório de CRM isolada com CEC em comparação com pacientes mais jovens.

Mild chronic kidney dysfunction and treatment strategies for stable coronary artery disease.

OBJECTIVE: Our objective was to evaluate the association of chronic kidney dysfunction in patients with multivessel chronic coronary artery disease, preserved left ventricular function, and the possible interaction between received treatment and cardiovascular events. METHODS: The glomerular filtration rate was determined at baseline on 611 patients who were randomized into three treatment groups: medical treatment, percutaneous coronary intervention, and coronary artery bypass surgery. Incidence of myocardial infarction, angina requiring a new revascularization procedure, and death were analyzed during 5 years in each group. RESULTS: Of 611 patients, 112 (18%) were classified as having normal renal function, 349 (57%) were classified as having mild dysfunction, and 150 (25%) were classified as having moderate dysfunction. There were significant differences among the cumulative overall mortality curves among the three renal function groups. Death was observed more frequently in the moderate dysfunction group than the other two groups (P < .001). Interestingly, in patients with mild chronic kidney dysfunction, we observed that coronary artery bypass treatment presented a statistically higher percentage of event-free survival and lower percentage of mortality than did percutaneous coronary intervention or medical treatment CONCLUSIONS: Our results confirm that coronary artery disease accompanied by chronic kidney dysfunction has a worse prognosis, regardless of the therapeutic strategy for coronary artery disease, when renal function is at least mildly impaired. Additionally, our data suggest that the different treatment strategies available for stable coronary artery disease may have differential beneficial effects according to the range of glomerular filtration rate strata.

Hemostatic changes and clinical sequelae after on-pump compared with off-pump coronary artery bypass surgery: a prospective randomized study.

OBJECTIVE: To delineate the effects of extracorporeal bypass on biomarkers of hemostasis, fibrinolysis, and inflammation and clinical sequelae. METHODS: Patients were assigned prospectively and randomly to either on-pump (n=41) or off-pump (n=51) coronary bypass surgery. The concentrations of C-reactive protein, fibrinogen, D-dimer, and plasminogen activator inhibitor type-1 in blood were quantified before and after (1 and 24 h) surgery. Similar surgical and anesthetic procedures were used for both groups. Clinical events were assessed during initial hospitalization and at the end of 1 year. RESULTS: The concentrations of plasminogen activator inhibitor type-1 and D-dimer were greater compared with preoperative values 1 and 24 h after surgery in both groups, but their concentrations increased to a greater extent 24 h after surgery in the on-pump group (P<0.01). The concentration of C-reactive protein did not change appreciably immediately after surgery in either group but increased in a parallel manner 24 h after either on-pump or off-pump surgery (P<0.01). Bypass surgery in the on-pump group was associated with greater blood loss during surgery and more bleeding after surgery (P< or =0.01). The incidence of all other complications was similar in the two groups. CONCLUSION: On-pump surgery was associated with biochemical evidence of a prothrombotic state early after surgery but no greater incidence of thrombotic events was observed. The prothrombotic state might be a consequence of extracorporeal bypass, compensation in response to more bleeding, or both in patients undergoing on-pump surgery.

Alterações hemostáticas e clínicas em cirurgias de revascularização miocárdica com e sem circulação extracorpórea: estudo prospectivo randomizado / Hemostatic changes and clinical sequelae after on-pump compared with off-pump coronary artery bypass surgery: a prospective randomized study

Introdução: a revascularização miocárdica (RM) sem circulação extracorpórea (CEC) tem sido associada a menores complicações quando comparadas à com CEC. Objetivos: determinar os efeitos da CEC em marcadores de hemostasia, fibrinólise, inflamação e correlacionar com eventos clínicos. Método: os pacientes foram incluídos de forma prospectiva e randomizada para cirurgia de RM com (n=41) ou sem CEC (n=51). As concentrações de proteína C reativa (PCR), fibrinogênio, dímero-D e inibidor do ativador do plasminogênio tipo 1 (PAI1) foram quantificadas antes e após (1 e 24 horas) a RM. As técnicas cirúrgicas e anestésicas foram padronizadas para ambos os grupos. Eventos clínicos foram avaliados durante a hospitalização inicial e após 1 ano de seguimento. Resultados: as concentrações de PAI1 e dímeros-d foram maiores quando comparados os valores pré-operatórios com os de 1 e 24 h, após a RM em ambos os grupos, porém as concentrações de PAI1 aumentadas estenderam-se por 24 h após a RM com CEC (p<0,01). A concentração de PCR teve um aumento de pequena magnitude imediatamente após a cirurgia em ambos os grupos e aumentou de modo similar 24h após a RM (p<0,01). A RM com CEC foi associada com maior perda sanguínea durante a cirurgia e mais sangramento pós-operatório (p<0,01). A incidência de todas as outras complicações foi similar nos dois grupos. Conclusão: a RM com CEC apresentou evidências bioquímicas de um estado pró-trombótico precoce após a cirurgia, porém, sem evidências no aumento no número de eventos trombóticos. O estado pró-trombótico pode ser consequência do circuito extracorpóreo, resposta compensatória ao sangramento, ou a ambos em pacientes submetidos à cirurgia com CEC.

Objective: To delineate the effects of extracorporeal bypass on biomarkers of hemostasis, fibrinolysis, and inflammation and clinical sequelae. Methods: Patients were assigned prospectively and randomly to either on-pump (n=41) or off-pump (n=51) coronary bypass surgery. The concentrations of C-reactive protein (CRP), fibrinogen, D-dimer, and plasminogen activator inhibitor type 1 (PAI-1) in blood were quantified before and after (1 hour and 24 hours) surgery. Similar surgical and anesthetic procedures were used for both groups. Clinical events were assessed during initial hospitalization and at the end of 1 year. Results: The concentrations of PAI-1 and d-dimer were greater compared with preoperative values 1 hour and 24 hours after surgery in both groups, but their concentrations increased to a greater extent 24 hours after surgery in the on-pump group (p<0.01). The concentration of CRP did not change appreciably immediately after surgery in either group but increased in a parallel fashion 24 hours after either on-pump or off-pump surgery (p<0.01). Bypass surgery in the on-pump group was associated with greater blood loss during surgery and more bleeding after surgery (p0.01). The incidence of all other complications was similar in the 2 groups. Conclusion: On-pump surgery was associated with biochemical evidence of a pro-thrombotic state early after surgery but no greater incidence of thrombotic events. The pro-thrombotic state may have been a consequence of extracorporeal bypass, compensation in response to more bleeding, or both in patients undergoing on-pump surgery.

Custos comparativos entre a revascularização miocárdica com e sem circulação extracorpórea / Comparative costs between myocardial revascularization with or without extracorporeal circulation

FUNDAMENTO: Técnicas cirúrgicas de revascularização miocárdica sem o uso de circulação extracorpórea (CEC) projetaram esperanças de resultados operatórios com menor dano sistêmico, menor ocorrência de complicações clínicas e menor tempo de internação hospitalar, gerando expectativas de menor custo hospitalar. OBJETIVO: Avaliar o custo hospitalar em pacientes submetidos à cirurgia de revascularização miocárdica com e sem o uso de CEC, e em portadores de doença multiarterial coronariana estável com função ventricular preservada. MÉTODOS: Os custos hospitalares foram baseados na remuneração governamental vigente. Acrescentaram-se aos custos uso de órteses e próteses, complicações e intercorrências clínicas. Consideraram-se o tempo e os custos de permanência na UTI e de internação hospitalar. RESULTADOS: Entre janeiro de 2002 e agosto de 2006, foram randomizados 131 pacientes para cirurgia com CEC (CCEC) e 128 pacientes sem CEC (SCEC). As características basais foram semelhantes para os dois grupos. Os custos das intercorrências cirúrgicas foram significativamente menores (p < 0,001) para pacientes do grupo SCEC comparados ao grupo CCEC (606,00 ± 525,00 vs. 945,90 ± 440,00), bem como os custos na UTI: 432,20 ± 391,70 vs. 717,70 ± 257,70, respectivamente. Os tempos de permanência na sala cirúrgica foram (4,9 ± 1,1 h vs. 3,9 ± 1,0 h), (p < 0,001) na UTI (48,2 ± 17,2 h vs. 29,2 ± 26,1h) (p < 0,001), com tempo de entubação (9,2 ± 4,5 h vs. 6,4 ± 5,1h) (p < 0,001) para pacientes do grupo com e sem CEC, respectivamente. CONCLUSÃO: Os resultados permitem concluir que a cirurgia de revascularização miocárdica, sem circulação extracorpórea, proporciona diminuição de custos operacionais e de tempo de permanência em cada setor relacionado ao tratamento cirúrgico.

BACKGROUND: Surgical techniques of myocardial revascularization without the use of extracorporeal circulation (ECC) have raised hopes of attaining operative results with less systemic damage, lower occurrence of clinical complications and shorter hospital stay duration, generating expectations of lower hospital costs. OBJECTIVE: To evaluate the hospital costs in patients submitted to myocardial revascularization with and without ECC and in those with stable multiarterial coronary disease with preserved ventricular function. METHODS: The hospital costs were based on the existing governmental reimbursement. The costs included that of ortheses and prostheses and clinical complications. The time and costs of ICU stay and hospital stay duration were considered. RESULTS: Between January 2002 and August 2006, 131 patients were randomized to surgery with ECC (SECC), whereas 128 were randomized to surgery without ECC (WECC). The basal characteristics were similar for both groups. The costs of surgical complications were significantly lower (p < 0.001) in patients from the WECC when compared to the SECC group (606.00 ± 525.00 vs. 945.90 ± 440.00), as well as ICU costs: 432.20 ± 391.70 vs. 717.70 ± 257.70, respectively. The duration of the operating room stay were 4.9 ± 1.1 h vs. 3.9 ± 1.0 h, p < 0.001; at the ICU it was 48.2 ± 17.2 h vs. 29.2 ± 26.1h) (p < 0.001), with intubation time of 9.2 ± 4.5 h vs. 6.4 ± 5.1h, p < 0.001 for patients from the group with and without ECC, respectively. CONCLUSION: The present study allowed us to conclude that the myocardial revascularization surgery without extracorporeal circulation results in the decrease of operational costs and duration of the stay in each section related to the surgical treatment.

Quality of life after on-pump and off-pump coronary artery bypass grafting surgery.

BACKGROUND: Coronary artery bypass grafting techniques without using cardiopulmonary bypass (off-pump CABG) result in less systemic damage, less clinical complications, less time spent in the intensive care unit, and shorter hospital stays, thereby raising the perspective of improved quality of life (QOL) for patients. OBJECTIVE: To assess quality of life in patients who underwent on-pump and off-pump CABG. METHODS: The Short-Form Health Survey (SF-36) Questionnaire was administered to patients with stable multivessel coronary artery disease (CAD) and preserved ventricular function before and at six and 12 months after surgery. RESULTS: Between January 2002 and December 2006, a total of 202 patients were randomized to either on-pump or off-pump CABG. Demographic, clinical, laboratory, and angiographic characteristics were similar in both groups. One hundred and five patients underwent off-pump CABG and 97 underwent on-pump CABG. In the postoperative course, 22 patients had myocardial infarction, 29 reported angina, one was reoperated, and three experienced stroke. No patient died. Quality of life, as measured by the SF-36 questionnaire, was shown to be similar in both groups regarding physical and mental components. However, male patients showed a significant improvement in physical functioning and role limitations due to physical problems. Also, a large number of patients in both groups returned to work. CONCLUSION: Progressive enhancement in quality of life and early return to work were observed for all patients, regardless of the surgical technique used. Save for a greater improvement in physical functioning and role limitations due to physical problems experienced by male patients, no statistically significant differences were found in the other domains between groups.

Impact of metabolic syndrome on the outcome of patients with stable coronary artery disease: 2-year follow-up of the MASS II study.

OBJECTIVE: We characterized the impact of the metabolic syndrome (MetS) and its components on cardiovascular adverse events in patients with symptomatic chronic multivessel coronary artery disease, which have been followed prospectively for 2 years. METHODS: Patients enrolled in the MASS II study were evaluated for each component of the MetS, as well as the full syndrome. RESULTS: The criteria for MetS were fulfilled in 52% of patients. The presence of MetS (P<0.05), glucose intolerance (P=0.007), and diabetes (P=0.04) was associated with an increased mortality in our studied population. Moreover, despite a clear tendency for each of its components to increase the mortality risk, only the presence of the MetS significantly increased the risk of mortality among nondiabetic study participants in a multivariate model (P=0.03, relative risk 3.5, 95% confidence interval 1.1-6). Finally, MetS was still associated with increased mortality even after adjustment for diabetes status. These results indicate a strong and consistent relationship of the MetS with mortality in patients with stable coronary artery disease. CONCLUSION: Although glucose homeostasis seems to be the major force driving the increased risk of MetS, the operational diagnosis of MetS still has information for stratifying patients when diabetes information is taken into account.