Chronic Coronary Syndrome: Medical Therapy or Myocardial Revascularization?

Abstract The best therapeutic strategy for chronic coronary syndrome (CCS) is still controversial. The lack of contemporaneity of medical treatment in many randomized clinical trials prior to the large-scale use of statins, antiplatelet agents, anti-diabetic drugs with cardiovascular protection, and changes in life habits with well-established goals limits the applicability of such studies in current clinical practice. Medical treatment is the only therapeutic option capable of reducing atherosclerotic damage and, therefore, of acting effectively in preventing the progression of this disease. The purpose of this brief review is to critically analyze the main contemporary studies that confront medical treatment with myocardial revascularization in CCS.

Predictive Value of Myocardial injury in Patients with COVID-19 Admitted to a Quaternary Hospital in the City of Rio de Janeiro

Abstract Background In Brazil the factors involved in the risk of death in patients with COVID-19 have not been well established. Objective To analyze whether elevations of high-sensitivity troponin I (hTnI) levels influence the mortality of patients with COVID-19. Methods Clinical and laboratory characteristics of hospitalized patients with COVID-19 were collected upon hospital admission. Univariate and binary logistic regression analyzes were performed to assess the factors that influence mortality. P-value<0.05 was considered significant. Results This study analyzed192 patients who received hospital admission between March 16 and June 2, 2020 and who were discharged or died by July 2, 2020. The mean age was 70±15 years, 80 (41.7%) of whom were women. In comparison to those who were discharged, the 54 (28.1%) who died were older (79±12 vs 66±15years; P=0.004), and with a higher Charlson´s index (5±2 vs 3±2; P=0.027). More patients, aged≥60years (P <0.0001), Charlson´s index>1 (P=0.004), lung injury>50% in chest computed tomography (P=0.011), with previous coronary artery disease (P=0.037), hypertension (P=0.033), stroke (P=0.008), heart failure (P=0.002), lymphocytopenia (P=0.024), high D-dimer (P=0.024), high INR (P=0.003), hTnI (P<0.0001), high creatinine (P<0.0001), invasive mechanical ventilation (P<0.0001), renal replacement therapy (P<0.0001), vasoactive amine (P<0.0001), and transfer to the ICU (P=0.001), died when compared to those who were discharged. In logistic regression analysis, elevated hTnI levels (OR=9.504; 95% CI=1.281-70.528; P=0.028) upon admission, and the need for mechanical ventilation during hospitalization (OR=46.691; 95% CI=2.360-923.706; P=0.012) increased the chance of in-hospital mortality. Conclusion This study suggests that in COVID-19 disease, myocardial injury upon hospital admission is a harbinger of poor prognosis.

Transcatheter Mitral Valve Repair, MitraClip, in a Nonagenarian Patient with Acute Regurgitation / Reparo Mitral Percutâneo pelo MitraClip em Paciente Nonagenária com Insuficiência Mitral Aguda

O implante transcateter de MitraClip é uma opção promissora de tratamento da insuficiência mitral (IM) em pacientes com risco cirúrgico elevado. Neste relato, descreve-se o caso de paciente nonagenária com IM aguda por ruptura de cordoalha que, devido a risco cirúrgico proibitivo, foi submetida a implante transcateter de MitraClip com sucesso...

MitraClip transcatheter implant is a promising option for treating mitral regurgitation (MR) in patients with high surgical risk. This report describes the case of a nonagenarian patient with acute MR for chordae rupture that, due to prohibitive surgical risk, underwent a successful MitraClip transcatheter implant...

Tratamento clínico da doença coronariana multiarterial estável. Menos é mais? / Medical therapy of stable multivessel coronary artery disease: less is more?

Apesar dos avanços de todas as formas de tratamento da doença arterial coronariana (DAC) estável, ainda háconsiderável controvérsia sobre as vantagens da revascularização miocárdica em comparação com o tratamento clínico (TC) contemporâneo. Na DAC multiarterial, os ensaios clínicos randomizados demonstraram que astécnicas de revascularização não reduziram a incidência de desfechos duros, como morte e infarto agudo domiocárdio não fatal. Desse modo, esses estudos sugerem que o TC, tratamento de menor custo, possa ser aplicadocomo terapia inicial nesses pacientes.

Despite the advances of all forms of treatment of stable coronary artery disease (CAD), there is still considerable controversy about the benefits of myocardial revascularization compared with medical therapy (CT). In multivessel CAD, randomized clinicaltrials have demonstrated that revascularization techniques did not reduce the incidence of hard outcomes, such as death and acute nonfatal myocardial infarction. Thus, these studies suggest that CT, lower cost treatment, may be applied as initial therapy for these patients.

Pneumonia em organização secundária ao uso de abciximab: relato de caso / Secondary organizing pneumonia after Abciximab use: case report

Relata-se o caso de paciente octogenária, com infarto agudo do miocárdio (IAM) em evolução, que desenvolveu quadro inflamatório pulmonar agudo, compatível com diagnóstico de pneumonia em organização secundária ao uso de abciximab intracoronariano, em angioplastia percutânea coronariana (APC). Esse diagnóstico foi firmado por meio de alterações clínicas, radiográficas e tomográficas típicas e pela regressão dessas alterações após terapia com corticosteroide.

This report presents the case of an octogenarian female patient with acute myocardial infarction who developed an acute inflammatory pulmonary condition compatible with a diagnosis of secondary organizing pneumonia after intracoronary abciximab during percutaneous coronary angioplasty. This diagnosis was grounded on typical clinical, radiographic and tomographic alterations and the regression of these alterations after corticoid treatment.

Age influences outcomes in 70-year or older patients undergoing isolated coronary artery bypass graft surgery.

OBJECTIVE: To analyze the results of isolated on-pump coronary artery bypass graft surgery (CABG) in patients >70 years-old in comparison to patients <70 years-old. METHODS: Patients undergoing isolated CABG were selected for the study. The patients were grouped in G1 (age > 70 years-old) and G2 (age <70 years-old). The endpoints were in-hospital mortality, acute myocardial infarction (AMI), stroke, reexploration for bleeding, intra-aortic balloon for circulatory shock, respiratory complications, acute renal failure, mediastinitis, sepsis, atrial fibrillation, and complete atrioventricular block (CAVB). RESULTS: 1,033 patients were included, 257 (24.8%) in G1 and 776 (75.2%) in G2. Patients in G1 were more likely to have in-hospital mortality than G2 (8.9% vs. 3.6%, respectively; P=0.001), while the incidence of AMI was similar (5.8% vs. 5.5%; P=0.87) than G2. More patients in G1 had re-exploration for bleeding (12.1% vs. 6.1%; P=0.003). G1 had more incidence of respiratory complications (21.4% vs. 9.1%; P<0.001), mediastinitis (5.1% vs. 1.9%; P=0.013), stroke (3.9% vs. 1.3%; P=0.016), acute renal failure (7.8% vs. 1.3%; P<0.001), sepsis (3.9% vs. 1.9%;P=0.003), atrial fibrillation (15.6% vs. 9.8%; P=0.016), and CAVB (3.5% vs. 1.2%; P=0.023) than G2. There was no significant difference in the use of intra-aortic balloon. In the forward stepwise multivariate logistic regression analysis age > 70-year-old was an independent predictive factor for higher in-hospital mortality (P=0.004), reexploration for bleeding (P=0.002), sepsis (P=0.002), respiratory complications (P<0.001), mediastinitis (P=0.016), stroke (P=0.029), acute renal failure (P<0.001), atrial fibrillation (P=0.021) and CAVB (P=0.031). CONCLUSION: This study suggests that patients > 70 years-old were at increased risk of death and other complications in the CABG's postoperative period in comparison to younger patients.

A idade influencia os desfechos em pacientes com idade igual ou superior a 70 anos submetidos à cirurgia de revascularização miocárdica isolada / Age influences outcomes in 70-year or older patients undergoing isolated coronary artery bypass graft surgery

OBJETIVO: Analisar os resultados da cirurgia de revascularização miocárdica (CRVM) isolada com circulação extracorpórea em pacientes com idade > 70 anos em comparação àqueles com < 70 anos. MÉTODOS: Pacientes submetidos consecutivamente à CRVM isolada. Os pacientes foram agrupados em G1 (idade e" 70 anos) e G2 (idade < 70 anos). Os desfechos analisados foram letalidade hospitalar, infarto agudo miocárdio (IAM), acidente vascular encefálico (AVE), reoperação para revisão de hemostasia (RRH), necessidade de balão intra-aórtico (BIA), complicações respiratórias, insuficiência renal aguda (IRA), mediastinite, sepse, fibrilação atrial (FA) e bloqueio atrioventricular total (BAVT). RESULTADOS: Foram estudados 1033 pacientes, 257 (24,8%) do G1 e 776 (75,2%) do G2. A letalidade hospitalar foi significantemente maior no G1 quando comparado ao G2 (8,9% vs. 3,6%, P=0,001), enquanto a incidência de IAM foi semelhante (5,8% vs. 5,5%; P=0,87). Maior número de pacientes do G1 necessitou de RRH (12,1% vs. 6,1%; P=0,003). Da mesma forma, no G1 houve maior incidência de complicações respiratórias (21,4% vs. 9,1%; P<0,001), mediastinite (5,1% vs. 1,9%; P=0,013), AVE (3,9% vs. 1,3%; P=0,016), IRA (7,8% vs. 1,3%, P<0,001), sepse (3,9% vs. 1,9%; P=0,003), fibrilação atrial (15,6% vs. 9,8%; P=0,016) e BAVT (3,5% vs. 1,2%; P=0,023) do que o G2. Não houve diferença significante na necessidade de BIA. Na análise regressão logística multivariada "forward stepwise", a idade >70 anos foi fator preditivo independente para maior letalidade operatória (P=0,004) e para RRH (P=0,002), sepse (P=0,002), complicações respiratórias (P<0,001), mediastinite (P=0,016), AVE (P=0,029), IRA (P<0,001), FA (P=0,021) e BAVT (P=0,031) no pós-operatório. CONCLUSÃO: Este estudo sugere que pacientes com idade > 70 anos estão sob maior risco de morte e outras complicações no pós-operatório de CRVM em comparação aos pacientes mais jovens.

OBJECTIVE: To analyze the results of isolated on-pump coronary artery bypass graft surgery (CABG) in patients >70 years-old in comparison to patients <70 years-old. METHODS: Patients undergoing isolated CABG were selected for the study. The patients were grouped in G1 (age > 70 years-old) and G2 (age <70 years-old). The endpoints were in-hospital mortality, acute myocardial infarction (AMI), stroke, reexploration for bleeding, intra-aortic balloon for circulatory shock, respiratory complications, acute renal failure, mediastinitis, sepsis, atrial fibrillation, and complete atrioventricular block (CAVB). RESULTS: 1,033 patients were included, 257 (24.8%) in G1 and 776 (75.2%) in G2. Patients in G1 were more likely to have in-hospital mortality than G2 (8.9% vs. 3.6%, respectively; P=0.001), while the incidence of AMI was similar (5.8% vs. 5.5%; P=0.87) than G2. More patients in G1 had re-exploration for bleeding (12.1% vs. 6.1%; P=0.003). G1 had more incidence of respiratory complications (21.4% vs. 9.1%; P<0.001), mediastinitis (5.1% vs. 1.9%; P=0.013), stroke (3.9% vs. 1.3%; P=0.016), acute renal failure (7.8% vs. 1.3%; P<0.001), sepsis (3.9% vs. 1.9%;P=0.003), atrial fibrillation (15.6% vs. 9.8%; P=0.016), and CAVB (3.5% vs. 1.2%; P=0.023) than G2. There was no significant difference in the use of intra-aortic balloon. In the forward stepwise multivariate logistic regression analysis age > 70-year-old was an independent predictive factor for higher in-hospital mortality (P=0.004), reexploration for bleeding (P=0.002), sepsis (P=0.002), respiratory complications (P<0.001), mediastinitis (P=0.016), stroke (P=0.029), acute renal failure (P<0.001), atrial fibrillation (P=0.021) and CAVB (P=0.031). CONCLUSION: This study suggests that patients > 70 years-old were at increased risk of death and other complications in the CABG's postoperative period in comparison to younger patients.

Circadian rhythm of hospital deaths: comparison between intensive care unit and non-intensive care unit.

OBJECTIVE: The demonstration that cardiovascular mortality follows a circadian rhythm led us to verify whether patients dying at the intensive unit care (ICU) and at the non-intensive unit care (non-ICU) follow that rhythm. METHODS: All hospital's deaths occurring between January 1, 2006 and July 31, 2010 were analyzed. The circadian pattern of the time of death was analyzed in twelve 2 hour intervals. The Chi-square test was used to compare proportions, and Student's t test or ANOVA single factor to compare continuous variables. A p-value < 0.05 was considered statistically significant. RESULTS: During the study period 700 deaths occurred in the hospital, 211 (30.1%) at the ICU and 88 (12.6%) at the non-ICU. There were more deaths in the first hours of the day, between 6 am and 12 am, at the non-ICU in comparison to the ICU (38% vs. 21%; p = 0.004). In the ICU, we observed that 21% of the deaths occurred between 6 am and 12 pm, 30% between 12 pm and 6 pm, 26% between 6 pm and 12 am and 24% between 12 am and 6 am (p = 0.13), whereas, at the non-ICU, 38% of the deaths occurred between 6 am and 12 pm, 18% between 12 pm and 6 pm, 19% between 6 pm and 12 am and 25% between 12 am and 6 am (p = 0.005). CONCLUSION: At the non-ICU, deaths occur more often in the morning period and follow a circadian rhythm, which does not occur at the ICU.

Ritmo circadiano em óbitos hospitalares: comparação entre unidade de tratamento intensivo e unidade de tratamento não intensivo / Circadian rhythm of hospital deaths: comparison between intensive care unit and non-intensive care unit

OBJETIVO: A demonstração de que a mortalidade cardiovascular segue um ritmo circadiano fez com que fosse verificado se pacientes que falecem em unidade de tratamento intensivo (UTI) e unidade clínica (UC) obedecem a este ritmo. MÉTODOS: Foram analisados todos os óbitos hospitalares ocorridos entre 1º de janeiro de 2006 e 31 de julho de 2010. O padrão circadiano dos óbitos foi analisado dividindo-se as 24 horas do dia em períodos de 2 horas. Utilizou-se o teste do qui-quadrado para comparação de variáveis categóricas e o teste t de Student ou a análise da variância fator único para comparação de variáveis contínuas. Um valor de p < 0,05 foi considerado estatisticamente significante. RESULTADOS: No período estudado, foram registrados 700 óbitos, 211 (30,1 por cento) na UTI e 88 (12,6 por cento) na UC. Houve mais óbitos nas primeiras horas do dia, entre 6 e 12 h, na UC, em comparação à UTI (38 por cento vs. 21 por cento; p = 0,004). Na UTI, 21 por cento dos óbitos ocorreram entre 6 e 12 h, 30 por cento entre 12 e 18 h, 26 por cento entre 18 e 24 h e 24 por cento entre 24 e 6 h (p = 0,13). Enquanto, na UC, 38 por cento ocorreram entre 6 e 12 h, 18 por cento entre 12 e 18h, 19 por cento entre 18 e 24 h e 25 por cento entre 24 e 6 h (p = 0,005). CONCLUSÃO: Na UC, os óbitos ocorrem com maior frequência no período da manhã e seguem um padrão circadiano, enquanto na UTI esse fenômeno não ocorre.

OBJECTIVE: The demonstration that cardiovascular mortality follows a circadian rhythm led us to verify whether patients dying at the intensive unit care (ICU) and at the non-intensive unit care (non-ICU) follow that rhythm. METHODS: All hospital's deaths occurring between January 1, 2006 and July 31, 2010 were analyzed. The circadian pattern of the time of death was analyzed in twelve 2 hour intervals. The Chi-square test was used to compare proportions, and Student's t test or ANOVA single factor to compare continuous variables. A p-value < 0.05 was considered statistically significant. RESULTS: During the study period 700 deaths occurred in the hospital, 211 (30.1 percent) at the ICU and 88 (12.6 percent) at the non-ICU. There were more deaths in the first hours of the day, between 6 am and 12 am, at the non-ICU in comparison to the ICU (38 percent vs. 21 percent; p = 0.004). In the ICU, we observed that 21 percent of the deaths occurred between 6 am and 12 pm, 30 percent between 12 pm and 6 pm, 26 percent between 6 pm and 12 am and 24 percent between 12 am and 6 am (p = 0.13), whereas, at the non-ICU, 38 percent of the deaths occurred between 6 am and 12 pm, 18 percent between 12 pm and 6 pm, 19 percent between 6 pm and 12 am and 25 percent between 12 am and 6 am (p = 0.005). CONCLUSION: At the non-ICU, deaths occur more often in the morning period and follow a circadian rhythm, which does not occur at the ICU.

Angina instável pós-infarto aumenta o risco de complicações na cirurgia de revascularização miocárdica? / Does post-infarction unstable angina increase the risk of coronary artery bypass graft surgery?

Fundamentos : Admite-se que os riscos de complicações pós-operatórias sejam maiores na angina instável pós-infarto.Objetivo: Verificar se a angina instável (AI) pósinfarto (classe C de Braunwald) aumenta o risco de eventos cardiovasculares maiores (ECMA) nacirurgia de revascularização miocárdica (CRVM) em comparação às síndromes coronarianas estáveis. Métodos: Em pacientes submetidos consecutivamenteà CRVM isolada, durante um período de dois anos, comparou-se a incidência de ECMA [morte, infarto agudo do miocárdio com onda Q (IAM) e acidentevascular encefálico (AVE)] entre aqueles com síndromes coronarianas estáveis (G1) e aqueles com AI classe B (G2) e AI classe C (G3) de Braunwald.Resultados: De 333 pacientes operados no período, 238 (71,0%) compunham o G1, 56 (17,0%) o G2 e 39 (12,0%) o G3. Mais pacientes dos G2 e G3apresentavam DPOC (12,5% e 10,0% vs 2,9%, p=0,005) e necessidade de cirurgia de urgência/emergência (18,0% e 33% vs 0,4%; p=0,0001) do que o G1. Não houve diferença significativa na morte hospitalar (4,6%, 8,9% e 5,1%; p=0,45), IAMQ (2,9%,3,6% e 5,1%; p=0,69) e AVE (5,5%, 0%, e 5,1%; p=0,17) ou ECMA (10,9%, 12,5% e 12,8%; p=0,85) entre osG1, G2 e G3, respectivamente.Conclusão: Este estudo sugere que a angina instável pós-IAM não aumenta o risco de eventos cardiovasculares maiores na CRVM em comparaçãoàs síndromes coronarianas estáveis.

Background: It is assumed that post-infarction unstable angina increases the risk of post-operative complications.Objective: To ascertain whether post-infarction unstable angina (Braunwald class C) increases the risk of major cardiovascular events (MACE) for coronary artery bypass surgery (CABG) in comparison to stable coronary syndromes. Methods: In patients undergoing individual CABGconsecutively for a period of two years, the incidence of MACE (hospital mortality, non-fatal Q-wave myocardial infarction [AMI], and stroke) wascompared for patients with stable coronary syndromes (G1) and patients with class B unstable angina (G2),and patients with Braunwald class C unstable angina (G3). Results: Among 333 patients operated during thatperiod, 238 (71%) belonged to G1, 56 (17%) to G2, and 39 (12%) to G3. More G2 and G3 patients presentedCOPD (12.5% and 10.0% vs 2.9%, p=0.005), and the need for emergency / urgent surgery (18.0% and 33.0%vs 0.4%; p=0.0001) than in G1. No significant difference appeared in hospital mortality (4.6%, 8.9%, and 5.1%; p=0.45), non-fatal AMI (2.9%, 3.6%, and 5.1%; p=0.69), and stroke (5.5%, 0%, and 5.1%; p=0.17) or MACE(10.9%, 12.5%, and 12.8%; p=0.85) among G1, G2, and G3 respectively.Conclusion: This study suggests that post-infarction unstable angina did not increase the risk of MACE in CABG compared to stable coronary syndromes.

Quem vê coronária não vê coração / Coronary artery no mirror for the heart

Oclusão de uma ou mais artérias coronárias se associa, em geral, a importante comprometimento da função ventricular. Relata-se o caso de um paciente de 64 anos sem história ou eletrocardiograma de infarto agudo do miocárdio prévio, com oclusão proximal de duas importantes artérias coronárias e função ventricular preservada.

In general, occlusion of one or more coronary arteries is associated with significant weakening of the leftventricular function. This case study describes a 64-year old man with no history or electrocardiographic signs ofprior acute myocardial infarction, with proximal occlusion of two main coronary arteries and preserved left ventricular function.

Disfunção sistólica do ventrículo esquerdo e prognóstico após cirurgia de revascularização do miocárdio / Left ventricular systolic dysfunction and prognosis after coronary artery bypass graft surgery

Fundamentos: A cirurgia de revascularização miocárdica (CRVM) promove uma melhora da sobrevivência de pacientes com doença arterial coronariana (DAC) e disfunção ventricular esquerda (DFVE).Objetivo: Analisar se a CRVM é capaz de igualar a sobrevivência de pacientes portadores de doença arterialcoronariana com DFVE e sem DFVE. Métodos: Pacientes (n=259) que sobreviveram à CRVM realizada entre 1/10/2001 e 31/1/2004 foramacompanhados por três anos após a cirurgia. A DFVE foi caracterizada por uma fração de ejeção do ventrículoesquerdo (FE) ≤40%. Foram formados dois grupos de acordo com a presença (G1; n=45) ou não (G2; n=214) deDFVE. Resultados: O G1 apresentava mais síndromes coronarianas agudas antes da CRVM (64,4% vs 40,2%;p=0,005); insuficiência cardíaca congestiva (17,8% vs 1,9%; p<0,0001); história prévia de infarto agudo do miocárdio (80% vs 60,3%; p=0,016) e doença pulmonarobstrutiva crônica (11,1% vs 2,3%; p=0,016) do que o G2. A sobrevivência cumulativa em três anos de seguimentofoi significantemente menor no G1 do que no G2 (88,8±4,7% vs 95,7±1,3%, respectivamente; p=0,05). ADFVE, no entanto, não foi fator independente para a menor sobrevivência no seguimento (p=0,119).Conclusão: Este estudo sugere que a CRVM não é capaz de igualar a sobrevivência de pacientes portadores de DAC e DFVE com a de pacientes com DAC sem DFVE.

Background: Coronary artery bypass graft (CABG) surgery prolongs the survival of patients with coronary artery disease (CAD) and left ventriculardysfunction (LVD). Objective: To verify whether CABG can match the survival times of CAD patients with and without LVD. Methods: 259 patients who survived CAGB performed between October 1, 2001 and January 31, 2004 were followed up for three years, with LVD characterized by a left ventricle ejection fraction of ≤40%. Two groups of patients were established, based on the presence (G1; n=45) or absence (G2; n=214) of LVD. Results: G1 patients presented more acute coronarysyndromes before CABG (64.4% vs 40.2%; p=0.005), congestive heart failure (17.8% vs 1.9%; p<0.0001),previous history of acute myocardial infarction (80% vs 60.3%; p=0.016), and chronic obstructive pulmonarydisease (11.1% vs 2.3%; p=0.016) than G2. The threeyear cumulative survival rate was significantly lowerin G1 than in G2 (88.8±4.7% vs 95.7±1.3%, respectively; p=0.05). However, LVD was not an independent factor for shorter survival times during the follow-up period (p=0.119).Conclusion: this study suggests that CABG is unable to match the survival of patients with CAD and LVD to the survival of patients with CAD without LVD.

Lesão não aterosclerótica do óstio do tronco da coronária esquerda / Non atherosclerotic left main coronary artery ostial lesion

Relata-se um caso de cardiopatia isquêmica como manifestação inicial da arterite de Takayasu (AT). Paciente internada para cirurgia de revascularização miocárdica(CRVM), devido à angina estável e lesão isolada do tronco de coronária esquerda, apresentava alterações vasculares ao exame físico que sugeriram o diagnóstico de AT. O presente caso leva à reflexão sobre a pesquisa de etiologias alternativas à doença aterosclerótica coronariana, especialmente em indivíduos jovens ou com poucos fatores de risco. O acometimento da artéria coronária na AT, embora infrequente se comparado a outras lesões vasculares encontradas nesta doença, determina elevada morbimortalidade.

Evidência de melhora na qualidade do cuidado assistencial no infarto agudo do miocárdio / Evidence of healthcare quality improvement in acute myocardial infarction

FUNDAMENTO: A monitoração dos indicadores de qualidade no cuidado com a saúde (IQS) é um processo de fundamental importância na atenção à saúde dos pacientes. OBJETIVO: Avaliar se a monitoração dos IQS e a análise da causa-raiz melhoram a qualidade do cuidado no infarto agudo do miocárdio (IAM). MÉTODOS: Foi realizada uma análise transversal e comparativa dos IQS em pacientes com IAM nos anos de 2006 e 2007. Dos 1.461 pacientes admitidos com dor torácica, 172 (11,7 por cento) tiveram o diagnóstico de IAM e foram incluídos na análise. RESULTADOS: A taxa de angioplastia primária foi 8,47 por cento maior em 2007 (97,3 por cento) do que em 2006 (89,7 por cento), mas esta diferença não alcançou significado estatístico (p = 0,35). Também não houve diferença estatística no tempo de hospitalização (4 vs 5 dias, p = 0,15) e na mortalidade intra-hospitalar (7,8 por cento vs 5,1 por cento, p = 0,67) entre 2007 e 2006, respectivamente. No entanto, o tempo até o resultado da primeira troponina foi 27 por cento menor em 2007 (69 min.; IC 95 por cento = 44-94 min.) do que em 2006 (95 min.; 53-136 min.) (p = 0,025). O tempo porta-balão foi 12 por cento menor (72 ± 29 min. vs 109 ± 85 min.; p = 0,03), a taxa de prescrição de aspirina na alta foi 35 por cento maior (94,7 por cento vs 70,3 por cento; p = 0,002) e a taxa de APCP, menor do que 90 minutos, foi 52 por cento maior (78,3 vs 51,4 por cento; p = 0,03) em 2007, quando comparada a 2006. CONCLUSÃO: Nossos resultados sugerem que a estratégia de monitorar os IQS e a de implementação da metodologia de análise da causa-raiz melhora o processo de cuidado com a saúde no IAM.

BACKGROUND: The monitoring of healthcare quality indicators (HCQI) is a process of utmost importance in patient healthcare services. OBJECTIVE: To evaluate whether the monitoring of HCQI and the root-cause analysis improve the healthcare quality in acute myocardial infarction (AMI). METHODS: A cross-sectional and comparative analysis of HCQI was performed in patients with AMI in the years 2006 and 2007. Of the 1,461 patients admitted with chest pain, 172 (11.7 percent) had a diagnosis of AMI and were included in the analysis. RESULTS: The rate of primary angioplasty was 8.47 percent higher in 2007 (97.3 percent) when compared to that in 2006 (89.7 percent), but this difference was not statistically significant (p = 0.35). Moreover, there was no difference regarding the time of hospitalization (4 vs 5 days, p = 0.15) and the in-hospital mortality (7.8 percent vs 5.1 percent, p = 0.67) between 2007 and 2006, respectively. However, the time to the first troponin level was 27 percent shorter in 2007 (69 min.; 95 percentCI = 44-94 min.) when compared to 2006 (95 min.; 53-136 min.) (p = 0.025). The door-to-balloon time was 12 percent shorter (72 ± 29 min. vs 109 ± 85 min.; p = 0.03), the rate of ASA prescription at hospital discharge was 35 percent higher (94.7 percent vs 70.3 percent; p = 0.002) and the rate of PCA shorter than 90 minutes was 52 percent higher (78.3 vs 51.4 percent; p = 0.03) in 2007, when compared to 2006. CONCLUSION: Our results suggest that the strategy of monitoring the HCQI and the implementation of the root-cause analysis methodology can improve the healthcare process in patients with AMI.

[Evidence of healthcare quality improvement in acute myocardial infarction].

BACKGROUND: The monitoring of healthcare quality indicators (HCQI) is a process of utmost importance in patient healthcare services. OBJECTIVE: To evaluate whether the monitoring of HCQI and the root-cause analysis improve the healthcare quality in acute myocardial infarction (AMI). METHODS: A cross-sectional and comparative analysis of HCQI was performed in patients with AMI in the years 2006 and 2007. Of the 1,461 patients admitted with chest pain, 172 (11.7%) had a diagnosis of AMI and were included in the analysis. RESULTS: The rate of primary angioplasty was 8.47% higher in 2007 (97.3%) when compared to that in 2006 (89.7%), but this difference was not statistically significant (p = 0.35). Moreover, there was no difference regarding the time of hospitalization (4 vs 5 days, p = 0.15) and the in-hospital mortality (7.8% vs 5.1%, p = 0.67) between 2007 and 2006, respectively. However, the time to the first troponin level was 27% shorter in 2007 (69 min.; 95%CI = 44-94 min.) when compared to 2006 (95 min.; 53-136 min.) (p = 0.025). The door-to-balloon time was 12% shorter (72 +/- 29 min. vs 109 +/- 85 min.; p = 0.03), the rate of ASA prescription at hospital discharge was 35% higher (94.7% vs 70.3%; p = 0.002) and the rate of PCA shorter than 90 minutes was 52% higher (78.3 vs 51.4%; p = 0.03) in 2007, when compared to 2006. CONCLUSION: Our results suggest that the strategy of monitoring the HCQI and the implementation of the root-cause analysis methodology can improve the healthcare process in patients with AMI.

Perfil demográfico de candidatos à cirurgia de revascularização do miocárdio: avaliação do controle de fatores de risco cardiovascular / Demographic profile of candidates for myocardial revascularization surgery: casriovascular risk factors control evaluation

Fundamentos: O tratamento da doença arterial coronariana (DAC) tem como base o controle dos seus fatores de risco. Com a divulgação de diretrizes para o manejo desses fatores, supõe-se que pacientes encaminhados para a cirurgia de revascularização do miocárdio (CRM), após otimização do tratamento clínico, encontrem-se de acordo com as metas estabelecidas. Objetivo: Avaliar, em pacientes internados para CRM, colesterol, glicemia, pressão arterial (PA) e índice de massa corporal (IMC), a fim de conhecer a adesão a metas estabelecidas para controle de hipercolesterolemia, diabetes, hipertensão arterial e obesidade. Métodos: Foram estudados 331 pacientes. Adesão a metas de controle foi considerada presente se colesterol total <200mg/dl, glicemia de jejum <110mg/dl, PA<140/90mmHg em não diabéticos e <130/80mmHg em diabéticos, e IMC <25kg/m². Resultados: Controle da hipercolesterolemia foi encontrado em 84 por cento dos pacientes e controle do diabetes, em 67 por cento. A PA encontrava-se dentro das metas...

Indicators of healthcare quality in isolated coronary artery bypass graft surgery performed at a tertiary cardiology center.

BACKGROUND: Quality indicators (QI) for cardiac surgery are important instruments for measuring healthcare quality in hospital centers and allow comparison with high-quality healthcare centers. OBJECTIVE: To evaluate QIs in isolated myocardial revascularization procedures (CABG) performed at a tertiary cardiology center. METHODS: One hundred and forty-four consecutive patients who had undergone isolated CABG were evaluated between October 2005 and March 2007. One hundred and eight patients were men (75%), the mean age was 65+/-11, and the EuroSCORE was 4+/-3. The following QIs were measured: time elapsed between the surgery date-setting appointment and the actual day of the CABG (TDC); surgery cancellation rate (SCR) due to problems in hospital infrastructure; length of hospital stay (LOS); operative mortality (OM) and rate of readmission (RHR) for infection in the surgical wound. RESULTS: The TDC (n=98) was 4+/-3 days (median: 4 days) and the SCR was zero. The OM recorded of 4.9% (95% confidence interval [CI] = 2.2 - 9.87%) was lower than the expected OM of 5.1% (95% CI = 1.4% to 14.37%), but with no statistical significance (p=0.65). The area under the ROC curve of the EuroSCORE for the OM was 0.702 (95% CI = 0.485 - 0.919). LOS was 11+/-9 days. The area under the ROC curve of the EuroSCORE for the LOS was 0.764 (95% CI = 0.675 - 0.852). The RHR recorded was 2.1%. CONCLUSION: The measurement of the QIs showed that, in a medical center with a low annual volume of CABG, the results were compatible with the risk profile of the population involved.

Indicadores de qualidade assistencial na cirurgia de revascularização miocárdica isolada em centro cardiológico terciário / Indicators of healthcare quality in isolated coronary artery bypass graft surgery performed at a tertiary cardiology center

FUNDAMENTO: Indicadores de qualidade (IQ) em cirurgia cardíaca são importantes instrumentos de avaliação da assistência médica em centros hospitalares. OBJETIVO: Avaliar os IQ da cirurgia de revascularização miocárdica (CRVM) isolada em centro terciário cardiológico. MÉTODOS: Foram avaliados 144 pacientes consecutivos submetidos a CRVM isolada entre outubro de 2005 e março de 2007: 108 pacientes eram do sexo masculino (75 por cento), com média de idade de 65±11 anos e EuroSCORE de 4±3. Os IQ avaliados foram: intervalo de tempo entre a marcação e a realização da cirurgia (TMC); taxa de cancelamento (TxC) decorrentes de problemas ligados à infra-estrutura hospitalar; tempo de permanência hospitalar (TPH); mortalidade operatória (MO) e taxa de reinternação hospitalar por infecção em ferida cirúrgica (TxRH). RESULTADOS: O TMC (n=98) foi de 4±3 dias (mediana de 4 dias) e a TxC foi zero. A MO observada de 4,9 por cento (Intervalo de Confiança [IC] 95 por cento = 2,2 - 9,87 por cento) foi menor do que a MO esperada de 5,1 por cento (IC 95 por cento = 1,4 por cento a 14,37 por cento), mas sem significância estatística (p=0,65). A área sob a curva ROC do EuroSCORE para MO observada foi de 0,702 (IC 95 por cento = 0,485 - 0,919). O TPH foi de 11±9 dias. A área sob a curva ROC do EuroSCORE para TPH foi de 0,764 (IC 95 por cento = 0,675 - 0,852). A TxRH observada foi de 2,1 por cento. CONCLUSÃO: A avaliação dos IQ demonstrou que, em um centro com baixo número anual de CRVM, os resultados alcançados foram compatíveis com o perfil de risco da população envolvida.

BACKGROUND: Quality indicators (QI) for cardiac surgery are important instruments for measuring healthcare quality in hospital centers and allow comparison with high-quality healthcare centers. OBJECTIVE: To evaluate QIs in isolated myocardial revascularization procedures (CABG) performed at a tertiary cardiology center. METHODS: One hundred and forty-four consecutive patients who had undergone isolated CABG were evaluated between October 2005 and March 2007. One hundred and eight patients were men (75 percent), the mean age was 65±11, and the EuroSCORE was 4±3. The following QIs were measured: time elapsed between the surgery date-setting appointment and the actual day of the CABG (TDC); surgery cancellation rate (SCR) due to problems in hospital infrastructure; length of hospital stay (LOS); operative mortality (OM) and rate of readmission (RHR) for infection in the surgical wound. RESULTS: The TDC (n=98) was 4±3 days (median: 4 days) and the SCR was zero. The OM recorded of 4.9 percent (95 percent confidence interval [CI] = 2.2 - 9.87 percent) was lower than the expected OM of 5.1 percent (95 percent CI = 1.4 percent to 14.37 percent), but with no statistical significance (p=0.65). The area under the ROC curve of the EuroSCORE for the OM was 0.702 (95 percent CI = 0.485 - 0.919). LOS was 11±9 days. The area under the ROC curve of the EuroSCORE for the LOS was 0.764 (95 percent CI = 0.675 - 0.852). The RHR recorded was 2.1 percent. CONCLUSION: The measurement of the QIs showed that, in a medical center with a low annual volume of CABG, the results were compatible with the risk profile of the population involved.