Characteristics of ST-Elevation Myocardial Infarction during the SARS-CoV-2 Outbreak

Abstract Background The SARS-CoV-2 outbreak has led to radical transformation in social, economic, and healthcare systems. This may lead to profound indirect consequences on clinical presentation and management of patients with ST-segment-elevation myocardial infarction. Objectives The objective of this study was to describe the characteristics, management, and outcomes of patients admitted with acute myocardial infarction with ST-segment elevation (STEMI), in two tertiary reference hospitals during the SARS-CoV-2 outbreak and compare them with patients admitted in the previous year. Methods We analyzed data from a multicenter STEMI registry from reference centers in the South Region of Brazil from March 2019 to May 2021. The beginning of the COVID-19 outbreak was considered to be March 2020 and compared to the same period in 2019. Only patients with STEMI submitted to primary percutaneous coronary intervention (PCI) were included in the analysis. Mortality rates were compared with chi-square test. All hypothesis tests had a two-sided significance level of 5%. Results A total of 1169 patients admitted with STEMI were enrolled in our registry, 635 of whom were admitted during the pandemic period. The mean age of our sample was 61.6 (± 12.4) years, and 66.7% of patients were male. Pain-to-door time and door-to-balloon time were longer during the pandemic period. However, there was no difference in mortality rates or major adverse cardiovascular outcomes (MACE). Conclusions We observed a stable incidence of STEMI cases in our registry during the SARS-CoV-2 outbreak with higher pain-to-door time and door-to-balloon time, without any influence on mortality rates however.

Overview of Percutaneous Coronary Interventions for Chronic Total Occlusions Treated at Brazilian Centers Participating in the LATAM CTO Registry. / Panorama das Intervenções Coronárias Percutâneas em Oclusões Totais Crônicas em Centros Participantes do LATAM CTO Registry no Brasil.

BACKGROUND: Major advances have been seen in techniques and devices for performing percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs), but there are limited real-world practice data from developing countries. OBJECTIVES: To report clinical and angiographic characteristics, procedural aspects, and clinical outcomes of CTO PCI performed at dedicated centers in Brazil. METHODS: Included patients underwent CTO PCI at centers participating in the LATAM CTO Registry, a Latin American multicenter registry dedicated to prospective collection of these data. Inclusion criteria were procedures performed in Brazil, age 18 years or over, and presence of CTO with PCI attempt. CTO was defined as a 100% lesion in an epicardial coronary artery, known or estimated to have lasted at least 3 months. RESULTS: Data on 1196 CTO PCIs were included. Procedures were performed primarily for angina control (85%) and/or treatment of moderate/severe ischemia (24%). Technical success rate was 84%, being achieved with antegrade wire approaches in 81% of procedures, antegrade dissection and re-entry in 9%, and retrograde approaches in 10%. In-hospital adverse cardiovascular events occurred in 2.3% of cases, with a mortality rate of 0.75%. CONCLUSIONS: CTOs can be treated effectively in Brazil by using PCI, with low complication rates. The scientific and technological development observed in this area in the past decade is reflected in the clinical practice of dedicated Brazilian centers.

FUNDAMENTO: Tem sido observado um grande avanço nas técnicas e nos dispositivos para a realização de intervenções coronárias percutâneas (ICP) em oclusões totais coronarianas crônicas (OTC), mas existem poucos dados da prática do mundo real em países em desenvolvimento. OBJETIVOS: Relatar as características clínicas e angiográficas, os aspectos dos procedimentos e os resultados clínicos da ICP de OTC em centros dedicados a esse procedimento no Brasil. MÉTODOS: Os pacientes incluídos foram submetidos à ICP de OTC em centros participantes do LATAM CTO Registry, um registro multicêntrico latino-americano dedicado à coleta prospectiva desses dados. Os critérios de inclusão foram procedimentos realizados no Brasil, idade acima de 18 anos e presença de OTC com tentativa de ICP. A definição de OTC foi lesão de 100% em uma artéria coronária epicárdica, conhecida ou estimada como tendo pelo menos 3 meses de evolução. RESULTADOS: Foram incluídos dados de 1.196 ICPs de OTC. Os procedimentos foram realizados principalmente para controle da angina (85%) e/ou tratamento de uma grande área isquêmica (24%). A taxa de sucesso técnico foi de 84% e foi alcançada com técnicas de fios anterógrados em 81%, dissecção/reentrada anterógrada em 9% e retrógrada em 10% dos procedimentos. Os eventos cardiovasculares adversos intra-hospitalares ocorreram em 2,3% dos casos, sendo a mortalidade de 0,75%. CONCLUSÕES: As OTC podem ser tratadas no Brasil por intervenção coronária percutânea de forma efetiva e com baixas taxas de complicações. O desenvolvimento científico e tecnológico observado nessa área na última década reflete-se na prática clínica de centros brasileiros dedicados a essa técnica.

Psychoeducational Intervention for Reducing Heart Failure Patients' Rehospitalizations and Promoting Their Quality of Life and Posttraumatic Growth at the 1-Year Follow-Up: A Randomized Clinical Trial.

OBJECTIVE: This study's aim was to verify whether a psychoeducational intervention, with a brief expressive posttraumatic growth (PTG) component, could reduce heart failure (HF) patients' hospital readmissions and promote their quality of life (QoL) and PTG. METHODS: It adopted a parallel randomized clinical trial design, and its participants comprised HF patients from a hospital in Southern Brazil. All the participants completed the World Health Organization Quality of Life Assessment and Posttraumatic Growth Inventory questionnaires at the pre (T1: baseline) and post (T2) assessments of the intervention. Although patients in the control group (CG) underwent only regular outpatient consultations, those in the intervention group (IG) supplemented their regular consultations, with two additional individual visits to promote health and psychological education. At the 1-year follow-up, hospital readmissions were assessed. RESULTS: Of the 142 patients recruited at baseline (72 and 70 in the CG and IG, respectively), as 19 dropped out at follow-up, only 123 (63 and 60 in the CG and IG, respectively) were reassessed after approximately 378 days. They included 65% men aged 64 (11) years, 58% had low incomes, and 67% had less than high school education. The IG participants' risk of readmission got reduced by 52% ( p = .023), and they also showed significant improvements in their total QoL and positive psychological growth at the 6-month follow-up assessment. CONCLUSIONS: The two-session psychoeducational intervention proved to be protective for Southern Brazilian HF patients in the IG, as it effectively reduced their hospital readmission rates by half compared with the CG, as well as improved their QoL and promoted their positive psychological growth. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04870918 .

Panorama das Intervenções Coronárias Percutâneas em Oclusões Totais Crônicas em Centros Participantes do LATAM CTO Registry no Brasil / Overview of Percutaneous Coronary Interventions for Chronic Total Occlusions Treated at Brazilian Centers Participating in the LATAM CTO Registry

Resumo Fundamento Tem sido observado um grande avanço nas técnicas e nos dispositivos para a realização de intervenções coronárias percutâneas (ICP) em oclusões totais coronarianas crônicas (OTC), mas existem poucos dados da prática do mundo real em países em desenvolvimento. Objetivos Relatar as características clínicas e angiográficas, os aspectos dos procedimentos e os resultados clínicos da ICP de OTC em centros dedicados a esse procedimento no Brasil. Métodos Os pacientes incluídos foram submetidos à ICP de OTC em centros participantes do LATAM CTO Registry, um registro multicêntrico latino-americano dedicado à coleta prospectiva desses dados. Os critérios de inclusão foram procedimentos realizados no Brasil, idade acima de 18 anos e presença de OTC com tentativa de ICP. A definição de OTC foi lesão de 100% em uma artéria coronária epicárdica, conhecida ou estimada como tendo pelo menos 3 meses de evolução. Resultados Foram incluídos dados de 1.196 ICPs de OTC. Os procedimentos foram realizados principalmente para controle da angina (85%) e/ou tratamento de uma grande área isquêmica (24%). A taxa de sucesso técnico foi de 84% e foi alcançada com técnicas de fios anterógrados em 81%, dissecção/reentrada anterógrada em 9% e retrógrada em 10% dos procedimentos. Os eventos cardiovasculares adversos intra-hospitalares ocorreram em 2,3% dos casos, sendo a mortalidade de 0,75%. Conclusões As OTC podem ser tratadas no Brasil por intervenção coronária percutânea de forma efetiva e com baixas taxas de complicações. O desenvolvimento científico e tecnológico observado nessa área na última década reflete-se na prática clínica de centros brasileiros dedicados a essa técnica.

Abstract Background Major advances have been seen in techniques and devices for performing percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs), but there are limited real-world practice data from developing countries. Objectives To report clinical and angiographic characteristics, procedural aspects, and clinical outcomes of CTO PCI performed at dedicated centers in Brazil. Methods Included patients underwent CTO PCI at centers participating in the LATAM CTO Registry, a Latin American multicenter registry dedicated to prospective collection of these data. Inclusion criteria were procedures performed in Brazil, age 18 years or over, and presence of CTO with PCI attempt. CTO was defined as a 100% lesion in an epicardial coronary artery, known or estimated to have lasted at least 3 months. Results Data on 1196 CTO PCIs were included. Procedures were performed primarily for angina control (85%) and/or treatment of moderate/severe ischemia (24%). Technical success rate was 84%, being achieved with antegrade wire approaches in 81% of procedures, antegrade dissection and re-entry in 9%, and retrograde approaches in 10%. In-hospital adverse cardiovascular events occurred in 2.3% of cases, with a mortality rate of 0.75%. Conclusions CTOs can be treated effectively in Brazil by using PCI, with low complication rates. The scientific and technological development observed in this area in the past decade is reflected in the clinical practice of dedicated Brazilian centers.

Técnicas para Manejo da Emoção de Raiva: Uma Revisão Sistemática / Anger Management Techniques: A Systematic Review / Técnicas para el Manejo de la Emoción de Rabia: Una Revisión Sistemática

Introdução: Dentre as inúmeras possibilidades que um indivíduo possui de experienciar e expressar a raiva ou a ira, não é raro que o sentimento fuja do controle e termine em hostilidade e agressões, podendo gerar consequências importantes na vida de uma pessoa e de outros ao seu redor. Diante disso, torna-se fundamental a aplicação de técnicas comprovadamente eficazes, objetivando uma maior qualidade de vida ao indivíduo e às pessoas que com ele convivem. Objetivos: Identificar as principais técnicas no manejo da raiva em adultos. Método: Revisão sistemática de artigos científicos de estudos clínicos. Resultados: Nove estudos clínicos randomizados com utilização de técnicas psicológicas para o manejo da ira foram utilizados na análise. A Terapia Cognitivo-Comportamental mostrou-se predominante nas intervenções analisadas e provou-se eficaz para o controle da ira. Conclusão: Técnicas cognitivo-comportamentais, em especial a psicoeducação e a reestruturação cognitiva, são as ferramentas mais frequentemente usadas para o manejo da raiva em distintos grupos clínicos de pacientes, com resultados positivos na regulação emocional.

Introduction: Among the innumerable possibilities that an individual has to experience and express anger, it is not rare that the feeling gets out of control and ends up in hostility and aggressions, which can lead to important consequences in a person's life and others around. Given this, it is fundamental to apply techniques which are proven effective, aiming at a higher quality of life for the individual and for people who live with them. Objectives: To identify the main techniques for anger management in adults. Method: Systematic review of scientific papers from clinical trials. Results: Nine randomized clinical trials using psychological techniques for anger management were used in the present analysis. Cognitive-Behavioral Therapy was shown to be predominant in the analyzed interventions and proved to be effective in controlling anger. Conclusion: Cognitive Behavioral Therapy, especially psychoeducation and cognitive restructuring, are the most frequently used techniques for anger management in several clinical groups of patients, with positive results in emotional regulation.

Introducción: Entre las innumerables posibilidades que un individuo tiene de experimentar y expresar rabia o ira, no es raro que el sentimiento huya del control y termine en hostilidad y agresiones, pudiendo generar consecuencias graves en la vida de una persona y de otros a su alrededor. Por eso, es fundamental la aplicación de técnicas comprobadamente eficaces, objetivando una mayor calidad de vida al individuo y a las personas que con él conviven. Objetivos: Identificar las principales técnicas para el manejo de la rabia en adultos. Método: Revisión Sistemática de artículos científicos de estudios clínicos. Resultados: Se utilizaron nueve estudios clínicos aleatorizados con utilización de técnicas psicológicas para el manejo de la ira en el análisis. Terapia Cognitivo-Conductual demostró ser predominante en las intervenciones analizadas y eficaz para controlar la ira. Conclusión: La Terapia Cognitivo-Conductual, en especial la psicoeducación y la reestructuración cognitiva, son las técnicas más frecuentemente usadas para el manejo de la rabia en varios grupos clínicos de pacientes, con resultados positivos en regulación emocional.

The Influence of Cognitive Behavioral Intervention for Anger Management on Endothelial Function in Patients With Recent Myocardial Infarction: A Randomized Clinical Trial.

OBJECTIVE: Anger may cause adverse cardiovascular responses, but the effects of anger management on clinical cardiovascular outcomes are insufficiently understood. We sought to assess the influence of anger management through a cognitive behavioral intervention on endothelial function in patients with a recent myocardial infarction (MI). METHODS: Patients with ST-elevation MI and a low anger control score were enrolled during hospitalization in a randomized, parallel, controlled clinical trial. Intervention was anger management with cognitive behavioral techniques implemented by a psychologist in two individual monthly sessions. The primary end point was the between-group difference in the variation of flow-mediated dilation (FMD) in the brachial artery from baseline to the 3-month follow-up. The second end point comprised major cardiovascular events at 24-month follow-up. RESULTS: A total of 43 patients (age = 56 [9] years; 23.3% women) were randomized to the intervention group and 47 patients (age = 58 [10] years; 19.1% women) to the control group. Baseline clinical characteristics were not statistically different between groups. Both groups showed a significant improvement in anger control from baseline to end point; however, the difference in intergroup variation was not statistically significant. The difference in FMD variation from baseline to the 3-month follow-up was significantly higher in the intervention group. The partial η2 was 0.057 (p = .024), indicating a medium effect size. There was no difference between groups regarding major cardiovascular events. CONCLUSIONS: Anger management by cognitive behavioral techniques may improve endothelial function in post-MI patients with low anger control, but it remains unclear via which mechanism these effects occurred. Further studies with larger numbers of patients, assessments of changes in anger, improved comparability of preintervention FMD, and longer follow-up are warranted.Trial Registration:ClinicalTrials.gov identifier: NCT02868216.

Immunohistochemical characteristics of coronary thrombi in ST-elevation myocardial infarction.

Background and aims: The dynamics and implications of intracoronary thrombus constituency in patients with ST-segment elevation myocardial infarction (STEMI) are not fully understood. We evaluated the expression of CD34, CD61and factor VIII surface markers in thrombi of patients with STEMI and its association with clinical and angiographic characteristics and major adverse cardiovascular events (MACE). Methods: Patients presenting with STEMI undergoing aspiration thrombectomy during primary percutaneous coronary intervention (pPCI) were included. Morphological, histopathological and immunohistochemical aspects of thrombi were assessed by two pathologists blinded to clinical variables and outcomes. Results: The mean age of the 245 patients included was 58 ± 12 years old, and 70 % were men. Regarding the thrombi microscopic patterns, 61 % were classified as recent, 20 % as lytic and 19 % as organized. There were higher levels of the CD61 index in patients with a history of heart failure. Smokers presented lower CD61 positive cells and CD61 index, but this association did not remain significant after multivariable analysis. There was an inverse correlation between CD61 positive cells and CD61 index with the time from onset of pain to the first medical contact, but no other significant association amongst clinical characteristics and antigenic expression. There was higher expression of the CD61 antigen in patients with in-hospital MACE, but statistical significance was borderline (p = 0.06). Conclusions: In this cohort of patients with STEMI, immunohistochemistry of coronary thrombus showed a significantly higher platelet content in patients with previous heart failure and a trend in those with in-hospital MACE. Thrombus' platelet content was inversely related to ischemic time.

Stress in Women with Acute Myocardial Infarction: A Closer Look. / Um Olhar sobre o Stress nas Mulheres com Infarto Agudo do Miocárdio.

BACKGROUND: Women seem to be more susceptible to psychosocial stress than men, and stress is associated with worse outcomes after acute myocardial infarction (AMI). OBJECTIVES: To investigate whether the female gender is an independent predictor of risk for stress and to compare stress levels between women and men after AMI. METHODS: Cross-sectional study of a case series. Patients aged 18 to 65 years who were treated for AMI at the study facility between January 2017 and June 2018 were eligible. The presence of stress was assessed using Lipp's Stress Symptoms Inventory for Adults (ISSL), which categorizes stress into four phases (alertness, resistance, near-exhaustion, and exhaustion), through a list of physical and psychological symptoms. Data were analyzed using SPSS Version 24.0. The significance level was set at p<0.05. RESULTS: Of the 330 respondents, 89% of women and 70% of men experienced stress. The female gender was associated with nearly threefold higher odds of experiencing stress (EXP (B)2.79, p = 0.02). Regarding the phases of stress, women were more often in the near-exhaustion and exhaustion phases, while men were more often in the resistance phase. CONCLUSIONS: This study showed that women are most often in the third and fourth phases of stress, i.e., in situations of long-standing psychosocial stress. These findings can assist in the development of gender-specific strategies for health promotion and disease prevention, aiming to minimize the effects of stress in this population.

FUNDAMENTO: As mulheres parecem ser mais suscetíveis ao estresse psicossocial quando comparadas aos homens, e o estresse está associado a piora na evolução clínica dos pacientes após o infarto agudo do miocárdio (IAM). OBJETIVOS: Investigar se o sexo feminino é preditor independente de risco para o estresse e comparar os níveis de estresse entre mulheres e homens com IAM. MÉTODOS: Estudo transversal de uma série de casos, realizado entre janeiro de 2017 e junho de 2018. Pacientes com idade entre 18 e 65 anos, atendidos na instituição por IAM nesse período. A existência de estresse foi avaliada por meio do Inventário de Sintomas de Stress para Adultos de LIPP (ISSL), que o categoriza em quatro fases: alerta, resistência, quase exaustão e exaustão, com base em uma lista de sintomas físicos e psicológicos. Os dados foram analisados pelo programa estatístico Statistical Package for Social Sciences (SPSS) versão 24.0. O nível de significância adotado foi um valor de p < 0,05. RESULTADOS: Dos 330 entrevistados, 89% das mulheres e 70% dos homens apresentaram estresse; o sexo feminino quase triplicou as chances de sofrê-lo (EXP (B) 2,79; p = 0,02). Quanto às quatro fases, as mulheres mostraram-se mais em quase exaustão e exaustão, e os homens, mais em resistência. CONCLUSÕES: Este estudo evidenciou que as mulheres se encontram na terceira e quarta fases do estresse, ou seja, em situações de estresse psicossocial duradouras. Tais resultados podem auxiliar no desenvolvimento de estratégias específicas para prevenção e promoção da saúde conforme os sexos, visando minimizar os efeitos do estresse nesses pacientes.

Um Olhar sobre o Stress nas Mulheres com Infarto Agudo do Miocárdio / Stress in Women with Acute Myocardial Infarction: A Closer Look

Resumo Fundamento: As mulheres parecem ser mais suscetíveis ao estresse psicossocial quando comparadas aos homens, e o estresse está associado a piora na evolução clínica dos pacientes após o infarto agudo do miocárdio (IAM). Objetivos: Investigar se o sexo feminino é preditor independente de risco para o estresse e comparar os níveis de estresse entre mulheres e homens com IAM. Métodos: Estudo transversal de uma série de casos, realizado entre janeiro de 2017 e junho de 2018. Pacientes com idade entre 18 e 65 anos, atendidos na instituição por IAM nesse período. A existência de estresse foi avaliada por meio do Inventário de Sintomas de Stress para Adultos de LIPP (ISSL), que o categoriza em quatro fases: alerta, resistência, quase exaustão e exaustão, com base em uma lista de sintomas físicos e psicológicos. Os dados foram analisados pelo programa estatístico Statistical Package for Social Sciences (SPSS) versão 24.0. O nível de significância adotado foi um valor de p < 0,05. Resultados: Dos 330 entrevistados, 89% das mulheres e 70% dos homens apresentaram estresse; o sexo feminino quase triplicou as chances de sofrê-lo (EXP (B) 2,79; p = 0,02). Quanto às quatro fases, as mulheres mostraram-se mais em quase exaustão e exaustão, e os homens, mais em resistência. Conclusões: Este estudo evidenciou que as mulheres se encontram na terceira e quarta fases do estresse, ou seja, em situações de estresse psicossocial duradouras. Tais resultados podem auxiliar no desenvolvimento de estratégias específicas para prevenção e promoção da saúde conforme os sexos, visando minimizar os efeitos do estresse nesses pacientes.

Abstract Background: Women seem to be more susceptible to psychosocial stress than men, and stress is associated with worse outcomes after acute myocardial infarction (AMI). Objectives: To investigate whether the female gender is an independent predictor of risk for stress and to compare stress levels between women and men after AMI. Methods: Cross-sectional study of a case series. Patients aged 18 to 65 years who were treated for AMI at the study facility between January 2017 and June 2018 were eligible. The presence of stress was assessed using Lipp's Stress Symptoms Inventory for Adults (ISSL), which categorizes stress into four phases (alertness, resistance, near-exhaustion, and exhaustion), through a list of physical and psychological symptoms. Data were analyzed using SPSS Version 24.0. The significance level was set at p<0.05. Results: Of the 330 respondents, 89% of women and 70% of men experienced stress. The female gender was associated with nearly threefold higher odds of experiencing stress (EXP (B)2.79, p = 0.02). Regarding the phases of stress, women were more often in the near-exhaustion and exhaustion phases, while men were more often in the resistance phase. Conclusions: This study showed that women are most often in the third and fourth phases of stress, i.e., in situations of long-standing psychosocial stress. These findings can assist in the development of gender-specific strategies for health promotion and disease prevention, aiming to minimize the effects of stress in this population.

Acute myocardial infarction in older adult patients / Infarto agudo do miocárdio em pacientes idosos

OBJECTIVES: To assess clinical and coronary angiographic characteristics, previous medical history, and clinical course, by age group, in older adults after myocardial infarction who underwent primary percutaneous coronary intervention (pPCI). METHODS: Single-center, cohort study that enrolled all patients with ST-segment elevation myocardial infarction who underwent pPCI at a specialized cardiology reference center in the South of Brazil. Older adults were defined as age ≥60 years, as set out in Brazilian legislation. Patients in the following age groups were compared: 60 to 64 years, 65 to 69 years, 70 to 74 years, 75 to 79 years, and ≥80 years. Patients' clinical course was assessed at initial hospital admissions and after 2 years of clinical follow-up. Data were analyzed using SPSS 19, and significance was established at p <0.05. RESULTS: From December 2015 to December 2018, a total of 636 patients were enrolled consecutively. Angiographic success rates were around 90% in all age groups. There were no differences in medications used, except for glycoprotein IIb/IIIa inhibitors, which were more frequently used in patients of lower age groups. Older patients had more in-hospital acute renal failure and higher in-hospital mortality. Predictors of mortality were age over 75, chronic renal failure, need for ventilatory support, severe arrhythmia, and sepsis. CONCLUSIONS: pPCI in older adult patients is a safe procedure with a high success rate.

OBJETIVOS: Avaliar características clínicas e angiográficas, história clínica pregressa e evolução clínica, por faixa etária, em idosos submetidos a intervenção coronária percutânea primária (ICPp) após infarto do miocárdio. METODOLOGIA: Estudo de coorte, de centro único, que incluiu todos os pacientes com infarto do miocárdio com supradesnivelamento do segmento ST submetidos ICPp em um centro de referência especializado em cardiologia no sul do Brasil. Os idosos foram definidos como aqueles com idade ≥60 anos, conforme estabelecido na legislação brasileira. Os pacientes nas seguintes faixas etárias foram comparados: 60 a 64 anos, 65 a 69 anos, 70 a 74 anos, 75 a 79 anos e ≥80 anos. O curso clínico dos pacientes foi avaliado nas admissões hospitalares iniciais e após 2 anos de acompanhamento clínico. Os dados foram analisados usando o SPSS 19, e p <0,05 foi considerado significativo. RESULTADOS: De dezembro de 2015 a dezembro de 2018, 636 pacientes foram incluídos consecutivamente. As taxas de sucesso angiográfico foram de cerca de 90% em todas as faixas etárias. Não houve diferenças nos medicamentos utilizados, com exceção dos inibidores da glicoproteína IIb/IIIa, que foram mais frequentemente utilizados em pacientes em faixas etárias mais baixas. Pacientes mais velhos apresentaram mais insuficiência renal aguda intra-hospitalar e maior mortalidade hospitalar. Os preditores de mortalidade foram: idade superior a 75 anos, insuficiência renal crônica, necessidade de suporte ventilatório, arritmia grave e sepse. CONCLUSÕES: O ICPp em pacientes idosos é um procedimento seguro e com alta taxa de sucesso.

Creation and Implementation of a Prospective and Multicentric Database of Patients with Acute Myocardial Infarction: RIAM. / Criação e Implementação de um Banco de Dados Prospectivo e Multicêntrico de Pacientes com Infarto Agudo do Miocárdio: RIAM.

BACKGROUND: Multicenter registries representing the real world can be a significant source of information, but few studies exist describing the methodology to implement these tools. OBJECTIVE: To describe the process of implementing a database of ST-segment elevation acute myocardial infarction (STEMI) at a reference hospital, and the application of this process to other centers by means of an online platform. METHODS: In 2009, our institution implemented an Registry of Acute Myocardial Infarction (RIAM), with the prospective and consecutive inclusion of every patient admitted to the institution who received a diagnosis of STEMI. From March 2014 to April 2016, the registries were uploaded to a web-based system using the REDCap software and the registry was expanded to other centers. Upon subscription, the REDCap platform is a noncommercial software made available by Vanderbilt University to institutions interested in research. RESULTS: The following steps were taken to improve and expand the registry: 1. Standardization of variables; 2. Implementation of institutional REDCap (Research Electronic Data Capture); 3. Development of data collection forms (Case Report Form - CRF); 4. Expansion of registry to other reference centers using the REDCap software; 5. Training of teams and participating centers following an SOP (Standard Operating Procedure). CONCLUSION: The description of the methodology used to implement and expand the RIAM may help other centers and researchers to conduct similar studies, share information between institutions, develop new health technologies, and assist public policies regarding cardiovascular diseases. (Arq Bras Cardiol. 2020; 114(3):446-455).

FUNDAMENTO: Registros multicêntricos representativos do mundo real podem fornecer informações importantes, mas existem poucos estudos descrevendo como implementar estas ferramentas. OBJETIVO: Descrever o processo de implementação de um banco de dados em infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCST) em um hospital de referência e sua aplicação para outros centros com uma plataforma online . MÉTODOS: Nossa instituição implementou em 2009 um Registro de Infarto Agudo do Miocárdio (RIAM), com a inclusão prospectiva e consecutiva de todos os pacientes com diagnóstico de IAMCST que internaram na instituição. No período de março de 2014 a abril de 2016 foi realizada a migração para o sistema online com o software REDCap e expansão do registro para outros centros. A plataforma REDCap é um software de uso gratuito disponibilizado pela Universidade Vanderbilt a instituições interessadas em pesquisa, mediante cadastramento prévio. RESULTADOS: Foram realizadas as seguintes etapas do aprimoramento e expansão do registro: 1. Padronização das variáveis; 2. Implementação do software REDCap ( Research Electronic Data Capture ) institucional; 3. Desenvolvimento de formulários de coleta de dados ( Case Report Form - CRF); 4. Expansão do registro para outros centros de referência utilizando o software REDCap; 5. Treinamento da equipe e dos centros participantes pelo POP (Procedimento Operacional Padrão). CONCLUSÕES: A descrição da metodologia utilizada para implementar e expandir o RIAM pode auxiliar outros centros e pesquisadores a realizar estudos semelhantes, compartilhar informações entre instituições, o desenvolvimento de novas tecnologias em saúde e auxiliar nas políticas públicas em doenças cardiovasculares. (Arq Bras Cardiol. 2020; 114(3):446-455).

Criação e Implementação de um Banco de Dados Prospectivo e Multicêntrico de Pacientes com Infarto Agudo do Miocárdio: RIAM / Creation and Implementation of a Prospective and Multicentric Database of Patients with Acute Myocardial Infarction: RIAM

Resumo Fundamento Registros multicêntricos representativos do mundo real podem fornecer informações importantes, mas existem poucos estudos descrevendo como implementar estas ferramentas. Objetivo Descrever o processo de implementação de um banco de dados em infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCST) em um hospital de referência e sua aplicação para outros centros com uma plataforma online . Métodos Nossa instituição implementou em 2009 um Registro de Infarto Agudo do Miocárdio (RIAM), com a inclusão prospectiva e consecutiva de todos os pacientes com diagnóstico de IAMCST que internaram na instituição. No período de março de 2014 a abril de 2016 foi realizada a migração para o sistema online com o software REDCap e expansão do registro para outros centros. A plataforma REDCap é um software de uso gratuito disponibilizado pela Universidade Vanderbilt a instituições interessadas em pesquisa, mediante cadastramento prévio. Resultados Foram realizadas as seguintes etapas do aprimoramento e expansão do registro: 1. Padronização das variáveis; 2. Implementação do software REDCap ( Research Electronic Data Capture ) institucional; 3. Desenvolvimento de formulários de coleta de dados ( Case Report Form - CRF); 4. Expansão do registro para outros centros de referência utilizando o software REDCap; 5. Treinamento da equipe e dos centros participantes pelo POP (Procedimento Operacional Padrão). Conclusões A descrição da metodologia utilizada para implementar e expandir o RIAM pode auxiliar outros centros e pesquisadores a realizar estudos semelhantes, compartilhar informações entre instituições, o desenvolvimento de novas tecnologias em saúde e auxiliar nas políticas públicas em doenças cardiovasculares. (Arq Bras Cardiol. 2020; 114(3):446-455)

Abstract Background Multicenter registries representing the real world can be a significant source of information, but few studies exist describing the methodology to implement these tools. Objective To describe the process of implementing a database of ST-segment elevation acute myocardial infarction (STEMI) at a reference hospital, and the application of this process to other centers by means of an online platform. Methods In 2009, our institution implemented an Registry of Acute Myocardial Infarction (RIAM), with the prospective and consecutive inclusion of every patient admitted to the institution who received a diagnosis of STEMI. From March 2014 to April 2016, the registries were uploaded to a web-based system using the REDCap software and the registry was expanded to other centers. Upon subscription, the REDCap platform is a noncommercial software made available by Vanderbilt University to institutions interested in research. Results The following steps were taken to improve and expand the registry: 1. Standardization of variables; 2. Implementation of institutional REDCap (Research Electronic Data Capture); 3. Development of data collection forms (Case Report Form - CRF); 4. Expansion of registry to other reference centers using the REDCap software; 5. Training of teams and participating centers following an SOP (Standard Operating Procedure). Conclusion The description of the methodology used to implement and expand the RIAM may help other centers and researchers to conduct similar studies, share information between institutions, develop new health technologies, and assist public policies regarding cardiovascular diseases. (Arq Bras Cardiol. 2020; 114(3):446-455)

Anger and Coronary Artery Disease in Women Submitted to Coronary Angiography: A 48-Month Follow-Up.

BACKGROUND: Anger control was significantly lower in patients with coronary artery disease (CAD), regardless of traditionally known risk factors, occurrence of prior events or other anger aspects in a previous study of our research group. OBJECTIVE: To assess the association between anger and CAD, its clinical course and predictors of low anger control in women submitted to coronary angiography. METHODS: This is a cohort prospective study. Anger was assessed by use of Spielberger's State-Trait Anger Expression Inventory (STAXI). Women were consecutively scheduled to undergo coronary angiography, considering CAD definition as ≥ 50% stenosis of one epicardial coronary artery. RESULTS: During the study, 255 women were included, being divided into two groups according to their anger control average (26.99). Those with anger control below average were younger and had a family history of CAD. Patients were followed up for 48 months to verify the occurrence of major cardiovascular events. CONCLUSION: Women with CAD undergoing coronary angiography had lower anger control, which was associated with age and CAD family history. On clinical follow-up, event-free survival did not significantly differ between patients with anger control above or below average.

Independent Predictors of Late Presentation in Patients with ST-Segment Elevation Myocardial Infarction.

BACKGROUND: In patients with acute ST-segment elevation myocardial infarction (STEMI), the time elapsed from symptom onset to receiving medical care is one of the main mortality predictors. OBJECTIVE: To identify independent predictors of late presentation in patients STEMI representative of daily clinical practice. METHODS: All patients admitted with a diagnosis of STEMI in a reference center between December 2009 and November 2014 were evaluated and prospectively followed during hospitalization and for 30 days after discharge. Late presentation was defined as a time interval > 6 hours from chest pain onset until hospital arrival. Multiple logistic regression analysis was used to identify independent predictors of late presentation. Values of p < 0.05 were considered statistically significant. RESULTS: A total of 1,297 patients were included, with a mean age of 60.7 ± 11.6 years, of which 71% were males, 85% Caucasians, 72% had a mean income lower than five minimum wages and 66% had systemic arterial hypertension. The median time of clinical presentation was 3.00 [1.40-5.48] hours, and approximately one-quarter of the patients had a late presentation, with their mortality being significantly higher. The independent predictors of late presentation were Black ethnicity, low income and diabetes mellitus, and a history of previous heart disease was a protective factor. CONCLUSION: Black ethnicity, low income and diabetes mellitus are independent predictors of late presentation in STEMI. The identification of subgroups of patients prone to late presentation may help to stimulate prevention policies for these high-risk individuals.

Independent Predictors of Late Presentation in Patients with ST-Segment Elevation Myocardial Infarction / Preditores de Apresentação Tardia em Pacientes com Infarto Agudo do Miocárdio com Supradesnivelamento do Segmento ST

Abstract Background: In patients with acute ST-segment elevation myocardial infarction (STEMI), the time elapsed from symptom onset to receiving medical care is one of the main mortality predictors. Objective: To identify independent predictors of late presentation in patients STEMI representative of daily clinical practice. Methods: All patients admitted with a diagnosis of STEMI in a reference center between December 2009 and November 2014 were evaluated and prospectively followed during hospitalization and for 30 days after discharge. Late presentation was defined as a time interval > 6 hours from chest pain onset until hospital arrival. Multiple logistic regression analysis was used to identify independent predictors of late presentation. Values of p < 0.05 were considered statistically significant. Results: A total of 1,297 patients were included, with a mean age of 60.7 ± 11.6 years, of which 71% were males, 85% Caucasians, 72% had a mean income lower than five minimum wages and 66% had systemic arterial hypertension. The median time of clinical presentation was 3.00 [1.40-5.48] hours, and approximately one-quarter of the patients had a late presentation, with their mortality being significantly higher. The independent predictors of late presentation were Black ethnicity, low income and diabetes mellitus, and a history of previous heart disease was a protective factor. Conclusion: Black ethnicity, low income and diabetes mellitus are independent predictors of late presentation in STEMI. The identification of subgroups of patients prone to late presentation may help to stimulate prevention policies for these high-risk individuals.

Resumo Fundamento: Em pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST), o tempo decorrido desde o início dos sintomas até a busca por atendimento médico é um dos principais preditores de mortalidade. Objetivo: Identificar preditores independentes de apresentação tardia em pacientes com IAMCSST representativos da prática clínica diária. Métodos: Todos os pacientes admitidos com diagnóstico de IAMCSST em um centro de referência, no período de dezembro de 2009 a novembro de 2014, foram avaliados e prospectivamente acompanhados, durante a hospitalização e por 30 dias após a alta. A apresentação tardia foi definida como tempo maior que 6 horas desde o início da dor torácica até a chegada ao hospital. Análise de regressão logística múltipla foi usada para identificar os preditores independentes de apresentação tardia. Foi considerado estatisticamente significativo p < 0,05. Resultados: Foram incluídos 1.297 pacientes, com idade média de 60,7 ± 11,6 anos, 71% do sexo masculino, 85% da raça branca, 72% com renda média menor que cinco salários mínimos e 66% com hipertensão arterial sistêmica. A mediana do tempo de apresentação clínica foi de 3,00 [1,40-5,48] horas, sendo que aproximadamente um quarto dos pacientes apresentou-se tardiamente, e a mortalidade deles foi significativamente maior. Os preditores independentes de apresentação tardia foram raça negra, baixa renda e diabetes melito, e história de doença cardíaca prévia foi fator protetor. Conclusão: Raça negra, baixa renda e diabetes melito são preditores independentes de apresentação tardia no IAMCSST. A identificação de subgrupos de pacientes propensos à apresentação tardia pode auxiliar a estimular políticas de prevenção nestes indivíduos de alto risco.

Anger and Coronary Artery Disease in Women Submitted to Coronary Angiography: A 48-Month Follow-Up / Raiva e Doença Arterial Coronariana em Mulheres Submetidas a Angiografia Coronariana: Acompanhamento de 48 Meses

Abstract Background: Anger control was significantly lower in patients with coronary artery disease (CAD), regardless of traditionally known risk factors, occurrence of prior events or other anger aspects in a previous study of our research group. Objective: To assess the association between anger and CAD, its clinical course and predictors of low anger control in women submitted to coronary angiography. Methods: This is a cohort prospective study. Anger was assessed by use of Spielberger's State-Trait Anger Expression Inventory (STAXI). Women were consecutively scheduled to undergo coronary angiography, considering CAD definition as ≥ 50% stenosis of one epicardial coronary artery. Results: During the study, 255 women were included, being divided into two groups according to their anger control average (26.99). Those with anger control below average were younger and had a family history of CAD. Patients were followed up for 48 months to verify the occurrence of major cardiovascular events. Conclusion: Women with CAD undergoing coronary angiography had lower anger control, which was associated with age and CAD family history. On clinical follow-up, event-free survival did not significantly differ between patients with anger control above or below average.

Resumo Fundamento: O controle da raiva mostrou-se significativamente mais baixo em pacientes com doença arterial coronariana (DAC), independentemente dos fatores de risco tradicionais conhecidos, da ocorrência de eventos prévios, ou de outros aspectos da raiva em estudo prévio do nosso grupo. Objetivo: Avaliar a associação entre raiva e DAC, sua evolução clínica e preditores de baixo controle de raiva em mulheres submetidas a coronariografia. Métodos: Trata-se de estudo de coorte prospectivo. Avaliou-se raiva com o Inventário de Expressão de Raiva como Estado e Traço de Spielberger (STAXI). Todas as mulheres agendadas para realização de angiografia coronariana durante o período de estudo foram abordadas consecutivamente. Definiu-se DAC como estenose de uma artéria coronária epicárdica ≥ 50%. Resultados: Este estudo incluiu 255 mulheres, que foram divididas em dois grupos, acima e abaixo da média do controle de raiva (26,99). Aquelas com controle abaixo da média eram mais jovens e tinham história familiar de DAC. As pacientes foram seguidas por 48 meses para verificar a ocorrência de eventos cardiovasculares maiores. Conclusão: As mulheres com DAC submetidas a coronariografia apresentaram menor controle de raiva, que se associou com idade e história familiar de DAC. No seguimento clínico, a sobrevida livre de evento não diferiu significativamente entre pacientes com controle de raiva acima da média e aquelas com controle abaixo.

Serious infections among unselected patients with ST-elevation myocardial infarction treated with contemporary primary percutaneous coronary intervention.

BACKGROUND: Contemporary studies assessing the frequency, characteristics, and outcomes of serious infections (SIs) in patients presenting a ST-elevation myocardial infarction are scarce. METHODS: Prospective cohort of consecutive patients undergoing primary percutaneous coronary intervention (pPCI). Serious infection was defined as the presence of infection that prolonged hospitalization. Community-acquired infection (CAI) was defined by SI diagnosed in the first 72 hours of hospitalization, whereas hospital-acquired infections (HAI) were those diagnosed after 72 hours of hospital admission. RESULTS: From December 2009 to November 2012, 1,486 patients were included in the analysis. Serious infection was present in 58 (3.9%) individuals; 30 (2%) patients had CAI and 28 (1.9%) patients had HAI. Respiratory tract infection was responsible for 82% of the SI. Patients with SI were older, had more comorbidities, and had worse angiographic results of the pPCI procedure when compared with those without SIs. After multivariable adjustment, SI was associated with an approximately 10-fold risk of 30-day death. Patients with CAI had more often a history of smoking, Killip III/IV on hospital admission, worse pPCI, and angiographic results than did patients with HAI. However, no differences were seen in 30-day major cardiovascular outcomes between patients with CAI and HAI. CONCLUSION: In a contemporary cohort of unselected ST-elevation myocardial infarction patients representative of the daily practice, SI was uncommon but associated with worse pPCI results and high risk of mortality. The occurrences of CAI or HAI were similar, but CAI patients presented distinctly worse angiographic outcomes than did patients with HAI.

Infarto Agudo do Miocárdio na Prática Clínica Diária / Myocardial Infarction in the Daily Practice

Fundamentos: As recomendações das diretrizes para o tratamento de pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST) são baseados principalmente em dados de estudos clínicos randomizados. Objetivos: Procuramos avaliar as tendências temporais das características, do tratamento e da evolução de pacientes com IAMCSST que representassem a prática clínica diária. Métodos: Estudo de coorte prospectivo incluindo todos os pacientes com IAMCSST que procuraram nosso serviço no período de 2010 a 2013. Foram avaliados os aspectos clínicos, angiográficos, laboratoriais e de tratamento, além dos eventos cardiovasculares maiores (ECVM) em 30 dias. Resultados: O escore de risco TIMI médio e a maioria das características clínicas e angiográficas iniciais dos 1973 pacientes incluídos se mantiveram estáveis de 2010 a 2013, com exceção de diabetes mellitus (cuja frequência aumentou de 21% para 28%; p < 0,01). Foi realizada ICP primária em 95% dos casos, e o tempo porta-balão diminuiu de 1,27 para 1,11 horas (p < 0,01). Em relação ao tratamento, houve aumento significativo do uso de clopidrogrel 600mg em bolus (de 75% em 2010 para 93% em 2013; p < 0,001), no uso de anticoagulação pré-cateterização (50% versus 91%; p<0,001), e de acesso radial na ICPp (9% versus 66%; p < 0,001); houve, ainda, um menor uso de beta-bloqueadores (72% versus 63%; p < 0,001). Houve redução de ECVM de 17,4% para 9,5% (p < 0,05). Foram fatores preditivos independentes de ECVM as características iniciais, o acesso radial, o uso de beta-bloqueadores e de anticoagulação pré-cateterização. Conclusões: As características iniciais de pacientes com IAMCSST mantiveram-se estáveis durante um período de quatro anos, com exceção de diabetes mellitus, cuja frequência aumentou significativamente. Houve mudanças significativas no tratamento clínico e intervencionista e diminuição significativa nos desfechos cardiovasculares adversos em curto prazo. Os preditores de melhor evolução foram as características iniciais, uso de betabloqueadores, de anticoagulação pré-cateterização e acesso radial

Background: Guideline recommendations for the management of patients with ST-elevation myocardial infarction (STEMI) are mainly based on data from randomized clinical trials. Objectives: We sought to assess temporal trends in characteristics, treatment and outcomes of patients with STEMI representative of the daily practice. Methods: Prospective cohort study including all patients with STEMI who presented at our institution from 2010 to 2013. Clinical, angiographic, laboratory, treatment aspects and 30-day major cardiovascular events (MACEs) were assessed and compared over the years. Results: The mean TIMI risk score, and most baseline clinical and angiographic characteristics of the 1973 patients included remained stable from 2010 to 2013, except for diabetes mellitus (whose frequency increased from 21% to 28%; p < 0.01). Primary PCI was performed in 95% of cases, and the door-to-balloon time decreased from 1.27 to 1.11 hours (p < 0.01). Regarding treatment, there were significant increases in the use of 600 mg boluses of clopidogrel (75% in 2010 vs 93% in 2013; p < 0.001), upstream anticoagulant (50% vs 91%; p < 0.001) and the radial approach in pPCI (9% vs 66%; p < 0.001), and lower use of beta-blockers (72% vs 63%; p < 0.001). MACE decreased from 17.4% to 9.5% (p < 0.05). Independent predictors of MACE were baseline characteristics, the radial approach, and use of beta-blockers and upstream anticoagulant. Conclusions: The baseline characteristics of patients with STEMI remained stable over a four-year period, except for the incidence of diabetes mellitus, which increased significantly. Medical and interventional treatments significantly changed, and short-term adverse cardiovascular outcomes significantly decreased. Predictors of better outcomes were baseline characteristics, use of beta-blockers and upstream anticoagulant, and the radial approach

Thrombosis in ST-elevation myocardial infarction: Insights from thrombi retrieved by aspiration thrombectomy.

In patients with ST-elevation myocardial infarction, recurrent cardiovascular events still remain the main cause of morbidity and mortality, despite significant improvements in antithrombotic therapy. We sought to review data regarding coronary thrombus analysis provided by studies using manual aspiration thrombectomy (AT), and to discuss how insights from this line of investigation could further improve management of acute coronary disease. Several studies investigated the fresh specimens retrieved by AT using techniques such as traditional morphological evaluation, optical microscopy, scanning electron microscopy, magnetic resonance imaging, and immunohistochemistry. These approaches have provided a better understanding of the composition and dynamics of the human coronary thrombosis process, as well as its relationship with some clinical outcomes. Recent data signaling to new antithrombotic therapeutic targets are still emerging.

The role of diabetes mellitus in the composition of coronary thrombi in patients presenting with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

BACKGROUND: Although diabetes mellitus (DM) is a predictor of poor outcomes in patients with ST-segment elevation myocardial infarction (STEMI), few studies have analyzed the impact of DM on the constituency of coronary thrombi. OBJECTIVES: Comparing morphologic and histopathologic aspects of coronary thrombi in STEMI patients with and without DM who underwent primary percutaneous coronary intervention. METHODS: All consecutive patients with STEMI admitted to our institution between April 2010 and December 2012 (n = 1,548) were considered for inclusion. Thrombus material was obtained by aspiration thrombectomy; morphologic and histopathologic aspects were assessed by 3 independent pathologists blinded to clinical characteristics and outcomes. Patients with DM were compared with those without DM. A sensitivity analysis was performed using a propensity score. RESULTS: During the study period, coronary thrombi material from 259 patients was obtained, of whom 19% (n = 49) had diabetes. Diabetic patients were older (P = .10), had a higher frequency of hypertension (P < .01) and dyslipidemia (P = .03), and had a trend to a longer time from the onset of chest pain to hospital arrival (P = .08). The number of retrieved fragments, the size of the thrombi and its composition (leukocytes, fibrin, and erythrocytes percent), and thrombus age and color were similar between patients with or without DM. There were also no statistically significant differences in thrombus constituency of the propensity score-matched patients (n = 92). CONCLUSIONS: In this study, morphologic and histopathologic constituency of coronary thrombi in the setting of a ST-elevation myocardial infarction was not significantly different between patients with or without DM. This finding was intriguing and deserves further investigation.