Emergency Department Visits and Deaths from Cardiovascular Diseases at a Referral Center for Cardiology During the COVID-19 Pandemic

Abstract Background The COVID-19 pandemic has imposed measures of social distancing and, during this time, there has been an elevation in cardiovascular mortality rates and a decrease in the number of emergency visits. Objectives To assess and compare in-hospital mortality for cardiovascular diseases and emergency department visits during the COVID-19 pandemic and the same period in 2019. Methods Retrospective, single-center study that evaluated emergency visits and in-hospital deaths between March 16, 2020 and June 16, 2020, when the steepest fall in the number of emergency admissions for COVID-19 was registered. These data were compared with the emergency visits and in-hospital deaths between March 16 and June 16, 2019. We analyzed the total number of deaths, and cardiovascular deaths. The level of significance was set at p < 0.05. Results There was a 35% decrease in the number of emergency visits and an increase in the ratio of the number of deaths to the number of emergency visits in 2020. The increase in the ratio of the number of all-cause deaths to the number of emergency visits was 45.6% and the increase in the ratio of the number of cardiovascular deaths to the number of emergency visits was 62.1%. None of the patients who died in the study period in 2020 tested positive for COVID-19. Conclusion In-hospital mortality for cardiovascular diseases increased proportionally to the number of emergency visits during the COVID-19-imposed social distancing compared with the same period in 2019. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

Analysis of the Appropriate Use Criteria for Coronary Angiography in Two Cardiology Services of Southern Brazil / Análise do Uso dos Critérios de Indicação de Coronariografia em Dois Serviços de Cardiologia do Sul do Brasil

Abstract Background: Despite its great relevance, there are no studies in our country evaluating the application of the 2012 guidelines for the appropriate use of cardiac diagnostic catheterization. Objective: To analyze the adequacy of coronary angiography performed in two hospitals in the southern region of Brazil. Methods: This is a multicenter cross-sectional study, which analyzed indications, results and proposals for the treatment of 737 coronary angiograms performed in a tertiary hospital with multiple specialties (Hospital A) and a tertiary cardiology hospital (Hospital B). Elective or emergency coronary angiographies were included, except for cases of acute myocardial infarction with ST segment elevation. The level of statistical significance adopted was 5% (p < 0.05). Results: Of the 737 coronary angiograms, 63.9% were performed in male patients. The mean age was 61.6 years. The indication was acute coronary syndrome in 57.1%, and investigation of coronary artery disease in 42.9% of the cases. Regarding appropriation, 80.6% were classified as appropriate, 15.1% occasionally appropriate, and 4.3% rarely appropriate. The proposed treatment was clinical for 62.7%, percutaneous coronary intervention for 24.6%, and myocardial revascularization surgery for 12.7% of the cases. Of the coronary angiographies classified as rarely appropriate, 56.2% were related to non-performance of previous functional tests, and 21.9% showed severe coronary lesions. However, regardless of the outcome of coronary angiography, all patients in this group were indicated for clinical treatment. Conclusion: We observed a low number of rarely appropriate coronary angiograms in our sample. The guideline recommendation in these cases was adequate, and no patient required revascularization treatment. Most of these cases are due to non-performance of functional tests.

Resumo Fundamento: Apesar de sua grande relevância, não existem trabalhos em nosso país que avaliem a aplicação das diretrizes de 2012 para uso apropriado do cateterismo cardíaco diagnóstico. Objetivo: Analisar a apropriação das coronariografias realizadas em dois hospitais da região sul do Brasil. Métodos: Estudo transversal multicêntrico, que analisou as indicações, resultados e propostas de tratamento de 737 coronariografias realizadas em um hospital terciário com múltiplas especialidades (Hospital A) e um hospital cardiológico terciário (Hospital B). Foram incluídas coronariografias eletivas ou de urgência, com exceção dos casos de infarto agudo do miocárdio com elevação do segmento ST. O nível de significância estatística adotado foi de 5% (p < 0,05). Resultados: Do total de 737 coronariografias, 63,9% foram realizadas em pacientes do sexo masculino. A média de idade foi 61,6 anos. A indicação foi síndrome coronariana aguda em 57,1% e investigação de doença arterial coronariana em 42,9% dos casos. Em relação à apropriação, 80,6% foram classificadas como apropriadas, 15,1% ocasionalmente apropriadas e 4,3% raramente apropriadas. O tratamento proposto foi clínico para 62,7%, intervenção coronária percutânea para 24,6% e cirurgia de revascularização miocárdica para 12,7% dos casos. Das coronariografias classificadas como raramente apropriadas, 56,2% foram relacionadas à não realização de provas funcionais prévias e 21,9% apresentaram lesões coronarianas graves. Porém, independentemente do resultado da coronariografia, todos os pacientes nesse grupo foram indicados para tratamento clínico. Conclusão: Observamos baixo número de coronariografias raramente apropriadas em nossa amostra. A recomendação da diretriz nesses casos foi adequada, sendo que nenhum paciente necessitou de tratamento de revascularização. A maior parte desses casos se deve à não realização de provas funcionais.

Analysis of the Appropriate Use Criteria for Coronary Angiography in Two Cardiology Services of Southern Brazil.

BACKGROUND: Despite its great relevance, there are no studies in our country evaluating the application of the 2012 guidelines for the appropriate use of cardiac diagnostic catheterization. OBJECTIVE: To analyze the adequacy of coronary angiography performed in two hospitals in the southern region of Brazil. METHODS: This is a multicenter cross-sectional study, which analyzed indications, results and proposals for the treatment of 737 coronary angiograms performed in a tertiary hospital with multiple specialties (Hospital A) and a tertiary cardiology hospital (Hospital B). Elective or emergency coronary angiographies were included, except for cases of acute myocardial infarction with ST segment elevation. The level of statistical significance adopted was 5% (p < 0.05). RESULTS: Of the 737 coronary angiograms, 63.9% were performed in male patients. The mean age was 61.6 years. The indication was acute coronary syndrome in 57.1%, and investigation of coronary artery disease in 42.9% of the cases. Regarding appropriation, 80.6% were classified as appropriate, 15.1% occasionally appropriate, and 4.3% rarely appropriate. The proposed treatment was clinical for 62.7%, percutaneous coronary intervention for 24.6%, and myocardial revascularization surgery for 12.7% of the cases. Of the coronary angiographies classified as rarely appropriate, 56.2% were related to non-performance of previous functional tests, and 21.9% showed severe coronary lesions. However, regardless of the outcome of coronary angiography, all patients in this group were indicated for clinical treatment. CONCLUSION: We observed a low number of rarely appropriate coronary angiograms in our sample. The guideline recommendation in these cases was adequate, and no patient required revascularization treatment. Most of these cases are due to non-performance of functional tests.

Permanent Pacing After Transcatheter Aortic Valve Implantation: Incidence, Predictors and Evolution of Left Ventricular Function.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a well-established procedure; however, atrioventricular block requiring permanent pacemaker implantation (PPI) is a common complication. OBJECTIVES: To determine the incidence, predictors and clinical outcomes of PPI after TAVI, focusing on how PPI affects left ventricular ejection fraction (LVEF) after TAVI. METHODS: The Brazilian Multicenter TAVI Registry included 819 patients submitted to TAVI due to severe aortic stenosis from 22 centers from January/2008 to January/2015. After exclusions, the predictors of PPI were assessed in 670 patients by use of multivariate regression. Analysis of the ROC curve was used to measure the ability of the predictors; p < 0.05 was the significance level adopted. RESULTS: Within 30 days from TAVI, 135 patients (20.1%) required PPI. Those patients were older (82.5 vs. 81.1 years; p = 0.047) and mainly of the male sex (59.3% vs 45%; p = 0.003). Hospital length of stay was longer in patients submitted to PPI (mean = 15.7 ± 25.7 vs. 11.8 ± 22.9 days; p < 0.001), but PPI affected neither all-cause death (26.7% vs. 25.6%; p = 0.80) nor cardiovascular death (14.1% vs. 14.8%; p = 0.84). By use of multivariate analysis, the previous presence of right bundle-branch block (RBBB) (OR, 6.19; 3.56-10.75; p ≤ 0.001), the use of CoreValve® prosthesis (OR, 3.16; 1.74-5.72; p ≤ 0.001) and baseline transaortic gradient > 50 mm Hg (OR, 1.86; 1.08-3.2; p = 0.025) were predictors of PPI. The estimated risk of PPI ranged from 4%, when none of those predictors was present, to 63%, in the presence of all of them. The model showed good ability to predict the need for PPI: 0.69 (95%CI: 0.64 - 0.74) in the ROC curve. The substudy of 287 echocardiograms during the 1-year follow-up showed worse LVEF course in patients submitted to PPI (p = 0.01). CONCLUSION: BRD prévio, gradiente aórtico médio > 50 mmHg e CoreValve® são preditores independentes de implante de MPD pós-TAVI. Ocorreu implante de MPD em aproximadamente 20% dos casos de TAVI, o que prolongou a internação hospitalar, mas não afetou a mortalidade. O implante de MPD afetou negativamente a FEVE pós-TAVI.

Desfechos Clínicos da Intervenção Percutânea na Doença Triarterial e de Tronco da Coronária Esquerda / Clinical Outcomes of Percutaneous Intervention in Triple-Vessel and Left Main Coronary Artery Diseases

Fundamentos: A revascularização do miocárdio na doença triarterial e de tronco da coronária esquerda (TCE) pode ser realizada por intervenção coronariana percutânea (ICP) ou cirurgia de revascularização do miocárdio (CRM). O estudo SYNTAX demonstrou resultados clínicos equivalentes em pacientes de baixa a moderada complexidade anatômica submetidos a CRM ou ICP. Objetivos: Avaliar a incidência de eventos cardiovasculares e taxa de nova revascularização coronariana em pacientes com lesão de TCE e triarterial submetidos à ICP. Métodos: Estudo de coorte observacional não randomizado que avaliou pacientes com doença coronariana triarterial ou de TCE submetidos à ICP com stent farmacológico no período de junho de 2013 a maio de 2015 no Hospital SOS Cardio de Florianópolis. Foram relatados dados basais, características anatômicas principais e desfechos clínicos durante a fase intra-hospitalar e durante seguimento de 12 meses. Resultados: Foram avaliados 46 pacientes com idade média de 69,9 anos. No momento basal, 39,1% apresentavam diabetes mellitus, 19,6% eram tabagistas, 78,3% eram dislipidêmicos, 10,9% apresentavam disfunção renal crônica e 15,2% disfunção ventricular moderada a severa. Quanto ao número de artérias acometidas, 24% eram triarteriais e 76% apresentavam lesão em TCE. Durante o período intra-hospitalar, ocorreu uma taxa de 4,34% de infarto agudo do miocárdio sem supradesnível de ST. Durante esse período, não foi necessária reintervenção e não ocorreram óbitos. No seguimento de 12 meses, a mortalidade por causa cardiovascular foi de 4,35%. A taxa de nova revascularização por CRM foi de 4,3% e por angioplastia foi de 2,2%. Conclusão: Ocorreram baixas taxas de eventos cardiovasculares, indicando que a ICP pode ser uma alternativa aceitável em casos selecionados

Background: Myocardial revascularization in triple-vessel and left main coronary artery (LMCA) diseases can be performed by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The SYNTAX trial demonstrated equivalent clinical results in patients with low to moderate anatomical complexity undergoing CABG or PCI. Objectives: To evaluate the incidence of cardiovascular events and rates of new myocardial revascularization in patients with LMCA and triple-vessel lesions undergoing PCI. Methods: Nonrandomized, observational cohort study that evaluated patients with triple-vessel or LMCA diseases undergoing PCI with drug-eluting stent in the period from June 2013 to May 2015 at the Hospital SOS Cardio in Florianópolis. Baseline data, main anatomical features, and clinical outcomes were reported during the in-hospital phase and during a 12-month follow-up. Results: In total, 46 patients with a mean age of 69.9 years were evaluated. At baseline, 39.1% had diabetes mellitus, 19.6% were smokers, 78.3% had dyslipidemia, 10.9% had chronic renal dysfunction, and 15.2% had moderate to severe ventricular dysfunction. As regards the number of arteries affected, 24% had triple-vessel disease and 76% had lesions in the LMCA. During the in-hospital period, there was a 4.34% rate of acute myocardial infarction without ST elevation. During this period, reintervention was not required and no deaths occurred. In the 12-month follow-up, mortality from cardiovascular causes was 4.35%. The rate of new revascularization was 4.3% by CABG and 2.2% by angioplasty. Conclusion: The rates of cardiovascular events were low, indicating that PCI may be an acceptable alternative in selected cases

Avaliação da dor durante o cateterismo por via transradial utilizando Escala Visual Analógica / Pain assessment during transradial catheterization using the Visual Analogue Scale

Pacientes submetidos a procedimentos por via transradial podem apresentar dor associada ao espasmo da artéria radial. A dor pode ser avaliada utilizando-se a Escala Visual Analógica (EVA), um método unidimensional de fácil aplicação. Analisamos a percepção de dor utilizando a EVA e a correlacionamos com a percepção de espasmo pelo operador. Métodos: Registro observacional, prospectivo, unicêntrico, que incluiu pacientes submetidos a procedimentos diagnósticos ou terapêuticos por acesso transradial. A EVA é constituída por uma linha horizontal de 100 mm, que traz nos extremos as inscrições “ausência de dor” e “dor insuportável”. O paciente foi instruído a marcar o ponto que representava a dor percebida no momento do procedimento. O operador quantificou o espasmo como zero se sem dor, 1 para dor sem resistência à movimentação dos cateteres, 2 para resistência leve, 3 para resistência moderada e 4 para resistência intensa.Resultados: A avaliação de dor pelo paciente por meio da EVA foi possível em todos os pacientes, e teve média de 25,5 ± 25,7 mm. Pelo operador, o espasmo foi classificado em grau zero em 53 casos (35,8%); grau 1 em 67 (45,3%); grau 2 em 24 (16,2%); grau 3 em 3 (2,0%); e grau 4 em 1 (0,7%). Os coeficientes de correlação tau b de Kendall e Ro de Spearman foram, respectivamente, de 0,527 e 0,647, mostrando correlação positivamoderada entre a percepção de dor pelo paciente e a percepção de espasmo pelo operador. Conclusões: A EVA pode ser utilizada para a avaliação de espasmo durante os procedimentos que utilizem avia transradial, tendo demonstrado correlação positiva com a avaliação de espasmo pelo operador...

Patients undergoing transradial procedures may experience pain associated with radial arteryspasm. The pain can be assessed using the Visual Analogue Scale (VAS), an easy-to-apply, one-dimensionalmethod. This study analyzed the perception of pain using the VAS and correlated it with the perception ofspasm by the interventionist. Methods: This was an observational, prospective, single-center registry, which included patients undergoing diagnostic or therapeutic transradial procedures. The VAS consists of a 100-mm horizontalline, which has at its extremes the words "no pain" and "unbearable pain". The patient was instructed to identify the point that represented the perceived pain during the procedure. The interventionist quantified the spasm as zero for no pain, 1 for pain with no resistance to catheter movement, 2 for mild resistance, 3 for moderate resistance, and 4 for intense resistance.Results: Pain assessment by patients using the VAS was possible in all patients, and had a mean of 25.5 ± 25.7 mm. For the interventionist, spasm was classified as grade zero in 53 cases (35.8%); grade 1 in 67 (45.3%); grade 2 in 24 (16.2%); grade 3 in 3 (2.0%); and grade 4 in 1 patient (0.7%). Kendall's tau b and Spearman’s (rho) rank correlation coefficients were, respectively, 0.527 and 0.647, showinga moderate positive correlation between the perception of pain by the patient and the perception of spasm by the operator...

Intervenção coronariana percutânea em multiarteriais com syntax score baixo e intermediário / Percutaneous coronary intervention in patients with multivessel coronary disease and low to medium syntax scores

Fundamentos: A doença arterial coronariana é importante causa de morte, com elevada prevalência. A cirurgia de revascularização do miocárdio é considerada o padrão-ouro para o tratamento em pacientes com lesões arteriais complexas, porém a intervenção coronariana percutânea também pode ser utilizada, e os pacientes devem ser estratificados para avaliar qual o melhor benefício terapêutico. Uma das formas de estratificar o risco nesses pacientes é através de escores como o Syntax score.Objetivos: Avaliar pacientes multiarteriais com Syntax score baixo e intermediário e suas características clínicas em relação a eventos cardiovasculares, infarto do miocárdio, necessidade de nova intervenção ou morte cardiovascular.Métodos: Estudo transversal, incluindo 76 pacientes de um único centro de cardiologia em Florianópolis, no período de janeiro 2007 a novembro 2009, para avaliar suas características clínicas e angiográficas em relação a eventos cardiovasculares. Para análise estatística utilizou-se o teste exato de Fisher. Resultados: Os pacientes com Syntax score baixo tiveram menor ocorrência de eventos cardiovasculares quando comparados àqueles com escore intermediário (p=0,0296). Outras variáveis clínicas estudadas, hipertensão arterial sistêmica, diabetes mellitus, dislipidemia, tabagismo, doença renal crônica e infarto do miocárdio prévio não mostraram associação com eventos cardiovasculares.Conclusões: A intervenção coronariana percutânea deve ser reservada para pacientes multiarteriais com Syntax score baixo.

Background: Coronary artery disease is a major and highly prevalent cause of death. Although coronary artery bypass grafts are rated as the gold standard treatment for patients with complex arterial lesions, percutaneous coronary intervention may also be used. Patients must be risk-rated in order to evaluate which offers the best therapeutic benefits. One way of ranking risks is through stratifying systems like the Syntax score.Objectives: Evaluate patients with multivessel coronary disease with low to medium Syntax scores and their clinical characteristics in terms of cardiovascular events, myocardial infarction, cardiovascular death or needing further intervention. Methods: Cross sectional study of 76 patients seen at a cardiology unit in Florianópolis between January 2007 and November 2009, in order to evaluate their clinical and angiographic characteristics with relation to cardiovascular events. The Fisher’s exact test was used for the statistical analysis.Results: Patients with low Syntax scores had fewer cardiovascular events compared to those with medium Syntax scores (p=0.0296). Other clinical variables studied, including hypertension, diabetes mellitus, dyslipidemia, smoking, chronic kidney diseases and prior myocardial infarctions, showed no association with cardiovascular events.Conclusions: Percutaneous coronary intervention should be reserved for patients with multivessel coronary disease and low Syntax scores.