Cardiogenic shock treated with temporary mechanical circulatory support in Brazil: The effect of learning curve.

AIMS: Treatment with mechanical circulatory support (MCS) has been proposed to mitigate mortality in cardiogenic shock (CS). However, there is a lack of data on MCS programs implementation and the effect of the learning curve on its outcomes in limited resources countries such as Brazil. METHODS: Prospective cohort of patients with CS admitted in four tertiary-care centers treated with Impella CP or veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Clinical outcomes were peri-procedural complications, short-term mortality rate, and the centers' learning curve. The cohort was divided into two periods: from April 2017 to July 2018 (n = 24), and from August 2018 to December 2020 (n = 25). RESULTS: The study enrolled 49 patients [age 59 (43-63) years; 34 (70%) males]. The most common causes for CS were acute myocardial infarction in 22 (45%) and acute decompensation of chronic heart failure in 10 (20%). VA-ECMO was employed in 35 (71%) and Impella CP in 14 (29%) of patients. Overall complications occurred in 37 (76%) of patients, where major bleeding in 19 (38%) was the most common. The overall mortality rate was 61%, but it was lower in the second period (40%) in comparison to the first period (83%), p = 0.002. The learning curve analysis showed a decrease in the mortality rate after 40 consecutive cases. CONCLUSIONS: Implementation of a temporary MCS program for refractory CS in a limited resource country is feasible. The learning curve effect might have played a role on survival rate since high morbimortality has decreased within time reaching optimal results by the end of the study.

Factors associated to serum paraoxonase 1 activity in patients with cardiovascular disease

ABSTRACT Objectives: Paraoxonase 1 (PON1) is an enzyme that has antioxidant potential, which confers a protective effect against the atherosclerotic process. However, studies associating genetics, dietary patterns and PON1 activity in individuals with cardiovascular disease (CVD) are scarce. Thus, the aim of the current study was to evaluate the influence of dietary factors on serum PON1 in CVD patients. Subjects and methods: Cross-sectional, sub-study of the BALANCE Program Trial. All patients aged 45 years or older and had evidence of established atherosclerotic disease in the preceding 10 years. Body weight, height, waist circumference, blood pressure, lipid profile and fasting glucose were collected. Food intake was assessed with 24-h dietary recall. Data was analyzed using SAS University Edition and a P value ≤ 0.05 was considered statistically significant. Sample was divided into three groups, according to the PON1 T(-107)C genotype (CC, CT and TT) and serum PON1 activity (Low, Medium, High). Results: There were no genotype differences for major factors. However, the systolic blood pressure was lower for CT individuals (p<0.05). Intake of cholesterol, saturated fatty acids (SFA) and monounsaturated fatty acids (MUFAS) was higher in patients with lower PON1 activity. Lipid ingestion tended to be higher in patients with lower PON1 activity (p=0.08). In the multivariate logistic regression model, SFA intake (P=0.03), genotype (P=0.09), gender (P=0.04), age (P=0.07) and carbohydrate intake (P=0.16) contributed the most to the serum PON1 activity. Conclusion: Based on these findings, nutritional guidance for these patients becomes essential, since dietary components interact with serum PON1 activity more than genotype.

Factors associated to serum paraoxonase 1 activity in patients with cardiovascular disease.

OBJECTIVE: Paraoxonase 1 (PON1) is an enzyme that has antioxidant potential, which confers a protective effect against the atherosclerotic process. However, studies associating genetics, dietary patterns and PON1 activity in individuals with cardiovascular disease (CVD) are scarce. Thus, the aim of the current study was to evaluate the influence of dietary factors on serum PON1 in CVD patients. METHODS: Cross-sectional, sub-study of the BALANCE Program Trial. All patients aged 45 years or older and had evidence of established atherosclerotic disease in the preceding 10 years. Body weight, height, waist circumference, blood pressure, lipid profile and fasting glucose were collected. Food intake was assessed with 24-h dietary recall. Data was analyzed using SAS University Edition and a P value ≤ 0.05 was considered statistically significant. Sample was divided into three groups, according to the PON1 T(-107)C genotype (CC, CT and TT) and serum PON1 activity (Low, Medium, High). RESULTS: There were no genotype differences for major factors. However, the systolic blood pressure was lower for CT individuals (p<0.05). Intake of cholesterol, saturated fatty acids (SFA) and monounsaturated fatty acids (MUFAS) was higher in patients with lower PON1 activity. Lipid ingestion tended to be higher in patients with lower PON1 activity (p=0.08). In the multivariate logistic regression model, SFA intake (P=0.03), genotype (P=0.09), gender (P=0.04), age (P=0.07) and carbohydrate intake (P=0.16) contributed the most to the serum PON1 activity. CONCLUSION: Based on these findings, nutritional guidance for these patients becomes essential, since dietary components interact with serum PON1 activity more than genotype.

Increased Mobility of the Atrial Septum in Aortic Root Dilation: An Observational Study on Transesophageal Echocardiography.

Background: There is a growing interest in the relationship between atrial septal anatomy and cardioembolic stroke. Anecdotal reports suggest that the enlargement of the aortic root could interfere with atrial septal mobility (ASM). We sought to investigate the association between ASM and aortic root dilation. Methods and Findings: From all consecutive clinically requested transesophageal echocardiogram (TEE) studies performed during the study period in a single institution, we were able to review and evaluate the ASM and anteroposterior length, aortic root diameter, and the prevalence of atrial septal aneurysm (ASA) and of patent foramen ovale (PFO) in 336 studies. Additional variables, such as left ventricular ejection fraction, left atrial diameter, diastolic dysfunction, age, sex, weight, height, previous stroke, atrial fibrillation, and TEE indication, were extracted from patient medical records and echocardiographic clinical reports. In 336 patients, we found a mean ASM of 3.4 mm, ranging from 0 to 21 mm; 15% had ASA and 14% had PFO. There was a 1.0 mm increase in ASM for every 10-mm increase in aortic root diameter adjusted for age, sex, weight, height, ejection fraction, and left atrial size (B = 0.1; P = 0.04). Aortic diameter was not associated with a smaller septal length (B = 0.03; P = 0.7). Conclusion: An increased motion of the atrial septum can occur in association with aortic dilation. These findings deserve attention for the relevance of aortic root anatomy in future studies involving atrial septal characteristics and embolic stroke risk.

Design of a multifaceted strategy based on automated text messaging in patients with recent heart failure admission.

AIMS: To evaluate a telemonitoring strategy based on automated text messaging and telephone support after heart failure (HF) hospitalization. METHODS AND RESULTS: The MESSAGE-HF study is a prospective multicentre, randomized, nationwide trial enrolling patients from 30 clinics in all regions of Brazil. HF patients with reduced left ventricular ejection fraction (<40%) and access to mobile phones are eligible after an acute decompensated HF hospitalization. Patients meeting eligibility criteria undergo an initial feasibility text messaging assessment and are randomized to usual care or telemonitoring intervention. All patients receive a HF booklet with basic information and recommendations about self-care. Patients in the intervention group receive four daily short text messages (educational and feedback) during the first 30 days of the protocol to optimize self-care; the feedback text messages from patients could trigger diuretic adjustments or a telephone call from the healthcare team. After 30 days, the frequency of text messages can be adjusted. Patients are followed up after 30, 90, and 180 days, with final status ascertained at 365 days by telephone. Our primary endpoint is the change in N-terminal pro-brain natriuretic peptide (NT-proBNP) levels after 180 days. Secondary endpoints include changes in NT-proBNP after 30 days; health-related quality of life, HF self-care, and knowledge scales after 30 and 180 days; and a composite outcome of HF hospitalization and cardiovascular death, adjudicated by a blinded and independent committee. CONCLUSIONS: The MESSAGE-HF trial is evaluating an educational and self-care promotion strategy involving a simple, intensive, and tailored telemonitoring system. If proven effective, it could be applied to a broader population worldwide.

Revisiting heart failure assessment based on objective measures in NYHA functional classes I and II.

OBJECTIVE: New York Heart Association (NYHA) functional class plays a central role in heart failure (HF) assessment but might be unreliable in mild presentations. We compared objective measures of HF functional evaluation between patients classified as NYHA I and II in the Rede Brasileira de Estudos em Insuficiência Cardíaca (ReBIC)-1 Trial. METHODS: The ReBIC-1 Trial included outpatients with stable HF with reduced ejection fraction. All patients had simultaneous protocol-defined assessment of NYHA class, 6 min walk test (6MWT), N-terminal pro-brain natriuretic peptide (NT-proBNP) levels and patient's self-perception of dyspnoea using a Visual Analogue Scale (VAS, range 0-100). RESULTS: Of 188 included patients with HF, 122 (65%) were classified as NYHA I and 66 (35%) as NYHA II at baseline. Although NYHA class I patients had lower dyspnoea VAS Scores (median 16 (IQR, 4-30) for class I vs 27.5 (11-49) for class II, p=0.001), overlap between classes was substantial (density overlap=60%). A similar profile was observed for NT-proBNP levels (620 pg/mL (248-1333) vs 778 (421-1737), p=0.015; overlap=78%) and for 6MWT distance (400 m (330-466) vs 351 m (286-408), p=0.028; overlap=64%). Among NYHA class I patients, 19%-34% had one marker of HF severity (VAS Score >30 points, 6MWT <300 m or NT-proBNP levels >1000 pg/mL) and 6%-10% had two of them. Temporal change in functional class was not accompanied by variation on dyspnoea VAS (p=0.14). CONCLUSIONS: Most patients classified as NYHA classes I and II had similar self-perception of their limitation, objective physical capabilities and levels of natriuretic peptides. These results suggest the NYHA classification poorly discriminates patients with mild HF.

Consumption of foods according to their degree of processing in patients with established atherosclerosis disease / Consumo de alimentos según su grado de procesamiento en pacientes con enfermedad aterosclerótica establecida

The aim of the present study was to analyze the consumption of foods according to their degree of processing in patients with established atherosclerosis disease. A cross-sectional study was performed with 74 patients of the BALANCE Program trial, a randomized, multicenter and national clinical trial occurring in Brazil. Body weight, height, waist circumference, blood pressure, lipid profile and fasting glucose were collected. Food intake was assessed with 24-h dietary recall. Consumption of nutrients was analyzed in quartiles of consumption of ultra-processed foods and their differences were obtained by one-way ANOVA with Tukey's post hoc test. Half of consumed calories came from natural or minimally processed foods (50.9%), followed by ultra-processed food products (35.1%). The largest contribution in calories came from meats, cereals/roots/tubers, breads, and sweets. No significant difference was found in quartiles of consumption of ultra-processed foods. In this sample, consumption of processed/ultra-processed food was almost the same as natural/minimally processed foods. Preferential consumption of unprocessed/minimally processed foods should be more widely advocated by health professionals.

El objetivo del presente estudio fue analizar el consumo de alimentos, de acuerdo con su grado de procesamiento, en pacientes con enfermedad arterioesclerótica establecida. Estudio transversal, en 74 pacientes del BALANCE Program trial que es un ensayo clínico randomizado, multicéntrico y nacional que se realiza en Brasil. Se midió el peso corporal, la talla, la circunferencia de la cintura, la presión arterial, el perfil lipídico y la glucosa en ayunas. La ingesta de alimentos se evaluó con un recordatorio de 24 horas. El consumo de nutrientes se analizó en cuartiles de consumo de alimentos ultraprocesados y sus diferencias se pusieron a prueba mediante ANOVA de una vía. La mitad de las calorías consumidas provino de alimentos naturales o mínimamente procesados (50.9%), seguidos por productos alimenticios ultraprocesados (35.1%). La mayor contribución en calorías provino de carnes, cereales/raíces/tubérculos, panes y dulces. No se encontraron diferencias significativas en los cuartiles de consumo de alimentos ultraprocesados. En esta muestra, el consumo de alimentos procesados/ultraprocesados fue casi el mismo que de los alimentos naturales/mínimamente procesados. El consumo preferencial de alimentos no procesados/mínimamente procesados debería ser defendido más ampliamente por profesionales de la salud.

Consumption of sugar-sweetened beverages in patients with established atherosclerosis disease. / Consumo de bebidas açucaradas em pacientes com doença aterosclerótica manifesta.

This study investigated the association between consumption of sugar-sweetened beverages and anthropometric and biochemical variables in a cross-sectional study conducted with secondary data from the first visit of the randomized clinical trial of the Brazilian Cardioprotective Nutritional Program (BALANCE Program) (2013-2014). Weight, height, waist circumference, lipid profile and fasting glycemia and a 24-hour diet recall were collected. Differences between consumption and non-consumption of sugar-sweetened beverages were evaluated by Student's t-test. The Chi-square test was employed to analyze the association between consumption and non-consumption of sugar-sweetened beverages and biochemical and anthropometric factors. The sample consisted of 2,172 individuals, mostly men (58.5%), elderly (63.6%), C-rated economic class (57.3%), and overweight (62.7%). A statistically significant difference was found between the consumption of sugar-sweetened beverages and higher BMI values (p=0.029), waist circumference (p=0.004) and triglycerides (p=0.023). These results emphasize the need for nutritional intervention regarding the consumption of sugar-sweetened beverages as part of the dietary treatment of this population.

O presente estudo investigou a associação entre o consumo de bebidas açucaradas e variáveis antropométricas e bioquímicas em análise transversal, realizado com dados secundários referentes à primeira consulta do ensaio clínico randomizado Dieta Cardioprotetora Brasileira (2013-2014). Foram coletados peso, altura, circunferência da cintura, perfil lipídico e glicemia de jejum e dados de um recordatório alimentar de 24 horas. Diferenças entre o consumo e não consumo de bebidas açucaradas foram avaliadas pelo teste T de student. Para analisar a associação entre o consumo de bebidas açucaradas e fatores bioquímicos e antropométricos foi utilizado o teste qui quadrado. A amostra foi de 2.172 indivíduos, sendo a maioria homens (58,5%), idosos (63,6%), do nível econômico C (57,3%), com ensino fundamental (45,8%) e com excesso de peso (62,7%). Houve associação significativa entre o consumo de bebidas açucaradas e maior valores de índice de massa corporal (p=0,029), circunferência da cintura (p=0,004) e triglicerídeos (p=0,023). Esses resultados reforçam a necessidade de intervenção nutricional quanto ao consumo de bebidas açucaradas como parte do tratamento dietético desta população.

Consumo de bebidas açucaradas em pacientes com doença aterosclerótica manifesta / Consumption of sugar-sweetened beverages in patients with established atherosclerosis disease

Resumo O presente estudo investigou a associação entre o consumo de bebidas açucaradas e variáveis antropométricas e bioquímicas em análise transversal, realizado com dados secundários referentes à primeira consulta do ensaio clínico randomizado Dieta Cardioprotetora Brasileira (2013-2014). Foram coletados peso, altura, circunferência da cintura, perfil lipídico e glicemia de jejum e dados de um recordatório alimentar de 24 horas. Diferenças entre o consumo e não consumo de bebidas açucaradas foram avaliadas pelo teste T de student. Para analisar a associação entre o consumo de bebidas açucaradas e fatores bioquímicos e antropométricos foi utilizado o teste qui quadrado. A amostra foi de 2.172 indivíduos, sendo a maioria homens (58,5%), idosos (63,6%), do nível econômico C (57,3%), com ensino fundamental (45,8%) e com excesso de peso (62,7%). Houve associação significativa entre o consumo de bebidas açucaradas e maior valores de índice de massa corporal (p=0,029), circunferência da cintura (p=0,004) e triglicerídeos (p=0,023). Esses resultados reforçam a necessidade de intervenção nutricional quanto ao consumo de bebidas açucaradas como parte do tratamento dietético desta população.

Abstract This study investigated the association between consumption of sugar-sweetened beverages and anthropometric and biochemical variables in a cross-sectional study conducted with secondary data from the first visit of the randomized clinical trial of the Brazilian Cardioprotective Nutritional Program (BALANCE Program) (2013-2014). Weight, height, waist circumference, lipid profile and fasting glycemia and a 24-hour diet recall were collected. Differences between consumption and non-consumption of sugar-sweetened beverages were evaluated by Student's t-test. The Chi-square test was employed to analyze the association between consumption and non-consumption of sugar-sweetened beverages and biochemical and anthropometric factors. The sample consisted of 2,172 individuals, mostly men (58.5%), elderly (63.6%), C-rated economic class (57.3%), and overweight (62.7%). A statistically significant difference was found between the consumption of sugar-sweetened beverages and higher BMI values (p=0.029), waist circumference (p=0.004) and triglycerides (p=0.023). These results emphasize the need for nutritional intervention regarding the consumption of sugar-sweetened beverages as part of the dietary treatment of this population.

Implementation of a Brazilian Cardioprotective Nutritional (BALANCE) Program for improvement on quality of diet and secondary prevention of cardiovascular events: A randomized, multicenter trial

Background Complex percutaneous coronary intervention (PCI) is associated with higher ischemic risk, which can be mitigated by long-term dual antiplatelet therapy (DAPT). However, concomitant high bleeding risk (HBR) may be present, making it unclear whether short- or long-term DAPT should be prioritized. Objectives This study investigated the effects of ischemic (by PCI complexity) and bleeding (by PRECISE-DAPT [PRE dicting bleeding Complications in patients undergoing stent Implantation and Sub sequent Dual Anti Platelet Therapy] score) risks on clinical outcomes and on the impact of DAPT duration after coronary stenting. Methods Complex PCI was defined as ≥3 stents implanted and/or ≥3 lesions treated, bifurcation stenting and/or stent length >60 mm, and/or chronic total occlusion revascularization. Ischemic and bleeding outcomes in high (≥25) or non-high (<25) PRECISE-DAPT strata were evaluated based on randomly allocated duration of DAPT. Results Among 14,963 patients from 8 randomized trials, 3,118 underwent complex PCI and experienced a higher rate of ischemic, but not bleeding, events. Long-term DAPT in non-HBR patients reduced ischemic events in both complex (absolute risk difference: −3.86%; 95% confidence interval: −7.71 to +0.06) and noncomplex PCI strata (absolute risk difference: −1.14%; 95% confidence interval: −2.26 to −0.02), but not among HBR patients, regardless of complex PCI features. The bleeding risk according to the Thrombolysis In Myocardial Infarction scale was increased by long-term DAPT only in HBR patients, regardless of PCI complexity. Conclusions Patients who underwent complex PCI had a higher risk of ischemic events, but benefitted from long-term DAPT only if HBR features were not present. These data suggested that when concordant, bleeding, more than ischemic risk, should inform decision-making on the duration of DAPT. (AU)

Short-term diuretic withdrawal in stable outpatients with mild heart failure and no fluid retention receiving optimal therapy: a double-blind, multicentre, randomized trial.

AIMS: Although loop diuretics are widely used to treat heart failure (HF), there is scarce contemporary data to guide diuretic adjustments in the outpatient setting. METHODS AND RESULTS: In a prospective, randomized and double-blind protocol, we tested the safety and tolerability of withdrawing low-dose furosemide in stable HF outpatients at 11 HF clinics in Brazil. The trial had two blindly adjudicated co-primary outcomes: (i) symptoms assessment quantified as the area under the curve (AUC) of a dyspnoea score on a visual-analogue scale evaluated at 4 time-points (baseline, Day 15, Day 45, and Day 90) and (ii) the proportion of patients maintained without diuretic reuse during follow-up. We enrolled 188 patients (25% females; 59 ± 13 years old; left ventricular ejection fraction = 32 ± 8%) that were randomized to furosemide withdrawal (n = 95) or maintenance (n = 93). For the first co-primary endpoint, no significant difference in patients' assessment of dyspnoea was observed in the comparison of furosemide withdrawal with continuous administration [median AUC 1875 (interquartile range, IQR 383-3360) and 1541 (IQR 474-3124), respectively; P = 0.94]. For the second co-primary endpoint, 70 patients (75.3%) in the withdrawal group and 77 patients (83.7%) in the maintenance group were free of furosemide reuse during follow-up (odds ratio for additional furosemide use with withdrawal 1.69, 95% confidence interval 0.82-3.49; P = 0.16). Heart failure-related events (hospitalizations, emergency room visits, and deaths) were infrequent and similar between groups (P = 1.0). CONCLUSIONS: Diuretic withdrawal did not result in neither increased self-perception of dyspnoea nor increased need of furosemide reuse. Diuretic discontinuation may deserve consideration in stable outpatients with no signs of fluid retention receiving optimal medical therapy. CLINICALTRIALS.GOV IDENTIFIER: NCT02689180.

Rational and design of a randomized, double-blind, multicenter trial to evaluate the safety and tolerability of furosemide withdrawal in stable chronic outpatients with heart failure: The ReBIC-1 trial.

AIMS: Furosemide is commonly prescribed for symptom relief in heart failure (HF) patients. Although few data support the continuous use of loop diuretics in apparently euvolemic HF patients with mild symptoms, there is concern about safety of diuretic withdrawal in these patients. The ReBIC-1 trial was designed to evaluate the safety and tolerability of withdrawing furosemide in stable, euvolemic, chronic HF outpatients. This multicenter initiative is part of the Brazilian Research Network in Heart Failure (ReBIC) created to develop clinical studies in HF and composed predominantly by university tertiary care hospitals. METHODS: The ReBIC-1 trial is currently enrolling HF patients in NYHA functional class I-II, left ventricular ejection fraction ≤45%, without a HF-related hospital admission within the last 6 months, receiving a stable dose of furosemide (40 or 80 mg per day) for at least 6 months. Eligible patients will be randomized to maintain or withdraw furosemide in a double-blinded protocol. The trial has two co-primary outcomes: (1) dyspnea assessment using a visual-analogue scale evaluated at 4 time points and (2) the proportion of patients maintained without diuretics during the follow-up period. Total sample size was calculated to be 220 patients. Enrolled patients will be followed up to 90 days after randomization, and diuretic will be restarted if clinical deterioration or signs of congestion are detected. Pre-defined sub-group analysis based on NT-proBNP levels at baseline is planned. PERSPECTIVE: Evidence-based strategies aiming to simplify HF pharmacotherapy are needed in clinical practice. The ReBIC-1 trial will determine the safety of withdrawing furosemide in stable chronic HF patients.

Cost-effectiveness of anatomical and functional test strategies for stable chest pain: public health perspective from a middle-income country.

OBJECTIVES: The aim of this research is to evaluate the relative cost-effectiveness of functional and anatomical strategies for diagnosing stable coronary artery disease (CAD), using exercise (Ex)-ECG, stress echocardiogram (ECHO), single-photon emission CT (SPECT), coronary CT angiography (CTA) or stress cardiacmagnetic resonance (C-MRI). SETTING: Decision-analytical model, comparing strategies of sequential tests for evaluating patients with possible stable angina in low, intermediate and high pretest probability of CAD, from the perspective of a developing nation's public healthcare system. PARTICIPANTS: Hypothetical cohort of patients with pretest probability of CAD between 20% and 70%. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome is cost per correct diagnosis of CAD. Proportion of false-positive or false-negative tests and number of unnecessary tests performed were also evaluated. RESULTS: Strategies using Ex-ECG as initial test were the least costly alternatives but generated more frequent false-positive initial tests and false-negative final diagnosis. Strategies based on CTA or ECHO as initial test were the most attractive and resulted in similar cost-effectiveness ratios (I$ 286 and I$ 305 per correct diagnosis, respectively). A strategy based on C-MRI was highly effective for diagnosing stable CAD, but its high cost resulted in unfavourable incremental cost-effectiveness (ICER) in moderate-risk and high-risk scenarios. Non-invasive strategies based on SPECT have been dominated. CONCLUSIONS: An anatomical diagnostic strategy based on CTA is a cost-effective option for CAD diagnosis. Functional strategies performed equally well when based on ECHO. C-MRI yielded acceptable ICER only at low pretest probability, and SPECT was not cost-effective in our analysis.

Long-term Cost-Effectiveness of Diagnostic Tests for Assessing Stable Chest Pain: Modeled Analysis of Anatomical and Functional Strategies.

Several tests exist for diagnosing coronary artery disease, with varying accuracy and cost. We sought to provide cost-effectiveness information to aid physicians and decision-makers in selecting the most appropriate testing strategy. We used the state-transitions (Markov) model from the Brazilian public health system perspective with a lifetime horizon. Diagnostic strategies were based on exercise electrocardiography (Ex-ECG), stress echocardiography (ECHO), single-photon emission computed tomography (SPECT), computed tomography coronary angiography (CTA), or stress cardiac magnetic resonance imaging (C-MRI) as the initial test. Systematic review provided input data for test accuracy and long-term prognosis. Cost data were derived from the Brazilian public health system. Diagnostic test strategy had a small but measurable impact in quality-adjusted life-years gained. Switching from Ex-ECG to CTA-based strategies improved outcomes at an incremental cost-effectiveness ratio of 3100 international dollars per quality-adjusted life-year. ECHO-based strategies resulted in cost and effectiveness almost identical to CTA, and SPECT-based strategies were dominated because of their much higher cost. Strategies based on stress C-MRI were most effective, but the incremental cost-effectiveness ratio vs CTA was higher than the proposed willingness-to-pay threshold. Invasive strategies were dominant in the high pretest probability setting. Sensitivity analysis showed that results were sensitive to costs of CTA, ECHO, and C-MRI. Coronary CT is cost-effective for the diagnosis of coronary artery disease and should be included in the Brazilian public health system. Stress ECHO has a similar performance and is an acceptable alternative for most patients, but invasive strategies should be reserved for patients at high risk.

Contemporary Context of Drug-Eluting Stents in Brazil: A Cost Utility Study.

BACKGROUND: Although drug-eluting stents (DES) have been widely incorporated into clinical practice in developed countries, several countries restrict their use mainly because of their high cost and unfavorable incremental cost-effectiveness ratios (ICER). OBJECTIVE: To evaluate the cost-effectiveness of DES in comparison with bare-metal stents (BMS) for treatment of coronary artery disease (CAD). DESIGN: Markov model. DATA SOURCES: Published literature, government database, and CAD patient cohort. TARGET POPULATION: Single-vessel CAD patients. TIME HORIZON: One year and lifetime. PERSPECTIVE: Brazilian Public Health System (SUS). INTERVENTION: Six strategies composed of percutaneous intervention with a BMS or 1 of 5 DES (paclitaxel, sirolimus, everolimus, zotarolimus, and zotarolimus resolute). OUTCOME MEASURES: Cost for target vessel revascularization avoided and cost for quality-adjusted life year gained. BASE CASE ANALYSIS: In the short-term analysis, sirolimus was the most effective and least costly among DES (ICER of I$20,642 per target vessel revascularization avoided), with all others DES dominated by sirolimus. Lifetime cumulative costs ranged from I$18,765 to I$21,400. In the base case analysis, zotarolimus resolute had the most favorable ICER among the DES (ICER I$62,761), with sirolimus, paclitaxel, and zotarolimus being absolute dominated and everolimus extended dominated by zotarolimus resolute, although all the results were above the willingness-to-pay threshold of 3 times the gross domestic product per capita (I$35,307). SENSITIVITY ANALYSIS: In deterministic sensitivity analysis, results were sensitive to cost of DES, number of stents used per patient, baseline probability, and duration of stent thrombosis risk. The probabilistic sensitivity analysis demonstrated a probability of 81% for BMS being the strategy of choice, with 9% for everolimus and 9% zotarolimus resolute, at the willingness-to-pay threshold. CONCLUSION: DES is not a good value for money in SUS perspective, despite its benefit in reducing target vessel revascularization. Since the cost-effectiveness of DES is mainly driven by the stents' cost difference, they should cost less than twice the BMS price to become a cost-effective alternative.

Fatores de risco cardiovascular e qualidade de vida de acadêmicos de Medicina da Universidade Federal de Pelotas / Cardiovascular risk factors and quality of life in medical students at the Universidade Federal de Pelotas

Introdução: Fatores de risco cardiovascular e qualidade de vida de estudantes de Medicina podem influenciar a capacidade de atuação e de aconselhamento a pacientes dos futuros médicos. Tendo isso em vista, o presente estudo teve como objetivo avaliar comportamentos e fatores de risco cardiovascular e qualidade de vida em acadêmicos de Medicina da Universidade Federal de Pelotas (UFPel), através de estudo de prevalência. Métodos: Estudo observacional transversal onde 298 estudantes de Medicina da Universidade Federal de Pelotas (UFPel) foram investigados utilizando questionário padronizado, levantando informações de idade, sexo, tabagismo, alimentação, ingestão de bebidas alcoólicas, rendimento acadêmico, atividade física, e qualidade de vida pelo escore WHOQOL. Resultados: A idade mediana foi de 22 anos, sendo 58% do sexo feminino. Sedentarismo foi relatado por 40% dos acadêmicos e consumo excessivo de sal por 44%. Consumo de álcool foi relatado por 88% dos acadêmicos, sem variação em função do semestre avaliado. Tabagismo foi relativamente incomum (8%), observando-se correlação positiva entre quantidade de álcool consumida e tabagismo (p=0,029). O desfecho composto de sedentarismo, consumo excessivo de sódio ou tabagismo foi relatado por 69% dos acadêmicos. A qualidade de vida dos acadêmicos foi influenciada pela época de formação e pela distância da família, mas não houve correlação com fatores de risco. Conclusão: A prevalência de fatores de risco cardiovascular e comportamento de risco é elevada entre os acadêmicos de Medicina da UFPel. Devem ser propostas intervenções visando à conscientização do benefício da adoção de um estilo de vida saudável entre os acadêmicos.

Introduction: Cardiovascular risk factors and quality of life of medical students can infl uence the future physicians’ ability to effectively work and advise patients. Keeping this in view, the present study aimed to evaluate behaviors, cardiovascular risk factors and quality of life among medical students of the Federal University of Pelotas (UFPel), using a prevalence approach. Methods: A cross-sectional observational study where 298 medical students of the Federal University of Pelotas (UFPel) were investigated using a standardized questionnaire, gathering information such as age, sex, smoking, diet, alcohol consumption, academic performance, physical activity, and quality of life by the WHOQOL score. Results: The median age was 22 years, 58% female. Sedentary lifestyle was reported by 40% of the students and excessive salt intake by 44%. Alcohol consumption was reported by 88% of the students, and did not vary as a function of the evaluated semester. Smoking was relatively uncommon (8%), with a positive correlation between amount of alcohol consumed and smoking (p = 0.029). The outcome composed of sedentary life style, excessive sodium intake, or smoking was reported by 69% of the students. Students’ quality of life was infl uenced by time of medical training and distance from the family, but these were not correlated with risk factors. Conclusion: The prevalence of cardiovascular risk factors and risky behaviors is high among UFPel medical students. Interventions aimed at raising awareness of the benefi ts of adopting a healthy lifestyle among academics should be proposed.