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1.
Heart ; 2021 Jan 27.
Artigo em Inglês | MEDLINE | ID: mdl-33504514

RESUMO

OBJECTIVE: To develop an ECG-based tool for rapid risk assessment of a cardiac cause of syncope in patients ≥40 years. METHODS: In a prospective international multicentre study, 2007 patients ≥40 years presenting with syncope were recruited in the emergency department (ED) of participating centres ranging from large university hospitals to smaller rural hospitals in eight countries from May 2010 to July 2017. 12-Lead ECG recordings were obtained at ED presentation following the syncopal event. The primary diagnostic outcome, a cardiac cause of syncope, was centrally adjudicated by two independent cardiologists using all available clinical information including 12-month follow-up. ECG predictors for a cardiac cause of syncope were identified using penalised backward selection and a continuous-scale likelihood was calculated based on regression analysis coefficients. Findings were validated in an independent US multicentre cohort including 2269 patients. RESULTS: In the derivation cohort, a cardiac cause of syncope was adjudicated in 267 patients (16%). Seven ECG criteria were identified as predictors for this outcome: heart rate and QTc-interval (continuous predictors), rhythm, atrioventricular block, ST-segment depression, bundle branch block and ventricular extrasystole/non-sustained ventricular tachycardia (categorical predictors). Diagnostic accuracy of these combined predictors for a cardiac cause of syncope was high (area under the curve 0.80, 95% CI 0.77 to 0.83). Overall, 138 patients (8%) were rapidly triaged towards rule-out and 181 patients (11%) towards rule-in of a cardiac cause of syncope. External validation showed similar performance. CONCLUSION: In patients ≥40 years with a syncopal event, a combination of seven ECG criteria enabled rapid assessment of the likelihood that syncope was due to a cardiac cause. TRIAL REGISTRATION NUMBER: NCT01548352 (BASEL IX), NCT01802398 (SRS study).

2.
Int J Cardiol ; 2020 Dec 07.
Artigo em Inglês | MEDLINE | ID: mdl-33301835

RESUMO

PURPOSE: To evaluate the predictive value of a bedside index in hospitalized patients with acute coronary syndromes (ACS). METHODS: We studied the association of leuko-platelet index (LPI: platelet count * leukocyte count/108) with risk of mortality, shock, or heart failure (combined end point-CEP), and with the response to antiplatelet therapy, measured by light transmission aggregometry. RESULTS: In the derivation cohort we included 1100 patients with non STEM-ACS, GRACE score of 133 ±â€¯52, Crusade score 24,3 ±â€¯14, 66% male, 65 + 11 years. LPI was 17 (12-24). LPI was higher (19 (13-25)) in patients with MI than in patients with unstable angina (16 (12-22) in (p < 0.001)). A total of 115 patients (10.5%) had the CEP. CEP was associated to LPI (OR 1.04 (1.002-1.08), p = 0.03), age (OR 1.01 (0.97-1.05), p = 0.62) and GRACE>140 (OR 8.1 (2.2-29), p = 0.02). LPI (OR 1.04 (1.004-1.07) p = 0.03) and GRACE score (OR 1.02 (1.01-1.03) p < 0.01) were associated to cardiovascular mortality. We confirmed these results in the validation cohort #1 (686 patients, 61 + 11 years old, 47% nonST-ACS, 53% ST-ACS, 21% had CEP) and in validation cohort #2 (218 patients, 56.8% males, 73 + 7 years old, 79% nonST-ACS, GRACE score 136 + 30) and 8.3% with CEP. We used the cutoff points of LPI obtained in the derivation cohort (>24). CONCLUSIONS: LPI > 24 was associated to CEP (OR (1.7-5.2), p 0.01), independently of age (OR 1 (0.98-1.02), p = 0.8), and GRACE score (OR 1.01 (0.99-1.01), p 0.69), and It was associated to antiplatelet resistance (OR 1.03 (95% CI 1.00-1.06) p = 0.05).

3.
Medicina (B.Aires) ; 80(3): 248-252, jun. 2020. graf
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-1125076

RESUMO

Existen crecientes informes sobre una drástica caída en consultas y realización de procedimientos cardiovasculares (incluyendo urgencias y emergencias) en regiones afectadas por la pandemia de COVID-19, con el consecuente incremento marcado de la mortalidad total que no se explica totalmente por las defunciones atribuidas a COVID-19. En Argentina, la enfermedad cardiovascular lidera el ranking de muertes en adultos con 280 muertes por día, y en las últimas décadas hemos reducido su mortalidad entre 20 y 30% mediante diversas intervenciones basadas en la evidencia. En el presente trabajo realizamos análisis predictivos para entender cuáles podrían ser las consecuencias de una peor implementación de dichas intervenciones. Estimamos que un menor control de los factores de riesgo cardiovascular de abril a octubre de 2020 podría causar hasta 10 500 nuevos casos prevenibles de enfermedad cardiovascular. En términos de infarto de miocardio, una caída del 40% al 60% del tratamiento de reperfusión podría incrementar la mortalidad del 3% al 5%. Un incremento marginal de riesgo relativo de 10% a 15% de muerte cardiovascular equivaldría a un exceso de 6000 a 9000 muertes evitables. En conclusión, dada la alta prevalencia y fatalidad de la enfermedad cardiovascular, incluso un pequeño impacto negativo en la eficacia de su cuidado se traducirá en grandes cantidades de afectados en Argentina. Es necesario informar a las autoridades y educar al público para que sigan controlando enfermedades cardiovasculares y sus factores de riesgo, siempre que existan recursos y minimizando el riesgo de contagio y propagación del virus.


There are increasing reports of a drastic drop in consultations and cardiovascular procedures (including urgencies and emergencies) in regions affected by the COVID-19 pandemic, with a consequent marked increase in total mortality that is not fully explained by COVID-19. Cardiovascular disease leads the ranking in deaths in adults in Argentina with 280 deaths per day, and in recent decades we have reduced its mortality by 20-30% through various evidence-based interventions. Herein we conducted predictive analyses to understand what could be the consequences of a worse implementation of those interventions. We estimate that less control of cardiovascular risk factors from April to October 2020 could cause up to 10 500 new preventable cases of cardiovascular disease. In terms of myocardial infarction, a drop from 40% to 60% of the reperfusion treatment could increase mortality by 3% to 5%. A marginal 10% to 15% increase in relative risk of cardiovascular death would be equivalent to an excess of 6000 to 9000 preventable deaths. In conclusion, given the high prevalence and fatality of cardiovascular disease, even a small negative impact on the efficacy of its care will translate into large numbers of people affected in Argentina. It is necessary to inform the authorities and educate the public so cardiovascular diseases and their risk factors remain a health priority, as long as resources exist and minimizing the risk of contagion and spread of the virus.

4.
Artigo em Inglês | MEDLINE | ID: mdl-32423731

RESUMO

OBJECTIVE: The present study was conducted to investigate the obesity paradox and assess the effect of body mass index (BMI) on early and late clinical outcomes after cardiac surgery. DESIGN: Cohort study with a retrospective analysis of prospectively collected data. DESIGN: Single-institution cardiology medical center. PARTICIPANTS: The study comprised consecutive patients undergoing cardiac surgery from January 2009 to January 2019. Patients were divided into the following 4 groups defined by BMI: underweight (UW) (≤18.5 kg/m2): 0.5%, n = 27; normal weight (18.5-25 kg/m2): 25.7%, n = 1,393; overweight (OW) (>25-30 kg/m2): 44.7%, n = 2,423; and obese (OB) (≥30 kg/m2): 29.1%, n = 1,576. INTERVENTIONS: No interventions. MEASUREMENTS AND MAIN RESULTS: A multivariate analysis was used to compare clinical outcomes among the different BMI groups. Overall 1-year survival of patients in the BMI categories was determined by the Kaplan-Meier method and compared using the log rank test. The study included 5,419 patients. The BMI groups were significantly different regarding presurgical variables. Mortality according to BMI exhibited a reverse J-shaped relationship: 7.4% in the UW group, 5.2% in the normal weight group, 3.2% in the OW group, and 4.3% in the OB group (p = 0.016). Low- cardiac- output syndrome and bleeding were more frequent in the UW group, whereas mediastinitis and hyperglycemia were more common in the OB group. After adjusting for other risk factors, BMI was not an independent predictor of in-hospital mortality. One-year follow-up was completed in 95% of the patients, and the analysis of long-term mortality did not show a difference among the BMI categories (p log rank = 0.16). CONCLUSION: OW patients had a lower mortality and better outcomes after cardiac surgery. However, when other preoperative variables were taken into account, BMI did not have independent effect on in-hospital and 1-year mortality.

5.
Perfusion ; 35(6): 484-491, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32449494

RESUMO

INTRODUCTION: Veno-arterial extracorporeal membrane oxygenation may be used to support patients with refractory cardiogenic shock. Many patients can be successfully weaned, the ability of some medications to facilitate weaning from veno-arterial extracorporeal membrane oxygenation were reported. To date, there are limited studies investigating the impact of levosimendan on veno-arterial extracorporeal membrane oxygenation weaning. The objective of this systematic review and meta-analysis was to assess the effects of levosimendan on successful weaning from veno-arterial extracorporeal membrane oxygenation and survival in adult patients with cardiogenic shock. METHODS: We performed a systematic review and meta-analysis (PubMed, the Cochrane Library, and the International Clinical Trials Registry Platform published from the year 2000 onwards) investigating whether levosimendan offers advantages compared to standard therapy or placebo, in cardiogenic shock adult patients treated with veno-arterial extracorporeal membrane oxygenation. The primary outcome was veno-arterial extracorporeal membrane oxygenation successful weaning, whereas secondary outcome was all-cause mortality at the longest follow-up available. We pooled risk ratio and 95% confidence interval using fixed and random effects models according to the heterogeneity. RESULTS: A total of five non-randomized clinical trials comprising 557 patients were included, 299 patients for levosimendan and 258 patients for control groups. The pooled prevalence of veno-arterial extracorporeal membrane oxygenation successful weaning was 61.4% (95% confidence interval 39.8-82.9%), and all-cause mortality was 36% (95% confidence interval 29.6-48.8%). There was a significant increase in veno-arterial extracorporeal membrane oxygenation successful weaning with levosimendan compared to the controls (risk ratio = 1.42 (95% confidence interval 1.12-1.8), p for effect = 0.004, I2 = 71%). A decrease risk of all-cause mortality in the levosimendan group was also observed, risk ratio = 0.62 (95% confidence interval 0.44-0.88), p for effect = 0.007, I2 = 36%. CONCLUSION: The use of levosimendan on adult patients with cardiogenic shock may facilitate the veno-arterial extracorporeal membrane oxygenation weaning and reduce all-cause mortality. Few articles of this topic are available, and prospective, randomized multi-center trials are warranted to conclude decisively on the benefits of levosimendan in this setting.

6.
Medicina (B Aires) ; 80(3): 248-252, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-32442939

RESUMO

There are increasing reports of a drastic drop in consultations and cardiovascular procedures (including urgencies and emergencies) in regions affected by the COVID-19 pandemic, with a consequent marked increase in total mortality that is not fully explained by COVID-19. Cardiovascular disease leads the ranking in deaths in adults in Argentina with 280 deaths per day, and in recent decades we have reduced its mortality by 20-30% through various evidence-based interventions. Herein we conducted predictive analyses to understand what could be the consequences of a worse implementation of those interventions. We estimate that less control of cardiovascular risk factors from April to October 2020 could cause up to 10 500 new preventable cases of cardiovascular disease. In terms of myocardial infarction, a drop from 40% to 60% of the reperfusion treatment could increase mortality by 3% to 5%. A marginal 10% to 15% increase in relative risk of cardiovascular death would be equivalent to an excess of 6000 to 9000 preventable deaths. In conclusion, given the high prevalence and fatality of cardiovascular disease, even a small negative impact on the efficacy of its care will translate into large numbers of people affected in Argentina. It is necessary to inform the authorities and educate the public so cardiovascular diseases and their risk factors remain a health priority, as long as resources exist and minimizing the risk of contagion and spread of the virus.


Assuntos
Betacoronavirus , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/prevenção & controle , Infecções por Coronavirus/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Argentina/epidemiologia , Feminino , Carga Global da Doença , Humanos , Masculino , Prevalência , Fatores de Risco
7.
Medicina (B Aires) ; 80(2): 138-142, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-32282319

RESUMO

Burnout syndrome is a very prevalent condition of physical and mental wear in the medical profession. It is associated with serious physical and emotional consequences in health professionals, and is generally produced by an adverse working environment. Several research papers have proven that resilience, defined as the capacity to overcome adversity, can be a protective factor against burnout. In this study, levels of resilience were evaluated through a validated questionnaire in cardiology fellows and residents, and a relationship with burnout syndrome was established. One third of participants showed low resilience levels and a similar amount had positive criteria for burnout syndrome. A statistically significant association was found between these two conditions. Resilience was also negatively associated with tiredness, and positively with the perception of personal realization. Therefore, it is important to incorporate procedures for detecting low resilience levels in residents in order to attempt to improve them and thus diminish the risk of experiencing burnout.


Assuntos
Esgotamento Profissional/psicologia , Cardiologia , Internato e Residência , Resiliência Psicológica , Adulto , Esgotamento Profissional/prevenção & controle , Estudos Transversais , Feminino , Humanos , Masculino , Inquéritos e Questionários
8.
Medicina (B.Aires) ; 80(2): 138-142, abr. 2020. graf, tab
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-1125054

RESUMO

El síndrome de burnout es un estado de desgaste mental y físico muy prevalente en el ambiente médico. Está asociado a serios detrimentos físicos y emocionales de los profesionales de la salud, y se produce generalmente en un clima de trabajo adverso. Varios trabajos han demostrado que la resiliencia, definida como la capacidad de reponerse frente a las adversidades, puede ser un factor protector del síndrome de burnout. En este estudio se evaluaron los niveles de resiliencia por medio de un cuestionario validado en residentes de cardiología y cardiólogos realizando subespecialidades, y se relacionaron con los criterios de burnout. Se comprobó que un tercio de los encuestados presentaban niveles bajos de resiliencia y criterios positivos de burnout, y se encontró una asociación estadísticamente significativa entre ambas variables. Por su parte, la resiliencia se asoció negativamente con el cansancio y positivamente con la percepción de la realización personal. Es importante incorporar técnicas de detección de niveles bajos de resiliencia en residentes para intentar modificarlos y disminuir así el riesgo de burnout.


Burnout syndrome is a very prevalent condition of physical and mental wear in the medical profession. It is associated with serious physical and emotional consequences in health professionals, and is generally produced by an adverse working environment. Several research papers have proven that resilience, defined as the capacity to overcome adversity, can be a protective factor against burnout. In this study, levels of resilience were evaluated through a validated questionnaire in cardiology fellows and residents, and a relationship with burnout syndrome was established. One third of participants showed low resilience levels and a similar amount had positive criteria for burnout syndrome. A statistically significant association was found between these two conditions. Resilience was also negatively associated with tiredness, and positively with the perception of personal realization. Therefore, it is important to incorporate procedures for detecting low resilience levels in residents in order to attempt to improve them and thus diminish the risk of experiencing burnout.

9.
J Adv Med Educ Prof ; 8(1): 25-31, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32039270

RESUMO

Introduction: The multiple mini-interview (MMI) model can be useful to evaluate non-cognitive domains and guide the selection process in medical residency programs. The aim of this study was to evaluate the reliability and acceptability of the MMI model for the selection of residents in a cardiology residency program. Methods: We conducted an observational and prospective study. It was performed in a tertiary-care center specialized in cardiology and included candidates for the cardiology residency program in March 2018. Ten stations were developed to evaluate different non-cognitive domains. Reliability was evaluated by the generalizability G coefficient. Candidates and interviewers were surveyed to evaluate the acceptability of the MMI model. Results: Nine faculty members were trained and 22 candidates were evaluated. The G study showed a relative G coefficient between 0.56 and 0.73, according to the design. 91% of the candidates stated that they preferred MMI over other types of interviews as a selection method for admission to the residency program, and all the interviewers considered they had enough time to evaluate the candidates and their strengths as future residents. Conclusion: The MMI is a reliable model to evaluate candidates for a residency program in cardiology with high acceptability among residents and observers.

10.
J Am Coll Cardiol ; 74(6): 744-754, 2019 08 13.
Artigo em Inglês | MEDLINE | ID: mdl-31395124

RESUMO

BACKGROUND: The prevalence of pulmonary embolism (PE) in patients presenting with syncope to the emergency department (ED) is largely unknown. This information, however, is necessary to balance the potential medical benefit or harm of systematic PE screening in patients presenting with syncope to the ED. OBJECTIVES: This study sought to determine the prevalence of PE in patients with syncope. METHODS: Unselected patients presenting with syncope to the ED were prospectively enrolled in a diagnostic multicenter study. Pre-test clinical probability for PE was assessed using the 2-level Wells score and the results of D-dimer testing using age-adapted cutoffs. Presence of PE was evaluated by imaging modalities, when ordered as part of the clinical assessment by the treating ED physician or by long-term follow-up data. RESULTS: Long-term follow-up was complete in 1,380 patients (99%) at 360 days and 1,156 patients (83%) at 720 days. Among 1,397 patients presenting with syncope to the ED, PE was detected at presentation in 19 patients (1.4%; 95% confidence interval [CI]: 0.87% to 2.11%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.5% to 1.5%). In the subgroup of patients hospitalized (47%), PE was detected at presentation in 15 patients (2.3%; 95% CI: 1.4% to 3.7%). The incidence of new PEs or cardiovascular death during 2-year follow-up was 0.9% (95% CI: 0.4% to 2.0%). CONCLUSIONS: PE seems to be a rather uncommon cause of syncope among patients presenting to the ED. Therefore, systematic PE-screening in all patients with syncope does not seem warranted. (BAsel Syncope EvaLuation Study [BASEL IX]; NCT01548352).


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Embolia Pulmonar/epidemiologia , Síncope/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Saúde Global , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Estudos Prospectivos , Embolia Pulmonar/etiologia , Fatores de Risco , Taxa de Sobrevida/tendências
11.
J Am Coll Cardiol ; 74(4): 483-494, 2019 07 30.
Artigo em Inglês | MEDLINE | ID: mdl-31345421

RESUMO

BACKGROUND: The European Society of Cardiology (ESC) recommends the 0/1-h algorithm for rapid triage of patients with suspected non-ST-segment elevation myocardial infarction (MI). However, its impact on patient management and safety when routinely applied is unknown. OBJECTIVES: This study sought to determine these important real-world outcome data. METHODS: In a prospective international study enrolling patients presenting with acute chest discomfort to the emergency department (ED), the authors assessed the real-world performance of the ESC 0/1-h algorithm using high-sensitivity cardiac troponin T embedded in routine clinical care and its associated 30-day rates of major adverse cardiac events (MACE) (the composite of cardiovascular death and MI). RESULTS: Among 2,296 patients, non-ST-segment elevation MI prevalence was 9.8%. In median, 1-h blood samples were collected 65 min after the 0-h blood draw. Overall, 94% of patients were managed without protocol violations, and 98% of patients triaged toward rule-out did not require additional cardiac investigations including high-sensitivity cardiac troponin T measurements at later time points or coronary computed tomography angiography in the ED. Median ED stay was 2 h and 30 min. The ESC 0/1-h algorithm triaged 62% of patients toward rule-out, and 71% of all patients underwent outpatient management. Proportion of patients with 30-day MACE were 0.2% (95% confidence interval: 03% to 0.5%) in the rule-out group and 0.1% (95% confidence interval: 0% to 0.2%) in outpatients. Very low MACE rates were confirmed in multiple subgroups, including early presenters. CONCLUSIONS: These real-world data document the excellent applicability, short time to ED discharge, and low rate of 30-day MACE associated with the routine clinical use of the ESC 0/1-h algorithm for the management of patients presenting with acute chest discomfort to the ED.


Assuntos
Algoritmos , Fidelidade a Diretrizes , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Fatores de Tempo , Triagem/normas
12.
Am J Med ; 132(12): 1431-1440.e7, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31306621

RESUMO

BACKGROUND: Many patients with atrial fibrillation have concomitant coronary artery disease with or without acute coronary syndromes and are in need of additional antithrombotic therapy. There are few data on the long-term clinical outcome of atrial fibrillation patients with a history of acute coronary syndrome. This is a 2-year study of atrial fibrillation patients with or without a history of acute coronary syndromes. METHODS: Adults with newly diagnosed atrial fibrillation and ≥1 investigator-defined stroke risk factor were enrolled in GARFIELD-AF between March 2010 and September 2015. The association between prior acute coronary syndromes and long-term outcomes was determined using a Cox proportional hazards model, adjusting for baseline risk factors, oral anticoagulation (OAC) ± antiplatelet (AP) therapy, and usual care. RESULTS: Of 39,679 patients, 10.5% had a history of acute coronary syndromes. At 2-year follow-up, patients with prior acute coronary syndromes had higher adjusted risks of stroke/systemic embolism (hazard ratio [HR] 1.39; 95% confidence interval [CI], 1.08-1.78), major bleeding (HR 1.30; 95% CI, 0.95 -1.79), all-cause mortality (HR 1.34; 95% CI, 1.21 -1.49), cardiovascular mortality (HR 1.85; 95% CI, 1.51-2.26), and new acute coronary syndromes (HR 3.42; 95% CI, 2.62-4.45). Comparing antithrombotic therapy in the acute coronary syndromes vs no acute coronary syndromes groups, most patients received OAC ± AP: 60.8% vs 66.1%, but AP therapy was more likely in the acute coronary syndromes group (68.1% vs 32.9%), either alone (34.9% vs 20.8%) or with OAC (33.2% vs 12.1%). Overall, 17.8% in the acute coronary syndromes group received dual AP therapy with (5.3%) or without OAC (12.5%). Among patients with moderate/high risk for stroke/systemic embolism, fewer in the acute coronary syndromes group received OAC with or without AP therapy (Congestive heart failure, Hypertension, Age 75 years, Diabetes mellitus, prior Stroke, TIA, or thromboembolism, Vascular disease, Age 65-74 years, Sex category [CHA2DS2-VASc] 2: 52.1% vs 64.6%; CHA2DS2-VASc ≥3: 62.0% vs 70.7%), and the majority with a Hypertension (uncontrolled systolic blood pressure >160 mm Hg), Abnormal renal or liver function, previous Stroke, Bleeding history or predisposition, Labile international normalized ratios, Elderly, and concomitant Drugs or alcohol excess (HAS-BLED) score ≥3 were on AP therapy (83.8% vs 65.5%). CONCLUSIONS: In GARFIELD-AF, previous acute coronary syndromes are associated with worse 2-year outcomes and a greater likelihood of under-treatment with OAC, while two-thirds of patients receive AP therapy. Major bleeding was more common with previous acute coronary syndromes, even after adjusting for all risk factors.


Assuntos
Síndrome Coronariana Aguda/complicações , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Idoso , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/mortalidade , Causas de Morte , Feminino , Seguimentos , Hemorragia/induzido quimicamente , Humanos , Masculino , Inibidores da Agregação de Plaquetas/efeitos adversos , Inibidores da Agregação de Plaquetas/uso terapêutico , Prognóstico , Modelos de Riscos Proporcionais , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade
13.
Rev. argent. cardiol ; 87(3): 197-202, mayo 2019. tab, graf
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-1057342

RESUMO

RESUMEN Introducción: La Sociedad Europea de Cardiología recomienda para la evaluación del dolor torácico un algoritmo con medición seriada de dos troponinas de alta sensibilidad separadas por una hora. Sin embargo, la alta eficacia y seguridad solo se han estimado según supuestos basados en modelos teóricos. Probamos por primera vez su desempeño en nuestro medio cuando se integra en la rutina diaria. Métodos: Estudio prospectivo unicéntrico que incluyó a pacientes no seleccionados que presentaban sospecha de infarto sin elevación del ST en el servicio de emergencias, a los que se les practicó el algoritmo SEC 0/1h utilizando troponina T de alta sensiblidad. Se evaluó el comportamiento en términos de incidencia a 30 días de los eventos de infarto agudo de miocardio, muerte cardiovascular y el combinado de infarto agudo de miocardio, muerte o revascularización coronaria. Resultados: Se incluyeron 1351 pacientes con una edad media de 61 ± 14 años, 12,4% de diabéticos y 35,8% de evento coronario previo. La tasa de infarto agudo de miocardio fue del 11% con una mortalidad del 0,29%. De acuerdo con la aplicación del algoritmo, 917 pacientes fueron catalogados como "externar" (67%); 270, como "observar" (20%); y 164, como "internar" (13%). La tasa del evento infarto agudo de miocardio resultó del 0,3% en "externar"; del 7%, en "observar"; y del 77,4%, en "internar" (p < 0,001). Por su lado, la muerte o revascularización coronaria resultó de 7,7% en "externar"; del 17,7%, en "observar"; y del 80,4%, en "internar" (p < 0,001). Conclusiones: El algoritmo de 1 hora presentó una buena capacidad para estratificar a pacientes que consultan con sospecha de infarto agudo de miocardio con un gran valor predictivo negativo para excluir el evento de infarto a los 30 días, aunque dicho valor disminuye cuando el evento considerado es la necesidad de revascularización coronaria.


ABSTRACT Background: The European Society of Cardiology (ESC) recommends an algorithm for the evaluation of chest pain with serial measurement of two high sensitivity troponins separated by one hour. However, the high efficacy and safety of the algorithm has only been estimated according to assumptions based on theoretical models. We tested for the first time its performance in the real world by incorporating it into the daily routine of our center. Methods: This is a prospective, single center study using the ESC 0/1h algorithm with high sensitivity troponin T on unselected patients who presented at the emergency department with suspected non-ST-segment elevation acute myocardial infarction. Efficacy and safety were assessed in terms of the 30-day incidence of acute myocardial infarction, cardiovascular death and the composite of acute myocardial infarction, death or coronary revascularization. Results: A total of 1,351 patients were included in the study. Mean age was 61±14 years, 12.4% were diabetics and 35.8% had previous history of coronary events. The rate of acute myocardial infarction was 11% and the rate of mortality 0.29%. According to the application of the algorithm, 917 patients were catalogued as "rule out" (67%), 270 as "observe" (20%) and 164 as "rule in" (13%). The rate of acute myocardial infarction was 0.3% in "rule out", 7% in "observe" and 77.4% in "rule in" (p <0.001). Moreover, death or coronary revascularization was 7.7% in "rule out", 17.7% in "observe" and 80.4% in "rule in" (p <0.001). Conclusions: The 1-hour algorithm showed a good capacity to stratify patients presenting with suspicion of acute myocardial infarction and a high negative predictive value to exclude infarction at 30 days, although this capacity decreases when the event considered is the need for coronary revascularization.

14.
Rev. urug. cardiol ; 33(3): 231-251, dic. 2018. tab
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-979068

RESUMO

Resumen: La miocardiopatía dilatada (MCD) es la forma más común de disfunción ventricular con una prevalencia en adultos de alrededor de 1/2.500 individuos. Durante muchos años la forma más descripta de MCD en los registros fue la idiopática. En los últimos diez años, los avances en las imágenes y la genética han permitido identificar formas específicas dentro de este grupo que llamábamos comúnmente idiopático. El estudio de los pacientes con MCD debe seguir los pasos habituales, comenzando con el trabajo clínico, evaluación de antecedentes personales y familiares, examen físico, y análisis profundo de electrocardiograma y ecocardiograma. La identificación de las características clínicas sugestivas de enfermedades específicas debería conducir a un trabajo de diagnóstico de segundo nivel que puede incluir análisis bioquímicos específicos, resonancia cardíaca, estudios anatomopatológicos y genéticos. A continuación repasamos estrategias para la mejor identificación de etiologías específicas.


Summary: Dilated cardiomyopathy is the most common form of ventricular dysfunction with an adult prevalence of about 1 / 2.500 individuals. For many years the most described form of dilated cardiomyopathy in the registries was the idiopathic form. In the last ten years, advances in imaging and genetics have made it possible to identify specific forms within this group that we commonly called idiopathic. The study of patients with dilated cardiomyopathy should follow the usually steps, beginning with clinical work, evaluation of personal and family history, physical examination, and deep electrocardiogram analysis and echocardiography. The identification of clinical features suggestive of specific diseases should lead to a second-level diagnostic work that may include specific biochemical analyzes, cardiac resonance, anatomopathological and genetic studies. Next, we review strategies for the best identification of specific etiologies.

15.
Rev. argent. cardiol ; 86(5): 15-24, oct. 2018.
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-1003219

RESUMO

RESUMEN Introducción: El score HEART consiste en una prueba sencilla que fue diseñada para estratificar a los pacientes que consultan al servicio de emergencias por dolor torácico, según su riesgo de presentar un síndrome coronario agudo a corto plazo. Fue creado inicialmente con troponina de cuarta generación, pero el advenimiento de la troponina de alta sensibilidad impuso su incorporación al score y la reevaluación de su comportamiento. Objetivo: Nos propusimos evaluar el comportamiento del score HEART con troponina de alta sensibilidad. Material y métodos: Se realizó un estudio prospectivo que incluyó 1464 pacientes (p) que consultaron al servicio de emergencia por dolor torácico y que tenían electrocardiograma sin elevación del segmento ST. Se evaluó la incidencia de MACE (combinado de infarto agudo de miocardio, muerte y revascularización) a 30 días. Resultados: El índice clasificó 739 pacientes (50,5 %) como de bajo riesgo, 515 pacientes (35,2%) de riesgo intermedio y 210 pacientes (14,3%) de alto riesgo. La incidencia de la combinación de infarto agudo de miocardio, muerte y revascularización fue del 1,35% en el primer grupo; del 20%, en el segundo; y del 71%, en el tercero (long rank test p < 0,001). El área bajo la curva global para la combinación de infarto agudo de miocardio, muerte y revascularización fue de 0,91 (0,89-0,93). Conclusiones: El score HEART que utiliza troponina de alta sensibilidad tiene una gran capacidad para clasificar pacientes con dolor torácico de acuerdo con su riesgo de presentar eventos cardiovasculares en el corto plazo.

16.
Rev. argent. cardiol ; 86(5): 68-70, oct. 2018.
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-1003225

RESUMO

RESUMEN Introducción: La disección coronaria espontánea (DCE) es una causa infrecuente de síndrome coronario agudo (SCA). Es conocida su mayor frecuencia en mujeres jóvenes; sin embargo, sus características clínicas y evolutivas permanecen insuficientemente estudiadas. Objetivo: Evaluar las características clínicas y la evolución de la DCE y su comparación con el síndrome coronario agudo ateroesclerótico (SCAA) en mujeres jóvenes. Material y métodos: Estudio de cohorte prospectivo, realizado entre 2015 y 2017, en el que se compararon mujeres menores de 60 años que ingresaron por SCA por DCE con otro cohorte que presentaba SCAA. Resultados: Se incluyeron 49 pacientes, 7 (14,29%) presentaban DCE. La mediana de seguimiento fue de 10 meses (Pc 25-75 2-18). La mediana de edad fue de 44 años (Pc 25-75 38-45) en grupo DCE y de 55 (Pc 25-75 49-58) en SCAA (P = 0,002), con mayor prevalencia de hipertensión arterial, dislipemia en grupo SCAA (69% vs. 14,3% P = 0,006 y 71% vs. 14% P = 0,004 respectivamente). En el grupo DCE hubo mayor estrés (57,1% vs. 4,8% P = 0,001) y uso de ergotamina (28,6% vs. 0% P = 0,0001) y se presentaron más frecuentemente como infarto agudo de miocardio con elevación del ST (71,4% vs. 28,6%; P = 0,02. El punto final primario ocurrió en 3 pacientes (42,9%) del grupo con DCE y fue menor en el SCAA (9,5%, P = 0,02. En el seguimiento, el 14,9% del grupo DCE y el 14,8% de SCAA presentaron el punto final secundario (P = 0,9). Conclusiones: Las mujeres con DCE tuvieron menor prevalencia de factores de riesgo cardiovascular y presentaron un SCA con peor impacto hemodinámico y mayores complicaciones. La evolución a largo plazo no mostró diferencias significativas.


ABSTRACT Background: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Its prevalence is higher in young women, but its clinical characteristics and outcome remain insufficiently studied. Objective: The aim of this study was to evaluate the baseline characteristics and outcome of SCAD compared with atheroscle-rotic acute coronary syndrome (AACS) in young women. Methods: This prospective cohort study compared women <60 years admitted with ACS due to SCAD with another cohort with AACS, between 2015 and 2017. Results: A total of 49 patients were included, 7 of which (14.29%) presented SCAD. Median follow-up was 10 months (25-75 IQR: 2-18). Median age was 44 years (25-75 IQR: 38-45) in the SCAD group and 55 years (25-75 IQR: 40-58) in the AACS group (p=0.002), with greater prevalence of hypertension and dyslipidemia (69% vs. 14.3%, p=0.006 and 71% vs. 14% p=0.004, respectively). Episodes of acute stress (57.1% vs. 4.8%, p=0.001) and use of ergotamine (28.6% vs. 0%, p=0.0001) were more common in the SCAD group, and ST-segment elevation myocardial infarction was the most frequent presentation (71.4% vs. 28.6%; p=0.02). The primary endpoint occurred in 3 patients (42.9%) of the SCAD group and was less frequent in the AACS group (9.5%, p=0.02). During follow-up, 14.9% of patients in the SCAD group and 14.8% in the AACS group presented the secondary endpoint (p=0.9). Conclusions: Women with SCAD had lower prevalence of cardiovascular risk factors and presented ACS with worse hemody-namic impact and more complications. The long-term outcome did not show significant differences.

17.
Medicina (B Aires) ; 78(2): 71-75, 2018.
Artigo em Espanhol | MEDLINE | ID: mdl-29659354

RESUMO

Apocal hypertrophic cardiomyopathy (AHCM) is a phenotypic variant within hypertrophic cardiomyopathies, in which ventricular repolarization alterations are present. These electrocardiographic disturbances can mimic an anterior infarction which triggers a series of studies and treatments that may be unnecessary. The aim of this study was to describe and compare electrocardiographic differences in a series of patients with AHCM and apical non-ST segment elevation myocardial infarction in patients (NSTEMI) with T-wave changes. We conducted an observational and retrospective study, including patients with diagnosed AHCM (N = 19) and apical NSTEMI (N = 19) with negative T waves in V1 and V6 lead of the EKG. Those with AHCM presented higher T-wave voltage (7 mV vs. 5 mV, p = 0.001) and peak voltage (29 mV vs. 17 mV, p = 0.003), higher R-waves (25 mV vs. 10 mV, p = 0.0001), and a maximum voltage of R and T sum (R + T) significantly higher (33 vs. 14, p = 0.00001). They also showed a greater T-wave asymmetry, with a TiTp / TpTf ratio > 1. At a cut-off value of 26.5 mV for the R + T variable, 68% sensitivity and 100% specificity were obtained to diagnose AHCM. This study shows the existence of major differences in electrocardiographic presentation of AHCM and apical NSTEMI.


Assuntos
Cardiomiopatia Hipertrófica/fisiopatologia , Eletrocardiografia , Infarto do Miocárdio/fisiopatologia , Adulto , Idoso , Cardiomiopatia Hipertrófica/diagnóstico , Estudos Transversais , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Sensibilidade e Especificidade
18.
Medicina (B.Aires) ; 78(2): 71-75, abr. 2018. graf, tab
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-954952

RESUMO

La miocardiopatía hipertrófica apical (MCHA) es una variante fenotípica dentro de las miocardiopatías hipertróficas que presenta alteraciones de la repolarización ventricular. Estos cambios electrocardiográficos pueden simular en muchos casos un infarto anterior, lo que dispara una serie de estudios y tratamientos que pueden ser innecesarios. El objetivo del trabajo fue describir y comparar las diferencias electrocardiográficas en una serie de pacientes con MCHA e infarto sin elevación del ST apicales (IAMSESTa) que presenten cambios tipo T en el electrocardiograma (ECG). Se realizó un estudio observacional y retrospectivo, incluyendo pacientes con diagnóstico de MCHA (n = 19) e IAMSESTa (n = 19) con ondas T negativas en ECG de ingreso en derivaciones V1-V6. Se excluyeron aquellos con MCHA y enfermedad coronaria asociada. Se analizaron las características clínicas y electrocardiográficas entre ambos grupos. Los pacientes con MCHA presentaron mayor voltaje de ondas T (7 mV vs. 5 mV; p = 0.001) y sumatoria de voltaje de las mismas (29 mV vs. 17 mV; p = 0.003), mayor voltaje de ondas R (25 mV vs. 10 mV; p = 0.0001), con una sumatoria de máximo voltaje de R y T (R+T) significativamente mayor (33 vs. 14; p = 0.00001). Presentaron además mayor asimetría de las ondas T negativas, objetivado mediante una relación TiTp/TpTf > 1. Con un valor de corte de 26.5 mV para la variable R+T, se obtuvo un 68% de sensibilidad y 100% de especificidad para diagnosticar MCHA. El presente trabajo demuestra la existencia de diferencias en el patrón del ECG en MCHA e IAMSESTa.


Apocal hypertrophic cardiomyopathy (AHCM) is a phenotypic variant within hypertrophic cardiomyopathies, in which ventricular repolarization alterations are present. These electrocardiographic disturbances can mimic an anterior infarction which triggers a series of studies and treatments that may be unnecessary. The aim of this study was to describe and compare electrocardiographic differences in a series of patients with AHCM and apical non-ST segment elevation myocardial infarction in patients (NSTEMI) with T-wave changes. We conducted an observational and retrospective study, including patients with diagnosed AHCM (N = 19) and apical NSTEMI (N = 19) with negative T waves in V1 and V6 lead of the EKG. Those with AHCM presented higher T-wave voltage (7 mV vs. 5 mV, p = 0.001) and peak voltage (29 mV vs. 17 mV, p = 0.003), higher R-waves (25 mV vs. 10 mV, p = 0.0001), and a maximum voltage of R and T sum (R + T) significantly higher (33 vs. 14, p = 0.00001). They also showed a greater T-wave asymmetry, with a TiTp / TpTf ratio > 1. At a cut-off value of 26.5 mV for the R + T variable, 68% sensitivity and 100% specificity were obtained to diagnose AHCM. This study shows the existence of major differences in electrocardiographic presentation of AHCM and apical NSTEMI.

19.
Rev. argent. cardiol ; 86(2): 126-130, abr. 2018.
Artigo em Espanhol | LILACS-Express | LILACS | ID: biblio-1003189

RESUMO

RESUMEN: Introducción: El síndrome de burnout genera impacto negativo en la actuación profesional, la seguridad del paciente y la vida del residente. Esta problemática ha tomado vigencia en las residencias argentinas; sin embargo, no se han evaluado medidas efectivas para prevenir su aparición. Objetivo: Evaluar la prevalencia del síndrome de burnout antes y después de la implementación del descanso postguardia en médicos residentes de cardiología. Material y métodos: Estudio analítico, prospectivo. Se implementó el cuestionario de Maslach en residentes de cardiología de una institución de la Ciudad de Buenos Aires, antes y después de la implementación de un período de descanso de 24 horas (DPG) luego de una guardia de 24h. Resultados: La encuesta fue respondida por 42 residentes (2014: 19; 2015: 23). Hubo una tendencia a menor prevalencia de burnout en el grupo con DPG (26,1% vs. 47,4% p = 0,152) y mejores resultados en la escala de despersonalización (19 11-21 vs. 10 [1-17] p = 0,023). Presentaron menor agotamiento y despersonalización las mujeres y los mudados a Buenos Aires. Conclusiones: La implementación del DPG se asoció a la reducción de la escala de despersonalización, principalmente en mujeres. Se remarca la importancia de crear estrategias de prevención que mejoren las condiciones de trabajo y la calidad de vida del residente.

20.
Echocardiography ; 35(7): 935-940, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29505666

RESUMO

INTRODUCTION: Atrial fibrillation (AF) occurs in about 20%-25% of patients with hypertrophic cardiomyopathy and is associated with increased risk of cardioembolism and heart failure impacting on patients' morbidity and mortality. The aim of this study was to identify echocardiographic predictors of AF in a cohort of patients with hypertrophic cardiomyopathy (HCM). METHODS: Patients were recruited from 2 centers: Buenos Aires Cardiovascular Institute and the Hospital Vall d'Hebron of Barcelona which were analyzed together. Retrospective study using electronic charts. RESULTS: A total of 321 patients with HCM and no documented history of AF were included. Median follow-up was 3 years. Mean age was 54 ± 16 years. Obstructive HCM was present in 41% of the patients, and 94.2% had preserved systolic function. Thirty-eight patients developed AF during the follow-up period (11.8%). Univariate analysis showed that age, maximum myocardial thickness, atrial area, an E/e' ratio ≥ 17, and systolic pulmonary pressure estimated by echocardiography were associated with new-onset AF. Multivariate analysis showed that E/e' ≥ 17 ratio {HR 3.27 ([1.10-9.27] P = .033)} and atrial area {HR 1.06 ([1.01-1.13] P = .037)} remained predictors of AF. CONCLUSIONS: An E/e' ratio ≥ 17, as an expression of left ventricular filling pressures with impact on the left atrium, and left atrial area ≥28 cm2 are strong predictors of AF in patients with HCM.


Assuntos
Fibrilação Atrial/diagnóstico , Função do Átrio Esquerdo/fisiologia , Cardiomiopatia Hipertrófica/complicações , Ecocardiografia/métodos , Átrios do Coração/diagnóstico por imagem , Função Ventricular Esquerda/fisiologia , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/etiologia , Cardiomiopatia Hipertrófica/diagnóstico , Cardiomiopatia Hipertrófica/fisiopatologia , Feminino , Átrios do Coração/fisiopatologia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Estudos Retrospectivos , Espanha/epidemiologia , Taxa de Sobrevida/tendências
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