Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 22.168
Filtrar
1.
Nat Commun ; 12(1): 4501, 2021 07 23.
Artigo em Inglês | MEDLINE | ID: mdl-34301958

RESUMO

Nitric oxide (NO) is a short-lived signaling molecule that plays a pivotal role in cardiovascular system. Organic nitrates represent a class of NO-donating drugs for treating coronary artery diseases, acting through the vasodilation of systemic vasculature that often leads to adverse effects. Herein, we design a nitrate-functionalized patch, wherein the nitrate pharmacological functional groups are covalently bound to biodegradable polymers, thus transforming small-molecule drugs into therapeutic biomaterials. When implanted onto the myocardium, the patch releases NO locally through a stepwise biotransformation, and NO generation is remarkably enhanced in infarcted myocardium because of the ischemic microenvironment, which gives rise to mitochondrial-targeted cardioprotection as well as enhanced cardiac repair. The therapeutic efficacy is further confirmed in a clinically relevant porcine model of myocardial infarction. All these results support the translational potential of this functional patch for treating ischemic heart disease by therapeutic mechanisms different from conventional organic nitrate drugs.


Assuntos
Implantes de Medicamento/metabolismo , Infarto do Miocárdio/metabolismo , Nitratos/metabolismo , Óxidos de Nitrogênio/metabolismo , Animais , Cardiotônicos/metabolismo , Cardiotônicos/farmacologia , Modelos Animais de Doenças , Implantes de Medicamento/farmacologia , Coração/efeitos dos fármacos , Coração/fisiopatologia , Ativação de Macrófagos/efeitos dos fármacos , Masculino , Camundongos , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Isquemia Miocárdica/metabolismo , Isquemia Miocárdica/prevenção & controle , Traumatismo por Reperfusão Miocárdica/metabolismo , Traumatismo por Reperfusão Miocárdica/prevenção & controle , Células RAW 264.7 , Ratos Sprague-Dawley , Taxa de Sobrevida , Suínos
2.
Int Heart J ; 62(4): 756-763, 2021 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-34276022

RESUMO

The clinical outcomes in acute myocardial infarction (AMI) patients with Killip class 3 are often inconsistent with those in the literature, and the factors associated with poor outcomes have not been sufficiently investigated. The purpose of this study was to identify factors associated with in-hospital death in AMI patients with Killip class 3. We included 205 AMI patients with Killip class 3, and divided them into a survived group (n = 189) and in-hospital death group (n = 16). The primary objective was to identify factors associated with in-hospital death using multivariate analysis. Age was significantly younger in the survived group than in the in-hospital death group (73.1 ± 11.2 versus 83.2 ± 6.2 years, P < 0.001). Systolic blood pressure (SBP) was significantly higher in the survived group than in the in-hospital death group (150.0 ± 31.2 versus 124.8 ± 25.3 mmHg, P = 0.002). The prevalence of TIMI thrombus grade ≥ 2 was significantly greater in the in-hospital death group than in the survived group (56.3 versus 22.2%, P = 0.005). In multivariate logistic regression analysis, in-hospital death was significantly associated with age [odds ratio (OR) 1.168, 95% confidence interval (CI) 1.061-1.287, P = 0.002] and TIMI thrombus grade ≥ 2 (versus ≤ 1: OR 5.743, 95% CI 1.717-19.214, P = 0.005), and inversely associated with SBP on admission (per 10 mmHg increase: OR 0.764, 95% CI 0.613-0.953, P = 0.017). In conclusion, in-hospital death was associated with age and coronary thrombus burden, and was inversely associated with SBP on admission in patients with Killip class 3. It may be important to recognize these high risk features to improve the clinical outcomes of patients with Killip class 3.


Assuntos
Infarto do Miocárdio/mortalidade , Índice de Gravidade de Doença , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Japão/epidemiologia , Masculino
3.
Turk Kardiyol Dern Ars ; 49(4): 293-302, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-34106063

RESUMO

OBJECTIVE: Acute ischemic cardiac events can complicate coronavirus disease 2019 (COVID-19). We report the in-hospital characteristics of patients with acute myocardial infarction and concomitant COVID-19. METHODS: This was a registry-based retrospective analysis of patients admitted with positive COVID-19 tests who suffered acute myocardial infarction either before or during hospitalization; from 1 March 2020 to 1 April 2020 in a tertiary cardiovascular center-Tehran Heart Center. We performed an exploratory analysis to compare the clinical characteristics of patients who died during hospitalization or were discharged alive. RESULTS: In March 2020, 57 patients who had acute myocardial infarction and a confirmed diagnosis of COVID-19 were included in the study. During hospitalization, 13 patients (22.8%) died after a mean hospital stay of 8.4 days. The deceased were older than the survivors. No significant association between mortality and sex or length of hospital stay was observed. Hypertensive individuals were more likely to have a fatal outcome. Previously receiving angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers did not show any association with mortality. Regarding the laboratory data during hospitalization, higher cardiac troponin T, neutrophil count, C-reactive protein, urea, and blood urea nitrogen/creatinine ratio were observed in the mortality group. The deceased had a lower lymphocyte count than the survivors. CONCLUSIONS: Markers of worsening renal function and immune system disturbance seem to be associated with mortality in concurrent acute myocardial infarction and COVID-19. Optimizing the management of acute coronary syndrome complicating COVID-19 requires addressing such potential contributors to mortality.


Assuntos
COVID-19 , Infarto do Miocárdio , Idoso , Idoso de 80 Anos ou mais , COVID-19/complicações , COVID-19/diagnóstico , COVID-19/epidemiologia , COVID-19/mortalidade , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Estudos Retrospectivos
4.
Lancet ; 397(10285): 1625-1636, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33933205

RESUMO

BACKGROUND: The effects of pharmacological blood pressure lowering at normal or high-normal blood pressure ranges in people with or without pre-existing cardiovascular disease remains uncertain. We analysed individual participant data from randomised trials to investigate the effects of blood pressure lowering treatment on the risk of major cardiovascular events by baseline levels of systolic blood pressure. METHODS: We did a meta-analysis of individual participant-level data from 48 randomised trials of pharmacological blood pressure lowering medications versus placebo or other classes of blood pressure-lowering medications, or between more versus less intensive treatment regimens, which had at least 1000 persons-years of follow-up in each group. Trials exclusively done with participants with heart failure or short-term interventions in participants with acute myocardial infarction or other acute settings were excluded. Data from 51 studies published between 1972 and 2013 were obtained by the Blood Pressure Lowering Treatment Trialists' Collaboration (Oxford University, Oxford, UK). We pooled the data to investigate the stratified effects of blood pressure-lowering treatment in participants with and without prevalent cardiovascular disease (ie, any reports of stroke, myocardial infarction, or ischaemic heart disease before randomisation), overall and across seven systolic blood pressure categories (ranging from <120 to ≥170 mm Hg). The primary outcome was a major cardiovascular event (defined as a composite of fatal and non-fatal stroke, fatal or non-fatal myocardial infarction or ischaemic heart disease, or heart failure causing death or requiring admission to hospital), analysed as per intention to treat. FINDINGS: Data for 344 716 participants from 48 randomised clinical trials were available for this analysis. Pre-randomisation mean systolic/diastolic blood pressures were 146/84 mm Hg in participants with previous cardiovascular disease (n=157 728) and 157/89 mm Hg in participants without previous cardiovascular disease (n=186 988). There was substantial spread in participants' blood pressure at baseline, with 31 239 (19·8%) of participants with previous cardiovascular disease and 14 928 (8·0%) of individuals without previous cardiovascular disease having a systolic blood pressure of less than 130 mm Hg. The relative effects of blood pressure-lowering treatment were proportional to the intensity of systolic blood pressure reduction. After a median 4·15 years' follow-up (Q1-Q3 2·97-4·96), 42 324 participants (12·3%) had at least one major cardiovascular event. In participants without previous cardiovascular disease at baseline, the incidence rate for developing a major cardiovascular event per 1000 person-years was 31·9 (95% CI 31·3-32·5) in the comparator group and 25·9 (25·4-26·4) in the intervention group. In participants with previous cardiovascular disease at baseline, the corresponding rates were 39·7 (95% CI 39·0-40·5) and 36·0 (95% CI 35·3-36·7), in the comparator and intervention groups, respectively. Hazard ratios (HR) associated with a reduction of systolic blood pressure by 5 mm Hg for a major cardiovascular event were 0·91, 95% CI 0·89-0·94 for partipants without previous cardiovascular disease and 0·89, 0·86-0·92, for those with previous cardiovascular disease. In stratified analyses, there was no reliable evidence of heterogeneity of treatment effects on major cardiovascular events by baseline cardiovascular disease status or systolic blood pressure categories. INTERPRETATION: In this large-scale analysis of randomised trials, a 5 mm Hg reduction of systolic blood pressure reduced the risk of major cardiovascular events by about 10%, irrespective of previous diagnoses of cardiovascular disease, and even at normal or high-normal blood pressure values. These findings suggest that a fixed degree of pharmacological blood pressure lowering is similarly effective for primary and secondary prevention of major cardiovascular disease, even at blood pressure levels currently not considered for treatment. Physicians communicating the indication for blood pressure lowering treatment to their patients should emphasise its importance on reducing cardiovascular risk rather than focusing on blood pressure reduction itself. FUNDING: British Heart Foundation, UK National Institute for Health Research, and Oxford Martin School.


Assuntos
Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea , Doenças Cardiovasculares/prevenção & controle , Hipertensão/prevenção & controle , Doenças Cardiovasculares/tratamento farmacológico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/mortalidade , Hospitalização/estatística & dados numéricos , Humanos , Hipertensão/tratamento farmacológico , Análise de Intenção de Tratamento , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Isquemia Miocárdica/epidemiologia , Isquemia Miocárdica/mortalidade , Prevenção Primária , Modelos de Riscos Proporcionais , Prevenção Secundária , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/mortalidade
5.
Mayo Clin Proc ; 96(7): 1822-1834, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33992454

RESUMO

OBJECTIVE: To define the diagnostic yield of cardiac magnetic resonance (CMR) in differentiating the underlying causes of myocardial infarction with nonobstructive coronary arteries (MINOCA) and to determine the long-term prognostic implications of such diagnoses. METHODS: Cardiac magnetic resonance evaluation was performed in 227 patients (mean age, 56.4±14.9 years; 120 [53%] female) with a "working diagnosis" of MINOCA as defined by presentation with a troponin-positive acute coronary syndrome (troponin I >0.04 µg/L) and nonobstructed coronary arteries between January 1, 2007, and February 28, 2013. Follow-up was performed to assess the primary composite end point of myocardial infarction, heart failure, and all-cause mortality. RESULTS: Cardiac magnetic resonance identified nonstructural cardiomyopathies in 97 (43%) patients, myocardial infarction in 55 (24%) patients, structural cardiomyopathies in 27 (12%) patients, and pulmonary embolism in 1 patient. No CMR abnormalities were identified in the remaining patients. Kaplan-Meier analysis demonstrated the ability of a CMR diagnosis to predict the risk of the primary composite end point (P=.005) at 5-year follow-up. Worse outcomes were seen among patients with "true" MINOCA and a normal CMR image compared with those with CMR-confirmed myocardial infarction (P=.02). Use of antiplatelets (78% [37/45] vs 95% [52/55]; P=.01), beta blockers (56% [25/45] vs 82% [45/55]; P=.004), and statins (64% [29/45] vs 85% [47/55]; P=.01) was significantly lower in patients with true MINOCA with normal CMR imaging compared with those with CMR-confirmed myocardial infarction. CONCLUSIONS: Cardiac magnetic resonance carries a high diagnostic yield in patients with MINOCA and predicts long-term prognosis. Patients with MINOCA with normal CMR imaging had an increased rate of major adverse cardiac events and lower use of guideline-recommended myocardial infarction therapy compared with those with CMR-confirmed myocardial infarction.


Assuntos
Síndrome Coronariana Aguda/diagnóstico , Cardiomiopatias , Vasos Coronários , Imagem Cinética por Ressonância Magnética/métodos , Infarto do Miocárdio , Troponina/sangue , Cardiomiopatias/complicações , Cardiomiopatias/diagnóstico , Cardiomiopatias/epidemiologia , Angiografia Coronária/métodos , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/patologia , Feminino , Seguimentos , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Mortalidade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Valor Preditivo dos Testes , Prognóstico , Medição de Risco/métodos
6.
J Cardiovasc Pharmacol Ther ; 26(5): 399-414, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33949887

RESUMO

In the era of the coronavirus disease 2019 (COVID-19) pandemic, acute cardiac injury (ACI), as reflected by elevated cardiac troponin above the 99th percentile, has been observed in 8%-62% of patients with COVID-19 infection with highest incidence and mortality recorded in patients with severe infection. Apart from the clinically and electrocardiographically discernible causes of ACI, such as acute myocardial infarction (MI), other cardiac causes need to be considered such as myocarditis, Takotsubo syndrome, and direct injury from COVID-19, together with noncardiac conditions, such as pulmonary embolism, critical illness, and sepsis. Acute coronary syndromes (ACS) with normal or near-normal coronary arteries (ACS-NNOCA) appear to have a higher prevalence in both COVID-19 positive and negative patients in the pandemic compared to the pre-pandemic era. Echocardiography, coronary angiography, chest computed tomography and/or cardiac magnetic resonance imaging may render a correct diagnosis, obviating the need for endomyocardial biopsy. Importantly, a significant delay has been recorded in patients with ACS seeking advice for their symptoms, while their routine care has been sharply disrupted with fewer urgent coronary angiographies and/or primary percutaneous coronary interventions performed in the case of ST-elevation MI (STEMI) with an inappropriate shift toward thrombolysis, all contributing to a higher complication rate in these patients. Thus, new challenges have emerged in rendering a diagnosis and delivering treatment in patients with ACI/ACS in the pandemic era. These issues, the various mechanisms involved in the development of ACI/ACS, and relevant current guidelines are herein reviewed.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , COVID-19/epidemiologia , Infarto do Miocárdio/epidemiologia , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/mortalidade , Fatores Etários , COVID-19/mortalidade , Técnicas de Imagem Cardíaca , Diagnóstico Diferencial , Cardiopatias/diagnóstico por imagem , Cardiopatias/epidemiologia , Humanos , Mediadores da Inflamação/metabolismo , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/mortalidade , SARS-CoV-2 , Fatores Sexuais , Estresse Psicológico/epidemiologia , Tempo para o Tratamento , Troponina I/sangue
7.
J Stroke Cerebrovasc Dis ; 30(7): 105831, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33940364

RESUMO

OBJECTIVES: Cardiocerebral infarction (CCI) is the rare occurrence of acute ischemic stroke (AIS) and acute myocardial infarction (AMI), either at the same time (simultaneous or synchronous) or one after the other (metachronous). The aim of this study is to describe the clinical profile, management and treatment outcomes of patients with CCI. MATERIALS AND METHODS: This is a 3-year cross-sectional study of patients with CCI describing their clinical presentation, management, and outcomes. The primary outcome measures were all-cause mortality and functional outcome measured with the modified Rankin Scale score (mRS) at discharge and at 30 days post-CCI. We also described the frequency of major and minor hemorrhagic events. RESULTS: Out of 1683 AIS patients and 1983 AMI patients admitted during our time period, 29 patients fulfilled the inclusion criteria (mean age 60 ±12, 79% males, median admission NIHSS 16 [range 1-26]). Of these, 20 (69%) had metachronous CCI while 9 (31%) had synchronous CCI. Most of the patients were given antithrombotics and only 14% were given reperfusion therapies. The all-cause mortality is 45% and 69% of which were cardiovascular deaths. Seventeen and 21% of CCI patients had a good functional outcome on discharge and at 30 days from CCI onset respectively. A total of 8 (28%) patients had hemorrhagic events. CONCLUSIONS: We present the largest single institutional series showing the prevalence rate of cardiocerebral infarction to be 0.79% (0.55% for metachronous, 0.25% for synchronous), with patients presenting as moderate-severe acute ischemic strokes and high-risk acute myocardial infarction. These patients have a high mortality rate with a significant proportion having cardiovascular deaths.


Assuntos
AVC Isquêmico/epidemiologia , Infarto do Miocárdio/epidemiologia , Adulto , Idoso , Estudos Transversais , Diabetes Mellitus/epidemiologia , Avaliação da Deficiência , Feminino , Fibrinolíticos/uso terapêutico , Estado Funcional , Humanos , Hipertensão/epidemiologia , AVC Isquêmico/diagnóstico , AVC Isquêmico/mortalidade , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Prevalência , Recuperação de Função Fisiológica , Reperfusão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fumar/efeitos adversos , Fumar/epidemiologia , Resultado do Tratamento
8.
Int Heart J ; 62(3): 499-509, 2021 May 29.
Artigo em Inglês | MEDLINE | ID: mdl-33994506

RESUMO

In this retrospective observational study, we have examined the incidence, characteristics, and treatment of serious myocardial infarction (MI) -associated mechanical complications (MCs) occurring in Japanese patients in this era of percutaneous coronary intervention (PCI), focusing on frailty, nutrition, and clinical implication of surgery. Included were 883 patients who, having suffered an MI, had been admitted to Nihon University Hospital between January 2013 and April 2020. Fifteen (1.70%) of these patients had suffered a potentially catastrophic MC-ventricular free wall rupture (VFWR, n = 8), ventricular septal rupture (VSR, n = 6), or papillary muscle rupture (PMR, n = 1). Factors associated with the MCs were age, poor nutritional status, a high Killip class, delayed diagnosis of MI, a high lactate concentration, a low thrombolysis in myocardial infarction flow grade, and single-vessel disease. Thirty-day mortality among MC patients was 60% (9/15): 87.5% associated with VFWR, 33.3% associated with VSR and 0% associated with PMR. On adjusted multivariate analysis, occurrence of an MC was independently associated with 30-day mortality. Despite a high surgical risk (EuroSCORE II: 11.8 ± 4.7) with less frailty, 30-day mortality was lower among patients whose MC was treated surgically than among those whose MC was treated conservatively (40.0% versus 100.0%, respectively; P = 0.044).Our data suggest that surgical intervention can save patients with a life-threatening MI-associated MC and should be considered, if they are not particularly frail.


Assuntos
Infarto do Miocárdio/complicações , Idoso , Idoso de 80 Anos ou mais , Feminino , Fragilidade/complicações , Humanos , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/cirurgia , Estado Nutricional , Estudos Retrospectivos , Ruptura Espontânea/mortalidade
9.
Medicine (Baltimore) ; 100(20): e25855, 2021 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-34011052

RESUMO

BACKGROUND: The existing meta-analyses and randomized studies on comparing the effects of carvedilol and metoprolol are of poor quality, with small sample sizes, and involve a homogeneous population. Therefore, to provide new evidence-based medical evidence for clinical treatment, we undertook a systematic review and meta-analysis to compare the mortality benefits of carvedilol with metoprolol head to head and determine the better beta-blocker in acute myocardial infarction (AMI) setting. METHODS: Seven electronic databases including Web of Science, Embase, PubMed, Wanfang Data, Scopus, Science Direct, Cochrane Library will be searched in May 2021 by 2 independent reviewers. The protocol was written following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement guidelines. The primary outcome is all-cause mortality; secondary outcomes include complex cardiovascular events, sudden death, cardiovascular death, reinfarction, revascularization, readmission, ventricular arrhythmias, and drug withdrawal for all causes except death. All outcomes are pooled on random-effect model. A P value of <.05 is considered to be statistically significant. RESULTS: The review will add to the existing literature by showing compelling evidence and improved guidance in clinic settings. OSF REGISTRATION NUMBER: 10.17605/OSF.IO/VSTJC.


Assuntos
Arritmias Cardíacas/epidemiologia , Carvedilol/administração & dosagem , Morte Súbita Cardíaca/epidemiologia , Metoprolol/administração & dosagem , Infarto do Miocárdio/tratamento farmacológico , Arritmias Cardíacas/etiologia , Arritmias Cardíacas/prevenção & controle , Morte Súbita Cardíaca/prevenção & controle , Humanos , Metanálise como Assunto , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Readmissão do Paciente/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Revisões Sistemáticas como Assunto , Resultado do Tratamento
10.
Front Immunol ; 12: 605857, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34046028

RESUMO

Aims: Latent cytomegalovirus (CMV) infection is associated with adverse cardiovascular outcomes. Virus-specific CX3CR1+ effector memory T-cells may be instrumental in this process due to their pro-inflammatory properties. We investigated the role of CX3CR1 (fractalkine receptor) in CMV-related lymphocyte kinetics and cardiac remodeling in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). Methods and Results: We retrospectively analysed lymphocyte count, troponin, and survival in 4874 STEMI/pPCI patients, evaluated lymphocyte kinetics during reperfusion in a prospective cohort, and obtained sequential cardiac MRI (cMRI) to assess remodeling. Pre-reperfusion lymphopenia independently predicted mortality at 7.5 years. Prior to reperfusion, CCR7+ T-lymphocytes appeared to be depleted. After reperfusion, T-lymphocytes expressing CX3CR1 were depleted predominantly in CMV-seropositive patients. During ischaemia/reperfusion, a drop in CX3CR1+ T-lymphocytes was significantly linked with microvascular obstruction in CMV+ patients, suggesting increased fractalkine-receptor interaction. At 12 weeks, CMV+ patients displayed adverse LV remodeling. Conclusion: We show that lymphopenia occurs before and after reperfusion in STEMI by different mechanisms and predicts long-term outcome. In CMV+ patients, increased fractalkine induction and sequestration of CX3CR1+ T-cells may contribute to adverse remodeling, suggesting a pro-inflammatory pathomechanism which presents a novel therapeutic target.


Assuntos
Receptor 1 de Quimiocina CX3C/genética , Infecções por Citomegalovirus/complicações , Linfócitos/metabolismo , Infarto do Miocárdio/complicações , Infarto do Miocárdio/metabolismo , Remodelação Ventricular , Idoso , Biomarcadores , Receptor 1 de Quimiocina CX3C/metabolismo , Citomegalovirus , Infecções por Citomegalovirus/virologia , Feminino , Testes de Função Cardíaca , Humanos , Imunofenotipagem , Linfócitos/imunologia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Receptores CCR7/metabolismo , Remodelação Ventricular/genética , Remodelação Ventricular/imunologia
11.
Sci Rep ; 11(1): 9959, 2021 05 11.
Artigo em Inglês | MEDLINE | ID: mdl-33976302

RESUMO

Coronavirus disease 2019 (COVID-19) is a global pandemic impacting nearly 170 countries/regions and millions of patients worldwide. Patients with acute myocardial infarction (AMI) still need to be treated at percutaneous coronary intervention (PCI) centers with relevant safety measures. This retrospective study was conducted to assess the therapeutic outcomes of PCI performed under the safety measures and normal conditions. AMI patients undergoing PCI between January 24 to April 30, 2020 were performed under safety measures for COVID-19. Patients received pulmonary computed tomography (CT) and underwent PCI in negative pressure ICU. Cardiac catheterization laboratory (CCL) staff and physicians worked with level III personal protection. Demographic and clinical data, such as door-to-balloon (DTB) time, operation time, complications for patients in this period (COVID-19 group) and the same period in 2019 (2019 group) were retrieved and analyzed. COVID-19 and 2019 groups had 37 and 96 patients, respectively. There was no significant difference in age, gender, BMI and comorbidity between the two groups. DTB time and operation time were similar between the two groups (60.0 ± 12.39 vs 58.83 ± 12.85 min, p = 0.636; 61.46 ± 9.91 vs 62.55 ± 10.72 min, p = 0.592). Hospital stay time in COVID-19 group was significantly shorter (6.78 ± 2.14 vs 8.85 ± 2.64 days, p < 0.001). The incidences of malignant arrhythmia and Takotsubo Syndrome in COVID-19 group were higher than 2019 group significantly (16.22% vs 5.21%, p = 0.039; 10.81% vs 1.04% p = 0.008). During hospitalization and 3-month follow-up, the incidence of major adverse cardiovascular events and mortality in the two groups were statistically similar (35.13% vs 14.58%, p = 0.094; 16.22% vs 8.33%, p = 0.184). The risk of major adverse cardiac events (MACE) was associated with cardiogenic shock (OR, 11.53; 95% CI, 2.888-46.036; p = 0.001), malignant arrhythmias (OR, 7.176; 95% CI, 1.893-27.203; p = 0.004) and advanced age (≥ 75 years) (OR, 6.718; 95% CI, 1.738-25.964; p = 0.006). Cardiogenic shock (OR, 17.663; 95% CI, 5.5-56.762; p < 0.001) and malignant arrhythmias (OR, 4.659; 95% CI, 1.481-14.653; p = 0.008) were also associated with death of 3 months. Our analysis showed that safety measures undertaken in this hospital, including screening of COVID-19 infection and use of personal protection equipment for conducting PCI did not compromise the surgical outcome as compared with PCI under normal condition, although there were slight increases in incidence of malignant arrhythmia and Takotsubo Syndrome.


Assuntos
COVID-19/patologia , Intervenção Coronária Percutânea , Resultado do Tratamento , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/etiologia , COVID-19/complicações , COVID-19/transmissão , COVID-19/virologia , Feminino , Humanos , Incidência , Estimativa de Kaplan-Meier , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea/efeitos adversos , Estudos Retrospectivos , SARS-CoV-2/isolamento & purificação , Choque Cardiogênico/epidemiologia , Choque Cardiogênico/etiologia , Cardiomiopatia de Takotsubo/epidemiologia , Cardiomiopatia de Takotsubo/etiologia
12.
J Am Geriatr Soc ; 69(7): 1713-1721, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33955546

RESUMO

BACKGROUND/OBJECTIVE: Emergency department (ED) visits have declined while excess mortality, not attributable to COVID-19, has grown. It is not known whether older adults are accessing emergency care differently from their younger counterparts. Our objective was to determine patterns of ED visit counts for emergent conditions during the COVID-19 pandemic for older adults. DESIGN: Retrospective, observational study. SETTING: Observational analysis of ED sites enrolled in a national clinical quality registry. PARTICIPANTS: One hundred and sixty-four ED sites in 33 states from January 1, 2019 to November 15, 2020. MAIN OUTCOME AND MEASURES: We measured daily ED visit counts for acute myocardial infarction (AMI), stroke, sepsis, fall, and hip fracture, as well as deaths in the ED, by age categories. We estimated Poisson regression models comparing early and post-early pandemic periods (defined by the Centers for Disease Control and Prevention) to the pre-pandemic period. We report incident rate ratios to summarize changes in visit incidence. RESULTS: For AMI, stroke, and sepsis, the older (75-84) and oldest old (85+ years) had the greatest decline in visit counts initially and the smallest recovery in the post-early pandemic periods. For falls, visits declined early and partially recovered uniformly across age categories. In contrast, hip fractures exhibited less change in visit rates across time periods. Deaths in the ED increased during the early pandemic period, but then fell and were persistently lower than baseline, especially for the older (75-84) and oldest old (85+ years). CONCLUSIONS: The decline in ED visits for emergent conditions among older adults has been more pronounced and persistent than for younger patients, with fewer deaths in the ED. This is concerning given the greater prevalence and risk of poor outcomes for emergent conditions in this age group that are amenable to time-sensitive ED diagnosis and treatment, and may in part explain excess mortality during the COVID-19 era among older adults.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Envelhecimento , COVID-19/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Infarto do Miocárdio , Sepse , Acidente Vascular Cerebral , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/fisiologia , Envelhecimento/psicologia , COVID-19/prevenção & controle , Emergências/epidemiologia , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/estatística & dados numéricos , Humanos , Mortalidade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , SARS-CoV-2 , Sepse/diagnóstico , Sepse/mortalidade , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Estados Unidos/epidemiologia
13.
Am J Cardiol ; 150: 1-7, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34001337

RESUMO

There are limited contemporary data on the management and outcomes of acute myocardial infarction (AMI) in patients with concomitant acute respiratory infections. Hence, using the National Inpatient Sample from 2000-2017, adult AMI admissions with and without concomitant respiratory infections were identified. We evaluated in-hospital mortality, utilization of cardiac procedures, hospital length of stay, hospitalization costs, and discharge disposition. Among 10,880,856 AMI admissions, respiratory infections were identified in 745,536 (6.9%). Temporal trends revealed a relatively stable tr end with a peak during 2008-2009. Admissions with respiratory infections were on average older (74 vs. 67 years), female (45% vs 39%), with greater comorbidity (mean Charlson comorbidity index 5.9 ± 2.2 vs 4.4 ± 2.3), and had higher rates of non-ST-segment-elevation AMI presentation (71.8% vs. 62.2%) (all p < 0.001). Higher rates of cardiac arrest (8.2% vs 4.8%), cardiogenic shock (10.7% vs 4.4%), and acute organ failure (27.8% vs 8.1%) were seen in AMI admissions with respiratory infections. Coronary angiography (41.4% vs 65.6%, p < 0.001) and percutaneous coronary intervention (20.7% vs 43.5%, p < 0.001) were used less commonly in those with respiratory infections. Admissions with respiratory infections had higher in-hospital mortality (14.5% vs 5.5%; propensity matched analysis: 14.6% vs 12.5%; adjusted odds ratio 1.25 [95% confidence interval 1.24-1.26], p < 0.001), longer hospital stay, higher hospitalization costs, and less frequent discharges to home compared to those without respiratory infections. In conclusion, respiratory infections significantly impact AMI admissions with higher rates of complications, mortality and resource utilization.


Assuntos
Infarto do Miocárdio/complicações , Infarto do Miocárdio/terapia , Infecções Respiratórias/complicações , Infecções Respiratórias/terapia , Idoso , COVID-19/epidemiologia , Angiografia Coronária/estatística & dados numéricos , Feminino , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Infarto do Miocárdio/mortalidade , Pandemias , Alta do Paciente/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Pontuação de Propensão , Infecções Respiratórias/mortalidade , SARS-CoV-2 , Estados Unidos/epidemiologia
14.
Am J Cardiol ; 150: 60-64, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34001341

RESUMO

The prognostic significance of incidental non-sustained ventricular tachycardia (NSVT) in subjects without apparent heart disease is unknown. We aimed to evaluate short- and long-term prognosis of NSVT in the Copenhagen Holter Study cohort. From the study, 678 middle-aged and elderly subjects had minimum 48 hours of Holter-recording, laboratory testing and physician-based examination and questionnaire performed. Median follow-up time was 14.7 years. NSVT was defined as runs of minimum three premature ventricular complexes. The primary end-point was a combination of cardiovascular mortality, acute myocardial infarction, coronary revascularization or stroke. Secondary endpoints were all-cause mortality and components of the primary end-point. We found that 72 (10.6%) had minimum one NSVT event on 48-hour Holter-recording. The primary end-point occurred more frequently in patients with NSVT than those without: 38.3 versus 17.7 events per 1,000 patient-years, hazard ratio 2.1, 95% CI 1.37 to 3.20 after adjustment for risk factors. Secondary end-points also occurred more frequently in the NSVT-group. A shorter-term follow-up revealed similar event rates for the primary outcome; 47.5 versus 21.2 events per 1,000 patient-years, hazard ratio 1.9, 95% CI 0.69 to 5.24. Besides stroke other secondary end-points occurred more frequently in the short-term follow-up. The prognosis in subjects with NSVT was not dependent of the length of the VT. In conclusion, incidental asymptomatic NSVT on Holter-recording in subjects without apparent or manifest structural heart disease is associated with increased risk of mortality and cardiovascular events, however the increased risk is not imminent but with a slow and steady pace over time.


Assuntos
Eletrocardiografia Ambulatorial , Taquicardia Ventricular/diagnóstico , Idoso , Dinamarca/epidemiologia , Feminino , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Prognóstico , Fatores de Risco , Inquéritos e Questionários , Taquicardia Ventricular/mortalidade , Complexos Ventriculares Prematuros/diagnóstico , Complexos Ventriculares Prematuros/mortalidade
15.
Am J Med ; 134(9): 1127-1134, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33864760

RESUMO

BACKGROUND: Limited data exist about relatively recent trends in the magnitude and characteristics of patients who are re-hospitalized after hospital admission for an acute myocardial infarction. This study examined trends in the frequency and sociodemographic and clinical characteristics of patients readmitted to the hospital within 30 days after an initial acute myocardial infarction. METHODS: We reviewed the medical records of 3116 individuals who were hospitalized for a validated first acute myocardial infarction in 6 study periods between 2003 and 2015 at the 3 major medical centers in central Massachusetts. RESULTS: The median age of our population was 67 years, and 42% were women. The risk of being readmitted to the hospital within 30 days after an initial acute myocardial infarction increased slightly during the most recent study years after controlling for potentially confounding factors. Overall, older adults and patients with previously diagnosed atrial fibrillation, heart failure, diabetes, chronic kidney disease, stroke, and peripheral vascular disease were at higher risk for being readmitted to the hospital than respective comparison groups. For those hospitalized in the most recent study years of 2011/2015, a higher risk of rehospitalization was associated with a previous diagnosis of chronic kidney disease, peripheral vascular disease, the presence of 3 or more chronic conditions, and having developed atrial fibrillation or heart failure during the patient's hospitalization for a first acute myocardial infarction. CONCLUSIONS: We identified several groups at higher risk for hospital readmission in whom enhanced surveillance efforts as well as tailored educational and treatment approaches remain needed.


Assuntos
Fibrilação Atrial/epidemiologia , Insuficiência Cardíaca/epidemiologia , Múltiplas Afecções Crônicas/epidemiologia , Infarto do Miocárdio , Readmissão do Paciente/tendências , Fatores Etários , Idoso , Feminino , Humanos , Masculino , Massachusetts/epidemiologia , Registros Médicos Orientados a Problemas/estatística & dados numéricos , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Determinação de Necessidades de Cuidados de Saúde , Medição de Risco , Fatores de Risco
16.
Am J Emerg Med ; 47: 145-148, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33812330

RESUMO

BACKGROUND: Percutaneous coronary intervention (PCI) represents the best therapeutic option for type-1 myocardial infarction (T1MI) in the majority of clinical settings; its role in the treatment of type-2 myocardial infarction (T2MI), however, remains unclear. We therefore sought to assess in a meta-regression analysis the impact of PCI rates on mortality in patients with T2MI according to available observational studies. METHODS: We performed a meta-regression analysis including all the studies involving in-patients affected by T2MI. We excluded studies not reporting the rate of T2MI patients undergoing PCI and not specifying absolute in-hospital or 1-year all-cause mortality. In the meta-regression analysis we used the in-hospital mortality and 1-year mortality as dependent variables and the rate of PCI as independent; regression was weighted for studies' size. RESULTS: After careful examination, 8 studies were selected for the assessment of in-hospital mortality and 8 for 1-year-mortality. We included 3155 and 3756 in-patients for in-hospital and 1-year mortality respectively. At meta-regression analysis, a borderline correlation between PCI rate and in-hospital mortality (p 0.05) and a statistically significant correlation with 1-year mortality (p < 0.01) in T2MI patients were found. CONCLUSIONS: In a meta-regression analysis higher rates of PCI on T2MI in-patients were associated with lower mortality rates both in-hospital and at 1 year. Whether this association is related to the direct effect of PCI or better general conditions of T2MI patients undergoing a PCI still remains unclear.


Assuntos
Mortalidade Hospitalar , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/mortalidade , Angioplastia Coronária com Balão , Feminino , Humanos , Masculino , Infarto do Miocárdio/cirurgia , Estudos Observacionais como Assunto
17.
Am Heart J ; 238: 66-74, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33848505

RESUMO

OBJECTIVES: To compare clinical features and outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) treated in the early experience with Impella percutaneous ventricular assist device and patients treated recently. BACKGROUND: Since pre-market approval (PMA) of Impella device as treatment for AMICS, use of the device has grown considerably. METHODS: We retrospectively analyzed 649 AMICS patients treated with perioperative Impella, with 291 patients treated from 2008 to 2014 comprising the early experience cohort and 358 patients treated from 2017 to 2019 comprising the recent experience cohort. The primary end point was risk adjusted in-hospital mortality. RESULTS: Mean age and gender distribution of patients was similar in the two cohorts. The recent cohort had more invasive hemodynamic monitoring (64% vs 46%; P < .001) and less use of an intra-aortic balloon pump prior to Impella (15% vs 41%; P < .001). Recently treated patients were significantly more likely to receive Impella support prior to PCI (58% vs 44%; P = .005). In-hospital mortality was lower in the recent cohort (48% vs 56%; P = .043). This difference was however no longer significant after risk adjustment (adjusted OR 0.89, 95% CI 0.59-1.34, P = .59). Rates of acute kidney injury, major bleeding, and vascular complications requiring surgery were also significantly lower in the recent cohort. CONCLUSIONS: Use of Impella for AMICS during recent years is associated with lower unadjusted in-hospital mortality, which may reflect better patient selection, earlier device implantation, and improved management algorithms. In-depth understanding of these factors may inform the development of future treatment protocols.


Assuntos
Coração Auxiliar/estatística & dados numéricos , Infarto do Miocárdio/terapia , Choque Cardiogênico/terapia , Injúria Renal Aguda/epidemiologia , Idoso , Estudos de Coortes , Intervalos de Confiança , Feminino , Monitorização Hemodinâmica , Hemorragia/epidemiologia , Mortalidade Hospitalar , Humanos , Balão Intra-Aórtico/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Razão de Chances , Intervenção Coronária Percutânea , Estudos Prospectivos , Sistema de Registros , Estudos Retrospectivos , Choque Cardiogênico/complicações , Choque Cardiogênico/mortalidade , Fatores de Tempo , Resultado do Tratamento , Doenças Vasculares/complicações , Doenças Vasculares/cirurgia
18.
Am J Clin Nutr ; 114(1): 59-69, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33826695

RESUMO

BACKGROUND: Population-based studies generally show neutral associations between dairy consumption and ischemic heart disease (IHD) mortality, whereas weak inverse associations were found for cardiovascular disease (CVD) and stroke mortality. Whether dairy consumption affects long-term survival after myocardial infarction (MI) is unknown. OBJECTIVES: We studied types of dairy and long-term mortality risk in drug-treated post-MI patients. METHODS: We included 4365 Dutch patients from the Alpha Omega Cohort aged 60-80 y (21% women) with an MI ≤10 y before enrollment. Dietary data were collected at baseline (2002-2006) using a 203-item FFQ and patients were followed for cause-specific mortality through December 2018. HRs of CVD, IHD, stroke, and all-cause mortality for types of dairy were obtained from Cox models, adjusting for age, sex, energy intake, physical activity, smoking, alcohol intake, diabetes, obesity, and dietary factors. RESULTS: Most patients were Dutch, 24% were obese, 20% had diabetes, and 97% used cardiovascular medication. Median intakes were 39 g/d for plain yogurt, 88 g/d for total nonfermented milk, and 17 g/d for hard cheeses. Of the cohort, 10% consumed high-fat milk. During ∼12 y of follow-up (48,473 person-years) 2035 deaths occurred, including 903 from CVD, 558 from IHD, and 170 from stroke. Yogurt was linearly inversely associated with CVD mortality (HR: 0.96; 95% CI: 0.93, 0.99; per 25 g/d) and nonlinearly inversely associated with all-cause mortality. Milk was not associated with any of the outcomes (HRs: ∼1.0 per 100 g/d), except for a higher mortality risk in high-fat milk consumers (HR: 1.30; 95% CI: 1.13, 1.49). Other dairy groups were not associated with mortality risk. CONCLUSIONS: In Dutch post-MI patients, yogurt consumption was inversely associated with CVD mortality and all-cause mortality. Associations for milk and other dairy products were neutral or inconsistent.This trial was registered at clinicaltrials.gov as NCT03192410.


Assuntos
Laticínios/efeitos adversos , Leite/efeitos adversos , Infarto do Miocárdio/complicações , Idoso , Idoso de 80 Anos ou mais , Animais , Estudos de Coortes , Gorduras na Dieta/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Isquemia Miocárdica/mortalidade , Países Baixos , Estudos Prospectivos , Fatores de Risco
19.
Medicine (Baltimore) ; 100(15): e25353, 2021 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-33847633

RESUMO

BACKGROUND: To our knowledge, no meta-analyses or reviews have investigated the efficacy and safety of metformin on cardiovascular outcomes after acute myocardial infarction (AMI) in patients with type 2 diabetes mellitus (T2DM). We thus conduct a high-quality systematic review and meta-analysis to assess the efficacy and safety of metformin on cardiovascular outcomes after AMI in patients with T2DM. METHODS: In this systematic review and meta-analysis, we will search PUBMED, Scopus, EMBASE, and Cochrane Library databases through April, 2021. The study is structured to adhere to PRISMA guidelines (i.e., Preferred Reporting Items for Systematic Reviews and Meta-analyses). The literature search, data extraction, and quality assessments are conducted independently by 2 authors. Outcome measures include all-cause mortality; complications such as acute kidney injury, lactic acidosis, hospitalization for AMI or stroke, or death. Where disagreement in the collection of data occurs, this is resolved through discussion. Review Manager Software (v 5.3; Cochrane Collaboration) is used for the meta-analysis. Two independent reviewers will assess the risk of bias of the included studies at study level. RESULTS: It is hypothesized that metformin use at the post-AMI is associated with decreased risk of cardiovascular disease and death in patients with T2DM. CONCLUSIONS: This study expects to provide credible and scientific evidence for the efficacy and safety of metformin on cardiovascular outcomes after AMI in patients with T2DM. REGISTRATION NUMBER: 10.17605/OSF.IO/S3MBP.


Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/epidemiologia , Hipoglicemiantes/uso terapêutico , Metformina/uso terapêutico , Infarto do Miocárdio/epidemiologia , Doenças Cardiovasculares/epidemiologia , Ensaios Clínicos como Assunto , Hemoglobina A Glicada , Humanos , Hipoglicemiantes/administração & dosagem , Metformina/administração & dosagem , Infarto do Miocárdio/mortalidade , Projetos de Pesquisa
20.
Medicine (Baltimore) ; 100(15): e25404, 2021 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-33847638

RESUMO

ABSTRACT: Previous studies have shown an independent association between increased red cell distribution width (RDW) and mortality after acute myocardial infarction (AMI). However, evidence regarding the predictive significance of repeated measures of RDW in patients with AMI remains scarce. We aimed to investigate the association between the dynamic profile of RDW and in-hospital mortality in patients with AMI.This was a cross-sectional study. We extracted clinical data from the Medical Information Mart for Intensive Care IIIV1.4 database. Demographic data, vital signs, laboratory test data, and comorbidities were collected from the database. The clinical endpoint was in-hospital mortality. Cox proportional hazards models were used to evaluate the prognostic values of basic RDW, and the Kaplan-Meier method was used to plot survival curves. Subgroup analyses were performed to measure mortality across various subgroups. The repeated-measures data were compared using a generalized additive mixed model.In total, 3101eligible patients were included. In multivariate analysis, adjusted for age, sex, and ethnicity, RDW was a significant risk predictor of in-hospital mortality. Furthermore, after adjusting for more confounding factors, RDW remained a significant predictor of in-hospital mortality (tertile 3 vs tertile 1: hazard ratio 2.3; 95% confidence interval 1.39-4.01; P for trend <.05). The Kaplan-Meier curve for tertiles of RDW indicated that survival rates were highest when RDW was ≤13.2% and lowest when RDW was ≥14.2% after adjustment for age, sex, and ethnicity. During the intensive care unit stay, the RDW of nonsurvivors progressively increased until death occurred.Our findings showed that a higher RDW was associated with an increased risk of in-hospital mortality in patients with AMI.


Assuntos
Índices de Eritrócitos , Eritrócitos/citologia , Mortalidade Hospitalar/tendências , Infarto do Miocárdio/mortalidade , Idoso , Comorbidade , Estudos Transversais , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Fatores Socioeconômicos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...