Hora da admissão na unidade de emergência e mortalidade hospitalar na síndrome coronária aguda / Emergency service admission time and in-hospital mortality in acute coronary syndrome

FUNDAMENTO: Há controvérsias sobre a hora da admissão e os desfechos hospitalares da síndrome coronária aguda (SCA). A admissão em horários não regulares seria associada ao pior prognóstico dos pacientes. OBJETIVO: Analisar a influência da hora da admissão na internação prolongada e na mortalidade de pacientes com SCA, segundo os períodos diurno (das 7h às 19h) e noturno (das 19h às 7h). MÉTODOS: Foram avaliados, prospectivamente, 1.104 pacientes consecutivos com SCA. O óbito intra-hospitalar e a internação igual ou superior a cinco dias foram os desfechos analisados. RESULTADOS: A admissão no período diurno foi maior em comparação ao noturno (63 por cento vs. 37 por cento; p < 0,001). A angina instável foi mais prevalente no período diurno (43 por cento vs. 32 por cento; p < 0,001) e o infarto sem supradesnivelamento do segmento ST (IAMssST) no noturno (33 por cento vs. 43 por cento; p = 0,001). Não se observaram diferenças na mortalidade e no tempo de internação nos períodos estudados. Os fatores de predição de internação igual ou superior a cinco dias foram: idade [OR 1,042 (IC 95 por cento 1,025 - 1,058), p < 0,001]; fração de ejeção (FE) [OR 0,977 (IC 95 por cento 0,966 - 0,988), p < 0,001]; IAMssST [OR 1,699 (IC 95 por cento 1,221 - 2,366), p = 0,001]; e tabagismo [OR 1,723 (IC 95 por cento 1,113 - 2,668), p = 0,014]. Para o óbito intra-hospitalar, foram: idade [OR 1,090 (IC 95 por cento 1,047 - 1,134), p < 0,001]; FE [OR 0,936 (IC 95 por cento 0,909 - 0,964), p < 0,001]; e tratamento cirúrgico [OR 3,781 (IC 95 por cento 1,374 - 10,409), p = 0,01]. CONCLUSÃO: A internação prolongada e óbito intra-hospitalar em pacientes com SCA independem do horário de admissão.

BACKGROUND: The relationship between admission time to an emergency service and in-hospital outcomes in acute coronary syndrome (ACS) is controversial. Admission during off-hours would be associated with worse prognosis. OBJECTIVE: To assess the influence of admission time on prolonged hospitalization and mortality for ACS patients, regarding regular hours (7AM-7PM) and off-hours (7PM-7AM). METHODS: The study assessed prospectively 1,104 consecutive ACS patients. In-hospital mortality and length of hospital stay > 5 days were the outcomes analyzed. RESULTS: Admission during regular hours was greater as compared with that during off-hours (63 percent vs. 37 percent; p < 0.001). Unstable angina was more prevalent during regular hours (43 percent vs. 32 percent; p < 0.001), while non-ST-segment elevation myocardial infarction (NSTEMI) was during off-hours (33 percent vs. 43 percent; p = 0.001). Differences in neither mortality nor length of hospital stay were observed in the time periods studied. Predictive factors for length of hospital stay > 5 days were as follows: age [OR 1.042 (95 percentCI: 1.025 - 1.058), p < 0.001]; ejection fraction (EF) [OR 0.977 (95 percentCI: 0.966 - 0.988), p < 0.001]; NSTEMI [OR 1.699 (95 percentCI: 1.221 - 2.366), p = 0.001]; and smoking [OR 1.723 (95 percentCI: 1.113 - 2.668), p = 0.014]. Predictive factors for in-hospital mortality were as follows: age [OR 1.090 (95 percentCI: 1.047 - 1.134), p < 0.001]; EF [OR 0.936 (95 percentCI: 0.909 - 0.964), p < 0.001]; and surgical treatment [OR 3.781 (95 percentCI: 1.374 - 10.409), p = 0.01]. CONCLUSION: Prolonged length of hospital stay and in-hospital mortality in ACS patients do not depend on admission time.

Warfarin doses for anticoagulation therapy in elderly patients with chronic atrial fibrillation

OBJECTIVE: Anticoagulation is a challenge for the prophylaxis of thromboembolic events in elderly patients with chronic atrial fibrillation. Stable anticoagulation is defined as the time within >70% of the therapeutic range. However, the dosage required to achieve stable anticoagulation remains unknown. The aim of this study was to analyze the warfarin dose necessary for the maintenance of stable oral anticoagulation therapy in elderly patients. METHODS: We analyzed 112 consecutive outpatients with atrial fibrillation who were >65 years of age, had received anticoagulation therapy with warfarin for more than 1 year and had a stable international normalized ratio between 2.0 and 3.0 for >6 months. The international normalized ratio was measured in the central laboratory using the traditional method. RESULTS: The patients were stratified according to the following age groups: <75 or >75 years and <80 or >80 years. The mean daily doses of warfarin were similar for patients <75 or >75 years (3.34+1.71 versus 3.26 +1.27 mg/ day, p = 0.794) and <80 or >80 years (3.36+ 1.49 versus 3.15 + 1.23 mg/day, p = 0.433). In 88 (79%) patients, the daily warfarin dose was between 2 and 5 mg/day; in 13 (11%) patients, the daily warfarin dose was <2.0 mg/day; and in 11 (10%) patients, the daily warfarin dose was >5.0 mg/day. The correlation between the daily warfarin dose and the international normalized ratio was 0.22 (p = 0.012). CONCLUSION: Stable anticoagulation was achieved in 80% of patients who received doses of 2 to 5 mg/day of warfarin, and the mean daily dose was similar across the age groups analyzed.