RESUMO
BACKGROUND: Clinical studies demonstrate that up to 40% of patients do not respond to cardiac resynchronization therapy (CRT), thus, appropriate patient selection is critical to the success of CRT in heart failure. OBJECTIVE: Evaluation of mortality predictors and response to CRT in the Brazilian scenario. METHODS: Retrospective cohort study including patients submitted to CRT in a tertiary hospital in southern Brazil from 2008 to 2014. Survival was assessed through a database of the State Department of Health (RS). Predictors of echocardiographic response were evaluated using Poisson regression. Survival analysis was performed by Cox regression and Kaplan Meyer curves. A two-tailed p value less than 0.05 was considered statistically significant. RESULTS: A total of 170 patients with an average follow-up of 1011 ± 632 days were included. The total mortality was 30%. The independent predictors of mortality were age (hazard ratio [HR] of 1.05, p = 0.027), previous acute myocardial infarction (AMI) (HR of 2.17, p = 0.049) and chronic obstructive pulmonary disease (COPD) (HR of 3.13, p = 0.015). The percentage of biventricular stimulation at 6 months was identified as protective factor of mortality ([HR] 0.97, p = 0.048). The independent predictors associated with the echocardiographic response were absence of mitral insufficiency, presence of left bundle branch block and percentage of biventricular stimulation. CONCLUSION: Mortality in patients submitted to CRT in a tertiary hospital was independently associated with age, presence of COPD and previous AMI. The percentage of biventricular pacing evaluated 6 months after resynchronizer implantation was independently associated with improved survival and echocardiographic response.
Assuntos
Bloqueio de Ramo/mortalidade , Bloqueio de Ramo/cirurgia , Terapia de Ressincronização Cardíaca/mortalidade , Desfibriladores Implantáveis/efeitos adversos , Idoso , Brasil/epidemiologia , Terapia de Ressincronização Cardíaca/métodos , Ecocardiografia , Feminino , Insuficiência Cardíaca/fisiopatologia , Hospitais , Humanos , Pneumopatias Obstrutivas/fisiopatologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Taxa de SobrevidaRESUMO
BACKGROUND: Scarce data are available to predict in-hospital mortality for decompensated heart failure (HF) in South American populations. METHODS AND RESULTS: We evaluated 779 consecutive HF admissions defined by the Boston criteria in a tertiary care hospital. Stepwise logistic regression was used to determine independent correlates of in-hospital mortality, derived from 83 potential predictors collected on hospital admission. A clinical score rule (HF Revised Score) was created using the regression coefficient estimates derived from multivariate modeling. During hospital stay, 77 (10%) deaths occurred and 6 clinical characteristics were independently associated with in-hospital mortality: presence of cancer (P < .001), systolic blood pressure < or =124 mm Hg (P < .001), serum creatinine >1.4 mg/dL (P = .02), blood urea nitrogen >37 mg/dL (P = .03), serum sodium <136 mEq/L (P = .03), and age >70 years old (P = .03). Both the Acute Decompensated Heart Failure National Registry stratification algorithm and the proposed HF Revised Score performed adequately to predict in-hospital mortality ("c" statistics = 0.71 and 0.76, respectively). The newly proposed score, however, discriminated a very low-risk group (101 [13%]) in whom all patients were discharged home, representing patients admitted with none of the 6 predictors of risk. CONCLUSION: HF risk stratification can be accurately accomplished during the first day of admission with simple and easily obtained clinical variables.
Assuntos
Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Mortalidade Hospitalar , Idoso , Envelhecimento , Pressão Sanguínea , Nitrogênio da Ureia Sanguínea , Estudos de Coortes , Creatinina/sangue , Feminino , Insuficiência Cardíaca/complicações , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Análise Multivariada , Neoplasias/complicações , Valor Preditivo dos Testes , Prognóstico , Medição de Risco/métodos , Sódio/sangueRESUMO
OBJECTIVES: Atrial fibrillation is the most common sustained arrhythmia and is associated with poor outcomes, including stroke. The ability of anticoagulation therapy to reduce the risk of stroke has been well established; however, the prevalence of anticoagulation therapy use in the Public Health System is unknown. The aim of this study is to evaluate both the prevalence of anticoagulation therapy among patients with atrial fibrillation and the indications for the treatment. METHODS: In this cross-sectional study, we included consecutive patients who had atrial fibrillation documented by an electrocardiogram performed between September 2011 and March 2012 at a university hospital of the Public Health System. The variables analyzed included the risk of a thromboembolic event and/or bleeding, the use of antiplatelet or anticoagulation therapy, the location where the electrocardiogram report was initially reviewed and the specialty of the physician who initially reviewed it. RESULTS: We included 162 patients (mean age 68.9 years, 56% men). Hypertension (90.1%), heart failure (53.4%) and stroke (38.9%) were the most prevalent diseases found. Only 50.6% of the patients knew that they had atrial fibrillation. Regarding the use of therapy, only 37.6% of patients classified as high risk according to the CHADS2 scores and 35.5% according to the CHA2DS2VASc used oral anticoagulation. A presumptive diagnosis of heart failure and the fact that the electrocardiogram was evaluated by a cardiologist were the only independent predictors of the use of anticoagulants. CONCLUSIONS: Our study found a low prevalence of oral anticoagulation therapy among patients with atrial fibrillation and an indication for stroke prophylaxis for the use of this therapy, including among those with high CHADS2 and CHA2DS2VASc scores.
Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Acidente Vascular Cerebral/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Eletrocardiografia/estatística & dados numéricos , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Tromboembolia/induzido quimicamente , Resultado do TratamentoRESUMO
Implantable cardiac pacing systems are a safe and effective treatment for symptomatic irreversible bradycardia. Under the proper indications, cardiac pacing might bring significant clinical benefit. Evidences from literature state that the action of the artificial pacing system, mainly when the ventricular lead is located at the apex of the right ventricle, produces negative effects to cardiac structure (remodeling, dilatation) and function (dissinchrony). Patients with previously compromised left ventricular function would benefit the least with conventional right ventricle apical pacing, and are exposed to the risk of developing higher incidence of morbidity and mortality for heart failure. However, after almost 6 decades of cardiac pacing, just a reduced portion of patients in general would develop these alterations. In this context, there are not completely clear some issues related to cardiac pacing and the development of this cardiomyopathy. Causality relationships among QRS widening with a left bundle branch block morphology, contractility alterations within the left ventricle, and certain substrates or clinical (previous systolic dysfunction, structural heart disease, time from implant) or electrical conditions (QRS duration, percentage of ventricular stimulation) are still subjects of debate. This review analyses contemporary data regarding this new entity, and discusses alternatives of how to use cardiac pacing in this context, emphasizing cardiac resynchronization therapy.
Assuntos
Estimulação Cardíaca Artificial/efeitos adversos , Cardiomiopatia Dilatada/etiologia , Bloqueio de Ramo/fisiopatologia , Estimulação Cardíaca Artificial/métodos , Cardiomiopatia Dilatada/fisiopatologia , Hemodinâmica , Humanos , Fatores de Risco , Volume Sistólico/fisiologia , Disfunção Ventricular/fisiopatologiaRESUMO
Abstract Background: Clinical studies demonstrate that up to 40% of patients do not respond to cardiac resynchronization therapy (CRT), thus, appropriate patient selection is critical to the success of CRT in heart failure. Objective: Evaluation of mortality predictors and response to CRT in the Brazilian scenario. Methods: Retrospective cohort study including patients submitted to CRT in a tertiary hospital in southern Brazil from 2008 to 2014. Survival was assessed through a database of the State Department of Health (RS). Predictors of echocardiographic response were evaluated using Poisson regression. Survival analysis was performed by Cox regression and Kaplan Meyer curves. A two-tailed p value less than 0.05 was considered statistically significant. Results: A total of 170 patients with an average follow-up of 1011 ± 632 days were included. The total mortality was 30%. The independent predictors of mortality were age (hazard ratio [HR] of 1.05, p = 0.027), previous acute myocardial infarction (AMI) (HR of 2.17, p = 0.049) and chronic obstructive pulmonary disease (COPD) (HR of 3.13, p = 0.015). The percentage of biventricular stimulation at 6 months was identified as protective factor of mortality ([HR] 0.97, p = 0.048). The independent predictors associated with the echocardiographic response were absence of mitral insufficiency, presence of left bundle branch block and percentage of biventricular stimulation. Conclusion: Mortality in patients submitted to CRT in a tertiary hospital was independently associated with age, presence of COPD and previous AMI. The percentage of biventricular pacing evaluated 6 months after resynchronizer implantation was independently associated with improved survival and echocardiographic response.
Resumo Fundamento: Estudos Clínicos demonstram que até 40% dos pacientes não respondem à terapia de ressincronização cardíaca (TRC), assim a seleção apropriada dos pacientes é fundamental para o sucesso da TRC na insuficiência cardíaca. Objetivo: Avaliação de preditores de mortalidade e resposta à TRC no cenário brasileiro. Métodos: Estudo de coorte retrospectivo incluindo os pacientes submetidos à TRC em hospital terciário no Sul do Brasil entre 2008-2014. A sobrevida foi avaliada através de banco de dados da Secretaria Estadual de Saúde (RS). Os preditores de resposta ecocardiográfica foram avaliados utilizando método de regressão de Poisson. A análise de sobrevida foi feita por regressão de Cox e curvas de Kaplan Meyer. Um valor de p bicaudal inferior a 0,05 foi considerado estatisticamente significativo. Resultados: Foram incluídos 170 pacientes com seguimento médio de 1011 ± 632 dias. A mortalidade total foi de 30%. Os preditores independentes de mortalidade identificados foram idade (hazzard ratio [HR] de 1,05; p = 0,027), infarto agudo do miocárdio (IAM) prévio (HR de 2,17; p = 0,049) e doença pulmonar obstrutiva crônica (DPOC) (HR de 3,13; p = 0,015). O percentual de estimulação biventricular em 6 meses foi identificado com fator protetor de mortalidade ([HR] 0,97; p = 0,048). Os preditores independentes associados à reposta ecocardiográfica foram ausência de insuficiência mitral, presença de bloqueio de ramo esquerdo e percentual de estimulação biventricular. Conclusão: A mortalidade nos pacientes submetidos à TRC em hospital terciário foi independentemente associada à idade, presença de DPOC e IAM prévio. O percentual de estimulação biventricular avaliado 6 meses após o implante do ressincronizador foi independentemente associado a melhora da sobrevida e resposta ecocardiográfica.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Bloqueio de Ramo/cirurgia , Bloqueio de Ramo/mortalidade , Desfibriladores Implantáveis/efeitos adversos , Terapia de Ressincronização Cardíaca/mortalidade , Brasil/epidemiologia , Ecocardiografia , Análise de Sobrevida , Taxa de Sobrevida , Estudos Retrospectivos , Fatores de Risco , Terapia de Ressincronização Cardíaca/métodos , Insuficiência Cardíaca/fisiopatologia , Hospitais , Pneumopatias Obstrutivas/fisiopatologia , Infarto do Miocárdio/fisiopatologiaRESUMO
OBJECTIVES: To analyze the impact of blood transfusion on the incidence of clinical outcomes postoperatively (PO) from cardiac surgery. METHODS: Retrospective cohort study. We analyzed 4028 patients undergoing coronary artery bypass grafting (CABG), valve (TV), or both, in Brazilian tertiary university hospital between 1996 and 2009. We compared the postoperative complications between patients with blood transfusion (n = 916) and non-blood transfusion (n = 3112). Univariate analysis was performed using the Student t test, and multivariate logistic regression bivariate (stepwise forward). Were considered significant variables with P <0.05. RESULTS: Patients who received blood transfusions had more infectious episodes as mediastinitis (4.9% vs. 2.2%, P <0.001), respiratory infection (27.8% vs 17.1%, P <0.001) and sepsis (6.2% vs. 2.5%, P <0.001). There were more episodes of atrial fibrillation (AF) (27% vs. 20.4%, P <0.001), acute renal failure (ARF) (14.5% vs 7.3%, P <0.001) and stroke (4.8% vs. 2.6%, P = 0.001). The length of PO hospital stay was higher in transfused (13 ± 12.07 days vs. 9.72 ± 7.66 days, P <0.001). However, mortality didn't differ between groups (10.9% vs. 9.1%, P = 0.112). The transfusion was shown to be a risk factor for: respiratory infection (OR: 1.91, 95% CI 1.59-2.29, P <0.001), AF (OR: 1.35, 95% CI 1.13-1.61, P = 0.01), sepsis (OR: 2.08, 95% CI 1.4-3.07, P <0.001), mediastinitis (OR: 2.14, 95% CI: 1.43-3.21, P <0.001), stroke (OR: 1.63, 95% CI 1.1-2.41, P = 0.014) and ARF (OR 1.8, 95% CI: 1.39-2.33, P <0.001). CONCLUSION: The blood transfusion is associated with increased risk of infectious events, episodes of AF, ARF and stroke, as well as the increased length of hospital stay but not mortality.
Assuntos
Implante de Prótese de Valva Cardíaca/efeitos adversos , Mortalidade Hospitalar , Revascularização Miocárdica/efeitos adversos , Reação Transfusional , Idoso , Transfusão de Sangue/mortalidade , Estudos de Coortes , Feminino , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Tempo de Internação , Masculino , Revascularização Miocárdica/mortalidade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors reduce the chance of death, myocardial infarction (MI) and cerebrovascular accident (CVA) in patients with coronary disease. However there is no consensus as to its indication in patients undergoing coronary artery bypass grafting (CABG). OBJECTIVE: To assess the relationship between preoperative use of ACE inhibitors and clinical outcomes after CABG. METHODS: Retrospective cohort study. We included data from 3,139 consecutive patients undergoing isolated CABG in Brazilian tertiary care hospital between January 1996 and December 2009. Follow-up was until discharge or death. Clinical outcomes after surgery were analyzed between users and nonusers of ACE inhibitors preoperatively. RESULTS: Fifty-two percent (n=1,635) of patients received ACE inhibitors preoperatively. The use of ACE inhibitors was an independent predictor of need for inotropic support (OR 1.24, 95% CI 1.01 to 1.47, P = 0.01), acute renal failure (OR 1.23, 95% CI 1.01 to 1.73, P = 0.04) and progression to atrial fibrillation (OR 1.32, 95% CI 1.02 to 1.7, P = 0.03) postoperatively. The mortality rate among patients receiving or not preoperative ACE inhibitors was similar (10.3% vs. 9.4%, P = 0.436), as well as the incidence of myocardial infarction and stroke (15.6% vs. 15.0%, P = 0.694 and 3.4% vs. 3.5%, P = 0.963, respectively). CONCLUSION: The use of preoperative ACE inhibitors was associated with increased need for inotropic support and higher incidence of acute renal failure and postoperative atrial fibrillation, not associated with increased rates of myocardial infarction, stroke or death.
Assuntos
Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Ponte de Artéria Coronária/efeitos adversos , Infarto do Miocárdio/prevenção & controle , Acidente Vascular Cerebral/prevenção & controle , Injúria Renal Aguda/induzido quimicamente , Fibrilação Atrial/induzido quimicamente , Cardiotônicos/uso terapêutico , Ponte de Artéria Coronária/mortalidade , Métodos Epidemiológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Contração Miocárdica , Infarto do Miocárdio/epidemiologia , Cuidados Pré-Operatórios/efeitos adversos , Acidente Vascular Cerebral/epidemiologia , Resultado do TratamentoRESUMO
Os dispositivos implantáveis de estimulação cardíaca artificial (marcapasso definitivo, cardiodesfibriladore terapia de estimulação multissítio para ressincronização cardíaca) têm benefícios bem estabelecidos e indicações sem expansão. Diversos estudos e publicações têm demonstrado que a estimulação cardíaca artificial convencional não é isenta de efeitos adversos (dissincronia ventricular, risco de insuficiência cardíaca e mortalidade). O progresso tecnológico da eletroterapia cardíaca trouxe novos algoritmos e estratégias de programação dos dispositivos, particularmente os que minimizam a estimulação do ventrículo direito por programação do intervalo atrioventricular. Atualmente, tanto para portadores de marcapasso definitivo como, particularmente, para portadores de cardiodesfibrilador implantável, são recomendadas estratégias que explorem ao máximo a condução atrioventricular intrínseca, quando esta é confiável, com o objetivo de produzir complexos com QRS estreito, evitando as potenciais consequências deletérias da ativação artificial do ventrículo direito. Esta revisão aborda as diferenças entre sequência atrioventricular e sincronia atrioventricular produzidas por esses algoritmos, e o surgimento de um outro virtual conflito de paradigmas: permitir intervalos atrioventriculares não fisiológicos, gerando potencialmente dissincronia atrioventricular mas com QRS estreito, ou estimular artificialmente o ventrículo direito com intervalo atrioventricular fisiológico e QRS largo?.
Implantable artificial cardiac pacing devices (permanent pacemakers, cardioverter-defibrillators and multisite pacing for cardiac resynchronization therapy) have well-established benefits and expanding indications. Several studies and publications have demonstrated that conventional artificial cardiac pacing is not free from adverse effects (ventricular desynchronization, risk of heart failure and mortality). Technological advances in cardiac electrotherapy have led to new algorithms and device programming strategies, particularly those that minimize right ventricle pacing by atrioventricular interval programming. Currently and when ever reliable, strategies that explore intrinsic atrioventricular conduction to a maximum are recommended for carriers of permanent pacemakers and implantable cardioverter-defibrillators to avoid the potential deleterious consequences of artificial right ventricle activation. This review addresses the differences between atrioventricular synchrony and atrioventricular sequencing produced by these algorithms and the emergence of another virtual paradigm conflict: should weallow long, non-physiological, atrioventricular intervals, potentially generating atrioventricular desynchronization with a narrow QRS or artificially stimulate the right ventricle with a physiological atrioventricular interval and awide QRS?.
Assuntos
Humanos , Estimulação Cardíaca Artificial , Insuficiência Cardíaca/terapia , Marca-Passo Artificial/efeitos adversos , Ventrículos do Coração , Desfibriladores Implantáveis , Eletrodos Implantados , Função Atrial , Guias como Assunto/normas , Volume SistólicoRESUMO
OBJECTIVES: Atrial fibrillation is the most common sustained arrhythmia and is associated with poor outcomes, including stroke. The ability of anticoagulation therapy to reduce the risk of stroke has been well established; however, the prevalence of anticoagulation therapy use in the Public Health System is unknown. The aim of this study is to evaluate both the prevalence of anticoagulation therapy among patients with atrial fibrillation and the indications for the treatment. METHODS: In this cross-sectional study, we included consecutive patients who had atrial fibrillation documented by an electrocardiogram performed between September 2011 and March 2012 at a university hospital of the Public Health System. The variables analyzed included the risk of a thromboembolic event and/or bleeding, the use of antiplatelet or anticoagulation therapy, the location where the electrocardiogram report was initially reviewed and the specialty of the physician who initially reviewed it. RESULTS: We included 162 patients (mean age 68.9 years, 56% men). Hypertension (90.1%), heart failure (53.4%) and stroke (38.9%) were the most prevalent diseases found. Only 50.6% of the patients knew that they had atrial fibrillation. Regarding the use of therapy, only 37.6% of patients classified as high risk according to the CHADS2 scores and 35.5% according to the CHA2DS2VASc used oral anticoagulation. A presumptive diagnosis of heart failure and the fact that the electrocardiogram was evaluated by a cardiologist were the only independent predictors of the use of anticoagulants. CONCLUSIONS: Our study found a low prevalence of oral anticoagulation therapy among patients with atrial fibrillation and an indication for stroke prophylaxis for the use of this therapy, including among those with high CHADS2 and CHA2DS2VASc scores. .
Assuntos
Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Acidente Vascular Cerebral/prevenção & controle , Estudos Transversais , Eletrocardiografia/estatística & dados numéricos , Hemorragia/induzido quimicamente , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Tromboembolia/induzido quimicamenteRESUMO
Implantable cardiac pacing systems are a safe and effective treatment for symptomatic irreversible bradycardia. Under the proper indications, cardiac pacing might bring significant clinical benefit. Evidences from literature state that the action of the artificial pacing system, mainly when the ventricular lead is located at the apex of the right ventricle, produces negative effects to cardiac structure (remodeling, dilatation) and function (dissinchrony). Patients with previously compromised left ventricular function would benefit the least with conventional right ventricle apical pacing, and are exposed to the risk of developing higher incidence of morbidity and mortality for heart failure. However, after almost 6 decades of cardiac pacing, just a reduced portion of patients in general would develop these alterations. In this context, there are not completely clear some issues related to cardiac pacing and the development of this cardiomyopathy. Causality relationships among QRS widening with a left bundle branch block morphology, contractility alterations within the left ventricle, and certain substrates or clinical (previous systolic dysfunction, structural heart disease, time from implant) or electrical conditions (QRS duration, percentage of ventricular stimulation) are still subjecte of debate. This review analyses contemporary data regarding this new entity, and discusses alternatives of how to use cardiac pacing in this context, emphasizing cardiac resynchronization therapy.
A estimulação cardíaca artificial (ECA) é o tratamento mais seguro e eficaz para a bradicardia sintomática irreversível. Nas indicações propícias, pode trazer grande benefício clínico. Contudo, as evidências mostram que a ação da ECA geraria, em alguns casos, efeitos deletérios à estrutura e fisiologia cardíacas. Este potencial efeito negativo da ECA convencional poderia ser mais acentuado principalmente em pacientes com comprometimento prévio da função ventricular esquerda e, sobretudo, quando o eletrodo é colocado em posição apical do ventrículo direito (VD). Intrigante é, contudo, que após quase 6 décadas de ECA do VD, apenas uma reduzida parcela de pacientes apresenta esta condição clinicamente manifesta. Os determinantes do surgimento ou não da cardiopatia por ECA não estão totalmente esclarecidos. Ainda é motivo de debate a existência de uma relação de causalidade entre o padrão de BRE artificial secundário à ativação antifisiológica ventricular, alterações da dinâmica contrátil ventricular, e condições clínicas (disfunção sistólica prévia, cardiopatia estrutural preexistente, tempo desde o implante) ou elétricas (duração do intervalo QRS, dose percentual de estimulação ventricular). Esta revisão aborda dados contemporâneos sobre esta nova entidade e discute alternativas de como utilizar a ECA neste contexto, com ênfase na terapia de ressincronização cardíaca.
Assuntos
Humanos , Estimulação Cardíaca Artificial/efeitos adversos , Cardiomiopatia Dilatada/etiologia , Bloqueio de Ramo/fisiopatologia , Estimulação Cardíaca Artificial/métodos , Cardiomiopatia Dilatada/fisiopatologia , Hemodinâmica , Fatores de Risco , Volume Sistólico/fisiologia , Disfunção Ventricular/fisiopatologiaRESUMO
FUNDAMENTO: Os inibidores da enzima conversora de angiotensina (IECA) reduzem o risco de óbito, infarto agudo do miocárdio (IAM) e acidente vascular encefálico (AVE) em portadores de doença coronariana. No entanto, não há consenso quanto à sua indicação em pacientes que serão submetidos à cirurgia de revascularização miocárdica (CRM). OBJETIVO: Avaliar a relação entre uso pré-operatório de IECA e eventos clínicos após realização da CRM. MÉTODOS: Estudo de coorte retrospectivo. Foram incluídos dados de 3.139 pacientes consecutivos submetidos à CRM isolada em hospital terciário brasileiro, entre janeiro de 1996 e dezembro de 2009. O seguimento dos pacientes foi realizado até a alta hospitalar ou óbito. Desfechos clínicos no pós-operatório foram analisados entre os usuários e os não-usuários de IECA no pré-operatório. RESULTADOS: Cinquenta e dois por cento (1.635) dos pacientes receberam IECA no pré-operatório. O uso de IECA foi preditor independente da necessidade de suporte inotrópico (RC 1,24, IC 1,01-1,47; P=0,01), de insuficiência renal aguda (IRA, RC 1,23, IC 1,01-1,73; P=0,04) e de evolução para fibrilação atrial (FA, RC 1,32, IC 1,02-1,7; P=0,03) no pós-operatório. A mortalidade entre os pacientes que receberam ou não IECA no pré-operatório foi semelhante (10,3 vs. 9,4%, P=0,436), bem como a incidência de IAM e AVE (15,6 vs. 15,0%, P=0,694 e 3,4 vs. 3,5%, P=0,963, respectivamente). CONCLUSÃO: O uso pré-operatório de IECA foi associado a maior necessidade de suporte inotrópico e maior incidência de IRA e FA no pós-operatório, não estando associado ao aumento das taxas de IAM, AVE ou óbito.
BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors reduce the chance of death, myocardial infarction (MI) and cerebrovascular accident (CVA) in patients with coronary disease. However there is no consensus as to its indication in patients undergoing coronary artery bypass grafting (CABG). OBJECTIVE: To assess the relationship between preoperative use of ACE inhibitors and clinical outcomes after CABG. METHODS: Retrospective cohort study. We included data from 3,139 consecutive patients undergoing isolated CABG in Brazilian tertiary care hospital between January 1996 and December 2009. Follow-up was until discharge or death. Clinical outcomes after surgery were analyzed between users and nonusers of ACE inhibitors preoperatively. RESULTS: Fifty-two percent (n=1,635) of patients received ACE inhibitors preoperatively. The use of ACE inhibitors was an independent predictor of need for inotropic support (OR 1.24, 95% CI 1.01 to 1.47, P = 0.01), acute renal failure (OR 1.23, 95% CI 1.01 to 1.73, P = 0.04) and progression to atrial fibrillation (OR 1.32, 95% CI 1.02 to 1.7, P = 0.03) postoperatively. The mortality rate among patients receiving or not preoperative ACE inhibitors was similar (10.3% vs. 9.4%, P = 0.436), as well as the incidence of myocardial infarction and stroke (15.6% vs. 15.0%, P = 0.694 and 3.4% vs. 3.5%, P = 0.963, respectively). CONCLUSION: The use of preoperative ACE inhibitors was associated with increased need for inotropic support and higher incidence of acute renal failure and postoperative atrial fibrillation, not associated with increased rates of myocardial infarction, stroke or death.
Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Ponte de Artéria Coronária/efeitos adversos , Infarto do Miocárdio/prevenção & controle , Acidente Vascular Cerebral/prevenção & controle , Injúria Renal Aguda/induzido quimicamente , Fibrilação Atrial/induzido quimicamente , Cardiotônicos/uso terapêutico , Ponte de Artéria Coronária/mortalidade , Métodos Epidemiológicos , Contração Miocárdica , Infarto do Miocárdio/epidemiologia , Cuidados Pré-Operatórios/efeitos adversos , Acidente Vascular Cerebral/epidemiologia , Resultado do TratamentoRESUMO
OBJETIVOS: Analisar o impacto da hemotransfusão sanguínea na incidência de desfechos clínicos no pós-operatório (PO) de cirurgias cardíacas. MÉTODOS: Estudo de coorte retrospectiva. Foram analisados 4.028 pacientes submetidos à cirurgia de revascularização miocárdica (CRM), troca valvar (TV) ou ambas, em hospital terciário universitário brasileiro, entre 1996 e 2009. Foram comparadas as complicações no PO entre os pacientes hemotransfundidos (n=916) e não-hemotransfundidos (n=3112). Foi realizada análise univariada através do teste t de Student, e análise multivariada com o uso de regressão logística Bivariada (Stepwise Forward). Foram consideradas significativas as variáveis com P<0,05. RESULTADOS: Os pacientes que receberam hemotransfusão apresentaram mais episódios infecciosos como mediastinite (4,9 por cento vs. 2,2 por cento, P<0,001), infecção respiratória (27,8 por cento vs 17,1 por cento, P<0,001), e sepse (6,2 por cento vs. 2,5 por cento, P<0,001). Ocorreram mais episódios de fibrilação atrial (FA) (27 por cento vs. 20,4 por cento, P<0,001), insuficiência renal aguda (IRA) (14,5 por cento vs. 7,3 por cento, P<0,001) e acidente vascular cerebral (AVC) (4,8 por cento vs. 2,6 por cento, P=0,001). O tempo de internação hospitalar no PO foi maior nos transfundidos (13±12,07 dias vs. 9,72±7,66 dias, P<0,001). Porém, a mortalidade não apresentou diferença entre os grupos (10,9 por cento vs. 9,1 por cento, P=0,112). A transfusão mostrou-se como fator de risco para: infecção respiratória (OR: 1,91; IC95 por cento: 1,59-2,29; P<0,001), FA (OR:1,35; IC95 por cento: 1,13-1,61; P=0,01), sepse (OR: 2,08; IC95 por cento: 1,4-3,07; P<0,001), mediastinite (OR: 2,14; IC95 por cento: 1,43-3,21; P<0,001), AVC (OR: 1,63; IC95 por cento: 1,1-2,41; P=0,014) e IRA (OR: 1,8; IC95 por cento: 1,39-2,33; P<0,001). CONCLUSÃO: A hemotransfusão está associada ao aumento do risco de eventos infecciosos, episódios de FA, IRA e AVC, bem como aumentou o tempo de permanência hospitalar, mas não a mortalidade.
OBJECTIVES: To analyze the impact of blood transfusion on the incidence of clinical outcomes postoperatively (PO) from cardiac surgery. METHODS: Retrospective cohort study. We analyzed 4028 patients undergoing coronary artery bypass grafting (CABG), valve (TV), or both, in Brazilian tertiary university hospital between 1996 and 2009. We compared the postoperative complications between patients with blood transfusion (n = 916) and non-blood transfusion (n = 3112). Univariate analysis was performed using the Student t test, and multivariate logistic regression bivariate (stepwise forward). Were considered significant variables with P <0.05. RESULTS: Patients who received blood transfusions had more infectious episodes as mediastinitis (4.9 percent vs. 2.2 percent, P <0.001), respiratory infection (27.8 percent vs 17.1 percent, P <0.001) and sepsis (6.2 percent vs. 2.5 percent, P <0.001). There were more episodes of atrial fibrillation (AF) (27 percent vs. 20.4 percent, P <0.001), acute renal failure (ARF) (14.5 percent vs 7.3 percent, P <0.001) and stroke (4.8 percent vs. 2.6 percent, P = 0.001). The length of PO hospital stay was higher in transfused (13 ± 12.07 days vs. 9.72 ± 7.66 days, P <0.001). However, mortality didn't differ between groups (10.9 percent vs. 9.1 percent, P = 0.112). The transfusion was shown to be a risk factor for: respiratory infection (OR: 1.91, 95 percent CI 1.59-2.29, P <0.001), AF (OR: 1.35, 95 percent CI 1.13-1.61, P = 0.01), sepsis (OR: 2.08, 95 percent CI 1.4-3.07, P <0.001), mediastinitis (OR: 2.14, 95 percent CI: 1.43-3.21, P <0.001), stroke (OR: 1.63, 95 percent CI 1.1-2.41, P = 0.014) and ARF (OR 1.8, 95 percent CI: 1.39-2.33, P <0.001). CONCLUSION: The blood transfusion is associated with increased risk of infectious events, episodes of AF, ARF and stroke, as well as the increased length of hospital stay but not mortality.
Assuntos
Idoso , Feminino , Humanos , Masculino , Transfusão de Sangue/efeitos adversos , Mortalidade Hospitalar , Implante de Prótese de Valva Cardíaca/efeitos adversos , Revascularização Miocárdica/efeitos adversos , Transfusão de Sangue/mortalidade , Estudos de Coortes , Implante de Prótese de Valva Cardíaca/mortalidade , Tempo de Internação , Revascularização Miocárdica/mortalidade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Fatores de RiscoRESUMO
A identificação e o impacto clínico da fração de ejeção (FE) preservada em pacientes hospitalizados por insuficiência cardíaca (IC) descompensada permanecem pouco estudados. Métodos. Foram analisadas admissões consecutivas por IC descompensada em um hospital terciário brasileiro. A inclusão foi realizada a partir de pontuação igual ou superior a 8 pontos no escore de Boston para definição de IC. FE preservada foi definida como FE de ventrículo esquerdo ) 50%. Cerca de 80 variáveis clínicas, laboratoriais e prognósticas foram obtidas ao longo da internação até o óbito ou a alta hospitalar através de protocolo estruturado. Resultados. Foram incluídas 721 admissões consecutivas por IC descompensada (idade= 66 ± 13 anos, FEVE= 42 ± 17%, 50% do sexo masculino). A prevalência de FE preservada foi de 31%. Pacientes com valores mais elevados de FE apresentaram características clínicas significativamente distintas das de pacientes com disfunção sistólica, tais como idade avançada, predominância do sexo feminino, maior proporção de etiologia não-isquêmica, prevalência elevada de fibrilação atrial crônica, níveis inferiores de hemoglobina, pressão de pulso reduzida e complexos QRS alargados. Não foi observada diferença significativa na mortalidade intrahospitalar de acordo com quintis de FE, porém houve uma tendência para um aumento de complicações clínicas em pacientes com FE elevada. Conclusões. FE preservada é uma condição prevalente e responsável por significativa morbi-mortalidade entre pacientes brasileiros hospitalizados por IC descompensada.
Identification and clinical impact of preserved EF (ejection fraction) on in-hospital outcomes in patients with acute decompensated heart failure (HF) remain poorly defined. Methods. Consecutive admissions for decompensated HF, defined by Boston criteria equal to or higher than to 8 points, at a tertiary care hospital in Brazil were included. Preserved systolic function was defined as left ventricular EF ) 50%. Approximately 80 clinical variables based on history, physical examination, laboratory and echocardiographic data were evaluated to identify predictors of preserved EF at admission. Included patients were followed up through hospitalization to discharge or death. Results. Overall, 721 consecutive HF admissions were enrolled (66 ± 13 years, EF= 42 ± 17%, 50% male) and preserved EF was identified in 224 (31%). Patients with acute decompensated HF and preserved EF presented with distinctive clinical characteristics: older age, female gender, non-ischemic etiology, higher prevalence of chronic atrial fibrillation, lower hemoglobin levels, lower pulse pressure and wider QRS complexes. No significant differences were observed on in-hospital mortality according to quintiles of EF, but we observed a trend toward increased clinical complications in patients with higher EF. Conclusions: Preserved EF is a prevalent and morbid condition among hospitalized HF patients.