Escore Prognóstico para Síndrome Coronariana Aguda em Hospital Terciário Privado

Fundamento: Os modelos prognósticos disponíveis para Síndrome Coronariana Aguda (SCA) podem ter limitações de performance, por terem sido elaborados há vários anos, ou problemas de aplicabilidade. Objetivos: Elaborar escores para predição de eventos desfavoráveis em 30 dias e 6 meses, em pacientes com SCA, com ou sem Supradesnivelamento de ST (SST), atendida em hospital privado terciário. Métodos: Coorte prospectiva de pacientes consecutivos com SCA admitidos entre agosto/2009 a junho/2012. O desfecho primário composto foi a ocorrência de óbito, infarto ou reinfarto, Acidente Vascular Cerebral (AVC), parada cardiorrespiratória e sangramento maior. As variáveis preditoras foram selecionadas de dados clínicos, laboratoriais, eletrocardiográficos e da terapêutica. O modelo final foi obtido por meio de regressão logística e submetido a validação interna, utilizando-se bootstraping. Resultados: Incluímos 760 pacientes, 132 com SCA com SST e 628 sem SST. A idade média foi 63,2 ± 11,7 anos, sendo 583 homens (76,7%). O modelo final para eventos em 30 dias contém cinco preditores: idade ≥ 70 anos, antecedente de neoplasia, Fração de Ejeção do Ventrículo Esquerdo (FEVE) < 40%, troponinaI > 12,4 ng/mL e trombólise. Na validação interna, o modelo mostrou ter boa performance com área sob a curva de 0,71.Os preditores do modelo para 6 meses são: antecedente de neoplasia, FEVE < 40%, trombólise, troponina I > 14,3 ng/mL, creatinina > 1,2 mg/dL, antecedente de doença pulmonar obstrutiva crônica e hemoglobina < 13,5 g/dL. Na validação interna, o modelo apresentou boa performance com área sob a curva de 0,69. Conclusões: Desenvolvemos escores de fácil utilização e boa performance para predição de eventos adversos em 30 dias e 6 meses em pacientes com SCA.

Healthcare-Associated Infective Endocarditis: a Case Series in a Referral Hospital from 2006 to 2011

Background: Healthcare-associated infective endocarditis (HCA-IE), a severe complication of medical care, shows a growing incidence in literature. Objective: To evaluate epidemiology, etiology, risk factors for acquisition, complications, surgical treatment, and outcome of HCA-IE. Methods: Observational prospective case series study (2006-2011) in a public hospital in Rio de Janeiro. Results: Fifty-three patients with HCA-IE from a total of 151 cases of infective endocarditis (IE) were included. There were 26 (49%) males (mean age of 47 ± 18.7 years), 27 (51%) females (mean age of 42 ± 20.1 years). IE was acute in 37 (70%) cases and subacute in 16 (30%) cases. The mitral valve was affected in 19 (36%) patients and the aortic valve in 12 (36%); prosthetic valves were affected in 23 (43%) patients and native valves in 30 (57%). Deep intravenous access was used in 43 (81%) cases. Negative blood cultures were observed in 11 (21%) patients, Enterococcus faecalis in 10 (19%), Staphylococcus aureus in 9 (17%), and Candida sp. in 7 (13%). Fever was present in 49 (92%) patients, splenomegaly in 12 (23%), new regurgitation murmur in 31 (58%), and elevated C-reactive protein in 44/53 (83%). Echocardiograms showed major criteria in 46 (87%) patients, and 34 (64%) patients were submitted to cardiac surgery. Overall mortality was 17/53 (32%). Conclusion: In Brazil HCA-IE affected young subjects. Patients with prosthetic and native valves were affected in a similar proportion, and non-cardiac surgery was an infrequent predisposing factor, whereas intravenous access was a common one. S. aureus was significantly frequent in native valve HCA-IE, and overall mortality was high.

Atrial Fibrillation in Decompensated Heart Failure: Associated Factors and In-Hospital Outcome

Background: Studies on atrial fibrillation (AF) in decompensated heart failure (DHF) are scarce in Brazil. Objectives: To determine AF prevalence, its types and associated factors in patients hospitalized due to DHF; to assess their thromboembolic risk profile and anticoagulation rate; and to assess the impact of AF on in-hospital mortality and hospital length of stay. Methods: Retrospective, observational, cross-sectional study of incident cases including 659 consecutive hospitalizations due to DHF, from 01/01/2006 to 12/31/2011. The thromboembolic risk was assessed by using CHADSVASc score. On univariate analysis, the chi-square, Student t and Mann Whitney tests were used. On multivariate analysis, logistic regression was used. Results: The prevalence of AF was 40%, and the permanent type predominated (73.5%). On multivariate model, AF associated with advanced age (p < 0.0001), non-ischemic etiology (p = 0.02), right ventricular dysfunction (p = 0.03), lower systolic blood pressure (SBP) (p = 0.02), higher ejection fraction (EF) (p < 0.0001) and enlarged left atrium (LA) (p < 0.0001). The median CHADSVASc score was 4, and 90% of the cases had it ≥ 2. The anticoagulation rate was 52.8% on admission and 66.8% on discharge, being lower for higher scores. The group with AF had higher in-hospital mortality (11.0% versus 8.1%, p = 0.21) and longer hospital length of stay (20.5 ± 16 versus 16.3 ± 12, p = 0.001). Conclusions: Atrial fibrillation is frequent in DHF, the most prevalent type being permanent AF. Atrial fibrillation is associated with more advanced age, non-ischemic etiology, right ventricular dysfunction, lower SBP, higher EF and enlarged LA. Despite the high thromboembolic risk profile, anticoagulation is underutilized. The presence of AF is associated with longer hospital length of stay and high mortality.

Testosterone Deficiency Increases Hospital Readmission and Mortality Rates in Male Patients with Heart Failure

Background:Testosterone deficiency in patients with heart failure (HF) is associated with decreased exercise capacity and mortality; however, its impact on hospital readmission rate is uncertain. Furthermore, the relationship between testosterone deficiency and sympathetic activation is unknown.Objective:We investigated the role of testosterone level on hospital readmission and mortality rates as well as sympathetic nerve activity in patients with HF.Methods:Total testosterone (TT) and free testosterone (FT) were measured in 110 hospitalized male patients with a left ventricular ejection fraction < 45% and New York Heart Association classification IV. The patients were placed into low testosterone (LT; n = 66) and normal testosterone (NT; n = 44) groups. Hypogonadism was defined as TT < 300 ng/dL and FT < 131 pmol/L. Muscle sympathetic nerve activity (MSNA) was recorded by microneurography in a subpopulation of 27 patients.Results:Length of hospital stay was longer in the LT group compared to in the NT group (37 ± 4 vs. 25 ± 4 days; p = 0.008). Similarly, the cumulative hazard of readmission within 1 year was greater in the LT group compared to in the NT group (44% vs. 22%, p = 0.001). In the single-predictor analysis, TT (hazard ratio [HR], 2.77; 95% confidence interval [CI], 1.58–4.85; p = 0.02) predicted hospital readmission within 90 days. In addition, TT (HR, 4.65; 95% CI, 2.67–8.10; p = 0.009) and readmission within 90 days (HR, 3.27; 95% CI, 1.23–8.69; p = 0.02) predicted increased mortality. Neurohumoral activation, as estimated by MSNA, was significantly higher in the LT group compared to in the NT group (65 ± 3 vs. 51 ± 4 bursts/100 heart beats; p < 0.001).Conclusion:These results support the concept that LT is an independent risk factor for hospital readmission within 90 days and increased mortality in patients with HF. Furthermore, increased MSNA was observed in patients with LT.

Post-Hospital Syndrome: A New Challenge in Cardiovascular Practice

AbstractThe image of the hospital representing the modern medicine and its diagnostic and therapeutic advances becomes more evident in the face of an aging population and patients with multiple comorbidities requiring highly complex care. However, recent studies have shown a growing number of hospital readmissions within 30 days after discharge. The post-hospital syndrome is a new clinical entity associated with multiple vulnerabilities that contribute to hospital readmissions. During hospitalization, the patient is exposed to different stressors of physical, environmental, and psychosocial natures that trigger pathophysiological and multisystemic responses and increase the risk of complications after hospital discharge. Patients with a cardiac disease have high rates of readmission within 30 days. Therefore, it is important for cardiologists to recognize the post-hospital syndrome since it may impact their daily practice. This review aims at discussing the current scientific evidence regarding predictors and stressors involved in the post-hospital syndrome and the measures that are currently being taken to minimize their effects.

Level of Physical Activity and In-Hospital Course of Patients with Acute Coronary Syndrome

Abstract Background: Acute coronary syndrome (ACS) is one of the main causes of morbidity and mortality in the modern world. A sedentary lifestyle, present in 85% of the Brazilian population, is considered a risk factor for the development of coronary artery disease. However, the correlation of a sedentary lifestyle with cardiovascular events (CVE) during hospitalization for ACS is not well established. Objective: To evaluate the association between physical activity level, assessed with the International Physical Activity Questionnaire (IPAQ), with in-hospital prognosis in patients with ACS. Methods: Observational, cross-sectional, and analytical study with 215 subjects with a diagnosis of ACS consecutively admitted to a referral hospital for cardiac patients between July 2009 and February 2011. All volunteers answered the short version of the IPAQ and were observed for the occurrence of CVE during hospitalization with a standardized assessment conducted by the researcher and corroborated by data from medical records. Results: The patients were admitted with diagnoses of unstable angina (34.4%), acute myocardial infarction (AMI) without ST elevation (41.4%), and AMI with ST elevation (24.2%). According to the level of physical activity, the patients were classified as non-active (56.3%) and active (43.7%). A CVE occurred in 35.3% of the cohort. The occurrence of in-hospital complications was associated with the length of hospital stay (odds ratio [OR] = 1.15) and physical inactivity (OR = 2.54), and was independent of age, systolic blood pressure, and prior congestive heart failure. Conclusion: A physically active lifestyle reduces the risk of CVE during hospitalization in patients with ACS.

Inquérito sôbre a doença de Chagas no hospital da Santa Casa de Misericórdia de Belo Horizonte (Minas Gerais, Brasil)

São relatados os resultados de um inquérito sôbre doença de Chagas realizado na Santa Casa de Misericórdia de Belo Horizonte (Minas Gerais, Brasil), com a finalidade de verificar a incidência desta moléstia e especialmente de sua forma cardíaca crônica entre os doentes ali internados. Foram examinados 181 pacientes adultos não selecionados, adotando-se os seguintes métodos: a) exame clínico geral e exame minucioso do aparelho circulatório; b) eletrocardiograma; c) reação de fixação do complemento para a doença de Chagas (antígeno de cultura do Schizotrypanum cruzi); d) reação de Wassermann; e) xenodiagnóstico e radiografia dos pacientes com reação de fixação do complemento (Guerreiro & Machado) positiva e de portadores de outras cardiopatias. Dos 181 pacientes examinados, 37 (20,44%) tinham provas de laboratório positivas para foença de Chagas. 49 (27,07%) eram portadores de cardiopatias, com as seguintes etiologias: doença de Chagas (18 casos); arteriosclerose (13 casos); hipertensão arterial (12 casos); sífilis (casos); febre reumática (3 casos); cardiopatia congênita (1 caso); cor pulmonale crônico (1 caso). De 34 pacientes com doença de Chagas, 18 (52,95%) apresentavam evidências eletrocardiográficas de comportamento miocárdico. As alterações eletrocardiográficas mais freqüentes foram: bloqueio do ramo direito, extra-sístoles ventriculares, alterações de QRS (isoladas ou associadas a alterações de T), bloqueios auriculo-ventriculares. Estes achados são semelhantes aos já descritos na cardiopatia chagásica crônica por Laranja e cols. (13,26). As alterações eletrocardiográficas mais frequentes no grupo de pacientes com provas de laboratório negativas para doença de Chagas foram: curvas de hipertrofia ventricular esquerda (strain) alteralçoes primárias de T e extra-sístoles vemtriculares. A idade de 50,0% dos pacientes com miocardite chagásica crônica não ultrapassou os 30 enquanto que 83,33% dos pacientes portafores de outras cardiopatias eram maiores de 30 anos. A reação de fixação do complemento (antígeno de cultura do Schizotrypanum cruzi), devido à sua especificidade e sensibilidade, mostrou ser muito util para o diagnóstico de laboratório da doença de Chagas em sua fase crônica. O xenodiagnóstico foi positivo em 8 casos (25,8%) de 31 pacientes com reação de Guerreiro & Machado positiva. Foi discutidoo problema da etiologia do megaesôfago e do megacolon, admitindo os Autores que adoença de Chagas possivelmente desempenhe, em determinadas zonas, papel significativo no desenvolvimento destas afecções. Foi brevemente relatada a distribuição geográfica dos triatomídeos no Estado de Minas Gerais. Os principais vetores são Panstrongylus megistus, Triatoma infestans e Triatoma sordida, se bem que outras 12 espécies ocorrem neste Estado. Estes triatomídeos existem em 204 (64,55%) dos 316 municípios do Estado de Minas. Vetores infetados foram encontrados em 143 municípios (70,09%). Foram assinaladas as áreas infetadas mais importantes. Os Autores salientaram a importância médica da doença de Chagas, acreditando ser esta infecção um dos mais importantes fatores de cardiopatia em amplas zonas rurais do Estado de Minas Gerais.