Medical care and deaths due to coronary artery disease in Brazil, 1980-1999

OBJECTIVE: To estimate the frequency of medical care preceding deaths due to coronary artery diseases (CAD) in different Brazilian regions and capitals and to describe trends in medical care from 1980 to 1999. METHODS: Information on medical care preceding deaths due to coronary artery diseases/acute myocardial infarction in adults > 20 years from 1980 to 1999 was collected in the DATASUS, the databank of the Brazilian Health Ministry. Sex, states, and capitals selected for 1999 were analyzed in the study. Medical care was stratified as follows: with, without, and ignored medical care. The descriptive analysis comprised frequencies, ratios of frequency, test for proportions, and increments or reductions in frequencies. RESULTS: Acute myocardial infarction (AMI) represented 75 to 85% of the CAD in the period; the frequency of deaths with medical care ranged from 48.9 to 63%, and that of ignored medical care ranged from 27.2 to 41.5%. The frequency of other CAD with medical care ranged from 56 to 76%. The frequency of deaths preceded by medical care decreased by 17.8%, and that with ignored medical care increased by 36.5% (RF=2). The values for the other CAD were -20.2% and +64.6% (RF=44.4). Deaths preceded by medical care were more frequent in females at all ages and in all Brazilian regions. CONCLUSION: The results show a high frequency of sudden death and suggest errors in diagnosis or codification and overestimation of the statistics about mortality. Validation of the death certificate diagnosis and frequent surveillance are required.

Comparison of immediate results and follow-up of patients with single-vessel and multivessel coronary artery disease younger than 50 years of age undergoing coronary stent implantation

OBJECTIVE: To assess the in-hospital results and clinical follow-up of young patients (< 50 years) with multivessel coronary artery disease undergoing stent implantation in native coronary arteries and to compare their results with those of patients with single-vessel coronary artery disease. METHODS: We retrospectively studied 462 patients undergoing coronary stent implantation. Patients were divided into 2 groups: group I (G-I) - 388 (84%) patients with single-vessel coronary artery disease; and group II (G-II) - 74 (16%) patients with multivessel coronary artery disease. RESULTS: The mean age of the patients was 45±4.9 years, and the clinical findings at presentation and demographic data were similar in both groups. The rate of clinical success was 95% in G-I and 95.8% in G-II (P=0.96), with no difference in regard to in-hospital evolution between the groups. Death, acute myocardial infarction, and the need for myocardial revascularization during clinical follow-up occurred in 10.1% and 11.2% (P=0.92) in G-I and G-II, respectively. By the end of 24 months, the actuarial analysis showed an event-free survival of 84.6 % in G-I and 81.1% in G-II (P=0.57). CONCLUSION: Percutaneous treatment with coronary stent implantation in young patients with multivessel disease may be safe with a high rate of clinical success, a low incidence of in-hospital complications, and a favorable evolution in clinical follow-up.

Quantifying the risk of coronary artery disease in a community: The Bambuí Project

OBJECTIVE: To determine the coronary risk profile in adults and elderly in a community. METHODS: The study comprised a sample of adults (30-59 years, n=547) and the entire elderly population (60-74 years, n=1165) residing in Bambuí town, Brazil. The Framingham score based on sex, age, smoking, diabetes mellitus, systolic and diastolic blood pressure, total cholesterol, and HDL-C was used. The score based on age and sex was defined as "expected" and compared with the mean score obtained by the sum of all risk factors in each age group and sex (score "observed"). RESULTS: The difference between the scores "observed" and "expected" increased with aging in both sexes. Smoking increased the difference from 30 years of age onwards, in both sexes, and hypertension was important in men above the age of 30 years and in women above the age of 50 years. Diabetes and elevated total cholesterol increased the risk of the disease above the age of 50 years in both sexes. A higher level of HDL-C reduced the risk among men above the age of 30 years, with no significant difference among women. Less schooling (< 4 years versus ³ 4 years) was associated with a higher score in adults of both sexes, but not among the elderly. CONCLUSION: Based on these results, in the community studied, the risk of coronary artery disease may be reduced up to 44% in men and 38% in women.

Dilatação mediada por fluxo no diagnóstico diferencial da síndrome de pré-eclâmpsia

FUNDAMENTO: A síndrome de pré-eclâmpsia se associa com a disfunção endotelial e o diagnóstico diferencial entre pré-eclâmpsia pura (PE) e sobreposta (PES) só pode ser feito após 12 semanas do parto. OBJETIVO: Comparar a avaliação da função endotelial através de dilatação mediada por fluxo de gestantes com pré-eclâmpsia pura e sobreposta. MÉTODOS: A dilatação mediada por fluxo da artéria braquial foi realizada utilizando as recomendações da International Brachial Artery Reactivity Task Force em gestantes com a Síndrome de Pré-eclâmpsia. Pré-eclâmpsia (n = 14) e pré-eclâmpsia sobreposta (n = 13) foram diagnosticadas no pós-parto segundo as definições do National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. RESULTADOS: A mediana da dilatação mediada por fluxo (DMF) na PES (6,0%; 1,9-10,3) foi reduzida em comparação com PE (13,6%; 4,4-17,1), uma disparidade aparentemente relevante, mas sem diferença estatisticamente significativa (p = 0,08). A DMF inferior a 10% foi detectada em 30,8% das PE e em 69,2% das PES (p = 0,057). Diferenças significativas não ocorreram na comparação entre a morfologia das artérias uterinas de PE e PES através do espectro do Doppler. CONCLUSÃO: A DMF da artéria braquial de pacientes com Síndrome de Pré-eclâmpsia não se mostrou ser um método capaz de diferenciar PE de PES. Entretanto, os dados sugerem que PES se associa com pior função endotelial em comparação a PE.

Ressonância magnética cardiovascular em veia cava inferior interrompida não prevista

A Veia Cava Inferior (VCI) interrompida é uma anomalia rara. As anomalias da VCI são clinicamente importantes para os cardiologistas e radiologistas que pretendem intervir na cavidade cardíaca direita. Descrevemos três casos de interrupção da VCI diagnosticados por meio de estudo imaginológico de ressonância magnética cardíaca.

Colapsibilidade da Veia Cava Inferior e sinais e sintomas de insuficiência cardíaca: novos insights e possíveis associações

FUNDAMENTO: Nos pacientes com Insuficiência Cardíaca Crônica (ICC) foram propostas medidas ultrassonográficas do Índice de Colapsibilidade da Veia Cava Inferior (ICVCI) para obter uma avaliação e classificação minuciosa da congestão hemodinâmica. OBJETIVO: A finalidade deste estudo era correlacionar os achados no exame físico com o ICVCI em pacientes com ICC. MÉTODOS: De acordo com um projeto de coorte retrospectivo, analisamos 54 pacientes com ICC, direita ou biventricular, classe NYHA III. O plano era determinar se alguma faixa de ICVCI basal poderia predizer uma persistência ou agravamento da congestão clínica achada no final do acompanhamento subsequente (isto é, após 1-2 meses do tratamento oral otimizado). Para essa finalidade, os pacientes foram subdivididos em três grupos de acordo com o valor de ICVCI basal: ≤ 15% (13 pts), 16 - 40% (21 pts) e > 40% (20 pts). Diversos critérios clínicos de congestão foram comparados por meio dos três grupos e incorporados subsequentemente ao modelo multivariado de Cox. RESULTADOS: Preditores multivariados de alto escore de congestão foram distensão da veia jugular (FC: 13,38 95% IC: 2,13 - 84 p = 0,0059) e estertores (FC: 11 95% C.I : 1,45 - 83,8 p = 0,0213). O ICVCI ≤ 15% esteve sempre associado com um alto escore de congestão na segunda visita; todavia, o ICVCI o ≤ 15% não predisse um alto escore de congestão na segunda visita. CONCLUSÃO: No âmbito da ICC, um baixo ICVCI não predisse, em forma confiável, um elevado escore de congestão. Não obstante, o conjunto com ICVCI ≤ 15% sempre se achou associado com sinais e sintomas de uma ICC descompensada, tanto do lado direito como do esquerdo. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

Caso 1/2013: homem de 69 anos com dor súbita em dorso e membro inferior direito e choque

MSM, homem, 69 anos, procurou atendimento médico por dor em dorso esquerdo e membro inferior direito. A radiografia de tórax revelou alargamento do mediastino. Estava em observação quando apresentou rebaixamento da consciência e choque. Foi observado enfisema subcutâneo em hemitórax esquerdo e abolição do murmúrio vesicular em base do mesmo pulmão. Foi feita a intubação orotraqueal e realizada drenagem de hemitórax esquerdo, com saída de líquido serossanguinolento. O ecocardiograma revelou ventrículo esquerdo (D/S): 44/29 mm; septo 12 mm; parede posterior 13 mm; discreta dilatação em raiz da aorta, presença de lâmina de dissecção e hematoma periaórtico. As valvas e pericárdio eram normais. O paciente foi transferido para o InCor. O exame físico (21 out 2004: 10h45) revelou paciente sedado, com intubação orotraqueal, com palidez cutânea, frequência cardíaca 90 bpm, pressão arterial 130 x 80 mmHg, drenagem torácica sanguinolenta do dreno tórax. Eletrocardiograma - frequência 90 bpm, ritmo sinusal, baixa voltagem no plano frontal e diminuição de voltagem em derivações esquerdas (fig. 1). A tomografia revelou enfisema subcutâneo bilateral, aorta torácica com contornos imprecisos na sua porção descendente (da artéria subclávia até porção média), colapso do pulmão esquerdo e grande coleção de características hemáticas em mesmo hemitórax e no mediastino médio e posterior. Pequeno pneumotórax à direita; pequeno derrame pleural à direita com alterações do parênquima subjacente. A análise do coração foi prejudicada pela presença do hemotórax. Durante a realização de tomografia apresentou ausência de pulsos, midríase, com assistolia, sem resposta às manobras de ressuscitação e faleceu (21 out 2011; 15h).

Impact of Intensive Physiotherapy on Cognitive Function after Coronary Artery Bypass Graft Surgery

Background: Coronary artery bypass graft (CABG) is a standard surgical option for patients with diffuse and significant arterial plaque. This procedure, however, is not free of postoperative complications, especially pulmonary and cognitive disorders. Objective: This study aimed at comparing the impact of two different physiotherapy treatment approaches on pulmonary and cognitive function of patients undergoing CABG. Methods: Neuropsychological and pulmonary function tests were applied, prior to and following CABG, to 39 patients randomized into two groups as follows: Group 1 (control) - 20 patients underwent one physiotherapy session daily; and Group 2 (intensive physiotherapy) - 19 patients underwent three physiotherapy sessions daily during the recovery phase at the hospital. Non-paired and paired Student t tests were used to compare continuous variables. Variables without normal distribution were compared between groups by using Mann-Whitney test, and, within the same group at different times, by using Wilcoxon test. The chi-square test assessed differences of categorical variables. Statistical tests with a p value ≤ 0.05 were considered significant. Results: Changes in pulmonary function were not significantly different between the groups. However, while Group 2 patients showed no decline in their neurocognitive function, Group 1 patients showed a decline in their cognitive functions (P ≤ 0.01). Conclusion: Those results highlight the importance of physiotherapy after CABG and support the implementation of multiple sessions per day, providing patients with better psychosocial conditions and less morbidity.

Association of Aortic Valve Sclerosis with Previous Coronary Artery Disease and Risk Factors

Background: Aortic valve sclerosis (AVS) is characterized by increased thickness, calcification and stiffness of the aortic leaflets without fusion of the commissures. Several studies show an association between AVS and presence of coronary artery disease. Objective: The aim of this study is to investigate the association between presence of AVS with occurrence of previous coronary artery disease and classical risk factors. Methods: The sample was composed of 2,493 individuals who underwent transthoracic echocardiography between August 2011 and December 2012. The mean age of the cohort was 67.5 ± 15.9 years, and 50.7% were female. Results: The most frequent clinical indication for Doppler echocardiography was the presence of stroke (28.8%), and the most common risk factor was hypertension (60.8%). The most prevalent pathological findings on Doppler echocardiography were mitral valve sclerosis (37.1%) and AVS (36.7%). There was a statistically significant association between AVS with hypertension (p < 0.001), myocardial infarction (p = 0.007), diabetes (p = 0.006) and compromised left ventricular systolic function (p < 0.001). Conclusion: Patients with AVS have higher prevalences of hypertension, stroke, hypercholesterolemia, myocardial infarction, diabetes and compromised left ventricular systolic function when compared with patients without AVS. We conclude that there is an association between presence of AVS with previous coronary artery disease and classical risk factors.