Hora da admissão na unidade de emergência e mortalidade hospitalar na síndrome coronária aguda

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% vs. 37%; p < 0,001). A angina instável foi mais prevalente no período diurno (43% vs. 32%; p < 0,001) e o infarto sem supradesnivelamento do segmento ST (IAMssST) no noturno (33% vs. 43%; 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% 1,025 - 1,058), p < 0,001]; fração de ejeção (FE) [OR 0,977 (IC 95% 0,966 - 0,988), p < 0,001]; IAMssST [OR 1,699 (IC 95% 1,221 - 2,366), p = 0,001]; e tabagismo [OR 1,723 (IC 95% 1,113 - 2,668), p = 0,014]. Para o óbito intra-hospitalar, foram: idade [OR 1,090 (IC 95% 1,047 - 1,134), p < 0,001]; FE [OR 0,936 (IC 95% 0,909 - 0,964), p < 0,001]; e tratamento cirúrgico [OR 3,781 (IC 95% 1,374 - 10,409), p = 0,01]. CONCLUSÃO: A internação prolongada e óbito intra-hospitalar em pacientes com SCA independem do horário de admissão.

Utilização de terapêuticas comprovadamente úteis no tratamento da coronariopatia aguda: comparação entre diferentes regiões brasileiras. Análise do Registro Brasileiro de Síndromes Coronarianas Agudas (BRACE - Brazilian Registry on Acute Coronary Syndromes)

FUNDAMENTO: Pouco se sabe, em nosso meio, sobre diferenças regionais no tratamento da coronariopatia aguda. OBJETIVO: Analisar o comportamento regional relativamente à utilização de terapêuticas comprovadamente úteis na coronariopatia aguda. MÉTODOS: Foram selecionados aleatoriamente 71 hospitais, respeitando-se a proporcionalidade do país em relação à localização geográfica, entre outros critérios. Na população global, foi analisada regionalmente a utilização de AAS, clopidogrel, inibidor da ECA/bloqueador de AT1, betabloqueador e estatina, isoladamente e agrupados por escore individual que variou de 0 (nenhum medicamento utilizado) a 100 (todos utilizados). No infarto com supradesnivelamento de ST (IAMCSST) foram analisadas diferenças regionais sobre utilização de terapêuticas de recanalização (fibrinolíticos e angioplastia primária). RESULTADOS: No global da população, nas primeiras 24 horas de hospitalização, a média de escore na região Norte-Nordeste (70,5 ± 22,1) foi menor (p < 0,05) do que nas regiões Sudeste (77,7 ± 29,5), Centro-Oeste (82 ± 22,1) e Sul (82,4 ± 21). Por ocasião da alta, o escore da região Norte-Nordeste (61,4 ± 32,9) foi menor (p < 0,05) do que nas regiões Sudeste (69,2 ± 31,6), Centro-Oeste (65,3 ± 33,6), e Sul (73,7 ± 28,1); adicionalmente, o escore do Centro-Oeste foi menor (p < 0,05) do que o do Sul. No IAMCSST, o uso de terapêuticas de recanalização foi maior no Sudeste (75,4%, p = 0,001 em relação ao restante do país), e menor no Norte-Nordeste (52,5%, p < 0,001 em relação ao restante do país). CONCLUSÃO: O uso de terapêuticas comprovadamente úteis no tratamento da coronariopatia aguda está aquém do desejável no país, com importantes diferenças regionais.

Variação Temporal no Prognóstico e Tratamento da Insuficiência Cardíaca Avançada - Antes e Após 2000

Fundamento: O tratamento da insuficiência cardíaca evoluiu nas últimas décadas, sugerindo que sua sobrevida tem aumentado. Objetivo: Verificar se houve melhora na sobrevida dos pacientes com insuficiência cardíaca avançada. Métodos: Comparamos retrospectivamente os dados de seguimento e tratamento de duas coortes de pacientes com insuficiência cardíaca sistólica admitidos para compensação até o ano 2000 (n = 353) e após 2000 (n = 279). Foram analisados: morte hospitalar, re-hospitalizações e morte no seguimento de 1 ano. Utilizamos os testes U de Mann-Whitney e qui-quadrado para comparação entre os grupos. Os preditores de mortalidade foram identificados pela análise de regressão por meio do método dos riscos proporcionais de Cox e análise de sobrevida pelo método de Kaplan-Meier. Resultados: Os pacientes internados até o ano 2000 eram mais jovens, tinham menor comprometimento ventricular esquerdo e receberam menor proporção de betabloqueadores na alta. A sobrevida dos pacientes hospitalizados antes de 2000 foi menor do que a dos hospitalizados após 2000 (40,1% vs. 67,4%; p < 0,001). Os preditores independentes de mortalidade na análise de regressão foram: a etiologia chagásica (hazard ratio: 1,9; intervalo de confiança de 95%: 1,3-3,0), inibidores da enzima conversora da angiotensina (hazard ratio: 0,6; intervalo de confiança de 95%: 0,4-0,9), betabloqueador (hazard ratio: 0,3; intervalo de confiança de 95%: 0,2-0,5), creatinina ≥ 1,4 mg/dL (hazard ratio: 2,0; intervalo de confiança de 95%: 1,3-3,0), sódio sérico ≤ 135 mEq/L (hazard ratio: 1,8; intervalo de confiança de 95%: 1,2-2,7). Conclusões: Pacientes com insuficiência cardíaca avançada apresentaram melhora significativa na sobrevida e redução nas re-hospitalizações. O bloqueio neuro-hormonal, com inibidores da enzima conversora da angiotensina e betabloqueadores, teve papel importante no aumento da sobrevida desses pacientes com insuficiência cardíaca avançada.

Sudden Cardiac Death in Brazil: A Community-Based Autopsy Series (2006-2010)

Background: Sudden cardiac death (SCD) is a sudden unexpected event, from a cardiac cause, that occurs in less than one hour after the symptoms onset, in a person without any previous condition that would seem fatal or who was seen without any symptoms 24 hours before found dead. Although it is a relatively frequent event, there are only few reliable data in underdeveloped countries. Objective: We aimed to describe the features of SCD in Ribeirão Preto, Brazil (600,000 residents) according to Coroners’ Office autopsy reports. Methods: We retrospectively reviewed 4501 autopsy reports between 2006 and 2010, to identify cases of SCD. Specific cause of death as well as demographic information, date, location and time of the event, comorbidities and whether cardiopulmonary resuscitation (CPR) was attempted were collected. Results: We identified 899 cases of SCD (20%); the rate was 30/100000 residents per year. The vast majority of cases of SCD involved a coronary artery disease (CAD) (64%) and occurred in men (67%), between the 6th and the 7th decades of life. Most events occurred during the morning in the home setting (53.3%) and CPR was attempted in almost half of victims (49.7%). The most prevalent comorbidity was systemic hypertension (57.3%). Chagas’ disease was present in 49 cases (5.5%). Conclusion: The majority of victims of SCD were men, in their sixties and seventies and the main cause of death was CAD. Chagas’ disease, an important public health problem in Latin America, was found in about 5.5% of the cases.

Correlation between C-Reactive Protein in Peripheral Vein and Coronary Sinus in Stable and Unstable Angina

Background: High sensitivity C-reactive protein (hs-CRP) is commonly used in clinical practice to assess cardiovascular risk. However, a correlation has not yet been established between the absolute levels of peripheral and central hs-CRP. Objective: To assess the correlation between serum hs-CRP levels (mg/L) in a peripheral vein in the left forearm (LFPV) with those in the coronary sinus (CS) of patients with coronary artery disease (CAD) and a diagnosis of stable angina (SA) or unstable angina (UA). Methods: This observational, descriptive, and cross-sectional study was conducted at the Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, and at the Hospital Beneficência Portuguesa de Sao Paulo, where CAD patients referred to the hospital for coronary angiography were evaluated. Results: Forty patients with CAD (20 with SA and 20 with UA) were included in the study. Blood samples from LFPV and CS were collected before coronary angiography. Furthermore, analysis of the correlation between serum levels of hs-CRP in LFPV versus CS showed a strong linear correlation for both SA (r = 0.993, p < 0.001) and UA (r = 0.976, p < 0.001) and for the entire sample (r = 0.985, p < 0.001). Conclusion: Our data suggest a strong linear correlation between hs-CRP levels in LFPV versus CS in patients with SA and UA.

Heart Rate and Systolic Blood Pressure Variability on Recently Diagnosed Diabetics

Background:Diabetes affects approximately 250 million people in the world. Cardiovascular autonomic neuropathy is a common complication of diabetes that leads to severe postural hypotension, exercise intolerance, and increased incidence of silent myocardial infarction.Objective:To determine the variability of heart rate (HR) and systolic blood pressure (SBP) in recently diagnosed diabetic patients.Methods:The study included 30 patients with a diagnosis of type 2 diabetes of less than 2 years and 30 healthy controls. We used a Finapres® device to measure during five minutes beat-to-beat HR and blood pressure in three experimental conditions: supine position, standing position, and rhythmic breathing at 0.1 Hz. The results were analyzed in the time and frequency domains.Results:In the HR analysis, statistically significant differences were found in the time domain, specifically on short-term values such as standard deviation of NN intervals (SDNN), root mean square of successive differences (RMSSD), and number of pairs of successive NNs that differ by more than 50 ms (pNN50). In the BP analysis, there were no significant differences, but there was a sympathetic dominance in all three conditions. The baroreflex sensitivity (BRS) decreased in patients with early diabetes compared with healthy subjects during the standing maneuver.Conclusions:There is a decrease in HR variability in patients with early type 2 diabetes. No changes were observed in the BP analysis in the supine position, but there were changes in BRS with the standing maneuver, probably due to sympathetic hyperactivity.

Variações morfológicas em Edessa rufomarginata e revalidação de E. albomarginata e E. marginalis (Heteroptera, Pentatomidae, Edessinae)

Based on the types of Edessa rufomarginata (De Geer, 1773) and its synonyms, on morphology of the paramere and coloration, seven patterns are described for E. rufomarginata. Pentatoma furcata Palisot de Beauvois, 1805, Cimex cruentus Fabricius, 1775, Aceratodes flavovirens Stål, 1855 and A. flavomarginatus Stål, 1855 are mantained as junior synonyms of E. rufomarginata. A. albomarginatus Stål, 1855 and A. marginalis Dallas, 1951 are removed from the synonymy of E. rufomarginata and are reinstated in Edessa. Aceratodes discolor Dallas, 1951 is removed from the synonymy of E. rufomarginata and is considered junior synonym of Edessa abdominalis Erichson, 1848.

Structure of the salivary glands of the unfed female tick Amblyomma cajennense (Fabricius) (Acarina: Ixodidae)

Acini in in the salivary glands of female tick specimens of Amblyomma ajennense unfed at both postnymphal and adult phases, were studied. The salivary glands are consisted by three acini, one agranular and two granular. The agranular acini are directly attached to the anterior portion of the main salivary duct, consisting of cells without valve. A relatively large, clear, central cell occupies most of the alveolar midsection. The central cell is in contact with the acini lumen. Granular acini consist of approximately seven to fourteen cells (type II acini) or seven to sixteen (type III acini). The type II acini have three types of granular cells ("a", "b" and "c") and valve; the type III acini have another three types of granular cells ("d", "e" and "f") also presenting a valve.

Structure of the salivary glands of the unfed male tick Amblyomma cajennense (Fabricius) (Acarina: Ixodidae)

Acini in the salivary glands of unfed male Amblyomma cajennense of different ages, were studied. The salivary glands consist of one agranular and three granular acini types. The agranular acini are directly attached to the medial and anterior portion of the main salivary duct, and to some branches of the secondary ducts. A large, clear, central cell occupies the centre and this cell is in contact with the acinar lumen. There is no valve to the lumen. Granular acini consist of approximately six to fourteen cells (type II acini) or eight to thirteen (type III acini). The type II acini have three types of granular cells ("a", "b" and "c") and a valve: the type III acini have three types of granular cells ("d", "e" and "f" and a valve.

Identification of environmental Serratia plymuthica strains with the new Combo panels Type 1S

Automated systems are required when numerous samples need to be processed, offering both high through put and test of a multiple simultaneously. This study was performed to compare the MicroScan WalkAway automated identification system in conjunction with the new MicroScan Combo Neg Panels Type 1S with conventional biochemical methods for identifying ten environmental Serratia plymuthica strains. High correlation between both methods were observed for all the 21 tests evaluated, and the MicroScan system was found capable of correctly identifying all S. plymuthica strains tested. In all tests, the percentage of correlation was 100%, except in raffinose test (91%).

Population genetic structure of the dengue mosquito Aedes aegypti in Venezuela

The mosquito Aedes aegypti is the main vector of dengue in Venezuela. The genetic structure of this vector was investigated in 24 samples collected from eight geographic regions separated by up to 1160 km. We examined the distribution of a 359-basepair region of the NADH dehydrogenase subunit 4 mitochondrial gene among 1144 Ae. aegypti from eight collections. This gene was amplified by the polymerase chain reaction and tested for variation using single strand conformation polymorphism analysis. Seven haplotypes were detected throughout Venezuela and these were sorted into two clades. Significant differentiation was detected among collections and these were genetically isolated by distance.

Chagas heart disease: pathophysiologic mechanisms, prognostic factors and risk stratification

Chagas heart disease (CHD) results from infection with the protozoan parasite Trypanosoma cruzi and is the leading cause of infectious myocarditis worldwide. It poses a substantial public health burden due to high morbidity and mortality. CHD is also the most serious and frequent manifestation of chronic Chagas disease and appears in 20-40% of infected individuals between 10-30 years after the original acute infection. In recent decades, numerous clinical and experimental investigations have shown that a low-grade but incessant parasitism, along with an accompanying immunological response [either parasite-driven (most likely) or autoimmune-mediated], plays an important role in producing myocardial damage in CHD. At the same time, primary neuronal damage and microvascular dysfunction have been described as ancillary pathogenic mechanisms. Conduction system disturbances, atrial and ventricular arrhythmias, congestive heart failure, systemic and pulmonary thromboembolism and sudden cardiac death are the most common clinical manifestations of chronic Chagas cardiomyopathy. Management of CHD aims to relieve symptoms, identify markers of unfavourable prognosis and treat those individuals at increased risk of disease progression or death. This article reviews the pathophysiology of myocardial damage, discusses the value of current risk stratification models and proposes an algorithm to guide mortality risk assessment and therapeutic decision-making in patients with CHD.