Cardiovascular Statistics - Brazil 2020

Burden of disease and direct costs to the health system attributable to high body mass index in Brazil

OBJECTIVES

Excess weight, measured by a high body mass index (BMI), is associated with the onset of many diseases, which can, in turn, lead to disability and premature death, subsequently placing a significant burden on healthcare services. This study analysed the burden of disease and the direct costs to the Brazilian Unified Health System (Sistema Único de Saúde [SUS]) attributable to high BMI in the Brazilian population.

STUDY DESIGN

Ecological study.

METHODS

This ecological study had two components: (1) a time-series assessment to analyse the burden of diseases attributable to high BMI from 1990 to 2019 in Brazil; and (2) a cross-sectional design to estimate the direct costs of SUS hospitalisations and outpatient procedures attributable to high BMI in 2019. Estimates from the Global Burden of Disease study and the costs of hospital admissions and outpatient procedures from the Department of Informatics of the Brazilian Unified Health System were used. Deaths, years of life lost to premature death (YLLs), years lived with disability (YLDs), and years of life lost adjusted for disability (DALYs) were analysed. The direct health cost was obtained in Brazilian Real (R$) and converted in international Dollars (INT$).

RESULTS

The current study found a reduction in the number of DALYs, YLLs, and deaths per 100,000 population of cardiovascular disease (CVD) attributable to high BMI and an increase in YLD due to diabetes and cardiovascular disease attributable to high BMI from 1990 to 2019. In 2019, high BMI resulted in 2404 DALYs, 658 YLDs, 1746 YLLs, and 76 deaths per 100,000 inhabitants. In the same year, INT$377.30 million was spent on hospitalisations and high- and medium-complexity procedures to control non-communicable diseases attributable to high BMI. The states in the South and Southeast regions of Brazil presented the highest total cost per 10,000 inhabitants. CVDs and chronic kidney disease showed the highest costs per hospital admission, whereas neoplasms and CVDs presented the highest costs for outpatient procedures.

CONCLUSIONS

High BMI causes significant disease burden and financial costs. The highest expenses observed were not in locations with the highest burden of disease attributable to high BMI. These findings highlight the need to improve current public policies and apply cost-effective intervention packages, focussing on equity and the promotion of healthier lifestyles to reduce overweight/obesity, especially in localities with low socioeconomic status.

Performance of contemporary cardiovascular risk stratification scores in Brazil: an evaluation in the ELSA-Brasil study

AIMS

Despite notable population differences in high-income and low- and middle-income countries (LMICs), national guidelines in LMICs often recommend using US-based cardiovascular disease (CVD) risk scores for treatment decisions. We examined the performance of widely used international CVD risk scores within the largest Brazilian community-based cohort study (Brazilian Longitudinal Study of Adult Health, ELSA-Brasil).

METHODS

All adults 40-75 years from ELSA-Brasil (2008-2013) without prior CVD who were followed for incident, adjudicated CVD events (fatal and non-fatal MI, stroke, or coronary heart disease death). We evaluated 5 scores-Framingham General Risk (FGR), Pooled Cohort Equations (PCEs), WHO CVD score, Globorisk-LAC and the Systematic Coronary Risk Evaluation 2 score (SCORE-2). We assessed their discrimination using the area under the receiver operating characteristic curve (AUC) and calibration with predicted-to-observed risk (P/O) ratios-overall and by sex/race groups.

RESULTS

There were 12 155 individuals (53.0±8.2 years, 55.3% female) who suffered 149 incident CVD events. All scores had a model AUC>0.7 overall and for most age/sex groups, except for white women, where AUC was <0.6 for all scores, with higher overestimation in this subgroup. All risk scores overestimated CVD risk with 32%-170% overestimation across scores. PCE and FGR had the highest overestimation (P/O ratio: 2.74 (95% CI 2.42 to 3.06)) and 2.61 (95% CI 1.79 to 3.43)) and the recalibrated WHO score had the best calibration (P/O ratio: 1.32 (95% CI 1.12 to 1.48)).

CONCLUSION

In a large prospective cohort from Brazil, we found that widely accepted CVD risk scores overestimate risk by over twofold, and have poor risk discrimination particularly among Brazilian women. Our work highlights the value of risk stratification strategies tailored to the unique populations and risks of LMICs.

Global Cardiac Surgery in Brazil: A Call to Action

Global Cardiac Surgery is an innovative initiative with a focus on improving health outcomes and achieving healthcare equity for individuals worldwide affected by cardiac surgical conditions or in need of cardiac surgical care. Considering the existing disparities in access to cardiac surgery and the substantial burden of cardiac conditions amenable to surgical procedures in Brazil, it is imperative to support and scale Global Cardiac Surgery initiatives and leave no Brazilian patient behind. Here, we advocate for national initiatives within this field and highlight opportunities and challenges to support their development.

In-Hospital Management and Long-term Clinical Outcomes and Adherence in Patients With Acute Decompensated Heart Failure: Primary Results of the First Brazilian Registry of Heart Failure (BREATHE)

BACKGROUND

Heart failure (HF), a common cause of hospitalization, is associated with poor short-term clinical outcomes. Little is known about the long-term prognoses of patients with HF in Latin America.

METHODS

BREATHE was the first nationwide prospective observational study in Brazil that included patients hospitalized due to acute heart failure (HF). Patients were included during 2 time periods: February 2011-December 2012 and June 2016-July 2018 In-hospital management, 12-month clinical outcomes and adherence to evidence-based therapies were evaluated.

RESULTS

A total of 3013 patients were enrolled at 71 centers in Brazil. At hospital admission, 83.8% had clear signs of pulmonary congestion. The main cause of decompensation was poor adherence to HF medications (27.8%). Among patients with reduced ejection fraction, concomitant use of beta-blockers, renin-angiotensin-aldosterone inhibitors and spironolactone decreased from 44.5% at hospital discharge to 35.2% at 3 months. The cumulative incidence of mortality at 12 months was 27.7%, with 24.3% readmission at 90 days and 44.4% at 12 months.

CONCLUSIONS

In this large national prospective registry of patients hospitalized with acute HF, rates of mortality and readmission were higher than those reported globally. Poor adherence to evidence-based therapies was common at hospital discharge and at 12 months of follow-up.

Length of Hospitalization and Mortality among Stroke Patients before and after the Implementation of a Specialized Unit: A Retrospective Cohort Study Using Real-World Data from One Reference Hospital in Southern Brazil

Stroke constitutes a significant global cause of mortality and disability. The implementation of stroke units influences hospital quality indicators, guiding care management. We aimed to compare hospital length of stay (LOS), in-hospital mortality, and post-discharge mortality between stroke patients admitted in the pre- and post-implementation periods of a stroke unit in a public hospital in southern Brazil. This retrospective cohort study used real-world data from one reference hospital, focusing on the intervention (stroke unit) and comparing it to the general ward (control). We analyzed the electronic medical records of 674 patients admitted from 2009 to 2012 in the general ward and 766 patients from 2013 to 2018 in the stroke unit. Admission to the stroke unit was associated with a 43% reduction in the likelihood of prolonged hospitalization. However, there was no significant difference in the risk of in-hospital mortality between the groups (Hazard ratio = 0.90; Interquartile range = 0.58 to 1.39). The incidence of death at three, six and twelve months post-discharge did not differ between the groups. Our study results indicate significant improvements in care processes for SU patients, including shorter LOS and better adherence to treatment protocols. However, our observations revealed no significant difference in mortality rates, either during hospitalization or after discharge, between the SU and GW groups. While SU implementation enhances efficiency in stroke care, further research is needed to explore long-term outcomes and optimize management strategies.

Evaluation of patients with implantable cardioverter-defibrillator in a Latin American tertiary center

INTRODUCTION

Despite advancements in implantable cardioverter-defibrillator (ICD) technology, sudden cardiac death (SCD) remains a persistent public health concern. Chagas disease (ChD), prevalent in Brazil, is associated with increased ventricular tachycardia (VT) and ventricular fibrillation (VF) events and SCD compared to other cardiomyopathies.

METHODS

This retrospective observational study included patients who received ICDs between October 2007 and December 2018. The study aims to assess whether mortality and VT/VF events decreased in patients who received ICDs during different time periods (2007-2010, 2011-2014, and 2015-2018). Additionally, it seeks to compare the prognosis of ChD patients with non-ChD patients. Time periods were chosen based on the establishment of the Arrhythmia Service in 2011. The primary outcome was overall mortality, assessed across the entire sample and the three periods. Secondary outcomes included VT/VF events and the combined outcome of death or VT/VF.

RESULTS

Of the 885 patients included, 31% had ChD. Among them, 28% died, 14% had VT/VF events, and 37% experienced death and/or VT/VF. Analysis revealed that period 3 (2015-2018) was associated with better death-free survival (p = .007). ChD was the only variable associated with a higher rate of VT/VF events (p < .001) and the combined outcome (p = .009).

CONCLUSION

Mortality and combined outcome rates decreased gradually for ICD patients during the periods 2011-2014 and 2015-2018 compared to the initial period (2007-2010). ChD was associated with higher VT/VF events in ICD patients, only in the first two periods.

Thrombin generation and all-cause mortality in The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

INTRODUCTION

Thrombin generation assay (TGA) is a laboratory method that provides the global evaluation of hemostasis. The association between thrombin generation and all-cause mortality is poorly investigated and results are contradictory. This study evaluated whether TGA parameters are associated with all-cause mortality in a prospective cohort.

METHODS

This study was conducted in 2,588 participants enrolled at baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). TGA was performed using the Calibrated Automated Thrombogram (CAT) method, and its parameters lagtime, time-to-peak, peak, Endogenous Thrombin Potential (ETP) and normalized ETP (nETP) were evaluated according to the reference interval (RI). The association between TGA parameters and all-cause mortality was estimated by Cox regression and adjusted for confounders.

RESULTS

The mean follow-up time was 6.6 ± 2.7 years and 85 deaths occurred. After adjustment, time-to-peak values above the RI at low and high tissue factor (TF) concentrations were associated with higher risk of death [HR = 2.45 (95 % CI: 1.17-5.13) and HR = 2.24 (95 % CI: 1.02-4.93), respectively] and nETP and peak values below RI at high TF concentration were associated with higher risk of death [HR = 3.85 (95 % CI: 1.39-10.68) and HR = 2.56 (95 % CI: 1.17-5.61), respectively].

CONCLUSIONS

Delayed thrombin generation was associated with higher risk of all-cause mortality.

The Brazilian Cardioprotective Nutritional (BALANCE) Program improves diet quality in patients with established cardiovascular disease: Results from a multicenter randomized controlled trial

Dietary modifications are essential strategies for cardiovascular disease prevention. However, studies are needed to investigate the diet quality of individuals undergoing secondary prevention in cardiology and who received dietary intervention based on cardiovascular disease management. We prospectively evaluated the diet quality in the Brazilian Cardioprotective Nutritional Program Trial (BALANCE Program Trial). We hypothesized that the BALANCE Program could improve patients' dietary pattern according to different indices of diet quality such as the Dietary Inflammatory Index (DII); the dietary total antioxidant capacity; overall, healthful, and unhealthful Plant-Based Diet Index (PDI, hPDI, and uPDI, respectively); and modified Alternative Healthy Eating Index (mAHEI). This multicenter randomized, controlled trial included patients aged ≥45 years randomly assigned to either the experimental or control group. Data from 2185 participants at baseline and after 12, 24, 36, and 48 months showed that the intervention group (n = 1077) had lower mean values of DII and higher dietary total antioxidant capacity, PDI, hPDI, and mAHEI than the control group. The results also showed differences between the follow-up times for DII, hPDI, and uPDI (48 months vs baseline) and for PDI and mAHEI (24 months vs baseline), regardless of group. The interaction analysis demonstrated that the intervention group showed better results than the control group at 12, 24, 36, and 48 months for the DII and at months 12, 36, and 48 for the mAHEI. Our results provide prospective evidence that the BALANCE Program improved the diet quality in those in secondary cardiovascular prevention according to different indices, with the intervention group showing better results than the control group.

Temporal-spatial analysis of mortality from cardiovascular diseases in the State of Ceará, Brazil, between 2009-2019

OBJECTIVE

To analyze the spatial distribution of mortality from cardiovascular diseases in the municipalities of the state of Ceará, Brazil, between 2009-2019.

METHODS

This is an ecological study with a spatial focus on the state of Ceará, considering the period from 2009 to 2019. Death data from the Brazilian Mortality Information System and population data from the Brazilian Institute of Geography and Statistics were used to calculate crude and standardized mortality rates from cardiovascular diseases. Temporal analysis was carried out using the Joinpoint Regression Program 4.9.0 software and spatial analysis of the municipalities' average mortality. The values were smoothed by the local empirical Bayesian method using QGIS 3.16. For spatial clusters, the Global and Local Moran Index was used through Moran Map and LISA Map, with analyses carried out in TerraView 4.2.2.

RESULTS

A total of 132,145 deaths from cardiovascular diseases were recorded in the period, with an average increase of 3% per year. Higher mortality rates were observed in men, people aged ≥80 years, mixed-race ethnicity/skin color, married, and with lower level of education. There was the formation of clusters of municipalities with high mortality rates in the regions of Vale do Jaguaribe, Sertão Central, Centro Sul, Sertão dos Inhamuns and Serra da Ibiapaba.

CONCLUSION

This study identified municipalities with high mortality and exposed the need for strategies aligned with the reality and particularities of these locations.

Cerebrovascular mortality: trend and seasonality in Brazilian capitals, 2000-2019

OBJECTIVE

To evaluate the trend and seasonality of cerebrovascular mortality rates in the adult population of Brazilian capitals from 2000 to 2019.

METHODS

This is an ecological and descriptive study of a time series of mortality due to cerebrovascular causes in adults (≥ 18 years) living in Brazilian capitals from 2000 to 2019, based on the Brazilian Mortality Information System. Descriptive statistical techniques were applied in the exploratory analysis of data and in the summary of specific, standardized rates and ratios by sociodemographic characteristics. The jointpoint regression model was used to estimate the trend of cerebrovascular mortality rates by gender, age groups, and geographic regions. The seasonal variability of rates by geographic regions was estimated using the generalized additive model by smoothing cubic splines.

RESULTS

People aged over 60 years comprised 77% of all cerebrovascular deaths. Women (52%), white individuals (47%), single people (59%), and those with low schooling (57%, elementary school) predominated in our sample. Recife (20/1,000 inhab.) and Vitória (16/1,000 inhab.) showed the highest crude mortality rates. Recife (49/10,000 inhab.) and Palmas (47/10,000 inhab.) prevailed after we applied standardized rates. Cerebrovascular mortality rates in Brazil show a favorable declining trend for adults of all genders. Seasonality influenced rate increase from July to August in almost all region capitals, except in the North, which rose in March, April, and May.

CONCLUSIONS

Deaths due to cerebrovascular causes prevailed in older single adults with low schooling. The trend showed a tendency to decline and winter, the greatest risk. Regional differences can support decision-makers in implementing public policies to reduce cerebrovascular mortality.

Burden of ischemic heart disease attributable to trans fatty acids, 1990-2019

BACKGROUND & AIM

The impact of cardiovascular disease attributable to trans fatty acids (TFAs) in the Brazilian population has not been systematically evaluated. This study aims to analyze the burden of ischemic heart disease (IHD) attributable to TFAs in Brazil between 1990 and 2019.

METHODS

Data from the Global Burden of Disease Study 2019 were used to investigate the attributable burden in Brazil and its 27 federative units, for both sexes-pooled adults aged ≥25 years. Mortality and disability-adjusted life years (DALYs) from IHD attributable to TFAs were expressed as crude and age-standardized rates and differences from 1990 to 2019 by percentage and annualized rate of change. Linear regression was used to investigate trends. National voluntary and regulatory policies for industrial TFAs (iTFAs) implemented until 2019, summary exposure value (SEV) and sociodemographic index (SDI) were examined.

RESULTS

Between 1990 and 2019, crude and age-standardized mortality rates from IHD attributable to TFAs decreased by -15.9% and -58.0%, respectively, in Brazil. A decrease in crude (-23.3%) and age-standardized (-56.4%) DALY rates of IHD attributable to TFAs was also noticed in the country. States of the South, Southeast, and the Federal District had the largest declines of IHD attributable to TFAs, while states of the Northeast and North had the smallest or even an increase. The policies already adopted had little effect on the IHD burden. A lower SEV and higher SDI value seemed to reduce the burden of IHD.

CONCLUSIONS

Although a downward trend in IHD attributable to TFAs and a reduction in exposure to TFAs were observed, this burden is still relevant in Brazil, reinforcing the importance of diet policies, such as banning iTFAs.

Factors associated with decision time to seek care in the face of ischemic stroke

OBJECTIVE

To verify the association between sociodemographic, clinical, environmental, cognitive, and emotional factors and the decision time of people with ischemic stroke to seek a health service after the onset of symptoms or wake up stroke.

METHOD

Cross-sectional study carried out from March to October 2019, with 304 patients, in a public hospital, a reference in neurology. Data obtained through interview and from medical records. Decision time was analyzed as a geometric mean. In the bivariate and multivariate analyses, linear regression was used and the Akaike Information Criterion was used to select the best model. Statistical significance of 5% was adopted.

RESULTS

The geometric mean of decision time was 0.30h (95% CI 0.23-0.39). The final model explained this time in 41%, showing an increase of 0.5 min for people with arterial hypertension; 10.8 min for those who waited for symptoms to improve; 1.4 min for those who were alone at the onset of symptoms; 3.9 min for those at home; 3.2 min for the ones at work; and 2.1 for those on the street/public space.

CONCLUSION

The mean decision time for seeking a health service was high and influenced by clinical, environmental, cognitive, and emotional variables. The results guide nurses regarding health education.

Assessing statins use in a real-world primary care digital strategy: a cross-sectional analysis of a population-wide digital health approach

Background

The digitization of the primary care system provides an opportunity to evaluate the current use of statins in secondary prevention populations (myocardial infarction or stroke).

Methods

We conducted a cross-sectional study (ClinicalTrials.gov, NCT05285085), analysing anonymised data routinely collected by community health workers (CHW) in Brazil between May 2016 and September 2021 to assess the proportion of self-reported statins use and associated factors.

Findings

From the 2,133,900 individuals on the database, 35,103 (1.6%), mean age 66.2 years (SD14.6), 49.5% (17,382/35,103) male sex, 50.5% (17,721/35,103) female sex, and 29.6% (10,381/34,975) Caucasians, had a previous myocardial infarction (MI) (n = 11,628; 33.1%) or stroke (n = 25,925; 73.9%). Approximately 50% (17,020/35,103) were from the Northeast region, 78.7% (27,605) from urban zones, and 39.4% (13,845) with social development index (SDI) >0.7. Overall, 6.7% (2346) and 0.6% (212) reported statins and high dose statins use, respectively. Age over 60 years old (OR 1.32 [95% CI 1.19-1.47), living in the Southern region (OR 4.53 [95% CI 3.66-5.60]), having a previous diagnosis of MI (OR 4.53 [95% CI 3.66-5.60]), heart failure (OR 2.29 [95% CI 1.13-1.47]), diabetes (OR 1.50 [95% CI 1.37-1.64]), dyslipidaemia (OR 2.90 [95% CI 2.55-3.29]), chronic kidney disease (OR 1.27 [95% CI 1.08-1.48]) and use of anti-hypertensives (OR 5.47 [95% CI 4.60-6.47]) were associated with statin use.

Interpretation

The analysis of a real-world database from a digitized primary care system, allowed us to identify a very low use of statins in secondary prevention Brazilian patients, mostly influenced by socio-demographic factors and co-morbidities.

Funding

Novartis Biociências, Brazil.

Sex Differences in Outcomes of ST Elevation Myocardial Infarction Patients Submitted to Primary Percutaneous Coronary Intervention

BACKGROUND

Several studies have shown that women are usually undertreated and have worse outcomes after ST-segment elevation myocardial infarction (STEMI), hence the need to investigate questions related to sex in Brazil to better deal with the problem.

OBJECTIVE

To determine whether female sex is still associated with adverse events in a contemporary cohort of patients with STEMI undergoing primary percutaneous coronary intervention (pPCI).

METHODS

This was a prospective cohort study of STEMI patients submitted to pPCI in a tertiary university hospital between March 2011 and December 2021. Patients were categorized into groups based on their sex at birth. The primary clinical outcome was long-term MACCE. Patients were followed-up for up to five years. All hypothesis tests had a two-sided significance level of 0.05.

RESULTS

Among 1457 patients admitted with STEMI in the study period, 1362 were included and 468 (34.4%) were women. Female patients had a higher prevalence of hypertension (73% vs. 60%, p <0.001), diabetes (32% vs. 25%, p=0.003) and Killip class 3-4 at hospital admission (17% vs. 12%, p=0.01); TIMI risk score was higher among women (4 [2, 6] vs. 3 [2, 5], p<0.001). In-hospital mortality was not different between groups (12.8% vs. 10.5%, p=0.20). In-hospital MACCE (16.0% vs. 12.6%, p=0.085) and long-term MACCE (28.7% vs. 24.4%, p=0.089) were numerically higher in women, with borderline significance. After multivariate analysis, female sex was not associated with MACCE (HR = 1.14; 95% CI 0.86 - 1.51; p = 0.36).

CONCLUSION

In a prospective cohort of STEMI patients submitted to pPCI, female patients were older and had more comorbidities at baseline, but no significant differences were found in terms of long-term adverse outcomes.

Use of Botulinum Toxin as a Treatment of Hemiplegic Shoulder Pain Syndrome: A Randomized Trial

OBJECTIVE

The primary objective of this paper is to assess whether the use of 200 units of abobotulinum in the pectoralis major and subscapularis muscles modifies the pain complaint assessed using the visual analog scale in subjects with shoulder pain after the onset of spastic hemiplegia due to cerebrovascular disease when compared to the application of a placebo to the same muscles.

DESIGN

A prospective, double-blind, randomized, and placebo-controlled clinical trial study in two different rehabilitation centers.

SETTING

Two distinct outpatient neurological rehabilitation services.

PARTICIPANTS

Patients older than 18 years who were included presented upper limb spasticity resulting from ischemic or hemorrhagic stroke and a diagnosis of Painful Hemiplegic Shoulder Syndrome (PHSS) that was independent of motor dominance.

INTERVENTIONS

Patients were divided into two groups, one of them underwent the application of botulinum toxin (TXB-A) in the pectoralis major and subscapularis muscles, at a total dose of 400 U.

MAIN OUTCOME MEASURE

Patients were assessed for a change in pain using the Visual Analog Scale (VAS) for at least 13 mm.

RESULTS

An improvement in pain and spasticity levels in both groups, more intense in the toxin group, but without statistical significance. The comparison between the groups showed a reduction in pain by VAS (p = 0.52).

CONCLUSIONS

The use of botulinum toxin in the subscapularis and pectoralis major muscles resulted in a reduction in shoulder pain in spastic hemiplegic patients without statistical significance.

Clinical Features and Management of Patients Assessed by Cardiology Teleconsultation in the Brazilian Region with the Highest Number of Isolated Cities

BACKGROUND

Cardiovascular diseases are the leading cause of adult mortality. Geographically remote and low-income Brazilian regions lack specialized consultations. The telemedicine management of this population by cardiologists is not fully known.

OBJECTIVES

To analyze cardiology teleconsultation in the Brazilian region with the highest number of isolated cities.

METHODS

From February 2020 to October 2021, patients from the North Region of Brazil evaluated by local general practitioners were referred for cardiological evaluation by telemedicine. Referral reasons, demographics, clinical history, physical examinations, tests, medications, and prescriptions pre- and post-telemedicine were analyzed (p<0.05 was considered statistically significant).

RESULTS

We analyzed 653 patients. The attendance rate was 85.7% (53.1% female, mean age: 54.2±6.5 years). The main reasons for referral were cardiovascular symptoms (58.1%) and risk factors among asymptomatic patients (13.3%). Only 12.6% had a diagnosed disease. Most patients had regular physical examinations and electrocardiograms. Few had recent complementary tests. The prescription of angiotensin receptor blockers (ARBs), calcium channel blockers and statins was significantly increased, while that of digoxin, noncardiac beta-blockers and acetylsalicylic acid (ASA) was decreased at the first teleconsultation. Most of the tests requested were of low complexity and cost: electrocardiogram (28.2%), chest X-ray (14%), echocardiogram (64.5%) and blood tests (71.8%). For 2.1% of patients, interventions were indicated, and 8% were discharged after the first consultation.

CONCLUSION

On-demand cardiology teleconsultation contributes to heart disease treatment optimization. Most patients were referred with syndromic diagnoses without previous complementary tests. The specialist workup requested was usually available locally and at a low cost but precluded early discharge. Local training could optimize the referral.

Cardiac Troponin I in Patients Undergoing Percutaneous and Surgical Myocardial Revascularization: Comparison of Analytical Methods

The myocardial infarction (MI) types 4a and 5 guidelines recommend cardiac troponin (cTn) diagnostic decision limits of 5 and 10 times the 99th percentile, respectively. Different cTn kits elicit different responses, so the MI diagnosis is still challenging. The study aimed to establish the cutoff values and the accuracy of three different cTnI kits in the diagnosis of post-procedural MI. We analyzed 115 patients with multivessel stable chronic coronary artery disease; 26 underwent percutaneous coronary intervention, and 89 underwent coronary artery bypass graft. Delayed-enhancement magnetic resonance imaging was performed before and after each intervention for definitive MI diagnoses. Two contemporary and one high-sensitivity cTnI immunoassays were used. ROC curves determined the accuracy of each assay. Low accuracy was observed after applying the current guidelines recommendations. The three cTnI assays accuracies improved when adjusted by the new ROC cutoffs, reaching 82% for MI type 5 for all assays, and 78%, 88%, and 87% for MI type 4 for Siemens, Beckman, and Abbott, respectively. The ultrasensitive and contemporary tests’ accuracy for MI types 4a and 5 diagnoses are equivalent when adjusted for these new cutoffs. The hs-cTnI assays had lower accuracy than contemporary tests for MI types 4a and 5 diagnoses.

Immediate Results after Multiple Arterial Grafts in Coronary Artery Bypass Graft Surgery in the São Paulo State: Cross Cohort Study

BACKGROUND

The short-term results after using arterial grafts still raise questions and doubts for medical society.

OBJECTIVE

To compare the immediate outcomes of patients undergoing single arterial graft versus multiple arterial grafts coronary artery bypass grafting surgery.

METHODS

Cross-sectional cohort study in the São Paulo Registry of Cardiovascular Surgery II (REPLICCAR II). Perioperative data from 3122 patients were grouped by the number of arterial grafts used, and their outcomes were compared: reoperation, deep sternal wound infection (DSWI), stroke, acute kidney injury, prolonged intubation (>24 hours), short hospital stay (<6 days), prolonged hospital stay (>14 days), morbidity and mortality. Propensity Score Matching (PSM) matched 1062 patients, adjusted for the mortality risk.

RESULTS

After PSM, the single arterial graft group showed patients with advanced age, more former smokers, hypertension, diabetes, stable angina, and previous myocardial infarction. In the multiple arterial grafts, there was a predominance of males, recent pneumonia, and urgent surgeries. After the procedure, there was a higher incidence of pleural effusion (p=0.042), pneumonia (p=0.01), reintubation (p=0.006), DSWI (p=0.007), and sternal debridement (p=0.015) in the multiple arterial grafts group, however, less need for blood transfusion (p=0.005), extremity infections (p=0.002) and shorter hospital stays (p=0.036). Bilateral use of the internal thoracic artery was not related to increased DSWI rate, but glycosylated hemoglobin >6.40% (p=0.048).

CONCLUSION

Patients undergoing the multiarterial technique had a higher incidence of pulmonary complications, and DSWI, where glycosylated hemoglobin ≥6.40%, had a greater influence on the infectious outcome than the choice of grafts.

Reasons for disagreement between screening and standard echocardiography in primary care: data from the PROVAR + study : Disagreement between screening and standard echo

We aimed to evaluate the reasons for disagreement between screening echocardiography (echo), acquired by nonexperts, and standard echo in the Brazilian primary care (PC). Over 20 months, 22 PC workers were trained on simplified handheld (GE VSCAN) echo protocols. Screening groups, consisting of patients aged 17-20, 35-40 and 60-65 years, and patients referred for clinical indications underwent focused echo. Studies were remotelyinterpreted in US and Brazil, and those diagnosed with major or severe HD were referred for standard echoperformed by an expert. Major HD was defined as moderate to severe valve disease, ventriculardysfunction/hypertrophy, pericardial effusion or wall-motion abnormalities. A random sample of exams wasselected for evaluation of variables accounting for disagreement. A sample of 768 patients was analyzed, 651(85%) in the referred group. Quality issues were reported in 5.8%, and the random Kappa for major HD between screening and standard echo was 0.51. The most frequent reasons for disagreement were: overestimation of mitral regurgitation (MR) (17.9%, N=138), left ventricular (LV) dysfunction (15.7%, N=121), aortic regurgitation (AR) (15.2%, N=117), LV hypertrophy (13.5%, N=104) and tricuspid regurgitation (12.7%, N=98). Misdiagnosis of mitral and aortic morphological abnormalities was observed in 12.4% and 3.0%, and underestimation of AR and MR occurred in 4.6% and 11.1%. Among 257 patients with suspected mild/moderate MR, 129 were reclassified to normal. In conclusion, although screening echo with task-shifting in PC is a promising tool in low-income areas, estimation of valve regurgitation and LV function and size account for considerable disagreement with standard exams.

Factors associated with demand for emergency medical services by people with hypertension and diabetes

OBJECTIVES

to analyze the association between recurrence of emergency service visits due to lack of blood pressure and/or glycemic control with sociodemographic variables and disease registration in Primary Care.

METHODS

quantitative study, which consulted medical records of people who attended these services two or more times for 26 months. Descriptive statistics and multiple logistic regression models were used in analysis.

RESULTS

most people did not have hypertension and/or diabetes record in their Primary Care records. The absence of this record was more frequent in males, aged between 18 and 59 years, with low education and lack of blood pressure. There was association between greater number of people seeking these services in the same year and not monitoring the chronic condition in specialized care.

CONCLUSIONS

people who do not follow up hypertension and/or diabetes in Primary Care are more likely to need assistance due to blood pressure and/or glycemic management.

Ischemic stroke mortality and time for hospital arrival: analysis of the first 90 days

OBJECTIVE

To analyze the association between time of arrival at a reference hospital and mortality of people with ischemic stroke.

METHOD

Descriptive and inferential statistics were used. Modifying and confounding variables between time of arrival and mortality were observed in the multivariate analysis. The Akaike Information Criterion was used to choose the model. Statistical significance of 5% and risk correction using the Poisson Model were adopted.

RESULTS

Most participants arrived within 4.5 hours of symptom onset or wake up stroke to the referral hospital and 19.4% died. The score of the National Institute of Health Stroke Scale was a modifier. In the multivariate model stratified by scale score ≥14, arrival time >4.5h was associated with lower mortality; and age ≥60 years and having Atrial Fibrillation, to higher mortality. In the model stratified by score ≤13, previous Rankin ≥3, and presence of atrial fibrillation were predictors of mortality.

CONCLUSION

The relationship between time of arrival and mortality up to 90 days was modified by the National Institute of Health Stroke Scale. Prior Rankin ≥3, atrial fibrillation, time to arrival ≤4.5h, and age ≥60 years contributed to higher mortality.

Arrival time at a referral hospital and functional disability of people with stroke: a cohort study

BACKGROUND

Stroke is a major cause of death and functional disability worldwide. Knowledge of the associated factors is essential for defining education, management, and healthcare strategies.

OBJECTIVE

To analyze the association between arrival time at a neurology referral hospital (ATRH) and functional disability in patients with ischemic stroke 90 days after the event.

DESIGN AND SETTING

Prospective cohort study conducted at a public institution of higher education in Brazil.

METHODS

This study included 241 people aged ≥ 18 years who presented ischemic stroke. The exclusion criteria were death, inability to communicate without companions who could answer the research questions, and > 10 days since ictus. Disability was assessed using the Rankin score (mR). Variables for which associations showed a P value ≤ 0.20 in bivariate analysis were tested as modifiers between ATRH and disability. Significant interaction terms were used for multivariate analysis. Multivariate logistic regression analysis was performed with all variables, arriving at the complete model and adjusted beta measures. The confounding variables were included in the robust logistic regression model, and Akaike's Information Criterion was adopted to choose the final model. The Poisson model assumes a statistical significance of 5% and risk correction.

RESULTS

Most participants (56.0%) arrived at the hospital within 4.5 hours of symptom onset, and 51.7% presented with mRs of 3 to 5 after 90 days of ictus. In the multivariate model, ATRH ≥ 4.5 hours and females were associated with more significant disability.

CONCLUSIONS

Arrival at the referral hospital 4.5 hours after the onset of symptoms or wake-up stroke was an independent predictor of a high degree of functional disability.

The direct and indirect costs of cardiovascular diseases in Brazil

OBJECTIVE

To evaluate the direct and indirect costs of cardiovascular diseases (such as coronary heart disease and stroke) by sex and age group, attributed to the excessive consumption of salt, saturated fat and trans fat in Brazil.

MATERIALS AND METHODS

The data for estimating the Population Attributable Fraction (PAF) corresponding to the consumption of salt, saturated fat and trans-fat were obtained from the Household Budget Survey 2017-2018. The calculation of direct costs for cardiovascular diseases (CVD) was made from the accounting sum of costs with hospitalizations and outpatient care found in the National Health System (Hospital Information System and Outpatient Information System), from 2017 to 2019, including the costs of treatment, such as medical consultations, medical procedures, and drugs. Regarding the indirect costs, they were measured by the loss of human capital, given the premature death, resulting in loss of productivity. To define the attributable costs, they were multiplied by the PAF.

RESULTS

Higher burden of CVD attributable to the consumption of salt, saturated fat and trans fat were observed in younger individuals, which progressively decreased with advancing age, but still generated economic costs in the order of US$ 7.18 billion, in addition to 1.53 million productive years of life lost (YLL) to premature death, if considering salt as an inducer. Although attributable burden of CVD is higher among younger individuals, the highest costs are associated with males aged 45 to 74 years old for direct costs and 45 to 64 years old for indirect costs.

CONCLUSION

The attributable fractions to consumption of salt are the ones that cause the most effects on CVD, followed by saturated fat and trans fat, with direct and indirect costs being higher for males.

Access to rehabilitation after stroke in Brazil (AReA study): multicenter study protocol

BACKGROUND

Most of the Brazilian population relies on public healthcare and stroke is a major cause of disability in this country of continental dimensions. There is limited information about access to rehabilitation after stroke in Brazil.

OBJECTIVE

To provide comprehensive information about Access to Rehabilitation After discharge from public hospitals in Brazil (AReA study), up to 6 months after stroke.

METHODS

The present study intends to collect information from 17 public health centers in 16 Brazilian cities in the 5 macroregions of the country. Each center will include 36 participants (n = 612). The inclusion criteria are: age ≥ 18 years old; ischemic or hemorrhagic stroke, from 6 months to 1 year prior to the interview; admission to a public hospital in the acute phase after stroke; any neurological impairment poststroke; patient or caregiver able to provide informed consent and answer the survey. Patients can only be recruited in public neurology or internal medicine outpatient clinics. Outcomes will be assessed by a standard questionnaire about rehabilitation referrals, the rehabilitation program (current status, duration in months, number of sessions per week) and instructions received. In addition, patients will be asked about preferences for locations of rehabilitation (hospitals, clinics, or at home).

TRIAL STATUS

The study is ongoing. Recruitment started on January 31^st, 2020 and is planned to continue until June 2022.

CONCLUSION

The AReA study will fill a gap in knowledge about access to stroke rehabilitation in the public health system in different Brazilian regions.

Tropical diseases and risk of hypertension in the Amazon Basin: a cross-sectional study

Although infectious diseases have been associated with cardiovascular conditions, little is known about tropical disease burden and hypertension. We hypothesized that a history of tropical infections was associated with hypertension. We examined participants from outpatient clinics in the Amazon Basin who were interviewed about prior exposure to tropical diseases, including dengue, malaria hospitalization, and leishmaniasis. Hypertension was defined as a prior physician diagnosis of hypertension, treatment with anti-hypertensive medication, or a systolic blood pressure ≥140 mmHg and/or a diastolic blood pressure ≥90 mmHg. We used logistic regression models to examine the relationship between tropical infectious disease and hypertension. We included 556 participants (mean age 41 ± 15 years, 61% women) of whom 214 (38%) had hypertension and 354 (64%) had a history of tropical infectious disease. The distribution of tropical diseases was: dengue 270 (76%), malaria hospitalization 104 (29%) and leishmaniasis 48 (14%). Any prior tropical infection was significantly associated with prevalent hypertension (odds ratio 1.76 [95% CI 1.22-2.54], P = 0.003) and the association remained significant after adjusting for age, sex, body mass index, diabetes, hypercholesterolemia, socioeconomic status, smoking, vegetable intake and serum creatinine. Persons with a history of ≥2 tropical infections (n = 64) had the greatest risk of hypertension (odds ratio 2.04 [95% CI 1.15-3.63], P = 0.015). In adjusted models, prior infection with dengue was associated with hypertension (P = 0.006), but no associations were found with malaria hospitalization (P = 0.39) or leishmaniasis (P = 0.98). In conclusion, a history of tropical infectious disease was associated with hypertension. This finding supports the idea that pathogen burden may be related to cardiovascular conditions.

Changes in childhood stroke mortality from 1990 to 2019 in Brazil and its federative units

This research analyzed the temporal trend of stroke mortality in children aged 0-14 years, from 1990 to 2019, in Brazil and its federative units. This ecological study used data from the Global Burden of Disease, a study led by the Institute for Health Metrics and Evaluation. Stroke definition considered the International Classification of Diseases according to codes G45, G46, and I60-I69. Age-standardized mortality rates and the mean annual percentage change (APC) in mortality rates were estimated. Stroke mortality trends decreased, with an APC of - 3.9% (95% CI - 4.5; - 3.3; p < 0.001). Reducing trends were found in all but two states, where they were stationary. Maranhão (- 6.5%; 95% CI - 7.6; - 5.4; p < 0.001) had the greatest reduction and Rondônia, the smallest (- 1.2%; 95% CI - 2.3; - 0.1, p = 0.027). Decrease was more important in children < 5 (- 5.8%; 95% CI - 6.3; - 5.2; p < 0.001) compared to 5-14 years old (- 2.1%; 95% CI - 2.9; - 1.3; p < 0.001); additionally, it was greater in girls (- 4.1%; 95% CI - 4.6; - 3.5; p < 0.001) than in boys (- 3.8%; 95% IC - 4.5; - 3.1; p < 0.001). Ischemic stroke had the highest APC (- 6.1%; 95% CI - 6.8; - 5.3; p < 0.001), followed by intracranial hemorrhage (- 5.3%; 95% CI - 6.1; - 4.5; p < 0.001) and subarachnoid hemorrhage (- 2.7%; 95% CI - 3.3; - 2.1; p < 0.001). Largest reductions were seen in states with more vulnerable socioeconomic contexts. The stationary trends and lowest APCs were concentrated in the northern region, which had greater impact of diseases and less favorable outcomes.

Approach to adult patients with primary hypothyroidism in some special situations: a position statement from the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM)

Primary hypothyroidism is a common disorder in clinical practice. The management of most cases of hypothyroidism is usually straightforward, but the best approach in some special situations may raise questions among physicians. This position statement was prepared by experts from the Brazilian Society of Endocrinology and Metabolism to guide the management of three special situations, namely, hypothyroidism in the elderly, subclinical hypothyroidism in patients with heart disease, and difficult-to-control hypothyroidism. The authors prepared the present statement after conducting a search on the databases MEDLINE/PubMed, LILACS, and SciELO and selecting articles with the best evidence quality addressing the selected situations. The statement presents information about the current approach to patients in these special situations.

Mortality from diseases of the circulatory system in Brazil and its relationship with social determinants focusing on vulnerability: an ecological study

Background

Deaths from diseases of the circulatory system and ischemic heart diseases are declining, but slowly in developing countries, emphasizing its probable relationship with determinants of social vulnerability.

Objectives

To analyze the temporal progression of mortality rates of diseases of the circulatory system and ischemic heart diseases from 1980 to 2019 and the association of the rates with the Municipal Human Development Index and Social Vulnerability Index in Brazil.

Methods

We estimated the crude and standardized mortality rates of diseases of the circulatory system and ischemic heart diseases and analyzed the relationship between the obtained data and the Municipal Human Development Index and Social Vulnerability Index. Data on deaths and population were obtained from the DATASUS. The Municipal Human Development Index and the Social Vulnerability Index of each federative unit were extracted from the websites Atlas Brazil and Atlas of Social Vulnerability, respectively.

Results

The age-standardized mortality rates of diseases of the circulatory system and ischemic heart diseases showed a downward trend nationwide, which was unequal across the federative units. There was an inversely proportional relationship between the standardized mortality rates of diseases of the circulatory system and ischemic heart diseases and the Municipal Human Development Index. The downward mortality trend was observed when the indices were greater than 0.70 and 0.75, respectively. The Social Vulnerability Index was directly proportional to the standardized mortality rates of diseases of the circulatory system and ischemic heart diseases. An upward mortality trend was observed with a Social Vulnerability Index greater than 0.35.

Conclusions

Social determinants represented by the Municipal Human Development Index and the Social Vulnerability Index were related to mortality from diseases of the circulatory system and ischemic heart diseases across the Brazilian federative units. The units with most development and least social inequalities had the lowest mortality from these causes. The most vulnerable die the most.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14294-3.

The collateral damage of COVID-19 to cardiovascular services: a meta-analysis

AIMS

The effect of the COVID-19 pandemic on care and outcomes across non-COVID-19 cardiovascular (CV) diseases is unknown. A systematic review and meta-analysis was performed to quantify the effect and investigate for variation by CV disease, geographic region, country income classification and the time course of the pandemic.

METHODS AND RESULTS

From January 2019 to December 2021, Medline and Embase databases were searched for observational studies comparing a pandemic and pre-pandemic period with relation to CV disease hospitalisations, diagnostic and interventional procedures, outpatient consultations, and mortality. Observational data were synthesised by incidence rate ratios (IRR) and risk ratios (RR) for binary outcomes and weighted mean differences for continuous outcomes with 95% confidence intervals. The study was registered with PROSPERO (CRD42021265930). A total of 158 studies, covering 49 countries and 6 continents, were used for quantitative synthesis. Most studies (80%) reported information for high-income countries (HICs). Across all CV disease and geographies there were fewer hospitalisations, diagnostic and interventional procedures, and outpatient consultations during the pandemic. By meta-regression, in low-middle income countries (LMICs) compared to HICs the decline in ST-segment elevation myocardial infarction (STEMI) hospitalisations (RR 0.79, 95% confidence interval [CI] 0.66-0.94) and revascularisation (RR 0.73, 95% CI 0.62-0.87) was more severe. In LMICs, but not HICs, in-hospital mortality increased for STEMI (RR 1.22, 95% CI 1.10-1.37) and heart failure (RR 1.08, 95% CI 1.04-1.12). The magnitude of decline in hospitalisations for CV diseases did not differ between the first and second wave.

CONCLUSIONS

There was substantial global collateral CV damage during the COVID-19 pandemic with disparity in severity by country income classification.

Is self-rated health associated with cardiovascular risk factors and disease in a low-income setting? A cross-sectional study from the Amazon Basin of Brazil

OBJECTIVE

Prior studies have suggested that self-rated health may be a useful indicator of cardiovascular disease. Consequently, we aimed to assess the relationship between self-rated health, cardiovascular risk factors and subclinical cardiac disease in the Amazon Basin.

DESIGN

Cross-sectional study.

SETTING, PARTICIPANTS AND INTERVENTIONS

In participants from the Amazon Basin of Brazil we obtained self-rated health according to a Visual Analogue Scale, ranging from 0 (poor) to 100 (excellent). We performed questionnaires, physical examination and echocardiography. Logistic and linear regression models were applied to assess self-rated health, cardiac risk factors and cardiac disease by echocardiography. Multivariable models were mutually adjusted for other cardiovascular risk factors, clinical and socioeconomic data, and known cardiac disease.

OUTCOME MEASURES

Cardiovascular risk factors and subclincial cardiac disease by echocardiography.

RESULTS

A total of 574 participants (mean age 41 years, 61% female) provided information on self-rated health (mean 75±21 (IQR 60-90) points). Self-rated health (per 10-point increase) was negatively associated with hypertension (OR 0.87 (95% CI 0.78 to 0.97), p=0.01), hypercholesterolaemia (OR 0.89 (95%CI 0.80 to 0.99), p=0.04) and positively with healthy diet (OR 1.13 (95%CI 1.04 to 1.24), p=0.004). Sex modified these associations (p-interaction <0.05) such that higher self-rated health was associated with healthy diet and physical activity in men, and lower odds of hypertension and hypercholesterolaemia in women. No relationship was found with left ventricular ejection fraction <45% (OR 0.97 (95% CI 0.77 to 1.23), p=0.8), left ventricular hypertrophy (OR 0.97 (95% CI 0.76 to 1.24), p=0.81) or diastolic dysfunction (OR 1.09 (95% CI 0.85 to 1.40), p=0.51).

CONCLUSION

Self-rated health was positively associated with health parameters in the Amazon Basin, but not with subclinical cardiac disease by echocardiography. Our findings are of hypothesis generating nature and future studies should aim to determine whether assessment of self-rated health may be useful for screening related to policy-making or lifestyle interventions.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov: NCT04445103; Post-results.

Consumers' Response to Sugar Label Formats in Packaged Foods: A Multi-Methods Study in Brazil

Providing information about the sugar content of packaged foods on product labels is an important strategy to lower consumers' sugar intake. This study assessed the effect of exposure to different sugar labels on consumers' understanding of the sugar content of foods and their food choices. In the first phase, five focus groups were conducted with a convenience sample of Brazilian adults to explore their perceptions about food labelling in general and sugar labelling in particular. Based on the qualitative results, four sugar label formats were developed and subsequently tested in a five-arm study on 1,277 adults via a randomised controlled online survey. The formats were: (i) no sugar information—control, (ii) total and added sugar content displayed in the Nutrition Information Panel (NIP), (iii) a front-of-package (FoP) octagonal warning for “high-in-sugar” products, (iv) a FoP magnifying glass warning for “high-in-sugar” products, and (v) a “high-in-sugar” warning text embedded on the NIP. Participants from the focus groups reported being confused about the meaning of “sugar” and “added sugar” on food labels and indicated that more interpretive labels, such as the FoP warnings, would help them choose products with low sugar content. In the experiment, all intervention sugar label formats improved participants' understanding of the sugar content of the tested food products, with the FoP warnings (iii and iv) showing the best results. While non-significant differences among label conditions were observed for food choices, the FoP octagonal warning prompted participants to choose high-in-sugar products less often. Given current public policy agendas aiming to reduce added sugar intake, there is a need to strengthen food labelling policies and nutrition disclosure policies that target the display of added sugar and build consumer awareness in using these tools to avoid high-in-sugar products.

The impact of the strategic action plan to combat chronic non-communicable diseases on hospital admissions and deaths from cardiovascular diseases in Brazil

Chronic Non-Communicable Diseases (NCDs) are the main causes of death worldwide, responsible for millions of hospital admissions per year, especially cardiovascular diseases (CVD). Several strategies for controlling and coping with these diseases have been developed in several countries. The aim of the study was to evaluate the impact of the Strategic Action Plan to Combat NCDs (2011-2022) on hospital admissions, deaths and mortality rate in Brazil, classified by CVD. This is a descriptive study, with secondary data from the Hospital Information System of the Unified Health System (SIH/SUS). Hospital admissions, deaths and mortality rate due to CVD in the Brazilian population aged over 20 years were analyzed, according to region, sex and age group. Statistical analysis was performed using the GraphPad Prism program. Data normality was assessed using the Komogorov Smirnov test and the comparison between groups and year periods was performed using the two-way ANOVA test with Tukey's post hoc test. A value of p<0.05 was considered significant. In this study, in most analyses, a reduction in the hospitalization rates of the adult population was observed after the implementation of the plan, however, there was no improvement in relation to the number of deaths and mortality rate from CVD. This shows that there is still a long way to go to reduce the impact of these diseases in Brazil, and they reaffirm the need for and importance of maintaining the prevention of their risk factors, the social determinants of health and the reorganization of care in the face of to population aging. Such findings contribute with information that allow better control and monitoring of CVD and should be considered when implementing new strategies for prevention, care and control of risk factors.

Achievement of LDL-Cholesterol Goals after Acute Myocardial Infarction: Real-World Data from the City of Curitiba Public Health System

BACKGROUND

Reduction of LDL-cholesterol (LDL-c) levels is the cornerstone in risk reduction, but many high-risk patients are not achieving the recommended lipid goals, even in high-income countries.

OBJECTIVE

To evaluate whether patients seen in the city of Curitiba public health system are reaching LDL-c goals after an acute myocardial infarction (AMI).

METHODS

This retrospective cohort explored the data of patients admitted with AMI between 2008 and 2015 in public hospitals from the city of Curitiba. In order to evaluate the attainment of the LDL-c target, we have used the last value registered in the database for each patient up to 2016. For those who had at least one LDL-c registered in the year before AMI, percentage of reduction was calculated. The level of significance adopted for statistical analysis was p<0.05.

RESULTS

Of 7,066 patients admitted for AMI, 1,451 were followed up in an out-patient setting and had at least one evaluation of LDL-c. Mean age was 60.8±11.4 years and 35.8%, 35.2%, 21.5%, and 7.4% of patients had LDL-c levels ≥100, 70-99, 50-69 and <50 mg/dL, respectively. Of these, 377 patients also had at least one LDL-c evaluation before the AMI. Mean LDL-c concentrations were 128.0 and 92.2 mg/dL before and after AMI, with a mean reduction of 24.3% (35.7 mg/dL). LDL-c levels were reduced by more than 50% in only 18.3% of the cases.

CONCLUSION

In the city of Curitiba public health system patients, after myocardial infarction, are not achieving adequate LDL-c levels after AMI.

Disparities in Stroke Patient-Reported Outcomes Measurement Between Healthcare Systems in Brazil

Introduction

Acute stroke interventions, such as stroke units and reperfusion therapy, have the potential to improve outcomes. However, there are many disparities in patient characteristics and access to the best stroke care. Thus, we aim to compare patient-reported outcome measures (PROMs) after stroke in two stroke centers representing the public and private healthcare systems in Brazil.

Methods

PROMs through the International Consortium for Health Outcomes Measures (ICHOM) were assessed at 90 days after the stroke to compare two Brazilian hospitals in southern Brazil: a public university and a private stroke center, both with stroke protocols and stroke units.

Results

When compared with the private setting (n = 165), patients from the public hospital (n = 175) were younger, had poorer control of risk factors, had more frequent previous strokes, and arrived with more severe strokes. Both hospitals had a similar percentage of IV thrombolysis treatment. Only 5 patients received mechanical thrombectomy (MT), all in the private hospital. Public hospital patients presented significantly worse outcomes at 3 months, including worse quality of life and functional dependence (60 vs. 48%, p = 0.03). Poor outcome, as measured by the mRS score, was significantly associated with older age, higher NIHSS score, and the presence of heart failure. However, the public practice was a strong predictor of any self-reported disability.

Conclusion

Patients assisted at a good quality public stroke center with the same protocol used in the private hospital presented worse disability as measured by mRS and patient-reported outcome measures, with greater inability to communicate, dress, toilet, feed, and walk.

Reperfusion Therapy Optimization in Acute Myocardial Infarction with ST-Segment Elevation using WhatsApp®-Based Telemedicine

BACKGROUND

About 40% of patients with ST-segment elevation myocardial infarction (STEMI) in Brazil do not receive reperfusion therapy.

OBJECTIVE

The use of a telemedicine network based on WhatsApp® could increase the percentage of patients receiving reperfusion therapy.

METHODS

A cross-sectional study analyzed outcomes before and after the organization of a telemedicine network to send the electrocardiogram via WhatsApp® of patients suspected of STEMI from 25 municipalities that are members of the Regional Health Department of Ribeirão Preto (DRS-XIII) to a tertiary hospital, which could authorize immediate patient transfer using the same system. The analyzed outcomes included the percentage of patients who received reperfusion therapy and the in-hospital mortality rate. A p value < 0.05 was considered statistically significant.

RESULTS

The study compared 82 patients before (February 1, 2016 to January 31, 2018) with 196 patients after this network implementation (February 1, 2018 to January 31, 2020). After implementing this network, there was a significant increase in the proportion of patients who received reperfusion therapy (60% vs. 92%), relative risk (RR): 1.594 [95% confidence interval (CI) 1.331 - 1.909], p < 0.0001 and decrease in the in-hospital mortality rate (13.4% vs. 5.6%), RR: 0.418 [95%CI 0.189 - 0.927], p = 0.028.

CONCLUSION

The use of WhatsApp®-based telemedicine has led to an increase in the percentage of patients with STEMI who received reperfusion therapy and a decrease in the in-hospital mortality rate.

Risk factors associated with hypertension among inmates in southern Brazil

Objective: To identify the association between risk factors for systemic arterial hypertension and blood pressure levels in prisoners under a closed regime. Materials and methods: Cross-sectional study conducted with prisoners under a closed regime between February and September 2019. A total of 240 men from a penitentiary complex in southern Brazil participated in the study. A semi-structured instrument based on the national guidelines for cardiovascular diseases was used for data collection. Results: Univariate analysis allowed us to identify that physical exercise was negatively associated with the development of systemic arterial hypertension (p = 0.034). However, body mass index and abdominal circumference were positively associated with cardiovascular risk and systemic arterial hypertension (p = 0.000). Through multivariate analysis, we noted the statistical significance of the body mass index when controlled for all other variables in the model (adjusted OR = 2.33). Conclusions: Risk factors for the development of systemic arterial hypertension are present in the prison environment to a similar degree as in the general population; particularly the absence ofphysical exercise and altered body mass index and abdominal circumference. It is worth mentioning that the body mass index was the variable of greater statistical significance, since, when altered, it increased 2.33 times the chance of inmates to develop systemic arterial hypertension.

Effect of Cell Therapy and Exercise Training in a Stroke Model, Considering the Cell Track by Molecular Image and Behavioral Analysis

The goal of this study is to see how combining physical activity with cell treatment impacts functional recovery in a stroke model. Molecular imaging and multimodal nanoparticles assisted in cell tracking and longitudinal monitoring (MNP). The viability of mesenchymal stem cell (MSC) was determined using a 3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide (MTT) assay and bioluminescent image (BLI) after lentiviral transduction and MNP labeling. At random, the animals were divided into 5 groups (control-G1, and experimental G2-G5). The photothrombotic stroke induction was confirmed by local blood perfusion reduction and Triphenyltetrazolium chloride (TTC), and MSC in the G3 and G5 groups were implanted after 24 h, with BLI and near-infrared fluorescence image (NIRF) tracking these cells at 28 h, 2, 7, 14, and 28 days. During a 28-day period, the G5 also conducted physical training, whereas the G4 simply did the training. At 0, 7, 14, and 28 days, the animals were functionally tested using a cylinder test and a spontaneous motor activity test. MNP internalization in MSC was confirmed using brightfield and fluorescence microscopy. In relation to G1 group, only 3% of cell viability reduced. The G2–G5 groups showed more than 69% of blood perfusion reduction. The G5 group performed better over time, with a progressive recovery of symmetry and an increase of fast vertical movements. Up to 7 days, BLI and NIRF followed MSC at the damaged site, demonstrating a signal rise that could be connected to cell proliferation at the injury site during the acute phase of stroke. Local MSC therapy mixed with physical activity resulted in better results in alleviating motor dysfunction, particularly during the acute period. When it comes to neurorehabilitation, this alternative therapy could be a suitable fit.

Impact of the COVID-19 pandemic on hospital admissions for cardiovascular diseases in a large Brazilian urban center

INTRODUCTION

The COVID-19 pandemic has had a great impact on the behavior of individuals and the organization of health systems. This study analyzed the COVID-19 pandemic's effect on public hospitalizations for cardiovascular diseases (CVD) in a large city in Brazil, Belo Horizonte, MG, with approximately 2.5 million inhabitants.

METHODS

In a time-series analysis, this study used administrative data from the national "Hospital Information System" from 2010 to February 2020 to estimate the expected number of hospitalizations for CVD by month during the COVID-19 pandemic in Belo Horizonte in 2020 using the Auto-Regressive Integrated Moving Average model. For CVD, this study compared the expected number of hospital admissions, intensive care use, deaths during hospitalization, and mean length of stay with the observed number during the period.

RESULTS

There were 6,517 hospitalizations for CVD from March to December 2020, a decrease of 16.3% (95% CI: 4.7-25.3) compared to the projected. The number of intensive care hospitalizations for CVD fell 24.1% (95% CI 13-32.7). The number of deaths also decreased (17.4% [80% CI: 0 - 0.30]), along with the reduction in hospitalizations, as did the length of stay for CVD hospitalizations. These reductions, however, were not significant.

CONCLUSIONS

Hospitalizations for CVD were 16.3% lower than expected in a large Brazilian city, possibly due to the fear of getting infected or going to hospitals. Public campaigns informing how to proceed in case of CVD show that prompt urgent attention is essential to mitigate the indirect effects of the pandemic on CVD.

Burden of Cardiovascular diseases attributable to risk factors in Brazil: data from the "Global Burden of Disease 2019" study

INTRODUCTION

To better understand trends in the main cause of death in Brazil, we sought to analyze the burden of cardiovascular risk factors (RF) and cardiovascular diseases (CVD) attributable to specific RFs in Brazil from 1990 to 2019, using the estimates from the GBD 2019 study.

METHODS

To estimate RF exposure, the Summary Exposure Value (SEV) was used, whereas for disease burden attributed to RF, mortality and disability-adjusted life-years (DALY) due to CVD were used. For comparisons over time and between states, we compared age-standardized rates. The sociodemographic index (SDI) was used as a marker of socioeconomic conditions.

RESULTS

In 2019, 83% of CVD mortality in Brazil was attributable to RF. For SEV, there was a reduction in smoking and environmental RF, but an increase in metabolic RF. High systolic blood pressure and dietary risks continue to be the main RF for CVD mortality and DALY. While there was a decline in age-standardized mortality rates attributable to the evaluated RF, there was also a stability or increase in crude mortality rates, with the exception of smoking. It is important to highlight the increase in the risk of death attributable to a high body mass index. Regarding the analysis per state, SEVs and mortality attributable to RF were higher in those states with lower SDIs.

CONCLUSIONS

Despite the reduction in CVD mortality and DALY rates attributable to RF, the stability or increase in crude rates attributable to metabolic RFs is worrisome, requiring investments and a renewal of health policies.

Prevalence of rheumatic heart disease in adults from the Brazilian Amazon Basin

BACKGROUND

Rheumatic heart disease (RHD) continues to be a burden in low- and middle-income countries and prevalence estimates are lacking from South America. We aimed to determine the prevalence of RHD in the Brazilian Amazon Basin.

METHODS

We examined a random sample of adults (≥18 years) from the general population, who underwent echocardiographic image acquisition by a medical doctor. All images were analyzed according to (i) the 2012 World Heart Federation criteria and (ii) a simplified algorithm for RHD from a previously validated risk score (categories: low-, medium-, high-risk) which involved assessment of the mitral valve (leaflet thickening and excessive motion, regurgitation jet length) and aortic valve (thickening and any regurgitation).

RESULTS

A total of 488 adults were screened (mean age 40 ± 15 years, 38% men). The prevalence of RHD was 39/1000 adults (n = 17 definite and n = 2 borderline). Fourteen (74%) had pathological mitral regurgitation, four (21%) mitral stenosis, 0 (0%) pathological aortic regurgitation and six (32%) both mitral and aortic valve disease. None had a prior diagnosis of RHD, 10 (53%) had positive cardiac auscultation and two (11%) reported a history of rheumatic fever. The simplified algorithm identified four (21%) adults as low-risk, six (32%) as intermediate, and nine (47%) as high-risk.

CONCLUSIONS

The prevalence of RHD was 39/1000 in adults from the Brazilian Amazon Basin, indicating the need for screening programs in remote areas. A simplified model was only able to categorize every second case of RHD as high-risk. External validation of simplified screening models to increase feasibility in clinical practice are encouraged.

Validação de checklist para utilização em cirurgia cardíaca segura

RESUMO Objetivo Construir e validar um instrumento no formato checklist para utilização em cirurgia cardíaca segura. Método Pesquisa metodológica realizada nas seguintes etapas: revisão da literatura; construção dos itens e validação de conteúdo por especialistas em duas etapas, a nível regional com 9 e nacional com 14 juízes. Para análise dos dados, aplicou-se a taxa de concordância por item construído. Resultados A construção da versão 1 resultou em 49 itens, a versão 2 apresentou 46 itens, e a versão final 41 itens distribuídos em Sign in (1 a 27), Time out (28 a 32) e Sign out (33 a 41). Na versão final, todos os itens foram validados com concordância superior a 80%. Conclusão O checklist foi construído e validado quanto ao conteúdo, composto por 41 itens,e poderá ser utilizado na área de cirurgia cardíaca para a implementação de assistência segura aos pacientes submetidos a esses procedimentos.

Checklist validation for use in safe heart surgery

ABSTRACT Objective Build and validate an instrument in checklist format for use in safe cardiac surgery. Method Methodological research carried out in the following stages: literature review; national construction of items and content validation by experts in two stages, at regional level 9 and with 41 judges. For data analysis, the agreement rate per constructed item was determined. Results The construction of version 1 resulted in 49 items, version 2 presented 46 items, and the final version 41 items distributed in Sign in (1 to 27), Time out (28 to 32) and Sign out (33 to 41). All items obtained agreement greater than 80%, considering validated. Conclusion The checklist was built and validated in terms of content, consisting of 41 items, and can be used in the area of cardiac surgery for the implementation of safe care for patients undergoing these procedures.