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Oliveira GMMD, Brant LCC, Polanczyk CA, Malta DC, Biolo A, Nascimento BR, Souza MDFMD, Lorenzo ARD, Fagundes Júnior AADP, Schaan BD, Silva CGDSE, Castilho FMD, Cesena FHY, Soares GP, Xavier Junior GF, Barreto Filho JAS, Passaglia LG, Pinto Filho MM, Machline-Carrion MJ, Bittencourt MS, Pontes Neto OM, Villela PB, Teixeira RA, Stein R, Sampaio RO, Gaziano TA, Perel P, Roth GA, Ribeiro ALP. Cardiovascular Statistics - Brazil 2023. Arq Bras Cardiol 2024; 121:e20240079. [PMID: 38896747 PMCID: PMC11185831 DOI: 10.36660/abc.20240079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Affiliation(s)
- Gláucia Maria Moraes de Oliveira
- Instituto do Coração Edson Saad da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | - Luisa Campos Caldeira Brant
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
- Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
| | - Carisi Anne Polanczyk
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
- Hospital Moinhos de Vento, Porto Alegre, RS - Brasil
- Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS - Brasil
| | | | - Andreia Biolo
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
- Hospital Moinhos de Vento, Porto Alegre, RS - Brasil
- Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS - Brasil
| | - Bruno Ramos Nascimento
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
- Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
- Hospital Madre Teresa, Belo Horizonte, MG - Brasil
| | | | - Andrea Rocha De Lorenzo
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
- Instituto Nacional de Cardiologia, Rio de Janeiro, RJ - Brasil
| | | | - Beatriz D Schaan
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
- Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS - Brasil
| | - Christina Grüne de Souza E Silva
- Instituto do Coração Edson Saad da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | - Fábio Morato de Castilho
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
- Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
| | | | - Gabriel Porto Soares
- Instituto do Coração Edson Saad da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
- Curso de Medicina da Universidade de Vassouras, Vassouras, RJ - Brasil
| | | | | | - Luiz Guilherme Passaglia
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
- Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
| | - Marcelo Martins Pinto Filho
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
- Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
| | | | | | - Octavio M Pontes Neto
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (USP), São Paulo, SP - Brasil
| | - Paolo Blanco Villela
- Instituto do Coração Edson Saad da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | - Ricardo Stein
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | - Roney Orismar Sampaio
- Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP - Brasil
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Thomaz A Gaziano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston - EUA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston - EUA
| | - Pablo Perel
- World Heart Federation, Geneva - Suíça
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, Londres - Inglaterra
| | - Gregory A Roth
- Division of Cardiology, Department of Medicine, University of Washington, Washington - EUA
| | - Antonio Luiz Pinho Ribeiro
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
- Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brasil
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Junior WBC, Ferreia NN, Santos LDM, Borges PBDA, de Albuquerque CP, Espindola LS, Nóbrega ODT, Gomes CM, da Mota LMH, Soares AADSM. Negative impact of SARS-CoV-2 infection in acute coronary syndrome mortality in a Latin American cohort study. Front Med (Lausanne) 2022; 9:959769. [PMID: 36213662 PMCID: PMC9532529 DOI: 10.3389/fmed.2022.959769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/24/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose COVID-19 infection has been associated with a high risk of complications and death among patients with acute coronary syndrome (ACS). However, there is little information on the simultaneous involvement in Latin American countries. Methods In the period between May 2020 and February 2021, an observational, longitudinal, prospective cohort study with two parallel branches was conducted in private and public hospitals in Brasilia, Brazil, including patients with ACS with and without a positive SARS-CoV-2 test result during hospitalization. Results A total of 149 patients with ACS were included (75 with COVID-19 and 74 controls). Patients with COVID-19 exhibited an average of 62 years of age, 57% men, 40% diabetics, 67% hypertensive, 48% had an ACS with ST-segment elevation, Killip I was predominant, a low Syntax Score in 72%, with an average Grace Score of 117, and a length of hospitalization of 43 days in average. The control branch was similar in clinical characteristics, except for a lower proportion of ST-segment elevation ACS (16%, p < 0.01) and a higher incidence of arrhythmias (8 vs. 20 %, p = 0.03). Using the Cox regression method of analysis of covariates collected in the study, it was identified that patients with COVID-19 had a risk of death 2.34 times higher than patients without COVID-19 (p = 0.049). Conclusion In this study conducted in a Latin American capital, SARS-CoV-2 infection predicted a higher chance of death in patients admitted with ACS, which is a finding that reinforces the need for greater care when diseases develop in overlapping ways.
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Affiliation(s)
- Wenderval Borges Carvalho Junior
- Graduate Program in Medical Sciences, Faculty of Medicine, University of Brasilia-UnB, Brazilia, Brazil
- University Hospital of Brasilia, HUB-UnB-EBSERH, Brazilia, Brazil
| | - Neila Nunes Ferreia
- Graduate Program in Medical Sciences, Faculty of Medicine, University of Brasilia-UnB, Brazilia, Brazil
| | - Luciano de Moura Santos
- Graduate Program in Medical Sciences, Faculty of Medicine, University of Brasilia-UnB, Brazilia, Brazil
| | | | - Cleandro Pires de Albuquerque
- Graduate Program in Medical Sciences, Faculty of Medicine, University of Brasilia-UnB, Brazilia, Brazil
- University Hospital of Brasilia, HUB-UnB-EBSERH, Brazilia, Brazil
| | - Laila Salmen Espindola
- Graduate Program in Medical Sciences, Faculty of Medicine, University of Brasilia-UnB, Brazilia, Brazil
| | - Otávio de Toledo Nóbrega
- Graduate Program in Medical Sciences, Faculty of Medicine, University of Brasilia-UnB, Brazilia, Brazil
| | - Ciro Martins Gomes
- Graduate Program in Medical Sciences, Faculty of Medicine, University of Brasilia-UnB, Brazilia, Brazil
- University Hospital of Brasilia, HUB-UnB-EBSERH, Brazilia, Brazil
| | - Licia Maria Henrique da Mota
- Graduate Program in Medical Sciences, Faculty of Medicine, University of Brasilia-UnB, Brazilia, Brazil
- University Hospital of Brasilia, HUB-UnB-EBSERH, Brazilia, Brazil
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Ahmad B, Skorska A, Wolfien M, Sadraddin H, Lemcke H, Vasudevan P, Wolkenhauer O, Steinhoff G, David R, Gaebel R. The Effects of Hypoxic Preconditioned Murine Mesenchymal Stem Cells on Post-Infarct Arrhythmias in the Mouse Model. Int J Mol Sci 2022; 23:ijms23168843. [PMID: 36012110 PMCID: PMC9408396 DOI: 10.3390/ijms23168843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022] Open
Abstract
Ventricular arrhythmias associated with myocardial infarction (MI) have a significant impact on mortality in patients following heart attack. Therefore, targeted reduction of arrhythmia represents a therapeutic approach for the prevention and treatment of severe events after infarction. Recent research transplanting mesenchymal stem cells (MSC) showed their potential in MI therapy. Our study aimed to investigate the effects of MSC injection on post-infarction arrhythmia. We used our murine double infarction model, which we previously established, to more closely mimic the clinical situation and intramyocardially injected hypoxic pre-conditioned murine MSC to the infarction border. Thereafter, various types of arrhythmias were recorded and analyzed. We observed a homogenous distribution of all types of arrhythmias after the first infarction, without any significant differences between the groups. Yet, MSC therapy after double infarction led to a highly significant reduction in simple and complex arrhythmias. Moreover, RNA-sequencing of samples from stem cell treated mice after re-infarction demonstrated a significant decline in most arrhythmias with reduced inflammatory pathways. Additionally, following stem-cell therapy we found numerous highly expressed genes to be either linked to lowering the risk of heart failure, cardiomyopathy or sudden cardiac death. Moreover, genes known to be associated with arrhythmogenesis and key mutations underlying arrhythmias were downregulated. In summary, our stem-cell therapy led to a reduction in cardiac arrhythmias after MI and showed a downregulation of already established inflammatory pathways. Furthermore, our study reveals gene regulation pathways that have a potentially direct influence on arrhythmogenesis after myocardial infarction.
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Affiliation(s)
- Beschan Ahmad
- Department of Cardiac Surgery, Rostock University Medical Center, 18057 Rostock, Germany
- Department of Life, Light & Matter, Interdisciplinary Faculty, Rostock University, 18059 Rostock, Germany
| | - Anna Skorska
- Department of Cardiac Surgery, Rostock University Medical Center, 18057 Rostock, Germany
- Department of Life, Light & Matter, Interdisciplinary Faculty, Rostock University, 18059 Rostock, Germany
| | - Markus Wolfien
- Department of Systems Biology and Bioinformatics, University of Rostock, 18051 Rostock, Germany
- Institute for Medical Informatics and Biometry, Faculty of Medicine Carl Gustav Carus, Technical University Dresden, 01307 Dresden, Germany
| | - Haval Sadraddin
- Department of Cardiac Surgery, Rostock University Medical Center, 18057 Rostock, Germany
- Department of Life, Light & Matter, Interdisciplinary Faculty, Rostock University, 18059 Rostock, Germany
| | - Heiko Lemcke
- Department of Cardiac Surgery, Rostock University Medical Center, 18057 Rostock, Germany
- Department of Life, Light & Matter, Interdisciplinary Faculty, Rostock University, 18059 Rostock, Germany
| | - Praveen Vasudevan
- Department of Cardiac Surgery, Rostock University Medical Center, 18057 Rostock, Germany
- Department of Life, Light & Matter, Interdisciplinary Faculty, Rostock University, 18059 Rostock, Germany
| | - Olaf Wolkenhauer
- Department of Systems Biology and Bioinformatics, University of Rostock, 18051 Rostock, Germany
| | - Gustav Steinhoff
- Department of Cardiac Surgery, Rostock University Medical Center, 18057 Rostock, Germany
- Department of Life, Light & Matter, Interdisciplinary Faculty, Rostock University, 18059 Rostock, Germany
| | - Robert David
- Department of Cardiac Surgery, Rostock University Medical Center, 18057 Rostock, Germany
- Department of Life, Light & Matter, Interdisciplinary Faculty, Rostock University, 18059 Rostock, Germany
- Correspondence: ; Tel.: +49-381-4988973; Fax: +49-381-4988970
| | - Ralf Gaebel
- Department of Cardiac Surgery, Rostock University Medical Center, 18057 Rostock, Germany
- Department of Life, Light & Matter, Interdisciplinary Faculty, Rostock University, 18059 Rostock, Germany
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4
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Krzowski B, Peller M, Boszko M, Hoffman P, Żurawska N, Jaruga K, Skoczylas K, Osak G, Kołtowski Ł, Grabowski M, Opolski G, Balsam P. Mobile app and digital system for patients after myocardial infarction (afterAMI): study protocol for a randomized controlled trial. Trials 2022; 23:522. [PMID: 35729626 PMCID: PMC9210045 DOI: 10.1186/s13063-022-06463-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 06/09/2022] [Indexed: 12/03/2022] Open
Abstract
Background Treatment of acute myocardial infarction has been the subject of studies over the past years. However, the initial months after myocardial infarction are crucial from the perspective of the patient’s prognosis. It is extremely important to take care of all cardiovascular risk factors and undergo a full rehabilitation program. Telemedical solutions are becoming more and more relevant in everyday practice. We describe a protocol of a study evaluating the use of the mobile application “afterAMI” in patients after myocardial infarction. The app offers an educational mode, calendar, vital signs diary, medication reminders, medical history card, and healthcare professional contact panel. It offers several solutions, which individually proved to be effective and improve a patient’s prognosis. Despite general promising results from previous studies regarding telemedical tools, there is a paucity of evidence when it comes to prospective randomized trials. Our aim was to perform a comprehensive evaluation of a newly developed mobile application in the clinical setting. Methods A group of 100 patients with myocardial infarction on admission at the 1st Chair and Department of Cardiology, Medical University of Warsaw, will be recruited into the study. The project aims to assess the impact of the application-supported model of care in comparison with standard rehabilitation. At the end of the study, cardiovascular risk factors will be analyzed, along with rehospitalizations, the patients’ knowledge regarding cardiovascular risk factors, returning to work, and quality of life. In this prospective, open-label, randomized, single-center study, all 100 patients will be observed for 6 months after discharge from the hospital. Endpoints will be assessed during control visits 1 and 6 months after inclusion into the study. Discussion This project is an example of a telemedical solution application embracing everyday clinical practices, conforming with multiple international cardiac societies’ guidelines. Cardiac rehabilitation process enhancements are required to improve patients’ prognosis. The evidence regarding the use of the mobile application in the described group of patients is limited and usually covers a small number of participants. The described study aims to discuss whether telemedicine use in this context is beneficial for the patients. Trial registration ClinicalTrials.govNCT04793425. Registered on 11 March 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06463-x.
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Affiliation(s)
- Bartosz Krzowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - Michał Peller
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091, Warsaw, Poland.
| | - Maria Boszko
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - Paulina Hoffman
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - Natalia Żurawska
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - Karolina Jaruga
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - Kamila Skoczylas
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - Gabriela Osak
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - Łukasz Kołtowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - Marcin Grabowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - Grzegorz Opolski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - Paweł Balsam
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091, Warsaw, Poland
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Hertz JT, Sakita FM, Kweka GL, Tarimo TG, Goli S, Prattipati S, Bettger JP, Thielman NM, Bloomfield GS. One-Year Outcomes and Factors Associated With Mortality Following Acute Myocardial Infarction in Northern Tanzania. Circ Cardiovasc Qual Outcomes 2022; 15:e008528. [PMID: 35300504 PMCID: PMC9018510 DOI: 10.1161/circoutcomes.121.008528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about long-term outcomes and uptake of secondary preventative therapies following acute myocardial infarction (AMI) in sub-Saharan Africa. METHODS Consecutive patients presenting with AMI (as defined by the Fourth Universal Definition of AMI Criteria) to a northern Tanzanian referral hospital were enrolled in this prospective observational study. Follow-up surveys assessing mortality, medication use, and rehospitalization were administered at 3, 6, 9, and 12 months following initial presentation, by telephone or in person. Multivariate logistic regression was performed to identify baseline clinical and sociodemographic factors associated with one-year mortality. RESULTS Of 152 enrolled patients with AMI, 5 were lost to one-year follow-up (96.7% retention rate). Mortality rates were 34.9% (53 of 152 participants) during the initial hospitalization, 48.7% (73 of 150 patients) at 3 months, 52.7% (78 of 148 patients) at 6 months, 55.4% (82 of 148 patients) at 9 months, and 59.9% (88 of 147 patients) at one year. Of 59 patients surviving to one-year follow-up, 43 (72.9%) reported persistent anginal symptoms, 5 (8.5%) were taking an antiplatelet, 8 (13.6%) were taking an antihypertensive, 30 (50.8%) had been rehospitalized, and 7 (11.9%) had ever undergone cardiac catheterization. On multivariate analysis, one-year mortality was associated with lack of secondary education (odds ratio, 0.26 [95% CI, 0.11-0.58]; P=0.001), lower body mass index (odds ratio, 0.90 [95% CI, 0.82-0.98]; P=0.015), and higher initial troponin (odds ratio, 1.30 [95% CI, 1.05-1.80]; P=0.052). CONCLUSIONS In northern Tanzania, AMI is associated with high all-cause one-year mortality and use of evidence-based secondary preventative therapies among AMI survivors is low. Interventions are needed to improve AMI care and outcomes.
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Affiliation(s)
- Julian T Hertz
- Division of Emergency Medicine (J.T.H.), Duke University School of Medicine, Durham, NC
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
| | - Francis M Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania (F.M.S., G.L.K., T.G.T.)
- Kilimanjaro Christian Medical Centre University College, Moshi, Tanzania (F.M.S.)
| | - Godfrey L Kweka
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania (F.M.S., G.L.K., T.G.T.)
| | - Tumsifu G Tarimo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania (F.M.S., G.L.K., T.G.T.)
| | - Sumana Goli
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
| | - Sainikitha Prattipati
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
| | - Janet P Bettger
- Department of Orthopaedic Surgery (J.P.B.), Duke University, Durham, NC
- Duke-Margolis Center for Health Policy, Duke University, Washington, District of Colombia (J.P.B.)
| | - Nathan M Thielman
- Department of Internal Medicine (N.M.T.), Duke University School of Medicine, Durham, NC
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
| | - Gerald S Bloomfield
- Division of Cardiology (G.S.B.), Duke University School of Medicine, Durham, NC
- Duke Global Health Institute (J.T.H., S.G., S.P., N.M.T., G.S.B.), Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC (G.S.B.)
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6
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Alkouri A, Cybularz M, Mierke J, Nowack T, Biedermann J, Ulbrich S, Fischer J, Heidrich FM, Jellinghaus S, Speiser U, Linke A, Pfluecke C. The predictive role of early CRP values for one-year mortality in the first two days after acute myocardial infarction. Biomarkers 2022; 27:293-298. [PMID: 35138209 DOI: 10.1080/1354750x.2022.2040591] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND An excessive inflammatory reaction after acute myocardial infarction (AMI) is known to be harmful. New anti-inflammatory therapies are required. PURPOSE This study assessed the predictive role of early CRP in patients with STEMI. METHODS 1003 patients with STEMI were analyzed. 180 patients with proven infection were excluded. CRP after 12 h, 24 h, and 48 h after pain onset were evaluated. RESULTS Of 823 patients, 103 (12.5%) died within one year after AMI. The deceased patients showed higher CRP, even after already 12 h (6 vs. 13 mg/l, p < 0.001), 24 h (13 vs. 25 mg/l, p < 0.001) and after 48 h (40 vs. 92 mg/l, p < 0.001). A CRP of ≥8 mg/l, 12 h after AMI, was found in 45% and was independently associated with long-term mortality (OR: 2.7, p = 0.03), after 24 h: CRP ≥18 mg/l in 44% (OR: 2.5, p = 0.03), after 48 h: CRP ≥53 mg/l in 44% (OR 1.9, p = 0.03). Early CRP values correlated strongly with the later maximum value of CRP (p < 0.001). CONCLUSIONS Already early CRP values are accurate for risk-prediction following AMI. By identifying patients who are beginning to develop an excessive inflammatory response, it may be possible to identify those who benefit from anti-inflammatory therapies.
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Affiliation(s)
- Ahmad Alkouri
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Technische Universität Dresden.,Department for Internal Medicine and Cardiology, Städtisches Klinikum Görlitz, Germany
| | - Maria Cybularz
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Technische Universität Dresden
| | - Johannes Mierke
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Technische Universität Dresden
| | - Thomas Nowack
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Technische Universität Dresden
| | - Jonathan Biedermann
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Technische Universität Dresden
| | - Stefan Ulbrich
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Technische Universität Dresden
| | - Julia Fischer
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Technische Universität Dresden
| | - Felix M Heidrich
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Technische Universität Dresden
| | - Stefanie Jellinghaus
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Technische Universität Dresden
| | - Uwe Speiser
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Technische Universität Dresden
| | - Axel Linke
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Technische Universität Dresden
| | - Christian Pfluecke
- Department for Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Technische Universität Dresden.,Department for Internal Medicine and Cardiology, Städtisches Klinikum Görlitz, Germany
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7
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Marathon-Induced Cardiac Strain as Model for the Evaluation of Diagnostic microRNAs for Acute Myocardial Infarction. J Clin Med 2021; 11:jcm11010005. [PMID: 35011745 PMCID: PMC8745173 DOI: 10.3390/jcm11010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 11/23/2022] Open
Abstract
Background: The current gold standard biomarker for myocardial infarction (MI), cardiac troponin (cTn), is recognized for its high sensitivity and organ specificity; however, it lacks diagnostic specificity. Numerous studies have introduced circulating microRNAs as potential biomarkers for MI. This study investigates the MI-specificity of these serum microRNAs by investigating myocardial stress/injury due to strenuous exercise. Methods: MicroRNA biomarkers were retrieved by comprehensive review of 109 publications on diagnostic serum microRNAs for MI. MicroRNA levels were first measured by next-generation sequencing in pooled sera from runners (n = 46) before and after conducting a full competitive marathon. Hereafter, reverse transcription quantitative real-time PCR (qPCR) of 10 selected serum microRNAs in 210 marathon runners was performed (>10,000 qPCR measurements). Results: 27 potential diagnostic microRNA for MI were retrieved by the literature review. Eight microRNAs (miR-1-3p, miR-21-5p, miR-26a-5p, miR-122-5p, miR-133a-3p, miR-142-5p, miR-191-5p, miR-486-3p) showed positive correlations with cTnT in marathon runners, whereas two miRNAs (miR-134-5p and miR-499a-5p) showed no correlations. Upregulation of miR-133a-3p (p = 0.03) and miR-142-5p (p = 0.01) went along with elevated cTnT after marathon. Conclusion: Some MI-associated microRNAs (e.g., miR-133a-3p and miR-142-5p) have similar kinetics under strenuous exercise and MI as compared to cTnT, which suggests that their diagnostic specificity could be limited. In contrast, several MI-associated microRNAs (miR-26a-5p, miR-134-5p, miR-191-5p) showed different release behavior; hence, combining cTnT with these microRNAs within a multi-marker strategy may add diagnostic accuracy in MI.
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Kumar B, Agstam S, Vijay J, Batta A. Long term safety and efficacy of the Yukon Choice Flex sirolimus-eluting coronary stent-a real-world data from India. Indian Heart J 2021; 73:733-736. [PMID: 34861983 PMCID: PMC8642663 DOI: 10.1016/j.ihj.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/09/2021] [Accepted: 09/08/2021] [Indexed: 01/18/2023] Open
Abstract
In-stent restenosis and stent thrombosis are the major concerns while choosing a coronary stent. This single-centre, retrospective study evaluated the one and three-year clinical outcomes following implantation of Yukon Choice Flex (YCF) sirolimus-eluting stent. A total of 168 consecutive patients with 217 lesions underwent stenting with YCF stent. The presentation was with acute coronary syndrome in 158 (94%) patients. At 3 years, 9 (5.3%) patients died due to cardiac cause. Myocardial infarction, and definite stent thrombosis occurred in 10 (6%) and 4 (2.4%) patients respectively. Redo stenting and coronary artery bypass surgery was performed in 3 (1.8%) and 1 (0.6%) patient respectively. The use of YCF sirolimus eluting stent was associated with a favourable safety and efficacy profile at one and three-years of follow-up in a high-risk population.
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Affiliation(s)
- Basant Kumar
- Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, 160012, India
| | - Sourabh Agstam
- Department of Cardiology, Vardhman Mahavir Medical College, New Delhi, 110029, India
| | - Jyothi Vijay
- Department of Cardiology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala 695011, India
| | - Akash Batta
- Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, 160012, India.
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9
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Marinho F. Prognosis of Coronary Artery Disease in Public Hospitals in Brazil: The ERICO Study and the Application of Knowledge in Public Health. Arq Bras Cardiol 2021; 117:986-987. [PMID: 34817007 PMCID: PMC8682102 DOI: 10.36660/abc.20210825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Fatima Marinho
- Universidade Federal de Minas GeraisPrograma de Pós-Graduação em Saúde PúblicaFaculdade de MedicinaBelo HorizonteMGBrasilPrograma de Pós-Graduação em Saúde Pública, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG – Brasil
- Organização Internacional de Saúde Pública Vital StrategiesNova IorqueEUAOrganização Internacional de Saúde Pública Vital Strategies, Nova Iorque – EUA
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Pirhonen L, Gyllensten H, Fors A, Bolin K. Modelling the cost-effectiveness of person-centred care for patients with acute coronary syndrome. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:1317-1327. [PMID: 32895879 PMCID: PMC7581585 DOI: 10.1007/s10198-020-01230-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/26/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Person-centred care has been shown to be cost-effective compared to usual care for several diseases, including acute coronary syndrome, in a short-term time perspective (< 2 years). The cost-effectiveness of person-centred care in a longer time perspective is largely unknown. OBJECTIVES To estimate the mid-term cost-effectiveness of person-centred care compared to usual care for patients (< 65) with acute coronary syndrome, using a 2-year and a 5-year time perspective. METHODS The mid-term cost-effectiveness of person-centred care compared to usual care was estimated by projecting the outcomes observed in a randomized-controlled trial together with data from health registers and data from the scientific literature, 3 years beyond the 2-year follow-up, using the developed simulation model. Probabilistic sensitivity analyses were performed using Monte Carlo simulation. RESULTS Person-centred care entails lower costs and improved effectiveness as compared to usual care, for a 2-year time and a 5-year perspective. Monte Carlo simulations suggest that the likelihoods of the person-centred care being cost-effective compared to usual care were between 80 and 99% and between 75 and 90% for a 2-year and a 5-year time perspective (using a 500,000 SEK/QALY willingness-to-pay threshold). CONCLUSIONS Person-centred care was less costly and more effective compared to usual care in a 2-year and a 5-year time perspective for patients with acute coronary syndrome under the age of 65.
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Affiliation(s)
- Laura Pirhonen
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30, Gothenburg, Sweden.
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden.
- Centre for Health Economics (CHEGU), Department of Economics, University of Gothenburg, Gothenburg, Sweden.
| | - Hanna Gyllensten
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Andreas Fors
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Sweden
| | - Kristian Bolin
- Centre for Health Economics (CHEGU), Department of Economics, University of Gothenburg, Gothenburg, Sweden
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11
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Santos RCO, Bensenor IM, Goulart AC, Lotufo PA, Santos IS. Frequency and Reasons for Non-Administration and Suspension of Drugs During an Acute Coronary Syndrome Event. The ERICO Study. Arq Bras Cardiol 2020; 115:830-839. [PMID: 33295445 PMCID: PMC8452196 DOI: 10.36660/abc.20190317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/26/2019] [Accepted: 10/23/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Few studies have discussed the reasons for pharmacological undertreatment of Acute Coronary Syndrome (ACS). OBJECTIVES To determine the frequency and reasons for the non-administration and suspension of medications during in-hospital treatments of ACS in the Strategy of Registry of Acute Coronary Syndrome (ERICO) study. METHODS The present study analyzed the medical charts of the 563 participants in the ERICO study to evaluate the frequency and reasons for the non-administration and/or suspension of medications. Logistic regression models were built to analyze if sex, age ≥65 years of age, educational level, or ACS subtype were associated with (a) the non-administration of ≥1 medications; and (b) the non-administration or suspension of ≥1 medications. The significance level was set at 5%. RESULTS This study's sample included 58.1% males, with a median of 62 years of age. In 183 (32.5%) participants, ≥1 medications were not administered, while in 288 (51.2%), ≥1 medications were not administered or were suspended. The most common reasons were the risk of bleeding (aspirin, clopidogrel, and heparin), heart failure (beta blockers), and hypotension (angiotensin-converting enzyme inhibitors and angiotensin receptor blockers). Individuals aged ≥65 (odds ratio [OR]:1.51; 95% confidence interval [95% CI]:1.05-2.19) and those with unstable angina (OR:1.72; 95% CI:1.07-2.75) showed a higher probability for the non-administration of ≥1 medication. Considering only patients with myocardial infarction, being ≥65 years of age was associated with both the non-administration and the non-administration or suspension of ≥1 medication. CONCLUSIONS Non-administration or suspension of ≥1 medication proved to be common in this ERICO study. Individuals of ≥65 years of age or with unstable angina showed a higher probability of the non-administration of ≥1 medication and may be undertreated in this scenario. (Arq Bras Cardiol. 2020; 115(5):830-839).
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Affiliation(s)
- Rafael C. O. Santos
- Universidade de São PauloHospital Universitário da USPCentro de Pesquisa Clínica e EpidemiológicaSão PauloSPBrasilUniversidade de São Paulo - Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da USP, São Paulo, SP - Brasil
| | - Isabela M. Bensenor
- Universidade de São PauloHospital Universitário da USPCentro de Pesquisa Clínica e EpidemiológicaSão PauloSPBrasilUniversidade de São Paulo - Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da USP, São Paulo, SP - Brasil
- Universidade de São PauloFaculdade de Medicina da USPDepartamento de Clínica MédicaSão PauloSPBrasilUniversidade de São Paulo - Departamento de Clínica Médica da Faculdade de Medicina da USP, São Paulo, SP - Brasil
| | - Alessandra C. Goulart
- Universidade de São PauloHospital Universitário da USPCentro de Pesquisa Clínica e EpidemiológicaSão PauloSPBrasilUniversidade de São Paulo - Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da USP, São Paulo, SP - Brasil
| | - Paulo A. Lotufo
- Universidade de São PauloHospital Universitário da USPCentro de Pesquisa Clínica e EpidemiológicaSão PauloSPBrasilUniversidade de São Paulo - Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da USP, São Paulo, SP - Brasil
- Universidade de São PauloFaculdade de Medicina da USPDepartamento de Clínica MédicaSão PauloSPBrasilUniversidade de São Paulo - Departamento de Clínica Médica da Faculdade de Medicina da USP, São Paulo, SP - Brasil
| | - Itamar S. Santos
- Universidade de São PauloHospital Universitário da USPCentro de Pesquisa Clínica e EpidemiológicaSão PauloSPBrasilUniversidade de São Paulo - Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da USP, São Paulo, SP - Brasil
- Universidade de São PauloFaculdade de Medicina da USPDepartamento de Clínica MédicaSão PauloSPBrasilUniversidade de São Paulo - Departamento de Clínica Médica da Faculdade de Medicina da USP, São Paulo, SP - Brasil
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Silva PGMDBE, Berwanger O, Santos ESD, Sousa ACS, Cavalcante MA, Andrade PBD, Neuenschwander FC, Vargas Filho H, Guimarães JI, Andrade J, Paola AAVD, Malachias MVB, Mattos LAPE, Precoma DB, Bacal F, Dutra OP. One year follow-up Assessment of Patients Included in the Brazilian Registry of Acute Coronary Syndromes (ACCEPT). Arq Bras Cardiol 2020; 114:995-1003. [PMID: 32638905 PMCID: PMC8416119 DOI: 10.36660/abc.20190879] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/08/2020] [Indexed: 11/30/2022] Open
Abstract
Fundamento Existe carência de informações prospectivas sobre a evolução em um ano após uma síndrome coronária aguda (SCA) em uma grande amostra de pacientes brasileiros. Objetivos Avaliar a prescrição de terapias baseadas em evidência, a ocorrência de desfechos graves e os preditores para estes desfechos em um registro brasileiro multicêntrico de pacientes com SCA. Métodos O ACCEPT é um estudo observacional prospectivo que incluiu pacientes internados com diagnóstico de SCA em 47 hospitais brasileiros. Os pacientes foram seguidos por 1 ano e coletou-se dados sobre prescrição médica e ocorrência de eventos cardiovasculares maiores (mortalidade cardiovascular, reinfarto e acidente vascular encefálico - AVE). Valores de p < 0,05 foram considerados estatisticamente significantes. Resultados Um total de 5.047 pacientes foram incluídos neste registro, de agosto de 2010 até abril de 2014. Foi confirmado o diagnóstico de SCA em 4.782 pacientes (94,7%) e, dentre os 3 diagnósticos possíveis, o mais comum foi SCA com elevação do segmento ST (35,8%). A taxa de eventos cardiovasculares maiores foi de 13,6 % em 1 ano. A prescrição completa de terapias baseadas em evidência na admissão hospitalar foi de 62,1%. Idade, atendimento público, infarto agudo do miocárdio, AVE, insuficiência renal, diabetes e qualidade da terapia estiveram associados de forma independente à ocorrência de eventos cardiovasculares maiores. Conclusões No seguimento de 1 ano do registro ACCEPT, mais de 10% dos pacientes apresentaram eventos cardiovasculares maiores e esta taxa variou de acordo com a qualidade da terapia. Há necessidade da elaboração de estratégias para melhorar o uso de terapias baseadas em evidência no sentido de minimizar os eventos cardiovasculares na população brasileira. (Arq Bras Cardiol. 2020; 114(6):995-1003)
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Fernando Bacal
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia, Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, Brasil
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Leocádio P, Menta P, Dias M, Fraga J, Goulart A, Santos I, Lotufo P, Bensenor I, Alvarez-Leite J. High Serum Netrin-1 and IL-1β in Elderly Females with ACS: Worse Prognosis in 2-years Follow-up. Arq Bras Cardiol 2020; 114:507-514. [PMID: 32267322 PMCID: PMC7792717 DOI: 10.36660/abc.20190035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 06/03/2019] [Indexed: 11/18/2022] Open
Abstract
Fundamento Vários marcadores têm sido avaliados quanto a um potencial impacto nas decisões clínicas ou na predição de mortalidade na síndrome coronariana aguda (SCA), incluindo Netrina-1 e IL-1β. Objetivo Examinamos o valor prognóstico de Netrina-1 e IL-1β em pacientes com SCA (2 anos de acompanhamento). Métodos Avaliamos Netrina-1, IL-1β e outros fatores de risco em amostras de soro de 803 pacientes. Curvas de Kaplan-Meier e regressão de Cox foram usadas para análise de óbito por todas as causas, óbito por doenças cardiovasculares (DCV) e desfecho combinado de infarto agudo do miocárdio (IAM) fatal ou novo IAM não fatal, considerando p < 0,05. Resultados Houve 115 óbitos por todas as causas, 78 óbitos por DCV e 67 eventos no desfecho combinado. Níveis de Netrina-1 acima da mediana (> 44,8 pg/mL) foram associados a pior prognóstico (óbito por todas as causas e por DCV) em mulheres idosas, mesmo após o ajuste do modelo (HR: 2,08, p = 0,038 e HR: 2,68, p = 0,036). Níveis de IL-1β acima da mediana (> 13,4 pg/mL) em mulheres idosas foram associados a risco aumentado para todos os desfechos após o ajuste (todas as causas - HR: 2,03, p = 0,031; DCV - HR: 3,01, p = 0,013; desfecho combinado - HR: 3,05, p = 0,029). Para homens, não foram observadas associações entre Netrina-1 ou IL-1β e os desfechos. Conclusão Níveis séricos elevados de Netrina-1 e IL-1β mostraram associação significativa com pior prognóstico em idosas do sexo feminino. Eles podem ser úteis como indicadores prognósticos em SCA. (Arq Bras Cardiol. 2020; 114(3):507-514)
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Affiliation(s)
- Paola Leocádio
- Departamento de Bioquímica e Imunologia - Universidade Federal de Minas Gerais, Belo Horizonte, MG - Brasil
| | - Penélope Menta
- Departamento de Bioquímica e Imunologia - Universidade Federal de Minas Gerais, Belo Horizonte, MG - Brasil
| | - Melissa Dias
- Departamento de Bioquímica e Imunologia - Universidade Federal de Minas Gerais, Belo Horizonte, MG - Brasil
| | - Júlia Fraga
- Departamento de Bioquímica e Imunologia - Universidade Federal de Minas Gerais, Belo Horizonte, MG - Brasil
| | - Alessandra Goulart
- Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Itamar Santos
- Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Paulo Lotufo
- Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da Universidade de São Paulo, São Paulo, SP - Brasil.,Departamento de Clínica Médica da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Isabela Bensenor
- Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da Universidade de São Paulo, São Paulo, SP - Brasil.,Departamento de Clínica Médica da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Jacqueline Alvarez-Leite
- Departamento de Bioquímica e Imunologia - Universidade Federal de Minas Gerais, Belo Horizonte, MG - Brasil
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Pirhonen L, Bolin K, Olofsson EH, Fors A, Ekman I, Swedberg K, Gyllensten H. Person-Centred Care in Patients with Acute Coronary Syndrome: Cost-Effectiveness Analysis Alongside a Randomised Controlled Trial. PHARMACOECONOMICS - OPEN 2019; 3:495-504. [PMID: 30825129 PMCID: PMC6861393 DOI: 10.1007/s41669-019-0126-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Costs associated with an ACS incident are most pronounced in the acute phase but are also considerably long after the initial hospitalisation, partly due to considerable productivity losses, which constitute a substantial part of the economic burden of the disease. Studies suggest that person-centred care may improve health-related quality of life and reduce the costs associated with the disease. OBJECTIVE The aim of this study was to calculate the cost-effectiveness of a person-centred care intervention compared with usual care in patients with acute coronary syndrome (ACS), in a Swedish setting. METHODS Primary data from a randomised controlled trial of a person-centred intervention in patients with ACS was used. The person-centred intervention involved co-creation of a health plan between the patient and healthcare professionals, based on the patient's narrative. Thereafter, goals for the recovery period were set and followed-up continuously throughout the intervention. The clinical data, collected during the randomised controlled trial, was complemented with data from national health registers and the Swedish Social Insurance Agency. The study was conducted at two hospitals situated in a Swedish municipality. Patients were enrolled between June 2011 and February 2014 (192 patients were included in this study; 89 in the intervention group and 103 in the control group). Incremental cost-effectiveness ratios were calculated separately for the age groups < 65 years and ≥ 65 years in order to account for the age of retirement in Sweden. The cost-effectiveness ratios were calculated using health-related quality of life (EQ-5D) and costs associated with healthcare and pharmaceutical utilisation, and productivity losses. RESULTS Treatment effects and costs differed between those below and those above the age of 65 years. The base-case calculations showed that person-centred care was more effective and less costly compared with usual care for patients under 65 years of age, while usual care was more effective and less costly in the older age group. Probabilistic sensitivity analyses resulted in a 90% likelihood that person-centred care is cost-effective compared with usual care for patients with ACS under the age of 65 years. CONCLUSIONS Person-centred care was found to be cost-effective compared with usual care for patients with acute coronary syndrome under the age of 65 years. This clinical trial is registered at Researchweb (ID 65791).
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Affiliation(s)
- Laura Pirhonen
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30, Göteborg, Sweden.
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Göteborg, Sweden.
- Department of Economics, Centre for Health Economics (CHEGU), University of Gothenburg, Göteborg, Sweden.
| | - Kristian Bolin
- Department of Economics, Centre for Health Economics (CHEGU), University of Gothenburg, Göteborg, Sweden
| | - Elisabeth Hansson Olofsson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30, Göteborg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Göteborg, Sweden
| | - Andreas Fors
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30, Göteborg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Göteborg, Sweden
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Göteborg, Sweden
| | - Inger Ekman
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30, Göteborg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Göteborg, Sweden
| | - Karl Swedberg
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Göteborg, Sweden
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- National Heart and Lung Institute, Imperial College, London, UK
| | - Hanna Gyllensten
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30, Göteborg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Göteborg, Sweden
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15
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Birck MG, Goulart AC, Lotufo PA, Benseñor IM. Secondary prevention of coronary heart disease: a cross-sectional analysis on the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). SAO PAULO MED J 2019; 137:223-233. [PMID: 31483010 PMCID: PMC9744003 DOI: 10.1590/1516-3180.2018.0531140319] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 12/18/2018] [Accepted: 03/14/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Coronary heart disease (CHD) remains a major cause of mortality worldwide and in Brazil. Use of standard medications after CHD has been proven to avoid new events and reduce early mortality. OBJECTIVES This study aimed to analyze secondary prevention of CHD and its association with the baseline characteristics of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). DESIGN AND SETTING Cross-sectional analysis on ELSA-Brasil data. METHODS Secondary prevention of CHD recommended in standard guidelines (antiplatelet plus beta-blocker plus lipid-lowering drug, with or without angiotensin-converting enzyme inhibitors, ACEI, or angiotensin receptor blockers, ARB) was evaluated in relation to sociodemographic data and the time since the coronary event. The chi-square test, one-way analysis of variance (ANOVA) and Mann-Whitney test were performed, as necessary. RESULTS Among 15,094 participants, 2.7% reported a previous diagnosis of CHD. Use of recommended drugs for secondary prevention was reported by almost 35% of the participants. Medication use for secondary prevention was generally more frequent among high-income participants than among low-income participants. Use of ARB and ACEI was different between participants who had private health insurance and those who only used the public healthcare system. Men were more likely to use medication than women. The frequency with which participants used the recommended drugs was similar in all time periods after CHD, but use of only one drug increased progressively across time periods. CONCLUSION The use of medication for secondary prevention of CHD was lower than what is recommended in standardized guidelines, especially among women and lower-income participants.
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Affiliation(s)
- Marina Gabriela Birck
- BSc, MSc. Postgraduate Student, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo (SP), Brazil.
| | - Alessandra Carvalho Goulart
- MD, PhD. Clinical Epidemiologist and Researcher, Center for Clinical and Epidemiological Research, Hospital Universitário da Universidade de São Paulo (HU-USP), São Paulo (SP), Brazil.
| | - Paulo Andrade Lotufo
- MD, DrPH. Full Professor, Department of Internal Medicine, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo (SP), Brazil.
| | - Isabela Martins Benseñor
- MD, PhD. Professor, Department of Internal Medicine, and Director of Center for Clinical and Epidemiological Research, Hospital Universitário da Universidade de São Paulo (HU-USP), São Paulo (SP), Brazil.
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16
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Jardim TV. Cohort Studies with Mortality Data from the Brazilian Population: a Rising National Requirement. Arq Bras Cardiol 2019; 112:238-239. [PMID: 30916185 PMCID: PMC6424037 DOI: 10.5935/abc.20190038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Thiago Veiga Jardim
- Universidade Federal de Goiás - Liga de Hipertensão Arterial, Goiânia, GO - Brazil
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17
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Castro LTD, Santos IDS, Goulart AC, Pereira ADC, Staniak HL, Bittencourt MS, Lotufo PA, Bensenor IM. Elevated High-Sensitivity Troponin I in the Stabilized Phase after an Acute Coronary Syndrome Predicts All-Cause and Cardiovascular Mortality in a Highly Admixed Population: A 7-Year Cohort. Arq Bras Cardiol 2019; 112:230-237. [PMID: 30916200 PMCID: PMC6424029 DOI: 10.5935/abc.20180268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/02/2018] [Indexed: 11/20/2022] Open
Abstract
Background High-sensitivity cardiac troponin I (hs-cTnI) has played an important role in
the risk stratification of patients during the in-hospital phase of acute
coronary syndrome (ACS), but few studies have determined its role as a
long-term prognostic marker in the outpatient setting. Objective To investigate the association between levels of hs-cTnI measured in the
subacute phase after an ACS event and long-term prognosis in a highly
admixed population. Methods We measured levels of hs-cTnI in 525 patients 25 to 90 days after admission
for an ACS event; these patients were then divided into tertiles according
to hs-cTnI levels and followed for up to 7 years. We compared all-cause and
cardiovascular mortality using Cox proportional hazards models and adopting
a significance level of 5%. Results After a median follow-up of 51 months, patients in the highest tertile had a
greater hazard ratio (HR) for all-cause mortality after adjustment for age,
sex, known cardiovascular risk factors, medication use, and demographic
factors (HR: 3.84, 95% CI: 1.92-8.12). These findings persisted after
further adjustment for estimated glomerular filtration rate < 60
ml/min/1.73 m2 and left ventricular ejection fraction < 0.40
(HR: 6.53, 95% CI: 2.12-20.14). Cardiovascular mortality was significantly
higher in the highest tertile after adjustment for age and sex (HR: 5.65,
95% CI: 1.94-16.47) and both in the first (HR: 4.90, 95% CI: 1.35-17.82) and
second models of multivariate adjustment (HR: 5.89, 95% CI: 1.08-32.27). Conclusions Elevated hs-cTnI levels measured in the stabilized phase after an ACS event
are independent predictors of all-cause and cardiovascular mortality in a
highly admixed population.
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Affiliation(s)
| | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP), São Paulo, SP - Brazil
| | - Alessandra C Goulart
- Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP), São Paulo, SP - Brazil
| | - Alexandre da Costa Pereira
- Instituto do Coração (InCor) - Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Henrique Lane Staniak
- Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP), São Paulo, SP - Brazil
| | - Marcio Sommer Bittencourt
- Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP), São Paulo, SP - Brazil
| | - Paulo Andrade Lotufo
- Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP), São Paulo, SP - Brazil
| | - Isabela Martins Bensenor
- Centro de Pesquisa Clínica e Epidemiológica da Universidade de São Paulo (USP), São Paulo, SP - Brazil
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18
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Eckner D, Popp S, Wicklein S, Pauschinger M. [Acute coronary syndrome in older people]. Z Gerontol Geriatr 2018; 51:461-475. [PMID: 29846808 DOI: 10.1007/s00391-018-1411-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/23/2018] [Accepted: 05/03/2018] [Indexed: 11/27/2022]
Abstract
The acute coronary syndrome (ACS) is subdivided into ST segment elevation myocardial infarction (STEMI), non-ST segment elevation acute coronary syndrome (NSTE-ACS) and unstable angina pectoris. It poses a particular challenge in terms of diagnostics and treatment, especially in the elderly. Starting with the possibly difficult anamnesis, through the laboratory chemical findings up to special features in the electrocardiogram (ECG), echocardiography and angiography, these patients should be considered in some ways different to the younger population. Because of the mortality and morbidity after ACS, especially in old age, it is important to adhere to evident strategies in diagnostics and treatment and to employ specially trained personnel for people with acute chest pain in order to improve the prognosis and quality of life. A first important step is to provide certified chest pain units which ensure smooth diagnostics and treatment and thus positively influence the clinical decision-making processes.
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Affiliation(s)
- D Eckner
- Kardiologie, Klinikum Nürnberg Süd, Paracelsus Medizinische Privatuniversität, Breslauer Str. 201, 90471, Nürnberg, Deutschland.
| | - S Popp
- Kardiologie, Klinikum Nürnberg Süd, Paracelsus Medizinische Privatuniversität, Breslauer Str. 201, 90471, Nürnberg, Deutschland
| | - S Wicklein
- Geriatrie, Klinikum Nürnberg Nord, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - M Pauschinger
- Kardiologie, Klinikum Nürnberg Süd, Paracelsus Medizinische Privatuniversität, Breslauer Str. 201, 90471, Nürnberg, Deutschland
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Maia FC, Goulart AC, Drager LF, Staniak HL, Santos IDS, Lotufo PA, Bensenor IM. Impact of High Risk for Obstructive Sleep Apnea on Survival after Acute Coronary Syndrome: Insights from the ERICO Registry. Arq Bras Cardiol 2017; 108:31-37. [PMID: 28146212 PMCID: PMC5245845 DOI: 10.5935/abc.20160195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 09/13/2016] [Indexed: 02/01/2023] Open
Abstract
Background Obstructive sleep apnea (OSA) is a very often clinical condition that can be
associated with high mortality risk, particularly in coronary heart disease
(CHD). The diagnosis of OSA is not always accessible via the gold-standard
method polysomnography. Objective To evaluate long-term influence of the high risk for OSA on fatal and
non-fatal outcomes after acute coronary syndrome (ACS) in the Acute Coronary
Syndrome Registry Strategy (ERICO) Study using the Berlin questionnaire as a
surrogate. Methods Berlin questionnaire, a screening questionnaire for OSA, was applied in 639
cases of ACS 30 days after the index event. Cox regression
proportional-hazards model was used to calculate the hazard ratio (HR) of
all-cause, cardiovascular and CHD (myocardial infarction) mortality, as well
as, the combined endpoint of fatal or recurrent non-fatal CHD. Results The high-risk group for OSA had higher frequencies of previous
personal/family history of CHD and diabetes, in addition to a poorer
event-free survival, as compared to the low-risk group (p-log-rank=0.03).
The HR for fatal or recurrent non-fatal CHD was 4.26 (95% confidence
interval, 1.18 - 15.36) in patients at high risk for OSA compared to those
at low risk for OSA after a 2.6-year mean follow-up. Conclusions Using Berlin questionnaire, we were able to identify high risk for OSA as an
independent predictor of non-fatal reinfarction or CHD mortality in post-ACS
individuals in a long-term follow-up.
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Affiliation(s)
- Flavia C Maia
- Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Henrique L Staniak
- Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Isabela M Bensenor
- Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brazil
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Lee WC, Fang HY, Chen HC, Chen CJ, Yang CH, Hang CL, Wu CJ, Fang CY. Anemia: A significant cardiovascular mortality risk after ST-segment elevation myocardial infarction complicated by the comorbidities of hypertension and kidney disease. PLoS One 2017; 12:e0180165. [PMID: 28749948 PMCID: PMC5531517 DOI: 10.1371/journal.pone.0180165] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 06/09/2017] [Indexed: 02/07/2023] Open
Abstract
Background The effect of anemia on patients with ST-segment elevation myocardial infarction (STEMI) remains a controversial issue. The aim of this study was to explore the effect of anemia on STEMI patients. Methods and results From January 2005 to December 2014, 1751 patients experienced STEMI checked serum hemoglobin initially before any administration of fluids or IV medications. 1751 patients then received primary percutaneous intervention immediately. A total of 1388 patients were enrolled in the non-anemia group because their serum hemoglobin level was more than 13 g/L in males, and 12 g/L in females. A total of 363 patients were enrolled in the anemia group because their serum hemoglobin level was less than 13 g/L in males, and 12 g/L in females. Higher incidences of major adverse cerebral cardiac events (22.9% vs. 33.8%; p<0.001) were also noted in the anemia group, and these were related to higher incidence of cardiovascular mortality (6.5% vs. 20.4%; p<0.001). A higher incidence of all-cause mortality (8.6% vs. 27.7%; p<0.001) was also noted in the anemia group. A Kaplan-Meier curve of one-year cardiovascular mortality showed significant differences between the non-anemia and anemia group in all patients (P<0.001), and the patients with hypertension (P<0.001), and chronic kidney disease (CKD) (P = 0.011). Conclusion Anemia is a marker of an increased risk in one-year cardiovascular mortality in patients with STEMI. If the patients have comorbidities such as hypertension, or CKD, the effect of anemia is very significant.
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Affiliation(s)
- Wei-Chieh Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
- * E-mail:
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
| | - Huang-Chung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
| | - Chien-Jen Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
| | - Cheng-Hsu Yang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
| | - Chi-Ling Hang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
| | - Chiung-Jen Wu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
| | - Chih-Yuan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
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Santos RCDOD, Goulart AC, Kisukuri ALX, Brandão RM, Sitnik D, Staniak HL, Bittencourt MS, Lotufo PA, Bensenor IM, Santos IDS. Time-To-Treatment of Acute Coronary Syndrome and Unit of First Contact in the ERICO Study. Arq Bras Cardiol 2016; 107:323-330. [PMID: 27849262 PMCID: PMC5102478 DOI: 10.5935/abc.20160138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 06/28/2016] [Indexed: 12/20/2022] Open
Abstract
Background To the best of our knowledge, there are no studies evaluating the influence
of the unit of the first contact on the frequency and time of
pharmacological treatment during an acute coronary syndrome (ACS) event. Objectives The main objective was to investigate if the unit of first contact influenced
the frequency and time of aspirin treatment in the Strategy of Registry of
Acute Coronary Syndrome (ERICO) study. Methods We analyzed the pharmacological treatment time in 830 ERICO participants -
700 individuals for whom the hospital was the unit of first contact and 130
who initially sought primary care units. We built logistic regression models
to study whether the unit of first contact was associated with a treatment
time of less than three hours. Results Individuals who went to primary care units received the first aspirin dose in
those units in 75.6% of the cases. The remaining 24.4% received aspirin at
the hospital. Despite this finding, individuals from primary care still had
aspirin administered within three hours more frequently than those who went
to the hospital (76.8% vs 52.6%; p<0.001 and 100% vs. 70.7%; p=0.001 for
non ST-elevation ACS and ST-elevation myocardial infarction, respectively).
In adjusted models, individuals coming from primary care were more likely to
receive aspirin more quickly (odds ratio: 3.66; 95% confidence interval:
2.06-6.51). Conclusions In our setting, individuals from primary care were more likely to receive
aspirin earlier. Enhancing the ability of primary care units to provide
early treatment and safe transportation may be beneficial in similar
settings.
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Affiliation(s)
| | - Alessandra Carvalho Goulart
- Hospital Universitário da Universidade de São Paulo, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | | | - Rodrigo Martins Brandão
- Hospital Universitário da Universidade de São Paulo, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Debora Sitnik
- Hospital Universitário da Universidade de São Paulo, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Henrique Lane Staniak
- Hospital Universitário da Universidade de São Paulo, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | - Marcio Sommer Bittencourt
- Hospital Universitário da Universidade de São Paulo, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
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Marino BCA, Marcolino MS, Reis Júnior RDS, França ALN, Passos PFDO, Lemos TR, Antunes IDO, Ferreira CG, Antunes AP, Ribeiro ALP. Epidemiological Profile and Quality Indicators in Patients with Acute Coronary Syndrome in Northern Minas Gerais - Minas Telecardio 2 Project. Arq Bras Cardiol 2016; 107:106-15. [PMID: 27355471 PMCID: PMC5074063 DOI: 10.5935/abc.20160095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/29/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Coronary artery disease is the main cause of death in Brazil. In the Brazilian public health system, the in-hospital mortality associated with acute myocardial infarction is high. The Minas Telecardio 2 Project (Projeto Minas Telecardio 2) aims at implementing a myocardial infarction system of care in the Northern Region of Minas Gerais (MG) to decrease hospital morbidity and mortality. The aim of this study was to describe the profile of the patients with acute coronary syndrome (ACS) cared for in the period that preceded the implementation of the system of care. METHODS Observational, prospective study of patients with ACS admitted between June 2013 and March 2014 to six emergency departments in Montes Claros, MG, and followed up until hospital discharge. RESULTS During the study period, 593 patients were admitted with a diagnosis of ACS (mean age 63 ± 12 years, 67.6% men), including 306 (51.6%) cases of unstable angina, 214 (36.0%) of ST-elevation myocardial infarction (STEMI), and 73 (12.3%) of non-ST-elevation myocardial infarction (NSTEMI). The total STEMI mortality was 21%, and the in-hospital mortality was 17.2%. In the STEMI patients, 46,0% underwent reperfusion therapy, including primary angioplasty in 88 and thrombolysis in six. Overall, aspirin was administered to 95.1% of the patients within 24 hours and to 93.5% at discharge, a P2Y12 inhibitor was administered to 88.7% participants within 24 hours and to 75.1% at discharge. A total of 73.1% patients received heparin within 24 hours. CONCLUSION We observed a low reperfusion rate in patients with STEMI and limited adherence to the recommended ACS treatment in the Northern Region of MG. These observations enable opportunities to improve health care.
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Affiliation(s)
| | - Milena Soriano Marcolino
- Centro de Telessaúde, Hospital das Clínicas, Universidade Federal de Minas Gerais, Minas Gerais, MG, Brazil
| | | | | | | | - Thais Ribeiro Lemos
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Minas Gerais, MG, Brazil
| | | | - Camila Gonçalves Ferreira
- Centro de Telessaúde, Hospital das Clínicas, Universidade Federal de Minas Gerais, Minas Gerais, MG, Brazil
| | - André Pires Antunes
- Centro de Telessaúde, Hospital das Clínicas, Universidade Federal de Minas Gerais, Minas Gerais, MG, Brazil
| | - Antonio Luiz Pinho Ribeiro
- Centro de Telessaúde, Hospital das Clínicas, Universidade Federal de Minas Gerais, Minas Gerais, MG, Brazil
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