Evaluation of 1-Year Follow-up of Patients Included in the Registry of Clinical Practice in Patients at High Cardiovascular Risk (REACT)

BACKGROUND

In clinical practice, there is evidence of failure to prescribe evidence-based therapies for patients at high cardiovascular risk. However, in Brazil, data on 1-year outcomes of these patients remain insufficient.

OBJECTIVES

To describe the use of evidence-based therapies and the occurrence of major cardiovascular outcomes and their major predictors in a 12-month follow-up of a Brazilian multicenter registry of patients at high cardiovascular risk.

METHODS

This prospective observational study documented the outpatient clinical practice of managing patients over 45 years of age and of high cardiovascular risk in both primary and secondary prevention. Patients were followed-up for 1 year, and the prescription of evidence-based therapies and the occurrence of major cardiovascular events (myocardial infarction, stroke, cardiac arrest, and cardiovascular death) were assessed. P-values < 0.05 were considered statistically significant.

RESULTS

From July 2010 to August 2014, a total of 5076 individuals were enrolled in 48 centers, 91% of the 4975 eligible patients were followed-up in cardiology centers, and 68.6% were in secondary prevention. At 1 year, the concomitant use of antiplatelet agents, statins, and angiotensin-converting enzyme inhibitors reduced from 28.3% to 24.2% (p < 0.001). Major cardiovascular event rate was 5.46%, and the identified predictors were age, patients in secondary prevention, and diabetic nephropathy.

CONCLUSIONS

In this large national registry of patients at high cardiovascular risk, risk predictors similar to those of international registries were identified, but medical prescription adherence to evidence-based therapies was inferior and significantly worsened at 1 year. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

One year follow-up Assessment of Patients Included in the Brazilian Registry of Acute Coronary Syndromes (ACCEPT)

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)

The Profile of the Brazilian Cardiologist - A Sample of Members of the Brazilian Society of Cardiology

BACKGROUND

Data from the international literature have shown changes in the profile of cardiologists and in their medical practices. However, there is no data on this in Brazilian cardiologists.

OBJECTIVE

To evaluate professional and personal characteristics of a sample of Brazilian cardiologists.

METHODS

This was a cross-sectional study; a questionnaire was sent by e-mail to cardiologists, active members of the Brazilian Society of Cardiology in 2017. The results were analyzed, and the level of significance set at p < 0.05.

RESULTS

The questionnaire was sent to 13,462 cardiologists, with 2,101 (15.6%) respondents, mostly men (71.8% versus 28.2%). Age distribution and marital status were significantly different between the sexes (p < 0.001). The number of cardiologists without children was higher among women (40.5% versus 16.1%; p < 0.001). The most common place of work was the public hospital (46.5%), followed by private hospital (28.5%) and private office (21.1%). The office was the main place of work for 23.9% of men and 14% of women (p < 0.001), with predominance of individuals older than 50 years (31.7% versus 10.1%, respectively; p < 0.001). Most cardiologists (64.2%) worked more than 40 hours a week (69% of them men and 51.9% of the women; p < 0.001). Eighty-eight percent of the sample earned more than BRL 11,000 (US$ 3,473.43), and 66.5% of the men earned more than BRL 20,000 (US$ 6,315.32) per month, versus 31.2% of the women (p < 0.001). A high level of work-related stress was reported by 11.3% of respondents.

CONCLUSION

Most cardiologists were men, who showed higher workload and higher income; 11.3% of the cardiologists perceived stress as a great deal.

[Wellens syndrome]

The assessment of chest pain is a routine in emergency health services. Although this is a common complaint with a broad differential diagnosis. the major concern is the possibility of acute coronary syndrome (ACS). Electrocardiography and cardiac enzyme levels are important tools in the investigation of these patients; however. negative results may actually be overlooking the identification of some conditions. We report the case of a female patient with angina. whose baseline tests in the emergency room were negative for changes suggestive of ischemic heart disease. The Wellens syndrome. a recently described disease. is a variant of unstable angina which. if not identified. may result in significant morbidity and mortality.

A multicenter, randomized study of argatroban versus heparin as adjunct to tissue plasminogen activator (TPA) in acute myocardial infarction: myocardial infarction with novastan and TPA (MINT) study

OBJECTIVES

This study examined the effect of a small-molecule, direct thrombin inhibitor, argatroban, on reperfusion induced by tissue plasminogen activator (TPA) in patients with acute myocardial infarction (AMI).

BACKGROUND

Thrombin plays a crucial role in thrombosis and thrombolysis. In vitro and in vivo studies have shown that argatroban has advantages over heparin for the inhibition of clot-bound thrombin and for the enhancement of thrombolysis with TPA.

METHODS

One hundred and twenty-five patients with AMI within 6 h were randomized to heparin, low-dose argatroban or high-dose argatroban in addition to TPA. The primary end point was the rate of thrombolysis in myocardial infarction (TIMI) grade 3 flow at 90 min.

RESULTS

TIMI grade 3 flow was achieved in 42.1% of heparin, 56.8% of low-dose argatroban (p = 0.20 vs. heparin) and 58.7% of high-dose argatroban patients (p = 0.13 vs. heparin). In patients presenting after 3 h, TIMI grade 3 flow was significantly more frequent in high-dose argatroban versus heparin patients: 57.1% versus 20.0% (p = 0.03 vs. heparin). Major bleeding was observed in 10.0% of heparin, and in 2.6% and 4.3% of low-dose and high-dose argatroban patients, respectively. The composite of death, recurrent myocardial infarction, cardiogenic shock or congestive heart failure, revascularization and recurrent ischemia at 30 days occurred in 37.5% of heparin, 32.0% of low-dose argatroban and 25.5% of high-dose argatroban patients (p = 0.23).

CONCLUSIONS

Argatroban, as compared with heparin, appears to enhance reperfusion with TPA in patients with AMI, particularly in those patients with delayed presentation. The incidences of major bleeding and adverse clinical outcome were lower in the patients receiving argatroban.

[Bedside cardiac catheterization. Advantages and disadvantages]

Three hundred patients submitted to bedside heart catheterization (BHC) from 1973 to 1985 were studied, in order to assess advantages and risks of the procedure. Two-hundred and sixty seven patients (89%) suffered a myocardial infarction (MI) and 146 of them were in functional class (Killip) II, 36 in FC III and 71 in FC IV. Thirty cases were submitted to BHC due to congestive heart failure. BHC was successful in 288 patients (96%) and the wedge pressure (WP) could be measured in 236 cases (78.7%). The WP was less than 18 mmHg in 47.2% of the patients in FC II, in 44.9% of the patients in FC III and in 35.3% of those in FC IV. Minor complications occurred in 33 cases (11.0%); balloon rupture in 12 (4.0%), transient arrhythmias in 11 (3.7%) and lumen obstruction in another 10 cases (3.3%). Forty five patients (15.0%) presented major complications related to the procedure: pulmonary infarction (PI) in 18 cases (6%), phlebitis in 15 cases (5%), sustained arrhythmias in 10 cases (3.3%), pulmonary artery rupture and endocarditis each in 1 case. The mean age between the group of patients with and without complications was similar the maintenance time as greater in the group of patients with complications: 3.4 +/- 0.2 vs 2.7 +/- 0.1 days (p less than 0.05). We concluded that many patients with clinical evidence of heart failure had WP smaller than 18 mmHg, emphasizing the value of the procedure in patients with complicated MI. The maintenance time was associated with the occurrence of complications, mainly PI and phlebitis.

[Changes in the ST segment in unstable angina pectoris. Its prognostic value]

Out of 145 patients with unstable angina hospitalized at CCU of the Instituto de Cardiologia do Rio Grande do Sul (Brazil) in 1981, 69 were studied: group I = 23 case (33.3%) with transient ST segment depression, group II = 13 cases (18.8%) with transient ST segment elevation, group III (control) = 33 cases (47.8%) without acute EKG changes. Group I showed a higher incidence of double-triple coronary artery involvement: 71.4% VS 53.8 and 63.3% respectively (non significant). This group also showed a higher number of patients with severe angina and who suffered acute myocardial infarction during follow-up, although without statistical significance. There were 8 deaths (34.8%) in group I, 3 (23.1%) in group II and 4 (12.1%) in group III (chi 2 = 4.11, p greater than 0.05). The 36 months survival rate was lower in group I than in groups II and III: 52.9% VS. 75.2% (NS) and 89.7% (P less than 0.02) respectively. We conclude that acute EKG changes, mainly transient ST segment depression, in unstable angina, are markers of high risk patients.