Prognosis Related to Reperfusion Therapy Post-Acute Coronary Syndrome in Secondary Care: Long-Term Survival Analysis in the ERICO Study

BACKGROUND

Relationship between reperfusion therapy post-acute coronary syndrome (ACS) and mortality in secondary care is not well-known.

OBJECTIVES

To evaluate the impact of three therapeutic strategies: (1) exclusive medical therapy, (2) percutaneous coronary intervention (PCI) and (3) coronary artery bypass grafting (CABG) on long-term survival of participants in the Strategy of Registry of Acute Coronary Syndrome (ERICO) study.

METHODS

Survival analyses for all-cause, cardiovascular (CVD) and coronary artery disease (CAD) mortality were performed according to three therapeutic strategies (exclusive medical therapy, PCI or CABG). Cox regression models were used to estimate the hazard ratio (HR) with respective 95% confidence interval (95%CI) from 180 days to four years of follow-up after ACS. Models are presented as crude, age-sex adjusted and further adjusted for previous CAD, ACS subtype, smoking, hypertension, dyslipidemia, left ventricular ejection fraction and according to the number of obstructed (≥ 50%) major coronary arteries.

RESULTS

Among 800 participants, the lowest crude survival rates were detected among individuals who underwent CABG (all-cause and CVD). CABG was correlated to CAD (HR: 2.19 [95% CI: 1.05-4.55]). However, this risk lost significance in the full model. PCI was associated to lower probability of fatal events during four-year follow-up: all-cause [multivariate HR: 0.42 (95% CI: 0.26-0.70)], CVD [HR: 0.39 (95% CI: 0.20-0.73)] and CAD [multivariate HR: 0.24 (95% CI: 0.09-0.63)] compared to those submitted to exclusive medical therapy.

CONCLUSION

In the ERICO study, PCI after ACS was associated to better prognosis, particularly CAD survival.

Cardiovascular Statistics from the Good Practices in Cardiology Program - Data from a Brazilian Tertiary Public Hospital

BACKGROUND

The Good Practices in Cardiology Program is an initiative created by the Brazilian Society of Cardiology (SBC) to improve the quality of care of cardiovascular disease patients in Brazilian public hospitals.

OBJECTIVES

To characterize patients admitted to a tertiary public hospital with diagnosis of acute coronary syndrome (ACS) or heart failure (HF) and to evaluate performance indicators in both ACS and HF arms, with a pre-established target of 85% adherence to the SBC recommendations.

METHODS

This was a descriptive cross-sectional study through data collection of patients hospitalized between May 2016 and September 2019.

RESULTS

A total of 1,036 patients were included, 273 in the HF arm and 763 in the ACS arm. Mean age was 59.8 ± 12.0 years in the ACS and 57.0 ± 14.1 years in the HF, with a predominance of male patients in both groups. More than half of patients had some primary education and more than 90% reported a monthly income of less than five minimum wages. In ACS, the diagnosis of ACS with ST segment elevation was predominant (66.3%), and 2.9% of patients died. In HF, the most common etiology was Chagas disease (25.8%), and 17.9% died. Analysis of the performance indicators revealed an adherence rate higher than 85% to nine of the 12 indicators.

CONCLUSION

Quality programs are essential for improvement of quality of care. Performance indicators pointed to a good adherence to the SBC guidelines, mainly in the ACS arm.

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.

Comparison of the Outcomes between Coronary No-Reflow and Slow-Flow Phenomenon in Non-STEMI Patients

BACKGROUND

Coronary slow-flow phenomenon (CSFP) and coronary no-reflow phenomenon (CNP) are associated with increased risk of major cardiovascular adverse events (MACE).

OBJECTIVES

This study aimed to evaluate and compare the one-year clinical follow-up outcomes among patients with CNP and CSFP who underwent percutaneous coronary interventions (PCI) in non-ST elevation myocardial infarction (NSTEMI).

METHODS

This study included a total of 858 patients who were diagnosed with NSTEMI and underwent PCI within 24 h of symptom onset. The patients were divided into two groups, the CSFP group (n=221) and the CNP group (n=25), regarding the angiographic characteristics of thrombolysis in myocardial infarction (TIMI) flow of the infarct-related artery. Patients were followed for one-year. A p-value of <0.05 was considered significant.

RESULTS

CNP was observed in 2.91%, and CSFP was observed in 25.75% of the patients. Clinical endpoints analyzed that stroke was significantly higher in the CNP group than in the CSFP group (6 (24%) vs. 6 (2.70%), p<0.001) and MACE was significantly higher in the CNP group than in the CSFP group (11 (44%) vs. 51 (23.10%), p=0.022). Forward conditional logistic regression analysis demonstrated that body mass index (BMI) (OR=1.11, 95%CI: 1.00-1.24, p=0.038) and baseline heart rate (HR) (OR=0.923, 95%CI: 0.88-0.96, p<0.001) were the independent predictors of CNP in NSTEMI.

CONCLUSION

CNP patients have worse clinical outcomes and a higher risk of stroke compared with CSFP patients in NSTEMI. (Arq Bras Cardiol. 2021; 116(5):856-864).

SAPS 3, APACHE IV or GRACE: which score to choose for acute coronary syndrome patients in intensive care units?

CONTEXT AND OBJECTIVE Acute coronary syndromes (ACS) are a common cause of intensive care unit (ICU) admission. Specific prognostic scores have been developed and validated for ACS patients and, among them, GRACE (Global Registry of Acute Coronary Events) has had the best performance. However, intensive care clinicians generally use prognostic scores developed from heterogeneous populations of critically ill patients, such as APACHE IV (Acute Physiologic and Chronic Health Evaluation IV) and SAPS 3 (Simplified Acute Physiology Score 3). The aim of this study was to evaluate and compare the performance of these three scores in a non-selected population of ACS cases. DESIGN AND SETTING Retrospective observational study to evaluate three prognostic scores in a population of ACS patients admitted to three general ICUs in private hospitals in São Paulo. METHODS All patients with ACS admitted from July 2008 to December 2009 were considered for inclusion in the study. Score calibration and discrimination were evaluated in relation to predicting hospital mortality. RESULTS A total of 1065 patients were included. The calibration was appropriate for APACHE IV and GRACE but not for SAPS 3. The discrimination was very good for all scores (area under curve of 0.862 for GRACE, 0.860 for APACHE IV and 0.804 for SAPS 3). CONCLUSIONS In this population of ACS patients admitted to ICUs, GRACE and APACHE IV were adequately calibrated, but SAPS 3 was not. All three scores had very good discrimination. GRACE and APACHE IV may be used for predicting mortality risk among ACS patients.