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Therapeutic anticoagulation showed inconsistent results in hospitalized patients with COVID-19 and selection of the best patients to use this strategy still a challenge balancing the risk of thrombotic and hemorrhagic outcomes. The present post-hoc analysis of the ACTION trial evaluated the variables independently associated with both bleeding events (major bleeding or clinically relevant non-major bleeding) and the composite outcomes thrombotic events (venous thromboembolism, myocardial infarction, stroke, systemic embolism, or major adverse limb events). Variables were assessed one by one with independent logistic regressions and final models were chosen based on Akaike information criteria. The model for bleeding events showed an area under the curve of 0.63 (95% confidence interval [CI] 0.53 to 0.73), while the model for thrombotic events had an area under the curve of 0.72 (95% CI 0.65 to 0.79). Non-invasive respiratory support was associated with thrombotic but not bleeding events, while invasive ventilation was associated with both outcomes (Odds Ratio of 7.03 [95 CI% 1.95 to 25.18] for thrombotic and 3.14 [95% CI 1.11 to 8.84] for bleeding events). Beyond respiratory support, creatinine level (Odds Ratio [OR] 1.01 95% CI 1.00 to 1.02 for every 1.0 mg/dL) and history of coronary disease (OR 3.67; 95% CI 1.32 to 10.29) were also independently associated to the risk of thrombotic events. Non-invasive respiratory support, history of coronary disease, and creatinine level may help to identify hospitalized COVID-19 patients at higher risk of thrombotic complications.ClinicalTrials.gov: NCT04394377., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a powerful predictor of perioperative outcomes. We evaluated the burden of CSA-AKI in patients with preserved baseline renal function., Methods: The data of 2,162 adult patients who underwent cardiac surgery from January 2005 to December 2020 were analyzed. Logistic regression models were used to determine predictors of CSA-AKI and their associations with hospital mortality up to 30 days., Results: The prevalence of acute kidney injury was 43.0%, and 2.0% of patients required renal replacement therapy. Hospital mortality rate was 5.6% (non-acute kidney injury = 2.0% vs. CSA-AKI = 10.4%, P<0.001), and any degree of CSA-AKI was associated with a significant increase in death rates (stage 1 = 4.3%, stage 2 = 23.9%, stage 3 = 59.7%). Multivariable logistic regression analysis identified age, obesity, left ventricular dysfunction, previous cardiac surgery, and cardiopulmonary bypass duration as predictors of CSA-AKI. Moreover, CSA-AKI was confirmed as independent predictor of hospital mortality for stage 1 (odds ratio, 2.02; 95% confidence interval, 1.16 to 3.51; P=0.013), stage 2 (odds ratio, 9.18; 95% confidence interval, 4.54 to 18.58; P<0.001), and stage 3 (odds ratio, 37.72; 95% confidence interval, 18.87 to 75.40; P<0.001) patients., Conclusion: Age, obesity, left ventricular dysfunction, previous cardiac surgery, and cardiopulmonary bypass duration are independent predictors of CSA-AKI in patients with preserved baseline renal function. The development of CSA-AKI is significantly associated with worse outcomes, and there is a dose-response relationship between acute kidney injury stages and hospital mortality.

Background: The efficacy and safety of tofacitinib, a Janus kinase inhibitor, in patients who are hospitalized with coronavirus disease 2019 (Covid-19) pneumonia are unclear., Methods: We randomly assigned, in a 1:1 ratio, hospitalized adults with Covid-19 pneumonia to receive either tofacitinib at a dose of 10 mg or placebo twice daily for up to 14 days or until hospital discharge. The primary outcome was the occurrence of death or respiratory failure through day 28 as assessed with the use of an eight-level ordinal scale (with scores ranging from 1 to 8 and higher scores indicating a worse condition). All-cause mortality and safety were also assessed., Results: A total of 289 patients underwent randomization at 15 sites in Brazil. Overall, 89.3% of the patients received glucocorticoids during hospitalization. The cumulative incidence of death or respiratory failure through day 28 was 18.1% in the tofacitinib group and 29.0% in the placebo group (risk ratio, 0.63; 95% confidence interval [CI], 0.41 to 0.97; P = 0.04). Death from any cause through day 28 occurred in 2.8% of the patients in the tofacitinib group and in 5.5% of those in the placebo group (hazard ratio, 0.49; 95% CI, 0.15 to 1.63). The proportional odds of having a worse score on the eight-level ordinal scale with tofacitinib, as compared with placebo, was 0.60 (95% CI, 0.36 to 1.00) at day 14 and 0.54 (95% CI, 0.27 to 1.06) at day 28. Serious adverse events occurred in 20 patients (14.1%) in the tofacitinib group and in 17 (12.0%) in the placebo group., Conclusions: Among patients hospitalized with Covid-19 pneumonia, tofacitinib led to a lower risk of death or respiratory failure through day 28 than placebo. (Funded by Pfizer; STOP-COVID ClinicalTrials.gov number, NCT04469114.)., (Copyright © 2021 Massachusetts Medical Society.)

Background: COVID-19 is associated with a prothrombotic state leading to adverse clinical outcomes. Whether therapeutic anticoagulation improves outcomes in patients hospitalised with COVID-19 is unknown. We aimed to compare the efficacy and safety of therapeutic versus prophylactic anticoagulation in this population., Methods: We did a pragmatic, open-label (with blinded adjudication), multicentre, randomised, controlled trial, at 31 sites in Brazil. Patients (aged ≥18 years) hospitalised with COVID-19 and elevated D-dimer concentration, and who had COVID-19 symptoms for up to 14 days before randomisation, were randomly assigned (1:1) to receive either therapeutic or prophylactic anticoagulation. Therapeutic anticoagulation was in-hospital oral rivaroxaban (20 mg or 15 mg daily) for stable patients, or initial subcutaneous enoxaparin (1 mg/kg twice per day) or intravenous unfractionated heparin (to achieve a 0·3-0·7 IU/mL anti-Xa concentration) for clinically unstable patients, followed by rivaroxaban to day 30. Prophylactic anticoagulation was standard in-hospital enoxaparin or unfractionated heparin. The primary efficacy outcome was a hierarchical analysis of time to death, duration of hospitalisation, or duration of supplemental oxygen to day 30, analysed with the win ratio method (a ratio >1 reflects a better outcome in the therapeutic anticoagulation group) in the intention-to-treat population. The primary safety outcome was major or clinically relevant non-major bleeding through 30 days. This study is registered with ClinicalTrials.gov (NCT04394377) and is completed., Findings: From June 24, 2020, to Feb 26, 2021, 3331 patients were screened and 615 were randomly allocated (311 [50%] to the therapeutic anticoagulation group and 304 [50%] to the prophylactic anticoagulation group). 576 (94%) were clinically stable and 39 (6%) clinically unstable. One patient, in the therapeutic group, was lost to follow-up because of withdrawal of consent and was not included in the primary analysis. The primary efficacy outcome was not different between patients assigned therapeutic or prophylactic anticoagulation, with 28 899 (34·8%) wins in the therapeutic group and 34 288 (41·3%) in the prophylactic group (win ratio 0·86 [95% CI 0·59-1·22], p=0·40). Consistent results were seen in clinically stable and clinically unstable patients. The primary safety outcome of major or clinically relevant non-major bleeding occurred in 26 (8%) patients assigned therapeutic anticoagulation and seven (2%) assigned prophylactic anticoagulation (relative risk 3·64 [95% CI 1·61-8·27], p=0·0010). Allergic reaction to the study medication occurred in two (1%) patients in the therapeutic anticoagulation group and three (1%) in the prophylactic anticoagulation group., Interpretation: In patients hospitalised with COVID-19 and elevated D-dimer concentration, in-hospital therapeutic anticoagulation with rivaroxaban or enoxaparin followed by rivaroxaban to day 30 did not improve clinical outcomes and increased bleeding compared with prophylactic anticoagulation. Therefore, use of therapeutic-dose rivaroxaban, and other direct oral anticoagulants, should be avoided in these patients in the absence of an evidence-based indication for oral anticoagulation., Funding: Coalition COVID-19 Brazil, Bayer SA., Competing Interests: Declaration of interests JHA reports grants and personal fees from Bristol-Myers Squibb and CSL Behring; grants from AstraZeneca, CryoLife, US Food & Drug Administration, US National Institutes of Health, Sanofi, VoluMetrix, and Boehringer Ingelheim; personal fees from Pfizer, AbbVie Pharmaceuticals, Portola Pharmaceuticals, Quantum Genetics, Teikoku Pharmaceuticals, VA Cooperative Studies Program, and Zafgen, outside of the submitted work. AA reports consultant and lecture fees from Bayer, NovoNordisk, and LillyBaxter; lecture fees from Daichii-Sankyo; and research grants from Bayer, EMS Pharma, and the Population Health Research Institute, outside of the submitted work. LCPA reports personal fees from Baxter, Pfizer, and Halex-Istar; and grants from Ache Laboratorios Farmaceuticos, outside of the submitted work. OB reports grants from AstraZeneca, Pfizer, Bayer, Boehringer Ingelheim, Servier, and Amgen, and advisory board and personal fees from Novartis, outside of the submitted work. ABC reports grants from Bayer outside of the submitted work. GEC-S reports grants from Novartis and Air Liquide, outside of the submitted work. PGMdBeS reports grants from Bayer, Roche, and Pfizer, outside of the submitted work. MDAD reports personal fees, non-financial support, and other (advisory board participation) from Pfizer; personal fees and non-financial support from Bayer; personal fees and other (advisory board participation) from Servier; and personal fees from Boehringer Ingelheim, Daiichi Sankyo, and AstraZeneca, outside of the submitted work. RHMF reports grants from Bayer during the conduct of the study; and grants and personal fees from AstraZeneca and Servier, personal fees and non-financial support from Bayer, grants and non-financial support from EMS Pharma, and grants from Aché, Health Canada, and the Brazilian Ministry of Health, outside of the submitted work. MBG reports personal fees from COALITION COVID-19 Brazil and Bayer during the conduct of the study. RDL reports grants and personal fees from Bristol-Myers Squibb, Pfizer, GlaxoSmithKline, Medtronic PLC, and Sanofi; and personal fees from Amgen, Bayer, and Boehringer Ingelheim, outside of the submitted work. AVSM reports personal fees, non-financial support, and other (advisory board participation) from Bayer and Pfizer; personal fees and other (advisory board participation) from Novartis; personal fees and non-financial support from Zodiac; and personal fees from Ferring, Janssen, Sanofi, and AstraZeneca, outside of the submitted work. FCN reports grants and personal fees from Boehringer Ingelheim; and personal fees from Bayer and Pfizer, outside of the submitted work. ER reports grants and consulting fees from Bayer and Pfizer; grants from the Brazilian Ministry of Science and Technology; and personal fees from Aspen Pharma, Biomm Pharma, and Daiichi Sankyo, outside of the submitted work. ATR reports personal fees from Sanofi and Bayer, outside of the submitted work. VCV reports grants from Aspen Pharma, Pfizer, and Cristalia, outside of the submitted work. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background Increased high-sensitivity cardiac troponin T (hs-cTnT) above the upper reference limit (URL) after noncardiac surgery identifies patients at risk for mortality. Prior studies have not analyzed hs-cTnT as a continuous variable or probed age- and sex-specific URLs. This study compared the prediction of 30-day mortality using continuous postoperative hs-cTnT levels to the use of the overall URL and age- and sex-specific URLs. Methods and Results Patients (876) >40 years of age who underwent noncardiac surgery were included. Hs-cTnT was measured on postoperative day 1. Cox proportional hazards models were used to compare associations between 30-day mortality and using hs-cTnT as a continuous variable, or above the overall or age- and sex-specific URLs. Comparisons were performed by the area under the receiver operating characteristic curve analysis. Mortality was 4.2%. For each 1 ng/L increase in postoperative hs-cTnT, there was a 0.3% increase in mortality ( P <0.001). Patients with postoperative hs-cTnT >14 ng/L were 37% of the cohort, while those above age- and sex-specific URLs were 25.3%. Both manifested higher mortality (hazard ratio [HR], 3.19; 95% CI, 1.20-8.49; P =0.020) and (HR, 2.76; P =0.009) than those with normal levels. The area under receiver operating characteristic curve was 0.89 using hs-cTnT as a continuous variable, 0.87 for age- and sex-specific URLs, and 0.86 for the overall URL. Conclusions Hs-cTnT as a continuous variable was independently associated with 30-day mortality and had the highest accuracy. Hs-cTnT elevations using overall and/or age- and sex-specific URLs were also associated with higher mortality.

Objectives: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil., Methods: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment., Results: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment., Conclusion: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

Background:  Periprocedural myocardial injury after coronary artery bypass grafting (CABG) may affect the patient's prognosis and may be due to a different set of factors beyond the atherosclerotic plaque instability. Considering the challenges in the diagnosis of myocardial injury after CABG, the aim of this study was to determine the association between postoperative early elevation of high-sensitivity troponin T (hsTnT) and all-cause 30-day mortality after CABG., Methods:  We enrolled 600 consecutive patients who underwent CABG. The hsTnT value was measured immediately before surgery and in the morning of the first postoperative day., Results:  The baseline hsTnT was 13 ng/L (7-26 ng/L) and 273 patients (45.7%) had baseline hsTnT above the 99th percentile/upper reference limit (URL) (14 ng/L). The median for hsTnT at first postoperative day was 235 ng/L (152-425 ng/L). We calculated the postoperative hsTnT ratio to URL for each patient, representing the number of times exceeding the URL (hsTnT value divided by 14 ng/L). The multivariate analysis by Cox proportional hazard model revealed that age (years) (hazard ratio [HR] = 1.13, 95% confidence interval [CI]: 1.07-1.20; p  < 0.001) and postoperative hsTnT ratio to URL (per 10-fold increase) (HR = 1.06, 95% CI: 1.04-1.08; p  < 0.001) were independent predictors of all-cause 30-day mortality after CABG., Conclusion:  In our series, age and higher postoperative hsTnT levels were independent and reliable predictors of all-cause 30-day mortality after CABG., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Preliminary evidence suggests that statins may prevent major perioperative vascular complications., Methods: We randomized 648 statin-naïve patients who were scheduled for noncardiac surgery and were at risk for a major vascular complication. Patients were randomized to a loading dose of atorvastatin or placebo (80 mg anytime within 18hours before surgery), followed by a maintenance dose of 40 mg (or placebo), started at least 12hours after the surgery, and then 40 mg/d (or placebo) for 7days. The primary outcome was a composite of all-cause mortality, nonfatal myocardial injury after noncardiac surgery, and stroke at 30days., Results: The primary outcome was observed in 54 (16.6%) of 326 patients in the atorvastatin group and 59 (18.7%) of 316 patients in the placebo group (hazard ratio [HR] 0.87, 95% CI 0.60-1.26, P=.46). No significant effect was observed on the 30-day secondary outcomes of all-cause mortality (4.3% vs 4.1%, respectively; HR 1.14, 95% CI 0.53-2.47, P=.74), nonfatal myocardial infarction (3.4% vs 4.4%, respectively; HR 0.76, 95% CI 0.35-1.68, P=.50), myocardial injury after noncardiac surgery (13.2% vs 16.5%; HR 0.79, 95% CI 0.53-1.19, P=.26), and stroke (0.9% vs 0%, P=.25)., Conclusion: In contrast to the prior observational and trial data, the LOAD trial has neutral results and did not demonstrate a reduction in major cardiovascular complications after a short-term perioperative course of statin in statin-naïve patients undergoing noncardiac surgery. We demonstrated, however, that a large multicenter blinded perioperative statin trial for high-risk statin-naïve patients is feasible and should be done to definitely establish the efficacy and safety of statin in this patient population., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Preoperatively elevated serum creatinine (SCr) is considered an independent risk factor for morbidity and mortality after cardiac surgery. The aim of this study was to apply the Kidney Disease Improving Global Outcomes classification for acute kidney injury in a population of patients with preoperatively elevated serum creatinine who underwent cardiac surgery (coronary artery bypass grafting or cardiac valve surgery) and to evaluate the acute worsening of renal function as a predictor of 30-day mortality., Methods: This was a single-center retrospective study that included patients from the Postoperative Cardiac Surgery Intensive Care Unit of the Hospital de Base, São José do Rio Preto Medical School. Demographics, type of surgery, laboratory data and pre, peri and postoperative data were obtained from a prospectively collected database. From January 2003 to June 2013, 2,878 patients underwent cardiac surgery, either coronary artery bypass grafting or cardiac valve surgery, at the Hospital de Base of São José do Rio Preto Medical School. Out of those, 918 showed elevated preoperative serum creatinine, with SCr > 1.30 mg/dL for men and > 1.00 mg/dL for women. Five hundred and forty nine patients (60%) undergoing coronary artery bypass grafting and 369 patients (40%) undergoing cardiac valve surgery. A Multivariate Cox Proportional Hazard Model (stepwise) was used to assess the relationship between AKI and mortality at 30 days., Results: Out of the 918 patients studied, 391 (43%) had postoperative AKI: 318 (35%) had Kidney Disease Improving Global Outcomes stage 1, 27 (2.9%) had Kidney Disease Improving Global Outcomes stage 2, and 46 (5.0%) had Kidney Disease Improving Global Outcomes stage 3. Patients in every stage of acute kidney injury showed progressive increase in EuroSCORE values, 30-day mortality rates, cardiopulmonary bypass duration, and intensive care length of stay. Among patients classified as Kidney Disease Improving Global Outcomes stage 3, 76% required dialysis with a 30-day mortality of 66%. The Cox proportional hazards model showed that the hazard ratio for 30-day mortality was 4.8 for Kidney Disease Improving Global Outcomes stage 1 patients, 13.5 for Kidney Disease Improving Global Outcomes stage 2 patients, and 20.8 for Kidney Disease Improving Global Outcomes stage 3 patients (P<0.001 for all). Subgroup analyses (coronary artery bypass grafting and cardiac valve surgery) had similar results., Conclusion: In this population, acute kidney injury based on the Kidney Disease Improving Global Outcomes criteria was a powerful predictor of 30-day mortality in patients with elevated preoperative serum creatinine who underwent cardiac surgery (coronary artery bypass grafting or cardiac valve surgery).

Objectives: The definition of acute renal failure has been recently reviewed, and the term acute kidney injury (AKI) was proposed to cover the entire spectrum of the syndrome, ranging from small changes in renal function markers to dialysis needs. This study was aimed to evaluate the incidence, morbidity and mortality associated with AKI (based on KDIGO criteria) in patients after cardiac surgery (coronary artery bypass grafting or cardiac valve surgery) and to determine the value of this feature as a predictor of hospital mortality (30 days)., Methods: From January 2003 to June 2013, a total of 2,804 patients underwent cardiac surgery in our service. Cox proportional hazard models were used to determine the association between the development of AKI and 30-day mortality., Results: A total of 1,175 (42%) patients met the diagnostic criteria for AKI based on KDIGO classification during the first 7 postoperative days: 978 (35%) patients met the diagnostic criteria for stage 1 while 100 (4%) patients met the diagnostic criteria for stage 2 and 97 (3%) patients met the diagnostic criteria for stage 3. A total of 63 (2%) patients required dialysis treatment. Overall, the 30-day mortality was 7.1% (2.2%) for patients without AKI and 8.2%, 31% and 55% for patients with AKI at stages 1, 2 and 3, respectively. The KDIGO stage 3 patients who did not require dialysis had a mortality rate of 41%, while the mortality of dialysis patients was 62%. The adjusted Cox regression analysis revealed that AKI based on KDIGO criteria (stages 1-3) was an independent predictor of 30-day mortality (P<0.001 for all. Hazard ratio = 3.35, 11.94 and 24.85)., Conclusion: In the population evaluated in the present study, even slight changes in the renal function based on KDIGO criteria were considered as independent predictors of 30-day mortality after cardiac surgery.

Objective: We evaluated patients underwent cardiac valve surgery in the presence of infective endocarditis in an attempt to identify independent predictors of 30-day mortality., Methods: We evaluated 837 consecutive patients underwent cardiac valve surgery from January 2003 to May 2010 in a tertiary hospital in São José do Rio Preto, São Paulo (SP), Brazil. The study group comprised patients who underwent intervention in the presence of infective endocarditis and was compared to the control group (without infective endocarditis), evaluating perioperative clinical outcomes and 30-day all cause mortality., Results: In our series, 64 patients (8%) underwent cardiac valve surgery in the presence of infective endocarditis, and 37.5% of them had surgical intervention in multiple valves. The study group had prolonged ICU length of stay (16%), greater need for dialysis (9%) and higher 30-day mortality (17%) compared to the control group (7%, P=0.020; 2%, P=0.002 and 9%, P=0.038; respectively). In a Cox regression analysis, age (P = 0.007), acute kidney injury (P = 0.004), dialysis (P = 0.026), redo surgery (P = 0.026), re-exploration for bleeding (P = 0.013), tracheal reintubation (P <0.001) and type I neurological injury (P <0.001) were identified as independent predictors for death. Although the manifestation of infective endocarditis influenced on mortality in univariate analysis, multivariate Cox regression analysis did not confirm such variable as an independent predictor of death., Conclusion: Age and perioperative complications stand out as predictors of hospital mortality in Brazilian population. Cardiac valve surgery in the presence of active infective endocarditis was not confirmed itself as an independent predictor of 30-day mortality.

Objective: To compare mechanical ventilation weaning based on a protocol using the spontaneous breathing trial against mechanical ventilation weaning without a standardized protocol in heart patients., Methods: Prospective, open, randomized study. In 2006, 36 patients undergoing mechanical ventilation for over 24 hours were randomized into two groups: control group - eighteen patients whose mechanical ventilation weaning was performed according to the different procedures adopted by the multidisciplinary team; and experimental group - eighteen patients weaned according to previously established protocol., Results: Control group patients started the weaning process sooner than experimental group patients (74.7 ± 14.7 hours vs. 185.7 ± 22.9 hours, P=0.0004). However, after the experimental group patients were ready for weaning, the extubation was carried out more rapidly than in the control group (149.1 ± 3.6 min vs. 4179.1 ± 927.8 min, P < 0.0001) with significantly lower reintubation rates (16.7% vs. 66.7%, P = 0.005)., Conclusion: The use of a specific protocol based on the spontaneous breathing trial for mechanical ventilation weaning in heart patients had better outcomes than weaning carried out without a standardized protocol, with shorter weaning times and lower reintubation rates.

Background: The acute kidney injury (AKI) is a complex disease for which there is no accepted standard definition nowadays. The Acute Kidney Injury Network (AKIN) represents an attempt to standardize the criteria for diagnosis and staging of acute renal dysfunction based on recently published RIFLE criteria, that means, (Risk, Injury, Failure, Loss, and End-stage kidney disease)., Objectives: To evaluate the incidence and associated mortality of AKI in patients submitted to on-pump coronary artery bypass graft surgery (on-pump CABG)., Methods: A total of 817 patients were divided into two groups: negative AKI (-), with 421 patients (51.5%), and positive AKI (+), with 396 patients (48.5%). Increase of 0.3 mg/dL in creatinine or of 50% in creatinine's basal value was considered as AKI., Results: The rate of patient's mortality with or without AKI within 30 days after cardiac surgery was 12.6% and 1.4%, respectively (p<0.0001). In a multivariate logistic regression model, AKI after on-pump CABG was an independent predictor of death within 30 days (OR=6.7; p=0.0002). This group of patients presented a longer period of permanency in intensive care unit (ICU) [median 2 days (2 to 3) versus 3 days (2 to 5); p=0.0001] and a bigger proportion of patients with prolonged permanence in intensive care (>14 days) (14 versus 2%; p=0.0001)., Conclusion: In the studied population, even a discrete alteration in renal function, based on AKIN criteria, was an independent predictor of death in 30 days after on-pump CABG.

Background: Several infectious agents have been investigated since the association between atherosclerosis and infection was demonstrated; however, the results of these studies are contradictory., Objective: To test the association between serum titers of anti-Chlamydia and anti-Mycoplasma antibodies in different forms of acute coronary syndromes (ACS)., Methods: One hundred and twenty-six patients were divided in 4 groups: ACS with ST-segment elevation (32 patients), ACS without ST-segment elevation (30 patients), chronic coronary artery disease (30 patients) and blood donors without known coronary disease (34 patients--control group). In the two first groups, serum samples were collected at hospital admission (first 24 hours of hospitalization) and after a 6-month follow-up. In the other two groups, only a basal sample was collected. Anti-Chlamydia and anti-Mycoplasma antibodies were measured by indirect immunofluorescence in all samples., Results: Significant differences were observed between the basal sample and the one measured after a 6-month follow-up in patients with myocardial infarction with ST-segment elevation for Chlamydia (650+/-115.7 versus 307+/-47.5, p=0.0001) as well as Mycoplasma (36.5+/-5.0 versus 21.5+/-3.5, p=0.0004). The groups with ACS had higher anti-Chlamydia and anti-Mycoplasma serum antibody levels in the basal measurement, when compared to the patients with chronic coronary disease and the control group, but the differences were not statistically significant., Conclusion: The present study showed an association between the serum titers of anti-Chlamydia and anti-Mycoplasma antibodies in the acute phase of patients with unstable angina or myocardial infarction.

Objective: It is common to obtain femoral venous approach in patients undergoing combined heart surgery or as an alternative to superior approach (internal jugular vein or subclavian vein). The aim of this study was to compare the measures of central venous pressure (CVP) at two different sites (superior versus femoral)., Methods: We prospectively and openly allocated 60 patients who underwent heart surgery between July from November 2006. Three measures were obtained from each patient at each site (admission, 6 and 12 hours after surgery) in two different inclinations of the headboard (zero and 30 degrees) totaling 720 measures., Results: Fifty five percent of patients who underwent coronary artery bypass grafting, 38% heart valve surgery and 7% other surgeries. The mean of CVP +/- standard deviation (SD) measured in superior approach was 13.0 +/- 5.5 mmHg (zero degree) and 13.3 +/- 6.1 mmHg (30 degrees) while the measures in inferior approach were 11.1 +/- 4.9 mmHg (zero degree) and 13.7 +/- 4.6 mmHg (30 degrees). The linear correlation (r) between the measures in both sites was 0.66 (zero degree) and 0.53 (30 degrees), both with p value<0.0001., Conclusion: The CVP can be measured with accuracy in the femoral venous approach in the immediate postoperative period of heart surgery with better linear correlation obtained with the measures made with the headboard positioned at zero degree.

Syphilis is an infectious disease occurring through a series of frequently overlapping stages. It can impair the cardiovascular and neurological system. In 30% of the non treated patients, syphilis develops its tertiary form. We report a case of a 46-year-old male patient admitted due to edema pulmonary and acute coronary syndrome with left bundle branch block, submitted to fibrinolytic therapy successfully. Coronary angiography showed a 90% ostial lesion of left main coronary artery and occlusion of the right coronary artery ostium. VDRL was titrated to 1/128. The patient was undergone to CABG and was discharged after treatment with crystalline penicillin.

In patients with acute myocardial infarction (AMI), the mechanisms behind the increased mortality related to glucose levels (GL) are poorly understood. The main purpose of this study is to analyze the relationship between baseline glucose and left ventricular enlargement (LVE). We analyzed 52 patients with a first ST-elevation AMI <24 h of evolution. Glucose levels were obtained upon admission (median time, 3 h after the beginning of chest pain). The median GL was 123.5 mg/dl, and patients above this limit were considered hyperglycemic (n=26). Left ventricular enlargement was analyzed comparing two radionuclide ventriculographies, the first obtained within 4 days post-AMI (median, 55 h) and the second 6 months later (median, 188.5 days), taking into account the difference in the obtained end-systolic volumes. Myocardial reperfusion was evaluated comparing ST resolution between a first ECG done immediately upon hospital arrival with a second ECG performed 2 h after treatment. By univariate analysis, LVE correlated significantly with baseline hyperglycemia (P<.001), failed reperfusion by ECG criteria (P<.001), and no use of ACE inhibitors or AT1 blockers (P=.046) and aspirin (P=.046). A history of previous diabetes did not correlate significantly with LVE at 6 months. In the adjusted model, basal hyperglycemia (P<.001) and failed reperfusion (P=.001) were the only variables independently correlated with LVE. In conclusion, baseline glucose is a powerful and independent predictor of LVE after AMI, which reinforces the importance of a tight glucose control during the initial phase of the disease.

Objective: To evaluate the length of time required for atherosclerotic plaque stabilization in acute coronary syndromes (ACS), using inflammatory markers., Methods: In this prospective study, C-reactive protein (CRP), fibrinogen, factor VIIIc, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) levels were measured on admission, at discharge, and three and six months post-discharge in 40 patients with non-ST-segment elevation ACS (NSTE-ACS) and 40 healthy subjects., Results: C-reactive protein levels were significantly higher on admission and at discharge, but not at three and six months post-discharge, compared with the control group. Fibrinogen levels remained unchanged, except at six months, when they were significantly lower than in the control group. Factor VIII-c did not differ from that of the control group on admission, but it was significantly higher at discharge, with no differences at three and six months. Interleukin-6 levels were significantly higher than in the control group in all time points. However, they declined significantly between discharge and three months. In no time point was TNF-alpha significantly different from that of the control group. Only IL-6 correlated significantly and independently with future cardiovascular events., Conclusion: With respect to CRP and factor VIIIc, plaque stabilization is suggested in up to three months; IL-6 analysis suggests stabilization as from the third month, although it remained higher than that of the control group for up to six months. Only IL-6 showed prognostic value for further events within a year.

The European Society of Cardiology and the American College of Cardiology redefined the concept of myocardial infarction in the presence of highly positive markers of myocardial injury associated with at least one of the following: ischemic symptoms; development of pathologic Q waves on the ECG or ECG changes indicative of ischemia (positive or negative deviation of the ST segment), making troponins one of the most important aspects in the evaluation and stratification of patients with chest pain in the emergency room. However, although troponin gives excellent accuracy in the identification of myocardial necrosis, it is known that it can also be elevated in a series of nonatherosclerotic heart diseases. We present the case of a 49-year-old female patient admitted to the Chest Pain Unit with a history of supraventricular tachycardia associated with chest discomfort, nausea and diaphoresis. During risk stratification, the patient presented with a high serum troponin T level (0.143 ng/ml) but with a normal coronary angiography., (Copyright 2006 S. Karger AG, Basel)

The assessment and stratification of patients with chest pain in the emergency unit may indicate the appropriate therapy for each patient based on the probability of the presence of acute coronary artery disease and on the risk of its major cardiac events. That assessment is based on the triplet: clinical setting, electrocardiographic findings, and markers of myocardial lesion. We report the case of a 58-year-old male chagasic patient admitted to the emergency unit due to chest pain and palpitations, with an electrocardiogram showing sustained ventricular tachycardia and positive troponin measurement (0.99 ng/mL). The patient underwent cine coronary angiography, which evidenced no obstructive coronary artery disease.

Background: Previous studies have compared angiotensin receptor blockers and angiotensin-converting enzyme inhibitors in patients with heart failure, but there are few data about the effect of these drugs regarding left ventricular remodeling after myocardial infarction., Methods: Fifty-two consecutive patients with first anterior wall myocardial infarction within 24 hours of evolution were randomized to receive enalapril (as much as 20 mg; mean, 14.6 mg), or losartan (as much as 50 mg; mean, 48 mg). Left ventricular ejection fraction and ventricular volumes were analyzed in 2 serial radionuclide ventriculograpies, carried out within 4 days after the infarction (mean, 97.4 +/- 114.2 hours) and after 6 months (mean, 177.7 +/- 16.7 days). Ventriculographies were analyzed by a single blinded observer. Mainly because of the unexpected large SD values obtained, the power of the study to demonstrate equivalence between the groups was only 15.7%., Results: The differences obtained between the first and the second ventriculographies, for the enalapril and losartan groups, were: for left ventricular ejection fraction, -0.4% +/- 6.6% versus -1.1% +/- 5.9% (P =. 67; 95% CI, 2.77-4.23); for final systolic volume, 0.07 +/- 7.7 mL/m(2) versus -0.2 +/- 6.1mL/m(2) (P =. 85; 95% CI, -3.57-4.26); for final diastolic volume -0.7 +/- 12.1 mL/m(2) versus -3.6 - 9.9 mL/m(2) (P =. 34; 95% CI, -3.22-9.17)., Conclusion: This study, although underpowered, suggests that neither enalapril nor losartan was superior as compared with each other for left ventricular remodeling after myocardial infarction; however, powerful evidence of equivalence was not provided.

Purpose: To develop a survey about risk factors for atherosclerosis in a > or = 20-year-old population from São José do Rio Preto, and compare the results with those obtained in a similar survey in 1991., Methods: Quantitative survey with sample stratified by sex and age. The individuals (a total of 646, 303 men) where contacted in outpatient facilities from the Health Secretary and other populated sites, distributed by geographic zone and social class of different neighborhoods. The standard error of the survey was 4%, and the confidence interval was 95%., Results: A) Mean HDL-cholesterol (only in 1997): male gender 43.7 +/- 15 mg/dL, female gender 49.6 +/- 13.5 mg/dL (p < 0.001, 95% CI 3.7 a 8.1). B) Mean total cholesterol in 1991 vs 1997: for the global population 192.5 +/- 48.9 mg/dL vs 190.5 +/- 42.5 mg/dL (p = NS); for men 187.6 +/- 53.3 mg/dL vs 190.5 +/- 42.5 mg/dL (p = NS); for women 196.8 +/- 40 mg/dL vs 187.6 +/- 37.8 mg/dL (p = 0.008, 95% CI 2.4 a 15.9). C) By regression analysis, the variables that correlated significantly with cholesterol levels, in both surveys, were: age (p < 0.001), systolic (p < 0.001) and diastolic (p < 0.001) arterial pressure, diet (p < 0.001). Female gender showed correlation only in the 1991 survey (p = 0.011), and sedentarism only in 1997 (p = 0.014)., Conclusion: The mean cholesterol levels in the adult population of São José do Rio Preto are very favorable and, in female gender, showed a significant decrease in the 1997 survey, relatively to the 1991 survey.

Purpose: Multicenter, open and non-controlled study to evaluated the efficacy and the tolerability of a low-dose combination of two anti-hypertensive agents: a cardioselective beta-blocker, bisoprolol (2.5 and 5.0 mg) with 6.25 mg of hydrochlorothiazide., Methods: One hundred and six patients in the stage I and stage II of the systemic hypertension (mild to moderate) were given the bisoprolol/hydrochlorothiazide combination once daily and the diastolic and systolic blood pressures were monitored during the 8-week trial., Results: The bisoprolol/hydrochlorothiazide combination reduced the initial mean values of systolic and diastolic blood pressures, respectively, from the 157.4 mmHg and 98.8 mmHg to 137.3 mmHg and 87.4 mmHg. At the end of the treatment period, 61% of the patients normalized blood pressure values (< 90 mmHg) and 22.9% of them had responded to the treatment, resulting in a total response rate (normalized + responsive) of 83.9% of cases. Adverse events were described only in 18.9% of the patients and dizziness and headache were the most common. There were no clinically significant changes on plasma levels of potassium, uric acid, glucose, or in the lipid profile., Conclusion: The combination of low dosages of bisoprolol and hydrochlorothiazide may be considered an effective, well tolerated and rational alternative for the initial treatment of the patients with mild to moderate hypertension.