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Resumo Fundamento São restritos os dados sobre o manejo e o prognóstico dos pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST) com acometimento multiarterial no Brasil, o que mostra a necessidade de investigar as estratégias de revascularização disponíveis. Objetivo Avaliar os desfechos relacionados à revascularização completa em comparação com o tratamento da artéria culpada em pacientes multiarteriais com IAMCSST. Métodos Foi realizada um estudo de coorte prospectiva em dois centros de hemodinâmica do Sul do Brasil, com seguimento de 1 ano após a intervenção índice. O desfecho primário foi composto de óbito cardiovascular, reinfarto ou angina recorrente e secundários acidente vascular encefálico, parada cardiorrespiratória não fatal, sangramento maior ou necessidade de reintervenção. A probabilidade de ocorrência de desfechos foi comparada entre os grupos através de regressão logística binária. Considerou-se como estatisticamente significativo o valor de probabilidade < 0,05. Resultados Participaram 85 pacientes, com média de idade de 62±12 anos, sendo 61 (71,8%) do sexo masculino. Cinquenta e oito (68,2%) pacientes receberam a estratégia de revascularização completa e 27 (31,8%), a de revascularização incompleta. A chance de ocorrência tanto do desfecho primário quanto do secundário foi significativamente maior entre os indivíduos tratados com revascularização incompleta quando comparados com os tratados com estratégia completa [razão de chances (OR) 5,1, intervalo de confiança de 95% (IC95%) 1,6-16,1 vs. OR 5,2, IC95% 1,2-22,9, respectivamente], assim como os óbitos cardiovasculares (OR 6,4, IC95% 1,2-35,3). Conclusão Dados deste registro regional, de dois centros do Sul do Brasil, demonstram que a estratégia de revascularização completa esteve associada à redução significativa dos desfechos primário e secundário no seguimento de 1 ano quando comparada à estratégia de revascularização incompleta. (Arq Bras Cardiol. 2020; 115(2):229-237) Abstract Background Data on the management and prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease are limited in Brazil, showing that the available revascularization strategies should be investigated Objective To assess the outcomes of complete revascularization versus treatment of the culprit artery only in patients with STEMI and multivessel disease. Methods A prospective cohort study was conducted at two medical centers in southern Brazil with a 1-year follow-up after the index procedure. The primary outcome was a composite of cardiac death, reinfarction, or recurrent angina, while the secondary outcome was stroke, nonfatal cardiac arrest, major bleeding, or need for reintervention. The probability of outcomes occurring was compared between the groups using binary logistic regression. A p-value < 0.05 was considered statistically significant. Results Eighty-five patients were included. Their mean age was 62±12 years, and 61 (71.8%) were male. Fifty-eight (68.2%) were treated with complete revascularization and 27 (31.8%) with incomplete revascularization. The chance of both the primary and secondary outcomes occurring was significantly greater among patients treated with incomplete revascularization when compared to those treated with complete revascularization (odds ratio [OR] 5.1, 95% confidence interval [CI] 1.6-16.1 vs. OR 5.2, 95% CI 1.2-22.9, respectively), as well as cardiac death (OR 6.4, 95% CI 1.2-35.3). Conclusion Registry data from two centers in southern Brazil demonstrate that the complete revascularization strategy is associated with a significant reduction in primary and secondary outcomes in a 1-year follow-up when compared to the incomplete revascularization strategy (Arq Bras Cardiol. 2020; 115(2):229-237)

AIM To assess the effect of periodontal therapy (PT) on cardiovascular blood biomarkers. MATERIALS AND METHODS This single-blind, parallel-design, randomized controlled trial included patients with stable coronary artery disease and periodontitis. The test group (TG) received non-surgical PT, whereas the control group (CG) received one session of plaque removal. Plasma levels of C-reactive protein (CRP), glycated haemoglobin, lipids and cytokines (IL-1β, IL-6, IL-8, IL-10, IFN-γ and TNF-α) were measured at baseline and after 3 months. RESULTS Eighty-two patients (74.4% women, mean age 59.6 years) were analysed. TG had significantly better periodontal parameters than CG after 3 months, but no significant differences in blood markers were observed between them. In a post hoc subgroup analysis in patients with baseline CRP

Background: Despite the complexity of SYNTAX score (SS), guidelines recommend this tool to help choosing between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with left main of three-vessel coronary artery disease. The aim of this study was to compare the inter-observer variation in SS performed by clinical cardiologists (CC), interventional cardiologists (IC), and cardiac surgeons (CS). Methods: Seven coronary angiographies from patients with left main and/or three-vessel disease chosen by a heart team were analyzed by 10 CC, 10 IC and 10 CS. SS was calculated via SYNTAX website. Results: Kappa concordance was very low between CC and CS (k = 0.176), moderate between CS and IC (k = 0.563), and moderate between CC and IC (0.553). There was a statistically significant difference between CC, who classified more cases as low complexity (70%), and CS, who classified more cases as moderate complexity (80%) ( p = 0.041). Conclusion: Concordance between SS analyzed by CC, CS and IC is low. The usefulness of SS in decision-making of revascularization strategy is undeniable and evidence supports its use. However, this study highlights the importance of well-trained professionals on calculating the SS. It could avoid misclassification of borderline cases.

Introduction Evidence of telehealth for chronic disease management is scarce and contradictory. Objectives We aimed to evaluate the safety and efficacy of teleconsultations as support in the care transition of patients with stable coronary artery disease (CAD) from tertiary to primary care. Methods A randomized noninferiority clinical trial was undertaken in patients with CAD from a tertiary hospital in a middle-income country. Patients with functional angina class 1 or 2 and meeting discharge criteria were randomized to remain in the cardiology outpatient clinic for 12 months (control group, CG) or continue follow-up in a primary care unit with clinical support via telemedicine (intervention group, IG). The primary outcome was the maintenance of the functional angina class after 12 months. Secondary outcomes included control of risk factors and clinical outcomes. Results In total 271 patients (mean age, 66 years) were included; 81.1% and 91% of the IG and CG, respectively, maintained stable angina symptoms, thus noninferiority could not be shown between the groups. Regarding emergency room visits at 1 year, the IG (7.6%) was noninferior to the CG (6.0%) (absolute difference, 1.6%; noninferiority margin (NIM), –4.8% to 8.2%). For control of risk factors, 30.7% and 29.6% of the IG and CG, respectively, had blood pressure Conclusions In our study, the difference in the patients’ angina functional class did not result in greater seeking of emergency care, supporting that discharge from the outpatient clinic with telemedicine is safe for patients with stable CAD treated at the tertiary level. The control of risk factors in these patients was noninferior to patients followed up in primary care. ClinicalTrials.gov (NCT02489565).

Aim: Describe the oral health condition and oral health related behavioral habits of individuals with chronic coronary artery disease that have been followed in a cardiologic unit in the University Hospital of Porto Alegre. Materials and Methods: 100 consecutive patients that frequented the unit were evaluated between June 2011 and March 2012. Demographics, socioeconomic and behavioral data were obtained from all participants. An oral examination with the following variables was performed: visible plaque and gingival bleeding indexes, gingival recession (GR), periodontal probing depth (PPD), BOP, clinical attachment loss derived by the sum of GR and PPD, and DMFT. Results: The majority of individuals were from male gender and were over 60 years of age. Approximately half of the individuals were former smokers. More than three quarters of the sample reported to have irregular dental visits. The parameters related to the supragingival biofilm presented high means for plaque and gingival bleeding indexes equalig 68% and 47% respectively. More than half of the examined teeth presented PPD ≥4 mm, and subgingival bleeding was present in approximately three quarters of the examined sites. Most of the examined teeth presented CAL ≥6 mm. The mean tooth loss in the individuals of the present study was 13.2. Mean DMFT was 10.9. Conclusion: The present sample of chronic cardiovascular disease patients presented oral health conditions compatible with the epidemiology of oral diseases most prevalent in the Brazilian population. However, this condition is alarming in a health context since tooth loss and periodontal diseases have been associated with higher risks of cardiovascular events., Objetivo: Descrever as condições de saúde bucal e hábitos comportamentais relacionados à saúde de indivíduos com doença arterial coronariana crônica (DAC) em acompanhamento em uma unidade de atendimento cardiológico do Hospital de Clínicas de Porto Alegre. Materiais e Métodos: Foram avaliados 100 pacientes consecutivos que frequentaram a unidade entre junho de 2011 e março de 2012. Dados demográficos, socioeconômicos e comportamentais foram obtidos. Um exame bucal foi realizado avaliando os índices de placa visível (IPV) e sangramento gengival (ISG), recessão gengival (RG), profundidade de sondagem (PS), sangramento à sondagem (SS) e perda de inserção (PI), além do índice CPO-D. Resultados: Observou-se um predomínio de indivíduos do gênero masculino, sendo que a faixa etária predominante foi a partir de 60 anos na amostra do estudo. Cerca de metade dos indivíduos era ex-fumante. Mais de três quartos da amostra relatou visitas ao dentista de maneira irregular. Os parâmetros relacionados ao biofilme supragengival apresentaram médias elevadas, contabilizando índices de placa e sangramento médios de cerca de 68% e 47%, respectivamente. Mais da metade dos dentes examinados possuíam PS ≥4 mm, e o sangramento subgengival (SS) esteve presente em aproximadamente três quartos dos sítios examinados. A maior parte dos dentes examinados apresentou PI ≥6 mm. Em média, os indivíduos do presente estudo apresentaram 13,2 dentes perdidos. O CPO-D médio encontrado foi de 10,9 dentes. Conclusão: A presente amostra apresentou condições de saúde bucal compatíveis com a epidemiologia das doenças bucais mais prevalentes na população brasileira. Porém, esta condição é alarmante no contexto de saúde, uma vez que cada vez mais tem-se associado perda dentária e doenças periodontais a maiores riscos de eventos cardiovasculares.

Objective To assess the effects of periodontal treatment on endothelial function in patients with coronary artery disease. Materials and methods A randomized controlled trial was conducted with 69 patients with stable coronary disease and severe periodontitis. The test group received nonsurgical periodontal therapy consisting of personalized oral hygiene instructions, subgingival scaling, and root planing per quadrant, whereas the control group received equal treatment after the study period. Endothelial function was assessed by measurement of brachial artery flow-mediated dilation, concentrations of sVCAM-1, sICAM-1, and P-selectin in serum before and 3 months after periodontal therapy. Results The test group exhibited statistically better periodontal parameters-plaque, probing depth, periodontal attachment loss, and bleeding on probing. No significant improvements were observed in the control (1.37%) and test (1.39%) groups in flow-mediated dilation, with no significant between-group difference. sVCAM-1 concentration increased in the control group (997.6 ± 384.4-1201.8 ± 412.5; p = 0.03), whereas in the test group, no significant changes were observed (915.1 ± 303.8-1050.3 ± 492.3; p = 0.17), resulting in a significant difference between the two groups (p = 0.04). The same pattern was observed for concentrations of sICAM-1. Conclusion Periodontal treatment did not provide better vasodilation in patients with coronary disease in a short-term follow-up period, although it maintained blood concentrations of markers of vascular inflammation.

Background: Myocardial injury after noncardiac surgery (MINS) includes patients with traditional myocardial infarction and those with ischemic myocardial injury after surgery. This study evaluated the prognostic value of MINS on major cardiovascular events and 30-day mortality, and determined independent preoperative predictors of MINS in patients after noncardiac surgery. Methods: This multicenter prospective cohort study was part of the VISION Study. The sample consisted of 2,504 patients who underwent noncardiac surgery at two tertiary hospitals in Brazil between September 2008 and July 2012. Troponin Ts were measured 6-12 hours, and on days 1, 2, and 3 after surgery. Cox regression analyses were performed to identify independent variables of major outcomes. Results: A total of 314 (13%) patients were diagnosed with MINS, of which 26 (8%) died. Length-of-hospital stay of MINS patients was three times higher (18±22 days vs. 5.8±11 days). In multivariate analysis, 30-day mortality was significantly higher among patients with MINS (hazard ratio [HR] 3.17 (95% CI 1.56-6.41)), and major bleeding (HR 5.76 (95% CI 2.75-12.05)), sepsis (HR 5.08 (95% CI 2.25-11.46)), active cancer (HR 4.22 (95% CI 1.98- 8.98)) and general surgery (HR 3.11 (95% CI 1.51-6.41)). Multivariable analysis indicated a higher chance of MINS in patients ≥75 years of age, history of diabetes mellitus, hypertension, heart failure, coronary disease, and end-stage renal failure. Conclusion: The incidence of MINS within 30 days after noncardiac surgery is related to higher mortality. Postoperative troponin monitoring in elder patients and with risk factors for atherosclerotic disease may help reduce postoperative cardiovascular events.

Background Despite the association between cardiovascular diseases and periodontitis, there are scarce data on the impact of oral health in the dietary intake of patients with coronary artery disease (CAD). The aim of this study was to assess the association between dietary intake with periodontitis and present teeth in individuals with stable CAD. Methods This cross-sectional study included 115 patients with stable CAD (76 males, aged 61.0 ± 8.3 years) who were under cardiovascular care in an outpatient clinic for at least 3 months. Dietary intake was recorded applying a food frequency questionnaire previously validated. Periodontal examinations were performed by two calibrated examiners in six sites per tooth from all present teeth. Blood samples were collected to determine serum levels of lipids. Multivariable logistic and linear regression models were fitted to evaluate the association between dietary outcomes and oral health variables. Results Individuals with periodontitis had significantly higher percentage of total energy intake from fried foods, sweets, and beans, and also had lower consumption of fruits than those without periodontitis. Presence of periodontitis was associated with lower percentage of individuals who reached the nutritional recommendation of monounsaturated fatty acids and higher blood concentration of triglycerides. Having a greater number of present teeth (≥20 teeth) was associated with higher intake of fibers and total calories. Conclusion In patients with stable CAD, the presence of periodontitis and tooth loss were associated with a poor dietary intake of nutrients and healthy foods, which are important for cardiovascular prevention.

Background: Coronary artery bypass grafting surgery (CABG) and percutaneous coronary intervention (PCI) are widely-used strategies in the management of stable coronary artery disease (CAD). Objective: To evaluate the prognosis of patients with stable CAD initially treated by medical therapy (MT), compared to the patients who were submitted to revascularization procedures. Methods: We conducted a prospective cohort study of 560 patients from an outpatient clinic in a tertiary hospital, with a mean follow-up of 5 years. Patients were classified into MT (n = 288), PCI (n = 159) and CABG (n=113) groups according to their initial treatment strategy. Primary endpoints were overall mortality and combined events of death, acute coronary syndrome, and stroke. Results: During follow-up, death rates were 11.1% in MT, 11.9% in PCI and 15.9% in CABG patients, with no statistical difference (hazard ratio [HR] for PCI, 1.05; 95% confidence interval [95%CI], 0.59 to 1.84; and HR for CABG, 1.20; 95% CI: 0.68 to 2.15). Combined outcomes occurred more often among patients initially submitted to PCI compared to MT (HR 1.50, 95% CI 1.05 to 2.14), and did not differ between MT and CABG patients (HR 1.24, 95% CI 0.84 to 1.83). Among patients with diabetes (n=198), PCI was the only therapeutic strategy predictive of combined outcomes (HR 2.14; 95% CI 1.25 to 3.63). Conclusion: In this observational study of stable coronary artery disease, there was no difference in overall mortality between initial medical therapy or revascularization surgery strategies. Patients initially treated with PCI had greater chance to develop combined major cardiovascular events. Resumo Fundamento: A cirurgia de revascularização miocárdica (CRM) e a intervenção coronária percutânea (ICP) são estratégias amplamente utilizadas no manejo da doença arterial coronariana (DAC) estável. Objetivo: Avaliar o prognóstico de pacientes com DAC estável inicialmente tratada com terapia médica (TM), em comparação com os pacientes submetidos a procedimentos de revascularização. Métodos: Estudo prospectivo de coorte com 560 pacientes ambulatoriais de um hospital terciário com seguimento médio de 5 anos. Os pacientes foram classificados nos grupos TM (n = 288), ICP (n = 159) e CRM (n = 113) de acordo com sua estratégia inicial de tratamento. Os desfechos primários foram mortalidade global e eventos combinados de morte, síndrome coronária aguda e AVC. Resultados: Durante o seguimento, as taxas de mortalidade foram de 11,1% em TM, 11,9% em ICP e 15,9% em pacientes submetidos à CRM, sem diferença estatística (Hazard Ratio [HR] para ICP, 1,05; Intervalo de Confiança de 95% [IC95%], 0,59 a 1,84; e HR para CRM, 1,20; IC95%, 0,68 a 2,15). Os desfechos combinados ocorreram com maior frequência entre os pacientes inicialmente submetidos à ICP em relação à TM (HR 1,50, IC 95% 1,05 a 2,14) e não diferiram entre TM e CRM (HR 1,24, IC95% 0,84 a 1,83). Entre os pacientes com diabetes (n = 198), a ICP foi a única estratégia terapêutica preditiva de desfechos combinados (HR 2,14; IC 95%: 1,25 a 3,63). Conclusão: Neste estudo observacional de doença arterial coronariana estável, não houve diferença na mortalidade global entre as estratégias iniciais de terapia médico ou de cirurgia de revascularização. Os pacientes inicialmente tratados com ICP tiveram maior chance de desenvolver eventos cardiovasculares maiores combinados.

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study’s four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated “abnormal” laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors’ diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6–41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

Background Emergency department (ED) care for acute vascular diseases faces the challenge of overcrowding. A vascular unit is a specialized, protocol-oriented unit in the ED with a team trained to manage acute vascular disorders, including stroke, coronary syndromes, pulmonary embolism (PE), and aortic diseases. Objectives The objective was to compare case fatality rates for selected cardiovascular conditions before and after the implementation of a vascular unit. Methods Patients with the selected diagnoses admitted to the ED in two different time periods, 2002 through 2005 (before unit opening) and 2007 to 2010 (after vascular unit opening), were identified by ICD-10 codes, and their electronic records were reviewed. Case fatality rates were calculated and compared for both time periods. Results The period prior to unit implementation (2002 through 2005) included 4,164 patients, and the vascular unit period (2007 to 2010) included 6,280 patients. Overall, the case fatality rate for acute vascular conditions decreased from 9% to 7.3% with vascular unit implementation (p = 0.002). The in-hospital mortality rates for acute coronary syndrome (ACS) dropped from 6% to 3.8% (p = 0.003), and for acute PE dropped from 32.1% to 10.8% (p

Background. Cardiac troponin levels have been reported to add value in the detection of cardiovascular complications in noncardiac surgery. A sensitive cardiac troponin I (cTnI) assay could provide more accurate prognostic information.Methods. This study prospectively enrolled 142 patients with at least one Revised Cardiac Risk Index risk factor who underwent noncardiac surgery. cTnI levels were measured postoperatively. Short-term cardiac outcome predictors were evaluated.Results. cTnI elevation was observed in 47 patients, among whom 14 were diagnosed as having myocardial infarction (MI). After 30 days, 16 patients had major adverse cardiac events (MACE). Excluding patients with a final diagnosis of MI, predictors of cTnI elevation included dialysis, history of heart failure, transoperative major bleeding, and elevated levels of pre- and postoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP). Maximal cTnI values showed the highest sensitivity (94%), specificity (75%), and overall accuracy (AUC 0.89; 95% CI 0.80–0.98) for postoperative MACE. Postoperative cTnI peak level (OR 9.4; 95% CI 2.3–39.2) and a preoperative NT-proBNP level ≥917 pg/mL (OR 3.47; 95% CI 1.05–11.6) were independent risk factors for MACE.Conclusions. cTnI was shown to be an independent prognostic factor for cardiac outcomes and should be considered as a component of perioperative risk assessment.

Many Brazilian patients with complex diseases who are treated in tertiary referral clinics have been stable for long periods. The main needs of these patients involve monitoring of risk factors and review of drug prescriptions, which could be satisfactorily done in primary care facilities. The goal of this protocol is to evaluate the safety and effectiveness of telemedicine services to support the transition of patients with stable chronic coronary artery disease from the tertiary to the primary level of care. We designed a randomized non-inferiority protocol that will include 280 patients with stable coronary artery disease (for at least 12 months). Patients will be selected from the Ischemic Heart Disease Clinic in a tertiary care hospital in southern Brazil. Enrolled participants will be randomized into one of two groups: 12 months of follow-up at the same clinic; or 12 months of follow-up at a primary care facility with clinical support from a telemedicine platform including a toll-free line for physicians (intervention group). In the intervention group, decisions to refer patients to tertiary care during follow-up will be made jointly by primary physicians and medical teleconsultants. The groups will be compared in terms of the primary outcome—maintenance of baseline functional class 1 or 2 after 12 months. Secondary outcomes include control of risk factors and instability of the disease. We intend to determine the effectiveness of using telemedicine to qualify the transition of patients with chronic coronary disease from the tertiary to the primary level of care. This should facilitate the access of patients to the healthcare system, since care will be provided closer to their homes, and provide more opportunities for treatment of severe cases at tertiary care hospitals that are often overcrowded. ClinicalTrials.gov # NCT02489565 – trial registration date May 13, 2015

Fundamento: A equação de Friedewald (EF) é amplamente utilizada para estimar o LDL-c sem utilizar ultracentrifugação. Entretanto, a equação tem limitações em determinados cenários clínicos. Objetivo: O nosso objetivo era investigar a possível importância das diferenças entre a EF e a medição direta de LDL-c em pacientes com diabetes. Métodos: Realizamos um estudo transversal entre 466 pacientes com doença coronária estável. Colesterol total, triglicérides, HDL-c e LDL-c foram coletados, e a EF foi calculada. A acurácia foi calculada como percentagem de estimativas dentro de 30% (P30) do LDL medido. O viés foi calculado como a diferença média entre o LDL-c medido e o estimado. A concordância entre os métodos foi avaliada utilizando gráficos de Bland-Altman. Resultados: O viés foi de 3,7 (p=0,005) e 1,1 mg/dl (p=0,248), e a acurácia foi de 86% e 93% em pacientes diabéticos e não-diabéticos, respectivamente. Entre os pacientes com diabetes, o viés foi de 5 mg/dl (p=0,016) e 1,93 mg/dl (p=0,179), e a acurácia foi de 83% e 88% em indivíduos com hemoglobina A1c superior a 8 mg/dl versus abaixo do ponto de corte, respectivamente. O viés foi similar em pacientes sem diabetes comparados com pacientes com diabetes e HbA1C < 8 (1,1 e 1,93 mg/dl). Conclusão: A EF é imprecisa entre indivíduos gerais com diabetes. Porém, ao estratificar pacientes com diabetes em bom e mau controle da doença, o primeiro grupo se comporta como se não tivesse diabetes, com uma boa correlação entre o LDL-c calculado e o mensurado. É importante saber quando é razoável usar a EF, porque uma estimativa imprecisa dos níveis de LDL-c pode resultar no subtratamento da dislipidemia e predispor estes pacientes a eventos agudos. Background: Friedewald equation (FE) is widely used to estimate the LDL-c without the use of ultra-centrifugation. However, the equation has limitations in some clinical settings. Objective: Our goal was to investigate the potential importance of differences between FE and direct measurement of LDL-c in patients with diabetes. Methods: We conducted a cross-sectional study among 466 patients with stable coronary disease. Total cholesterol, triglycerides, HDL-c and LDL-c were collected, and FE was calculated. Accuracy was calculated as the percentage of estimates within 30% (P30) of measured LDL. Bias was calculated as the mean difference between measured and estimated LDL-c. Agreement between methods was evaluated using Bland-Altman plots. Results: Bias was 3.7 (p=0.005) and 1.1 mg/dl (p=0.248), and accuracy was 86% and 93% in diabetic and non-diabetic patients, respectively. Among patients with diabetes, bias was 5 mg/dl (p=0.016) and 1.93 mg/dl (p=0.179), and accuracy was 83% and 88% in subjects with Hemoglobin A1C above 8 mg/dl versus below cutoff point, respectively. Bias was similar in patients without diabetes compared to patients with diabetes and HbA1C < 8 (1.1 and 1.93 mg/dl). Conclusion: FE is inaccurate among overall individuals with diabetes. However, when stratifying patients with diabetes into good and poor disease control, the first group behaves as if it does not have diabetes, with a good correlation between calculated and measured LDL-c. It is important to know when is it reasonable to use FE because an inaccurate estimation of LDL-c levels could result in undertreatment of dyslipidemia and predispose these patients to acute events.

Background: Different strategies have been described to increase promptness and efficiency in the assessment and management of patients with acute chest pain and acute coronary syndrome (ACS) in the emergency department (ED). Objective: The objective of this study is to evaluate the results of implementing a Chest Pain Unit (CPU) to assist patients with ACS, and to determine its impact on quality of health care indexes and clinical outcomes. Methods: A study was conducted with a prospective cohort of patients admitted to the ED with a chief complaint of acute chest pain or suspected ACS at two different time periods: before (n = 663) and after (n = 450) introducing a CPU as part of the ED. Quality-of-care indexes analyzed in this study were adherence to a critical pathway, length of hospital stay, and hospital mortality. Results: There was increased adherence to a critical pathway during the CPU period compared to the period with no designated CPU area, including compliance with prescribing aspirin, beta-blockers, and angiotensin-converting enzyme inhibitor, and performing coronary angiography in high-risk patients. After adjustment to baseline characteristics, admissions to a CPU resulted in a 65% reduction in mortality (odds ratio 0.35; 95% confidence interval 0.14–0.88; p = 0.03). There was no difference in median length of hospital stay, 7 days (interquartile range [IQR] 4–12) before CPU and 6 days (IQR 4–11) after introducing the CPU ( p = 0.10). Conclusion: In the scenario of a crowded ED, implementation of a CPU was associated with greater adherence to a critical pathway for patients with ACS, with a concomitant reduction in mortality rates.

Diabetes mellitus é uma doença associada com elevada incidência de doença aterotrombótica, especialmente cardíaca. Diversos estudos demonstraram que é possível reduzir a carga de doença nesta população através de estratégias preventivas. Este artigo revisa as evidências sobre a estimativa de risco cardiovascular nessa população e ações de prevenção, levando em consideração as principais recomendações na área. Modificações no estilo de vida, como dieta pobre em carboidratos, redução de peso e prática regular de atividade física, devem ser instituídas. Todo paciente de alto risco ou com evidências de doença cardiovascular deve manter sua glicemia < 100 mg/dl e A1c < 7%. É recomendado uso diário de AAS em doses baixas e estatinas para controle de lípides, tendo como alvo LDL < 100 mg/dl, HDL > 50 mg/dl e triglicerídios < 150 mg/dl. O controle da pressão arterial deve ser buscado com medidas não-farmacológicas e anti-hipertensivos, sendo inibidores do sistema renina-angiotensina indicados na maioria dos casos, especialmente naqueles pacientes com nefropatia, associado a diuréticos tiazídicos na sua maioria para alcançar níveis tensionais-alvo < 130/80 mmHg.

Background Although redefinition for acute myocardial infarction (AMI) has been proposed few years ago, to date it has not been universally adopted by many institutions. The purpose of this study is to evaluate the diagnostic, prognostic and economical impact of the new diagnostic criteria for AMI. Methods Patients consecutively admitted to the emergency department with suspected acute coronary syndromes were enrolled in this study. Troponin T (cTnT) was measured in samples collected for routine CK-MB analyses and results were not available to physicians. Patients without AMI by traditional criteria and cTnT≥0.035 ng/mL were coded as redefined AMI. Clinical outcomes were hospital death, major cardiac events and revascularization procedures. In-hospital management and reimbursement rates were also analyzed. Results Among 363 patients, 59 (16%) patients had AMI by conventional criteria, whereas additional 75 (21%) had redefined AMI, an increase of 127% in the incidence. Patients with redefined AMI were significantly older, more frequently male, with atypical chest pain and more risk factors. In multivariate analysis, redefined AMI was associated with 3.1 fold higher hospital death (95% CI: 0.6–14) and a 5.6 fold more cardiac events (95% CI: 2.1–15) compared to those without AMI. From hospital perspective, based on DRGs payment system, adoption of AMI redefinition would increase 12% the reimbursement rate [Int $3552 per 100 patients evaluated]. Conclusions The redefined criteria result in a substantial increase in AMI cases, and allow identification of high-risk patients. Efforts should be made to reinforce the adoption of AMI redefinition, which may result in more qualified and efficient management of ACS.

Although several advances have been made in the management of acute coronary syndromes, the adoption of such measures in clinical practice has been suboptimal. The implementation of critical pathways has been suggested as a strategy to improve clinical effectiveness, although its effect is still to be demonstrated. The objective was to evaluate the impact of a critical pathway on the process of care of patients admitted with acute coronary syndromes in a teaching hospital. In a prospective cohort study, patients 30 years or older admitted to the emergency department with suspected acute coronary syndromes were evaluated. Primary outcomes were major cardiovascular events, percutaneous coronary intervention, and in-hospital mortality during 1 semester before and 4 semesters after implementation of the pathway. Multivariate logistic regression analysis was used to adjust for differences between the periods studied and to identify predictors of poor prognosis. Of the 1003 patients evaluated, 150 (15%) had myocardial infarction, and 240 (24%) had unstable angina. There was no difference in clinical characteristics and risk assessment in the periods evaluated. Overall, the quality of care improved after the pathway, with a significant decrease in complication and mortality rates in the last 2 years. In multivariate analysis, patients admitted in the last semester showed fewer major cardiovascular events (odds ratio = 0.74; P = 0.02) and more percutaneous coronary intervention (odds ratio = 1.3; P = 0.03). The implementation of a critical pathway may have a positive impact on the quality of care of patients with acute coronary syndromes. Further studies are needed to evaluate better this and other initiatives aimed at maximizing clinical effectiveness.

The association between epistaxis and hypertension is still disputed. In a cross-sectional study, we evaluated this association in a sample of 1174 individuals older than 18 years, representative of inhabitants of Porto Alegre, RS, Brazil. Epistaxis was defined as any episode of non-traumatic nosebleeding after 18 years of age. Hypertension was defined as the mean of two blood pressure readings > or = 160/95 mmHg or the use of antihypertensive drugs. The prevalence of epistaxis and hypertension were 14.7% (95% confidence interval, CI 12.7-16.7) and 24.1% (95% CI 21.7-26.6), respectively. History of epistaxis in the adulthood (risk ratio = 1.24, 95% CI 0.83-1.85), and in the previous 6 months (risk ratio 0.79, 95% CI 0.40-1.56; p = 0.510) were not associated with hypertension after controlling for gender, age, race, history of allergic rhinitis or nasal abnormalities, alcohol abuse, smoking and years of study. History of epistaxis was positively associated with history of allergic rhinitis and inversely associated with years at school. In conclusion, we demonstrated that hypertension is not associated with history of epistaxis in the adulthood in free-living individuals.

There are scarce data on the impact of the periodontal condition in the control of biomarkers in patients with cardiovascular disease (CVD). The aim of this study is to assess whether periodontal inflammation and tissue breakdown are associated with C-reactive protein (CRP) and lipids in patients with stable heart disease.This cross-sectional study included 93 patients with stable coronary artery disease (57 males; mean age: 63.5 ± 9.8 years) who were in outpatient care for at least 6 months. After applying a structured questionnaire, periodontal examinations were performed by two calibrated periodontists in six sites per tooth at all teeth. Blood samples were collected from patients on the day of periodontal examination to determine levels of CRP, lipids, and glycated hemoglobin. Multiple linear regression models were fitted to evaluate the association among different periodontal and blood parameters controlling for sex, body mass index, glycated hemoglobin, use of oral hypoglycemic drugs, and smoking.Overall, the sample presented high levels of periodontal inflammation and tissue breakdown. Unadjusted mean concentrations of triglycerides (TGs), very-low-density lipoprotein cholesterol, and glucose were significantly higher in individuals with severe periodontitis. When multiple linear regression models were applied, number of teeth with clinical attachment loss ≥6 mm and presence of severe periodontitis were significantly associated with higher CRP concentrations. Bleeding on probing was significantly associated with TGs, total cholesterol, and non-high-density lipoprotein cholesterol.In this sample of patients with stable CVD, current periodontal inflammation and tissue breakdown are associated with cardiovascular inflammatory markers, such as CRP and lipid profile.

FUNDAMENTO: Ja foi demonstrado o uso do NT-proBNP pre-operatorio para prever resultado cardiaco adverso, embora estudos recentes tenham sugerido que a determinacao do NT-proBNP pos-operatorio possa fornecer um valor adicional em pacientes submetidos a cirurgia nao cardiaca. OBJETIVO: Avaliar o valor prognostico perioperatorio do NT-proBNP em pacientes de intermediario e alto risco cardiovascular submetidos a cirurgia nao cardiaca. METODOS: Este estudo incluiu prospectivamente 145 pacientes com idade > 45 anos, com pelo menos um fator de risco do Indice de Risco Cardiaco Revisado e submetidos a cirurgia de medio ou alto risco nao-cardiaca. Os niveis de NTproBNP foram medidos no pre e pos-operatorio. Preditores cardiacos de curto prazo foram avaliados por modelos de regressao logistica. RESULTADOS: Durante uma mediana de acompanhamento de 29 dias, 17 pacientes (11,7%) apresentaram eventos cardiacos adversos importantes (MACE - 14 infartos do miocardio nao fatais, 2 paradas cardiacas nao-fatais e 3 mortes cardiacas). Os niveis otimos de limiar discriminatorio para o NT-proBNP pre e pos-operatorio foram 917 e 2962 pg/ mL, respectivamente. O NT-proBNP pre e pos-operatorio (OR = 4,7, IC 95%: 1,62-13,73, p = 0,005 e OR 4,5, IC 95%: 1,53-13,16, p = 0,006) foram associados de forma significativa com MACE (eventos cardiacos adversos maiores). O NTproBNP pre-operatorio foi significativa e independentemente associado com eventos cardiacos adversos em analise de regressao multivariada (OR ajustado 4,2, IC 95%: 1,38-12,62, p = 0,011). CONCLUSAO: O NT-proBNP e um importante marcador de curto prazo de eventos cardiovasculares perioperatorios em pacientes de alto risco. Os niveis pos-operatorios foram menos informativos do que os niveis pre-operatorios. Uma unica medicao de NT-proBNP pre-operatorio deve ser considerada na avaliacao de risco pre-operatorio.

Interleukin-18 (IL-18), a proinflammatory cytokine, has been associated with atherogenesis and plaque rupture in acute coronary syndrome (ACS). Recent studies suggest that IL-18 may have a long-term prognostic value. The aim of this study was to evaluate the relationship between IL-18 levels and major adverse cardiovascular events within 6 months of follow-up in post-ACS patients.One hundred and twelve consecutive patients admitted to a university hospital with ACS were included in the study. IL-18 and C-reactive protein were measured within the first 24 h of admission. Six months after hospital discharge, the incidence of major adverse cardiovascular events (cardiovascular death, new episode of ACS, and need for unplanned revascularization) was assessed.Mean age of patients was 64 +/- 11 years, and 58 (52%) were male. During the 6 months of follow-up, 33 patients (31.4%) experienced major adverse cardiovascular events. Median IL-18 serum levels were higher among patients who had events than among those who did not: 271.7 pg/ml (interquartile range: 172.9-389.6) and 139.7 pg/ml (interquartile range: 99.9-265.7), respectively (P0.01). In the Cox multivariate analysis, after adjustment for clinical risk factors and serum troponin, elevated levels of IL-18 were associated with higher incidence of events (hazard ratio: 2.5; 95% confidence interval: 1.14-5.52; P = 0.023). In this population, C-reactive protein was of borderline significance for events.Serum IL-18 levels in ACS patients were independent predictors of long-term cardiovascular events. These findings support the association between inflammation and prognosis of ACS patients, as well as the clinical impact of this biomarker.

Diabetes mellitus is a condition associated with cardiac complications, especially artherothrombotic disease. Several studies have demonstrated the importance of reducing cardiovascular burden on this population by adopting prevention strategies. This article revised clinical evidences on cardiovascular risk assessment and prevention actions, taking into consideration major recommendations in the field. Life-style changes with low-carbohydrate diet, weight control, and regular physical activity must be implemented. High-risk patients or with established cardiovascular disease ought to have glycemic levels100 mg/dL and A1c7%. It is recommended low dose of aspirin and statin for lipid management, targeting LDL100 mg/dL, HDL50 mg/dL and tryglycerides150 mg/dL. Blood pressure control with non-pharmacological and antihypertensive drugs must be instituted, favoring ACE inhibitors as first option, mainly in patients with renal disease, and combined with tiazydes for the majority to achieve target blood pressure of130/80 mmHg.

Inflammation and endothelial dysfunction are linked to the pathogenesis of atherosclerotic disease. Recent studies suggest that periodontal infection and the ensuing increase in the levels of inflammatory markers may be associated with myocardial infarction, peripheral vascular disease and cerebrovascular disease. The present article aimed at reviewing contemporary data on the pathophysiology of vascular endothelium and its association with periodontitis in the scenario of cardiovascular disease.

The number of cardiac diagnostic and therapeutic procedures involving ionizing radiation has increased rapidly in recent years, raising concerns about patients (pts) radiation exposure. The annual pts effective radiation dose (ED) should not exceed 1mSv, which is equivalent to 50 chest X-rays. We

Periodontal disease has been associated with elevations of blood cytokines involved in atherosclerosis in systemically healthy individuals, but little is known about this association in stable cardiovascular patients. The aim of this study was to assess the association between periodontal disease (exposure) and blood cytokine levels (outcomes) in a target population of patients with stable coronary artery disease (CAD). Material and Methods This cross-sectional study included 91 patients with stable CAD who had been under optimized cardiovascular care. Blood levels of IL-1β, IL-6, IL-8, IL-10, IFN-γ, and TNF-α were measured by Luminex technology. A full-mouth periodontal examination was conducted to record probing depth (PD) and clinical attachment (CA) loss. Multiple linear regression models, adjusting for gender, body mass index, oral hypoglycemic drugs, smoking, and occurre:nce of acute myocardial infarction were applied. Results CAD patients that experienced major events had higher concentrations of IFN-γ (median: 5.05 pg/mL vs. 3.01 pg/mL; p=0.01), IL-10 (median: 2.33 pg/mL vs. 1.01 pg/mL; p=0.03), and TNF-α (median: 9.17 pg/mL vs. 7.47 pg/mL; p=0.02). Higher numbers of teeth with at least 6 mm of CA loss (R2=0.07) and PD (R2=0.06) were significantly associated with higher IFN-γ log concentrations. Mean CA loss (R2=0.05) and PD (R2=0.06) were significantly related to IL-10 concentrations. Elevated concentrations of TNF-α were associated with higher mean CA loss (R2=0.07). Conclusion Periodontal disease is associated with increased systemic inflammation in stable cardiovascular patients. These findings provide additional evidence supporting the idea that periodontal disease can be a prognostic factor in cardiovascular patients.

Background Scarce information exists regarding the preventive effect of periodontal treatment in the recurrence of cardiovascular events. Prevention may be achieved by targeting risk factors for recurrent coronary artery disease (CAD) in patients with previous history of cardiovascular events. The aim of this trial is to compare the effect of two periodontal treatment approaches on levels of C-reactive protein, lipids, flow-mediated dilation and serum concentrations of proinflammatory and endothelial markers in stable CAD patients with periodontitis over a period of 12 months. Methods/design This is a randomized, parallel design, examiner blinded, controlled clinical trial. Individuals from both genders, 35 years of age and older, with concomitant diagnosis of CAD and periodontitis will be included. CAD will be defined as the occurrence of at least one of the following events 6 months prior to entering the trial: documented history of myocardial infarction; surgical or percutaneous myocardial revascularization and lesion >50% in at least one coronary artery assessed by angiography; presence of angina and positive noninvasive testing of ischemia. Diagnosis of periodontitis will be defined using the CDC-AAP case definition (≥2 interproximal sites with clinical attachment loss ≥6 mm and ≥1 interproximal site with probing depth ≥5 mm). Individuals will have to present at least ten teeth present to be included. One hundred individuals will be allocated to test (intensive periodontal treatment comprised by scaling and root planing) or control (community periodontal treatment consisting of one session of supragingival plaque removal only) treatment groups. Full-mouth six sites per tooth periodontal examinations and subgingival biofilm samples will be conducted at baseline, 3, 6 and 12 months after treatment. The primary outcome of this study will be C-reactive protein changes over time. Secondary outcomes include levels of total cholesterol, LDL-C, HDL-C, triglycerides, IL-1β, IL-6, TNFα, fibrinogen, ICAM-1, VCAM-1 and E-selectin. These outcomes will be assessed at all time points over 12 months. Flow-mediated dilation will be assessed at baseline, 1, 3 and 6 months after periodontal therapy. Discussion This trial will provide new evidence regarding the effect of periodontal treatment on risk markers for recurrence of cardiovascular events in stable coronary artery disease patients. Trial registration number ClinicalTrials.gov Identifier, NCT01609725

CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico Introdução: Programas de serviço de mensagens curtas (SMS) para promover a assistência à saúde mostraram resultados benéficos no controle de fatores de risco cardiovasculares, mas ainda faltam evidências em países de baixa e média renda. O objetivo deste estudo é avaliar se o uso de SMS aumenta o controle dos fatores de risco dentro de seis meses após a alta por síndrome coronariana aguda (SCA) em um Hospital Universitário Público Brasileiro participante de um programa de qualidade assistencial, o Programa Boas Práticas Clínicas em Cardiologia. Métodos: Realizamos um estudo randomizado, cegamento simples, com dois braços paralelos, que incluiu 180 pacientes (> 18 anos) internados por SCA. Os pacientes elegíveis foram randomizados (1:1) para uma intervenção por SMS (G1) ou atendimento cardiovascular padrão da instituição (G2). O desfecho primário foi atingir 4 ou 5 pontos em um escore de controle de fatores de risco, consistindo em um conjunto de 5 fatores de risco modificáveis: LDL-C 18 years) admitted due to ACS at a Public General Hospital in Brazil. Eligible patients were randomized (1:1) to a SMS intervention (G1) or standard discharge cardiovascular care (G2). The primary outcome was achieving 4 or 5 points in a risk factor control score, consisting of a cluster of 5 modifiable risk factors: LDL-C

Introdução: No Brasil, existe disparidade no acesso aos cuidados de saúde. A mortalidade intra-hospitalar em em pacientes infarto agudo do miocárdio (IAM) tratados no sistema público de saúde é mais elevada quando comparada a pacientes atendidos em serviços privados devido as dificuldades ao acesso do tratamento em terapia intensiva, aos métodos de reperfusão e às medidas terapêuticas de eficácia estabelecida para o IAM. A telecardiologia pode ser uma ferramenta para melhorar o atendimento cardíaco e reduzir as desigualdades de acesso para atendimento especializado. Objetivo: O objetivo deste estudo foi a implantação da linha de cuidado do infarto agudo do miocárdio com supra ST (IAMCSST) para aprimorar a qualidade do cuidado e os desfechos em uma região remota brasileira com consideráveis desigualdades sociais. Métodos e Resultados: A qualidade do cuidado do IAMCSST foi avaliada em duas coortes, antes (n = 214) e depois (n = 143) da implantação do protocolo. Antes da implantação, foi mensurado os tempos de transporte pelo serviço pré-hospitalar; adaptado o protocolo de sindrome coronariana aguda (SCA) do Ministério da Saúde as necessidades regionais, e o fluxo proposto foi apresentado em reuniões locais; padronizadas as medicações; e desenvolvido um eletrocardiograma (ECG) digital em um tablet e testado nas ambulâncias. Central a este protocolo estava transmissão do ECG digital no tablet das ambulâncias da região para análise por profissionais treinados, e um fluxograma para orientar a escolha da terapia de reperfusão do IAMCSST, de acordo com o tempo de transporte. Se o ECG pré-hospitalar fosse diagnóstico, desencadeava-se uma cascata de resposta considerando os tempos de transporte (1) menos de 2 horas: a transferência direta para o centro de intervenção regional para reperfusão por intervenção coronária percutânea primária; ou (2) maior do que 2 horas: fibrinólise pré-hospitalar. Após a implantação do protocolo, o atraso médico ajustado (atraso do sistema menos tempo de transporte) reduziu 40%, 221 minutos, (intervalo de confiança de 95%: -66%, -13%). A proporção de pacientes que receberam terapia de reperfusão aumentou de 70,6% para 80,8% (p = 0,045), com aumento no tratamento com aspirina (94,2% a 100% [p = 0,003]) e inibidores P2Y12 (87,5% a 100% [P