RESUMEN
BACKGROUND: Pulmonary hypertension (PH) is a marker of poor outcome in mitral stenosis (MS), which improves after percutaneous mitral valvuloplasty (PMV). However, mechanical interventions for relief of valve obstruction often but not always reduce pulmonary pressures. This study aimed to assess the parameters associated with abnormal pulmonary artery pressure (PAP) response immediately after a successful PMV, and also its impact on long-term outcome. METHODS: A total of 181 patients undergoing PMV for rheumatic MS were prospectively enrolled. Invasive hemodynamic and echocardiographic measures were examined in all patients. Abnormal PAP response was defined as the mean PAP (mPAP) values unchanged at the end of the procedure. Long-term outcome was a composite endpoint of death, mitral valve replacement, repeat PMV, new onset of atrial fibrillation (AF), or stroke. RESULTS: The mean age was 44.1 ± 12.6 years, and 157 patients were women (86.7%). In the overall population, mPAP decreased from 33.4 ± 13.1 mmHg pre to 27.6 ± 9.8 mmHg post (p < 0.001). Following PMV, 52 patients (28.7%) did not have any reduction of mPAP immediately after the PMV. Multivariable analysis adjusting for baseline values of PAP and mitral valve area revealed that AF (Odds ratio [OR] 2.7, 95% [confidence interval] CI 1.3 to 6.7), maximum mitral valve leaflets displacement (OR 0.8, 95% CI 0.7 to 0.9), and post-procedural left ventricular compliance (OR 0.7, 95% CI 0.5 to 0.9) were predictors of a lack of improvement in mPAP. During a median follow-up of 4.4 years, the endpoint was reached in 56 patients (31%). The pulmonary pressure response to PMV was not an independent predictor of long-term events. CONCLUSIONS: In patients with MS undergoing PMV, pulmonary pressures may not reduce immediately after the procedure, despite adequate opening of the valve. Abnormal PAP response can be predicted from baseline clinical and valvular characteristics as well as post-procedural left ventricular compliance. The lack of any immediate reduction in mPAP is not associated with long-term adverse outcomes.
Asunto(s)
Valvuloplastia con Balón , Estenosis de la Válvula Mitral , Adulto , Valvuloplastia con Balón/efectos adversos , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Estenosis de la Válvula Mitral/complicaciones , Estenosis de la Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/terapia , Arteria Pulmonar/diagnóstico por imagen , Resultado del TratamientoRESUMEN
BACKGROUND: Severe valve disease, which requires intervention, remains strongly associated with mortality in patients with rheumatic heart disease. Percutaneous mitral commissurotomy (PMC) is the procedure of choice for the treatment of patients with isolated or predominantly rheumatic mitral stenosis. This procedure has been performed under sedation to avoid the potential effects of general anesthesia on intracardiac pressure measurements. However, there are limited data on sedation during PMC, especially using easily available medications in low- and middle-income countries. OBJECTIVES: This study was designed to evaluate the efficacy and hemodynamic effects of conscious sedation during PMC in patients with significant mitral stenosis. METHODS: This study prospectively enrolled 23 patients who underwent PMC with the Inoue balloon technique for hemodynamically significant mitral stenosis. For conscious sedation, midazolam 25 µg/kg and fentanyl 1 µg/kg were administered, and 5 min after the infusion, the level of sedation was evaluated by Ramsay sedation scale. A range of invasive hemodynamic measurements, including cardiac output and pulmonary artery pressures, were recorded before and immediately after sedation. RESULTS: The mean age was 44.9 ± 10.8 years, and 19 patients (83%) were women. After sedation, the majority of patients were in categories 2 and 3 of the Ramsay sedation scale (cooperative, orientated, tranquil, and responding to commands). Oxygen saturation dropped from an average of 98.5% to 96.0% without supplementary oxygen. Left ventricular systolic pressure and central aortic pressures decreased after sedation. However, none of the other parameters changed significantly after sedation, including pulmonary artery pressures, pulmonary vascular resistance, and cardiac index. CONCLUSIONS: This simple model of conscious sedation was able to promote anxiolysis, analgesia, and comfort for the procedure without serious hemodynamic effects, which can be a reasonable choice in developing countries.
Asunto(s)
Sedación Consciente , Países en Desarrollo , Procedimientos Endovasculares/métodos , Estenosis de la Válvula Mitral/cirugía , Cardiopatía Reumática/cirugía , Adulto , Femenino , Hemodinámica/fisiología , Humanos , Masculino , Válvula Mitral/cirugía , Estenosis de la Válvula Mitral/fisiopatología , Estudios Prospectivos , Cardiopatía Reumática/fisiopatología , Resultado del TratamientoRESUMEN
BACKGROUND: Conventional hemodynamic parameters may not accurately predict symptomatic improvement after percutaneous mitral valvuloplasty (PMV). Changes in left heart chamber compliance following adequate relief o0066 mitral stenosis (MS) may be useful in determining functional capacity after PMV. This study aims to determine the acute effects of PMV on compliance of the left heart and whether its changes relate to the patient's functional capacity. METHODS: One-hundred thirty-seven patients with severe MS undergoing PMV were enrolled. Left atrial (Ca ) and left ventricular (Cv ) compliance were invasively estimated and net atrioventricular compliance (Cav ) was calculated before and immediately after the procedure. B-type natriuretic peptide (BNP) levels were obtained before and 24 hr after the procedure. The primary endpoint was functional status at 6-month follow-up, and the secondary endpoint was a composite of death, mitral valve (MV) replacement, repeat PMV, new onset of atrial fibrillation, or stroke in patients in whom PMV was successful. RESULTS: The mean age was 43 ± 12 years, and 119 patients were female (87%). After PMV, Ca and Cav improved significantly from 5.3 [IQR 3.2-8.2] mL/mmHg to 8.7 [5.3-19.2] mL/mmHg (P < 0.001) and 2.2 [1.6-3.4] to 2.8 [2.1-4.1] mL/mmHg (P < 0.001), respectively, whereas Cv did not change (4.6 [3.2-6.8] to 4.4 [3.1-5.6]; P = 0.637). Plasma BNP levels significantly decreased after PMV, with no correlation between its variation and changes in left chamber compliance. At 6-month follow-up, NYHA functional class remained unchanged in 32 patients (23%). By multivariable analyses, changes in Ca immediately after PMV (adjusted OR 1.42; 95% CI 95% 1.02 to 1.97; P = 0.037) and younger age (adjusted OR 0.95; CI 95% 0.92-0.98; P = 0.004), predicted improvement in functional capacity at 6-month follow-up, independent of postprocedural data. The secondary endpoint were predicted by post-PMV mean gradient (adjusted HR 1.363; 95% CI 95% 1.027-1.809; P = 0.032), and lack of functional improvement at 6-month follow-up (adjusted HR 4.959; 95% 1.708-14.403; P = 0.003). CONCLUSIONS: Ca and Cav increase significantly after PMV with no change in Cv . The improvement of Ca is an important predictor of functional status at 6-month follow up, independently of other hemodynamic data. Postprocedural mean gradient and lack of short-term symptomatic improvement were predictors of adverse outcome.
Asunto(s)
Función del Atrio Izquierdo , Valvuloplastia con Balón , Hemodinámica , Estenosis de la Válvula Mitral/terapia , Válvula Mitral/fisiopatología , Adulto , Valvuloplastia con Balón/efectos adversos , Adaptabilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/fisiopatología , Recuperación de la Función , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: Rheumatic mitral stenosis (MS) is a progressive disease, and risk of death may persist despite relief of the obstruction. Net atrioventricular compliance (Cn) modulates the overall haemodynamic burden of the MS and may be useful in predicting cardiovascular death after percutaneous mitral valvuloplasty (PMV). METHODS: A total of 427 patients (mean age 50±16 years, 84% female) with severe MS undergoing PMV were enrolled. Doppler-derived Cn was estimated at baseline using a previously validated equation. The primary endpoint was late cardiovascular death, and the secondary endpoint was a composite of all-cause mortality, mitral valve (MV) replacement or repeat PMV over a median follow-up of 31 months (IQR: 7.8-49.2 months). RESULTS: At baseline, 209 patients (49%) were in New York Heart Association (NYHA) functional class III or IV. During follow-up, 49 patients died (41 cardiovascular deaths), 50 underwent MV replacement and 12 required repeat PMV, with an overall incidence of cardiac mortality and adverse events of 4.1 deaths and 11.1 events per 100 patient-years, respectively. Low baseline Cn was a strong predictor of both cardiac death (adjusted HR 0.70, 95% CI 0.49 to 0.86) and composite endpoint (adjusted HR 0.81, 95% CI 0.67 to 0.91) after adjusting for clinical factors, baseline pulmonary artery pressure, tricuspid regurgitation severity, right ventricular function and immediate procedural haemodynamic data. The inclusion of Cn in a model with conventional parameters resulted in improvement in 5-year cardiovascular mortality risk prediction. CONCLUSIONS: Baseline Cn is a strong predictor of cardiovascular death in patients with MS undergoing PMV, independent of other prognostic markers of decreased survival in MS, including baseline patient characteristics and postprocedural data. Cn assessment therefore has potential value in evaluation of cardiovascular mortality risk in the setting of MS.
Asunto(s)
Función Atrial , Hemodinámica , Estenosis de la Válvula Mitral/mortalidad , Estenosis de la Válvula Mitral/fisiopatología , Válvula Mitral/fisiopatología , Cardiopatía Reumática/mortalidad , Cardiopatía Reumática/fisiopatología , Función Ventricular , Adulto , Anciano , Anciano de 80 o más Años , Valvuloplastia con Balón , Boston , Brasil , Causas de Muerte , Ecocardiografía Doppler , Femenino , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Estenosis de la Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/terapia , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Cardiopatía Reumática/diagnóstico por imagen , Cardiopatía Reumática/terapia , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The status of intrinsic left ventricular (LV) contractility in patients with isolated rheumatic mitral stenosis (MS) has been debated. The acute changes in loading conditions after percutaneous mitral valvuloplasty (PMV) may affect LV performance. We aimed to examine the acute effects of PMV on LV function and identify factors associated with LV ejection fraction (LVEF) changes, and determinants of long-term events following the procedure. METHODS: One hundred and forty-two patients who underwent PMV for symptomatic rheumatic MS (valve area of 0.99±0.3cm2) were prospectively enrolled. LV volumes and LVEF were measured by three-dimensional (3D) echocardiography. Long-term outcome was a composite endpoint of death, mitral valve (MV) replacement, repeat PMV, new onset of atrial fibrillation, and stroke. RESULTS: The mean age was 42.3±12.1years, and 125 patients were women (88%). After PMV, LVEF increased significantly (51.4 vs 56.5%, p<0.001), primary due to a significant increase in LV end-diastolic volume (65.8mL vs 67.9mL, p=0.002), and resultant increase in the stroke volume (33.9mL vs 39.6mL, p<0.001). Changes in cardiac index and systolic pulmonary artery pressure were associated with LVEF changes after PMV. During a mean follow-up period of 30.8months, 28 adverse clinical events were observed. Postprocedural mitral regurgitation, MV area, and mean gradient were independent predictors of composite endpoints. CONCLUSIONS: In patients with rheumatic MS, PMV resulted in a significant improvement in LV end-diastolic volume, stroke volume and consequently increased in LVEF. Changes in cardiac index and systolic pulmonary artery pressure were associated with LVEF changes after PMV. The predictors of long-term adverse events following PMV were post-procedural variables, including mitral regurgitation, valve area, and mean gradient.
Asunto(s)
Valvuloplastia con Balón/tendencias , Ecocardiografía Tridimensional/tendencias , Estenosis de la Válvula Mitral/diagnóstico por imagen , Cardiopatía Reumática/diagnóstico por imagen , Función Ventricular Izquierda/fisiología , Adulto , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estenosis de la Válvula Mitral/fisiopatología , Estenosis de la Válvula Mitral/terapia , Estudios Prospectivos , Cardiopatía Reumática/fisiopatología , Cardiopatía Reumática/terapia , Resultado del TratamientoRESUMEN
Percutaneous mitral commissurotomy (PMC) is the first-line therapy for managing rheumatic mitral stenosis. Over the past two decades, the indications of the procedure have expanded to include patients with unfavourable valve anatomy as a consequence of epidemiological changes in patient population. The procedure is increasingly being performed in patients with increased age, more deformed valves and associated comorbidities. Echocardiography plays a crucial role in patient selection and to guide a more efficient procedure. The main echocardiographic predictors of immediate results after PMC are mitral valve area, subvalvular thickening and valve calcification, especially at the commissural level. However, procedural success rate is not only dependent on valve anatomy, but a number of other factors including patient characteristics, interventional management strategies and operator expertise. Severe mitral regurgitation continues to be the most common immediate procedural complication with unchanged incidence rates over time. The long-term outcome after PMC is mainly determined by the immediate procedural results. Postprocedural parameters associated with late adverse events include mitral valve area, mitral regurgitation severity, mean gradient and pulmonary artery pressure. Mitral restenosis is an important predictor of event-free survival rates after successful PMC, and repeat procedure can be considered in cases with commissural refusion. PMC can be performed in special situations, which include high-risk patients, during pregnancy and in the presence of left atrial thrombus, especially in centres with specialised expertise. Therefore, procedural decision-making should take into account the several determinant factors of PMC outcomes. This paper provides an overview and update of PMC techniques, complications, immediate and long-term results over time, and assessment of suitability for the procedure.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Efectos Adversos a Largo Plazo , Estenosis de la Válvula Mitral , Válvula Mitral , Cardiopatía Reumática/complicaciones , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Ecocardiografía/métodos , Humanos , Efectos Adversos a Largo Plazo/diagnóstico , Efectos Adversos a Largo Plazo/cirugía , Válvula Mitral/patología , Válvula Mitral/cirugía , Estenosis de la Válvula Mitral/diagnóstico , Estenosis de la Válvula Mitral/etiología , Estenosis de la Válvula Mitral/cirugía , Evaluación de Resultado en la Atención de Salud , ReoperaciónAsunto(s)
Enfermedades Cardiovasculares/terapia , Telemedicina/normas , Síndrome Coronario Agudo/economía , Síndrome Coronario Agudo/epidemiología , Síndrome Coronario Agudo/terapia , Brasil , Enfermedades Cardiovasculares/economía , Enfermedades Cardiovasculares/epidemiología , Humanos , Telemedicina/métodos , Telemedicina/organización & administración , Resultado del TratamientoRESUMEN
OBJECTIVES: We aimed to assess the accuracy of the simple, contemporary and well-designed Toronto PCI mortality risk score in ICP-BR registry, the first Brazilian PCI multicenter registry with follow-up information. BACKGROUND: Estimating percutaneous coronary intervention (PCI) mortality risk by a clinical prediction model is imperative to help physicians, patients and family members make informed clinical decisions and optimize participation in the consent process, reducing anxiety and improving quality of care. At a healthcare system level, risk prediction scores are essential to measure and benchmark performance. METHODS: Between 2009 and 2013, a cohort of 4,806 patients from the ICP-BR registry, treated with PCI in eight tertiary referral medical centers, was included in the analysis. This population was compared to 10,694 patients of the derivation dataset from the Toronto study. To assess predictive performance, an update of the model was performed by three different methods, which were compared by discrimination, calculating the area under the receiver operating characteristic curve (AUC), and by calibration, assessed through Hosmer-Lemeshow (H-L) test and graphical analysis. RESULTS: Death occurred in 2.6% of patients in the ICP-BR registry and in 1.3% in the Toronto cohort. The median age was 64 and 63 years, 23.8 and 32.8% were female, 28.6 and 32.3% were diabetics, respectively. Through recalibration of intercept and slope (AUC = 0.8790; H-L P value = 0.3132), we achieved a well-calibrated and well-discriminative model. CONCLUSIONS: After updating to our dataset, we demonstrated that the Toronto PCI in-hospital mortality risk score performed well in Brazilian hospitals.
Asunto(s)
Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/terapia , Mortalidad Hospitalaria/tendencias , Intervención Coronaria Percutánea/mortalidad , Sistema de Registros , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Angioplastia Coronaria con Balón/métodos , Angioplastia Coronaria con Balón/mortalidad , Brasil , Canadá , Estudios de Cohortes , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Resultado del TratamientoRESUMEN
BACKGROUND: Net atrioventricular compliance (Cn) has been reported to be an important determinant of pulmonary hypertension in mitral stenosis (MS). We hypothesized that it may be useful in assessing prognosis because Cn reflects hemodynamic consequences of MS. To date, limited data with an assumed Cn cutoff have indicated the need for larger prospective studies. This prospective study was designed to determine the impact of Cn on clinical outcome and its contribution to pulmonary pressure in MS. In addition, we aimed to identify a cutoff value of Cn for outcome prediction in this setting. METHODS AND RESULTS: A total of 128 patients with rheumatic MS without other significant valve disease were prospectively enrolled. Comprehensive echocardiography was performed and Doppler-derived Cn estimated using a previously validated equation. The end point was either mitral valve intervention or death. Cn was an important predictor of pulmonary pressure, regardless of classic measures of MS severity. During a median follow-up of 22 months, the end point was reached in 45 patients (35%). Baseline Cn predicted outcome, adding prognostic information beyond that provided by mitral valve area and functional status. Cn ≤4 mL/mm Hg best predicted unfavorable outcome in derivation and validation sets. A subgroup analysis including only initially asymptomatic patients with moderate to severe MS without initial indication for intervention (40.6% of total) demonstrated that baseline Cn predicted subsequent adverse outcome even after adjustment for classic measures of hemodynamic MS severity (hazard ratio, 0.33; 95% confidence interval, 0.14-0.79; P=0.013). CONCLUSIONS: Cn contributes to pulmonary hypertension beyond stenosis severity itself. In a wide spectrum of MS severity, Cn is a powerful predictor of adverse outcome, adding prognostic value to clinical data and mitral valve area. Importantly, baseline Cn predicts a progressive course with subsequent need for intervention in initially asymptomatic patients. Cn assessment therefore has potential value for clinical risk stratification and monitoring in MS patients.
Asunto(s)
Hipertensión Pulmonar/fisiopatología , Estenosis de la Válvula Mitral/fisiopatología , Resistencia Vascular/fisiología , Adulto , Ecocardiografía Doppler , Prueba de Esfuerzo , Femenino , Estudios de Seguimiento , Humanos , Hipertensión Pulmonar/diagnóstico por imagen , Hipertensión Pulmonar/etiología , Masculino , Estenosis de la Válvula Mitral/complicaciones , Estenosis de la Válvula Mitral/diagnóstico por imagen , Pronóstico , Estudios Prospectivos , Presión Esfenoidal PulmonarRESUMEN
OBJECTIVES: We aimed to explore the relationship between brain natriuretic peptide (BNP) levels and right ventricular (RV) function in patients with mitral stenosis (MS), and to investigate the hemodynamic parameters that predict reduction of BNP levels after percutaneous mitral valvuloplasty (PMV). BACKGROUND: Few studies have evaluated BNP in the context of MS, specifically the impact of the RV stroke work (RVSW) on serum BNP levels has not been defined. METHODS: Thirty patients with symptomatic rheumatic MS in sinus rhythm who were referred for a PMV were enrolled. Right and left heart pressures were obtained before and after valvuloplasty. RVSW index (RVSWI) was calculated by cardiac catheterization. RESULTS: Basal BNP levels were elevated in MS patients and correlated with several hemodynamic parameters including pulmonary pressure, pulmonary vascular resistance index, cardiac index (CI), and RVSWI. In multivariate analysis, CI and RVSWI were independent predictors of raised basal BNP levels. PMV resulted in a significant decrease in the RVSWI with a concurrent increase in CI (2.4 ± 0.43 to 2.9 ± 0.8 L/min/m(2), P = 0.010). Overall, plasma BNP levels significantly decreased from 124 (63/234) to 73 (48/148) pg/ml postvalvuloplasty. Multivariate analysis revealed that the reduction of left atrial (LA) pressure post-PMV was an independent predictor of change in BNP levels. CONCLUSIONS: Elevated baseline BNP level in MS patients was independently associated with CI and RVSWI. Plasma BNP levels were reduced after successful PMV, which was associated with the reduction of the LA pressure.
Asunto(s)
Ventrículos Cardíacos/fisiopatología , Estenosis de la Válvula Mitral/sangre , Estenosis de la Válvula Mitral/fisiopatología , Péptido Natriurético Encefálico/sangre , Adulto , Ecocardiografía , Femenino , Humanos , Masculino , Estenosis de la Válvula Mitral/cirugíaRESUMEN
BACKGROUND: The creation of an acute myocardial infarction (AMI) system of care aims to optimize the management of patients from early diagnosis to proper and timely treatment. OBJECTIVE: To assess the establishment of an AMI System of Care in the city of Belo Horizonte, state of Minas Gerais, and its impact on AMI in-hospital mortality. METHODS: The AMI system of care was established in the city of Belo Horizonte between 2010 and 2011, aiming at increasing the access of patients of the public health system to the treatment recommended by the existing guidelines. The teams at the emergency care units were trained, and the tele-electrocardiography system was implanted in those units. The primary outcomes of this retrospective observational study were the number of admissions and AMI in-hospital mortality, from 2009 to 2011. RESULTS: During the study period, 294 professionals were trained and 563 electrocardiograms (ECGs) transmitted from emergency care units to coronary care units. A significant reduction was observed in the in-hospital mortality rate (12.3% in 2009 versus 7.1% in 2011, p < 0.001), while the number of admissions due to AMI remained stable. The mean cost of admission increased (mean R$ 2,480.00 versus R$ 3,501.00; p < 0.001), the proportion of admissions including intensive care unit stay increased (32.4% in 2009 versus 66.1% in 2011; p < 0.001), and the number of patients admitted to tertiary hospitals increased (47.0% versus 69.6%; p < 0.001). CONCLUSION: The establishment of the AMI system of care improved the access of the population to proper treatment, thus reducing AMI in-hospital mortality. [corrected].
Asunto(s)
Unidades de Cuidados Coronarios/métodos , Servicio de Urgencia en Hospital/organización & administración , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Infarto del Miocardio , Brasil , Unidades de Cuidados Coronarios/normas , Electrocardiografía/métodos , Servicio de Urgencia en Hospital/normas , Femenino , Mortalidad Hospitalaria , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapia , Estudios Retrospectivos , Estadísticas no Paramétricas , Telemedicina/métodosRESUMEN
FUNDAMENTO: A criação de sistemas ou linhas de cuidado ao infarto agudo do miocárdio (IAM) tem o objetivo de otimizar o atendimento ao paciente, desde o diagnóstico precoce até o tratamento adequado e em tempo hábil. OBJETIVO: Avaliar a implantação da linha de cuidado do IAM, em Belo Horizonte, Minas Gerais, e seu impacto na mortalidade hospitalar por IAM. MÉTODOS: A linha de cuidado do IAM foi implantada em Belo Horizonte entre 2010 e 2011 com intuito de ampliar o acesso dos pacientes do sistema público de saúde ao tratamento preconizado pelas diretrizes vigentes. As equipes das unidades de pronto atendimento foram treinadas e foi implantado sistema de tele-eletrocardiografia nessas unidades. Os desfechos primários deste estudo observacional retrospectivo foram o número de internações e a mortalidade hospitalar por IAM, de 2009 a 2011. RESULTADOS: No período avaliado, 294 profissionais foram treinados e 563 ECGs foram transmitidos das unidades de pronto atendimento para as unidades coronarianas. Houve redução importante da taxa de mortalidade hospitalar (12,3% em 2009 versus 7,1% em 2011, p < 0,001), enquanto o número de internações por IAM permaneceu estável. Ocorreu aumento do custo médio de internação (média R$ 2.480,00 versus R$ 3.501,00, p < 0,001), aumento da proporção de internações contemplando diárias de terapia intensiva (32,4% em 2009 versus 66,1% em 2011, p < 0,001) e de pacientes internados em hospitais de alta complexidade (47,0% versus 69,6%, p < 0,001). CONCLUSÃO: A implantação da linha de cuidado do IAM permitiu maior acesso da população ao tratamento adequado e, consequentemente, redução na mortalidade hospitalar por IAM.
BACKGROUND:The creation of an acute myocardial infarction (AMI) management systems is aimed at optimizing the management of patients from early diagnosis to proper and timely treatment. OBJECTIVE: To assess the implantation of an AMI management system in the municipality of Belo Horizonte, state of Minas Gerais, and its impact on in-hospital mortality due to AMI. METHODS: The AMI management system was implanted in the municipality of Belo Horizonte between 2010 and 2011, aiming at increasing the access of patients of the public health system to the treatment recommended by the existing guidelines. The teams at the prompt care units were trained, and the system of tele-electrocardiography was implanted in those units. The primary outcomes of this retrospective observational study were the number of admissions and in-hospital mortality due to AMI, from 2009 to 2011. RESULTS: In the period studied, 294 professionals were trained and 563 electrocardiograms (ECGs) transmitted from prompt care units to coronary units. A significant reduction was observed in the in-hospital mortality rate (12.3% in 2009 versus 7.1% in 2011, p < 0.001), while the number of admissions due to AMI remained stable. The mean cost of admission increased (mean R$ 2,480.00 versus R$ 3,501.00; p < 0.001), the proportion of admissions including intensive care unit stay increased (32.4% in 2009 versus 66.1% in 2011; p < 0.001), and the number of patients admitted to tertiary hospitals increased (47.0% versus 69.6%; p < 0.001). CONCLUSION: The AMI management system implantation increased the access of the population to proper treatment, thus reducing in-hospital mortality due to AMI.
Asunto(s)
Femenino , Humanos , Masculino , Persona de Mediana Edad , Unidades de Cuidados Coronarios/métodos , Servicio de Urgencia en Hospital/organización & administración , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Infarto del Miocardio , Brasil , Unidades de Cuidados Coronarios/normas , Electrocardiografía/métodos , Servicio de Urgencia en Hospital/normas , Mortalidad Hospitalaria , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapia , Estudios Retrospectivos , Estadísticas no Paramétricas , Telemedicina/métodosRESUMEN
BACKGROUND: The role of intravascular ultrasound (IVUS) in percutaneous coronary interventions (PCI) is still controversial despite several previously published meta-analyses. A meta-analysis to evaluate the controversial role of IVUS-guided PCI with bare-metal stenting was performed and a previous published meta-analysis was re-evaluated in order to clarify the discrepancy between results of these studies. METHODS: A systematic review was performed by an electronic search of the PubMed, Embase and Web of Knowledge databases and by a manual search of reference lists for randomized controlled trials published until April 2011, with clinical outcomes and, at least, six months of clinical follow-up. A meta-analysis based on the intention to treat was performed with the selected studies. RESULTS: Five studies and 1,754 patients were included. There were no differences in death (OR = 1.86; 95% CI = 0.88-3.95; p = 0.10), non-fatal myocardial infarction (OR = 0.65; 95% CI = 0.27-1.58; p = 0.35) and major adverse cardiac events (OR = 0.74; 95% CI = 0.49-1.13; p = 0.16). An analysis of the previous published meta-analysis strongly suggested the presence of publication bias. CONCLUSIONS: There is no evidence to recommend routine IVUS-guided PCI with bare-metal stent implantation. This may be explained by the paucity and heterogeneity of the studies published so far.
Asunto(s)
Intervención Coronaria Percutánea , Stents , Ultrasonografía Intervencional , Humanos , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoRESUMEN
INTRODUÇÃO: A intervenção coronária percutânea cresceu de modo expressivo nas últimas décadas. Entretanto, relatos de resultados imediatos e a longo prazo desse procedimento em instituições brasileiras são esporádicos e restritos a alguns centros. A presente proposta objetiva descrever um sistema nacional para a avaliação dos indivíduos tratados por intervenção coronária percutânea no Brasil. Método: O Registro ICP-BR foi constituído por meio de rede informatizada para a captação de dados, via web, sobre angioplastias coronárias realizadas no dia a dia da cardiologia intervencionista, sem critérios de exclusão. Em sua fase piloto, 8 centros nacionais foram selecionados para a coleta inicial de dados. Relatamos o perfil clínico e a evolução intra-hospitalar dos primeiros pacientes incluídos. Resultados: De março de 2009 a dezembro de 2009, foram incluídos 1.249 pacientes na base de dados. No total, 60 por cento foram tratados pelo Sistema Único de Saúde, 38 por cento por planos de saúde e 2 por cento eram pagantes. A média de idade era de 63,7 + ou - 11,3 anos, 36 por cento eram diabéticos, 12 por cento tinham cirúrgia prévia e 27 tinham angioplastia prévia. À admissão, 39 por cento eram estáveis e 18 por cento tinham infartro com supradesnivelamento do segmento ST. Ultrassom intracoronário...
BACKGROUND: Percutaneous coronary intervention has grown dramatically in recent decades. However, reports of immediate and long-term results of this procedure in Brazilian institutions are sporadic and limited to some centers. This study is aimed at describing a national system to evaluate patients treated by percutaneous coronary intervention in Brazil. METHODS: The ICP-BR Registry was established by a computerized network for data capture on coronary angioplasties performed in day-to-day interventional cardiology, without exclusion criteria. In the pilot phase 8 national centers were selected for the initial data collection. We report the clinical profile and in-hospital evolution of the first patients included. RESULTS: From March 2009 to December 2009, 1,249 patients were included in the database. In total, 60% were treated by the Unified Health System, 38% by health insurance plans and 2% were private patients. Mean age was 63.7 ± 11.3 years, 36% were diabetic, 12% had prior surgery and 27% prior angioplasty. Upon admission, 39% were stable and 18% had ST elevation myocardial infarction. Intracoronary ultrasound or fractional flow reserve was performed in 2.8% cases. Stents were used in 93% of procedures, and drug-eluting stents in 16.2% of the patients. Mortality was 0.2% in stable patients, 2.4% in patients with acute coronary syndromes without ST elevation, 6.1% in patients with ST elevation myocardial infarction and 3.6% in those with anginal equivalent. CONCLUSIONS: We describe the development and implementation of a computerized system to collect detailed data on percutaneous coronary intervention procedures in Brazil. Given the inclusive unrestricted character (all-comers) and prospective follow-up of patients, this data capture and recording system may contribute decisively to profile percutaneous coronary intervention in our country.