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BACKGROUND: Brazil's Universal Health System is the world's largest and covers every citizen without out-of-pocket costs. Nonetheless, healthcare inequities across regions have never been systematically evaluated. METHODS: We used government databases to compare healthcare resource utilization, outcomes, expenditure, and years of life lost between 2016 and 2019. The maps used patients' residences as reference and adjusted for age and private health insurance coverage. RESULTS: The Atlas shows that for several comparisons, there were no procedures in some regions, including primary coronary angioplasty, thrombolysis for stroke, bariatric surgery, and kidney transplant. Colonoscopy varied 1481.2-fold, asthma hospitalizations varied 257.5-fold, and mammograms varied 133.9-fold. Cesarean births ranged from 19.5% to 84.0%, and myocardial infarction and stroke case-fatalities were 1.1% to 33.7% and 5.0% to 39.0%, respectively. Higher private health insurance coverage in each region was associated with increased resource utilization in the public system in most comparisons. CONCLUSION: These findings demonstrate that the SUS does not fulfill the Brazilian constitutional rights due to underutilization, overutilization, and access disparities. The Atlas outlines multiple opportunities to generate value in the SUS.
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OBJECTIVES: Value-based healthcare (VBHC) is a health system reform gradually being implemented in health systems worldwide. A previous national-level survey has shown that Latin American countries were in the early stages of alignment with VBHC. Data at the healthcare provider organisations (HPOs) level are lacking. This study aim was to investigate how HPOs in five Latin American countries are implementing VBHC. DESIGN: Mixed-methods research was conducted using online questionnaire, semistructured interviews based on selected elements of the value agenda (from December 2018 to June 2020), analyses of aggregated data and documents. Qualitative analysis was performed using NVivo QSR International, 1.6.1 (4830). Quantitative analysis used Fisher's exact test. Univariate analysis was used to compare organisations in relation to the implementation of VBHC initiatives. A p≤0.05 was considered significant. PARTICIPANTS: Top and middle-level executives from 70 HPOs from Argentina, Brazil, Chile, Colombia and Mexico. RESULTS: The definition of VBHC varied across participating organisations. Although the value equation had been cited by 24% of participants, its composition differed in most case from the original Equation. Most VBHC initiatives were related to care delivery organisation (56.9%) and outcomes measurement (22.4%) but in most cases, integrated practice unit features had not been fully developed and outcome data was not used to guide improvement. Information, stakeholders buy-in, compensation and fragmented care delivery were the most cited challenges to VBHC implementation. Fee-for-service predominated, although one-third of organisations were experimenting with alternative payment models. CONCLUSIONS: A wide variation in the definition and level of VBHC implementation existed across organisations. Our finding suggests investments in information systems and on education of key stakeholders will be key to foster VBHC implementation in the region. Further research is needed to identify successful implementation cases that may serve as regional benchmark for other Latin American organisations advancing with VBHC.
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Atención a la Salud , Personal de Salud , Argentina , Brasil , Chile , Colombia , Humanos , América Latina , México , Encuestas y CuestionariosRESUMEN
Although Value-Based Health Care (VBHC) is widely debated and cited, there are few empirical studies focused on how its concepts are understood and applied in real-world contexts. This comparative case study of two prominent adopters in Brazil and Sweden, situated at either end of the spectrum in terms of contextual prerequisites, provides insights into the complex interactions involved in the adoption of value-based strategies. We found that the adoption of VBHC emphasized either health outcomes or costs - not both as suggested by the value equation. This may be linked to broader health system and societal contexts. Implementation can generate tensions with traditional business models, suggesting that providers should first analyze how these strategies align with their internal context. Adoption by a single provider organization is challenging, if not impossible. An effective VBHC transformation seems to require a systematic and systemic approach where all stakeholders need to clearly define the purpose and the scope of the transformation, and together steer their actions and decisions accordingly.
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Baile , Brasil , Atención a la Salud , Programas de Gobierno , Humanos , SueciaRESUMEN
OBJECTIVES: As health systems start to discuss alternative payment models for fostering value in healthcare, there is increased interest in understanding how physicians will cope with different remuneration schemes. We conducted a survey of physicians practicing at Hospital Israelita Albert Einstein, a nonprofit private healthcare provider in Brazil, aimed at capturing their awareness of value-based healthcare (VBHC). METHODS: Our study uses data from a survey administered to doctors practicing at Einstein between September and November 2018. Descriptive statistics and adjusted multivariate logistic regression analyses were used to describe physicians' characteristics associated with their views on VBHC. RESULTS: A total of 1000 physicians completed the survey (response rate: 13%). Although only 25% knew the value equation, 67% defined value in health according to Porter's-the outcomes that matter to patients in relation to the costs of offering such outcomes. Most participants identified increased healthcare costs as the main reason for the discussions over new financing models. Only 27% of physicians rated their awareness of VBHC as high or very high. In the multivariate analysis, awareness of VBHC was associated with holding a management position, scoring high in the hospital's physician segmentation program, being familiar with the value equation, and attributing high importance to developing new VBHC financing models for health system transformation. CONCLUSIONS: Physician awareness of key VBHC concepts is still heterogeneous in our clinical setting. Promoting opportunities for involving physicians in the discussion of VBHC is key for a successful value-driven transformation of healthcare.
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Médicos/psicología , Mecanismo de Reembolso/normas , Brasil , Costos de la Atención en Salud/normas , Humanos , Médicos/estadística & datos numéricos , Práctica Privada/organización & administración , Práctica Privada/estadística & datos numéricos , Mecanismo de Reembolso/estadística & datos numéricos , Encuestas y CuestionariosRESUMEN
OBJECTIVE: We aim to examine the effect of benchmarking on quality-of-care metrics in patients presenting with ST-elevation myocardial infarction (STEMI) through the implementation of the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) ACTION Registry. DESIGN: From January 2005 to December 2017, 712 patients underwent primary percutaneous coronary intervention PCI-499 before NCDR ACTION Registry implementation (prior to 2013) and 213 after implementation. SETTING: STEMI. PARTICIPANTS: 712 patients. INTERVENTION(S): Primary PCI. MAIN OUTCOME MEASURE(S): We examined hospital performance for the quality indicators in processes and outcomes of the management of patients presenting with STEMI. Outcome measures include door-to-balloon time (DBT), antiplatelet therapy and anti-ischemic drugs prescribed at discharge from pre-NCDR ACTION Registry to post-implementation. RESULTS: There was improvement in DBT, decreasing from 94 min in 2012 (before NCDR adoption) to reach a median of 47 min in 2017 (Ptrend < 0.001). The percentage of cases with the optimal DBT of < 90 min increased from 55.8% before to 90.1% after the implementation of the NCDR ACTION Registry (Ptrend < 0.001). The rate of aspirin (90.3-100%, P < 0.001), P2Y12 inhibitor (70.1-78.4%, P = 0.02), beta-blocker (76.8-100%, P < 0.001) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (60.1-99.5%, P < 0.001) prescribed at discharge increased from pre-NCDR ACTION Registry to post-implementation. Adjusted mortality before and after NCDR ACTION Registry implementation showed significant change (from 9.04 to 5.92%; P = 0.027). CONCLUSIONS: The introduction of the ACC NCDR ACTION Registry led to incremental gains in the quality in STEMI management through the benchmarking of process of care and clinical outcomes, achieving reduced DBT, improving guideline-directed medication adherence and increasing patient safety, treatment efficacy and survival.
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Benchmarking/métodos , Mejoramiento de la Calidad/organización & administración , Infarto del Miocardio con Elevación del ST/tratamiento farmacológico , Infarto del Miocardio con Elevación del ST/cirugía , Antagonistas Adrenérgicos beta/uso terapéutico , Anciano , Inhibidores de la Enzima Convertidora de Angiotensina , Brasil , Femenino , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Intervención Coronaria Percutánea/estadística & datos numéricos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Sistema de Registros , Infarto del Miocardio con Elevación del ST/mortalidad , Factores de TiempoAsunto(s)
Fibrilación Atrial/cirugía , Ablación por Catéter , Criocirugía , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Resultado del TratamientoAsunto(s)
Humanos , Masculino , Femenino , Adulto , Anciano , Fibrilación Atrial/cirugía , Ablación por Catéter , Criocirugía , Estudios de Seguimiento , Resultado del TratamientoRESUMEN
BACKGROUND: Brazil, the largest country and economy in South America, is a major driving force behind the development of new medical technologies in the region. Robotic cardiac surgery (RCS) has been evolving rapidly since 2010, when the first surgery using the DaVinci® robotic system was performed in Latin America. The aim of this article is to evaluate short and mid-term results in patients undergoing robotic cardiac surgery in Brazil. METHODS: From March 2010 to December 2015, 39 consecutive patients underwent robotic cardiac surgery. Twenty-seven patients were male (69.2%), with the mean age of 51.3±17.9 years. Participants had a mean ejection fraction of 62±5%. The procedures included in this study were mitral valve surgery, surgical treatment of atrial fibrillation, atrial septal defect closure, resection of intra-cardiac tumors, totally endoscopic coronary artery bypass and pericardiectomy. RESULTS: The mean time spent on cardiopulmonary bypass (CPB) during RCS was 154.9±94.2 minutes and the mean aortic cross-clamp time was 114.48±75.66 minutes. Thirty-two patients (82%) were extubated in the operating room immediately after surgery. The median intensive care unit (ICU) length of stay was 1 day (ranging from 0 to 25) and the median hospital length of stay was 5 days (ranging from 3 to 25). For each type of procedure, endpoints were individually reported. There were no conversions to sternotomy and no intra-operative complications. Patient follow-up was complete in 100% of the participants, with two early deaths unrelated to the procedures and no re-operations at mid-term. CONCLUSIONS: Despite the heterogeneity of this series, RCS appears to be feasible, safe and effective when used for the correction of various intra- and extra-cardiac pathologies. Adopting the robotic system has been a challenge in Brazil, where its limited clinical application may be related to the lack of specific training and the high cost of technology.
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PURPOSE: Patients with acute myocardial infarction (AMI) and respiratory impairment may be treated with either invasive or non-invasive mechanical ventilation (MV). However, there has been little testing of non-invasive MV in the setting of AMI. Our objective was to evaluate the incidence and associated clinical outcomes of patients with AMI who were treated with non-invasive or invasive MV. METHODS: This was a retrospective observational study in which consecutive patients with AMI (n = 1610) were enrolled. The association between exclusively non-invasive MV, invasive MV and outcomes was assessed by multivariable models. RESULTS: Mechanical ventilation was used in 293 patients (54% invasive and 46% exclusively non-invasive). In-hospital mortality rates for patients without MV, with exclusively non-invasive MV, and with invasive MV were 4.0%, 8.8%, and 39.5%, respectively (P<0.001). The median lengths of hospital stay were 6 (5.8-6.2), 13 (11.2-4.7), and 28 (18.0-37.9) days, respectively (P<0.001). Exclusively non-invasive MV was not associated with in-hospital death (adjusted HR = 0.90, 95% CI 0.40-1.99, P = 0.79). Invasive MV was strongly associated with a higher risk of in-hospital death (adjusted HR = 3.07, 95% CI 1.79-5.26, P<0.001). CONCLUSIONS: In AMI setting, 18% of the patients required MV. Almost half of these patients were treated with exclusively non-invasive strategies with a favorable prognosis, while patients who needed to be treated invasively had a three-fold increase in the risk of death. Future prospective randomized trials are needed to compare the effectiveness of invasive and non-invasive MV for the initial approach of respiratory failure in AMI patients.
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Infarto del Miocardio/terapia , Respiración Artificial , Insuficiencia Respiratoria/terapia , Anciano , Anciano de 80 o más Años , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Pronóstico , Insuficiencia Respiratoria/mortalidad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Background: Despite the availability of guidelines for treatment of heart failure (HF), only a few studies have assessed how hospitals adhere to the recommended therapies. Objectives: Compare the rates of adherence to the prescription of angiotensin-converting enzyme inhibitor or angiotensin II receptor blockers (ACEI/ARB) at hospital discharge, which is considered a quality indicator by the Joint Commission International, and to the prescription of beta-blockers at hospital discharge, which is recommended by national and international guidelines, in a hospital with a case management program to supervise the implementation of a clinical practice protocol (HCP) and another hospital that follows treatment guidelines (HCG). Methods: Prospective observational study that evaluated patients consecutively admitted to both hospitals due to decompensated HF between August 1st, 2006, and December 31st, 2008. We used as comparing parameters the prescription rates of beta-blockers and ACEI/ARB at hospital discharge and in-hospital mortality. Results: We analyzed 1,052 patients (30% female, mean age 70.6 ± 14.1 years), 381 (36%) of whom were seen at HCG and 781 (64%) at HCP. The prescription rates of beta-blockers at discharge at HCG and HCP were both 69% (p = 0.458), whereas those of ACEI/ARB were 83% and 86%, respectively (p = 0.162). In-hospital mortality rates were 16.5% at HCP and 27.8% at HCG (p < 0.001). Conclusion: There was no difference in prescription rates of beta-blocker and ACEI/ARB at hospital discharge between the institutions, but HCP had lower in-hospital mortality. This difference in mortality may be attributed to different clinical characteristics of the patients in both hospitals.
Fundamento: Apesar da disponibilidade de diretrizes de tratamento para insuficiência cardíaca (IC), há poucos estudos avaliando a adesão dos hospitais ao tratamento preconizado. Objetivos: Comparar as taxas de adesão à prescrição de inibidor da enzima conversora da angiotensina ou antagonista do receptor de angiotensina II (IECA/BRA) na alta hospitalar, considerada indicadora de qualidade pela Joint Commission International, e à prescrição de betabloqueador na alta hospitalar, preconizada por diretrizes nacionais e internacionais, em um hospital que utiliza gerenciamento de casos para supervisionar a implementação de um protocolo assistencial (HPA) e outro que utiliza diretrizes de tratamento (HDT). Métodos: Estudo observacional prospectivo que avaliou pacientes consecutivamente admitidos em ambos os hospitais por IC descompensada entre 1º de agosto de 2006 a 31 de dezembro de 2008. Os parâmetros comparados entre os hospitais foram as taxas de prescrição de betabloqueador e IECA/BRA na alta hospitalar e a mortalidade intra-hospitalar. Resultados: Analisamos 1.052 pacientes (30% do sexo feminino, média de idade 70,6 ± 14,1 anos) dos quais 381 (36%) eram do HDT e 781 (64%) do HPA. No HDT e no HPA, as taxas de prescrição de betabloqueador na alta foram ambas de 69% (p = 0,458), e de prescrição de IECA/BRA foi de 83% e 86%, respectivamente (p = 0,162). A mortalidade intra-hospitalar foi de 16,5% no HPA e de 27,8% no HDT (p < 0,001). Conclusão: Não houve diferença entre as instituições em relação à prescrição de betabloqueador e IECA/BRA na alta hospitalar, mas a mortalidade intra-hospitalar foi menor no HPA. Esta diferença na mortalidade pode ser atribuída às características clínicas distintas dos pacientes em ambos os hospitais.
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Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adhesión a Directriz/estadística & datos numéricos , Insuficiencia Cardíaca/tratamiento farmacológico , Hospitalización/estadística & datos numéricos , Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Brasil/epidemiología , Protocolos Clínicos/normas , Mortalidad Hospitalaria , Insuficiencia Cardíaca/mortalidad , Hospitales/normas , Hospitales/estadística & datos numéricos , Estudios Prospectivos , Alta del Paciente/estadística & datos numéricos , Indicadores de Calidad de la Atención de SaludRESUMEN
BACKGROUND: Despite the availability of guidelines for treatment of heart failure (HF), only a few studies have assessed how hospitals adhere to the recommended therapies. OBJECTIVES: Compare the rates of adherence to the prescription of angiotensin-converting enzyme inhibitor or angiotensin II receptor blockers (ACEI/ARB) at hospital discharge, which is considered a quality indicator by the Joint Commission International, and to the prescription of beta-blockers at hospital discharge, which is recommended by national and international guidelines, in a hospital with a case management program to supervise the implementation of a clinical practice protocol (HCP) and another hospital that follows treatment guidelines (HCG). METHODS: Prospective observational study that evaluated patients consecutively admitted to both hospitals due to decompensated HF between August 1st, 2006, and December 31st, 2008. We used as comparing parameters the prescription rates of beta-blockers and ACEI/ARB at hospital discharge and in-hospital mortality. RESULTS: We analyzed 1,052 patients (30% female, mean age 70.6 ± 14.1 years), 381 (36%) of whom were seen at HCG and 781 (64%) at HCP. The prescription rates of beta-blockers at discharge at HCG and HCP were both 69% (p = 0.458), whereas those of ACEI/ARB were 83% and 86%, respectively (p = 0.162). In-hospital mortality rates were 16.5% at HCP and 27.8% at HCG (p < 0.001). CONCLUSION: There was no difference in prescription rates of beta-blocker and ACEI/ARB at hospital discharge between the institutions, but HCP had lower in-hospital mortality. This difference in mortality may be attributed to different clinical characteristics of the patients in both hospitals.
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Adhesión a Directriz/estadística & datos numéricos , Insuficiencia Cardíaca/tratamiento farmacológico , Hospitalización/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Brasil/epidemiología , Protocolos Clínicos/normas , Femenino , Insuficiencia Cardíaca/mortalidad , Mortalidad Hospitalaria , Hospitales/normas , Hospitales/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Alta del Paciente/estadística & datos numéricos , Estudios Prospectivos , Indicadores de Calidad de la Atención de SaludRESUMEN
AbstractBackground:The prevalence and clinical outcomes of heart failure with preserved left ventricular ejection fraction after acute myocardial infarction have not been well elucidated.Objective:To analyze the prevalence of heart failure with preserved left ventricular ejection fraction in acute myocardial infarction and its association with mortality.Methods:Patients with acute myocardial infarction (n = 1,474) were prospectively included. Patients without heart failure (Killip score = 1), with heart failure with preserved left ventricular ejection fraction (Killip score > 1 and left ventricle ejection fraction ≥ 50%), and with systolic dysfunction (Killip score > 1 and left ventricle ejection fraction < 50%) on admission were compared. The association between systolic dysfunction with preserved left ventricular ejection fraction and in-hospital mortality was tested in adjusted models.Results:Among the patients included, 1,256 (85.2%) were admitted without heart failure (72% men, 67 ± 15 years), 78 (5.3%) with heart failure with preserved left ventricular ejection fraction (59% men, 76 ± 14 years), and 140 (9.5%) with systolic dysfunction (69% men, 76 ± 14 years), with mortality rates of 4.3%, 17.9%, and 27.1%, respectively (p < 0.001). Logistic regression (adjusted for sex, age, troponin, diabetes, and body mass index) demonstrated that heart failure with preserved left ventricular ejection fraction (OR 2.91; 95% CI 1.35–6.27; p = 0.006) and systolic dysfunction (OR 5.38; 95% CI 3.10 to 9.32; p < 0.001) were associated with in-hospital mortality.Conclusion:One-third of patients with acute myocardial infarction admitted with heart failure had preserved left ventricular ejection fraction. Although this subgroup exhibited more favorable outcomes than those with systolic dysfunction, this condition presented a three-fold higher risk of death than the group without heart failure. Patients with acute myocardial infarction and heart failure with preserved left ventricular ejection fraction encounter elevated short-term risk and require special attention and monitoring during hospitalization.
ResumoFundamento:A prevalência e os desfechos clínicos em pacientes com insuficiência cardíaca com fração de ejeção do ventrículo esquerdo preservada pós-infarto agudo do miocárdio ainda não foram bem elucidados.Objetivo:Analisar a prevalência de insuficiência cardíaca com fração de ejeção do ventrículo esquerdo preservada no infarto agudo do miocárdio e sua associação com a mortalidade.Métodos:Pacientes com infarto agudo do miocárdio (n = 1.474) foram incluídos prospectivamente. Pacientes admitidos sem insuficiência cardíaca (Killip = 1), com insuficiência cardíaca com fração de ejeção do ventrículo esquerdo preservada (Killip > 1 e fração de ejeção do ventrículo esquerdo ≥ 50%) e com insuficiência cardíaca sistólica (Killip > 1 e fração de ejeção do ventrículo esquerdo < 50%) foram comparados. A associação entre insuficiência cardíaca sistólica e com fração de ejeção do ventrículo esquerdo preservada, com a mortalidade hospitalar foi testada em modelos ajustados.Resultados:Dentre os incluídos, 1.256 (85,2%) pacientes foram admitidos sem insuficiência cardíaca (72% homens, 67 ± 15 anos), 78 (5,3%) com insuficiência cardíaca com fração de ejeção do ventrículo esquerdo preservada (59% homens, 76 ± 14 anos) e 140 (9,5%) com insuficiência cardíaca sistólica (69% homens, 76 ± 14 anos), com mortalidade, respectivamente, de 4,3; 17,9 e 27,1% (p < 0,001). A regressão logística (ajustada para sexo, idade, troponina, diabetes e índice de massa corporal) demonstrou que insuficiência cardíaca com fração de ejeção do ventrículo esquerdo preservada (odds ratio de 2,91; intervalo de confiança de 95% de 1,35-6,27; p = 0,006) e insuficiência cardíaca sistólica (odds ratio de 5,38; intervalo de confiança de 95% de 3,10-9,32; p < 0,001) se associaram à mortalidade intra-hospitalar.Conclusão:Um terço dos pacientes com infarto agudo do miocárdio admitidos com insuficiência cardíaca apresentou fração de ejeção do ventrículo esquerdo preservada. Apesar de esse subgrupo ter evolução mais favorável que os pacientes com insuficiência cardíaca sistólica, ele apresentou risco de morte três vezes maior do que o grupo sem insuficiência cardíaca. Pacientes com infarto agudo do miocárdio e insuficiência cardíaca com fração de ejeção do ventrículo esquerdo preservada apresentaram elevado risco em curto prazo e mereceram especial atenção e monitorização durante a internação hospitalar.
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Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/fisiopatología , Infarto del Miocardio/epidemiología , Infarto del Miocardio/fisiopatología , Volumen Sistólico/fisiología , Brasil/epidemiología , Diástole/fisiología , Métodos Epidemiológicos , Hospitalización , Pronóstico , Sístole/fisiología , Disfunción Ventricular Izquierda/fisiopatología , Función Ventricular Izquierda/fisiologíaRESUMEN
BACKGROUND: Familial hypercholesterolemia is characterized by elevated plasma cholesterol and early coronary arterial disease onset. However, few studies investigated the association of heterozygous familial hypercholesterolemia with peripheral arterial disease. METHODS: In a cross sectional study 202 heterozygous familial hypercholesterolemia patients (91% confirmed by molecular diagnosis) were compared to 524 normolipidemic controls. Peripheral arterial disease was diagnosed by ankle-brachial index values ≤0.90. RESULTS: Compared with controls, familial hypercholesterolemia patients were older, more often female, with higher rates of hypertension, diabetes, previous coronary disease and higher total cholesterol levels. Smoking (previous and former) was more common among controls. The prevalence of peripheral arterial disease was 17.3 and 2.3% respectively in familial hypercholesterolemia and controls (p < 0.001). Results persisted after matching familial hypercholesterolemia and controls by a propensity score. Regression analyses demonstrated that age (odds ratio- OR = 1.03 95% CI 1.00-1.05, p = 0.033), previous cardiovascular disease (OR = 3.12 CI 95% 1.56-6.25, p = 0.001) and familial hypercholesterolemia diagnosis (OR = 5.55 CI 95% 2.69-11.44, p< 0.001) were independently associated with peripheral arterial disease. Among familial hypercholesterolemia patients, age (OR 1.05, 95% CI 1.02-1.09, p = 0.005), intermittent claudication (OR 6.32, 95% CI 2.60-15.33, p< 0.001) and smoking (OR 2.44, 95% CI 1.08-5.52, p = 0.032) were associated with peripheral arterial disease. CONCLUSIONS: Peripheral arterial disease is more frequent in familial hypercholesterolemia than in normolipidemic subjects and it should routine screened in these individuals even if asymptomatic. However, its role as predictor of cardiovascular events needs to be ascertained prospectively.
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Heterocigoto , Hiperlipoproteinemia Tipo II/epidemiología , Hiperlipoproteinemia Tipo II/genética , Enfermedad Arterial Periférica/epidemiología , Adulto , Factores de Edad , Índice Tobillo Braquial , Brasil/epidemiología , Estudios de Casos y Controles , Distribución de Chi-Cuadrado , Comorbilidad , Estudios Transversales , Femenino , Marcadores Genéticos , Predisposición Genética a la Enfermedad , Humanos , Hiperlipoproteinemia Tipo II/diagnóstico , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/fisiopatología , Prevalencia , Puntaje de Propensión , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Fumar/efectos adversos , Fumar/epidemiologíaRESUMEN
BACKGROUND: The prevalence and clinical outcomes of heart failure with preserved left ventricular ejection fraction after acute myocardial infarction have not been well elucidated. OBJECTIVE: To analyze the prevalence of heart failure with preserved left ventricular ejection fraction in acute myocardial infarction and its association with mortality. METHODS: Patients with acute myocardial infarction (n = 1,474) were prospectively included. Patients without heart failure (Killip score = 1), with heart failure with preserved left ventricular ejection fraction (Killip score > 1 and left ventricle ejection fraction ≥ 50%), and with systolic dysfunction (Killip score > 1 and left ventricle ejection fraction < 50%) on admission were compared. The association between systolic dysfunction with preserved left ventricular ejection fraction and in-hospital mortality was tested in adjusted models. RESULTS: Among the patients included, 1,256 (85.2%) were admitted without heart failure (72% men, 67 ± 15 years), 78 (5.3%) with heart failure with preserved left ventricular ejection fraction (59% men, 76 ± 14 years), and 140 (9.5%) with systolic dysfunction (69% men, 76 ± 14 years), with mortality rates of 4.3%, 17.9%, and 27.1%, respectively (p < 0.001). Logistic regression (adjusted for sex, age, troponin, diabetes, and body mass index) demonstrated that heart failure with preserved left ventricular ejection fraction (OR 2.91; 95% CI 1.35-6.27; p = 0.006) and systolic dysfunction (OR 5.38; 95% CI 3.10 to 9.32; p < 0.001) were associated with in-hospital mortality. CONCLUSION: One-third of patients with acute myocardial infarction admitted with heart failure had preserved left ventricular ejection fraction. Although this subgroup exhibited more favorable outcomes than those with systolic dysfunction, this condition presented a three-fold higher risk of death than the group without heart failure. Patients with acute myocardial infarction and heart failure with preserved left ventricular ejection fraction encounter elevated short-term risk and require special attention and monitoring during hospitalization.
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Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/fisiopatología , Infarto del Miocardio/epidemiología , Infarto del Miocardio/fisiopatología , Volumen Sistólico/fisiología , Anciano , Anciano de 80 o más Años , Brasil/epidemiología , Diástole/fisiología , Métodos Epidemiológicos , Femenino , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Sístole/fisiología , Disfunción Ventricular Izquierda/fisiopatología , Función Ventricular Izquierda/fisiologíaRESUMEN
OBJECTIVES: Elevated B-type natriuretic peptide (BNP) levels following acute myocardial infarction (AMI) are associated with adverse outcomes. The role of serial BNP monitoring after AMI has been poorly investigated. We aimed to evaluate the prognostic value of in-hospital serial BNP measurements in AMI patients. METHODS: Patients with AMI (n=1,924) were retrospectively evaluated. We selected patients with at least 2 in-hospital BNP measurements. The association between in-hospital mortality and BNP measurements (earliest, highest follow-up and the variation between measurements) were tested in multivariate models. RESULTS: Serial BNP levels were determined in 176 patients. Compared to the rest of the population, these patients were older and had higher mortality rates. In the adjusted models, only the highest follow-up BNP remained associated with in-hospital death (odds ratio 1.06; 95% confidence interval, CI, 1.01-1.15; p=0.014). Receiver-operating characteristic curve analysis demonstrated that the highest follow-up BNP was the best predictor of in-hospital death (area under the curve=0.75; 95% CI 0.64-0.86). CONCLUSIONS: Serial BNP monitoring was performed in a high-risk subgroup of AMI patients. The highest follow-up BNP was a better predictor of short-term death than the baseline and in-hospital variation values. In AMI patients, a later in-hospital BNP assessment may be more useful than an early measurement.
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Infarto del Miocardio/mortalidad , Péptido Natriurético Encefálico/metabolismo , Anciano , Biomarcadores/metabolismo , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Masculino , Infarto del Miocardio/sangre , Pronóstico , Curva ROC , Estudios RetrospectivosRESUMEN
A eliminação do feixe anômalo em atletas portadores de síndrome de Wolff-Parkinson-White deve sempreser o objetivo do tratamento. O comportamento dofeixe durante exercício máximo pode ser avaliado como preditor de risco de morte súbita...