RESUMO
CONTEXT: International studies have shown a large variation in the utilization patterns of interventions, in acute myocardial infarction. OBJECTIVE: To analyze utilization patterns of pharmacological interventions in acute myocardial infarction and their corresponding effects on hospital mortality. DESIGN: Cross-sectional study. LOCAL: Hospitals of the Brazilian National Health System (SUS) in the municipal district of Rio de Janeiro. SAMPLE: A stratified hospital sample of 391 medical records selected from the 1,936 admissions registered in the SUS Hospital Information System (SIH/SUS) with a main diagnosis of acute myocardial infarction, in the studied district in 1997. MAIN MEASUREMENTS: Sex, age, time to treatment, risk factors, severity factors, diagnosis confirmation, use of pharmacological interventions, hospital death, contraindication of the use of thrombolytic therapy, contraindication of aspirin use. RESULTS: We reviewed 98.2% of the sampled medical records. Acute myocardial infarction diagnosis was confirmed in 91.7% (95% CI 88.3 to 94.2). 61.5% were men and 38.5% women, with an average age of 60.2 years (SD 2.4). The median time interval between symptom onset and hospital admission was 11 hours. Hospital mortality was 20.6% (95% CI 16.7 to 25.0). Intravenous thrombolytic therapy was used in 19.5% (95% CI 15.8 to 23.9) of the cases; aspirin in 86.5% (95% CI 82.5 to 89.6); beta-blockers in 49.0% (95% CI 43.8 to 54.1); angiotensin-converting enzyme (ACE) inhibitors in 63.3% (95% CI 58.2 to 68.1); nitrates in 82.0% (95% CI 82.4 to 89.6); heparin in 81.3% (95% CI 76.9 to 85.0); calcium antagonists in 30.5% (95% CI 26.0 to 35.4). There was a significant variation in the use of thrombolytic therapy, beta-blockers, ACE inhibitors, calcium antagonists and heparin among hospitals of different juridical nature. CONCLUSIONS: There was underutilization of some interventions with well-established efficacy (thrombolytic therapy, aspirin, beta-blockers and intravenous nitrates). The use of calcium antagonists, not supported by scientific evidence in acute myocardial infarction, was quite frequent. A logistic model documented the benefit of aspirin, beta-blockers and ACE inhibitor use in reducing the chance of hospital death.
Assuntos
Infarto do Miocárdio/tratamento farmacológico , Idoso , Análise de Variância , Brasil/epidemiologia , Contraindicações , Estudos Transversais , Feminino , Fibrinolíticos/uso terapêutico , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Terapia TrombolíticaRESUMO
OBJECTIVE: To analyze the incidence of intraventricular and atrioventricular conduction defects associated with acute myocardial infarction and the degree of in hospital mortality resulting from this condition during the era of thrombolytic therapy. METHODS: Observational study of a cohort of 929 consecutive patients with acute myocardial infarction. Multivariate analysis by logistic regression. Was used. RESULTS: Logistic regression showed a greater incidence of bundle branch block in male sex (odds ratio = 1.87, 95% CI = 1.02-3.42), age over 70 years (odds ratio = 2.31, 95% CI = 1.68-5.00), anterior localization of the infarction (odds ratio = 1.93, 95% CI = 1.03-3.65). There was a greater incidence of complete atrioventricular block in inferior infarcts (odds ratio = 2.59, 95% CI 1.30-5.18) and the presence of cardiogenic shock (odds ratio = 3.90, 95% CI = 1.43-10.65). Use of a thrombolytic agent was associated with a tendency toward a lower occurrence of bundle branch block (odds ratio = 0.68) and a greater occurrence of complete atrioventricular block (odds ratio = 1.44). The presence of bundle branch block (odds ratio = 2.45 95%, CI = 1.14-5.28) and of complete atrioventricular block (odds ratio = 13.59, 95% CI = 5.43-33.98) was associated with a high and independent probability of inhospital death. CONCLUSION: During the current era of thrombolytic therapy and in this population, intraventricular disturbances of electrical conduction and complete atrioventricular block were associated with a high and independent risk of inhospital death during acute myocardial infarction.
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Bloqueio Cardíaco/etiologia , Infarto do Miocárdio/complicações , Terapia Trombolítica , Idoso , Bloqueio de Ramo/epidemiologia , Bloqueio de Ramo/etiologia , Bloqueio de Ramo/mortalidade , Estudos de Coortes , Feminino , Fibrinolíticos/uso terapêutico , Bloqueio Cardíaco/epidemiologia , Bloqueio Cardíaco/mortalidade , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/tratamento farmacológico , Prognóstico , Tromboembolia/epidemiologia , Tromboembolia/etiologia , Tromboembolia/mortalidadeRESUMO
The simultaneous existence of a biotechnoscientific paradigm (which emphasizes technological incorporation) and a culture of limits (which selects technologies) challenges current health systems, raising ethical and political discussions as to the choices to be made. Health care technology assessment is mainly concerned with the consequences of health care and health care policies. Thus, there is significant overlap between this activity and bioethics, even though they are different fields of knowledge. Although the importance of ethical and social issues arising in technology assessment has been recognized, most publications emphasize only methodological and scientific aspects. There are different interests involved in technological incorporation, and many value conflicts arise. Ethical implications include those related to clinical trials, medical care assessment, incorporation of technology, resource allocation, equity, and the effectiveness gap. Incorporating the ethical dimension into technology assessment will foster a better understanding of health care practice and progress in its improvement.
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Bioética , Qualidade da Assistência à Saúde , Avaliação da Tecnologia Biomédica , HumanosRESUMO
PURPOSE: To study the predischarge exercise testing importance in determining prognosis after acute myocardial infarction (AMI). PATIENTS AND METHODS: Treadmill exercise testing was performed in 50 stable and without complications patients with AMI, just before hospital discharge; there were 43 men and 7 women, mean age of 53.6 +/- 9.3 years. It was used the modified Naughton protocol and there were no casualties during the exercise testing. Patients were followed up for a mean period of 22.2 +/- 7.7 months. RESULTS: The test was positive in 32% of the patients, abnormal (inadequate blood pressure, heart rate response or arrhythmia) in 36% and normal in 42%. During the first year of follow-up, eleven patients presented with a serious cardiac event. There was one cardiovascular death, 6 patients with unstable angina, 2 reinfarctions and 7 patients had a coronary bypass revascularization. The cumulative risk for these events at one year after myocardial infarction was 50% in patients with a positive exercise test, and 5% in those with a normal exercise test (p less than 0.005). CONCLUSION: The predischarge exercise testing proved to be a simple and safe method to determine prognosis after acute myocardial infarction, identifying a high risk group early after the acute event.
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Teste de Esforço , Infarto do Miocárdio/fisiopatologia , Adulto , Idoso , Feminino , Seguimentos , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Prognóstico , Fatores de RiscoRESUMO
PURPOSE: To evaluate safety and usefulness of dipyridamole-radionuclide ventriculography (D-RVG), soon after acute myocardial infarction (MI), in the prediction of future cardiac events. Traditionally performed tests were also compared. PATIENTS AND METHODS: Forty-one patients (4 females) with recent MI underwent rest and dipyridamole (0.58 mg/kg of body weight) radionuclide ventriculography. The criteria for a positive test for ischemia was failure to increase left ventricular ejection fraction in 0.05 from baseline value. All patients had also coronary angiography and 36 patients underwent thallium-201 scintigraphy for comparison. The mean follow-up was 16 +/- 3 months. The following findings were considered future for events: cardiac death, reinfarction, significant angina or heart failure. RESULTS: During the follow-up 18 of the 20 patients who had cardiac events had shown positive dipyridamole-RVG, as opposed to 5 of 21 event-free patients (p less than 0.01). The ventriculographic criteria for a positive test and dipyridamole left ventricular ejection fraction were the strongest predictors of those medical events (p less than 0.01 and p less than 0.001). Among the 36 patients who had thallium-201 imaging, 16 subsequently had cardiac events and the scans were positive in 82% (p less than 0.01). Twelve (29%) patients experienced reactions during dipyridamole infusion although no fatal complications were noted. CONCLUSION: Dipyridamole-RVG is relatively safe and a sensitive predictor of future cardiac events soon after acute MI, although additional experience is required before this new technique should be routinely recommended as an alternative approach.