RESUMO
OBJECTIVE: To investigate the cost effectiveness of ticagrelor versus clopidogrel in patients with acute coronary syndromes (ACS) in the Platelet Inhibition and Patient Outcomes (PLATO) study who were scheduled for non-invasive management. METHODS: A previously developed cost effectiveness model was used to estimate long-term costs and outcomes for patients scheduled for non-invasive management. Healthcare costs, event rates and health-related quality of life under treatment with either ticagrelor or clopidogrel over 12â months were estimated from the PLATO study. Long-term costs and health outcomes were estimated based on data from PLATO and published literature sources. To investigate the importance of different healthcare cost structures and life expectancy for the results, the analysis was carried out from the perspectives of the Swedish, UK, German and Brazilian public healthcare systems. RESULTS: Ticagrelor was associated with lifetime quality-adjusted life-year (QALY) gains of 0.17 in Sweden, 0.16 in the UK, 0.17 in Germany and 0.13 in Brazil compared with generic clopidogrel, with increased healthcare costs of 467, 551, 739 and 574, respectively. The cost per QALY gained with ticagrelor was 2747, 3395, 4419 and 4471 from a Swedish, UK, German and Brazilian public healthcare system perspective, respectively. Probabilistic sensitivity analyses indicated that the cost per QALY gained with ticagrelor was below conventional threshold values of cost effectiveness with a high probability. CONCLUSIONS: Treatment of patients with ACS scheduled for 12â months' non-invasive management with ticagrelor is associated with a cost per QALY gained below conventional threshold values of cost effectiveness compared with generic clopidogrel. TRIAL REGISTRATION NUMBER: NCT000391872.
Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Adenosina/análogos & derivados , Ticlopidina/análogos & derivados , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/economia , Síndrome Coronariana Aguda/psicologia , Adenosina/economia , Adenosina/uso terapêutico , Brasil , Clopidogrel , Análise Custo-Benefício , Gerenciamento Clínico , Eletrocardiografia , Feminino , Alemanha , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Cadeias de Markov , Avaliação de Resultados em Cuidados de Saúde , Inibidores da Agregação Plaquetária/economia , Inibidores da Agregação Plaquetária/uso terapêutico , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Prevenção Secundária/economia , Prevenção Secundária/métodos , Suécia , Ticagrelor , Ticlopidina/economia , Ticlopidina/uso terapêutico , Reino UnidoAssuntos
Angina Instável/prevenção & controle , Angina Instável/reabilitação , Infarto do Miocárdio/prevenção & controle , Infarto do Miocárdio/reabilitação , Doenças Cardiovasculares/prevenção & controle , Depressão/prevenção & controle , Humanos , Hiperlipidemias/prevenção & controle , Obesidade/prevenção & controle , Medição de Risco , Prevenção do Hábito de Fumar , Estresse Psicológico/prevenção & controleAssuntos
Cardiologia/educação , Competência Clínica , Currículo , Especialização , Humanos , Sociedades MédicasAssuntos
Angina Instável/diagnóstico , Infarto do Miocárdio/diagnóstico , Idoso , Angina Instável/fisiopatologia , Angina Instável/terapia , Biomarcadores/análise , Ecocardiografia , Eletrocardiografia , Humanos , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia , Infarto do Miocárdio/terapia , Prognóstico , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
BACKGROUND: Modern and sophisticated technology for the management of myocardial infarction has progressively devalued medical evaluation. HYPOTHESIS: This study was undertaken to assess the importance of the findings of medical evaluation at hospital presentation, in patients with acute myocardial infarction. METHODS: Data from 590 thrombolytic-treated myocardial infarction patients were analyzed. The patients were grouped according to their clinical status on arrival at hospital. A modified Forrester classification--subset II was divided according to the absence (IIa) or presence (IIb) of symptoms--was applied. Short- (14 days) and long-term (up to 10 years) survival was analyzed and 19 independent variables were included in the multivariate models. RESULTS: Short-term survival was 95.6% for subset I, 83.3% for subset IIa, 60% for subset IIb, 54.6% for subset III, and 34.8% for subset IV (P<0.001). By multiple regression analysis, lower clinical subsets (P<0.001), fewer coronary arteries with disease (P=0.006), younger age (P=0.014), absence of reinfarction (P=0.034), longer interval between streptokinase infusion and coronary arteriography (P=0.016), and higher left ventricular ejection fraction (P=0.037) demonstrated significant and independent correlation with short-term survival. Long-term survival for the total population was 71+/-3.6% for subset I, 54.4+/-8.5% for subset IIa, 20.8+/-9.4% for subset IIb, 54.5+/-15% for subset III, and 0% for subset IV (P<0.001). Using Cox regression analysis, lower clinical subsets (P<0.001), younger age (P<0.001), higher global left ventricular ejection fraction (P<0.001), and fewer coronary arteries with disease (P=0.021) correlated independently and significantly with long-term survival. When excluding data from patients who died before the short-term follow-up (n=532), lower clinical subsets remained an important predictor of long-term survival (P<0.001). CONCLUSION: Clinical classification at hospital presentation is a powerful predictor of short- and long-term survival post-myocardial infarction.
Assuntos
Infarto do Miocárdio/tratamento farmacológico , Terapia Trombolítica , Angiografia Coronária , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Prognóstico , Taxa de Sobrevida , Fatores de TempoRESUMO
OBJECTIVE: To report about a group of physicians' understanding of the recommendations of the II Brazilian Guidelines Conference on Dyslipidemias, and about the state of the art of primary and secondary prevention of atherosclerosis. METHODS: Through the use of a questionnaire on dyslipidemia, atherosclerosis prevention, and recommendations for lipid targets established by the II Brazilian Guidelines Conference on Dyslipidemias, 746 physicians, 98% cardiologists, were evaluated. RESULTS: Eighty-seven percent of the respondents stated that the treatment of dyslipidemia changes the natural history of coronary disease. Although most of the participants followed the total cholesterol recommendations (<200mg/dL for atherosclerosis prevention), only 55.8% would adopt the target of LDL-C <100 mg/dL for secondary prevention. Between 30.5 and 36.7% answered, in different questions, that the recommended level for HDL-C should be <35mg/dL. Only 32.7% would treat their patients indefinitely with lipid- lowering drugs. If the drug treatment did not reach the proposed target, only 35.5% would increase the dosage, and 29.4% would change the medication. Participants did not know the targets proposed for diabetics. CONCLUSION: Although the participating physicians valued the role played by lipids in the prevention of atherosclerosis, serious deficiencies exist in their knowledge of the recommendations given during the II Brazilian Guidelines Conference on Dyslipidemias.
Assuntos
Colesterol/sangue , Competência Clínica , Doença da Artéria Coronariana/prevenção & controle , Hiperlipidemias/tratamento farmacológico , Inquéritos e Questionários , Adulto , Colesterol/metabolismo , Coleta de Dados , Feminino , Humanos , Hipercolesterolemia/prevenção & controle , Masculino , Pessoa de Meia-Idade , Médicos , Valores de ReferênciaRESUMO
AIM: To assess the impact of cholesterol lowering on positive exercise stress tests in hypercholesterolaemic patients with normal coronary angiograms. METHODS: 43 non-diabetic patients aged 43-61 years, with total serum cholesterol concentrations of more than 7.75 mmol/l, positive exercise tests, and normal coronary angiograms, were started on the American Heart Association step 1 diet. After 12 weeks these patients were randomly assigned to treatment for another 16 weeks with the diet alone (diet group, n = 20) or with the diet plus lovastatin or simvastatin (statin group, n = 23). After this 28 week run in period, statins were withdrawn and lipid profile tests and exercise tests were done and repeated 20 weeks later. RESULTS: At week 28, the statin group but not the diet group had significant reductions from baseline (week 12) in plasma total cholesterol (p < 0.0001), low density lipoprotein (p < 0.0001), and triglyceride (p < 0.0001). The number of patients with positive exercise tests decreased from 23 to three in the statin group and from 20 to 15 in the diet group (p = 0.01). After the final 20 weeks without statins, lipid profiles returned to baseline levels in all 17 patients remaining in the statin group, and exercise tests were again positive in 15 of these patients. CONCLUSIONS: In hypercholesterolaemic patients with normal coronary arteries, cholesterol lowering treatment reduces myocardial ischaemia, as shown by the beneficial effects on exercise testing.
Assuntos
Dieta com Restrição de Gorduras , Tolerância ao Exercício , Hipercolesterolemia/terapia , Hipolipemiantes/uso terapêutico , Lovastatina/uso terapêutico , Sinvastatina/uso terapêutico , Adulto , Análise de Variância , Colesterol/sangue , HDL-Colesterol/sangue , LDL-Colesterol/sangue , Terapia Combinada , Angiografia Coronária , Teste de Esforço , Feminino , Seguimentos , Humanos , Hipercolesterolemia/sangue , Hipercolesterolemia/diagnóstico por imagem , Masculino , Pessoa de Meia-IdadeRESUMO
Blood pressure (BP) reduction was compared between patients receiving angiotensin-converting enzyme inhibitors alone and patients receiving these medications plus statins after 3 months of dietary intervention. Although BP was similarly reduced at week 4, the statin-treated group had a greater reduction in BP and total cholesterol levels at week 16, suggesting a synergistic effect between cholesterol lowering with statins and angiotensin-converting enzyme inhibitor treatment for hypertensive patients.
Assuntos
Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anticolesterolemiantes/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Enalapril/uso terapêutico , Hipercolesterolemia/tratamento farmacológico , Lisinopril/uso terapêutico , Lovastatina/uso terapêutico , Pravastatina/uso terapêutico , Interações Medicamentosas , Feminino , Frequência Cardíaca/efeitos dos fármacos , Humanos , Hipercolesterolemia/complicações , Hipertensão/complicações , Masculino , Pessoa de Meia-IdadeRESUMO
It is known that acutely developed collaterals can prevent the onset of acute myocardial infarction (AMI) in the presence of a total coronary occlusion. However, there still is controversy concerning long-term follow-up of coronary collateral circulation to the infarct-related artery. In this study we analyze the prognostic role of collateral flow (degrees 0 to 3) as well as anterograde flow (degrees 0 to 3) in patients with AMI treated with thrombolytic therapy. Four hundred twenty-two patients (median age 57 years, 355 men) with AMI were treated with intravenous streptokinase and followed prospectively for up to 8 years. At the end of the study period, patients with collateral coronary flow 3 (n = 30) and those with flow <3 (n = 392) at in-hospital coronary arteriography had survival rates of 66% and 85%, respectively (p <0.12). Meanwhile, patients with coronary anterograde flow 3 (n = 189) and those with flow <3 (n = 233) had survival rates of 89% and 80%, respectively (p <0.04). By censored regression analysis, a negative correlation was found between coronary collateral flow degree and survival (p = 0.0498) and, inversely, a positive correlation was found between coronary anterograde flow degree and survival (p = 0.0053). By Cox multivariate analysis, the following variables showed significant correlations with long-term survival: global left ventricular ejection fraction (p = 0.0003), anterograde flow degree (p = 0.0006), collateral flow degree (negative correlation, p = 0.0179), and medical treatment (negative correlation, p = 0.0464). Thus, patients treated with intravenous streptokinase during AMI and with adequate coronary collateral circulation had a worse prognosis than those who developed adequate anterograde flow, probably because of residual myocardial ischemia. Such patients may benefit from coronary revascularization (angioplasty or surgery) to restore anterograde blood flow and minimize myocardium at risk.
Assuntos
Circulação Colateral , Circulação Coronária , Fibrinolíticos/uso terapêutico , Infarto do Miocárdio/fisiopatologia , Ativadores de Plasminogênio/uso terapêutico , Estreptoquinase/uso terapêutico , Terapia Trombolítica , Cateterismo Cardíaco , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/tratamento farmacológico , Prognóstico , Estudos Prospectivos , Análise de Regressão , Análise de Sobrevida , Resultado do TratamentoRESUMO
Differentiation of right coronary artery (RCA) from left circumflex artery (LCxA) occlusion may be difficult since both can present an electrocardiographic pattern of inferior myocardial infarction (IMI). We studied 133 patients with IMI, 92 patients with RCA occlusion and 41 patients with LCxA occlusion. Risk factors such as previous MI, arterial hypertension, diabetes, smoking, and dislipemia, were similar for RCA and LCxA occlusions. Patients with RCA occlusion had a higher incidence of isolated IMI than patients with LCxA occlusion, 50% vs. 17%, respectively (P<0.001). Arterial hypotension was more prevalent (P<0.05) among patients with RCA (18%) rather than those with LCxA occlusion (2%). RCA occlusion presented an association with sinus bradycardia, an association not observed with LCxA occlusion (15% vs. 0%, respectively; P<0.01). Total atrioventricular block was only present among patients with RCA (18%). Proximal occlusions of the RCA presented lower heart rates (sinus bradycardia) than medial and distal occlusions (13% vs. 1% and 1%, respectively; P<0.0001 and P<0.001). Therefore, regarding patients with IMI: (1) sinus bradycardia is more frequent when the infarct-related artery is the RCA; (2) proximal occlusions of the right coronary predispose low heart rates; and (3) occlusion of the LCxA rarely induces sinus bradycardia.
Assuntos
Bradicardia/etiologia , Doença das Coronárias/diagnóstico , Doença das Coronárias/fisiopatologia , Infarto do Miocárdio/complicações , Distribuição de Qui-Quadrado , Estudos de Coortes , Angiografia Coronária , Eletrocardiografia , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/tratamento farmacológico , Fatores de RiscoRESUMO
Há alta incidência de arritmias no pós-infarto agudo do miocárdio. Distúrbios no ritmo e na condução estão entre as primeiras complicaçöes descritas. Embora eses distúrbios sejam claramente menos comuns em pacientes tratados com terapia fibrinolítica, permanecem uma contínua fonte de problemas para os clínicos que cuidam de pacientes com infarto agudo do miocárdio. Além disso, incertezas acerca da utilização de medidas terapêuticas, medidas profiláticas e prognóstico a curto e longo prazos têm estimulado a realização de vários estudos no sentido de definição de prognóstico a curto e longo prazos têm estimulado a realização de vários estudos no sentido de definição de prognóstico, prevenção e tratamento das arritmias no infarto agudo do miocárdio. Neste artigo, os autores abordam o manuseio clínico das arritmias no infarto agudo do miocárdio, com ênfase na incidência, no prognóstico, na prevenção e no tratamento.
Assuntos
Humanos , Arritmias Cardíacas/classificação , Bradicardia , Infarto do Miocárdio , Taquicardia Sinusal/terapia , Doença Aguda , Incidência , Estudos Prospectivos , Sensibilidade e EspecificidadeRESUMO
PURPOSE: To develop a survey about risk factors for atherosclerosis in a > or = 20-year-old population from São José do Rio Preto, and compare the results with those obtained in a similar survey in 1991. METHODS: Quantitative survey with sample stratified by sex and age. The individuals (a total of 646, 303 men) where contacted in outpatient facilities from the Health Secretary and other populated sites, distributed by geographic zone and social class of different neighborhoods. The standard error of the survey was 4%, and the confidence interval was 95%. RESULTS: A) Mean HDL-cholesterol (only in 1997): male gender 43.7 +/- 15 mg/dL, female gender 49.6 +/- 13.5 mg/dL (p < 0.001, 95% CI 3.7 a 8.1). B) Mean total cholesterol in 1991 vs 1997: for the global population 192.5 +/- 48.9 mg/dL vs 190.5 +/- 42.5 mg/dL (p = NS); for men 187.6 +/- 53.3 mg/dL vs 190.5 +/- 42.5 mg/dL (p = NS); for women 196.8 +/- 40 mg/dL vs 187.6 +/- 37.8 mg/dL (p = 0.008, 95% CI 2.4 a 15.9). C) By regression analysis, the variables that correlated significantly with cholesterol levels, in both surveys, were: age (p < 0.001), systolic (p < 0.001) and diastolic (p < 0.001) arterial pressure, diet (p < 0.001). Female gender showed correlation only in the 1991 survey (p = 0.011), and sedentarism only in 1997 (p = 0.014). CONCLUSION: The mean cholesterol levels in the adult population of São José do Rio Preto are very favorable and, in female gender, showed a significant decrease in the 1997 survey, relatively to the 1991 survey.
Assuntos
Arteriosclerose/epidemiologia , Colesterol/sangue , Vigilância da População , Adulto , Distribuição por Idade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Arteriosclerose/sangue , HDL-Colesterol/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Análise de Regressão , Fatores de Risco , Distribuição por Sexo , Fatores SexuaisRESUMO
UNLABELLED: The aim of the study was to analyze the relationship between antegrade and collateral flow degree to the "culprit" coronary artery, and between both variables and left ventricular systolic function. We analyzed five hundred patients with acute myocardial infarction, treated prospectively and consecutively within 6 h of evolution with intravenous streptokinase. The degree of antegrade (0-3) and collateral blood flow (0-3) were correlated with 18 other variables. RESULTS: (a) By simple regression analysis, antegrade flow degree correlated positively (p < 0.0001), and collateral flow degree negatively (p = 0.0073) with left ventricular ejection fraction; (b) By multiple regression analysis, antegrade flow degree (p = 0.0032), but not collateral flow degree (p > 0.1), correlated independently with left ventricular ejection fraction; (c) In the subgroup of patients with occluded "culprit" coronary artery, the mean ejection fraction was significantly higher for those with collateral flow 3 (60.2% +/- 13.3 in relation to those with collateral flow < 3 (53.9% +/- 13.1, p = 0.032, 95% CI. 11.96 to (0.53%). In conclusion, antegrade coronary flow degree, but not collateral flow degree, correlated significantly and independently with left ventricular ejection fraction. However, in the subgroup of patients with occluded "culprit" coronary artery, collateral flow 3 led to better left ventricular systolic function, in relation to collateral flow < 3.
Assuntos
Circulação Colateral/fisiologia , Circulação Coronária/fisiologia , Infarto do Miocárdio/fisiopatologia , Função Ventricular Esquerda/fisiologia , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/tratamento farmacológico , Estudos Prospectivos , Análise de Regressão , Estreptoquinase/uso terapêutico , Volume Sistólico , Terapia TrombolíticaRESUMO
The role of diltiazem on left ventricular systolic function was analyzed in 101 patients with acute myocardial infarction treated with streptokinase, being obtained, for the total of the population, higher LV global ejection fraction (p = 0.022), LV regional shortening (p = 0.046) and LV global shortening (p = 0.064) for the treated group, relative to the placebo group; the p values were, respectively, 0.005, 0.009, and 0.012, for patients that achieved TIMI-3 antegrade coronary flow. It is concluded that diltiazem is useful as adjuvant to streptokinase, especially when antegrade coronary blood flow TIMI-3 is obtained.
Assuntos
Bloqueadores dos Canais de Cálcio/uso terapêutico , Diltiazem/uso terapêutico , Fibrinolíticos/uso terapêutico , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/fisiopatologia , Estreptoquinase/uso terapêutico , Terapia Trombolítica , Função Ventricular Esquerda/efeitos dos fármacos , Idoso , Método Duplo-Cego , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sístole/efeitos dos fármacos , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: To compare the doses of 750,000 and 1.5 million units (U) of streptokinase (SK), relatively to the left ventricular (LV) systolic function analyzed through contrasted ventriculography. METHODS: We included 110 patients with acute myocardial infarction (AMI) within 6h of the onset (mean-age 60 years, 83.6% men), that were randomized to receive 750,000U of SK in 15 min (55 patients), or 1.5 million U in 30 min (55 patients). The study main goal was the comparison between the groups relatively to LV ejection fraction, global and regional shortening, obtained at the fifth day of the AMI. RESULTS: The 750,000 and 1.5 million groups were homogeneous relatively to 15 analyzed variables. Relatively to the main goal of the study, it was found respectively: a) ejection fraction analysis (median): 64% and 60.5% for the total population (p = 0.25, 95% CI -2.7 to 10), 64% and 57.5% for anterior AMI (p = 0.2, 95% CI -3.6 to 16.3), 65% and 65% for inferior AMI (p = 0.99, 95% CI -8.4 to 8.4); b) global shortening analysis: -2.53 and -2.66 for the total population (p = 0.3, 95% CI -0.47 to 0.87), -2.27 and -2.53 for anterior AMI (p = 0.18, 95% CI -0.3 to 1.4), -1.82 and 1.72 for inferior AMI (p = 0.9, 95% CI -0.82 to 0.75); c) regional shortening analysis: anterior AMI -2.6 and -2.67 (p = 0.47, 95% CI -0.7 to 1.5), inferior AMI -2.3 and -2.32 (p = 0.9, 95% CI -0.82 to 0.75). CONCLUSION: The dose of 750,000U was as efficacious as the 1.5 million relatively to LV systolic function, one of the best survival predictors of short-medium and long-term survival post AMI.
Assuntos
Infarto do Miocárdio/tratamento farmacológico , Estreptoquinase/administração & dosagem , Função Ventricular Esquerda/efeitos dos fármacos , Idoso , Feminino , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia , Estudos Prospectivos , Estreptoquinase/farmacologia , Volume Sistólico/efeitos dos fármacosRESUMO
Conventional ECG still plays an important role in the overall knowledge of Chagas' cardiopathy, because of its importance in longitudinal and epidemiological studies, its diagnostic value, and its utility in prognostic evaluation. The authors discuss these aspects, as well as the use of eCG in the acute phase and the significance of a normal ECG in Chagas' disease. Correlations were made between ECG and Hemodynamic/angiographic variables among 1010 patients with positive laboratory tests for Chagas' disease: a) in the group with normal ECG there was no significant differences between symptomatic and non-symptomatic patients with regard to ejection fraction and angiographic abnormalities; b) slight abnormalities on the ECG corresponded to an intermediate level of severity of the disease, that is, between normal ECG and ECG with significant abnormalities C) fibrosis on the ECG was not predictive of akinesia in the related area on the angiography; d) combined ECG abnormalities generally correlated with greater myocardial compromises compared to isolated abnormalities; e) under multiple regression analysis the ECG abnormalities that independently correlated with depressed ejection fraction were: premature ventricular beats, ventricular tachycardia, left bundle branch block, atrial fibrillation, complete AV block, and anterior and inferior fibrosis. Male sex, cardiac insufficiency and cardiomegaly on the throat radiography were also significantly related.
Assuntos
Cardiomiopatia Chagásica/diagnóstico , Eletrocardiografia , Doença Aguda , Adulto , Cardiomiopatia Chagásica/epidemiologia , Doença Crônica , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Análise de RegressãoRESUMO
The authors report a case of pheochromocytoma in which the echocardiographic features suggested obstructive hypertrophic cardiomyopathy. The angiographic study and the computed tomography showed the tumor and its arterial supply. One month after resection of the tumor the echocardiographic features showed a tendency to normalization. The preoperative echocardiographic aspect was probably due to excessive production of catecholamines by the tumor.