Acute Myocardial Infarction – ABC CARDIOL

IJCS

Original Article

Effect of Ticagrelor on Left Ventricular Function in Patients with Mildly Reduced Ejection Fraction after Acute Myocardial Infarction

Ilkin Guliyev et al. Engin Algül Gökhan Gökalp Faruk Aydınyılmaz … Nail Burak Özbeyaz Hamza Sunman

Abstract

Background

There are limited data about the effect of new P2Y₁₂ inhibitors on left ventricular ejection fraction (LVEF) after acute myocardial infarction (AMI).

Objectives

We aimed to investigate the effect of ticagrelor on left ventricular function, compared to clopidogrel in patients with heart failure with mildly reduced ejection fraction (HFmrEF) after AMI.

Methods

In this cross-sectional, single-center study, we included 251 patients with LVEF between 40% and 50% after AMI before discharge. The patients were divided into 2 groups according to the use of ticagrelor (166 patients) and clopidogrel (85 patients). At the end of the 12-month period, LVEF changes were assessed by echocardiography. P < 0.05 was considered statistically significant.

Results

The mean LVEF before discharge was 46.5% ± 3.6%, and no difference was observed between the ticagrelor and clopidogrel groups (p = 0.20). At the end of the first year, the mean LVEF of the patients increased to 49.8% ± 7.6% in both groups. The use of ticagrelor (β ± SE = 2.05 ± 0.93; p = 0.029), low creatinine level (β ± SE = −10.44 ± 2.35; p < 0.001), low troponin level (β ± SE = −0.38 ± 0.14; p = 0.006), and low heart rate (β ± SE = −0.98 ± 0.33; p = 0.003) were found to be independent predictors of the increase in LVEF (β ± SE 2.05 ± 0.93; 95% confidence interval: 0.21 to 3.90; p = 0.029).

Conclusion

In our study, ticagrelor improved left ventricular function in 12 months follow-up compared to clopidogrel in patients with HFmrEF after AMI.

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Original Article

Acute Myocardial Infarction: The First Manifestation of Ischemic Heart Disease and Relation to Risk Factors

Waldomiro Carlos Manfroi et al. Carolina Peukert Clarissa Bacha Berti Clarissa Noer … Danielle de Ávila Gutierres Felipe Theodoro Bezerra Gaspar Carvalho da Silva

OBJECTIVE: To assess the association between cardiovascular risk factors and acute myocardial infarction as the first manifestation of ischemic heart disease, correlating them with coronary angiographic findings. METHODS: We carried out a cross-sectional study of 104 patients with previous acute myocardial infarction, who were divided into 2 groups according to the presence or absence of angina prior to acute myocardial infarction. We assessed the presence of angina preceding acute myocardial infarction and risk factors, such as age >55 years, male sex, smoking, systemic arterial hypertension, lipid profile, diabetes mellitus, obesity, sedentary lifestyle, and familial history of ischemic heart disease. On coronary angiography, the severity of coronary heart disease and presence of left ventricular hypertrophy were assessed. RESULTS: Of the 104 patients studied, 72.1% were males, 90.4% were white, 73.1% were older than 55 years, and 53.8% were hypertensive. Acute myocardial infarction was the first manifestation of ischemic heart disease in 49% of the patients. The associated risk factors were systemic arterial hypertension (RR=0.19; 95% CI=0.06-0.59; P=0.04) and left ventricular hypertrophy (RR=0.27; 95% CI=0,.8-0.88; P=0.03). The remaining risk factors were not statistically significant. CONCLUSION: Prevalence of acute myocardial infarction as the first manifestation of ischemic heart disease is high, approximately 50%. Hypertensive individuals more frequently have symptoms preceding acute myocardial infarction, probably due to ventricular hypertrophy associated with high blood pressure levels.

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Original Article

Secular trends in a population with ischemic heart disease admitted to the Instituto do Coração in São Paulo

Bruno Caramelli et al. Luciana Savoy Fornari Maristela Monachini Dália Ballas … Nilson Roberto Fachini Antônio de Pádua Mansur José Antônio Franchini Ramires

OBJECTIVE: To assess the clinical and demographic characteristics of a population with ischemic heart disease admitted in the final decades of the 20th century. METHODS: This study retrospectively assessed patients hospitalized with ischemic heart disease divided into the following 2 groups: acute group – 11.181 patients with acute myocardial infarction admitted from 1/1/82 to 12/31/94; and chronic group – 4.166 patients undergoing coronary artery bypass graft surgery from 1/1/84 to 12/31/94. RESULTS: In the acute group, an increase in the percentage of females (from 22.7% to 27.7%, P<0.001) and diabetic individuals (from 12.4% to 17.5%, P<0.001) was observed, as was an increase in age (from 57.4±11.5 to 59.9±12.1 years, P<0.05). In-hospital mortality was greater among females (27.8% and 15.7%, P=0.001), among diabetic individuals (24.2% and 17.8%, P=0.001), and among the elderly (60.9±15.2 and 57.7±11.8 years, P=0.0001). In the chronic group, an increase in the percentage of females (from 17.5% to 27.2%, P=0.001) was observed, as was an increase in age (from 56.3±8.6 to 60.5±9.6 years, P=0.0001). In-hospital mortality was greater among females (8.3% and 5.8%, P<0.05) and among the elderly (58.1±9.1 and 62.1±7.9 years, P=0.0001). CONCLUSION: The characteristics of the population studied with ischemic heart disease point towards a worse prognosis, due to the greater percentages of females, older patients, and diabetic patients, groups known to have greater in-hospital mortality.

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Original Article

Demographic characteristics of the population undergoing cine coronary angiography at the Instituto do Coração of the Medical School of USP from 1986 to 1995

Bruno Caramelli et al. Luciana Savoy Fornari Maristela Monachini Dália Ballas … Nilson Roberto Fachini Antônio de Pádua Mansur José Antônio Franchini Ramires

OBJECTIVE: To obtain information about the profile and behavior of a population with ischemic heart disease undergoing cine coronary angiography and to determine disease severity. METHODS: Retrospective study assessing patients hospitalized at InCor from 1986 to 1995, in which the variables age, sex, and number of major coronary arteries with obstruction degree > 40% were analyzed. RESULTS: We studied 18,221 patients and observed a significant increase in the number of females (22.8% to 25.2%, P=0.001) and an increase in age (57.1±29.3 to 60.4±10.7 years, P=0.0001). A significant increase in the incidence of multivessel disease was observed, which was more frequent among males (69.2% and 64.5%) and among the older patients (59.8±9.8 and 56.8±10.7 years, P=0.0001). A reduction in the incidence of single-vessel disease was also observed (66.2% vs 69.2% and 33.8% vs 30.5%, respectively, P<0.0001). CONCLUSION: A change in the profile of the population studied was observed as follows: patients undergoing cine coronary angiography at InCor were older, had a greater number of impaired major coronary arteries, and the number of females affected increased, leading to indices suggestive of a poorer prognosis.

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Original Article

Coinfection with Mycoplasma Pneumoniae and Chlamydia Pneumoniae in ruptured plaques associated with acute myocardial infarction

Maria de Lourdes Higuchi et al. Marcia Martins Reis Nádia Vieira Sambiase Suely Aparecida Pinheiro Palomino … Jussara Bianchi Castelli Paulo Sampaio Gutierrez Vera Demarchi Aiello José Antonio Franchini Ramires

OBJECTIVE: To study atheromas, Mycoplasma pneumoniae (M. pneumoniae), and Chlamydia pneumoniae (C. pneumoniae). METHODS: C. pneumoniae was studied with immunohistochemistry and M. pneumoniae with in situ hybridization (ISH), in segments of coronary arteries (SCA) as follows: group A – thrombosed ruptured plaques (TRP) of 23 patients who died due to acute myocardial infarction (AMI); group B – 23 nonruptured plaques (NRP) of group A patients; group C – NRP of 11 coronary patients who did not die due to AMI; and group D – 11 SCA from patients with dilated cardiomyopathy or Chagas’ disease without atherosclerosis. RESULTS: The mean number of C. pneumoniae+ cells/400x in groups A, B, C, and D was, respectively, 3.3±3.6; 1.0±1.3; 1.2±2.4; and 0.4±0.3; and the percentage of M. pneumoniae area was, respectively, 3.9±3.5; 1.5± 1.6; 0.9±0.9; and 0.4±0.2. More M. pneumoniae and C. pneumoniae were found in of group A than in group B (P<0.01). Good correlation was seen between the area of the vessel and the M. pneumoniae area in the plaque (r = 0.46; P=0.001) and between C. pneumoniae+ cells and CD4+ T lymphocytes (r = 0.42; P<0.01). The number of C. pneumoniae+ cells correlated with CD20+ B cells (r=0.48; P<0.01). CONCLUSION: M. pneumoniae and C. pneumoniae are more frequently found in TRP correlate with the intensity of the inflammation and diameter of the vessel (positive remodeling).

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Acute myocardial infarction: clinical and epidemiological profile and factors associated with in-hospital death in the municipality of Rio de Janeiro

Claudia Caminha Escosteguy et al. Margareth Crisóstomo Portela Roberto de Andrade Medronho Maurício Teixeira Leite de Vasconcellos

OBJECTIVE: To study the factors associated with the risk of in-hospital death in acute myocardial infarction in the Brazilian public health system in Rio de Janeiro, Brazil. METHODS: Sectional study of a sample with 391 randomly drawn medical records of the hospitalizations due to acute myocardial infarction recorded in the hospital information system in 1997. RESULTS: The diagnosis was confirmed in 91.7% of the cases; 61.5% males; age = 60.2 ± 2.4 years; delta time until hospitalization of 11 hours; 25.3% were diabetic; 58.1% were hypertensive; 82.6% were in Killip I class. In-hospital mortality was 20.6%. Thrombolysis was used in 19.5%; acetylsalicylic acid (ASA) 86.5%; beta-blockers 49%; angiotensin-converting enzyme (ACE) inhibitors 63.3%; calcium channel blockers 30.5%. Factors associated with increased death: age (61-80 years: OR=2.5; > 80 years: OR=9.6); Killip class (II: OR=1.9; III: OR=6; IV: OR=26.5); diabetes (OR=2.4); ventricular tachycardia (OR=8.5); ventricular fibrillation (OR=34); recurrent ischemia (OR=2.7). The use of ASA (OR=0.3), beta-blockers (OR=0.3), and ACE inhibitors (OR=0.4) was associated with a reduction in the chance of death. CONCLUSION: General lethality was high and some interventions of confirmed efficacy were underutilizated. The logistic model showed the beneficial effect of beta-blockers, and ACE inhibitors on the risk of in-hospital death.

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Original Article

Influence of balloon pressure inflation in patients undergoing primary coronary stent implantation during acute myocardial infarction: a quantitative coronary angiography analysis

Luiz Alberto Mattos et al. Amanda G.M.R. Sousa Áurea Chaves Fausto Feres … Ibraim Pinto Luiz Tanajura Marinella Centemero Alexandre Abizaid Ana C. Seixas Andréa Abizaid Galo Maldonado Rodolfo Staico J. Eduardo M.R. Sousa

OBJECTIVE:To verify the influence of moderate- or high-pressure balloon inflation during primary coronary stent implantation for acute myocardial infarction. METHODS: After successful coronary stent implantation, 82 patients were divided into 2 groups according to the last balloon inflation pressure: group 1 (³12 to <16 atm) and group 2 (³16 to 20 atm), each with 41 cases. All patients underwent late coronary angiography. RESULTS: In group 1, the mean stent deployment pressure was 13.58±0.92 atm, and in the group 2 it was 18.15±1.66 atm. Stents implanted with moderate pressures (³12 to <16 atm) had a significantly smaller postprocedural minimal lumen diameter, compared to with those with higher pressure, with lesser acute gain (2.7± 0.4 mm vs 2.9±04 mm; p=0.004), but the late lumen loss (0,9±0,8 mm vs 0,9±0,6 mm) and the restenosis (22% vs. 17.1%) and target-vessel revascularization rates (9.8% vs 7.3%) were similar between the groups. CONCLUSION: During AMI stenting, the use of high pressures (³16 atm) did not cause a measurable improvement in late outcome, either in the late loss, its index, and the net gain, or in clinical and angiographic restenosis rates.

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Original Article

Risk factors for acute myocardial infarction during the postoperative period of myocardial revascularization

José Ribamar Costa Jr. et al. Dinaldo C. Oliveira Alexei DerBedrossian Enilton T. Egito … Edson R. Romano Marcos O. Barbosa Ieda M. Liguori Jorge Fahran Luis C. B. Souza Adib D. Jatene Leopoldo S. Piegas

OBJECTIVE: To identify risk factors for acute myocardial infarction during the postoperative period after myocardial revascularization. METHODS: This was a case-control study paired for sex, age, number, type of graft used, coronary endarterectomy, type of myocardial protection, and use of extracorporeal circulation. We assessed 178 patients (89 patients in each group) undergoing myocardial revascularization, and the following variables were considered: dyslipidemia, systemic hypertension, smoking, diabetes mellitus, previous myocardial revascularization surgery, previous coronary angioplasty, and acute myocardial infarction. RESULTS: Baseline clinical characteristics did not differ in the groups, except for previous myocardial revascularization surgery, prevalent in the case group (34 patients vs. 12 patients; p = 0.0002). This was the only independent predictor of risk for acute myocardial infarction in the postoperative period, based on a multivariate logistic regression analysis (p=0.0001). Mortality and the time of hospital stay of the case group were significantly higher (19.1% vs. 1.1%; p<0.001 and 15.7 days vs. 10.6 days; p<0.05 respectively) than those of the control. CONCLUSION: Only previous myocardial revascularization was an independent predictor of acute myocardial infarction in the postoperative period, based on multivariate logistic regression analysis.

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Original Article

Comparison between young males and females with acute myocardial infarction

Ricardo Augusto Slaibi Conti et al. Maria Cecília Solimene Protásio Lemos da Luz Alexandre Miguel Benjó … Pedro Alves Lemos Neto José Antônio Franchini Ramires

OBJECTIVE: To assess the differences between young males and females after acute myocardial infarction. METHODS: We retrospectively studied 236 patients (54 females and 182 males) after acute myocardial infarction and during hospital stay assessed the following parameters: risk factors; the treatment used; the pattern of coronary artery obstruction; left ventricular ejection fraction; complications; and, using a logistic regression model, the factors related to the occurrence of reinfarction and death. RESULTS: No significant difference was observed between the sexes in risk factors, pattern of coronary artery obstruction, and left ventricular function. The time interval between symptom onset and treatment was longer in females (p=0.03), who underwent thrombolysis (p=0.01) and angioplasty (p=0.03) less frequently than males did, but not myocardial revascularization. Female sex (OR = 5.98) and diabetes (OR = 14.52) were independent factors related to the occurrence of reinfarction and death. CONCLUSION: Young males and females after acute myocardial infarction did not differ in coronary risk factors, and clinical and hemodynamic characteristics. Females had their treatment started later, and they underwent chemical thrombolysis and angioplasty less frequently than males did. Female sex and diabetes were related to the occurrence of reinfarction and death.

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Original Article

Acute myocardial infarction in elderly patients: comparative analysis of the predictors of mortality. The elderly versus the young

Marisa F. Leal et al. Newton Fernando Stadler de Souza Filho Hermínio Haggi Filho Estela Regina Klosoviski Eva Cantalejo Munhoz

OBJECTIVE: To study the in-hospital evolution of patients aged 65 years and older, with acute myocardial infarction, who were treated by direct coronary angioplasty with no fibrinolytic therapy. METHODS: We studied 885 patients divided into 2 groups as follows: group I (GI) – 293 (33.4%) patients aged ³ 65 years (72±5 years), and group II (GII) – 592 patients aged < 65 years (57±9 years). Multivessel disease was more frequent in GI (63.5% x 49.7%; p=0.001). A greater number of GII patients were class I or II of the clinical Killip-Kimball classification (K) (80.2% x 67.2%; p=0.00002), while a significant number of GI patients were KIII and KIV (24.3% x 12.8%; p=0.00003). RESULTS: Group I had a lower index of success (84.6% x 94%; p=0.0002) and a greater in-hospital mortality (12.2% x 4.7%; p=0.00007). The predictors of mortality in GI were as follows: previous infarction (20.5% x 6.3%; p=0.02), anterior location (13.4% x 6.4%; p=0.03), and male sex (10.4% x 4.4%; p=0.007). CONCLUSION: Elderly patients had more severe acute myocardial infarction and more extensive disease, a lower index of success, and greater in-hospital mortality. Previous infarction, anterior location and male sex were identified as predictors of mortality in the elderly group (GI).

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Original Article

The use of abciximab associated with primary angioplasty for treating acute myocardial infarction

Manuel Lisandro Hernández Brito et al. Newton F. Stadler de Souza Filho Álvaro Vieira Moura Luiz Augusto Lavalle … Rubens Zenobio Darwich Marisa Leal Eva Cantalejo Munhoz

OBJECTIVE: To assess the benefit resulting from the use of abciximab associated with primary angioplasty. The following parameters were analyzed in-hospital, at 30 days, and 6 months: (a) flow in the culprit artery; (b) ventricular function; (c) combined outcome of death, acute myocardial infarction, and aditional revascularization. METHODS: From November 1997 to June 1999, a longitudinal nonrandomized study with historical data of 137 patients with acute myocardial infarction within the first 12 hours. Patients undergoing primary angioplasty and were divided into 2 groups: those receiving (A) abciximab (26) or (B) conventional therapy (111). TIMI flow and regional ventricular function estimated by the standard deviation (SD)/chordis index were analyzed. RESULTS: At the end of angioplasty, TIMI 3 flow was observed in 76.9% and 83.8% of the patients in groups A and B, respectively (P=0.58). In the reevaluation, patients with TIMI flow <3 showed a 100% improvement in group A and a 33% in group B (P<0.0001). A significant improvement (P<0.0001) in regional ventricular function, by SD/chordis index, occurred in each group; no significant difference between groups however, was observed (29.9% x 20.2%; P=0.58). A nonsignificant reduction in the combined outcome in the in-hospital phase (3.85% A x 9.0% B; P=0.34) and on the 30th day (4.0% x 12.0%; P=0.22) was observed in group A. CONCLUSION: Abciximab improved blood flow. Primary angioplasty improved regional ventricular function independent of antithrombotic therapy. Abciximab showed a trend toward reducing the combined outcome in the in-hospital phase and on the 30th day.

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Original Article

Efficacy of a diagnostic strategy for patients with chest pain and no ST-segment elevation in the emergency room

Roberto Bassan et al. Roberto Gamarski Lúcia Pimenta André Volschan … Marcelo Scofano Hans Fernando Dohmann Monica Araujo Cristina Clare Marcelo Fabrício Carlos Henrique Sanmartin Kalil Mohallem Renato Macaciel Sergio Gaspar

PURPOSE: To evaluate the efficacy of a systematic model of care for patients with chest pain and no ST segment elevation in the emergency room. METHODS: From 1003 patients submitted to an algorithm diagnostic investigation by probability of acute ischemic syndrome. We analyzed 600 ones with no elevation of ST segment, then enrolled to diagnostic routes of median (route 2) and low probability (route 3) to ischemic syndrome. RESULTS: In route 2 we found 17% acute myocardial infarction and 43% unstable angina, whereas in route 3 the rates were 2% and 7%, respectively. Patients with normal/non–specific ECG had 6% probability of AMI whereas in those with negative first CKMB it was 7%; the association of the 2 data only reduced it to 4%. In patients in route 2 the diagnosis of AMI could only be ruled out with serial CKMB measurement up to 9 hours, while in route 3 it could be done in up to 3 hours. Thus, sensitivity and negative predictive value of admission CKMB for AMI were 52% and 93%, respectively. About one-half of patients with unstable angina did not disclose objective ischemic changes on admission. CONCLUSION: The use of a systematic model of care in patients with chest pain offers the opportunity of hindering inappropriate release of patients with ACI and reduces unnecessary admissions. However some patients even with normal ECG should not be released based on a negative first CKMB. Serial measurement of CKMB up to 9 hours is necessary in patients with medium probability of AMI.

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Original Article

Protective effect of left ventricular hypertrophy in right coronary artery occlusions

Marne de Freitas Gomes et al. Carlos Antônio Mascia Gottschall

OBJECTIVE: To test the hypothesis that left ventricular hypertrophy (LVH) reduces the electrocardiographic and functional effects of right coronary artery occlusion. METHODS: We analysed 215 patients (166 males and 49 women,age of 58.9±10.6 years), with occlusion of the right coronary artery without other associated lesions. There was no significant difference (p>0.05) in age and gender distribution between the 78 patients with LVH (left ventricular mass >100g/m²) (Group A) when compared with the 137 patients without LVH (left ventricular mass <100g/m²) (Group B). RESULTS: The electrocardiographic finding of transmural necrosis was more often found in group B patients than in group A patients (56.9% and 30.8%, respectively; p<0.05). The left ventricular function parameters of group A were better than those of group B: the ratio end-diastolic pressure/systolic pressure (EDP/SP) (A: 0.108±0.036; B: 0.121±0.050; p<0.05); the end-diastolic volume index (A: 75.9±31.3ml/m²; B: 88.0±31.0ml/m²; p<0.01); the end-systolic volume index (A: 16.0±10.0ml/m²; B: 27.0 ±20.0ml/m²; p<0.001); the ejection fraction (A 78.6±10.8%; B 67.7±17.9%; p<0.001); the anteroinferior shortening (A: 43.9±10.3%; B: 35.1±12.8%; p<0.001). A higher degree of coronary tortuosity was observed in group A than in group B (78.2% and 24.1%; p<0.001) and also a more frequent absent or minimal diaphragmatic hypokinetic area (A: 80.8%; B: 54.0%; p<0.05). CONCLUSION: LVH reduces the effects of myocardial sequela and protects LV function when right coronary occlusion develops.

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Original Article

Effectiveness of primary angioplasty in the treatment of acute myocardial infarction. Analysis of in-hospital and late outcomes in 135 consecutive cases

Rogério Sarmento Leite et al. Ana Maria Krepsky Carlos A.M. Gottschall

OBJECTIVE: Evaluate early and late evolution of patients submitted to primary coronary angioplasty for acute myocardial infarction. METHODS: A prospective study of 135 patients with acute myocardial infarction submitted to primary transcutaneous coronary angioplasty (PTCA). Success was defined as TIMI 3 flow and residual lesion <50%. We performed statistical analyses by univariated, multivariated methods and survival analyze by Kaplan-Meier. RESULTS: PTCA success rate was 78% and early mortality 18,5%. Killip classes III and IV was associated to higher mortality, odds ratio 22.9 (95% CI: 5,7 to 91,8) and inversely related to age <75 years (OR = 0,93; 95% CI: 0.88 to 0.98). If we had chosen success flow as TIMI 2 and had excluded patients in Killip III/IV classes, success rate would be 86% and mortality 8%. The survival probability at the end or study, follow-up time 142 ± 114 days, was 80% and event free survival 35%. Greater survival was associated to stenting (OR = 0.09; 0.01 to 0.75) and univessel disease (OR = 0.21; 0.07 to 0.61). CONCLUSION: The success rate was lower and mortality was higher than randomized trials, however similar to that of non randomized studies. This demonstrated the efficacy of primary PTCA in our local conditions.

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Original Article

Prognostic factors of the results of cardiopulmonary resuscitation in a cardiology hospital

Ari Timerman et al. Naim Sauaia Leopoldo Soares Piegas Rui F. Ramos … Carlos Gun Elizabeth Silva Santos Antonio C. Mugayar Bianco J. Eduardo M. R. Sousa

OBJECTIVE: To analyze the early and late results of cardiopulmonary resuscitation in a cardiology hospital and to try to detect prognostic determinants of both short- and long-term survival. METHODS: A series of 557 patients who suffered cardiorespiratory arrest (CRA) at the Dante Pazzanese Cardiology Institute over a period of 5 years was analyzed to examine factors predicting successful resuscitation and long-term survival. RESULTS: Ressuscitation maneuvers were tried in 536 patients; 281 patients (52.4%) died immediately, and 164 patients (30.6%) survived for than 24 hours. The 87 patients who survived for more than 1 month after CRA were compared with nonsurvivors. Coronary disease, cardiomyopathy, and valvular disease had a better prognosis. Primary arrhythmia occurred in 73.5% of the >1-month survivor group and heart failure occurred in 12.6% of this group. In those patients in whom the initial mechanism of CRA was ventricular fibrillation, 33.3% survived for more than 1 month, but of those with ventricular asystole only 4.3% survived. None of the 10 patients with electromechanical dissociation survived. There was worse prognosis in patients included in the extreme age groups (zero to 10 years and 70 years or more). The best results occurred when the cardiac arrest took place in the catheterization laboratories. The worst results occurred in the intensive care unit and the hemodialysis room. CONCLUSION: The results in our series may serve as a helpful guide to physicians with the difficult task of deciding when not to resuscitate or when to stop resuscitation efforts.

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Is female sex an independent predictor of in-hospital mortality in acute myocardial infarction?

Lúcia Pimenta et al. Roberto Bassan Alfredo Potsch José Francisco Soares Francisco Manes Albanesi Filho

OBJECTIVE: To assess whether female sex is a factor independently related to in-hospital mortality in acute myocardial infarction. METHODS: Of 600 consecutive patients (435 males and 165 females) with acute myocardial infarction, we studied 13 demographic and clinical variables obtained at the time of hospital admission through uni- and multivariate analysis, and analyzed their relation to in-hospital death. RESULTS: Females were older (p<0.001) and had a higher incidence of hypertension (p<0.001). Males were more frequently smokers (p<0.001). The remaining risk factors had a similar incidence among both sexes. All variables underwent uni- and multivariate analysis. Through univariate analysis, the following variables were found to be associated with in-hospital death: female sex (p70 years (p<0.001), the presence of previous coronary artery disease (p=0.0004), previous myocardial infarction (p<0.001), infarction in the anterior wall (p=0.007), presence of left ventricular dysfunction (p<0.001), and the absence of thrombolytic therapy (p=0.04). Through the multivariate analysis of logistic regression, the following variables were associated with in-hospital mortality: female sex (p=0.001), age (p=0.008), the presence of previous myocardial infarction (p=0.02), and left ventricular dysfunction (p<0.001). CONCLUSION: After adjusting for all risk variables, female sex proved to be a variable independently related to in-hospital mortality in acute myocardial infarction.

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Clinical significance of in-hospital reocclusion after mechanical reperfusion and percutaneous transluminal coronary angioplasty for acute myocardial infarction

Eva Cantalejo Munhoz et al. Paulo Franco de Oliveira

OBJECTIVE: To analyze the effects of in-hospital reocclusion of reperfused AMI culprit coronary arteries in mortality and to identify the predictors. METHODS: The present study comprises a sample of 155 patients with AMI who underwent successful mechanical reperfusion by direct coronary angioplasty and angiographic control during hospitalization or before discharge. Patients were classified into group A: reoccluded patients (n=30) and group B: non-reoccluded patients (n=125). RESULTS: We identified in-hospital reocclusion predictors and found a greater significance in mortality among reoccluded patients (23,3% x 1.6%; p=0.00004). Silent reocclusion or typical angina at reocclusion had a good prognosis. The independent predictors of in-hospital mortality were hypertension, multiarterial lesions, totally occluded AMI culprit lesions, failed redilatation, failed redilatation in comparison with no intention to redilate, no redilatation in comparison with no atempt to redilate, and reocclusion within the first 48 to 72 hours. The decision to redilate, independently of the result, led to a 50.0% reduction in hospital mortality (p=0.0366). CONCLUSION: In-hospital AMI culprit coronary artery reocclusion had an adverse effect similar to that reported in clinical studies with high mortality rates (23.3% x 1.6%; p=0.00004). The major contribution of this study is to recommend the reopening of reoccluded AMI culprit coronary arteries as a means for the management of coronary artery reocclusion.

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Acute myocardial infarction in the Brazilian State of São Paulo. In-hospital deaths from 1979 to 1996 and hospital fatality from 1984 to 1998 in the public health system

Luiz Francisco Marcopito et al. Artur Jaques Goldfeder Simone Schenkman

OBJECTIVE: To determine the following parameters in the Brazilian State of São Paulo: 1) the percentage of deaths due to acute myocardial infarction (AMI) occurring in hospitals; 2) the percentage of deaths due to AMI occurring in public health system hospitals as compared with all in-hospital deaths due to AMI between 1979 and 1996; 3) the fatality due to AMI in public health system hospitals from 1984 to 1998. METHODS: Data were available on the Datasus Web site (the health information agency of the Brazilian Department of Health) that provided the following: a) number of deaths resulting from AMI in hospitals; b) number of deaths resulting from AMI in public health system hospitals; c) number of hospital admissions due to AMI in public health system hospitals. RESULTS: The percentage of in-hospital deaths due to AMI increased from 54.9 in 1979 to 68.6 in 1996. The percentage contribution of the public health system to total number of deaths due to AMI occurring in hospitals decreased from 22.9 in 1984 to 13.7 in 1996; fatality due to AMI occurring in public health system hospitals had an irregular evolution from 1984 to 1992 and showed a slight trend for increased frequency from 1993 to 1998. CONCLUSION: The percentage of in-hospital deaths due to AMI has been increasing. Deaths resulting from AMI in public health system hospitals have decreased when compared with the total number of deaths due to AMI in all hospitals. Fatality due to AMI in public health system hospitals did not decrease from 1992 to 1998.

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Chest pain in the emergency room. Importance of a systematic approach

Roberto Bassan et al. Marcelo Scofano Roberto Gamarski Hans Fernando Dohmann … Lúcia Pimenta André Volschan Mônica Araujo Cristina Clare Marcelo Fabrício Carlos Henrique Sanmartin Kalil Mohallem Sergio Gaspar Renato Macaciel

OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74% of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12%) had AMI without ST segment elevation and 202 (31%) had unstable angina (UA). In route 2 (high probability of ACS) 17% of patients had AMI and 43% had UA, whereas in route 3 (low probability) 2% had AMI and 7 % had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI ( 49%), with a positive predictive value considered only satisfactory (79%). CONCLUSION: A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.

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