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Browsing HB - CAR - Artigos by Author "Álvares-Pereira, M"
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- Impact of atrial fibrillation type during acute coronary syndromes: Clinical features and prognosis.Publication . Galvão-Braga, C; Ramos, V; Martins, J; Arantes, C; Abreu, G; Vieira, C; Salgado, A; Gaspar, A; Azevedo, P; Álvares-Pereira, M; Magalhães, S; Marques, JINTRODUCTION: Atrial fibrillation (AF) is widely recognized as an adverse prognostic factor during acute myocardial infarction, although the impact of AF type - new-onset (nAF) or pre-existing (pAF) - is still controversial. OBJECTIVES: To identify the clinical differences and prognosis of nAF and pAF during acute coronary syndromes (ACS). METHODS: We performed a retrospective observational cohort study including 1373 consecutive patients (mean age 64 years, 77.3% male) admitted to a single center over a three-year period, with a six-month follow-up. RESULTS: AF rhythm was identified in 14.5% patients, of whom 71.4% presented nAF and 28.6% pAF. When AF types were compared, patients with nAF more frequently presented with ST-elevation ACS (p=0.003). Patients with pAF, in turn, were older (p=0.032), had greater left atrial diameter (p=0.001) and were less likely to have significant coronary lesions (p=0.034). Regarding therapeutic strategy, nAF patients were more often treated by rhythm control during hospital stay (p<0.001) and were less often anticoagulated at discharge (p=0.001). Compared with the population without AF, nAF was a predictor of death during hospital stay in univariate (p<0.001) and multivariate analysis (OR 2.67, p=0.047), but pAF was not. During follow-up, pAF was associated with higher mortality (p=0.014), while nAF patients presented only a trend towards worse prognosis. CONCLUSIONS: AF during the acute phase of ACS appears to have a negative prognostic impact only in patients with nAF and not in those with pAF.
- Impacto da fibrilhação auricular nas síndromes coronárias agudasPublication . Torres, M; Rocha, S; Marques, J; Nabais, S; Rebelo, A; Álvares-Pereira, M; Azevedo, P; Correia, AINTRODUCTION: Atrial fibrillation (AF) is a relatively common arrhythmia in the context of acute coronary syndromes (ACS). However, the impact of AF on these patients' survival is not well established. The present study aimed to estimate the prevalence of AF in ACS patients and to evaluate its impact on in-hospital and six-month post-event mortality, from any cause. METHODS: This was a retrospective cohort study that included 1183 patients admitted consecutively to a Coronary Care Unit with ACS. Demographic and clinical data and information from various complementary exams were collected and occurrence of AF during the first 48 hours of hospitalization was analyzed. Six-month follow-up was achieved in 95.9% of the patients. Logistic regression statistical analysis was used to identify independent predictors of in-hospital and six-month post-event mortality. RESULTS: AF was diagnosed in 140 patients (11.8%); these patients were older (73.89 +/- 8.69 vs. 63.20 +/- 12.73 years; p<0.0001) and less likely to be male (60.0% vs. 74.1%; p=0.001), and had a lower prevalence of dyslipidemia (32.9% vs. 44.1%; p=0.001) and smoking (10.0% vs. 25.9%; p<0.0001). Fewer patients with AF underwent reperfusion therapy (19.3% vs. 29.7%; p=0.006), beta-blocker therapy (72.1% vs. 85.7%; p<0.0001), and cardiac catheterization (48.2% vs. 62.9%; p=0.001) or percutaneous coronary intervention (14.3% vs. 23.4%; p=0.01). These patients more frequently developed heart failure (54.3% vs. 28.5%; p<0.0001) and more often presented left ventricular dysfunction (69.3% vs. 57.2%; p=0.002). In patients presenting AF, there were significant increases in in-hospital (12.1% vs. 4.2%; p<0.0001) and six-month mortality (27.2% vs. 8.2%. p<0.0001). In multivariate analysis, AF remained an independent marker of in-hospital (OR 1.95; 95% CI 1.03-3.69; p=0.03) and six-month mortality (OR 2.89; 95% CI 1.67-5.00; p=0.0001), as was age >75 years, severe left ventricular dysfunction and heart failure. The performance of coronary angiography correlated with improved prognosis. CONCLUSIONS: AF in the context of ACS is an independent predictor of increased in-hospital and six-month mortality. These findings should be taken into consideration in the management and treatment of such patients.
- Ischemic rupture of the anterolateral papillary musclePublication . Vieira, C; Gaspar, A; Álvares-Pereira, M; Salomé, N; Almeida, J; Amorim, MJWe describe the case of a 59-year-old man who presented with chest pain and ST-segment elevation in the inferior leads, R>S in V1 and ST depression in the anterior leads due to proximal occlusion of the first obtuse marginal. Primary coronary angioplasty and stenting of this artery were performed. Twelve hours later the patient became hemodynamically unstable and severe mitral regurgitation due to rupture of one of the heads of the anterolateral papillary muscle was diagnosed. Emergency surgery was performed (papillary muscle head reimplantation, mitral annuloplasty with a rigid ring, tricuspid annuloplasty and coronary artery bypass grafting). On surgical inspection, it was observed that the detached muscle head had become trapped in the left ventricle by a secondary cord attached to the other head. This case is unusual in presenting two uncommon features of ischemic papillary muscle: rupture of the anterolateral muscle in myocardial infarction involving the inferoposterior walls, and the fact that the ruptured muscle head did not prolapse because it had become trapped in the left ventricle by secondary cord attachment.
- Multimarker approach with cystatin C, N-terminal pro-brain natriuretic peptide, C-reactive protein and red blood cell distribution width in risk stratification of patients with acute coronary syndromesPublication . Vieira, C; Nabais, S; Ramos, V; Galvão-Braga, C; Gaspar, A; Azevedo, P; Álvares-Pereira, M; Salomé, N; Correia, AINTRODUCTION AND AIM: Biomarkers have emerged as interesting predictors of risk in patients with acute coronary syndromes (ACS). The aim of this study was to determine the utility of the combined measurement of cystatin C (CysC), C-reactive protein (CRP), N-terminal pro-brain natriuretic peptide (NT-proBNP) and red blood cell distribution width (RDW) in the risk stratification of patients with ACS. METHODS: In this prospective study including 682 patients consecutively admitted to a coronary care unit for ACS, baseline measurements of CysC, CRP, NT-proBNP and RDW were performed. Patients were categorized on the basis of the number of elevated biomarkers at presentation. The primary outcome was 6-month mortality. RESULTS: The number of biomarkers elevated on admission (study score) was an independent predictor of 6-month mortality; patients with four biomarkers elevated on admission had a significantly higher risk of 6-month mortality compared with patients with none or one. In addition, in patients with high risk defined by the GRACE score, our multimarker score was able to further categorize their risk of 6-month mortality. CONCLUSIONS: A multimarker approach using CysC, NT-proBNP, CRP and RDW was an independent predictor of 6-month mortality and added prognostic information to the GRACE risk score in patients with ACS and high risk defined by GRACE, with increasing mortality in patients with a higher number of elevated biomarkers on admission.
- Prognostic impact of hemoglobin drop during hospital stay in patients with acute coronary syndromesPublication . Nabais, S; Gaspar, A; Costa, J; Azevedo, P; Rocha, S; Torres, M; Álvares-Pereira, MINTRODUCTION: Bleeding is currently the most common non-cardiac complication of therapy in patients with acute coronary syndromes (ACS), and may itself be associated with adverse outcomes. The aim of this study was to determine the effect of hemoglobin drop during hospital stay on outcome among patients with ACS. METHODS: Using Cox proportional-hazards modeling, we examined the association between hemoglobin drop and death or myocardial infarction (MI) at 6 months in 1172 patients admitted with ACS to an intensive cardiac care unit. Patients were stratified according to quartiles of hemoglobin drop: Q1, < or = 0.8 g/dL; Q2, 0.9-1.5 g/dL; Q3, 1.6-2.3 g/dL; Q4, > or = 2.4 g/dL. We also identified independent predictors of increased hemoglobin drop (> or =2.4 g/dL) using multivariate logistic regression analysis. RESULTS: Median nadir hemoglobin concentration was 1.5 g/dL lower (IQR 0.8-2.3) compared with baseline hemoglobin (p < 0.0001). Independent predictors of increased hemoglobin drop included older Sage, renal dysfunction, lower weight, and use of thrombolytic therapy, glycoprotein IIb/IIIa inhibitors, nitrates, and percutaneous coronary intervention. Higher levels of hemoglobin drop were associated with increased rates of 6-month mortality (8.0% vs. 9.4% vs. 9.6% vs. 15.7%; p for trend = 0.014) and 6-month death/ MI (12.4% vs. 17.0% vs. 17.2% vs. 22.1%; p for trend = 0.021). Using Q1 as reference group, the adjusted hazard ratio (HR) for 6-month mortality and 6-month death/MI among patients in the highest quartile of hemoglobin drop was 1.83 (95% confidence interval [CI] 1.08-3.11; p = 0.026) and 1.60 (95% CI 1.04-2.44; p = 0.031) respectively. Considered as a continuous variable, the adjusted HR for 6-month mortality was 1.16 (95% CI 1.01-1.32; p = 0.030) per 1 g/dL increase in hemoglobin drop. CONCLUSIONS: A decrease in hemoglobin frequently occurs during hospitalization for ACS and is independently associated with adverse outcomes.
- Tabaco nas síndromas coronárias agudas: o "paradoxo dos fumadores" revisitadoPublication . Gaspar, A; Nabais, S; Rocha, S; Torres, M; Pinto, J; Azevedo, P; Brandão, A; Álvares-Pereira, M; Correia, AINTRODUCTION: Although a well-known risk factor for coronary disease, smoking has long been associated with lower short-term mortality in acute coronary syndromes (ACS). There are few recent works on Portuguese populations examining all aspects of smoking in ACS, particularly the interaction between smoking and other risk factors, and the management and prognosis of patients according to smoking status. OBJECTIVE: We sought to examine clinical characteristics, presentation, in-hospital treatment, angiographic features and prognosis of patients with and without smoking history admitted with ACS. METHODS: A total of 1228 patients consecutively admitted with ACS from January 2004 to March 2007 were analyzed. Patients were classified into two groups, those with present or past smoking habits (n=450) making up Group I and those without smoking habits (n=778), Group II. The main outcome analyzed was overall mortality during hospital stay and at 6 months. RESULTS: Smokers and former smokers were younger and more frequently male (odds ratio [OR] = 22.46; 95% confidence interval [CI]: 12.94-38.96), and less often had diabetes (OR = 0.41; 95% CI: 0.30-0.54), hypertension (OR = 0.31; 95% CI: 0.24-0.39) and renal insufficiency (OR = 0.26; 95% CI: 0.18-0.36). Patients with smoking habits more frequently presented with ST elevation (OR = 1.32; 95% CI: 1.04-1.67), more often received evidence-based medical therapy, namely beta blockers (during hospital stay, OR = 2.42; 95% CI: 1.63-3.56 and at discharge, OR = 1.45; 95% CI: 1.03-2.1) and statins (at discharge, OR = 2.48; 95% CI: 1.2-6.1), and more frequently underwent coronary angiography (OR = 2.15; 95% CI: 1.63-2.84). Although smokers and former smokers had lower in-hospital mortality on univariate analysis (OR = 0.54; 95% CI: 0.31-0.96), this association was not confirmed on multivariate analysis, with adjustment for known short-term mortality predictors (OR = 1.25; 95% CI: 0.61-2.54). Similarly, multivariate analysis failed to confirm lower 6-month mortality for smokers and former smokers (OR = 2.0; 95% CI: 1.17-3.41). CONCLUSIONS: Clinical characteristics and management options differed between ACS patients with and without smoking habits. These differences explained the lower shortterm mortality initially observed between the two groups. In our population of patients admitted with ACS, we did not find a real "smoker's paradox".