Browsing by Author "Azevedo, P"
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- Acute coronary syndrome in elderly patients - prognostic impact of revascularizationPublication . Arantes, C; Abreu, G; Martins, J; Galvão-Braga, C; Ramos, V; Vieira, C; Azevedo, P; Álvares-Pereira, M; Rocha, S; Correia, A
- Admission glycemia: a predictor of death after acute coronary syndrome in non-diabetic patients?Publication . Rocha, S; Nabais, S; Magalhães, S; Salgado, A; Azevedo, P; Marques, J; Torres, M; Pereira, MA; Correia, ABACKGROUND: Previous studies have demonstrated that acute phase hyperglycemia is associated with increased in-hospital mortality in diabetic patients admitted with acute coronary syndrome (ACS), but this has not been clearly demonstrated in non-diabetic patients. The present study was designed to determine whether admission hyperglycemia (AG) is an independent predictor of in-hospital and six-month mortality after ACS in non-diabetic patients. METHODS: This was a retrospective cohort study of 426 non-diabetic patients consecutively admitted with ACS. The patients were stratified into quartile groups according to AG, which was also analyzed as a continuous variable. Vital status was obtained at six-month follow-up in 96.8% of the patients surviving hospitalization. Logistic regression analysis was used to identify independent predictors of in-hospital and six-month death. RESULTS: Of the 426 patients included in the study (age 62.6 years+/-13.1, 77% male), 22 (5.4%) patients died during hospitalization and 20 (5.2% of the patients surviving hospitalization) within six months of ACS. Mean AG was 134.89 mg/dl+/-51.95. The higher the AG, the more probable was presentation with ST-segment elevation ACS (STEMI), anterior STEMI, higher heart rate, Killip class higher than one (KK >1), higher serum creatinine and greater risk of in-hospital and six-month death. In multivariate analysis, only age (OR=1.10; 95% CI 1.04-1.17), STEMI (OR=3.02; 95% CI 1.07-8.50), AG (OR=1.073; 95% CI 1.004-1.146), serum creatinine (OR=1.10; 95% CI 1.009-1.204) and KK >1 on admission (OR=4.65; 95% CI 1.59-13.52) were independently associated with in-hospital death. Age (OR=1.07; 95% CI 1.03-1.12), serum creatinine (OR=1.09; 95% CI 1.01-1.18) and in-hospital development of heart failure (OR=2.34; 95% CI 1.07-5.10) were independently associated with higher risk of death within six months of ACS. CONCLUSIONS: AG is an independent predictive factor of in-hospital death after ACS in non-diabetic patients. Although it did not show an independent association with higher risk of six-month death, AG appears to contribute to it, since the risk is greater the higher the AG. Its predictive value may have been blunted by the insufficient power of the sample and/or by the time interval between acquisition of AG and the evaluated endpoint.
- After an acute coronary syndrome: oral tolerance test for all patients?Publication . Ribeiro, S; Azevedo, P; Gaspar, A; Vieira, C; Ramos, V; Nabais, S; Basto, L; Pereira, MA; Correia, A
- An unusual trigger causing Takotsubo SyndromePublication . Abreu, G; Rocha, S; Bettencourt, N; Azevedo, P; Vieira, C; Rodrigues, C; Arantes, C; Braga, C; Martins, J; Marques, J
- Are there differences on prognosis among patients with previous ischemic heart disease versus cerebrovascular disease admitted with acute coronary syndrome?Publication . Abreu, G; Galvão-Braga, C; Arantes, C; Martins, J; Quina-Rodrigues, C; Vieira, C; Azevedo, P; Álvares-Pereira, M; Marques, JBackground: It is known that patients with previous vascular disease (PVD) have a poorer outcome than those without these previous conditions, and prognosis worsens as the number of affected vascular beds increases. Aim: To evaluate if there are differences in in-hospital and 6-month mortality among patients admitted with acute coronary syndromes with previous ischemic heart disease (IHD) versus cerebrovascular disease (CVD). Methods: We analysed 4871 patients (pts) admitted consecutively in our coronary care unit with a diagnosis of acute coronary syndrome and included in a prospective registry, from January 2002 to October 2013. Patients were divided in three groups: group 1 - pts without PVD, n=3718, 76,3%); group 2 – pts with previous IHD (n=825, 16.9%); group 3 - pts with previous CVD (n=257, 5.3%). We excluded pts with previous IHD plus CVD (n=71, 1.5%). For each group we compared clinical and laboratory features and adverse events. Primary endpoint was the occurrence of death at 6 months; follow-up was completed in 98% of patients. Results: The group with previous CVD were older (63±13 vs 67±12 vs 71±11; p<0.001), had higher proportion of women (25% vs 21.9% vs 32.3%; p<0.001) and hypertension (58% vs 73.1% vs 83.7%; p<0.001). Patients with previous IHD had more often body mass index >25kg/m2 (47.1% vs 52.5% vs 50.8%; p=0.016), dyslipidaemia (46% vs 69.3% vs 52.1%; p<0.001), diabetes (23.5% vs 38.8% vs 36.6%; p<0.001). They also were taking more often aspirin (11.6% vs 75% vs 35.8%; p<0.001) and statin (21.6% vs 70.5% vs 37.4%; p<0.001). Patients without PVD had more frequently history of smoking (29.5% vs 19.0% vs 12.8%; p<0.001) and absence of risk factors (8.7% vs 4.0% vs 3.9%; p<0.001). On admission, those with previous CVD presented more often with Killip >1 (19.6 % vs 29.6% vs 34.2%; p<0.001), anaemia (19.8% vs 28.6% vs 33.9%; p<0.001) and renal insufficiency (eGFR <60 ml/min) (19.2% vs 31% vs 40.9%; p<0,001). Patients with previous IHD presented more severe coronary artery disease (left main coronary artery or three vessels) (11.7% vs 22.2% vs 16.7%; p<0.001) and higher prevalence of left ventricular dysfunction (56.2% vs 61.8% vs 58.4%; p=0.034). ST-segment myocardial infarction was more prevalent in patients without PVD (54.5% vs 25.6% vs 51%; p<0.001) on the other hand myocardial infarction without ST-elevation was more frequent in patients with previous IHD (41.2% vs 65% vs 45.5%; p<0.001). In-hospital (4.5% vs 4.7% vs 7.0%; p<0.001) and 6-month mortality (8.7% vs. 10.6% vs. 16.5%; p<0.001) were higher in patients with previous CVD. In multivariate analysis and after adjusting for different baseline characteristics, patients with previous CVD had higher risk of 6-month mortality compared to those without PVD [OR 1.67, 95% CI (1.06-2.63), p=0.026]. Conclusion: Patients with previous vascular disease had higher prevalence of risk factors. Previous cerebrovascular disease remained as a strong predictor of 6-month mortality in patients admitted with acute coronary syndrome.
- Are there differences on prognosis among patients with previous ischemic heart disease versus cerebrovascular disease admitted with acute coronary syndrome?Publication . Abreu, G; Arantes, C; Martins, J; Quina-Rodrigues, C; Vieira, C; Álvares-Pereira, M; Azevedo, P; Marques, JBackground: It is known that patients with previous vascular disease (PVD) have a poorer outcome than those without these previous conditions, and prognosis worsens as the number of affected vascular beds increases. Aim: To evaluate if there are differences in in-hospital and 6-month mortality among patients admitted with acute coronary syndromes with previous ischemic heart disease (IHD) versus cerebrovascular disease (CVD). Methods: We analysed 4871 patients (pts) admitted consecutively in our coronary care unit with a diagnosis of acute coronary syndrome and included in a prospective registry, from January 2002 to October 2013. Patients were divided in 3 groups: group 1 - pts without PVD (n=3718, 76.3%); group 2 – pts with previous IHD (n=825, 16.9%); group 3 - pts with previous CVD (n=257, 5.3%). We excluded pts with previous IHD plus CVD (n=71, 1.5%). For each group we compared clinical features and adverse events. Primary endpoint was the occurrence of death at 6 months; follow-up was completed in 98% of patients. Results: Pts in group 3 were older (63±13 vs 67±12 vs 71±11;p<0.001), had higher proportion of women (25% vs 21.9% vs 32.3%;p<0.001) and hypertension (58% vs 73.1% vs 83.7%;p<0.001). Group 2 had more often body mass index >25kg/m2 (47.1% vs 52.5% vs 50.8%; p=0.016), dyslipidaemia (46% vs 69.3% vs 52.1%;p<0.001) and diabetes (23.5% vs 38.8% vs 36.6%;p<0.001). Group 1 had more frequently history of smoking (29.5% vs 19.0% vs 12.8%;p<0.001) and absence of conventional risk factors (8.7% vs 4.0% vs 3.9%;p<0.001). On admission, those with previous CVD presented more often Killip >1 (19.6 % vs 29.6% vs 34.2%;p<0.001), anaemia (19.8% vs 28.6% vs 33.9%;p<0.001) and renal insufficiency (eGFR <60 ml/min) (19.2% vs 31% vs 40.9%;p<0,001). Group 2 presented more severe coronary artery disease (11.7% vs 22.2% vs 16.7%;p<0.001) and higher prevalence of left ventricular dysfunction (56.2% vs 61.8% vs 58.4%;p=0.03). ST-segment myocardial infarction was more prevalent in Group 1 (54.5% vs 25.6% vs 51%;p<0.001), while myocardial infarction without ST-elevation was more frequent in group 2 (41.2% vs 65% vs 45.5%;p<0.001). In-hospital (4.5% vs 4.7% vs 7.0%;p<0.001) and 6-month mortality (8.7% vs 10.6% vs 16.5%;p<0.001) were higher in patients with previous CVD. In multivariate analysis and after adjusting for different baseline characteristics, pts with previous CVD had higher risk of 6-month mortality compared to those without PVD [OR 1.67, 95% CI (1.06-2.63),p=0.026]. Conclusion: Previous CVD remained as a strong predictor of 6-month mortality in patients admitted with acute coronary syndrome.
- Associação entre o índice de anisocitose (RDW) e a ocorrência de morte ou enfarte aos seis meses em doentes com síndrome coronária agudaPublication . Nabais, S; Losa, N; Gaspar, A; Rocha, N; Costa, J; Azevedo, P; Basto, L; Pereira, MA; Correia, ABACKGROUND: Higher values of red ceildistribution width (RDW) may be associated with adverse outcomes in patients with heart failure and in those with stable coronary artery disease. We assessed the hypothesis that higher RDW values are associated with adverse cardiovascular outcomes in patients with acute coronary syndromes (ACS). METHODS: We studied 1796 patients with ACS admitted to a coronary care unit. We analyzed clinical and laboratory characteristics, management, and outcomes of patients according to tertiles of baseline RDW. The primary outcome was death or myocardial infarction (MI) during six-month follow-up. RESULTS: Patients with higher RDW values tended to be older, were more likely to be female and have a history of MI, and more often had renal dysfunction, anemia, and Killip class >I on admission (p < 0.05). Higher RDW values were associated with increased 6-month mortality (tertile 1: 8.2%; tertile 2: 10.9%; tertile 3: 15.5%; p = 0.001 for trend) and increased 6-month death/MI rates (tertile 1, 13.0%; tertile 2, 17.2%; tertile 3, 22.9%; p < 0.0001 for trend). An association between higher RDW and increased 6-month death/MI rates was found in patients with non-ST-elevation ACS (10.5% vs. 15.3% vs. 22.7%; p < 0.001 for trend), with a tendency in patients admitted with ST-elevation MI (15.1% vs. 19.1% vs. 23.1%; p = 0.053 for trend). After adjustment for baseline characteristics and treatment, higher RDW values remained independently associated with the study's primary composite outcome but not with all-cause death. Using the first tertile of RDW as reference, the adjusted odds ratio (OR) for 6-month death/MI among patients in the highest RDW tertile was 1.43 (95% confidence interval [CI], 1.00-2.05; p = 0.049). Using RDW as a continuous variable, the adjusted OR for 6-month death/MI was 1.16 (95% CI, 1.03-1.30; p = 0.017) per 1% increase in RDW.
- Atypical presentation of an intracardiac massPublication . Abreu, G; Azevedo, P; Bettencourt, N; Vieira, C; Arantes, C; Quina, C; Vilaça, A; Marques, J
- Biventricular Takotsubo vs Myocarditis – a diagnostic challengePublication . Abreu, G; Azevedo, P; Vieira, C; Arantes, C; Martins, J; Galvão-Braga, C; Rodrigues, C; Salomé, N; Vieira, JBackground: Takotsubo cardiomyopathy (TCM) is an important differential diagnosis of acute coronary syndrome and myocarditis. It is characterized by normal or near-normal coronary arteries and regional wall motion abnormalities that extend beyond a single coronary vascular bed. Variants of the classical left ventricular (LV) apical ballooning are increasing in recognition as cardiac magnetic resonance (CMR) is more extensively used. Case report: We present a case of 69-year-old woman with a previous history of hypertension, diabetes and dyslipidaemia, transferred to our emergency department due to suspected acute coronary syndrome. She had a history of two episodes of an oppressive chest pain longer than 1 hour, orthopnoea and paroxysmal nocturnal dyspnoea 36 hours before. Two weeks before she had had a lower tract respiratory infection, that was not totally resolved. On admission, she only had dyspnoea. On examination, she had wheezing, arrhythmic pulse and hypertension. Breath sounds were absent in lower chest and rales were also noted. Electrocardiogram showed rapid atrial fibrillation, poor R wave progression in anteroseptal leads and inverted T waves in I, aVL and V2-V6 leads. Modest elevation in cardiac troponin (4.55 ng/mL) was observed. Chest x-ray showed bilateral pleural effusion. A transthoracic echocardiography (TTE) was immediately performed and revealed akinesis/dyskinesis of mid to apical segments (apical ballooning) of both ventricles, extended beyond a single epicardial coronary distribution, compatible with biventricular TCM. Cardiac catheterization showed absence of obstructive coronary disease. A CMR, performed two days later, showed moderate biventricular systolic dysfunction, hypokinesis in mid to apical segments of LV and hypokinesis in apical right ventricle. It also showed non-ischemic late gadolinium enhancement in antero-apical and lateral apical segments. After several days of medical management, the patient was discharged from the hospital in stable condition. TTE performed 6-month after evidenced complete biventricular function recovery and no segmental contractility changes. CMR supported the functional recovery and the resolution of contractility abnormalities, but noticed the intramyocardial late gadolinium enhancement in the segments previously reported. Conclusion: There are fewer reports of this unusual presentation of TCM, described by ETT. This case represents a good example of the diagnostic challenge between myocarditis and takotsubo cardiomyopathy. Taking in account the exuberance of the case, the mild elevation of troponin, the full recovery of biventricular function and resolution of contractility abnormalities, it seems more probably to be a TCM, in a patient who, probably had a previous scar of myocarditis. Although, the hypothesis of acute myocarditis as the primary diagnosis cannot be excluded.
- Biventricular Takotsubo vs Myocarditis – a diagnostic challengePublication . Abreu, G; Azevedo, P; Vieira, C; Arantes, C; Martins, J; Galvão-Braga, C; Rodrigues, C; Salomé, N; Marques, JBackground: Takotsubo cardiomyopathy (TCM) is an important differential diagnosis of acute coronary syndrome and myocarditis. It is characterized by normal or near-normal coronary arteries and regional wall motion abnormalities that extend beyond a single coronary vascular bed. Variants of the classical left ventricular (LV) apical ballooning are increasing in recognition as cardiac magnetic resonance (CMR) is more extensively used. Case report: We present a case of 69-year-old woman with a previous history of hypertension, diabetes and dyslipidaemia, transferred to our emergency department due to suspected acute coronary syndrome. She had a history of two episodes of an oppressive chest pain longer than 1 hour, orthopnoea and paroxysmal nocturnal dyspnoea 36 hours before. Two weeks before she had had a lower tract respiratory infection, that was not totally resolved. On admission, she only had dyspnoea. On examination, she had wheezing, arrhythmic pulse and hypertension. Breath sounds were absent in lower chest and rales were also noted. Electrocardiogram showed rapid atrial fibrillation, poor R wave progression in anteroseptal leads and inverted T waves in I, aVL and V2-V6 leads. Modest elevation in cardiac troponin (4.55 ng/mL) was observed. Chest x-ray showed bilateral pleural effusion. A transthoracic echocardiography (TTE) was immediately performed and revealed akinesis/dyskinesis of mid to apical segments (apical ballooning) of both ventricles, extended beyond a single epicardial coronary distribution, compatible with biventricular TCM. Cardiac catheterization showed absence of obstructive coronary disease. A CMR, performed two days later, showed moderate biventricular systolic dysfunction, hypokinesis in mid to apical segments of LV and hypokinesis in apical right ventricle. It also showed non-ischemic late gadolinium enhancement in antero-apical and lateral apical segments. After several days of medical management, the patient was discharged from the hospital in stable condition. TTE performed 6-month after evidenced complete biventricular function recovery and no segmental contractility changes. CMR supported the functional recovery and the resolution of contractility abnormalities, but noticed the intramyocardial late gadolinium enhancement in the segments previously reported. Conclusion: There are fewer reports of this unusual presentation of TCM, described by ETT. This case represents a good example of the diagnostic challenge between myocarditis and takotsubo cardiomyopathy. Taking in account the exuberance of the case, the mild elevation of troponin, the full recovery of biventricular function and resolution of contractility abnormalities, it seems more probably to be a TCM, in a patient who, probably had a previous scar of myocarditis. Although, the hypothesis of acute myocarditis as the primary diagnosis cannot be excluded.