HB - CAR - Comunicações e Conferências
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- O “paradoxo dos fumadores” revisitado.Publication . Gaspar, A; Nabais, S; Torres, M; Rocha, S; Brandão, A; Azevedo, P; Álvares-Pereira, M; Correia, AIntrodução: O termo “paradoxo dos fumadores” surgiu na sequência de vários estudos que descreveram uma menor mortalidade a curto prazo nos doentes com história de tabagismo, internados com Síndrome Coronário Agudo (SCA). No entanto, trabalhos mais recentes têm contestado a existência deste fenómeno. Objectivo: Avaliar a ocorrência do “paradoxo dos fumadores” na nossa população de doentes internados por SCA. Métodos: Foram analisados 1228 doentes admitidos consecutivamente por SCA de Janeiro 2004 a Março 2007. Os doentes foram classificados em 2 grupos, o grupo I incluindo os doentes sem história de tabagismo (n=778) e o grupo II os doentes com história de tabagismo (n=450). Os “endpoints” foram a morte no internamento e morte total aos 6 meses. Resultados: Verificou-se que os doentes sem história de tabagismo eram mais idosos (68,25 ± 12,22 anos contra 58,13 ± 11,91 anos), mais frequentemente do sexo feminino, e apresentavam com maior frequência diabetes mellitus (DM), hipertensão arterial (HTA) e insuficiência renal (p <0,05). Os doentes que nunca fumaram tiveram mais frequentemente enfarte agudo do miocárdio (EAM) sem supra de ST enquanto os doentes com história de tabagismo tiveram mais EAM com supra de ST (p <0,05). Os doentes sem história de tabagismo eram mais frequentemente medicados com nitratos, diuréticos e antagonistas de cálcio e menos com β – bloqueadores (p <0,05), não se tendo encontrado diferenças quanto à restante terapêutica médica. Os doentes com história tabágica foram mais frequentemente submetidos a coronariografia (p <0,01). Apesar de se observar, na análise univariável, maior mortalidade intra-hospitalar e aos 6 meses nos doentes sem antecedente de tabagismo (p <0,05), a análise multivariável, com o ajuste para os factores de risco mais reconhecidos (idade, classe KK na admissão, pressão arterial sistólica e frequência cardíaca na admissão, disfunção ventricular esquerda, presença de insuficiência renal) não permitiu confirmar esta associação. Conclusão: Na nossa população de doentes internados por SCA, não se verificou nenhum “paradoxo dos fumadores”. A ocorrência de maior mortalidade observada entre os doentes sem história de tabagismo correlaciona-se provavelmente com as diferenças das características basais dos doentes, nomeadamente idade mais avançada e maior número de co-morbilidades (DM, HTA e insuficiência renal).
- Prognostic value of in-hospital worsening of renal function in patients with acute coronary syndromePublication . Gaspar, A; Nabais, S; Torres, M; Rocha, S; Brandão, A; Azevedo, P; Álvares-Pereira, M; Correia, APurpose: The association between a history of renal insufficiency and poor outcome in patients with acute coronary syndrome (ACS) is well known. However, little information is available about in-hospital worsening of renal function. Our goal was to determine the prognostic impact of in-hospital worsening of renal function in patients with ACS. Methods: A total of 1228 patients consecutively admitted with ACS from January 2004 to March 2007 were reviewed. Patients deceased in hospital and patients with < 2 analysis and/or without creatinine value on admission were excluded. The selected patients were classified into 2 groups. Group I included patients with an increase in creatinine <0,5 mg/dL. Group II included patients with an increase in creatinine ≥ 0,5 mg/dL. The primary endpoint was 6-month mortality from any cause. Results: Of the 1134 patients finally selected, 1028 belonged to group I and 106 to group II. Patients of group II were older (74,08±8,8 vs 63,2±12,9; p <0,001), more frequently women (39,6% vs 26,1%; p= 0,003) and more often had diabetes mellitus (42,5% vs 25,7%; p=0,001), arterial hypertension (77,4% vs 62,0%; p=0,001) and renal insufficiency (63,5% vs 19,8%; p <0,001). Patients of group II had higher 6-month mortality compared with patients in group I (24,5% vs 5,0%; p <0,001). After adjustment for known risk factors by multivariate analysis (age, history of renal insufficiency, diabetes mellitus, creatinine value on admission, history of myocardial infarction, Killip class on admission, heart rate on admission, systolic blood pressure on admission and left ventricular systolic dysfunction), an increase in creatinine remained a independent predictor of 6-month mortality (OR=2,45; 95% confidence interval 1,42 to 4,24; p=0,0013). Conclusions: In-hospital worsening of renal function is associated with increased 6-month mortality in patients with ACS.
- Proton Pump Inhibitors In Patients Treated With Aspirin And ClopidogrelPublication . Gaspar, A; Ribeiro, S; Nabais, S; Rocha, S; Azevedo, P; Álvares-Pereira, M; Brandão, A; Correia, A
- Contrast-induced nephropathy after an acute coronary syndrome.Publication . Gaspar, A; Nabais, S; Ribeiro, S; Rocha, S; Azevedo, P; Álvares-Pereira, M; Brandão, A; Correia, APurpose: Contrast-induced nephropathy (CIN) is a form of hospital-acquired acute renal failure that sometimes develops after giving iodinated radiocontrast agents. The growing number of patients who undergo coronary angiography and percutaneous revascularization after acute coronary syndrome (ACS) brought more relevance to this entity. It’s actually one of the most frequent forms of hospital-acquired acute renal failure. The purpose of this study was to define the predictors and prognostic value of CIN in a population of patients admitted with ACS. Methods: A total of 558 patients consecutively admitted with ACS and submitted to cardiac catheterization procedure, from January 2004 to April 2006, were reviewed. CIN was defined as impairment of renal function occurring within 48 hours after administration of contrast media and manifested by an absolute increase in the serum creatinine level of at least 0.5 mg/dL or by a relative increase of at least 25% over the baseline value (in the absence of another cause). The patients were classified in 2 groups according to the occurrence of CIN. The primary endpoint was in-hospital mortality. Results: Of the 558 patients reviewed, 5% (n=28) developed CIN. Patients with CIN were older (69.6 ± 10.5 vs 61.5 ± 11.7; p <0.001) and more often had diabetes mellitus (42.9% vs 24%; p=0.02) and renal insufficiency (48% vs 14.7%; p <0.001). There were no differences regarding ACS presentation (with or without elevation in the ST segment) and in-hospital medical treatment. Patients with CIN had higher in-hospital mortality (10.7% vs 0.6%; p <0.001). After adjustment for confounding variables by multivariate analysis (age, renal insufficiency, heart rate on admission, systolic blood pressure on admission and Killip class on admission), CIN remained an independent predictor of in-hospital mortality. Conclusions: CIN occurred in 5% of our patients admitted with ACS. Risk factors associated with CIN were advanced age, diabetes and pre-existing renal insufficiency. CIN was an independent predictor of in-hospital mortality.
- Como diminuir iatrogenia laboratório hemodinâmica: Como reduzir as complicações vascularesPublication . Marques, J; Serviço de Cardiologia
- Impacto prognóstico da insuficiência mitral isquémica no EAM sem supraSTPublication . Ramos, V; Vieira, C; Galvão-Braga, C; Martins, J; Ribeiro, S; Rocha, S; Gaspar, A; Marques, J; Azevedo, P; Álvares-Pereira, M; Correia, A
- Cistatina C e valor prognóstico nas síndromes coronárias agudasPublication . Vieira, C; Nabais, S; Ramos, V; Ribeiro, S; Gaspar, A; Galvão-Braga, C; Salomé, N; Rocha, S; Azevedo, P; Álvares-Pereira, M; Correia, A
- How to improve pre-hospital transportationPublication . Marques, J
- Nonsecretory Multiple Myeloma – a diagnostic challenge!Publication . Abreu, G; Pacheco, AP; Fernandes, N; Costa, J; Esperança, S; Gonçalves, FThe Nonsecretory Multiple Myeloma is a rare variant (1-5 %) of the classical form of multiple myeloma (MM). Although clinically similar to MM, nonsecretory multiple myeloma is not associated with a monoclonal gammopathy in serum or urine, making it difficult diagnosis this entity. The authors describe the case of an eighty-year-old man, who was admitted in September 2012 in our hospital, by acute renal failure, low back pain and disorientation. He had been well until approximately 6 months earlier, when he experienced adynamia, asthenia and weight loss (8kg). On examination, he showed no significant alterations except urinary retention requiring catheterization. The analytical study performed pointed out normocytic normochromic anemia (Hb 9.9 g/dl), renal failure and increase of B2 microglobulin (11684). The electrophoresis of serum proteins was normal, as well as urinary light chains and serum. Renal ultrasound was normal. Thoracic-abdominal-pelvic computed tomography (CT) revealed multiple osteolytic metastases, associated to a mass of soft tissue, in pelvis bones and in several vertebral bodies. Following the study of an occult primary tumor, upper and lower endoscopy, bronchofibroscopy with bronchoalveolar lavage, prostate and thyroid ultrasound were performed and showed no changes. The magnetic resonance imaging of the spine revealed multiple infiltrative lesions of the cervical-dorsal-lumbar-sacred vertebrae, pathological fractures of the vertebral bodies of D4, D7 and D9 and a mass of soft tissue/infiltrative component in D12. It also displayed secondary infiltrative lesions of iliac bones and some ribs. The positron emission tomography (PET) showed avidity for 18FDG in iliac and sternal body. The patient underwent CT-guided aspiration biopsy of iliac lesion, which result was negative for neoplastic involvement. This result led to the completion of two additional biopsies directed at D12, both inconclusive. It was instituted systemic corticosteroid therapy and fluid therapy with good clinical outcome, which allowed the patient’s discharge to the outpatients’ department. Five months later, he was re-admitted for low back pain, decreased strength in the lower limbs, worsening of renal function and hypercalcemia. He made a new thoracic-abdominal-pelvic CT scan, which revealed progression of lytic lesions, affecting all bone parts and increasing bone mass on D12, conditioning extensive lysis of the vertebral bodies. Given the exuberance of the lesion on D12 and the consequent damage to adjacent structures, an open biopsy was held and radiotherapy for symptomatic control was initiated. The histological result of the biopsy revealed plasmacytoma/multiple myeloma with restriction of kappa light chains. The patient was referred to the Oncology Service, and started dexamethasone in high doses. The bone biopsy showed 49% of plasmocytes, all with abnormal phenotypic characteristics. The nonsecretory multiple myeloma is an uncommon entity, with clinical presentation similar to MM, which diagnosis requires histological evidence of plasmocytic infiltration. Limitations inherent to biopsy may delay correct treatment. However, whenever we are faced with an elderly with bone pain, acute renal failure and anemia of unknown etiology, one need to persist in the diagnosis of MM, not forgetting this rare entity that is nonsecretory multiple myeloma.