Efetividade de um protocolo assistencial para redução do tempo porta-balão da angioplastia primária Effectiveness of a myocardial infarction protocol in reducing door-to-ballon time

FUNDAMENTO: Tempo porta-balão adequado (BACKGROUND: An adequate door-to-balloon time (<120 minutes) is the necessary condition for the efficacy of primary angioplasty in infarction to translate into effectiveness. OBJECTIVE: To describe the effectiveness of a quality of care protocol in reducing the door-to-balloon time. METHODS: Between May 2010 and August 2012, all individuals undergoing primary angioplasty in our hospital were analyzed. The door time was electronically recorded at the moment the patient took a number to be evaluated in the emergency room, which occurred prior to filling the check-in forms and to the triage. The balloon time was defined as the beginning of artery opening (introduction of the first device). The first 5 months of monitoring corresponded to the period of pre-implementation of the protocol. The protocol comprised the definition of a flowchart of actions from patient arrival at the hospital, the team's awareness raising in relation to the prioritization of time, and provision of a periodic feedback on the results and possible inadequacies. RESULTS: A total of 50 individuals were assessed. They were divided into five groups of 10 sequential patients (one group pre- and four groups post-protocol). The door-to-balloon time regarding the 10 cases recorded before protocol implementation was 200 ± 77 minutes. After protocol implementation, there was a progressive reduction of the door-to-balloon time to 142±78 minutes in the first 10 patients, then to 150±50 minutes, 131±37 minutes and, finally, 116±29 minutes in the three sequential groups of 10 patients, respectively. Linear regression between sequential patients and the door-to-balloon time (r = - 0.41) showed a regression coefficient of - 1.74 minutes. CONCLUSION: The protocol implementation proved effective in the reduction of the door-to-balloon time

Prognostic Value of TIMI Score versus GRACE Score in ST-segment Elevation Myocardial Infarction

Background: The TIMI Score for ST-segment elevation myocardial infarction (STEMI) was created and validated specifically for this clinical scenario, while the GRACE score is generic to any type of acute coronary syndrome. Objective: Between TIMI and GRACE scores, identify the one of better prognostic performance in patients with STEMI. Methods: We included 152 individuals consecutively admitted for STEMI. The TIMI and GRACE scores were tested for their discriminatory ability (C-statistics) and calibration (Hosmer-Lemeshow) in relation to hospital death. Results: The TIMI score showed equal distribution of patients in the ranges of low, intermediate and high risk (39 %, 27 % and 34 %, respectively), as opposed to the GRACE Score that showed predominant distribution at low risk (80 %, 13 % and 7%, respectively). Case-fatality was 11%. The C-statistics of the TIMI score was 0.87 (95%CI = 0.76 to 0.98), similar to GRACE (0.87, 95%CI = 0.75 to 0.99) - p = 0.71. The TIMI score showed satisfactory calibration represented by χ2 = 1.4 (p = 0.92), well above the calibration of the GRACE score, which showed χ2 = 14 (p = 0.08). This calibration is reflected in the expected incidence ranges for low, intermediate and high risk, according to the TIMI score (0 %, 4.9 % and 25 %, respectively), differently to GRACE (2.4%, 25% and 73%), which featured middle range incidence inappropriately. Conclusion: Although the scores show similar discriminatory capacity for hospital death, the TIMI score had better calibration than GRACE. These findings need to be validated populations of different risk profiles

Assessment of speckle tracking strain predictive value for myocardial fibrosis in subjects with Chagas disease

One of the most challenging issues of chronic Chagas disease is to provide earlier detection of heart involvement. Two-dimensional speckle tracking (2-D ST) echocardiography, a new imaging modality with useful applications in several cardiac diseases, has been validated for subjects with myocardial infarction against cardiac magnetic resonance (CMR). Here we hypothesize that the longitudinal global strain (LGS) has an incremental value to ejection fraction for predicting myocardial fibrosis in subjects with Chagas disease. This observational study comprised 58 subjects with Chagas disease, confirmed by two positive serologic tests. All subjects underwent conventional Doppler echocardiogram plus speckle tracking strain, and cardiac magnetic resonance. The ROC curve analysis revealed that both LGS (area under the curve: 0.78, p = 0.001) and ejection fraction (area under the curve: 0.82, p < 0.001) were significant predictors of myocardial fibrosis. Regarding the percentage of fibrosis, a high correlation was observed with both ejection fraction assessed by echocardiography (r = 0.70, p < 0.001) and LGS (r = 0.64, p < 0.001). However, when adjusted through multiple linear regression, the LGS lost statistical significance as a predictor of myocardial fibrosis (p = 0.111). LGS has no incremental value to conventional ejection fraction measurement in the prediction of myocardial fibrosis in subjects with Chagas disease

Effectiveness of a Myocardial Infarction Protocol in Reducing Door-to-Ballon Time

FUNDAMENTO: Tempo porta-balão adequado (< 120 minutos) é a condição necessária para que a eficácia da angioplastia primária no infarto se traduza em efetividade. OBJETIVO: Descrever a efetividade de um protocolo de qualidade assistencial para redução do tempo porta-balão. MÉTODOS: Entre maio de 2010 e agosto de 2012, foram analisados todos os indivíduos que realizaram angioplastia primária em nosso hospital. O momento porta foi registrado eletronicamente, pela retirada de senha para atendimento na emergência, o que antecede o preenchimento da ficha e a triagem. O momento balão foi definido como o início da abertura da artéria (passagem do primeiro dispositivo). Os primeiros 5 meses de monitoramento corresponderam ao período pré-implementação do protocolo. O protocolo se constituiu de definição do fluxo de ações, desde a chegada do paciente ao hospital, a sensibilização da equipe quanto à priorização do tempo e a apresentação periódica de parecer dos resultados e de possíveis inadequações. RESULTADOS: Foram avaliados 50 indivíduos, divididos em cinco grupos de 10 pacientes sequenciais (um grupo pré e quatro grupos pós-protocolo). O tempo porta-balão referente aos 10 casos registrados antes da implementação do protocolo foi de 200 ± 77 minutos. Após a implementação do protocolo, houve progressiva melhora do tempo porta-balão, para 142 ± 78 minutos nos 10 primeiros pacientes, seguida de 150±50 minutos, 131±37 minutos e, finalmente, 116 ± 29 minutos no três grupos sequenciais de 10 pacientes, respectivamente. Regressão linear entre pacientes sequenciais e tempo porta-balão (r = - 0,41) evidenciou coeficiente de regressão de - 1,74 minutos. CONCLUSÃO: A implementação do protocolo se mostrou efetiva na redução do tempo porta-balão

Comparison of ACUITY and CRUSADE Scores in Predicting Major Bleeding during Acute Coronary Syndrome

<sec><title>Background:</title><p>The ACUITY and CRUSADE scores are validated models for prediction of major bleeding events in acute coronary syndrome (ACS). However, the comparative performances of these scores are not known.</p></sec><sec><title>Objective:</title><p>To compare the accuracy of ACUITY and CRUSADE in predicting major bleeding events during ACS.</p></sec><sec><title>Methods:</title><p>This study included 519 patients consecutively admitted for unstable angina, non-ST-elevation or ST-elevation myocardial infarction. The scores were calculated based on admission data. We considered major bleeding events during hospitalization and not related to cardiac surgery, according to the Bleeding Academic Research Consortium (BARC) criteria (type 3 or 5: hemodynamic instability, need for transfusion, drop in hemoglobin ≥ 3 g, and intracranial, intraocular or fatal bleeding).</p></sec><sec><title>Results:</title><p>Major bleeding was observed in 31 patients (23 caused by femoral puncture, 5 digestive, 3 in other sites), an incidence of 6%. While both scores were associated with bleeding, ACUITY demonstrated better C-statistics (0.73, 95% CI = 0.63 - 0.82) as compared with CRUSADE (0.62, 95% CI = 0.53 - 0.71; p = 0.04). The best performance of ACUITY was also reflected by a net reclassification improvement of + 0.19 (p = 0.02) over CRUSADE’s definition of low or high risk. Exploratory analysis suggested that the presence of the variables ‘age’ and ‘type of ACS’ in ACUITY was the main reason for its superiority.</p></sec><sec><title>Conclusion:</title><p>The ACUITY Score is a better predictor of major bleeding when compared with the CRUSADE Score in patients hospitalized for ACS.</p></sec

Does C-reactive Protein Add Prognostic Value to GRACE Score in Acute Coronary Syndromes?

Fundamento: O valor prognóstico incremental da dosagem plasmática de Proteína C-reativa (PCR) em relação ao Escore GRACE não está estabelecido em pacientes com síndromes coronarianas agudas sem supradesnivelamento do segmento ST (SCA). Objetivo: Testar a hipótese de que a medida de PCR na admissão incrementa o valor prognóstico do escore GRACE em pacientes com SCA. Métodos: Foram estudados 290 indivíduos, internados consecutivamente por SCA, os quais tiveram material plasmático colhido na admissão para dosagem de PCR por método de alta sensibilidade (nefelometria). Desfechos cardiovasculares durante hospitalização foram definidos pela combinação de óbito, infarto não fatal ou angina refratária não fatal. Resultados: A incidência de eventos cardiovasculares durante hospitalização foi 15% (18 óbitos, 11 infartos, 13 anginas), tendo a PCR apresentado estatística-C de 0,60 (95% IC = 0,51 - 0,70; p = 0,034) na predição desses desfechos. Após ajuste para o Escore GRACE, PCR elevada (definida pelo melhor ponto de corte) apresentou tendência a associação com eventos hospitalares (OR = 1,89; 95% IC = 0,92 - 3,88; p = 0,08). No entanto, a adição da variável PCR elevada no modelo GRACE não promoveu incremento significativo na estatística-C, a qual variou de 0,705 para 0,718 (p = 0,46). Da mesma forma, não houve reclassificação de risco significativa com a adição da PCR no modelo preditor (reclassificação líquida = 5,7%; p = 0,15). Conclusão Embora PCR possua associação com desfechos hospitalares, esse marcador inflamatório não incrementa o valor prognóstico do Escore GRACE