Existe concordância no acometimento renal e retiniano da microangiopatia diabética?

Associations of microangiopathy with risk factors, correlation of diabetic nephropathy (DN) and retinopathy (DR) as well as the concordance between different degrees of these complications were evaluated. 157 patients submitted to indirect ophtalmoscopy were referred to the Diabetes Center for the screening of DN. A standardized questionnaire including socio-demographic and clinical aspects was applied. Glycemic control was assessed by glycated hemoglobin and DN by the presence of microalbuminuria. Scores were given to DR and DN to test correlation and concordance. 103 patients (57.9±12.9 yrs) completed all the steps of the study; 72% of the referred patients had any DR, who did not differ from those without DR concerning their main characteristics. Patients were stratified into 4 groups according to the presence or absence of each complication. No difference was observed concerning gender and skin color distributions and years in school among the groups. Duration of DM was longer in patients with DN+DR as compared to those without DR, with or without DN (14.8±6.4 vs. 7.2±5.3 and 9.2±5.6 yrs, p< 0.05, respectively). Frequencies of smokers and self-reported dyslipidemia, BMI, glycemia and glycated hemoglobin did not differ among the groups. Patients with both complications showed higher mean blood pressure than those without DR, with or without DN (147±23 vs. 128±20 and 118±18mmHg, p< 0.05, respectively). Patients with DN, independent of the presence of DR, had higher A/C than those without DN (p< 0.05); A/C of the normal group and that with only DR were not different. High A/C levels in patients with both complications did not differ from the DN patients without DR. 80% of DN patients showed DR, while 74% of DR patients also had DN (c2= 6.39, p< 0.05). Significant correlation was detected between the 2 complications (r= 0.47, p< 0.05), as well as the concordance between their degrees, whose kappa was 0.154 (95%CI, 0.031-0.276, p< 0.01). Hypertension was associated with severe cases with both complications. The occurrence of microvascular complication in the absence of the other may suggest organ-specific pathogenetic factors. Our data indicated concordance between degrees of renal or retinal lesions in the microangiopathy of DM2. Patients with DN had higher risk of retinal disease. Even in microalbuminuric phase, the finding of abnormal A/C in a diabetic patient requires screening for DR.Avaliamos associações da microangiopatia a fatores de risco, a correlação entre nefropatia (ND) e retinopatia (RD) diabéticas, assim como a concordância entre os graus de acometimento destes territórios. 157 pacientes, submetidos a oftalmoscopia indireta, foram encaminhados ao Centro de Diabetes para pesquisa de ND, sendo obtidos dados sócio-demográficos e clínicos. Avaliou-se o controle glicêmico pela hemoglobina glicosilada e a presença de ND pela microalbuminúria. Atribuiu-se escores à RD e ND para análises de correlação e concordância. 103 pacientes (57,9±12,9 anos) completaram todas as etapas do estudo; 72% dos encaminhados apresentavam algum grau de RD, sendo que normais e retinopatas tinham características comparáveis. Foram subdivididos em 4 grupos segundo a presença ou ausência de cada complicação. Não houve diferença na distribuição quanto a sexo, raça e escolaridade. O tempo de DM foi maior naqueles com ND+RD quando comparados ao grupo sem RD, com ou sem ND (14,8±6,4 vs. 7,2±5,3 e 9,2±5,6 anos, p< 0,05, respectivamente). A freqüência de fumantes e dislipidemia auto-referida, o IMC, glicemia e hemoglobina glicosilada não diferiram entre os grupos. Pacientes com ambas as complicações tinham pressão arterial média maior que os grupos sem RD, com ou sem ND (147±23 vs. 128±20 e 118±18mmHg, p< 0,05, respectivamente). Indivíduos com ND, independente da presença de RD, apresentaram razão Albumina/Creatinina (A/C) mais alta que os grupos sem ND (p< 0,05); o grupo com apenas RD não diferiu do grupo normal. Os maiores níveis de A/C do grupo com ambas as complicações não diferiram estatisticamente dos nefropatas sem RD. 80% dos pacientes nefropatas apresentavam RD, enquanto 74% dos retinopatas tinham também ND (c2= 6,39; p< 0,05). Detectou-se correlação significante entre estas complicações (r= 0,47; p< 0,05), assim como a concordância entre seus graus, resultando em kappa de 0,154 (IC 95%: 0,031-0,276; p< 0,01). A hipertensão se associou aos casos de maior gravidade, caracterizados pela concomitância de RD e ND. A ocorrência de uma complicação microvascular na ausência de outra sugere a existência de fatores etiopatogênicos órgão-específicos. Nossos dados indicam correspondência entre os graus de lesão renal e retiniana na microangiopatia do DM2. Pacientes com ND se associam a maior risco de lesões retinianas, de modo que o encontro de A/C alterada em paciente diabético requer, ainda que na faixa microalbuminúrica, a investigação de acometimento retiniano.Universidade Federal de São Paulo (UNIFESP) Oftalmologia e Medicina Departamentos de Medicina PreventivaUNIFESP, Oftalmologia e Medicina Depto.s de Medicina PreventivaSciEL

Predictors of rescue percutaneous coronary intervention after pharmacoinvasive strategy in women

AbstractBackgroundPharmacoinvasive therapy (PIT) is feasible in patients with acute myocardial infarction with ST-segment elevation (STEMI) when timely primary percutaneous coronary intervention (PCI) is unavailable. In this study, we compared women who underwent successful reperfusion PIT with those who required rescue PCI, to identify potential predictors of thrombolytic failure.MethodsFrom January 2010 to November 2014, 327 consecutive women with STEMI were referred to a tertiary hospital, 206 after successful thrombolysis (63%) and 121 who required rescue PCI. The groups were compared regarding demographic, clinical and angiographic outcomes, and clinical (TIMI, GRACE, and ZWOLLE CADILLAC) and bleeding (CRUSADE) risk scores. A multivariate logistic regression model was used to identify predictors of thrombolytic failure.ResultsThere was no significant difference between the demographic characteristics or the medical history of the groups. Rescue PCI group had significantly higher values of the evaluated scores. Clinical hospital complications and mortality (2.5% vs. 22.0%; p < 0.0001) were more frequent in rescue PCI group. The independent variables associated with rescue PCI were pain-to-needle time > 3h (OR: 3.07, 95%CI: 1.64 to 5.75; p < 0.0001), ZWOLLE score (OR: 1.25; 95%CI: 1.14 to 1.37; p = 0.0001) and creatinine clearance (OR: 1.009, 95%CI: 1.0 to 1.02; p = 0.04).ConclusionsWomen with STEMI who underwent PIT and who required rescue PCI had significantly higher mortality compared to those who achieved initial success of PIT with elective PCI. Pain-to-needle time > 3h, ZWOLLE score and creatinine clearance were independent predictors of the need for rescue PCI