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OBJECTIVE: To assess whether female sex is a factor independently related to in-hospital mortality in acute myocardial infarction. METHODS: Of 600 consecutive patients (435 males and 165 females) with acute myocardial infarction, we studied 13 demographic and clinical variables obtained at the time of hospital admission through uni- and multivariate analysis, and analyzed their relation to in-hospital death. RESULTS: Females were older (p<0.001) and had a higher incidence of hypertension (p<0.001). Males were more frequently smokers (p<0.001). The remaining risk factors had a similar incidence among both sexes. All variables underwent uni- and multivariate analysis. Through univariate analysis, the following variables were found to be associated with in-hospital death: female sex (p<0.001), age >70 years (p<0.001), the presence of previous coronary artery disease (p=0.0004), previous myocardial infarction (p<0.001), infarction in the anterior wall (p=0.007), presence of left ventricular dysfunction (p<0.001), and the absence of thrombolytic therapy (p=0.04). Through the multivariate analysis of logistic regression, the following variables were associated with in-hospital mortality: female sex (p=0.001), age (p=0.008), the presence of previous myocardial infarction (p=0.02), and left ventricular dysfunction (p<0.001). CONCLUSION: After adjusting for all risk variables, female sex proved to be a variable independently related to in-hospital mortality in acute myocardial infarction.

Assuntos

Assuntos

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Chest pain is one of the most common reasons for patients coming to emergency departments. Most of these individuals end up being hospitalized due to uncertainty of the cause of their complaint. This aggressive and defensive attitude is taken by emergency physicians because some 10 to 30% of these patients actually have acute coronary syndrome. As the admission electrocardiogram and serum CK-MB level have a sensitivity of about 50% for the diagnosis of acute myocardial infarction, serial evaluation is mandatory for non-low risk patients. Inspite of this knowledge, an average of 2-3% of patients with acute myocardial infarction are erroneously released from emergency departments, what is responsible for expensive malpractice suits in the United States. Chest Pain Units were introduced in emergency practice two decades ago to improve medical care quality, reduce inappropriate hospital discharges, reduce unnecessary hospital admissions and reduce medical costs, thus making patient's assessment cost-effective. This is achieved mostly with the use of systematic diagnostic protocols by qualified and trained personnel in the emergency department setting and not in the coronary care unit.

Assuntos

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OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a preestablished process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74% of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12%) had AMI without ST segment elevation and 202 (31%) had unstable angina (UA). In route 2 (high probability of ACS) 17% of patients had AMI and 43% had UA, whereas in route 3 (low probability) 2% had AMI and 7% had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI (49%), with a positive predictive value considered only satisfactory (79%). CONCLUSION: A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.

Assuntos

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PURPOSE: To evaluate the efficacy of a systematic model of care for patients with chest pain and no ST segment elevation in the emergency room. METHODS: From 1003 patients submitted to an algorithm diagnostic investigation by probability of acute ischemic syndrome. We analyzed 600 ones with no elevation of ST segment, then enrolled to diagnostic routes of median (route 2) and low probability (route 3) to ischemic syndrome. RESULTS: In route 2 we found 17% acute myocardial infarction and 43% unstable angina, whereas in route 3 the rates were 2% and 7%, respectively. Patients with normal/non-specific ECG had 6% probability of AMI whereas in those with negative first CKMB it was 7%; the association of the 2 data only reduced it to 4%. In patients in route 2 the diagnosis of AMI could only be ruled out with serial CKMB measurement up to 9 hours, while in route 3 it could be done in up to 3 hours. Thus, sensitivity and negative predictive value of admission CKMB for AMI were 52% and 93%, respectively. About one-half of patients with unstable angina did not disclose objective ischemic changes on admission. CONCLUSION: The use of a systematic model of care in patients with chest pain offers the opportunity of hindering inappropriate release of patients with ACI and reduces unnecessary admissions. However some patients even with normal ECG should not be released based on a negative first CKMB. Serial measurement of CKMB up to 9 hours is necessary in patients with medium probability of AMI.

Assuntos

RESUMO

OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74% of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12%) had AMI without ST segment elevation and 202 (31%) had unstable angina (UA). In route 2 (high probability of ACS) 17% of patients had AMI and 43% had UA, whereas in route 3 (low probability) 2% had AMI and 7 % had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI ( 49%), with a positive predictive value considered only satisfactory (79%). CONCLUSION: A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.

RESUMO

OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74% of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12%) had AMI without ST segment elevation and 202 (31%) had unstable angina (UA). In route 2 (high probability of ACS) 17% of patients had AMI and 43% had UA, whereas in route 3 (low probability) 2% had AMI and 7% had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI (49%), with a positive predictive value considered only satisfactory (79%). CONCLUSION: A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.

Assuntos

RESUMO

PURPOSE: To identify clinical variables on admission that are related to hospital mortality in acute myocardial infarction (AMI) and to generate a mathematic model to predict accurately this mortality. METHODS: Prospective study with 347 consecutive patients with AMI in which clinical variables related to mortality were identified by univariate and multivariate analysis. The mathematic model generated by multivariate logistic regression analysis was applied in each patient to determine his/her probability (P) of hospital death. Model's accuracy was validated by reliability and discrimination tests. RESULTS: Admission variables directly and independently related to hospital mortality: female gender, age, absence of history of hypertension, history of previous infarction, non-inferior AMI and Killip class. These six variables, when present cumulatively, showed increasing mortality rates. Mean P value for non-survivors was significantly greater than for survivors (43.2 +/- 31.4% vs 9.1 +/- 12.5%, p < 0.00001). Reliability of the model to predict death, assessed by stratifying patients in three risk groups (low, medium and high) or continuously (by linear regression analysis) showed excellent predictive performance. Discrimination between survivors and non-survivors, assessed by C-index (concordance probability), disclosed 85% rate of success. CONCLUSION: Risk variables can be used in a mathematic model that is capable of predicting accurately in-hospital mortality of each patient with AMI. Mortality prediction can allow physicians to be more efficient in assessing risk-benefit ratios in these patients when faced with therapeutic decisions.

Assuntos

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PURPOSE: To determine the relationship among clinical data, attenuated treadmill stress test (ST), cinecoronaryarteriography (CINE), ejection fraction (EF) with early-late mortality in patients after acute myocardial infarction (AMI). METHODS: Prospective study in 96 consecutive patients aged < 70 with AMI that were submitted to ST and CINE. Assessment of cardiac mortality was made 1-3 years post-AMI (period I) and at the end of follow-up (7-10 years-period II). RESULTS: First year and 10th year mortalities were 8% and 36%, respectively. Positive predictive value for cardiac death in period I was 10% for ST, 7% for multivessel coronary artery disease (MVCAD) and 9% for left ventricular ejection fraction (LVEF) < 30, while in period II they were 45%, 42% and 50%, respectively. Actuarial survival analysis (Kaplan-Meyer) disclosed mortality rates of 53% and 20% (p = 0.06) on period II for positive and negative ST, respectively, 45% and 22% (p < 0.03) for MVCAD and single-vessel disease, respectively, and 73% and 35% (p < 0.001) for those with and without left main coronary artery obstruction, respectively. In the multivariate regression analysis (Cox's model), only MVCAD (p < 0.002), LVEF < 30 (p < 0.003), positive ST (p < 0.007) and post-AMI angina (p < 0.01) were independently related to late mortality. CONCLUSION: Both attenuated ST and CINE are poor predictors of post-AMI early and late mortalities. However, multivariate regression analysis disclosed positive ST, MVCAD and LVEF < 30 as independent variables related to late mortality. This data indicate that myocardial ischemia, number of obstructed coronary arteries and poor left ventricular systolic function are the true determinants of post-infarction cardiac mortality.

Assuntos