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- ItemOutcomes of patients with left main coronary artery disease undergoing medical or surgical treatment: a propensity- matched analysis(Coronary Artery Disease, 2011)Objective: To evaluate the outcomes of patients with significant (≥ 50%) left main coronary artery disease (LMCAD) undergoing medical treatment (MT) or coronary artery bypass grafting surgery (CABG). Methods: A total of 181 patients with significant LMCAD were followed for 4 ± 2 years. MT was done when patients refused CABG or because of either thin native vessels or high clinical risk. Events were defined as all-cause death, myocardial infarction, percutaneous coronary intervention, or subsequent CABG. Logistic regression analysis was used to identify independent predictors of death. A propensity score was created to compare outcomes of patients from the two treatment groups. Results: CABG was performed in 78.5% of the patients. Overall, there were no significant differences in the incidences of death or other events between treatment groups. In patients with normal left ventricular (LV) function (ejection fraction, ≥ 45%), there were no significant differences in event rates with MT or CABG (death, 7.7 vs. 12.1%; myocardial infarction, 0 vs. 1.9%; percutaneous coronary intervention, 3.8 vs. 5.6%). For patients with LV dysfunction, death was more frequent with MT than with CABG (53.8 vs. 22.9%, P<0.001), whereas the incidence of other events was not statistically different. Age and LV dysfunction, but not treatment type, were independent predictors of death. When comparing propensity-matched patients from both treatment groups, there was also no difference in survival. Conclusion: Patients with 50% or more LMCAD and LV dysfunction had increased survival with CABG. However, outcomes of patients with 50% or more LMCAD and normal LV function were not significantly different with either MT or CABG.
- ItemAcetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial (ACT)(Circulation, 2011)Background: It remains uncertain whether acetylcysteine prevents contrast-induced acute kidney injury. Methods and results: We randomly assigned 2308 patients undergoing an intravascular angiographic procedure with at least 1 risk factor for contrast-induced acute kidney injury (age >70 years, renal failure, diabetes mellitus, heart failure, or hypotension) to acetylcysteine 1200 mg or placebo. The study drugs were administered orally twice daily for 2 doses before and 2 doses after the procedure. The allocation was concealed (central Web-based randomization). All analysis followed the intention-to-treat principle. The incidence of contrast-induced acute kidney injury (primary end point) was 12.7% in the acetylcysteine group and 12.7% in the control group (relative risk, 1.00; 95% confidence interval, 0.81 to 1.25; P=0.97). A combined end point of mortality or need for dialysis at 30 days was also similar in both groups (2.2% and 2.3%, respectively; hazard ratio, 0.97; 95% confidence interval, 0.56 to 1.69; P=0.92). Consistent effects were observed in all subgroups analyzed, including those with renal impairment. Conclusions: In this large randomized trial, we found that acetylcysteine does not reduce the risk of contrast-induced acute kidney injury or other clinically relevant outcomes in at-risk patients undergoing coronary and peripheral vascular angiography. Clinical trial registration: http://www.clinicaltrials.gov. Unique identifier: NCT00736866.
- ItemThe Association Between Physical Performance and Health-Related Quality of Life Based on the EQ-5D-3L Questionnaire in Patients With Chagas Disease(Value in Health Regional Issues, 2021)Objectives: Chagas disease (CD) is a chronic disease to millions worldwide, and many patients develop heart disease. In addition, they are part of an aging population. These characteristics can be associated with a reduction in physical performance and health-related quality of life (HRQoL). This study evaluated HRQoL, and the relationship between physical performance and HRQoL in patients with chronic CD. Methods: We used the 3-level version of EuroQol 5-dimensional questionnaire (EQ-5D-3L), with the visual analog scale (VAS). Physical performance was measured with 30-s chair-stand test (30sCST) and timed up and go test (TUGT). Results: Sixty-three patients were evaluated. The majority were women (68.2%) aged 67.7 ± 9.7 years. Overall EQ-5D-3L utility index was 0.65 ± 0.28, and VAS score was 68.4 ± 25.1. Most patients with intermediate and high performance in 30sCST referred no problems in the domains "mobility," "usual activities," and "pain/feeling ill" (P < .001, P = .01, and P = .025, respectively). In a similar way, most patients with intermediate and high performance in TUGT referred no problems in "mobility" (P < .0001) and "usual activities" (P = .001). Higher performance in both tests was associated with higher overall EQ-5D-3L utility and VAS scores. HRQoL measured by EQ-5D-3L was associated with physical status in a cohort of patients with chronic CD. The results underscore the contribution of physical performance, measured by 2 inexpensive and safe physical tests, to HRQoL in these patients. Conclusion: Strategies aiming the improvement of HRQoL in patients with CD may focus on mobility skills and force. Future studies evaluating interventions in physical performance should be a priority in these patients.
- ItemBudget Impact of Cryoablation Versus Radiofrequency Ablation of Atrial Fibrillation in the Brazilian Public Healthcare System(Value in Health Regional Issues, 2019)Background: Cryoablation is a new technology for ablation of atrial fibrillation (AF), effective and safe when compared with standard radiofrequency (RF) ablation. Nevertheless, the economic impact of its incorporation is unknown, especially considering the public health system of a developing country. This study analyzed the budget impact of cryoablation incorporation for treatment of paroxysmal AF in the Brazilian public health system. Methods: The budget impact was calculated as the cost difference between the current scenario (RF ablation guided by electroanatomic mapping) and the new scenario (cryoablation). The cost of each intervention was obtained by multiplying the price of a single procedure by the number of candidates for it. Other technologies (RF ablation guided by intracardiac echocardiography or with a nonirrigated catheter) were considered in a sensitivity analysis. Results: The budget impact showed savings of $43 097 096.84 with cryoablation. In the sensitivity analysis, cryoablation resulted in cost savings compared with RF ablation guided by intracardiac echocardiography, whereas in comparison to RF ablation with the nonirrigated catheter, cryoablation was more expensive. A market share assessment, performed using an incorporation rate of 3% per year, indicated savings of approximately $800 000 per 5 years. Conclusions: Cryoablation of AF resulted in cost savings compared with the current scenario (RF ablation guided by electroanatomic mapping). When alternative technologies were considered, cryoablation was more expensive than RF ablation with a nonirrigated catheter, but it also resulted in savings compared with RF ablation guided by intracardiac echocardiography. Overall, cryoablation of AF may reduce expenditures in the Brazilian public health system.
- ItemFeasibility analysis of changing the decision-making in health management with scarce resources(Business and Management Review, 2014)Heart failure is the final pathway of most diseases that involve the heart, as a challenge in health management. Heart transplantation is a viable strategy for patients in end-stage disease. The donor shortage requires a process to ensure the appropriate selection of the recipient. In Brazil there is a single list of candidates in chronological order of arrival, the existence of a risk score could dynamically allocate these patients. The purpose of this analysis is to assess the feasibility of changing the allocation process of candidates for heart transplantation according to the IMPACT score. This research is prospective observational retrospective analysis of transplanted cohort at the National Institute of Cardiology. The study included 42 patients and IMPACT score of six or more is associated with the highest mortality after transplantation. Allocation of patients according to their IMPACT score can facilitate decision making about which candidate must be transplanted.