Risk scores and acute coronary syndrome

Rosa, Eduardo Maffini da; Tormen, William Cenci; May, William Schalins

doi:10.1590/S0066-782X2010001500018

Acute coronary syndrome/therapy; diagnostic; prognosis

LETTER TO THE EDITOR

Universidade de Caxias do Sul - Liga Acadêmica de Estudos e Ações em Cardiologia, Caxias do Sul, RS - Brazil

Mailing address

Keywords: Acute coronary syndrome/therapy; diagnostic; prognosis.

Dear Editor,

Our study group on coronary diseases would like to congratulate the authors for the original article publication in this journal (Arq. Bras. Cardiol. 2009; 93(4): 343-351)¹, presenting a risk score for acute coronary syndrome without ST segment supra-unlevelling

First of all, despite the existence of other risk stratification models, we believe that the new scores are necessary, because they reflect not only the natural history of the disease, but the interaction between this and the moment diagnostic, therapeutic and prognostic capacity. Thus, the risk scores that were good in the past may not be so precise in the future^2-4.

Finally, as we find it a relevant issue, we would like to know the therapeutic strategies used in such study patients.

References

1. Santos ES, Timerman A, Baltar VT, Castillo MTC, Pereira MP, Minuzzo L, et al. Escore de risco Dante Pazzanese para síndrome coronariana aguda sem supradesnivelamento do segmento ST. Arq Bras Cardiol. 2009; 93 (4): 343-51.

2. Laurenti R, Buchalla CM, Caratin V de S. Ischemic heart disease: hospitalization, length of stay and expenses in Brazil from 1993 to 1997. Arq Bras Cardiol. 2000; 74 (6): 483-92.

3. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Jr., et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation. 2007; 116 (7): e148-304.

4. Boersma E, Pieper KS, Steyerberg EW, Wilcox RG, Chang WC, Lee KL, et al. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation: results from an international trial of 9461 patients. The PURSUIT Investigators. Circulation. 2000; 101 (22): 2557-67.

Reply to the editor

Dear Editor,

The First Aid Clinic of Instituto Dante Pazzanese de Cardiologia corresponds to an emergency section open to care and hospitalization in the most different clinical situations, where patients with acute coronary syndrome (ACS) correspond to almost 40.0% of these hospitalizations¹. The patient's medical conduct with ACS without ST supra (unstable angina or acute infarctation of the myocardium) is based on the recommendations of the national and international guidelines^2,3.

The population of patients of risk score development Dante Pazzanese⁴ receives intensive medication with betablockers (93,0%), acetylsalicylic acid (97.5%), endovenous nitroglycerin (94.3%), antithrombinics (84.3%), thienopyridinics (89.5%), angiotensin converter enzyme inhibitor (84.1%) and statins (94.4%). All medications were started in the hospitalization.

The indication of cinecoronariography was based on the presence of independent variables for the adverse event risks, such as: clinical history data, acute ischemic changes of the electrocardiogram or increase of the myocardic necrosis markers. The cinecoronariography was requested in the first 48 hours after the hospitalization and was performed in 734 patients (71.5%).

The myocardic revascularization (MR) procedure, percutaneous coronary intervention (PCI) or surgery, was indicated in 417 patients (40.6%) of the global population [PCI 276 patients (26.9%); MR surgery 141 patients (13.7%)].

Analyzing only the patients who underwent the cinecoronariography, the MR procedure indication occurred in 373 patients (50.8%), where the PCI indication occurred in 259 (35.3%) and surgery in 114 (15.5%).

References

Resposta aos autores

Prezado Editor,

O Pronto-Socorro do Instituto Dante Pazzanese de Cardiologia corresponde a uma seção de emergências aberta a atendimentos e internações das mais diversas situações clínicas, onde pacientes com síndrome coronariana aguda (SCA) correspondem a quase 40,0% destas internações¹. A conduta médica dos pacientes com SCA sem supra de ST (angina instável ou infarto agudo do miocárdio) é baseada nas recomendações das diretrizes nacionais e internacionais^2,3.

Os pacientes da população de desenvolvimento do escore de risco Dante Pazzanese⁴ foram intensamente medicados com betabloqueador (93,0%), ácido acetilsalicílico (97,5%), nitroglicerina endovenosa (94,3%), antitrombínicos (84,3%), tienopiridínicos (89,5%), inibidor da enzima conversora da angiotensina (84,1%) e estatina (94,4%). Todos os medicamentos foram iniciados na admissão hospitalar.

A indicação de cinecoronariografia foi baseada na presença de variáveis independentes para o risco de eventos adversos, como: dados da história clínica, alterações isquêmicas agudas do eletrocardiograma ou elevação dos marcadores de necrose miocárdica. A cinecoronariografia foi solicitada nas primeiras 48 horas da internação e foi realizada em 734 pacientes (71,5%).

O procedimento de revascularização miocárdica (RM), seja intervenção coronariana percutânea (ICP) ou cirurgia, foi indicado em 417 pacientes (40,6%) da população global [ICP 276 pacientes (26,9%); cirurgia de RM 141 pacientes (13,7%)].

Analisando apenas os pacientes submetidos à cinecoronariografia, a indicação de procedimento de RM ocorreu em 373 pacientes (50,8%), onde a indicação de ICP ocorreu em 259 (35,3%) e de cirurgia em 114 (15,5%).

Referências

1. Santos ES, Timerman A, Baltar VT, Castillo MTC, Pereira MP, Minuzzo L, et al. Escore de risco Dante Pazzanese para síndrome coronariana aguda sem supradesnivelamento do segmento ST. Arq Bras Cardiol. 2009; 93 (4): 343-51.
2. Laurenti R, Buchalla CM, Caratin V de S. Ischemic heart disease: hospitalization, length of stay and expenses in Brazil from 1993 to 1997. Arq Bras Cardiol. 2000; 74 (6): 483-92.
3. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Jr., et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation. 2007; 116 (7): e148-304.
4. Boersma E, Pieper KS, Steyerberg EW, Wilcox RG, Chang WC, Lee KL, et al. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation: results from an international trial of 9461 patients. The PURSUIT Investigators. Circulation. 2000; 101 (22): 2557-67.
1. Santos ES, Minuzzo L, Pereira MP, Castillo MTC, Palacio MA, Ramos RF, et al. Registro de síndrome coronariana aguda em um centro de emergências em cardiologia. Arq Bras Cardiol. 2006; 87 (5): 597-602.
2. Sociedade Brasileira de Cardiologia. Diretrizes sobre Angina instável e infarto agudo do miocárdio sem supradesnível do segmento ST: Parte II: condutas nos pacientes de risco intermediário e alto. Arq Bras Cardiol. 2001; 77 (supl 2): 23-37.
3. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et al. ACC/AHA 2007 Guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2007; 116 (7): e148 - 304.
4. Santos ES, Timerman A, Baltar VT, Castillo MTC, Pereira MP, Minuzzo L, et al. Escore de risco Dante Pazzanese para Síndrome Coronariana Aguda sem Supradesnivelamento do Segmento ST. Arq Bras Cardiol. 2009; 93 (4): 343-51.