à Use of Class III is discouraged by the ESC. Levels of EvidenceLevel of Evidence A Data derived from multiple randomized clinical trials or meta-analyses Level of Evidence B Data derived from a single randomized clinical trial or large nonrandomized studies Level of Evidence C Consensus of opinion of the experts and/or small studies; retrospective studies and registriesFigure 1 Clinical classification of the mode of heart failure (Forrester classification).H I-IV refers to haemodynamic severity, with reference figures for CI and pulmonary capillary pressures shown on the vertical and horizontal axes, respectively.C I-IV refers to clinical severity.
O enfarte agudo do miocárdio com elevação de ST (EAMcST) constitui uma emergência médica, beneficiando de um acesso rápido a cuidados diferenciados. O objetivo deste estudo foi avaliar a evolução do transporte através da emergência pré‐hospitalar (EPH) e o seu impacto nos eventos clínicos. Estudo retrospetivo de doentes com EAMcST, submetidos a intervenção coronária percutânea primária entre janeiro de 2008 e julho de 2015. Os doentes foram divididos de acordo com o modo de transporte/admissão. Para cada grupo foi analisado tempo isquémico total (TIT), tempo porta‐balão (TPB) e eventos intra‐hospitalares e a um ano. De um total de 764 doentes, 33,5% foram transportados pela EPH, 45,8% chegaram por meios próprios, 13,7% transferidos de outra instituição e 6,9% pelos bombeiros. Nos últimos oito anos, verificou‐se uma tendência para uma utilização crescente da EPH. O grupo EPH, comparado com os restantes (não‐EPH), englobou uma percentagem maior de doentes com enfarte prévio, em classe III/IV Killip e apresentou uma redução significativa do TIT e TPB (195 versus 286 minutos p < 0,001 e 61 versus 90 minutos p < 0,001), mas não se verificaram diferenças significativas na taxa de eventos hospitalares ou a um ano. Os doentes que se apresentaram mais precocemente obtiveram taxas mais elevadas de reperfusão eficaz e menor mortalidade intra‐hospitalar (6,9 versus 33,9% p < 0,001). Verificou‐se um impacto significativo da ativação da EPH na redução dos tempos de isquemia. Apesar de essa melhoria não se ter associado de forma direta a diferenças significativas na taxa de eventos, associou‐se a taxas mais elevadas de reperfusão eficaz, que se refletiram numa redução da mortalidade intra‐hospitalar. ST‐elevation myocardial infarction (STEMI) is a medical emergency that benefits from rapid access to specialized care. The objective of this study was to describe developments in patient transport via the pre‐hospital emergency medical system (EMS) and its impact on clinical outcomes. We retrospectively studied STEMI patients who underwent primary percutaneous coronary intervention between January 2008 and July 2015. Patients were divided according to type of admission. Total ischemic time (TIT), door‐to‐balloon time (DBT) and in‐hospital and one‐year clinical outcomes were assessed for each group. A total of 764 patients were included, of whom 33.5% were transported by the EMS and 45.8% by their own means, 13.7% were transferred from another institution and 6.9% were transported by non‐EMS ambulance. There was a trend for more frequent recourse to the EMS over the eight‐year period. There was a higher percentage of patients with prior myocardial infarction and Killip class III/IV in the EMS group compared to the non‐EMS group. Significant differences were seen between groups in reperfusion times, EMS patients having the shortest TIT and DBT (195 vs. 286 min, p<0.001 and 61 vs. 90 min, p<0.001, respectively), but no significant difference in event rates was observed. Patients presenting to the hospital early had higher rates of effective reperfusion and lower in‐hospital mortality (6.9% vs. 33.9%, p<0.001). Recourse to the EMS significantly reduced ischemic times. Although this improvement was not directly associated with significant differences in event rates, it was associated with higher rates of effective reperfusion that were reflected in lower in‐hospital mortality.
Proton pump inhibitors (PPIs) are usually prescribed to patients undergoing dual antiplatelet therapy to decrease the risk of gastrointestinal bleeding. Recent studies have raised concerns that PPIs could reduce clopidogrel's efficacy by competitive inhibition of cytochrome P450 2C19 isoenzyme. All PPIs are metabolized by cytochrome P450 2C19, although to varying degrees, and according to in-vitro studies, pantoprazole is the weakest inhibitor of this isoenzyme. We hypothesized that this drug interaction might not be a class effect.One month after an acute myocardial infarction 34 consecutive patients undergoing dual antiplatelet therapy were prospectively analyzed. Platelet function was measured (VerifyNow system), in each patient, in three consecutive clinical scenarios: (i) first, after a 1-month washout period, without any PPI, (ii) after a 4-week period taking omeprazole 40 mg, and (iii) after another 1-month washout period, followed by 4-weeks taking pantoprazole 40 mg. In this crossover trial, patients were first randomized to receive either omeprazole or pantoprazole.We observed a significant reduction in clopidogrel's effect when patients were initiated with omeprazole; the mean P2Y12 reaction units (PRU) increased from 202±52 to 235±58 with omeprazole (P<0.001). With pantoprazole, clopidogrel efficacy was preserved (PRU 215±54, P=0.16). Without any PPI, 26% of patients were 'nonresponders' to clopidogrel (PRU >240) but when patients started omeprazole, this proportion increased to 45 versus 23% with pantoprazole.In this randomized crossover study analyzing patients after acute myocardial infarction, omeprazole coadministration showed a significant pharmacodynamic interaction with clopidogrel, whereas pantoprazole did not. These data suggest that the clopidogrel-PPIs drug interaction may not be a class effect.
The association of the Mediterranean diet and exercise appears to have a protective role, reducing cardiovascular risk. This study investigated the effects of education sessions on the Mediterranean diet and an exercise program in modifying eating behaviors, body composition and abdominal fat. An experimental study was performed on 20 subjects with known coronary heart disease randomly assigned to experimental (n=10) and control (n=10) groups. Both groups received education sessions on the Mediterranean diet, but the experimental group also followed an eight-week program of specific exercises. A semiquantitative food frequency questionnaire was administered to analyze food intake, bioimpedance was used to measure weight, fat mass and lean mass, and waist circumference was measured to calculate waist-to-height ratio. After eight weeks, protein (p<0.05) and cholesterol (p<0.05) intake in the experimental group had decreased significantly compared with the control group. Between the beginning and end of the study, there were significant decreases in the control group in carbohydrate (p<0.05) and saturated fat intake (p<0.05). In both groups the percentage of total fat (p<0.05) and fat mass (p<0.05) was significantly decreased. In the experimental group the waist-to-height ratio was significantly reduced (p<0.05). The Mediterranean diet reduced carbohydrate and saturated fat intake, reflected in reduced fat mass. The association of the exercise program showed additional benefits in reduction of protein and cholesterol intake and abdominal fat. A associação da dieta mediterrânica e de exercício físico parecem apresentar um papel protetor na diminuição do risco cardiovascular. Este estudo pretende verificar os efeitos de sessões de educação fundamentadas na dieta mediterrânica e de um programa de exercícios na modificação de comportamentos alimentares, composição corporal e gordura abdominal. Estudo experimental composto por 20 indivíduos, com doença arterial coronária conhecida, distribuídos aleatoriamente em dois grupos: experimental (n = 10) e controlo (n = 10). Ambos os grupos foram sujeitos às sessões de educação para a saúde, mas o grupo experimental executou um programa suplementar de exercícios específicos durante oito semanas. Foi utilizado o questionário semiquantitativo de frequência alimentar para análise da ingestão de alimentos, a bioimpedância para medição do peso, massa gorda e massa magra, e o perímetro da cintura para cálculo da razão cintura-estatura. Após as oito semanas, o grupo experimental ingeriu significativamente menos proteínas (p < 0,05) e colesterol (p < 0,05) em comparação com o grupo controlo. Do momento inicial para o final, verificou-se apenas no grupo controlo uma diminuição significativa na ingestão de hidratos de carbono (p < 0,05) e de gorduras saturadas (p < 0,05). Ambos os grupos diminuíram significativamente a percentagem de gordura total (p < 0,05) e massa gorda (p < 0,05). O grupo experimental diminuiu significativamente a razão cintura-estatura (p < 0,05). A dieta mediterrânica reduziu a ingestão alimentar de hidratos de carbono e gorduras saturadas, refletindo-se na redução da massa gorda. A associação do programa de exercícios demonstrou benefícios acrescidos na diminuição da ingestão de proteínas e de colesterol, assim como na redução da gordura abdominal.
Synthesis and physico-chemical properties of six 3-(4-bromophenacyl)-5-arylidene-thiazolidine-2,4-diones and eight 3-(4-chlorobenzyl)-5-arylidene-4-thio-imidazolidine-2-ones are described. These products were synthesized by an aldolisation-crotonisation reaction from aromatic aldehydes and 3-substituted thiazolidine-2,4-diones or 4-thio-imidazolidine-2-ones. Hypoglycemic and peripheral antinociceptive activities were investigated for these compounds.
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