Journal Information
Vol. 30. Issue 10.
Pages 771-779 (October 2011)
Vol. 30. Issue 10.
Pages 771-779 (October 2011)
Artigo original
Open Access
Implicações prognósticas da pressão telediastólica do ventrículo esquerdo nas síndromes coronárias agudas com fracção de ejecção maior ou igual a 40%
Prognostic implications of left ventricular end-diastolic pressure in acute coronary syndromes with left ventricular ejection fraction of 40% or over
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Rogério Teixeira
Corresponding author
rogeriopteixeira@gmail.com

Autor para correspondência.
, Carolina Lourenço, Rui Baptista, Elisabete Jorge, Paulo Mendes, Fátima Saraiva, Sílvia Monteiro, Francisco Gonçalves, Pedro Monteiro, Maria João Ferreira, Mário Freitas, Luís Providência
Serviço de Cardiologia, Hospitais da Universidade de Coimbra, Coimbra, Portugal
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Article information
Resumo
Introdução

Permanecem dúvidas sobre o impacto prognóstico a longo prazo da pressão telediastólica do ventrículo esquerdo (PTDVE) no contexto de uma síndrome coronária aguda (SCA).

Objectivo

Caracterizar a PTDVE e o seu impacto prognóstico numa população de doentes com SCA e fracção de ejecção ventricular esquerda (FEVE) ≥ a 40%.

População e métodos

Estudo prospectivo, longitudinal e contínuo de 1329 doentes admitidos (n=489) numa unidade de cuidados intensivos coronários entre 2004 e 2006. Foram seleccionados os doentes submetidos a uma estratégia invasiva, no qual foi determinada a PTDVE, com FEVE ≥ 40%. A população foi divida em três grupos: A — PTDVE ≤ 19mmHg (n=186); grupo B — PTDVE > 19 ≤ 27mmHg (n=172) e; grupo C — PTDVE > 27mmHg (n=131). O resultado primário desta análise foi a readmissão por insuficiência cardíaca congestiva (ICC) no ano seguinte à SCA.

Resultados

A PTDVE média da população foi de 22,8mmHg±7,8 mmHg. Os grupos eram homogéneos entre si no que disse respeito ao género, idade, factores de risco cardiovascular, história cardiovascular e medicação prévia à admissão. Quanto maior a PTDVE maior a probabilidade de uma admissão por enfarte agudo do miocárdio com supradesnivelamento do segmento ST (35,4 versus 45,9 versus 56,7%, p<0,01), maior a libertação de marcadores de necrose miocárdica, e menor a FEVE (56,5±7,0 versus 55,3±7,6 versus 53,0±7,5%, p<0,01). Não foram detectadas diferenças entre os grupos relativamente à anatomia coronária, revascularização, terapêutica médica intra-hospitalar e à data de alta, e mortalidade intra-hospitalar. Quanto ao resultado primário desta análise, a sobrevida livre de readmissão por ICC foi superior para os doentes com menor PTDVE — 99,4 versus 97,6 versus 94,4%, log rank p=0,02. A PTDVE (sob a forma de um incremento de 5 em 5mmHg), foi um preditor independente para a readmissão por ICC, quando ajustada para as seguintes variáveis: idade (incremento de 10 em 10 anos), FEVE (incremento de 5 em 5%), pico de troponina I (incremento de 5 em 5U/L) insuficiência renal (taxa de filtração glomerular menor a 60ml/min), fibrilhação auricular, prescrição de diuréticos às 24 horas, e de beta-bloqueante à data de alta. Por cada 5mmHg de aumento da PTDVE o risco de uma readmissão por ICC um ano após a SCA aumentou 1,97 vezes (RR 1,97, IC 95% 1,10–3,54, p=0,02).

Conclusão

Na população referida a PTDVE teve um impacto prognóstico importante a longo prazo relativamente à readmissão, hospitalar por ICC.

Palavras-chave:
Síndromes coronárias agudas
Pressão telediastólica do ventrículo esquerdo
Prognóstico
Abstract
Introduction

There is still debate concerning the impact of left ventricular end-diastolic pressure (LVEDP) on long-term prognosis after an acute coronary syndrome (ACS).

Objective

To assess LVEDP and its prognostic implications in ACS patients with left ventricular ejection fraction (LVEF) ≥40%.

Methods

We performed a prospective, longitudinal study of 1329 ACS patients from a single center between 2004 and 2006. LVEDP was assessed at the beginning of the coronary angiogram. Patients with LVEF >40% were excluded (n=489). The population was divided into three groups: A — LVEDP ≤19mmHg (n=186); B — LVEDP >19 and ≤27mmHg (n=172); and C — LVEDP >27mmHg (n=131). The primary endpoint of the analysis was readmission for congestive heart failure in the year following the index admission.

Results

Mean LVEDP was 22.8±7.8mmHg. The groups were similar age, gender, cardiovascular risk factors, cardiovascular history, and medication prior to admission. There was an association between higher LVEDP and: admission for ST-elevation acute myocardial infarction (35.4 vs. 45.9 vs. 56.7%, p<0.01), higher peak levels of cardiac biomarkers, and lower LVEF (56.5±7.0 vs. 55.3±7.6 vs. 53.0±7.5%, p<0.01). There were no significant differences between the groups in terms of coronary anatomy, medical therapy during hospital stay and at discharge, or in-hospital mortality. With regard to the primary endpoint, cumulative freedom from congestive heart failure was higher in group A patients (99.4 vs. 97.6 vs. 94.4%, log rank p=0.02). In a multivariate Cox regression model, a 5-mmHg increase in LVEDP (HR 1.97, 95% CI 1.10–3.54, p=0.02) remained an independent predictor of the primary endpoint when adjusted for age, systolic function, atrial fibrillation, peak troponin I, renal function, and prescription of diuretics and beta-blockers.

Conclusion

In selected population LVEDP was a significant prognostic marker of future admission for congestive heart failure.

Keywords:
Acute coronary syndromes
Left ventricular end-diastolic pressure
Prognosis
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