Editorial Original Articles Review Articles Case Report Brief Communication

103 Pages·2017·6 MB·English

7
4
6
5
9-
5
3 Editorial Association of Central Obesity with The Incidence of
2
e Cardiovascular Diseases and Risk Factors
n Are my Values Different from Yours? The Value of
nli
N o Coronary Artery Disease Invasive Care in Brazil Review Articles
S
S
2 | I Original Articles Cardiorenal Syndrome Type 2: A Strong Prognostic Factor
0 of Survival
48 Chimó, a Smokeless Tobacco Preparation, is Associated
59- With a Lower Frequency of Hypertension in Subjects with Arterial Stiffness: Pathophysiological and Genetic Aspects
3
2 Type 2 Diabetes
N Antiplatelet Agents in Acute Coronary Syndromes
S
S Temporal Evaluation of Coronary Revascularization
er | I Procedures Performed through the Unified Health System Case Report
b
o (SUS) in Brazil: a 20-year overview
ct Use of Thrombolysis in PE Said to be of no High-Risk, which
O
er/ Doppler Echocardiographic Follow-Up of Mitral and Aortic Presents Acute Cor Pulmonale
b
m Regurgitation in Children and Adolescents with Subclinical
e
pt and Mild Rheumatic Carditis Brief Communication
e
S
5 | Hypertensive Adolescents: Correlation with Body Mass Risk Correlation between Obstructive Sleep Apnea and
er Index and Lipid and Glucose Profiles Heart Failure in Primary Care
b
m
Nu Effectiveness of Medical and Revascularization Procedures
0 - as the Initial Strategy in Stable Coronary Artery Disease:
3
e A Cohort Study
m
u
ol
V
SUMARY
• Editorial
Are my Values Different from Yours? The Value of Coronary Artery Disease Invasive Care in Brazil ................. 369
Alexandre Siciliano Colafranceschi
• Original Articles
Chimó, a Smokeless Tobacco Preparation, is Associated With a Lower Frequency of Hypertension in Subjects
with Type 2 Diabetes ................................................................................................................................................................ 373
Juan P. González-Rivas, Raul José García Santiago, Jeffrey I. Mechanick, Ramfis Nieto-Martínez
Temporal Evaluation of Coronary Revascularization Procedures Performed through the Unified Health
System (SUS) in Brazil: a 20-year overview ......................................................................................................................... 380
Igor Ribeiro de Castro Bienert, Alexandre Rodrigues, Érika Airi Harada, Karoline Lopes Silva, Amanda Ribeiro Valente,
Paulo André da Silva, Joao Carlos Moron Saes Braga, Fabio Salerno Rinaldi, Fábio Villaça Guimarães Filho, Pedro
Beraldo de Andrade
Doppler Echocardiographic Follow-Up of Mitral and Aortic Regurgitation in Children and Adolescents with
Subclinical and Mild Rheumatic Carditis ............................................................................................................................ 391
Lelia Maria de Almeida Carvalho, Fátima Derlene da Rocha Araújo, Zilda Maria Alves Meira
Hypertensive Adolescents: Correlation with Body Mass Index and Lipid and Glucose Profiles ............................. 401
Liz Andréa Villela Baroncini, Lucimary de Castro Sylvestre, Camila Varotto Baroncini, Marcieli da Luz Giroldo,
Dalton Bertolim Précoma, Roberto Pecoits Filho
Effectiveness of Medical and Revascularization Procedures as the Initial Strategy in Stable Coronary Artery
Disease: A Cohort Study .......................................................................................................................................................... 408
Mariana Vargas Furtado, Gustavo Neves de Araujo, Mariana Ferreira Jost, Andre Dias Americo, Nicolas Peruzzo,
Guilherme Nasi, Guilherme Heiden Telo, Flavia Kessler Borges, Carisi Anne Polanczyk
Association of Central Obesity with The Incidence of Cardiovascular Diseases and Risk Factors ......................... 416
Taianah Almeida Barroso, Lucas Braga Marins, Renata Alves, Ana Caroline Souza Gonçalves, Sérgio Girão Barroso,
Gabrielle de Souza Rocha
Cardiorenal Syndrome Type 2: A Strong Prognostic Factor of Survival ........................................................................ 425
Arous Salim, Mohamed El Ghali Benouna, Monia El Mourid, Rachida Habbal
• Review Articles
Arterial Stiffness: Pathophysiological and Genetic Aspects ............................................................................................ 433
Rafael de Oliveira Alvim, Paulo Caleb Junior Lima Santos, Luiz Aparecido Bortolotto, José Geraldo Mill, Alexandre da
Costa Pereira
Antiplatelet Agents in Acute Coronary Syndromes ........................................................................................................... 442
Pedro Beraldo de Andrade e Leonardo Silva Roever Borges
• Case Report
Use of Thrombolysis in PE Said to be of no High-Risk, which Presents Acute Cor Pulmonale ............................... 452
Nicolle Lopes Guenther, Nágela Simão Vinhosa Nunes, Valdênia Pereira de Souza, Ronaldo Vegni e Souza
• Brief Communication
Risk Correlation between Obstructive Sleep Apnea and Heart Failure in Primary Care ........................................... 459
Adson Renato Leite, Erica de Abreu Macedo, Antonio José Lagoeiro Jorge, Maria Luiza Garcia Rosa
• News .................................................................................................................................................................... 464
• See in the next issue .......................................................................................................................................... 465
ISSN 2359-4802 / IJCS ONLINE: ISSN 2359-5647
Editor Guilherme Vianna e Silva (Interventionist Cardiology Area) – Texas Heart
Institute, USA
Cláudio Tinoco Mesquita – Hospital Universitário Antônio Pedro (HUAP),
Universidade Federal Fluminense (UFF), Niterói, Rio de Janeiro, RJ – Brazil João Augusto Costa Lima (Integrative Imaging Area) – Johns Hopkins
Hospital – Baltimore, USA
Lauro Casqueiro Vianna (Multiprofessional Area) – Faculdade de Educação
Associated Editors
Física, Universidade de Brasília (UnB), Brasília, DF – Brazil
Clério Francisco Azevedo Filho (Cardiovascular Imaging Area) – Miguel Mendes (Ergometric and Cardiac Rehabilitation Area) – Sociedade
Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brazil Portuguesa de Cardiologia, Portugal
Gláucia Maria Moraes de Oliveira (Clinical Cardiology Area) – Departamento Ricardo Mourilhe-Rocha (Heart Failure and Myocardiopathy Area) –
de Clínica Médica, Faculdade de Medicina (FM), Universidade Federal do Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de
Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brazil Janeiro (UERJ), Rio de Janeiro, RJ - Brazil
EDITORIAL BOARD Leonardo Silva Roever Borges – Departamento de Pesquisa Clínica,
Universidade Federal de Uberlândia (UFU), MG – Brazil
Brazil Leopoldo Soares Piegas – Fundação Adib Jatene, Instituto Dante Pazzanese
de Cardiologia (IDPC/FAJ), São Paulo, SP - Brazil
Andréia Biolo – Faculdade de Medicina, Universidade Federal do Rio Grande
do Sul (UFRGS), Porto Alegre, RS – Brazil Luís Alberto Oliveira Dallan – Serviço Coronariopatias, Instituto do Coração
(INCOR), São Paulo, SP - Brazil
Angelo Amato Vincenzo de Paola – Escola Paulista de Medicina (EPM),
Marcelo Iorio Garcia – Clínica de Insuficiência Cardíaca, Universidade Federal
Universidade Federal de São Paulo (UNIFESP), São Paulo, SP – Brazil
do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brazil
Antonio Cláudio Lucas da Nóbrega – Centro de Ciências Médicas,
Marcelo Westerlund Montera – Centro de Insuficiência Cardíaca, Hospital
Universidade Federal Fluminense (UFF), Niterói, Rio de Janeiro, RJ – Brazil
Pró Cardíaco (PROCARDIACO), Rio de Janeiro, RJ – Brazil
Ari Timerman – Unidades de Internação, Instituto Dante Pazzanese de
Marcio Luiz Alves Fagundes – Divisão de Arritmia e Eletrofisiologia, Instituto
Cardiologia (IDPC), São Paulo, SP - Brazil
Nacional de Cardiologia Laranjeiras (INCL), Rio de Janeiro, RJ – Brazil
Armando da Rocha Nogueira – Departamento de Clínica Médica,
Marco Antonio Mota Gomes - Fundação Universitária de Ciências da Saúde
Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brazil
Governador Lamenha Filho (UNCISAL), Maceió, AL - Brazil
Carísi Anne Polanczyk – Hospital de Clínicas de Porto Alegre, Universidade
Marco Antonio Rodrigues Torres – Departamento de Medicina Interna,
Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS – Brazil
Hospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brazil
Carlos Eduardo Rochitte – Departamento de Cardiopneumologia, Hospital
Marcus Vinicius Bolivar Malachias – Instituto de Pesquisas e Pós-
das Clínicas da Faculdade de Medicina da Universidade de São Paulo
graduação (IPG), Faculdade de Ciências Médicas de Minas Gerais
(HCFMUSP), São Paulo, SP – Brazil
(FCMMG), Belo Horizonte, MG – Brazil
Carlos Vicente Serrano Júnior – Faculdade de Medicina da Universidade de
Maria Eliane Campos Magalhães – Departamento de Especialidades Médicas,
São Paulo, Instituto do Coração (InCor), São Paulo, SP – Brazil
Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ – Brazil
Cláudio Gil Soares de Araújo – Instituto do Coração Edson Saad, Universidade
Mário de Seixas Rocha – Unidade Coronariana, Hospital Português,
Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brazil
Salvador, BA – Brazil
Cláudio Pereira da Cunha – Departamento de Clínica Médica, Universidade
Maurício Ibrahim Scanavacca – Unidade Clínica de Arritmia, Instituto do
Federal do Paraná (UFPR), Paraná, PR – Brazil
Coração do Hospital das Clínicas da FMUSP, São Paulo, SP – Brazil
Cláudio Tinoco Mesquita – Hospital Universitário Antônio Pedro (HUAP),
Nadine Oliveira Clausell – Faculdade de Medicina, Universidade Federal do
Universidade Federal Fluminense (UFF), Niterói, Rio de Janeiro, RJ – Brazil
Rio Grande do Sul (UFRGS), Porto Alegre, RS – Brazil
Denílson Campos de Albuquerque – Faculdade de Ciências Médicas,
Nazareth de Novaes Rocha – Centro de Ciências Médicas, Universidade
Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ – Brazil
Federal Fluminense, UFF - Rio de Janeiro, RJ – Brazil
Denizar Vianna Araujo – Departamento de Clínica Médica, Universidade do
Nelson Albuquerque de Souza e Silva – Departamento de Clínica
Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ – Brazil
Médica, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro,
Esmeralci Ferreira – Hospital Universitário Pedro Ernesto (HUPE), RJ – Brazil
Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brazil
Paola Emanuela Poggio Smanio – Seção Médica de Medicina Nuclear,
Evandro Tinoco Mesquita – Hospital Universitário Antônio Pedro (HUAP), Instituto Dante Pazzanese de Cardiologia (IDPC) São Paulo, SP - Brazil
Universidade Federal Fluminense (UFF), Niterói, Rio de Janeiro, RJ – Brazil
Paulo Cesar Brandão Veiga Jardim – Liga de Hipertensão Arterial,
Fernando Nobre – Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade Federal de Goiás (UFGO), Goiânia, GO – Brazil
Universidade de São Paulo, São Paulo, SP – Brazil
Ronaldo de Souza Leão Lima – Pós-Graduação em Cardiologia, Universidade
Gabriel Blacher Grossman – Serviço de Medicina Nuclear, Hospital Moinhos Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brazil
de Vento, Porto Alegre, RS – Brazil Salvador Manoel Serra – Setor de Pesquisa Clínica, Instituto Estadual de
Henrique César de Almeida Maia – Governo do Distrito Federal (GDF), Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro, RJ – Brazil
Brasília, DF - Brazil Sandra Cristina Pereira Costa Fuchs – Departamento de Medicina Social,
Humberto Villacorta Júnior – Hospital Universitário Antônio Pedro (HUAP), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS – Brazil
Universidade Federal Fluminense (UFF), Niterói, Rio de Janeiro, RJ – Brazil Tiago Augusto Magalhães – Ressonância Magnética e Tomografia Cardíaca,
Iran Castro – Fundação Universitária de Cardiologia (FUC), Instituto de Hospital do Coração (HCor), São Paulo, SP – Brazil
Cardiologia do Rio Grande do Sul (IC), Porto Alegre, RS – Brazil Walter José Gomes – Departamento de Cirurgia, Universidade Federal de
João Vicente Vitola – Quanta Diagnóstico e Terapia (QDT), Curitiba, PR – Brazil São Paulo (UFESP), São Paulo, SP – Brazil
José Geraldo de Castro Amino – Sessão Clínica, Instituto Nacional de Washington Andrade Maciel – Serviço de Arritmias Cardíacas, Instituto
Cardiologia (INC), Rio de Janeiro, RJ – Brazil Estadual de Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro, RJ – Brazil
José Márcio Ribeiro – Clínica Médica (Ambulatório), União Educacional Vale Wolney de Andrade Martins – Centro de Ciências Médicas, Universidade
do Aço (UNIVAÇO), Ipatinga, MG - Brazil Federal Fluminense (UFF), Niterói, Rio de Janeiro, RJ – Brazil
Exterior James A. Lang - Des Moines University, Des Moines – USA
Amalia Peix - Instituto de Cardiología y Cirugía Cardiovascular, Havana – Cuba James P. Fisher - University of Birmingham, Birmingham – England
Amelia Jiménez-Heffernan - Hospital Juan Ramón Jiménez, Huelva – Spain
João Augusto Costa Lima - Johns Hopkins Medicine, Baltimore – USA
Ana Isabel Venâncio Oliveira Galrinho - Hospital Santa Marta, Lisboa – Portugal
Jorge Ferreira - Hospital de Santa Cruz, Carnaxide, Portugal
Ana Maria Ferreira Neves Abreu - Hospital Santa Marta, Lisboa – Portugal
Ana Teresa Timóteo - Hospital Santa Marta, Lisboa – Portugal Manuel de Jesus Antunes - Centro Hospitalar de Coimbra, Coimbra – Portugal
Charalampos Tsoumpas - University of Leeds, Leeds – England Marco Alves da Costa - Centro Hospitalar de Coimbra, Coimbra – Portugal
Chetal Patel - All India Institute of Medical Sciences, Delhi – Indian Maria João Soares Vidigal Teixeira Ferreira - Universidade de Coimbra,
Edgardo Escobar - Universidad de Chile, Santiago – Chile
Coimbra – Portugal
Enrique Estrada-Lobato - International Atomic Energy Agency, Vienna – Austria
Massimo Francesco Piepoli - Ospedale “Guglielmo da Saliceto”, Piacenza – Italy
Erick Alexanderson - Instituto Nacional de Cardiología - Ignacio Chávez, Ciudad
de México – México Nuno Bettencourt - Universidade do Porto, Porto – Portugal
Fausto Pinto - Universidade de Lisboa, Lisboa - Portugal Raffaele Giubbini - Università degli Studi di Brescia, Brescia – Italy
Ganesan Karthikeyan - All India Institute of Medical Sciences, Delhi – Indian
Ravi Kashyap - International Atomic Energy Agency, Vienna – Austria
Guilherme Vianna e Silva - Texas Heart Institute, Texas – USA
Roberto José Palma dos Reis - Hospital Polido Valente, Lisboa – Portugal
Horacio José Faella - Hospital de Pediatría S.A.M.I.C. “Prof. Dr. Juan P. Garrahan”,
Caba – Argentina Shekhar H. Deo - University of Missouri, Columbia – USA
BIENNIUM BOARD 2016/2017
SOCIEDADE BRAZILEIRA DE Chief Editor of the Brazilian Archives of SBC/MA – Márcio Mesquita Barbosa
CARDIOLOGIA/ BRAZILIAN Cardiology SBC/MG – José Carlos da Costa Zanon
SOCIETY OF CARDIOLOGY Luiz Felipe Pinho Moreira SBC/MS – Delcio Gonçalves da Silva Junior
SBC/MT – Max Wagner de Lima
Governador - ACC Brazil Chapter SBC/NNE – Claudine Maria Alves Feio
President Roberto Kalil Filho SBC/PA – Sônia Conde Cristino
Marcus Vinícius Bolívar Malachias SBC/PE – Paulo Sérgio Rodrigues Oliveira
ADJUNCT COORDINATION SBC/PB – Miguel Pereira Ribeiro
Vice-President SBC/PI – Wildson de Castro Gonçalves Filho
Eduardo Nagib Gaui SBC/PR – Gerson Luiz Bredt Júnior
International Relations Coordinator SBC/RJ (SOCERJ) – Ricardo Mourilhe Rocha
President-Elect David de Pádua Brazil SBC/RN – Maria de Fátima Azevedo
Oscar Pereira Dutra SBC/RO (SOCERON) – João Roberto Gemelli
Universidade Corporativa Coordinator SBC/RS (SOCERGS) – Gustavo Glotz de Lima
Scientific Director Gilson Soares Feitosa Filho SBC/SC – Maria Emilia Lueneberg
SBC/SE – Sergio Costa Tavares Filho
Raul Dias dos Santos Filho
Standards and Guidelines Coordinator SBC/SP (SOCESP) – Ibraim Masciarelli
Financial Director José Francisco Kerr Saraiva Francisco Pinto
SBC/TO – Andrés Gustavo Sánchez
Gláucia Maria Moraes Oliveira
Cardiovascular Records Coordinator
Otávio Rizzi Coelho DEPARTAMENTS AND STUDY GROUPS
Administrative Director
Denilson Campos de Albuquerque
Professional Valuation Coordinator SBC/DA – André Arpad Faludi
Carlos Japhet da Matta Albuquerque SBC/DCC – José Carlos Nicolau
Government Liaison Director
SBC/DCC/CP – Maria Angélica Binotto
Renault Mattos Ribeiro Júnior
New Projects Coordinator SBC/DCM – Elizabeth Regina Giunco Alexandre
Fernando Augusto Alves da Costa SBC/DECAGE – José Maria Peixoto
Information Technology Director
SBC/DEIC – Luis Eduardo Paim Rohde
Osni Moreira Filho Continuing Education Coordinator SBC/DERC – Salvador Manoel Serra
Marcelo Westerlund Montera e Rui Manuel dos SBC/DFCVR – João Jackson Duarte
Communication Director Santos Póvoa SBC/DHA – Eduardo Costa Duarte Barbosa
Celso Amodeo SBC/DIC – Samira Saady Morhy
SBCCV – Fabio Biscegli Jatene
Strategic Planning Concil
Research Director SBHCI – Marcelo José de Carvalho Cantarelli
Andrea Araújo Brandão, Ari Timeman, Dalton
Leandro Ioshpe Zimerman SOBRAC – Denise Tessariol Hachul
Bertolin Precoma, Fábio Biscegli Jatene
GAPO – Bruno Caramelli
Assistance Quality Director GECC – Mauricio Wajngarten
SBC Newsletter Editor
Walter José Gomes GECESP – Daniel Jogaib Daher
Carlos Eduardo Suaide Silva GECETI – Gilson Soares Feitosa Filho
Specialized Departments Director GECHOSP – Evandro Tinoco Mesquita
PRESIDENTS OF STATE AND GECIP – Gisela Martina Bohns Meyer
João David de Sousa Neto
REGIONAL BRAZILIAN SOCIETIES GECN – Andréa Maria Gomes Marinho Falcão
State and Regional Relations Director OF CARDIOLOGY GECO – Roberto Kalil Filho
GEECABE – José Antônio Marin Neto
José Luis Aziz
GEECG – Nelson Samesima
SBC/AL – Pedro Ferreira de Albuquerque GEICPED – Estela Azeka
Cardiovascular Health Promotion Director - SBC/BA – Nivaldo Menezes Filgueiras Filho GEMCA – Álvaro Avezum Junior
SBC/Funcor SBC/CE – Sandro Salgueiro Rodrigues GEMIC – Felix Jose Alvarez Ramires
Weimar Kunz Sebba Barroso de Souza SBC/CO – Danilo Oliveira de Arruda GERCPM – Tales de Carvalho
SBC/DF – José Roberto de Mello Barreto Filho GERTC – Marcello Zapparoli
General Ombudsman SBC/ES – Bruno Moulin Machado GETAC – João David de Souza Neto
Lázaro Fernandes de Miranda SBC/GO – Aguinaldo Figueiredo Freitas Jr. GEVAL – Luiz Francisco Cardoso
INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES
This work is available per
guidelines from the Creative
Volume 30, Nº 3, September/October 2017
Indexing: Index Medicus Latino-Americano – LILACS and Commons License. Attribution
Scientific Electronic Library Online - SciELO 4.0 International. Partial or total
reproduction of this work is
Commercial Department permitted upon citation.
Telephone Number: (11) 3411-5500
e-mail: [email protected]
Editorial Production
SBC - Gerência Científica - Núcleo de Publicações
Desktop Publishing and Graphic Design
Alodê Produções Artísticas & Eventos
Former SOCERJ Magazine (ISSN 0104-0758) up to December
2009; Revista Brazileira de Cardiologia
(print ISSN 2177-6024 and online ISSN 2177-7772)
from January 2010 up to December 2014.
International Journal of Cardiovascular Sciences
(print ISSN 2359-4802 and online ISSN 2359-5647)
from January 2015.
ÓRGÃO OFICIAL DA
SOCIEDADE BrazilEIRA DE CARDIOLOGIA - SBC
PUBLICAÇÃO BIMESTRAL / PUBLISHED BIMONTHLY
INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES
(INT J CARDIOVASC SCI)
The International Journal of Cardiovascular Sciences (ISSN 2359-4802)
bi-monthly edited by SBC:
Av. Marechal Câmara, 160 - 3º andar - Sala 330
20020-907 • Centro • Rio de Janeiro, RJ • Brazil
Telephone number: (21) 3478-2700
e-mail: [email protected]
<www.onlineijcs.org>
International Journal of Cardiovascular Sciences. 2017;30(5):369-372
369
EDITORIAL
Are my Values Different from Yours? The Value of Coronary Artery Disease Invasive
Care in Brazil
Alexandre Siciliano Colafranceschi
Instituto Nacional de Cardiologia and Hospital Pró-Cardíaco, Rio de Janeiro, RJ – Brazil
Coronary Artery Disease (CAD) has been consistently and surgery) in the last 20 years performed by the Unified
associated with the leading cause of death and disability Health System (SUS) in Brazil follows this second CAD
in most western industrialized countries since the epidemic wave in developing countries and may help to
mid-1950s. Although it still has a major impact on the rethink the model of care that we will need to build in
health of society in these countries, CAD rates have the next decades for our society.
considerably decreased in recent decades.1 The more expressive growth in the number of
There are significant differences in the prevalence of angioplasties in relation to surgeries in SUS is also
CAD, as different world regions face varying stages of paralleled by different countries worldwide in the same
this epidemic. An epidemiological transition model for period. The use of angioplasty has increased rapidly
cardiovascular disease describes a series of stages starting over the past 20 years in most of the Organization for
from a population profile with low life expectancy and Economic Cooperation and Development (OECD)
cardiovascular diseases mainly due to infectious diseases countries, surpassing myocardial revascularization
and malnutrition, which is a pattern commonly observed surgery as the preferred method for revascularization
in developing countries. As the economic and public in the mid-1990s.3 On average, in OECD countries,
health development improves the population’s nutrition angioplasty now accounts for 78% of all revascularization
and decreases infectious disease rates, life expectancy procedures and exceeds 85% in France, Spain, and
increases, and the pattern and rates of cardiovascular Israel.3 In Brazil, 66% of myocardial revascularization
disease are changed. In the last phase, commonly seen procedures performed by SUS in 2015 were carried out
in high-income countries, life expectancy increases, and by transcatheter approach.
degenerative cardiovascular diseases at advanced age Dissimilarly, following the last stage of this epidemic,
predominate. Variable rates of incidence, prevalence, US hospitals observed a significant reduction in the
and mortality reflect the different levels of risk factors, number of myocardial revascularization surgeries
other concurrent causes of death, and the availability of and a non-significant reduction (stabilization) in the
resources to fight cardiovascular disease.2 number of angioplasties performed in the first decade
Despite large variations in the number of of the 21st century, during which time more hospitals
revascularization procedures in different countries, the performed both procedures, reducing the average
number of interventions does not seem to be related to volume of each institution, which can have a negative
the incidence of CAD.3 impact on the quality, safety and costs associated with
The increase in the number of interventional these interventions.4
procedures for myocardial revascularization (angioplasty These observations have led several legislators and
managers to rethink the cardiovascular care model
through the construction of consolidated health systems
Keywords
and through the creation of disease-specific centers of
Coronary Artery Disease; Cardiovascular Diseases/ excellence, which offer integrated care, per time cycle,
epidemiology; Minimally Invasive Procedures focused on the demands of the individual, as a way of
Angioplasty; Balloon, Coronary generating value for care in the United States.
Mailing Address: Alexandre Siciliano Colafranceschi
Rua Dona Mariana,143, sala A 12. Postal Code: 22280-020, Botafogo, Rio de Janeiro, RJ – Brazil
E-mail: [email protected]
DOI: 10.5935/2359-4802.20170074
Colafranceschi Int J Cardiovasc Sci. 2017;30(5):369-372
370 Value in coronary artery disease in Brazil Editorial
Coronary angioplasty is an expensive intervention, Patient selection for one or another invasive strategy,
but it is much less costly than coronary artery bypass based only on available scientific evidence and
grafting, as it is less invasive. On average, the estimated disregarding local institutional results, as well as patient
price of an angioplasty for the 24 OECD countries values and preferences, can impose a great burden on
was approximately US $7,400.00 in 2010, compared to society, especially in a poorly consolidated model of
US$ 17,400 for conventional surgery.5 These are much institutions that are performing an increasingly lower
higher values than the ones that were reimbursed, on volume of tertiary-complexity procedures.4
average, by SUS per HAA for each of these interventions Regional and national averages can mask important
in 2015 in Brazil. Consequently, for patients who would variations in the assistance outcomes of different
otherwise receive a surgical (arterial and/or venous) institutions. Therefore, an important aspect to consider
graft, the introduction of angioplasty not only reduced is the adequacy of scientific study results to the local
the morbimortality of the interventional procedure, scenario of each hospital due to the great variability
but also reduced costs. Currently, up to 18% of elective of the indicators, mainly those related to myocardial
coronary angioplasty procedures in the United States revascularization surgery. In this analysis, performed
is performed without the need for hospital admission, in Brazil in 2015, the mortality rate after myocardial
aiming to further reduce the costs associated with the revascularization surgery non-adjusted by SUS varied
care of CAD patients.4 from 5.3% in the Southeast Region to 8.3% in the North of
Inflation-adjusted aggregated hospitalization costs for the country, that is, a difference of 65%, while mortality
five of the six most expensive procedures in the United after angioplasty varied from 1.9% to 3.1% in the
States have increased since 1999. Southeast and North Regions, respectively. Despite the
lower mortality rate (non-adjustably compared to
In 2007, the United States spent US$ 697 billion
surgical mortality rates), regional differences also
on in-hospital patient care, where the more complex
exceed 60% for percutaneous interventions.
procedures are performed and the more complex
technologies used, accounting for 37% of health care Many see quality health care as a comprehensive
costs in that year. Three of the six procedures that umbrella, under which lies patient safety. For instance,
the Institute of Medicine (IOM) considers patient safety
contributed the most to hospital costs in the United States
“indistinguishable from the delivery of quality health care.”6
are associated with cardiovascular diseases and include
coronary angioplasty, myocardial revascularization Working groups, such as the IOM, have tried to
surgery and pacemaker implantation, ventricular define the quality of health care in terms of standards.
resynchronization therapy and defibrillator implantation. Initially, the institute defined quality as “The degree to
The number of hospital discharges after coronary which health services for individuals and populations
angioplasty has steadily increased since 1999 to 828,000, increase the likelihood of desired health outcomes and
and inflation-adjusted hospital costs have increased 108% are consistent with current professional knowledge.”7
– to US$ 13.3 billion. In contrast, hospitalizations due to This led to a definition of quality, which seemed to be
myocardial revascularization surgeries decreased 24%, a list of indicators that are expressions of the standards.
to 245,000. However, the aggregate costs for conventional Most of these standards have been and generally continue
surgery declined only 3 percent, to US$ 8.1 billion.5 to comprise the five domains (death, disease, disability,
Although more expensive and the fact that it is discomfort, and dissatisfaction) rather than more positive
associated with higher morbidity and mortality rates, components of quality.8
some patients benefit from myocardial revascularization Periprocedural mortality, although still widely used
surgery, such as those with a more complex anatomy, as a quality and safety standard, especially because it is
with left ventricular dysfunction and diabetic patients. a simple and accurate measure, but also because of the
The selection of the best candidates for the best impact its measurement generates, cannot express other
intervention should always be considered and discussed domains related to the quality of care. High mortality
by teams of specialized professionals, who have rates in relation to an established standard deserve
complementary technical skills for the care of patients attention, as they definitely express a low care VALUE.
with CAD. However, low mortality rates are not necessarily
Int J Cardiovasc Sci. 2017;30(5):369-372 Colafranceschi
Editorial Value in coronary artery disease in Brazil 371
associated with high-VALUE care. The institutional and proportionate benefits (quality of life and life
capacity to care for post-intervention complications expectancy) for individuals and may have a negative
and morbidities (avoidable or not) can minimize the impact on society in general. The association between
impact of their occurrence on periprocedural mortality health systems’ costs and health care outcomes is of
rates, generating wastage and a negative impact on the interest to managers, considering the steady increases in
patient's experience. health care spending for most industrialized countries.
For instance, the United States stands out because they
The most recent work of IOM to identify quality
spend much more on health than any other country,
care components for the 21st century focuses on the
but the life expectancy of the American population is
conceptual components of quality, rather than on
not longer, it is actually shorter than in other countries
measured indicators: quality care is safe, effective,
that spend much less. In the most extreme case, we
patient-centered, timely, efficient, and equitable.
see that Americans spend more than five times what
Thus, safety is the foundation upon which all other
Chileans do, even though Chileans actually live longer
aspects of quality care are built.9
than Americans.10
In addition to the conceptual evolution on patient
Nevertheless, the establishment of causal relationships
quality and safety, in recent years there has been a
is complex because, first, health care costs comprise just
growing concern regarding cost control in the health
one of many quantitative and qualitative factors that
area. Several aspects justify this concern: the increasing
contribute to health outcomes, and second, health status
public spending in the area, problems related to the
measurement is an imperfect process.
financing of these expenses, the great need and the
The meaning of VALUE in the health area, in addition
still little dissemination of adequate cost calculation
to not being well understood yet, is difficult to practice.
or measurement methods, the importance of cost
Conceptually, care VALUE can be determined as the
management and monitoring, its control, and its use as a
association between care outcomes (including patient
tool for decision-making, analysis and choice of programs
experience) and the economic costs related to the
and establishment of policies for the area.
individual’s care over an entire time cycle (not just for
Cost, price, and value are not synonymous. Value is a
specific interventions). Therefore, providing quality care,
difficult term to be defined, as it has several meanings,
without wastage, is one of the challenges of any health
depending on its context.
system in the current global scenario.11
In philosophy, values are the set of characteristics of a
Myocardial revascularization surgery, coronary
particular person or organization, which determine how
angioplasty, or clinical treatment are care strategies that
the person or organization behaves and interacts with
need to be customized for the individual with CAD,
other individuals and with the environment. Emphasis is
relying on the best current scientific evidence and the
placed on ethics as a vital value.
results of the institution's assistance, considering the
For economics, economic value is the non-monetary, patient’s values and preferences. The fee-for-service
but estimated value of particular goods or services, that and the misalignment of values among patients, health
is, the degree of importance of these goods or services professionals, hospital institutions, and paying sources
for society. The financial value can be understood as are at the center of discussions on the sustainability
how many monetary units – for instance, how many of the health system. Only with clear and transparent
dollars – one would be willing to pay to have access to values, in an environment of trust, can new leaderships
these goods or services. support, with courage and resilience, a value-based
Life has no price (since what is priced can be replaced health system organized in high-reliability institutions,
by something else, an equivalent). This aphorism in which high-performance teams and shared decision-
has justified the behavior of health professionals, making have great VALUE.
institutions and industries for the development and To understand, however, why the monetary values
incorporation (into care practice) of drugs, devices of medical and institutional fee refunds in Brazil over
and processes that, in general, add costs to the the last 20 years have remained on average well below
health system. This development cycle and its costs, inflation, especially in the group of percutaneous
however, are not necessarily directly related to concrete revascularizations – that is another story!
Colafranceschi Int J Cardiovasc Sci. 2017;30(5):369-372
372 Value in coronary artery disease in Brazil Editorial
References
1. Sanchis-Gomar F, Perez-Quillis C, Leischik, R, Lucia, A. Epidemiology of 7. Lohr K. Committee to Design a Strategy for Quality Review and
coronary heart disease and acute coronary syndrome. Ann Transl Med. Assurance. In: Medicare a strategy for quality assurance. Washington,
2016; 4(13): 256. Doi: 10.21037/atm.2016.06.33. DC: National Academy Press; 1990.
2. Reid CM, Owen AJ, Freedman B. Coronary artery disease epidemics: 8. Lohr KN. Outcome measurements: concepts and questions. Inquiry.
not all the same. Medicographia. 2014;36:11-8. 1988;25(1):37–50. PMID:2966125.
3. Kumar, A, Schoenstein M. Managing Hospital Volumes: Germany and 9. Committee on the Quality of Health Care in America. Crossing the
Experiences from OECD Countries. France: OECD Health Working quality chasm: A new health system for the 21st century. Washington,
Papers, OECD Publishing ; 2013 . DC: National Academy Press; 2001.
4. Epstein AJ, Polsky D, Yang F, Yang L, Groeneveld PW. Coronary
10. Organisation for Economic Co-Operation and Development. OECD.Stat.
Revascularization Trends in the United States, 2001-2008. JAMA.
[Internet]. [Cited in 2016 Dec 10]; Available from: https://stats.oecd.org/
2011;305(17):1769-76. Doi:10.1001/jama.2011.551.
Index.aspx?DatasetCode=HEALTH_STAT
5. Center for Disease Control and Prevention. Table 36. [Internet]]. [Cited
11. Porter ME, Lee TH. The strategy that will fix health care. Harvard Review
in 2016 Dec 10]. Available from: http://www.cdc.gov/nchs/hus.htm
Business. Oct 2013:1-19.
6. Aspden P, Corrigan J, Wolcott J, Institute of Medicine, Board Health Care
Services. Patient safety: achieving a new standard for care. Washington,
DC: National Academies Press; 2004.