ABSTRACT Introduction: In patients undergoing coronary artery bypass grafting (CABG), stroke is a major complication that increases morbidity and mortality. The presence of carotid stenosis (CS) increases risk of stroke, and the optimal treatment remains uncertain due to the lack of randomized clinical trials. The aim of this study is to compare three management approaches to CS in patients submitted to CABG. Methods: From 2005 to 2015, 79 consecutive patients with significant CS submitted to CABG were retrospectively evaluated. Patients were divided in three groups, according to CS treatment: 17 underwent staged carotid endarterectomy (CEA)-CABG, 26 underwent synchronous CEA-CABG, and 36 underwent isolated CABG without carotid intervention. The primary outcomes were composed by 30-day postoperative acute myocardial infarction (MI), 30-day postoperative stroke, and death due to all causes during the follow-up. Results: Patients were evaluated during an average 2.05 years (95% confidence interval = 1.51-2.60) of follow-up. Major adverse cardiac events, including death, postoperative MI, and postoperative stroke, occurred in 76.5% of the staged group, 34.6% of the synchronous group, and 33.3% of the isolated CABG group (P=0.007). As for MI, the rates were 29.4%, 3.85%, and 11.1% (P=0.045), respectively. There was no statistically significant difference in total mortality rates (35.3%, 30.8%, and 25.0%, respectively; P=0,72) and stroke (29.4%, 7.7%, and 8.3%, respectively; P=0,064) between groups. Conclusion: Staged CEA-CABG is associated with higher major adverse cardiac events and MI rate when compared to the strategy of synchronous and isolated CABG, but without statistically difference in total mortality during the entire follow-up.

Resumo Fundamento: O BNP foi exaustivamente avaliado para a determinação do prognóstico em curto e médio prazo em pacientes com síndrome coronariana aguda, mas o seu papel para a mortalidade a longo prazo é incerta. Objetivo: Determinar o papel prognóstico a muito longo prazo do peptídeo natriurético do tipo B (BNP) para a mortalidade por todas as causas em pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST (SCASSST). Métodos: Coorte de 224 pacientes consecutivos com SCASSST, prospectivamente atendidos no setor de emergência, em que se mediu o BNP na chegada para estabelecer o prognóstico ao longo do seguimento mediano de 9,34 anos para a mortalidade por todas as causas. Resultados: Diagnosticou-se angina instável em 52,2% e infarto do miocárdio sem supradesnivelamento do segmento ST em 47,8%. A mediana do BNP da admissão foi de 81,9 pg/mL (intervalo IQ = 22,2; 225) e a taxa de mortalidade correlacionou-se com quartis crescentes de BNP: 14,3; 16,1; 48,2; e 73,2% (p < 0,0001). A curva ROC revelou 100 pg/mL como o melhor ponto de corte de BNP para a predição de mortalidade (área sob a curva = 0,789, 95% CI = 0,723-0,854) sendo um forte preditor de mortalidade tardia: BNP < 100 = 17,3% vs. BNP ≥ 100 = 65,0%, RR = 3,76 (IC 95% = 2,49-5,63, p < 0,001). Na análise de regressão logística, idade>72 anos (OR = 3,79, IC 95% = 1,62-8,86, p = 0,002), BNP ≥ 100 pg/mL (OR = 6,24, IC 95% = 2,95-13,23, p < 0,001) e taxa de filtração glomerular estimada (OR = 0,98, IC 95% = 0,97-0,99, p = 0,049) foram preditores independentes de mortalidade tardia. Conclusões: O BNP medido na admissão hospitalar em pacientes com SCASSST é um forte preditor independente de mortalidade por todas as causas de muito longo prazo. Este estudo permite que se levante a hipótese de que o BNP deva ser medido em todos os pacientes com SCASSST no evento-índice para a estratificação de risco a longo prazo.

Abstract Background: BNP has been extensively evaluated to determine short- and intermediate-term prognosis in patients with acute coronary syndrome, but its role in long-term mortality is not known. Objective: To determine the very long-term prognostic role of B-type natriuretic peptide (BNP) for all-cause mortality in patients with non-ST segment elevation acute coronary syndrome (NSTEACS). Methods: A cohort of 224 consecutive patients with NSTEACS, prospectively seen in the Emergency Department, had BNP measured on arrival to establish prognosis, and underwent a median 9.34-year follow-up for all-cause mortality. Results: Unstable angina was diagnosed in 52.2%, and non-ST segment elevation myocardial infarction, in 47.8%. Median admission BNP was 81.9 pg/mL (IQ range = 22.2; 225) and mortality rate was correlated with increasing BNP quartiles: 14.3; 16.1; 48.2; and 73.2% (p < 0.0001). ROC curve disclosed 100 pg/mL as the best BNP cut-off value for mortality prediction (area under the curve = 0.789, 95% CI= 0.723-0.854), being a strong predictor of late mortality: BNP < 100 = 17.3% vs. BNP ≥ 100 = 65.0%, RR = 3.76 (95% CI = 2.49-5.63, p < 0.001). On logistic regression analysis, age >72 years (OR = 3.79, 95% CI = 1.62-8.86, p = 0.002), BNP ≥ 100 pg/mL (OR = 6.24, 95% CI = 2.95-13.23, p < 0.001) and estimated glomerular filtration rate (OR = 0.98, 95% CI = 0.97-0.99, p = 0.049) were independent late-mortality predictors. Conclusions: BNP measured at hospital admission in patients with NSTEACS is a strong, independent predictor of very long-term all-cause mortality. This study allows raising the hypothesis that BNP should be measured in all patients with NSTEACS at the index event for long-term risk stratification.