Estudo comparativo entre os custos dos tratamentos clínico, cirúrgico ou percutâneo em portadores de doença multiarterial coronária estável - 5 anos de seguimento [tese]. São Paulo: Faculdade de Medicina, Universidade de São Paulo, 2013. INTRODUÇÃO: As principais opções terapêuticas para a doença multiarterial coronária incluem cirurgia de revascularização miocárdica (CRM), intervenção coronária percutânea (ICP) e tratamento clínico (TC). Essas três estratégias terapêuticas apresentam eficácia similar em determinados subgrupos de pacientes. No presente momento, estudos direcionados à análise econômica são escassos, e contemplam, principalmente, os custos comparativos entre as intervenções cirúrgica e percutânea. OBJETIVOS: Analisar, prospectivamente, o custo comparativo das três formas terapêuticas da doença multiarterial coronária estável, durante cinco anos de seguimento. MÉTODOS: Foi computado o custo terapêutico global de 611 pacientes do ensaio clínico The Second Medicine, Angioplasty, or Surgery Study (MASS II), baseado na remuneração provida pelo sistema de saúde suplementar do Instituto do Coração do HC/FMUSP, tomando-se os valores em moeda nacional corrente. Realizou-se, posteriormente, análise de custo-efetividade para o tempo livre de eventos clínicos e o tempo livre de eventos acrescido de tempo livre de angina. RESULTADOS: O TC apresentou 3.79 e 2.07 QALY (quality-adjusted lifeyears); o ICP apresentou 3.59 e 2.77 QALY; e o CRM apresentou 4.4 e 2.81 QALY, respectivamente, para sobrevida livre de eventos e sobrevida livre de eventos e angina. Os custos para sobrevida livre de eventos foram R$ 16.327,80 para TC, R$ 35.940,60 para ICP e R$ 32.873,40 para CRM. A análise pareada dos custos para sobrevida livre de eventos mostrou que houve diferença significante favorecendo TC contra ICP (P < 0,01), e em comparação com CRM (P < 0,01); e CRM versus ICP (P = 0,01). Os custos para sobrevida livre de eventos e angina foram R$ 29.795,40, R$ 46.495,80 e R$ 44.305,20, respectivamente. A comparação pareada dos custos livres de eventos mais livres de angina demonstrou que houve diferença significante favorecendo TC contra ICP (P = 0,04), e em comparação com CRM (P < 0,001). Não houve diferença entre CRM e ICP (P > 0,05). CONCLUSÃO: A análise comparativa entre as diferentes opções terapêuticas desta amostra revelou que TC foi mais custo-efetivo que CRM, e esta, por sua vez, mais custo-efetivo que ICP / BACKGROUND: The therapeutic options for multivessel coronary artery disease are coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), or medical treatment alone (MT). These three therapeutic strategies present similar efficacy for specific subgroups. At the present moment, economic outcome trials are scant, and contemplate comparative cost between surgical or percutaneous intervention. OBJECTIVE: To analyze, prospectively, the comparative cost from three therapeutic strategies in multivessel coronary artery disease, at 5-year of follow-up. METHODS: We analyzed cumulative costs of 611 patients from clinical trial The Second Medicine, Angioplasty, or Surgery Study (MASS II). The economic analysis is based on remuneration provided by the supplementary health system of the Heart Institute of the Clinical Hospital of FMUSP, expressing these values in Brazilian currency. It was compared to the cumulative costs of each therapeutic strategy in the 5-year follow-up period. A cost-effectiveness analysis was then conducted for event-free survival and event plus angina-free survival. Cost-effectiveness analysis was performed by quality-adjusted life- year (QALY) analysis. RESULTS: Respectively, for event-free survival and event plus angina-free survival, MT presented 3.79 quality-adjusted life-years (QALY) and 2.07 QALY; PCI presented 3.59 and 2.77 QALY; and CABG demonstrated 4.4 and 2.81 QALY. The event-free costs were R$ 16327.80 for MT; R$ 35940.60 for PCI; and R$ 32873.40 for CABG. The paired comparison of the event-free costs showed that there was a significant difference favoring MT versus PCI (P < 0.01) and versus CABG (P < 0.01) and CABG versus PCI (P =0.01). The event-free plus angina-free costs were R$ 29795.40, R$ 46495.80 e R$ 44305.20, respectively. The paired comparison of the event-free plus angina-free costs showed that there was a significant difference favoring MT versus PCI (P =0.04), and versus CABG (P < 0.001); there was no difference between CABG and PCI (P > 0.05). CONCLUSION: The comparative analysis among the different therapeutic strategies demonstrated that MT was more cost-effective than CABG, and this than PCI

Introdução: A abordagem terapêutica da doença coronária multiarterial é possível por meio da aplicação de farmacologia dedicada em associação à revascularização miocárdica, seja por meio de intervenção coronária percutânea ou de cirurgia. Visando a reduzir os maiores limitantes destas duas estratégias, surge como alternativa o procedimento de revascularização híbrida, que objetiva combinar o que cada uma das técnicas tradicionais mais oferece em relação a benefícios para os pacientes. Objetivos: Avaliar a segurança e a eficácia da revascularização híbrida quando comparada à cirurgia convencional por meio da aferição da ocorrência da taxa de eventos cardiovasculares adversos compostos, como mortalidade global, infarto agudo do miocárdio, revascularização não programada e acidente vascular cerebral ao término de dois anos de acompanhamento clínico. Metodologia: Estudo piloto, prospectivo, unicêntrico e randomizado, que visa à inclusão de 60 pacientes, na proporção 2:1 para revascularização miocárdica híbrida ou convencional. Anatomicamente, os pacientes devem exibir acometimento coronariano triarterial e escore SYNTAX de valor intermediário a alto ( > 22), além de consenso do time cardíaco de que ambas as estratégias, cirúrgica ou percutânea, sejam viáveis para o tratamento. Resultados: Entre agosto de 2014 e outubro de 2018 foram incluídos 60 pacientes no estudo, sendo 40 no grupo híbrido e 20, no grupo controle, com período de acompanhamento clínico médio de 802 ± 500 dias. As características clínicas e demográficas da população foram semelhantes entre os grupos. O escore SYNTAX foi de 29,0 ± 4,3 no grupo cirurgia convencional e de 28,3 ± 4,7 no grupo híbrido (p = 0,60). A taxa total de eventos cardiovasculares adversos ao final de dois anos foi de 19,3% no grupo híbrido e de 5,9% no grupo controle, com incidência de mortalidade global (5,0% vs. 0%), infarto agudo do miocárdio (12,5% vs. 5,9%) e revascularização não programada (14,5% vs. 5,9%), sem diferença estatisticamente significativa. Conclusões: Nesse estudo piloto, a revascularização miocárdica híbrida mostrou-se factível porém associada a taxas crescentes de eventos cardiovasculares adversos ao longo de 2 anos de seguimento, ao passo que o grupo controle, tratado com cirurgia tradicional, mostrou-se com baixa incidência de complicações maiores no mesmo período. Esses resultados sugerem a necessidade de futuros estudos que visem otimizar e melhor avaliar o desempenho clínico da abordagem híbrida de revascularização miocárdica / Introduction: Coronary artery bypass grafting and percutaneous coronary intervention with drug eluting stents are the standard invasive strategies treatments for coronary artery disease. Hybrid myocardial revascularization merges the benefits of surgical approach with the advantages of state of the art percutaneous coronary intervention with second-generation drug eluting stents. Objective: This study aims to assess the long term safety and efficacy of hybrid procedures in comparison with traditional coronary artery bypass grafting regarding the combined end point rate of all cause death, acute myocardial infarction, unplanned revascularization and stroke at the end of 2 years of follow up. Methods: Pilot, prospective, randomized, single center trial enrolling 60 patients with multivessel coronary artery disease. Following diagnostic angiography demonstrating significant multivessel coronary disease (SYNTAX Score > 22) and consensus of the heart team, patients were consented and randomized 2:1 to hybrid treatment or conventional coronary artery bypass grafting. All patients were evaluated by the composite measure of major adverse cardiovascular events, defined as all cause death, myocardial infarction, stroke or unplanned revascularization. Results: From August 2014 to October 2018, 60 patients were enrolled with a mean follow-up of 802 ± 500 days. Clinical characteristics were similar between groups. The mean SYNTAX Score was 29.0 ± 4.3 at the control group and 28.3 ± 4.7 at the hybrid group (p=0.60). The total event rate was 19.3% at the hybrid group and 5.9% at the surgical group (p=0.35), with incidences of all-cause death (5.0% vs. 0%), acute myocardial infarction (12.5% vs. 5.9%) and unplanned revascularization (14.5% vs. 5.9%), not statistically different. Conclusions: In this trial, hybrid myocardial revascularization was feasible, but associated with increasing rates of major adverse cardiovascular events during 2 years of clinical follow up, while the control group treated with conventional surgery presented with low rates of complications during the same period. The small sample number does not provide precision for the analysis and the results warrant careful attention in future clinical trials

Made available in DSpace on 2016-03-22T17:27:18Z (GMT). No. of bitstreams: 1 taiane.pdf: 500923 bytes, checksum: bb4a10bbb2a2448b84aceb8f2e29daa6 (MD5) Previous issue date: 2013-01-17 / Introduction: The literature indicates high occurrence of anxiety symptoms in people who have depression, this index simultaneously suggests the importance of studying the impact of anxiety symptoms in treatment for depression. Objective: To evaluate the impact of anxiety symptoms in remission of depressive symptoms in brief psychotherapies for depression at follow-up six months. Methods: Randomized clinical trial with youth of 18 to 29 years old who met diagnostic criteria for depression assessed by the Structured Clinical Interview for DSM (SCID). Depressive symptoms were assessed using the Hamilton Depression Scale (HAM-D), while the anxiety symptoms were assessed using the Hamilton Anxiety Scale (HAM-A). The protocols of psychotherapy used were: Cognitive Narrative Psychotherapy (CNP) and Cognitive Behavioral Psychotherapy (CBP), both with seven sessions. At the end of treatment and at follow-up six months an evaluation was made with the HAM-D and HAM-A. Results: The sample included 97 patients divided evenly between the protocols of psychotherapy. There was a significant positive moderate correlation between the severity of anxiety symptoms at baseline and remission of depressive symptoms at post-intervention (r = 0.444 p <0.001), while at follow-up six months not there was a significant correlation (r = 0.181 p = 0.164). There was remission of anxiety symptoms (8.69 ± 7.93) and depressive symptoms (6.38 ± 5.4o) after the brief psychotherapies. The remission of anxiety symptoms remained at follow-up of six months (7.59 ± 8.31, p = 0,228) and the same was true for the remission if depressive symptoms (6.48 ± 5.04, p = 0,879). Conclusion: The severity of anxiety symptoms contributed to greater remission of depressive symptoms after brief psychotherapies in the short term. However, in long term, the severity of the anxiety symptoms has no impact on the remission of the depressive symptoms. The brief psychotherapies for depression demonstrate efficacy in the remission of depressive and anxious symptoms / Introdução: A literatura aponta alta ocorrência de sintomas ansiosos em indivíduos que apresentam depressão, este índice simultâneo sugere a importância de se estudar o impacto dos sintomas ansiosos no tratamento para depressão. Objetivo: Avaliar o impacto dos sintomas ansiosos na remissão de sintomas depressivos em psicoterapias breves para depressão no follow-up de seis meses. Método: Ensaio clínico randomizado com jovens de 18 à 29 anos que preencheram critério diagnóstico de depressão avaliado através da Structured Clinical Interview for DSM (SCID). Os sintomas depressivos foram avaliados através da Hamilton Depression Scale (HAM-D), enquanto os sintomas ansiosos foram avaliados através da Hamilton Anxiety Scale (HAM-A). Os protocolos de psicoterapia utilizados foram: Psicoterapia Cognitiva Narrativa (PCN) e Psicoterapia Cognitivo Comportamental (PCC), ambos com sete sessões. Ao fim do tratamento, bem como, no follow-up de seis meses foi realizada uma avaliação com as escalas HAM-D e HAM-A. Resultados: A amostra total contou com 97 pacientes distribuídos homogeneamente entre os protocolos de psicoterapia. Houve uma correlação moderada positiva significativa entre a severidade dos sintomas ansiosos no baseline e a remissão de sintomas depressivos no pós-intervenção (r=0,444 p<0,001), no entanto, no follow-up de seis meses a correlação não foi estatisticamente significativa (r=0,181 p=0,164). Houve remissão de sintomas ansiosos (8,69±7,93) e de sintomas depressivos (6,38±5,40) após as psicoterapias breves. A remissão dos sintomas ansiosos manteve-se no follow-up de seis meses (7,59±8,31; p=0,228) e o mesmo ocorreu para a remissão se sintomas depressivos (6,48±5,04; p=0,879). 47 Conclusão: A severidade dos sintomas ansiosos contribuiu para maior remissão de sintomas depressivos após psicoterapias breves em curto prazo. Contudo, a longo prazo, a severidade dos sintomas ansiosos não apresenta impacto sobre a remissão dos sintomas depressivos. As psicoterapias breves para depressão demonstram eficácia na remissão de sintomas ansiosos e depressivos

Made available in DSpace on 2016-03-22T17:27:22Z (GMT). No. of bitstreams: 1 Thaise Mondi.pdf: 848457 bytes, checksum: ce6247b63ce139703f095380bed2e4ad (MD5) Previous issue date: 2013-01-17 / Background: There is evidence that the biological rhythm influence mood disorders. Studies indicate that individuals with mood disorders are more likely to present a new mood episode when the biological rhythms markers are deregulated. Objective: To verify the capacity regulation of biological rhythms in two models of brief psychotherapy for the remission of depressive symptoms Methods: We conducted a randomized clinical trial with young adults aged 18 to 29 years old who met diagnostic criteria for depression according to the Structured Clinical Interview for DSM (SCID). In order to assess the biological rhythm the Biological Rhythm of assessment in Neuropsychiatry (BRIAN) interview was used, whereas the severity of depression was assessed by the Hamilton Depression Scale (HAM-D). The psychotherapy models consisted on two cognitive psychotherapies: Cognitive Narrative Therapy (CNT) and Cognitive-Behavioral Therapy (CBT). Results: The sample included 97 individuals evenly distributed between the models of psychotherapy. Patients obtained regulation in biological rhythm in CBT and CNT models: the baseline means were 40.89 (±8.32) and 41.17 (±7.81) and at six-month follow-up the means were 32.61 (±11.53) and 29.82 (±9.66), respectively.. Regarding the biological rhythm, there were no differences between the models at post-intervention (p=0.209) and at 6-months follow-up (p=0.323). Concerning the remission of depressive symptoms CBT was more effective at the final evaluation (p = 0.018), however, at 6-months follow-up the effectiveness of the psychotherapies were homogeneous (p=0178). There was a moderate positive correlation (r = 0566 p&#8804;0.001) between the regulation of biological rhythms and the remission of depressive symptoms. 52 Conclusion: The two models of brief psychotherapies were effective in the remission of depressive symptoms as well as the regulation of biological rhythms in the follow-up of 6 months. Brief psychotherapies are low cost to public health and this study demonstrates that act regulating the biological rhythm / Introdução: Há evidências de que o ritmo biológico influencia nos transtornos de humor de forma a contribuir para manutenção dos sintomas. Estudos indicam que quando os marcadores de ritmo biológico estão desregulados há uma maior probabilidade de ocorrer um episódio de transtorno de humor. Objetivo: O objetivo do estudo foi verificar a capacidade da psicoterapia cognitiva atuar na regularização do ritmo biológico em pacientes deprimidos atendidos em dois modelos de psicoterapia breve para remissão de sintomas depressivos. Método: Trata-se de um ensaio clínico randomizado com jovens de 18 a 29 anos que preencheram critérios diagnósticos para depressão segundo a Structured Clinical Interview for DSM (SCID). O ritmo biológico foi avaliado através da Biological Rythm interview of assessment in neuropsychiatry (BRIAN), enquanto a severidade da depressão foi avaliada através da Hamilton Depression Scale (HAM-D). Os modelos de psicoterapia cognitiva utilizados foram: Terapia Cognitivo Narrativa (TCN) e Terapia Cognitivo Comportamental (TCC), ambos com sete sessões. Foram realizadas avaliações pós-intervenção e follow-up de 6 meses. Resultados: A amostra final contou com 97 indivíduos distribuídos de forma homogênea entre os modelos de psicoterapia. Os pacientes regularizaram o ritmo biológico nos dois modelos TCC e TCN, obtendo no baseline em média 40.89(±8.32) e 41.17(±7.81) pontos, e no follow-up de seis meses 32,61(±11,53) e 29,82(±9,66) pontos respectivamente. Na avaliação do ritmo biológico não houve diferenças entre os modelos no pós - intervenção (p=0.209) e follow-up de 6 meses (p=0.323). Para a remissão dos sintomas depressivos a TCC obteve uma maior eficácia na avaliação final (p=0.018), no entanto, no follow-up de 6 meses as psicoterapias mostraram-se homogêneas quanto sua eficácia (p=0.178). Houve uma correlação moderada positiva 50 (r= 0.566 p&#8804;0.001) entre a regularização do ritmo biológico e a remissão dos sintomas depressivos. Conclusão: Os dois modelos de psicoterapia breve mostraram-se eficazes na remissão da sintomatologia depressiva bem como na regularização do ritmo biológico no follow-up de 6 meses. Psicoterapias breves são de baixo custo para saúde pública e demonstram neste estudo que atuam regulando o ritmo biológico

Les pratiques obstétricales utilisées lors des accouchements sont nombreuses et certaines peuvent avoir un impact sur son déroulement ainsi que sur les issues maternelles et foetales. Durant le travail, ces pratiques reposent sur l’utilisation de différentes positions ou de techniques antalgiques pharmacologiques (analgésie péridurale, protoxyde d’azote) ou non (déambulation, utilisation de la baignoire, de la douche, du ballon etc.). Au moment de l’accouchement, il existe également différentes techniques de poussée, de maintien de la tête foetale, de soutien périnéal ou encore différentes positions d’accouchement. Cependant, à ce jour, ces pratiques ne sont pas ou très peu étudiées en France et ne répondent à aucune recommandation pour la pratique clinique. Dans le premier volet de cette thèse (n=1496), nous avons réalisé un état des lieux des pratiques déclarées par les sages-femmes et étudié si les pratiques différaient en fonction du lieu d’exercice et de l’ancienneté. Les sages-femmes françaises proposaient largement le recours à l’analgésie péridurale, surtout celles exerçant en maternité de type II ou III. Le décubitus latéral était la position préférée des sages-femmes durant le 1er stade avec analgésie péridurale et durant la phase de descente du 2ème stade. Pour l’accouchement, la plupart des sages-femmes conseillaient des positions en décubitus. La poussée en bloquant était celle la plus conseillée par les sages-femmes et majoritairement par celles ayant ≤ 5 ans d’ancienneté. Ces données ont montré que les pratiques des sages-femmes françaises étaient hétérogènes et variaient selon le niveau des maternités et l’ancienneté des sages-femmes. Notre deuxième volet repose sur un essai randomisé multicentrique (n=250) dont l’objectif principal était d’évaluer l’efficacité de la poussée dirigée à glotte ouverte vs celle à glotte fermée. Le critère de jugement principal était un critère de jugement composite : accouchement spontané, sans lésion du périnée (épisiotomie ou lésion spontanée des 2ème, 3ème ou 4ème degrés). Les femmes éligibles étaient celles ayant suivi intégralement la séance de formation aux types de poussées, avec une grossesse monofoetale en présentation céphalique, un accouchement par voie basse acceptée, admises en maternité entre 37 et 42 semaines d’aménorrhée pour un travail spontané ou induit, à partir d’une dilatation cervicale utérine ≥ 7 cm. Les critères d’exclusion étaient une pathologie contre-indiquant des efforts expulsifs ou un antécédent d’utérus cicatriciel, ou une anomalie du rythme cardiaque foetal avant la randomisation. Nous n’avons pas retrouvé de risques absolus ou bruts statistiquement différents en terme d’efficacité de la poussée, ni sur la morbidité maternelle (déchirures périnéales sévères ou hémorragies du post-partum) et néonatale immédiate (pH défavorable). Après prise en compte des facteurs de confusion et des facteurs pronostiques cliniquement pertinents, l’efficacité de la poussée n’était pas, non plus, statistiquement différente entre les deux types de poussées (RR ajusté : 0,92 [IC95% : 0,74-1,14]). En conclusion, les pratiques maïeutiques différent durant l’accouchement en France et il n’y a pas lieu de conseiller un type de poussée plutôt qu’un autre. Les femmes doivent, toutefois, être informées des différentes positions et des types de poussées lors des préparations à l’accouchement et doivent pouvoir choisir la position et la poussée qui leur conviennent, voir en changer, au cours du travail (Fédération Internationale de Gynécologie Obstétrique, 2012). / Many different obstetric practices are used during delivery, and some of them can affect the course of labor and delivery as well as maternal and fetal outcomes. During labor, these practices mainly concern the use of different positions and of analgesic techniques, both pharmacological (epidural analgesia, nitrous oxide) or not (walking, water immersion in a pool, large tub, or shower, birthing balls, etc.). At delivery, there are also different techniques of pushing, of fetal head management, perineal support, and birthing positions. Nonetheless, until now, the use of these practices in France has been studied little if at all, and there are no Clinical Practice Guidelines to help midwives choose their practices based on scientific evidence.The first component of this dissertation describes our inventory of practices reported by midwives (n=1496) and examines whether these practices differ as a function of either place of practice or experience. French midwives very frequently offer women epidural analgesia, especially those practicing in level II or III maternity units. Lateral decubitus was the position midwives preferred during the first stage for women with epidural analgesia and during the descent phase of the second stage. For delivery, most midwives advised decubitus positions. Pushing with Valsalva breathing was advised most often, mostly by midwives with ≤ 5 years of experience. These data show that French midwives use heterogeneous practices that vary according to the maternity unit level and the midwife's experience.The second component of this dissertation is based on a multicenter randomized trial (n=250) to assess the effectiveness of directed pushing when used with open glottis or closed glottis (Valsalva) breathing. The principal endpoint was a composite criterion: spontaneous delivery without perineal lesion (episiotomy, or spontaneous 2nd, 3rd, or 4th degree lacerations). Women were eligible if they have taken an antenatal class that includes a specific training in the types of pushing, and had a singleton pregnancy in cephalic presentation, planned vaginal delivery, and were admitted to the maternity ward between 37 and 42 weeks of gestation in spontaneous or induced labor when cervical dilation was ≥ 7 cm. The exclusion criteria were a disorder contraindicating expulsive efforts, previous cesarean or other uterine scar, or a fetal heart rate anomaly before randomization. The unadjusted analysis show no difference between the groups in the effectiveness of pushing, in maternal morbidity (severe perineal lacerations or postpartum hemorrhage), or immediate neonatal morbidity (unfavorable pH). After adjustment for confounding factors and clinically relevant prognostic factors, there was still no statistically significant difference in the effectiveness of the type of pushing (RR adjusted: 0.92, 95% CI 0.74-1.14).In conclusion, midwifery practices during delivery in France differ, and there is no evidence to recommend one type of pushing over another. Women must nonetheless be informed about the different positions and types of pushing during their preparation for delivery and must be able to choose the position and type of pushing they prefer, and be able to change it, during labor (International Federation of Gynecology and Obstetrics, 2012).

Introdução e Objetivo: Nos pacientes com fissura labiopalatina unilateral (FLPU) as cirurgias primárias afetam, em graus variados, o crescimento da face, comprometendo a estética facial e a oclusão dentária. Diversos estudos enfatizam a necessidade de se estabelecer protocolos cirúrgicos que apresentem repercussões positivas no crescimento facial e no desempenho fonoarticulatório dos pacientes, visando a diminuição do custo biológico, social e financeiro do tratamento integral. Este estudo objetivou comparar os efeitos de dois protocolos cirúrgicos para palatoplastia primária, em um e em dois tempos cirúrgicos, este com o fechamento tardio do palato duro (FTPD) sobre o complexo maxilo-mandibular de pacientes com FLPU completa. A hipótese do autor é que o protocolo com FTPD propicie um melhor crescimento dentofacial. Métodos: Foi realizado um ensaio clínico randomizado no qual 64 pacientes, atendidos em um centro de referência no nordeste do Brasil, foram divididos em dois grupos que receberam tratamentos cirúrgicos distintos. O grupo de intervenção (GI) foi constituído por 32 pacientes submetidas à palatoplastia em dois tempos cirúrgicos: veloplastia realizada entre os 6 e 9 meses de idade e FTPD realizado entre 36 e 48 meses de vida. O grupo controle (GC) foi constituído por 30 pacientes submetidos a palatoplastia completa entre os 9 e 15 meses. A relação entre os arcos dentários foi avaliada, de maneira cega, por três ortodontistas calibrados usando o índice FYOI (Atack,1997). Também foram investigadas as alterações dimensionais na maxila, a gravidade da fissura e as complicações pós-cirúrgicas em relação aos dois protocolos cirúrgicos. Resultados: Os modelos de gesso para avaliação pelo FYOI foram obtidos dos pacientes de ambos os grupos com idade média de 55,5 meses. O grau de concordância foi excelente (Kappa = 0,76-0,90) entre os examinadores e bom intra-examinadores (Kappa = 0,67-0,87). Os escores médios do índice FYOI variaram de 2,04 no GI a 2,76 no GC, com diferença estatisticamente significante (p = 0,007). Quando os scores foram agrupados em três categorias, bom (escores 1 e 2), Regular (escore 3) e ruim (escores 4 e 5) verificou-se diferença significativa (p < 0,006) na categoria bom (escores 1 e 2) entre os grupos GI (74%) e GC (52%). Ao serem comparadas as distribuições pela mediana, foi encontrada diferença significativa (p = 0,024) entre os escores 1 dos grupos GI (31,2%) e GC (3,3%). A correlação entre a largura da fissura e a relação maxilo-mandibular avaliada pelo FYOI não foi evidenciada pelo método de Spearman. A ocorrência de fístulas oronasais foi de 9,4% no GI e 6,7% no GC, sem diferença significativa entre eles. Conclusões: a palatoplastia realizada em dois tempos cirúrgicos com FTPD, apresenta melhores desfechos relativos ao crescimento dentofacial em crianças com FLPU. Não foi encontrada associação entre a gravidade da fissura e os desfechos relacionados ao crescimento maxilar. Não há diferenças estatisticamente significantes entre os dois protocolos cirúrgicos em relação à ocorrência de fístulas e à diminuição da distância intercaninos e diminuição do comprimento do arco maxilar / Background and Objective: An adequate growth of dentofacial structures is one of the most important goals of unilateral cleft lip and palate(UCLP) treatment and has a definitive role in getting good aesthetic and dental occlusion outcomes. To the present date several papers highlight the need of evidence-based studies to find surgical protocols that can improve facial growth and speech results aiming to reduce the burden of care of overall treatment. This study has evaluated and compared the dental arch relationship at 5 years of age after two treatment protocols, one submitted to one stage cleft palate repair (CPR) and the other to a two stage CPR with delayed hard palate closure (DHPC). The author\'s hypothesis is that the DCHP protocol provides a better dentofacial growth. Methods: A randomized clinical trial was held to evaluate the maxilo-mandibular relations in two groups of initially 32 patients each, randomly chosen. The GI group (n=32) was submitted to veloplasty between 6-9 months of age and a DCHP palatoplasty between three and four years of of age. The immediate complications were evaluated, oronasal fistulas, and cleft severity and their relationships to the surgical protocols. The dental arch relationships were assessed by a blind panel of three independent orthodontists using the FYOI index. The Kappa statistics were calculated to ensure the level of confidence. The results were statistically tested by t and Q-squared tests. Results: The GI group consisted of 32 patients while the GC group consisted of 30 patients. The oronasal fistulas incidence rate was 9.4% (GI) and 6.7% (GC), and there was no association to surgical techniques. Study models of 62 patients at the average age of 55.5 months were available for assessment. Good to very good levels of intra- and interrater reliability were obtained (0.67-0.87 and 0.76-0.90). The mean index scores varied between 2.04 (GI) and 2.76 (GC) with a statistically significant difference (p=0.007). When all evaluations were distributed between indexes good (1 and 2), regular (3) and bad (4 and 5); a statistically significant difference was observed between the GI and GC groups (p = 0.006),. The GI Group presented a 74% rate of good scores, while the GC Group rated 52% in good scores. When comparing the distributions by median, a difference (p = 0.024) was found between scores 1 of the GI (31.2%) and GC (3.3%) groups. The correlation between the cleft severity and the dental arch relationships assessed by the FYOI was not evidenced by the Spearman method. Conclusions: The ECR results provide statistical evidence that the DCHP protocol delivers better outcomes related to dentofacial growth. There was no correlation found between the cleft severity, palatal width and the results related to maxilar growth. The prevalence of oronasal fistules is similar in both surgical protocols

L’augmentation de la population âgée dans la société indique que les systèmes de soins de la santé font face à de nouveaux défis. Les hauts niveaux d’incapacité qui en résultent peuvent être réduits par les nouvelles technologies, la promotion de la santé ainsi que des stratégies de prévention. Les écrits scientifiques récents soulignent la supériorité des prothèses dentaires implanto-portées par rapport aux prothèses conventionnelles en termes de satisfaction et de qualité de la vie des patients. Cependant, il n'est toujours pas clair si ces avantages ont des effets positifs à long terme sur la santé orale et générale ainsi que sur la qualité de vie des populations âgées. Objectifs, Hypothèses : Notre but était de mesurer l’impact des prothèses mandibulaires retenues par 2 implants sur la qualité de vie associée à la santé bucco-dentaire et générale ainsi que sur la santé orale et la qualité du sommeil des aînés édentés. Nous avons évalué les hypothèses nulles suivantes : il n'y a aucune différence entre les individus portants des prothèses mandibulaires retenues par 2 implants (IODs) et ceux qui portent des prothèses conventionnelles (CDs), par rapport à la qualité de vie reliée à la santé bucco-dentaire et générale, la santé orale et la qualité du sommeil, un an après avoir reçu leurs nouvelles prothèses. Méthodes : Dans cette étude randomisée contrôlée, 255 aînés ont reçu au hasard IODs ou les CDs, les deux types de prothèses étant opposés à des prothèses maxillaires conventionnelles. La qualité de la vie reliée à la santé bucco-dentaire (OHRQoL) et la santé générale subjective ont été mesurées avec les questionnaires Oral Health Impact Profile (OHIP-20) et Short Form-36 (SF-36) en condition pré-traitement et après un an. La qualité du sommeil et la somnolence diurne ont été mesurées à l’aide du questionnaire Qualité de Sommeil de Pittsburg et de l'Échelle de Somnolence Epworth. La santé orale a été évaluée par un examen clinique. Les variables indépendantes étaient le sens de cohérence et le type de prosthèse, ainsi que des variables socio-démographiques. En utilisant des analyses statistiques bi et multi-factorielles, des comparaisons à l’intérieur d’un même groupe et entre deux groupes ont été effectuées. Résultats : Les différences pré et post traitement pour les cotes OHIP étaient significativement plus grandes pour le groupe IOD que le groupe CD (p<0.05). Le type de traitement et la cote pré-traitement étaient des facteurs significatifs à OHRQoL (p < 0.0001). Dans le groupe CD, il y avait une diminution significative par rapport aux cotes de «Physical Component Scores (PCS)», le fonctionnement physique, le rôle physique et la douleur physique entre les données pré-traitement et un an après le traitement, ce qui indique une diminution au niveau de la santé générale subjective. Dans le groupe IOD, une diminution statistiquement non significative a été remarquée par rapport à toutes les cotes des sous-échelles de SF-36, sauf pour la douleur physique. Le modèle final de régression a démontré qu’après ajustement pour les variables âge, sexe, statut marital et type de traitement, la cote totale finale d’OHIP et les données de bases de PCS prédisaient la cote finale de PCS (p < 0.0001). Aucune corrélation significative entre sens de cohérence et OHRQoL n'a été détectée (r =-0.1; p > 0.05). Les aînés porteurs des prothèses conventionnelles avaient presque 5 fois plus de chance d’avoir une stomatite prothétique que ceux portant des prothèses mandibulaires hybrides retenues par 2 implants (p < 0.0001). Les aînés ayant subjectivement une mauvaise santé générale avaient une qualité de sommeil moins bonne que ceux avec une meilleure santé générale subjective (p < 0.05). Les personnes qui avaient une OHRQoL moins bonne étaient presque 4 fois plus somnolentes pendant le jour que celles avec une meilleure OHRQoL (p=0.003, χ2; OR =3.8 CI 1.5 to 9.8). L'analyse de régression a montré que la santé générale subjective et OHRQoL prévoient la qualité du sommeil (p=0.022 et p=0.001, respectivement) et la somnolence diurne (p=0.017 et p=0.005, respectivement). Conclusions: Les résultats de cette étude suggèrent que, chez les aînés édentés, des prothèses mandibulaires hybrides retenues par deux implants amènent une amélioration significative de la qualité de vie reliée à la santé bucco-dentaire et maintiennent la sensation d’une meilleure santé physique. Des prothèses hybrides implanto-portées peuvent contribuer à la santé orale en réduisant les traumatismes infligés à la muqueuse orale et en contrôlant la stomatite prothétique. Les aînés édentés dont le niveau de qualité de vie reliée à la santé bucco-dentaire est bas, peuvent aussi avoir des troubles de qualité du sommeil. / The global greying of society indicates that health care systems face new challenges. High levels of disability can be reduced through new technologies, health promotion and preventive strategies. Recent literature has underlined the superiority of mandibular implant overdentures over conventional dentures for patient satisfaction and quality of life. However, it is still not clear whether this benefit has any long-term positive effects on oral and general health, as well as on the quality of life of elderly populations. Objectives, Hypotheses: We aimed to measure the impact of mandibular two-implant overdentures on the general and oral health quality of life, as well as on oral health and sleep quality of edentulous elders. We tested the null hypothesis that there is no difference in the general and oral health quality of life, as well as, on oral health and sleep quality of those wearing mandibular two-implant overdentures (IODs) and those who wear conventional dentures (CDs), one year following prosthesis delivery. Methods: In this randomized controlled trial, 255 elders randomly received IODs or CDs, both opposed by conventional maxillary dentures. OHRQoL and perceived general health were measured with the Oral Health Impact Profile (OHIP-20) and the Short Form-36 (SF-36) at baseline and after one year. Sleep quality and daytime sleepiness were measured with the Pittsburg Sleep Quality global score and the Epworth Sleepiness Scale. Clinical exams were conducted to evaluate oral health. Independent variables included sense of coherence and prosthesis type, as well as socio-demographic variables. Between and within group comparisons were performed using bivariate and multivariate statistical tests. Results: Pre/post treatment differences in OHIP scores were significantly greater for the IOD than the CD group (p<0.05). Type of treatment and pre-treatment scores were significant contributors to OHRQoL (p<0.0001). In the CD group, there was a statistically significant decrease in physical component scores (PCS), physical functioning, role physical and bodily pain from baseline to one year follow up, indicating decreased perceived general health. In the IOD group, no statistically significant decrease was seen in SF-36 subscale scores from baseline to one year, except for bodily pain. The final regression model demonstrated that, after controlling for age, sex, marital status and type of treatment, the OHIP total final and the PCS baseline scores predict PCS final scores (p<0.0001). No significant correlation between sense of coherence and OHRQoL was detected (r= -0.1; p> 0.05). Elders wearing conventional dentures were almost 5 times more likely to have denture stomatitis than those wearing mandibular two-implant retained overdentures (p < 0.0001). Elders with low perceived general health had poorer sleep than those with high perceived general health (p<0.05). Those with low oral health related quality of life were almost 4 times sleepier during the day than those with high OHRQoL (p=0.003, χ2; OR =3.8 CI 1.5 to 9.8). Regression analysis showed that perceived general health and OHRQoL predict sleep quality (p=0.022 and p=0.001, respectively) and daytime sleepiness (p=0.017 and p=0.005, respectively). Conclusions: The results of this study suggest that, in edentulous elders, mandibular two-implant overdentures provide significant improvement in oral health related quality of life and maintain perceived physical health. Implant overdentures may contribute to oral health by reducing oral mucosa trauma and control denture stomatitis. Edentulous elders whose oral health related quality of life is low may also have poor sleep quality.

Problématique : La satisfaction des patients et la qualité de vie reliée à la santé bucco-dentaire (OHRQoL) sont deux mesures de résultats fréquemment utilisées durant les études cliniques. Néanmoins, chez les patients totalement édentés, les évidences scientifiques relatives au niveau de relation entre ces deux mesures sont faibles. De plus, on ignore toujours quels éléments de la satisfaction des patients relativement à leurs prothèses partagent la meilleure relation avec la OHRQoL. Objectifs : Déterminer, chez les patients totalement édentés, s’il existe un lien entre leur satisfaction de leurs prothèses et leur OHRQoL et identifier les déterminants de satisfaction qui démontrent le meilleur niveau de relation avec la OHRQoL. Méthodologie : Les données provenant de 255 patients totalement édentés qui ont participé à une étude randomisée et contrôlée ont été utilisées. La OHRQoL a été évaluée à l’aide du questionnaire Oral Health Impact Profile (OHIP-20). Le McGill Denture Satisfaction Instrument a été utilisé pour estimer la satisfaction des patients. Ces mesures ont été prises au temps initial, à 6 mois et à 12 mois suivants la mise en bouche des prothèses. Des analyses statistiques de régression linéaire simples et multiples ont été utilisées afin d’évaluer la relation entre les deux mesures. Résultats : Une relation positive et considérable existe entre la satisfaction des patients totalement édentés et leur OHRQoL. La difficulté masticatoire (P = .005) et la condition buccale (P = .002) sont les éléments de la satisfaction qui possèdent le meilleur lien avec la OHRQoL. Ces deux facteurs expliquent 46.4% (P = .0001) de la variance dans l’amélioration d’OHIP suivant un traitement prosthodontique. La relation décrite est dépendante du temps, mais pas du type de traitement ni des variables sociodémographiques. Conclusions : Dans les limites de l’étude, il est conclu qu’une relation positive existe entre la satisfaction des patients et leur OHRQoL. La difficulté masticatoire et la condition buccale sont les deux éléments de la satisfaction les plus importants. / Statement of problem: Patients’ satisfaction and oral health-related quality of life (OHRQoL) are two commonly used patient-reported outcomes. Convincing evidence is lacking to demonstrate the relation between these two outcomes in completely edentate patients who receive prosthodontic treatments. In addition, it is still unclear which elements of denture satisfaction share the best association with OHRQoL. Objectives: To evaluate the level of association between patients’ denture satisfaction and OHRQoL in edentulous patients, and to identify the determinants of satisfaction that best predict OHRQoL. Methods: Data from 255 edentulous elders who participated in a randomized clinical trial were used to analyze the relationship between OHRQoL and denture satisfaction. OHRQoL was evaluated with the Oral Health Impact Profile (OHIP-20) questionnaire. The McGill Denture Satisfaction Instrument was used to assess patients’ satisfaction with treatment. Outcomes were measured prior to treatment and 6 and 12 months after delivery of new dentures. Simple and multiple linear regressions analyses were performed to statistically assess the relationship between the variables. Results: A highly positive association exists between oral health-related quality of life and denture satisfaction ratings. Chewing ability (P = .005) and oral condition (P = .002) are the aspects of satisfaction presenting the best association with OHRQoL. These two variables explained 46.4% (P = .0001) of the variance in OHIP’s change score following treatment. This association varied with time, but not with type of treatment or socio-demographic variables. Conclusions: Within the limitations of this study, a highly positive association exists between OHRQoL and denture satisfaction. Chewing ability and oral condition are the determinant of denture satisfaction best associated with OHRQoL, predicting 46.4% of its improvement following a treatment.

Made available in DSpace on 2014-08-20T14:30:10Z (GMT). No. of bitstreams: 1 tese_anelise_fernandes_montagner.pdf: 2069040 bytes, checksum: f8827dc228fd6085f72280a7c6d30b98 (MD5) Previous issue date: 2013-08-29 / The aim of this study was to evaluate the influence of chlorhexidine digluconate and sodium hypoclorite application on dentin after acid ecthing on the performance of adhesive restorations subjected to aging of the adhesive interface. For this, three studies were performed (in vitro, in situ and a systematic review). The in vitro study aimed to evaluate the effect of chlorhexidine digluconate (CHX) and sodium hypochlorite (NaOCl) on the microtensile bond strength values (μTBS) in dentin after cariogenic challenge and aging. Thirty sound human molars were selected and randomly assigned into 3 dentin pre-treatments (control, 2% chlorhexidine and 10% NaOCl) and 4 different types of aging (control -C-, biofilm without cariogenic challenge -NCC-, biofilm with cariogenic challenge -CC- and 18-month water storage -WS-). The same etch-and-rinse adhesive system (Adper Single Bond 2, 3M ESPE) and composite resin (Z250, 3M ESPE) were used for all the groups (n=30). For NCC and CC groups, dental biofilm in microcosm derived from saliva of a healthy donor was added on the samples. The biofilm grew up in a defined medium enriched with mucin (DMM), with or without 10% sucrose, according to the group. After the experimental period, all the samples were cleaned up and microtensile test was carried out. The data, in MPa, were subjected to ANOVA and a post-hoc Tukey Test (p < 0.05). The pre-treatment did not influence the μTBS, for all the aging conditions (p = 0.188); however the type of aging statistically affected the bond strength (p = 0.000). The bond strength values showed the following trend: C = NCC < CC = WS. Cariogenic challenge and water storage aging affected the bond strength stability and the former seems to be a suitable short-term methodology to assess the degradation of the resin-dentin. The in vivo study aimed to evaluate the effect of chlorhexidine (CHX) application in etched dentin on the 6-month retention of restorations of noncarious cervical lesions (NCCLs). A randomized controlled splitmouth and blind trial was carried out. Patients (n = 42) with at least two noncarious cervical lesions were included. NCCLs were randomly assigned according to the type of tooth into two groups: control (application of a placebo solution) or experimental group (application of 2% CHX for 60s after acid etching). Class V restorations (n = 169) were performed with an etch-and-rinse adhesive system (Adper Single Bond 2) and a composite resin (Filtek Z350) according to the manufacturer instructions, by 10 previously trained operators. The restorations were evaluated by a calibrated examiner at 1 week (baseline) and 6-month using the FDI criteria. The outcome was retention of the restoration. The analysis of factors associated to the failure of restoration was carried out through Fisher s Exact Test (α = 0.05). After 6 months of follow-up, 3.4% (CI 95% 1.3 - 7.3) of the Class V restorations failed. There was no significant difference between control and CHX (p = 0.920). Regarding the cavity s variables, deeper (p = 0.024) and wider cavities (p = 0.004) showed more failures, and wedge-shaped cavities failed more than saucer-shaped ones (p = 0.033). Regarding the patient s variables, restorations in patients with lower salivation 8 showed a higher percentage of failure (p = 0.034). Both treatments provided acceptable clinical performance of the restorations. The use of CHX as a coadjuvant in dentin adhesion did not influence the retention of Class V restorations after 6 months of follow-up. The systematic review aimed to systematically review the literature for in vitro and ex vivo studies that evaluated the resin-dentin bond strength immediately and longitudinal with the use of MMP inhibitor on the adhesive procedure. The systematic review was conducted sourcing the following databases (Pubmed, TRIP, LILACS, Scielo, Cochrane and ISI web Science) with no publication year or language limit. From 1.336 potentially eligible studies, 48 were selected for full text analysis and 30 were included for review. Two independently reviewers selected the studies, abstracted information and assessed the risk of bias on standardize scales. The results showed high heterogeneity in some comparisons and showed no difference for CHX 2% and control at baseline, however after 6-month of aging the CHX 2% and 0.2% presented a trend showing higher bond strength values than control groups (p < 0.05). The literature review was possible to observe the trend towards the decreased of the bond strength through time most for the control groups than for the experimental one. From of the 30 studies included, only 5 studies (16.6%) presented medium risk of bias while 25 (83.4%) showed high risk of bias and none showed low risk of bias. The use of MMPs inhibitor did not negatively affect the immediate bond strength, and it influenced the bond strength values long-time regarding the dentin adhesion stability. / O objetivo deste estudo foi avaliar a influência da aplicação do digluconato de clorexidina (CRX) e hipoclorito de sódio (NaOCl) em dentina, após o condicionamento ácido, na performance da interface adesiva submetida a envelhecimento da interface adesiva. Para isto, foram realizados 3 estudos (in vitro, in vivo e revisão sistemática). O estudo in vitro objetivou avaliar o efeito do prétratamento da dentina nos valores de resistência de união (RU) após diferentes tipos de envelhecimentos da interface adesiva. A dentina de todos os espécimes foi submetida ao condicionamento com ácido fosfórico por 15s e em seguida a 3 tipos de pré-tratamento: água destilada (controle - soluçao placebo - 60s), digluconato de clorexidina 2% - 60s, ou hipoclorito de sódio 10% - 60s. O sistema desivo (Single Bond 2 3M/ESPE) foi aplicado na superfície dentinária conforme indicação do fabricante. Palitos resina-dentina foram obtidos e submetidos a 4 níveis de envelhecimento: controle (CO), biofilme sem desafio cariogênico (BSD), biofilme com desafio cariogênico (BCD) e armazenamento em água por 18 meses (AGU). Nos grupos com biofilme, modelo de microcosmo foi utilizado e o biofilme foi crescido em meio definido enriquecido com mucina, com (BCD) ou sem (BSD) sacarose por 14 dias. Após o período experimental os espécimes foram limpos e preparados para o teste de microtração e o padrão de fratura foi analisado. Os valores de RU, em MPa, foram submetidos a ANOVA e teste post hoc Tukey (p < 0,05). O pré-tratamento não influenciou nos valores de RU, para todos os envelhecimentos avaliados (p = 0,188), entretanto o tipo de envelhecimento estatisticamente influenciou os valores de RU (p = 0,000). O envelhecimento CO foi similar ao BSD, com valores RU maiores que o BCD e AGU. A interface adesiva foi negativamente afetada pelo desafio cariogênico e pela degradação em água. No estudo in vivo, com objetivo de avaliar a retenção de restaurações classe V em dentina tratada ou não com CRX, um ensaio clínico controlado randomizado, boca dividida e triplo-cego foi conduzido. Pacientes (n = 42) com no mínimo 2 lesões cervicais não cariosas (LCNC) foram selecionados. As LCNC foram randomizadas em 2 grupos: tratamento controle e tratamento experimental (CRX 2% - 60s). Restaurações (n = 169) foram realizadas com Single Bond 2 (3M EPSE) e Filtek Z350 por 10 operadores previamente treinados. As restaurações foram avaliadas por um examinador calibrado em 1 semana e 6 meses após, usando os critérios da FDI. A análise dos fatores associados às falhas nas restaurações foi conduzida através do teste exato de Fisher (α = 0,05). Após 6 meses de acompanhamento, 3,4% (IC95% 1,3 - 7,3) das restaurações falharam devido a retenção. Não houve diferença significante entre os tratamentos controle e CRX para retenção (p = 0,920) e para manchamento marginal (p = 0,734). Em relação às variáveis relativas à cavidade, cavidades com maior profundidade (p = 0,024) e com maior altura (p = 0,004) 6 apresentaram maior ocorrência de falhas. Ainda, cavidades em formato de V apresentaram mais falhas que aquelas em formato de U (p = 0,033). Quanto as variáveis relativas aos pacientes, restaurações em pacientes que apresentavam boca seca falharam em maior porcentagem (p = 0,034). O uso de clorexidina como um coadjuvante na adesão a dentina não influenciou na retenção das restaurações após 6 meses de acompanhamento. E a revisão sistemática teve o objetivo de revisar a literatura acerca de estudos in vitro que avaliaram a RU resina-dentina imediata e após envelhecimento com o uso de inibidores de MMPs no procedimento adesivo. A revisão sistemática foi conduzida em 6 databases (Pubmed, TRIP, LILACS, Scielo, Cochrane and ISI web Science) sem limite de ano ou língua. De 1.336 estudos potencialmente elegíveis, 48 foram selecionados para análise de todo texto e 30 estudos foram incluiídos na revisāo. Dois revisores selecionaram os estudos, extraíram as informações e dados e verificaram o risco de viés em escalas padronizadas. Os resultados demostraram uma grande heterogeneidade em algumas comparações e nāo mostraram diferenças entre clorexidina 2% e o grupo controle sem envelhecimento, porém após 6 meses de envelhecimento observou-se uma tendência a favor dos grupos controle (p < 0,05). Todavia, foi possível observar na revisāo de literatura descritiva a tendência da diminuiçāo dos valores de RU (porcentagem) ao longo do tempo, mais para o grupo controle do que para o grupo experimental. De 30 estudos incluídos, apenas 5 estudos (16,6%) apresentaram médio risco de viés, enquanto 25 estudos (83,4%) mostraram alto risco de vieés e nenhum mostrou baixo risco. Os inibidores de MMPs nāo afetaram negativamente a RU da resina a dentina sem envelhecimento, e nāo influenciaram os valores de RU após envelheciemento.

Estudo comparativo entre os custos dos tratamentos clínico, cirúrgico ou percutâneo em portadores de doença multiarterial coronária estável - 5 anos de seguimento [tese]. São Paulo: Faculdade de Medicina, Universidade de São Paulo, 2013. INTRODUÇÃO: As principais opções terapêuticas para a doença multiarterial coronária incluem cirurgia de revascularização miocárdica (CRM), intervenção coronária percutânea (ICP) e tratamento clínico (TC). Essas três estratégias terapêuticas apresentam eficácia similar em determinados subgrupos de pacientes. No presente momento, estudos direcionados à análise econômica são escassos, e contemplam, principalmente, os custos comparativos entre as intervenções cirúrgica e percutânea. OBJETIVOS: Analisar, prospectivamente, o custo comparativo das três formas terapêuticas da doença multiarterial coronária estável, durante cinco anos de seguimento. MÉTODOS: Foi computado o custo terapêutico global de 611 pacientes do ensaio clínico The Second Medicine, Angioplasty, or Surgery Study (MASS II), baseado na remuneração provida pelo sistema de saúde suplementar do Instituto do Coração do HC/FMUSP, tomando-se os valores em moeda nacional corrente. Realizou-se, posteriormente, análise de custo-efetividade para o tempo livre de eventos clínicos e o tempo livre de eventos acrescido de tempo livre de angina. RESULTADOS: O TC apresentou 3.79 e 2.07 QALY (quality-adjusted lifeyears); o ICP apresentou 3.59 e 2.77 QALY; e o CRM apresentou 4.4 e 2.81 QALY, respectivamente, para sobrevida livre de eventos e sobrevida livre de eventos e angina. Os custos para sobrevida livre de eventos foram R$ 16.327,80 para TC, R$ 35.940,60 para ICP e R$ 32.873,40 para CRM. A análise pareada dos custos para sobrevida livre de eventos mostrou que houve diferença significante favorecendo TC contra ICP (P < 0,01), e em comparação com CRM (P < 0,01); e CRM versus ICP (P = 0,01). Os custos para sobrevida livre de eventos e angina foram R$ 29.795,40, R$ 46.495,80 e R$ 44.305,20, respectivamente. A comparação pareada dos custos livres de eventos mais livres de angina demonstrou que houve diferença significante favorecendo TC contra ICP (P = 0,04), e em comparação com CRM (P < 0,001). Não houve diferença entre CRM e ICP (P > 0,05). CONCLUSÃO: A análise comparativa entre as diferentes opções terapêuticas desta amostra revelou que TC foi mais custo-efetivo que CRM, e esta, por sua vez, mais custo-efetivo que ICP / BACKGROUND: The therapeutic options for multivessel coronary artery disease are coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), or medical treatment alone (MT). These three therapeutic strategies present similar efficacy for specific subgroups. At the present moment, economic outcome trials are scant, and contemplate comparative cost between surgical or percutaneous intervention. OBJECTIVE: To analyze, prospectively, the comparative cost from three therapeutic strategies in multivessel coronary artery disease, at 5-year of follow-up. METHODS: We analyzed cumulative costs of 611 patients from clinical trial The Second Medicine, Angioplasty, or Surgery Study (MASS II). The economic analysis is based on remuneration provided by the supplementary health system of the Heart Institute of the Clinical Hospital of FMUSP, expressing these values in Brazilian currency. It was compared to the cumulative costs of each therapeutic strategy in the 5-year follow-up period. A cost-effectiveness analysis was then conducted for event-free survival and event plus angina-free survival. Cost-effectiveness analysis was performed by quality-adjusted life- year (QALY) analysis. RESULTS: Respectively, for event-free survival and event plus angina-free survival, MT presented 3.79 quality-adjusted life-years (QALY) and 2.07 QALY; PCI presented 3.59 and 2.77 QALY; and CABG demonstrated 4.4 and 2.81 QALY. The event-free costs were R$ 16327.80 for MT; R$ 35940.60 for PCI; and R$ 32873.40 for CABG. The paired comparison of the event-free costs showed that there was a significant difference favoring MT versus PCI (P < 0.01) and versus CABG (P < 0.01) and CABG versus PCI (P =0.01). The event-free plus angina-free costs were R$ 29795.40, R$ 46495.80 e R$ 44305.20, respectively. The paired comparison of the event-free plus angina-free costs showed that there was a significant difference favoring MT versus PCI (P =0.04), and versus CABG (P < 0.001); there was no difference between CABG and PCI (P > 0.05). CONCLUSION: The comparative analysis among the different therapeutic strategies demonstrated that MT was more cost-effective than CABG, and this than PCI