2020;114(3) – ABC CARDIOL

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Original Article

High Serum Netrin-1 and IL-1β in Elderly Females with ACS: Worse Prognosis in 2-years Follow-up

Paola Leocádio et al. Penélope Menta Melissa Dias Júlia Fraga … Alessandra Goulart Itamar Santos Paulo Lotufo Isabela Bensenor Jacqueline Alvarez-Leite

Abstract

Background

Several markers have been evaluated for a potential impact on clinical decisions or mortality prediction in acute coronary syndrome (ACS), including Netrin-1 and IL-1β that have been associated with cardiovascular disease.

Objective

Our study examined the prognostic value of Netrin-1 and IL-1β in patients with ACS (2-year follow-up).

Methods

We evaluate Netrin-1, IL-1β and other risk factors in the serum sample of 803 patients. Kaplan-Meier curves and Cox regression were used for the analysis of all-cause mortality, cardiovascular mortality, and a combined outcome of fatal myocardial infarction (MI) or new non-fatal MI, considering p-value < 0.05.

Results

There were 115 deaths from all causes, 78 deaths due to cardiovascular causes and 67 events in combined outcomes. Netrin-1 levels above the median (>44.8 pg/mL) were associated with a worse prognosis (all-cause mortality and cardiovascular mortality) in elderly females, even after model adjustment (HR: 2.08, p = 0.038 and HR: 2.68, p = 0.036). IL-1β levels above the median (>13.4 pg/mL) in elderly females were associated with increased risk of all outcomes after adjustment (all-cause mortality – HR: 2.03, p = 0.031; cardiovascular mortality – HR: 3.01, p = 0.013; fatal MI or new non-fatal MI – HR: 3.05, p = 0.029). For males, no associations were observed between Netrin-1 or IL-1β and outcomes.

Conclusion

High serum levels of Netrin-1 and IL-1β showed significant association with worse prognosis in elderly females. They may be useful as prognostic indicators in ACS. (Arq Bras Cardiol. 2020; 114(3):507-514)

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Editorial

Exercise and Six-Minute Walk Test in Lower Extremity Occlusive Peripheral Arterial Disease

Tales de Carvalho

The article “Exercise Intensity During 6-min Test in Patients with Peripheral Artery Disease” provides original, practically useful information to be considered in the diagnosis, prognosis and mainly in the functional assessment that allows a better prescription of physical exercise in the medical treatment of the disease. The study was conducted with the aim of determining whether overground walking would allows the detection of the first ventilatory threshold, also known as anaerobic threshold (AT), in symptomatic patients with lower extremity occlusive peripheral arterial disease (LE-OPAD). AT is a marker of exercise intensity, useful for the determination of the optimal zone for physical training focused on improvement in cardiorespiratory fitness.

LE-OPAD is an important public health problem. According to global epidemiology report, the disease affected 202 million individuals in 2010, and 237 million in 2015, with a 22% increase during this period. The association of OPAD with major cardiovascular events (MACE) has been well documented; in the severe stage of the disease, with presence of critical ischemia, there is a high risk of cardiovascular events, lower limb amputation and death, with association with elevated levels of cardiac troponin and N terminal pro-brain natriuretic peptide (NT-proBNP).

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Review Article

The Top 10 Original Articles Published in the Arquivos Brasileiros de Cardiologia and in the Revista Portuguesa de Cardiologia in 2019

Gláucia Maria Moraes de Oliveira et al. Ricardo Fontes-Carvalho Lino Gonçalves Nuno Cardim Carlos Eduardo Rochitte

Introduction

For centuries, Portugal and Brazil have shared a tradition of cooperation, which applies to medicine. In cardiology, for example, their national scientific societies – the Brazilian Society of Cardiology and the Portuguese Society of Cardiology – have a long history of collaboration, which extends to their journals.

The Arquivos Brasileiros de Cardiologia ( Arq Bras Cardiol ), the official scientific publication of the Brazilian Society of Cardiology, with an impact factor of 1.679 in 2018 (JCR), is the most influential cardiology journal in Brazil and Latin America. This can be exemplified by the increasing number of submissions to the Arq Bras Cardiol (650 in 2017, 771 in 2018, and 734 in 2019), and by its h5 index of 31 and h5 median of 39, with acceptance rate lower than 20%.

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Original Article

Waist Circumference Percentiles and Cut-Off Values for Obesity in a Large Sample of Students from 6 To 10 Years Old Of The São Paulo State, Brazil

José Luiz F Santos et al. Valentin P. Valério Rafael N. Fernandes Ligia Duarte … Antonio C. Assumpção Jayme Guerreiro Antonio L. Sickler Álvaro A. R. Lemos Jayro G Goulart Filho Luiz Antonio Machado Cesar Ibraim Masciarelli Pinto Carlos Magalhães Maria Fernanda Hussid Cleber Camacho Alvaro Avezum Carine T. Sangaleti Fernanda Marciano Consolim-Colombo

Abstract

Backgroud

The prevalence of obesity has systematically been increased in the population, including children and adolescents, around the world.

Objectives

To describe reference percentile curves for waist circumference (WC) in Brazilian children and provide cut-off values of WC to identify children at risk for obesity.

Methods

A multicenter, prospective, cross-sectional study was performed with children aged from 6 to 10 years old, enrolled in public and private elementary schools from 13 cities of the São Paulo State. Height, weight, and WC were measured in duplicate in 22,000 children (11,199 boys). To establish the WC best cut-off value for obesity diagnosis, ROC curves with children classified as normal weight and obese were calculated, according to BMI curves, stratified by gender and age, and the Youden Index was utilized as the maximum potential effectiveness of this biomarker. A p < 0.05 was considered statistically significant.

Results

WC values increased with age in both boys and girls. The prevalence of obesity in each age group varied from 17% (6 years old) to 21.6% (9 years old) among boys, and from 14.1% (7 years old) to 17.3 % (9 years old) among girls. ROC analyses have shown the 75^th percentile as a cut-off for obesity risk, and the diagnosis of obesity is classified on the 85^th percentile or more.

Conclusion

Age and gender specific reference curves of WC for Brazilian children and cut-off values for obesity risk may be used for national screening and interventional studies to reduce the obesity burden in Brazil. (Arq Bras Cardiol. 2020; 114(3):530-537)

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Editorial

Interaction among Cardiovascular Scientific Journals in Brazil: A Model that should be Better Explored

Carlos Eduardo Rochitte

In the environment of intense, and apparently unlimited competition among scientific journals for the best article, and the highest number of citations and impact factor (IF), the Arquivos Brasileiros de Cardiologia (ABC Cardiol) has taken actions to foster the growth of other journals with similar scope in the national scientific community. The main objective is to promote dissemination of our best science by journals of increasingly higher quality, so that it can attract deserving attention and make a stronger contribution to the world scientific community.

With the current IF of nearly 1.7 according to the Journal of Citation Reports (JCR), the ABC Cardiol has attracted more and more submissions from national and international authors.^, Our acceptance rate is no more than 15% and tends to decrease even more. In this scenario, many papers of significant quality cannot be accepted for publication in the ABC Cardiol, including articles from studies developed in our successful postgraduate programs. This has an undesirable effect – the reduced exposure of our best science in indexation sources such as PubMED, Scielo, among others.

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Statement

Brazilian Position Statement on Resistant Hypertension – 2020

Juan Carlos Yugar-Toledo et al. Heitor Moreno Júnior Miguel Gus Guido Bernardo Aranha Rosito … Luiz César Nazário Scala Elizabeth Silaid Muxfeldt Alexandre Alessi Andrea Araújo Brandão Osni Moreira Filho Audes Diógenes de Magalhães Feitosa Oswaldo Passarelli Júnior Dilma do Socorro Moraes de Souza Celso Amodeo Weimar Kunz Sebba Barroso Marco Antônio Mota Gomes Annelise Machado Gomes de Paiva Eduardo Costa Duarte Barbosa Roberto Dischinger Miranda José Fernando Vilela-Martin Wilson Nadruz Júnior Cibele Isaac Saad Rodrigues Luciano Ferreira Drager Luiz Aparecido Bortolotto Fernanda Marciano Consolim-Colombo Márcio Gonçalves de Sousa Flávio Antonio de Oliveira Borelli Sérgio Emanuel Kaiser Gil Fernando Salles Maria de Fátima de Azevedo Lucélia Batista Neves Cunha Magalhães Rui Manoel dos Santos Póvoa Marcus Vinícius Bolívar Malachias Armando da Rocha Nogueira Paulo César Brandão Veiga Jardim Thiago de Souza Veiga Jardim

1. Definition and Epidemiology

Coordinator: Heitor Moreno Júnior.

Authors: Juan Carlos Yugar-Toledo, Heitor Moreno Júnior, Miguel Gus, Guido Bernardo Aranha Rosito, and Luiz César Nazário Scala.

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Editorial

Acute Coronary Syndrome in Elderly Women: Inflammation Strikes Again

Bruno Rocha et al. Carlos Aguiar

Atherosclerosis is the most common pathological mechanism underlying coronary artery disease (CAD), encompassing both acute coronary syndromes (ACS) and chronic coronary syndromes (CCS). Traditionally, the plaque formation process has been perceived as a consequence of cholesterol accumulation (particularly scavenger receptor-mediated uptake of modified low-density lipoprotein), leading to continuous plaque growth. Subendothelial intimal layer build-up further leads to progressive stenosis, reduced blood flow, and, eventually, tissue hypoxia. In addition, spontaneous thrombotic vessel occlusion and embolic events may constitute the common pathophysiological pathway for acute major cardiovascular events, namely myocardial infarction (MI) and stroke.

Although John Hunter first pioneered the inflammatory theory in 1794, it was not until 1994 that worse outcomes in patients with ACS were linked to higher C-reactive protein (CRP) levels, and it was proposed that plaque inflammation could be responsible for plaque fissuring. Hence, inflammation was finally linked to atherosclerosis and thrombosis. Moreover, it was later demonstrated that interleukin (IL) 1β, a pro-inflammatory cytokine, facilitates hematopoietic progenitor cell proliferation through glucose and cholesterol metabolism, thus promoting neutrophil extracellular trap formation in the growing plaque. Indeed, MI is accompanied by neutrophil infiltration, which is paramount to inflammation regulation.

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Original Article

Exercise Intensity during 6-Minute Walk Test in Patients with Peripheral Artery Disease

Breno Quintella Farah et al. Raphael Mendes Ritti-Dias Polly Montgomery Gabriel Grizzo Cucato Andrew Gardner

Abstract

Background

Non-supervised ground walking has been recommended for patients with symptomatic peripheral artery disease (PAD). However, the magnitude of the effort required by this activity and the characteristics of patients whose ground walking is more intense are unclear.

Objectives

To determine whether ground walking exceeds the ventilatory threshold (VT), a recognized marker of exercise intensity, in patients with symptomatic PAD.

Methods

Seventy patients (61.4% male and aged 40 to 85 years old) with symptomatic PAD were recruited. Patients performed a graded treadmill test for VT determination. Then, they were submitted to a 6-minute walk test so the achievement of VT during ground ambulation could be identified. Multiple logistic regression was conducted to identify predictors of VT achievement during the 6-minute walk test. The significance level was set at p < 0.05 for all analyses.

Results

Sixty percent of patients achieved VT during the 6-minute walk test. Women (OR = 0.18 and 95%CI = 0.05 to 0.64) and patients with higher cardiorespiratory fitness (OR = 0.56 and 95%CI = 0.40 to 0.77) were less likely to achieve VT during ground walking compared to men and patients with lower cardiorespiratory fitness, respectively.

Conclusion

More than half of patients with symptomatic PAD achieved VT during the 6-minute walk test. Women and patients with higher cardiorespiratory fitness are less likely to achieve VT during the 6-minute walk test, which indicates that ground walking may be more intense for this group. This should be considered when prescribing ground walking exercise for these patients. (Arq Bras Cardiol. 2020; 114(3):486-492)

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Editorial

Prognostic Scores for Mortality in Cardiac Surgery for Infective Endocarditis

Alexandre Bahia Barreiras Martins et al. Cristiane da Cruz Lamas

The article by Pivatto F Jr et al. allows us to discuss the important issue of prognostic scores in patients who have cardiac surgery for infective endocarditis (IE). The management of left- sided IE often involves surgery during the index admission, and the main challenge is to rapidly and correctly identify patients at high risk and to transfer them to institutions with a surgical team with expertise in endocarditis surgery.

Prognostic scores are important for several reasons: a reasonable estimate of the risk of death is important in clinical decision-making regarding surgical indication; the estimate is necessary to inform patients and their families of the surgical risk; risk stratification permits a fair comparison of cardiac surgery results, so that surgeons and hospitals treating high-risk patients will not appear to have worse results than others. For operative mortality to remain a valid measure of quality of care, it must be related to the risk profile of the patients receiving surgery.

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Editorial

Uninterrupted Direct Oral Anticoagulants in Atrial Fibrillation Catheter Ablation: Ready for Prime Time

Rhanderson Cardoso et al. André D’Avila

Catheter ablation is a well-established, safe, and effective strategy to achieve rhythm control in patients with symptomatic atrial fibrillation (AF) who are either intolerant or refractory to pharmacologic rhythm control or who wish to avoid long-term use of anti-arrhythmic drugs. Historically, when vitamin-K antagonists (VKAs) were the only option for oral anticoagulation, catheter ablation was performed after interruption of the VKA for several days and a transition (bridge) to subcutaneous or parenteral anticoagulation, typically with low-molecular-weight heparin. This strategy, however, was cumbersome and fraught with bleeding complications. Furthermore, the COMPARE randomized trial and observational studies showed that the thromboembolic risk was 10 to 15-fold higher with VKAs and heparin bridging as compared to uninterrupted VKAs. After these results, uninterrupted VKAs with a therapeutic international normalized ratio (INR) became the standard of care for periprocedural anticoagulation, and patients would routinely undergo catheter ablation with INR ranging between 2 and 3.5.

This option, however, also has two important setbacks. First, ablation becomes contingent on a therapeutic INR on the day of the procedure. A supra-therapeutic INR may entail a decision to postpone the procedure or administer blood products for correction, whereas a sub-therapeutic INR would typically imply deferring ablation to another day or require IV heparin until an ideal INR is reached. Second, the use of uninterrupted VKAs conflicts with the ever growing use of direct oral anticoagulants (DOACs). Electrophysiologists planning catheter ablation for patients on DOACs are faced with the following decision: (1) transition to VKAs for uninterrupted periprocedural anticoagulation or (2) continue periprocedural DOAC.

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Original Article

Software for Post-Processing Analysis of Strain Curves: The D-Station

Rafael Duarte de Sousa et al. Carlos Danilo Miranda Regis Ittalo dos Santos Silva Paulo Szewierenko … Renato de Aguiar Hortegal Henry Abensur

Abstract

Background

The use of speckle-tracking echocardiography for evaluation of cardiac function has great applicability in different scenarios. The broad use of this method requires tools that allow the extraction of relevant data from strain curves and inclusion of these data in traditionally used parameters.

Objectives

The present study aimed to present and validate a free software, called D-station, for analysis of strain curves.

Methods

From raw data files, the D-Station determines the phases of the cardiac cycle, and simultaneously exhibits the strain and strain rate curves of different cardiac chambers. Validation of the software was done by global longitudinal strain (GLS), and the analyses were performed: 1) graphical comparison of EchoPAC and D-Station paired measurements in relation to equality line; 2) by coefficient of correlation of these measurements; 3) test of hypothesis (p > 0.05); and 4) Bland-Altman analysis.

Results

The Spearman’s rho correlation coefficient indicated a strong correlation between the measurements. Results of the test of hypothesis showed a p-value = 0.6798 >> 0.05, thus also indicating an equivalence between the softwares. The Bland-Altman analysis revealed a bias ≤ 1% and dispersion ≤ 2% between the measurements. The tests showed that, for GLS values lower than 10%, there was a trend for higher percentage difference between the values, although the absolute values remained low.

Conclusion

The D-Station software was validated as an additional tool to the EchoPAC, which uses the raw data from the strain and strain rate curves exported from a proprietary software. (Arq Bras Cardiol. 2020; 114(3):496-506)

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Editorial

Takotsubo Syndrome: A Recurrent Disease?

Fábio Fernandes et al. Marcelo Westmoreland Montera

Several terms (such as happy heart syndrome, broken heart syndrome, and takotsubo cardiomyopathy) have been used to refer to the recently defined Takotsubo Syndrome (TTS). The first case of TTS was described in Japan (Hiroshima City Hospital) in 1983 and a report of five cases was published in a Japanese medical textbook in 1990.

However, in contrast to other cardiomyopathies that are usually not transient in nature, TTS is characterized by a temporary wall motion abnormality of the LV in the absence of pheochromocytoma, myocarditis and shares common features with acute coronary syndrome (ACS) similar symptoms at presentation, ECG abnormalities, elevated cardiac biomarkers, as well as a comparable in-hospital mortality with ST-segment elevation myocardial infarction (STEMI) and non-STEMI, specifically in terms of a microvascular ACS form. The European Society of Cardiology (ESC) has also established the International Takotsubo Diagnostic Criteria (InterTAK Diagnostic Criteria), which implement a diagnostic algorithm and assign a score to TTS.

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Editorial

Short Editorial: “Creation and Implementation of a Prospective Multicenter Registry of Acute Myocardial Infarction: RIAM”

José Mariani Junior

Cardiovascular diseases, including acute myocardial infarction (AMI), represent a major public health issue in Brazil and worldwide, with elevated incidence and mortality rates. The rates of Brazilian mortality for this group of causes (183.3/100,000)^, are amongst the highest in the world and is similar to that of countries such as China and areas such as the east of Europe.^,

The implementation of health promotion policies, early diagnosis and effective treatment are some of the most important prevention and treatment strategies for these diseases, which remain the leading cause of mortality among adult patients globally. However, the recognition of these diseases, as well as their real and effective measurements, are among the strategies that must be optimized in our field.

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Editorial

Dietary Salt Reduction: Illusion or Reality?

Nereida Kilza da Costa Lima

In spite of ample knowledge regarding systemic arterial hypertension as the main risk factor for cardiovascular diseases, the rates of control have shown a modest progressive increase, especially in Brazil. Brazilian studies have provided evidence that 50% to 60% of people with hypertension are receiving treatment, while only 20% to 30% of all people with hypertension are controlled.

The main difficulty in controlling systemic arterial hypertension lies in managing long-term patient adherence, given that the majority of patients are asymptomatic, and they eventually begin to have symptoms as a result of antihypertensive medication use.

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Editorial

Waist Circumference: A Simple Measure for Childhood Obesity?

Luciana Nicolau Aranha et al. Gláucia Maria Moraes de Oliveira

Childhood obesity has been increasing all over the world and considered one of the major challenges in public health. The prevalence increased from less than 1% in 1975 to 5.6% and 7.8% among girls and boys, respectively, in 2016. No less worrying are the recent data from the Brazilian Institute of Geography and Statistics (IBGE) showing that in 2008-2009, 51.4% of boys and 43.8% of girls aged between 5 and 9 years were overweight or obese.

Obese children and adolescents are five times more likely to become obese adults. Besides, childhood obesity has been associated with hypertension, insulin resistance, diabetes mellitus, dyslipidemia, and increased morbidity and mortality in adult life. Therefore, it is important to screen for excess body fat in this population and create strategies to prevent the development of chronic diseases in the future.

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Original Article

Creation and Implementation of a Prospective and Multicentric Database of Patients with Acute Myocardial Infarction: RIAM

Jacqueline Vaz et al. Anibal Pereira Abelin Marcia Moura Schmidt Pedro Piccaro de Oliveira … Carlos A. M. Gottschall Clarissa Garcia Rodrigues Alexandre Schaan de Quadros

Abstract

Background

Multicenter registries representing the real world can be a significant source of information, but few studies exist describing the methodology to implement these tools.

Objective

To describe the process of implementing a database of ST-segment elevation acute myocardial infarction (STEMI) at a reference hospital, and the application of this process to other centers by means of an online platform.

Methods

In 2009, our institution implemented an Registry of Acute Myocardial Infarction (RIAM), with the prospective and consecutive inclusion of every patient admitted to the institution who received a diagnosis of STEMI. From March 2014 to April 2016, the registries were uploaded to a web-based system using the REDCap software and the registry was expanded to other centers. Upon subscription, the REDCap platform is a noncommercial software made available by Vanderbilt University to institutions interested in research.

Results

The following steps were taken to improve and expand the registry: 1. Standardization of variables; 2. Implementation of institutional REDCap (Research Electronic Data Capture); 3. Development of data collection forms (Case Report Form – CRF); 4. Expansion of registry to other reference centers using the REDCap software; 5. Training of teams and participating centers following an SOP (Standard Operating Procedure).

Conclusion

The description of the methodology used to implement and expand the RIAM may help other centers and researchers to conduct similar studies, share information between institutions, develop new health technologies, and assist public policies regarding cardiovascular diseases. (Arq Bras Cardiol. 2020; 114(3):446-455)

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Editorial

Coronary Slow Flow Phenomenon – Adding Myocardial Fibrosis to the Equation

Filipe Penna de Carvalho et al. Clério Francisco de Azevedo

Initially described more than 40 years ago by Tambe et al., coronary slow flow phenomenon (CSFP) is characterized by delayed contrast medium progression in the absence of obstructive coronary epicardial disease during invasive coronary angiography. CSFP typically affects young male smokers, who often presents with acute coronary syndrome (ACS) or recurrent refractory resting angina requiring hospital admission.^– Moreover, life-threatening arrhythmias and sudden cardiac death have also been associated with CSFP.

Despite increased awareness and research, CSFP remains an elusive and poorly understood condition, with many proposed pathogenic mechanisms including endothelial, vasomotor and microvascular dysfunction.^, Indeed, an abnormal regulation of microvascular tone that occurs only during resting conditions, while coronary flow reserve is within normal range, has been described in CSFP.

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Viewpoint

The Evolving Landscape of the Geriatric Cardiology Field in Brazil: New Challenges for a New World

Caio de Assis Moura Tavares et al. André Feitosa Wanderley Cavalcanti Wilson Jacob Filho

The essence of geriatric cardiology

Because it is a recent and not widespread specialty, Geriatric Cardiology is often confused with Geriatrics that is practiced by a cardiologist or simply with Cardiology that is applied to elderly patients. Although this is part of the discipline’s core, it does not represent the whole picture. It would be more adequate to define it as integrated and age-adequate cardiovascular care, centered on the patients and their functionalities – a concept previously presented by our colleagues^,– that has been evolving and taking shape, as a result of the use of specific and predetermined tools.

Objectively, one could consider it as cardiology practice integrated with the Geriatric’s 5 Ms: medication (focusing on prescribing the absolutely necessary, targeting at reducing polypharmacy, minimizing interactions and adverse reactions; following Beers criteria to select appropriate medication for the elderly), mentation (vigilance, prevention and treatment of cognitive disturbances), mobility (valuing and implementing strategies that seek to maintain the patient’s mechanical functionality), multimorbidity (approaching the patient not only by looking up the cardiovascular system, but also by considering the occurrence of multiple comorbidities to be the rule, not the exception, in these individuals), and last, but literally not least is matters most (always consider the patient’s opinion regarding the benefits and burdens of the treatment, taking into account the biography and personal values, bringing the patient into the center of decision making). We would also add a sixth and last M, multidisciplinary, for the care of the elderly, remembering it must be coordinated in a horizontal fashion by a professional, but never concentrated in only one person, giving due importance to the participation of other specialists and healthcare professionals. At our institute, in the Geriatric Cardiology Unit, we perform in all patients a Comprehensive Geriatric Assessment with the aid of the 10-TaGA (10-Minute Targeted Geriatric Assessment) tool.^,

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Original Article

Effects of added salt reduction on central and peripheral blood pressure

Ana Carolina Arantes et al. Ana Luiza Lima Sousa Priscila Valverde de O. Vitorino Paulo Cesar B. Veiga Jardim … Thiago de Souza Veiga Jardim Jeeziane Marcelino Rezende Ellen de Souza Lelis Rafaela Bernardes Rodrigues Antonio Coca Weimar Kunz Sebba Barroso

Abstract

Background

Although the effects of salt intake reduction on casual blood pressure have been extensively studied in hypertensive individuals, data on reductions of added salt on arterial stiffness in both normotensive and prehypertensive subjects are scarce.

Objective

To evaluate the effects of progressive reduction in added salt intake (from 6 grams to 4 grams per day) on peripheral and central blood pressure and arterial stiffness in normotensive, prehypertensive and hypertensive individuals.

Methods

This was a single-blinded clinical trial with 13 weeks of follow-up. Normotensive (≤ 130/85 mmHg), prehypertensive (≥ 130 e < 139/≥ 85 e < 90 mmHg) and stage 1 hypertensive individuals (< 139/≥ 85 and < 90 mmHg) were assessed. Casual blood pressure measurements and ambulatory blood pressure monitoring were performed using the automated OMRON 705CP device, and central blood pressure was measured using the Sphygmocor^®. Twenty-four-hour urinary sodium excretion and the amounts of added salt consumed were measured. Statistically significance level was set at p < 0.05 for all analysis.

Results

A total of 55 participants (18 normotensive, 15 prehypertensive and 22 hypertensive), median age 48 years (IQR:39-54) were studied. The groups were not different in age or sex. No difference was observed in blood pressure or sodium excretion levels before and after the intervention. No significant changes in arterial stiffness parameters were observed.

Conclusion

The progressive reduction in added salt intake during a period of 13 weeks did not cause significant reductions in peripheral and central blood pressure. (Arq Bras Cardiol. 2020; 114(3):554-561)

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Letter to the Editor

Response to “Readmission of Patients with Acute Coronary Syndrome and its Determinants”: An Overview of PHC

Laís Cruz Lima et al. Eliane Mazzuco André Luís Prudêncio

Reply

We are thankful to the comments and for the interest in our study, which is about a relevant topic, i.e., readmission of patients with acute coronary syndrome (ACS) and its determinants to both public hospitals (Brazil’s public health system — SUS) and private hospitals. A better understanding of the findings we reached, which certainly reflect what happens in the country, will result in benefits for the therapeutic approach of those who have this major disease.

The expressive rate of readmissions observed, which certainly has a significant impact on health costs, results not only from clinical factors, but also from the type of assistance received by the patient, both during hospitalization and after discharge. It is worth noting that about 72% of the Brazilian population depends exclusively on the public health system. Therefore, as we said, Primary Health Care (PHC) can play a pivotal role in the adoption and reinforcement of secondary prevention measures that will surely be successful for those particularly affected by ACS. According to Ordinance No. 2436 of the Ministry of Health, published on 21/9/2017, Brazil’s Policy on Primary Health Care provides for the longitudinality of care, with monitoring of the effects of health interventions and coordination of care. Therefore, person-centered care, also advocated in this ordinance, places PHC in a fundamental role of helping patients to develop knowledge, skills and competence to better take care of their own health. Health education actions are essential to stress self-care and the prevention of subsequent readmissions. Finally, co-responsibility between health professionals and patients in the implementation of actions to prevent complications of the disease, health promotion and proper therapeutic adherence can positively influence the reduction of readmission rates.

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Original Article

Determination of Myocardial Scar Tissue in Coronary Slow Flow Phenomenon and The Relationship Between Amount of Scar Tissue and Nt-ProBNP

Mustafa Candemir et al. Asife Şahinarslan Merve Yazol Yusuf Ali Öner Bülent Boyacı

Abstract

Background

Pathophysiology and prognosis are not clearly determined in patients with the coronary slow flow phenomenon (CSFP). These patients present with various clinical conditions ranging from being asymptomatic to being admitted with sudden cardiac death.

Objectives

We aimed at assessing the findings of late gadolinium enhancement (LGE) in cardiac magnetic resonance imaging (CMR) as an indicator of myocardial fibrosis. We also aimed at determining the relationship between the presence of myocardial fibrosis and NT-proBNP levels in patients with CSFP in the left anterior descending coronary artery (LAD).

Methods

A total of 35 patients were enrolled within an age range of 31-75. The study patients (n=19) had normal epicardial coronary arteries at angiography, but they presented with CSFP in the LAD. The control group patients (n=16) had normal epicardial coronary arteries and TIMI scores at normal levels in angiography. In both groups, the patients were examined with CMR for the presence of myocardial fibrosis. In addition, plasma NT-proBNP levels were measured. A p-value < 0.05 was considered significant.

Results

The rate of myocardial fibrosis was significantly higher in CMR in the patients with CSFP (p=0.018). A variable amount of myocardial scar tissue was detected at the left ventricular apex in 7 patients and at the inferior and inferolateral regions in 3 patients. There was no difference in the level of NT-proBNP in patients with CSFP. However, the NT-proBNP levels were higher in patients with CSFP, who had scar tissue in CMR (p=0.022).

Conclusions

In conclusion, LGE in CMR showed that ischemic myocardial scarring may exist in patients with CSFP. These results indicate that CSFP may not always be innocent. (Arq Bras Cardiol. 2020; 114(3):540-551)

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Original Article

Analysis of Risk Scores to Predict Mortality in Patients Undergoing Cardiac Surgery for Endocarditis

Fernando Pivatto Júnior et al. Clarissa Carmona de Azevedo Bellagamba Eduardo Gatti Pianca Fernando Schmidt Fernandes … Maurício Butzke Stefano Boemler Busato Miguel Gus

Abstract

Background

Risk scores are available for use in daily clinical practice, but knowing which one to choose is still fraught with uncertainty.

Objectives

To assess the logistic EuroSCORE, EuroSCORE II, and the infective endocarditis (IE)-specific scores STS-IE, PALSUSE, AEPEI, EndoSCORE and RISK-E, as predictors of hospital mortality in patients undergoing cardiac surgery for active IE at a tertiary teaching hospital in Southern Brazil.

Methods

Retrospective cohort study including all patients aged ≥ 18 years who underwent cardiac surgery for active IE at the study facility from 2007-2016. The scores were assessed by calibration evaluation (observed/expected [O/E] mortality ratio) and discrimination (area under the ROC curve [AUC]). Comparison of AUC was performed by the DeLong test. A p < 0.05 was considered statistically significant.

Results

A total of 107 patients were included. Overall hospital mortality was 29.0% (95%CI: 20.4-37.6%). The best O/E mortality ratio was achieved by the PALSUSE score (1.01, 95%CI: 0.70-1.42), followed by the logistic EuroSCORE (1.3, 95%CI: 0.92-1.87). The logistic EuroSCORE had the highest discriminatory power (AUC 0.77), which was significantly superior to EuroSCORE II (p = 0.03), STS-IE (p = 0.03), PALSUSE (p = 0.03), AEPEI (p = 0.03), and RISK-E (p = 0.02).

Conclusions

Despite the availability of recent IE-specific scores, and considering the trade-off between the indexes, the logistic EuroSCORE seemed to be the best predictor of mortality risk in our cohort, taking calibration (O/E mortality ratio: 1.3) and discrimination (AUC 0.77) into account. Local validation of IE-specific scores is needed to better assess preoperative surgical risk. (Arq Bras Cardiol. 2020; 114(3):518-524)

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Editorial

Are DOACs a Good Bang for Your Buck in Atrial Fibrillation Prevention in Real-Life?

Márcio Bittencourt

Mr. D., a 75-year-old retired university professor with a prior stroke, wakes up in the morning, drives to the hospital to have blood drawn to adjust his warfarin dosage and then goes to work. A couple of hours later, he gets a call from the nursing team telling him how to adjust the dose: “starting today you should take 7.5 mg of warfarin on Mondays, Wednesdays and Fridays. On the other days of the week you can keep up with the 5 mg pill you are used to. If you do not have a 7.5 mg pill you can cut the 5 mg in half and take one and a half pills on those days. It is not too complicated, is it? By the way, remember to go slow on that kale and spinach I know you like!”. Were it not for the fact the Mr. D. also takes enalapril and atenolol for his blood pressure and to control the heart rate of his atrial fibrillation (AF), a statin for secondary prevention since the stroke, and metformin for his diabetes; cutting pills in half and remembering on what day he should take which dosage should be too complicated.

Unfortunately, Mr. D. is about the average non-valvular AF patient seen in clinics in private practices in Brazil and places around the world, though patients from the Brazilian Unified Health System (Sistema Unico de Saúde, SUS) usually spend substantially more time at the hospital waiting for the results in person or coming back the next day to check them, due to more limited resources to contact patients over the phone.

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Editorial

Discordance of Low-Density Lipoprotein Cholesterol and Non-High-Density Lipoprotein Cholesterol with Severity of Coronary Artery Disease

Iran Castro et al. Hugo Fontana Filho

Cardiovascular diseases (CVDs) are the leading cause of mortality world. Dyslipidemia is a risk and causal factor and is the focus of the therapy for primary and secondary prevention of CVDs.

There is consensus and broad understanding of the causal mechanisms of low-density lipoproteins (LDL) in CVDs, and the benefit of the hypolipidemic therapy, with a magnitude of effect proportional to the reduction in serum levels. However, despite intensive use of lipid lowering agents, there remains a residual risk, a constant target of research and therapy.

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