2022;118(6) – ABC CARDIOL

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Original Article

Albumin-Bilirubin Score to Predict Outcomes in Patients with Idiopathic Dilated Cardiomyopathy

Mei Jiang et al. Xue-biao Wei Jie-leng Huang Ze-da-zhong Su … Ying-wen Lin Dan-qing Yu

Abstract

Background:

Liver dysfunction is a postulated variable for poor prognosis in dilated cardiomyopathy (DCM).

Objective:

This study aimed to investigate the prognostic value of the albumin-bilirubin (ALBI) score, a relatively new model for evaluating liver function, in patients with idiopathic DCM.

Methods:

A total of 1025 patients with idiopathic DCM were retrospectively included and divided into three groups based on ALBI scores: grade 1 (≤ −2.60, n = 113), grade 2 (−2.60 to −1.39, n = 835), and grade 3 (> −1.39, n = 77). The association of ALBI score with in-hospital major adverse clinical events (MACEs) and long-term mortality was analyzed. P-value less than 0.05 was considered statistically significant.

Results:

The in-hospital MACEs rate was significantly higher in the grade 3 patients (2.7% versus 7.1% versus 24.7%, p < 0.001). Multivariate analysis showed that ALBI score was an independent predictor for in-hospital MACEs (adjusted odds ratio = 2.80, 95%CI: 1.63 – 4.80, p < 0.001). After a median 27-month follow-up, 146 (14.2%) patients died. The Kaplan–Meier curve indicated that the cumulative rate of long-term survival was significantly lower in patients with higher ALBI grade (log-rank = 45.50, p < 0.001). ALBI score was independently associated with long-term mortality (adjusted hazard ratio = 2.84, 95%CI: 1.95 – 4.13, p < 0.001).

Conclusion:

ALBI score as a simple risk model could be considered a risk-stratifying tool for patients with idiopathic DCM.

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Editorial

Transcatheter Aortic Valve Implant in Latin America – We will Get There!

Silvio Gioppato et al. Rodrigo Modolo

As with percutaneous coronary intervention, the Transcatheter Aortic Valve Implantation (TAVI) is making great strides toward overcoming the surgical approach and becoming the predominant procedure in treating aortic stenosis. Since the first percutaneous implantation made by Dr. Alain Cribier, who turns 2 decades old this year, TAVI has demonstrated, study after study, robust evidence of its efficacy and safety. At each stage of this journey, the challenges were successively overcome both by the improvement of the devices and the skills acquired by the operators, which allowed us to move consistently from the prohibitive surgical risk scenario to the low-risk scenario in just over 15 years.^– Furthermore, evolution is unfolding^– – ongoing studies investigate the expansion of TAVI for young patient populations, bicuspid aortic valve, asymptomatic and even pure aortic regurgitation.

Today the million-dollar question is about the durability of devices that, in part, starts to be answered. In 2019, Thyregod et al. published the 5-year result of the NOTION study (The Nordic Aortic Valve Intervention Trial), showing no differences in either the primary composite endpoint of death from any cause, stroke or heart attack (TAVR 38% vs. SAVR 36%; p=0.86) as in individual events. More recently, at the American College of Cardiology Congress (ACC 2022), Michael Reardon presented the 5-year results combining the CoreValve US Pivotal and SURTAVI studies showing that in intermediate- or high-risk patients, the rate of valve structural deterioration was significantly lower in the TAVI group compared to the surgical group (2.57% x 4.38%; p=0.0095). Nevertheless, these data are still insufficient to answer whether TAVI will be the Gold Standard for treating aortic valve diseases, regardless of etiology, age or type of dysfunction.

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Original Article

Burden of Cardiovascular Diseases Attributable to Risk Factors in Portuguese-Speaking Countries: Data from the “Global Burden of Disease 2019” Study

Bruno Ramos Nascimento et al. Luisa Campos Caldeira Brant André Dias Nassar Naback Guilherme Augusto Veloso … Carisi Anne Polanczyk Antonio Luiz Pinho Ribeiro Deborah Carvalho Malta Albano Vicente Lopes Ferreira Gláucia Maria Moraes de Oliveira

Abstract

Background:

The impact of risk factors (RF) on morbidity and mortality from cardiovascular disease (CVD) for most Portuguese-speaking countries (PSC) is little known.

Objectives:

We aimed to analyze the morbidity and mortality from CVD attributable to RF and its variation, from 1990 to 2019, in PSC, based on estimates from the Global Burden of Disease (GBD) 2019 study.

Methods:

We evaluated changes in cardiovascular RF, mortality rates and age-standardized disability-adjusted life years (DALYs) between 1990 and 2019. The correlation between percentage changes in mortality rates and the sociodemographic index (SDI) of each PSC was evaluated by the Spearman method. A p-value <0.05 was considered statistically significant.

Results:

Elevated systolic blood pressure (SBP) was the main RF for mortality and DALYs for CVD for all PSC. Mortality from CVD showed a downward trend in 2019, more accentuated in Portugal (-66.6%, 95%CI -71.0 – -61.2) and in Brazil (-49.8%, 95%CI -52.5 – -47.1). There was a trend towards an inverse correlation between SDI and the percent change in mortality, which was significant for dietary risks (r=-0.70, p=0.036), high LDL cholesterol (r=-0.77, p=0.015) and high SBP (r=-0.74, p=0.023).

Conclusions:

In addition to SBP, dietary and metabolic RF justified a greater variation in the burden of CVD correlated with SDI in the PSC, suggesting the need to adopt health policies adapted to the reality of each country, aiming to reduce their impact on population.

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Research Letter

Physical Exercise and MicroRNAs: Molecular Mechanisms in Hypertension and Myocardial Infarction

Alex Cleber Improta-Caria

Introduction

Scientific evidence shows that the regular practice of physical exercise (PE) is beneficial for various organs and systems of the human body, mainly for the heart and cardiovascular system. In both systems, aerobic and strength PE promote physiological cardiac hypertrophy, respectively eccentric and concentric, improving myocardial function.

In addition to the benefits for the heart, PE impacts blood vessels through shear stress and alters long-term vascular function, improving endothelial cell and smooth muscle cell function, generating arterial remodeling and a potential antiatherogenic effect. These benefits on the cardiovascular system occur in both healthy individuals and individuals with cardiovascular diseases, such as systemic arterial hypertension (SAH) and myocardial infarction (MI), for example.

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Editorial

Evaluation of Various Pathophysiological Pathways in the Prognosis of Heart Failure with Reduced Ejection Fraction: Seeing Beyond the Heart

João Marcos Barbosa-Ferreira et al. Andreza Araújo de Oliveira

The manuscript “Albumin-bilirubin score to predict outcomes in patients with idiopathic dilated cardiomyopathy” provides an important way to assess the prognosis of patients with dilated cardiomyopathy (DCM) by demonstrating a higher rate of major adverse clinical events (MACEs) in patients with a higher score. Furthermore, this score works as an independent predictor of long-term mortality.

Heart Failure with reduced ejection fraction (HFrEF), often characterized as DCM, has its pathophysiological aspects closely related to its therapy and prognosis. The study of the pathophysiology of HFrEF is based on cardiovascular hemodynamic alterations and intense neurohumoral activation (mainly of the autonomic nervous system, renin-angiotensin-aldosterone system and natriuretic peptides system). These pathophysiological aspects are widely used in the therapy and prognostic assessment of patients with HFrEF.

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Research Letter

Mechanical Mitral Valve Thrombosis in a Patient with COVID-19 Infection

Emre Aruğaslan et al. Yunus Çalapkulu Ender Örnek Mustafa Karanfil … Hüseyin Bayram Seref Alp Küçüker

Introduction

The novel coronavirus disease-2019 (COVID-19) caused by “Severe Acute Respiratory Syndrome Coronavirus-2” (SARS-CoV-2) became a global pandemic. Although respiratory involvement is the predominant presentation, current evidence has shown that COVID-19 is a multisystemic disease with coagulopathy and thromboembolic complications. Increased production of tissue factor and thrombin reduced fibrinolysis due to hyperinflammation are the proposed mechanisms of COVID-19 induced thrombosis.

We present a case of a COVID-19 infected patient with thrombosis of the mechanical mitral valve.

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Editorial

Troponin – Use it wisely. And as Another Instrument in the Clinic

Ricardo Wang et al. Estevāo Lanna Figueiredo

Acute myocardial infarction (AMI) and stable chronic coronary disease are the main causes of mortality in Brazil. In 2019, it was responsible for more than 170,000 deaths in Brazil. Given its severity, the Cardiology made a great effort to constantly improve the tools for the correct diagnosis to avoid the release of patients with Acute Coronary Syndrome (ACS) and its clinical and legal consequences. They are considered pillars for the diagnosis and a good anamnesis with the characterization of the type of pain, electrocardiographic changes, and biomarkers (mainly troponin).

Biomarkers play an important role in recognizing ACS, and diagnostic algorithms have adapted as they evolve. At first, they were nonspecific markers (e.g., lactic dehydrogenase, oxacetic transaminase, total creatine phosphokinase – CK). Then they evolved to a slightly more specific marker (creatine phosphokinase MB portion) with its difficult criteria: e.g., total CK/MB). Finally, we have an extremely specific marker of myocardial injuries, such as troponin. The evolution of biomarkers has allowed the simplification of chest pain protocols and the reduction of inappropriate discharge of patients with ACS. Due to troponin’s high sensitivity and specificity, in the fourth consensus on the universal definition of myocardial infarction, it was concluded that to establish the clinical diagnosis, an elevation above the 99th percentile of this biomarker was associated with clinical evidence of myocardial infarction ischemia. Given the low cutoff for troponin, there are doubts in this consensus regarding the clinical relevance.

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Editorial

Is it Possible to Non-Invasively Study the Hemodynamic Adaptations of Chagas Cardiomyopathy by the Volume-Time Curve Using 3D Echocardiography?

José Luiz Barros Pena

Three-dimensional echocardiography (3DE) represents a great innovation in cardiovascular ultrasound. Increased computer processing power and advances in the development of transducers have allowed acquiring of cardiac structures from any spatial point of view, without assumptions about their shape. Recent studies have demonstrated that when cardiac chamber sizes are quantified using 3DE, their volumes are similar to those obtained using cardiac magnetic resonance imaging compared to two-dimensional echocardiography (2DE).^, The usefulness of 3DE has particularly been demonstrated primarily in realistic anatomical heart valve images and in guiding and monitoring cardiac procedures.

3DE allows volume calculation of the left ventricle (LV) throughout the cardiac cycle, making it possible to construct a volume-time curve. This method is more accurate than 2DE because the left ventricular volume is constructed by analyzing hundreds of points at the edge of the endocardium. No specific plane or geometric model is necessary to describe the complex LV structure. In this paper, Pinto et al. tested the hypothesis of studying the hemodynamic adaptations of non-invasive Chagas cardiomyopathy using the volume-time curve generated by 3DE. They generated a polynomial adjusted to the LV volume curve using specific software. Their objective was to present a cross-sectional study evaluating LV function, comparing volume curves in 20 patients with Chagas cardiomyopathy (CC) and 15 gender- and age-matched healthy controls.

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Editorial

Achievement of LDL-cholesterol Targets: Why do We Fail, and How Can We Improve?

Fernando Cesena

Atherosclerotic cardiovascular disease (ASCVD) remains the first cause of death in the world, and Brazil.^, Individuals with previous ASCVD are at the highest risk of subsequent events, and guidelines recommend aggressive lowering of low-density lipoprotein cholesterol (LDL-c) levels to prevent bad outcomes.^,

However, several reports from around the world indicate a gap between guideline recommendations and clinical practice, and a large proportion of the population, especially in secondary prevention, lives with LDL-c levels above those considered reasonable to prevent events.^– Indeed, lack of adherence to guideline-recommended therapies was independently associated with major cardiovascular events in a Brazilian population after acute coronary syndrome.

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Research Letter

Coxiella Burnetii Endocarditis: Can Positron Emission Tomography be an Alternative to Diagnosis?

Marjorie Hayashida Mizuta et al. Cristhian Espinoza Romero Santiago Castro Vintimilla Tatiana de Carvalho Andreucci Torres Leal … Paulo Rogério Soares Alexandre de Matos Soeiro

Introduction

Coxiella burnetii infective endocarditis (IE) represents a rarely reported zoonosis in Brazil. It is estimated that Coxiella burnetii is responsible for up to 5% of all IE cases worldwide. The disease affects mostly valvulopathy patients and immunocompromised subjects.

Different from the classical acute and sub-acute endocarditis, the clinical picture is frustrating, and, because this is an obligate intracellular microorganism, hemocultures (HMC) are predominantly negative, which makes the clinical suspicion more difficult.

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Editorial

Cost-Effectiveness of Using the Coronary Calcium Score to Guide Therapeutic Decisions in Primary Prevention in the Brazilian Population

Cardiovascular diseases (CVD) statistics never fail to impress even the most hardened and experienced physician. One-third of deaths worldwide are still due to cardiovascular causes (85% of those are myocardial infarction and stroke), and 75% occur in mid-to-low income countries.^, Half the people who died of myocardial infarction never had symptoms before the tragic event, and most never had the diagnosis of coronary artery disease. Despite our best efforts, the prevalence of ischemic heart disease (IHD) has been steadily rising for the last 30 years worldwide due to population aging, but even if we standardize by age, the prevalence has been stable, and notwithstanding fallen. This fact highlights the importance of lifestyle changes that allow for a healthier heart and the need to focus on implementing existing cost-effective policies and interventions.

Coronary calcification is almost always a marker of atherosclerosis. The coronary calcium score (CCS) is a number that quantifies coronary calcification as a surrogate for total coronary atherosclerotic burden. Even though calcification results from plaque healing, higher-risk plaques tend to have proportionately greater non-calcified components; CCS has been proven to be a strong predictor of CVD and IHD events in multiple large, solid, population-based studies.

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Review Article

LncRNAs are Involved in the Process of Atherosclerosis at Diverse Levels

Shiyi Liang et al. Weicheng Xv Chijian Li Yuxiang Huang … Ge Qian Yuxiang Yan Hequn Zou Yongqiang Li

Abstract

Atherosclerosis is the most common cause of cardiovascular disease globally, associated with a high incidence of clinical events. Accumulating evidence has elucidated that long non-coding RNAs (lncRNAs) as a novel class of transcripts with critical roles in the pathophysiological processes of atherosclerosis. In this review, we summarize the recent progress of lncRNAs in the development of atherosclerosis. We mainly describe the diverse regulatory mechanisms of lncRNAs at the transcriptional and post-transcriptional levels. This study may provide helpful insights about lncRNAs as therapeutic targets or biomarkers for atherosclerosis treatment.

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Editorial

Should we Consider the Stimulation of Soluble Guanylyl Cyclase as Beneficial for Treating Pre-Capillary Pulmonary Hypertension?

Allan Kardec Nogueira de Alencar

One of the rarest and most complex group of diseases that affects the cardiopulmonary system is known as pulmonary hypertension (PH), a life-threatening clinical condition that in advanced stages eventually results in irreversible dysfunction of the right heart chamber and sudden cardiac death. Pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH) are two different groups within the PH clinical classification system, in which loss and obstructive remodeling of the lung vessels is responsible for a significant rise in pulmonary arterial (PA) pressure and pulmonary vascular resistance (PVR), resulting in a functional decline of the heart performance and progressive right ventricle (RV) failure.

PAH is a pre-capillary-type PH (Group 1), hemodynamically defined by a mean pulmonary arterial pressure (mPAP) >20 mmHg, PA wedge pressure ≤15 mmHg, and PVR ≥3 Wood units. Remodeling of pulmonary vessels in PAH is depicted by the accumulation of pulmonary artery smooth muscle (PASMCs) and endothelial cells (PAECs), fibroblasts, myofibroblasts, and pericytes in the PA walls. In addition, this remodeling process results in a loss of pre-capillary arteries and exacerbates perivascular inflammation. The excessive loss of PAECs is a key pathobiological feature of PAH. This phenomenon triggers the development of an apoptosis-resistant and hyperproliferative phenotype of PAECs. Subsequently, an intense proliferation of PAECs induces the formation of plexogenic lesions in the lung vessels, a histopathologic hallmark of PAH.

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Original Article

Cost-Effectiveness of Using the Coronary Artery Calcium Score in Guiding Therapeutic Decisions in Primary Prevention in the Brazilian Population

Raul Serra Valério et al. Giuliano Generoso Juliano Lara Fernandes Khurram Nasir … Jonathan C. Hong Marcio Sommer Bittencourt

Abstract

Background:

The use of the coronary artery calcium score to aid cardiovascular risk stratification may be a more cost-effective tool than the conventional strategy.

Objectives:

Evaluation of the cost-effectiveness of the use of the calcium score in therapeutic guidance for primary cardiovascular prevention.

Methods:

A microsimulation model to assess the clinical and economic consequences of atherosclerotic cardiovascular disease, comparing the prevention strategy using the calcium score and the conventional strategy.

Results:

The results obtained demonstrated a better cost-effectiveness of the therapeutic strategy guided by the calcium score, by reducing incremental costs and increasing quality-adjusted life years (QALY), which corresponds, in number, to improving the quality of life of the individual.

Conclusions:

The use of the coronary artery calcium score proved to be more cost-effective than the conventional strategy, both in terms of cost and QALY, in most of the scenarios studied.

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Editorial

NYHA Classification and Cardiopulmonary Exercise Test Variables in Patients with Heart Failure

Ricardo Vivacqua Cardoso Costa

Heart failure (HF) is considered a prevalent disease, limiting survival and constituting one of the leading causes of hospitalization or death in several countries, including Brazil. Therefore, clinical classification in patients with HF can be considered important as an initial reference, as it informs the functional condition of these patients. Classically, the subjective classification of the New York Heart Association (NYHA) and the objective classification of Weber are the most used. The NYHA functional classification and oxygen consumption at peak exertion were decisive in determining the functional condition of patients with Chagas disease. However, certain patients with minor symptoms are at high risk of hospitalization or death.

In patients with HF, the 6-minute walk test is also considered in assessing functional and prognostic capacity. This test has a predictive value for mortality in patients with HF functional class II and III (NYHA).

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Original Article

Recent Developments and Current Status of Transcatheter Aortic Valve Replacement Practice in Latin America – the WRITTEN LATAM Study

Fernando Luiz de Melo Bernardi et al. Henrique Barbosa Ribeiro Luis Nombela-Franco Enrico Cerrato … Gabriel Maluenda Tamim Nazif Pedro Alves Lemos Matias Sztejfman Pablo Lamelas Dario Echeverri Marcelo Antonio Cartaxo Queiroga Lopes Fábio Sândoli de Brito Jr Alexandre A. Abizaid José A. Mangione Helene Eltchaninoff Lars Søndergaard Josep Rodes-Cabau

Abstract

Background:

Transcatheter aortic valve replacement (TAVR) is a worldwide adopted procedure with rapidly evolving practices. Regional and temporal variations are expected to be found.

Objective:

To compare TAVR practice in Latin America with that around the world and to assess its changes in Latin America from 2015 to 2020.

Methods:

A survey was applied to global TAVR centers between March and September 2015, and again to Latin-American centers between July 2019 and January 2020. The survey consisted of questions addressing: i) center’s general information; ii) pre-TAVR evaluation; iii) procedural techniques; iv) post-TAVR management; v) follow-up. Answers from the 2015 survey of Latin-American centers (LATAM15) were compared with those of other centers around the world (WORLD15) and with the 2020 updated Latin-American survey (LATAM20). A 5% level of significance was adopted for statistical analysis.

Results:

250 centers participated in the 2015 survey (LATAM15=29; WORLD15=221) and 46 in the LATAM20. Combined centers experience accounted for 73 707 procedures, with WORLD15 centers performing, on average, 6- and 3-times more procedures than LATAM15 and LATAM20 centers, respectively. LATAM centers performed less minimalistic TAVR than WORLD15 centers, but there was a significant increase in less invasive procedures after 5 years in Latin-American centers. For postprocedural care, a lower period of telemetry and maintenance of temporary pacing wire, along with less utilization of dual antiplatelet therapy was observed in LATAM20 centers.

Conclusion:

Despite still having a much lower number of procedures, many aspects of TAVR practice in Latin-American centers have evolved in recent years, followingthe trend observed in developed country centers.

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Editorial

Differences among Angiotensin Receptor Blockers (BRA) in the Treatment of Arterial Hypertension

José Geraldo Mill

Cardiovascular diseases (CVD) are the main cause of death and disability in Brazil, and arterial hypertension (AH) is the main risk factor for cardiovascular morbidity and mortality. Early diagnosis and correct treatment are priority actions to face the problem. The National Health Survey conducted by the Ministry of Health in 2013 (PNS-2013) determined the prevalence of AH by direct measurement of blood pressure (BP) and use of antihypertensive drugs in a representative sample of the Brazilian adult population. Prevalence of 32.3% (95%CI: 31.7 – 33.0) indicated nearly 50 million hypertensive patients. Around 70% depend on the Unified Health System (SUS) for both diagnosis and pharmaceutical care, an essential aspect of the Chronic Noncommunicable Diseases (NCD) plan.

According to the current guidelines, the initial treatment of AH should be carried out with general measures, including regular aerobic physical activity, reduction of salt intake, increased consumption of fruits and vegetables and weight reduction when obesity or overweight is present. These measures benefit everyone and not only hypertensive patients indeed. Even adopting these strategies, many patients still depend on the regular use of drugs to get high BP control. Thus, the use of these drugs shows great importance because, given the dimension of the problem, even small pressure reductions generate a positive impact for millions of individuals affecting the morbidity and mortality rates due to CVD. Thus, the search for effective treatments for BP control has paramount importance to adopt public policies in this area.

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Erratum

April 2022 Issue, vol. 118(42), pages 797-857

In the “Joint Guideline on Venous Thromboembolism – 2022”, with doi number: , published in the journal Arquivos Brasileiros de Cardiologia, 118(4): 797-857, the following corrections were made:

Included the institution Hospital DF Star, Rede D’Or, Brasília, DF – Brazil, for the author Simone Nascimento dos Santos.

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Image

Value of18F-FDG PET/CT in the Diagnosis and Assessment of Response to Treatment of Lupus Myocarditis

Alvaro M. Perazzo et al. Larissa G. F. Andrade Leonardo G. A. Venancio Pedro Alves da Cruz Gouveia … Mariana Feitosa Ramalho Galvão Esdras M. Lins Fernando Moraes Neto Simone Cristina Soares Brandão

Systemic Lupus Erythematosus (SLE) is an autoimmune disease with a wide spectrum of clinical manifestations. The cardiovascular system has relevant clinical importance among the affected organs because it is associated with higher mortality in these patients. The heart can be affected in any structure, and lupus myocarditis is a major diagnostic challenge in clinical practice.

Non-invasive tests such as electrocardiograms and echocardiograms are not sensitive or specific enough for this diagnosis. Cardiac magnetic resonance imaging (CMR) is the preferred imaging modality for diagnosing myocarditis, but it has contraindications, such as patients with metallic implants or using gadolinium in chronic kidney disease.

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Original Article

Soluble Guanylate Cyclase Stimulators (Riociguat) in Pulmonary Hypertension: Data from Real-Life Clinical Practice in a 3-Year Follow-Up

Fernanda Brum Spilimbergo et al. Taís Silveira Assmann Marcelo Bellon Laís Machado Hoscheidt … Cássia Ferreira Braz Caurio Márcia Puchalski Bruno Hochhegger Gabriela Roncato Gisela Martina Bohns Meyer

Abstract

Background

Pulmonary hypertension (PH) is a rare and complex disease with poor prognosis, which requires lifelong treatment.

Objective

To describe 3-year follow-up real-life data on treatment with soluble guanylate cyclase stimulators (Riociguat) of patients with PH, measuring current risk assessment parameters.

Methods

This study retrospectively collected clinical and epidemiological data of patients with PH of group 1 (pulmonary arterial hypertension) and group 4 (chronic thromboembolic PH). Non-invasive and invasive parameters corresponding to the risk assessment were analyzed at baseline and follow-up. Statistical analyses were performed using the SPSS 18.0 software, and p-values < 0.050 were considered statistically significant.

Results

In total, 41 patients receiving riociguat were included in the study. Of them, 31 had already completed 3 years of treatment and were selected for the following analysis. At baseline, 70.7% of patients were in WHO functional class III or IV. After 3 years of treatment, the WHO functional class significantly improved in all patients. In addition, the median of the 6-minute walk test (6MWT) significantly increased from 394 ± 91 m at baseline to 458 ± 100 m after 3 years of follow-up (p= 0.014). The three-year survival rate was 96.7%.

Conclusion

In our real-life cohort, most patients with PH treated with riociguat showed stable or improved risk parameters, especially in the 6MWT, at 3 years of follow-up.

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Original Article

Achievement of LDL-Cholesterol Goals after Acute Myocardial Infarction: Real-World Data from the City of Curitiba Public Health System

André Bernardi et al. Marcia Olandoski Lucas Olandoski Erbano Luiz Cesar Guarita-Souza … Cristina Pellegrino Baena José Rocha Faria-Neto

Abstract

Background

Reduction of LDL-cholesterol (LDL-c) levels is the cornerstone in risk reduction, but many high-risk patients are not achieving the recommended lipid goals, even in high-income countries.

Objective

To evaluate whether patients seen in the city of Curitiba public health system are reaching LDL-c goals after an acute myocardial infarction (AMI).

Methods

This retrospective cohort explored the data of patients admitted with AMI between 2008 and 2015 in public hospitals from the city of Curitiba. In order to evaluate the attainment of the LDL-c target, we have used the last value registered in the database for each patient up to 2016. For those who had at least one LDL-c registered in the year before AMI, percentage of reduction was calculated. The level of significance adopted for statistical analysis was p<0.05.

Results

Of 7,066 patients admitted for AMI, 1,451 were followed up in an out-patient setting and had at least one evaluation of LDL-c. Mean age was 60.8±11.4 years and 35.8%, 35.2%, 21.5%, and 7.4% of patients had LDL-c levels ≥100, 70–99, 50–69 and <50 mg/dL, respectively. Of these, 377 patients also had at least one LDL-c evaluation before the AMI. Mean LDL-c concentrations were 128.0 and 92.2 mg/dL before and after AMI, with a mean reduction of 24.3% (35.7 mg/dL). LDL-c levels were reduced by more than 50% in only 18.3% of the cases.

Conclusion

In the city of Curitiba public health system patients, after myocardial infarction, are not achieving adequate LDL-c levels after AMI.

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Original Article

Universal Definition of Myocardial Infarction 99th Percentile versus Diagnostic Cut-off Value of Troponin I for Acute Coronary Syndromes

Antonio Haddad Tapias Filho et al. Gustavo Bernardes de Figueiredo Oliveira João Italo Dias França Rui Fernando Ramos

Abstract

Background

Contemporary diagnosis of ACS and risk stratification are essential for appropriate management and reduction of mortality and recurrent ischemic events, in the acute phase of disease and after hospitalization. The Universal Definition of Myocardial Infarction recommends the detection of troponin levels above the 99^th percentile.

Objectives

To evaluate the occurrence of early death and acute myocardial infarction (AMI) in patients without elevation of troponin (<0.034 ng/mL), patients with mild elevation (above the 99^th percentile [>0.034 ng/mL and <0.12 ng/mL)], and patients with significant elevation of troponin (above the diagnostic cutoff for AMI defined by the troponin kit (≥0.12 ng/mL)]; and to analyze the impact of troponin on the indication for invasive strategy and myocardial revascularization.

Methods

Cross-sectional cohort study of patients with ACS with assessment of peak troponin I, risk score, prospective analysis of 30-day clinical outcomes and two-sided statistical tests, with statistical significance set at p<0.05.

Results

A total of 494 patients with ACS were evaluated. Troponin > 99^th percentile and below the cutoff point, as well as values above the cutoff, were associated with higher incidence of composite endpoint (p<0.01) and higher rates of percutaneous or surgical revascularization procedures (p<0.01), without significative difference in 30-day mortality.

Conclusions

Troponin levels above the 99^th percentile defined by the universal definition of AMI play a prognostic role and add useful information to the clinical diagnosis and risk scores by identifying those patients who would most benefit from invasive risk stratification and coronary revascularization procedures.

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Original Article

Angiotensin Receptor Blockers Evaluated by Office and Home Blood Pressure Measurements. TeleHBPM Study

Weimar Kunz Sebba Barroso et al. Andréa Araujo Brandão Priscila Valverde de Oliveira Vitorino Audes Diógenes de Magalhães Feitosa … Eduardo Costa Duarte Barbosa Roberto Dischinger Miranda Josep Redon Miguel Camafort-Babkowski Antonio Coca Marco Antônio Mota Gomes

Abstract

Background

Adequate treatment of arterial hypertension and achieving arterial hypertension goals in are important in reducing cardiovascular outcomes.

Objectives

To describe angiotensin receptor blockers in monotherapy or double combination therapy and the rate of arterial hypertension control.

Methods

This cross-sectional study evaluated patients who were using angiotensin receptor blockers between 2017 and 2020. Those using three or more antihypertensive drugs were excluded. The analyzed variables included sex, age, body mass index, valid home blood pressure monitoring (HBPM) measurements, casual and HBPM systolic and diastolic blood pressure measurements, blood pressure variability, and antihypertensive and angiotensin receptor blocker class. Paired t, chi-square, and Fisher’s exact tests were used, as well as overlapping 95% confidence intervals and a significance level of 5% (p < 0.05).

Results

Of 17,013 patients, 12,813 met the inclusion criteria, 62.1% of whom were female. The mean number of valid measurements was 23.3 (SD, 2.0). The mean HBPM and casual measurements for systolic blood pressure were 126.8 (SD, 15.8) mmHg and 133.5 (SD, 20.1) mmHg (p <0.001), respectively, while those for diastolic blood pressure were 79.1 (SD, 9.7 mmHg) and 83.6 (SD, 11.9) mmHg (p <0.001), respectively. Losartan was the most common angiotensin receptor blocker and resulted in the highest blood pressure values. Combinations of angiotensin receptor blockers with diuretics or calcium channel antagonists resulted in lower blood pressure values.

Conclusions

More than half of the patients used losartan, although it was the least efficient drug for reducing and controlling blood pressure.

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Original Article

The Volume-Time Curve by Three-Dimensional Echocardiography in Chagas Cardiomyopathy: Insights into the Mechanism of Hemodynamic Adaptations

Airandes de Sousa Pinto et al. Maria Carmo Pereira Nunes Carlos Alberto Rodrigues Bráulio Muzzi Ribeiro de Oliveira … João da Rocha Medrado Neto Timothy C. Tan Manoel Otavio da Costa Rocha

Abstract

Background

Three-dimensional echocardiography (3D ECHO) allows the generation of a volume-time curve representative of changes in the left ventricular (LV) volume throughout the entire cardiac cycle.

Objective

This study aims to demonstrate the hemodynamic adaptations present in Chagas cardiomyopathy (CC) by means of the volume and flow measurements obtained by the volume-time curve by 3D ECHO.

Methods

Twenty patients with CC and 15 healthy subjects were prospectively enrolled in a cross-sectional design study. 3D ECHO was performed in all subjects and the volume over time curves of the LV was generated. The flow was obtained by the first derivative of the volume-time curve using the software MATLAB. Statistical significance was set at p<0.05.

Results

Although CC patients had lower LV ejection fraction compared to the control group (29.8±7.5 vs. 57.7±6.1, p<0.001), stroke volume (61.5±25.2 vs. 53.8±21.0, p=0.364) and maximum ejection flow during systole (-360.3±147.5 vs. -305.6±126.0, p=0.231) were similar between the groups. Likewise, the maximum flow in the early diastolic filling phase and during atrial contraction was similar between groups. An increase in preload expressed by LV end diastolic volume (204.8±79.4 vs. 93.0±32.6), p<0.001) may maintain the flow and stroke volumes similar to the controls.

Conclusion

Using a non-invasive tool, we demonstrated that an increase in LV end-diastolic volume may be the main adaptation mechanism that maintains the flow and stroke volumes in the setting of severe LV systolic dysfunction.

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