2022;119(2) – ABC CARDIOL

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Editorial

Friedewald, Martin/Hopkins, or Sampson/NIH: Which is the Best Method to Estimate LDL-Cholesterol?

Fernando Cesena

Atherosclerotic cardiovascular disease (ASCVD) is the main cause of death in Brazil and most of the world. Reduction in low-density lipoprotein cholesterol (LDL-c) is the first lipid goal to prevent ASCVD. The decision on the initiation or intensification of LDL-c lowering drug therapy is based on the risk of events and the LDL-c level, so an accurate determination of LDL-c is highly desirable.

The gold standard method to determine the plasma concentration of LDL-c is β-quantification, an expensive, time-consuming procedure based on ultracentrifugation and precipitation. Direct methods that use proprietary chemicals instead of ultracentrifugation are also time-consuming and costly. Moreover, they lack standardization, and the accuracy is not always good.

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Editorial

Waist Circumference: A Parameter of Vascular Health

Erika Maria Gonçalves Campana et al. Andréa Araujo Brandão

Obesity plays a central role in chronic noncommunicable diseases due to its high prevalence and strong correlation with risk factors like hypertension, dyslipidemia, diabetes mellitus, and morbidity and mortality. In particular, abdominal obesity has been renowned as an emerging risk factor for an inflammatory and prothrombotic state, which is associated with an increased prevalence of hypertension and increased risk of cardiovascular (CV) events. These data are of utmost importance in the scenario of increasing prevalence of obesity not only in adults, but also among children and adolescents.^, Results of a study conducted in Rio de Janeiro showed an unfavorable relationship of elevated blood pressure (BP) and excess weight in adolescents with increased BP levels and anthropometric and metabolic variables in young adults.

Over the last years, the understanding of the CV continuum has grown, and CV disease has been seen in the context of vascular damage. In this sense, endothelial dysfunction, which results in atherosclerotic disease and its complications, involves the tunica media of large arteries, affected by an accelerated aging of the vessel, resulting in early arterial stiffness and arteriosclerosis, which in turn contributes to CV morbidity and mortality.^–

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Review Article

Screening, Diagnosis and Management of Atrial Fibrillation in Cancer Patients: Current Evidence and Future Perspectives

Pedro Gonçalves-Teixeira et al. Telma Costa Isabel Fragoso Diogo Ferreira … Mariana Brandão Adelino Leite-Moreira Francisco Sampaio José Ribeiro Ricardo Fontes-Carvalho

Abstract

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population, carrying a high morbimortality burden, and this also holds true in cancer patients. The association between AF and cancer goes even further, with some studies suggesting that AF can be a marker of occult cancer. There is, however, a remarkable paucity of data concerning specific challenges of AF management in cancer patients. AF prompt recognition and management in this special population can lessen the arrhythmia-related morbidity and have an important prognostic benefit. This review will focus on current AF diagnosis and management challenges in cancer patients, with special emphasis on AF screening strategies and devices, and anticoagulation therapy with non-vitamin K antagonist oral anti-coagulants (NOACs) for thromboembolic prevention in these patients. Some insights concerning future perspectives for AF prevention, diagnosis, and treatment in this special population will also be addressed.

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Editorial

Systematic Reviews and Meta-Analyses: Lighthouses in the Data Storm from the COVID-19 Pandemic

Henrique Turin Moreira et al. André Schmidt

Since recognizing the COVID-19 pandemic as a public health emergency, the global scientific community has driven efforts to understand the infection by the new coronavirus SARS-CoV-2. The World Health Organization soon proclaimed the need to fast-track research to reduce mortality and avoid crisis escalation. As a result, we now observe an extraordinary amount of data on COVID-19 obtained in a short time. Indeed, a search in the Pubmed database promptly reveals more than 164,000 papers on the disease in less than two and a half years, an unprecedented phenomenon in the medical literature. Putting this into perspective, this profusion of publications is numerically greater than papers identified by the term “myocardial infarction” in the last four decades.

Although this outstanding scientific advance has been crucial to fighting the pandemic, at the same time, it went along with a data storm with marked adverse effects. Health professionals had challenges searching, interpreting, and summarizing this dizzying volume of evidence. Conflicting results, typical of the twisted paths of science, were frequent causes of confusion and disagreement. In this setting, systematic reviews and meta-analyses can serve as lighthouses, guiding us to safer routes. They offer organized and integrated assessment of multiple data sources, thus allowing more robust estimates and reliable answers to clinical practice dilemmas.

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Research Letter

Home Blood Pressure Monitoring and Blood Pressure Control in Treated Hypertensives

Andréa Araujo Brandão et al. Weimar Kunz Sebba Barroso Audes Feitosa Eduardo Costa Duarte Barbosa … Roberto Dischinger Miranda Priscila Valverde de Oliveira Vitorino Roberto Pozzan Lucio Paulo Ribeiro Abraham Epelman Giovanni Alves Saraiva Fabio Serra Silveira Antônio Almeida Braga Marco Mota Gomes

Introduction

Blood pressure (BP) control rates are very low in Brazil and in the world, around 20% only.^– Patients with uncontrolled hypertension despite treatment remain at high risk for cardiovascular (CV) events and mortality, comparably to untreated individuals.

According to recent recommendations,^,,, BP control should be monitored by both office BP and out-of-office BP measurements. In this way, it is possible to determine different hypertension phenotypes,^,,, which is very important to determine the prognosis and individualized therapy.^,,-

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Image

“Lightning The Heart” with 3D Echo: Transillumination of a Prosthetic Mitral Valve Dehiscence

Mariana Ribeiro Silva et al. Ana Isabel Azevedo Francisco Sampaio José Ribeiro Ricardo Fontes-Carvalho

Case 1

A 55-year-old man underwent mitral valve replacement with a caged-ball prosthesis (3M Starr-Edwards) at the age of 29. He was admitted with acute heart failure, functional New York Heart Association (NYHA) class III. Transthoracic echocardiography (TTE) showed a moderate-severe mitral periprosthetic leak; 3D-transesophageal echocardiography (TOE) showed prosthesis dehiscence, with a severe periprosthetic leak (). TI improved depth perception and accurate definition of the degree of prosthetic dehiscence, demonstrating a disinsertion of the mitral prosthesis, involving more than 50% of mitral circumference (; ).

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Original Article

(-)-Carvone Modulates Intracellular Calcium Signaling with Antiarrhythmic Action in Rat Hearts

Gilmara Beatriz Andrade da Silva et al. Diego Santos Souza José Evaldo Rodrigues Menezes-Filho Júlio Alves da Silva-Neto … Jader dos Santos Cruz Danilo R. Roman-Campos Lucindo José Quintans-Júnior Carla Maria Lins de Vasconcelos

Abstract

Background:

(-)-Carvone is a monoterpene found in essential oils with antioxidant and anti-inflammatory activity.

Objective:

The aim of this paper was to analyze the antiarrhythmic property of (-)-carvone in the rat heart and its effects on the intracellular Ca²⁺ signaling.

Methods:

The effects of (-)-carvone were evaluated on the ventricular (0.5 mM) and atrial contractility (0.01 – 4 mM) and on electrocardiogram (0.5 mM). Fractional shortening, L-type calcium current (I_Ca,L) and Ca²⁺ signaling were measured in the isolated cardiomyocyte (0.5 mM). Antiarrhythmic effect was evaluated in arrhythmia model induced by calcium overload (0.5 mM) (n = 5). P < 0.05 was used as the significance level.

Results:

In the atrium, (-)-carvone evoked negative inotropism that was concentration-dependent (EC50 0.44 ± 0.11 mM) and decreased the positive inotropism evoked by CaCl₂ (0.1 to 8.0 mM) or BAY K8644 (5 to 500 nM), an agonist of L-type Ca²⁺ channel. In isolated heart, (-)-carvone (0.5 mM) promoted reduction of ventricular contractility (73%) and heart rate (46%), increased PRi (30.7%, time from the onset of the P wave until the R wave) and QTc (9.2%, a measure of the depolarization and repolarization of the ventricles) without changing the QRS complex duration. (-)-Carvone decreased the fractional shortening (61%), I_Ca,L (79%) and Ca²⁺ intracellular transient (38%). Furthermore, (-)-carvone showed antiarrhythmic action, verified by decrease of the arrhythmia score (85%) and occurrence of ventricular fibrillation.

Conclusion:

(-)-Carvone decreases Ca²⁺ entry through L-type Ca²⁺ channels, reducing the cardiac contractility and intracellular Ca²⁺, and, therefore, presenting promising antiarrhythmic activity in the rat hearts.

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Editorial

The Influence of Obesity and Physical Activity on Cardiovascular Risk

Claudio Leinig Pereira da Cunha

Atherosclerotic cardiovascular disease (ACVD) is common in the general population, affecting most adults over 60 years of age. The disease includes four main areas: (1) Coronary heart disease, (2) Cerebrovascular disease, (3) Peripheral arterial disease, and (4) Aortic atherosclerosis with aneurysms. The conditions traditionally associated with the installation of ACVD (the so-called “risk factors”) are dyslipidemia, diabetes mellitus, arterial hypertension, smoking, obesity, sedentary lifestyle and a family history of ACVD. Atherosclerotic vascular changes may begin in childhood, setting the stage for cardiovascular events in adulthood. Tornquist et al. present in this issue of Arquivos Brasileiros de Cardiologia some aspects of obesity and cardiorespiratory fitness in relation to cardiometabolic risk in children.

Obesity is a public health problem that has expanded worldwide. According to a report by the World Health Organization in 2016, obesity has tripled since 1980. The prevalence of obesity and overweight also increased among young people, from 16% in 1980 to 23% in 2013.

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Editorial

Utility of Biomarkers in Suspected Cardiac Amyloidosis: Opportunity for More Frequent and Early Diagnosis

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

The meta-analysis entitled “Diagnostic Role of NT-proBNP in Patients with Cardiac Amyloidosis Involvement: A Meta-Analysis” brings us an important review of the usefulness of NT-proBNP measurement in patients with cardiac involvement by amyloidosis. The demonstration of good sensitivity and specificity of this biomarker reinforces its usefulness in the diagnosis of cardiac amyloidosis (CA).

Cardiac amyloidosis has been increasingly diagnosed, especially in patients with the heart failure phenotype of preserved ejection fraction. Just over half of the patients with symptoms of heart failure have preserved ejection fraction, especially elderly individuals. This finding is usually considered only as age-related diastolic dysfunction and associated comorbidities. However, this factor should be one of the warning signs for diagnosing CA, especially when associated with high levels of biomarkers. A great variability in the frequency of diagnosis of CA in the general population has been described, ranging from 5 to 74% between the various studies. This variability may be related to factors such as low clinical suspicion or difficulties accessing complementary exams necessary for diagnosing cardiac involvement in amyloidosis. The diagnostic flowchart in patients with suspected cardiac involvement by amyloidosis is mainly based on imaging tests.^– These tests can be expensive, such as myocardial scintigraphy, strain echocardiography and cardiac magnetic resonance, and, often, they are only available at cardiology referral centers, making the diagnosis of CA more difficult and delayed. In addition, it is important to note that the late diagnosis of these patients can directly influence the prognosis by delaying the start of treatment, leading to a median of 6 months of survival after the development of symptoms in the AL form of amyloidosis for example.

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Viewpoint

Translational Medicine and Implementation Science: How to Transform What We Know Into What We Do

Protásio Lemos da Luz et al. Francisco Rafael Martins Laurindo

Basis of preventive medicine: a healthy lifestyle

When medical knowledge is to be applied to the general population, the concept of healthy lifestyle should be highlighted, especially in terms of preventive medicine.

Most cardiovascular events, such as myocardial infarction and death, are associated with risk factors such as dyslipidemia, smoking, hypertension and diabetes. Genetic factors are less representative. Another example is the Whitehall study, conducted with British civil servants, that showed that servants in lower grades of employments had a mortality rate three to four times higher than of those in the higher grades. The basis of preventive medicine is related to a healthy lifestyle, including a diet composed predominantly of fruit, vegetable and fish, and low intake of meat and carbohydrates. At least 150 minutes per week of aerobic and strength exercises are strongly recommended, including for protection of cognitive functions and Alzheimer prevention.

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Research Letter

Predictors of Atrial Fibrillation in Holter Monitoring after Stroke – A Ten Year Flashback

Tânia Proença et al. Ricardo Alves Pinto Miguel Martins de Carvalho Carla Sousa … Paula Dias Manuel Campelo Filipe Macedo

Introduction

Atrial fibrillation (AF) is a major risk factor for thromboembolic events, increasing five times the risk of stroke; it is also associated with more severe events and a higher risk of stroke recurrence. ^, On the other hand, the diagnosis of AF as the cause of ischaemic stroke shifts the therapeutic approach with a major prognostic impact.^, Detection of previously unknown AF after stroke is crucial, and several studies have established the effectiveness of ECG monitoring for post-stroke AF detection. According to ESO Guidelines for managing ischaemic stroke and transient ischaemic attack (TIA), after the acute phase, a 24-hour Holter ECG monitoring should be performed. New ESC Guidelines recommend short-term ECG recording for at least the first 24 h and continuous ECG monitoring for at least 72 h whenever possible in cryptogenic stroke.

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Letter to the Editor

Previous Chronic Diseases and their Relationship with COVID-19 Infection

Bruna Redivo de Souza et al. Eliane Mazzuco Layse Wiggers Kemper

Dear editor,

Due to the current global pandemic, the subject addressed is of great relevance. It is known that there is a certain urgency in the production and dissemination of scientific and epidemiological data about the new Coronavirus. Therefore, research that helps profile the population most vulnerable to this disease contributes to preventing an even greater number of deaths and sequelae resulting from COVID-19.

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Original Article

Clinical Implementation of Different Strategies for Exercise-Based Rehabilitation in Kidney and Liver Transplant Recipients: A Pilot Study

Paula A. B. Ribeiro et al. Mathieu Gradassi Sarah-Maude Martin Jonathan Leenknegt … Mathilde Baudet VyVan Le Marie-Pascale Pomey Agnes Räkel François Tournoux

Abstract

Background:

Cardiovascular disease is among the leading causes of death in solid organ transplant recipients with a functional graft. Although these patients could theoretically benefit from exercise-based rehabilitation (EBR) programs, their implementation is a challenge.

Objective:

We present our initial experience on different delivery modes of a pilot EBR program in kidney and liver transplant recipients.

Methods:

Thirty-two kidney or liver transplant recipients were invited for a 6-month EBR program delivered at the hospital gym, community gym or at home, according to the patient’s preference. The significance level adopted was 5%.

Results:

Ten patients (31%) did not complete their program. Among the 22 who did, 7 trained at the hospital gym, 7 at the community gym, and 8 at home. The overall effect was an 11.4% increase in maximum METs (Hedges’ effect size g = 0.39). The hospital gym group had an increase in METs of 25.5% (g= 0.58, medium effect size) versus 10% (g= 0.25), and 6.5% (g= 0.20) for the community gym and home groups, respectively. There was a beneficial effect on systolic and diastolic blood pressures, greater for the hospital gym (g= 0.51 and 0.40) and community gym (g= 0.60 and 1.15) groups than for the patients training at home (g= 0.07 and 0.10). No significant adverse event was reported during the follow-up.

Conclusion:

EBR programs in kidney and liver transplant recipients should be encouraged, even if they are delivered outside a hospital gym, since they are safe with positive effects on exercise capacity and cardiovascular risk factors.

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Editorial

COVID-19 and Late Cardiovascular Manifestations – Building Up Evidence

In early 2020, the world faced the outbreak of a new pandemic, Coronavirus Disease 2019 (COVID-19), caused by a novel coronavirus (SARS-CoV-2 virus). We soon discovered that while the respiratory tract was the prime target, many other organ systems might also be affected. COVID-19 cardiovascular (CV) manifestations are among the most common and feared and may manifest as myocardial injury, arrhythmias, acute coronary syndromes, heart failure, vascular dysfunction, and thromboembolic disease. Both pre-existing and comorbid cardiovascular disease and the concurrent presence of CV risk factors are harbingers of a poorer disease course and prognosis. Notably, acute CV involvement is a strong independent predictor of COVID-19 in-hospital mortality. The way in which the infection interacts with the CV system remains a subject of study, but apart from direct cell injury by the virus, the activation of inflammatory pathways is thought to play a key role. A comprehensive account of the pathophysiology of CV involvement in COVID-19 is beyond the scope of this commentary and has been extensively covered elsewhere.

While it is now clear that both cardiac and vascular dysregulations are to be expected during the active stage of the infection, concerns now focus on long-term residual CV abnormalities. Huang et al. reported that more than half of convalescent COVID-19 patients displayed signs of myocardial inflammation or fibrosis on cardiac magnetic resonance (CMR) imaging. Similarly, the meta-analysis by Kim et al. showed that nearly half of recovered COVID-19 patients exhibited one or more abnormal CMR results. Likewise, and somewhat unsurprisingly, the infection may also induce enduring vascular injury. In light of the tropism of SARS-CoV-2 for membrane-bound angiotensin-converting enzyme 2-expressing cells, it is no wonder that the vascular endothelium is a major player in the infection. Nonetheless, the effects of COVID-19 infection on vascular endothelium and the complex interplay between the two are still poorly understood. In essence, CV homeostasis is primarily dependent on the role of the endothelium. It regulates vascular tone, cell adhesion, thromboresistance, smooth muscle cell proliferation, and ultimately, vessel wall inflammation. Whenever the endothelium is activated, resulting in endothelial dysfunction, cell-signaling shifts from nitric oxide – mediated vasodilatory to vasoconstrictor redox processes. This can occur as a transient acute phenomenon, with little to no consequences, or as a sustained detrimental endothelium activation, eventually leading to a pro-atherogenic, pro-thrombotic milieu.

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Editorial

Exercise-Based Rehabilitation for Pre- and Post-Solid Organ Transplant Patients

Rosane Maria Nery

In the last decades, numerous advances in solid organ transplantation (SOT) have resulted in greater patient survival, resulting in a considerable increase in the number of transplants performed in the world.^, SOT is a life-saving intervention in patients with heart disease, pulmonary, renal or hepatic. Although the recipients improve both in functional capacity and quality of life (QoL), these are still not equivalent to the same levels of healthy individuals.

The long waiting period, caused by the lack of organ donors, often makes patients unprepared for the transplant physically and mentally. In addition to the classic cardiovascular risk factors, we still have the patient’s lack of adherence to the programs, knowledge deficits about the rules of conduct after transplantation, non-acceptance of the new organ, fear of rejection, lack of a physical exercise routine, strategies for coping and occupational health issues and social rights.^,

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Editorial

The First Stage Norwood Operation, in Brazil – The Bar Was Raised

Walter Villela de Andrade Vicente

Outcomes of the first stage Norwood operation in Brazil have been scarcely reported. Countrywide dismal results, contrasting to those from the developed world, possibly explain this finding.

Contrariwise to this scenario, in this issue of The Braz J Cardiol, da Silva´s group presents their single-center experience comprising the largest series of the first-stage Norwood operation with adjuvant postoperative extracorporeal membrane oxygenation (ECMO) support in our country. Their 30-day 91.3% survival, an outstanding surgical result, is on par with those from just a few international elite institutions where ECMO is also available.

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Editorial

Where are We Going with Natural Products? Exploring the True Potential of New Plant-Based Drugs in the Cardiovascular Field

Artur Santos-Miranda

Cardiovascular diseases are a leading cause of death worldwide. In the Brazilian population, it is estimated that approximately 41.6% of women and 63.5% of men are at medium to high risk of developing cardiovascular diseases in the next 10 years. Cardiac arrhythmias are common manifestations of cardiovascular diseases and configure an important cause of morbidity and mortality among cardiac diseases. After Vaughan-Williams’ classification of antiarrhythmic drugs based on their pharmacological actions, several new therapies and drugs were proposed, aiming to achieve a high efficacy with the least adverse effects. However, treatments with antiarrhythmic drugs and other agents used to treat cardiovascular conditions such as heart failure are often prone to pro-arrhythmic adverse responses.^, In addition, cardiac complications, such as arrhythmias, are also observed in treating other pathologies, including cancer, and during the use of antidepressants.^,

Plant-based medicines have long been used in traditional/alternative medicine for the most diverse purposes. Its uses correlate with several factors, including family tradition, age, sex, education, socioeconomic status, and failure of conventional therapies. Among plant-based drugs, different types of terpenes have been explored as fragrances/repellents but also according to their medical potential in treating parasitic diseases, bacterial infection, wound healing, and as anti-inflammatory antioxidant agents. Moreover, the antiarrhythmic properties of some terpenes have been addressed using in vitro and experimental model approaches,^, while other terpenes might actually have pro-arrhythmogenic activity.

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Editorial

Much More Than Just Women: Wonder Women

Marcia Koike et al. Luciana Aikawa

The impact of the SARS-Cov2 pandemic hit the world quickly and overwhelmingly and highlighted the heroes of the white cover: healthcare professionals. It took more than two years of uninterrupted work, facing various challenges and external and internal conflicts to preserve the patient’s life, colleagues, their families and themselves. A complicated scenario, not only due to the overload of professional demand but also the scientific lack of knowledge of what we were facing. Scientists worldwide have joined forces to disseminate scientific evidence, and, at the same time, medical societies have mobilized to optimize care procedures with protection for active professionals.

Stress and Burnout syndrome are part of occupational diseases in health professionals. However, the particular scenario of Covid-19 has shown that although it is not easy to be on the front lines in the fight against SARS-CoV2, nurses and doctors demonstrated high stress and exhaustion in studies, so behavioral/collective strategies can help.^– This mini-editorial is dedicated to female doctors.

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Research Letter

An Incidental Finding of a Cardiac Sarcoma

Rita Reis Santos et al. João Abecasis Daniel A. Gomes Mariana Sousa Paiva … Bruno Rocha Regina Ribeiras Pedro Freitas Miguel Abecasis Marisa Trabulo

Introduction

Primary cardiac tumors are rare, and their clinical presentation ranges from incidental discovery on imaging tests to life-threatening presentations.^–

We report a case of a young female with a history of atrial fibrillation (AF) who was found a left atrial mass in an elective cardiac computed tomography performed before AF-ablation and was qualified for surgical resection of the mass. A pathological exam revealed a primary undifferentiated pleomorphic cardiac sarcoma.

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Original Article

Abnormal Echocardiographic Findings in Hospitalized Patients with Covid-19: A Systematic Review and Meta-analysis

Silvio Henrique Barberato et al. Eduardo G. Bruneto Gabriel S. Reis Paula Rauen Franco de Oliveira … Alexandre F. Possamai Odilson Silvestre Miguel M. Fernandes Silva

Abstract

Background

Coronavirus disease 2019 (Covid-19) can lead to severe respiratory distress and acute cardiac injury, but it is unclear how often it can cause cardiac dysfunction.

Objective

In this systematic review, we aimed to summarize the main echocardiographic findings in patients with Covid-19.

Methods

We systematically searched in PUBMED, EMBASE, LILACS and Cochrane databases, in addition MedRxiv and Scielo preprints from inception to July 21^st, 2021. Studies reporting echocardiographic data in patients with Covid-19 were included. Demographic characteristics, previous cardiovascular disease (CVD), and echocardiographic findings were extracted. We performed a meta-analysis of proportions to estimate the main echocardiographic findings. The level of significance was p < 0.05.

Results

From 11,233 studies, 38 fulfilled inclusion criteria and were included in the meta-analysis. The estimated proportions of left ventricular (LV) systolic dysfunction were 25% (95%CI: 19, 31; I²93%), abnormal global longitudinal strain 34% (95% CI 23, 45; I²90%), righ ventricular (RV) systolic dysfunction 17% (95%CI 13, 21; I²90%), pericardial effusion 17% (95%CI: 9, 26; I²97%), and pulmonary hypertension 23% (95%CI: 15, 33, I2 96%). LV systolic dysfunction was directly associated with study-specific prevalence of previous abnormal echocardiogram (p<0.001). The proportion of patients in mechanical ventilation, indicating severity of disease, did not explain the heterogeneity in the proportions of LV dysfunction (p=0.37).

Conclusion

Among hospitalized patients with Covid-19, LV dysfunction has been reported in one quarter, with smaller proportions of right ventricular dysfunction, pericardial effusion and pulmonary hypertension. However, there was a higher proportion of LV dysfunction among studies reporting the presence of prior heart disease, which suggests that cardiac dysfunction was mostly pre-existing.

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Original Article

Women Physicians: Burnout during the COVID-19 Pandemic in Brazil

Gláucia Maria Moraes de Oliveira et al. Viviana Guzzo Lemke Maria Sanali Moura de Oliveira Paiva Giordana Zeferino Mariano … Elizabeth Regina Giunco Alexandre Silva Sheyla Cristina Tonheiro Ferro da Silva Magaly Arrais dos Santos Imara Correia de Queiroz Barbosa Carla Janice Baister Lantieri Elizabeth da Rosa Duarte Maria Cristina Oliveira Izar Karin Jaeger Anzolch Milena Alonso Egea Gerez Mayara Viana de Oliveira Ramos Maria Antonieta Albanez Albuquerque de Medeiro Lopes Emilia Matos do Nascimento Nanette Kass Wenger

Abstract

Background

COVID-19 has placed a tremendous burden on physicians worldwide, especially women physicians, affected by increased workload and loss of quality of life.

Objective

To assess the effects of the COVID-19 pandemic on the quality of life, burnout and spirituality of Brazilian women physicians directly or indirectly providing care to COVID-19 patients.

Methods

Prospective, observational study performed from July 28 to September 27, 2020, in Brazil, with women physicians from 47 specialities, the most frequent being cardiology (22.8%), with no age restriction. They voluntarily answered an online survey with questions on demographic and socioeconomic characteristics, quality of life (WHOQOL-brief), spirituality (WHOQOL-SRPB), and statements from the Oldenburg Burnout Inventory. Statistical analysis used the R software, beta regression, classification trees, and polychoric correlation matrix, with a 5% of significance level.

Results

Of the 769 respondents, 61.6% reported signs of burnout. About 64% reported wage loss of up to 50% during the pandemic. Some reported lack of energy for daily tasks, frequent negative feelings, dissatisfaction with capability for work, and caring for others not adding meaning to their lives. Negative feelings correlated negatively with satisfaction with sexual life and personal relations, and energy for daily tasks. The inability to remain optimistic in times of uncertainty correlated positively with feeling unsafe daily and not acknowledging that caring for others brings meaning to life.

Conclusion

This study showed a high frequency of burnout among Brazilian women physicians who answered the survey during the COVID-19 pandemic. Nevertheless, they presented with a relatively good quality of life and believed that spirituality comforted and reassured them in hard times.

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Original Article

Comparison of Novel Martin/Hopkins and Sampson Equations for Calculation of Low-Density Lipoprotein Cholesterol in Diabetic Patients

Abdulrahman Naser et al. Khagani Isgandarov Tolga Sinan Güvenç Rengin Çetin Güvenç Müslüm Şahin

Abstract

Background

The accurate determination of low-density lipoprotein cholesterol (LDL-C) is important to reach guideline-recommended LDL-C concentrations and to reduce adverse cardiovascular outcomes in diabetic patients. The commonly used Friedewald equation (LDL-Cf), gives inaccurate results in diabetic patients due to accompanying diabetic dyslipidemia. Recently two new equations – Martin/Hopkins (LDL-Cmh) and Sampson (LDL-Cs) – were developed to improve the accuracy of LDL-C estimation, but data are insufficient to suggest the superiority of one equation over the other one.

Objective

The present study compared the accuracy and clinical usefulness of novel Martin/Hopkins and Sampson equations in diabetic patients.

Methods

This study included 402 patients with diabetes. Patients’ cardiovascular risk and LDL-C targets were calculated per European guidelines. Calculated LDL-Cmh, LDL-Cs, and LDL-Cf concentrations were compared with direct LDL-C concentration (LDL-Cd) to test agreement between these equations and LDL-Cd. A p-value <0.05 was accepted as statistically significant.

Results

Both LDL-Cmh and LDL-Cs had a better agreement with LDL-Cd as compared to LDL-Cf, but no statistical differences were found among novel equations for agreement with LDL-Cd (Cronbach’s alpha 0.955 for both, p=1). Likewise, LDL-Cmh and LDL-Cs showed a similar degree of agreement with LDL-Cd in determining whether a patient was in a guideline-recommended LDL-C target (96.3% for LDL-Cmh and 96.0% for LDL-Cs), which were marginally better than LDL-Cf (94.6%). In patients with a triglyceride concentration >400 mg/dl, agreement with LDL-Cd was poor, regardless of the method used.

Conclusion

Martin/Hopkins and Sampson’s equations show a similar accuracy for calculating LDL-C concentrations in patients with diabetes, and both equations were marginally better than the Friedewald equation.

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Original Article

Early Outcomes of the Norwood Procedure in a Reference Center in Brazil

Rodrigo Freire Bezerra et al. Juliana Torres Pacheco Sônia Meiken Franchi Rosangela Belbuche Fittaroni … José Francisco Baumgratz Rodrigo Moreira Castro Luciana da Fonseca da Silva José Pedro da Silva

Abstract

Background

Only two papers have addressed the early outcomes of patients with hypoplastic left heart syndrome (HLHS) undergoing the Norwood operation, in Brazil.

Objectives

We evaluated patients with HLHS undergoing the first-stage Norwood operation in order to identify the predictive factors for early (within the first 30 days after surgery) and intermediate (from early survival up to the Glenn procedure) mortality.

Methods

Patients with HLHS undergoing the stage I Norwood procedure from January 2016 through April 2019, in our service, were enrolled. Demographic, anatomical, and surgical data were analyzed. Endpoints were early mortality (within the first 30 days after surgery), intermediate mortality (from early survival up to the Glenn procedure) and the need for postoperative ECMO support. Univariate and multivariate analyses were performed, and odds ratios, with 95% confidence intervals, were calculated. A p-value <0.05 was considered statistically significant.

Results

A total of 80 patients with HLHS underwent the stage I Norwood procedure. The 30-day survival rate was 91.3% and the intermediate survival rate 81.3%. Fourteen patients (17.5%) required ECMO support. Lower weight (p=0.033), aortic stenosis (vs aortic atresia; p=0.036), and the need for postoperative ECMO support (p=0.009) were independent predictive factors for 30-day mortality. Mitral valve stenosis (vs mitral valve atresia; p=0.041) was an independent predictive factor for intermediate mortality.

Conclusion

The present study includes the largest Brazilian cohort of patients with HLHS undergoing the stage I Norwood procedure in the recent era. Our survival rates were comparable to the highest survival rates reported globally. Low body weight, aortic valve stenosis, and the need for postoperative ECMO support were independent predictors for 30-day mortality. Mitral valve stenosis was the only independent predictive factor for intermediate mortality.

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Original Article

Correlation among Waist Circumference and Central Measures of Blood Pressure

Gilberto Campos Guimarães Filho et al. Lucas Tavares Silva Ruth Mellina Castro e Silva

Abstract

Background:

Arterial stiffness is a strong predictor of cardiovascular disease (CVD). Body fat measures such as waist circumference (WC) have been associated with CVD in adulthood.

Objectives:

The objective of this study was to evaluate the association of arterial stiffness, measured by applanation tonometry-Sphygmocor, with WC.

Methods:

Observational study with 240 participants who make routine consultations at the outpatient clinic of a university hospital. Participants were interviewed and had central blood pressure measurements (CBPM), anthropometric parameters, abdominal fat and visceral fat measured. Paired and unpaired t and chi-square tests were used. A significance level of 5% was adopted.

Results:

Of the 240 participants, 51.82% were male with a mean age of 59.71(±14.81) years and a mean WC of 99.87 (11.54) cm. Mean CBPM values were: Central arterial pressure (CAP) = 130.23 (91-223) mmHg, pulse wave velocity (PWV) = 9.8 (5.28-19.6)m/s and Augmentation Index [Amplification Index (AI)] = 29.45 (-14-60). PWV and CAP were highly correlated with WC with p<0.001 and p=0.02, respectively; however, the same positive correlation was not found between WC and AI (p=0.06).

Conclusion:

The present study showed a positive association between WC and arterial stiffness, through the femoral carotid pulse wave velocity (cf-PWV) and AI, being stronger with cf-PWV, suggesting the evaluation of the effect of WC in vascular health as a method of aid in the early treatment of CVD and in the prevention of clinical outcomes.

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