2023;120(10) – ABC CARDIOL

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Editorial

Chronic Coronary Syndrome In Brazil: We Need To Know More

Adriana Lopes Latado et al. Julio Cesar Vieira Braga

Chronic coronary syndrome (CCS) is a heterogeneous group of diseases encompassing obstructive and non-obstructive coronary atherosclerotic disease with or without previous myocardial infarction (MI) or coronary revascularization, in addition to the disease diagnosed only by non-invasive tests. According to data from the Global Burden of Disease (GBD) Study, the total number of people living with ischemic heart disease in Brazil, whether symptomatic or not, increased from 1.48 million to more than 4 million between 1990 and 2019. Population growth, aging, and the increase in diagnosis are the main justifications for this phenomenon.^,

Although remaining the main cause of death, mortality from ischemic heart disease has decreased over the last three decades in practically all of Brazil, although some regional variations have been described.^– Men are more affected than women, and an inverse relationship is described between the mortality rate from ischemic heart disease and the educational or economic level of the regions.^, Despite the growing existence of national data on ischemic heart disease, regional or local cohorts to assess its long-term prognosis are scarce, even more so if we consider the need for frequent updates regarding emerging treatment strategies.

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Editorial

The Role of Atrial Fibrosis for Atrial Fibrillation: Not Always Essential?

Rodrigo Miguel-dos-Santos

The most common cardiac arrhythmia, atrial fibrillation (AF), is estimated to affect ∼2% of the worldwide population and is expected to impact more people as the population ages.^– This scenario is not different in Brazil, where ∼2.5% of the population is projected to be affected by AF.^, The situation is more alarming among pulmonary hypertension patients, in which ∼30% may present AF episodes and ∼70% atrial flutter.^, Hence, a better understanding of the mechanisms and substrates of AF is constantly needed in order to tailor patients’ treatment better.

In a recent publication of the Arquivos Brasileiros de Cardiologia, Teixeira-Fonseca et al. investigated the effects of the left atrial morphofunctional changes induced by pulmonary hypertension in the arrhythmogenesis in isolated left atria. Monocrotaline-induced pulmonary hypertension led to left atria hypertrophy, tissue fibrosis, and electrophysiological remodeling. Curiously, ex vivo electrical burst pacing of the left atrial tissue did not elicit increased atrial arrhythmias in the tissue from pulmonary hypertension animals. As pointed out by the authors, some factors may have contributed to the absence of arrhythmias ex vivo. Here, I am going to focus on the trigger and substrate relationship in AF and discuss the potential cause for the lack of arrhythmias inducibility.

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Original Article

A Nationwide Initiative to Improve Cardiology Quality: The Best Practice in Cardiology Program in Brazil

Fabio Papa Taniguchi et al. Sabrina Bernardez-Pereira Antônio Luiz Pinho Ribeiro Louise Morgan … Anne B. Curtis Kathryn Taubert Denilson Campos de Albuquerque Sidney C Smith Jr Angêlo Amato Vincenzo de Paola

Abstract

Background

Despite significant progress in improving the quality of cardiovascular care, persistent gaps remain in terms of inconsistent adherence to guideline recommendations.

Objective

This study evaluates the effects of implementing a quality improvement program adapted from the American Heart Association’s Get with the Guidelines™ initiative on adherence to guideline-directed medical therapy for acute coronary syndrome (ACS), atrial fibrillation (AF), and heart failure (HF).

Methods

We examined demographics, quality measures, and short-term outcomes in patients hospitalized with ACS, AF, and HF enrolled in the Best Practice in Cardiology (BPC) Program from 2016 to 2022.

Results

This study included 12,167 patients in 19 hospitals in Brazil. Mean age was 62.5 [53.8-71] y/o; 61.1% were male, 68.7% had hypertension, 32.0% diabetes mellitus, and 24.1% had dyslipidemia. Composite score had a sustainable performance in the period from baseline to the last quarter: 65.8±36.2% to 73± 31.2% for AF (p=0.024), 81.0± 23.6% to 89.9 ± 19.3% for HF (p<0.001), and from 88.0 ± 19.1 to 91.2 ±14.9 for ACS (p<0.001).

Conclusions

The BPC program is a quality improvement program in Brazil in which real-time data, obtained using cardiology guideline metrics, were implemented in a quality improvement program resulting in an overall sustained improvement in AF, HF, and ACS management.

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Editorial

Stress Reduction, Meditation and Mindfulness Program for Heart Failure Patients: Some Light in the Darkness

Luís Beck-da-Silva

The study entitled “Impact of a Stress Reduction, Meditation, and Mindfulness Program in Patients with Chronic Heart Failure: A Randomized Controlled Trial” has raised a very important subject to be addressed in patients with heart failure and aimed to do so by conducting a randomized clinical trial. The impact of patients’ stress, depression, lack of life purpose, and psychological changes imposed by a chronic and debilitating disease definitely contributes to worsening quality of life and possibly to worse prognosis.^, To assess this impact and to research possible therapies is deeply needed. The authors should be recognized for their interest and huge effort in conducting such a laborious trial.

The study, however, has some deficiencies. Although the authors claim to be a heart failure with reduced ejection fraction (HFrEF) trial, the study included approximately half of the patients with HFrEF. Despite the heterogeneity of the sample, one-third of patients in the intervention group were lost to follow-up, while no patients were lost in the control group. Therefore, even having screened more than two hundred individuals, only 13 patients were actually submitted to intervention. The authors do not inform us of how these patients were pharmacologically treated, but given that the study was conducted four years ago, one can assume patients’ treatment was outdated.

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Editorial

Mindset Shift in Coronary Artery Disease: Reflections Triggered by the Diamond Anniversary of the Bruce Protocol

Nuno Bettencourt et al. Eduardo Vilela António Miguel Ferreira

From classical ECG exercise testing to modern modalities

The ECG exercise test, introduced several decades ago and whose most visible face was evolved to what would become the Bruce protocol, was a paradigm shift in CAD evaluation.It provided a non-invasive means to assess the heart’s response to physical stress, offering valuable insights into aspects like ischemic changes and arrhythmias.^,The simplicity of this method, coupled with the provision of data on different components of the cardiovascular response, led to its widespread adoption.However, the evolving landscape of medical technology has introduced alternative methods such as stress echocardiography and nuclear imaging and, more recently, ancillary advanced imaging techniques such as cardiac magnetic resonance imaging and computed tomography angiography (CTA).^{, ,}Slowly but steadily these techniques have prevailed in several scenarios, and current guidelines reserve a somewhat secondary role for ECG exercise testing in the diagnosis of CAD. Meanwhile, they highlight its value in a plethora of other clinical contexts, namely in terms of assessment of functional capacity, symptoms, heart rhythm and conduction disturbances, exercise prescription, and sports cardiology.^{, , ,}

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Editorial

The “Coming of Age” of Coronary Calcium Score?

António Miguel Ferreira et al. Rita Lima Nuno Bettencourt

The use of coronary artery calcium (CAC) score to guide the primary prevention of atherosclerosis and its manifestations has grown in popularity in recent years. Its advantages over the current paradigm of risk-factor-based calculators include better discrimination and greater predictive power, with the promise of better treatment decisions and timely implementation of personalized preventive measures.^–

CAC results are usually expressed as an absolute value and as a percentile among individuals of the same age and sex. Importantly, conveying this information to patients seems to improve their adherence to lifestyle modifications and pharmacological therapy. One of the ways developed for making patients understand their risk is the concept of vascular age. Quite simply, an individual’s vascular age assessed by CAC score is the average age at which people of the same sex have a similar degree of coronary calcification. So, if a person’s vascular age is higher than their chronological age, this indicates a higher risk of cardiovascular events than one would suppose. For instance, a 50-year-old female smoker with a vascular age of 70 may realize that she needs to take preventive measures to reduce her risk. Conversely, when vascular age is lower than chronological age, it suggests a lower risk compared to their age group. Although vascular age provides a clear and relatable way to communicate cardiovascular risk to patients, it should be noted that it might convey the false notion that atherosclerosis is part of the natural aging process. It is not. Nevertheless, despite this imprecision, its clinical usefulness remains.

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Editorial

Heart Failure and Sarcopenia: What is in between?

Humberto Villacorta

Heart failure (HF) is a progressive and lethal disease if not treated correctly.Patients with severe HF often progress to a state of cachexia and loss of muscle strength called sarcopenia.^–Sarcopenia and cachexia are not exactly the same thing. According to the European Consensus, cachexia is characterized as severe body weight, fat, muscle loss, and increased protein catabolism.On the other hand, the term sarcopenia is defined as age-related loss of skeletal muscle and a decline in muscle strength and/or physical performance, not necessarily associated with weight loss.

Although widely overlapping and sometimes difficult to recognize, these two conditions are highly prevalent in patients with severe HF. In the Studies Investigating Comorbidities Aggravating Heart Failure (SICA-HF), which analyzed 200 patients with either reduced (69% of the cases) or preserved ejection fraction, 32% had muscle wasting. Of these, 30 (14.4%) presented with sarcopenia alone, 25 (12%) with cachexia alone, and 14 (6.7%) with sarcopenia and cachexia together.

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Review Article

Challenges and Applications of Genetic Testing in Dilated Cardiomyopathy: Genotype, Phenotype and Clinical Implications

Silas Ramos Furquim et al. Bianca Linnenkamp Natália Quintella Sangiorgi Olivetti Fernando Rabioglio Giugni … Layara Fernanda Vicente Pereira Lipari Fernanda Almeida Andrade José Eduardo Krieger

Abstract

Genetic tests for dilated cardiomyopathy (DCM) have a diagnostic yield of up to 40%, but there is significant genetic heterogeneity and other challenges, such as variable expressivity and incomplete penetrance. Pedigree analysis is essential for distinguishing between sporadic and familial DCM cases by assessing family history. Familial DCM yields higher results in genetic testing, but sporadic DCM does not rule out the possibility of a genetic cause. Some genes have specific phenotypes, with the Lamin gene ( LMNA ) being associated with a phenotype of malignant arrhythmias and advanced heart failure (HF). The presence of a causal genetic variant can also aid in prognostic evaluation, identifying more severe cases with lower rates of reverse remodeling (RR) compared to individuals with a negative genotype. Current guidelines recommend genetic evaluation and counseling for individuals with DCM, along with cascade screening in first-degree relatives in cases where one or more variants are identified, offering an opportunity for early diagnosis and treatment. Relatives with a positive genotype and negative phenotype are candidates for serial evaluation, with frequency varying by age. Genotype also assists in individualized recommendations for implantable cardioverter-defibrillator (ICD) placement and advice regarding physical activity and family planning. Ongoing studies are progressively elucidating the details of genotype/phenotype relationships for a large number of variants, making molecular genetics increasingly integrated into clinical practice.

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Editorial

Pharmacological Conditioning is Salvageable by Dexmedetomidine: How a Sedative Can Mitigate I/R Injuries?

Leonardo Maciel

Acute myocardial infarction (AMI) is a severe condition affecting millions worldwide.During AMI, the blood supply to the heart muscle is interrupted, reducing the availability of nutrients and oxygen. Restoring blood flow is essential to save the heart muscle; paradoxically, reperfusion is not an entirely benign mechanism, and it induces reperfusion injuries.Therefore, treatments to mitigate ischemia-reperfusion (I/R) injuries are necessary. So far, there are no entirely effective pharmacological treatments to relieve I/R injuries in patients under AMI. However, pharmacological conditioning with Dexmedetomidine, a medication primarily used as a sedative and analgesic, has been reported as a promising cardioprotective agent against I/R injuries.

Due to its sedative and analgesic effects, Dexmedetomidine is a selective agonist of the alpha-2 adrenergic receptor (α2-AR) commonly used in hospitals, especially in intensive care units and surgery rooms. Although its association with cardiac protection has been suggested in previous studies,^–the work of Chen et al.,the topic of this short editorial, delved into understanding Dexmedetomidine’s underlying mechanism of cardioprotection. Thus, in addition to demonstrating that pharmacological preconditioning with Dexmedetomidine improves cardiac function and reduces the myocardial infarct area after I/R, one of the most significant findings of this study was the relationship between Dexmedetomidine and mitophagy.

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Editorial

Etiology of Pericardial Disease – Seek It, or You Shall not Find It!

Alexandre Siciliano Colafranceschi et al. Sofia Vega Colafranceschi

The pericardial sac consists of fibroelastic layers, known as the visceral and parietal layers, separated by the pericardial cavity. This cavity typically contains 15 to 50 ml of a plasma-derived ultrafiltrate in healthy individuals. Pericardial diseases are relatively common in clinical practice, presenting either in isolation or as a part of systemic disorders.

The causes of these diseases vary and are intricate, but the pericardium typically responds with inflammation of its layers and potential increased production of pericardial fluid. Persistent inflammation may lead to a stiffened and calcified pericardium, often thickened, with possible progression to pericardial constriction. In some instances, acute pericardial inflammation dominates the clinical presentation, rendering excess pericardial fluid less relevant. In contrast, in other cases, the accumulation of fluid and its clinical consequences, such as cardiac tamponade and constrictive pericarditis, take center stage. Congenital abnormalities like the absence of the pericardium and pericardial cysts are generally rare and asymptomatic. Despite the non-essential nature of the pericardium for normal cardiac function, diseased pericardium, presenting as acute or recurrent pericarditis, pericardial effusion, cardiac tamponade, and pericardial constriction, can pose significant challenges in management and even become life-threatening.

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Editorial

A National Quality Improvement Initiative in Cardiology: The Good Practices in Cardiology Program in Brazil

Henrique Tria Bianco

Conclusions

The BPC program determines and measures care quality metrics, guided by specialized guidelines, applicable in managing some cardiovascular diseases, especially AF, HF, and ACS.

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Atualização

Recommendation Update for Vascular Ultrasound Evaluation of Carotid and Vertebral Artery Disease: DIC, CBR and SABCV – 2023

Ana Cristina Lopes Albricker et al. Claudia Maria Vilas Freire Simone Nascimento dos Santos Monica Luiza de Alcantara … Armando Luis Cantisano Carmen Lucia Lascasas Porto Salomon Israel do Amaral Orlando Carlos Glória Veloso Domingos de Morais Filho José Aldo Ribeiro Teodoro Ana Cláudia Gomes Pereira Petisco Mohamed Hassan Saleh Marcio Vinícius Lins de Barros Fanilda Souto Barros Ana Luiza Dias Valiente Engelhorn Carlos Alberto Engelhorn Érica Patrício Nardino Melissa Andreia de Moares Silva Luisa Ciucci Biagioni Adriano José de Souza Anna Karina Paiva Sarpe Arthur Curtarelli de Oliveira Marcelo Rodrigo de Souza Moraes Miguel José Francisco Neto Peter Célio Françolin Carlos Eduardo Rochitte Rogerio Iquizli Alair Augusto Sarmet Moreira Damas dos Santos Valdair Francisco Muglia Bruno de Lima Naves

Contents

1. Class of Recommendation and Level of Evidence 5

2. Summary of the Main Recommendations 5

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Research Letter

Intrapericardial Cisplatin Instillation for Malignant Pericardial Effusion: A Single-center Experience

Paulo Medeiros et al. Jorge Rodrigues António Gaspar

Introduction

Heart and pericardium involvement occurs in about 10% of cancer patients, significantly impacting survival. Lung and breast carcinomas, melanoma, and lymphoma are the most common malignant tumors affecting the heart and pericardium. Involvement of the heart is a marker of very poor prognosis, representing end-stage neoplastic disease.

Pericardial decompression via pericardiocentesis results in immediate dyspnea relief and plays an important role in symptomatic treatment. Notwithstanding, the need for multiple procedures in the same patient is not uncommon. During the last decades, reports emerged regarding the utilization of cytotoxic agents for chemical pericardiodesis, but literature is scarce overall, and no systematization document has been published. The authors aimed to assess the recurrence of clinically significant malignant pericardial effusion in patients submitted to pericardiocentesis and cisplatin instillation.

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Research Letter

Mitral Valve Endocarditis – An Unusual Culprit in a Cancer Patient

Fabiana Duarte et al. Carina Machado Luis Oliveira Duarte Machado Raquel Dourado

Introduction

Cancer patients are prone to infective endocarditis (IE), associated with specific causative agents, leading to poorer outcomes. The prevalence of IE in cancer patients ranges from 5.6% to 18%, with a reported 1-year mortality rate of nearly 30%. ^– Risk factors, such as a suppressed immune system, intravascular catheter use, and hypercoagulability, predispose malignancy patients to IE. ^,

Clinical evolution is unfavorable due to high mortality rates related to antibiotic resistance, underlying medical conditions, lack of performed surgical interventions, and antitumoral therapy regimen discontinuation. ^–

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Original Article

Dexmedetomidine Preconditioning Attenuates Myocardial Ischemia/Reperfusion Injury in Rats by Suppressing Mitophagy Via Activating Α2-Adrenergic Receptor

YaHua Chen et al. Hui Chen YuJiao Chen ZaiQun Yang … Tao Zhou Wei Xu

Abstract

Background

Dexmedetomidine (DEX), a specific α2-adrenergic receptor agonist, is protective against myocardial ischemia/reperfusion injury (MIRI). However, the association between DEX preconditioning-induced cardioprotection and mitophagy suppression remains unclear.

Objective

Hence, we aimed to investigate whether DEX preconditioning alleviates MIRI by suppressing mitophagy via α2-adrenergic receptor activation.

Method

Sixty isolated rat hearts were treated with or without DEX before inducing ischemia and reperfusion; an α2-adrenergic receptor antagonist, yohimbine (YOH), was also administered before ischemia, alone or with DEX. The heart rate (HR), left ventricular diastolic pressure (LVDP), left ventricular end-diastolic pressure (LVEDP), maximal and minimal rate of left ventricular pressure development (±dp/dtmax), and myocardial infarction size were measured. The mitochondrial ultrastructure and autophagosomes were assessed using transmission electron microscopy. Mitochondrial membrane potential and reactive oxygen species (ROS) levels were measured using JC-1 and dichloride hydrofluorescein diacetate assays, respectively. The expression levels of the mitophagy-associated proteins Beclin1, LC3II/I ratio, p62, PINK1, and Parkin were detected by western blotting.

Results

Compared with the control group, in the ischemia/reperfusion group, the HR, LVDP, and ±dp/dtmax were remarkably decreased (p< 0.05), whereas LVEDP and infarct sizes were significantly increased (p< 0.05). DEX preconditioning significantly improved cardiac dysfunction reduced myocardial infarction size, maintained mitochondrial structural integrity, increased mitochondrial membrane potential, inhibited autophagosomes formation, and decreased ROS production and Beclin1, LC3II/I ratio, PINK1, Parkin, and p62 expression(p< 0.05). When DEX and YOH were combined, YOH canceled the effect of DEX, whereas the use of YOH alone had no effect.

Conclusion

Therefore, DEX preconditioning was cardioprotective against MIRI in rats by suppressing mitophagy via α2-adrenergic receptor activation.

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Original Article

Determination of Vascular Age in Men Using the Coronary Calcium Score and its Impact on Restratification of Cardiovascular Risk

Ismael Polli et al. Neide Maria Bruscato Protasio Lemos Da Luz Douglas Dal Más Freitas … Angélica Oliveira de Almeida Waldemar De Carli Emilio Hideyuki Moriguchi

Abstract

Background

Identifying asymptomatic individuals at risk of developing cardiovascular disease is one of the main goals of preventive cardiology. The coronary calcium score (CCS) makes it possible to estimate vascular age, which has shown to be more reliable than chronological age for determining cardiovascular risk.

Objectives

To reclassify cardiovascular risk based on arterial age and evaluate CCS progression during follow-up.

Methods

We included 150 asymptomatic men who underwent clinical and CCS evaluation in 2 evaluations with an interval of 7.6 years. We classified patients by traditional risk scores and arterial age. We evaluated which variables were associated with greater CCS progression during the period, considering a statistical significance level of 5% (p < 0.05).

Results

The use of arterial age in the stratification of cardiovascular risk in comparison with the Framingham risk score (FRS) reclassified 29% of individuals to a higher risk category and 37% to a lower risk category. Regarding the American Heart Association and American College of Cardiology score (ASCVD), 31% were reclassified as higher risk and 36% as lower risk. The initial classification by arterial age was directly related to the progression of CCS throughout follow-up (p < 0.001). This was not observed for the FRS (p = 0.862) or ASCVD (p = 0.153). The individual variables most associated with CCS progression were high systolic blood pressure and low HDL.

Conclusion

Cardiovascular risk stratification using arterial age showed a better association than the FRS and ASCVD in identifying individuals with higher risk of atherosclerosis progression.

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Editorial

Pulse Wave Velocity: Is It Time to Reduce the Cutoff Point?

Marcelo Antônio Oliveira Santos-Veloso

Systemic arterial hypertension (SAH) is Brazil’s most prevalent chronic non-communicable disease, commonly aggravated by metabolic disorders, such as diabetes mellitus, dyslipidemia, and obesity. Due to its silent course, research into subclinical injuries in the early stages is essential to establish measures to prevent cardiovascular complications. Risk identification with sensitive markers enables early therapy, reducing morbidity and mortality associated with cardiovascular diseases.

Pulse wave velocity (PWV) is the gold standard for identifying arteriosclerosis. There is a dose-response relationship between increased PWV and the occurrence of major cardiovascular outcomes, such as acute coronary syndrome, cerebrovascular syndromes, and death.

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Original Article

Pulse Wave Velocity of 8.2 m/s as a Threshold Associated with Cardiovascular Target Organ Damage Presence

Sayuri Inuzuka et al. Priscila Valverde de Oliveria Vitorino Adriana Sebba Barroso Fabrício Galdino Magalhães … Andrea Cristina Sousa Robson Pierre Pacífico Alves Filho Victoria Alves Melo Luiz Fernando de Oliveira Ana Luiza Lima Sousa Paulo Cesar B. Veiga Jardim Antonio Coca Weimar Kunz Sebba Barroso

Abstract

Background

Previous studies have established normal and reference values for Pulse Wave Velocity (PWV). However, the PWV value that has the strongest association with cardiovascular biomarkers remains poorly understood.

Objective

This study aimed to determine the PWV value more likely to be associated with left ventricular hypertrophy (LVH), increased intima-media thickness (IMT), and presence of carotid plaques in patients with hypertension.

Methods

This cross-sectional study included 119 patients. Analysis of receiver operating characteristic (ROC) curves was performed for each cardiovascular biomarker. Statistical significance was set at p < 0.05.

Results

According to the ROC curve analysis, the PWV values were 8.1 m/s, 8.2 m/s, and 8.7 for the LVH, IMT, and presence of carotid plaques, respectively. A PWV value of 8.2 m/s was identified as the best parameter to determine the three TOD biomarkers. PWV above 8.2 m/s was associated with increased CIMT (p = 0.004) and the presence of carotid plaques (p = 0.003) and LVH (p<0.001). PWV above 8.2 showed greater sensitivity for increased CIMT (AUC = 0.678, sensitivity = 62.2), LVH (AUC = 0.717, sensitivity = 87.2), and the presence of plaques (AUC = 0.649, sensitivity = 74.51) in the ROC curve analysis.

Conclusion

The PWV value 8.2 m/s was more sensitive in early identifying the existence of cardiovascular biomarkers of TOD.

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Letter to the Editor

Death by Covid-19 in Individuals with Hypertension and Overweight: Can Diabetes be a Risk Factor?

Nayara Ribeiro Máximo de Almeida et al. Brenda dos Santos Teixeira Breno Rennan de Souza Carvalho Egidio Bezerra da Silva Neto … Maria Alice Leitão Araújo de Melo Júlio Martinez Santos Johnnatas Mikael Lopes

In China, December 2019, the SARS-CoV-2 virus infection rapidly evolved into a pandemic. The S protein from the SARS-CoV-2 virus binds to angiotensin-converting enzyme 2 (ACE 2), which is part of the renin-angiotensin-aldosterone system (RAAS), to serve as a cell-entry receptor. These receptors are widely expressed in the heart, intestines, kidneys, pancreas and respiratory tract.

The RAAS is a signaling pathway that acts as a homeostatic regulator of vascular function, responsible for blood pressure control. ACE 2 is an enzyme that catalyzes the cleavage of Angiotensin II into Angiotensin (1-7), Angiotensin I into Angiotensin (1-9) and participates in the hydrolysis of other peptides. Thus, Angiotensin-Converting Enzyme Inhibitors (ACE) and Angiotensin 2 AT1 Receptor Blockers (ARB) have been extensively studied due to the possibility of increasing ACE expression 2.

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Original Article

Two-Year Follow-Up of Chronic Ischemic Heart Disease Patients in a Specialized Center in Brazil

Eduardo Martelli Moreira et al. Henrique Trombini Pinesi Eduardo Bello Martins Fábio Grunspun Pitta … Paula Mathias Paulino Bolta Carlos Alexandre Wainrober Segre Desiderio Favarato Fabiana Hanna Rached Whady Armindo Hueb Eduardo Gomes Lima Roberto Kalil Filho Cibele Larrosa Garzillo Carlos Vicente Serrano Jr

Abstract

Background

The incidence of cardiovascular events in patients with chronic ischemic heart disease (CIHD) may vary significantly among countries. Although populous, Brazil is often underrepresented in international records.

Objectives

This study aimed to describe the quality of care and the two-year incidence of cardiovascular events and associated prognostic factors in CIHD patients in a tertiary public health care center in Brazil.

Methods

Patients with CIHD who reported for clinical evaluation at Instituto do Coração (São Paulo, Brazil) were registered and followed for two years. The primary endpoint was a composite of myocardial infarction (MI), stroke, or death. A significance level of 0.05 was adopted.

Results

From January 2016 to December 2018, 625 participants were included in the study. Baseline characteristics show that 33.1% were women, median age 66.1 [59.6 – 71.9], 48.6% had diabetes, 83.1% had hypertension, 62.6% had previous MI, and 70.4% went through some revascularization procedure. At a median follow-up (FU) of 881 days, we noted 37 (7.05%) primary endpoints. After adjustments, age, previous stroke, and LDL-cholesterol were independently associated with the primary endpoint. Comparing baseline versus FU, participants experienced relief of angina based on the Canadian Cardiovascular Society (CCS) scale according to the following percentages: 65.7% vs. 81.7% were asymptomatic and 4.2% vs. 2.9% CCS 3 or 4 (p < 0.001). They also experienced better quality of medication prescription: 65.8% vs. 73.6% (p < 0.001). However, there was no improvement in LDL-cholesterol or blood pressure control.

Conclusion

This study shows that CIHD patients had a two-year incidence of the primary composite endpoint of 7.05%, and the reduction of LDL-cholesterol was the only modifiable risk factor associated with prognosis.

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Original Article

Impact of a Stress Reduction, Meditation, and Mindfulness Program in Patients with Chronic Heart Failure: A Randomized Controlled Trial

Vaisnava Nogueira Cavalcante et al. Evandro Tinoco Mesquita Ana Carla Dantas Cavalcanti Jacqueline Sampaio dos Santos Miranda … Paola Pugian Jardim Glaucio Martins da Silva Bandeira Lais Marcelle Rufino Guimarães Isabella Christina Diniz de Lemos Venâncio Nathalia Manoela Condeixa Correa Angela Maria Rodrigues Dantas João Carlos Tress Ana Catarina Romano Fabiana Bergamin Muccillo Marina Einstoss Barbosa Siqueira Glaucia Cristina Andrade Vieira

Abstract

Background

Heart Failure is a significant public health problem leading to a high burden of physical and psychological symptoms despite optimized therapy.

Objective

To evaluate primarily the impact of a Stress Reduction, Meditation, and Mindfulness Program on stress reduction of patients with Heart Failure.

Methods

A randomized and controlled clinical trial assessed the effect of a stress reduction program compared to conventional multidisciplinary care in two specialized centers in Brazil. The data collection period took place between April and October 2019. Thirty-eight patients were included and allocated to the intervention or control groups. The intervention took place over 8 weeks. The protocol assessed the scales of perceived stress, depression, quality of life, anxiety, mindfulness, quality of sleep, a 6-minute walk test, and biomarkers analyzed by a blinded team, considering a p-value <0.05 statistically significant.

Results

The intervention resulted in a significant reduction in perceived stress from 22.8 ± 4.3 to 14.3 ± 3.8 points in the perceived stress scale-14 items in the intervention group vs. 23.9 ± 4.3 to 25.8 ± 5.4 in the control group (p-value<0.001). A significant improvement in quality of life (p-value=0.013), mindfulness (p-value=0.041), quality of sleep (p-value<0.001), and the 6-minute walk test (p-value=0.004) was also observed in the group under intervention in comparison with the control.

Conclusion

The Stress Reduction, Meditation, and Mindfulness Program effectively reduced perceived stress and improved clinical outcomes in patients with chronic Heart Failure.

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Original Article

Bioinformatics and Systems Biology Approach to Identify the Pathogenetic Link between Heart Failure and Sarcopenia

Rui Xu et al. Ling-ling Ma Shuai Cui Ling Chen Hong Xu

Abstract

Background

Despite increasing evidence that patients with heart failure (HF) are susceptible to sarcopenia, the reason for the association is not well understood.

Objective

The purpose of this study is to explore further the molecular mechanism of the occurrence of this complication.

Methods

Gene expression datasets for HF (GSE57345) and Sarcopenia (GSE1428) were obtained from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) were identified using ‘edgeR’ and “limma” packages of R, and their functions were analyzed using Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG). Protein-protein interaction (PPI) networks were constructed and visualized using Search Tool for the Retrieval of Interacting Genes (STRING) and Cytoscape. Hub genes were selected using the plugin cytoHubba and validation with GSE76701 for HF and GSE136344 for Sarcopenia. The related pathways and molecular mechanisms of the hub genes were performed by Gene set enrichment analysis (GSEA). The statistical analyses were performed using R software. P < 0.05 was considered statistically significant.

Results

A total of 114 common DEGs were found. Pathways related to growth factor, Insulin secretion and cGMP-PKG were enriched in both HF and Sarcopenia. CYP27A1, KCNJ8, PIK3R5, TIMP2, CXCL12, KIT, and VCAM1 were found to be significant hub genes after validation, with GSEA emphasizing the importance of the hub genes in the regulation of the inflammatory response.

Conclusion

Our study reveals that HF and Sarcopenia share common pathways and pathogenic mechanisms. These findings may suggest new directions for future research into the underlying pathogenesis.

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Original Article

Survival of Heart Transplant Patients with Chagas’ Disease Under Different Antiproliferative Immunosuppressive Regimens

Silas Ramos Furquim et al. Luana Campoli Galbiati Monica S. Avila Fabiana G. Marcondes-Braga … Julia Fukushima Sandrigo Mangini Luis Fernando Bernal da Costa Seguro Iascara Wozniak de Campos Tania Mara Varejão Strabelli Fernanda Barone Audrey Rose da Silveira Amancio de Paulo Luciana Akutsu Ohe Mariana Cappelletti Galante Fabio Antonio Gaiotto Fernando Bacal

Abstract

Background

Chagas’ disease (CD) is an important cause of heart transplantation (HT). The main obstacle is Chagas’ disease reactivation (CDR), usually associated to high doses of immunosuppressants. Previous studies have suggested an association of mycophenolate mofetil with increased CDR. However, mortality predictors are unknown.

Objectives

To identify mortality risk factors in heart transplant patients with CD and the impact of antiproliferative regimen on survival.

Methods

Retrospective study with CD patients who underwent HT between January 2004 and September 2020, under immunosuppression protocol that prioritized azathioprine and change to mycophenolate mofetil in case of rejection. We performed univariate regression to identify mortality predictors; and compared survival, rejection and evidence of CDR between who received azathioprine, mycophenolate mofetil and those who changed from azathioprine to mycophenolate mofetil after discharge (“Change” group). A p-value < 0.05 was considered statistically significant.

Results

Eighty-five patients were included, 54.1% men, median age 49 (39-57) years, and 91.8% were given priority in waiting list. Nineteen (22.4%) used azathioprine, 37 (43.5%) mycophenolate mofetil and 29 (34.1%) switched therapy; survival was not different between groups, 2.9 (1.6-5.0) x 2.9 (1.8-4.8) x 4.2 (2.0-5.0) years, respectively; p=0.4. There was no difference in rejection (42%, 73% and 59% respectively; p=0.08) or in CDR (T. cruzi positive by endomyocardial biopsy 5% x 11% x 7%; p=0.7; benznidazole use 58% x 65% x 69%; p=0.8; positive PCR for T. cruzi 20% x 68% x 42% respectively; p=0.1) rates.

Conclusions

This retrospective study did not show difference in survival in heart transplant patients with CD receiving different antiproliferative regimens. Mycophenolate mofetil was not associated with statistically higher rates of CDR or graft rejection in this cohort. New randomized clinical trials are necessary to address this issue.

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Original Article

Isolated Left Atrium Morphofunctional Study of an Experimental Pulmonary Hypertension Model in Rats

Jorge Lucas Teixeira-Fonseca et al. Julliane Vasconcelos Joviano-Santos Fabiana da Silva Alcântara Polyana Leal da Silva … Michael Ramon Lima Conceição Danilo Roman-Campos

Abstract

Background

The high incidence of atrial arrhythmias in pulmonary hypertension (PH) might be associated with poor prognosis, and the left atrium (LA) may play a role in this. An important finding in PH studies is that LA remodeling is underestimated.

Objective

This study investigated LA morphology and mechanical function, as well as the susceptibility to develop arrhythmias in a monocrotaline-induced PH (MCT-PH) model.

Methods

Wistar rats aged 4 weeks received 50 mg/kg of MCT. Electrocardiography and histology analysis were performed to evaluate the establishment of the MCT-PH model. The tissue was mounted in an isolated organ bath to characterize the LA mechanical function

Results

Compared with the control group (CTRL), the MCT-PH model presented LA hypertrophy and changes in cardiac electrical activity, as evidenced by increased P wave duration, PR and QT interval in MCT-PH rats. In LA isolated from MCT-PH rats, no alteration in inotropism was observed; however, the time to peak contraction was delayed in the experimental MCT-PH group. Finally, there was no difference in arrhythmia susceptibility of LA from MCT-PH animals after the burst pacing protocol.

Conclusion

The morphofunctional remodeling of the LA did not lead to increased susceptibility to ex vivo arrhythmia after application of the burst pacing protocol.

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