2025;122(7) – ABC CARDIOL

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Editorial

Achieving LDL-Cholesterol Goals: Can Implementation Science Save Us?

Fernando Yue Cesena

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death worldwide,^, and individuals who have already experienced an ASCVD event are at the highest risk of a new event. Achieving low levels of LDL-cholesterol (LDL-c) is a proven and safe strategy for preventing subsequent events. Current guidelines recommend LDL-c levels below 50 mg/dL or 55 mg/dL in secondary prevention.^, Available therapies, including statins, ezetimibe, anti-PCSK9 agents, and bempedoic acid, are sufficient for most patients to achieve LDL-c targets. Nevertheless, the widespread failure to attain these goals has been extensively reported globally.^–

This issue of Arquivos Brasileiros de Cardiologia presents a study that investigated the prescription practices of 29 Brazilian cardiologists for LDL-c management in secondary prevention, estimating the number of patients potentially eligible for therapies beyond statins and ezetimibe. Physicians working in the Public Health System (PHS) or Supplementary Health System (SHS) completed a questionnaire regarding their clinical practices. The authors estimated that, among patients whose cardiologists aimed for LDL-c targets (92% of the total), 79% in the PHS and 86% in the SHS would achieve the desired LDL-c levels using statins and ezetimibe alone. By estimating the total number of individuals in secondary prevention in Brazil in 2024, the authors concluded that over one million individuals in the PHS and ~150.000 in the SHS would be potential candidates to lipid-lowering therapy beyond statins and ezetimibe. These results provide compelling support for improving access to modern lipid-lowering medications, such as anti-PCSK9 agents.

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Editorial

Esophageal Temperature Monitoring during Atrial Fibrillation Ablation: Evolving Evidence and New Perspectives

Silvia Helena Cardoso Boghossian

Radiofrequency (RF) ablation of atrial fibrillation (AF) is a widely used therapeutic strategy, with increasing efficacy and technical sophistication. However, the procedure is not without risks, with atrioesophageal fistula being a rare but extremely serious complication. In this context, luminal esophageal temperature (LET) monitoring has emerged as an additional protective measure, although its effectiveness has been the subject of controversy in the literature.

The study “Esophageal Temperature Monitoring during Atrial Fibrillation Ablation: A Randomized Study” presents relevant and timely evidence regarding the clinical impact of LET, especially in comparing single-sensor versus multi-sensor probes during AF ablation. It is a methodologically robust, randomized study that significantly contributes to refining safety practices in this procedure.

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Editorial

From Cholesterol Metabolism to Comprehensive Lipid Management and Crosstalk of Inflammation: Expanding the Frontiers of Cardiovascular Prevention

Eduardo Vilela et al. Nuno Bettencourt

Lipids and cardiovascular disease (CVD)

Lipid metabolism involves a wide range of complex pathways that play key roles in both normal physiology and disease. Lipids are essential for maintaining cell membrane integrity and supporting energy balance and metabolic homeostasis. Among them, cholesterol has drawn particular attention for its strong association with CVD.^–

While cholesterol is vital for several physiological functions — such as those related to nervous system structure and steroid hormone production — its role in the development of CVD has also been extensively studied.^, CVD, and particularly atherosclerotic CVD (ASCVD), remains a leading global health burden, and advances in our understanding of lipid metabolism have significantly shaped prevention strategies over the past decades.^,,

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Letter to the Editor

How to Demonstrate the Prognostic Benefit of Aggressive Screening of Atrial Fibrillation

Naoya Kataoka et al. Teruhiko Imamura

To Editor

The early detection of asymptomatic atrial fibrillation (AF) is considered essential for preventing thromboembolic events and the progression of heart failure. Numerous wearable devices have been developed to facilitate this objective. The authors employed stroke risk analysis (SRA), a method that stratifies the risk of paroxysmal AF through the evaluation of electrocardiogram data. This algorithm proved effective in screening patients with asymptomatic paroxysmal AF, with 29.4% of participants categorized as high-risk. Among these high-risk individuals, AF was detected in 38.7% following a 7-day screening period. Nevertheless, several critical concerns merit discussion.

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Letter to the Editor

Predictors of Atrial Arrhythmia Recurrence after Catheter Ablation: Socioeconomic Impact in Low to Middle-Income Countries

Marwan Shawki et al. Thalys Sampaio Rodrigues Levindo Jose Garcia Quarto

To the Editor,

We read with great interest the article by Ternes et al., recently published in the Arquivos Brasileiros de Cardiologia, with its accompanying insightful editorial.^, This multicentre prospective cohort study of consecutive patients across three centres in Brazil provided valuable insights into the predictors of atrial arrhythmia recurrence following first-time catheter ablation. It highlighted its clinical setting in a middle-income country and reported outcomes similar to those in high-income countries. However, the results must be interpreted cautiously, and some points merit further discussion.

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Editorial

Beyond Cholesterol and Triglycerides in the Lipid Clinic: The Challenging Task of Identifying Lysosomal Acid Lipase Deficiency

Marjorie H. Mizuta et al. Raul D. Santos

Lysosomal acid lipase deficiency (LAL-D) is a rare, autosomal recessive genetic disorder. Biallelic pathogenic variants within the LIPA gene result in a deficiency of the lysosomal acid lipase (LAL) enzyme, which is crucial for the hydrolysis of cholesteryl esters (CE) via the endocytic pathway. This enzymatic defect consequently leads to the lysosomal accumulation of CE and triglycerides. The phenotype of LAL-D varies significantly depending on the specific genetic variation. Specifically, null allelic variants, characterized by the absence of residual enzymatic function, manifest as Wolman’s disease, while variants with some residual LAL enzymatic activity result in cholesterol ester storage disease (CESD). Notably, identifying individuals with LAL-D poses a significant challenge, given the phenotypic heterogeneity of the disease, which can potentially overlap with various differential diagnoses.

Wolman’s disease usually manifests in infancy. The clinical presentation includes vomiting, steatorrhea, and abdominal distension within the first few days of life. Hepatosplenomegaly may occur due to lipid deposition in the liver and spleen, and hepatic steatosis can lead to liver failure. The accumulation of CE and triglycerides in the gastrointestinal tract leads to intestinal wall thickening, which in turn causes malabsorption and subsequent malnutrition. Calcification of the adrenal glands is a classic feature of the disease and can lead to adrenal cortical insufficiency. Individuals with Wolman’s disease rarely survive beyond their first year of life, primarily due to severe malnutrition, liver failure, and adrenal cortical insufficiency. Although enzyme replacement therapy is considered, life expectancy remains limited due to the disease’s severity. Hematopoietic stem cell transplantation represents another therapeutic option; however, further studies are necessary due to conflicting findings reported in the literature.^,

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Editorial

Renal Function and Cardiovascular Risk: An Overlooked Prognostic Ally

Gabriel Porto Soares et al. Thais Rocha Salim

The subanalysis of the Catarina Heart Study brings relevant and timely evidence to a well-known yet often underappreciated clinical relationship: the impact of renal function on cardiovascular outcomes. By showing that lower creatinine clearance at hospital admission independently predicts major adverse cardiovascular events (MACE) and mortality after acute myocardial infarction (AMI), the study reinforces the kidney as an essential prognostic organ in cardiology.

Cardiorenal interaction is not a novel concept. The bidirectional relationship between the heart and kidneys has been documented in large-scale studies like the Chronic Kidney Disease Prognosis Consortium and ARIC. What makes the present analysis relevant is its practical and local applicability: in a Brazilian population, using a simple, widely available tool—creatinine clearance by the Cockcroft-Gault formula—clinicians can identify high-risk patients early in the course of AMI.

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Image

Multiple Thrombotic Complications in a Patient With Polycythemia Vera

Barbara Zdzierak et al. Bernadeta Chyrchel Andrzej Surdacki Stanisław Bartuś Artur Dziewierz

Introduction

Polycythemia vera (PV) is a rare Philadelphia chromosome–negative myeloproliferative neoplasm characterized by the clonal proliferation of multipotent bone marrow progenitor cells, leading to erythrocytosis and increased red blood cell mass. It may coexist with other hematologic disorders. PV results in blood hyperviscosity, which predisposes patients to thrombosis — the most common and clinically significant complication of PV. Post-PV myelofibrosis (post-PV MF) represents an advanced stage in the natural progression of PV. In patients with post-PV MF, thrombosis also remains one of the major complications. We present a case of multiple thrombotic events, namely acute coronary syndrome, digital arterial thrombosis, and ischemic stroke, in a patient with PV.

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Erratum

Erratum

June 2025 Issue, vol. 122(6):e20240586

In the Review Article “Direct Oral Anticoagulants versus Aspirin for Secondary Stroke Prevention in Patients with Embolic Stroke of Undetermined Source: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials”, with DOI: , published in the journal Arquivos Brasileiros de Cardiologia, Arq Bras Cardiol. 2025; 122(6):e20240586, on page 1, change the name of the author Thomas Costa Alexandre to: Thomaz Alexandre Costa.

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Editorial

Atrial Fibrillation Ablation: Are We Still Looking for the Best Shot?

Lucas Simonetto Faganello et al. Mauricio Pimentel

Atrial fibrillation (AF) is independently associated with increased risks of mortality, stroke, heart failure, impaired quality of life, and cognitive decline. Rhythm control has proven superior to rate control in reducing cardiovascular outcomes, with catheter ablation demonstrating greater efficacy than antiarrhythmic drug therapy.^– Continuous advances in techniques and technologies have progressively established ablation as a cornerstone in the management of AF.

In recent years, 3D mapping and point-by-point ablation have evolved significantly with the introduction of contact force-sensing catheters and the development of lesion quality metrics, such as the Ablation Index and Lesion Size Index. These improvements have translated into better outcomes, reduced procedure times, and enhanced safety.^– Pulmonary vein isolation remains the cornerstone of invasive AF treatment, with radiofrequency (RF) point-by-point ablation still being the most widely used technique despite the emergence of alternative energy sources. Procedural success relies on delivering continuous, irreversible, and transmural lesions encircling the pulmonary veins while sparing adjacent structures, such as the esophagus and phrenic nerve.

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Editorial

Applying EASIX in Osteoarthritis. The Link between Inflammation and Cardiovascular Risk

Marcio Roberto Moraes de Carvalho

Osteoarthritis (OA), long regarded as a mechanical wear-and-tear disease of the joints, is increasingly being reinterpreted in light of evidence identifying it as a chronic low-grade inflammatory disease. This shift is more than semantic; it fundamentally reshapes how we assess the systemic risks faced by these patients, particularly their cardiovascular risk (CVR). Given the growing recognition of endothelial dysfunction as a key manifestation of the inflammatory process involved in vascular event development, the pursuit of tools capable of detecting indicators of these underlying mechanisms is of substantial importance.

In this issue, we present a new application of the Endothelial Activation and Stress Index (EASIX) to predict CVR in OA patients. Originally developed for hematological conditions, particularly graft-versus-host disease (GVHD), EASIX integrates three widely available markers – LDH, serum creatinine, and platelet count – into a single index that reflects endothelial stress.^,

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Editorial

Diabetic Cardiomyopathy: Unraveling Pathophysiological Mechanisms via Non-coding RNAs

Elida Paula Benquique Ojopi et al. Éder Anderson Rodrigues Gustavo Augusto Ferreira Mota Marina Politi Okoshi Luana Urbano Pagan

Diabetic cardiomyopathy (DCM) is a serious complication of diabetes mellitus (DM) characterized by changes that result in cardiac remodeling with ventricular dysfunction and eventually heart failure in the absence of other conditions such as arterial hypertension, valvular heart disease, coronary artery disease, and congenital heart disease. DCM develops independently of other cardiovascular risk factors and is associated with metabolic abnormalities, including hyperglycemia and hyperlipidemia. Multiple mechanisms contribute to DCM pathogenesis, such as impaired cardiac insulin signaling, mitochondrial dysfunction, oxidative stress, inflammation, and calcium handling defects. Despite its increasing prevalence, the underlying mechanisms of DCM remain largely unelucidated, and effective treatment is still needed.

Non-coding RNAs (ncRNAs) are transcriptional outputs that do not translate into proteins, exhibiting a diverse range of biogenesis, size, shape, and function. The most extensively studied ncRNAs are microRNAs (miRNAs) and long non-coding RNAs (lncRNAs). It has become a broadly accepted definition that ncRNAs over 200 nucleotides in length are classified as lncRNAs. miRNAs belong to a broader class of ncRNAs known as ‘small RNAs’, which are defined by their size (20–28 nucleotides) and association with Argonaute (Ago) family proteins. Small RNAs act as guides, directing Ago proteins to target nucleic acids to induce gene silencing. miRNAs and lncRNAs regulate various processes involved in DCM, including oxidative stress, inflammation, apoptosis, and autophagy. Therefore, they have been explored as potential biomarkers and therapeutic targets.^,

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Original Article

Estimate of Brazilians Under Secondary Prevention of Cardiovascular Events Who Do Not Achieve LDL Cholesterol Targets with Lipid-Lowering Therapy

Andressa Braga et al. Marisa Santos Carlos Magliano Katia Senna … Bernardo Tura Ione Oliveira

ABSTRACT

Background:

The 2017 Brazilian Guideline on Dyslipidemias recommends a low-density lipoprotein (LDL-c) target of <50 mg/dL for patients under secondary prevention of cardiovascular events, with statin therapy and the addition of ezetimibe if necessary. For patients who do not achieve this target, additional pharmacotherapy is indicated.

Objectives:

This study combined population data from the Brazilian Unified Health System (SUS) and the supplementary health system, epidemiological data, and the Delphi method, with participation from 29 specialists in the first round and 24 in the second, to estimate the size of the secondary prevention population not achieving LDL-c targets.

Results:

The population under secondary prevention was estimated at 5,8 million in the public health system and 1,2 million in the supplementary health system. Approximately one million patients in SUS and 150 thousand in the supplementary system are not expected to reach the LDL-c target with oral lipid-lowering therapy.

Conclusion:

Between 9% and 19% of patients under secondary prevention do not reach the recommended LDL-c target, making them potential candidates for additional LDL-c–lowering therapies.

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Original Article

Association between Renal Function and the Incidence of Major Adverse Cardiovascular Outcomes 1 Year After the First Acute Myocardial Infarction

Daniel Medeiros Moreira et al. Marco Antônio de Sousa Maria Fernanda Scarduelli Cechinel Roberto Léo da Silva … Tammuz Fattah Rodrigo de Moura Joaquim

Abstract

Background

Cardiovascular diseases are the leading cause of death worldwide, with substantial social and economic impacts. These conditions are frequently associated with comorbidities, including renal dysfunction.

Objectives

To evaluate the association between creatinine clearance and the incidence of cardiovascular outcomes within 1 year in patients diagnosed with acute myocardial infarction (AMI).

Methods

This prospective cohort study included patients hospitalized for their first AMI. Creatinine clearance was assessed in relation to cardiovascular outcomes, including recurrent AMI, stroke, and cardiovascular death. A p-value of <0.05 was considered statistically significant.

Results

A total of 1,324 patients were analyzed, with a mean age of 60.9 ± 11.4 years; 67.4% were male. Creatinine clearance <60 mL/min was significantly associated with systemic arterial hypertension (79.6% vs. 55.1%, p<0.001), diabetes mellitus (40.8% vs. 24.5%, p<0.001), and dyslipidemia (38.8% vs. 31.4%, p=0.043). Higher creatinine clearance values were associated with a reduced risk of major adverse cardiovascular events (MACE) at 1 year (HR: 0.992; 95% CI: 0.984-0.999; p=0.030). Additionally, higher clearance was linked to lower overall mortality (HR: 0.984; 95% CI: 0.970-0.998; p=0.021).

Conclusion

Higher creatinine clearance values are associated with a lower hazard ratio for MACE and overall mortality within 1 year following AMI.

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Editorial

Coronary Compression in Pulmonary Hypertension: A Treatable Threat Hidden in Plain Sight

Allan K. N. Alencar

Pulmonary hypertension (PH) represents a severe, progressive condition associated with right ventricular failure, impaired functional capacity, and increased mortality.^, Although angina is not a hallmark symptom of PH, it can affect up to 30% of patients and is frequently overlooked in clinical practice. The study published in this issue of Arquivos Brasileiros de Cardiologia addresses a rare yet critical cause of chest pain in PH: extrinsic compression of the left main coronary artery (LMCA) by a dilated pulmonary artery. The authors present an observational case series of 12 patients undergoing percutaneous coronary intervention (PCI) with stenting for LMCA compression, reporting both feasibility and sustained symptom relief.

While LMCA atherosclerosis is well recognized for its prognostic impact, compression of this vessel due to pulmonary artery dilation in PH remains underdiagnosed. The authors highlight that up to 76% of patients with advanced PH exhibit pulmonary artery enlargement, which may result in significant extrinsic compression of the LMCA, even in the absence of coronary atherosclerosis.^, Importantly, LMCA compression has been associated with sudden cardiac death in PH cohorts, emphasizing the need for high clinical suspicion.^–

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Original Article

Pulsed Field Ablation Versus Very High-Power Short-Duration Radiofrequency Ablation in Atrial Fibrillation: A Systematic Review and Meta-Analysis

Asad Iqbal et al. Wellgner Fernandes Oliveira Amador Martin Cevallos-Cueva Maaz Ahmad … Juan Alejandro Pinilla Alarcón Radamés Vieira Diniz

Abstract

Background

Pulmonary vein isolation (PVI) is a cornerstone treatment for atrial fibrillation (AF). Pulsed-field ablation (PFA) and very high-power short-duration (vHPSD) radiofrequency (RF) ablation are emerging technologies, but their comparative efficacy and safety remain unclear.

Objectives

To assess the efficacy and safety of PFA compared to vHPSD RF ablation for AF.

Methods

A systematic search of PubMed, Embase, Web of Science, and Cochrane databases identified studies comparing PFA and vHPSD ablation. Outcomes included PVI success, skin-to-skin procedure time, fluoroscopy time, freedom from atrial arrhythmias, and complications such as cardiac tamponade, stroke, and vascular access events. Continuous outcomes were analyzed using mean differences (MD), while binary outcomes were assessed with risk ratios (RR) and 95% confidence intervals (CI). A significance threshold of p < 0.05 was considered for statistical analyses. This study is registered in PROSPERO (CRD42024619301).

Results

Four observational studies with 605 patients were included, of whom 315 (52%) underwent PFA. PFA and vHPSD achieved similar PVI success (RR 1.00; 95% CI 0.99–1.01; p = 1). PFA reduced procedure time (MD -30.07 min; 95% CI -31.41 to -28.74; p<0.01) but increased fluoroscopy time (MD 6.87 min; 95% CI 3.66–10.08; p<0.01). Freedom from atrial arrhythmias was comparable (RR 1.03; 95% CI 0.94–1.14; p=0.5). Complication rates, including cardiac tamponade, stroke, and vascular access issues, showed no significant differences between groups.

Conclusion

PFA significantly shortens procedure time but requires longer fluoroscopy compared to vHPSD. Both techniques exhibit comparable efficacy for PVI and arrhythmia freedom, with similar safety profiles.

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Research Letter

Whipple’s Disease as a Differential Diagnosis of Blood Culture-Negative Endocarditis: A Case Report

Carolina Kuchenbecker Soares et al. Rafaela Clara Resende da Silva Geraldo Brasileiro Filho Claudio Leo Gelape … Jésus Faria Rosa Júnior Luiz Guilherme Passaglia

Abstract

Whipple’s endocarditis is a rare infectious condition caused by the bacterium Tropheryma whipplei. Although its systemic form is the most widely recognized, the infection exhibits a broad spectrum of extraintestinal manifestations, with blood culture-negative infective endocarditis being the most common form of cardiac involvement. The case presented in this study underscores the importance of clinical investigation for accurate diagnosis and the application of appropriate treatment.

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Original Article

Screening for Lysosomal Acid Lipase Deficiency in a Lipid Clinic

Zenia Brasil et al. Francisco Antonio H. Fonseca Marco Antonio Curiati Sandra Obikawa Kyosen … Vanessa Gonçalves Pereira Waleria Toledo Fonzar João Bosco Pesquero Francy Reis da Silva Patrício Marcelo Hideki Yamamoto Joyce Umbelino Yamamoto Vania D’Almeida Ana Maria Martins Maria Cristina Izar

Abstract

Background

Lysosomal acid lipase deficiency (LAL-D) is a rare autosomal recessive disease, with massive accumulation of cholesteryl esters and triglycerides in many organs, leading to hepatosplenomegaly, microvesicular steatosis, cirrhosis and premature death. Early recognition is crucial for timely enzyme replacement therapy.

Objectives

To screen for LAL-D in subjects with dyslipidemias and/or liver disease at an outpatient lipid clinic.

Methods

We retrospectively assessed records from 2,018 adults and children using a screening algorithm including ALT/AST elevation >1.5 x upper limit of normality, LDL-C>160 mg/dL, HDL-C<40 (males) or 130 mg/dL, HDL-C<45 mg/dL, in children. High-risk patients for LAL-D were selected for LAL enzymatic activity assay in dried blood spots using LAL inhibitor, Lalistat-2.

Results

Among 2,018 screened patients, 21 (0.92%) were selected for LAL activity test, but only eight performed the test with normal results [mean LAL activity 0.077 ± 0.03 nmol/punch/h (reference value >0.024 nmol/punch/h)]. A child whose mother did not perform the test, had a post-mortem undetectable LAL activity. Further, the mother and three half-brothers confirmed LAL-D. Sequencing (NGS) of LIPA gene did not find pathogenic variants, not allowing to discard changes in non-coding region of the gene analyzed.

Conclusions

Identifying LAL-D remains a challenge, and an algorithm based on clinical and laboratory criteria may assist in selecting patients for LAL-D screening. Given its rarity and overlapping features with other genetic dyslipidemias, LAL-D is primarily a diagnosis of exclusion, often considered when other conditions have been ruled out.

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Research Article

Orientin Alleviates Oxidative Stress And Apoptosis In Diabetic Cardiomyopathy Via The Lncrna H19/Mir-103-3p/ALDH2/PI3K/AKT Axis

Xun Wang et al. Xiaofang Xiong Wei Jiang Shanshan Xu Jun Li

Abstract

Background

Diabetic cardiomyopathy (DCM) is an irreversible cardiovascular complication of diabetes mellitus characterized by detrimental cardiac remodeling. Orientin, a water-soluble flavonoid present in many medicinal plants, exerts various pharmacological effects.

Objectives

To investigate the cardioprotective effects of orientin in diabetic conditions and elucidate the mechanisms associated with non-coding RNAs.

Methods

The streptozotocin-induced DCM model was established by a combined use of streptozotocin and a high-fat diet. Cardiac structure and function in diabetes mellitus mice were evaluated using histological and echocardiographic analyses. Masson, TUNEL, western blot, and ELISA in mouse hearts were performed to analyze cardiac fibrosis, apoptosis, and oxidative stress. Expression levels of lncRNA H19, miR-103-3p, ALDH2, and PI3K/AKT-related proteins in mouse heart and HL-1 cells were evaluated using real-time qPCR or western blot. The significance level was set at p<0.05.

Results

Orientin improved cardiac function and ameliorated cardiac injury in diabetic mice. Orientin inhibited cardiac fibrosis, reduced cardiomyocyte apoptosis, and increased the activities of antioxidant enzymes. In pathological conditions, H19 and ALDH2 levels were reduced while miR-103-3p levels increased, which were reversed by orientin. H19 upregulated ALDH2 expression by binding to miR-103-3p and activated the PI3K/AKT pathway in high glucose-treated HL-1 cells. H19 depletion or PI3K inhibitor reversed the effects of orientin on apoptosis and oxidative stress in HL-1 cells under high glucose conditions.

Conclusions

These findings reveal a protective mechanism of orientin in DCM, which involves the regulation of the H19/miR-103-3p/ALDH2/PI3K/AKT signaling axis, providing a potential strategy for treating DCM.

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Review Article

Medical Reversals, Spins and Divergent Results in Cardiology Trials

José Nunes de Alencar et al. Bruno Robalinho Cavalcanti Guilherme Augusto Teodoro Athayde

Abstract

Cardiovascular medicine has witnessed remarkable breakthroughs, yet even highly regarded interventions can be undermined by flawed reasoning, excessive mechanistic assumptions, and the selective reporting of data. This article examines crucial pitfalls in contemporary cardiology, such as medical reversals, the impact of spin, and how bayesian methods can offer greater clarity in evaluating evidence, as they integrate prior knowledge with new data to generate more probabilistic, context-driven conclusions. This review advocates for a measured, critical approach to research appraisal, cautioning cardiologists against uncritically accepting trial conclusions at face value. Adopting this vigilant stance will help ensure that emerging therapies and interventions genuinely advance patient outcomes, guiding physicians toward more credible, transparent, and beneficial strategies in the ever-evolving field of cardiovascular medicine. Such vigilance is important to preserve the integrity of scientific inquiry and meaningful progress in patient care. This approach promotes reliability of published data.

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Original Article

Temporal Trends in the Epidemiology of Acute Rheumatic Fever: A Nationwide Analysis from 2008 to 2022

Antonio Mutarelli et al. Larissa Armelin Alexandre Negrão Pantaleão Alleh Nogueira … Carla Jorge Machado José Luiz P Silva Jagdip Kang Walderez O. Dutra Maria C. P. Nunes

Abstract

Background

Acute rheumatic fever (ARF) remains a significant public health challenge, especially in low- and middle-income countries. It disproportionately affects non-white populations in underprivileged regions and may lead to rheumatic heart disease (RHD), which has high morbidity and mortality.

Objectives

Analyze hospitalizations and deaths related to ARF in Brazil between 2008 and 2022, highlighting regional and demographic inequalities.

Methods

We conducted a cross-sectional study analyzing hospitalization and mortality data caused by ARF from 2008 to 2022 in Brazil, collected through the Hospital Information System (SIH/SUS). Data were stratified by demographics, region, and hospital visit type (urgent or elective) and analyzed using generalized linear autoregressive moving average models to assess the impact of age, sex, and race. Statistical significance was set at p < 0.05.

Results

Of 11,061 hospitalizations and 65 deaths from ARF, 53% were male and 16% were white. The 10–14-year-old age group had the highest hospitalization rates, while the 15–19-year-old group had more deaths. Hospitalizations were higher among non-white individuals and concentrated in Brazil’s Northeast. Over time, ARF-related hospitalizations declined across all demographics, with a gradual convergence between male and female rates by 2022.

Conclusion

Our findings highlight a decline in ARF-related hospitalizations across regions and demographics, though disparities remain. There is no significant difference in ARF cases between men and women. The study highlights a correlation between socioeconomic factors and disease burden, with low-income groups experiencing a higher rate of ARF hospitalizations.

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Original Article

Left Main Coronary Artery Angioplasty for the Treatment of Extrinsic Compression in Patients with Pulmonary Hypertension

Luciana Dornfeld Bichuette et al. Daniela Calderaro Pedro Alves Lemos Neto Eduardo Kaiser Ururahy Nunes Fonseca … Luiza Sarmento Tatagiba Tulio Martins Vieira Yally Priscila Pessoa Nascimento Marcela Araujo Castro Taysa Antônia Félix Silva Yuri de Deus Montalverne Parente Caio Julio Fernandes Francisco Akira Malta Cardozo Cesar Higa Nomura Pedro Henrique Almeida Marins Rogerio Souza Carlos Vianna Poyares Jardim

Abstract

Background

The most common clinical presentation of pulmonary hypertension (PH) includes exertional dyspnea, signs of systemic congestion, and syncope. Angina pectoris can also be a relevant manifestation, especially in cases where the left main coronary artery (LMCA) is externally compressed by a dilated pulmonary artery. However, significant gaps remain regarding the most appropriate diagnostic and therapeutic strategies for coronary obstruction in this clinical scenario.

Objectives

To assess the feasibility and impact of coronary angioplasty with stent implantation on symptom relief in patients with PH and extrinsic compression of LMCA.

Methods

This descriptive study included 12 patients with PH who were followed at the Pulmonary Circulation Outpatient Clinic of the Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. All patients underwent coronary angioplasty with stent implantation to treat extrinsic compression of LMCA.

Results

A total of 12 patients were analyzed, with a mean age of 47.9 years, predominantly with group 1 PH and under specific therapy. All procedures achieved excellent immediate results, with angina relief observed at 30 days. During a mean follow-up of 33 months, no procedure-related complications were reported, and angina symptoms remained controlled. Four patients died due to progressive heart failure.

Conclusion

The findings support the feasibility of coronary angioplasty as a strategy for symptomatic relief of angina in patients with LMCA compression associated with PH. Further studies are needed to evaluate the impact of this intervention on hard clinical outcomes, as well as the role of screening in asymptomatic patients.

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Original Article

Association of Endothelial Activation and Stress Index with Risk of Cardiovascular Disease and All-cause Mortality in Patients with Osteoarthritis

Ruoyan Li et al. Chaoqun Feng Kexin Lin Nan Wang Xiaohong Fan

Abstract

Background

Osteoarthritis is a prevalent type of arthritis characterized by chronic degenerative changes in the musculoskeletal system, which can result in joint damage and chronic pain.

Objective

This study was to investigate the associations between the endothelial activation and stress index (EASIX) and the increased risk of atherosclerotic cardiovascular disease (ASCVD) and all-cause mortality among patients diagnosed with osteoarthritis.

Methods

The cohort study encompassed 2028 individuals aged 40-79 years with osteoarthritis, utilizing data from the National Health and Nutrition Examination Surveys (NHANES) database spanning the years 2007 to 2018. The univariate weighted logistic regression model and weighted Cox model were respectively established to screen possible confounders. A significance level of p < 0.05 was adopted for all statistical analyses.

Results

The study revealed an elevated risk of ASCVD in correlation with an increased log (EASIX) (Odds Ratio: 1.94, with 95% Confidence Interval:1.57-2.41). When compared to individuals with log (EASIX) -0.78 demonstrated a heightened risk of ASCVD (Odds Ratio: 2.31, with 95% Confidence Interval:1.68-3.18). A higher log (EASIX) value was also linked to an increased risk of mortality from all causes (Hazard Ratio: 1.59, with 95% Confidence Interval:1.14 -2.23). Among individuals diagnosed with osteoarthritis, those exhibiting log (EASIX)> -0.78 faced a greater risk of dying from any cause, as compared to patients with log (EASIX) <-1.29.

Conclusion

The presence of a high EASIX index was linked to an increased risk of ASCVD and all-cause mortality among patients with osteoarthritis.

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Original Article

Esophageal Temperature Monitoring during Atrial Fibrillation Ablation: A Randomized Study

Daniel Moreira Costa Moura et al. Renner Augusto Raposo Pereira Cristiano Faria Pisani Tan Chen Wu … Muhieddine Omar Chokr Carina Abigail Hardy Sissy Lara de Melo Francisco Carlos da Costa Darrieux Denise Tessariol Hachul Mauricio Ibrahim Scanavacca

Abstract

Background

Pulmonary vein isolation (PVI) for atrial fibrillation (AF) ablation carries a risk of esophageal thermal injury (ETI), which can lead to severe complications.

Objective

To evaluate three luminal esophageal temperature (LET) monitoring strategies and assess their effectiveness in reducing the incidence of ETI.

Methods

Patients with AF were randomized into three PVI groups according to the temperature monitoring strategy: no LET monitoring (Group 1), LET monitoring with a single-sensor probe (SSP) thermometer (Group 2), and LET monitoring with a multisensor probe (MSP) thermometer (Group 3). In Group 1, AF ablation was performed at a fixed power of 20 W on the left atrial posterior wall. In Groups 2 and 3, AF ablation power was titrated based on LET measurements, with a cutoff temperature of 37.5 °C. Each group included 20 patients. A two-sided p-value <0.05 was considered statistically significant. The trial was registered on ClinicalTrials.gov (#NCT03645070) and International Clinical Trials Registry Platform (#RBR-2yvgyf).

Results

All patients underwent PVI and esophagogastroduodenoscopy. No ETI was observed in patients monitored with an MSP thermometer. In contrast, five patients without LET monitoring and six patients monitored with an SSP thermometer developed ETI (p=0.006). Higher temperatures were recorded with an MSP thermometer (37.9 vs. 38.45 °C, p=0.018). There were no significant differences in PVI duration or total radiofrequency application time (p=0.250 and p=0.253, respectively).

Conclusions

LET monitoring with an MSP thermometer during PVI significantly reduces the incidence of ETI compared to no monitoring or SSP monitoring. Implementing advanced LET monitoring strategies may enhance patient safety without compromising procedural efficiency.

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