2025;122(8) – ABC CARDIOL

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Editorial

Herbal Therapy in Post-Menopause

Rosana dos Santos e Silva Martin et al. Luis Cuadrado Martin

Traditional Chinese medicine and its modern products have shown potential in treating atherosclerosis. The possible mechanisms include regulation of blood lipids, anti-lipid peroxidation, anti-polymerization, anticoagulation, and pro-fibrinolysis, inhibition of smooth muscle cell proliferation, and protection of vascular endothelial function. Ginseng derivatives are being used in menopause treatment and andropause treatment.

The paper “Chronic Treatment with Panax ginseng and Angelica keiskei Decreases Blood Pressure and Improves Endothelial Function in Ovariectomized Rats”, published in this journal, obtained improvement in blood pressure in ovariectomized rats treated by Panax ginseng and Angelica keiskei This effect was associated with amelioration of endothelial function.

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Editorial

Unveiling the Link between MASLD-Associated Liver Fibrosis and Subclinical Atherosclerosis

Maria Cristina Izar et al. Francisco Antonio Helfenstein Fonseca

Metabolically-dysfunction-associated steatotic liver disease (MASLD) is quickly becoming the most prevalent chronic liver condition globally, encompassing the broad metabolic spectrum formerly attributed to non-alcoholic fatty liver disease.^, Its progression to fibrosis and cirrhosis carries not only hepatic risks but systemic implications—chief among them, cardiovascular disease, now recognized as the leading cause of mortality in MASLD patients.^,

The prospective study titled “Relationship between Liver Fibrosis Due to Metabolic Dysfunction-Associated Steatotic Liver Disease and Subclinical Atherosclerosis” offers timely and significant insights into this hepatic-cardiovascular interplay. By evaluating non-invasive vascular markers such as carotid intima-media thickness (cIMT) and vascular age (VA), the authors provide evidence of accelerated vascular aging in MASLD patients, particularly those with liver fibrosis.

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Editorial

To Silence or to Stabilize: That is the Question

João Bicho Augusto

Transthyretin amyloid cardiomyopathy (ATTR-CM) was previously considered an inescapable progressive disease leading to devastating outcomes. Clinicians often disregarded ATTR-CM, as the therapeutical arsenal available was very limited. Historically, treatments have offered mostly symptomatic relief without altering disease progression. Fortunately, the last decade brought us disease-modifying treatments with the potential to transform the course of ATTR-CM.

At a molecular level, ATTR-CM develops when transthyretin (TTR), usually a stable transport protein for thyroxine and vitamin A, dissociates from its tetrameric configuration into monomers and amyloid fibrils that accumulate in the myocardium. Two key drug classes have been studied for the treatment of ATTR-CM: stabilizers and silencers. Stabilizers, such as tafamidis and acoramidis, act by stabilizing the TTR tetramer configuration, thus preventing its breakdown and subsequent deposition of amyloid fibrils.^, In contrast, silencers, such as patisiran and vutrisiran, inhibit the hepatic production of TTR via RNA interference mechanisms, essentially reducing the source of the amyloid precursor.^, Historically, the ATTR-ACT study was the first Phase III trial to demonstrate that a drug for ATTR-CM, tafamidis, could reduce all-cause mortality, giving stabilizers a competitive edge. However, with newer drug classes, which option is the best for our patients?

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Editorial

Beyond Biological Factors: The Social Face of Cardiovascular Disease in Brazil

Lucas Borges Pereira et al. Maria Olívia Barboza Zanetti

Cardiovascular diseases (CVD), which include ischemic heart disease (IHD) and cerebrovascular diseases (CVD), represent the leading cause of death globally and in Brazil. Although significant advances have been made in prevention and treatment, CVD mortality still exhibits striking disparities, often correlated with socioeconomic and vulnerability indicators.^–

Historically, understanding CVD risk factors has focused on biological aspects. However, evidence points to the crucial role of Social Determinants of Health (SDH), which encompass social, economic, cultural, ethnic, educational, and environmental conditions, in formulating strategies for comprehensive health care.^–

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Original Article

Disease-Modifying Therapies for Transthyretin Amyloid Cardiomyopathy: A Systematic Review and Meta-Analysis

Ligia Carolina Facin et al. Igor Pacheco Fiuza Romeiro Kaushiki Sapahia Beatriz Austregésilo de Athayde de Hollanda Morais … Juliana Queiroz Vasconcelos Muniz Juliana Domenes Pereira Cintia Gomes Celina Borges Migliavaca André Zimerman Andreia Biolo

Abstract

Background:

Transthyretin (TTR) amyloid cardiomyopathy (ATTR-CM) is the most common form of restrictive cardiomyopathy. Emerging pharmacological therapies aim to alter the natural history of disease and delay its advancement. However, data directly comparing the efficacy of different drug classes versus placebo remain limited.

Objectives:

This systematic review assessed the efficacy of TTR stabilizers and silencers compared with placebo on all-cause mortality, hospitalizations, functional outcomes, and serum levels of the biomarker NT-proBNP in patients with ATTR-CM.

Methods:

A comprehensive search of PubMed, Embase, and Cochrane databases was conducted for randomized controlled trials (RCTs) published through April 2025. Eligible studies compared patisiran, tafamidis, inotersen, revusiran, acoramidis, or vutrisiran to placebo in patients with ATTR-CM. Analyses were stratified by drug class, and statistical significance was set at p<0.05.

Results:

Seven RCTs involving 2,526 participants were included; 42.5% received TTR stabilizers and 57.5% received TTR silencers. Compared with placebo, TTR stabilizers significantly reduced all-cause mortality (RR: 0.71; 95% CI 0.59-0.87; p=0.0006) and hospitalizations (RR: 0.81; 95% CI 0.73-0.89; p<0,0001). TTR silencers did not significantly reduce mortality (RR: 0.79; 95% CI 0.37-1.68; p=0.54) or hospitalizations (RR: 1.11; 95% CI 0.83-1.48; p=0.48). Both therapies were associated with improvements in 6-minute walk distance, quality of life, and reductions in serum NT-proBNP levels.

Conclusion:

TTR stabilizers significantly reduced all-cause mortality and hospitalizations in patients with ATTR-CM compared with placebo. These benefits were not observed with TTR silencers, potentially due to shorter follow-up durations in the studies evaluated. Both therapies improved functional status and serum levels of NT-proBNP.

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Editorial

Recent Advances in Oxidative Stress and Cardiovascular Diseases

Gabriela Brandão et al. Carolina R. Tonon Marina P. Okoshi

Cardiovascular diseases are the leading causes of morbidity and mortality worldwide. Oxidative stress plays an important role in the pathogenesis and progression of cardiovascular diseases such as atherosclerosis, myocardial ischemia, heart failure, and systemic and pulmonary arterial hypertension.^,

Oxidative stress is characterized by an imbalance between free radical production and antioxidant defenses. Free radicals are molecules with an unpaired electron, making them highly reactive and capable of causing cellular damage. The most common free radicals are reactive oxygen species (ROS) and reactive nitrogen species (RNS). ROS include superoxide, hydroxyl radical, and hydrogen peroxide, whereas RNS comprise nitric oxide, peroxynitrite, and nitrogen dioxide. Free radicals can be produced in various cellular compartments, such as the cytoplasm, cell membrane, endoplasmic reticulum, mitochondria, and peroxisomes, mainly resulting from enzymatic reactions.

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Editorial

The ELSA-BRASIL Study and Physical Activity in Protecting Against the Development of Type 2 Diabetes

Rodrigo Delevatti et al. Larissa dos Santos Leonel Leandro Franzoni

Type 2 diabetes mellitus (T2DM) is a highly prevalent disease, considered a major public health problem, which implies personal costs, as well as representing a significant financial burden on health services.^, In its preventive and therapeutic approach, the protective role of physical education has been established, but the optimization of its benefits, especially analyzing the relationship between characteristics inherent to the practice of physical activity and the development of DMT2, is still open.

In this scenario, the article “Dose-Response Association between Leisure-Time Physical Activity Intensity Trajectories and Diabetes among Men and Women in ELSA-Brasil” collaborates significantly, following a significant sample of individuals from different locations in Brazil, testing the association between different doses of leisure-time physical activity and pre-diabetes and T2DM in adults and older adults. The exposure is based on the different activity profiles, considered here as doses (the product of frequency, duration, and intensity), classified as low, moderate, and high, terms that refer to the intensity of the effort.

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Editorial

Inflammation and Contrast-Induced Nephropathy: The Emerging Role of the Glucose-to-Lymphocyte Ratio

Rafaela Andrade Penalva Freitas

The interplay between systemic inflammation, glucose metabolism, and cardiovascular outcomes has been extensively explored in the literature, with significant implications for clinical practice. The article titled “Association between Glucose/lymphocytes Ratio and ContrastInduced Acute Kidney Injury in Patients with Myocardial Infarction without Diabetes Mellitus” provides a valuable contribution by investigating the glucose-to-lymphocyte ratio (GLR) as an independent predictor of contrast-induced acute kidney injury (CI-AKI) in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). This editorial examines the study’s findings, contextualizes their significance, and discusses clinical implications and future research.

CI-AKI is a significant iatrogenic complication following procedures involving iodinated contrast media, with reported incidence rates ranging from 5% to 20% in STEMI populations. This condition is associated with worse outcomes, including higher mortality and progression to chronic kidney disease.^, Factors such as systemic inflammation and metabolic stress, often exacerbated in the context of acute myocardial infarction (AMI), play critical roles in the pathogenesis of CI-AKI.^, The study introduces the GLR as a composite biomarker that integrates information on glucose metabolism and inflammatory response, offering an innovative approach to risk stratification.

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Editorial

The REBECGA Registry: A Landmark in the Care of Pregnant Women with Heart Disease in Brazil

Imara Correia de Queiroz Barbosa et al. Gláucia Maria Moraes de Oliveira

Pregnancy is a major life event for almost every woman. It has been estimated that 1-4% of pregnant women have some form of congenital or acquired cardiac disease, the main non-obstetric cause of maternal mortality worldwide.^– Although many women with heart disease tolerate the hemodynamic changes of pregnancy, others may face significant immediate or late risks of pregnancy, including volume overload, arrhythmias, progressive cardiac dysfunction, and death.^,

There is a growing prevalence of heart disease during pregnancy, driven by two main factors: advances in the treatment of congenital heart disease (CHD), which have allowed more children to survive into adulthood and consider pregnancy, and the trend of delayed childbearing.^,, As maternal age increases, so does the prevalence of comorbidities such as hypertension, diabetes, and hypercholesterolemia, contributing to a higher incidence of acquired heart disease complicating pregnancy.^,

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Editorial

Applicability of Machine Learning Algorithms in the Diagnosis of Arrhythmias – How Long Until The Machine Starts Teaching Us?

Marcelo Martins Pinto Filho

The electrocardiogram (ECG), in clinical use since the early 1900s, remains a beloved tool for cardiologists, clinicians, and medical students. It is arguably the most important bedside instrument in cardiology, essential for managing arrhythmias and acute ischemic syndromes, as well as guiding electrophysiologic care. Still, advances in electrocardiography interpretation have been only modest in the last hundred years. Devices have become more portable, digital, and capable of longer recordings, but core interpretive principles remain rooted in early 20th-century methods. In recent years, this has been reshaped by the rise of computational technologies, especially artificial intelligence (AI). Tools such as deep neural networks (DNNs) and machine learning models (MLMs) are enabling a new era in ECG analysis, the AI-enhanced electrocardiography (AI-enhanced ECG).

In this issue of the ABC Cardiol, Guimarães do Nascimento et al. report on a systematic review of studies evaluating the applicability of AI-enhanced ECG in the diagnosis of cardiac arrhythmias. They included studies of different methodologies that addressed the role of AI-enhanced ECG in the detection of long-QT syndrome (LQTS) (one study), corrected QT interval (cQTi) (one study), and atrial fibrillation (AF) (eleven studies).

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Original Article

Chronic Treatment with Panax ginseng and Angelica keiskei Decreases Blood Pressure and Improves Endothelial Function in Ovariectomized Rats

Nayara Formenton da Silva et al. Luis Henrique Oliveira de Moraes Camila Pereira Sabadini Rita Cristina Cotta Alcântara … Patrícia Corrêa Dias Gerson Jhonatan Rodrigues

Abstract

Background

Menopause is a natural physiological process that can impact various systems and organs, often leading to increased blood pressure. The combination of Panax ginseng and Angelica keiskei (Pg + Ak) is a formulation known to improve vascular function.

Objective

This study aimed to evaluate the in vivo effects of these combined plants on cardiovascular parameters in female rats experiencing menopause induced by ovariectomy.

Methods

Twenty-four 70-day-old female Wistar rats were randomly assigned to three groups: sham-operated (Sham), ovariectomized (OVX), and ovariectomized with Pg + Ak treatment (OVX + Pg + Ak). The rats in the Pg + Ak treatment group received an intraperitoneal injection of 100 mg/kg/day for two weeks. Blood pressure was measured using tail plethysmography, and endothelial function was assessed through vascular reactivity tests.

Results

At the end of the treatment, mean blood pressure in the SH group was lower than in the control group (OVX), and the Pg + Ak treatment improved the endothelial dysfunction caused by ovariectomy. This was evident in the restored endothelium-dependent vasodilation in the aortic rings of the OVX rats treated with Pg + Ak compared to untreated OVX rats.

Conclusions

Our findings suggest that the Pg + Ak combination effectively reduces blood pressure and reverses endothelial dysfunction in ovariectomized rats.

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Original Article

Relationship between Liver Fibrosis Due to Metabolic Dysfunction-Associated Steatotic Liver Disease and Subclinical Atherosclerosis

Daniele Araujo de Azeredo Coutinho et al. Jenaine Rosa Godinho Raphael Carreiro Moura Rogério Martins Oliveira … Hevila Faria Passos Jordana de Paula Felipe Mendes Carlos Roberto Moraes de Andrade Junior Luis Guillermo Coca-Velarde Maria Auxiliadora Nogueira Saad Priscila Pollo Flores Debora Vieira Soares

Abstract

Background

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent liver disease worldwide. MASLD can progress to fibrosis and related complications, with cardiovascular disease being the leading cause of death in affected individuals. Carotid atherosclerosis markers can predict cardiovascular outcomes, underscoring the relevance of their association with liver fibrosis.

Objective

To evaluate the relationship between liver fibrosis in MASLD and subclinical atherosclerosis by assessing carotid intima-media thickness (cIMT), vascular age (VA), and the presence of atherosclerotic plaques.

Methods

This prospective study included participants at risk for MASLD. Liver steatosis and fibrosis were assessed via ultrasound and liver elastography using controlled attenuation parameter measurements. Carotid atherosclerosis was evaluated through carotid ultrasound, cIMT measurements, and VA. A significance level of 5% (p < 0.05) was adopted.

Results

A total of 114 participants were included, with a median age of 64 years (IQR: 55–68), and 96 (84%) were women. Steatosis was identified in 99 participants (86.8%) and fibrosis in 31 (27.2%). Atherosclerotic plaques were present in 33 participants (28.9%), with no significant difference in frequency between groups. However, the fibrosis group showed higher cIMT and elevated VA. In a subgroup analysis of 85 participants with type 2 diabetes mellitus (T2DM), 27 (31.8%) had fibrosis. These individuals had a higher cIMT (0.742 mm vs. 0.653 mm; p < 0.05), and VA exceeded chronological age by 9 years in the fibrosis group compared to those without fibrosis (p < 0.05).

Conclusion

This study demonstrates that individuals with MASLD and liver fibrosis exhibit greater vascular aging and increased cardiovascular risk, as reflected by elevated cIMT and VA.

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Original Article

Social Vulnerability Index and Mortality from Ischemic Heart Diseases and Cerebrovascular Diseases in Brazil from 2000 to 2021

José Lucas Bichara et al. Luiz Antônio Bastos Eric Delgado dos Santos Mafra Lino Paolo Blanco Villela Gláucia Maria Moraes de Oliveira

Abstract

Background:

Previous studies have observed a correlation between mortality rates from ischemic heart diseases (IHDs), cerebrovascular diseases (CBVDs), and the Social Vulnerability Index (SVI). However, doubts persist about the association between the overall SVI and its dimensions and mortality stratified by sex, ethnicity, and population clusters.

Objective:

To analyze the evolution of the overall SVI and its dimensions and correlate it with mortality rates due to IHD and CBVD in Brazil and its Federative Units (FUs) from 2000 to 2021.

Methods:

Ecological study of time series of standardized mortality rates (using the direct method with the Brazilian population in 2000) due to IHD and CBVD categorized by age, sex, and FUs between 2000 and 2021, correlated with the SVI and its dimensions. Data on the underlying causes of death were obtained from the Mortality Information System, while SVI data were sourced from the Social Vulnerability Atlas. Spearman correlation (considered significant if p<0.05) was employed to calculate each analyzed stratum.

Results:

The SVI and its Human Capital (SVI-HC) dimension and Income and Employment (SVI-IE) dimension in 2010 showed a strong correlation with variations in mortality rates due to CBVD and IHD (SVI x CBVD: Rho(p)=0.85; SVI x IHD: Rho(p)=0.75; SVI-HC x CBVD: Rho(p)=0.84; SVI-HC x IHD: Rho(p)=0.84; SVI-IE x CBVD: Rho(p)=0.81; SVI-IE x IHD: Rho(p)=0.71). The Urban Infrastructure dimension (SVI-UI) showed a weak correlation with CBVD and IHD, respectively (SVI-UI x CBVD: Rho(p)=0.33; SVI-UI x IHD: Rho(p)=0.25).

Conclusion:

Both SVI-HC and SVI-IE demonstrated strong correlations with variations in mortality rates from IHD and CBVD.

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Original Article

Clinical and Laboratory Predictors for the Development of Heart Valve Diseases in Chronic Kidney Disease: A Systematic Review

Hayala Machado Cavalcante Conceição et al. Ana Luísa Vaz Valois Erick Magalhães Silva Ramos Ana Marice Ladeia

Abstract

Background:

Chronic kidney disease (CKD) is associated with a higher prevalence of valvular diseases and increased mortality from cardiovascular causes. Factors that influence the genesis of cardiac valve calcification (CVC) in these patients are not well-defined.

Objective:

To determine the risk factors for valvular calcification in patients with CKD.

Methods:

Systematic review based on PRISMA, which included observational studies evaluating the association of clinical and laboratory data with CVC in patients with CKD, undergoing or not hemodialysis or peritoneal dialysis. Articles were retrieved from databases (MEDLINE; SCIELO; CENTRAL; EMBASE; LILACS/BVS) and selected blindly by two authors; discrepancies were resolved by a third author. Data collection and synthesis were carried out by the main author. The assessment of methodological quality and risk of bias was based on STROBE and Newcastle-Ottawa guidelines.

Results:

A total of 783 studies were identified, of which 20 were included, encompassing 13,314 patients from 10 countries. The factors most strongly associated with CVC were age >55 years, glomerular filtration rate <53 mL/min/1.73m², renal replacement therapy (RRT) >20 months, hypoalbuminemia, C-reactive protein (CRP), serum levels of IL-6, TNF-α, parathyroid hormone, hyperphosphatemia, hypercalcemia, Ca × P product, and FGF-23 resulting from secondary hyperparathyroidism. Both mitral and aortic valves were studied, and no differences were observed between hemodialysis and peritoneal dialysis.

Conclusion:

Age, RRT, chronic inflammation, and secondary hyperparathyroidism promote calcium and phosphate deposition in the valves, making CKD patients more susceptible to CVC) Monitoring these parameters provides opportunities for prevention and treatment.

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Review Article

Temperature Control after Cardiac Arrest: A Narrative Review from a Developing Country Perspective

Rafaela dos Santos Braga et al. Gisele Sampaio Silva Pedro Kurtz Sergio Timerman

Abstract

Targeted temperature management (TTM) is currently the only potentially neuroprotective intervention recommended for post-cardiac arrest care. However, there are concerns among the scientific community regarding conflicting evidence supporting this recommendation. Moreover, the bulk of trials included in systematic reviews that inform guidelines and recommendations have been conducted in developed countries, with case mix and patient characteristics that significantly differ from the reality of developing countries such as Brazil. Elevated body temperatures induce changes in the blood-brain barrier integrity and increase the brain’s demand for oxygen. They can cause imbalances in cerebral oxygen metabolism and blood flow, leading to inflammation and apoptosis. The primary aim of temperature control (TTM) is to control the secondary injury pathways by avoiding high temperatures. TTM, previously named therapeutic hypothermia, was first used to treat post-cardiac arrest brain injury in the 1950s. After that, we have been having relevant trials regarding TTM, with conflicting results as follows: TTM1, HACA study, TTM2, HYPERION study, and some meta-analyses kept the temperature management after a cardiac arrest in the discussion. In addition to individualizing the optimal target temperature for specific clinical scenarios and patient profiles, other aspects of high-quality TTM delivery are critical. The timing of target temperature achievement, duration of cooling, rewarming rates, and sedation practices have been evaluated in recent trials. In conclusion, it is crucial to determine the most effective TTM approach to achieve the best possible neurological outcomes while minimizing potential adverse effects.

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Editorial

Beyond Atherosclerosis: Mind the Valves in Chronic Kidney Disease

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality among patients with chronic kidney disease (CKD), far surpassing the risk of progression to end-stage renal disease, and accounting for approximately 40% to 50% of all deaths in the advanced stages.^– Growing attention has been directed toward the intersection of renal dysfunction and valvular heart disease (VHD), which plays a major role in the cardiovascular complications and adverse outcomes observed in this population.^, Valvular calcification, particularly affecting the aortic and mitral valves, is the hallmark manifestation of VHD in this setting, representing a highly prevalent, progressive, and prognostically significant process driven by disordered mineral metabolism, its crosstalk with persistent inflammation, and the toxic uremic milieu.^, Despite growing acknowledgment of its clinical impact, the biological underpinnings remain incompletely understood, even as emerging evidence begins to clarify the processes driving valvular calcification in CKD.

While several mechanistic pathways have been identified, robust clinical and laboratory markers that predict its development remain elusive. In this regard, the study by Conceição et al. offers valuable insight into the factors associated with valvular calcification, helping to address a relevant blind spot in current knowledge and underscoring the need for continued research into its clinical implications and underlying mechanisms in this high-risk population. Their systematic review was based on twenty observational studies involving 13,314 patients from varied geographic contexts, including individuals both on and off dialysis. Most were cross-sectional in design, with fewer cohort studies and a single case-control study, reflecting the predominantly descriptive and observational nature of the available evidence. The breadth of the population analyzed, combined with the methodological rigor adopted, offers a comprehensive overview of the existing body of evidence in this still underexplored domain. Among the thirty-eight risk factors identified, advanced age (tipically above 55 years),was the most consistently associated with valvular calcification, reported in half of the studies reviewed. These findings lend further support to the concept that ageing represents a major determinant in valvular degeneration in CKD, as it does in the broader context of age-related valve disease in the general population.

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Letter to the Editor

Analysis of Factors Affecting False Lumen Thrombosis in Type B Aortic Dissection

Beatriz Vitória Carvalho Lordêlo et al. Álvaro Eduardo Santos Oliveira Henri Jun Iti Okubo Luana Macedo da Silva Nascimento … Luiz Henrique Cardoso da Silva Pedro Pereira Tenório

Dear editor,

The study published by Tang et al., entitled “Factors Affecting False Lumen Thrombosis in Type B Aortic Dissection,” highlighted the influence of morphological aspects of type B aortic dissection (TBAD), according to the Stanford classification, on false lumen thrombosis prior to treatment with endovascular repair of the thoracic aorta. It has been shown that false lumen thrombosis occurs significantly less frequently in patients with TBAD and renal failure, when compared with those with TBAD and normal renal function.

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Original Article

Dose-Response Association between Leisure-Time Physical Activity Intensity Trajectories and Diabetes among Men and Women in ELSA-Brasil

André Luis Messias dos Santos Duque et al. Daniela Polessa Paula Danilo de Paula Santos Maria Del Carmen Bisi Molina … Luana Giatii Maria Inês Schmidt Maria de Jesus Mendes da Fonseca Rosane Harter Griep

Abstract

Background

Physical activity (PA) plays a fundamental role in the prevention of type 2 diabetes mellitus (DM-2). However, findings regarding the influence of PA intensity on DM-2 over time remain inconsistent.

Objective

To examine the dose-response association between leisure-time PA intensity trajectories and DM-2.

Methods

The study included data from the Longitudinal Study of Adult Health (ELSA-Brasil), at baseline (2008-2010) and from 11 years’ follow-up, of 5777 women and 4590 men, aged from 35 to 75 years. Leisure-time PA intensity trajectories were assessed by means of the International Physical Activity Questionnaire, while DM-2 was identified by self-reporting, use of medication or laboratory criteria. Ordinal logistical regression was used to estimate odds ratios (OR) and 95% confidence intervals (95%CIs).

Results

A lower proportion of participants with DM-2 (14.4% of men and 5% of women) and a higher proportion without diabetes (22.1% of men and 40.8% of women) were observed in those with a high-intensity trajectory. Compared to the moderate-intensity trajectory, high-intensity conferred protection against DM-2 (OR=0.63 [95% CI=0.40-0.98]) for men and women (OR=0.33 [95% CI=0.14-0.79]) and the low-intensity trajectory conferred a greater chance of pre-diabetes among men OR=1.36 [95% CI=1.09-1.69].

Conclusion

Higher-intensity PA over time was associated with a lower proportion of DM-2 cases among men and women. Thus, programs aimed at preventing and controlling DM-2 should emphasize the importance of maintaining high-intensity activities over time.

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Original Article

Applicability of Machine Learning Algorithms in Diagnosis of Atrial Fibrillation and LQTS by Electrocardiogram Interpretation: A Systematic Review

Paulo Cainan Guimarães do Nascimento et al. Matthews Silva Martins Alex Cleber Improta-Caria Roque Aras Junior

Abstract

Background

Machine Learning (ML) is a type of algorithm that autonomously learns to recognize complex patterns. In the diagnostic context of cardiac arrhythmias, these algorithms have shown significant advancements due to their ability to provide automated interpretation and pattern recognition in electrocardiograms (ECGs).

Objective

To analyze and identify the applicability, validity, and feasibility of ML algorithm models in the diagnostic process of cardiac arrhythmias through automated electrocardiogram interpretation.

Methods

This systematic literature review was reported according to the PRISMA guidelines. The searches were conducted in the Cochrane Library, EMBASE, LILACS, and PubMed between February 2022 and November 2022. The study period encompasses articles published between 2017 and 2022.

Results

The database search yielded 119 results, covering three subthemes: Long QT Syndrome (LQTS), corrected QT interval (QTc), and atrial fibrillation (AF). AF was the most prevalent theme. The sample sizes were quite variable. The outcomes were mostly satisfactory. In the diagnosis of LQTS using Artificial Intelligence (AI), the algorithm outperformed conventional methods in diagnostic distinction. In the evaluation of QTc, there was no difference between the AI-integrated ECG and the conventional ECG. In the diagnosis of AF, the algorithms, models, and devices demonstrated high sensitivity and specificity, along with greater accuracy.

Conclusion

ML models in the diagnostic process of cardiac arrhythmias are feasible and rapidly developing. They demonstrate accuracy values between 96.4% and 98.2%, sensitivity between 92.8% and 99.4%, and specificity between 95% and 98.1%, particularly in the diagnosis of atrial fibrillation.

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Viewpoint

Artificial Intelligence Assistance in the Peer Review Analysis of Medical Articles: Advantages, Disadvantages, and Ethical Considerations

André Zimerman et al. Andre d’Avila

AI talks about the role of AI as a reviewer of medical papers:

The peer review process is a cornerstone of scientific integrity, particularly in the field of medicine, where rigorous evaluation ensures that published research is credible, reproducible, and safe for clinical application. However, the growing volume of medical articles submitted for publication, coupled with the complexity of modern research, has strained the traditional peer review system.

The use of AI in the peer review of medical articles represents a transformative opportunity to address the mounting challenges of academic publishing in a field where accuracy, timeliness, and reliability are paramount. However, alongside its potential benefits, AI introduces significant drawbacks and notable challenges. This essay examines the benefits and shortcomings of AI in the peer review analysis of medical articles, as well as the ethical implications of its integration.

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Original Article

REBECGA: Brazilian Registry of Heart Disease and Pregnancy. Multicenter Epidemiological Study of Heart Diseases in Pregnancy: Retrospective Cohort

Walkiria Samuel Avila et al. Alexandre Jorge Gomes de Lucena Claudia Maria Vilas Freire Fabio Bruno da Silva … Ivan Romero Rivera Juliana Rodrigues Soares Oliveira Maria Alayde Mendonça Rivera Regina Coeli de Carvalho Vicente Avila Neto Flávio Tarasoutchi

Abstract

Background

Heart disease, which affects approximately 4% of pregnancies, is the leading non-obstetric cause of maternal death. It is estimated that 40% of these deaths could be prevented with a better understanding of pregnancy risks.

Objectives

To develop the Brazilian Registry of Heart Diseases in Pregnancy (REBECGA) to study the prevalence, complications, and maternal mortality associated with heart diseases during pregnancy and postpartum.

Methods

A multicenter retrospective study of pregnancy and postpartum follow up until 12 months after delivery in women with heart diseases, including analysis of predictive variables for maternal outcomes. A two-tailed significance level of 5% was adopted for statistical analysis.

Results

A total of 638 pregnant women were included, with the following diagnoses: valvular disease (37.8%), congenital heart diseases (35.7%), arrhythmias without structural heart damage (14.7%), cardiomyopathies (11.3%), and other heart diseases (6.4%). The main complications were heart failure (16.7%), arrhythmia (10.7%), and syncope (8.0%), with 18 maternal deaths (2.8%), 10 of which occurred during the postpartum period. Cesarean delivery was indicated in 62.9% of cases, with 25.7% preterm births and 3.2% fetal losses. Multivariate analysis identified WHO class IV risk classification (OR 3.51; 95% CI 1.75–7.04; p < 0.001); NYHA class III/IV (OR 2.27; 95% CI 1.12–4.60; p = 0.023), and pulmonary hypertension (OR 2.45; 95% CI 1.05–5.70; p = 0.037) as predictive variables for maternal complications and deaths.

Conclusions

REBECGA highlighted the prevalence of valvular disease, heart failure as the main complication, the postpartum period as a critical time for maternal deaths, and identified predictive risk variables for adverse pregnancy outcomes in women with heart disease.

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Original Article

Prognostic Value of Troponin to Lymphocyte Ratio in Patients with Immune Checkpoint Inhibitor-associated Myocarditis

Wanwen Chen et al. Wenhao Zhang Caiyin Luo Junying Cai … Xinqing Lin Chengzhi Zhou Yuwen He

Abstract

Background

Immune checkpoint inhibitor (ICI)-associated myocarditis is a rare but life-threatening immune-related adverse event (irAE). Cardiac troponin (cTn) and absolute lymphocyte count (ALC) have been reported to be associated with ICI-myocarditis.

Objective

We aimed to investigate the prognostic value of the combination of these two features (cTn/ALC ratio) in ICI-associated myocarditis.

Methods

Our center performed a retrospective analysis of 46 patients with ICI myocarditis (cases) and 46 patients without myocarditis after receiving ICI (controls). We obtained data on cardiac enzymes, routine blood parameters, and other clinical biomarkers. Statistical significance was defined as a two-sided α level of 0.05. The association between these covariates and the clinical outcomes of ICI-mediated myocarditis was also tested.

Results

Abnormally elevated cTn (p < 0.001), cTn/ALC ratio (p < 0.001), and decreased ALC (p < 0.001) were observed in patients who developed ICI-myocarditis. The cTn/ALC ratio was associated with the development of severe myocarditis (OR, 5.05; 95% CI, 1.22-20.84; p = 0.025). Survival analysis and Cox regression analysis indicated that a higher cTn/ALC ratio emerged as a significant independent predictor for major adverse cardiac events (MACE) [HR, 5.64; 95%CI, 1.43-22.34; p = 0.014].

Conclusions

An increase in the cTn/ALC ratio was associated with the severity of ICI-myocarditis and could be an effective predictor of poor prognosis in patients with ICI-associated myocarditis.

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Original Article

Association between Glucose/lymphocytes Ratio and Contrast-Induced Acute Kidney Injury in Patients with Myocardial Infarction without Diabetes Mellitus

Murat Gök et al. Alparslan Kurtul Orçun Demir Kenan Yalta

Abstract

Background

Glucose metabolism and systemic inflammation appears to be strongly related to many cardiovascular diseases. Glucose to lymphocyte ratio (GLR), a novel promising marker, has been recognized as a reliable predictor of prognosis in various cancers. However, there are still no studies on the association of cardiovascular disease with GLR.

Objectives

This analysis aimed to uncover the potential association between GLR and the risk for contrast-induced acute kidney injury (CI-AKI) after primary percutaneous coronary intervention (PPCI) in a ST-elevation acute myocardial infarction (STEMI) population.

Methods

Clinical data of 592 nondiabetic STEMI patients managed with PPCI from February 2021 to February 2023 were retrospectively analyzed. Patients with end-stage kidney disease, missing laboratory data, cancers, inflammatory/infectious diseases, or died during the procedure or within 24 hours after the procedure were excluded. The receiver operating characteristic curve was used to determine the optimal cutoff of GLR in CI-AKI. Based on the cutoff value, the study population was categorized into high-GLR (≥4.16) and low-GLR (<4.16) groups. The level of significance adopted in the statistical analysis was 5%.

Results

The overall CI-AKI incidence was 7.4%. The high-GLR group showed a higher CI-AKI incidence in comparison to the low-GLR group (30.9%vs1.3%, p<0.001). Following adjustment for potential confounders, high-GLR still served as an independent predictor for CI-AKI (odds ratio [OR] 45.100, 95% confidence interval [CI] 7.312-278.174, p<0.001), as well as creatinine at admission (OR:10.459, 95%CI 1.169-93.583, p=0.036).

Conclusions

In conclusion, a high GLR level served as an independent risk factor for CI-AKI evolution after PPCI in subjects with STEMI without diabetes mellitus.

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