2026;123(9)

Editorial

Beyond Ejection Fraction: Analysis of Cardiac Strain for Early Detection of Myocardial Dysfunction in Duchenne Muscular Dystrophy

Duchenne muscular dystrophy (DMD) is a progressive, degenerative, X-linked genetic neuromuscular disorder that affects motor, respiratory, and cardiac function.^, DMD is the most severe presentation of neuromuscular diseases related to dystrophin mutations.^, Clinically, it manifests as progressive impairment of motor function in boys, with wheelchair dependence before the age of 12.

Advances in multidisciplinary care and ventilatory management have improved survival, making cardiac complications a leading cause of mortality in patients with Duchenne muscular dystrophy (DMD).^– However, to date, no temporal correlation has been established between cardiac and skeletal muscle impairment, making the screening for cardiac dysfunction challenging, since the classic symptoms of heart failure are masked by progressive motor limitation.

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Original Article

Association of Germanic Cultural Preservation with Cardiovascular Risk and Subclinical Atherosclerosis in Adults from Southern Brazil

Ribanna Aparecida Marques Braga et al. Marcello Ricardo Paulista Markus Marcus Dörr Henry Völzke … Martin Bahls Siegmar Starke Sergio Luiz Zimmermann Ernani Tiaraju de Santa Helena Raul D. Santos Luiz Aparecido Bortolotto Joany Coronado Nagila Raquel Teixeira Damasceno

Abstract

Background

Migration involves cultural and lifestyle transitions that may influence cardiovascular disease (CVD) risk. Cultural preservation and adaptation may affect cardiovascular health through behavioral and social mechanisms.

Objective

To assess the association of Germanic cultural preservation with CVD risk and subclinical atherosclerosis among residents of Pomerode, southern Brazil, stratified by age group and sex.

Methods

This cross-sectional study used baseline data collected from 2014 to 2018 from the Study of Health in Pomerode cohort and included 727 individuals aged 20-79 years with complete data. Germanic cultural preservation was defined as regularly speaking German at home and participating in German cultural associations. Subclinical atherosclerosis was defined as the presence of three or more carotid plaques. 10-year atherosclerotic CVD risk was estimated using the American College of Cardiology/American Heart Association Pooled Cohort Equations. Statistical significance was set at p < 0.05.

Results

Mean age was 43.7 years, and 51.9% of participants were women. Germanic cultural preservation was reported by 65.61% of participants and was more common among older adults, White individuals, Protestants, and individuals of middle socioeconomic status (p < 0.05). Participants reporting Germanic cultural preservation also had less sedentary behavior, greater use of antihypertensive medications, and a less favorable cardiometabolic profile. In adjusted age-stratified models, Germanic cultural preservation was associated with hypertension (odds ratio [OR]: 2.79; 95% CI: 1.49-5.22) and subclinical atherosclerosis (OR: 3.01; 95% CI: 1.07-8.40) among individuals aged 50 years or older. After adjustment for hypertension, the association with subclinical atherosclerosis was attenuated and was no longer statistically significant.

Conclusions

Germanic cultural preservation was associated with hypertension and subclinical atherosclerosis among adults aged 50 years or older, highlighting the importance of considering cultural context when characterizing cardiovascular risk in aging populations.

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Original Article

Real-World 2-Year Outcomes of the Inspiron™ Biodegradable Polymer Sirolimus-Eluting Stent

Ricardo Czarnobai Soccol et al. Henrique Barbosa Ribeiro Ricardo Lasevitch Denise Pellegrini … Expedito Eustáquio Ribeiro da Silva Carlos Alberto Santos de Mattos Augusto Lima Filho Noriaki Takeshita Sílvio Sérgio Pontes Câmara José de Ribamar Costa Junior Leandro Zacarias Figueiredo de Freitas Marcelo Sabedotti Pablo Tomé Teixeirense Márcio Augusto Meirelles Truffa Ricardo de Gasperi Ewerton de Souza Abreu Ismael Arcari Bassani José Armando Mangione Maurício Cavalieri Gustavo Martins Pereira Alves Pedro Beraldo de Andrade Rafael Maestri Rafael Rebêlo César Cavalcanti Maria Sanali Paiva Marcelo de Oliveira Hirga José Airton de Arruda Flávio Correa Pivatelli Julia Gonçalves Zandomenico Paulo R. A. Caramori

Abstract

Background

The Inspiron™ sirolimus-eluting stent (SES) is a third-generation coronary stent featuring thin struts and an abluminal biodegradable polymer coating. Although it is widely used in Brazil, long-term real-world evidence remains limited.

Objectives

To evaluate the safety and effectiveness of the Inspiron™ SES over 24 months in an unselected population undergoing percutaneous coronary intervention (PCI).

Methods

This pooled analysis included 2,803 consecutive patients who underwent Inspiron™ SES implantation between June 2017 and January 2022 at 25 Brazilian centers. The primary endpoint was major adverse cardiovascular events (MACE), defined as the composite of cardiovascular death, MI, and target lesion revascularization (TLR) at 24 months. Kaplan-Meier survival analysis, Cox proportional hazards regression, and restricted cubic spline models were used. A two-sided p-value < 0.05 was considered statistically significant.

Results

At 24 months, the cumulative incidence of MACE was 6.7%, with rates of 5.4% for all-cause mortality, 2.3% for cardiovascular mortality, 1.2% for MI, 0.9% for TLR, and 0.6% for definite or probable stent thrombosis (ST). Patients with a vessel diameter < 2.5 mm had significantly higher rates of MACE, cardiovascular death, repeat revascularization, and ST (p = 0.022). Independent predictors of MACE included older age (p = 0.034), left main or three-vessel coronary artery disease (p = 0.024), and acute coronary syndrome as the indication for PCI (p < 0.001).

Conclusions

In this large real-world registry, the Inspiron™ SES demonstrated favorable safety and effectiveness through 24 months, with low rates of ST and repeat revascularization despite the inclusion of complex coronary lesions.

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Editorial

Coronary Computed Tomography Angiography: A New Paradigm for the Assessment of Coronary Artery Disease in the Brazilian Public Health System?

Henrique Turin Moreira et al. Gustavo Jardim Volpe

For decades, Cardiology sought noninvasive methods capable of identifying patients with significant coronary stenoses. From exercise testing to stress cardiovascular imaging, the paradigm of myocardial ischemia became established as the central element for prognostic stratification and decision-making in coronary artery disease (CAD). In recent years, however, technological advances in computed tomography have made it possible to noninvasively visualize coronary anatomy with a level of image quality previously achievable only with invasive coronary angiography. For many, however, this new method seemed difficult to reconcile with the prevailing paradigm, compounded by concerns that the anatomical identification of stenoses might trigger an oculostenotic reflex and a consequent increase in coronary interventions.

The evidence, however, followed a very different course. In patients without known CAD, large trials demonstrated that coronary computed tomography angiography (CCTA), when used as an initial diagnostic strategy, performed at least as well as functional testing and, in some studies, was associated with a reduction in cardiovascular events.^, The feared sustained increase in invasive coronary angiography and revascularization likewise failed to materialize. Subsequent analyses showed that a substantial proportion of the benefit resulted from changes in clinical management, particularly the greater use of preventive therapies after the identification of coronary atherosclerosis. In another clinical setting, among patients already referred for invasive angiography, additional assessment with CCTA was also shown to reduce invasive procedures and their complications.

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Editorial

Stress Echocardiographic Dyssinchrony, Ventricular Myocardial Longitudinal Strain in Chagas Cardiomyopathy Patients: Prognostic Phenotypes Beyond Ejection Fraction

Marcelo Luiz Campos Vieira et al. Bruno Pereira Valdigem Edgar Daminello

Left ventricular (LV) myocardial deformation (Strain) study is an echocardiographic modality capable of identifying systolic dysfunction even before the drop in ejection fraction (EF).^– Strain can be performed in the longitudinal, radial, and circumferential planes, as well as in their combination, bringing new physiological cardiac parameters such as twist, torsion, and area strain. LV longitudinal axis strain is the cardiac deformation parameter with the most robust scientific evidence and the most relevant use in clinical practice.^– Cardiac resynchronization therapy (CRT) is a therapeutic option already consolidated in international guidelines and promotes a significant reduction in morbidity and mortality, as demonstrated by landmark studies such as MADIT-CRT and CARE-HF.^,, It is recommended as a class I treatment for patients with dilated cardiomyopathy, symptomatic, under optimized clinical treatment, electrocardiogram with left bundle branch block (LBBB) pattern, QRS duration ≥ 150 ms, and LV ejection fraction below 35%.

The analysis of cardiac dyssynchrony can be performed using multiple echocardiographic techniques, including M-mode, conventional Doppler, tissue Doppler, three-dimensional echocardiography, and even ventricular strain analysis.^-,,- The observation of specific patterns of cardiac motion and mechanics, such as apical rocking and septal flash, has been described as important parameters for determining a positive response to CRT in patients with advanced heart failure.^,

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Editorial

Bioresorbable Polymer Drug-Eluting Stents: A Solid Presence in Cath-Labs, but Enough?

Monica Verdoia et al. Maria Antonieta Albanez Andrea Rognoni

Several generations of drug-eluting stents (DES) have followed, trying to reduce the invasiveness of metal struts and device-related complications. Yet, despite the achievement of very low rates of stent thrombosis (<1%) and restenosis (<5%), these events still impact the outcomes of patients with coronary artery disease, especially in more complex anatomical or clinical subsets.^,

The progressive reduction of metal strut thickness, with the development of new materials and stent design, has allowed to improve trackability and prevented the excessive caging of the vessel, being more respectful of vasomotion and side branches. In addition, diminishing the traumatic and inflammatory stimulus with thinner struts could account for fewer restenotic events.

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Original Article

Association between the Inflammatory Atherosclerosis Index and Non-Alcoholic Fatty Liver Disease: NHANES 2017–2020

Yun Jiang et al. Jingying Xie Ying Dong

Abstract

Background

The Non-alcoholic fatty liver disease (NAFLD) prevalence is increasing globally and is closely associated with dysregulated lipid metabolism and inflammation. However, the relationship between NAFLD and the inflammatory atherosclerosis index (IAI), which reflects these processes, is unclear.

Objectives

To investigate the association between IAI and NAFLD in a representative sample of U.S. adults.

Methods

This cross-sectional study included 5,309 adults from the U.S. NHANES database. Multivariate weighted logistic regression was used to assess the association between IAI and NAFLD. Restricted cubic splines explored nonlinear relationships, and ROC analysis evaluated diagnostic performance.

Results

A total of 5,309 participants were included, of whom 37.6% had NAFLD. Obesity and metabolic abnormalities were more pronounced in the NAFLD group, and IAI levels were significantly higher (P < 0.001). Multivariate analysis demonstrated that IAI was independently and positively associated with NAFLD (OR = 1.538, 95% CI: 1.421–1.665). RCS analysis indicated a nonlinear relationship (P for nonlinearity = 0.0473), with an inflection point at IAI = 0.145. When IAI < 0.145, the risk increased steeply (OR = 2.341, 95% CI: 2.037–2.690), whereas when IAI ≥ 0.145, the increase was attenuated (OR = 1.399, 95% CI: 1.263–1.548). Subgroup analyses showed consistent results, with no significant interactions across subgroups. ROC analysis showed that IAI exhibited the best diagnostic performance (AUC = 0.722), significantly outperforming other indicators (all P < 0.001).

Conclusions

Among U.S. adults, IAI demonstrates a strong, positive, and nonlinear association with NAFLD. These findings suggest IAI is a promising population-level marker for NAFLD, though prospective studies are required for validation.

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Original Article

Individual Effects of Angiotensin II Receptor Blockers on Major Adverse Cardiovascular Events: A Systematic Review and Network Meta-Analysis

Eurico Joaquim Lutucuta Ernesto et al. Ana Claudia Cavalcante Nogueira Luis Gustavo Sedenho-Prado Louise Buonalumi Tácito Yugar … Marília Paiva Martins Daniel Campos Jesus Jairo Lins Borges Wilson Nadruz Luiz Sérgio F Carvalho Andrei C. Sposito

Abstract

Background

Angiotensin II receptor blockers (ARBs) antagonize the AT1 receptor and are effective antihypertensives. Modest differences in blood pressure-lowering efficacy have been reported, reflecting variations in pharmacokinetics, receptor binding, duration of action, and potential pleiotropic effects. However, data on their comparative effects on cardiovascular outcomes in patients are scarce.

Objective

To assess the effects of ARBs on MACE, hospitalization for heart failure (HHF), and all-cause mortality in randomized trials not primarily designed to evaluate heart failure (HF).

Methods

MEDLINE/PubMed, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched until May 2025. Published RCTs reporting major adverse cardiovascular events (MACE), HHF or all-cause death, involving ARBs, with at least 100 individuals per arm and ≥12 months of follow-up, were included. Studies focusing primarily on patients with existing HF were excluded. Incidence rates of HHF, MACE, and all-cause death. A random-effects network meta-analysis including 27 RCTs and 702,584 patient-years was performed.

Results

Candesartan reduced MACE versus placebo (OR 0.79; 95% CI, 0.63–0.97; SUCRA=0.85), ranking highest among ARBs, while telmisartan showed a smaller but significant reduction (OR 0.90; 95% CI, 0.80–0.99; SUCRA=0.61). The analysis relied on study-level data; included moderately sparse treatment networks with predominantly indirect comparisons between ARBs.

Conclusion

This network meta-analysis in patients without baseline HF indicates that candesartan and telmisartan reduce MACE, suggesting clinically meaningful differences among ARBs. Given the predominantly indirect nature of several comparisons, these findings should be interpreted cautiously.

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Original Article

Cost-effectiveness and Budget Impact Analysis of Coronary CT Angiography in the Brazilian Unified Health System

Isabela Bispo Santos da Silva Costa et al. Jorge A. Torreão Afonso Shiozaki Henrique Simão Trad … Luana Emanuelly Sinhori Lopes Marcio S. Bittencourt Miguel Antônio Moretti Silvio Henrique Barberato Carlos E. Rochitte

Abstract

Background

Coronary artery disease (CAD) represents a major clinical and economic burden for the Brazilian Unified Health System (SUS). Although coronary computed tomography angiography (CCTA) has excellent diagnostic accuracy, cost-effectiveness analyses (CEA) based on national data are lacking.

Objective

To evaluate the cost-effectiveness and budget impact of incorporating CCTA as the initial diagnostic strategy for patients with suspected stable CAD from the SUS perspective.

Methods

A cost-effectiveness analysis (CEA) and a budget impact analysis (BIA) were conducted, comparing CCTA with invasive coronary angiography (ICA) and with a panel of functional tests in patients with suspected stable CAD. A one-year time horizon was adopted for the CEA and five years for the BIA. Effectiveness outcomes included the incidence of acute myocardial infarction (AMI), revascularization rates, and hospitalizations. Deterministic and probabilistic sensitivity analyses were performed.

Results

CCTA proved to be cost-effective, reducing costs related to AMI (R$610.18 vs. R$867.80), revascularization (R$1,378.14 vs. R$1,833.84), and hospitalization (R$602.86 vs. R$932.79), resulting in savings of R$329.93 per patient. Compared with functional tests, CCTA also reduced costs associated with AMI (R$610.18 vs. R$658.36), revascularization (R$1,378.14 vs. R$1,659.18), and hospitalization (R$602.86 vs. R$628.16). The BIA projected cumulative savings for SUS ranging from R$34.1 million to R$73 million over five years, depending on the comparator and diffusion scenario.

Conclusions

The results suggest that using CCTA as the initial diagnostic test for patients with low-to-moderate risk of CAD in SUS may represent an economically favorable strategy, with potential to generate substantial cost savings compared with the evaluated alternatives.

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Original Article

Regional Left Ventricular Myocardial Strain Alterations in Patients with Duchenne Muscular Dystrophy and Correlation with Electrocardiographic and Motor Function Alterations

Fernanda Aparecida Costa et al. André Timóteo Sapalo Pedro Oliveira Neto Ana Claudia Mattielo-Sverzut … Claudia Ferreira da Rosa Sobreira André Schmidt Minna Moreira Dias Romano

Abstract

Background

: Duchenne Muscular Dystrophy (DMD) is characterized by progressive degradation of muscle function. Myocardial dysfunction is a major cause of mortality; however, its correlation with skeletal motor function remains unclear.

Objective

To assess myocardial function and to correlate it with motor function in patients with DMD.

Methods

This was a cross-sectional observational study of patients with DMD. Evaluations included the Motor Function Measurement (MFM) scale, electrocardiogram (ECG), and echocardiography (Echo) with speckle-tracking (STE) imaging of the left ventricle (LV). The level of significance adopted in the statistical analysis was 5%.

Results

Thirty-three patients with a mean age of 14.30 ± 4.09 years. The average MFM score was 52.30 ± 16.32%. Electrocardiographic abnormalities were observed in 75% of patients. Left ventricular ejection fraction (LVEF) was preserved (57.80 ± 9.62%). Global longitudinal strain (GLS) was reduced in 70% of the patients (-15.06 ± 2.46%; normal ≤ -18%), global circumferential strain (GCS) was decreased in 76% (-12.99 ± 2.89; normal ≤ -18%), and global radial strain (GRS) was reduced in 80% (20.52 ± 15.72; normal ≥ 40%). Hypokinesia and a significant reduction in regional myocardial strain (REGLSi) were also observed in the inferior and inferolateral segments of the LV. No significant correlation was found between MFM and ECHO variables.

Conclusion

: Patients with DMD exhibit early compromise in STE parameters (GLS, GRS and GCS) and in REGLSi, particularly in the inferior and inferolateral LV regions, even with preserved LVEF (Central Figure). No significant correlation was observed between motor and cardiac function parameters.

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Original Article

Stress Echocardiographic Strain–Dyssynchrony Interactions Identify Prognostic Phenotypes in Chagas Cardiomyopathy: A Pilot Study

Guilherme Augusto Teodoro Athayde et al. Bruno Campanha Carter Borges Andreia Oliveira Pinheiro Aline L. Souza … Camila Parente Oliveira Sérgio Augusto Mezzalira Martins Ricardo Alkmim Teixeira Sérgio F. Siqueira Wilson Mathias Martino Martinelli Filho

Abstract

Background

Mechanical heterogeneity is a hallmark of advanced cardiomyopathy, although stress echocardiography traditionally focuses on ischemia or global systolic reserve. Exercise stress echocardiography may identify distinct mechanical phenotypes in chronic Chagas cardiomyopathy (CCC) through integrated assessment of strain and dyssynchrony behavior.

Objective

To investigate the interaction between contractile reserve and intraventricular dyssynchrony (IVD) during exercise stress echocardiography and its association with clinical outcomes in patients with CCC.

Methods

Forty patients with severe CCC (left ventricular ejection fraction ≤ 35%, non-LBBB QRS morphology) underwent symptom-limited treadmill stress echocardiography. Global longitudinal strain (GLS), IVD, and conventional echocardiographic parameters were assessed at rest and immediately after peak exercise. Patients were stratified into four groups according to GLS and IVD variation. The primary endpoint was a composite of death, heart transplantation, or hospitalization for heart failure over a 2-year follow-up. Statistical significance was defined as p < 0.05.

Results

After a median follow-up of 729 days, 20 patients (50%) reached the primary endpoint. Patients without contractile reserve and without dyssynchrony improvement during exercise had significantly lower event-free survival compared with the remaining groups (p < 0.01). When analyzed separately, both absence of contractile reserve and unfavorable dyssynchrony response were associated with adverse outcomes. In multivariable analysis, only right ventricular function remained independently associated with the primary outcome (hazard ratio 0.83, 95% confidence interval 0.71–0.96; p = 0.014).

Conclusions

Integration of strain-derived contractile reserve and IVD during physiologic stress may help identify prognostic phenotypes beyond ejection fraction in CCC and supports the concept of dynamic mechanical phenotyping in advanced cardiomyopathy.

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Original Article

Development and External Validation of the SCORE2 Models in Latin America and the Caribbean (SCORE2-LAC) to Estimate 10-Year Cardiovascular Disease Risk

Stella Bijkerk et al. Carlos I. Ponte-Negretti Ko Ko Maung Louisa Gnatiuc Friedrichs … Jesús Alegre-Díaz Simon G. Anderson Claudia Bambs Mauricio L. Barreto Antonio Bernabe-Ortiz Stefan Blankenberg Alfredo Cabrera-Villamizar Rodrigo M. Carrillo-Larco Luis F.S. Castro-de-Araujo William Checkley Sandra Cortés Jannick A.N. Dorresteijn Walter G. Espeche Catterina Ferreccio Patrícia Fortes C. de Macêdo Oscar H Franco Sergio Gimenez Gonzalo C. Grazioli Christina Howitt Vilma E. Irazola Stephen Kaptoge Pablo Kuri-Morales Fernando Lanas Bernardo Layerle José P. Lopez-Lopez Thiess Lorenz Paulo A. Lotufo Claudia Marco J. Jaime Miranda Carolina Nazzal José Ortellado Julia M. Pescarini Franco Peverelli Alejandro Pomi Luiz E. Ritt Carlos Daniel Rodríguez-Ariza Martín Salazar Carlos A. Sánchez-Vallejo Pamela Seron Itamar de Souza Santos Roberto Tapia-Conyer Pedro Zitko Emanuele Di Angelantonio Pedro M. Marques-Vidal Ana M. Abreu Frank L.J. Visseren Steven H.J. Hageman em nome da Cardiovascular Risk Collaboration da European Society of Cardiology e da European Association of Preventive Cardiology (ESC CRC) Interamerican Society of Cardiology (SIAC)

Abstract

Background and Aims

Despite the high burden of cardiovascular disease (CVD) in Latin America and the Caribbean (LAC), risk prediction models adapted for use in LAC populations remain limited. The aim of this study was to recalibrate the Systematic COronary Risk Evaluation 2 (SCORE2) risk models for estimating 10-year CVD risk in individuals without prior CVD or diabetes mellitus in LAC, resulting in the SCORE2 Latin America and the Caribbean (SCORE2-LAC) models.

Methods

Sex-specific, competing risk-adjusted SCORE2 models were recalibrated to contemporary CVD incidence across four risk regions, defined by country-level age- and sex-standardized CVD mortality rates, using region-specific risk factor distributions. Cardiovascular disease incidence was estimated from CVD mortality data and ratios of the total first-to-fatal CVD events, derived from 40 237 152 individuals (1 261 329 CVD events). External validation included 132 512 individuals without prior CVD or diabetes from 11 cohorts across seven countries (3938 CVD events). Discrimination was assessed using Harrell’s C-index.

Results

In the external validation datasets, the pooled C-index of SCORE2-LAC was .740 [95% confidence interval (CI) .716–.763], with cohort-specific C-indices ranging from .674 (95% CI .588–.761) to .789 (95% CI .747–.831). Estimated CVD risk varied several-fold across the four LAC risk regions. For a 50-year-old non-smoker with a systolic blood pressure of 140 mmHg, total cholesterol of 213 mg/dL (5.5 mmol/L), and HDL cholesterol of 50 mg/dL (1.3 mmol/L), the predicted risk ranged from 3% in low-risk countries to 10% in very-high-risk countries for women, and from 4% to 10% for men.

Conclusions

The SCORE2-LAC models provide region-specific contemporary estimates of 10-year CVD risk in apparently healthy individuals, enabling identification of individuals at high CVD risk across LAC. Structured Graphical Abstract.

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