Death – ABC CARDIOL

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Original Article

Comparison of Coronary Computed Tomography Angiography and Invasive Coronary Angiography in Nonobstructive Coronary Artery Disease: The Brazilian Coronary ARtery Disease (BARD) Study

Protásio Lemos Da Luz et al. Desiderio Favarato Alexandre A. Abizaid Luiz Antonio Machado César … Carlos Vicente Serrano Antônio Carlos Palandri Chagas Carlos E. Rochitte Marco A. Gutierrez

Abstract

Background

The prognosis of nonobstructive coronary artery disease (CAD) is not well established. Comparative data between coronary computed tomography angiography (CCTA) and invasive coronary angiography (ICA) are limited.

Objectives

To compare CCTA- and ICA-derived information in nonobstructive CAD regarding detection and clinical outcomes.

Methods

We followed 4,004 adult patients who underwent either ICA (n = 2,355) or CCTA (n = 1,649) for a median of 9 years. The primary endpoint was a composite of all-cause mortality, acute coronary syndrome/acute myocardial infarction, and stroke. Propensity score matching was performed to compare outcomes between groups. The significance level was set at 5%.

Results

The overall event rate was 6.9%. ICA was associated with worse outcomes than CCTA (hazard ratio [HR] 0.54; 95% CI 0.42-0.68; p < 0.001). Patients with nonobstructive CAD had worse outcomes than those without CAD (HR 1.73; 95% CI 1.32-2.27; p < 0.001). Normal coronary findings on CCTA were associated with better outcomes than normal findings on ICA (HR 0.39; 95% CI 0.24-0.62; p < 0.001). Event rates increased proportionally with plaque burden. In 1,187 matched pairs, CCTA was associated with improved survival (HR 0.57; 95% CI 0.42-0.78; p < 0.001).

Conclusion

CCTA more closely reflects clinical outcomes than ICA. Nonobstructive CAD carries a substantial risk regardless of imaging modality.

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Original Article

A New Risk Score Based on Machine Learning in Patients with Acute Heart Failure: The ML-HF score

Matheus Bissa Duarte Ferreira et al. Jorge Tadashi Daikubara Neto Gustavo S. Pereira da Cunha Rafael Moretti … Jessica Tamires Reichert Lucas Müller Prado Raphael Henrique Déa Cirino Sidney C Smith Jr Fábio Papa Taniguchi Andrei C. Sposito Odilson M. Silvestre Wilson Nadruz Miguel Morita Fernandes-Silva

Abstract

Background

Conventional prognostic assessment scores often fall short in performance to predict mortality in patients with acute heart failure (AHF).

Objective

To develop and validate a machine learning-based prognostic score to predict in-hospital death in patients with AHF and compare its performance with the main traditional scores.

Methods

Patients admitted for AHF in Brazilian hospitals from the “Best Practices in Cardiology Program” from 2016 – 2022 were included. Clinical data, laboratory results, and the World Health Organization Quality of Life (WHOQOL-Bref) at hospital admission were collected. The outcome was in-hospital death. The model was trained using 70% of admissions (training set) and validated with the remaining 30% (test set). The ML-HF score area under the ROC curve (AUC) was compared with the AUC of the traditional scores Acute Decompensated Heart Failure National Registry (ADHERE) and Get With the Guidelines–Heart Failure (GWTG-HF). The level of significance was p<0.05.

Results

One thousand and one hundred fifty-seven patients hospitalized for AHF were included. The five most important variables of the ML-HF score were: Physical Health Domain Quality (WHOQOL-BREF), serum sodium, serum urea, serum creatinine, and systolic blood pressure at hospital admission. In the test set, the ML-HF score showed an adequate model calibration (Hosmer-Lemeshow test p value=0.056) and discrimination (AUC=0.722 [CI95%, 0.661-0.783]), which was superior to GWTG-HF (AUC=0.616 [CI95%, 0.529-0.702; p=0.014]) and the ADHERE (AUC=0.601 [CI95%, 0.511-0.691; p=0.006]) scores.

Conclusion

We developed and validated a score using machine learning to predict in-hospital death in patients with AHF, which outperformed the traditional scores.

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Letter to the Editor

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

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

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

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

[…]

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Letter to the Editor

Mechanical Valve Implants: What Are Their Long-Term Effects?

Eldys Myler Santos Marinho et al. Júlio Martinez Martinez Santos Bruno da Silva Brito Achilles de Souza Andrade Johnnatas Mikael Lopes

Surgical procedures for replacing body structures through prostheses are perhaps the medical interventions that require great expertise and continuous monitoring, prolonging the lives and health of countless people. This was a theme of the research entitled “ Clinical Features and Survival Analysis of Patients after Mechanical Heart Valve Replacement, with an Emphasis on Prosthetic Valve Thrombosis ” by Tagliari et al. published in volume 119, number 5 of this journal.

Among the various contributions the study brings us, some findings need further clarification so mechanical valve implant interventions can be useful clinically and in public health.

[…]

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Case Report

Subacute Myocarditis with Malignant Progression in a Young Patient: Contribution of Cardiac Magnetic Resonance

Roberto Ramos Barbosa et al. Guilherme Rodrigues Moreira Gabriella Martins Curcio Osmar Araujo Calil … Renato Giestas Serpa Luiz Fernando Machado Barbosa

Introduction

Myocarditis can have a varied clinical presentation ranging from chest pain and mild dyspnea to cardiogenic shock and sudden death. It is defined as myocardial inflammation with myocyte necrosis or degeneration without ischemia and may result from infectious and non-infectious causes, with viral myocarditis being the most prevalent etiology. Myocarditis most commonly affects young male adults, being detected in up to 12% of patients aged under 40 years who had sudden death. Its diagnosis is fundamentally based on clinical suspicion due to recent viral infection associated with a current myocardial lesion, the absence of previous heart disease, and heart failure (HF) of no other apparent cause. Cardiac magnetic resonance (CMR) imaging findings can currently help confirm the diagnosis.

The low availability of endomyocardial biopsy, the gold standard diagnostic method, brings major challenges to the management of myocarditis. On the other hand, the increased use of CMR provides important diagnostic and prognostic data. This report describes the clinical issues and CMR contribution in a case of myocarditis in a young patient.

[…]

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Original Article

In- and Out-of-Hospital Deaths by Acute Myocardial Infarction in Brazilian State Capitals

Sterffeson Lamare Lucena de Abreu et al. Joana D’Arc Matos França de Abreu Maria dos Remédios Freitas Carvalho Branco Alcione Miranda dos Santos

Abstract

Background:

Acute myocardial infarction (AMI) is the main cause of death in Brazil and the world. Approximately half of these deaths occur outside the hospital.

Objectives:

To analyze the distribution, temporal evolution, and sociodemographic characteristics (SDC) of in- and out-of-hospital deaths by AMI in Brazilian state capitals and their relationship with municipal development indicators (MDI).

Methods:

This is an ecological study of the number of deaths due to AMI reported annually by the 27 Brazilian state capitals from 2007 to 2016; these were divided into 2 groups: in-hospital (H) and out-of-hospital (OH). We evaluated the temporal evolution of mortality rates in each group and differences in SDC. Negative binomial regression models were used to compare the temporal evolution of the number of deaths in each group with the following variables: residing in the South/Southeast regions (S/SE), municipal human development index (MHDI), Gini coefficient, and expected years of schooling (EYS). We considered p-values<0.05 as statisticallysignificant.

Results:

The OH mortality rate increased with time for all state capitals. All studied SDC were different between groups (p<0.001). In the OH group, most deaths were of men and patients aged 80 years or older and not married. S/SE increased the incidence of OH deaths (incidence rate ratio [IRR]=2.84; 95% confidence interval [CI]=1.67–4.85), while higher EYS reduced it (IRR=0.86; 95% CI=0.77–0.97). In the H group, higher MHDI reduced the incidence of deaths (IRR=0.44; 95% CI=0.33–0.58), while higher EYS increased it (IRR=1.09; 95% CI=1.03–1.15).

Conclusions:

In- and out-of-hospital deaths due to AMI in Brazilian state capitals were influenced by MDI, presented sociodemographic differences and a progressive increase in out-of-hospital occurrences.

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Artigo Original

Ventricular repolarization in diabetic patients: characterization and clinical implications

David Clemente et al. Telmo Pereira Susana Ribeiro

BACKGROUND: Diabetes mellitus is a chronic and very common condition, and there has been lately a considerable increase in its prevalence and incidence. Diabetic patients have increased cardiovascular mortality, in which malignant ventricular arrhythmias seem to be implicated. OBJECTIVE: To study the effects of diabetes on ventricular repolarization parameters responsible for an increased susceptibility to malignant ventricular arrhythmias and/or sudden death. METHODS: We selected a group of 110 diabetic patients and a group of 110 controls with the same distribution of age, gender and race. We evaluated the following parameters of ventricular repolarization: QTmax, QTmean, QTmin, QTc max, QTc mean, QTc min, QT and QTc dispersions, Tpeak-Tend and jTpeak-jTend intervals (D II, V2 and V5), Tpeak-Tend and jTpeak-jTend dispersions. The electrocardiograms (ECG) were performed by the same operator and reviewed by the same observers. QT intervals were corrected according to Bazzet’s formula. RESULTS: We found significantly higher values of QTc max (p < 0.001), QTc mean (p < 0.001), QT dispersion (p < 0.001), QTc dispersion (p < 0.001), Tpeak-Tend dispersion ( p < 0.001), and jTpeak-jTend dispersion (p < 0.001) in diabetic patients than in controls. In diabetic patients, we observed prolonged values of QTc interval (5.5%), QT dispersion (0.9%), QTc dispersion (0%), Tpeak-Tend interval (7.3%), jTpeak-jTend interval (6.4%), Tpeak-Tend dispersion (16.4%), and jTpeak-jTend dispersion (12.7%). In the controls there were no prolonged values of any of the parameters. CONCLUSION: We concluded that diabetes causes prolongation and spatial dispersion of repolarization, and it may contribute to a greater ventricular electrical instability, whose expected clinical expression may be malignant ventricular arrhythmias.

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Case Report

Echocardiographic features of non-compaction cardiomyopathy: missed and misdiagnosed disease

Francisco Martínez-Baca López et al. Rosa Marisol Alonso Bravo Domingo Arturo Rodríguez Huerta

Non-compaction cardiomyopathy is a rare disease, anatomically characterized by a prominent trabecular pattern and deep intertrabecular recesses. Its clinical manifestations include severe left ventricular dysfunction, arrhythmias, systemic embolism, and sudden death. In this report, two cases of patients of different ages with non-compaction cardiomyopathy are described: a male schoolboy whose pathology was associated with mitral stenosis and regurgitation and a 50-year-old female with history of high blood pressure and cardiac failure.

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Artigo Original

Postoperative atrial fibrillation following coronary artery bypass graft: clinical factors associated with in-hospital death

Dinaldo Cavalcanti de Oliveira et al. Carlos Romério Ferro João Bosco de Oliveira Guilherme Jose Prates … Audrey Torres Enilton Sergio Tabosa do Egito Magali Santos Arraes Luis Carlos Bento de Souza Adib Domingos Jatene Leopoldo Soares Piegas

OBJECTIVE: To identify factors associated with a higher likelihood of in-hospital death in patients submitted to coronary artery bypass graft surgery (CABG) who developed atrial fibrillation (AF) postoperatively. METHODS: The authors analyzed data from 397 consecutive patients submitted to CABG that developed AF postoperatively between 2000 and 2003. The patients were divided into 2 groups: group 1 (G1) comprised patients who survived (n=369); and group 2 (G2) comprised patients who died during hospital stay (n=28). Statistical analysis was performed using Student’s t test and chi-square test, and p values < 0.05 were considered significant. RESULTS: A comparative analysis between G1 and G2 showed that there was no difference between the groups as regards age (67.3 ± 8.4 versus 69.3 ± 9.6; p = 0.4), male gender (75.9% versus 64.3%; p = 0.1), systemic arterial hypertension (75.3% versus 85.7%; p = 0.2) and congestive heart failure (17% versus 17%; p = 1). Group 2 presented higher rates for previous acute myocardial infarction (14.6% versus 28.6%; p = 0.05), left ventricular ejection fraction < 40% (12.2% versus 32.1%; p = 0.003), previous cerebrovascular accident (0.8% versus 17.9%; p = 0.03), previous percutaneous coronary intervention (19.5% versus 39.3%; p = 0.01) and previous CABG (19.3% versus 35.7%; p = 0.03). CONCLUSION: Clinical history of acute myocardial infarction, CABG, percutaneous coronary intervention, cerebrovascular accident and severe ventricular dysfunction were significantly more frequent in the group that died during hospital stay, which suggests a possible association of these factors with a higher likelihood of death following CABG.

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