Drug Therapy – ABC CARDIOL

IJCS

Letter to the Editor

Access to Guideline-Directed Heart Failure Therapy in Brazil: Methodological and Policy Considerations

While the study’s findings are valuable, some methodological aspects could affect how we interpret them. The analysis is based solely on the presence of medications in Municipal Lists of Essential Medicines (REMUMEs), rather than on actual dispensing records or pharmacy inventory data. However, the fact that a medication is on an official list does not mean that patients can actually receive it in practice. Local procurement rules, supply chain issues, and prescribing practices can significantly affect the availability of drugs when patients need them. Conversely, medications absent from REMUMEs may still be accessible through other mechanisms within SUS. Therefore, relying solely on documentary evidence may not fully reflect the real accessibility of HF therapies. Dispensing records or pharmacy-level availability data could provide a more accurate representation of patient access.

Another important point to consider is how we understand the limited use of newer HF treatments, particularly angiotensin receptor–neprilysin inhibitors and sodium–glucose cotransporter-2 inhibitors. These treatments are often provided through specific national programs, such as the Specialized Pharmaceutical Assistance Component (CEAF), rather than being included in REMUMEs. Consequently, assessing REMUMEs alone may underestimate the availability of these agents within the broader SUS framework. Moreover, the regulatory and reimbursement processes for drugs like dapagliflozin and sacubitril/valsartan have changed quickly in recent years. This makes it especially important to understand how long they have been available.

[…]

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ABC

Review Article

Impact of Catheter Ablation on LVEF in Patients with Atrial Fibrillation and Heart Failure with Reduced Ejection Fraction: A Systematic Review

Antonio Maria Zacarias Araújo Monteiro et al. Maria Giovanna da Cruz Tocantins Jéssica Batista Souza Renan de Jesus da Silva Albuquerque … João Vitor Ferreira de Oliveira Roni Oliveira Pinheiro Ster Marques de Lima Silva

Abstract

Atrial fibrillation (AF) is a condition that frequently affects patients with heart failure with reduced ejection fraction (HFrEF) and is associated with worsening left ventricular ejection fraction (LVEF) and unfavorable clinical outcomes. Catheter ablation has been proposed as a strategy to restore sinus rhythm; however, its effects on LVEF remain heterogeneous in the literature. To evaluate the impact of catheter ablation, compared with medical therapy, on LVEF in patients with AF and HFrEF. A systematic review of randomized clinical trials was conducted in accordance with the PRISMA guidelines. The primary outcome was improvement in LVEF, while secondary outcomes included cardiovascular mortality, all-cause mortality, and hospitalizations due to heart failure. Other exploratory outcomes were also considered. The included randomized clinical trials demonstrated improvement in LVEF among patients undergoing catheter ablation compared with those receiving medical therapy. In the CAMERA-MRI study, an absolute increase of 18.3% in LVEF was observed after six months. In the CASTLE-AF trial, catheter ablation was also associated with a lower incidence of cardiovascular mortality and heart failure hospitalizations. In the absence of a meta-analysis, no quantitative synthesis of the effects was performed. The available evidence from individual randomized trials suggests that catheter ablation may be associated with improvement in LVEF and more favorable clinical outcomes in patients with AF and HFrEF. However, given the lack of quantitative synthesis, these findings should be interpreted with caution.

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ABCIC

Editorial

Chemotherapy-Induced Cardiotoxicity in the Pediatric Population: What Are the Unique Aspects of Cardiovascular Imaging Follow-Up?

Jéssica Laureano Martins et al. Maria do Carmo Menezes Bezerra Duarte Fabiana Gomes Aragão Magalhães Feitosa Maria Verônica Câmara dos Santos

Special considerations for the pediatric population^,

The pediatric perspective in cardio-oncology presents particular challenges, given that cardiotoxicity related to cancer treatment is not limited to an acute event, but represents a dynamic process that can interfere with myocardial growth and maturation over time. The vulnerability of the developing heart, associated with early exposure to potentially cardiotoxic therapies, confers a prolonged risk of progressive myocardial dysfunction. In this context, the use of more sensitive, reproducible, and integrated cardiovascular imaging strategies becomes fundamental. The multimodal approach, with emphasis on echocardiography (and cardiac magnetic resonance imaging in selected situations), increases diagnostic accuracy and contributes to better risk stratification. Additionally, structured longitudinal follow-up, with interpretation based on clinical individualization, is essential for adequate follow-up of these patients.

Finally, the incorporation of genetic, clinical, and therapeutic factors into risk models, coupled with continuous imaging monitoring, represents a promising perspective for precision medicine, with the goal of reducing cardiovascular morbidity and mortality and improving the quality of life of pediatric cancer survivors.

[…]

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IJCS

Original Article

Evidence-Based Pharmacological Treatment for Heart Failure in Brazil

Luísa Preiss Marques da Rocha et al. Kathleen Asturian Isabel Machado Canabarro Lidia Einsfeld Diogo Pilger

Abstract

Background:

Heart failure (HF) affects an estimated 64 million individuals globally. Current guideline-directed medical therapy (GDMT) comprises four cornerstone pharmacological medications proven to reduce hospitalization and/or mortality: renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter 2 inhibitors (SGLT2i).

Objective:

This study aimed to describe, through an exploratory analysis, access to HF drug therapy in Primary Health Care in Brazil, via the Brazilian Unified Health System (SUS).

Methods:

This was a descriptive, cross-sectional study based on data extracted from Municipal Lists of Essential Medicines (REMUMEs) published on official municipalities’ websites from Brazilian metropolitan regions in June 2024.

Results:

A total of 387 municipalities were included, of which only 50.9% had a REMUME publicly available. Among these, 61.4% had been published within the previous 2 years. The frequency of each drug class was as follows: angiotensin-converting enzyme inhibitors in 92.4% of municipalities, angiotensin II receptor blockers in 80.2%, cardioselective beta-blockers in 91.9%, and MRAs in 85.8%. No REMUME simultaneously included all four GDMT medications. In 22.3% of the metropolitan cities, only two or fewer drug classes were available to patients’ access.

Conclusion:

The remarkable variability in the composition of REMUMEs, along with the frequent omission of at least one of the four essential pharmacological pillars, indicates a potential suboptimal management of HF at the population level. Given the importance of comprehensive pharmacological treatment in HF, these findings highlight ongoing challenges in access to essential medicines within the SUS, even in metropolitan areas.

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ABCHF

Original Article

Prevalence and Clinical Determinants of Optimized Pharmacological Therapy in Heart Failure with Reduced Ejection Fraction

Anderson Oliveira Estevan et al. Ana Luísa Guedes de Franca e Silva Salvador Rassi Filho Aguinaldo Figueiredo de Freitas Júnior Salvador Rassi

Abstract

Background

In heart failure with reduced ejection fraction (HFrEF), optimized medical therapy (OMT) with beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs) (or sacubitril/valsartan), spironolactone, and sodium-glucose cotransporter-2 inhibitors (SGLT2i), at target or maximally tolerated doses, reduces morbidity and mortality. However, real-world data show its underuse.

Objective

To estimate the prevalence and clinical associations that influence the use of OMT in clinical practice.

Methods

Cross-sectional observational study including outpatients with HFrEF treated at a tertiary hospital. Clinical factors associated with therapy were assessed using binary logistic regression (95% confidence interval).

Results

A total of 266 patients were analyzed (mean age 61 years; 62.4% male), 113 (42.5%) with Chagas disease etiology. Mean ejection fraction was 34.2%. Vasodilators, beta-blockers, spironolactone, and SGLT2i were prescribed in 88%, 95.9%, 85.3%, and 27.4% of patients, respectively. The prevalence of OMT was 7.9% (21 patients). Diabetes was associated with a higher likelihood of OMT use (p = 0.034). Chagas disease was associated with lower probability of receiving vasodilators (p = 0.015) and greater use of furosemide, amiodarone, and digoxin (p 60 years, systolic blood pressure < 100 mmHg, and use of furosemide were associated with lower use of vasodilators (p = 0.003; 0.025; 0.010; and 0.046). CKD was associated with lower use of spironolactone (p = 0.002). Diabetes (p = 0.002) and use of furosemide (p = 0.005) were associated with SGLT2i use.

Conclusion

Despite the high prevalence of prescription of disease-modifying drugs, the use of OMT was significantly lower than expected. CKD, advanced age, arterial hypotension, and concomitant use of furosemide were associated with a reduced likelihood of receiving these agents, whereas diabetes was associated with a higher probability of OMT use.

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IJCS

Original Article

Evaluation of Different Therapeutic Approaches for Acute Coronary Syndromes in Patients Undergoing Chronic Dialysis: A Retrospective Cohort Study

Matheus Eduardo França et al. Ana Luiza de Fragas Franciani Rodrigues da Rocha Leonardo Claudino Ribeiro Silvia R. Froes Toniazzo

Abstract

Background:

Cardiovascular disease (CVD) is the leading cause of death among individuals with chronic kidney disease (CKD), particularly those undergoing dialysis, accounting for approximately 40% of deaths. The prevalence of ischemic coronary disease among patients undergoing hemodialysis over the age of 45 reaches 41%.

Objective:

To analyze outcomes of symptomatic coronary artery disease (CAD) in patients undergoing chronic dialysis, stratified by invasive assessment, and treated with one of three approaches: medical therapy alone (MTA), percutaneous coronary intervention (PCI), or coronary artery bypass grafting.

Methods:

This was a retrospective, analytical, observational cohort study based on data from electronic medical records collected between 2013 and 2023, including a total of 68 patients. Quantitative variables were analyzed using one-way Analysis of Variance (ANOVA), and qualitative variables were assessed using Pearson’s chi-square test. A p-value <0.05 was considered statistically significant.

Results:

The mean age was 60.2 ± 13.1 years, with a male predominance of 42 patients (62.8%). The highest mortality was observed in the MTA group with 25 deaths (69.4%), followed by PCI with 10 deaths (56.6%), and the lowest in the coronary artery bypass grafting group with six deaths (42.9%). Among patients who did not use statins, 19 (82.6%) died (p < 0.01). The lowest rate of readmission due to coronary syndrome occurred in the MTA group (two patients; 18.2%), while the highest was in the PCI group (six patients; 54.5%) (p = 0.02).

Conclusion:

Although no statistically significant difference in mortality was found among the three therapeutic strategies, MTA was associated with lower rates of readmission and repeat cardiac catheterization. In contrast, PCI was linked to a higher risk of readmission due to coronary syndrome.

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ABC

Original Article

Systematic Review on the Efficacy of Atenolol in Antihypertensive Treatment: Recommendation from the Brazilian Society of Cardiology

Andréa Araujo Brandão et al. Cibele Isaac Saad Rodrigues Wilson Nadruz Paulo Cesar B Veiga Jardim … Fernando Nobre Sergio Emanuel Kaiser Otavio Rizzi Coelho Fernanda Marciano Consolim Colombo Leonardo Castro Luna Andressa Braga Quenia Dias Morais Luiz Bortolotto

Abstract

Background

Hypertension (HTN) is a global public health issue, with high prevalence and a significant impact on cardiovascular morbidity and mortality. Cardioselective beta-blockers, such as atenolol, are widely used in the treatment of HTN, although their indication as first-line therapy remains controversial.

Objective

To evaluate the efficacy and safety of atenolol in the treatment of primary HTN, compared with other first-line classes of antihypertensive drugs.

Methods

A systematic review was conducted based on a research question structured using the PICO format. Randomized clinical trials comparing atenolol with other antihypertensive agents were included. Searches were performed in three international databases. Methodological quality was assessed using the RoB 2 tool, and the certainty of evidence was rated using the GRADE system. The primary composite outcome was the occurrence of major cardiovascular events. Secondary outcomes included all-cause mortality, acute myocardial infarction, and stroke, each analyzed separately.

Results

Seven clinical trials met the inclusion criteria. Compared with amlodipine and losartan, atenolol was associated with a slightly higher incidence of cardiovascular events, with low and moderate certainty of evidence, respectively. The combination of hydrochlorothiazide and amiloride demonstrated a greater reduction in cardiovascular events compared to atenolol, although with very low certainty of evidence. Blood pressure (BP) reduction was similar across the compared treatments.

Conclusions

Despite the limitations of available evidence, atenolol showed comparable efficacy in BP reduction, with small differences in cardiovascular outcomes favoring other antihypertensive classes. Its use may be considered among the options for combination therapy in the treatment of primary HTN in adults. Other beta-blockers were not evaluated in this systematic review.

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ABCHF

Review Article

New Perspectives in the Treatment of Heart Failure with Preserved Ejection Fraction with SGLT-2 Inhibitors

José Natthananel de Aquino Gomes et al. Milena dos Santos Barros Campos Carlos Aurélio Santos Aragão Antonio Carlos Sousa

Abstract

The treatment of heart failure with preserved ejection fraction (HFpEF) has always represented a challenge in clinical management. The discovery of sodium-glucose cotransporter 2 inhibitors (SGLT2i) as efficient cardiac protectors brought the possibility of treating HFpEF, a topic driven by robust studies such as EMPEROR-Preserved and DELIVER. The present work aims to identify the main studies on SGLT2i and primary outcomes in HFpEF.

The qualified search was carried out in the BVS and Pubmed indexed databases, with the inclusion criteria being randomized clinical trials, meta-analyses and analyses of clinical trials, full text available, and publication in the last 5 years.

11 articles were selected to compose the review.

SGLT2i shows efficacy in the treatment of HFpEF, reducing hospitalization for heart failure in this population and improving ventricular diastolic function in these patients, but not altering the risk of cardiac death alone.

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ABC

Original Article

Systematic Review of the Effectiveness of Intensive Antihypertensive Treatment Goals: Brazilian Society of Cardiology (SBC) Recommendation

Andréa Araujo Brandão et al. Cibele Isaac Saad Rodrigues Luiz Aparecido Bortolotto Leonardo Castro Luna … Bruno Monteiro Barros Mario Fritsch Toros Neves Ana Flávia de Souza Moura Frida Liane Plavnik Luciano Ferreira Drager Osni Moreira Filho Weimar Kunz Sebba Barroso de Souza Wilson Nadruz

Abstract

Background

Strict blood pressure control has been investigated as a strategy to reduce severe cardiovascular events in patients with hypertension. However, there are still doubts about the impact of intensive antihypertensive treatment goals (< 130/80 mmHg) compared to conventional goals (≥ 130/80 mmHg) in preventing myocardial infarction, stroke, mortality, and possible treatment-related adverse effects.

Objective

To evaluate the effectiveness of intensive antihypertensive treatment goals in reducing critical cardiovascular events compared to usual goals.

Methods

This systematic review included randomized controlled trials (RCTs) that compared intensive blood pressure control goals with conventional goals in adults aged 18 years or older. Studies with at least one of the following outcomes were included: mortality, myocardial infarction, stroke, progression to stage 4 or 5 chronic kidney disease, need for dialysis, or kidney transplantation. Medline, Embase, and Cochrane Library databases were searched up to May 2024. Risk of bias assessment was performed by two independent reviewers using the Cochrane Collaboration’s Risk of Bias 2 (RoB 2) tool. Synthesis of results was conducted through meta-analysis for the composite outcome of myocardial infarction, stroke, and all-cause mortality. The certainty of scientific evidence and strength of recommendation followed the methods proposed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.

Results

Nine RCTs with more than 34,000 participants were included. Intensive treatment was associated with a 13% reduction in cardiovascular events. In the studies with low risk of bias, the reduction was 17%, with high certainty of evidence. Separately, a significant reduction was observed in the outcomes of myocardial infarction and stroke, but not in all-cause mortality. Limited data were found on the progression of kidney disease and the need for dialysis or kidney transplantation.

Conclusion

High-quality evidence suggests that more intensive antihypertensive treatment goals significantly reduce cardiovascular events. However, the choice of treatment goals should be individualized, considering factors such as age, frailty, individual cardiovascular risk, and the possibility of adverse events. Adherence to treatment is essential to therapeutic success.

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ABC

Original Article

Incidence of Cardiovascular Complications in Pediatric Patients Treated with Anthracyclines at a Brazilian Cancer Center

Cristina Chaves dos Santos de Guerra et al. Geisa Sant'Ana Osório Luiz Rangel de Almeida

Abstract

Background:

The introduction of anthracyclines in the treatment of children and adolescents with cancer has promoted a significant increase in survival, but also in morbidity and mortality rates due to cardiovascular (CV) complications.

Objectives:

To determine the cardiovascular profile of pediatric patients treated with anthracyclines at a cancer center in Brazil and the incidence of CV complications.

Methods:

The following data were collected from the medical records of patients of both sexes, aged younger than 19 years – frequency and form of clinical presentation of general CV complications (G1) and CV complications related to ventricular dysfunction (G2) – and correlated with risk factors, age range and vital status, cardiovascular and cardioprotective medications. A p<0.05 was considered statistically significant.

Results:

A total of 326 patients were included, 214 (65.6%) were younger than 10 years and 192 (58.9%) of male sex. G1 complications occurred in 141 (43.3%) patients, and the most frequent was systemic arterial hypertension; G2 complications occurred in 84 patients (25.8%). Cumulative dose (CD) of anthracyclines > 250mg/m² was used in 26.7% of patients and the association of G2 complications with this CD was not statistically significant (p=0.305; OR=1.330 and [95% CI = 0.770- 2.296]). The most used cardiac medications were diuretics (34.7% of patients).

Conclusions:

In accordance with literature, the study showed a high incidence of CV complications in the treatment of children and adolescents with cancer, with general CV complications as the most prevalent.

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ABC

Letter to the Editor

Cost-Effectiveness of the Use of the Coronary Calcium Score in Primary Prevention as a Guide for the Therapeutic Decision

Cristian Rodrigues do Nascimento et al. Júlio Martinez Santos Rodrigo Mendes Johnnatas Mikael Lopes Pedro Pereira Tenório

To the Editor,

We read with great interest the article: “Cost-Effectiveness of Using the Coronary Calcium Score to Guide Therapeutic Decisions in Primary Prevention in the Brazilian Population” The study aimed to evaluate the cost-effectiveness of using the calcium score in therapeutic guidance for primary cardiovascular prevention. The analysis was based on population data from the “ Multi-Ethnic Study of Atherosclerosis (MESA),” a cohort of 6,814 participants from different study centers in the United States. The inferences made by the authors are important, especially when it comes to identifying factors related to pharmacoeconomics in the prevention of cardiovascular diseases. However, we identified that the procedures suggested using the calcium score (CE) to define the use or not of statins could lead to attrition bias, as there are clinical situations in which more imaging studies on the involvement of the vascular structure are necessary, especially the coronary arteries so that subsequent management can be defined.

[…]

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ABCHF

Brief Communication

Evidence Based Treatment of Heart Failure: Challenges of Drug Access

Lidia Einsfeld et al. Diogo Pilger Cassiela Roman

Abstract

Heart failure (HF) is a complex clinical syndrome with high prevalence, significant morbi-mortality and is the leading cause of hospital admissions of Brazilian patients over 65 years of age. Drug therapy plays a key role in the care of HF patients, aimed to control symptoms, improve functional classification, reduce hospital readmissions and HF-related mortality rates. Despite the evidence of drug therapy proven benefits in HF, their access through the Unified Health System (Sistema Único de Saúde, SUS) remains unexplored. The present study aims to analyze the dynamics of access to HF therapy, based on the list of drugs made available by the SUS through a descriptive and documental methodology. Data were collected from the Municipal Lists of Essential Medicines in a metropolitan region in southern Brazil. Municipalities with a population over 80,000 inhabitants were included, and the respective lists of available drugs were reachable electronically by the health departments themselves. The results showed a partial access to HF treatment via the SUS, especially spironolactone and furosemide, present in 72.7% and 81.8% of the municipalities, respectively. Although drug treatment for HF has proven a high level of evidence, access via SUS represents a challenge to overcome in the continuum of care of patients with heart failure in Brazil

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ABC

Research Letter

Mitral Valve Endocarditis – An Unusual Culprit in a Cancer Patient

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

Introduction

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

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

[…]

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IJCS

Review Article

One Size Does Not Fit All: The Need to Rethink the Metabolic Syndrome in Women

Maria Cristina Costa de Almeida et al. Marildes Luiza Castro Larissa Espíndola Neto Luciana Nicolau Aranha … Thaís Salim Gláucia Maria Moraes de Oliveira

Abstract

Metabolic syndrome (MetS) is increasing at epidemic proportions worldwide. MetS and its components are frequent among Brazilian women (41.8%). Women are affected by changes in adipose tissue distribution, lipid profile, insulin resistance (IR), and vascular remodeling during their lives. These changes result from the lack of estrogen after menopause. There have been various attempts to propose a uniform origin for the clustering of the MetS components, including genetics, IR, obesity, lifestyle, sleep disturbances, inflammation, fetal and neonatal programming, and disturbed circadian rhythm of the body functions. The proinflammatory and prothrombotic state in MetS is well-defined. Socioeconomic and lifestyle-related factors are also essential triggers of MetS, which is associated with a higher risk for coronary artery diseases (CAD) and stroke in women. Population measures in health and community medicine, such as continuing education on the importance of lifestyle change to reduce cardiovascular risks from early childhood, are fundamental strategies. Statins reduce high-sensitivity C-reactive protein blood levels and treat high cholesterol. According to the patient, hypoglycemic agents, such as dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1(GLP-1a), and sodium-glucose transport protein 2 (SGLT2) inhibitors, in addition to metformin, have their indication due to their beneficial cardiometabolic and vascular effects. Angiotensin-converting enzyme inhibitor (ACEI) and angiotensin-receptor blocker (ARB) should be the first choice to treat hypertension in postmenopausal womem. The recognition of the different gender- and age-specific risk factors, allowing for specific and targeted interventions, is fundamental, especially for women.

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ABCHF

Review Article

Diagnosis and Treatment of Hypertrophic Cardiomyopathy

Fernando Saraiva et al. Fabio Fernandes Minna Moreira Dias Romano Juliano Novaes Cardoso … Marília Taily Soliani Mariani Mendes Madisson Bernardo André Schmidt Marcus Vinicius Simões

Abstract

The concept of hypertrophic cardiomyopathy has undergone profound changes with the advent of cardiogenomics and the increase in knowledge about the sarcomeric structure and the mutations that lead to cardiomyocyte hypertrophy. In this review article, we address the state of the art in terms of diagnosis, contemplating the genetic heart diseases responsible for differential diagnoses of hypertrophic cardiomyopathy, known as phenocopies, which are a major challenge in clinical practice. We also discuss the current evidence that guides treatment.

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ABC

Original Article

Diagnostic Value of Three-Dimensional Speckle Tracking Imaging Strain Parameters for Detection of Cancer Chemotherapy-Related Cardiac Dysfunction: A Meta-Analysis

Abstract

Background

Chemotherapeutic agents (e.g., anthracyclines, trastuzumab) commonly used for treating malignant tumors have been demonstrated to have cardiotoxic effects, which is associated with poor prognosis. Three-dimensional echocardiography has been used to predict cancer chemotherapy-induced cardiac dysfunction.

Objectives

Evaluation of the diagnostic performance of strain parameters, global area strain (GAS), longitudinal strain (GLS), circumferential strain (GCS), and radial strain (GRS) by meta-analysis.

Methods

Relevant studies were searched from the Embase, PubMed, and Web of Science databases. Statistical analysis was performed using Stata 12. The summary receiver operating characteristic curve, sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and corresponding 95% confidence interval for the four strain parameters were pooled. P<0.05 was considered statistically significant.

Results

Nine studies involving 650 participants were included. GAS and GLS showed significant diagnostic advantages over GCS and GRS. For GAS, the sensitivity was 0.85 (0.70, 0.93) and specificity was 0.82(0.78, 0.86) with PLR of 4.76 (3.55, 6.39) and NLR of 0.18 (0.09, 0.39) and an area under the curve (AUC) of 0.85 (0.82, 0.88). For GLS, the sensitivity was 0.81 (0.74, 0.86) and specificity was 0.81(0.68, 0.90) with PLR of 4.35(2.42, 7.80) and NLR of 0.23 (0.17, 0.33) and an AUC of 0.85 (0.82, 0.88). The GCS showed a sensitivity of 0.63 and a specificity of 0.79 with an AUC of 0.77. The GRS showed a sensitivity of 0.74 and a specificity of 0.66 with an AUC of 0.73.

Conclusion

3D-STI strain parameters GAS and GLS showed good performance in detecting early cardiac dysfunction in patients with tumors receiving chemotherapy.

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ABC

Editorial

Renin-Angiotensin System Inhibition and Beta Blockade Adrenergic May Be Useful to Attenuate Cardiotoxicity by Anthracyclines

Mario Fritsch Neves

Cardiotoxicity related to the use of anthracyclines is a major concern in oncology, as it can increase the morbidity of many patients receiving chemotherapy for various types of cancer. This toxicity can lead to left ventricular systolic dysfunction and, therefore, a higher incidence of heart failure, which can result in mortality in severe cases. A better understanding of the mechanisms involved and a better definition of diagnostic methods have provided significant advances in detecting this complication. However, there is still no consensus on the most accurate biomarkers for early identification of cardiotoxicity. Despite this, troponin measurement after each chemotherapy cycle can be a valid tool to indicate immediate intervention.^,

Manifestations of cardiotoxicity may remain restricted to myocardial cell damage detectable only by measuring circulating biomarkers or vary between silent ventricular dysfunction and clinically manifest heart failure. Strategies to avoid or at least attenuate anthracycline-induced cardiotoxicity are essential to improve the prognosis of patients using this class. The current recommendations include treating pre-existing cardiovascular risk factors,^– choosing less cardiotoxic analogues, and administering low cumulative doses of anthracyclines.^,

[…]

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ABC

Original Article

Renin-angiotensin System Antagonists and Beta-blockers in Prevention of Anthracycline Cardiotoxicity: a Systematic Review and Meta-analysis

Monica Samuel Avila et al. Suellen Rodrigues Rangel Siqueira Lucas Waldeck Silvia Moreira Ayub-Ferreira … Richard Takx Marcio Sommer Bittencourt Edimar Alcides Bocchi

Abstract

Background

The evidence supporting the use of renin-angiotensin-aldosterone system (RAAS) inhibitors and beta-blockers for the prevention of anthracycline-induced cardiomyopathy is controversial.

Objective

We performed a meta-analysis to assess the effectiveness of these drugs in preventing cardiotoxicity.

Methods

The meta-analysis included prospective, randomized studies in adults receiving anthracycline chemotherapy and compared the use of RAAS inhibitors or beta-blockers versus placebo with a follow-up of 6 to 18 months. The primary outcome was change in left ventricular ejection fraction (LVEF) during chemotherapy. Secondary outcomes were the incidence of heart failure, all-cause mortality, and changes in end-diastolic measurement. Heterogeneity was assessed by stratification and meta-regression. A significance level of p < 0.05 was adopted.

Results

The search resulted in 17 studies, totaling 1,530 patients. The variation (delta) in LVEF was evaluated in 14 studies. Neurohormonal therapy was associated with a lower delta in pre- versus post-therapy LVEF (weighted mean difference 4.42 [95% confidence interval 2.3 to 6.6]) and higher final LVEF (p < 0.001). Treatment resulted in a lower incidence of heart failure (risk ratio 0.45 [95% confidence interval 0.3 to 0.7]). There was no effect on mortality (p = 0.3). For analysis of LVEF, substantial heterogeneity was documented, which was not explained by the variables explored in the study.

Conclusion

The use of RAAS inhibitors and beta-blockers to prevent anthracycline-induced cardiotoxicity was associated with less pronounced reduction in LVEF, higher final LVEF, and lower incidence of heart failure. No changes in mortality were observed. (CRD PROSPERO 42019133615)

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ABC

Original Article

Secondary Pharmacological Prevention of Coronary Artery Disease among Patients Submitted to Clinical Management, Percutaneous Coronary Intervention, or Coronary Artery Bypass Graft Surgery

Marcelo B. Lucca et al. Felipe C. Fuchs Adriana S. Almeida Marco V. Wainstein … Flavio D. Fuchs Sandra C. Fuchs

Abstract

Background

Secondary prevention is recommended for patients with evidence of coronary artery disease (CAD) regardless of the indication for treatment by coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI).

Objectives

This study evaluated whether clinical treatment, PCI or CABG had an influence on adherence to the pharmacological secondary prevention in patients with stable CAD.

Methods

This cohort included patients aged ≥40 years with stable CAD confirmed by coronary angiography. The decision for medical treatment alone, or additionally with PCI or CABG, was made by the attending physicians. Adherence to the prescribed drugs recommended by the guidelines for secondary prevention (optimal pharmacological treatment), including antiplatelet agents, lipid-lowering drugs, beta-blockers, and renin-angiotensin-aldosterone system blockers, was assessed at follow-up. Differences were considered significant for p values <0.05.

Results

From 928 patients enrolled at baseline, 415 had mild CAD and 66 moderate to severe CAD. The average follow-up was 5.2 ± 1.5 years. Patients submitted to CABG were more likely to receive the optimal pharmacological treatment than those submitted to PCI or treated clinically (63.5% versus 39.1% versus 45.7% respectively, p=0.003). Baseline factors independently associated with greater probability of having a prescription of optimal treatment at follow-up were CABG [39% higher (6% – 83%, p=0.017) and diabetes [25% higher (1% – 56%), p=0.042] than their counterparts treated by other methods and participants without diabetes, respectively.

Conclusions

Patients with CAD submitted to CABG are more commonly treated with optimal pharmacological secondary prevention than patients treated by PCI or exclusively with medical therapy.

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ABCHF

Review Article

Myocarditis in Cancer Patients: A Review of an Emerging Problem in Cardio-Oncology

Wolney de Andrade Martins et al. Eduardo Schlabendorff

Abstract

Patients with cancer have a multitude of etiological factors for developing myocarditis. Classical or conventional chemotherapy, radiation therapy, and, more recently, immunotherapy have all been described as possible etiologies of myocarditis. Furthermore, patients with cancer are immunosuppressed and more susceptible to bacterial and viral infections that can cause myocarditis. This narrative review addresses the many possible causes of myocarditis in patients with cancer. Particular emphasis will be given to immune checkpoint inhibitor (ICI)-induced myocarditis. ICI myocarditis generally affects male patients, over the age of 50, who are being treated for lung cancer, melanoma, or renal cell carcinoma and have multiple comorbidities. Clinical manifestations present early, with elevated troponin and electrocardiogram changes. The case fatality rate is high. Treatment consists of discontinuation of the offending ICI and corticosteroid therapy. Myocarditis due to cyclophosphamide, anthracyclines, 5-fluorouracil, cisplatin, carboplatin, proteasome inhibitors, immunomodulators, tyrosine kinase inhibitors, and radiation therapy will also be addressed.

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ABC

Research Letter

Concomitant Use of Ranolazine and Trimetazidine in Patients with Refractory Angina: An Initial Experience

Luciana Oliveira Cascaes Dourado et al. Cristian Paul Delgado Moreno Sarah Fagundes Grobe Luis Henrique Wolff Gowdak Luiz Antonio Machado Cesar

Introduction

Refractory angina (RA), an extremely debilitating condition, requires specialized medical treatment with often complex therapeutic adjustments in an attempt to improve symptoms and quality of life as much as possible.

Medical treatment usually comprises a combination of antianginal drugs (AAD). Among them, trimetazidine (T) and ranolazine (R) are an add-on therapy due to their efficacy and safety profile in the treatment of patients with RA.^– However, in the recent “diamond approach”, depicting preferred combinations of different classes of AAD for the treatment of patients with angina, does not consider the concomitant use of T and R a useful strategy due to their related mechanism of action. Although no known interaction between both drugs has been described, there is no data on the efficacy and safety of the use of R in patients already on T. Therefore, we aimed to evaluate the effect of the concomitant use of R and T in patients with RA.

[…]

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ABC

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Rare Presentation of Yolk Sac Tumor with Cardiac Involvement: Characteristics Detected by MRI

Cristhian Espinoza Romero et al. Williams Roberto Lata Guacho Kevin Rafael de Paula Robert Paladines Jimenez Eduardo Kaiser Ururahy Nunes Fonseca

Introduction

Primary cardiac tumors are extremely rare, with their incidence varying between 0.0017 and 0.28%, among which is the malignant germ cell yolk sac tumor (YST).

Although transthoracic echocardiography (TTE) is often the first line in the evaluation of cardiac tumors, currently, due to its good spatial resolution and tissue characterization, cardiac magnetic resonance (CMR) imaging is the technique of choice for the evaluation of these tumors.^, The intracardiac YST is a rare neoplasm, with few reported cases.^–

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ABCHF

Original Article

Association of Age with Optimal Medical Therapy in Patients with Chronic Heart Failure

Vitoria A. A. Koga et al. Luiza Dall’Asta Thiago L. P. Jacyntho Leonardo C. De-Marchi … Rodrigo P. Mulinari Bruna A. Ladeira Maria E. R. F. Nemeth Odilson M. Silvestre Marcely Gimenes Bonatto Lidia Ana Zytynski Moura Miguel Morita Fernandes-Silva

Abstract

Background:

The adherence to guideline-directed medical therapy in patients with heart failure (HF) remains suboptimal.

Objectives:

We evaluated the association between age and adherence to guideline-directed medical therapy in patients with chronic HF and explored whether polypharmacy and comorbidities might explain this association.

Methods:

We performed a cross-sectional study of 374 patients with chronic HF and left ventricle ejection fraction < 50% (23 to 89 years old, 33% women) between 2018 and 2019. GDMT was defined as using HF-related disease-modifying medications at the target dose according to guidelines. Patients were classified in 3 age groups (23 to 57, 58 to 67, and 68 to 89 years old).

Results:

Older patients were less likely to receive optimal therapy (33% versus 24% versus 15%, p < 0.001 for each age category, respectively). After adjusting for potential confounders, the chances of receiving medical therapy at optimal dose significantly reduced for each age-decade increase (OR 0.66 [95% confidence interval 0.48 – 0.92], p = 0.013). The proportion of this association that was explained by polypharmacy (0% [0% – 3.5%]) or comorbidities (7% [0% – 41%]) was negligible.

Conclusion:

We found that age was inversely associated with optimal drug therapy for HF, and polypharmacy or comorbidities do not appear to explain this.

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ABC

Research Letter

An Unusual Manifestation of Rejection

Carlos Xavier Correia de Resende et al. Pedro Grilo Diogo Sandra Amorim Gonçalo Pestana … José Pinheiro Torres Filipe Macedo

Introduction

Orthotopic heart transplantation is the current treatment of choice for selected patients with end-stage heart failure. With the improvement of surgical techniques and the efficiency of new immunosuppressive treatments, short-term survival has markedly improved throughout the years. However, these patients still suffer from important comorbidities caused by chronic transplant complications such as rejection, coronary allograft vasculopathy (CAV) and malignancy. Rhythm disorders are common in heart transplant patients and in some circumstances, they can be the first clinical manifestation of rejection. Coronary vasospasm has been recently associated with acute rejection and CAV, but the mechanisms underlying this phenomenon are still speculative.

We present a clinical case of acute heart transplant rejection, manifested by coronary vasospasm and advanced rhythm disorder.

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