Practice Guideline – ABC CARDIOL

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Research Letter

Hypertension in Pregnancy: From Guidelines to the Cardiologist's Clinical Practice

Introduction

The Brazilian Guidelines of Hypertension– 2025 of the Brazilian Society of Cardiology objectively address hypertension during pregnancy, dedicating a specific chapter to the topic. The document covers diagnostic definitions, strategies for the prediction and prevention of preeclampsia, therapeutic management during pregnancy and the postpartum period as well as the assessment of future cardiovascular risk associated with hypertensive disorders of pregnancy (HDPs).

In the international setting, the 2025 European Society of Cardiology (ESC) Guidelines for the Management of Cardiovascular Disease During Pregnancy provide detailed algorithms for proteinuria assessment, emergency management, and the treatment of hypertension and preeclampsia. Their recommendations are based predominantly on expert consensus, reflecting the scarcity of randomized clinical trials in this field.

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ABC

Letter to the Editor

Reply to the Letter to the Editor: "Should Resistance Training Also Be Considered a Mandatory Component?"

Cibele Isaac Saad Rodrigues et al. Claudia Lucia de Moraes Forjaz Luiz Aparecido Bortolotto Wilson Nadruz Andréa A. Brandão

Resistance training (RT) is undoubtedly an essential component of a comprehensive exercise program for improving and maintaining physical fitness, global health, and quality of life. Aerobic, resistance, and stretching exercises performed together on a regular basis promote significant physiological, motor, cognitive, and emotional benefits and are recommended for adults and older adults.^,

Although both aerobic training (AT) and RT have impacts on different health dimensions, there is high quality, robust evidence that RT is the most efficient mode of training for improving muscle structure and function, and it is mandatory for prevention and treatment of musculoskeletal diseases, making it particularly important for older adults.^– On the other hand, evidence about the effects of RT on cardiovascular parameters and diseases is more recent and less robust.

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IJCS

Original Article

Impact of Updated Guidelines on TAVI Outcomes in a Health Maintenance Organization in Brazil: A Decade-Long Retrospective Study

Maria da Gloria Cruvinel Horta et al. Marcus Carvalho Borin Julia Teixeira Tupinambas Luciano Rios Scherrer … Mateus Goncalves Souza Matheus del-Valle Carina Rejane Martins Daniel Pitchon dos Reis Geraldo Jose Coelho Ribeiro Karina de Castro Zocrato Lelia Maria de Almeida Carvalho Marcela Pinto Freitas Mariana Michel Barbosa Mariza Cristina Torres Talim Fernando Biscione Martin Silvana Marcia Bruschi Kelles

Abstract

Background

Aortic stenosis is a progressive condition that leads to significant morbidity and mortality if untreated. Transcatheter aortic valve implantation (TAVI) provides a less invasive alternative to surgical aortic valve replacement (SAVR), particularly for high-risk patients.

Objectives

This study evaluates the outcomes of TAVI procedures performed in a Health Maintenance Organization (HMO) in Brazil from 2013 to 2023, focusing on the impact of clinical guidelines updated in 2018.

Methods

A retrospective cohort study included 325 patients diagnosed with severe symptomatic aortic stenosis who underwent TAVI. Patients were divided into two groups: those treated before January 2019 (n=56) and those treated from January 2019 onwards (n=269). The primary outcomes included all-cause mortality and major complications, while the secondary outcomes encompassed procedural success rates and specific complication rates. Continuous variables were analyzed using the Mann-Whitney test, and categorical variables were analyzed using the chi-square test or Fisher’s exact test. Statistical significance was defined as p < 0.05.

Results

After January 2019, the shift to self-expanding valves was associated with a statistically significant reduction in pacemaker implantation rates (from 28.6% to 18.2%, p=0.03), whereas other outcomes did not reach statistical significance.

Conclusions

The implementation of updated protocols was associated with improved TAVI outcomes, especially a reduced need for pacemaker implantation, supporting its expanded use in intermediate-risk patients.

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Editorial

Brazilian Society of Cardiology Guidelines: New Norms, New Challenges

Carisi A. Polanczyk et al. Leonardo Castro Luna Helena Cramer Veiga Rey Humberto Graner Moreira … José Airton de Arruda Pedro Gabriel Melo de Barros e Silva Mario de Seixas Rocha

Brazilian Society of Cardiology Guidelines

The first Brazilian Society of Cardiology (SBC) guidelines also emerged in the 1980s and 1990s, addressing issues related to the diagnosis and treatment of prevalent cardiovascular diseases, such as high blood pressure, coronary artery disease, and heart failure. In 2006, the SBC’s Clinical Practice Guidelines Committee (ConDir) was established. It is responsible for coordinating the development of guidelines and technical standards for clinical practice among Brazilian cardiologists. The guidelines of other international cardiology societies have clear goals, including: improved care quality; safe and effective treatment for the greatest number of patients, regardless of location or health care provider; curbing unscientific practices; and optimal use of the available resources, avoiding waste and promoting the health system’s sustainability.

SBC Guidelines have become an important reference for cardiovascular care in Brazil, serving as a guide for health professionals and the entire ecosystem: providers, payment sources, and health managers.

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Review Article

The Six Pillars of Lifestyle Medicine in Managing Noncommunicable Diseases – The Gaps in Current Guidelines

Rafaella Rogatto de Faria et al. Sergio Freitas de Siqueira Francisco Aguerre Haddad Gustavo Del Monte Silva … Caio Vitale Spaggiari Martino Martinelli Filho

Abstract

Background:

Noncommunicable diseases (NCDs), also known as chronic diseases that are long-lasting, are considered the major cause of death and disability worldwide, and the six pillars of lifestyle medicine (nutrition, exercise, toxic control, stress management, restorative sleep, and social connection) play an important role in a holistic management of their prevention and treatment. In addition, medical guidelines are the most accepted documents with recommendations to manage NCDs.

Objective:

The present study aims to analyze the lack of lifestyle pillars concerning the major Brazilian medical guidelines for NCDs and identify evidence in the literature that could justify their inclusion in the documents.

Method:

Brazilian guidelines were selected according to the most relevant causes of death in Brazil, given by the Mortality Information System, published by the Brazilian Ministry of Health in 2019. Journals were screened in the PUBMED library according to the disease and non-mentioned pillars of lifestyle.

Results:

Relevant causes of deaths in Brazil are acute myocardial infarction (AMI), diabetes mellitus (DM), and chronic obstructive pulmonary diseases (COPD). Six guidelines related to these NCDs were identified, and all address aspects of lifestyle, but only one, regarding cardiovascular prevention, highlights all six pillars. Despite this, a literature search involving over 50 articles showed that there is evidence that all the pillars can help control each of these NCDs.

Conclusion:

Rarely are the six pillars of lifestyle contemplated in Brazilian guidelines for AMI, DM, and COPD. The literature review identified evidence of all lifestyle pillars to offer a holistic approach for the management and prevention of NCDs.

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ABCHF

Review Article

Point-of-Care Ultrasound in Acute Heart Failure: Basic Concepts for Clinical Practice

Leticia Kunst et al. Luiz Claudio Danzmann Keslly Krauspenhar Cuchinski João Ricardo Cambruzzi Zimmer

Introduction

Heart failure (HF) is a complex clinical syndrome that promotes a system of poor tissue perfusion in conditions of low cardiac output and elevated filling pressures, resulting in circulatory congestion and hypoperfusion. The exacerbation of this condition is responsible for 40% of consultations due to dyspnea in emergency rooms, and the main cause is worsening congestion due to poor medication adherence. In in-hospital clinical assessment, the most prevalent HF profiles are B (warm and wet) and C (cold and wet), both of which are characterized by circulatory congestion.

Although it causes great demand in the emergency room, it is sometimes difficult to identify signs of hypervolemia in acute decompensated HF in the context of differential diagnosis with other determining syndromes of dyspnea and hypoperfusion. Clinical findings are fundamental for the initial investigation, but objective and rapid confirmation of diagnosis reduces door-to-furosemide time, which is directly related to in-hospital mortality. Natriuretic peptides are tools with high negative predictive value for congestion; however, moderately elevated serum levels represent a diagnostic gray area, as the increase in this marker is related to several diseases that are independent of HF. The use of bedside point-of-care ultrasound (POCUS) has emerged as an excellent tool for comprehensive assessment of this condition, with analysis of cardiac structure and function, the pulmonary interstitium, and some venous vessels. It also offers a rapid, non-invasive, and low-cost opportunity, with greater accuracy than conventional assessment methods for detecting circulatory congestion.

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IJCS

Editorial

Is Spirituality a New or Renewed Tool?

Mario Borba

Editorial referring to the article: Religiosity and Spirituality: The Relationship Between Psychosocial Factors and Cardiovascular Health

The topic of spirituality and religiosity has become more prevalent in scientific publications and clinical practice. Researchers recognize that studying this area can lead to a better understanding of physiology and potential therapeutic interventions. There are even discussions about establishing a prognosis based on spirituality and religiosity, and we are finding evidence related to this topic.

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Letter to the Editor

Comments Regarding the Athlete’s Electrocardiogram in the Brazilian Society of Cardiology Guidelines on the Analysis and Issuance of Electrocardiographic Reports – 2022

Filipe Ferrari et al. Anderson Donelli da Silveira Ricardo Stein

Dear Editor,

It was with great interest that we had access to the document entitled “Brazilian Society of Cardiology Guidelines on the Analysis and Issuance of Electrocardiographic Reports – 2022”, developed by Brazilian experts on the subject. It is our opinion that an update was necessary, as it is detailed and pleasant to read.

However, we draw attention to two pieces of information presented about the interpretation of the athlete’s electrocardiogram that caused us concern. The first is found in the section “ Cardiac Chambers Hypertrophy” (Page 18), in which the authors describe that the Sokolow-Lyon Criteria SHOULD NOT be used to determine left ventricular hypertrophy (LVH) IN ATHLETES.

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Editorial

Fibrillatory Wave Amplitude: Should We Use It Routinely in Clinical Practice?

Andre Assis L. Carmo

Atrial fibrillation (AF) is the most prevalent sustained arrhythmia worldwide and is associated with an increased burden of morbidity and mortality in different clinical scenarios, even for patients with optimal anticoagulation and rate control treatment.^, Although previous studies did not show the benefit of rhythm control strategy compared to rate-control,^, recent data suggest that current rhythm control strategies, in addition to symptom control, can improve hard clinical outcomes, including mortality and stroke.^,

Rhythm control strategy refers to attempts to restore or maintain sinus rhythm and includes antiarrhythmic drugs, electrical cardioversion and atrial fibrillation ablation. Despite progressive improvement in rhythm control strategies over the years, a substantial amount of failure in maintaining sinus rhythm, mainly in patients with persistent forms of AF, underscores the importance of properly selecting patients for rhythm-control strategies.

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Viewpoint

Guidelines, Position Statements, and Standardizations: Documents to Assist Medical Practice

Antônio Carlos Sobral Sousa et al. Harry Corrêa Filho Bruno Nascimento Aurora Castro Issa … Marcelo Luiz Campos Vieira Brivaldo Markman Filho

Clinical practice guidelines

CPG are made up of systematically developed statements, and they are designed to support decision-making processes in patient care, under specific conditions. Unlike documents that provides guidance, guidelines address a topic where there is moderate to high quality evidence, generally from randomized trials with a satisfactory number of participants, to make the most appropriate clinical practice possible.

In drafting them, a process is used to summarize the evidence and provide a standardized method to express the classes of recommendations with their respective levels of evidence. For a guideline to be reliable, it is advisable to observe the following criteria: a) be based on systematic reviews of the literature; b) be developed by a multidisciplinary and experienced panel of experts; c) consider the values and preferences of patients, as well as their subgroups; d) be based on an explicit and transparent process that minimizes distortions, biases, and conflicts of interest; e) provide a clear explanation of the relationships between alternative care options and clinical outcomes, and f) be updated when important new evidence warrants changes to recommendations.

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Editorial

Achievement of LDL-cholesterol Targets: Why do We Fail, and How Can We Improve?

Fernando Cesena

Atherosclerotic cardiovascular disease (ASCVD) remains the first cause of death in the world, and Brazil.^, Individuals with previous ASCVD are at the highest risk of subsequent events, and guidelines recommend aggressive lowering of low-density lipoprotein cholesterol (LDL-c) levels to prevent bad outcomes.^,

However, several reports from around the world indicate a gap between guideline recommendations and clinical practice, and a large proportion of the population, especially in secondary prevention, lives with LDL-c levels above those considered reasonable to prevent events.^– Indeed, lack of adherence to guideline-recommended therapies was independently associated with major cardiovascular events in a Brazilian population after acute coronary syndrome.

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Point of view

The Brazilian cardiology trainee: guidelines and freedom

Max Grinberg

POINT OF VIEW

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