systematic review – ABC CARDIOL

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Original Article

Systematic Review on the Safety of Physical Exercise in Hypertrophic Cardiomyopathy: Recommendations from the Brazilian Society of Cardiology

Ricardo Stein et al. Rodrigo Otávio Bougleux Alô Luiz Eduardo Fonteles Ritt Alexsandro Alves Fagundes … Anderson Donelli da Silveira Artur Haddad Herdy Clea Colombo Cristiano Faria Pisani Fabrício Braga Frank Nunes Luciana Sacilotto Marconi Gomes Silva Mauricio Milani Mauricio Pimentel Milena dos Santos Barros Campos Nágela Simão Vinhosa Nunes Pablo Marino Nascimento Susimeire Buglia José Ronyeryson dos Santos Evangelista Filipe Ferrari Leonardo Castro Luna

Abstract

Background

Although historically discouraged due to the risk of arrhythmias and sudden cardiac death (SCD), physical exercise (PE) may be safe and beneficial for individuals with hypertrophic cardiomyopathy (HCM).

Objective

To evaluate the association between PE and the incidence of mortality and arrhythmic events in adults with HCM, stratifying the analysis according to different types and intensities of exercise.

Methods

Systematic review of randomized clinical trials (RCTs) and observational studies identified in PubMed, Embase, and the Cochrane Library through December 2024. Studies including individuals exposed to different intensities of PE were eligible. Risk of bias was assessed using the RoB 2 and ROBINS-I tools, and certainty of evidence using GRADE. Recommendations were developed by an expert panel of the Brazilian Society of Cardiology.

Results

Eight studies (four RCTs and four observational studies; 9,744 participants) were included. None reported an increased risk of mortality or severe arrhythmic events associated with PE, even at moderate or vigorous intensities. Syncope was rare. Additionally, a Korean observational study involving more than 7,000 participants (mean age: 59 years) demonstrated reduced all-cause mortality with higher physical activity intensity (dose–response curve). In low-risk athletes, competitive sports were not associated with severe adverse events. The quality of evidence ranged from moderate to very low.

Conclusion

PE in HCM should be encouraged based on individualized assessment. In patients without high-risk criteria for SCD, benefits appear to outweigh risks. For higher-risk subgroups, recommendations are more cautious and based on expert consensus.

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IJCS

Original Article

Evaluation of Cardiovascular Risks Associated with Calcium Use: A Systematic Review and Meta-Analysis

Paulo Henrique Gouveia et al. Joyce da Silva Guimarães Astrid Wiens

Abstract

Background

Calcium plays vital roles in both physiological and pathological processes, and its use as a therapeutic agent is primarily indicated for osteoporosis and osteopenia. It may increase cardiovascular risk, thereby increasing cardiovascular morbidity and mortality.

Objective

To synthesize the available evidence on cardiovascular risks in patients using calcium-based medications and supplements.

Methods

This systematic review and meta-analysis utilized three major international databases and included intervention studies and comparative observational studies with data on the intake of calcium-based medications or supplements in adult populations and associated cardiovascular outcomes. A p-value < 0.05 was considered for all analyses, and the certainty of evidence was assessed using the GRADE approach.

Results

A total of fourteen articles were included: three pivotal intervention studies, four post hoc analyses, and seven observational studies. The outcomes assessed were mortality from cardiovascular events, myocardial infarction, stroke, and coronary artery disease. Although an increased incidence of coronary artery disease was observed among users of calcium-based medications or supplements when considering only observational studies (RR 1.08; 95% CI 1.02–1.15), this finding was not confirmed in interventional studies. Therefore, further investigation is warranted. No increased risk of cardiovascular mortality, myocardial infarction, or stroke was observed. The quality of the evidence was considered low or very low for all outcomes due to the risk of bias and limitations inherent to the meta-analyses themselves.

Conclusions

Caution is recommended when interpreting the results, particularly in the development of clinical protocols. The importance of pharmacotherapeutic monitoring for patients using these medications is emphasized, and further research to explore additional outcomes is suggested.

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Original Article

Ultra-Low Contrast versus Conventional Percutaneous Coronary Intervention for Patients with Baseline Renal Impairment: A Systematic Review and Meta-Analysis of Clinical Outcomes

Marcos Danillo Oliveira et al. Ricardo Fonseca Oliveira Suruagy-Motta Leonardo Dexheimer da Silva Karlos Daniell Araújo dos Santos Adriano Caixeta

Abstract

Background

Contrast-associated acute kidney injury (CA-AKI) results in increased morbidity and mortality, prolonged hospitalization, and worse clinical outcomes. Prior studies have shown that limiting contrast volume (CV) to less than 3 times the estimated glomerular filtration rate (eGFR) implies a lower risk of CA-AKI, and both efficacy and superior outcomes are associated with ultra-low contrast (ULC) volume coronary procedures (total CV ≤ eGFR).

Objectives

This systematic review and meta-analysis aimed to compare clinical outcomes of ULC versus conventional percutaneous coronary intervention (PCI) in patients with chronic kidney disease.

Methods

The search was conducted in the databases PubMed/MEDLINE, Cochrane, Embase, Scopus, and Web of Science, including all studies reporting clinical outcomes of ULC PCI. The primary efficacy endpoint was the incidence of CA-AKI, and secondary endpoints were need for dialysis, all-cause mortality, and major adverse cardiovascular events (MACE), defined as the composite endpoint of all-cause mortality, non-fatal myocardial infarction, and clinically driven target lesion revascularization.

Results

Six studies met the inclusion criteria and were included in the final analysis, encompassing a total of 274,102 patients. ULC PCI was associated with a statistically significant reduction of CA-AKI (risk ratio=0.27; 95% CI=0.13–0.56; p=0.0004). In turn, ULC PCI did not result in statistically significant reduction of need for dialysis (risk ratio=0.33; 95% CI=0.06–1.72; p=0.186), all-cause mortality (risk ratio=0.48; 95% CI=0.17–1.39; p=0.18), and MACE (risk ratio=0.52; 95% CI= 0.21–1.30; p=0.16).

Conclusions

ULC, as compared to conventional PCI, in patients with chronic kidney disease, was found to be safe, feasible, and associated with a statistically significant reduction of CA-AKI. Further, larger, well-powered, randomized, and controlled trials are warranted in order to reassure these findings.

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Review Article

Systematic Review: Mineralocorticoid Receptor Antagonists in Heart Failure with Preserved and Mildly Reduced Ejection Fraction

Marcus Vinicius Simões et al. Luiz Claudio Danzmann Sílvia Marinho Martins José Albuquerque de Figueiredo Neto … Fabiana G. Marcondes-Braga Ricardo Mourilhe-Rocha Denilson Campos de Albuquerque Mucio Tavares de Oliveira Jr Lidia Ana Zytynski Moura

Abstract

Heart failure with preserved ejection fraction (HFpEF) or mildly reduced ejection fraction (HFmrEF) is a prevalent condition associated with significant morbidity and mortality, and the benefits of mineralocorticoid receptor antagonists (MRAs) remain unclear. To develop a systematic review on the use of MRAs in patients with HFpEF or HFmrEF, a systematic review and meta-analysis were conducted using a broad search strategy in the following databases: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). Randomized controlled trials that evaluated the use of MRAs in patients with HFpEF compared to control groups were included. The quality of evidence and the strength of the recommendation were assessed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Eight studies were included. No statistically significant differences were observed for the outcomes of overall mortality and cardiovascular mortality compared to the control group for any of the MRAs. A benefit was observed with a reduced risk of hospitalization for heart failure (relative risk: 0.87; 95% confidence interval: 0.79 to 0.96; moderate certainty of evidence) and of worsening heart failure events (relative risk: 0.83; 95% confidence interval: 0.77 to 0.89; high certainty of evidence). The results of the meta-analysis indicate a significant benefit from MRAs, spironolactone or finerenone, to reduce hospitalizations and worsening heart failure events in patients with HFpEF or HFmrEF. Mineralocorticoid Receptor Antagonists; Diastolic Heart Failure; Systolic Heart Failure; Systematic Review; Meta-Analysis.

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ABCIC

Original Article

Diagnostic Performance Of Contrast-Enhanced Echocardiography In Differentiating Cardiac Masses: A Systematic Review And Meta-analysis

João Guilherme G. Pedrosa et al. Felizardo José Leandro Pereira Antonio Lacerda Cavalcanti Neto Renata Ramos Stropp … Giordano Persuhn Rolim de Moura Marcelo Tavares Sadrak Lyon Dantas Pontes Alex dos Santos Felix

Abstract

Background

Conventional echocardiography often struggles to differentiate intracardiac masses, particularly in patients with poor acoustic windows. Contrast-enhanced Echocardiography (CEE) overcomes this limitation by visualizing perfusion patterns — distinguishing avascular thrombi from vascularized tumors. We aimed to synthesize existing evidence to evaluate the diagnostic accuracy of CEE.

Objectives

To evaluate the diagnostic accuracy of CEE for differentiating cardiac masses in adults, using histopathology as reference and reporting AUC, sensitivity, specificity, PPV, and NPV.

Methods

Systematic searches of PubMed, Web of Science, Cochrane Library, and EMBASE were performed on August 10, 2025. Studies meeting PICOTT criteria were included; extracted data included sensitivity, specificity, AUC, and 2×2 tables. Pooled estimates were obtained using standard bivariate and SROC models for diagnostic meta-analysis. Statistical significance set at P < 0.05.

Results

Five prospective cohort studies (total n = 381 patients) were included. For tumor vs non-tumor, pooled sensitivity = 100% and specificity = 100% (95% CI 99.5–100%; I² = 0%; heterogeneity P = 0.985), diagnostic odds ratio (DOR) = 3,890.65, AUC = 0.989. For malignant vs benign tumors, pooled sensitivity = 94.3% (95% CI 88.5–97.3%; I² = 0%; P = 0.681), specificity = 96.1% (95% CI 91.5–98.2%; I² = 0%; P = 0.970), DOR = 341.71, SROC AUC = 0.976.

Conclusions

CEE showed very high diagnostic accuracy in the available prospective series. However, the small number of studies and limited sample sizes warrant cautious interpretation; larger prospective multicenter studies with standardized CEE protocols are needed to confirm these results.

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IJCS

Editorial

The Growing Role of Simulation-Based Learning in Cardiology Education

Diandro Marinho Mota et al. Fabiano Barcellos Filho

Introduction

Simulation-based learning has emerged as a cornerstone in modern medical education, offering a safe and controlled environment for trainees to acquire and refine complex clinical skills.^– This pedagogical approach is particularly pertinent in dynamic and high-stakes specialties such as cardiology, where precision, rapid decision-making, and technical proficiency are paramount. The systematic review by Silva, Souza, and Santos titled “The Use of Simulation-Based Learning in Cardiology Education: A Systematic Review” provides a comprehensive overview of the current evidence supporting the integration of simulation into cardiology curricula. This mini-editorial aims to reflect on the significant contributions of this review and to articulate the journal’s perspective on the evolving landscape of simulation in cardiovascular education.

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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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Original Article

Diagnostic Test Accuracy of Exercise Testing in Detecting High-Risk Accessory Pathways in WPW: A Systematic Review and Meta-Analysis

José Nunes de Alencar et al. Fabio Mahamad Rassi Raquel Pereira Rios Matheus Kiszka Scheffer Guilherme Dagostin de Carvalho

Abstract

Background

Wolff-Parkinson-White (WPW) syndrome is characterized by ventricular pre-excitation, which can lead to severe arrhythmic events such as supraventricular tachycardia and pre-excited atrial fibrillation. The diagnostic value of non-invasive exercise tests in detecting high-risk accessory pathways remains inconsistent in the literature.

Objectives

To evaluate the diagnostic accuracy of non-invasive exercise tests compared to invasive electrophysiological studies (EPS) for identifying high-risk accessory pathways in WPW syndrome.

Methods

Following PRISMA-DTA guidelines, a comprehensive search was conducted in PubMed, Scopus, and Web of Science databases. Eligible studies assessed the sensitivity, specificity, and likelihood ratios of non-invasive exercise tests in WPW patients, using EPS as the reference standard. A bivariate random-effects model was applied for meta-analysis.

Results

Six studies, comprising a total of 765 patients, met the inclusion criteria. The pooled sensitivity was 92.7% (95% CI: 88.0% – 94.0%), while the pooled specificity was 28.1% (95% CI: 23% – 35.1%). A negative likelihood ratio (LR-) of 0.260 (95% CI: 0.174 – 0.387) indicated that the presence of a high-risk accessory pathway is about four times less likely after a negative test result. Sensitivity analysis restricted to pediatric patients showed consistent results.

Conclusion

Non-invasive exercise tests demonstrate a reasonable diagnostic utility for ruling out high-risk pathways in WPW syndrome. However, caution is advised when using these tests as standalone criteria for risk stratification.

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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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Editorial

Adipose-Derived Mesenchymal Stem Cell Therapy for Ischemic Heart Disease: Safe but Not Effective?

Anurag Jamaiyar et al. Aspasia Tzani

Cardiovascular disease continues to be the leading cause of death in adults globally. Obstructive coronary artery disease involves a gradual narrowing of coronary artery branches due to the build-up of atherosclerotic plaque, leading to reduced blood flow to the myocardium. This myocardial infarction initiates a cascade of pathological processes such as oxidative stress, inflammation, and fibrosis, which eventually lead to heart failure. A heart transplant is sometimes the only viable option for many patients with progressive ischemic heart failure refractory to anti-anginal medication or revascularization. Novel therapeutics such as stem cells, RNAs, CRISPR, growth factors, etc., hold great promise for meeting this clinical need. Stem cells have been tested in pre-clinical studies extensively for many years now. Paracrine factors, instead of differentiation potential, are now widely agreed upon as the most likely cause of their therapeutic effects. Contemporary studies continue to employ either native or genetically reprogrammed stem cells for treating various diseases. Stem cells can be derived from diverse niches in the adult human body, such as blood, bone marrow, fat, skeletal muscle, and more. However, many of these tissues can only be harvested in very small quantities. Also, access to some of them, e.g., bone marrow, requires invasive procedures. Adipose remains one of the most abundant and easily retrievable tissues for this purpose.

In the current issue, the authors present a systematic review of clinical studies in which adipose-derived stem cells (ADSCs) have been used as a therapeutic for ischemic heart disease (IHD). This review summarizes the safety and efficacy of ADSCs in ten such studies (comprising 29 publications), with 8 randomized controlled clinical trials and 2 uncontrolled trials. The studies reviewed by the authors administered varying numbers of ADSCs (from 400,000 cells in the Athena I trial to 100 million cells in the DANISH and SCIENCE studies. Apart from the AdiFLAP study, which used an adipose patch, these studies administered ADSCs via intramyocardial or intracoronary injections. Follow-up for these trials ranged from 6 months (APOLLO, Kastrup et al.) to 36 months (MyStromalCell and PRECISE). In the early days of stem cell therapy, one of the main safety concerns was teratoma formation. This was largely due to the pluripotent nature of stem cells being tested. As the human body is a complex milieu of growth factors, cytokines, hormones, etc., stem cells could also differentiate into unintended cell types, making stem cell therapy a risky endeavor that could cause more harm than good. In the last decade, these therapies have come of age, with multipotent instead of pluripotent stem cells as candidates.

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Original Article

Resistance Exercise Training Mitigates Cardiac Remodeling Induced by a High-Fat Diet in Rodents: A Systematic Review

Alexandre Martins Oliveira Portes et al. Sebastião Felipe Ferreira Costa Luciano Bernardes Leite Victor Neiva Lavorato … Denise Coutinho de Miranda Anselmo Gomes de Moura Leôncio Lopes Soares Mauro César Isoldi Antônio José Natali

Abstract

Background

Obesity is associated with the development of cardiovascular diseases and is a serious public health problem. In animal models, high-fat diet (HFD) feeding impairs cardiac structure and function and promotes oxidative stress and apoptosis. Resistance exercise training (RT), however, has been recommended as coadjutant in the treatment of cardiometabolic diseases, including obesity, because it increases energy expenditure and stimulates lipolysis.

Objective

In this systematic review, we aimed to assess the benefits of RT on the heart of rats and mice fed HFD.

Methods

Original studies were identified by searching PubMed, Scopus, and Embase databases from December 2007 to December 2022. This study was conducted in accordance with the criteria established by PRISMA and registered in PROSPERO (CRD42022369217). The risk of bias and methodological quality was evaluated by SYRCLE and CAMARADES, respectively. Eligible studies included original articles published in English that evaluated cardiac outcomes in rodents submitted to over 4 weeks of RT and controlled by a sedentary, HFD-fed control group (n = 5).

Results

The results showed that RT mitigates cardiac oxidative stress, inflammation, and endoplasmic reticulum stress. It also modifies the activity of structural remodeling markers, although it does not alter biometric parameters, histomorphometric parameters, or the contractile function of cardiomyocytes.

Conclusion

Our results indicate that RT partially counteracts the HFD-induced adverse cardiac remodeling by increasing the activity of structural remodeling markers; elevating mitochondrial biogenesis; reducing oxidative stress, inflammatory markers, and endoplasmic reticulum stress; and improving hemodynamic, anthropometric, and metabolic parameters.

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Editorial

Sacubitril/Valsartan: A Breakthrough in Heart Failure Management – Addressing Quality of Life and Mortality

Allan K. N. Alencar

Heart failure (HF) remains a major global cause of mortality, morbidity, and hospitalizations. Over the past two decades, the management of chronic HF has seen significant improvements with the introduction of novel diagnostic procedures and pharmacological therapies. However, achieving a clinically significant improvement in functional capacity and quality of life (QoL) might be more important to patients than simply prolonging life. HF negatively affects health-related quality of life (HRQoL) in physical, mental, and social domains. Consequently, HF patients experience impaired QoL even when compared to individuals with other debilitating chronic conditions. In contemporary times, many HF patients value the enhancement of HRQoL through treatment as highly as extending their lifespan.

This editorial discusses the findings of a recently published work that aims to review the improvement in quality of life with sacubitril/valsartan in HF patients with reduced or preserved ejection fraction (HFrEF/HFpEF) based on prospective clinical trials. The authors conducted a systematic literature search in PubMed, Embase, and the Cochrane Library for randomized clinical trials (RCTs) and prospective cohort studies published until July 2021. A total of six clinical trials and 16,854 HF patients were included in the analysis. The primary outcome was the change from baseline in the Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score (KCCQ-CSS). Secondary outcomes included scores in other domains of the KCCQ, occurrence of serious adverse events (SAEs), and overall mortality.

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Editorial

Transcatheter Aortic Valve Implantation: What has Happened and What is Yet to Come

David Costa de Souza Le Bihan et al. Rodrigo Bellio de Mattos Barretto Wilson Mathias Junior

In April 2002, the first transcatheter aortic valve implantation (TAVI) was performed in humans, still as an experimental procedure, in a patient with aortic stenosis and cardiogenic shock, unable to undergo surgical intervention, with this compassionate procedure being his only possibility to survive. To get to this moment, much effort had already been taken into developing prototypes for almost 20 years previous, but probably Dr. Alain Cribier already had the idea, at that time of the first implant, of the revolution to come.

After 21 years of the first case, TAVI has now come of age. Today, it is part of the routine of clinical cardiologists, who have come to trust it as a real alternative to conventional surgical treatment. TAVI has revolutionized how we treat the most prevalent valve disease in developed countries, affecting up to 7% of the population over 65.

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Original Article

Transcatheter Valve Replacement in Patients with Aortic Valve Stenosis: An Overview of Systematic Reviews and Meta-Analysis with Different Populations

Henrique Diegoli et al. Marcia Regina Dias Alves Lucas Miyake Okumura Caroline Kroll … Dayane Silveira Luiz Henrique Picolo Furlan

Abstract

Background

Randomized controlled trials (RCTs) and observational studies have compared the efficacy and safety of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis.

Objectives

Compare TAVR and SAVR in patients with different surgical risks, population characteristics, and different transcatheter prosthetic valves.

Methods

An overview of systematic reviews (SRs) was conducted following a structured protocol. Results were grouped by surgical risk, population characteristics, and different valves. RCTs in the SRs were reanalyzed through meta-analyses, and the results were summarized using the GRADE method. The adopted level of statistical significance was 5%.

Results

Compared to SAVR, patients with high surgical risk using TAVR had a lower risk of (odds ratio, 95% confidence interval, absolute risk difference) atrial fibrillation (AF) (0.5, 0.29-0.86, -106/1000) and life-threatening bleeding (0.29, 0.2-0.42, -215/1000). Patients with intermediate surgical risk had a lower risk of AF (0.27, 0.23-0.33, -255/1000), life-threatening bleeding (0.15, 0.12-0.19, -330/1000), and acute renal failure (ARF) (0.4, 0.26-0.62, -21/1000). Patients with low surgical risk had a lower risk of death (0.58, 0.34-0.97, -16/1000), stroke (0.51, 0.28-0.94, -15/1000), AF (0.16, 0.12-0.2, -295/1000), life-threatening bleeding (0.17, 0.05-0.55, -76/1000), and ARF (0.27, 0.13-0.55, -21/1000), and had a higher risk of permanent pacemaker implantation (PPI) (4.22, 1.27-14.02, 141/1000). Newer generation devices had a lower risk of AF than older generations, and patients using balloon-expandable devices did not experience higher risks of PPI.

Conclusions

This paper provides evidence that patients at low, intermediate, and high surgical risks have better outcomes when treated with TAVR compared with SAVR.

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IJCS

Original Article

Adherence and Quality of Life in Non-Valvular Atrial Fibrillation With Direct Oral Anticoagulants Versus Vitamin K Antagonists: A Systematic Review

Vanelise Zortea et al. Karine Duarte Curvello Diogo Pilger Antonios Douros … Lisiane Freitas Leal Tatiana da Silva Sempé Tatiane da Silva Dal Pizzol

Abstract

Background

Direct anticoagulants (DOACs) and vitamin K antagonists (VKAs) differ in pharmacokinetic characteristics, intensity of required laboratory monitoring, and costs. These differences could affect patients’ adherence to treatment and quality of life (QoL).

Objective

To assess whether patients with non-valvular atrial fibrillation (AF) using DOACs have better treatment adherence and QoL when compared to patients using VKAs.

Methods

We conducted a systematic review in Medline, Embase, LILACS, SciELO, CINAHL, and Cochrane Central, until June 9, 2021. We included studies that estimated and compared treatment adherence and QoL between DOACs and VKAs in adults with non-valvular AF. The methodological quality of the studies was assessed using the Joanna Briggs Institute (JBI) tools. The protocol was registered in the PROSPERO (CRD 42020165238).

Results

Sixteen studies, including 122,458 patients with non-valvular AF, evaluated adherence, and eleven studies, including 5,687 patients, assessed QoL. A variety of methods was used to measure adherence. Eleven studies showed no difference in adherence between DOACs and VKAs, while three studies favored VKAs over DOACs and two studies favored DOACs over VKAs. QoL was measured by specific (n = 3) or generic questionnaires (n = 8); results favored DOACs over VKAs in four studies, while in the other seven studies the results showed no difference between the groups. Meta-analyses were not performed due to high methodological heterogeneity among studies.

Conclusions

Available evidence regarding treatment adherence and QoL with DOACs and VKAs is characterized by methodological heterogeneity and conflicting findings.

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Original Article

General Approach to Acute Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): A Systematic Review

Marcos Aurélio Barboza de Oliveira et al. Alan Vinicius Gamero Ósti Bruno Vargas Teixeira Cavalheiro Déborah Barbosa Naves … Emanuelle Ribeiro de Oliveira Gabriel Freitas de Campos Gabriel Mael Sussuarana Silva Lobo Gabriely de Oliveira Marcela Paula Mainardi Marília Cardoso Guimarães Robert Filipe Barbosa Vilian Veloso de Moura Fé

Abstract

Background

Acute myocardial infarction (AMI) without obstructive coronary arteries (MINOCA) is a medical condition of great relevance, with clinical characteristics of AMI, but without evidence of coronary artery obstruction. The mechanism involved in the pathophysiology of the disease and its possible etiologies are important objects of study due to their impact on the morbidity and mortality of affected patients.

Objectives

The aim of this study was to systematically review MINOCA and its characteristics, with emphasis on the clinical profile of patients, etiology, pathophysiology, diagnosis, and treatment of the syndrome.

Methods

Relevant articles related to MINOCA were analyzed in the PubMed and LILACS databases. In the initial search stage, 619 eligible articles were obtained, with final inclusion criteria being: original systematic reviews with clinical, epidemiological, diagnostic, or treatment data on MINOCA, published in Portuguese or English, with an abstract, and a publication date limit of September 2020.

Results

A total of 10 articles classified as systematic reviews that considered clinical data on MINOCA were included in this review.

Conclusion

After analyzing various literature, the present study provided a tool to better understand MINOCA, not only regarding its casuistry but also in grouping parameters and information that contribute to a healthy approach to this clinical situation. It was possible to identify and better outline the clinical profile of patients who presented this condition and the use of appropriate tools for correct diagnosis and ideal treatment.

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Original Article

Covid-19 and Heart Involvement: A Systematic Review of Literature

Francisco Cezar Aquino de Moraes et al. Rafael Reis do Espírito Santos Joel Campos de Moraes Aline Carolina Castro Mota … Fernando Rocha Pessoa Dayanne Coutinho Sarges Davi Alexandrino Moraes Dilma do Socorro Moraes de Souza

Abstract

Background

Recent reports in the literature have indicated that infection by coronavirus disease 2019 (COVID-19) causes cardiac complications, such as heart failure, arrhythmia, myocardial infarction, and even fulminant myocarditis. These complications have been identified as the cause of death in some patients infected with SARS-CoV-2.

Objectives

To analyze echocardiographic and electrocardiographic changes, treatments used, and clinical outcomes in patients with myocarditis and COVID-19.

Methods

The items described for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were followed. This review included articles in English, Portuguese, and Spanish that reported cardiac involvement, injury, or myocardial inflammation in patients who acquired COVID-19 (SARS-CoV-2).

Results

Five databases were consulted to find 1,726 articles. After applying the eligibility criteria, a total of 22 studies were considered qualified. ST-segment (section of the electrocardiogram corresponding the end of the S wave to the beginning of the T wave) elevation and tachyarrhythmia were the most common changes found in the electrocardiographic analysis of patients affected with COVID-19. Concerning echocardiography, there was a high frequency of decreased ejection fraction and occurrence of pericardial effusion.

Conclusion

This systematic review provides a potential tool for the analysis of cardiac changes and implications caused in patients affected by SARS-CoV-2 infection, with emphasis on the presence of tachyarrhythmia on electrocardiogram (ECG) and decreased ejection fraction on echocardiogram.

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Original Article

Hospital Mortality from Myocardial Infarction in Latin America and the Caribbean: Systematic Review and Meta-Analysis

Leonardo Alves et al. Patrícia K. Ziegelmann Victor Ribeiro Carisi Polanczyk

Abstract

Background:

Most cardiovascular deaths occur in low- and middle-income countries and myocardial infarction is one of the main life-threatening conditions.

Objective:

We assessed all-cause in-hospital mortality in patients admitted for myocardial infarction (STEMI and NSTEMI) in Latin America and the Caribbean from 2000 onward.

Methods:

We systematically searched in electronic bibliographic databases for cohort studies which reported in-hospital mortality due to STEMI and NSTEMI. A meta-analysis was performed and a p-value < 0.05 was considered significant.

Results:

We identified 38 studies (29 STEMI, 3 NSTEMI and 6 both). Pooled STEMI in-hospital mortality was 9.9% (95% CI: 9.1 – 10.7). Heterogeneity was not trivial (I² = 74% and prediction interval = 6.6 – 14.5). The percentage of reperfusion therapy and decade explain part of the heterogeneity (I² = 54%). The higher the rate of reperfusion therapy, the lower the in-hospital mortality (coefficient = −0.009, 95% CI: −0.013 to −0.006, p<0.001). This mortality was higher in the first decade as compared with the second (coefficient = −0.14, 95% CI: −0.27 to −0.02, p=0.047). Pooled NSTEMI in-hospital mortality was 6.3% (95% CI: 5.4 – 7.4) and heterogeneity was null.

Conclusion:

Pooled STEMI in-hospital mortality in low- and middle-income countries was high in comparison with rates reported in high income countries. To improve these estimates, higher use of reperfusion therapy must be pursued. Pooled NSTEMI in-hospital mortality was similar to the ones found in high-income countries; however, it was based on few studies and most of them were carried out in two countries.

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Original Article

Deduction, Induction and the Art of Clinical Reasoning in Medical Education: Systematic Review and Bayesian Proposal

Marcos Roberto de-Sousa et al. Túlio Roberto Xavier de Aguiar

Abstract

Background

Clinical reasoning is at the core of medical practice and entangled in a conceptual confusion. The duality theory in probability allows to evaluate its objective and subjective aspects.

Objectives

To conduct a systematic review of the literature about clinical reasoning in decision making in medical education and to propose a “reasoning based on the Bayesian rule” (RBBR).

Methods

A systematic review on PubMed was conducted (until February 27, 2022), following a strict methodology, by a researcher experienced in systematic review. The RBBR, presented in the discussion section, was constructed in his undergraduate dissertation in Philosophy at Minas Gerais Federal University. Heart failure was used as example.

Results

Of 3,340 articles retrieved, 154 were included: 24 discussing the uncertainty condition, 87 on vague concepts (case discussion, heuristics, list of cognitive biases, choosing wisely) subsumed under the term “art”, and 43 discussing the general idea of inductive or deductive reasoning. RBBR provides coherence and reproducibility rules, inference under uncertainty, and learning rule, and can incorporate those vague terms classified as “art”, arguments and evidence, from a subjective perspective about probability.

Conclusions

This systematic review shows that reasoning is grounded in uncertainty, predominantly probabilistic, and reviews possible errors of the hypothetico-deductive reasoning. RBBR is a two-step probabilistic reasoning that can be taught. The Bayes theorem is a linguistic tool, a general rule of reasoning, diagnosis, scientific communication and review of medical knowledge according to new evidence.

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Original Article

Efficacy and Risks of Therapeutic Hypothermia after Pediatric Cardiac Arrest: A Systematic Review

Anna Luíza Machado Nogueira et al. Ana Luísa dos Santos Maciel Amanda Campos Querubino Roberta Teixeira Prado Jussara Regina Martins

Abstract

Background:

Therapeutic hypothermia is used in adults and neonates after cardiac arrest, but its efficiency in children under 18 years old is still uncertain.

Objective:

To evaluate the effectiveness and risks of therapeutic hypothermia after cardiac arrest in children under 18 years of age through a systematic review.

Methods:

A systematic review was performed in January 2022 in the MEDLINE, SciELO, Cochrane, and LILACS databases. Inclusion criteria: randomized controlled trials (RCTs) performed in humans. Articles from other typologies, published more than 10 years ago, or with volunteers over 18 years old were excluded.

Results:

Four studies were identified, of which 3 were analyzed; all of them were of moderate quality according to the Jadad Scale and the Cochrane Collaboration tool. The studies indicated that lowering the temperature did not improve data on mortality and adverse events. Two studies did not identify statistically significant differences (p > 0.05) considering hypothermia in relation to normothermia in terms of survival, safety, and global neurobehavioral and cognitive function. The other study did not show improved serum biomarker concentrations.

Conclusion:

The results found in this review do not support the use of therapeutic hypothermia after pediatric cardiac arrest, as this intervention did not provide any apparent benefits in terms of safety, adverse events, survival, and neurological impact. We recommend the conduction of new RCTs using the measurement of serum biomarkers to better evaluate the effectiveness of the intervention.

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Original Article

Accuracy of Self-Reported Arterial Hypertension in Brazil: Systematic Review and Meta-Analysis

Jessica Pronestino de Lima Moreira et al. Renan Moritz Varnier Rodrigues de Almeida Ronir Raggio Luiz

Abstract

Background

Self-reported hypertension is a useful method to estimate prevalence in the population. However, it is necessary to evaluate its accuracy, in relation to the gold-standard diagnostic methods of the disease.

Objectives

To estimate combined measures of sensitivity and specificity for self-reported hypertension, using Brazilian validation studies that included gold standard methods.

Methods

A systematic review and a meta-analysis were developed. Two independent examiners evaluated 1389 and read 113 potentially eligible articles. Since self-reported morbidity is influenced by the cultural and economic characteristics of a population, as well as by its accessibility to medical care, only studies from one country (Brazil) were included. First, a qualitative analysis was performed, evaluating the relationship between self-reported hypertension and its measurement through gold-standard methods. Subsequently, a meta-analysis estimated the combined sensitivity and specificity for the included studies. Due to a high heterogeneity among studies, the meta-analysis used a random effects model. Bias risks were evaluated by the QUADAS-2 protocol and the standard significance level of 10% was used in all modelling.

Results

Five studies were included in the qualitative analysis; and four had the necessary information for inclusion in the meta-analysis. Patient selection and Index Test (the question allowing for self-reporting) were the domains with the highest risk of bias. In the meta-analysis, combined sensitivity and specificity were 77%(95%CI:[74.5-79.0%]) and 88%(95%CI:[86.3-88.6%]), respectively.

Conclusions

The analysed studies allowed for the estimation of more reliable values for combined sensitivity and specificity. These values were higher than those usually found in studies with greater population heterogeneity.

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Editorial

Pre-Clinical Meta-Analysis: Another Brick in the Wall

Amanda Gomes Pereira et al. André Monti Garzesi Sergio Alberto Rupp Paiva Bertha Furlan Polegato

Currently, systematic review and meta-analysis are considered level 1 of scientific evidence and it is widely used in epidemiology and evidence-based medicine. The term meta-analysis comes from the Greek and means “analysis of analyses”, referring to its definition “statistical analysis of a large collection of analysis results from individual studies for the purpose of integrating the findings” proposed by the statistician Gene V. Glass in 1976.

Despite the similarities, it is important to note that meta-analysis and systematic review are not synonymous. Meta-analysis is often, but not always, preceded by a systematic review, which aim to gather similar studies that meet the strict approach eligibility criteria in order to answer a specific research question, whereas meta-analysis integrates the results of included studies by statistical techniques.^,

[…]

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Review Article

Aromatherapy in Patients with Cardiovascular Diseases: A Systematic Review

Lissandra de Souza Lopes et al. Daiana Bündchen Felipe Cardozo Modesto Monica Quintão … Sergio Chermont Ana Carla Dantas Cavalcanti Evandro Tinoco Mesquita

Abstract

Background

Aromatherapy consists in the use of volatile aromatic compounds of plant essential oils. Application methods include massage, baths, and mainly inhalation. Lavender essential oil is considered the most effective treatment for emotional disorders, such as stress and anxiety, due to its anxiolytic and sedative agents, which are known to interfere with physiological cardiovascular reactions.

Objectives

To investigate the effects of aromatherapy using lavender essential oil on hemodynamic responses and emotional aspects of patients with cardiovascular diseases.

Methods

A systematic review was conducted using Embase, Bireme, MEDLINE, PEDro, and Scopus electronic databases. Randomized clinical trials that evaluated hemodynamic and emotional outcomes using interventions with lavender essential oil in patients with cardiovascular diseases were selected. Of 539 studies initially identified, 51 were read in full and only 5 were eligible for inclusion.

Results

Reductions were demonstrated in hemodynamic responses, such as systolic and diastolic blood pressure, mean arterial pressure, and heart rate, as well as a decrease in anxiety, depression, stress, and fatigue compared with the control group. Statistical significance was set at p<0.05. Conclusion: Aromatherapy with the use of lavender essential oil provided benefits to hemodynamic parameters, such as anxiety, stress, depression, and fatigue levels, in patients with cardiovascular diseases. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

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Letter to the Editor

Recurrent Takotsubo Cardiomyopathy: A Puzzle Yet to be Solved

Kenan Yalta et al. Caglar Kaya

Reply

First, we thank the authors for the comments regarding our recent article in Arquivos Brasileiros de Cardiologia entitled “Factors Associated with Recurrence in Takotsubo Syndrome: A Systematic Review”. In the letter, the authors made some interesting additional comments regarding the mechanisms of Takotsubo recurrence related to mechanical triggers related to mid-ventricular gradient that may be related to associated hypertrophic cardiomyopathy (HCM) and a second mechanism related to severe adrenergic discharge.

One question they posed was related to the incidence of HCM and hypertensive heart disease in the data we analyzed. Actually, in the original papers that were revised, the authors did not mention HCM or hypertensive heart disease incidence. Some patients with Takotsubo Syndrome (TS) may present with systolic anterior motion of the mitral valve and ventricular obstruction; it is sometimes difficult to determine whether these features are related to TS or associated to HCM or even their combination and the clinic, electrocardiographic and image follow-up may reveal the diagnosis.^, About the impact of the surgical reconstruction on recurrence, in a brief review of literature we found one article describing a case of ventricular reconstruction in a female who remained with apical aneurism and recurrent embolic events. Therefore, in the case of permanent ventricular outflow obstruction in HCM who has TS, one may consider the indication of the HCM guidelines for surgical intervention.

[…]

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