2024;37 – ABC CARDIOL

IJCS

Família ABC | IJCS

Original Article

Catheter-Directed Therapy for the Management of Intermediate-High-Risk and High-Risk Pulmonary Embolism: Experience from a Single-Centre in Portugal

André Alexandre et al. Bárbara Gonçalves Bruno Brochado David Sá-Couto … Mariana Santos Diana Ribeiro Raquel Baggen-Santos André Luz João Silveira Severo Torres

Abstract

Background:

Acute pulmonary embolism (PE) is a significant cause of morbimortality. Epidemiological data in Portugal are limited, potentially leading to underdiagnosis. Catheter-directed therapy (CDT) is a promising alternative treatment, particularly for high-risk patients.

Objectives:

To evaluate the impact of CDT on intermediate-high-risk and high-risk acute PE.

Methods:

This is a retrospective single-centre study conducted from 2019 to 2023 in Portugal. Data included patient demographics, clinical presentation, procedural characteristics, and outcomes. Comparisons before and after the procedure were carried out, using two-sided paired Student´s T-test or McNemar´s test. P-value < 0.05 was considered statistically significant.

Results:

Among the 21 patients included in this study, the mean age was 62.5 (±16.8) years and 57% (n = 12) were female. Bilateral PE was predominant (n=18, 86%), with fifteen patients (75%) classified as high-risk PE and five (25%) as intermediate-high-risk PE. Overweight (n = 12, 57%), hypertension (n = 9, 45%), dyslipidaemia (n = 8, 40%), immobility (n = 4, 20%), and active cancer (n=3, 14%) were prevalent comorbidities. The median Charlson Comorbidity Index score was 3.5 (IQR 1.2–4.0). Two-thirds (n = 10, 67%) of the patients with high-risk PE exhibited contraindications to systemic fibrinolysis, while one-third (n = 5, 33%) had previously undergone failed thrombolysis. CDT improved hemodynamic parameters, significantly reducing the right ventricular (RV) dysfunction after the procedure (72.2% vs 23.5%, p=0.008). There was a low incidence of bleeding complications, with only one patient (5%) experiencing life-threatening haemorrhage. Despite these improvements, in-hospital mortality remained high (n = 5, 24%). No deaths occurred within three months post-discharge.

Conclusions:

Despite being in its early stages, CDT showed encouraging results in improving hemodynamic and clinical parameters in intermediate-high-risk and high-risk acute PE patients. Larger trials are warranted to further evaluate its efficacy and establish its role in treatment protocols.

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Original Article

The Association Between IL-4 Expression and Thrombus Events in Rheumatic Heart Disease Patients

Arini Rizky Wijayanti et al. Dyah Samti Mayasari Erika Maharani Hasanah Mumpuni … Sofia Pranacipta Emilia Theresia Nungki Anggorowati Ery Kus Dwianingsih

Abstract

Background:

Rheumatic heart disease (RHD) is the leading cause of valve disease in developing countries, with intracardiac thrombus events as one of the frequent manifestations. Based on Trias Virchow, a thrombus occurs because of endothelial injury, blood flow abnormality, and hypercoagulability. In RHD, this condition is caused by inflammation, mitral stenosis (MS), and atrial fibrillation (AF). Pro-inflammatory cytokines promote thrombus formation, and anti-inflammatory cytokines inhibit it. IL-4 is an anti-inflammatory cytokine that can potentially inhibit thrombus formation because it can inhibit other pro-inflammatory cytokines and polarize M2 macrophages.

Objectives:

This study aims to know the association of IL-4 expression with thrombus events in RHD patients.

Methods:

Twenty-five (25) patients enrolled in this study were diagnosed with RHD and underwent mitral valve replacement surgery. Valve tissues were collected for histopathological and immunohistochemical examination using IL-4. Thrombus event obtained from echocardiography result. The Mann-Whitney test was used to compare IL-4 expression in thrombus and non-thrombus patients. A p-value of less than 0.05 (p<0.05) was considered the significance level.

Results:

Of the 25 patients, 88% were older than 30 years. Thrombus occurs in 28% of RHD patients and is associated with AF (p 0.001). Patients with moderate and high IL-4 expression did not have less thrombus than patients with low IL-4 expression.

Conclusions:

Intracardiac thrombus formation in RHD patients is not associated with IL-4 expression but is strongly associated with AF. Further research that identifies other cytokines coexisting with IL-4 at the site of injury may reveal better insight into the event.

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Original Article

Epidemiological Profile and Comparison of Mortality Due to Stroke and Atrial Fibrillation in Brazil Over the Past 26 Years

Leticia Da Costa Santana Silva et al. Luana Yasmim Fernández Avelaneda Castanheira Maria Dalila Santos Salim Ohara Rumayane Paiva Santos Rebouças Ruy Felipe Melo Viegas

Abstract

Background:

Atrial fibrillation (AF) stands out as the most prevalent arrhythmia, and its incidence increases with age. Stroke ranks as the second leading cause of mortality in Brazil and represents the primary contributor to global disability.

Objective:

Considering the severity of these conditions, this study seeks to elucidate the epidemiological landscape of AF and stroke-related deaths in Brazil from 1996 to 2022.

Methods:

The following variable were analyzed in the study – geographic region, federative state, age demographics, gender distribution, year of mortality, race/ethnicity, educational attainment, and place of death. This research adopted a descriptive approach through a retrospective, exploratory, epidemiological analysis of data sourced from the Mortality Information System (SIM) accessible through the Department of Health Informatics of the Brazilian Unified Health System (DATASUS) website.

Results:

Over the 26-year period, 1,201,327 deaths from AF and stroke were registered in Brazil. These deaths were mostly caused by stroke (94.5%) and were more concentrated in the southeast region, where the highest number of doctors capable of identifying and notifying these deaths are also concentrated.

Conclusion:

This study claims for a paradigm shift in disease control strategies and underscores the imperative of bolstering the efficacy of public health policies to address the huge impact of stroke and AF-related mortality on population health.

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Case Report

Six-Year Follow-Up of an Octogenarian With a Left Atrial Myxoma: Case Report

Miguel Bernardino Antunes Vicente et al. Tânia Amaro Elsa Fernandes

Abstract

Myxoma is the most common primary cardiac tumour, especially in adults. However, reports on this nosological entity in patients over the age of 80 are scarce in the medical literature. Echocardiography is a useful diagnostic tool for detecting cardiac myxomas. These tumours are usually surgically removed soon after diagnosis, limiting knowledge of their natural evolution. In this report, we describe the case of an 86-year-old woman who had been followed irregularly for arterial hypertension since 2016, when an echocardiogram showed a left atrial myxoma adhered to the interatrial septum, initially without impairment of the mitral valve (MV) or obstruction of the pulmonary veins (PV). The patient refused surgical removal at the time. Six years later, she was hospitalized for urinary sepsis. A new echocardiogram revealed an increase in the size of the myxoma, which occupied around 80% of the left atrium (LA), obstructing the PV and MV. New suggestion of surgery was refused by the patient.

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Editorial

COVID-19 and History of Coronary Artery Bypass Surgery

María del Carmen Lacy-Niebla et al. Alfonso Buendia-Hernandez

In this study conducted in Brazil, a group of patients with a history of coronary artery bypass surgery with or without COVID-19 disease was analyzed to determine if their quality of life significantly changed after infection. They observed that patients with a history of COVID-19 infection had a worse quality of life during the four years of follow-up. No significant differences were found in the incidence of acute myocardial infarction, cerebral vascular events or thromboembolism, which is surprising and differs from what was expected.

On March 11, 2019, the World Health Organization declared the COVID-19 disease a pandemic. From that moment on, we believed that COVID-19 mainly affected the respiratory system and that in approximately 20% of patients, the disease was very serious with a high mortality rate. Over time we learned that COVID-19 is a multisystem inflammatory disease that is associated with cardiovascular manifestations. About half of patients hospitalized for COVID-19 have cardiovascular conditions that include coronary heart disease or a history of cerebral ischemic event, and 15-20% of them have complications like myocardial ischemia, heart failure, arrhythmias and dysautonomia.^– Patients with previous cardiovascular disease may become unstable when COVID-19 occurs, mainly due to a decrease in myocardial reserve and increase in oxygen consumption and metabolic demands.

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Original Article

Agreement Between a Portable Cholesterol Device and Laboratory-Based Testing in Older Adults

Odilon Abrahin et al. Naicha Stefanie Félix Souza Rejane P. Abrahin Alex Harley Crisp

Abstract

Background:

It is crucial to monitor blood lipid levels accurately in older adults to assess cardiovascular risk. Although several portable strip-based devices are commercially available, their accuracy has not been well established.

Objective:

To evaluate the agreement of the Mission Cholesterol device and standard laboratory method results, using samples from older adults.

Methods:

Forty-nine patients (42 females) with an average age of 70 ± 8 years were included. The participants were instructed to fast for 12 hours before undergoing venous and capillary blood sampling for lipid analysis (total cholesterol [TC], high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], and triglyceride [TG] levels). The agreement between the Mission Cholesterol device and laboratory test results was assessed using the concordance correlation coefficient (CCC) and Bland–Altman plots. The accuracy levels were assessed based on the percentage bias recommended by the National Cholesterol Education Program (NCEP).

Results:

The TC measurement had a better accuracy level (bias = 10.91%; CCC = 0.89) than other lipid measurements. However, none of them met the NCEP’s acceptable standards for bias and concordance (CCC ≥ 0.90). Furthermore, the device demonstrated modest overall agreement in classifying lipid risk according to clinical reference values (agreement rates: TC, 67.3%; HDL-C, 65.3%; LDL-C, 49.0%; and TG, 61.2%).

Conclusion:

The Mission Cholesterol device exhibited insufficient agreement levels for effective lipid profile monitoring and screening in older adults.

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Original Article

Prevalence of Cardiac Amyloidosis in Elderly Patients With Aortic Stenosis

Ng Kin Key et al. Adelina Sanches de Melo Joberto Pinheiro Sena Adriano Dias Dourado … Julia Micheli Perez Jose Carlos Raimundo Brito Gilson Feitosa Gilson Soares Feitosa-Filho

Abstract

Background:

Aortic Stenosis (AS) is one of the most common valvular heart diseases in adults, especially the elderly. The persistence of heart failure symptoms and worse outcomes despite valve replacement treatment may be associated with the coexistence of Cardiac Amyloidosis (CA).

Objective:

To determine the prevalence of CA in patients with calcific AS.

Methods:

This was a cross-sectional study. Elderly patients with moderate to severe AS underwent cardiac scintigraphy with bone radiotracer for diagnosis of CA. Patients diagnosed with Transthyretin (TTR) amyloidosis by scintigraphy underwent genetic studies. Groups with altered and unaltered scintigraphy results for continuous variables were compared using an independent t-test for normally distributed variables and a Mann-Whitney test for those with asymmetric distribution. Statistical significance was set at p-value < 0.05

Results:

Forty-one patients with AS underwent pyrophosphate scintigraphy. The mean age of the cases was 79 ± 6 years, 23 (56%) were female, 23 (56%) had classic severe AS pattern, and 8 (19.5%) had low-flow low-gradient AS with reduced Ejection Fraction (EF). Carpal tunnel syndrome was present in 2 (4%) patients, 8 (19%) had polyneuropathy. A RAISE score ≥ 2 was found in 4 patients (9%). Four patients were diagnosed with TTR amyloidosis, one of whom had a Val122I genetic mutation. Three (75%) of the patients diagnosed with AE/AI were male. There were no statistically significant differences between the isolated AS and AS/CA groups.

Conclusion:

The prevalence of CA in patients with moderate to severe AS of probable calcified etiology in our sample was 10%.

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Original Article

Distal Transradial Access for Coronary Procedures: Insights from 6,800 Consecutive All-Comers Patients from the DISTRACTION Registry

Marcos Danillo Oliveira et al. Ricardo Fonseca Oliveira Suruagy Motta Adriano Caixeta

Abstract

Background:

Distal transradial access (dTRA), an improvement of the conventional proximal transradial access (pTRA), has advantages in terms of faster hemostasis and lower rates of proximal radial artery occlusion (RAO).

Objectives:

We aim to describe our real-world experience with dTRA as the default approach for routine coronary angiography and percutaneous coronary interventions (PCI) in a large-scale sample of all-comers patients.

Methods:

From February 2019 to April 2024, 6,800 consecutive patients undergoing coronary procedures via dTRA were enrolled in the DISTRACTION (DIStal TRAnsradial access as default approach for Coronary angiography and intervenTIONs) Registry.

Results:

Mean patient age was 63.8 ± 15.7 years; 65% were male. Overall, 20.8% of patients had non-ST-elevation myocardial infarction (NSTEMI); 22.3% had ST-elevation myocardial infarction (STEMI), and 2.5% presented in cardiogenic shock. There were only 2% access site crossovers, mainly to ipsilateral pTRA. In only 119 patients dTRA sheath insertion could not be obtained. Right dTRA was the most frequent access, followed by redo ipsilateral dTRA, left dTRA, and simultaneous bilateral dTRA. PCI was performed in 59.5% of all cases, and the left anterior descending artery was the most treated vessel. No significant access site-related bleeding and no hand/thumb dysfunction after any procedure were documented. There were neither major complications nor major adverse cerebrovascular and cardiac events directly related to dTRA.

Conclusions:

In this real-world large-scale registry of all-comers patients, the adoption of dTRA by proficient operators as the default for routine coronary angiography and interventions was safe and feasible.

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Editorial

Chagas Disease and Maternal Mortality: An Overlooked Link in a Neglected Disease in Brazil

Maria Alayde Mendonça Rivera et al. Ivan Romero Rivera Glaucia Maria Moraes de Oliveira Ana G. Múnera Echeverri Walkiria Avila

Maternal mortality (MM), defined as the death of a woman during pregnancy, childbirth, or within 42 days postpartum, is a key indicator of maternal health and the quality of care provided by the health care system to prevent and manage complications during this period.

In 2020, there were 287,000 maternal deaths worldwide, resulting in a maternal mortality ratio (MMR) of 223 deaths per 100,000 live births. According to the World Health Organization (WHO), 95% of these deaths will occur in low- and middle-income countries, and 90% will be preventable.

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Original Article

Prognostic Value of the 6-Minute Walk Test and Clinical Characteristics of Patients With Transthyretin Amyloid Cardiomyopathy

Cristhian Espinoza Romero et al. Natalia Melo Pereira Georgina Del Cisne Jadán Luzuriaga Bruno Vaz Kerges Bueno … Suenia Carvalhal Thais Borges Barbara Reis Fábio Fernandes

Abstract

Background:

In transthyretin amyloid cardiomyopathy (ATTR-CM), the assessment of functional capacity is of great importance. A distance < 300m covered in the 6-minute walk test (6MWT) is linked to a poorer prognosis in heart failure (HF) patients. However, in ATTR-CM, this association is not well-established, particularly among its various presentations and variants.

Objectives:

To evaluate functional capacity and, the prognostic value of the 6MWT in patients with ATTR-CM and to identify their clinical characteristics according to the type of ATTR-CM.

Methods:

This was a retrospective, single-center study that included patients with a confirmed diagnosis of ATTR-CM who performed the 6MWT. Median follow-up was 19 months (8 – 29). The significance level was set at P < 0.05.

Results:

A total of 32 patients were analyzed; 59.4% had the hereditary form (ATTRh), of which 63.2% were Val142Ile. Mean left ventricular ejection fraction (LVEF) was lower in the ATTRh group when compared to the wild-type form (ATTRwt) [42 ±11 versus 52± 9 %; p = 0.029]. Median distance walked in the 6MWT was 328 m (269 – 397; IQR) in ATTRwt and 304 m (246 – 387; IQR) in ATTRh, with no difference between groups (p = 0.833). In patients with a distance <300 m in the 6MWT, survival was lower (28.8 vs 36.3 months; p = 0.041).

Conclusions:

A distance <300 m walked in the 6MWT was linked to shorter event-free survival in patients with ATTR-CM. Functional capacity of most patients was very low, and no differences were observed in the distance covered between the wild-type form and the hereditary form of ATTR.

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Original Article

Evaluation of Prevalence, Management and Recording of Risk Factors in Outpatient Patients with Coronary Artery Disease

Alexandre Felipe Pacini et al. Gerson Luiz Bredt Junior Eline da Rós Moro Alcirley de Almeida Luiz Ana Paula de Oliveira Francez

Abstract

Background

Coronary artery disease (CAD) is the leading cause of mortality worldwide. Adequate management of risk factors is directly correlated with better outcomes.

Objectives

This study aims to identify risk factors and evaluate the indicated medical treatment (both pharmacological and non-pharmacological) in patients with CAD.

Methods

Epidemiological data were collected from electronic medical records of patients treated at Cardiology outpatient clinics of a Tertiary Hospital and a descriptive analysis of the data was performed.

Results

Patients with documented CAD (n = 230) were selected for the study, with a predominance of white (60%) men (62%), most of whom were monitored following an Acute Coronary Syndrome (ACS) (63.9%). High prevalence and irregular control of risk factors such as smoking, hypertension, dyslipidemia, diabetes, obesity, and sedentary lifestyle were observed. Target blood pressure was achieved in 52.6% of patients, low-density lipoprotein (LDL) in 5.7%, and HbA1c in 50.8%, despite appropriate prescriptions for most patients – 100% were prescribed statins, and over 90% received antiplatelet agents, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers, and beta-blockers. Few patients were encouraged to quit smoking and engage in physical activities.

Conclusion

Significant recording errors were noted in the medical records, along with inadequate control of CAD-related risk factors. Improvements in both recording and management of these risk factors are necessary to enhance CAD outcomes. The study utilized a straightforward and cost-effective model, which effectively mapped the local population profile and managed CAD risk factors.

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Editorial

Challenges in Worldwide Cardiovascular Urgencies and Emergencies

Daniel Piskorz et al. Ignacio Piskorz

The Sustainable Health Agenda for the Americas 2018-2030 represents the highest level of strategic planning and policy framework in the Americas. Approved by the Pan American Sanitary Conference — the top authority of the Pan American Health Organization (PAHO) — one of its main objectives is to achieve the highest attainable standard of health care. In this context, timely, affordable, and high-quality access to urgent and emergency health care is an essential requirement. The original research by Uchimura et al. aimed to identify the various challenges that hinder the effectiveness of urgent and emergency care networks. These challenges include inadequate regulatory mechanisms, difficulties in financial management across different levels of government, a lack of evaluation and monitoring culture, and weaknesses in information systems.

Over the past decade, the mortality profile in the Americas was dominated by noncommunicable diseases, which accounted for 78% of all deaths. The leading causes of death in the region were ischemic heart diseases (I20-I25), which accounted for 14.1% of total deaths, and cerebrovascular diseases (I60-I69), which accounted for 7.2% of total deaths.

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Review Article

Evolving Therapies for Transthyretin Cardiac Amyloidosis: New Clinical Trials with Amyloid Fibrils Depleter

Marcus Vinícius Simões et al. Fábio Fernandes André Dabarian Flavio Henrique Valicelli Claudio Tinoco Mesquita

Abstract

Amyloidosis is caused by the extracellular deposition of insoluble protein arrangements, formed from structural changes in different precursor proteins. The prominent clinical and epidemiological relevance of transthyretin amyloid cardiomyopathy (ATTR-CM), whose increased incidence is associated with the aging of the global population, given its high prevalence in the elderly population, has motivated the intensification of the search for specific therapeutic targets capable of altering the natural course of the disease. The past few years have been especially prolific with the emergence of significant new therapies for ATTR-CM, with important trials demonstrating positive results and changing the natural history of an inexorable and deadly disease. Up to now, the available drugs mainly promote stabilization of disease progression in patients with no advanced heart disease but grant no reversal of the structural cardiac disease in most cases. The transthyretin (TTR)-depleters based on monoclonal antibodies directed against the deposited amyloid fibers hold promise to fulfill these expectations. The DepleTTR-CM will test the safety and efficacy of a monoclonal antibody directed against TTR fibrils deposited in the myocardium of patients with ATTR-CM. This will be the first multicenter randomized controlled trial to test this new class of anti-amyloid treatment, the “amyloid fibril depleters”. This is a strategy designed to revert the amyloid accumulation in the cardiac interstitium, which is expected to translate into relevant clinical benefits, with the potential to close a gap in the ATTR-CM treatment strategies, mainly in patients with more severe disease.

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Original Article

Triglyceride-Glucose Index: Evaluation as a Potential New Risk Marker for SYNTAX Score in Acute Coronary Syndrome

Murat Özmen et al. Erhan Arikan Faik Ozel İsa Ardahanlı

Abstract

Background:

The triglyceride glucose (TyG) index is known to indicate conditions such as metabolic syndrome and atherosclerotic process. SYNergy between PCI with TAXUS (SYNTAX) and Cardiac Surgery scoring systems (SS) can show coronary anatomic severity and complexity because it is a quantitative and reproducible basic measurement before revascularization. There is no study in the literature investigating the relationship between the TyG index and the SYNTAX SS.

Objective:

This study aims to investigate a potential association between the TyG index and the SYNTAX score in patients with acute coronary syndrome (ACS).

Methods:

We retrospectively analyzed 214 patients hospitalized for ACS. Patient demographics and clinical characteristics were recorded, and participants were categorized into low, intermediate, and high SYNTAX score groups. The relationship between SS and TyG index was then evaluated using statistical analysis (chi-square test, p < 0.05).

Results:

The mean age of participants was 63.15 ± 12.69 years, with 67.8% being male. The majority (65.4%) had low SS, while 24.3% had intermediate SS, and 10.3% had high SS. As expected, the SYNTAX score correlated significantly with diabetes mellitus (DM) (p < 0.001). However, no statistically significant association was found between the SYNTAX score and the TyG index (p = 0.312).

Conclusion:

In patients diagnosed with ACS and undergoing coronary angiography (CAG), our study confirmed a strong link between SYNTAX score and DM. Unexpectedly, we did not find a significant relationship between the TyG index and SYNTAX score, suggesting that TyG may not directly reflect coronary artery disease (CAD) complexity as assessed by the SS.

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Editorial

Factors Associated with Variation in Time in Therapeutic Range (TTR)

Felipe Costa de Souza

Anticoagulant therapy is recommended for several conditions, including atrial fibrillation (AF), venous thromboembolism, and after heart valve replacement. While warfarin is commonly used to prevent ischemic stroke in patients with AF, direct oral anticoagulants (DOACs) and nonpharmacologic therapies may be equally or more effective than traditional warfarin.^, In addition, warfarin has a narrow therapeutic index and can interact with many drugs and foods, which poses a challenge to using it.

A key strategy for reducing the risk of stroke or bleeding associated with warfarin is to maintain an optimal time in therapeutic range (TTR). TTR refers to the length of time a patient’s international normalized ratio (INR) remains between 2 and 3, which is a widely accepted measure of effective warfarin management. While there is no universally accepted safe range for TTR, patients whose INR is in the therapeutic range more than 70% of the time have better outcomes in terms of stroke prevention. In addition, those with INR control greater than 40% of the time have improved survival.

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Case Report

Arrhythmogenic Substrate Ablation in a Patient With Brugada Syndrome and Electrical Storm

Arnóbio Dias da Ponte Filho et al. Ronaldo Vasconcelos Tavora Francisco Rodrigues dos Santos Neto André Gustavo da Silva Rezende Ieda Prata Costa

Abstract

Despite being a rare condition, Brugada syndrome (BrS) poses a significant risk of arrhythmic death, and managing associated ventricular arrhythmias is particularly challenging. Here, we present a case where percutaneous ablation targeted an arrhythmogenic substrate in a patient with BrS and recurrent ventricular fibrillation (VF). Epicardial mapping revealed abnormal potential areas in the right ventricle’s outflow tract and free wall. Injection of warmed saline into the pericardial space caused further delay in local electrograms and expanded the abnormal potential area. Radiofrequency applications in this region successfully eliminated abnormal electrograms, leading to the disappearance of the coved-shape ST-segment elevation in leads V1-V2. No recurrence of ventricular arrhythmias was reported in a twelve-month follow-up.

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Viewpoint

Biomarkers and Mononuclear Inflammatory Activity in COVID-19 Survivors

Marcio Carvalho et al. Antonio Lagoeiro

Introduction

COVID-19 has globally impacted 522 million people and caused 6 million deaths, despite the administration of 12 billion vaccine doses. Beyond respiratory effects, the virus has led to complications in the cardiovascular, hematological, and nervous systems, potentially resulting in organ dysfunction and death. Individuals with pre-existing medical conditions such as hypertension, diabetes mellitus, coronary artery disease, heart failure, and chronic kidney disease are associated with worse prognoses. Increased long-term mortality risk is observed, especially in the elderly population, regardless of the acute phase severity.

COVID-19 affects multiple organs beyond the lungs, including various cardiovascular diseases such as myocarditis, acute myocardial infarction, stress cardiomyopathy, arterial and venous thromboembolism, pericarditis, and arrhythmias. The pathophysiological mechanisms include systemic inflammation (cytokine storm), coagulopathy, direct viral invasion, hypoxemia, electrolyte imbalance, and fever.

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Review Article

Current Role of Myocardial Blood Flow Quantification with PET/CT in the Management of Coronary Artery Disease

Raffaele Giubbini et al. Elisa Milan

Abstract

The ability to measure myocardial blood flow (MBF) offers significant advantages in interpreting the phenomena underlying myocardial ischemia. Nuclear cardiology using hybrid positron emission tomography/computed tomography (PET/CT) systems allows accurate measurement of MBF using noninvasive techniques. Short- or very short-lived radiopharmaceuticals are now available, as well as standardized analytical models and software for clinical use. The incremental value of quantitative measurement of MBF in the pathophysiologic assessment of ischemic heart disease compared with anatomic variables or qualitative or semi-quantitative assessment by single-photon emission computed tomography (SPECT) with gamma-emitting tracers will be analyzed. The clinical role of MBF, myocardial flow reserve (MFR), and coronary flow capacity (CFC) will be clarified. However, the widespread availability of this technology is limited by the need for on-site cyclotron tracer production or the purchase of expensive radionuclide generators. The ability to obtain quantitative measurements using newer SPECT with cadmium-zinc-telluride technology and technetium-labeled tracers may offer the possibility of extending MBF measurement to most nuclear cardiology units in the near future.

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Viewpoint

Disparities in Women's Cardiovascular Health in Brazil

Larissa Franco de Andrade et al. Paolo Blanco Villela Jose Lucas Peres Bichara Luiz Antonio Viegas de Miranda Bastos Glaucia Maria Moraes de Oliveira

Cardiovascular diseases (CVD) are the leading cause of death in women worldwide, responsible for 30.4% of female deaths in 2021, according to the Global Burden Disease (GBD) study. In Brazil, between 1990 and 2020, CVD was the leading cause of death in the female population, represented mainly by ischemic heart disease (IHD) and stroke. In 2021, during the coronavirus pandemic period, COVID-19 was the major cause of death among Brazilian women, reaching 21.9% of total deaths, and the percentage of deaths attributed to IHD and CVD was 8.5% and 7.8%, respectively (). Additionally, from 1990 to 2021, proportional mortality from CVD was higher in females compared to males, with a similar percentage of deaths from IHD between the sexes and a higher percentage of deaths from stroke in women.

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Original Article

Development and Implementation of a Computerized Decision Support System for Screening Hypertension and Diabetes in a Resource-Constrained Region

Laura Defensor Ribeiro de Melo et al. Antonio Luiz Pinho Ribeiro João Antonio de Queiroz Oliveira Junia Xavier Maia … Thábata Queiroz Vivas de Sá Vânia Soares de Oliveira e Almeida Pinto Marcia Maria Oliveira Lima Patrick Wander Enlich Leonardo Bonisson Ribeiro Christiane Correa Rodrigues Cimini Milena Soriano Marcolino

Abstract

Background

Strategies aimed at improving the diagnosis and treatment of cardiovascular diseases (CVD) are of utmost importance. Clinical decision support systems (CDSS) are guided by updated guidelines and may be capable of benefiting screening and early diagnosis initiatives in remote regions.

Objective

To develop a CDSS for screening hypertension and diabetes mellitus (DM), as well as to assess its feasibility and usability in the context of a primary care setting in a resource-constrained region.

Methods

This research focused on the strategy of screening hypertension and DM based on CDSS. A software was developed and implemented in 10 municipalities in the Northeast of the state of Minas Gerais, Brazil, from April 2017 to October 2018. Patients of 30 to 69 years of age were attended by primary care practitioners using the software. A Likert-scale questionnaire with 15 questions to assess usability (System Usability Scale) and satisfaction was applied to the professionals at the end of study. Groups were compared by applying the chi-squared test for categorical variables. Statistical significance was considered as p < 0.05.

Results

In the field study, 13,775 individuals were assessed; 185 patients were diagnosed with hypertension; 35 were diagnosed with DM, and 5 were diagnosed with both diseases. For the usability and satisfaction assessment, 258 healthcare professionals participated. Fifty-one percent considered their prior knowledge for the use of technologies to be good; 53.7% reported a desire to use the application frequently, and 78.4% would recommend the platform.

Conclusion

The implementation of a CDSS developed to assist in the screening of hypertension and DM was feasible in the context of a primary care setting in a resource-constrained region, with good user satisfaction.

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Original Article

Quality of Life Assessment of Patients Infected With COVID-19 and Prior Coronary Artery Bypass Graft Surgery in Brazil: Four Years Follow-up

Adnaldo da Silveira Maia et al. Matheus Maia Adnaldo Lucas da Silveira Maia Magaly Arrais dos Santos

Abstract

Background

The COVID-19 pandemic has been a worldwide challenge. In patients with coronary artery disease (CAD), previously submitted to coronary artery bypass graft surgery (CABG), such impact should be analyzed.

Objectives

Evaluate the impact on quality of life of COVID-19 infection in patients with prior CABG.

Methods

Patients undergoing isolated CABG between July 2016 and July 2017 were enrolled. This is an observational, cross-sectional, prospective study. Patients were divided into two groups: Group (COVID-19) and Group (No-COVID), for analysis of variables. The World Health Organization’s (WHO) definitions of confirmed cases were used to define the diagnosis of COVID-19 infection. Quality of life was assessed using the Quality of Life in Cardiovascular Surgery (QLCS) questionnaire, applied 30 days, 6 months, 1 year, and 4 years after surgery. The primary endpoint was improvement in quality of life at 4 years after CABG. The local ethics committee approved the study. Continuous variables were described by their means and standard deviations (SD). Categorical variables were described using absolute or relative frequencies. The items that make up the quality of life questionnaire were added together to calculate the score. A linear mixed model was used to assess the effect of time on the score. The significance level adopted was 5%. The analyses were carried out using R software, version 4.2.1.

Results

The total sample consisted of 434 patients who underwent isolated CABG; the mean age was 63 years, with a prevalence of males (71%). Among the patients followed up at the 4-year follow-up (115), 60 (52%) were positive according to the WHO’s definitions. After multiple comparisons, there was a statistical difference in quality of life in all periods (P<0.001). Between patients with and without COVID-19, a statistical difference was observed at 1 and 4 years (p = 0.0039).

Conclusion

Patients who underwent CABG and had a history of COVID-19 infection experienced worsening quality of life within 4 years. There was no difference between groups regarding new acute myocardial infarction (AMI), stroke, or hospitalization.

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Review Article

Cardiac Amyloidosis in Women: An Underappreciated Diagnosis

Larissa Neto Espíndola et al. Gláucia Maria Moraes de Oliveira Cláudia Maria Vilas Freire Marildes Luiza de Castro Maria Cristina Costa de Almeida

Abstract

Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy that affects the heart mostly in two forms: immunoglobulin light chain amyloidosis (AL-CM) and transthyretin amyloidosis.

Transthyretin amyloid cardiomyopathy (ATTR-CM) predominantly affects the elderly population, mainly men (about 70-80%), and usually manifests with symptoms of heart failure (HF).

Despite technological advances in medicine, CA is still an underdiagnosed condition, especially in women, partly due to the known male predominance and high level of suspicion required for diagnosis. It is important to remember that amyloidosis is a systemic disease with a heterogeneous and non-specific presentation. It’s worth paying attention to the patient’s medical history and red flags in clinical and diagnostic tests (electrocardiogram [ECG], echocardiogram [ECHO], cardiac magnetic resonance [CMR]).

Accurate and timely diagnosis is crucial for appropriate management and prognosis.

So far, the under-representation of women in clinical trials may have also limited the evidence on sex-specific diagnosis, and outcomes.

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Original Article

A Geoprocessing Approach for Mortality and Social Vulnerability Analysis during the COVID-19 Pandemic

Andres Felipe Valencia Rendon et al. Isabela Mendes Volschan Manoella Novais Pereira Wagner Lima Monteiro … Alessandra de Freitas Pimentel Emilia Matos do Nascimento Basilio de Bragança Pereira Glaucia Maria Moraes de Oliveira

Abstract

Background

Brazil had high COVID-19 lethality/mortality with multiple social inequalities, where color/race was highly relevant, especially in Rio de Janeiro. Therefore, we hypothesize that COVID-19 hospitalized patients with a highly socially vulnerable background would have more significant in-hospital mortality.

Objective

To analyze the socioeconomic factors of social vulnerability and their association with COVID-19 mortality.

Methods

This work was a prospective study of 274 confirmed adult COVID-19 hospitalized patients in the University Hospital of Clementino Fraga Filho (HUCFF). The clinical features/blood chemistry information were collected from the clinical record. The ArcGIS Pro Software (Esri Gis mapping software, Redlands California-US) and a Python-based algorithm were used to determine in-app/in-map variable management relevance to the socioeconomic variables, inequity markers, and vulnerability. Our study also analyzed the transfers from other primary care institutions to our hospital in order to examine its potential delays in advanced medical care. Logistic regression and ROC curve were used to investigate in-hospital mortality for our statistical analysis. The significance level adopted in the statistical analysis was 5% Results: Male sex, total days of hospitalization, age, having more than three comorbidities, intensive care unit (ICU) admission, hemodialysis, and transfer from other hospitals showed statistical significance. Patients living in low-adequate households (p = 0.030) with high in-house individual agglomeration markers (p = 0.017) and transfers from another Primary Health Care (PHC) institution (p = 0.047) were associated with increased in-hospital mortality, with high ICU admission and mechanical ventilation.

Conclusions

In-hospital mortality due to COVID-19 was influenced by social individual background characteristics of vulnerability. Among other clinical parameters, these markers should be considered to predict the likelihood of complications related to the COVID-19 pandemic.

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Original Article

Evolution of Patients With Atrial Fibrillation According to the EHRA Categorization

Rose Mary Ferreira Lisboa da Silva et al. Letícia Tanure Diniz Laura Selga da Silva Gomes Lucas Espíndola Borges

Abstract

Background

The lifetime risk of developing Atrial Fibrillation (AF) is one in three adults, with a prevalence ranging from 2% to 4%. In 2017, the Evaluated Heart valves, Rheumatic or Artificial (EHRA) classification was introduced to guide oral anticoagulation (OAC) for patients with AF and valvular heart disease.

Objective

To analyze the evolution of patients with AF according to the EHRA categorization type 1, type 2, and those without valvular heart disease (group 3).

Method

Prospective, observational, and longitudinal study with 421 patients with AF, divided into three groups. Baseline risk scores for embolism, bleeding, and OAC quality were calculated. Events were verified during the 12-month clinical follow-up. Chi-square, parametric, and non-parametric tests were used for statistical analysis, in addition to the Kaplan-Meier curve. P-value < 0.05 was the statistical significance criterion.

Results

The average age was 58.6 years; 227 patients were women and 269 had OAC. There were 113 OAC EHRA type 1 patients, 53 type 2, and 255 patients from group 3. Age was lower, the proportion of women and OAC usage was higher in group 1 and there was a lower ejection fraction in group 3. During follow-up, the OAC percentage was 87.6% in type 1; 62.2% in type 2; and 56.0% in group 3 (p < 0.0001), with no difference regarding OAC quality, bleeding rate, embolism, or combined events. A higher total mortality rate was observed in group 3 (p = 0.02).

Conclusion

Despite the higher use of OAC in EHRA type 1, there were no differences between the groups regarding bleeding, embolism, or combined events. Group 3, characterized by greater systolic dysfunction, exhibited higher total mortality rates.

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