Arquivos brasileiros de cardiologia最新文献

Background: Risk scores (RS) for patients with acute coronary syndromes (ACS) and coronary artery bypass grafting (CABG) have been tested previously, but little is known about their value in ACS patients undergoing CABG during the index hospitalization.

Objectives: To compare five different RS in ACS patients undergoing CABG during the index hospitalization.

Methods: The analyzed RS were GRACE, TIMI-non-ST-elevation ACS (TIMI-NSTEACS), TIMI-ST-elevation acute myocardial infarction (TIMI-STEMI), ACUITY/HORIZONS (A-H) bleeding, and EuroSCORE II. The RS were evaluated regarding their performance during the in-hospital phase and the long-term follow-up after discharge; a p-value <0.05 was considered significant.

Results: A total of 999 patients were included between 1998 and 2022. The mean time from symptom onset to CABG was 6.3 ± 5.5 days. The areas under the ROC curves were 0.82 (95% CI 0.74 - 0.89, p<0.001) for GRACE, 0.78 (95% CI 0.62-0.93, P=0.004) for TIMI-STEMI, 0.75 (95% CI 0.61-0.83, p<0.001) for EuroSCORE II, 0.67 (95% CI 0.59-0.76, P<0.001) for A-H bleeding, and 0.58 (95% CI 0.49-0.67, p=0.131) for TIMI-NSTEACS. Excluding in-hospital deaths, only GRACE and TIMI-STEMI were significantly associated with long-term mortality (mean follow-up of 5.5 ± 4 years). In the multivariable analyses, the GRACE score was the only RS significantly associated with in-hospital and long-term mortality in all adjusted models.

Conclusion: In patients with ACS who underwent CABG during the index hospitalization, the GRACE score was the only risk score that remained independently associated with both in-hospital and long-term mortality across all developed models, after adjustment for potential confounders. Moreover, the GRACE score performed better than others in predicting in-hospital deaths. These findings may influence the clinical decision-making process in this high-risk population.

Background: Between 2020 and 2023, the COVID-19 pandemic had a direct impact on population health. In Brazil, there is a lack of studies on the correlation between mortality from diseases of the circulatory system (DCS) and cardiorespiratory arrest (CRA) among people younger than 20 years during this period.

Objective: To analyze, using DCS and CRA, the mortality rates (MRs) due to underlying causes of death among people younger than 20 years in Brazil from 2019 to 2022 to understand the impact of the pandemic.

Methods: Ecological time-series study conducted between 2019 and 2022, focusing on deaths among people younger than 20 years. The analysis included the MRs and proportional mortality (PM) by cause of death, with data obtained from the DATASUS. Stata and Excel were used for statistical analysis.

Results: Between 2019 and 2022, there were 243,358 deaths among people younger than 20 years, with an MR of 101.7 per 100,000 inhabitants, which was higher among children younger than 1 year. The main causes of death were perinatal, external, and congenital malformations. There was a 9% reduction in MR between 2019 and 2020, followed by a 4.08% increase between 2021 and 2022, along with a 10% decrease in the number of live births. The highest MRs were in the North and Northeast regions. The MRs by DCS decreased between 2019 and 2021 but increased in 2022. Reporting of CRA as the cause of death was infrequent.

Conclusion: There was a reduction in MRs due to all causes and an increase in DCS in people older than 15 years during the pandemic, with disparities in lower-income regions.

Background: The financial burden faced by patients with advanced heart failure (HF) who are ineligible for heart transplantation or lack have access to advanced therapy with left ventricular assist devices (LVADs) has not been described in Latin American.

Objective: To conduct a microcosting study in patients who were otherwise eligible for LVAD therapy who did not have access to it.

Methods: We evaluated the direct costs of care in a cohort of advanced HF patients treated at a Brazilian public hospital who were candidates for LVAD therapy (and ineligible for transplantation) but lacked access to the procedure. A patient-level cost analysis was performed from the time LVAD need was identified until death or end of follow-up. The total cost per patient was calculated using the time-driven activity-based costing methodology and expressed in international dollars (Int$). Patients were stratified by disease severity and all-cause mortality to assess cost variability.

Results: Figure 2.

Conclusions: This study highlights the financial burden associated with ongoing medical management of advanced HF in patients who would otherwise be eligible for LVAD therapy. These findings provide a basis for evaluating the cost-effectiveness of device-based, life-saving interventions in selected advanced HF populations.

Complete atrioventricular block may be associated with Takotsubo syndrome, and the decision of device implantation in such patients is challenging. We present a case of a 76-year-old woman admitted after out-of-hospital cardiac arrest that was reverted after defibrillation treatment. Post-resuscitation electrocardiogram documented complete atrioventricular block, and echocardiogram revealed severe left ventricular dysfunction with apical ballooning. Coronary angiography excluded coronary artery disease, and Takotsubo syndrome was diagnosed based on clinical and imaging features. Atrioventricular block persisted despite normalization of left ventricular function; therefore, cardiac arrest was considered secondary to a ventricular arrhythmia induced by atrioventricular block, and a pacemaker, rather than an implantable cardioverter-defibrillator, was implanted. During follow-up, complete atrioventricular block persisted, with 99% of ventricular pacing observed upon device interrogation. This case supports that the stress of atrioventricular block may trigger Takotsubo syndrome, which is reinforced by the persistence of conduction abnormalities despite reversal of ventricular defects. Therefore, early implantation of a cardiac device should be carefully considered on a case-by-case basis.

Background: The role of the long noncoding RNA ZEB1-AS1 in cardiac hypertrophy (CH) remains unclear.

Objectives: To investigate the function of ZEB1-AS1 in the development and progression of CH as well as elucidate its underlying molecular mechanism.

Methods: RNA expression levels were quantified by quantitative real-time PCR. Surface area of AC16 cells was assessed by immunofluorescence staining. Protein expression was evaluated by Western blotting. Interactions among RNAs were examined using luciferase reporter assays and RNA immunoprecipitation. Statistical significance was set at p < 0.05.

Results: The expression of ZEB1-AS1 was upregulated in myocardial tissues and in isoproterenol (ISO)-stimulated AC16 cells. The knockdown of ZEB1-AS1 mitigated ISO-induced hypertrophic responses. Mechanistically, ZEB1-AS1 modulated histone deacetylase 2 (HDAC2) expression by acting as a molecular sponge for miR-186-5p. Consistently, the knockdown of ZEB1-AS1 reduced HDAC2 and decreased the expression of hypertrophic markers, including B-type natriuretic peptide, atrial natriuretic peptide, and β-myosin heavy chain, thereby restraining the progression of CH.

Conclusions: ZEB1-AS1 is upregulated in myocardial tissues and ISO-stimulated AC16 cells. Our findings indicate the ZEB1-AS1/miR-186-5p/HDAC2 axis contributes to CH, providing a mechanistic basis and potential therapeutic target for clinical intervention.

Background: Chronic obstructive pulmonary disease (COPD) is a progressive disease with high mortality, and understanding the predictors of adverse outcomes can aid in developing individualized therapeutic approaches and in making decisions regarding hospital or intensive care unit admissions.

Objective: To assess the epidemiological and laboratory profiles of patients with COPD and to correlate clinical, echocardiographic, and biomarker variables with unfavorable outcomes due to exacerbation.

Method: This was a prospective study involving patients with COPD who underwent clinical evaluation, spirometry, transthoracic echocardiography, and laboratory tests. Patients were followed for 1 year to monitor for unfavorable outcomes. The significance level considered for all analyses was p < 0.05.

Results: A total of 228 patients were included, with the mean age of 71 ± 9 years. The majority of patients were male (58%), and smoking (72%), hypertension (66%), and GOLD B (55%) were predominant. Indexed left atrial volume (ILAV) demonstrated good accuracy in detecting hospitalization for exacerbation, with a cutoff point of 36.5 ml/m2, yielding 100% sensitivity and 70% specificity. Patients with ILAV > 36.5 ml/m2 exhibited worsening diastolic and systolic function, as indicated by mitral E wave peak velocity in the rapid filling phase/E' velocity of displacement of the septal or lateral mitral annulus in the rapid filling phase (E/E') (p = 0.02) and left ventricle ejection fraction (p = 0.01), along with elevated levels of tumor necrosis factor alpha (p = 0.05) and NT-proBNP (p = 0.03).

Conclusion: ILAV may be a reliable marker for predicting unfavorable outcomes in patients with COPD. Individualized strategies should be implemented to improve disease severity and cardiovascular function.

Background: Cardiovascular diseases are the leading cause of death in Brazil, with acute myocardial infarction (MI) accounting for a significant share of these fatalities. Women tend to experience MI at older ages and in the presence of more comorbidities - factors that may negatively impact prognosis. Locally generated evidence is essential to guide targeted strategies within the public health care system.

Objective: To assess the influence of age and sex on post-MI mortality among patients treated within the Brazilian Unified Health System.

Methods: This retrospective cohort study included patients residing in Curitiba who were hospitalized for MI (International Classification of Diseases, 10th Revision code I21) between 2008 and 2015. Mortality data were obtained from the Brazilian Mortality Information System. In-hospital mortality, as well as mortality at 6 and 12 months and at the end of follow-up, were analyzed. Age (both as a continuous and categorical variable) and sex, as well as their interaction, were included in the analysis. Statistical significance was set at 5% (p < 0.05).

Results: The sample included 4,896 patients (mean age 62 ± 12.4 years; 34.1% women), with an average follow-up of 50.9 months. Overall mortality was 29.5%. On average, women experienced MI 5 years later than men (65.1 vs. 60.3 years; p < 0.001) and had higher follow-up mortality (p < 0.001). However, in the multivariate analysis, only age remained significantly associated with mortality. Age-stratified analysis revealed a higher risk of death among women aged 45-54.9 years (p = 0.004).

Conclusion: Older age contributes to the worse post-MI prognosis observed among women compared to men. However, women in early middle age showed an increased risk of death, representing a potentially vulnerable group requiring specific attention.

Caseous necrosis of the mitral valve is the term used to describe the liquefaction of calcium present in its fibrous ring and the consequent formation of a pseudotumor with a thick, pasty content within. Although rare, this degenerative process has been widely described in the context of the mitral valve; however, it is little known in the context of constrictive pericarditis. We describe a series of seven cases that presented with constrictive pericarditis associated with caseous necrosis. Of the seven patients, six were male, with a mean age of 42±14 years, all in functional class III/IV, with clinical signs related to restrictive syndrome. Chest tomography showed intense pericardial calcification with caseous necrosis, confirmed by pericardiectomy.

Background: Atherosclerotic cardiovascular disease - particularly ischemic heart disease (IHD), stroke, and peripheral artery disease (PAD) - is the leading cause of cardiovascular mortality in Brazil.

Objectives: This study aimed to project mortality trends for IHD, stroke, and PAD in Brazil through 2040.

Methods: Annual death counts (1990-2021) for IHD, stroke, and PAD among individuals aged 40-79 years were obtained from the Global Burden of Disease (GBD) 2021 study. Mid-year population estimates for both observed (1990-2021) and projected (2022-2040) periods were used. Crude and age-standardized mortality rates were calculated. Bayesian age-period-cohort models were applied to project mortality rates from 2022 to 2040. Relative percentage changes and estimated annual percentage changes (EAPCs) were computed. Projections (per 100,000 population) are reported as medians with 95% uncertainty intervals (UIs), and EAPCs include bootstrap-derived confidence intervals (CIs).

Results: Between 1990 and 2040, Brazil's population aged 40-79 years is projected to grow by 237.82%. The age-standardized mortality rate for IHD is expected to decline by 14.16% [from 118.61 in 2021 to 101.82 in 2040 (95% UI, 0.36-203.27)] (EAPC: -0.83% [95% CI, -0.84 to -0.83]); and for stroke by 17.36% [from 84.58 to 69.90 (95% UI, 0-152.48)] (EAPC: -1.07% [95% CI, -1.10 to -1.04]). In contrast, PAD mortality is projected to increase by 10.99% [from 1.82 to 2.02 (95% UI, 0-5.03)] (EAPC: 0.45% [95% CI, 0.30-0.59]). Additionally, sex-specific age-standardized mortality rates showed considerable variation. For IHD, rates are projected to decline by 25.31% among men (EAPC: -1.56% [95% CI, -1.57 to -1.55]), while increasing by 4.12% among women (EAPC: 0.14% [95% CI, 0.13-0.16]). Stroke mortality is expected to decrease by 30.00% in men (EAPC: -1.94% [95% CI, -1.96 to -1.91]) and by 4.52% in women (EAPC: -0.33% [95% CI, -0.37 to -0.29]). In contrast, PAD mortality is projected to rise by 14.64% in men (EAPC: 0.55% [95% CI, 0.38 to 0.71]) and by 21.92% in women (EAPC: 0.91% [95% CI, 0.78-1.02]).

Conclusion: While mortality rates for IHD and stroke are projected to decline, PAD mortality is expected to rise - particularly among women - highlighting the urgent need for sex-specific and disease-specific public health interventions.

Background: Transcatheter aortic valve implantation (TAVI) has emerged as a preferred treatment for severe, symptomatic aortic stenosis (AS). However, comparative data with surgical aortic valve replacement (SAVR) within the Brazilian public health system (SUS) remain limited.

Objective: To compare clinical outcomes and perform a cost-analysis of TAVI versus SAVR in SUS patients.

Methods: This retrospective, single-center study evaluated clinical outcomes and direct medical costs, using a statistical significance threshold of 5%.

Results: Between 01/2018 and 12/2022, 320 patients (139 TAVI, 181 SAVR) were included. TAVI patients were older (77.9 vs. 64.9 years, p<0.001) and had higher surgical risk (STS 3.62% vs. 1.64%, p<0.001). Mortality (2.9% vs. 5.0%) and stroke rates (1.4% vs. 3.3%) were numerically lower for TAVI, but not statistically significant. In a risk-adjusted composite outcome (death, stroke, re-hospitalization), TAVI showed potential superiority (5.8% vs. 12%, OR 2.68, 95% CI 1.04-7.65, p=0.05), though not statistically significant. TAVI was associated with a shorter hospital stay (2.0 vs. 8.0 days, p<0.001). TAVI's total cost was significantly higher than SAVR's (R$ 55,750.90 [52,345.30; 92,286.80] vs R$ 22,518.10 [19,130.60; 25,875.10, - p<0.001]).

Conclusions: In this study, TAVI displayed similar clinical outcomes compared to SAVR, while being performed on older patients with higher surgical risk. From an economic perspective, costs of TAVI treatment were significantly higher than SAVR, driven mainly by device costs, while in-hospital length of stay was significantly lower. With extended follow-up and reduced procedural costs, TAVI may become a cost-effective option in the SUS.