Arquivos brasileiros de cardiologia最新文献

Background: Both fondaparinux and radial access have been associated with lower rates of major adverse cardiovascular events (MACE) in acute coronary syndrome (ACS).

Objective: To evaluate the association between the use of fondaparinux plus radial access and clinical outcomes.

Methods: In this study, 956 patients admitted with ACS and treated with an invasive strategy were analyzed. The primary outcome - a composite of major bleeding (according to OASIS-5 criteria) and MACE - was compared across groups defined by anticoagulation regimen (fondaparinux or enoxaparin) plus arterial access site (femoral vs. radial). A p-value < 0.05 was considered statistically significant.

Results: The mean age of the study population was 65 ± 12.4 years, and 49.5% presented with non-ST segment elevation myocardial infarction (NSTEMI). Fondaparinux and radial access were used concurrently in 366 patients. The primary endpoint occurred in 78 patients (8.1%): MACE in 50 (5.2%) and major bleeding in 32 (3.3%). The event rate was lowest in the fondaparinux plus radial access group (3.3%), compared with enoxaparin plus radial access (9.8%), fondaparinux plus femoral access (8.6%), and enoxaparin plus femoral access (14.4%) (p < 0.001). Multivariable analysis showed that the use of fondaparinux was associated with a 43% reduction in the primary outcome (OR, 0.57; 95% CI, 0.34-0.96; p < 0.05), and radial access was independently associated with a 54% reduction (OR, 0.46; 95% CI, 0.26-0.83; p = 0.01).

Conclusion: The combination of fondaparinux and radial access was associated with the lowest rates of MACE and major bleeding, compared to either strategy alone.

Background: Handgrip strength (HGS) is a key indicator of overall muscle strength and functional capacity in patients with heart failure (HF). However, no reference equations specific to this population have been previously published.

Objectives: This study aimed to develop and validate a reference equation for predicting HGS in patients with HF.

Methods: A cross-sectional study was conducted on patients with stable HF, aged 18-79 years, diagnosed for at least three months. Maximum HGS value was obtained from three consecutive measurements. Clinical data and anthropometric assessments were collected. The sample was randomly divided into two-thirds (n=174) for derivation and one third (n=100) for validation. A multivariate regression model was applied to develop the predictive equation, including variables with a p-value < 0.25 as determined by the Wald test.

Results: Derivation and validation samples showed no significant differences at baseline. Patients were predominantly male, older adults, and white. The derived equation was: Predicted HGS = -39.732 + (10.771 * gender [female = 0; male = 1]) - (0.158 * age [years]) + (35.096 * height [m]) + (0.448 * calf circumference [cm]) - (4.224 * the New York Heart Association class [I /II = 0; III/IV = 1]). When applied to the validation sample, the equation underestimated actual HGS by 0.68 ± 8.93 Kg.

Conclusion: Age, sex, height, calf circumference, and NYHA class were key determinants of HGS in HF patients. The derived equation showed good predictive accuracy and may serve as a useful reference for interpreting grip strength in this population.

Background: Cardiovascular disease is the leading cause of mortality worldwide. Strategies that prioritize early diagnosis can reduce the incidence of related complications and cost.

Objective: To assess the cost-effectiveness of coronary computed tomography angiography (CCTA) as the initial diagnostic strategy for stable chest pain in patients with intermediate pre-test probability of stable coronary artery disease (CAD), in comparison with invasive coronary angiography (ICA).

Methods: A cost-effectiveness analysis was conducted comparing CCTA and ICA, considering data from the Brazilian private healthcare system. The model considered the direct costs of diagnostic exams, medical supplies, hospitalization for myocardial infarction, and myocardial revascularization in the 5 regions of Brazil. A budget impact analysis was performed regarding the gradual incorporation of CCTA over 5 years, considering 100,000 lives as the eligible population.

Results: The cost-effectiveness analysis comparing CCTA to ICA, estimated for a population of 100,000 lives, demonstrated cost savings of BRL 1,021.00 per life or a total of BRL 102,069,703.00 by the end of the fifth year. When considering the regional average cost of CCTA, for a population of 100,000 over 5 years, we observed the following cost savings per life and in 5 years, respectively: BRL 1,226.00 and BRL 122,577,793.00 in the North Region; BRL 1,460.00 and BRL 145,988,367.00 in the Northeast Region; BRL 1,625.00 and BRL 162,502,626.00 in the Central-West Region; BRL 1,313.00 and BRL 131,270,230.00 in the Southeast Region; and BRL 1,043.00 and BRL 104,268,937.00 in the South Region.

Conclusion: As an initial strategy for investigating stable chest pain, CCTA is cost-effective compared to ICA and is associated with significant cost reductions in the Brazilian private healthcare system.

Background: Advanced heart failure (HF) is associated with high morbidity and mortality rates, compromising the functionality and quality of life of patients and their families. Hospitalizations exacerbate disease severity, particularly when inotropic therapy is required. Palliative care (PC) supports the management of suffering caused by severe illnesses but is infrequently utilized in cardiology.

Objective: To evaluate the integration of PC in the management of decompensated HF, identifying opportunities to enhance patient care.

Method: This unicentric, retrospective, observational study was conducted between February 2015 and May 2018 with HF patients undergoing inotropic therapy. The study analyzed referrals for PC, the approach adopted by the PC-consultation team, and patient outcomes, including an analysis of 5-year survival rates. Statistical significance level: 5%.

Results: A total of 492 patients were included (66.9% male, median age 63 years, IQR 52-72). PC referral occurred in 23% of cases, with a median of 8.0 days (IQR 4.0-20) before death. Only 14% of intensive care patients were referred, and no transplant patients received PC evaluations. Patients assessed by the PC team were more involved in decision-making and received more opioid prescriptions for symptom management than those managed exclusively by cardiologists (p<0.01). In-hospital and 5-year mortality rates were 42% and 80%, respectively.

Conclusions: Patients experiencing decompensated HF demonstrate high mortality rates and are rarely referred to PC, often in the final days of life, limiting the potential benefits of this approach. Enhanced medical education in PC and the development of strategies to promote its integration may improve patient outcomes.

Background: Pulmonary valve regurgitation (PR) is often encountered in cardiac conditions, including heart failure (HF). Although typically tolerated, severe PR can lead to right ventricular dysfunction and negative clinical outcomes; however, its specific impact within the wider HF population needs further clarification.

Objectives: This study was designed to evaluate the association between the severity of PR and N-terminal pro-B-type natriuretic peptide (pro-BNP) levels, its effect on functional capacity measured by the six-minute walk test (6MWT), and the incidence of significant clinical problems in patients with HF.

Methods: Between 2016 and 2023, we conducted a retrospective study involving 579 HF patients who underwent echocardiography at two tertiary institutions. Based on semi-quantitatively evaluated PR severity, patients were classified into four groups: No PR, Mild PR, Moderate PR, and Severe PR. Group comparisons used Chi-square tests and Kruskal-Wallis. Multivariate linear regression and Spearman correlation analyses were performed to assess associations.

Results: Pro-BNP levels significantly increased across PR severity groups (Median: 2,157 pg/mL [No PR] to 23,541 pg/mL [Severe PR], p<0.0001). In contrast, 6MWT distance significantly decreased with deteriorating PR severity (Median: 254 m [No PR] to 72 m [Severe PR], p<0.0001). The prevalence of orthopnea and pleural effusion also increased with PR severity. After multivariate adjustment, PR severity remained independently associated with higher pro-BNP levels (β=0.48, p=0.002) and lower 6MWT distance (β=-0.39, p=0.008).

Conclusion: In patients with HF, increasing severity of PR is independently associated with elevated pro-BNP levels, reduced functional capacity, and a higher burden of clinical complications.

Background: Evidence on the safety and anti-ischemic effects of exercise-based cardiac rehabilitation (ECR) in patients with refractory angina (RA) remains limited.

Objective: To evaluate the safety and efficacy of a 12-week ECR program in patients with RA, focusing on improvements in symptoms, functional capacity, and ischemic burden assessed by exercise stress echocardiography (ESE).

Methods: This was a prospective, single-center, randomized controlled trial evaluating a 12-week ECR program in patients with RA. Forty-five patients were randomized to either the rehabilitation group (RG), receiving ECR, or the control group (CG), receiving medical treatment (MT) alone. Outcomes included mortality, cardiovascular events, anginal symptoms, and parameters from ESE and cardiopulmonary exercise testing (CPET). Statistical significance was set at p < 0.05.

Results: In ESE, exercise duration was significantly greater in RGpost (after ECR) compared to RGpre (before ECR) (∆ = 63.24 ± 19.87 s; p < 0.01). Angina quantification was lower in RGpost than in RGpre, CGpost (after MT alone), and CGpre (before MT alone) (∆ = -1.64 ± 0.48 n, p < 0.01; -3.10 ± 0.97 n, p < 0.01; and -2.73 ± 0.92 n, p = 0.01, respectively). The angina threshold was higher in RGpost than in RGpre and CGpost (∆ = 89.66 ± 33.16 s, p = 0.04; and 111.76 ± 42.25 s, p = 0.04, respectively). Improvement in ischemic burden on ESE was demonstrated by increased time to ischemic threshold in RGpost compared to RGpre, CGpost, and CGpre (∆ = 83.23 ± 21.84 s, p < 0.01; 98.44 ± 35.11 s, p = 0.03; and 109.34 ± 34.00 s, p < 0.01, respectively). In CPET, RGpost showed increased exercise duration (∆ = 104.54 ± 28.09 s, p < 0.01) and distance covered (∆ = 131.23 ± 30.48 m, p < 0.01) compared to RGpre. No significant differences in VO2 were observed between groups. Two patients in the CG group died. One patient in the RG group experienced prolonged angina during training. No significant differences in major cardiovascular events were observed between groups.

Conclusion: The 12-week ECR-program was safe and effective in improving exercise duration, distance covered and ischemic burden on ESE in patients with RA.

Background: There is a gap in information regarding the reperfusion strategies used and the evolution of patients with ST-segment elevation myocardial infarction (STEMI) in the state of Rio de Janeiro.

Objective: To assess thrombolysis time in the diverse regions of the state capital and metropolitan area of Rio de Janeiro, as well as the outcome of post-infarction heart failure.

Methods: EQUITY-MI is a prospective cohort study of patients diagnosed with STEMI and referred to a single reperfusion center. Continuous variables were analyzed using the Kruskal-Wallis test, and categorical variables were analyzed using the chi-square test. In order to estimate the effect of door-to-needle time (DNT), generalized linear regression models with gamma distribution and log link function were applied, in addition to quantile regression to estimate the effect at the 25%, 50%, and 75% quantiles, both adjusted for sex, age, race, and education level. The significance level applied was 0.05.

Results: The study included 457 patients, with a mean age of 60.4 years, 79% of whom received thrombolysis, with a median DNT of 77 minutes, and 20.9% were thrombolyzed within 30 minutes, with no statistical difference between regions (p = 0.23). The Baixada Fluminense region presented the highest adjusted mean DNT (165.9 minutes), with a time difference compared to the North Zone (0.61; 0.44 to 0.87; p = 0.003) and West Zone (0.69; 0.51 to 0.96; p = 0.022). It also presented the highest DNT in all intervals (Q25, Q50, Q75). After infarction, 63.5% of patients presented heart failure.

Conclusion: There was a general delay in DNT for patients included in the EQUITY-MI study, with worse systematic performance in the Baixada Fluminense region, in addition to a high incidence of post-infarction heart failure.

Background: Initial clinical and imaging associations in Takayasu's arteritis (TAK) are poorly defined.

Objectives: To characterize initial manifestations, their associations, and long-term outcomes in a TAK cohort.

Methods: A single-center retrospective cohort study (2000 to 2024) included patients diagnosed with TAK. The significance level was set at p<0.05.

Results: Among 203 patients identified, 54 were excluded due to incomplete data. The final cohort comprised 149 patients (89.9% female), with a median age at diagnosis of 31 years. At diagnosis, 92.6% were symptomatic. Claudication of upper (36.2%) and lower (30.9%) limbs was frequent, alongside advanced vascular damage like stenosis (85.9%) and occlusions (52.3%). Upper limb claudication was independently predicted by reduced upper limb pulses (OR=4.83; 95%CI=2.08-11.24; p=0.001) and right subclavian artery occlusion (OR=8.06; 95%CI=1.94-33.44; p=0.004). Lower limb claudication was predicted by right subclavian artery occlusion (OR=6.65; 95%CI=2.05-21.61; p=0.002), right subclavian artery thickening (OR=5.12; 95%CI=1.18-22.71; p=0.029), and left subclavian artery stenosis (OR=2.71; 95%CI=1.21-60.56; p=0.016). Over a median 10-year follow-up, despite 91.3% remission, cardiovascular comorbidities increased, and 26.8% required surgery.

Conclusions: Limb claudication is a key prognostic indicator of advanced radiological damage and diagnostic delay. This is reinforced by a long-term dissociation between high clinical remission and progressive vascular disease, demanding vigilant monitoring.

Background: Conduction system pacing (CSP) has emerged as an alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT), with potential clinical benefits and lower costs. PhysioSync-HF is a multicenter, randomized trial comparing these strategies from both clinical and economic perspectives in patients with heart failure with reduced ejection fraction (HFrEF).

Objective: To describe the rationale and design of the trial-based economic evaluation embedded within the PhysioSync-HF trial.

Methods: The PhysioSync-HF trial enrolled 179 patients with 1-year follow-up. Procedural cost data will be collected using a time-driven activity-based costing approach. Costs associated with the device, adverse clinical events, and ambulatory care during follow-up will be estimated using resource-based accounting methods. Appropriate methods will address missing data, and statistical analyses will account for the skewed distribution of cost variables.

Results: The primary economic outcome is the between-group difference in total direct medical costs per patient over the 1-year follow-up (CSP vs BVP). Secondary outcomes include component-level cost breakdowns of direct medical expenses and a budget impact analysis estimating the annual effect on Brazil's health care system if all eligible patients received CSP instead of BVP.

Conclusion: By leveraging a multicenter cardiovascular trial to measure costs of CSP versus BVP, this economic evaluation aims to identify cost-saving opportunities that could expand equitable access to CRT for individuals with HFrEF in Brazil, while providing insights relevant to other health care settings worldwide.

Trial registration: NCT05572736.