Arquivos brasileiros de cardiologia最新文献

Patients undergoing cardiac surgery often face multiple challenges, including comorbidities, frailty, and psychosocial factors, which complicate recovery. Multimodal prehabilitation programs have emerged as a promising strategy to address these issues, aiming to reduce the length of hospital stay, mitigate pulmonary complications, and enhance functional recovery. This Review Article examines the components and benefits of a comprehensive cardiac prehabilitation program, with a focus on exercise-based prehabilitation. Additionally, it underscores the importance of integrating prehabilitation into Brazilian clinical guidelines as a valuable preoperative opportunity. Emerging evidence, albeit of low to moderate quality, suggests that exercise-based prehabilitation, as a unimodal approach or integrating a multimodal program, can significantly improve functional capacity and postoperative outcomes in patients undergoing elective cardiac surgery. International guidelines have already supported cardiac prehabilitation as a valuable approach in this context. Globally, ongoing multicenter intervention trials seek to refine this evidence, pinpointing the ideal patient population and the most effective cardiac prehabilitation program. Given the growing burden of cardiovascular disease in Brazil, there is an unmet need for local research to assess the benefits of prehabilitation in patients undergoing cardiac surgery.

Background: Postural Orthostatic Tachycardia Syndrome (POTS) is an autonomic dysfunction characterized by symptoms of orthostatic intolerance, associated with an increase in heart rate within 10 minutes of assuming an upright position or head-up tilt, in the absence of hypotension. There are three phenotypes of POTS - neuropathic, hypovolemic, and hyperadrenergic - and all result in tachycardia and altered cerebral perfusion. Pharmacological therapy is indicated in certain cases; however, no specific medication has yet been approved for this condition. Some studies have shown that ivabradine may be beneficial, as it reduces heart rate without affecting blood pressure.

Objectives: To evaluate the efficacy and safety of ivabradine in the treatment of POTS.

Method: Systematic review using the descriptors "Ivabradine" and "Postural Orthostatic Tachycardia Syndrome" in the PubMed, Scielo, LILACS, and Google Scholar databases. Articles were grouped and assessed using the PICO strategy.

Results: A total of 52 articles were identified, of which seven were included in the review - three prospective and four retrospective studies. In total, 203 patients were evaluated, the majority of whom were female. All studies reported a significant reduction in heart rate and improvement in symptoms of orthostatic intolerance, with most patients not reporting adverse effects, regardless of their POTS phenotype.

Conclusion: Ivabradine proved to be effective and safe in the treatment of patients with POTS.

Background: Aerobic training (AT), whether moderate or high intensity, is widely employed in cardiovascular rehabilitation. Photobiomodulation therapy (PBMT) has shown potential to enhance exercise performance in athletes; however, its effects in patients with heart failure (HF) remain uncertain.

Objective: To investigate whether the addition of PBMT to moderate- or high-intensity AT improves cardiopulmonary exercise performance in individuals with HF.

Methods: This nonrandomized clinical trial included 49 patients with HF (mean age 62.7 years; ejection fraction < 40%), allocated into 5 groups: i) moderate training alone, ii) moderate training + PBMT, iii) high-intensity training alone, iv) high-intensity training + PBMT, and iv) control group. All participants underwent a 10-week intervention. Cardiopulmonary exercise testing was used to assess VO2peak, ventilatory efficiency, and exercise tolerance. Statistical analysis was performed using Generalized Estimating Equations, with alpha set at 5% (p < 0.05).

Results: Significant improvements in speed and grade during the exercise test were observed in the training groups, particularly in the high-intensity training group. This group demonstrated a greater increase in oxygen consumption (mean difference: 1.80 ml.kg-1.min-1 ± 0.59 ml.kg-1.min-1; p = 0.002) and superior performance in time to exhaustion (speed: p = 0.05; grade: p < 0.01). Comparisons across groups revealed that PBMT did not provide any relevant additional effects when combined with training.

Conclusion: AT, especially at high intensity, enhances exercise performance in patients with HF. The addition of PBMT did not confer significant additional benefits in this study. Further trials using optimized PBMT protocols are warranted.

Atrial fibrillation (AF) ablation has been increasingly employed as an effective strategy for rhythm control, leading to a reduction in arrhythmia burden, improved quality of life, and, in selected cases, decreased mortality. However, as an invasive procedure, it carries inherent risks. Severe esophageal complications-such as esophageal perforation or atrioesophageal fistula- though rare (with an incidence ranging from 0.025% to 0.113%), are associated with significant morbidity and mortality. Multiple risk factors for esophageal injury have been identified, including both patient-related and procedure-related characteristics. To mitigate these risks during radiofrequency (RF) ablation, several preventive measures have been adopted, including the use of contact force catheters, high-power short-duration energy applications, and protective strategies such as esophageal temperature monitoring, displacement devices, and cooling techniques. Deep esophageal lesions detected through surveillance endoscopy are considered potential precursors to more serious complications and, therefore, warrant close attention. Enhanced monitoring of patients with such lesions may be crucial for enabling early diagnosis and timely intervention to prevent the progression to more severe complications. While pulsed field ablation therapy, which poses a lower risk to the esophagus and other surrounding structures, is not yet widely available, the implementation of robust monitoring strategies can significantly improve clinical outcomes and enhance patient safety in the context of RF AF ablation.

Background: Conventional prognostic assessment scores often fall short in performance to predict mortality in patients with acute heart failure (AHF).

Objective: To develop and validate a machine learning-based prognostic score to predict in-hospital death in patients with AHF and compare its performance with the main traditional scores.

Methods: Patients admitted for AHF in Brazilian hospitals from the "Best Practices in Cardiology Program" from 2016 - 2022 were included. Clinical data, laboratory results, and the World Health Organization Quality of Life (WHOQOL-Bref) at hospital admission were collected. The outcome was in-hospital death. The model was trained using 70% of admissions (training set) and validated with the remaining 30% (test set). The ML-HF score area under the ROC curve (AUC) was compared with the AUC of the traditional scores Acute Decompensated Heart Failure National Registry (ADHERE) and Get With the Guidelines-Heart Failure (GWTG-HF). The level of significance was p<0.05.

Results: One thousand and one hundred fifty-seven patients hospitalized for AHF were included. The five most important variables of the ML-HF score were: Physical Health Domain Quality (WHOQOL-BREF), serum sodium, serum urea, serum creatinine, and systolic blood pressure at hospital admission. In the test set, the ML-HF score showed an adequate model calibration (Hosmer-Lemeshow test p value=0.056) and discrimination (AUC=0.722 [CI95%, 0.661-0.783]), which was superior to GWTG-HF (AUC=0.616 [CI95%, 0.529-0.702; p=0.014]) and the ADHERE (AUC=0.601 [CI95%, 0.511-0.691; p=0.006]) scores.

Conclusion: We developed and validated a score using machine learning to predict in-hospital death in patients with AHF, which outperformed the traditional scores.

Background: Computed Tomography (CT) angiography is widely used as a basic non-invasive modality to evaluate coronary artery disease. Inflammatory burden index (IBI) is a systemic inflammation indicator reflecting the inflammatory status. It is still difficult to determine the high risk of future acute myocardial infarction (MI) in patients with plaque detected by CT angiography.

Objective: This study aimed to evaluate the effectiveness of CAC scores and IBI in predicting MI risk among patients undergoing CT angiography for chest pain. We sought to assess the individual and combined predictive value of these indices, determine their optimal cut-off values, and compare MI risk across patient groups with varying CAC and IBI scores. We also aimed to evaluate the potential role of these markers in identifying 'vulnerable patients' at high risk for future cardiovascular events.

Methods: This retrospective study included 1235 patients who underwent CT angiography due to chest pain and were followed for 3 years (2.8-3.4). Patients were categorized into three models based on their CAC and IBI scores. The primary outcome was the occurrence of MI during the follow-up period. Statistical significance was established at p < 0.05 for all analyses.

Results: Patients who experienced MI had significantly higher IBI and CAC scores compared to those without MI. Logistic regression analysis identified CAC score and IBI as independent predictors of MI. ROC analysis determined optimal cut-off values for IBI (128) and CAC (102) in predicting MI. Kaplan-Meier analysis revealed a significant gradient in MI risk across the three models, with the highest risk observed in patients with both high IBI and CAC scores.

Conclusion: The combination of IBI and CAC scores provides improved risk stratification for the prediction of future MI (vulnerable plaque) in patients with plaque detected by CT angiography. This approach may facilitate more specific treatment strategies for high-risk patients.

Background: Cardiovascular disease (CVD) remains the world's leading cause of death. Because of its substantial public health burden, further research is needed to define risk factors that are both modifiable and measurable.

Objective: We examined the association between plasma osmolality (Osm) and CVDs - namely, heart failure, coronary heart disease, angina, and myocardial infarction - using data from the National Health and Nutrition Examination Survey (NHANES).

Methods: We analyzed nine NHANES cycles (1999-2018). Associations between Osm and CVD were assessed with weighted logistic regression. Odds ratios (ORs) and 95% CIs were estimated, and subgroup analyses were conducted. Restricted cubic spline (RCS) models were used to evaluate potential nonlinear relationships. Statistical significance was set at p < 0.05.

Results: Higher Osm was associated with increased odds of heart failure, coronary heart disease, angina, and myocardial infarction in unadjusted and partially adjusted models. After full adjustment, the associations remained significant for all outcomes except angina. RCS analyses indicated a significant U-shaped relationship for heart failure and angina across all models, with the lowest risk around 278 mmol/kg. Subgroup analyses were consistent with the primary results.

Conclusion: Increased Osm is significantly associated with CVD risk. Osm may serve as a useful biomarker for assessment and management of CVD risk in clinical practice, pending confirmation in prospective cohort studies.

Background: Patients hospitalized for acute heart failure present a high mortality rate, so risk stratification for in-hospital death is of utmost importance. Risk scores can help physicians to identify patients at higher risk, but it is important to validate those scores in different populations, since sociodemographic characteristics may be very heterogeneous.

Objectives: This study aimed to evaluate the ADHERE (Acute Decompensated Heart Failure Registry) risk score in a Brazilian quaternary teaching care center.

Methods: This was a retrospective cohort study involving 304 patients with acute heart failure aged ≥ 18 years old, conducted between September 2019 and July 2022. The primary endpoint was the evaluation of the ADHERE score by analysis of the discriminatory index and classification. The secondary endpoint was the evaluation of other prognostic factors for in-hospital mortality. A p-value < 0.05 was considered statistically significant.

Results: ADHERE score presented a discriminatory index of 0.69. ADHERE classification index was suboptimal, since the score did not stratify mortality risk on five strata as proposed originally. Furthermore, the score underestimates risk in the studied population. Admission serum urea was the only isolated prognostic factor for the endpoint (OR 1.043; CI 95% 1.024-1.062; p<0.001).

Conclusion: The ADHERE risk score cannot be entirely validated in our cohort, since classification was not achieved despite an ideal discriminatory index. Admission serum Urea was the only independent risk factor associated with in-hospital mortality. Our study emphasizes the importance of correct external validation of a prognostic score, especially if the demographic and clinical characteristics of cohorts are not comparable.

Background: The no-reflow phenomenon is a critical complication of percutaneous coronary intervention (PCI), especially in patients with saphenous vein graft (SVG) disease. Identifying predictors of no-reflow is crucial to improving risk stratification. The atherogenic index of plasma (AIP), calculated as log(triglyceride/HDL-C), is a marker of atherosclerosis and microvascular dysfunction. However, its role in predicting no-reflow during SVG interventions remains unclear.

Objective: This study aimed to evaluate the association between AIP and the no-reflow phenomenon in patients undergoing PCI for SVG lesions presenting with non-ST elevation myocardial infarction (NSTEMI).

Methods: This single-center retrospective study included 287 patients who underwent PCI for significant SVG stenosis. Patients were categorized into normal reflow and no-reflow groups based on post-PCI TIMI (Thrombolysis in Myocardial Infarction) flow grades. Baseline demographic, clinical, laboratory, and angiographic data were extracted. AIP was calculated using formula log (TG/HDL-C). Logistic regression analyses were performed to determine independent predictors of the no-reflow. Statistical significance was set at p<0.05.

Results: The no-reflow group was older and had a higher prevalence of comorbidities, including diabetes, atrial fibrillation, chronic heart failure, chronic kidney disease, and stroke history. They also exhibited lower HDL-C levels, higher triglyceride levels, and consequently higher AIP values compared to the normal reflow group. Multivariate analysis identified degenerated SVG (OR: 4.65, p<0.001), thrombus presence (OR: 5.65, p<0.001), reduced left ventricular ejection fraction (OR: 0.927, p<0.001), and elevated AIP (OR: 3.141, p=0.001) as independent predictors of the no-reflow.

Conclusion: Elevated AIP is an independent risk factor for no-reflow in NSTEMI patients undergoing PCI for Saphenous Vein Graft, highlighting its potential role in early risk stratification.