Arquivos brasileiros de cardiologia最新文献

Background: Transthyretin (TTR) amyloid cardiomyopathy (ATTR-CM) is the most common form of restrictive cardiomyopathy. Emerging pharmacological therapies aim to alter the natural history of disease and delay its advancement. However, data directly comparing the efficacy of different drug classes versus placebo remain limited.

Objectives: This systematic review assessed the efficacy of TTR stabilizers and silencers compared with placebo on all-cause mortality, hospitalizations, functional outcomes, and serum levels of the biomarker NT-proBNP in patients with ATTR-CM.

Methods: A comprehensive search of PubMed, Embase, and Cochrane databases was conducted for randomized controlled trials (RCTs) published through April 2025. Eligible studies compared patisiran, tafamidis, inotersen, revusiran, acoramidis, or vutrisiran to placebo in patients with ATTR-CM. Analyses were stratified by drug class, and statistical significance was set at p<0.05.

Results: Seven RCTs involving 2,526 participants were included; 42.5% received TTR stabilizers and 57.5% received TTR silencers. Compared with placebo, TTR stabilizers significantly reduced all-cause mortality (RR: 0.71; 95% CI 0.59-0.87; p=0.0006) and hospitalizations (RR: 0.81; 95% CI 0.73-0.89; p<0,0001). TTR silencers did not significantly reduce mortality (RR: 0.79; 95% CI 0.37-1.68; p=0.54) or hospitalizations (RR: 1.11; 95% CI 0.83-1.48; p=0.48). Both therapies were associated with improvements in 6-minute walk distance, quality of life, and reductions in serum NT-proBNP levels.

Conclusion: TTR stabilizers significantly reduced all-cause mortality and hospitalizations in patients with ATTR-CM compared with placebo. These benefits were not observed with TTR silencers, potentially due to shorter follow-up durations in the studies evaluated. Both therapies improved functional status and serum levels of NT-proBNP.

Background: Mortality in heart failure (HF) may be underestimated when analyses rely solely on the underlying cause of death from death certificates (DCs), whereas including multiple causes of death enables a broader examination of mortality and its determinants.

Objective: To analyze the multiple causes of in-hospital and late death in patients with decompensated HF and reduced ejection fraction (EF) (HFrEF), mildly reduced EF (HFmrEF), and preserved EF (HFpEF).

Methods: Retrospective analysis of a prospective cohort of patients admitted for decompensated HF to a cardiac intensive care unit at a private hospital. The analysis included multiple causes of in-hospital and late deaths. A significance level of 5% was adopted.

Results: The analysis included 519 individuals with a mean age of 74.87 ± 13.56 years, of whom 57.6% were male. The distribution of HFpEF, HFmrEF, and HFrEF was 25.4%, 27%, and 47.6%, respectively. Cardiovascular diseases (I) were the main causes of in-hospital and late death across all three EF groups, with no significant differences among them. The primary isolated causes of in-hospital and late death were septicemia (A41), HF (I50, I50.0, I50.9), and pneumonia (J12-J18). In late death, septicemia and pneumonia showed significant differences among the groups. Chronic respiratory causes were more frequent in patients with lower EF (HFrEF and HFmrEF). Correspondence analysis revealed an association between circulatory causes and HFrEF, neoplastic causes and HFpEF, and endocrine and metabolic causes and HFmrEF.

Conclusion: The analysis of multiple causes of death reveals a high rate of non-circulatory deaths in patients with decompensated HF, regardless of EF, linked to age and chronic comorbidities.

Background: Studies suggest a possible link between low levels of testosterone and sex hormone binding globulin (SHBG) and adverse cardiovascular outcomes; however, this relationship remains poorly defined.

Objectives: This systematic review aimed to evaluate the predictive value of baseline levels of testosterone, dihydrotestosterone (DHT), and SHBG for the incidence of heart failure (HF), providing deeper insight into the hormonal influence on HF risk.

Methods: We conducted a comprehensive search of the MEDLINE, Scopus, and Web of Science databases to identify cohort and nested case-control studies that measured hormone levels in adults without prior HF. Risk of bias was assessed using the ROBINS-E tool. Pooled hazard ratios (HRs) and odds ratios (ORs) were estimated using bivariate random-effects models. A statistical significance level of 0.05 was applied to all analyses.

Results: Out of 1,209 articles screened, 738 remained after deduplication. Six studies, including 233,474 participants (11,663 women), met the inclusion criteria. A one standard deviation decrease in testosterone levels was modestly associated with an increased risk of HF in men (HR 1.10, 95% CI: 1.03-1.17), but not in women (HR 1.05, 95% CI: 0.98-1.16). Comparisons across quartiles or quintiles did not reveal significant associations, and SHBG levels were not significant predictors of HF risk. Bayesian analysis provided weak evidence for the association (Bayes factor = 0.99).

Conclusions: This meta-analysis suggests that low testosterone levels are modestly associated with an increased risk of HF in men, highlighting a potentially important yet underexplored aspect of cardiovascular health. The heterogeneity in study designs and population characteristics, combined with the weak associations observed, underscores the need for further rigorous investigation. Well-designed randomized controlled trials are essential to confirm these findings and to elucidate the underlying biological mechanisms.

Background: The diagnostic utility of new or presumed new left bundle branch block (LBBB) for acute myocardial infarction (AMI) in the setting of acute coronary syndrome (ACS) remains controversial.

Objective: To evaluate whether the timing of LBBB predicts AMI and to compare its diagnostic accuracy with ischemic electrocardiography (ECG) criteria, particularly the Modified Sgarbossa Criteria (MSC).

Methods: We searched PubMed and Scopus for studies involving patients with ACS with LBBB through December 2023. Sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios, and diagnostic odds ratios (DOR) were calculated to assess diagnostic accuracy. Incidence and mortality data were also analyzed. Risk of bias was evaluated using the Newcastle-Ottawa Scale (NOS) and the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

Results: A total of 51 studies were included. LBBB occurred in 3.3% of ACS presentations and was associated with higher in-hospital mortality. Differentiating new from old LBBB was diagnostically neutral: LR+ 1.30 (95% CI: 0.75 to 1.85), LR- 0.90 (95% CI: 0.79 to 1.02), and DOR 1.44 (95% CI: 0.93 to 2.24); all confidence intervals crossed the null value of 1.0. In contrast, MSC demonstrated 83.6% sensitivity (95% CI: 55.4 to 95.5%) and 92.6% specificity (95% CI: 78.9 to 97.7%) for angiographically confirmed occlusive AMI, with LR+ 11.34 (95% CI: 3.67 to 34.99) and LR- 0.18 (95% CI: 0.054 to 0.575).

Conclusion: LBBB chronology alone does not significantly impact the likelihood of AMI. Ischemic ECG criteria - especially the MSC - provide substantially greater diagnostic accuracy and should guide clinical decision-making in ACS patients with LBBB.

Aortic stenosis (AS) is one of the most prevalent valve lesions, and transcatheter aortic valve replacement (TAVI) has emerged as an alternative to surgical aortic valve replacement (SAVR). TAVI is a minimally invasive procedure that has proven to be a safer option in several aspects. The objective is to review the impact of TAVI compared to surgical aortic valve replacement on mortality, postoperative complications, hospitalization, and quality of life in patients with AS. A systematic review was conducted using the PICO strategy, with searches in the PubMed, Central, and LILACS databases, employing the following descriptors: aortic stenosis, hospitalization, mortality, clinical trial, transcatheter aortic valve implantation, quality of life, postoperative complications, combined with the Boolean operators "AND" and "OR." A total of 29 articles were found after reading the titles and abstracts. Of these, nine showed lower mortality in patients undergoing TAVI, while three reported lower mortality in the SAVR group. Eight articles had similar findings regarding complications, with six showing a lower incidence of postoperative complications in TAVI and three in SAVR. Additionally, three articles showed better quality of life in TAVI patients, while one study indicated a shorter hospital stay for TAVI patients. In all studies, the patients analyzed were over 70 years old. TAVI reduced mortality compared to SAVR in patients with AS. Furthermore, TAVI was associated with a reduction in hospital stay and improvement in quality of life. Regarding postoperative complications, the results indicated that TAVI tends to have a lower complication rate, although variations exist between studies.