Eight years of experience

Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.INTRODUCTION: Aortic stenosis is the most prevalent type of valvular disease in Europe. Surgical aortic valve replacement (SAVR) is the standard therapy, while transcatheter aortic valve implantation (TAVI) is an alternative in patients at unacceptably high surgical risk. Assessment by a heart team is recommended by the guidelines but there is little published evidence on this subject. The purpose of this paper is to describe the experience of a multidisciplinary TAVI program that began in 2008. METHODS: The heart team prospectively assessed 473 patients using a standardized approach. A total of 214 patients were selected for TAVI and 80 for SAVR. Demographic, clinical and procedural characteristics and long-term success rates were compared between the groups. RESULTS: TAVI patients were older than the SAVR group (median 83 vs. 81 years), and had higher surgical risk scores (median EuroSCORE II 5.3 vs. 3.6% and Society of Thoracic Surgeons score 5.1 vs. 3.1%), as did the patients under medical treatment only. These scores were unable to assess multiple comorbidities. Patients' outcomes were different between the three groups (mortality with SAVR 25% vs. TAVI 37.6% vs. conservative therapy 57.6%, p=0.001). CONCLUSIONS: The heart team program was able to select candidates appropriately for TAVI, SAVR and conservative treatment, taking into account the risk of both invasive treatments. The use of a prospective standardized heart team approach is recommended, but requires continuous monitoring to ensure effectiveness in a timely manner.publishersversionpublishe

A practical clinical score

Copyright © 2022 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.INTRODUCTION AND OBJECTIVES: Obstructive coronary artery disease (CAD) remains the most common etiology of heart failure with reduced ejection fraction (HFrEF). However, there is controversy whether invasive coronary angiography (ICA) should be used initially to exclude CAD in patients presenting with new-onset HFrEF of unknown etiology. Our study aimed to develop a clinical score to quantify the risk of obstructive CAD in these patients. METHODS: We performed a cross-sectional observational study of 452 consecutive patients presenting with new-onset HFrEF of unknown etiology undergoing elective ICA in one academic center, between January 2005 and December 2019. Independent predictors for obstructive CAD were identified. A risk score was developed using multivariate logistic regression of designated variables. The accuracy and discriminative power of the predictive model were assessed. RESULTS: A total of 109 patients (24.1%) presented obstructive CAD. Six independent predictors were identified and included in the score: male gender (2 points), diabetes (1 point), dyslipidemia (1 point), smoking (1 point), peripheral arterial disease (1 point), and regional wall motion abnormalities (3 points). Patients with a score ≤3 had less than 15% predicted probability of obstructive CAD. Our score showed good discriminative power (C-statistic 0.872; 95% CI 0.834-0.909: p<0.001) and calibration (p=0.333 from the goodness-of-fit test). CONCLUSIONS: A simple clinical score showed the ability to predict the risk of obstructive CAD in patients presenting with new-onset HFrEF of unknown etiology and may guide the clinician in selecting the most appropriate diagnostic modality for the assessment of obstructive CAD.proofepub_ahead_of_prin

The coronary artery disease equivalent revisited

(1) To study the prevalence and severity of coronary artery disease (CAD) in diabetic patients. (2) To provide a detailed characterization of the coronary atherosclerotic burden, including the localization, degree of stenosis and plaque composition by coronary computed tomography angiography (CCTA). Single center prospective registry including a total of 581 consecutive stable patients (April 2011-March 2012) undergoing CCTA (Dual-source CT) for the evaluation of suspected CAD without previous myocardial infarction or revascularization procedures. Different coronary plaque burden indexes and plaque type and distribution patterns were compared between patients with (n = 85) and without diabetes (n = 496). The prevalence of CAD (any plaque; 74.1 vs. 56 %; p = 0.002) and obstructive CAD (≥50 % stenosis; 31.8 vs. 10.3 %; p<0.001) were significantly higher in diabetic patients. The remaining coronary atherosclerotic burden indexes evaluated (plaque in LM-3v-2v with prox. LAD; SIS; SSS; CT-LeSc) were also significantly higher in diabetic patients. In the per segment analysis, diabetics had a higher percentage of segments with plaque in every vessel (2.6/13.1/7.5/10.5 % for diabetics vs. 1.4/7.1/3.3/4.4 % for nondiabetics for LM, LAD, LCx, RCA respectively; p<0.001 for all) and of both calcified (19.3 vs. 9.2 %, p<0.001) and noncalcified or mixed types (14.4 vs. 7.0 %; p<0.001); the ratio of proximal-to-distal relative plaque distribution (calculated as LM/proximal vs. mid/distal/branches) was lower for diabetics (0.75 vs. 1.04; p = 0.009). Diabetes was an independent predictor of CAD and was also associated with more advanced CAD, evaluated by indexes of coronary atherosclerotic burden. Diabetics had a significantly higher prevalence of plaques in every anatomical subset and for the different plaque composition. In this report, the relative geographic distribution of the plaques within each subgroup, favored a more mid-to-distal localization in the diabetic patients.publishersversionpublishe

Ten-year survival of patients undergoing coronary angioplasty with first-generation sirolimus-eluting stents and bare-metal stents

Introduction: Compared to bare-metal stents (BMS), drug-eluting stents reduce stent restenosis and improve subsequent revascularization rates. The impact on patients’ survival has been the subject of debate. Objective: To assess the long-term (10-year) survival of patients undergoing percutaneous coronary intervention (PCI) with first-generation sirolimus-eluting stents (SES) in comparison with BMS. Methods: In a single-center registry, 600 consecutive patients who underwent successful PCI with SES between April 2002 and February 2003 were compared to 594 patients who underwent PCI with BMS between January 2002 and April 2002, just before the introduction of SES. Clinical and procedural data were collected at the time of intervention and 10-year survival status was assessed via the national life status database. Results: All baseline characteristics were similar between groups except for smaller stent diameter (2.84±0.38 vs. 3.19±0.49 mm; p<0.001), greater stent length (18.50±8.2 vs. 15.96±6.10 mm; p<0.001) and higher number of stents per patient (1.95 vs. 1.46, p<0.001) in the SES group. Overall five- and 10-year all-cause mortality was 9.6% (n=110) and 22.7% (n=272), respectively. The adjusted HR for 10-year mortality in patients undergoing PCI with SES was 0.74 (95% CI 0.58-0.94; p=0.013), corresponding to a relative risk reduction of 19.8%. Other than PCI with BMS, older age, chronic kidney disease, chronic obstructive pulmonary disease and lower ejection fraction were independent predictors of 10-year mortality. Conclusion: To date, this is the longest follow-up study ever showing a potential survival benefit of first-generation sirolimus-eluting stents versus bare-metal stents, supporting prior observations on their sustained efficacy and safety relative to contemporary BMS.publishersversionpublishe

Coronary computed tomography angiography-adapted Leaman score as a tool to noninvasively quantify total coronary atherosclerotic burden

To describe a coronary computed tomography angiography (CCTA)-adapted Leaman score (CT-LeSc) as a tool to quantify total coronary atherosclerotic burden with information regarding localization, type of plaque and degree of stenosis and to identify clinical predictors of a high coronary atherosclerotic burden as assessed by the CT-LeSc. Single center prospective registry including a total of 772 consecutive patients undergoing CCTA (Dual-source CT) from April 2011 to March 2012. For the purpose of this study, 581 stable patients referred for suspected coronary artery disease (CAD) without previous myocardial infarction or revascularization procedures were included. Pre-test CAD probability was determined using both the Diamond-Forrester extended CAD consortium method (DF-CAD consortium model) and the Morise score. Cardiovascular risk was assessed with the HeartScore. The cut-off for the 3rd tercile (CT-LeSc ≥8.3) was used to define a population with a high coronary atherosclerotic burden. The median CT-LeSc in this population (n = 581, 8,136 coronary segments evaluated; mean age 57.6 ± 11.1; 55.8 % males; 14.6 % with diabetes) was 2.2 (IQR 0-6.8). In patients with CAD (n = 341), the median CT-LeSc was 5.8 (IQR 3.2-9.6). Among patients with nonobstructive CAD, most were classified in the lowest terciles (T1, 43.0 %; T2, 36.1 %), but 20.9 % were in the highest tercile (T3). The majority of the patients with obstructive CAD were classified in T3 (78.2 %), but 21.8 % had a CT-LeSc in lower terciles (T1 or T2). The independent predictors of a high CT-LeSc were: Male sex (OR 1.73; 95 % CI 1.04-2.90) diabetes (OR 2.91; 95 % CI 1.61-5.23), hypertension (OR 2.54; 95 % CI 1.40-4.63), Morise score ≥16 (OR 1.97; 95 % CI 1.06-3.67) and HeartScore ≥5 (OR 2.42; 95 % CI 1.41-4.14). We described a cardiac CT adapted Leaman score as a tool to quantify total (obstructive and nonobstructive) coronary atherosclerotic burden, reflecting the comprehensive information about localization, degree of stenosis and type of plaque provided by CCTA. Male sex, hypertension, diabetes, a HeartScore ≥5 % and a Morise score ≥16 were associated with a high coronary atherosclerotic burden, as assessed by the CT-LeSc. About one fifth of the patients with nonobstructive CAD had a CT-LeSc in the highest tercile, and this could potentially lead to a reclass

Data from Portuguese centers

© 2022 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U.INTRODUCTION: During the Covid-19 pandemic there has been a general belief that hospital admissions for non-infectious causes, especially cardiovascular disease, have fallen. OBJECTIVES: To assess the impact of the pandemic on admissions for ST-elevation myocardial infarction (STEMI) during the first pandemic wave. METHODS: We performed a multicenter retrospective analysis of consecutive patients presenting with STEMI in two Portuguese hospital centers in two sequential periods - P1 (March 1 to April 30) and P2 (May 1 to June 30). Patients' clinical data and hospital outcomes were compared between the two periods for the years 2017 to 2019 and for 2020. RESULTS: During P1 in 2020, a reduction in the number of STEMI patients was observed in comparison with previous years (26.0±4.2 vs. 16.5±4.9 cases per month; p=0.033), as well as an increase in the number of mechanical complications (0.0% vs. 3.0%; p=0.029). Percutaneous coronary interventions in the setting of failed thrombolysis were more frequent (1.9% vs. 9.1%; p=0.033). An overall trend for longer delays in key timings of STEMI care bundles was noted. Mortality was higher during P1 compared to previous years (1.9% vs. 12.1%; p=0.005). CONCLUSIONS: During the first Covid-19 wave fewer patients presented with STEMI at the catheterization laboratory for percutaneous coronary intervention. These patients presented more mechanical complications and higher mortality.proofepub_ahead_of_prin

Definições para a padronização da pesquisa de auto-anticorpos contra constituintes do núcleo (FAN HEp-2), nucléolo, citoplasma e aparelho mitótico e suas associações clínicas

OBJECTIVE: The Second Brazilian Consensus on Antinuclear Antibodies (ANA) in HEp-2 Cells approved and extended the decision trees developed during the First Brazilian Consensus in order to also offer information about mixed patterns of fluorescence. METHODS: Since this test elicits reactions not only to nuclear autoimmune antigens but also to different cell compartments, new denominations for the test were approved. Results and CONCLUSIONS: These new denominations encompass variations on the autoantibody testing against the nucleus (ANA HEp-2), nucleolus, cytoplasm, and mitotic apparatus issue. Furthermore, major clinical associations were described for each immunofluorescent pattern, facilitating the interpretation of laboratory results in the clinical practice.OBJETIVO: O Segundo Consenso Brasileiro de Fator Antinuclear (FAN) em Células HEp-2 ratificou os algoritmos de decisão para leitura dos padrões do FAN na imunofluorescência indireta vistos na primeira edição do Consenso Brasileiro, adicionando ainda um novo algoritmo relacionado com os padrões mistos. MÉTODOS: Tendo em vista a habilidade do teste em detectar autoantígenos nos distintos compartimentos celulares, e não apenas no núcleo, propõe-se novas denominações para este exame laboratorial. RESULTADOS E CONCLUSÕES: Como novas denominações algumas sugestões foram igualmente aceitas, dentro do tema pesquisa de auto-anticorpos contra constituintes do núcleo (FAN HEp-2), nucléolo, citoplasma e aparelho mitótico. Foram abordadas as principais relevâncias clínicas com os padrões de FAN descritos, facilitando o melhor uso do ensaio pelo médico.FMUSPUNIFESPBio-Rad Laboratório BrasilHospital Geral de GoiâniaBiomédicaUniversidade Federal de UberlândiaUFMG HCPUCRS HCNew Life Produtos HospitalaresUniversidade Católica de GoiásFMUSP HC Laboratório CentralPatologista ClínicaFMUSP HCFrischmann Aisengart Unidad InmunologíaUniversidade Católica de Goiás Laboratório de Auto-ImunidadeExame Medicina LaboratorialFMUFG HC Laboratório de Imuno-Reumatologia e HLALab. Santa LuziaMedivax/BionHSPE/SPUniversidade Católica de Goiás Laboratório da Área de SaúdeFarmacêutica-BioquímicaUniv. Fed. Mato GrossoFMUFG Serviço de ReumatologiaHospital Durand Unidad InmunologíaLaboratório ClínicoUFRGS HCPA Serviço de ReumatologiaUERJ FCMUFMG FMHospital Universitário de Brasília Laboratório de ReumatologiaUNIFESPSciEL

TRATAMENTO CIRÚRGICO DA SÍNDROME NEFRÓTICA: ESTRATÉGIAS PARA O CONTROLE DA PROTEINÚRIA E PRESERVAÇÃO DA FUNÇÃO RENAL

Nephrotic syndrome is a kidney condition that causes a large loss of protein in the urine, leading to edema, hypoalbuminemia and other symptoms. Surgical treatment may be an option in specific cases to control proteinuria and preserve kidney function. Objectives: To evaluate the different surgical strategies used in the treatment of nephrotic syndrome, with a focus on controlling proteinuria and preserving renal function. Methodology: They consisted of a systematic literature review, where relevant articles were searched in academic databases. The inclusion criteria were defined to select studies that evaluated the surgical treatment of nephrotic syndrome and its strategies to control proteinuria and preserve renal function. For data collection, the following databases were used: Nursing Database (BDENF), Scientific Electronic Library Online (SCIELO), PubMed and Latin American Caribbean Literature in Health Sciences (LILACS). Various types of publications, such as scientific articles, monographs and magazines, were consulted to obtain relevant information on the topic. Results and Discussions: Surgical strategies used to treat nephrotic syndrome have demonstrated variable efficacy in controlling proteinuria and preserving renal function. Interventions are necessary to better understand the benefits and limitations of each surgical approach, considering the different patient profiles and characteristics of the disease. Conclusion: In conclusion, surgical treatment of nephrotic syndrome offers a range of strategies to control proteinuria and preserve renal function. However, the selection of the most appropriate surgical approach must take into account the severity of the disease, the response to conservative treatment and the individual characteristics of the patient. More studies are needed to validate the long-term efficacy and safety of these strategies.A síndrome nefrótica é uma condição renal que causa grande perda de proteínas na urina, levando a edema, hipoalbuminemia e outros sintomas. O tratamento cirúrgico pode ser uma opção em casos específicos para controlar a proteinúria e preservar a função renal. Objetivos: Avaliar as diferentes estratégias cirúrgicas utilizadas no tratamento da síndrome nefrótica, com foco no controle da proteinúria e na preservação da função renal. Materiais e Métodos: Consistiram em uma revisão sistemática da literatura, onde foram pesquisados artigos relevantes nas bases de dados acadêmicas. Os critérios de inclusão foram definidos para selecionar estudos que avaliassem o tratamento cirúrgico da síndrome nefrótica e suas estratégias para controlar a proteinúria e preservar a função renal. Para a coleta de dados, foram utilizados os bancos de dados: Base de dados Scientific Electronic Library Online (SCIELO), PubMed e Literatura Latino-Americana do Caribe em Ciências da Saúde (LILACS). Diversos tipos de publicações, como artigos científicos, monografias e revistas, foram consultados para obter informações relevantes sobre o tema. Resultados e Discussões: As estratégias cirúrgicas empregadas no tratamento da síndrome nefrótica demonstraram eficácia variável no controle da proteinúria e na preservação da função renal. Sendo necessárias intervenções para compreender melhor os benefícios e limitações de cada abordagem cirúrgica, considerando-se os diferentes perfis de pacientes e as características da doença. Conclusão:&nbsp; Em conclusão, o tratamento cirúrgico da síndrome nefrótica oferece uma gama de estratégias para controlar a proteinúria e preservar a função renal. No entanto, a seleção da abordagem cirúrgica mais adequada deve levar em consideração a gravidade da doença, a resposta ao tratamento conservador e as características individuais do paciente. Mais estudos são necessários para validar a eficácia e segurança dessas estratégias a longo prazo

Concepção dos desafios médicos no diagnóstico de abdome agudo em gestantes: um artigo original

The objective of this study is to expose the main concepts regarding the acute abomen and show its main etiologies in pregnant women. A review of articles was performed in the databases Medical Literature Analysis and Retrieval System Online (MEDLINE), Scientific Electronic Library Online (SciELO), Latin American and Caribbean Literature in Health Sciences (LILACS), Directory of Open Access Journals (DOAJ) and PubMed, with the following Health Sciences Descriptors (DeCS): Acute abdomen; Abdominal pain; Diffuse pain; Pregnancy. Selecting articles between the periods 2005 to 2023, in English, Portuguese, German and Spanish. Regarding AA, even though it is a pathology considered to be infrequently recurrent during pregnancy, it is essential that health professionals are prepared to diagnose it accurately and quickly, given the potential risks for pregnancy when the diagnosis is late. It is concluded that the lack of a standard protocol for approaching these patients impairs medical decision-making and contributes to worse prognoses.O objetivo deste estudo é expor os principais conceitos a respeito do abômen agudo e mostrar suas principais etiologias em gestantes. Foi realizada revisão de artigos nas bases de dados Medical Literature Analysis and Retrieval System Online (MEDLINE), Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Directory of Open Access Journals (DOAJ) e PubMed, com os seguintes Descritores em Ciências da Saúde (DeCS): Abdome agudo; Dor abdominal; Dor difusa; Gravidez. Seleção de artigos entre os períodos de 2005 a 2023, nos idiomas inglês, português, alemão e espanhol. Em relação à AA, mesmo sendo uma patologia considerada pouco recorrente durante a gravidez, é fundamental que os profissionais de saúde estejam preparados para diagnosticá-la com precisão e rapidez, dados os riscos potenciais para a gravidez quando o diagnóstico é tardio. Conclui-se que a falta de um protocolo padrão para abordagem desses pacientes prejudica a tomada de decisão médica e contribui para piores prognósticos.Objetiva-se, neste estudo, expor os principais conceitos no que tange o abomen agudo e mostrar suas etiologias principais em gestantes.&nbsp;Foi realizada uma revisão de artigos nas bases de dados Medical Literature Analysis and Retrievel System Online (MEDLINE), Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Directory of Open Access Journals (DOAJ) e PubMed, com os seguintes Descritores em Ciências da Saúde (DeCS): Abdome agudo; Dor abdominal; Dor difusa; Gravidez. Selecionando artigos entre os períodos de 2005 a 2023, nos idiomas Inglês, Português, Alemão e Espanhol. Em relação ao AA, mesmo sendo uma patologia considerada pouco recorrente durante a gestação, é essencial que os profissionais da saúde estejam preparados para diagnosticá-la com precisão e rapidez, visto o potencial de riscos para a gestação quando o diagnóstico é tardio. Conclui-se que a falta de um protocolo padrão na abordagem desses pacientes, prejudica a tomada de decisões médicas e corrobora para piores prognósticos