Resumo Fundamento A estratificação ode risco é uma importante etapa na avaliação perioperatória. No entanto, os principais escores de risco não incorporam biomarcadores em seus conjuntos de variáveis. Objetivo Avaliar o poder incremental da troponina à estratificação de risco tradicional. Métodos Um total de 2230 pacientes admitidos na unidade de terapia intensiva após cirurgia não cardíaca foram classificados de acordo com três tipos de risco: Risco Cardiovascular (RCV), Índice de Risco Cardíaco Revisado (IRCR), e Risco Inerente da Cirurgia (RIC). O principal desfecho foi mortalidade por todas as causas. A regressão de Cox foi usada, assim como a estatística C antes e após a adição de troponina ultrassensível (pelo menos uma medida até três dias após a cirurgia). Finalmente, o índice de reclassificação líquida e a melhoria de discriminação integrada foram usadas para avaliar o poder incremental da troponina para a estratificação de risco. O nível de significância usado foi de 0,05. Resultados A idade média dos pacientes foi 63,8 anos e 55,6% eram do sexo feminino. A prevalência de lesão miocárdica após cirurgia não cardíaca (MINS) foi 9,4%. Pacientes com um RCV elevado apresentaram uma maior ocorrência de MINS (40,1% x 24,8%, p<0,001), bem como pacientes com alto RIC (21,3 x 13,9%, p=0,004) e aqueles com IRCR≥3 (3,0 x 0,7%, p=0,009). Pacientes sem MINS, independentemente do risco avaliado, apresentaram taxa de mortalidade similar. A adição de troponina à avaliação de risco melhorou a capacidade preditiva de mortalidade em 30 dias e de mortalidade em um ano em todas as avaliações de risco. Conclusão A prevalência de MINS é mais alta na população de alto risco. No entanto, sua prevalência na população de risco mais baixo não é desprezível e causa um maior risco de morte. A adição da troponina ultrassensível melhorou a capacidade preditiva da avaliação de risco em todos os grupos. perioperatória entanto variáveis tradicional 223 RCV, , (RCV) IRCR, IRCR (IRCR) RIC. . (RIC) causas usada pelo cirurgia. cirurgia) Finalmente 005 0 05 0,05 638 63 8 63, 556 55 6 55,6 feminino (MINS 94 9 4 9,4% 40,1% 401 40 1 (40,1 248 24 24,8% p<0,001, p0001 p p<0,001 001 p<0,001) 21,3 213 21 3 (21, 139 13 13,9% p=0,004 p0004 004 IRCR3 IRCR≥ 3,0 (3, 07 7 0,7% p=0,009. p0009 p=0,009 009 p=0,009) avaliado similar morte grupos 22 (RCV (IRCR (RIC 00 0,0 5 55, 9,4 40,1 (40, 2 24,8 p000 p<0,00 21, (21 13,9 p=0,00 3, (3 0,7 0, 9, 40, (40 24, p00 p<0,0 (2 13, p=0,0 ( (4 p0 p<0, p=0, p<0 p=0 p< p=

Abstract Background Risk stratification is an important step in perioperative evaluation. However, the main risk scores do not incorporate biomarkers in their set of variables. Objective Evaluate the incremental power of troponin to the usual risk stratification Methods A total of 2,230 patients admitted to the intensive care unit after non-cardiac surgery were classified according to three types of risk: cardiovascular risk (CVR), Revised Cardiac Risk Index (RCRI); and inherent risk of surgery (IRS). The main outcome was all-cause mortality. Cox regression was used as well as c-statistics before and after addition of high-sensitivity troponin (at least one measurement up to three days after surgery). Finally, net reclassification index and integrated discrimination improvement were used to assess the incremental power of troponin for risk stratification. Significance level was set at 0.05. Results Mean age of patients was 63.8 years and 55.6% were women. The prevalence of myocardial injury after non-cardiac surgery (MINS) was 9.4%. High CVR-patients had a higher occurrence of MINS (40.1 x 24.8%, p<0.001), as well as high IRS-patients (21.3 x 13.9%, p=0.004) and those with a RCRI≥3 (3.0 x 0.7%, p=0.009). Patients without MINS, regardless of the assessed risk, had similar mortality rate. The addition of troponin to the risk assessment improved the predictive ability of death at 30 days and at 1 year in all risk assessments. Conclusion The prevalence of MINS is higher in the high-risk population. However, its prevalence in lower-risk population is not negligible and causes a higher risk of death. The addition of high-sensitivity troponin increased the predictive ability of risk assessment in all groups. evaluation However variables 2230 2 230 2,23 noncardiac non cardiac CVR, CVR , (CVR) RCRI (RCRI) IRS. IRS . (IRS) allcause cause cstatistics c statistics highsensitivity sensitivity surgery. surgery) Finally 005 0 05 0.05 638 63 8 63. 556 55 6 55.6 women (MINS 94 9 4 9.4% CVRpatients 40.1 401 40 (40. 248 24 24.8% p<0.001, p0001 p p<0.001 001 p<0.001) IRSpatients 21.3 213 21 3 (21. 139 13 13.9% p=0.004 p0004 004 RCRI3 RCRI≥ 3.0 (3. 07 7 0.7% p=0.009. p0009 p=0.009 009 p=0.009) rate assessments highrisk lowerrisk lower groups 223 23 2,2 (CVR (RCRI (IRS 00 0.0 5 55. 9.4 40. (40 24.8 p000 p<0.00 21. (21 13.9 p=0.00 3. (3 0.7 22 2, 0. 9. (4 24. p00 p<0.0 (2 13. p=0.0 ( p0 p<0. p=0. p<0 p=0 p< p=

Abstract Background Brazil had high COVID-19 lethality/mortality with multiple social inequalities, where color/race was highly relevant, especially in Rio de Janeiro. Therefore, we hypothesize that COVID-19 hospitalized patients with a highly socially vulnerable background would have more significant in-hospital mortality. Objective To analyze the socioeconomic factors of social vulnerability and their association with COVID-19 mortality. Methods This work was a prospective study of 274 confirmed adult COVID-19 hospitalized patients in the University Hospital of Clementino Fraga Filho (HUCFF). The clinical features/blood chemistry information were collected from the clinical record. The ArcGIS Pro Software (Esri Gis mapping software, Redlands California-US) and a Python-based algorithm were used to determine in-app/in-map variable management relevance to the socioeconomic variables, inequity markers, and vulnerability. Our study also analyzed the transfers from other primary care institutions to our hospital in order to examine its potential delays in advanced medical care. Logistic regression and ROC curve were used to investigate in-hospital mortality for our statistical analysis. The significance level adopted in the statistical analysis was 5% Results: Male sex, total days of hospitalization, age, having more than three comorbidities, intensive care unit (ICU) admission, hemodialysis, and transfer from other hospitals showed statistical significance. Patients living in low-adequate households (p = 0.030) with high in-house individual agglomeration markers (p = 0.017) and transfers from another Primary Health Care (PHC) institution (p = 0.047) were associated with increased in-hospital mortality, with high ICU admission and mechanical ventilation. Conclusions In-hospital mortality due to COVID-19 was influenced by social individual background characteristics of vulnerability. Among other clinical parameters, these markers should be considered to predict the likelihood of complications related to the COVID-19 pandemic. COVID19 COVID 19 COVID-1 lethalitymortality lethality inequalities colorrace color race relevant Janeiro Therefore inhospital 27 HUCFF. HUCFF . (HUCFF) featuresblood features blood record Esri software CaliforniaUS California US California-US Pythonbased Python based inapp/inmap inappinmap app/in map app variables 5 Results sex hospitalization age comorbidities (ICU hemodialysis lowadequate low adequate p 0.030 0030 0 030 inhouse house 0.017 0017 017 PHC (PHC 0.047 0047 047 ventilation Inhospital In parameters pandemic COVID1 1 COVID- 2 (HUCFF inapp inmap appin 0.03 003 03 0.01 001 01 0.04 004 04 0.0 00 0.

Resumo Fundamento O implante valvar aórtico transcateter (TAVI) apresenta crescimento exponencial de suas indicações e foi incorporado ao Sistema Único de Saúde em 2022, sendo necessário avaliar seu uso no Brasil. Objetivo Conhecer os fatores associados a mortalidade e complicações não fatais intra-hospitalares, em ambos os gêneros, na população do Registro Brasileiro de Implante de Bioprótese Aórtica por Cateter e Novas Tecnologias (RIBAC-NT). Método Análise do banco de dados RIBAC-NT de 2008 a 2022. Aplicados modelos logísticos e machine learning na avaliação estatística da associação das variáveis com os desfechos, empregando o software R e nível de significância de 5%. Resultados Analisados 2.588 pacientes (mulheres, 51,2%; óbito intra-hospitalar, 8,2%). Mortalidade associou-se a complicações do procedimento, dentre elas destacam-se complicações vasculares (CV) maiores e insuficiência renal aguda (IRA) (p< 0,001). A CV maior ocorreu em 6%, com 34% de mortalidade; IRA ocorreu em 8,8%, com 13% de mortalidade, que aumentou até 8 vezes quando IRA coexistiu com outras complicações. Complicações não fatais ocorreram em 50,5% do total de pacientes, acometendo 63% daqueles com bioprótese de 1a geração (1G) e 39% daqueles com bioprótese de 2a geração (2G) p<0,001. O acesso não femoral e o ritmo cardíaco influenciaram as complicações não fatais nas próteses 1G, enquanto complicações das próteses 2G associaram-se ao gênero feminino (39,6% vs. 30,4%, p= 0,003). Conclusão A mortalidade intra-hospitalar na população do RIBAC-NT associou-se diretamente a complicações do procedimento, principalmente CV maior e IRA. A ocorrência de complicações não fatais diferiu conforme o gênero e o tipo da bioprótese. TAVI (TAVI 2022 Brasil intrahospitalares, intrahospitalares intra hospitalares, hospitalares intra-hospitalares gêneros RIBACNT. RIBACNT RIBAC NT . (RIBAC-NT) 200 desfechos 5 5% 2588 2 588 2.58 mulheres, mulheres (mulheres 51,2% 512 51 intrahospitalar, intrahospitalar hospitalar, hospitalar 8,2%. 82 8,2% 8,2%) associouse associou se procedimento destacamse destacam (CV (IRA p< p (p 0,001. 0001 0,001 0 001 0,001) 6 6% 34 88 8,8% 13 505 50 50,5 63 1G G (1G 39 (2G p0001 p<0,001 associaramse associaram 39,6% 396 (39,6 vs 304 30 4 30,4% 0,003. 0003 0,003 003 0,003) 202 (RIBAC-NT 20 258 58 2.5 51,2 8,2 000 0,00 00 3 8,8 1 50, p000 p<0,00 39,6 (39, 30,4 25 2. 51, 8, 0,0 p00 p<0,0 39, (39 30, 0, p0 p<0, (3 p<0 (

Abstract Background Transcatheter aortic valve implantation (TAVI) has had an exponential increase of its indication, being incorporated into the Brazilian Unified Public Health System in 2022, thus requiring assessment of its use in Brazil. Objeticve To assess the factors associated with in-hospital mortality and non-fatal complications in both genders in the Brazilian Registry of Transcatheter Aortic Valve Implantation and New Technologies (RIBAC-NT) population. Method Analysis of the RIBAC-NT database from 2008 to 2022 was performed. Logistic models and machine learning were used for statistical assessment of the association between variables and outcomes. The software R was used and a 5% significance level, adopted. Results Analysis of 2588 patients (women, 51.2%; in-hospital death, 8.2%). Mortality was associated with procedural complications, of which major vascular complication (VC) and acute kidney injury (AKI) stood out (p<0.001). Major VC occurred in 6% of the patients, with 34% mortality; AKI occurred in 8.8%, with 13% mortality, which increased up to 8 times when AKI coexisted with other complications. Non-fatal complications occurred in 50.5% of all patients, affecting 63% of those with 1st generation (1G) bioprosthesis and 39% of those with 2nd generation (2G) bioprosthesis (p<0,001). Non-femoral access and heart rhythm influenced non-fatal complications in patients with 1G prostheses, while complications in patients with 2G prosthesis associated with the female gender (39.6% vs. 30.4%, p=0.003). Conclusion In-hospital mortality in the RIBAC-NT population was directly associated with procedural complications, mainly major VC and AKI. The occurrence of non-fatal complications differed according to gender and bioprosthesis type. TAVI (TAVI indication Brazil inhospital hospital nonfatal non fatal RIBACNT RIBAC NT (RIBAC-NT 200 202 performed outcomes 5 level adopted 258 women, women (women 51.2% 512 51 2 death 8.2%. 82 8.2% . 8.2%) (VC (AKI p<0.001. p0001 p p<0.001 0 001 (p<0.001) 6 34 88 8.8% 13 Nonfatal Non 505 50 50.5 63 st G (1G 39 nd (2G p<0,001. p<0,001 (p<0,001) Nonfemoral femoral prostheses 39.6% 396 (39.6 vs 304 30 4 30.4% p=0.003. p0003 p=0.003 003 p=0.003) Inhospital In type 20 25 51.2 8.2 p000 p<0.00 00 (p<0.001 3 8.8 1 50. p<0,00 (p<0,001 39.6 (39. 30.4 p=0.00 51. 8. p00 p<0.0 (p<0.00 p<0,0 (p<0,00 39. (39 30. p=0.0 p0 p<0. (p<0.0 p<0, (p<0,0 (3 p=0. p<0 (p<0. (p<0, ( p=0 p< (p<0 p= (p< (p

Abstract Background Literature is scarce on echocardiographic characteristics of COVID-19 patients admitted to the intensive care unit (ICU). Objectives To describe echocardiographic characteristics of ICU COVID-19 patients and associate them with clinical signals/symptoms, laboratory findings and outcomes. Methods Patients with RT-PCR-confirmed COVID-19, admitted to the ICU, who underwent echocardiography were included. Clinical characteristics associated with an abnormal echocardiogram (systolic ventricular dysfunction of any degree — left and/or right ventricle — and/or high filling pressures and/or moderate to severe pericardial effusion) were analyzed. Groups were compared using the Student’s t-test, chi-square, and logistic regression. A p < 0.05 was considered statistically significant. Results A total of 140 patients met inclusion criteria, and 74 (52.9%) had an abnormal echocardiogram. A low number of left and right ventricular systolic dysfunction was observed, and 35% of the population had a normal diastolic function. In the univariate analysis, characteristics associated with abnormal echocardiogram were age, chronic kidney disease, elevated troponin, previous heart failure, and simplified acute physiology score 3 (SAPS 3). In the regression model, troponin and SAPS3 score were independent markers of abnormal echocardiogram. An abnormal echocardiogram was associated with a higher prevalence of in-hospital death (RR 2.10; 95% CI 1.04-4.24) and orotracheal intubation (RR 2.3; 95% CI 1.14-4.78). Conclusions COVID-19 has little effect on ventricular function, but it is common to find increased filling pressures. Elevated serum troponin level and SAPS3 score were the independent markers of an abnormal echocardiogram. In addition, the prevalence of in-hospital death and need for mechanical ventilation were higher in patients with abnormal echocardiogram. COVID19 COVID 19 COVID-1 ICU. . (ICU) signalssymptoms signals symptoms signals/symptoms outcomes RTPCRconfirmed RT PCR confirmed COVID19, 19, included andor or effusion analyzed Students Student s ttest, ttest t test, test t-test chisquare, chisquare chi square, square chi-square 005 0 05 0.0 significant 14 criteria 7 52.9% 529 52 9 (52.9% observed 35 function analysis age disease failure SAPS 3. 3) model inhospital hospital RR 2.10 210 2 10 95 1.044.24 104424 1.04 4.24 1 04 4 24 1.04-4.24 2.3 23 1.144.78. 114478 1.14 4.78 78 1.14-4.78) addition COVID1 COVID- (ICU 00 0. 52.9 5 (52.9 2.1 21 044 1.044.2 10442 104 1.0 424 4.2 1.04-4.2 2. 144 1.144.78 11447 114 1.1 478 4.7 1.14-4.78 52. (52. 1.044. 1044 1. 42 4. 1.04-4. 1.144.7 1144 11 47 1.14-4.7 (52 1.044 1.04-4 1.144. 1.14-4. (5 1.04- 1.144 1.14-4 ( 1.14-

Resumo Fundamento Alguns estudos demonstraram uma maior prevalência de óbitos em portadores de fatores de risco cardiovascular (FRC) durante internação por COVID-19. Objetivos Avaliar o impacto do alto risco cardiovascular em pacientes internados em terapia intensiva por COVID-19 Métodos Estudo retrospectivo com pacientes admitidos em terapia intensiva, com diagnóstico confirmado de COVID-19 por RT-PCR e com pelo menos uma dosagem de troponina durante a internação. Os critérios para definição de paciente de alto risco cardiovascular (ARC) foram: histórico de doença cardiovascular estabelecida (infarto, AVC ou doença arterial periférica), diabetes, doença renal crônica com clearance < 60ml/min ou presença de 3 FRC (hipertensão, tabagismo, dislipidemia ou idade > 65 anos). O desfecho primário deste estudo é mortalidade hospitalar por todas as causas. P<0,05 foi considerado significativo. Resultados Foram incluídos 236 pacientes, média de idade= 61,14±16,2 anos, com 63,1% homens, 55,5% hipertensos e 33,1% diabéticos. Um total de 47,4% dos pacientes apresentavam ARC. Observou-se um aumento significativo da mortalidade conforme aumento do número de fatores de risco (0 FRC: 5,9%; 1 FRC: 17,5%; 2 FRC: 32,2% e ≥3 FRC: 41,2%; p=0,001). Na regressão logística ajustada para gravidade (escore SAPS3), o grupo de alto risco cardiovascular e troponina elevada apresentou maior ocorrência de mortalidade hospitalar (OR 40,38; IC95% 11,78-138,39). Pacientes sem alto risco cardiovascular, mas com troponina elevada, também exibiram associação significativa com o desfecho primário (OR 16,7; IC95% 4,45-62,74). Conclusão Em pacientes internados em terapia intensiva por COVID-19, a presença de alto risco cardiovascular afeta a mortalidade hospitalar somente em pacientes que apresentaram elevação de troponina.

Abstract Background Some studies have shown a higher prevalence of deaths in patients with cardiovascular risk factors (CRF) during hospitalization for COVID-19. Objectives To assess the impact of high cardiovascular risk in patients hospitalized in intensive care for COVID-19 Methods Retrospective study with patients admitted to an intensive care unit, with a diagnosis of COVID-19 confirmed by RT-PCR, and with at least one troponin measurement during hospitalization. The criteria for defining high cardiovascular risk (HCR) patients were: history of established cardiovascular disease (myocardial infarction, stroke, or peripheral arterial disease), diabetes, chronic kidney disease with clearance < 60ml/min, or presence of 3 CRFs (hypertension, smoking, dyslipidemia, or age > 65 years). The primary outcome of this study is all-cause in-hospital mortality. P<0.05 was considered significant. Results This study included 236 patients, mean age = 61.14±16.2 years, with 63.1% men, 55.5% hypertensive, and 33.1% diabetic; 47.4% of the patients also presented HCR. A significant increase in mortality was observed as the number of risk factors increased (0 FRC: 5.9%; 1 FRC: 17.5%; 2 FRC: 32.2% and ≥3 FRC: 41.2%; p=0.001). In the logistic regression adjusted for severity (SAPS3 score), the HCR and myocardial injury group had a higher occurrence of in-hospital mortality (OR 40.38; 95% CI 11.78-138.39). Patients without HCR but with myocardial injury also exhibited a significant association with the primary outcome (OR 16.7; 95% CI 4.45-62.74). Conclusion In patients hospitalized in intensive care for COVID-19, HCR impacts in-hospital mortality only in patients with myocardial injury.

Resumo Fundamento A importância prognóstica da classificação ‘insuficiência cardíaca (IC) com fração de ejeção (FE) intermediária’ permanece incerta. Objetivo Analisar as características clínicas, comorbidades, complicações e mortalidade hospitalar e tardia de pacientes classificados em IC com FE intermediária (ICFEi - FE: 40%-49%) e comparar às daqueles em IC com FE preservada (ICFEp - FE > 50%) e IC com FE reduzida (ICFEr - FE < 40%) na internação por IC descompensada. Métodos Coorte ambispectiva de pacientes internados por IC descompensada em unidade cardiointensiva. Foram avaliadas características clínicas, comorbidades, complicações e mortalidade hospitalar e tardia. Utilizou-se o software R, com significância de 5%, para a realização dos testes qui-quadrado, análises de variância, multivariada de Cox e curva de sobrevida de Kaplan Meier, além de técnicas de machine learning (Elastic Net, árvore de sobrevida). Resultados Foram incluídos 519 indivíduos entre setembro de 2011 e junho de 2019, com média da idade de 74,87±13,56 anos, sendo 57,6% homens. Observou-se frequência de ICFEp, ICFEi e ICFEr de 25,4%, 27% e 47,6%, respectivamente. O infarto prévio foi mais frequente na ICFEi. O tempo médio de seguimento foi 2,94±2,55 anos, sem diferença estatística da mortalidade entre os grupos (53,8%, 52,1% e 57,9%). Na curva de sobrevida, não houve diferença entre os grupos ICFEp e ICFEi, nem entre ICFEp e ICFEr, mas houve entre os grupos ICFEi e ICFEr. Idade maior que 77 anos, IC prévia, história de readmissão, demência e necessidade de vasopressores foram associadas com maior mortalidade tardia na árvore de sobrevida. Conclusão A FE não foi selecionada como variável associada a mortalidade nos pacientes com IC descompensada.

Abstract Background The prognostic importance of the classification ‘heart failure (HF) with mid-range ejection fraction (EF)’ remains uncertain. Objective To analyze the clinical characteristics, comorbidities, complications, and in-hospital and late mortality of patients classified as having HF with mid-range EF (HFmrEF – EF: 40%-49%), and to compare them to those of patients with HF with preserved EF (HFpEF – EF > 50%) and with HF with reduced EF (HFrEF – EF < 40%) on admission for decompensated HF. Methods Ambispective cohort of patients admitted to the cardiac intensive care unit due to decompensated HF. Clinical characteristics, comorbidities, complications, and in-hospital and late mortality were assessed. The software R was used, with a 5% significance, for the tests chi-square, analysis of variance, Cox multivariate, and Kaplan-Meier survival curve, in addition to machine-learning techniques (Elastic Net and survival tree). Results 519 individuals were included between September 2011 and June 2019 (mean age, 74.87 ± 13.56 years; 57.6% were men). The frequencies of HFpEF, HFmrEF and HFrEF were 25.4%, 27% and 47.6%, respectively. Previous infarction was more frequent in HFmrEF. The mean follow-up time was 2.94 ± 2.55 years, with no statistical difference in mortality between the groups (53.8%, 52.1%, 57.9%). In the survival curve, there was difference between neither the HFpEF and HFmrEF groups, nor the HFpEF and HFrEF groups, but between the HFmrEF and HFrEF groups. Age over 77 years, previous HF, history of readmission, dementia and need for vasopressors were associated with higher late mortality in the survival tree. Conclusion The EF was not selected as a variable associated with mortality in patients with decompensated HF.

Resumo Fundamento: Na cardiomiopatia chagásica crônica (CCC), impõem-se estudos com a proposta de identificar fatores de risco arritmogênicos em pacientes nos quais a disfunção ventricular de moderada a grave não está presente. Objetivos: Verificar a dependência entre arritmias ventriculares frequentes (ARV), fração de ejeção de ventrículo esquerdo (FEVE), extensão da fibrose pela ressonância magnética cardíaca (RMC) e dosagem de norepinefrina urinária (NOREPI) na CCC com FEVE preservada ou minimamente comprometida. Métodos: Foi analisada no Holter a presença de extrassístoles ventriculares >30/hora. Na RMC, avaliou-se a FEVE e a quantificação de massa fibrosada. Foi realizada a dosagem de NOREPI pelo método de Muskiet. A matriz de correlação foi calculada para aferir a capacidade de as variáveis preverem outra sendo considerado significante p<0,05. Resultados: Foram incluídos no estudo 59 pacientes, com idade média de 57,9±10,94 anos. Arritmia ventricular frequente (ARV) foi detectada em 28 pacientes. A variável fibrose mostrou-se inversamente proporcional à fração de ejeção de ventrículo esquerdo (FEVE) (R de −0,61) e à norepinefrina urinária (NOREPI) (R de −0,68), assim como a variável ARV mostrou-se inversamente proporcional à FEVE (R de −0,33) e à NOREPI (R de −0,27). Já a FEVE mostrou-se diretamente proporcional à NOREPI (R de 0,83). Conclusão: Nesta amostra, em pacientes com CCC com FEVE preservada ou discretamente reduzida, observa-se a integridade do sistema nervoso autonômico em corações com pouca fibrose e FEVE mais elevada, apesar da presença de tradicionais fatores de risco para morte súbita cardíaca. Há dependência entre os níveis de NOREPI, FEVE e fibrose miocárdica, mas não com ARV.

Abstract Background: In Chronic Chagas Cardiomyopathy (CCC), studies are needed to identify arrhythmogenic risk factors in patients in which moderate to severe ventricular dysfunction is not present. Objective: To verify the correlation between frequent ventricular arrhythmias (PVC), left ventricular ejection fraction (LVEF), extension of fibrosis by cardiac magnetic resonance (CMR), and urinary norepinephrine measurement (NOREPI) in CCC with preserved or mildly compromised LVEF. Methods: The presence of ventricular extrasystoles > 30/h was analyzed on Holter. At CMR, LVEF and quantification of fibrosis mass were evaluated. The dosage of NOREPI was performed using the Muskiet method. The correlation coefficient matrix was calculated to measure the predictive ability of the variables to predict another variable, with p < 0.05 being considered significant. Results: A total of 59 patients were included. The mean age was 57.9 + 10.94 years. PVC was detected in 28 patients. The fibrosis variable was inversely proportional to LVEF (R of −0.61) and NOREPI (R of −0.68). Also, the variable PVC was inversely proportional to LVEF (R of −0.33) and NOREPI (R of −0.27). On the other hand, LVEF was directly proportional to NOREPI (R of 0.83). Conclusion: In this sample, in patients with CCC with preserved or slightly reduced LVEF, integrity of the autonomic nervous system is observed in hearts with little fibrosis and higher LVEF despite the presence of traditional risk factors for sudden cardiac death. There is correlation between the levels of NOREPI, LVEF, and myocardial fibrosis, but not with PVC.

Resumo Fundamento: A insuficiência cardíaca (IC) é uma síndrome multifatorial com repercussões sobre a qualidade de vida (QV). Objetivo: Investigar os principais fatores que interagem e pioram a qualidade de vida de pacientes ambulatoriais com IC. Métodos: Estudo transversal observacional com 99 pacientes, de ambos os sexos, atendidos no ambulatório de IC de um hospital universitário, todos com uma fração de ejeção reduzida (<40%) pela ecocardiografia. Os participantes foram avaliados usando-se um questionário sociodemográfico, um questionário clínico, o Minnesota Living with Heart Failure (MLwHF), e Hospital Anxiety and Depression scale (HADS). QV foi a variável de desfecho. Foram usados dois modelos de análise multivariada, a regressão beta (paramétrica) e a árvore de regressão (não paramétrica), considerando um p < 0,05 e 0,05 < p < 0,10 para significância estatística e clínica, respectivamente. Resultados: A análise por regressão beta mostrou que os sintomas de depressão e ansiedade pioraram a QV de pacientes com IC, bem como o sexo masculino, idade inferior a 60 anos, nível educacional mais baixo, renda familiar mensal menor, internações recorrentes e comorbidades tais como doenças cardíacas isquêmicas e hipertensão arterial. A árvore de regressão confirmou que as classes funcionais da NYHA III e IV pioraram todas as dimensões do MLwHF, interagindo com sintomas de ansiedade, e influenciando direta ou indiretamente, a presença de pior escore total e dimensão emocional do MLwHF. Internações anteriores, na dimensão emocional, e idade inferior a 60 anos, na dimensão geral, associaram-se com ansiedade e classe funcional NYHA, piorando também a QV dos pacientes com IC. Conclusão: IC com fração de ejeção reduzida associou-se com pior resultado do MLwHF. Sintomas de ansiedade, internação prévia e idade mais jovem também associaram-se com pior MLwHF. O conhecimento desses fatores de risco pode, portanto, orientar a avaliação e o tratamento dos pacientes com IC.

Abstract Background: Heart failure (HF) is a multifactorial syndrome with repercussions on quality of life (QoL). Objectives: To investigate the main interacting factors responsible to worsen quality of life of outpatients with HF. Methods: Cross-sectional observational study with 99 patients of both genders, attending a HF outpatient clinic at a university hospital, all with a reduced ejection fraction (<40%) by echocardiography. They were evaluated using sociodemographic and clinical questionnaires, the Minnesota Living with Heart Failure (MLwHF), and the Hospital Anxiety and Depression scale (HADS). QoL was the outcome variable. Two multivariate models were used: the parametric beta regression analysis, and the non-parametric regression tree, considering p < 0.05 and 0.05 < p < 0.10 for statistical and clinical significance, respectively. Results: Beta regression showed that depression and anxiety symptoms worsened the QoL of HF patients, as well as male sex, age younger than 60 years old, lower education level, lower monthly family income, recurrent hospitalizations and comorbidities such as ischemic heart diseases and arterial hypertension. The regression tree confirmed that NYHA functional class III and IV worsen all dimensions of MLwHF by interacting with anxiety symptoms, which influenced directly or indirectly the presence of poorer total score and emotional dimension of MLwHF. Previous hospitalization in the emotional dimension and age younger than 60 years in general dimension were associated with anxiety and NYHA functional class, also worsening the QoL of HF patients. Conclusion: HF with reduced ejection fraction was associated with poorer MLwHF. Anxiety symptoms, previous hospitalization and younger age were also associated with worsened MLwHF. Knowledge of these risk factors can therefore guide assessment and treatment of HF patients.

Abstract INTRODUCTION: Nutritional status has been implicated in the modulation of the immune response, possibly augmenting the pathogenesis of Chagas disease (Cd). We evaluated diet quality and nutritional status in adults and elderly patients with chronic Cd in a tertiary hospital. METHODS: A case-control study of Cd patients was conducted, paired for gender, age, and co-morbidities with non-Cd patients. Anthropometric measurements and food frequency questionnaire was used, and diet quality was assessed by the Brazilian Healthy Eating Index-Revised (BHEI-R). The Estimated Average Requirement cut-off points were used to determine the dietary micronutrient adequacy. The Cd group was further grouped according to Los Andes classification. RESULTS: The study participants were 67 ± 10 years old, 73.6% elderly and 63% female. The prevalence of overweight/obesity and abdominal fat was high in both groups; however, Cd group showed a lower prevalence of obesity and increased risk of disease according to waist circumference classification. There was no difference in BHEI-R score between groups (p=0.145). The Cd group had sodium and saturated fat intake above recommendations and low intake of unsaturated fat, vitamin D, E, selenium, magnesium, and dairy products; but higher intake of iron. According to Los Andes classification, group III presented lower intake of whole fruit and dietary fiber. CONCLUSIONS: Patients with Cd were overweight and the quality of their diet was unsatisfactory based on the recommended diet components for age and sex.

Resumo Pacientes com probabilidade intermediária de doença coronariana são um desafio diagnóstico e é justamente nessa população onde o grau de incerteza é maior que os testes diagnósticos têm sua maior aplicabilidade. Entretanto, de acordo com a definição vigente, submeter uma população com probabilidade de doença entre 10 e 90% pode gerar exames desnecessários e resultados equivocados. Conhecer as características de cada teste, assim como riscos e benefícios do tratamento medicamentoso para doença coronariana e conjugar essas informações através dos limiares de diagnóstico trazem uma nova perspectiva à tomada de decisão. Objetivos: Revisar a origem dos conceitos atualmente preconizados de probabilidade intermediária e determinar os limiares de diagnóstico e tratamento dos testes não invasivos e, com base neles, propor um novo conceito de probabilidade intermediária de doença coronariana. Através da revisão bibliográfica foram extraídas metanálises nas quais dados de sensibilidade, especificidade, razão de verossimilhança positiva e negativa, riscos e benefícios dos testes e tratamento foram fornecidos. Utilizando-se algoritmo desenvolvido por Pauker e colaboradores foi possível obter os limiares de diagnóstico e tratamento ajustados para cada exame em questão. O conceito de probabilidade intermediária de doença coronariana é bastante amplo, variando, conforme os autores, entre 10 e 90%, 1 e 92%, 15 e 85%, com racionalidade distinta. Contemplando-se o poder discriminatório de cada exame, riscos dos testes, riscos e benefícios do tratamento, os limiares de diagnóstico e tratamento foram definidos para teste ergométrico (22-58%), eco-stress (10-72), cintilografia miocárdica (12-80%), ressonância nuclear magnética (16-80%) e angiotomografia de coronárias (6,7-81%). A decisão quanto à submissão aos testes diagnósticos deve ser individualizada, levando-se em consideração os limiares de diagnóstico e tratamento de cada método em questão.

Abstract Patients with intermediate probability of coronary disease are a diagnostic challenge and it is precisely in this population where the degree of uncertainty is greater that the diagnostic tests have their greater applicability. However, according to the current definition, subjecting to tests a population with a disease probability between 10 and 90% can generate unnecessary tests and misleading results. Knowing the characteristics of each test, as well as risks and benefits of drug treatment for coronary disease and combining this information through diagnostic thresholds brings a new perspective to decision making. To review the origin of the currently recommended concepts of intermediate probability and to determine the thresholds for diagnosis and treatment of noninvasive tests and, based on them, propose a new concept of intermediate probability of coronary disease. Through the bibliographic review, meta-analyses were extracted in which data of sensitivity, specificity, positive and negative likelihood ratio, risks and benefits of the tests and treatment were provided. Using an algorithm developed by Pauker et al. it was possible to obtain the diagnostic and treatment thresholds adjusted for each tests in question. The concept of intermediate probability of coronary disease is quite broad, ranging, according to the authors, between 10 and 90%, 1 and 92%, 15 and 85%, with different rationale. Considering the discriminatory power of each test, risks and treatment benefits, the diagnostic and treatment thresholds were defined for exercise testing (22-58%), eco-stress (10-72%), myocardial scintigraphy (12-80%), nuclear magnetic resonance (16-80%) and coronary angiotomography (6.7-81%). The decision to submit to diagnostic tests should be individualized, taking into account the diagnostic and treatment thresholds of each method in question.

Resumo Fundamento: O transtorno depressivo maior (TDM) é um dos distúrbios mentais mais comuns em psiquiatria, sendo um fator de risco para síndrome coronariana aguda (SCA). Objetivo: Avaliar a prevalência de TDM em pacientes com SCA, assim como analisar os fatores associados através da interdependência de variáveis sociodemográficas, clínicas e de estilo de vida. Métodos: Estudo observacional, descritivo e transversal conduzido em pacientes hospitalizados consecutivamente nas unidades coronarianas de três hospitais públicos na cidade do Rio de Janeiro num período de 24 meses. Todos os participantes responderam a um questionário padrão sobre dados sociodemográficos, clínicos e de estilo de vida, assim como participaram de uma entrevista clínica estruturada do DSM-IV sobre episódio depressivo maior atual. Aplicou-se um modelo log-linear de análise multivariada para avaliar associação e interdependência, com nível de significância de 5%. Resultados: Análise de 356 pacientes (229 homens) com idade média e mediana de 60 anos (DP ± 11,42; 27-89). Encontrou-se uma prevalência pontual de TDM de 23%, e significativa associação de TDM com as variáveis sexo, estado civil, sedentarismo, classificação Killip e história de TDM. Ao controlar por sexo, observou-se associação estatisticamente significativa entre TDM e sexo, idade ≤ 60 anos, sedentarismo e história de TDM. O modelo log-linear identificou as variáveis história de TDM, sexo, sedentarismo e idade ≤ 60 anos como tendo a maior associação com TDM. Conclusão: Os resultados indicam a necessidade de abordagens distintas para diagnosticar e tratar TDM em mulheres jovens com SCA, história de TDM, sedentarismo e que não estejam em relações estáveis.

Abstract Background: Major Depressive Disorder (MDD) is one of the most common mental illnesses in psychiatry, being considered a risk factor for Acute Coronary Syndrome (ACS). Objective: To assess the prevalence of MDD in ACS patients, as well as to analyze associated factors through the interdependence of sociodemographic, lifestyle and clinical variables. Methods: Observational, descriptive, cross-sectional, case-series study conducted on patients hospitalized consecutively at the coronary units of three public hospitals in the city of Rio de Janeiro over a 24-month period. All participants answered a standardized questionnaire requesting sociodemographic, lifestyle and clinical data, as well as a structured diagnostic interview for the DSM-IV regarding ongoing major depressive episodes. A general log-linear model of multivariate analysis was employed to assess association and interdependence with a significance level of 5%. Results: Analysis of 356 patients (229 men), with an average and median age of 60 years (SD ± 11.42, 27-89). We found an MDD point prevalence of 23%, and a significant association between MDD and gender, marital status, sedentary lifestyle, Killip classification, and MDD history. Controlling for gender, we found a statistically significant association between MDD and gender, age ≤ 60 years, sedentary lifestyle and MDD history. The log-linear model identified the variables MDD history, gender, sedentary lifestyle, and age ≤ 60 years as having the greatest association with MDD. Conclusion: Distinct approaches are required to diagnose and treat MDD in young women with ACS, history of MDD, sedentary lifestyle, and who are not in stable relationships.

ABSTRACT Despite medical advances, mortality due to acute coronary syndrome remains high. For this reason, it is important to identify the most critical factors for predicting the risk of death in patients hospitalized with this disease. To improve medical decisions, it is also helpful to construct models that enable us to represent how the main driving factors relate to patient outcomes. In this study, we compare the capability of Artificial Neural Network (ANN) and Support Vector Machine (SVM) models to distinguish between patients hospitalized with acute coronary syndrome who have low or high risk of death. Input variables are selected using the wrapper approach associated with a mutual information filter and two new proposed filters based on Euclidean distance. Because of missing data, the use of a filter is an important step in increasing the size of the usable data set and maximizing the performance of the classification models. The computational results indicate that the SVM model performs better. The most relevant input variables are age, any previous revascularization, and creatinine, regardless of the classification algorithms and filters used. However, the Euclidean filters also identify a second important group of input variables: age, creatinine and systemic arterial hypertension.

Fundamento:A polineuropatia amiloidótica familiar (PAF) é uma doença rara diagnosticada no Brasil e no mundo. A frequência de envolvimento cardiovascular em pacientes brasileiros com PAF é desconhecida.Objetivos:Detectar a frequência de envolvimento cardiovascular e correlacionar os achados cardiovasculares com o escore PND (Polyneuropathy Disability Score) modificado.Métodos:Em um centro de referência nacional, 51 pacientes foram avaliados com exame clínico, eletrocardiograma (ECG), ecocardiograma (ECO) e Holter de 24 horas. Os pacientes foram classificados de acordo com o escore PND modificado e divididos em grupos: PND 0, PND I, PND II e PND > II (que incluiu o PND IIIa, IIIb e IV). Nós escolhemos a árvore de classificação como o método estatístico para analisar a associação entre achados nos exames cardiovasculares e a classificação neurológica (PND).Resultados:Anormalidades no ECG estiveram presentes em quase 2/3 dos pacientes com PAF, enquanto que anormalidades no ECO ocorreram em cerca de 1/3 deles. Todos os pacientes com ECO anormal também apresentaram ECG anormal, mas o oposto não ocorreu. A árvore de classificação identificou o ECG e o ECO como variáveis relevantes (p < 0,001 e p = 0,08, respectivamente). A probabilidade de um paciente estar no grupo PND 0 quando apresentava um ECG normal foi superior a 80%. Quando ambos o ECG e o ECO eram anormais, essa probabilidade era nula.Conclusões:Pacientes brasileiros com PAF apresentam anormalidades frequentes ao ECG. O ECG é um bom exame para discriminar portadores assintomáticos da mutação daqueles que desenvolveram a doença, enquanto que o ECO contribui para esta discriminação.

Background:Familial amyloidotic polyneuropathy (FAP) is a rare disease diagnosed in Brazil and worldwide. The frequency of cardiovascular involvement in Brazilian FAP patients is unknown.Objective:Detect the frequency of cardiovascular involvement and correlate the cardiovascular findings with the modified polyneuropathy disability (PND) score.Methods:In a national reference center, 51 patients were evaluated with clinical examination, electrocardiography (ECG), echocardiography (ECHO), and 24-hour Holter. Patients were classified according to the modified PND score and divided into groups: PND 0, PND I, PND II, and PND > II (which included PND IIIa, IIIb, and IV). We chose the classification tree as the statistical method to analyze the association between findings in cardiac tests with the neurological classification (PND).Results:ECG abnormalities were present in almost 2/3 of the FAP patients, whereas ECHO abnormalities occurred in around 1/3 of them. All patients with abnormal ECHO also had abnormal ECG, but the opposite did not apply. The classification tree identified ECG and ECHO as relevant variables (p < 0.001 and p = 0.08, respectively). The probability of a patient to be allocated to the PND 0 group when having a normal ECG was over 80%. When both ECG and ECHO were abnormal, this probability was null.Conclusions:Brazilian patients with FAP have frequent ECG abnormalities. ECG is an appropriate test to discriminate asymptomatic carriers of the mutation from those who develop the disease, whereas ECHO contributes to this discrimination.

Fundamento: A ressonância magnética cardíaca fornece informações anatômicas detalhadas do infarto, porém poucos estudos investigaram a associação desses dados com mortalidade pós-infarto agudo do miocárdio. Objetivo: Verificar a associação entre os dados de anatomia e magnitude do infarto, obtidos da ressonância magnética cardíaca pós-infarto agudo do miocárdio, e mortalidade em longo prazo. Métodos: Foram identificados 1.959 laudos com “massa infartada” em 7.119 exames de ressonância magnética cardíaca, dos quais 420 possuíam documentação clínica e laboratorial de infarto agudo do miocárdio prévio. As variáveis estudadas foram os fatores de risco clássicos, fração de ejeção do ventrículo esquerdo, função ventricular categorizada e localização do infarto agudo do miocárdio. Massa infartada, extensão e transmuralidade do infarto agudo do miocárdio foram analisadas de maneira isolada e conjuntamente, pela variável denominada “MET-IAM”. A análise estatística foi feita pelo elastic net regularization, pelo modelo de Cox e por árvores de sobrevida. Resultados: A idade média foi 62,3 ± 12 anos, sendo 77,3% de homens. Durante o seguimento de 6,4 ± 2,9 anos, foram identificados 76 óbitos (18,1%). Creatinina sérica, diabetes melito e infarto agudo do miocárdio prévio demonstraram associação independente com mortalidade. A idade foi o principal fator explicativo. As variáveis da ressonância magnética cardíaca que se associaram de forma independente com a mortalidade foram: transmuralidade do infarto agudo do miocárdio (p = 0,047), disfunção ventricular (p = 0,0005) e massa infartada (p = 0,0005) − sendo essa última a principal variável explicativa para morte por doença isquêmica cardíaca. A variável MET-IAM exibiu a maior associação de risco para morte por doença isquêmica cardíaca (HR: 16,04; IC95%: 2,64-97,5; p = 0,003). Conclusão: Os dados anatômicos do infarto obtidos da ressonância magnética cardíaca pós-infarto agudo do miocárdio se associaram de forma independente com mortalidade em longo prazo, sendo, porém, mais relevantes para morte por doença isquêmica cardíaca.

Background: Cardiac magnetic resonance imaging provides detailed anatomical information on infarction. However, few studies have investigated the association of these data with mortality after acute myocardial infarction. Objective: To study the association between data regarding infarct size and anatomy, as obtained from cardiac magnetic resonance imaging after acute myocardial infarction, and long-term mortality. Methods: A total of 1959 reports of “infarct size” were identified in 7119 cardiac magnetic resonance imaging studies, of which 420 had clinical and laboratory confirmation of previous myocardial infarction. The variables studied were the classic risk factors – left ventricular ejection fraction, categorized ventricular function, and location of acute myocardial infarction. Infarct size and acute myocardial infarction extent and transmurality were analyzed alone and together, using the variable named “MET-AMI”. The statistical analysis was carried out using the elastic net regularization, with the Cox model and survival trees. Results: The mean age was 62.3 ± 12 years, and 77.3% were males. During the mean follow-up of 6.4 ± 2.9 years, there were 76 deaths (18.1%). Serum creatinine, diabetes mellitus and previous myocardial infarction were independently associated with mortality. Age was the main explanatory factor. The cardiac magnetic resonance imaging variables independently associated with mortality were transmurality of acute myocardial infarction (p = 0.047), ventricular dysfunction (p = 0.0005) and infarcted size (p = 0.0005); the latter was the main explanatory variable for ischemic heart disease death. The MET-AMI variable was the most strongly associated with risk of ischemic heart disease death (HR: 16.04; 95%CI: 2.64-97.5; p = 0.003). Conclusion: The anatomical data of infarction, obtained from cardiac magnetic resonance imaging after acute myocardial infarction, were independently associated with long-term mortality, especially for ischemic heart disease death.