Abstract Background: Recent studies show Silent Myocardial Infarction (SMI) as a quite frequent event. However, regarding severe tertiary care patients that frequently present consequences of Coronary Artery Disease (CAD) and Left Ventricular Dysfunction (LVD), the occurrence of this manifestation is unexpected and its associated factors aren't clear in the literature. Aim: To compare clinical, laboratorial, ventricular and angiographic factors between silent and classical presentation of MI in patients with CAD and LVD. Methods: Patients with multivessel CAD with over 70 % obstructive lesions and LVD with EF less than 35 % were evaluated for MASS VI trial and later included in the present study. The ventricular function and coronary assessment were measured by echocardiography and SYNTAX score, respectively. The population was stratified in a SMI group and Clinically Manifested Myocardial Infarction (CMMI) group based on MI presentation for a comparison of medical parameters. Results: From 132 patients, 47 (35.6 %) were classified as SMI and 85 (64.4 %) as CMMI. No differences were observed between groups regarding age, sex, diabetes mellitus, SYNTAX score, or collateral circulation. Higher proportion of NYHA II classification, inferior wall MI and lower creatinine clearance were found in SMI group. After multivariate analysis, peripheral diabetic neuropathy (OR = 4.6 [1.1-12.7] p = 0.032) and inferior wall MI (OR = 4.1 [1.5-11.4] p = 0.007) were significantly associated with SMI. Conclusion: Peripheral diabetic neuropathy and inferior wall MI were associated with SMI presentation. Overall, associated factors tend to be similar comparing SMI and CMMI, but in the specific population of diabetic patients with chronic neuropathy a special care should be taken. Background (SMI event However (CAD LVD, , (LVD) arent aren t literature Aim clinical laboratorial Methods 7 3 study score respectively CMMI (CMMI parameters Results 13 4 35.6 356 6 (35. 8 64.4 644 64 (64. age sex mellitus circulation classification analysis OR 46 4. 1.112.7 11127 1.1 12.7 1 12 [1.1-12.7 0.032 0032 0 032 41 1.511.4 15114 1.5 11.4 5 11 [1.5-11.4 0.007 0007 007 Conclusion Overall taken (LVD 35. (35 64. (64 112 1.112. 1112 1. 127 12. [1.1-12. 0.03 003 03 511 1.511. 1511 15 114 11. [1.5-11. 0.00 000 00 (3 (6 1.112 111 [1.1-12 0.0 51 1.511 151 [1.5-11 ( 1.11 [1.1-1 0. 1.51 [1.5-1 [1.1- [1.5- [1.1 [1.5 [1. [1 [

SUMMARY OBJECTIVE: Our study aimed to evaluate the correlation of cardiac troponin T levels with comorbidities and in-hospital outcomes in patients with coronavirus disease-2019 in Brazil. METHODS: Data from a cohort of 3,596 patients who were admitted with suspected coronavirus disease-2019 in a Brazilian tertiary center, between March and August 2020, were reviewed. A total of 2,441 (68%) patients had cardiac troponin T determined in the first 72 h of admission and were stratified into two groups: elevated cardiac troponin T (cardiac troponin T >0.014 ng/mL) and normal cardiac troponin T. Associations between troponin, comorbidities, biomarkers, and outcomes were assessed. Regression models were built to assess the association of several variables with in-hospital mortality. RESULTS: A total of 2,441 patients were embraced, of which 924 (38%) had normal cardiac troponin T and 1,517 (62%) had elevated cardiac troponin T. Patients with elevated cardiac troponin T were older and had more comorbidities, such as cardiovascular disease, hypertension, diabetes, arrhythmia, renal dysfunction, liver disease, stroke, cancer, and dementia. Patients with abnormal cardiac troponin T also had more altered laboratory parameters on admission (i.e., leukocytes, C-reactive protein, D-dimer, and B-type natriuretic peptide), as well as more need for intensive care unit, vasoactive drugs, mechanical ventilation, dialysis, and blood transfusion. All-cause mortality was markedly higher among patients with increased cardiac troponin T (42 vs. 16%, P<0.001). Multiple regression analysis demonstrated that in-hospital mortality was not independently associated with troponin elevation. CONCLUSION: This study showed that cardiac troponin T elevation at admission was common and associated with several comorbidities, biomarkers, and clinical outcomes in patients hospitalized with coronavirus disease-2019, but it was not an independent marker of in-hospital mortality. OBJECTIVE inhospital hospital disease2019 disease 2019 disease-201 Brazil METHODS 3596 3 596 3,59 center 2020 reviewed 2441 2 441 2,44 68% 68 (68% 7 groups 0014 0 014 >0.01 ng/mL ngmL ng mL biomarkers assessed RESULTS embraced 92 38% 38 (38% 1517 1 517 1,51 62% 62 (62% hypertension diabetes arrhythmia dysfunction stroke cancer dementia i.e., ie i e (i.e. leukocytes Creactive C reactive protein Ddimer, Ddimer D dimer, dimer D-dimer Btype B type peptide, peptide , peptide) unit drugs ventilation dialysis transfusion Allcause All cause 42 (4 vs 16 16% P<0.001. P0001 P P<0.001 . 001 P<0.001) CONCLUSION disease2019, 2019, disease201 201 disease-20 359 59 3,5 202 244 44 2,4 6 (68 01 >0.0 9 (38 151 51 1,5 (62 i.e. (i.e 4 ( P000 P<0.00 00 disease20 20 disease-2 35 5 3, 24 2, (6 >0. (3 15 1, i.e P00 P<0.0 disease2 disease- >0 P0 P<0. > P<0 P<

Abstract Background Anabolic androgenic steroid (AAS) abuse has been associated with coronary artery disease (CAD). Pericoronary fat attenuation (pFA) is a marker of coronary inflammation, which is key in the atherosclerotic process. Objective To evaluate pFA and inflammatory profile in AAS users. Methods Twenty strength-trained AAS users (AASU), 20 AAS nonusers (AASNU), and 10 sedentary controls (SC) were evaluated. Coronary inflammation was evaluated by mean pericoronary fat attenuation (mPFA) in the right coronary artery (RCA), left anterior descending coronary artery (LAD), and left circumflex (LCx). Interleukin (IL)-1 (IL-1), IL-6, IL-10, and TNF-alpha were evaluated by optical density (OD) in a spectrophotometer with a 450 nm filter. P<0.05 indicated statistical significance. Results AASU had higher mPFA in the RCA (-65.87 [70.51-60.70] vs. -78.07 [83.66-72.87] vs.-78.46 [85.41-71.99] Hounsfield Units (HU), respectively, p<0.001) and mPFA in the LAD (-71.47 [76.40-66.61] vs. -79.32 [84.37-74.59] vs. -82.52 [88.44-75.81] HU, respectively, p=0.006) compared with AASNU and SC. mPFA in the LCx was not different between AASU, AASNU, and SC (-72.41 [77.17-70.37] vs. -80.13 [86.22-72.23] vs. -78.29 [80.63-72.29] HU, respectively, p=0.163). AASU compared with AASNU and SC, had higher IL-1, (0.975 [0.847-1.250] vs. 0.437 [0.311-0.565] vs. 0.530 [0.402-0.780] OD, respectively, p=0.002), IL-6 (1.195 [0.947-1.405] vs. 0.427 [0.377-0.577] vs. 0.605 [0.332-0.950] OD, p=0.005) and IL-10 (1.145 [0.920-1.292] vs. 0.477 [0.382-0.591] vs. 0.340 [0.316-0.560] OD, p<0.001). TNF-α was not different between the AASU, AASNU, and SC groups (0.520 [0.250-0.610] vs. 0.377 [0.261-0.548] vs. 0.350 [0.182-430]), respectively. Conclusion Compared with ASSNU and controls, AASU have higher mPFA and higher systemic inflammatory cytokines profile suggesting that AAS may induce coronary atherosclerosis through coronary and systemic inflammation. (AAS CAD. CAD . (CAD) (pFA process strengthtrained strength trained , (AASU) 2 (AASNU) 1 (SC (mPFA RCA, (RCA) LAD, (LAD) LCx. (LCx) IL1 IL (IL)- IL1, (IL-1) IL6, IL6 6, 6 IL10, IL10 10, TNFalpha TNF alpha OD (OD 45 filter P005 P 0 05 P<0.0 significance 65.87 6587 65 87 (-65.8 70.5160.70 70516070 70.51 60.70 70 51 60 [70.51-60.70 vs 78.07 7807 78 07 -78.0 83.6672.87 83667287 83.66 72.87 83 66 72 [83.66-72.87 vs.78.46 vs7846 78.46 46 vs.-78.4 85.4171.99 85417199 85.41 71.99 85 41 71 99 [85.41-71.99 HU (HU) respectively p<0.001 p0001 p 001 71.47 7147 47 (-71.4 76.4066.61 76406661 76.40 66.61 76 40 61 [76.40-66.61 79.32 7932 79 32 -79.3 84.3774.59 84377459 84.37 74.59 84 37 74 59 [84.37-74.59 82.52 8252 82 52 -82.5 88.4475.81 88447581 88.44 75.81 88 44 75 81 [88.44-75.81 p=0.006 p0006 006 72.41 7241 (-72.4 77.1770.37 77177037 77.17 70.37 77 17 [77.17-70.37 80.13 8013 80 13 -80.1 86.2272.23 86227223 86.22 72.23 86 22 23 [86.22-72.23 78.29 7829 29 -78.2 80.6372.29 80637229 80.63 72.29 63 [80.63-72.29 p=0.163. p0163 p=0.163 163 p=0.163) 1, IL-1 0.975 0975 975 (0.97 0.8471.250 08471250 0.847 1.250 847 250 [0.847-1.250 0437 437 0.43 0.3110.565 03110565 0.311 0.565 311 565 [0.311-0.565 0530 530 0.53 0.4020.780 04020780 0.402 0.780 402 780 [0.402-0.780 p=0.002, p0002 p=0.002 002 p=0.002) IL- 1.195 1195 195 (1.19 0.9471.405 09471405 0.947 1.405 947 405 [0.947-1.405 0427 427 0.42 0.3770.577 03770577 0.577 377 577 [0.377-0.577 0605 605 0.60 0.3320.950 03320950 0.332 0.950 332 950 [0.332-0.950 p=0.005 p0005 005 1.145 1145 145 (1.14 0.9201.292 09201292 0.920 1.292 920 292 [0.920-1.292 0477 477 0.47 0.3820.591 03820591 0.382 0.591 382 591 [0.382-0.591 0340 340 0.34 0.3160.560 03160560 0.316 0.560 316 560 [0.316-0.560 p<0.001. TNFα α 0.520 0520 520 (0.52 0.2500.610 02500610 0.250 0.610 610 [0.250-0.610 0377 0.37 0.2610.548 02610548 0.261 0.548 261 548 [0.261-0.548 0350 350 0.35 0.182430, 0182430 0.182 430 182 [0.182-430]) (CAD (AASU (AASNU (RCA (LAD (LCx (IL) (IL-1 4 P00 P<0. 65.8 658 8 (-65. 5160 70.5160.7 7051607 7051 70.5 6070 60.7 7 5 [70.51-60.7 78.0 -78. 6672 83.6672.8 8366728 8366 83.6 7287 72.8 [83.66-72.8 vs.78.4 vs784 7846 78.4 vs.-78. 4171 85.4171.9 8541719 8541 85.4 7199 71.9 9 [85.41-71.9 (HU p<0.00 p000 00 71.4 714 (-71. 4066 76.4066.6 7640666 7640 76.4 6661 66.6 [76.40-66.6 79.3 793 3 -79. 3774 84.3774.5 8437745 8437 84.3 7459 74.5 [84.37-74.5 82.5 825 -82. 4475 88.4475.8 8844758 8844 88.4 7581 75.8 [88.44-75.8 p=0.00 72.4 724 (-72. 1770 77.1770.3 7717703 7717 77.1 7037 70.3 [77.17-70.3 80.1 801 -80. 2272 86.2272.2 8622722 8622 86.2 7223 72.2 [86.22-72.2 78.2 782 6372 80.6372.2 8063722 8063 80.6 7229 [80.63-72.2 p016 p=0.16 16 0.97 097 97 (0.9 8471 0.8471.25 0847125 0847 0.84 1250 1.25 25 [0.847-1.25 043 43 0.4 3110 0.3110.56 0311056 0311 0.31 0565 0.56 31 56 [0.311-0.56 053 53 0.5 4020 0.4020.78 0402078 0402 0.40 0780 0.78 [0.402-0.78 1.19 119 19 (1.1 9471 0.9471.40 0947140 0947 0.94 1405 1.40 94 [0.947-1.40 042 42 3770 0.3770.57 0377057 0577 0.57 57 [0.377-0.57 060 0.6 3320 0.3320.95 0332095 0332 0.33 0950 0.95 33 95 [0.332-0.95 1.14 114 14 9201 0.9201.29 0920129 0920 0.92 1292 1.29 92 [0.920-1.29 047 3820 0.3820.59 0382059 0382 0.38 0591 0.59 38 [0.382-0.59 034 34 0.3 3160 0.3160.56 0316056 0316 0560 [0.316-0.56 0.52 052 (0.5 2500 0.2500.61 0250061 0250 0.25 0610 0.61 [0.250-0.61 037 2610 0.2610.54 0261054 0261 0.26 0548 0.54 26 54 [0.261-0.54 035 35 182430 0.182430 018243 0182 0.18 18 [0.182-430] (IL (IL- P0 P<0 65. (-65 516 70.5160. 705160 705 70. 607 60. [70.51-60. 78. -78 667 83.6672. 836672 836 83. 728 72. [83.66-72. vs.78. vs78 784 vs.-78 417 85.4171. 854171 854 85. 719 71. [85.41-71. p<0.0 p00 (-71 406 76.4066. 764066 764 76. 666 66. [76.40-66. 79. -79 84.3774. 843774 843 84. 745 74. [84.37-74. 82. -82 447 88.4475. 884475 884 88. 758 75. [88.44-75. p=0.0 (-72 177 77.1770. 771770 771 77. 703 [77.17-70. 80. -80 227 86.2272. 862272 862 86. 722 [86.22-72. 637 80.6372. 806372 806 [80.63-72. p01 p=0.1 0.9 09 (0. 0.8471.2 084712 084 0.8 125 1.2 [0.847-1.2 04 0. 0.3110.5 031105 031 056 [0.311-0.5 0.4020.7 040207 040 078 0.7 [0.402-0.7 1.1 11 (1. 0.9471.4 094714 094 140 1.4 [0.947-1.4 0.3770.5 037705 057 [0.377-0.5 06 0.3320.9 033209 033 095 [0.332-0.9 0.9201.2 092012 092 129 [0.920-1.2 0.3820.5 038205 038 059 [0.382-0.5 03 0.3160.5 031605 [0.316-0.5 0.2500.6 025006 025 0.2 061 [0.250-0.6 0.2610.5 026105 026 054 [0.261-0.5 18243 0.18243 01824 018 0.1 [0.182-430 P< (-6 70.5160 70516 [70.51-60 -7 83.6672 83667 [83.66-72 vs.78 vs7 vs.-7 85.4171 85417 [85.41-71 p<0. p0 (-7 76.4066 76406 [76.40-66 84.3774 84377 [84.37-74 -8 88.4475 88447 [88.44-75 p=0. 77.1770 77177 [77.17-70 86.2272 86227 [86.22-72 80.6372 80637 [80.63-72 (0 0.8471. 08471 08 12 1. [0.847-1. 0.3110. 03110 [0.311-0. 0.4020. 04020 [0.402-0. (1 0.9471. 09471 [0.947-1. 0.3770. 03770 [0.377-0. 0.3320. 03320 [0.332-0. 0.9201. 09201 [0.920-1. 0.3820. 03820 [0.382-0. 0.3160. 03160 [0.316-0. 0.2500. 02500 02 [0.250-0. 0.2610. 02610 [0.261-0. 1824 0.1824 01 [0.182-43 (- 70.516 [70.51-6 - 83.667 [83.66-7 vs.7 vs.- 85.417 [85.41-7 p<0 76.406 [76.40-6 84.377 [84.37-7 88.447 [88.44-7 p=0 77.177 [77.17-7 86.227 [86.22-7 80.637 [80.63-7 ( 0.8471 [0.847-1 0.3110 [0.311-0 0.4020 [0.402-0 0.9471 [0.947-1 0.3770 [0.377-0 0.3320 [0.332-0 0.9201 [0.920-1 0.3820 [0.382-0 0.3160 [0.316-0 0.2500 [0.250-0 0.2610 [0.261-0 [0.182-4 [70.51- [83.66- [85.41- p< [76.40- [84.37- [88.44- p= [77.17- [86.22- [80.63- [0.847- [0.311- [0.402- [0.947- [0.377- [0.332- [0.920- [0.382- [0.316- [0.250- [0.261- [0.182- [70.51 [83.66 [85.41 [76.40 [84.37 [88.44 [77.17 [86.22 [80.63 [0.847 [0.311 [0.402 [0.947 [0.377 [0.332 [0.920 [0.382 [0.316 [0.250 [0.261 [0.182 [70.5 [83.6 [85.4 [76.4 [84.3 [88.4 [77.1 [86.2 [80.6 [0.84 [0.31 [0.40 [0.94 [0.37 [0.33 [0.92 [0.38 [0.25 [0.26 [0.18 [70. [83. [85. [76. [84. [88. [77. [86. [80. [0.8 [0.3 [0.4 [0.9 [0.2 [0.1 [70 [83 [85 [76 [84 [88 [77 [86 [80 [0. [7 [8 [0 [

Resumo Fundamento O uso abusivo de esteroides anabólicos androgênicos (EAA) tem sido associado à doença arterial coronariana (DAC). A atenuação de gordura pericoronária (AGp) é um marcador de inflamação coronária, a qual exerce um papel chave no processo aterosclerótico. Objetivo Avaliar AGp e perfil inflamatório em usuários de EAA. Método Vinte indivíduos que realizavam treinamento de força, usuários de EAA (UEAA), 20 não usuários de EAA (NUEAA), e 10 indivíduos sedentários controle (SC) foram avaliados. Inflamação coronária foi avaliada por atenuação de gordura pericoronária média (AGPm) artéria coronária direita (ACD), artéria descendente anterior esquerda (ADA) e artéria circunflexa (ACX). Interleucina (IL)-1 (IL-1), IL-6, IL-10, e TNF-alfa foram avaliados por densidade ótica (DO) em um espectrofotômetro com um filtro de 450 nm. Um p<0,05 indicou significância estatística. Resultados Os UEAA apresentaram maior AGPm na ACD [-65,87 (70,51-60,70) vs. -78,07 (83,66-72,87) vs.-78,46 (85,41-71,99] unidades Hounsfield (HU), respectivamente, p<0,001) e AGPm na ADA [-71,47 (76,40-66,610 vs. -79,32 (84,37-74,59) vs. -82,52 (88,44-75,81) HU, respectivamente, p=0,006) em comparação aos NUEAA e CS. A AGPm na ACX não foi diferente entre os grupos UEAA, NUEAA e CS [-72,41 (77,17-70,37) vs. -80,13 (86,22-72,23) vs. -78,29 (80,63-72,29) HU, respectivamente, p=0,163). Em comparação aos NUEAA e aos CS, o grupo UEAA apresentaram maiores níveis de IL-1 [0,975 (0,847-1,250) vs. 0,437 (0,311-0,565) vs. 0,530 (0,402-0,780) DO, respectivamente, p=0,002), IL-6 [1,195 (0,947-1,405) vs. 0,427 (0,377-0,577) vs. 0,605 (0,332-0,950) DO, p=0,005) e IL-10 [1,145 (0,920-1,292) vs. 0,477 (0,382-0,591) vs. 0,340 (0,316-0,560) DO, p<0,001]. TNF-α não foi diferente entre os grupos UEAA, NUEAA e CS [0,520 (0,250-0,610) vs. 0,377 (0.261-0,548) vs. 0,350 (0,182-430)]. Conclusão Em comparação aos NUEAA e controles, os UEAA apresentam maior AGPm e maior perfil de citocinas inflamatórias sistêmicas, sugerindo que os EAA podem induzir aterosclerose por inflamação coronária e sistêmica. (EAA DAC. DAC . (DAC) (AGp aterosclerótico força , (UEAA) 2 NUEAA, (NUEAA) 1 SC (SC (AGPm ACD, (ACD) (ADA ACX. (ACX) IL1 IL (IL)- IL1, (IL-1) IL6, IL6 6, 6 IL10, IL10 10, TNFalfa TNF alfa DO (DO 45 nm p005 p 0 05 p<0,0 estatística 65,87 6587 65 87 [-65,8 70,5160,70 70516070 70,51 60,70 70 51 60 (70,51-60,70 vs 78,07 7807 78 07 -78,0 83,6672,87 83667287 83,66 72,87 83 66 72 (83,66-72,87 vs.78,46 vs7846 78,46 46 vs.-78,4 85,4171,99 85417199 85,41 71,99 85 41 71 99 (85,41-71,99 HU (HU) respectivamente p<0,001 p0001 001 71,47 7147 47 [-71,4 76,4066,610 764066610 76,40 66,610 76 40 610 (76,40-66,61 79,32 7932 79 32 -79,3 84,3774,59 84377459 84,37 74,59 84 37 74 59 (84,37-74,59 82,52 8252 82 52 -82,5 88,4475,81 88447581 88,44 75,81 88 44 75 81 (88,44-75,81 p=0,006 p0006 006 72,41 7241 [-72,4 77,1770,37 77177037 77,17 70,37 77 17 (77,17-70,37 80,13 8013 80 13 -80,1 86,2272,23 86227223 86,22 72,23 86 22 23 (86,22-72,23 78,29 7829 29 -78,2 80,6372,29 80637229 80,63 72,29 63 (80,63-72,29 p=0,163. p0163 p=0,163 163 p=0,163) IL- 0,975 0975 975 [0,97 0,8471,250 08471250 0,847 1,250 847 250 (0,847-1,250 0437 437 0,43 0,3110,565 03110565 0,311 0,565 311 565 (0,311-0,565 0530 530 0,53 0,4020,780 04020780 0,402 0,780 402 780 (0,402-0,780 p=0,002, p0002 p=0,002 002 p=0,002) 1,195 1195 195 [1,19 0,9471,405 09471405 0,947 1,405 947 405 (0,947-1,405 0427 427 0,42 0,3770,577 03770577 0,577 377 577 (0,377-0,577 0605 605 0,60 0,3320,950 03320950 0,332 0,950 332 950 (0,332-0,950 p=0,005 p0005 005 1,145 1145 145 [1,14 0,9201,292 09201292 0,920 1,292 920 292 (0,920-1,292 0477 477 0,47 0,3820,591 03820591 0,382 0,591 382 591 (0,382-0,591 0340 340 0,34 0,3160,560 03160560 0,316 0,560 316 560 (0,316-0,560 p<0,001. p<0,001] TNFα α 0,520 0520 520 [0,52 0,2500,610 02500610 0,250 0,610 (0,250-0,610 0377 0,37 0.2610,548 02610548 0.261 0,548 261 548 (0.261-0,548 0350 350 0,35 0,182430. 0182430 0,182 430 182 (0,182-430)] controles sistêmicas sistêmica (DAC (UEAA (NUEAA (ACD (ACX (IL) (IL-1 4 p00 p<0, 65,8 658 8 [-65, 5160 70,5160,7 7051607 7051 70,5 6070 60,7 7 5 (70,51-60,7 78,0 -78, 6672 83,6672,8 8366728 8366 83,6 7287 72,8 (83,66-72,8 vs.78,4 vs784 7846 78,4 vs.-78, 4171 85,4171,9 8541719 8541 85,4 7199 71,9 9 (85,41-71,9 (HU p<0,00 p000 00 71,4 714 [-71, 4066 76,4066,61 76406661 7640 76,4 66610 66,61 61 (76,40-66,6 79,3 793 3 -79, 3774 84,3774,5 8437745 8437 84,3 7459 74,5 (84,37-74,5 82,5 825 -82, 4475 88,4475,8 8844758 8844 88,4 7581 75,8 (88,44-75,8 p=0,00 72,4 724 [-72, 1770 77,1770,3 7717703 7717 77,1 7037 70,3 (77,17-70,3 80,1 801 -80, 2272 86,2272,2 8622722 8622 86,2 7223 72,2 (86,22-72,2 78,2 782 6372 80,6372,2 8063722 8063 80,6 7229 (80,63-72,2 p016 p=0,16 16 0,97 097 97 [0,9 8471 0,8471,25 0847125 0847 0,84 1250 1,25 25 (0,847-1,25 043 43 0,4 3110 0,3110,56 0311056 0311 0,31 0565 0,56 31 56 (0,311-0,56 053 53 0,5 4020 0,4020,78 0402078 0402 0,40 0780 0,78 (0,402-0,78 1,19 119 19 [1,1 9471 0,9471,40 0947140 0947 0,94 1405 1,40 94 (0,947-1,40 042 42 3770 0,3770,57 0377057 0577 0,57 57 (0,377-0,57 060 0,6 3320 0,3320,95 0332095 0332 0,33 0950 0,95 33 95 (0,332-0,95 1,14 114 14 9201 0,9201,29 0920129 0920 0,92 1292 1,29 92 (0,920-1,29 047 3820 0,3820,59 0382059 0382 0,38 0591 0,59 38 (0,382-0,59 034 34 0,3 3160 0,3160,56 0316056 0316 0560 (0,316-0,56 0,52 052 [0,5 2500 0,2500,61 0250061 0250 0,25 0610 0,61 (0,250-0,61 037 2610 0.2610,54 0261054 0261 0.26 0548 0,54 26 54 (0.261-0,54 035 35 182430 0,182430 018243 0182 0,18 18 (0,182-430) (IL (IL- p0 p<0 65, [-65 516 70,5160, 705160 705 70, 607 60, (70,51-60, 78, -78 667 83,6672, 836672 836 83, 728 72, (83,66-72, vs.78, vs78 784 vs.-78 417 85,4171, 854171 854 85, 719 71, (85,41-71, [-71 406 76,4066,6 7640666 764 76, 6661 66,6 (76,40-66, 79, -79 84,3774, 843774 843 84, 745 74, (84,37-74, 82, -82 447 88,4475, 884475 884 88, 758 75, (88,44-75, p=0,0 [-72 177 77,1770, 771770 771 77, 703 (77,17-70, 80, -80 227 86,2272, 862272 862 86, 722 (86,22-72, 637 80,6372, 806372 806 (80,63-72, p01 p=0,1 0,9 09 [0, 0,8471,2 084712 084 0,8 125 1,2 (0,847-1,2 04 0, 0,3110,5 031105 031 056 (0,311-0,5 0,4020,7 040207 040 078 0,7 (0,402-0,7 1,1 11 [1, 0,9471,4 094714 094 140 1,4 (0,947-1,4 0,3770,5 037705 057 (0,377-0,5 06 0,3320,9 033209 033 095 (0,332-0,9 0,9201,2 092012 092 129 (0,920-1,2 0,3820,5 038205 038 059 (0,382-0,5 03 0,3160,5 031605 (0,316-0,5 0,2500,6 025006 025 0,2 061 (0,250-0,6 0.2610,5 026105 026 0.2 054 (0.261-0,5 18243 0,18243 01824 018 0,1 (0,182-430 p< [-6 70,5160 70516 (70,51-60 -7 83,6672 83667 (83,66-72 vs.78 vs7 vs.-7 85,4171 85417 (85,41-71 [-7 76,4066, 764066 666 66, (76,40-66 84,3774 84377 (84,37-74 -8 88,4475 88447 (88,44-75 p=0, 77,1770 77177 (77,17-70 86,2272 86227 (86,22-72 80,6372 80637 (80,63-72 [0 0,8471, 08471 08 12 1, (0,847-1, 0,3110, 03110 (0,311-0, 0,4020, 04020 (0,402-0, [1 0,9471, 09471 (0,947-1, 0,3770, 03770 (0,377-0, 0,3320, 03320 (0,332-0, 0,9201, 09201 (0,920-1, 0,3820, 03820 (0,382-0, 0,3160, 03160 (0,316-0, 0,2500, 02500 02 (0,250-0, 0.2610, 02610 0. (0.261-0, 1824 0,1824 01 (0,182-43 [- 70,516 (70,51-6 - 83,667 (83,66-7 vs.7 vs.- 85,417 (85,41-7 76,4066 76406 (76,40-6 84,377 (84,37-7 88,447 (88,44-7 p=0 77,177 (77,17-7 86,227 (86,22-7 80,637 (80,63-7 [ 0,8471 (0,847-1 0,3110 (0,311-0 0,4020 (0,402-0 0,9471 (0,947-1 0,3770 (0,377-0 0,3320 (0,332-0 0,9201 (0,920-1 0,3820 (0,382-0 0,3160 (0,316-0 0,2500 (0,250-0 0.2610 (0.261-0 (0,182-4 (70,51- (83,66- (85,41- 76,406 (76,40- (84,37- (88,44- p= (77,17- (86,22- (80,63- (0,847- (0,311- (0,402- (0,947- (0,377- (0,332- (0,920- (0,382- (0,316- (0,250- (0.261- (0,182- (70,51 (83,66 (85,41 (76,40 (84,37 (88,44 (77,17 (86,22 (80,63 (0,847 (0,311 (0,402 (0,947 (0,377 (0,332 (0,920 (0,382 (0,316 (0,250 (0.261 (0,182 (70,5 (83,6 (85,4 (76,4 (84,3 (88,4 (77,1 (86,2 (80,6 (0,84 (0,31 (0,40 (0,94 (0,37 (0,33 (0,92 (0,38 (0,25 (0.26 (0,18 (70, (83, (85, (76, (84, (88, (77, (86, (80, (0,8 (0,3 (0,4 (0,9 (0,2 (0.2 (0,1 (70 (83 (85 (76 (84 (88 (77 (86 (80 (0, (0. (7 (8 (0 (

Abstract Background The incidence of cardiovascular events in patients with chronic ischemic heart disease (CIHD) may vary significantly among countries. Although populous, Brazil is often underrepresented in international records. Objectives This study aimed to describe the quality of care and the two-year incidence of cardiovascular events and associated prognostic factors in CIHD patients in a tertiary public health care center in Brazil. Methods Patients with CIHD who reported for clinical evaluation at Instituto do Coração (São Paulo, Brazil) were registered and followed for two years. The primary endpoint was a composite of myocardial infarction (MI), stroke, or death. A significance level of 0.05 was adopted. Results From January 2016 to December 2018, 625 participants were included in the study. Baseline characteristics show that 33.1% were women, median age 66.1 [59.6 – 71.9], 48.6% had diabetes, 83.1% had hypertension, 62.6% had previous MI, and 70.4% went through some revascularization procedure. At a median follow-up (FU) of 881 days, we noted 37 (7.05%) primary endpoints. After adjustments, age, previous stroke, and LDL-cholesterol were independently associated with the primary endpoint. Comparing baseline versus FU, participants experienced relief of angina based on the Canadian Cardiovascular Society (CCS) scale according to the following percentages: 65.7% vs. 81.7% were asymptomatic and 4.2% vs. 2.9% CCS 3 or 4 (p < 0.001). They also experienced better quality of medication prescription: 65.8% vs. 73.6% (p < 0.001). However, there was no improvement in LDL-cholesterol or blood pressure control. Conclusion This study shows that CIHD patients had a two-year incidence of the primary composite endpoint of 7.05%, and the reduction of LDL-cholesterol was the only modifiable risk factor associated with prognosis. (CIHD countries populous records twoyear year São Paulo years MI , (MI) stroke death 005 0 05 0.0 adopted 201 2018 62 331 33 1 33.1 women 661 66 66. 59.6 596 59 6 [59. 71.9, 719 71.9 71 9 71.9] 486 48 48.6 diabetes 831 83 83.1 hypertension 626 62.6 704 70 70.4 procedure followup follow up FU (FU 88 days 7.05% 705 7 (7.05% endpoints adjustments LDLcholesterol LDL cholesterol (CCS percentages 657 65 65.7 vs 817 81 81.7 42 2 4.2 29 2.9 p 0.001. 0001 0.001 . 001 0.001) prescription 658 8 65.8 736 73 73.6 However control prognosis (MI 00 0. 20 33. 59. 5 [59 71. 48. 83. 62. 70. 7.05 (7.05 65. 81. 4. 2. 000 0.00 73. [5 7.0 (7.0 [ 7. (7. (7 (

Resumo Fundamento A incidência de eventos cardiovasculares em pacientes com doença cardíaca isquêmica crônica (DCIC) pode variar significativamente entre os países. Embora populoso, o Brasil é frequentemente sub-representado nos registros internacionais. Objetivos Este estudo teve como objetivo descrever a qualidade do atendimento e a incidência de eventos cardiovasculares em dois anos, além de fatores prognósticos associados em pacientes com DCIC em um centro terciário de saúde pública no Brasil. Métodos Pacientes com DCIC que compareceram para avaliação clínica no Instituto do Coração (São Paulo, Brasil) foram cadastrados e acompanhados por dois anos. O desfecho primário foi um composto de infarto do miocárdio (IM), acidente vascular encefálico ou morte. Um nível de significância de 0,05 foi adotado. Resultados De janeiro de 2016 a dezembro de 2018, 625 participantes foram incluídos no estudo. As características basais mostram que 33,1% eram mulheres, a idade mediana era de 66,1 [59,6 – 71,9], 48,6% tinham diabetes, 83,1% tinham hipertensão, 62,6% tinham IM prévio e 70,4% passaram por algum procedimento de revascularização. Em um acompanhamento mediano de 881 dias, 37 (7,05%) desfechos primários foram observados. Após ajustes, idade, acidente vascular encefálico prévio e colesterol LDL foram independentemente associados ao desfecho primário. Comparando a linha de base com o acompanhamento, os participantes relataram alívio da angina com base na escala da Sociedade Cardiovascular Canadense (SCC) de acordo com as seguintes porcentagens: 65,7% vs. 81,7% eram assintomáticos e 4,2% vs. 2,9% eram SCC 3 ou 4 (p < 0,001). Eles também relataram melhor qualidade na prescrição de medicamentos: 65,8% vs. 73,6% (p < 0,001). No entanto, não houve melhora no colesterol LDL ou no controle da pressão arterial. Conclusão O presente estudo mostra que pacientes com DCIC apresentaram uma incidência de 7,05% do desfecho primário composto em um período de dois anos, sendo a diminuição do colesterol LDL o único fator de risco modificável associado ao prognóstico. (DCIC países populoso subrepresentado sub representado internacionais anos São Paulo IM, , (IM) morte 005 0 05 0,0 adotado 201 2018 62 331 33 1 33,1 mulheres 661 66 66, 59,6 596 59 6 [59, 71,9, 719 71,9 71 9 71,9] 486 48 48,6 diabetes 831 83 83,1 hipertensão 626 62,6 704 70 70,4 revascularização 88 dias 705 7 (7,05% observados ajustes (SCC porcentagens 657 65 65,7 vs 817 81 81,7 42 2 4,2 29 2,9 p 0,001. 0001 0,001 . 001 0,001) medicamentos 658 8 65,8 736 73 73,6 entanto arterial 7,05 prognóstico (IM 00 0, 20 33, 59, 5 [59 71, 48, 83, 62, 70, (7,05 65, 81, 4, 2, 000 0,00 73, 7,0 [5 (7,0 7, [ (7, (7 (

Resumo Fundamento Diante de dados demográficos referentes às áreas de atuação dos cardiologistas no Brasil, a coordenação do Programa de Residência Médica em Cardiologia do Instituto do Coração (PRM INCOR) entendeu a necessidade de uma atualização de seu conteúdo programático, a fim de adaptar o processo de formação à realidade profissional do cardiologista. Objetivo O presente artigo tem como objetivo descrever à comunidade científica as atualizações recentemente implementadas no PRM INCOR. Métodos No artigo, descrevemos as atualizações recentes do PRM INCOR, comparando a grade teórica pregressa e a atual. Expomos também o racional por trás de tais mudanças com dados de literatura relacionados à atuação do médico cardiologista no mercado de trabalho. Resultado Houve uma redução da carga horária destinada a estágios de terapia intensiva, e um incremento nas atividades ambulatoriais relacionadas a medidas de prevenção primária e secundária. Além disso, o programa passou por uma reformulação de seu conteúdo didático, organizado agora por núcleos de competência. Conclusão A atualização da grade curricular decorre da necessidade de adequar o PRM INCOR à realidade atual do mercado de trabalho brasileiro. O grupo envolvido na atualização está ciente que se trata de um processo dinâmico e que pode exigir modificações no decorrer do tempo.

Abstract Background Considering demographic data related to the cardiologist’s fields of work in Brazil, the administrative board of the InCor medical residency program decided for an update of its curriculum content, to adapt the educational process to the cardiologist’s work reality. Objective This article aimed to describe the recent updates applied to the InCor medical residency program. Methods In the article, we described the recent updates on the InCor residency program, and compared the current curriculum track with the previous one. We also presented the rationale for these changes, based on the literature on the participation of cardiologists in the labor market. Results There was a reduction in the working hours of residents in training in the intensive care unit, and an increase in the outpatient activities of primary and secondary prevention. Also, the didactic content was reformulated and became organized by the corresponding division. Conclusion The update of the curriculum track of the InCor medical residency program was required in order to adapt it to the Brazilian labor market. The commission in charge of this update is aware that this is a dynamic process that may need changes over time.

ABSTRACT BACKGROUND: Severe pulmonary arterial hypertension (PAH) is a contraindication for heart transplantation (HT). It has been correlated with increased early and late mortality, mainly associated with right ventricular failure. Ventricular assistance devices (VADs) can promote reduction of intracardiac pressures and consequent reduction of PAH over the medium and long terms, thus enabling future candidature for HT. The diminution of early pulmonary pressure within this scenario remains unclear. OBJECTIVE: To evaluate the reduction of PAH and correlate data from right catheterization with the earliness of this reduction. DESIGN AND SETTING: Cross-sectional study in a general hospital in São Paulo, Brazil. METHODS: This was a retrospective analysis on the medical records of patients undergoing VAD implantation in a single hospital. Patients for whom VAD had been indicated as a bridge to candidature for HT due to their condition of constant PAH were selected. RESULTS: Four patients with VADs had constantly severe PAH. Their mean pulmonary artery systolic pressure (PASP) before VAD implantation was 66 mmHg. Over the 30-day period after the procedure, all the patients evolved with a drop in PASP to below 60 mmHg. Their new average was 36 mmHg, which was a drop of close to 50% from baseline values. The one-year survival of this sample was 100%. CONCLUSION: VAD implantation can reduce PAH levels. Early reduction occurred in all patients. Thus, use of VAD is an important bridge tool for enabling candidature for HT among patients with constantly severe PAH.

Resumo Fundamento Demonstrou-se recentemente que a aplicação de ultrassom de alta energia com microbolhas, técnica conhecida como sonotrombólise, causa a dissolução de trombos intravasculares e aumenta a taxa de recanalização angiográfica no infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAM-CSST). Objetivo Avaliar o efeito da sonotrombólise nos índices de motilidade e perfusão miocárdicas em pacientes com IAM-CSST, utilizando a ecocardiografia com perfusão miocárdica em tempo real (EPMTR). Método Uma centena de pacientes com IAM-CSST foram randomizados em dois grupos: Terapia (50 pacientes tratados com sonotrombólise e angioplastia coronária primária) e Controle (50 pacientes tratados com angioplastia coronária primária). Os pacientes realizaram EPMTR para analisar a fração de ejeção do ventrículo esquerdo (FEVE), o índice de escore de motilidade segmentar (IEMS) e o número de segmentos com defeito de perfusão miocárdica, 72 horas após o IAM-CSST e com 6 meses de acompanhamento. Foi considerado significativo p < 0,05. Resultados Pacientes tratados com sonotrombólise apresentaram FEVE mais alta que o grupo Controle em 72 horas (50 ± 10% vs. 44 ± 10%; p = 0,006), e essa melhora foi mantida em seis meses (53 ± 10% vs. 48 ± 12%; p = 0,008). O IEMS foi similar nos grupos Terapia e Controle em 72 horas (1,62 ± 0,39 vs. 1,75 ± 0,40; p = 0,09), mas tornou-se menor no grupo Terapia em 6 meses (1,46 ± 0,36 vs. 1,64 ± 0,44; p = 0,02). O número de segmentos com defeito de perfusão não foi diferente entre os grupos em 72 horas (5,92 ± 3,47 vs. 6,94 ± 3,39; p = 0,15), mas ficou menor no grupo Terapia em 6 meses (4,64 ± 3,31 vs. 6,57 ± 4,29; p = 0,01). Conclusão A sonotrombólise em pacientes com IAM-CSST resulta na melhora dos índices de motilidade e perfusão ventricular ao longo do tempo.

Abstract Background It has recently been demonstrated that the application of high-energy ultrasound and microbubbles, in a technique known as sonothrombolysis, dissolves intravascular thrombi and increases the angiographic recanalization rate in patients with ST-segment–elevation myocardial infarction (STEMI). Objective To evaluate the effects of sonothrombolysis on left ventricular wall motion and myocardial perfusion in patients with STEMI, using real-time myocardial perfusion echocardiography (RTMPE). Methods One hundred patients with STEMI were randomized into the following 2 groups: therapy (50 patients treated with sonothrombolysis and primary coronary angioplasty) and control (50 patients treated with primary coronary angioplasty). The patients underwent RTMPE for analysis of left ventricular ejection fraction (LVEF), wall motion score index (WMSI), and number of segments with myocardial perfusion defects 72 hours after STEMI and at 6 months of follow-up. P < 0.05 was considered statistically significant. Results Patients treated with sonothrombolysis had higher LVEF than the control group at 72 hours (50% ± 10% versus 44% ± 10%; p = 0.006), and this difference was maintained at 6 months of follow-up (53% ± 10% versus 48% ± 12%; p = 0.008). The WMSI was similar in the therapy and control groups at 72 hours (1.62 ± 0.39 versus 1.75 ± 0.40; p = 0.09), but it was lower in the therapy group at 6 months (1.46 ± 0.36 versus 1.64 ± 0.44; p = 0.02). The number of segments with perfusion defects on RTMPE was similar in therapy and control group at 72 hours (5.92 ± 3.47 versus 6.94 ± 3.39; p = 0.15), but it was lower in the therapy group at 6 months (4.64 ± 3.31 versus 6.57 ± 4.29; p = 0.01). Conclusion Sonothrombolysis in patients with STEMI resulted in improved wall motion and ventricular perfusion scores over time.

Resumo Fundamento Amiloidose sistêmica é uma doença com manifestações clínicas diversas. O diagnóstico envolve suspeita clínica, aliada a métodos complementares. Objetivo Descrever o perfil clínico, laboratorial, eletrocardiográfico e de imagem no acometimento cardíaco da amiloidose sistêmica. Métodos Estudo de uma amostra de conveniência, analisando dados clínicos, laboratoriais, eletrocardiográficos, ecocardiográficos, medicina nuclear e ressonância magnética. Considerou-se significância estatística quando p < 0,05. Resultados Avaliaram-se 105 pacientes (com mediana de idade de 66 anos), sendo 62 homens, dos quais 83 indivíduos apresentavam amiloidose por transtirretina (ATTR) e 22 amiloidose por cadeia leve (AL). Na ATTR, 68,7% eram de caráter hereditário (ATTRh) e 31,3% do tipo selvagem (ATTRw). As mutações mais prevalentes foram Val142Ile (45,6%) e Val50Met (40,3%). O tempo de início dos sintomas ao diagnóstico foi 0,54 e 2,15 anos nas formas AL e ATTR (p < 0,001), respectivamente. O acometimento cardíaco foi observado em 77,9% dos ATTR e 90,9% dos AL. Observaram-se alterações de condução atrioventricular em 20% e intraventricular em 27,6% dos pacientes, sendo 33,7 % na ATTR e 4,5% das AL (p = 0,006). A forma ATTRw apresentou mais arritmias atriais que os ATTRh (61,5% x 22,8%; p = 0,001). Ao ecocardiograma a mediana da espessura do septo na ATTRw x ATTRh x AL foi de 15 mm x 12 mm x 11 mm (p = 0,193). Observou-se BNP elevado em 89,5% dos indivíduos (mediana 249 ng/mL, IQR 597,7) e elevação da troponina em 43,2%. Conclusão Foi possível caracterizar, em nosso meio, o acometimento cardíaco na amiloidose sistêmica, em seus diferentes subtipos, através da história clínica e dos métodos diagnósticos descritos.

Abstract Background Systemic amyloidosis is a disease with heterogeneous clinical manifestations. Diagnosis depends on clinical suspicion combined with specific complementary methods. Objective To describe the clinical, laboratory, electrocardiographic, and imaging profile in patients with systemic amyloidosis with cardiac involvement. Methods This study was conducted with a convenience sample, analyzing clinical, laboratory, electrocardiographic, echocardiographic, nuclear medicine, and magnetic resonance data. Statistical significance was set at p < 0.05. Results A total of 105 patients were evaluated (median age of 66 years), 62 of whom were male. Of all patients, 83 had transthyretin (ATTR) amyloidosis, and 22 had light chain (AL) amyloidosis. With respect to ATTR cases, 68.7% were the hereditary form (ATTRh), and 31.3% were wild type (ATTRw). The most prevalent mutations were Val142Ile (45.6%) and Val50Met (40.3%). Time from onset of symptoms to diagnosis was 0.54 and 2.15 years, in the AL and ATTR forms, respectively (p < 0.001). Cardiac involvement was observed in 77.9% of patients with ATTR and in 90.9% of those with AL. Alterations were observed in atrioventricular and intraventricular conduction in 20% and 27.6% of patients, respectively, with 33.7% in ATTR and 4.5% in AL (p = 0.006). In the ATTRw form, there were more atrial arrhythmias than in ATTRh (61.5% versus 22.8%; p = 0.001). On echocardiogram, median septum thickness in ATTRw, ATTRh, and AL was 15 mm, 12 mm, and 11 mm, respectively (p = 0.193). Elevated BNP was observed in 89.5% of patients (median 249, ICR 597.7), and elevated troponin was observed in 43.2%. Conclusion In this setting, it was possible to characterize cardiac involvement in systemic amyloidosis in its different subtypes by means of clinical history and the diagnostic methods described.

ABSTRACT CONTEXT: Heart failure in Brazil is a major public health problem and, even with advances in treatment, it still presents high morbidity and mortality. As a treatment option, mechanical circulatory assist devices (MCADs) have greatly increased in importance over the last decade. CASE REPORT: This report concerns a case of refractory cardiogenic shock due to acute myocarditis in a 35-year-old puerperal female patient who presented with retrosternal pain, fatigue and dyspnea. At the hospital, she was diagnosed with myocarditis. There was no improvement in perfusion even after receiving dobutamine, intra-aortic balloon passage (IAB) and venoarterial extracorporeal membrane oxygenation (VA-ECMO). Therefore, it was decided to implant a MCAD (CentriMag). During hospitalization, recovery from the bi-ventricular dysfunction was achieved. The CentriMag device was removed 10 days after it had been implanted, and the patient was discharged after another 8 days. The myocarditis was proven to be due to the Coxsackie virus. CONCLUSIONS: The decision to implant a MCAD should be individualized, as patient profiles do not always match the indications in the guidelines and protocols. In this study, clinical discussion of the case among the medical and multi-professional teams was essential in order to be able to successfully reverse the patient’s severe clinical condition without sequelae, through using a CentriMag implant.

SUMMARY The extracorporeal membrane oxygenation (ECMO) is a procedure that has been used for a long time in reference centers worldwide. Its fundamental precept is to serve as a bridge to a definitive treatment in patients with severe, but potentially reversible, clinical conditions. Despite this, its use in cardiopulmonary arrest (ECPR) is still a matter of debate, especially when indicated in the emergency department. There is not yet a sufficient level of evidence to support its routine use. In Brasil, the procedure stopped being considered an experimental technique by the Federal Council of Medicine only in 2017. The objective of the present case is to share the pioneering spirit of a Brazilian reference center with ECPR in the emergency room and to discuss the future challenges of the ECMO technique.