Abstract Background Infective endocarditis (IE) is a serious disease with a high mortality rate. Antibiotic prophylaxis for bacterial endocarditis before invasive procedures has been recommended in patients with predisposing cardiac conditions since 1960, but contemporary guidelines worldwide have proposed changes. Objective To evaluate the knowledge and pattern of prescription by cardiologists and dentists regarding antibiotic prophylaxis for bacterial endocarditis before risky oral procedures. Methods This is an observational and cross-sectional study. Data were obtained from an online questionnaire, sent to cardiologists and dentists linked to specialty societies, in the first semester of 2021. Data analysis was performed using descriptive statistics, and comparisons between variables were done in an exploratory approach. The significance level adopted was 5%. Results From 613 responders, 82.5% of cardiologists and 79.5% of dentists reported prescribing antibiotic prophylaxis for patients at high and moderate risk for IE. Of dental procedures capable of generating bacteremia, all were correctly identified by more than 50.0% of the sample. As for the habits of daily living, flossing and toothbrushing had almost 50.0% of correct answers, chewing had only 17.3%, and 40.9% reported that none of the actions presented a risk of bacteremia. When comparing variables, the correct prescription of amoxicillin (2 g, 30–60 minutes before the procedure) was more prevalent among cardiologists and in responders with less than 20 years of graduation (p<0.01). Conclusion In the present study, the prescription of antibiotic prophylaxis for IE were frequent for high- and moderate-risk patients, before oral/dental procedures. Partial knowledge was found about endocarditis, which highlights the need for continuous medical/dental education.

Resumo Fundamento: Em associação às estatinas, os inibidores da pró-proteína convertase subtilisina/kexina tipo 9 (PCSK9) demonstraram ser eficazes na redução de eventos cardiovasculares em pacientes de alto risco. Objetivo: Analisar a custo-efetividade da implementação de evolocumabe para pacientes com alto risco de eventos cardiovasculares no contexto do Sistema Único de Saúde (SUS) no Brasil. Métodos: Um modelo de Markov foi utilizado, baseando-se em uma amostra ambulatorial de pacientes com doença arterial coronariana. Os desfechos primários analisados foram infarto agudo do miocárdio, acidente vascular cerebral isquêmico (AVCi), revascularização do miocárdio e morte cardiovascular. O resultado foi expresso por meio da razão de custo-efetividade incremental (RCEI), considerando-se uma taxa de desconto de 5% ao ano, e uma análise de sensibilidade foi realizada, tendo em vista a imprecisão de valores. Resultados: Selecionaram-se 61 pacientes com risco cardiovascular estimado em 35% em 10 anos, se em uso de atorvastatina 80mg/dia, e em 22,75%, se adicionado o evolocumabe. O custo global por paciente no período de 10 anos foi de R$ 46.522,44 no grupo em monoterapia com atorvastatina versus R$ 236.141,85 na terapia combinada, com uma efetividade global de 0,54 e 0,73, respectivamente. Isso resultou em uma RCEI R$ 1.011.188,07 (R$ 864.498,95 a R$ 1.296.748,43) por desfecho cardiovascular evitado. Conclusões: Apesar de não existirem padrões nacionais para custo-efetividade, os dados encontrados sugerem que a estratégia de associação do evolocumabe à terapia com estatina não é, no momento, custo-efetiva.

Abstract Background: Hypertrophic cardiomyopathy (HCM) and left ventricular hypertrophy (LVH) secondary to systemic hypertension (HTN) may be associated with left atrial (LA) functional abnormalities. Objectives: We aimed to characterize LA mechanics in HCM and HTN and determine any correlation with the extent of left ventricular (LV) fibrosis measured by cardiac magnetic resonance (CMR) in HCM patients. Methods: Two-dimensional speckle tracking-derived longitudinal LA function was acquired from apical views in 60 HCM patients, 60 HTN patients, and 34 age-matched controls. HCM patients also underwent CMR, with measurement of late gadolinium enhancement (LGE) extension. Association with LA strain parameters was analyzed. Statistical significance was set at p<0.05. Results: Mean LV ejection fraction was not different between the groups. The E/e’ ratio was impaired in the HCM group and preserved in the control group. LA mechanics was significantly reduced in HCM, compared to the HTN group. LA strain rate in reservoir (LASRr) and in contractile (LASRct) phases were the best discriminators of HCM, with an area under the curve (AUC) of 0.8, followed by LA strain in reservoir phase (LASr) (AUC 0.76). LASRr and LASR-ct had high specificity (89% and 91%, respectively) and LASr had sensitivity of 80%. A decrease in 2.79% of LA strain rate in conduit phase (LASRcd) predicted an increase of 1cm in LGE extension (r2=0.42, β 2.79, p=0.027). Conclusions: LASRr and LASRct were the best discriminators for LVH secondary to HCM. LASRcd predicted the degree of LV fibrosis assessed by CMR. These findings suggest that LA mechanics is a potential predictor of disease severity in HCM.

Abstract Introduction: Risk scores are important tools for predicting adverse events in cardiac surgery, but their accuracy varies when applied to different populations. The objective of this study is to evaluate the performance of the Brazilian score InsCor as a predictor of mortality after coronary artery bypass grafting (CABG) compared to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Society of Thoracic Surgeons (STS) scores. Methods: This is an observational and retrospective study, with patients undergoing surgical myocardial revascularization in a cardiology hospital in Salvador (Bahia, Brazil), between 2010 and 2015. InsCor, STS, and EuroSCORE were compared for accuracy in predicting mortality within 30 days after surgery. Discrimination capacity of models was assessed using areas under receiver operating characteristic (ROC) curves. Significance level was 5%. Results: Four hundred sixty-one patients were evaluated (mean age 63 [± 8.6] years, 77% men). Thirty-day mortality was 2.6%. InsCor classified 88, 210, and 163 patients as having low, medium, and high risk of death, respectively. According to EuroSCORE and STS, 379 and 430 patients were classified as having low risk and 77 and 29 as medium risk, respectively. Area under the ROC curve was 0.734 (P=0.002) for InsCor, 0.615 (P=0.027) for EuroSCORE, and 0.623 (P=0.033) for STS. ROC curve of InsCor maintained statistical significance after adjustment for other models. Conclusion: The InsCor score, derived from a Brazilian sample, showed good predictive accuracy of death up to 30 days in patients undergoing CABG in relation to STS and EuroSCORE scores.

Abstract Background: Mortality from cardiovascular diseases has reduced in Brazil in recent decades, but this phenomenon is not clear in the northeast region of the country. Objectives: To describe the mortality trends from cardiovascular disease in Bahia from 2000-2015, in total population and by sex and age groups, and by specific causes (ischemic heart disease, cerebrovascular diseases, rheumatic heart disease and heart failure). Methods: This was a time series study. Data were obtained from SIM-DATASUS and IBGE, and the 10th revision of the ICD used for disease classification. Mortality rates (per 100,000 inhabitants) were calculated from total cardiovascular disease and specific causes, by sex and age groups. Direct standardization was used to adjust for age, using the population of 2010 as reference. Linear regression models estimated percentage variation. The significance level of 5% was adopted. Results: In Bahia, crude mortality rates from cardiovascular disease increased in the period; however, after standardization by age, mortality rates became stable for the total and female populations, with a slight reduction for the male population. An increase in mortality rates from cardiovascular disease was found in the elderly groups. For ischemic heart disease, a progressive increase in adjusted mortality rates was observed: 43%, 24% and 29% for the total, male, and female population, respectively. There was a progressive reduction in crude and age-standardized mortality rates from heart failure in all groups, a modest reduction in age-adjusted mortality rates from cerebrovascular diseases, and a slight reduction in age-standardized mortality rate from rheumatic heart disease, especially in the subgroup <40 years. Conclusions: Mortality from cardiovascular disease in Bahia did not follow the decreasing trend of other Brazilian states, especially in relation to ischemic heart disease, which showed an increase in mortality rates.

Resumo Fundamento: Uma significativa variação nas tendências de mortalidade por embolia pulmonar (EP) foi documentada em todo o mundo. Investigamos as tendências na taxa de mortalidade por EP no Brasil no período de 21 anos, assim como suas diferenças regionais e de gênero. Métodos: Utilizando uma base de dados nacionais de certificados de óbito, buscamos todos os casos de EP como causa básica de morte entre 1989 e 2010. Dados populacionais foram obtidos no Instituto Brasileiro de Geografia e Estatística. Calculamos as taxas de mortalidade específica por idade, gênero e região para cada ano, usando a população brasileira do ano 2000 para padronização direta. Resultados: Nos 21 anos, a taxa de mortalidade padronizada por idade (TMPI) caiu 31%, passando de 3,04/100.000 para 2,09/100.000. Em cada ano entre 1989 e 2010, a TMPI foi maior nas mulheres do que nos homens, tendo ambos mostrado uma significativa tendência decrescente, de 3,10/100.000 para 2,36/100.000 e de 2,94/100.000 para 1,80/100.000, respectivamente. Embora todas as regiões do país tenham apresentado um declínio em suas taxas de mortalidade padronizada por idade, as maiores quedas concentraram-se nas regiões de mais alta renda do Sul e Sudeste do Brasil. As regiões Norte e Nordeste, que têm as mais baixas rendas, apresentaram uma queda menos marcante nas taxas de mortalidade, sem qualquer alteração na taxa de mortalidade por EP nas mulheres. Conclusões: Nosso estudo mostrou uma redução na taxa de mortalidade por EP nas duas décadas no Brasil. Entretanto, houve uma significativa variação nessa tendência entre as cinco regiões do país e entre gêneros, indicando uma possível disparidade no acesso aos cuidados de saúde e sua qualidade nesses grupos.

Abstract Background: A significant variation in pulmonary embolism (PE) mortality trends have been documented around the world. We investigated the trends in mortality rate from PE in Brazil over a period of 21 years and its regional and gender differences. Methods: Using a nationwide database of death certificate information we searched for all cases with PE as the underlying cause of death between 1989 and 2010. Population data were obtained from the Brazilian Institute of Geography and Statistics (IBGE). We calculated age-, gender- and region-specific mortality rates for each year, using the 2000 Brazilian population for direct standardization. Results: Over 21 years the age-standardized mortality rate (ASMR) fell 31% from 3.04/100,000 to 2.09/100,000. In every year between 1989 and 2010, the ASMR was higher in women than in men, but both showed a significant declining trend, from 3.10/100,000 to 2.36/100,000 and from 2.94/100,000 to 1.80/100,000, respectively. Although all country regions showed a decline in their ASMR, the largest fall in death rates was concentrated in the highest income regions of the South and Southeast Brazil. The North and Northeast regions, the lowest income areas, showed a less marked fall in death rates and no distinct change in the PE mortality rate in women. Conclusions: Our study showed a reduction in the PE mortality rate over two decades in Brazil. However, significant variation in this trend was observed amongst the five country regions and between genders, pointing to possible disparities in health care access and quality in these groups.

OBJETIVO: Avaliar se existe evidência que apóie diferentes intervenções para tratar insuficiência cardíaca baseada na raça ou etnia. MÉTODOS: Revisão sistemática de ensaios clínicos randomizados que permitiram comparar negros e brancos com insuficiência cardíaca sistólica crônica quanto à eficácia de inibidores da enzima conversora da angiotensina (ECA), betabloqueadores e combinação hidralazina/nitrato na redução dos riscos de morte e hospitalização. A pesquisa foi baseada em artigos publicados entre 1980 e dezembro de 2006, citados no Medline ou Lilacs. RESULTADOS: Três estudos preencheram os critérios da revisão. No SOLVD, enalapril foi eficaz em reduzir similarmente o risco de morte ou hospitalização em brancos (redução relativa do risco(RRR)=18%) e negros (RRR= 17%). No US Carvedilol, carvediol foi também associado a importante redução do risco de morte ou hospitalização tanto em brancos (RRR=49%) quanto em negros (RRR=43%). No V-HeFT II, enalapril foi superior a hidralazina/nitrato em reduzir o risco de morte apenas em brancos. CONCLUSÃO: De acordo com os dados, inibidores da ECA e betabloqueadores devem ser considerados os medicamentos básicos para melhorar o prognóstico da insuficiência cardíaca tanto em negros quanto em brancos. O estudo A-HeFT não foi incluído na revisão por ser restrito a negros; contudo deve ser visto como evidência que a combinação hidralazina e nitrato é eficaz em melhorar a sobrevida de pacientes com insuficiência cardíaca avançada. Os dados apóiam o desenvolvimento de um ensaio clinico especialmente desenhado para avaliar se a combinação hidralazina/nitrato é também eficaz em pacientes com insuficiência cardíaca avançada não classificados como negros.

OBJECTIVE: To assess if there is evidence to support different interventions for treatment of heart failure based upon race/ethnicity. METHODS: Systematic review of randomized clinical trials permitted comparisons between blacks and whites with systolic heart failure concerning the efficacy of angiotensin converting enzyme (ACE) inhibitors, beta blockers and a combination of hydralazine/ nitrate to reduce the risks of death and hospitalization. The literature search was based on articles published between 1980 and December 2006 cited in MEDLINE or LILACS. RESULTS: Three studies fulfilled the criteria of the reiew. In SOLVD, enalapril was efficient in reducing the risks of death or hospitalization similarly in whites (relative risk reduction (RRR) =18%) and blacks (RRR=17%). In US Carvedilol, carvediol was also associated with significant reduction in the risk of death or hospitalization both in whites (RRR=49%) and blacks (RRR=43%). In V-HeFT II, enalapril was superior to the combination hydralazine with nitrate in reducing the death risk only in whites. CONCLUSION: According to the data ACE inhibitors and beta blockers should be considered as the essential drugs to improve the prognosis of heart failure both in blacks and whites. The A-HeFT study was not included in the review because it was restricted to blacks; however, it should be viewed as evidence that the combination hydralazine/nitrate is beneficial to improve survival in patients with advanced heart failure. Data support development of a clinical trial especially designed to assess if the combination hydralazine/nitrate is also efficient in patients not classified as blacks, with advanced heart failure.

OBJETIVO: Descrever as características clínicas e identificar potenciais fatores de risco para letalidade hospitalar em pacientes com insuficiência cardíaca descompensada, admitidos em unidade de terapia intensiva. MÉTODOS: Pacientes consecutivamente admitidos por insuficiência cardíaca descompensada numa unidade de terapia intensiva, de junho/2001 a dezembro/2003, foram selecionados e seguidos durante a internação. Características clínicas na admissão foram coletadas e avaliadas por meio de modelos de regressão logística múltipla como preditores de risco para letalidade hospitalar. RESULTADOS: Foram avaliados 299 pacientes, 54% do sexo masculino, com média de idade de 69±13 anos. Doença arterial coronariana foi a causa principal da falência cardíaca em 49% dos casos. Diabetes mellitus e hipertensão arterial sistêmica ocorreram em 37,5% e 78% dos pacientes, respectivamente. Na admissão, 22% dos pacientes apresentavam fibrilação atrial; 21,5%, disfunção renal e 48% dos casos, anemia (16,5% com anemia importante). Encontrou-se disfunção sistólica grave (fração de ejeção do ventrículo esquerdo <30%) em 44% dos pacientes. A letalidade hospitalar foi 17,4%. Após análise multivariada, história prévia de acidente vascular encefálico (AVE), fibrilação atrial, insuficiência renal, idade >70 anos e hiponatremia foram independentemente associados com letalidade hospitalar. CONCLUSÃO: Pacientes internados por insuficiência cardíaca descompensada em unidade intensiva apresentam letalidade hospitalar elevada. Neste estudo, variáveis da admissão puderam predizer letalidade hospitalar, como AVE prévio, fibrilação atrial, hiponatremia, insuficiência renal e idade >70 anos.

OBJECTIVE: Describe the clinical characteristics and identify potential risk factors for in-hospital lethality in patients with decompensated heart failure admitted to an intensive care unit. METHODS: Decompensated heart failure patients consecutively admitted to an intensive care unit between June 2001 and December 2003 were selected and followed during hospitalization until discharge or death. Clinical characteristics at admission were recorded and evaluated as independent risk predictors for in-hospital mortality by multiple logistic regression analysis. RESULTS: A total of 299 patients (69±13 years of age and 54% men) were enrolled. Coronary artery disease was the main cause of heart failure in 49% of the cases. Diabetes mellitus and systemic arterial hypertension occurred in 37.5% and 78% of the patients, respectively. At admission, 22% of them had atrial fibrillation, 21.5% had renal dysfunction, and 48% anemia (16.5% with severe anemia). Severe systolic dysfunction (left ventricular ejection fraction <30%) affected 44% of the patients. In-hospital mortality was 17.4%. After the multivariate analysis had been performed, previous history of stroke, atrial fibrillation, renal failure, age > 70 years, and hyponatremia were independently associated with in-hospital mortality. CONCLUSION: Patients admitted to an intensive care unit due to decompensated heart failure have high in-hospital lethality. In this study, variables recorded at admission, such as previous stroke, atrial fibrillation, hyponatremia, renal failure, and age > 70 years were predictors of in-hospital lethality.

OBJETIVO: Descrever as características clínicas e terapêuticas de pacientes com insuficiência cardíaca (IC) secundária a miocardiopatia chagásica crônica, bem como avaliar se estas são diferentes nas demais etiologias. MÉTODOS: Foram analisados prospectivamente pacientes atendidos no período de agosto de 2003 a junho de 2004, em um ambulatório de referência para IC. RESULTADOS: Foram incluídos 356 pacientes com o diagnóstico de IC. Miocardiopatia chagásica foi a etiologia mais freqüente, (48% dos casos). Outras etiologias foram miocardiopatia hipertensiva em 19%, dilatada idiopática em 11%, e isquêmica em 9%. Pacientes com IC secundária a miocardiopatia chagásica tinham com maior freqüência etnia não-branca (88 x 75%; p = 0,002), história familiar de doença de Chagas (57 x 21%; p = 0,001), maior tempo de doença (71 x 56 meses; p = 0,034), menor escolaridade (4,4 ± 4,1 x 5,7 ± 4,2 anos de estudo; p = 0,004), menor freqüência cardíaca (69 ± 12 x 73 ± 13; p = 0,03) e pressão arterial sistólica (121 ± 25 x 129 ± 28 mmHg; p = 0,006). Utilizavam com maior freqüência amiodarona (22 x 13%; p = 0,036) marcapassos artificiais (15 x 1%; p = 0,001) e com menor freqüência drogas betabloqueadoras (39 x 59%; p = 0,001). CONCLUSÃO: Nessa amostra de pacientes ambulatoriais com IC, em um estado com alta prevalência de doença de Chagas, miocardiopatia chagásica foi a etiologia mais freqüente, apresentando algumas características clínicas e terapêuticas diferentes dos demais pacientes.

OBJECTIVE: Describe the clinical and therapeutic characteristics of patients with heart failure (HF) secondary to chronic chagasic cardiomyopathy and evaluate if these characteristics are different from those found in other etiologies. METHODS: A prospective analysis of the patients treated between August 2003 and June 2004 at a HF referral outpatient clinic was conducted. RESULTS: Three hundred and fifty six patients diagnosed with HF were included in the study. Chagasic cardiomyopathy was the most common etiology (48% of the cases). Other etiologies included hypertensive cardiomyopathy in 19% of the patients, idiopathic dilated in 11% and ischemic in 9%. Patients with HF secondary to chagasic cardiomyopathy were more frequently from non-white ethnic groups (88 vs. 75%; p = 0.002), had a family history of Chagas disease (57 vs. 21%; p = 0.001), had the disease for a longer length of time (71 vs. 56 months; p = 0.034), had lower levels of education (4.4 ± 4.1 vs. 5.7 ± 4.2 years of study; p = 0.004), had a lower heart rate (69 ± 12 vs. 73 ± 13; p = 0.03) and a lower systolic blood pressure (121 ± 25 vs. 129 ± 28 mmHg; p = 0.006). There was also a higher incidence of the use of amiodarone (22 vs. 13%; p = 0.036) and artificial pacemakers (15 vs. 1%; p = 0.001). There was a lower usage of beta-blockers (39 vs. 59%; p = 0.001). CONCLUSION: In this sample of HF outpatients, in a state with a high prevalence of Chagas disease, chagasic cardiomyopathy was the most common etiology and they presented some unique clinical and therapeutic characteristics in comparison to other heart failure patients.

OBJETIVO: Avaliar a tendência da mortalidade por insuficiência cardíaca (IC) em Salvador - Bahia, no período de 1979-1995. MÉTODOS: A IC foi definida pelas notações da 9ª Revisão do Código Internacional de Doenças (CID9) 428.0, 428.1 e 428.9. Dados de óbitos por IC e populacionais (região metropolitana de Salvador) foram obtidos por meio da Secretaria de Saúde da Bahia e do Instituto Brasileiro de Geografia e Estatística. As taxas de mortalidade (/100.000) foram totais ou por gênero e idade, e brutas ou ajustadas por idade (padronização direta). RESULTADOS: As taxas de mortalidade por IC sofreram redução progressiva no período de tempo avaliado, para ambos os gêneros, especialmente até o ano de 1992. A partir daí e até 1995, ocorreu uma aparente estabilização das curvas. A taxa de mortalidade bruta passou de 25,0/10(5), em 1979, para 16,4/10(5) habitantes, em 1995 (queda de 34,4%). A redução foi de 34,0% (23,3/10(5), em 1979, para 15,4/10(5) habitantes, em 1995) para o sexo masculino e de 35,2% (26,7/10(5), em 1979, para 17,3/10(5) habitantes, em 1995), para o sexo feminino. A mesma tendência ocorreu nas diversas faixas etárias, inclusive para a população > 40 anos, de maior risco para IC. Após o ajuste por idade (população padrão de 1979), observa-se que as reduções relativas nas taxas foram ainda maiores. CONCLUSÃO: A mortalidade por IC, em Salvador-Bahia, declinou de 1979 a 1992, estabilizando-se a partir de então até 1995.

OBJECTIVE: To assess mortality trend due to heart failure (HF) in Salvador - Bahia, from 1979 to 1995. METHODS: HF was defined by notations from the 9th Review of International Disease Code (IDC9) 428.0, 428.1 and 428.9. HF death and population data (metropolitan area of Salvador) were obtained by means of Secretaria de Saúde da Bahia (Bahia State Health Secretariat) and Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics). Mortality rates (/100,000) were total or per gender and age, and gross or adapted per age (straight standardization). RESULTS: Mortality rates due to HF had a progressive reduction in the period of time assessed, for both genders, especially up to 1992. From then and up to 1995, there was an apparent stabilization of the curves. Gross mortality rate went from 25.0/10(5), in 1979, to 16.4/10(5) inhabitants, in 1995 (a decrease of 34.4%). The reduction was 34.0% (23.3/10(5), in 1979, to 15.4/10(5) inhabitants, in 1995) for male sex and 35.2% (26.7/10(5), in 1979, to 17.3/10(5) inhabitants, in 1995), for female sex. The same trend took place in several age ranges, including the population > 40 years old, which has a greater risk for HF. After adaptation per age (standard population of 1979), it is observed that relative reductions in the rates were even greater. CONCLUSION: Mortality due to HF, in Salvador-Bahia, decreased from 1979 to 1992, becoming stable from then to 1995.