Efficacy of peritoneal dialysis in patients with refractory congestive heart failure: a systematic review and meta-analysis.

Refractory congestive heart failure (RCHF) is a common complication in the natural history of advanced heart failure. Peritoneal dialysis (PD) is a possible alternative in those patients, but studies are scarce, and mostly with small samples. We conducted this meta-analysis to evaluate the effects of PD in patients with RCHF. Articles published before July 2020 in the following databases: PubMed, Web of Science, and CENTRAL. Mean differences (MD) and 95% confidence intervals (CIs) were computed to generate a pooled effect size with a random effects model. We also assessed heterogeneity, risk of bias, publication bias, and quality of evidence. Twenty observational studies (n = 769) were included, with a "before and after intervention" design. PD was associated with a significant reduction in NYHA functional class (MD -1.37, 95% CI -0.78 to -1.96) and length of hospitalisation (MD -34.8, 95% CI -20.6 to -48.9 days/patient/year), a small but significant increase in left ventricular ejection fraction (MD 4.3, 95%CI 1.9 to 6.8%) and a non-significant change in glomerular filtration rate (MD -3.0, 95% CI -6.0 to 0 mL/min/1.73m2). Heterogeneity among studies was significant and overall risk of bias was rated from moderate to critical. No significant publication bias was found, and the overall quality of evidence was very low for all outcomes. PD in patients with RCHF improved functional class, length of hospitalisation, and ventricular functional, and had no impact in renal function. Further randomised clinical trials are warranted to confirm our results that showed some limitations.

Malignant Primary and Metastatic Cardiac Tumors: A Single-Center 27-Year Case Review.

BACKGROUND: Malignant primary cardiac tumors are exceedingly rare, and despite surgical exeresis or chemotherapy, their prognosis remains poor. Cardiac invasion by metastatic tumors, while more common, also entails an unsatisfactory outcome. This study aimed to review patients diagnosed with malignant primary and secondary cardiac tumors in a tertiary center between 1995 and 2022. METHODS: Clinical data, echocardiographic, computed tomography, and magnetic resonance assessments of tumor location and morphology, histology, treatment, and survival were retrospectively analyzed. RESULTS: Sixty malignant cardiac tumors were diagnosed: 17 primary (A) and 43 metastatic (B) tumors. A: the most common types were angiosarcoma (41%), undifferentiated sarcoma (23%), and fibrosarcoma (18%). Patients with primary tumors were younger than patients with metastatic tumors (41 ± 13 years vs. 57 ± 18 years, p = 0.001), with no significant gender difference. The most frequent presentations were heart failure (59%) and arrhythmia (23%). The most prevalent tumor location was the right heart chambers (71%), mostly in the right atrium (35%). 47% were submitted to tumor resection, and 29% received chemotherapy. The mortality rate was 82% with a median survival of 6.0 (interquartile range: 1.0-11.8) months after diagnosis (minimum of 12 days and maximum of 19 years). One patient with fibrosarcoma underwent heart transplantation and was still alive and well after 19 years. B: regarding metastatic cardiac invasion, the most common primary tumor sites were lung carcinomas (38%), thymomas (17%), and lymphomas (14%). Presentation with pericardial effusion was common (33%). The mortality rate was 72%, with a median survival of 3.6 (1.0-13.4) months (minimum of 7 days, maximum of 5 years). CONCLUSION: Diagnosis of metastatic cardiac tumors was more common than that of malignant primary tumors, both with a dismal prognosis. When radical exeresis is not possible, heart transplantation can be an option with a favorable outcome in carefully selected patients with sarcomas.

Outcomes of culture-negative vs. culture-positive infective endocarditis: the ESC-EORP EURO-ENDO registry.

AIM: Fatality of infective endocarditis (IE) is high worldwide, and its diagnosis remains a challenge. The objective of the present study was to compare the clinical characteristics and outcomes of patients with culture-positive (CPIE) vs. culture-negative IE (CNIE). METHODS AND RESULTS: This was an ancillary analysis of the ESC-EORP EURO-ENDO registry. Overall, 3113 patients who were diagnosed with IE during the study period were included in the present study. Of these, 2590 (83.2%) had CPIE, whereas 523 (16.8%) had CNIE. As many as 1488 (48.1%) patients underwent cardiac surgery during the index hospitalization, 1259 (48.8%) with CPIE and 229 (44.5%) with CNIE. The CNIE was a predictor of 1-year mortality [hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.04-1.56], whereas surgery was significantly associated with survival (HR 0.49, 95% CI 0.41-0.58). The 1-year mortality was significantly higher in CNIE than CPIE patients in the medical subgroup, but it was not significantly different in CNIE vs. CPIE patients who underwent surgery. CONCLUSION: The present analysis of the EURO-ENDO registry confirms a higher long-term mortality in patients with CNIE compared with patients with CPIE. This difference was present in patients receiving medical therapy alone and not in those who underwent surgery, with surgery being associated with reduced mortality. Additional efforts are required both to improve the aetiological diagnosis of IE and identify CNIE cases early before progressive disease potentially contraindicates surgery.

Age Differences in Cardiopulmonary Exercise Testing Parameters in Heart Failure with Reduced Ejection Fraction.

Background and Objectives: Cardiopulmonary exercise testing (CPET) is a cornerstone of risk stratification in heart failure with reduced ejection fraction (HFrEF). However, there is a paucity of evidence on its predictive power in older patients. The aim of this study was to evaluate the prognostic power of current heart transplantation (HTx) listing criteria in HFrEF stratified according to age groups. Materials and Methods: Consecutive patients with HFrEF undergoing CPET between 2009 and 2018 were followed-up for cardiac death and urgent HTx. Results: CPET was performed in 458 patients with HFrEF. The composite endpoint occurred in 16.8% of patients ≤50 years vs. 14.1% of patients ≥50 years in a 36-month follow-up. Peak VO2 (pVO2), VE/VCO2 slope and percentage of predicted pVO2 were strong independent predictors of outcomes. The International Society for Heart and Lung Transplantation thresholds of pVO2 ≤ 12 mL/kg/min (≤14 if intolerant to ß-blockers), VE/VCO2 slope > 35 and percentage of predicted pVO2 ≤ 50% presented a higher overall diagnostic effectiveness in younger patients (≤50 years). Specific thresholds for each age subgroup outperformed the traditional cut-offs. Conclusions: Personalized age-specific thresholds may contribute to an accurate risk stratification in HFrEF. Further studies are needed to address the gap in evidence between younger and older patients.

Multimodality imaging in cardiac amyloidosis: State-of-the-art review.

Amyloidosis is a systemic disease, characterized by deposition of amyloid fibrils in various organs, including the heart. For the diagnosis of cardiac amyloidosis (CA) it is required a high level of clinical suspicion and in the presence of clinical, laboratorial, and electrocardiographic red flags, a comprehensive multimodality imaging evaluation is warranted, including echocardiography, magnetic resonance, scintigraphy, and computed tomography, that will confirm diagnosis and define the CA subtype, which is of the utmost importance to plan a treatment strategy. We will review the use of multimodality imaging in the evaluation of CA, including the latest applications, and a practical flow-chart will sum-up this evidence.

Has carotid intima-media thickness prognostic impact in patients with high cardiovascular risk? A long-term cohort study.

BACKGROUND: Carotid intima-media thickness (CIMT) is an established surrogate marker for cardiovascular events in patients with intermediate risk. In patients with high cardiovascular risk or established cardiovascular disease, the impact of CMIT measurement on risk stratification for future events is less clear. Our objective was to evaluate the impact of CIMT on the occurrence of cardiovascular events in a cohort of individuals with high cardiovascular risk, in long-term follow-up. METHODS: We analyzed 296 individuals, mean follow-up of 6.9 ± 2.2 years. Individuals were divided into tertiles according to CIMT. Tertiles were compared in terms of baseline characteristics and outcomes during follow-up-all-cause mortality and composite outcome (mortality, acute coronary syndromes, coronary revascularization, stroke/transient ischemic attack, heart failure, or cardiovascular admission). RESULTS: Our population had a mean age of 65 ± 9 years at the beginning of the study, 55% males. Patients with higher CIMT showed a trend for higher cardiovascular mortality (P = 0.084) and for the composite outcome (P = 0.049). A CIMT ≥ 0.85 mm was also associated with higher rate of events; however, CIMT was not an independent predictor of outcome after adjustment for age and gender. CIMT assessment was useful in patients with hypertension, hyperlipidemia, and metabolic syndrome and in nondiabetic patients. For the composite outcome, it was also useful in females, smokers, and in patients without coronary artery disease. CONCLUSIONS: Patients with higher CIMT have worst outcome, but this was mainly driven by age and gender. CIMT is useful as a prognostic marker in specific subsets of patients.

Cardiotoxicity in breast cancer treatment: What about left ventricular diastolic function and left atrial function?

AIMS: Cardiotoxicity is a possible complication of cancer treatment, particularly with anthracyclines and anti-HER2 drugs. Systolic dysfunction has already been described. Diastolic dysfunction and left atrial function are less studied. We sought to analyze the impact of cardiotoxic treatments on left ventricular diastolic function and left atrial (LA) function. METHODS AND RESULTS: Retrospective study of 100 patients (all women, with a mean age of 54 ± 12 years) with three exams in the span of 1 year during treatment for breast cancer. Patients with previous cancer treatment, coronary artery disease, significant valvular disease, and atrial arrhythmias were excluded. Diastolic dysfunction was classified according to international guidelines and left atrial strain was analyzed by two-dimensional speckle tracking. In our sample, 74% received anthracyclines, 83% anti-HER2, and 76% radiation treatment. In the follow-up, 20% developed new or worsening diastolic dysfunction. Age was the only independent predictor (OR 1.93, 95% CI 1.04-3.58, P = .037). In left atrial function, only the contractile function was significantly reduced in 20.8% of the patients and age was also the only independent predictor, but with a protective effect (OR 0.51, 95% CI 0.28-0.91, P = .023). CONCLUSIONS: During breast cancer treatment, 20% of the patients develop new or worsening diastolic dysfunction, being age the main determinant, suggesting higher impact of chemotherapy in older patients. Contractile left atrial function is also compromised but, in this case, age seems to be protective. Our results support a stricter surveillance in older patients together to eventually adjust chemotherapy regimens.

RoPE Score as a Predictor of Recurrent Ischemic Events After Percutaneous Patent Foramen Ovale Closure.

The benefits of patent foramen ovale (PFO) closure for cryptogenic stroke secondary prevention are still debated. The Risk of Paradoxical Embolism (RoPE) study developed a score to improve patient selection for this procedure. We proposed to assess the validity of this score to assess the prognostic impact of PFO closure.From 2000 to 2014, all consecutive patients submitted to PFO closure were included in a prospective registry in a university center. The primary endpoint was recurrent ischemic cerebrovascular events and the secondary endpoints were all-cause, neurological, and cardiac mortality rates and new-onset atrial fibrillation (NOAF) rates. In total, 403 patients were included in the study (women: 52.1%; mean age: 44.7 ± 10.9 years). The mean follow-up period was 6.4 ± 3.7 years. Immediate success was achieved in 97% patients. There were 23 (5.8%) ischemic cerebrovascular events, 8 (2.0%) deaths, and 17 (4.3%) NOAFs. The mean RoPE score was 6.10 ± 1.79. Smoker status, coronary artery disease, lower RoPE score, and higher left atrial dimensions were predictors of the primary endpoint. However, a lower RoPE score and coronary artery disease remained independent predictors in multivariate analysis.RoPE score was shown to be an independent predictor of recurrent ischemic cerebrovascular events, and a score of ≤ 6 was shown to identify patients with significantly higher risk of mortality and recurrent ischemic events.

Pericardium, epicardial adipose tissue, and heart failure with preserved ejection fraction: Pathophysiology, quantification and treatment target.

Heart failure is an important cause of mortality and morbidity worldwide. Heart failure with preserved ejection fraction (HFpEF) incidence and prevalence is increasing, and the phenotype associated with obesity is the most frequent. Epicardial adipose tissue (EAT) is directly associated with systemic obesity and several previous studies have shown a clear link between EAT and HFpEF. Moreover, the restriction induced by the pericardium is also linked to HFpEF. In this review we will describe the epidemiological association between the pericardium, EAT and HFpEF, how to quantify EAT, what are the pathophysiological mechanism to explain theses association and how can the pericardium and EAT be a treatment target in patients with HFpEF.

Perceptions of cardiology, professional preferences and impact on career choices among Portuguese cardiologists: Results from the Portuguese Society of Cardiology's Women and Cardiology Task Force survey.

INTRODUCTION AND OBJECTIVES: Cardiology has not been seen as an attractive specialty, and women have avoided it for many years. Some surveys have been performed in other countries, but in Portugal, the situation is largely unknown. METHODS: An online survey on perceptions of cardiology and professional preferences was sent to 1371 members of the Portuguese Society of Cardiology, of whom 18.2% completed the survey. RESULTS: We included 219 cardiologists or cardiology trainees, of whom 50.2% were female, with decreasing proportions from younger to older age groups, in which males still predominate. Women are less often married and more frequently childless, particularly those working in an invasive subspecialty, where they represent only 16% of all respondents working in these areas. Men's perception is that women do not choose these areas due to family reasons, radiation concerns and difficult working conditions, but from the female perspective, male dominance, lack of female role models and restricted access are the main barriers. Women consider it is difficult for them to obtain a leadership role, but men do not think the same (75.5% vs. 27.5%). CONCLUSION: In Portugal, females predominate in younger age groups, suggesting a paradigm change. Women are less frequently married and more frequently childless, particularly women working in invasive subspecialties. Women consider that it is more difficult for them to obtain a leadership role. Moreover, the barriers reported by women are substantially different from men regarding the reasons for not choosing an invasive subspecialty.

Global left ventricular myocardial work index and medium-term adverse cardiovascular events after ST-elevation myocardial infarction.

BACKGROUND: Left ventricular global longitudinal strain (GLS) has incremental prognostic value over ejection fraction (EF) in patients with ST-segment-elevation myocardial infarction (STEMI), but it is also load dependent. It has been recently demonstrated that Myocardial work (MW), integrating blood pressure with GLS, predicts long-term all-cause mortality. We aimed to further explore the prognostic value of MW for cardiovascular endpoints in patients with STEMI. METHODS AND RESULTS: Retrospective study of 200 consecutive patients admitted with a STEMI, mean age of 62 (SD 12) years, 79.5% males, that survived to discharge. Transthoracic echocardiography was performed before discharge (5 ± 3 days after admission). Mean follow-up was 790 days. The primary outcome was a composite of cardiovascular death, non-fatal myocardial infarction, and unplanned cardiovascular admission (ACE). During follow-up, 26 patients had a ACE. In univariable Cox regression analysis, male gender, body mass index, GRACE risk score and Global Work Index (GWI) were selected to the multivariable analysis, in which, only GWI (per 100 mmHg% decrease: hazard ratio estimate 1.19, 95% confidence interval 1.07-1.34, p-value = 0.002) remained independently associated with ACE, with effective reclassification of non-events. The best GWI cut-off to predict ACE was ≤1165 mmHg% (Log-rank, p = 0.034). CONCLUSIONS: LV GWI is independently associated with medium-term ACE. Nevertheless, prospective studies in a larger sample of patients are warranted to confirm this finding.

Evaluation of left atrial strain imaging and integrated backscatter as predictors of recurrence in patients with paroxysmal, persistent, and long-standing persistent atrial fibrillation undergoing catheter ablation.

BACKGROUND: Impaired left atrial (LA) strain predicts atrial fibrillation (AF) recurrence after catheter ablation (CA), but currently there is no cut-off to guide patient selection for CA. Integrated backscatter (IBS) is a promising tool for noninvasive quantification of myocardial fibrosis. The aim of this study was to compare LA strain and IBS between paroxysmal, persistent, and long-standing persistent AF and evaluate their association with AF recurrence after CA. METHODS: Analysis of consecutive patients with symptomatic paroxysmal and persistent AF who underwent CA. LA phasic strain, strain rate and IBS were assessed by two-dimensional speckle-tracking at baseline. RESULTS: We analyzed 78 patients, 31% with persistent AF (46% long-standing AF), 65% male, mean age 59 ± 14 years, who underwent CA and were followed-up for 12 months. AF recurrence occurred in 22 (28%) patients. LA phasic strain parameters were significantly impaired in patients with AF recurrence and were independent predictors of AF recurrence in a multivariable analysis. LA reservoir strain (LASr) < 18% predicted AF recurrence with 86% sensitivity and 71% specificity, with a higher predictive power compared to LA volume index (LAVI). LASr < 22% in paroxysmal AF and LASr < 12% in persistent AF correlated with AF recurrence. Increased IBS was a predictor of AF recurrence in patients with paroxysmal AF. CONCLUSION: LA phasic strain parameters were predictors of AF recurrence after CA, independently of LAVI and AF subtype. LASr < 18% showed a higher predictive power compared to LAVI. Further studies are needed to investigate the role of IBS as a predictor of AF recurrence.

"O meu coração bate saudável" - Results from a pilot project for health education in Portuguese children.

INTRODUCTION AND OBJECTIVES: Childhood offers an excellent window of opportunity to start interventions to promote behavioral changes before unhealthy lifestyles become established, leading to cardiovascular diseases. The goal of this pilot educational project for children is the promotion of healthy lifestyles and cardiovascular health. METHODS: This project was implemented in 4th grade children and included teacher-led classroom activities, a lesson given by a cardiologist and a practical lesson with dietitians. The teacher received a manual containing information on the topics to be discussed in class with the pupils and the children received a book that addresses cardiovascular risk factors and prevention. The components included were diet (D), physical activity (PA) and human body and heart awareness (BH). At the beginning and at the end of the schoolyear, a questionnaire was applied to the children to assess knowledge (K), attitudes (A) and habits (H) on these topics. RESULTS: A total of 73 children from an urban public school in Lisbon, in a low to medium income area, participated in the project. Following the intervention, there was a 9.5% increase in the overall KAH score, mainly driven by the PA component (14.5%) followed by the BH component (12.3%). No improvement was observed for component D. The benefits were also more significant in children from a lower income area, suggesting that socioeconomic status is a determinant in the response obtained. CONCLUSIONS: An educational project for cardiovascular health can be implemented successfully in children aged 9 years, but longer and larger studies are necessary.

What do Portuguese cardiologists think and feel about their work?

INTRODUCTION AND OBJECTIVES: This study reports the results of an online survey carried out by the Portuguese Society of Cardiology about its medical members' work characteristics before and during the COVID-19 pandemic, their job satisfaction, work motivation, and burnout. METHODS: A sample of 157 participants answered a questionnaire with demographic, professional, and health-related information, followed by questionnaires on job satisfaction and motivation designed and validated for this study and a Portuguese version of the Maslach Burnout Inventory. Data were analyzed through descriptive statistics, ANOVA, and MANOVA, considering gender, professional level, and sector of activity, respectively. Multiple regression was used to assess the impact of job satisfaction and motivation on burnout. RESULTS: The only variable that distinguished participants was sector of activity. Cardiologists working in the private sector worked fewer weekly hours during COVID-19, while those in the public sector worked more. The latter expressed more desire to reduce their working hours than those who worked in private medicine and in both sectors. There were no differences between sectors in work motivation, while job satisfaction was higher in the private sector. Moreover, job satisfaction negatively predicted burnout. CONCLUSIONS: Our findings point to a deterioration in working conditions during the COVID-19 pandemic, with its consequences being felt especially in the public sector, which may have contributed to the lower levels of satisfaction among cardiologists who worked exclusively in this sector, but also for those working in both public and private sectors.

Cardiovascular diseases in women - Consensus document of the Sociedade Portuguesa de Cardiologia, Sociedade Portuguesa de Ginecologia, Sociedade Portuguesa de Obstetrícia e Medicina Materno-Fetal, Sociedade Portuguesa de Contraceção e Associação Portuguesa de Medicina Geral e Familiar. / Saúde cardiovascular da mulher ­ Documento de Consenso da Sociedade Portuguesa de Cardiologia, Sociedade Portuguesa de Ginecologia, Sociedade Portuguesa de Obstetrícia e Medicina Materno­Fetal, Sociedade Portuguesa de Contraceção e Associação Portuguesa de Medicina Geral e Familiar.

The main objective of this consensus statement from the Portuguese Society of Cardiology, the Portuguese Society of Gynecology, the Portuguese Society of Obstetrics and Maternal-Fetal Medicine, Portuguese Society of Contraception, Portuguese Association of General Practice and Family Medicine is to improve cardiovascular care for women. It includes a brief review of the state-of-the-art of cardiovascular diseases in women and of the links to other fields such as Gynaecology, Obstetrics and Endocrinology. It also provides final recommendations to help clinicians working in care of women's health.

Global warming and heat wave risks for cardiovascular diseases: A position paper from the Portuguese Society of Cardiology.

Global warming is a result of the increased emission of greenhouse gases. The consequences of this climate change threaten society, biodiversity, food and resource availability. The consequences include an increased risk of cardiovascular (CV) disease and cardiovascular mortality. In this position paper, we summarize the data from the main studies that assess the risks of a temperature increase or heat waves in CV events (CV mortality, myocardial infarction, heart failure, stroke, and CV hospitalizations), as well as the data concerning air pollution as an enhancer of temperature-related CV risks. The data currently support global warming/heat waves (extreme temperatures) as cardiovascular threats. Achieving neutrality in emissions to prevent global warming is essential and it is likely to have an effect in the global health, including the cardiovascular health. Simultaneously, urgent steps are required to adapt the society and individuals to this new climatic context that is potentially harmful for cardiovascular health. Multidisciplinary teams should plan and intervene healthcare related to temperature changes and heat waves and advocate for a change in environmental health policy.