Social Distancing, Stroke Admissions and Stroke Mortality During the COVID-19 Pandemic: A Multicenter, Longitudinal Study.

OBJECTIVES: We aimed to evaluate the relationship between social distancing, stroke admissions and stroke mortality during the COVID-19 pandemic, while accounting for the rate of COVID-19 admissions. METHODS: We performed a longitudinal analysis of a multicenter, prospective, hospital-based registry of intensive care units from 19 hospitals from Brazil, comprising a 14-month period of the COVID-19 pandemic. We investigated whether the daily rate of admissions (DRAstroke) and daily mortality rate for stroke were associated with the social distancing index (SDI), taking into account the daily rate of admissions for COVID-19 (DRACOVID) in univariate and multivariate regression models. We also compared the clinical characteristics of patients with stroke admitted before and during the pandemic. RESULTS: We found that DRAstroke decreased significantly in association with a strong rise in the SDI during the early months of the pandemic. However, in the latter period of the pandemic, only minor changes were observed in the SDI, and still, DRAstroke was inversely associated with the DRACOVID. Throughout the pandemic, higher SDI and DRACOVID were associated with higher in-hospital mortality for stroke. CONCLUSIONS: The severity of surges of the COVID-19 pandemic were independently and persistently associated with declines in stroke admissions, even during periods when social distancing policies were not intensified.

Smoking Cessation Is Associated With Short-Term Improvement of Vascular Health in a Cohort of People Living With HIV in Rio de Janeiro, Brazil.

Smoking is highly prevalent in people living with HIV/AIDS (PLHA), leading to detrimental effects in different tissues. We examined the effects of nicotine replacement therapy (NRT) on smoking cessation and vascular health. From December 2019 to October 2021, we prospectively enrolled PLHA who were actively smoking. The primary outcome was endothelial function measured by brachial artery flow-mediated dilatation (FMD). We evaluated the percent change in FMD compared to the baseline measure (Δ%FMD) to detect improvements among participants who quit smoking. To confirm the results, we used linear regression models to account for classical cardiovascular (CV) confounders. We included 117 participants with median age of 45.5 years (IQR= 36.4-54.8); 22 (20.4%) had hypertension, 9 (8.3%) had diabetes, almost half were smoking 20+ cigarettes/day (41.7%). After 12 weeks 30.76% participants quit smoking. Comparison of Δ%FMD change from baseline to week 12 showed that among participants adherent to therapy, there has been an increase in Δ%FMD when compared to those who relapsed (1.17% [0.29-2.98] vs -0.19% [-1.95-0.91], p<0.001). After adjustment for CV factors, multiple linear regression showed that Δ%FMD in participants who quit smoking presented a 2.54 mean increase in comparison to those who continued smoking (p=0.007). In conclusion, this study provides evidence that a strategy of NRT and counseling is modestly effective for smoking cessation in PLHA and improves vascular health in a short period of time. This reinforces the importance of the widespread anti-tobacco programs in HIV clinics and the expected impact lowering the incidence of future cardiovascular events.

Association between obesity and COVID-19 mortality and length of stay in intensive care unit patients in Brazil: a retrospective cohort study.

The present study aimed to evaluate the association between obesity and COVID-19 mortality and length of stay in ICU patients, and how these associations were modified by age groups. We performed a retrospective multicenter cohort study with data obtained from a hospital-based registry. The sample consisted of 8183 ICU hospitalized patients who tested positive for SARS-CoV-2. Cox proportional models were used to evaluate the association between BMI categories and COVID-19 mortality and generalized linear models for the length of stay in the ICU. After adjusting for confounders, those in the younger group with severe obesity had an increased risk of COVID-19 mortality compared to those with normal/overweight (HR 1.27; 95% CI 1.01-1.61). An increased risk of death was also observed for patients with underweight (HR 3.74; 95% CI 1.39-10.07). For patients aged ≥ 60 year, mild/moderate obesity was associated with reduced mortality risk (HR 0.87; 95% CI 0.78-0.97). For the age group < 60 year, the length of stay in ICU for those patients with severe obesity was 35% higher compared to the normal/overweight category (eß 1.35; 95% CI 1.21-1.51). Conversely, for the survivors in the underweight category, the length of stay in ICU was 51% lower compared to the normal/overweight group (eß 0.49; 95% CI 0.31-0.78). In the age group ≥ 60 year, mild/moderate obesity was associated with an increased length of stay in the ICU (eß 1.10; 95% CI 1.01-1.21), adjusting for confounders. These findings could be helpful for health professionals to identify subgroups at higher risk for worse outcomes.

Intracoronary stem-cell injection after myocardial infarction: microcirculation sub-study.

BACKGROUND: The injection of stem cells in the context of acute myocardial infarction (AMI) has been tested almost exclusively by anterograde intra-arterial coronary (IAC) delivery. The retrograde intravenous coronary (IVC) delivery may be an additional route. OBJECTIVE: To compare the cell distribution and retention pattern in the anterograde and retrograde routes. To investigate the role of microvascular obstruction by magnetic resonance imaging in cell retention by cardiac tissue after the injection of bone marrow mononuclear cells (BMMC) in AMI. METHODS: This was a prospective, open label, randomized study. Patients with AMI who presented: (1) successful chemical or mechanical reperfusion within 24 hours of symptom onset and (2) infarction involving more than 10% of the left ventricle (LV) at the myocardial scintigraphy were included in the study. One hundred million BMMC were injected into the infarction-related artery through IAC route, or vein through the IVC route. One percent of the injected cells were labeled with 99mTc-hexamethyl-propylene-amine-oxime (99mTc-HMPAO). Cell distribution was evaluated at 4 and 24 hours after the myocardial scintigraphy injection. Cardiac magnetic resonance imaging was performed before cell injection. RESULTS: Thirty patients were randomized into three groups. There were no serious adverse events related to the procedure. The early and late retention of labeled cells was higher in the IAC group than in IVC group, regardless of the presence of microcirculation obstruction. CONCLUSION: The injection using the retrograde approach was feasible and safe. Cell retention by cardiac tissue was higher using the anterograde approach. More studies are needed to confirm these findings.

Injeção intracoronariana de células tronco após infarto do miocárdio: subestudo da microcirculação / Intracoronary stem-cell injection after myocardial infarction: microcirculation sub-study

FUNDAMENTO: A injeção de células-tronco no contexto do infarto agudo do miocárdio (IAM) tem sido testada quase exclusivamente pela via anterógrada intra-arterial coronariana (IAC). A via retrógrada intravenosa coronariana (IVC) pode ser uma via adicional. OBJETIVO: Comparar o padrão de distribuição e retenção celular nas vias anterógrada e retrógrada. Investigar o papel da obstrução microvascular pela ressonância magnética na retenção de células pelo tecido cardíaco após a injeção de células mononucleares da medula óssea (CMMO) no IAM. MÉTODOS: Estudo prospectivo, aberto, randomizado. Foram incluídos pacientes com IAM que apresentassem: (1) reperfusão mecânica ou química com sucesso em até 24 horas do início dos sintomas e (2) infarto acometendo mais de 10 por cento da área do ventrículo esquerdo (VE) pela cintilografia miocárdica. Cem milhões de CMMO foram injetadas na artéria relacionada ao infarto pela via IAC ou veia, pela via IVC. Um por cento das células injetadas foi marcado com Tc99m-hexametil-propileno-amina-oxima(99mTc-HMPAO). A distribuição das células foi avaliada 4 e 24 horas após a injeção da cintilografia miocárdica. Ressonância magnética cardíaca foi realizada antes da injeção de células. RESULTADOS: Trinta pacientes foram distribuídos aleatoriamente em três grupos. Não houve eventos adversos graves relacionados ao procedimento. A retenção precoce e tardia das células marcadas foi maior no grupo IAC do que no grupo IVC, independentemente da presença de obstrução da microcirculação. CONCLUSÃO: A injeção pela abordagem retrógrada mostrou-se viável e segura. A retenção de células pelo tecido cardíaco foi maior pela via anterógrada. Mais estudos são necessários para confirmar esses achados.

BACKGROUND: The injection of stem cells in the context of acute myocardial infarction (AMI) has been tested almost exclusively by anterograde intra-arterial coronary (IAC) delivery. The retrograde intravenous coronary (IVC) delivery may be an additional route. OBJECTIVE: To compare the cell distribution and retention pattern in the anterograde and retrograde routes. To investigate the role of microvascular obstruction by magnetic resonance imaging in cell retention by cardiac tissue after the injection of bone marrow mononuclear cells (BMMC) in AMI. METHODS: This was a prospective, open label, randomized study. Patients with AMI who presented: (1) successful chemical or mechanical reperfusion within 24 hours of symptom onset and (2) infarction involving more than 10 percent of the left ventricle (LV) at the myocardial scintigraphy were included in the study. One hundred million BMMC were injected into the infarction-related artery through IAC route, or vein through the IVC route. One percent of the injected cells were labeled with 99mTc-hexamethyl-propylene-amine-oxime (99mTc-HMPAO). Cell distribution was evaluated at 4 and 24 hours after the myocardial scintigraphy injection. Cardiac magnetic resonance imaging was performed before cell injection. RESULTS: Thirty patients were randomized into three groups. There were no serious adverse events related to the procedure. The early and late retention of labeled cells was higher in the IAC group than in IVC group, regardless of the presence of microcirculation obstruction. CONCLUSION: The injection using the retrograde approach was feasible and safe. Cell retention by cardiac tissue was higher using the anterograde approach. More studies are needed to confirm these findings.

Infarto agudo do miocárdio: síndrome coronária aguda com supradesnivelamento do segmento ST - parte 2 / Acute myocardial infarction: ST elevation acute coronary syndrome: part 2

O infarto agudo do miocárdio (IAM) é uma das principais causas de mortalidade em todo o mundo. A incidência de morte por IAM era alta na década de 50. Com o surgimento das unidades de tratamento intensivo e das unidades coronarianas, essa mortalidade foi reduzida pela metade. Na década de 80 - com o início da recanalização da artéria coronária relacionada ao IAM, através do uso de fibrinolítico ou dos novos processos de intervenção percutânea - houve queda na incidência de óbitos de 6 por cento a 10 por cento. O presente artigo visa demonstrar os principais aspectos do tratamento do IAM.

Acute myocardial infarction (AMI) is a leading cause of mortality worldwide. The mortality rate for AMI had high incidence in the 50's, with the emergence of intensive Care Units and Coronary Units, mortality was reduced by half. In the 80's the early recanalization of coronary artery related to the AMI with the use of fibrinolytic and new procedures for percutaneous intervention, there was a decrease in the incidence of deaths in patients from 6 percent to 10 percent. This article aims to demonstrate the main aspects of the treatment of AMI.

Curso de atualização em cardiologia: aula 9: angina instável e infarto sem supradesnível do segmento ST / Updating cardiology course: class 9: instable angina and non ST element elevation infarction

A doença arterial coronariana é altamente prevalente na população e uma das principais causas de óbito em nossa sociedade. O reconhecimento precoce e o adequado tratamento desta síndrome clínica podem evitar complicações e minimizar os riscos. Em 2007, o American College of Cardiology e a American Heart Association revisaram o Guideline de Manejo de Pacientes com AI e IAM SSST, produzido em 2002, com o intuito de facilitar o reconhecimento, diagnóstico e tratamento desta importante síndrome clínica. O presente artigo tem como objetivo salientar as características principais dessas síndromes clínicas, assim como transmitir os principais aspectos abordados pelo Guideline publicado em 2007 pelo American College of Cardiology e a American Heart Association.

Coronary artery disease is highly prevalent in general population and one of the main causes of death in our society. Early recognition and proper therapy of this syndrome can avoid complications and curtail risks. In 2007 the American College of Cardiology and the American Heart Association reviewed the Guidelines for Patient Management with UA and non-STMI, published in 2002, in order to ease the recognition, diagnosis and therapy of this important clinical condition. This paper aims to give a clear picture of the main characteristics of these syndromes, as well as the highlights of the Guideline published in 2007 by the American College of Cardiology and the American Heart Association.

Curso de atualização em cardiologia: aula 10. Miocardite como modelo de doença imunológica: aspectos clínicos e diagnósticos / Cardiology updating course: class 10. Miocardite as model of disease imunológica: clinical aspects and diagnoses

Miocardites são um grupo de doenças heterogêneas que podem ser compreendidas com uma fisiopatologia imunológica. Os autores discutem aspectos históricos e a imunologia dessas doenças, correlacionando o trabalho de cientistas como Carlos Chagas, Noel Rose e Nelson Vaz. Levam em consideração a evolução histórica do conhecimento científico e a mudança de paradigma em andamento na imunologia. Também analisam as principais manifestações clínicas e estratégias para o diagnóstico e abordam novas propostas para investigação clínica dessas síndromes.

Curso de Atualização em Cardiologia: aula 2: Angina estável crônica / Actualization in Cargiology: class 2: stable chronic angina

A doença cardiovascular ainda é altamente prevalente no mundo inteiro, e a angina estável é uma de suas apresentações mais comuns. Três controvérsias principais são o manejo dos fatores de risco, o tratamento clínico e a intervenção. Com relação ao tratamento clínico, alé, de aspirina, inibidores da enzina conversora da angiotensina e betabloqueadores. A intervenção coronária percutânea alivia os sintomas sem prolongar a sobrevida além do tratamento clínico. Porém, dados de mortalidade favorecem a cirurgia de revascularização miocárdica em indivíduos com doença bivascular ou trivascular. Novas opções de tratamento sob investigação incluem drogas antianginosas, assim como a terapia celular. Assim, a angina de esforço precisa de uma ampla avaliação, mudanças no estilo de vida e tratamento individualizado para cada paciente.

Curso de atualização em cardiologia: aula 6: dislipidemia / Updating cardiology course: class 6: dyslipidemia

A doença aterosclerótica é a principal causa de mortalidde em homens e mulheres em todo o mundo. Um dos principais fatores de risco modificáveis para doença aterosclerótica é a dislipidemia. A atenção para se alcançar a meta dos níveis de lipídios deve ser inicialmente direcionada para terapêutica não farmacológica. Recomenda-se terapia com estatina para a maioria dos pacientes, mas, freqüentemente, uma combinação de agentes hipolipemiantes é necessária.

Curso de Atualização em Cardiologia: aula 4: Avaliação pré-operatória do paciente cardiopata / Updating in Cardiology Course: class 4: Preoperative evaluation of cardiopath patient

Mundialmente, cerca de 500 mil a 900 mil pacientes operados sofrem um evento cardiovascular relacionado ao ato cirúrgico, tal como morte cardiovascular, infarto do miocárdio (IM) ou parada cardiorrespiratória não-fatais. Os pacientes acometidos por IM relacionado a cirurgia não-cardíaca apresentam mortalidade intra-hospitalar de 15 por cento a 25 por cento, sendo tal evendo um fator de risco independente para morte cardiovascular e IM em até seis meses após a cirurgia. A fisiopatologia do IM no contexto peroperatório é menos conhecida. A correta identificação de pacientes de alto risco cardiovascular é fundamental para determinar quais medidas devem ser tomadas visando diminuir o risco de eventos peroperatórios. Há vários índices publicados (de Lee, Goldman, Lersen e Gilbert) usados para estimar o risco cirúrgico de um paciente, os quais levam em conta o número de preditores de risco (p. ec.: história de angina, diabetes ou cirurgia de emergência que o paciente possui. Todos são limitados, uma vez que a maioria se baseia em resultados de estudos que ocorreram em um único centro, em geral um hospital universitário, além do que a maioria não avaliou desfechos compostos com semelhantes graus de relevância. Para escolher qual teste não-invasivo solicitar, deve-se considerar os resultados das meta-análises relevantes e de suas limitações. Intervenções atualmente utilizadas para a prevenção de eventos cardíacos peroperatórios carecem de evidências científicas mais robustas que as justifiquem.

Curso de atualização em Cardiologia: aula 7: Pericardite / Cardiology Updating Course: class 7: Pericardittis

Pericardite é a inflamação da serosa que envolve o coração. Pode ter diversas causas, sendo a principal idiopática, presumivelmente viral ou auto-imune. Freqüentemente simula sinais de isquemia ou infarto agudo miocárdico (IAM). A pericardite pode causar derrame (efusão) e levar à compressão do coração (tamponamento cardíaco), e em pacientes com inflamação crônica, constrição do coração. Na maioria dos pacientes se resolve espontaneamente, embora o tratamento com uma droga antiinflamatória não-esteroidal, colchicina ou corticosteróide possa ser útil