Familial breast cancer, pregnancy and cardiotoxicity associated with the use of doxorubicin and reaction with trastuzumab.

INTRODUCTION: Breast Cancer (BC) is a neoplasm with the highest prevalence in women in Brazil and worldwide. Pregnancy-associated with BC is defined as that which occurs during pregnancy or within 1 to 2 years postpartum. The objective is to present a clinical case of a young patient with a history of familial BC who had cancer during pregnancy. The patient had cardiotoxicity after using doxorubicin and trastuzumab. CASE REPORT: She was a young patient within infiltrating ductal carcinoma in the right breast She was diagnosed within nine weeks of gestation and submitted to neoadjuvant chemotherapy with AC protocol (doxorubicina and cyclophosphamide) and mastectomy. Developed left atrial overload after treatment and still responding to hypersensitivity to trastuzumab. MANAGEMENT AND OUTCOME: The patient presented an alteration in the electrocardiogram (ECG) after the use of doxorubicin. The exam was repeated and the ECG was normal. Trastuzumab was started after delivery and the patient had a hypersensitivity reaction. Administration of trastuzumab was stopped and hydrocortisone was administered. The patient showed improvement in symptoms with cessation of trastuzumab. DISCUSSION: Although anthracycline-induced cardiotoxicity and hypersensitivity reactions to trastuzumab are common reactions, there are few studies on the effects of these drugs in patients with Gestational breast cancer (GBC). Monitoring cardiotoxicity in breast cancer treatment in pregnant patients is essential to avoid two complications: for the pregnant woman and the fetus.

Biomarkers and prediction of anthracyclic cardiotoxicity in breast cancer.

BACKGROUND: Chemotherapy with doxorubicin may lead to left ventricular dysfunction. There is a controversial recommendation that biomarkers can predict ventricular dysfunction, which is one of the most feared manifestations of anthracycline cardiotoxicity. OBJECTIVE: The aim of this study was to evaluate the behavior of biomarkers such as Troponin I, type B natriuretic peptide, creatine phosphokinase fraction MB, and myoglobin in predicting cardiotoxicity in a cohort of women with breast cancer undergoing chemotherapy with anthracycline. METHODS: This is an observational, prospective, longitudinal, unicentric study, which included 40 women with breast cancer, whose therapeutic proposal included treatment with doxorubicin. The protocol had a clinical follow-up of 12 months. Biomarkers such as Troponin I, type B natriuretic peptide, creatine phosphokinase fraction MB, and myoglobin were measured pre-chemotherapy and after the first, third, fourth, and sixth cycles of chemotherapy. RESULTS: There was a progressive increase in type B natriuretic peptide and myoglobin values in all chemotherapy cycles. Although creatine phosphokinase fraction MB showed a sustained increase, this increase was not statistically significant. Troponin, type B natriuretic peptide, myoglobin, and creatine phosphokinase fraction MB were the cardiotoxicity markers with the earliest changes, with a significant increase after the first chemotherapy session. However, they were not able to predict cardiotoxicity. CONCLUSION: Troponin I, type B natriuretic peptide, myoglobin, and creatine phosphokinase fraction MB are elevated during chemotherapy with doxorubicin, but they were not able to predict cardiotoxicity according to established clinical and echocardiographic criteria. The incidence of subclinical cardiotoxicity resulting from the administration of doxorubicin was 12.5%.

Cardiovascular adverse effects associated with the use of anti-HER2 in breast cancer treatment.

Background: Cancer represents an important public health problem with increasing incidence, prevalence, and mortality, affecting the entire Western population, especially in developed and developing countries. The use of monoclonal antibodies has revolutionized the treatment of cancer, but this treatment can cause adverse cardiovascular effects (AE). Objective: The objective of this paper is to identify and classify AE in breast cancer patients in the use of Trastuzumab in two health institutions. Methods: Retrospective study of medical records of patients with breast cancer Her 2+ submitted the therapy with trastuzumab in early and advanced stage of the disease. Review conducted in a university hospital and a private clinic, both located in Rio de Janeiro State, Brazil. Results: Cardiovascular events were late for trastuzumab, with predominance of moderate reactions. There was a predominance of dyspnea, increased blood pressure, fatigue and reduced left ventricular ejection. Conclusion: The results resemble similarities in the pattern of the institutions' reactions. Identify possible AE and know the toxicity profile of trastuzumab can contribute to a safer therapy.

Myocardial Injury after Non-cardiac Surgery - State of the Art. / Lesão Miocárdica após Cirurgia Não Cardíaca ­ Estado da Arte.

Approximately 300 million non-cardiac surgeries are performed annually worldwide and adverse cardiovascular events are the main cause of morbidity and mortality in the peri- and postoperative period. Myocardial injury after non-cardiac surgery (MINS) is a new clinical entity associated with adverse cardiovascular outcomes. MINS is defined as myocardial injury that can result in necrosis due to ischemia, marked by increase in biomarker levels. It has prognostic relevance and occurs within up to 30 days after non-cardiac surgery. The diagnostic criteria for MINS are an elevated postoperative measure of troponin judged as secondary to myocardial ischemia, i.e., with no evidence of a non-ischemic etiology, during or within 30 days after non-cardiac surgery, and without the requirement of an ischemic symptom or electrocardiographic finding of ischemia. Recently, patients at higher risk for MINS have been recognized using clinical variables and biomarkers and established protocols for greater surveillance in relation to electrocardiographic monitoring and cardiac troponin dosage. Elderly patients with previous atherosclerotic disease need to measure troponin daily in the postoperative period. The aim of the present work is to describe this new public health problem, its clinical impact and contemporary therapeutic approach.

Aproximadamente 300 milhões de cirurgias não cardíacas são realizadas anualmente no mundo, e eventos cardiovasculares adversos são as principais causas de morbimortalidade no período perioperatório e pós-operatório. A lesão miocárdica após cirurgia não cardíaca (MINS, do inglês myocardial injury after non-cardiac surgery) é uma nova entidade clínica associada com desfechos cardiovasculares adversos. MINS é definida como uma lesão miocárdica que pode resultar em necrose secundária à isquemia, com elevação dos biomarcadores. A lesão tem importância prognóstica e ocorre em até 30 dias após a cirurgia não cardíaca. Os critérios diagnósticos para MINS são: níveis elevados de troponina durante ou em até 30 dias após a cirurgia não cardíaca, sem evidência de etiologia não isquêmica, sem que haja necessariamente sintomas isquêmicos ou achados eletrocardiográficos de isquemia. Recentemente, pacientes com maior risco para MINS têm sido identificados por variáveis clínicas e biomarcadores, bem como por protocolos de vigilância quanto ao monitoramento eletrocardiográfico e dosagem de troponina cardíaca. Pacientes idosos com doença aterosclerótica prévia necessitam medir troponina diariamente no período pós-operatório. O objetivo deste trabalho é descrever este novo problema de saúde pública, seu impacto clínico e a abordagem terapêutica contemporânea.

Is lipid accumulation product a better cardiovascular risk predictor in elderly individuals than anthropometric measures?

INTRODUCTION: Population aging is associated with increased prevalence of cardiovascular diseases that have a significant impact on overall morbidity and mortality. Insulin resistance (IR) and visceral obesity are risk factors for vascular damage and cardiometabolic diseases. AIMS: Estimating the correlation between lipid accumulation product (LAP) and IR in elderly individuals and comparing them to traditional anthropometric indices. METHODS: Cross-sectional study comprising 411 individuals >60 years, who were treated in a primary care service. Body mass index (BMI), neck circumference (NC), waist circumference (WC), hip circumference (HC), arm circumference (AC), sagittal abdominal diameter (SAD) and waist-hip ratio (WHR) were recorded. IR was estimated based on HOMA-IR (homeostasis model assessment IR index). LAPa index was calculated as [WC-65]×[triglyceride (TG)] in men, and as [WC-58]×[TG] in women, whereas LAPb was calculated by using the minimum WC values recorded for the current sample, i.e., 61.5 cm for women and 71.5 cm for men. RESULTS: There was correlation among LAPa (0.506), LAPb (0.515) and HOMA-IR. LAP was better correlated to HOMA-IR and showed higher area under the curve than BMI, NC, WHR and SAD. Based on the receiver operating characteristic curve analysis, LAPb≥47.40 and LAPa≥52.5 were the best cut-off values used to identify individuals with IR presenting 68.8% and 68.2% sensitivity, and 68.6% and 68.6% specificity, respectively. CONCLUSION: LAP may be a useful and simple clinical marker to assess cardiometabolic risk factors in the elderly population treated at a primary care service.

Characteristics and Temporal Trends in the Mortality of Different Heart Failure Phenotypes in Primary Care. / Características e Tendências na Mortalidade em Diferentes Fenótipos de Insuficiência Cardíaca na Atenção Primária.

BACKGROUND: The classification of heart failure (HF) by phenotypes has a great relevance in clinical practice. OBJECTIVE: The study aimed to analyze the prevalence, clinical characteristics, and outcomes between HF phenotypes in the primary care setting. METHODS: This is an analysis of a cohort study including 560 individuals, aged ≥ 45 years, who were randomly selected in a primary care program. All participants underwent clinical evaluations, b-type natriuretic peptide (BNP) measurements, electrocardiogram, and echocardiography in a single day. HF with left ventricular ejection fraction (LVEF) < 40% was classified as HF with reduced ejection fraction (HFrEF), LVEF 40% to 49% as HF with mid-range ejection fraction (HFmrEF) and LVEF ≥ 50% as HF with preserved ejection fraction (HFpEF). After 5 years, the patients were reassessed as to the occurrence of the composite outcome of death from any cause or hospitalization for cardiovascular disease. RESULTS: Of the 560 patients included, 51 patients had HF (9.1%), 11 of whom had HFrEF (21.6%), 10 had HFmrEF (19.6%) and 30 had HFpEF (58.8%). HFmrEF was similar to HFpEF in BNP levels (p < 0.001), left ventricular mass index (p = 0.037), and left atrial volume index (p < 0.001). The HFmrEF phenotype was similar to HFrEF regarding coronary artery disease (p = 0.009). After 5 years, patients with HFmrEF had a better prognosis when compared to patients with HFpEF and HFrEF (p < 0.001). CONCLUSION: The prevalence of ICFEI was similar to that observed in previous studies. ICFEI presented characteristics similar to ICFEP in this study. Our data show that ICFEi had a better prognosis compared to the other two phenotypes.

FUNDAMENTO: A classificação da insuficiência cardíaca (IC) por fenótipos possui grande relevância na prática clínica. OBJETIVO: O estudo visou analisar a prevalência, as características clínicas e os desfechos entre os fenótipos de IC no contexto da atenção primária. MÉTODOS: Trata-se de uma análise de um estudo de coorte que incluiu 560 indivíduos, com idade ≥ 45 anos, que foram selecionados aleatoriamente em um programa de atenção primária. Todos os participantes foram submetidos a avaliações clínicas, dosagem do peptídeo natriurético tipo B (BNP), eletrocardiograma e ecocardiografia em um único dia. A IC com fração de ejeção do ventrículo esquerdo (FEVE) < 40% foi classificado como IC com fração de ejeção reduzida (ICFEr), FEVE de 40% a 49% como IC com fração de ejeção intermediária (ICFEi) e FEVE ≥ 50% como IC com fração de ejeção preservada (ICFEp). Após 5 anos, os pacientes foram reavaliados quanto à ocorrência do desfecho composto de óbito por qualquer causa ou internação por doença cardiovascular. RESULTADOS: Dos 560 pacientes incluídos, 51 pacientes tinham IC (9,1%), 11 dos quais tinham ICFEr (21,6%), 10 tinham ICFEi (19,6%) e 30 tinham ICFEp (58,8%). A ICFEi foi semelhante à ICFEp nos níveis de BNP (p < 0,001), índice de massa do ventrículo esquerdo (p = 0,037) e índice de volume do átrio esquerdo (p < 0,001). O fenótipo de ICFEi foi semelhante ao de ICFEr em relação à doença arterial coronariana (p = 0,009). Após 5 anos, os pacientes com ICFEi apresentaram melhor prognóstico quando comparados aos pacientes com ICFEp e ICFEr (p < 0,001). CONCLUSÃO: A prevalência de ICFEI foi semelhante ao observado em estudos anteriores. A ICFEI apresentou características semelhantes a ICFEP neste estudo. Nossos dados mostram que a ICFEi teve melhor prognóstico em comparação com os outros dois fenótipos.

Trends in Mortality Rates from Cardiovascular Disease and Cancer between 2000 and 2015 in the Most Populous Capital Cities of the Five Regions of Brazil.

BACKGROUND: In many cities around the world, the mortality rate from cancer (CA) has exceeded that from disease of the circulatory system (DCS). OBJECTIVES: To compare the mortality curves from DCS and CA in the most populous capital cities of the five regions of Brazil. METHODS: Data of mortality rates from DCS and CA between 2000 and 2015 were collected from the Mortality Information System of Manaus, Salvador, Goiania, Sao Paulo and Curitiba, and categorized by age range into early (30-69 years) and late (≥ 70 years), and by gender of the individuals. Chapters II and IX of the International Classification of Diseases-10 were used for the analysis of causes of deaths. The Joinpoint regression model was used to assess the tendency of the estimated annual percentage change of mortality rate, and the Monte Carlo permutation test was used to detect when changes occurred. Statistical significance was set at 5%. RESULTS: There was a consistent decrease in early and late mortality from DCS in both genders in the cities studied, except for late mortality in men in Manaus. There was a tendency of decrease of mortality rates from CA in São Paulo and Curitiba, and of increase in the rates from CA in Goiania. In Salvador, there was a decrease in early mortality from CA in men and women and an increase in late mortality in both genders. CONCLUSION: There was a progressive and marked decrease in the mortality rate from DCS and a maintenance or slight increase in CA mortality in the five capital cities studied. These phenomena may lead to the intersection of the curves, with predominance of mortality from CA (old and new cases).

Quantification of Calcified Coronary Plaques by Chest Computed Tomography: Correlation with the Calcium Score Technique. / Quantificação das Placas Coronarianas Calcificadas pela Tomografia Computadorizada do Tórax: Correlação com a Técnica do Escore de Cálcio.

BACKGROUND: Cardiovascular disease is the leading cause of mortality in the world. Parietal calcifications of the arteries may be visualized and quantified at initial and subclinical states by computed tomography (CT), and expressed as calcium score (CS). It is possible to estimate the prognosis of future cardiovascular events using this score. OBJECTIVES: To correlate the detection and quantification of the CS obtained by chest CT with that obtained by electrocardiography (ECG)-synchronized cardiac computed tomography (the gold-standard). METHOD: Cross-sectional, descriptive study of 73 consecutive patients in investigation for coronary artery disease who underwent cardiac CT between June 2013 and October 2014. Chest computed tomography and CS protocols were performed in a 64-channel TC scanner. P-values <0.05 were considered statistically significant. RESULTS: In the per-patient analysis, after logarithmic transformation, mean CS was 8.7 and 9.4 by the ECG-synchronized method and chest CT, respectively. The prevalence of disease was 49.3% (n=36), with a sensitivity of 97.2% and specificity of 100.0%. There was an excellent correlation between the methods (r= 0.993, p<0.001). In the per-segment analysis, after logarithmic transformation, mean CS was 3.0 and 3.2 by the ECG-synchronized method and chest CT, respectively. The prevalence of disease was 29.5% (n=86), with a sensitivity of 95.3% and specificity of 97.5%. There was an excellent correlation between the methods (r= 0.985, p<0.001). CONCLUSION: ECG-synchronized CT is well correlated with the non-ECG-synchronized CT for CS determination, without statistical difference between the methods. (Arq Bras Cardiol. 2020; 115(3):493-500).

FUNDAMENTO: A doença cardiovascular representa a principal causa de mortalidade no mundo. Calcificações parietais nas artérias podem ser visualizadas e quantificadas por tomografia computadorizada (TC) em estágios iniciais e subclínicos, sendo expressa em escore de cálcio (EC). Com esse número, é possível estimar o prognóstico de eventos cardiovasculares futuros. OBJETIVOS: Correlacionar a detecção e quantificação do EC pela TC do tórax utilizando como padrão-ouro a TC cardíaca sincronizada ao eletrocardiograma. MÉTODOS: Estudo transversal e descritivo que selecionou pacientes (n=73) consecutivos para investigação de doença arterial coronariana estável e que realizaram TC cardíaca no período de junho de 2013 a outubro de 2014. Realizado protocolo com TC do tórax e EC, em aparelho de 64 canais. Os valores de p<0,05 foram considerados estatisticamente significativos. RESULTADOS: Na avaliação por paciente, após a transformação logarítmica a média do EC sincronizado foi de 8,7 e na TC de tórax foi de 9,4. Prevalência de doença de 49,3% (n= 36). A sensibilidade foi de 97,2% e a especificidade de 100,0%. Observou-se excelente correlação entre os métodos (r= 0,993 com p<0,001). Na avaliação por segmento, a média do EC sincronizado foi de 3,0. Já a média do EC na TC de tórax foi de 3,2. Prevalência de doença de 29,5% (n= 86), com sensibilidade de 95,3% e especificidade de 97,5%. Observou-se também excelente correlação entre os métodos (r= 0,985 com p<0,001). CONCLUSÃO: O EC sincronizado e não sincronizado têm boa correlação entre si e não mostram resultados estatisticamente diferentes. (Arq Bras Cardiol. 2020; 115(3):493-500).

Left Ventricular Remodeling Patterns in Primary Healthcare.

BACKGROUND: Left ventricular remodeling (LVR) is related to both non-fatal and fatal outcomes. OBJECTIVE: To describe the geometric patterns of the LV and their associations. METHODS: A total of 636 individuals between the ages of 45 and 99 years in Rio de Janeiro, Brazil, were submitted to clinical evaluation, laboratory tests, electrocardiogram, and tissue Doppler echocardiography (TDE). The difference between categories was tested with Kruskall-Wallis with post hoc tests, once all variables studied are non-normally distributed and Pearson's Qui-square (categorical variables). Gross and adjusted ORs were estimated by logistic regression. The level of significance was 5% for all tests. Subjects had LVR characterized as: normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH), and eccentric hypertrophy (EH). RESULTS: The prevalence of altered patterns was 33%. Subjects presented NG (n = 423; 67%); EH (n = 186; 29%); CH (n = 14; 2%); and CR (n = 13; 2%). The variables of gender, age, level of education and albumin/creatinine ratio (A/C), showed a relationship with the chance of EH even after adjustment. CONCLUSION: Approximately one third of the studied individuals had LVR and were at risk for developing heart failure. Altered A/C in urine was associated with EH, indicating an early relationship between cardiac and renal dysfunction.

Sagittal abdominal diameter as a marker of visceral obesity in older primary care patients.

BACKGROUND: Longevity, combined with a higher prevalence of obesity, particularly visceral obesity, has been associated with an increased risk of cardiovascular diseases. Insulin resistance (IR) is an important link between visceral obesity and cardiovascular diseases. An important association has been found between sagittal abdominal diameter, visceral obesity and IR. The objective of this study is to evaluate sagittal abdominal diameter as a marker of visceral obesity and correlate it with IR in older primary health care patients. METHODS: A cross-sectional study was performed with 389 patients over 60 years of age (70.6 ± 6.9), of whom 74% were female. Their clinical, anthropometric and metabolic profiles were assessed and their fasting serum insulin level was used to calculate the homeostasis model assessment insulin resistance (HOMA-IR). Sagittal abdominal diameter was measured in the supine position at the midpoint between the iliac crest and the last rib with abdominal calipers. RESULTS: Sagittal abdominal diameter was significantly correlated with anthropometric measures of general and visceral obesity and with HOMA-IR in both genders. There was no change in the association between sagittal abdominal diameter and HOMA-IR after adjusting for age, sex, diabetes and hypertension. CONCLUSION: It is feasible to use sagittal abdominal diameter in older primary care patients as a tool to evaluate visceral obesity, which is an indicator of cardiovascular risk.

Acute Cardiorenal Syndrome: Which Diagnostic Criterion to Use And What is its Importance for Prognosis? / Síndrome Cardiorrenal Aguda: Qual Critério Diagnóstico Utilizar e sua Importância para o Prognóstico?

The absence of a consensus about the diagnostic criteria for acute cardiorenal syndrome (ACRS) affects its prognosis. This study aimed at assessing the diagnostic criteria for ACRS and their impact on prognosis. A systematic review was conducted using PRISMA methodology and PICO criteria in the MEDLINE, EMBASE and LILACS databases. The search included original publications, such as clinical trials, cohort studies, case-control studies, and meta-analyses, issued from January 1998 to June 2018. Neither literature nor heart failure guidelines provided a clear definition of the diagnostic criteria for ACRS. The serum creatinine increase by at least 0.3 mg/dL from baseline creatinine is the most used diagnostic criterion. However, the definition of baseline creatinine, as well as which serum creatinine should be used as reference for critical patients, is still controversial. This systematic review suggests that ACRS criteria should be revised to include the diagnosis of ACRS on hospital admission. Reference serum creatinine should reflect baseline renal function before the beginning of acute kidney injury.

Risk of Obstructive Sleep Apnea and Echocardiographic Parameters.

BACKGROUND: Obstructive sleep apnea (OSA) is a chronic progressive disorder with high mortality and morbidity rate, associated with cardiovascular diseases (CVD), especially heart failure (HF). The pathophysiological changes related to OSA can directly affect the diastolic function of the left ventricle. OBJECTIVES: To assess the association of the risk of OSA, evaluated by the Berlin Questionnaire (BQ), and echocardiographic (ECHO) parameters related to diastolic dysfunction in individuals without HF assisted in primary care. METHODS: A cross-sectional study that included 354 individuals (51% women) aged 45 years or older. All individuals selected were submitted to an evaluation that included the following procedures: consultation, filling out the BQ, clinical examination, laboratory examination and transthoracic Doppler echocardiography (TDE). Continuous data are presented as medians and interquartile intervals, and categoric variables in absolute and relative frequencies. The variables associated with risk of OSA and at the 0.05 level integrated the gamma regression models with a log link function. A value of p < 0.05 was considered an indicator of statistical significance. Exclusion criteria were presence of HF, to fill out the BQ and patients with hypertension and obesity not classified as high risk for OSA by other criteria. All individuals were evaluated on a single day with the following procedures: medical appointment, BQ, laboratory tests and ECHO. RESULTS: Of the 354 individuals assessed, 63% were classified as having high risk for OSA. The patients with high risk for OSA present significantly abnormal diastolic function parameters. High risk for OSA confirmed positive and statistically significant association, after adjustments, with indicators of diastolic function, such as indexed left atrium volume LAV-i (p = 0.02); E'/A' (p < 0.01), A (p = 0.02), E/A (p < 0.01). CONCLUSION: Our data show that patients at high risk for OSA present worsened diastolic function parameters measured by TDE.

Biomarkers and prediction of anthracyclic cardiotoxicity in breast cancer

SUMMARY BACKGROUND: Chemotherapy with doxorubicin may lead to left ventricular dysfunction. There is a controversial recommendation that biomarkers can predict ventricular dysfunction, which is one of the most feared manifestations of anthracycline cardiotoxicity. OBJECTIVE: The aim of this study was to evaluate the behavior of biomarkers such as Troponin I, type B natriuretic peptide, creatine phosphokinase fraction MB, and myoglobin in predicting cardiotoxicity in a cohort of women with breast cancer undergoing chemotherapy with anthracycline. METHODS: This is an observational, prospective, longitudinal, unicentric study, which included 40 women with breast cancer, whose therapeutic proposal included treatment with doxorubicin. The protocol had a clinical follow-up of 12 months. Biomarkers such as Troponin I, type B natriuretic peptide, creatine phosphokinase fraction MB, and myoglobin were measured pre-chemotherapy and after the first, third, fourth, and sixth cycles of chemotherapy. RESULTS: There was a progressive increase in type B natriuretic peptide and myoglobin values in all chemotherapy cycles. Although creatine phosphokinase fraction MB showed a sustained increase, this increase was not statistically significant. Troponin, type B natriuretic peptide, myoglobin, and creatine phosphokinase fraction MB were the cardiotoxicity markers with the earliest changes, with a significant increase after the first chemotherapy session. However, they were not able to predict cardiotoxicity. CONCLUSION: Troponin I, type B natriuretic peptide, myoglobin, and creatine phosphokinase fraction MB are elevated during chemotherapy with doxorubicin, but they were not able to predict cardiotoxicity according to established clinical and echocardiographic criteria. The incidence of subclinical cardiotoxicity resulting from the administration of doxorubicin was 12.5%.

Antiplatelet Therapy in Breast Cancer Patients Using Hormonal Therapy: Myths, Evidence and Potentialities - Systematic Review.

Breast cancer is the most frequently diagnosed tumor in women worldwide, with a significant impact on morbidity and mortality. Chemotherapy and hormone therapy have significantly reduced mortality; however, the adverse effects are significant. Aspirin has been incorporated into clinical practice for over 100 years at a low cost, making it particularly attractive as a potential agent in breast cancer prevention and as an adjunct treatment to endocrine therapy in the prophylaxis of cardiovascular complications. The objective of this study was to evaluate the role of aspirin in reducing the incidence of breast cancer and to evaluate the impact of its use on morbidity and mortality and reduction of cardiovascular events as adjuvant therapy during breast cancer treatment with selective estrogen receptor modulators. A systematic review was performed using the PRISMA methodology and PICO criteria, based on the MEDLINE, EMBASE and LILACS databases. The original articles of clinical trials, cohort, case-control studies and meta-analyses published from January 1998 to June 2017, were considered. Most studies showed an association between the use of selective estrogen receptor modulators and the increase in thromboembolic events. The studies suggest a protective effect of aspirin for cardiovascular events during its concomitant use with selective estrogen receptor modulators and in the prevention of breast cancer. This systematic review suggests that aspirin therapy combines the benefit of protection against cardiovascular events with the potential reduction in breast cancer risk, and that the evaluation of the benefits of the interaction of endocrine therapy with aspirin should be further investigated.

Pulmonary Ultrasound in Patients with Heart Failure - Systematic Review.

Pulmonary congestion is an important clinical finding in patients with heart failure (HF). Physical examination and chest X-ray have limited accuracy in detecting congestion. Pulmonary ultrasound (PU) has been incorporated into clinical practice in the evaluation of pulmonary congestion. This paper aimed to perform a systematic review of the use of PU in patients with HF, in different scenarios. A search was performed in the MEDLINE and LILACS databases in February 2017 involving articles published between 2006 and 2016. We found 26 articles in the present review, 11 of which in the emergency setting and 7 in the outpatient setting, with diagnostic and prognosis defined value and poorly studied therapeutic value. PU increased accuracy by 90% as compared to physical examination and chest X-ray for the diagnosis of congestion, being more sensitive and precocious. The skill of the PU performer did not interfere with diagnostic accuracy. The presence of B-lines ≥ 15 correlated with high BNP values (≥ 500) and E/e' ratio ≥ 15, with prognostic impact in IC patients at hospital discharge and those followed up on an outpatient basis. In conclusion, when assessing pulmonary congestion in HF, PU has an incremental value in the diagnostic and prognostic approach in all scenarios studied.

Left atrium and pulmonary artery compression due to aortic aneurysm causing heart failure symptoms.

Patients with thoracic aortic aneurysm (TAA) are mostly asymptomatic and TAA is rarely related to heart failure (HF). We report the case of an 80-year-old female patient, with type A TAA without dissection, with right pulmonary artery and left atrium compression, who presented with HF, preserved ejection fraction and acute pulmonary edema.

Comparison of two smoking cessation interventions for inpatients.

OBJECTIVE: This study aimed to compare the effectiveness of two cognitive behavioral therapy-based smoking cessation interventions initiated during hospitalization and to evaluate the factors related to relapse after discharge. METHODS: This was a prospective randomized study involving 90 smokers hospitalized in a university hospital. We collected data related to sociodemographic characteristics, reasons for admission, smoking-related diseases, smoking history, the degree of nicotine dependence (ND), and the level of craving. Patients were divided into two treatment groups: brief intervention (BrInter, n = 45); and intensive intervention with presentation of an educational video (InInterV, n=45). To assess relapse, all patients were assessed by telephone interview in the first, third, and sixth months after discharge. Abstinence was confirmed by measurement of exhaled carbon monoxide (eCO). RESULTS: Of the 90 patients evaluated, 55 (61.1%) were male. The mean age was 51.1 ± 12.2 years. The degree of ND was elevated in 39 (43.4%), and withdrawal symptoms were present in 53 (58.9%). The mean eCO at baseline was 4.8 ± 4.5 ppm. The eCO correlated positively with the degree of ND (r = 0.244; p = 0.02) and negatively with the number of smoke-free days (r = -0.284; p = 0.006). There were no differences between the groups in terms of the variables related to socioeconomic status, smoking history, or hospitalization. Of the 81 patients evaluated at 6 months, 33 (40.7%) remained abstinent (9 and 24 BrInter and InInterV group patients, respectively; p = 0.001), and 48 (59.3%) had relapsed (31 and 17 BrInter and InInterV group patients, respectively; p= 0.001). Moderate or intense craving was a significant independent risk factor for relapse, with a relative risk of 4.0 (95% CI: 1.5-10.7; p < 0.00001). CONCLUSIONS: The inclusion of an educational video proved effective in reducing relapse rates. Craving is a significant risk factor for relapse.