Temporal Trends in Transcatheter Aortic Valve Implantation: 10-Year Analysis of the TAVIDOR Registry. / Tendência Temporal no Implante Percutâneo de Bioprótese Aórtica: Análise de 10 Anos do Registro TAVIDOR.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has established itself as the preferential strategy to approach severe aortic stenosis. Information on procedural improvements and nationwide results obtained with the technique throughout the past decade are unknown. OBJECTIVES: To assess the temporal variation of the demographic profile, procedural characteristics, and in-hospital outcomes of patients undergoing TAVI procedures at the Rede D'Or São Luiz. METHODS: Observational registry comprising 29 national institutions, comparing the characteristics of the TAVI procedures performed from 2012 to 2017 (Group 1) to those performed from 2018 to 2023 (Group 2). The statistical significance level adopted was p < 0.05. RESULTS: This study assessed 661 patients, 95 in Group 1 and 566 in Group 2, with a mean age of 81.1 years. Group 1 patients had a higher prevalence of New York Heart Association functional class III or IV and STS risk score > 8%. In addition, they more often underwent general anesthesia, transesophageal echocardiographic monitoring, and access through femoral dissection. Group 2 patients had a higher success rate of the TAVI procedure (95.4% versus 89.5%; p = 0.018), lower mortality (3.9% versus 11.6%; p = 0.004), and less often needed permanent pacemaker implantation (8.5% versus 17.9%; p = 0.008). CONCLUSIONS: The 10-year temporal trends analysis of the TAVIDOR Registry shows a reduction in patients' clinical complexity over time. Furthermore, the advance to minimalistic implantation techniques, added to the technological evolution of the devices, may have contributed to the favorable outcomes observed among those whose implantation occurred in the last 5 years studied.

FUNDAMENTO: O implante percutâneo de bioprótese valvar aórtica (TAVI) consolidou-se como opção terapêutica da estenose aórtica de grau importante. Dados sobre as características evolutivas dos procedimentos e dos resultados obtidos com a técnica ao longo da última década, em escala nacional, são desconhecidos. OBJETIVOS: Analisar a tendência temporal referente ao perfil demográfico, características dos procedimentos e desfechos hospitalares de pacientes submetidos a TAVI na Rede D'Or São Luiz. MÉTODOS: Registro observacional envolvendo 29 instituições nacionais. Comparou-se características dos procedimentos realizados de 2012 a 2017 (Grupo 1) e de 2018 a 2023 (Grupo 2). Foram considerados significantes os resultados com valor de p < 0,05. RESULTADOS: Foram analisados 661 casos, 95 pertencentes ao Grupo 1 e 566 ao Grupo 2. A média de idade foi 81,1 anos. Observou-se no Grupo 1 maior prevalência de pacientes em classe funcional III ou IV e escore de risco > 8%. Foi mais frequente o emprego de anestesia geral, monitorização ecocardiográfica transesofágica e via de acesso por dissecção. Maior taxa de sucesso do procedimento (95,4% versus 89,5%; p = 0,018) foi aferida em implantes efetivados a partir de 2018, assim como menor mortalidade (3,9% versus 11,6%; p = 0,004) e necessidade de marcapasso definitivo (8,5% versus 17,9%; p = 0,008). CONCLUSÕES: A análise temporal de 10 anos do Registro TAVIDOR demonstra uma queda na complexidade clínica dos pacientes. Além disso, o avanço para técnicas de implante minimalistas, somadas à evolução tecnológica dos dispositivos, podem ter contribuído para desfechos favoráveis dentre aqueles cujo implante ocorreu no último quinquênio.

Independent assessment of the atrial fibrillation - hypertrophic cardiomyopathy score in a brazilian cohort

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia in hypertrophic cardiomyopathy (HCM), frequently related to adverse outcomes. The AF-HCM point-score is a recently validated predictive model for the assessment of AF risk. OBJECTIVES: We sought to independently evaluate the novel AF-HCM score in a tertiary HCM center cohort in Brazil. METHODS: A longitudinal HCM cohort followed between 2007-2022 was retrospectively stratified for new onset AF, according to the presence of left atrial dimension (+2 points per 6mm increase), age at clinical evaluation (+3 points per 10-year increase), age at HCM diagnosis (-2 points per 10-year increase) and heart failure symptoms (+3 points if symptomatic). The AF-HCM score was classified as low (2,0%/year; score ≥22) for AF development. Cox regression model and Kaplan-Meier survival free from AF were analyzed, P< 0.001]. The intermediate and high-risk groups were associated with developing arrhythmia with a hazard ratio of 56.8 (95% CI 3.4-944.6), P=0.005. The specificity and the negative predictive value were 100%. On the contrary of the previous North-America study population, most patients of the Brazilian cohort were in the high-risk category (37% vs. 52%). CONCLUSION: The AF-HCM score is a reasonable tool for recognizing patients not prone to develop AF among those stratified as low risk in a Brazilian cohort. However, the model was limited to identify intermediate and high risk individuals in contrast to the previously stratified North-American population.

Protective Barriers and Radiant Exposure Delivered from Light-curing Units.

OBJECTIVE: To evaluate the influence of different protective barriers as a function of the photoactivation distances on the radiant exposure of several light-curing units (LCU). The influence of the protective barriers on the degree of conversion of an adhesive resin was also evaluated. METHODS: Five LCUs were evaluated: Valo Cordless-used in standard mode (Ultradent, South Jordan, USA); Radii-cal-used in continuous mode (SDI, Bayswater, AU); Emitter D-used in continuous mode (Schuster, Santa Maria, BR); Bluephase N-used in high-intensity mode (Ivoclar Vivadent, Schaan, LI); and Rainbow Curing Light-used in continuous mode (Axdent, Guangdong, CN). For each LCU, radiant exposure was measured with a spectrometer (MARC Resin Calibrator) using three different protective barriers (low-density polyethylene, polyvinyl chloride, or Radii-cal barrier sleeves) and five photoactivation distances (0, 2, 5, 10, and 20 mm). The degree of conversion of an adhesive resin (Adper Scotchbond Multi-Purpose, 3M ESPE, St. Paul, USA) was measured through Fourier-transform infrared spectroscopy. The translucency parameter of protective barriers was measured with a spectrophotometer. For all statistical tests, a significance level of α = 0.05 was set. RESULTS: For all LCUs tested, radiant exposure was found to be significantly influenced by both protective barriers and curing distance (p≤0.001). In general terms, all the protective barriers significantly decreased the radiant exposure. Radii-cal barrier sleeves were the protective barrier that most decreased the radiant exposure. Irrespective of the protective barrier used, none of the LCU equipment reached the required minimum radiant exposure of 16 J/cm2 at 10 mm of curing distance. The degree of conversion was not effected by either LCU or a protective barrier (p≥0.211). CONCLUSIONS: Protective barriers and photoactivation distance reduced the radiant exposure emitted by different LCUs.

Hair determination of per- and polyfluoroalkyl substances (PFAS) in the Italian population.

Per- and polyfluoroalkyl substances (PFAS) are anthropogenic chemicals present in the environment and defined as persistent organic pollutants (POPs). The interest in these forms of contaminants is related to the toxic consequences for health derived from exposures and bioaccumulation processes. The present research aims at assessing differences in the exposure of PFAS in the Italian population by hair analyses. To this aim, 20 compounds of the PFAS family were investigated in hair of 86 Italian subjects distributed across the regions of Veneto, Emilia-Romagna, Lombardy and Marche. The applied method was ad hoc developed in a previous research and included SPE extraction and LC-QTOF analysis. In the analyzed population, 66.4 % had quantifiable amounts of one or more PFAS molecules (up to 4 compounds); mean PFAS content, expressed as sum of PFAS, was 0.1457 ng/g, ranging from "not detected" to 0.85 ng/g (SD 0.1867). PFOA and PFOS were the chemicals most frequently detected, with mean concentrations of 0.1402 ng/g and 0.1155 ng/g, respectively. PFBA was detected in 9.3 % of subjects with a mean concentration of 0.3760 ng/g; PFNA in 3.5 % of subjects with mean concentration 0.12 ng/g; PFDA was found in one subject at the concentration of 0.541 ng/g. PFUnA and PFHxS were detected below the limit of quantification. The overall results displayed differences in the presence and prevalence of PFAS in hair of the Italian population on a geographical base. On the contrary, no significatively differences in the amount of PFAS were observed when considering gender or age classes. On this base, hair can be considered a good diagnostic tool to assess PFAS exposure on a regional-scaled base. Of course, more studies are required to infer PFAS internal dose from hair results due to its peculiar detection window and to interpretative issues derived from external contamination.

Avaliação do Seguimento de 1 Ano dos Pacientes Incluídos no Registro da Prática Clínica em Pacientes de Alto Risco Cardiovascular (REACT) / Evaluation of 1-Year Follow-up of Patients Included in the Registry of Clinical Practice in Patients at High Cardiovascular Risk (REACT)

Resumo Fundamento Na prática clínica, há evidências de falhas na prescrição de terapias baseadas em evidências para pacientes de alto risco cardiovascular. Entretanto, no Brasil, ainda são insuficientes os dados sobre a evolução ao longo de 1 ano desses pacientes. Objetivos Descrição no acompanhamento de 12 meses da utilização de terapias baseadas em evidência e da ocorrência de desfechos cardiovasculares maiores e seus principais preditores em um registro brasileiro multicêntrico de pacientes de alto risco cardiovascular. Métodos Estudo observacional prospectivo que documentou a prática clínica ambulatorial de indivíduos acima de 45 anos e de alto risco cardiovascular tanto em prevenção primária como secundária. Os pacientes foram seguidos por 1 ano e avaliou-se a prescrição de terapias baseadas em evidência e a ocorrência de eventos cardiovasculares maiores (infarto agudo do miocárdio [IAM], acidente vascular cerebral [AVC], parada cardíaca e mortalidade por causa cardiovascular). Valores de p < 0,05 foram considerados estatisticamente significantes. Resultados De julho de 2010 até agosto de 2014, 5.076 indivíduos foram incluídos em 48 centros, sendo 91% dos 4.975 pacientes elegíveis acompanhados em centros de cardiologia e 68,6% em prevenção secundária. Em 1 ano, o uso concomitante de antiplaquetários, estatinas e inibidores da enzima conversora de angiotensina (IECA) reduziu de 28,3% para 24,2% (valor de p < 0,001). A taxa de eventos cardiovasculares maiores foi de 5,46%, e os preditores identificados foram: idade, pacientes em prevenção secundária e nefropatia diabética. Conclusões Neste grande registro nacional de pacientes de alto risco cardiovascular, foram identificados preditores de risco semelhantes aos registros internacionais, porém a adesão da prescrição médica a terapias baseadas em evidência esteve abaixo dos dados da literatura internacional e apresentou piora significativa em 1 ano. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Abstract Background In clinical practice, there is evidence of failure to prescribe evidence-based therapies for patients at high cardiovascular risk. However, in Brazil, data on 1-year outcomes of these patients remain insufficient. Objectives To describe the use of evidence-based therapies and the occurrence of major cardiovascular outcomes and their major predictors in a 12-month follow-up of a Brazilian multicenter registry of patients at high cardiovascular risk. Methods This prospective observational study documented the outpatient clinical practice of managing patients over 45 years of age and of high cardiovascular risk in both primary and secondary prevention. Patients were followed-up for 1 year, and the prescription of evidence-based therapies and the occurrence of major cardiovascular events (myocardial infarction, stroke, cardiac arrest, and cardiovascular death) were assessed. P-values < 0.05 were considered statistically significant. Results From July 2010 to August 2014, a total of 5076 individuals were enrolled in 48 centers, 91% of the 4975 eligible patients were followed-up in cardiology centers, and 68.6% were in secondary prevention. At 1 year, the concomitant use of antiplatelet agents, statins, and angiotensin-converting enzyme inhibitors reduced from 28.3% to 24.2% (p < 0.001). Major cardiovascular event rate was 5.46%, and the identified predictors were age, patients in secondary prevention, and diabetic nephropathy. Conclusions In this large national registry of patients at high cardiovascular risk, risk predictors similar to those of international registries were identified, but medical prescription adherence to evidence-based therapies was inferior and significantly worsened at 1 year. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Evaluation of 1-Year Follow-up of Patients Included in the Registry of Clinical Practice in Patients at High Cardiovascular Risk (REACT). / Avaliação do Seguimento de 1 Ano dos Pacientes Incluídos no Registro da Prática Clínica em Pacientes de Alto Risco Cardiovascular (REACT).

BACKGROUND: In clinical practice, there is evidence of failure to prescribe evidence-based therapies for patients at high cardiovascular risk. However, in Brazil, data on 1-year outcomes of these patients remain insufficient. OBJECTIVES: To describe the use of evidence-based therapies and the occurrence of major cardiovascular outcomes and their major predictors in a 12-month follow-up of a Brazilian multicenter registry of patients at high cardiovascular risk. METHODS: This prospective observational study documented the outpatient clinical practice of managing patients over 45 years of age and of high cardiovascular risk in both primary and secondary prevention. Patients were followed-up for 1 year, and the prescription of evidence-based therapies and the occurrence of major cardiovascular events (myocardial infarction, stroke, cardiac arrest, and cardiovascular death) were assessed. P-values < 0.05 were considered statistically significant. RESULTS: From July 2010 to August 2014, a total of 5076 individuals were enrolled in 48 centers, 91% of the 4975 eligible patients were followed-up in cardiology centers, and 68.6% were in secondary prevention. At 1 year, the concomitant use of antiplatelet agents, statins, and angiotensin-converting enzyme inhibitors reduced from 28.3% to 24.2% (p < 0.001). Major cardiovascular event rate was 5.46%, and the identified predictors were age, patients in secondary prevention, and diabetic nephropathy. CONCLUSIONS: In this large national registry of patients at high cardiovascular risk, risk predictors similar to those of international registries were identified, but medical prescription adherence to evidence-based therapies was inferior and significantly worsened at 1 year. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

FUNDAMENTO: Na prática clínica, há evidências de falhas na prescrição de terapias baseadas em evidências para pacientes de alto risco cardiovascular. Entretanto, no Brasil, ainda são insuficientes os dados sobre a evolução ao longo de 1 ano desses pacientes. OBJETIVOS: Descrição no acompanhamento de 12 meses da utilização de terapias baseadas em evidência e da ocorrência de desfechos cardiovasculares maiores e seus principais preditores em um registro brasileiro multicêntrico de pacientes de alto risco cardiovascular. MÉTODOS: Estudo observacional prospectivo que documentou a prática clínica ambulatorial de indivíduos acima de 45 anos e de alto risco cardiovascular tanto em prevenção primária como secundária. Os pacientes foram seguidos por 1 ano e avaliou-se a prescrição de terapias baseadas em evidência e a ocorrência de eventos cardiovasculares maiores (infarto agudo do miocárdio [IAM], acidente vascular cerebral [AVC], parada cardíaca e mortalidade por causa cardiovascular). Valores de p < 0,05 foram considerados estatisticamente significantes. RESULTADOS: De julho de 2010 até agosto de 2014, 5.076 indivíduos foram incluídos em 48 centros, sendo 91% dos 4.975 pacientes elegíveis acompanhados em centros de cardiologia e 68,6% em prevenção secundária. Em 1 ano, o uso concomitante de antiplaquetários, estatinas e inibidores da enzima conversora de angiotensina (IECA) reduziu de 28,3% para 24,2% (valor de p < 0,001). A taxa de eventos cardiovasculares maiores foi de 5,46%, e os preditores identificados foram: idade, pacientes em prevenção secundária e nefropatia diabética. CONCLUSÕES: Neste grande registro nacional de pacientes de alto risco cardiovascular, foram identificados preditores de risco semelhantes aos registros internacionais, porém a adesão da prescrição médica a terapias baseadas em evidência esteve abaixo dos dados da literatura internacional e apresentou piora significativa em 1 ano. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

A systematic review of microRNAs in patients with hypertrophic cardiomyopathy.

BACKGROUND: Several microRNAs (miRNA) have been associated with hypertrophic cardiomyopathy (HCM), but studies differ regarding methods employed. In an attempt to understand their role in the disease, we performed a systematic review of studies assessing miRNAs and their association with HCM. METHODS: The literature search was based on The Medical Subject Headings (MeSH) terms "Hypertrophic Cardiomyopathy" and "MicroRNA" combined with other synonyms on Embase, Medline and LILACS databases in April 2020. The selected studies and data extraction were independently evaluated. Only human reports with a clear definition of HCM diagnosis were included. RESULTS: The search found 68 studies, 13 fulfilled the selection criteria, with a total of 329 patients. Eighty-seven miRNA were differentially expressed in HCM patients, being mir-21, mir-29a and mir-133 the most reported. The miRNA were mainly up-regulated, where mir-29a was up-regulated in 6 studies, followed by mir-133 in 4 and mir-21 in 3. The other miRNAs were mainly up-regulated. Blood samples were evaluated in the majority of patients (86%), but a greater number of miRNAs (79%) were assessed in myocardium. Six studies evaluating the phenotype correlation demonstrated that several miRNAs, mainly mir-1-3p, mir-19b, mir-21, mir-29a, mir-155, and mir-221, were related to either hypertrophy or fibrosis. Mir-29a showed a more consistent phenotypic correlation. CONCLUSION: Eighty-seven miRNAs were differentially expressed in HCM patients, the majority in up-regulation. Mir-21, mir-29a and mir-133 were the most reported. Correlation with left ventricular hypertrophy and fibrosis was evaluated in six studies for several miRNAs, nevertheless, mir-29a showed more consistent findings and seems to be a promising biomarker.

Vascular Closure Devices Attenuate Femoral Access Complications of Primary Percutaneous Coronary Intervention.

OBJECTIVES: To compare severe complications related to radial access and those related to femoral access using vascular closure devices for patients undergoing primary percutaneous coronary intervention (PCI). BACKGROUND: Femoral artery access is still used for acute myocardial infarction management; studies comparing state-of-the-art radial and femoral techniques are required to minimize bias regarding the outcomes associated with operator preferences. METHODS: We performed a randomized study comparing radial access with a compression device and anatomic landmark-guided femoral access with a hemostatic vascular closure device. The severe complication rates related to the access site were assessed until hospital discharge. A meta- analysis including studies with comparable populations reporting severe bleeding and major adverse cardiovascular event rates was performed. RESULTS: A total of 250 patients were included who underwent PCI between January 2016 and February 2019. Mean age was 61.5 ± 12.2 years, 73.2% were men, and 28.4% had diabetes. There were no differences between groups or in vascular access-related severe complication rates (8.0% for femoral group vs 5.6% for radial group; P=.45). Although radial access was associated with decreased vascular complications related to the access site when compared with the femoral approach (relative risk [RR], 0.64; 95% confidence interval [CI], 0.43-0.95), the meta-analysis did not show an impact on severe bleeding (RR, 0.74; 95% CI, 0.37-1.46) or severe cardiovascular adverse events (RR, 0.69; 95% CI, 0.30-1.58). CONCLUSIONS: Compliance with femoral artery puncture techniques and routine use of a vascular closure device promoted low severe complication rates.

Discrepancy between International Guidelines on the Criteria for Primary Prevention of Sudden Cardiac Death in Hypertrophic Cardiomyopathy. / Discordância entre Diretrizes Internacionais sobre Critérios de Prevenção Primária de Morte Súbita na Cardiomiopatia Hipertrófica.

BACKGROUND: Risk stratification for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) is based on different algorithms proposed by the 2011 ACCF/AHA and 2014 ESC guidelines. OBJECTIVE: To analyze the 2014 ESC model for SCD risk stratification and primary prevention ICD (implantable cardioverter defibrillator) in HCM in comparison to the North American guideline. METHODS: An HCM cohort was evaluated and the ESC HCM-Risk SCD score was calculated. Agreement of ICD recommendations criteria between the two guidelines was analyzed with Kappa coefficient. P<0.05 was adopted for the statistical analysis. RESULTS: In 90 consecutive patients followed for 6±3 years, the mean calculated ESC risk score was 3.2±2.5%. The risk predictors that have mainly contributed to the score calculation in the low (1.88% [1.42-2.67]), intermediate (5.17% [4.89-5.70]) and high-risk (7.82% [7.06-9.19]) categories were: maximal left ventricular wall thickness (1.60% [1.25-2.02]; 3.20% [3.18-3.36]; 4.46% [4.07-5.09]), left atrial diameter (0.97% [0.83-1.21]; 1.86% [1.67-2.40]; 2.48% [2.21-3.51]) and age (-0.91% [0.8-1.13]; -1.90% [1.12-2.03]; -2.34% [1.49-2.73]). The European model decreased the ICD recommendations in 32 (36%) patients. Among the 43 (48%) individuals with class IIa recommendation under the 2011 ACCF/AHA guideline, 8 (18%) were downgraded to class IIb and 24 (56%) to class III. Low agreement was found between the two systems: Kappa=0.355 and p=0.0001. In 8 (9%) patients with SCD or appropriate shock, 4 (50%) met class IIa indication with the 2011 ACCF/AHA guideline, but none achieved this class of recommendation with the 2014 ESC model. CONCLUSION: Low agreement was found between the two strategies. The novel ESC model decreased the ICD recommendations, especially in those with class IIa recommendation, but left unprotected all patients with SCD or appropriate shock. (Arq Bras Cardiol. 2020; 115(2):197-204).

FUNDAMENTO: A estratificação de risco para morte súbita (MS) na cardiomiopatia hipertrófica (CMH) baseia-se em algoritmos distintos propostos pela diretriz norte-americana, ACCF/AHA 2011 e europeia, ESC 2014. OBJETIVO: Analisar o modelo ESC 2014 na determinação do risco de MS e indicação de cardiodesfibrilador implantável (CDI) em prevenção primária na CMH por meio de confrontação com a normativa norte-americana. MÉTODOS: Foi avaliada uma coorte de pacientes com CMH, calculado o escore ESC HCM-Risk-SCD e analisada a concordância dos critérios de indicação de CDI entre as duas diretrizes pelo coeficiente de Kappa. O nível de significância adotado nas análises estatísticas foi de 5%. RESULTADOS: Em 90 pacientes consecutivos, seguidos por 6±3 anos, o escore calculado foi de 3,2±2,5%. Os preditores que mais contribuíram para o cálculo nas faixas de baixo (1,88% [1,42-2,67]), médio (5,17% [4,89-5,70]) e alto risco (7,82% [7,06-9,19]) foram espessura parietal máxima do ventrículo esquerdo (1,60% [1,25-2,02] ; 3,20% [3,18-3,36] ; 4,46% [4,07-5,09]), diâmetro do átrio esquerdo (0,97% [0,83-1,21]; 1,86% [1,67-2,40]; 2,48% [2,21-3,51]) e idade (-0,91% [0,8-1,13]; -1,90% [1,12-2,03]; -2,34% [1,49-2,73]). O modelo europeu reduziu as recomendações de CDI em 32 (36%) pacientes. Entre os 43 (48%) em classe IIa pela ACCF/AHA , 8 (18%) migraram para IIb e 24 (56%) para III. Baixa concordância foi identificada entre as duas sistematizações, Kappa = 0,355, p = 0,0001. Dos 8 (9%) pacientes com MS ou choque apropriado, 4 (50%) atingiram indicação IIa pela ACCF/AHA , mas nenhum pela ESC . CONCLUSÃO: Baixa concordância foi identificada entre as diretrizes analisadas. O novo modelo reduziu as indicações de CDI, notadamente em classe IIa, mas deixou desprotegida a totalidade de pacientes com MS ou choque apropriado. (Arq Bras Cardiol. 2020; 115(2):197-204).

Discordância entre Diretrizes Internacionais sobre Critérios de Prevenção Primária de Morte Súbita na Cardiomiopatia Hipertrófica / Discrepancy between International Guidelines on the Criteria for Primary Prevention of Sudden Cardiac Death in Hypertrophic Cardiomyopathy

Resumo Fundamento A estratificação de risco para morte súbita (MS) na cardiomiopatia hipertrófica (CMH) baseia-se em algoritmos distintos propostos pela diretriz norte-americana, ACCF/AHA 2011 e europeia, ESC 2014. Objetivo Analisar o modelo ESC 2014 na determinação do risco de MS e indicação de cardiodesfibrilador implantável (CDI) em prevenção primária na CMH por meio de confrontação com a normativa norte-americana. Métodos Foi avaliada uma coorte de pacientes com CMH, calculado o escore ESC HCM-Risk-SCD e analisada a concordância dos critérios de indicação de CDI entre as duas diretrizes pelo coeficiente de Kappa. O nível de significância adotado nas análises estatísticas foi de 5%. Resultados Em 90 pacientes consecutivos, seguidos por 6±3 anos, o escore calculado foi de 3,2±2,5%. Os preditores que mais contribuíram para o cálculo nas faixas de baixo (1,88% [1,42-2,67]), médio (5,17% [4,89-5,70]) e alto risco (7,82% [7,06-9,19]) foram espessura parietal máxima do ventrículo esquerdo (1,60% [1,25-2,02] ; 3,20% [3,18-3,36] ; 4,46% [4,07-5,09]), diâmetro do átrio esquerdo (0,97% [0,83-1,21]; 1,86% [1,67-2,40]; 2,48% [2,21-3,51]) e idade (-0,91% [0,8-1,13]; -1,90% [1,12-2,03]; -2,34% [1,49-2,73]). O modelo europeu reduziu as recomendações de CDI em 32 (36%) pacientes. Entre os 43 (48%) em classe IIa pela ACCF/AHA , 8 (18%) migraram para IIb e 24 (56%) para III. Baixa concordância foi identificada entre as duas sistematizações, Kappa = 0,355, p = 0,0001. Dos 8 (9%) pacientes com MS ou choque apropriado, 4 (50%) atingiram indicação IIa pela ACCF/AHA , mas nenhum pela ESC . Conclusão Baixa concordância foi identificada entre as diretrizes analisadas. O novo modelo reduziu as indicações de CDI, notadamente em classe IIa, mas deixou desprotegida a totalidade de pacientes com MS ou choque apropriado. (Arq Bras Cardiol. 2020; 115(2):197-204)

Abstract Background Risk stratification for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) is based on different algorithms proposed by the 2011 ACCF/AHA and 2014 ESC guidelines. Objective To analyze the 2014 ESC model for SCD risk stratification and primary prevention ICD (implantable cardioverter defibrillator) in HCM in comparison to the North American guideline. Methods An HCM cohort was evaluated and the ESC HCM-Risk SCD score was calculated. Agreement of ICD recommendations criteria between the two guidelines was analyzed with Kappa coefficient. P<0.05 was adopted for the statistical analysis. Results In 90 consecutive patients followed for 6±3 years, the mean calculated ESC risk score was 3.2±2.5%. The risk predictors that have mainly contributed to the score calculation in the low (1.88% [1.42-2.67]), intermediate (5.17% [4.89-5.70]) and high-risk (7.82% [7.06-9.19]) categories were: maximal left ventricular wall thickness (1.60% [1.25-2.02]; 3.20% [3.18-3.36]; 4.46% [4.07-5.09]), left atrial diameter (0.97% [0.83-1.21]; 1.86% [1.67-2.40]; 2.48% [2.21-3.51]) and age (-0.91% [0.8-1.13]; -1.90% [1.12-2.03]; -2.34% [1.49-2.73]). The European model decreased the ICD recommendations in 32 (36%) patients. Among the 43 (48%) individuals with class IIa recommendation under the 2011 ACCF/AHA guideline, 8 (18%) were downgraded to class IIb and 24 (56%) to class III. Low agreement was found between the two systems: Kappa=0.355 and p=0.0001. In 8 (9%) patients with SCD or appropriate shock, 4 (50%) met class IIa indication with the 2011 ACCF/AHA guideline, but none achieved this class of recommendation with the 2014 ESC model. Conclusion Low agreement was found between the two strategies. The novel ESC model decreased the ICD recommendations, especially in those with class IIa recommendation, but left unprotected all patients with SCD or appropriate shock. (Arq Bras Cardiol. 2020; 115(2):197-204)

One year follow-up Assessment of Patients Included in the Brazilian Registry of Acute Coronary Syndromes (ACCEPT). / Avaliação do Seguimento de um Ano dos Pacientes Incluídos no Registro Brasileiro de Síndromes Coronárias Agudas (ACCEPT).

Background There is lack of prospective data on evolution within one year of acute coronary syndromes (ACS) in a representative population of Brazilian patients. Objectives To assess the prescription of evidence-based therapies, the incidence of severe outcomes and the predictors for these outcomes in a multicenter Brazilian registry of ACS patients. Methods The ACCEPT is a prospective observational study, which included patients hospitalized with a diagnostic of ACS in 47 Brazilian hospitals. The patients were followed for a 1 year and data were collected on the medical prescription and the occurrence of major cardiovascular events (cardiovascular mortality, reinfarction and cerebrovascular accident - CVA). Values of p < 0.05 were considered statistically significant. Results A total of 5,047 patients were included in this registry from August 2010 to April 2014. The diagnosis of ACS was confirmed in 4,782 patients (94.7%) and, among those, the most frequent diagnosis was ACS with ST segment elevation (35.8%). The rate of major cardiovascular events was 13.6 % within 1 year. Adherence to prescription of evidence-based therapy at admission was of 62.1%. Age, public service, acute myocardial infarction, CVA, renal failure, diabetes and quality of therapy were associated independently with the occurrence of major cardiovascular events. Conclusions During the one-year follow-up of the ACCEPT registry, more than 10% of the patients had major cardiovascular events and this rate ranged according with the quality of therapy. Strategies must be elaborated to improve the use of evidence-based therapies to minimize the cardiovascular events among the Brazilian population. (Arq Bras Cardiol. 2020; 114(6):995-1003).

Avaliação do seguimento de um ano dos pacientes incluídos no registro brasileiro de síndromes coronárias agudas (ACCEPT) / One year follow-up assessment of patients included in the brazilian registry of acute coronary syndromes (ACCEPT)

RESUMO FUNDAMENTO: Existe carência de informações prospectivas sobre a evolução em um ano após uma síndrome coronária aguda (SCA) em uma grande amostra de pacientes brasileiros. OBJETIVOS: Avaliar a prescrição de terapias baseadas em evidência, a ocorrência de desfechos graves e os preditores para estes desfechos em um registro brasileiro multicêntrico de pacientes com SCA. MÉTODOS: O ACCEPT é um estudo observacional prospectivo que incluiu pacientes internados com diagnóstico de SCA em 47 hospitais brasileiros. Os pacientes foram seguidos por 1 ano e coletou-se dados sobre prescrição médica e ocorrência de eventos cardiovasculares maiores (mortalidade cardiovascular, reinfarto e acidente vascular encefálico - AVE). Valores de p < 0,05 foram considerados estatisticamente significantes. RESULTADOS: Um total de 5.047 pacientes foram incluídos neste registro, de agosto de 2010 até abril de 2014. Foi confirmado o diagnóstico de SCA em 4.782 pacientes (94,7%) e, dentre os 3 diagnósticos possíveis, o mais comum foi SCA com elevação do segmento ST (35,8%). A taxa de eventos cardiovasculares maiores foi de 13,6 % em 1 ano. A prescrição completa de terapias baseadas em evidência na admissão hospitalar foi de 62,1%. Idade, atendimento público, infarto agudo do miocárdio, AVE, insuficiência renal, diabetes e qualidade da terapia estiveram associados de forma independente à ocorrência de eventos cardiovasculares maiores. CONCLUSÕES: No seguimento de 1 ano do registro ACCEPT, mais de 10% dos pacientes apresentaram eventos cardiovasculares maiores e esta taxa variou de acordo com a qualidade da terapia. Há necessidade da elaboração de estratégias para melhorar o uso de terapias baseadas em evidência no sentido de minimizar os eventos cardiovasculares na população brasileira.

Avaliação do Seguimento de um Ano dos Pacientes Incluídos no Registro Brasileiro de Síndromes Coronárias Agudas (ACCEPT) / One year follow-up Assessment of Patients Included in the Brazilian Registry of Acute Coronary Syndromes (ACCEPT)

Resumo Fundamento Existe carência de informações prospectivas sobre a evolução em um ano após uma síndrome coronária aguda (SCA) em uma grande amostra de pacientes brasileiros. Objetivos Avaliar a prescrição de terapias baseadas em evidência, a ocorrência de desfechos graves e os preditores para estes desfechos em um registro brasileiro multicêntrico de pacientes com SCA. Métodos O ACCEPT é um estudo observacional prospectivo que incluiu pacientes internados com diagnóstico de SCA em 47 hospitais brasileiros. Os pacientes foram seguidos por 1 ano e coletou-se dados sobre prescrição médica e ocorrência de eventos cardiovasculares maiores (mortalidade cardiovascular, reinfarto e acidente vascular encefálico - AVE). Valores de p < 0,05 foram considerados estatisticamente significantes. Resultados Um total de 5.047 pacientes foram incluídos neste registro, de agosto de 2010 até abril de 2014. Foi confirmado o diagnóstico de SCA em 4.782 pacientes (94,7%) e, dentre os 3 diagnósticos possíveis, o mais comum foi SCA com elevação do segmento ST (35,8%). A taxa de eventos cardiovasculares maiores foi de 13,6 % em 1 ano. A prescrição completa de terapias baseadas em evidência na admissão hospitalar foi de 62,1%. Idade, atendimento público, infarto agudo do miocárdio, AVE, insuficiência renal, diabetes e qualidade da terapia estiveram associados de forma independente à ocorrência de eventos cardiovasculares maiores. Conclusões No seguimento de 1 ano do registro ACCEPT, mais de 10% dos pacientes apresentaram eventos cardiovasculares maiores e esta taxa variou de acordo com a qualidade da terapia. Há necessidade da elaboração de estratégias para melhorar o uso de terapias baseadas em evidência no sentido de minimizar os eventos cardiovasculares na população brasileira. (Arq Bras Cardiol. 2020; 114(6):995-1003)

Abstract Background There is lack of prospective data on evolution within one year of acute coronary syndromes (ACS) in a representative population of Brazilian patients. Objectives To assess the prescription of evidence-based therapies, the incidence of severe outcomes and the predictors for these outcomes in a multicenter Brazilian registry of ACS patients. Methods The ACCEPT is a prospective observational study, which included patients hospitalized with a diagnostic of ACS in 47 Brazilian hospitals. The patients were followed for a 1 year and data were collected on the medical prescription and the occurrence of major cardiovascular events (cardiovascular mortality, reinfarction and cerebrovascular accident - CVA). Values of p < 0.05 were considered statistically significant. Results A total of 5,047 patients were included in this registry from August 2010 to April 2014. The diagnosis of ACS was confirmed in 4,782 patients (94.7%) and, among those, the most frequent diagnosis was ACS with ST segment elevation (35.8%). The rate of major cardiovascular events was 13.6 % within 1 year. Adherence to prescription of evidence-based therapy at admission was of 62.1%. Age, public service, acute myocardial infarction, CVA, renal failure, diabetes and quality of therapy were associated independently with the occurrence of major cardiovascular events. Conclusions During the one-year follow-up of the ACCEPT registry, more than 10% of the patients had major cardiovascular events and this rate ranged according with the quality of therapy. Strategies must be elaborated to improve the use of evidence-based therapies to minimize the cardiovascular events among the Brazilian population. (Arq Bras Cardiol. 2020; 114(6):995-1003)

Is a calcium hydroxide liner necessary in the treatment of deep caries lesions? A systematic review and meta-analysis.

The aim of this systematic review and meta-analysis was to evaluate whether the use of calcium hydroxide (CH) liner improves the clinical success in the treatment of deep caries lesions of primary and permanent teeth. The review was reported in accordance with the PRISMA Statement. Only studies that evaluated deep carious lesions treated with and without a CH liner were included. The required outcomes had to be obtained by clinical, radiographic or laboratory evaluations. Statistical analyses were performed with the RevMan 5.2 program (The Cochrane Collaboration, Copenhagen, Denmark) for randomized clinical trials with at least 12 months of follow-up, using fixed-effect models at a significance level of P < 0.05. The literature search was performed in eight databases: PubMed (MEDLINE), Lilacs, IBECS, BBO, Web of Science, Scopus, SciELO and The Cochrane Library. A total of 17 studies were included (15 in primary teeth, two in permanent teeth). The overall risk difference for CH versus adhesive system in primary teeth was 0.06 [95% CI -0.01 to 0.13], and the overall risk difference for CH versus GIC was 0.10 [95% CI -0.01 to 0.22], with no significant differences between materials. CH liner did not influence the clinical success of treatment for deep caries lesions of primary or permanent teeth. Although the present analysis demonstrated that use of CH liner in deep caries lesions was unnecessary, the evidence was of moderate to very low quality; thus, further well-designed, randomized and controlled clinical trials are necessary to provide stronger recommendations.

Influence of Surface Treatment on Composite Adhesion in Noncarious Cervical Lesions: Systematic Review and Meta-analysis.

The purpose of this study was to analyze the influence of dentin surface treatments on the retention rate of resin composite restorations in non-carious cervical lesions (NCCLs). Seven randomized clinical trials were included in this review. Data regarding retention rate, type of surface treatment, and the main characteristics of studies were analyzed. Two reviewers performed a literature search up to December 2016 in eight databases: PubMed (Medline), Lilacs, Ibecs, Web of Science, BBO, Scopus, Scielo and The Cochrane Library. Only clinical trials evaluating dentin surface treatments in resin composite restoration in NCCLs were included. Noncontrolled clinical trials, reviews, editorial letters, case reports, case series and studies published in a language other than English, Portuguese, or Spanish were not included. The included studies evaluated different surface treatments, such as using an adhesive system with a frictional technique, drying the dentin, and removing sclerotic dentin by using a bur and applying EDTA before primer use. The analysis considering the mechanical removal of dentin surface with a bur and the application of an adhesive system in a frictional mode showed these treatments improved retention rates of the resin composite restorations in NCCLs ( p<0.05). There is evidence in the literature suggesting that the mechanical removal of dentin surface with a bur and the application of an adhesive system in a frictional mode could improve the retention rates of resin composite restorations in NCCLs. However, the studies showed high heterogeneity, and additional clinical trials are needed to determine the best dentin treatment option in NCCLs.

Disclosing the physiology of pulp tissue for vital pulp therapy.

The discovery that dentine is a reservoir of bioactive molecules that can be recruited on demand has attracted efforts to develop new protocols and materials for vital pulp therapy (VPT). The noncollagenous proteins (NCPs) present in the dentine extracellular matrix (ECM) include growth factors (TGF-ß1, BMP-7, FGF-2, IGF-1 and IGF-2, NGF and GDNF), extracellular matrix molecules (DSP, DPP, BSP, DMP-1 and DSPP) and both anti-inflammatory and pro-inflammatory chemokines and cytokines (TNF-α, IL-1, IL-6 and IL-10). Molecules such as DSP and DPP are mainly expressed by odontoblasts, and they are cleaved products from dentine sialophosphoprotein (DSPP). Some molecules, such as TGF-ß1, specifically interact with decorin/biglycan in dentine. Although TGF-ß1 increases the expression and secretion of NGF in human pulp cells, NGF induces mineralization and increases the expression of DSPP and DMP-1. Furthermore, GDNF may act as a cell survival factor and mitogen during tooth injury and repair. Pulp capping materials, such as MTA and calcium hydroxide, can solubilize bioactive dentine molecules (TGF-ß1, NGF and GDNF) that stimulate tertiary dentinogenesis. The binding of these signalling molecules leads to activation of several signalling transduction pathways involved in dentinogenesis, odontoblast differentiation and inflammatory responses, such as the p38 MAPK, NF-kß and Wnt/ß-catenin signalling pathways. Understanding the cascade of cellular and molecular events underlying the repair and regeneration processes provides a reasonable new approach to VPT through a targeted interaction between tooth tissue and bioactive molecules.

Seguimento de 12 Meses de Pacientes Submetidos à Estratégia Intervencionista Precoce pelo Acesso Radial ou Femoral com Dispositivo de Oclusão Vascular / 12-Month Clinical Follow-Up of Patients Undergoing Early Invasive Strategy by the Transradial or Transfemoral Approach with Vascular Closure Device

Fundamento: A técnica radial reduz a prevalência de complicações vasculares, sangramento grave e mortalidade quando cotejada à técnica femoral. Entretanto, esta ainda predomina como via de acesso preferencial para a efetivação de procedimentos coronários invasivos, requerendo a adoção de estratégias capazes de minimizar intercorrências. Objetivos: Comparar a sobrevida livre de eventos cardiovasculares adversos graves aos 12 meses de pacientes submetidos à estratégia intervencionista precoce pelo acesso radial ou femoral com dispositivo de oclusão vascular. Métodos: Estudo randomizado de não inferioridade envolvendo 240 pacientes com síndrome coronariana aguda sem supradesnível do segmento ST. A função de sobrevivência livre de morte, infarto agudo do miocárdio ou acidente vascular encefálico foi estimada pelo modelo de Kaplan-Meier e comparada utilizando-se o teste de log rank. Resultados: A taxa de complicações vasculares no sítio de punção arterial aos 30 dias foi de 12,5% no grupo Angio-Seal e de 13,3% no grupo radial (p = 1,000). A incidência de sangramento grave ou transfusão sanguínea aos 12 meses também não diferiu entre os grupos (2,5% versus 1,7%, p = 1,000). Não se observou diferença quanto à curva de sobrevida livre de eventos cardiovasculares adversos graves (90,8% versus 94,2%, p = 0,328). Conclusões: Não houve distinção entre as técnicas na sobrevida livre de eventos cardiovasculares adversos graves aos 12 meses de seguimento. Ensaios clínicos com maior poder estatístico são necessários para a validação desses achados

Background: The radial approach reduces the prevalence of vascular complications, major bleeding and mortality when compared to the femoral approach. However, the last still prevails as the preferred approach for the performance of invasive coronary procedures, requiring the adoption of strategies to minimize complications. Objectives: To compare the survival free of major adverse cardiovascular events at 12 months in patients undergoing early intervention strategy by the radial or femoral access with vascular closure device. Methods: Randomized non inferiority trial involving 240 non-ST-segment elevation acute coronary syndrome patients. The survival free of death, myocardial infarction or stroke was estimated by the Kaplan-Meier method and compared using the log rank test. Results: The 30-day rate of vascular complications in the arterial puncture site was 12.5% in the Angio-Seal group and 13.3% in the radial group (p = 1.000). The 12-month incidence of major bleeding or blood transfusion did not differ between groups (2.5% vs. 1.7%, p = 1.000). There was no difference in survival free of major adverse cardiovascular events (90.8% versus 94.2%, p = 0.328). Conclusions: There was no distinction between the techniques in survival free of major adverse cardiovascular events at 12 months of followup. Clinical trials with greater statistical power are needed to validate these findings

Polyclonal and monoclonal B lymphocytes response in HCV-infected patients treated with direct-acting antiviral agents.

Hepatitis C virus (HCV) chronic infection can be associated with extrahepatic manifestations such as mixed cryoglobulinaemia and lymphoproliferative disorders that are endowed with increased rates of morbidity and all-cause mortality. In this study, we used flow cytometry to evaluate the effect of interferon-free antiviral treatment on peripheral blood lymphocytes in HCV-infected patients with or without associated lymphoproliferative disorders. Flow cytometry analysis of peripheral blood lymphocytes was performed at baseline and at the end of treatment. In HCV-infected patients with lymphoproliferative disorders, we evaluated immunoglobulin (Ig) light chain κ/λ ratio variations as a measure of monoclonal B-cell response to antiviral therapy. Healthy volunteers were enrolled as controls. A total of 29 patients were included, nine with and 20 without lymphoproliferative disorders. Sustained virological response was achieved in 29 of 29 patients. We observed a significant reduction in the B-cell compartment (39% global reduction) in eight of nine HCV-infected patients with lymphoproliferative disorders after viral clearance. We recognized the same trend, even if less pronounced, in HCV-infected patients without lymphoproliferative disorders (9% global reduction). Among HCV-infected patients with lymphoproliferative disorders, three showed an improvement/normalization of the immunoglobulin light chain ratio, whereas in the remaining six patients monoclonal B cells persisted to be clonally restricted even 1 year after the end of treatment. Our data show that DAAs treatment can be effective in reducing the frequency of pathological B cells in the peripheral blood of HCV-infected patients affected by HCV-associated lymphoproliferative disorders; however, monoclonal populations can persist after viral eradication.