Mechanical dispersion is a superior echocardiographic feature to predict exercise capacity in preclinical and overt heart failure with preserved ejection fraction.

BACKGROUND: Heart Failure with Preserved Ejection Fraction (HFpEF) is a syndrome characterized by different degrees of exercise intolerance, which leads to poor quality of life and prognosis. Recently, the European score (HFA-PEFF) was proposed to standardize the diagnosis of HFpEF. Even though Global Longitudinal Strain (GLS) is a component of HFA-PEFF, the role of other strain parameters, such as Mechanical Dispersion (MD), has yet to be studied. In this study, we aimed to compare MD and other features from the HFA-PEFF according to their association with exercise capacity in an outpatient population of subjects at risk or suspected HFpEF. METHODS: This is a single-center cross-sectional study performed in an outpatient population of 144 subjects with a median age of 57 years, 58% females, referred to the Echocardiography and Cardiopulmonary Exercise Test to investigate HFpEF. RESULTS: MD had a higher correlation to Peak VO2 (r=-0.43) when compared to GLS (r=-0.26), MD presented a significant correlation to Ventilatory Anaerobic Threshold (VAT) (r=-0.20; p = 0.04), while GLS showed no correlation (r=-0.14; p = 0.15). Neither MD nor GLS showed a correlation with the time to recover VO2 after exercise (T1/2). In Receiver Operator Characteristic (ROC) analysis, MD presented superior performance to GLS to predict Peak VO2 (AUC: 0.77 vs. 0.62), VAT (AUC: 0.61 vs. 0.57), and T1/2 (AUC: 0.64 vs. 0.57). Adding MD to HFA-PEFF improved the model performance (AUC from 0.77 to 0.81). CONCLUSION: MD presented a higher association with Peak VO2 when compared to GLS and most features from the HFA-PEFF. Adding MD to the HFA-PEFF improved the model performance.

Afterload increase challenge unmasks systolic abnormalities in heart failure with preserved ejection fraction.

BACKGROUND: Provocative maneuvers have the potential to overcome the low sensitivity of resting echocardiography and biomarkers in the detection of heart failure with preserved ejection fraction (HFpEF). We investigate the mechanical response of the left ventricle to an afterload challenge in patients with preclinical and early-stage HFpEF (es-HFpEF). METHODS: Three groups of patients (non-HFpEF - n = 42, pre-HFpEF - n = 43, and es-HFpEF - n = 39) underwent echocardiography at rest and during an afterload challenge induced by handgrip maneuver combined with pneumatic constriction of limbs. RESULTS: Patients in the non-HF group displayed a median ΔLPSS = -4% (IQR: -10%, +2%), LPSS rest<16% in 3/42(7%) and LPSS stress<16% in 6/43(14%). Subjects in the pre-HFpEF group displayed median ΔLPSS = -3% (IQR: -10%, +5%) LPSS rest<16% in 13/43(30%) and LPSS stress<16% in 19/43 (44%). 11/43 (25%) subjects in this group increased at least one absolute point in LPSS during stress. Patients in es-HFpEF group displayed a median ΔLPSS = -10% (IQR: -18%, -1%), LPSS rest<16% in 15/39(38%) and LPSS stress<16% in 25/39(64%). Changes in LPSS (ΔLPSS) were significantly greater in es-HFpEF than pre-HFpEF (p = 0.022). In multivariate analysis, this group effect was maintained after adjustment of the LPSS for systolic blood pressure, use of ß-blockers, LV mass, RWT, age, and sex. CONCLUSION: Our data suggest that patients with HFpEF have a marked decrease in peak strain during acute pressure overload. Longitudinal studies are needed to test and compare the clinical impact of each pattern in early and long-term follow-ups.

Mechanical dispersion is a superior echocardiographic feature to predict exercise capacity in preclinical and overt heart failure with preserved ejection fraction

BACKGROUND: Heart Failure with Preserved Ejection Fraction (HFpEF) is a syndrome characterized by different degrees of exercise intolerance, which leads to poor quality of life and prognosis. Recently, the European score (HFA-PEFF) was proposed to standardize the diagnosis of HFpEF. Even though Global Longitudinal Strain (GLS) is a component of HFA-PEFF, the role of other strain parameters, such as Mechanical Dispersion (MD), has yet to be studied. In this study, we aimed to compare MD and other features from the HFA-PEFF according to their association with exercise capacity in an outpatient population of subjects at risk or suspected HFpEF. METHODS: This is a single-center cross-sectional study performed in an outpatient population of 144 subjects with a median age of 57 years, 58% females, referred to the Echocardiography and Cardiopulmonary Exercise Test to investigate HFpEF. RESULTS: MD had a higher correlation to Peak VO2 (r=-0.43) when compared to GLS (r=-0.26), MD presented a significant correlation to Ventilatory Anaerobic Threshold (VAT) (r=-0.20; p = 0.04), while GLS showed no correlation (r=-0.14; p = 0.15). Neither MD nor GLS showed a correlation with the time to recover VO2 after exercise (T1/2). In Receiver Operator Characteristic (ROC) analysis, MD presented superior performance to GLS to predict Peak VO2 (AUC: 0.77 vs. 0.62), VAT (AUC: 0.61 vs. 0.57), and T1/2 (AUC: 0.64 vs. 0.57). Adding MD to HFA-PEFF improved the model performance (AUC from 0.77 to 0.81). CONCLUSION: MD presented a higher association with Peak VO2 when compared to GLS and most features from the HFA-PEFF. Adding MD to the HFA-PEFF improved the model performance.

Afterload increase challenge unmasks systolic abnormalities in heart failure with preserved ejection fraction

BACKGROUND: Provocative maneuvers have the potential to overcome the low sensitivity of resting echocardiography and biomarkers in the detection of heart failure with preserved ejection fraction (HFpEF). We investigate the mechanical response of the left ventricle to an afterload challenge in patients with preclinical and early-stage HFpEF (es-HFpEF). METHODS: Three groups of patients (non-HFpEF - n = 42, pre-HFpEF - n = 43, and es-HFpEF - n = 39) underwent echocardiography at rest and during an afterload challenge induced by handgrip maneuver combined with pneumatic constriction of limbs. RESULTS: Patients in the non-HF group displayed a median ΔLPSS = -4% (IQR: -10%, +2%), LPSS rest<16% in 3/42(7%) and LPSS stress<16% in 6/43(14%). Subjects in the pre-HFpEF group displayed median ΔLPSS = -3% (IQR: -10%, +5%) LPSS rest<16% in 13/43(30%) and LPSS stress<16% in 19/43 (44%). 11/43 (25%) subjects in this group increased at least one absolute point in LPSS during stress. Patients in es-HFpEF group displayed a median ΔLPSS = -10% (IQR: -18%, -1%), LPSS rest<16% in 15/39(38%) and LPSS stress<16% in 25/39(64%). Changes in LPSS (ΔLPSS) were significantly greater in es-HFpEF than pre-HFpEF (p = 0.022). In multivariate analysis, this group effect was maintained after adjustment of the LPSS for systolic blood pressure, use of ß-blockers, LV mass, RWT, age, and sex. CONCLUSION: Our data suggest that patients with HFpEF have a marked decrease in peak strain during acute pressure overload. Longitudinal studies are needed to test and compare the clinical impact of each pattern in early and long-term follow-ups.

Longitudinal study comparing IgG antibodies induced by heterologous prime­boost COVID­19 vaccine

ABSTRACT: Vaccines are critical cost­effective tools to control the COVID­19 pandemic. The heterologous prime­boost vaccination has been used by many countries to overcome supply issues, so the effectiveness and safety of this strategy need to be better clarified. This study aims to verify the effect of heterologous prime­boost COVID­19 vaccination on healthcare professionals from Dante Pazzanese Hospital in Brazil. It was performed serological assays of vaccinated individuals after 2­dose of CoronaVac (Sinovac; n = 89) or ChAdOx1 nCoV­19 (Oxford­AstraZeneca; n = 166) followed by a BNT162b2 booster (Pfizer­BioNTech; n = 255). The serum antibodies anti­S (spike), anti­N (nucleocapsid), and anti­RBD (receptor binding domain) were assessed by enzyme­linked immunosorbent assay. The heterologous booster dose induced a 10­fold higher anti­Spike antibody regardless of the 2­dose of a prime vaccine. It was strikingly observed that BNT162b2 enhanced levels of anti­spike antibodies, even in those individuals who did not previously respond to the 2­dose of CoronaVac. In conclusion, the heterologous scheme of vaccination using mRNA as a booster vaccine efficiently enhanced the antibody response against SARS­CoV­2, especially benefiting those elderly who were seronegative with a virus­inactivated vaccine.

Longitudinal study comparing IgG antibodies induced by heterologous prime-boost COVID-19 vaccine.

Vaccines are critical cost-effective tools to control the COVID-19 pandemic. The heterologous prime-boost vaccination has been used by many countries to overcome supply issues, so the effectiveness and safety of this strategy need to be better clarified. This study aims to verify the effect of heterologous prime-boost COVID-19 vaccination on healthcare professionals from Dante Pazzanese Hospital in Brazil. It was performed serological assays of vaccinated individuals after 2-dose of CoronaVac (Sinovac; n = 89) or ChAdOx1 nCoV-19 (Oxford-AstraZeneca; n = 166) followed by a BNT162b2 booster (Pfizer-BioNTech; n = 255). The serum antibodies anti-S (spike), anti-N (nucleocapsid), and anti-RBD (receptor binding domain) were assessed by enzyme-linked immunosorbent assay. The heterologous booster dose induced a 10-fold higher anti-Spike antibody regardless of the 2-dose of a prime vaccine. It was strikingly observed that BNT162b2 enhanced levels of anti-spike antibodies, even in those individuals who did not previously respond to the 2-dose of CoronaVac. In conclusion, the heterologous scheme of vaccination using mRNA as a booster vaccine efficiently enhanced the antibody response against SARS-CoV-2, especially benefiting those elderly who were seronegative with a virus-inactivated vaccine.

Sequential IgG antibody monitoring for virus-inactivated and adenovirus-vectored COVID-19 vaccine in Brazilian healthcare workers.

Vaccination certainly is the best way to fight against the COVID-19 pandemic. In this study, the seroconversion effectiveness of two vaccines against severe acute respiratory syndrome coronavirus 2 was assessed in healthcare workers: virus-inactivated CoronaVac (CV, n = 303), and adenovirus-vectored Oxford-AstraZeneca (AZ, n = 447). The immunoglobulin G (IgG) antibodies anti-spike glycoprotein and anti-nucleocapsid protein were assessed by enzyme-linked immunosorbent assay at the time before vaccination (T1), before the second dose (T2), and 30 days after the second dose (T3). Of all individuals vaccinated with AZ, 100% (n = 447) exhibited seroconversion, compared to 91% (n = 276) that were given CV vaccine. Among individuals who did not respond to the CV, only three individuals showed a significant increase in the antibody level 4 months later the booster dose. A lower seroconversion rate was observed in elders immunized with the CV vaccine probably due to the natural immune senescence, or peculiarity of this vaccine. The AZ vaccine induced a higher humoral response; however, more common side effects were also observed. Nonvaccinated convalescent individuals revealed a similar rate of anti-spike IgG to individuals that were given two doses of CV vaccine, which suggests that only a one-shot COVID-19 vaccine could produce an effective immune response in convalescents.

Sequential IgG antibody monitoring for virus­inactivated and adenovirus­vectored COVID­19 vaccine in Brazilian health care workers

Vaccination certainly is the best way to fight against the COVID­19 pandemic. In this study, the seroconversion effectiveness of two vaccines against severe acute respiratory syndrome coronavirus 2 was assessed in healthcare workers: virus­inactivated CoronaVac (CV, n= 303), and adenovirus­vectored Oxford­AstraZeneca (AZ, n= 447). The immunoglobulin G (IgG) antibodies anti­spike glycoprotein and anti­nucleocapsid protein were assessed by enzyme­linked immunosorbent assay at the time before vaccination (T1), before the second dose (T2), and 30 days after the second dose (T3). Of all individuals vaccinated with AZ, 100% (n= 447) exhibited seroconversion, compared to 91% (n= 276) that were given CV vaccine. Among individuals who did not respond to the CV, only three individuals showed a significant increase in the antibody level 4 months later the booster dose. A lower seroconversion rate was observed in elders immunized with the CV vaccine probably due to the natural immune senescence, or peculiarity of this vaccine. The AZ vaccine induced a higher humoral response; however, more common side effects were also observed. Nonvaccinated convalescent individuals revealed a similar rate of anti­spike IgG to individuals that were given two doses of CV vaccine, which suggests that only a one­shot COVID­19 vaccine could produce an effective immune response in convalescents.

Avaliação da classe funcional após procedimento de ablação septal por radiofrequência em uma série de pacientes com miocardiopatia hipertrófica obstrutiva / Assessment of functional class after radiofrequency septal ablation procedure in a series of patients with obstructive hypertrophic cardiomyopathy

INTRODUÇÃO: A miocardiopatia hipertrófica obstrutiva (MCHO) é uma doença genética autossômica dominante com prevalência de 1 a cada 1500 indivíduos. A indicação de tratamento invasivo para redução do gradiente intraventricular ocorre nos pacientes refratários ao tratamento clínico com gradiente ≥50 mmHg. A ablação septal por radiofrequência (ARF) é atualmente uma das possibilidades de tratamento invasivo. OBJETIVO: Avaliação da classe funcional após procedimento de ablação septal por radiofrequência em uma série de pacientes com miocardiopatia hipertrófica obstrutiva. MÉTODOS: Incluídos 22 pacientes com MCHO. Os dados foram avaliados através de análise retrospectiva de prontuário. As variáveis contínuas foram expressas em média ± desvio padrão. As variáveis nominais em número absoluto (n) ou porcentagem (%). Os sintomas mais predominantes prévios ao procedimento, foram descritos, sendo a dispneia avaliada de acordo com a escala de New York Heart Association (NYHA). A evolução da classe funcional pela NYHA foi avaliada pré e 6 meses após procedimento. RESULTADOS: Idade média de 56,64 anos (± 12,23), 68,18% do sexo feminino, 72,7% hipertensos e 22,7% com miocardiopatia hipertrófica familiar. Em 63,6% da amostra válida ocorreu redução ≥50% do gradiente inicial. Com relação aos sintomas, 22 pacientes (100%) apresentavam dispneia, 12 (54,5%) angina, 6 (27,3%) palpitação, 7(31,8%) síncope e 5 (22,7%) lipotímia. A distribuição da % dos pacientes que apresenta classe funcional I, II, III e IV antes e após 6 meses do procedimento de Ablação Septal por Radiofrequência é mostrado na figura. CONCLUSÃO: a ablação septal por radiofrequência permite a redução significativa imediata do gradiente e melhora clínica sintomática de pacientes com MCPH obstrutiva.

Serological Testing for COVID-19, Immunological Surveillance, and Exploration of Protective Antibodies.

Serological testing is a powerful tool in epidemiological studies for understanding viral circulation and assessing the effectiveness of virus control measures, as is the case of SARS-CoV-2, the pathogenic agent of COVID-19. Immunoassays can quantitatively reveal the concentration of antiviral antibodies. The assessment of antiviral antibody titers may provide information on virus exposure, and changes in IgG levels are also indicative of a reduction in viral circulation. In this work, we describe a serological study for the evaluation of antiviral IgG and IgM antibodies and their correlation with antiviral activity. The serological assay for IgG detection used two SARS-CoV-2 proteins as antigens, the nucleocapsid N protein and the 3CL protease. Cross-reactivity tests in animals have shown high selectivity for detection of antiviral antibodies, using both the N and 3CL antigens. Using samples of human serum from individuals previously diagnosed by PCR for COVID-19, we observed high sensitivity of the ELISA assay. Serological results with human samples also suggest that the combination of higher titers of antiviral IgG antibodies to different antigen targets may be associated with greater neutralization activity, which can be enhanced in the presence of antiviral IgM antibodies.

Late Outcomes of Aortic Valve Replacement with Bioprosthesis and Mechanical Prosthesis. / Evolução Tardia das Próteses Biológicas e Mecânicas em Posição Aórtica.

BACKGROUND: Despite constant improvement and refinement of the prostheses, the decision between mechanical and biological valves for aortic valve replacement is still controversial. OBJECTIVE: To compare outcomes of aortic valve replacement with bioprosthesis and mechanical prosthesis. METHODS: This was an observational, historical cohort study with review of medical records. A total of 202 patients who underwent heart valve replacement surgery between 2004 and 2008 were selected, with a mean follow-up of 10 years. The level of significance set at 5%. RESULTS: Mean age of patients was approximately 50 years; most patients were male (70%). Overall mortality- and reoperation-free survival was significantly higher in patients with mechanical prosthesis (HR=0.33; 95%CI=0.13-0.79; p=0.013). No difference was found in late mortality between the two groups. On the other hand, the risk of reoperation was significantly higher in patients with bioprosthesis than mechanical prosthesis (HR=0.062; 95%CI=0.008-0.457; p=0.006). The risk of composite adverse events - stroke, bleeding, endocarditis, thrombosis and paravalvular leak - was similar between the groups (HR=1.20; 95%CI= 0.74-1.93; p=0.44). The risk of bleeding was significantly higher in patients with mechanical prosthesis (HR=3.65; 95%CI= 1.43-9.29; p = 0.0064), although no case of fatal bleeding was reported. CONCLUSION: No difference in 10-year mortality was found between the groups. The risk of reoperation significantly increases with the use of bioprosthesis, especially for patients younger than 30 years. Patients with mechanical prosthesis are at increased risk of nonfatal bleeding.

FUNDAMENTO: Apesar da constante renovação e do aprimoramento das próteses valvares cardíacas, a decisão sobre substituição por prótese biológica ou mecânica permanece controversa. OBJETIVO: Comparar pacientes submetidos à cirurgia para troca valvar aórtica utilizando substituto biológico ou mecânico. MÉTODOS: Estudo observacional, do tipo coorte histórica por análise de prontuário. Foram selecionados 202 operados entre 2004 e 2008, com seguimento médio de 10 anos. O nível de significância estatística adotado foi de 5%. RESULTADOS: A média de idade foi de aproximadamente 50 anos para ambos os grupos, com a maioria (70%) do sexo masculino. A probabilidade de sobrevida livre de óbito e reoperação foi significativamente maior nos pacientes com prótese mecânica (HR=0,33; IC 95%=0,13-0,79; p=0,013). Não houve diferença entre os grupos em relação à mortalidade tardia. Por outro lado, o risco de reoperação foi significativamente maior em pacientes tratados com prótese biológica em comparação com a prótese mecânica (HR=0,062; IC 95%=0,008-0,457; p=0,006). O risco de eventos adversos composto de acidente vascular encefálico (AVE), sangramento, endocardite, trombose e regurgitação paraprotética foi semelhante entre os grupos (HR=1,20; IC 95%=0,74-1,93; p=0,44). O risco de sangramento foi significativamente maior em pacientes tratados com prótese mecânica (HR=3,65; IC 95%=1,43-9,29; p=0,0064), porém não houve sangramento fatal. CONCLUSÃO: Não há diferença de mortalidade em 10 anos entre os dois grupos. Há aumento significativo no risco de reoperação ao se optar por próteses biológicas, principalmente para os menores de 30 anos de idade. Já os pacientes portadores de prótese mecânica têm maior risco de sangramento não fatal.

Evolução tardia das próteses biológicas e mecânicas em posição aórtica / Late outcomes of aortic valve replacement with bioprosthesis and mechanical prosthesis

FUNDAMENTO: Apesar da constante renovação e do aprimoramento das próteses valvares cardíacas, a decisão sobre substituição por prótese biológica ou mecânica permanece controversa. OBJETIVO: Comparar pacientes submetidos à cirurgia para troca valvar aórtica utilizando substituto biológico ou mecânico. MÉTODOS: Estudo observacional, do tipo coorte histórica por análise de prontuário. Foram selecionados 202 operados entre 2004 e 2008, com seguimento médio de 10 anos. O nível de significância estatística adotado foi de 5%. RESULTADOS: A média de idade foi de aproximadamente 50 anos para ambos os grupos, com a maioria (70%) do sexo masculino. A probabilidade de sobrevida livre de óbito e reoperação foi significativamente maior nos pacientes com prótese mecânica (HR=0,33; IC 95%=0,13-0,79; p=0,013). Não houve diferença entre os grupos em relação à mortalidade tardia. Por outro lado, o risco de reoperação foi significativamente maior em pacientes tratados com prótese biológica em comparação com a prótese mecânica (HR=0,062; IC 95%=0,008-0,457; p=0,006). O risco de eventos adversos composto de acidente vascular encefálico (AVE), sangramento, endocardite, trombose e regurgitação paraprotética foi semelhante entre os grupos (HR=1,20; IC 95%=0,74-1,93; p=0,44). O risco de sangramento foi significativamente maior em pacientes tratados com prótese mecânica (HR=3,65; IC 95%=1,43-9,29; p=0,0064), porém não houve sangramento fatal. CONCLUSÃO: Não há diferença de mortalidade em 10 anos entre os dois grupos. Há aumento significativo no risco de reoperação ao se optar por próteses biológicas, principalmente para os menores de 30 anos de idade. Já os pacientes portadores de prótese mecânica têm maior risco de sangramento não fatal.

BACKGROUND: Despite constant improvement and refinement of the prostheses, the decision between mechanical and biological valves for aortic valve replacement is still controversial. OBJECTIVE: To compare outcomes of aortic valve replacement with bioprosthesis and mechanical prosthesis. METHODS: This was an observational, historical cohort study with review of medical records. A total of 202 patients who underwent heart valve replacement surgery between 2004 and 2008 were selected, with a mean follow-up of 10 years. The level of significance set at 5%. RESULTS: Mean age of patients was approximately 50 years; most patients were male (70%). Overall mortality- and reoperation-free survival was significantly higher in patients with mechanical prosthesis (HR=0.33; 95%CI=0.13-0.79; p=0.013). No difference was found in late mortality between the two groups. On the other hand, the risk of reoperation was significantly higher in patients with bioprosthesis than mechanical prosthesis (HR=0.062; 95%CI=0.008-0.457; p=0.006). The risk of composite adverse events ­ stroke, bleeding, endocarditis, thrombosis and paravalvular leak ­ was similar between the groups (HR=1.20; 95%CI= 0.74-1.93; p=0.44). The risk of bleeding was significantly higher in patients with mechanical prosthesis (HR=3.65; 95%CI= 1.43-9.29; p = 0.0064), although no case of fatal bleeding was reported. CONCLUSION: No difference in 10-year mortality was found between the groups. The risk of reoperation significantly increases with the use of bioprosthesis, especially for patients younger than 30 years. Patients with mechanical prosthesis are at increased risk of nonfatal bleeding.

Serological Testing for COVID-19, Immunological Surveillance, and Exploration of Protective Antibodies

Serological testing is a powerful tool in epidemiological studies for understanding viral circulation and assessing the effectiveness of virus control measures, as is the case of SARS-CoV-2, the pathogenic agent of COVID-19. Immunoassays can quantitatively reveal the concentration of antiviral antibodies. The assessment of antiviral antibody titers may provide information on virus exposure, and changes in IgG levels are also indicative of a reduction in viral circulation. In this work, we describe a serological study for the evaluation of antiviral IgG and IgM antibodies and their correlation with antiviral activity. The serological assay for IgG detection used two SARS-CoV-2 proteins as antigens, the nucleocapsid N protein and the 3CL protease. Cross-reactivity tests in animals have shown high selectivity for detection of antiviral antibodies, using both the N and 3CL antigens. Using samples of human serum from individuals previously diagnosed by PCR for COVID-19, we observed high sensitivity of the ELISA assay. Serological results with human samples also suggest that the combination of higher titers of antiviral IgG antibodies to different antigen targets may be associated with greater neutralization activity, which can be enhanced in the presence of antiviral IgM antibodies.

Oxygen supplementation increases the total work and muscle damage markers but reduces the inflammatory response in COPD patients.

INTRODUCTION: Oxygen supplementation (O2-Suppl) is recommended for pulmonary rehabilitation with higher exercise intensities. However, high-intensity exercise tends toward muscle damage and a greater inflammatory response. We aimed to investigate the effect of O2-Suppl during exercise test (EET) on CRP level and muscle damage (CPK, LDH, lactate) in non-hypoxemic COPD patients. METHODS: Eleven non-depleted patients with COPD (FEV1 65.5 ± 4.3 %) performed two EET (room-air or O2-Suppl-100 %), through a blind, randomized, and placebo-controlled crossover design. CPK, LDH and CRP were measured before, immediately after and 24 h after EET. RESULTS: Exercise time was higher with O2-Suppl (49.9 ± 37.3 %; p = 0.001) and increases in CPK and LDH were observed compared to basal values in the O2-Suppl (28.4UI/L and 28.3 UI/L). The O2-Suppl protocol resulted in a lower increase in CRP (92.1 ± 112.4 % vs. 400.1 ± 384.9 %; p = 0.003). CONCLUSIONS: O2-Suppl increases exercise-tolerance, resulting in increased muscle injury markers in COPD. However, oxygen supplementation attenuates the inflammatory response, even upon increased physical exercise.

Evolução tardia das próteses biológicas e mecânicas em posição aórtica / Late evolution of biological and mechanical prostheses in aortic position

INTRODUÇÃO: Apesar da constante renovação e aprimoramento das próteses valvares cardíacas a decisão sobre substituição por prótese biológica ou mecânica permanece controversa. OBJETIVO: Esse estudo avalia pacientes submetidos à cirurgia para troca valvar aórtica utilizando substituto biológico ou mecânico. MÉTODOS: Estudo observacional, do tipo coorte histórica por análise de prontuário. Foram selecionados 202 pacientes operados entre 2004 e 2008, com seguimento médio de 10 anos. RESULTADOS: A probabilidade de sobrevida livre de óbito por qualquer causa e reoperação foi significativamente maior em pacientes tratados com prótese biológica em comparação com a prótese mecânica (HR = 0,33; 95% intervalo de confiança [IC] 0,13-0,79; p =0,013). Foram observados oito óbitos num período de 10 anos no grupo de pacientes portadores de prótese biológica e cinco no grupo de prótese mecânica. Esses dados correspondem a um percentual ajustado de 6,11% de mortalidade para o grupo de prótese biológica e 7,9% para prótese mecânica (p = 0,68). A análise de reoperação isolada evidenciou uma diferença significativa a favor da prótese mecânica (HR = 0,062; IC = 0,008-0,457; p = 0,006), principalmente para menores de 30 anos, quando analisados por subgrupo. Num período de 10 anos, dezenove pacientes portadores de prótese biológica foram reoperados, correspondendo a um percentual de 21,24% e nenhum paciente do grupo de prótese mecânica. O risco de eventos adversos composto de acidente vascular cerebral, sangramento, endocardite, trombose e regurgitação paraprotética não foi diferente entre os grupos (HR = 1,20; IC 95% = 0,74-1,93; p = 0,44). O risco de sangramento foi significativamente maior em pacientes tratados com prótese mecânica em comparação com a prótese biológica (HR = 3,65; IC 95% = 1,43-9,29; p = 0,0064), porém não houve sangramento fatal. CONCLUSÕES: Não há diferença de mortalidade em 10 anos entre os dois grupos. Há um aumento significativo no risco de reoperação ao se optar por próteses biológicas, principalmente para os menores de 30 anos. Já os pacientes portadores de prótese mecânica têm maior risco de sangramento não fatal. Figura 1 - Curva de Kaplan-Meier para avaliar probabilidade de sobrevida livre de eventos (óbito ou reoperação). Figura 2 - Gráfico de forest plot do efeito dos eventos adversos em relação ao tipo de prótese (mecânica ou biológica).

Cardiology Training in Brazil and Developed Countries: Some Ideas for Improvement.

Huge variations exist in cardiology training programs across the world. In developing (middle-income) countries, such as Brazil, to find the right balance between training improvements and social and economic conditions of the country may be a difficult task. Adding more training years or different mandatory rotations, for instance, may be costly and not have an immediate direct impact on enhancing patient care or public health. In this text, we compare the Brazilian cardiology training system with other proposals implemented in developed countries from North America and Europe, aiming to point out issues worth of future discussion. Factors such as training rotations and competencies, and program duration and distribution across the countries are presented. The number of first year cardiology trainees per inhabitants is similar between Brazil and the United States (0.24 medical residents/100,000 inhabitants in Brazil and 0.26 medical residents/100,000 inhabitants in the USA). These numbers should be analyzed considering the inequality in training program distribution across Brazil, since most centers are located in the Southeast and South regions. Having more residency programs in distant areas could improve cardiovascular care in these areas. Duration of cardiology Residency Training is shorter in Brazil (two years) in comparison with developed countries (> 3 years). Brazilian residency programs give less emphasis to scientific research and diagnostic methods. Unifying minimum training requirements across the globe would facilitate the development of international learning opportunities and even professional exchange around the world.

Cardiology training in Brazil and developed countries: some ideas for improvement / Residência em cardiologia no Brasil e em países desenvolvidos: ideias para melhoria

ABSTRACT: Huge variations exist in cardiology training programs across the world. In developing (middle-income) countries, such as Brazil, to find the right balance between training improvements and social and economic conditions of the country may be a difficult task. Adding more training years or different mandatory rotations, for instance, may be costly and not have an immediate direct impact on enhancing patient care or public health. In this text, we compare the Brazilian cardiology training system with other proposals implemented in developed countries from North America and Europe, aiming to point out issues worth of future discussion. Factors such as training rotations and competencies, and program duration and distribution across the countries are presented. The number of first year cardiology trainees per inhabitants is similar between Brazil and the United States (0.24 medical residents/100,000 inhabitants in Brazil and 0.26 medical residents/100,000 inhabitants in the USA). These numbers should be analyzed considering the inequality in training program distribution across Brazil, since most centers are located in the Southeast and South regions. Having more residency programs in distant areas could improve cardiovascular care in these areas. Duration of cardiology Residency Training is shorter in Brazil (two years) in comparison with developed countries (> 3 years). Brazilian residency programs give less emphasis to scientific research and diagnostic methods. Unifying minimum training requirements across the globe would facilitate the development of international learning opportunities and even professional exchange around the world.

RESUMO: Existe enorme variação nos programas de residência em cardiologia no mundo. Em países em desenvolvimento, tal como o Brasil, encontrar o equilíbrio correto entre melhorias nos programas de residência e condições socioeconômicas do país pode ser uma tarefa difícil. Aumentar a duração dos programas ou o número de estágios obrigatórios, por exemplo, pode ter um custo elevado e não ter um impacto imediato na melhoria do cuidado do paciente ou na saúde pública. Neste texto, comparamos o sistema de residência em cardiologia brasileiro com outras propostas implementadas em países desenvolvidos da América do Norte e Europa, com objetivo de indicar questões para discussões futuras. Apresentamos fatores como rodízios por estágios e competências, duração e distribuição dos programas pelos países. O número de alunos no primeiro ano de Residência em cardiologia por número de habitantes é similar entre o Brasil e os Estados Unidos (0,24 médicos residentes/100 mil habitantes no Brasil e 0,26 médicos residentes/100 mil habitantes nos EUA). Esses números devem ser analisados considerando a desigualdade na distribuição dos programas pelo país, uma vez que a maioria dos centros localiza-se nas regiões sul e sudeste do país. A existência de mais programas de residência em áreas distantes melhoraria o cuidado cardiovascular nessas áreas. O período de treinamento é menor no Brasil (dois anos) em comparação a países desenvolvidos (>3 anos). Os programas de residência no Brasil dão menos ênfase em pesquisa científica e métodos diagnósticos. O estabelecimento de exigências mínimas que sejam padronizadas a todos os países facilitaria o desenvolvimento de oportunidades de aprendizagem e mesmo o intercâmbio de profissionais pelo mundo.

Internações por causas sensíveis à atenção primaria relacionadas à distúrbios cardiovasculares na cidade de São Paulo no ano de 2018 / Hospitalizations for primary care-sensitive causes related to cardiovascular disorders in the city of São Paulo in 2018

INTRODUÇÃO: As internações por causas sensíveis à atenção primária representam condições de saúde que podem ter o risco de hospitalização desnecessária diminuído, por meio de ações efetivas da atenção primária. Essas internações vêm sendo usadas como indicador do acesso e qualidade da atenção básica. Levando em consideração a alta prevalência populacional na atual sociedade brasileira das doenças crônicas não transmissíveis, ressalta-se que grande parte destas internações seja por não tratamento ou mal controle dessas doenças, muitas delas que elevam o risco cardiovascular, como a hipertensão arterial, o diabetes, a obesidade, o tabagismo e entre outras. OBJETIVO: Analisar as tendências das principais causas de internações hospitalares entre aquelas sensíveis à atenção primária relacionadas à prevenção de eventos cardiovasculares na cidade de São Paulo no ano de 2018. MÉTODO: Trata-se de um estudo transversal descritivo e retrospectivo por notificação das internações sensíveis por causas sensíveis à atenção primária nos serviços hospitalares do Sistema Único de Saúde, da população residente na cidade de São Paulo. O período estudado foi de janeiro a dezembro de 2018. Resultados: As internações por causa sensíveis à atenção primária relacionadas a doenças cardiovasculares representam 39% do total de internações por causas sensíveis à atenção primaria. Neste sentido, deste total: 3,1% são por hipertensão (3% por hipertensão essencial e apenas 0,1% por doença cardíaca hipertensiva); 5,8% são por angina; 10,8% por insuficiência cardíaca (sendo 10,1% por insuficiência cardíaca e 0,7 por edema agudo de pulmão); 13,6% por doenças cerebrovasculares e 5,7% por diabetes mellitus (3,6% com complicações renais e/ou oftalmológicas, 1,4% com coma ou cetoacidose e 0,7% sem complicações especificas). CONCLUSÃO: Apesar das doenças relacionadas a distúrbios cardiovasculares estarem listadas em apenas 5 (hipertensão, angina, insuficiência cardíaca, doenças cérebro vasculares e diabetes mellitus) elas representam grande parte das internações por causas sensíveis à atenção primaria. Tal fato reflete a necessidade de mais e melhores políticas públicas para redução de prevalência e incidência dessas doenças, através de diagnósticos mais eficazes e também de tratamentos que realmente levem ao controle dessas moléstias. (AU)

Elevada prevalência de Burnout em médicos residentes de um grande Instituto de Cardiologia Brasileiro / High prevalence of burnout in resident physicians of a large Brazilian Institute of Cardiology

INTRODUÇÃO: A residência médica pode estar sujeita a fatores estressores magnificados e poderia aumentar a suscetibilidade à síndrome de exaustão emocional, despersonalização e reduzida realização profissional, conhecida como burnout. OBJETIVO: Determinar a prevalência de burnout e de cada uma de suas dimensões na população de médicos residentes de um dos maiores Institutos especializados de Cardiologia do Brasil. MÉTODOS: Estudo transversal com residentes, realizado em 2017, através da aplicação de um instrumento contendo dois questionários: um com variáveis sociodemográficas e o questionário Maslach Burnout Inventory...(AU)