Cardiovascular Ultrasound Predictors for Brain Alterations in Fetuses With Heart Disease: An Exploratory Review of the Literature.

OBJECTIVE: To identify cardiovascular ultrasound predictors for brain anomalies in fetuses with heart disease. METHODS: A literature search was performed in the following databases: MEDLINE through OVID, EMBASE, Cochrane Registry Center for Controlled Trials (CENTRAL), and LILACS, from their inception until May 2023. Clinical studies, cross-sectional studies, case-control studies, cohorts, and systematic reviews were included. Data extraction was performed, and the risk of bias was assessed using the QUADAS-2 tool. RESULTS: Among 2705 studies evaluated, after filtering information, 10 articles were selected that met the inclusion criteria. These studies noted the following outcomes: a decrease in fetal head circumference, changes in brain maturation measured in days, decreased depth of brain fissures, and a decrease in total brain volume. The studies show a statistically significant correlation with the presence of the following cardiovascular predictors: low or mixed oxygen content in the ascending aorta (p < 0.001), retrograde flow in the aortic arch (p < 0.001), lower z values of the MCA-PI (p < 0.05), higher UA-PI z values (p < 0.01), and lower CPR (p < 0.05). In addition, lower values of left ventricular flow (p < 0.01), ductus arteriosus (p < 0.0001), and combined cardiac output index (p < 0.01) were reported. CONCLUSIONS: This review describes the most relevant evidence correlating the effects of hemodynamic changes that lead to states of chronic hypoxia related to the aforementioned changes in the central nervous system.

The Impact of Severe Heart Disease on Causes of Death and Survival after Disability Retirement. / O Impacto da Cardiopatia Grave nas Causas de Óbito e Sobrevida após Aposentadoria por Invalidez.

BACKGROUND: Noncommunicable diseases contribute to premature deaths and limitations. Disability retirement is linked to chronic conditions, particularly cardiovascular diseases. The II Brazilian Guideline for Severe Heart Disease established criteria for cardiovascular disease classification. However, there is a lack of research in this topic within federal institutions. OBJECTIVES: Evaluate the survival and causes of death among disabled retirees at UFRJ, focusing on the impact of severe heart disease. METHODS: A retrospective cohort study based on retirement and death records over 15 years. Retirements were categorized into three groups: full retirement due to severe heart disease, full retirement due to other diseases and proportional. Causes of death were obtained from death certificates. Mortality rates, survival and the presence of matching diagnoses between retirement and death were evaluated. Chi-square, log-rank, Cox models, Kaplan-Meier curves were utilized. Statistical significance with a 95% confidence interval, considering p<0.05. RESULTS: There were 630 retirements, 368 (51.4%) in females, with an average age of 52.9 (SD=7.8) years, and 169 (26.8%) deaths. Mortality was higher in professors (37.0%; p=0.113), in the age group between 65 and 70 years (48.4%; p=0.004), in males (34.0%; p=0.001), and in full retirements due to severe heart disease (41.5%; p<0.001). Matching diagnoses between retirement and death were more frequent in professors (74.1%; p=0.026) and in full retirements due to severe heart disease (72.7%; p<0.001). CONCLUSIONS: Severe heart disease diagnosis is associated with higher mortality and shorter survival in disabled retirees. Its frequent occurrence in retirement and death diagnoses underscores its significance in this context.

FUNDAMENTO: As doenças não comunicáveis são responsáveis por mortes prematuras e limitações. A aposentadoria por invalidez está associada a condições crônicas, especialmente a doenças cardiovasculares. A II Diretriz Brasileira de Cardiopatia Grave definiu critérios para enquadramento das doenças cardiovasculares. Poucos estudos abordam esse tema em instituições federais. OBJETIVOS: Avaliar sobrevida e causas de óbito de servidores aposentados por invalidez na UFRJ, com ênfase no impacto da cardiopatia grave. MÉTODOS: Estudo de coorte retrospectivo baseado nos registros de aposentadorias e óbitos ao longo de 15 anos. As aposentadorias foram divididas em três grupos: integral por cardiopatia grave, integral por outras doenças e proporcional. As causas de óbito foram obtidas a partir das certidões de óbito. Foram avaliadas taxa de mortalidade, sobrevida e a presença de diagnósticos concordantes entre a aposentadoria e o óbito. Foram utilizados testes qui-quadrado, log-rank, modelos de Cox e curvas de Kaplan-Meier. Significância estatística com intervalo de confiança de 95%, considerando p < 0,05. RESULTADOS: Foram 630 aposentadorias, 368 (51,4%) no sexo feminino, com idade média de idade de 52,9 (DP=7,8) anos, e 169 (26,8%) óbitos. A mortalidade foi maior nos professores (37,0%; p=0,113), na faixa etária entre 65 e 70 anos (48,4%; p=0,004), no sexo masculino (34,0%; p=0,001), e nas aposentadorias integrais por cardiopatia grave (41,5%; p < 0,001). Diagnósticos concordantes entre aposentadoria e óbito foram mais frequentes em professores (74,1%; p=0,026) e nas aposentadorias integrais por cardiopatia grave (72,7%; p < 0,001). CONCLUSÕES: O diagnóstico de cardiopatia grave confere maior taxa de mortalidade e menor sobrevida aos aposentados por invalidez, e sua presença em maior frequência nos diagnósticos de aposentadoria e óbito ressalta sua importância neste contexto.

Cancer Therapy-Related Cardiac Dysfunction: Strategies for Enhancing Cardiac Recovery.

Chemotherapy has markedly improved cancer outcomes, yet cancer therapy-related cardiac dysfunction (CTRCD) poses a significant challenge, affecting around 10% of patients. CTRCD can be asymptomatic or present with heart failure symptoms. Multimodality imaging, particularly echocardiography, remains pivotal for monitoring cardiac function. Potential biomarkers for CTRCD assessment include troponin and B-type natriuretic peptide. Pharmacological interventions, such as dexrazoxane, angiotensin-converting enzyme inhibitors, and statins, play a crucial role in primary prevention and mitigating cardiotoxicity alongside cardiac rehabilitation programs. Thus, a comprehensive approach is essential for optimal cardiac recovery and improved patient outcomes.

Heart Disease in Mothers of Children with Duchenne Muscular Dystrophy.

Female carriers of Duchenne Muscular Dystrophy (DMD) carry a heterozygous pathogenic variant in the dystrophin gene and can transmit pathogenic variants to their offspring. DMD is an X-linked recessive disease that affects up to 19.8 in every 100,000 male births. Those carriers with symptoms can be referred to as women with dystrophinopathy. Even among asymptomatic carriers, cardiac involvement can be verified in between 2.5% and 75% through echocardiography. The most commonly affected wall of the left ventricle is the inferolateral, with myocardial fibrosis detected by cardiac nuclear resonance. Therefore, screening is recommended for these women carriers due to the risk of cardiomyopathy. There is a lack of longitudinal studies on the evolution of these carriers. In this article, data on clinical presentation, cardiac assessment for female patients with dystrophinopathy and DMD carriers, and approaches for these patients are discussed.

Direct Oral Anticoagulants versus Vitamin K Antagonists for Left Ventricular Thrombus: A Meta-Analysis with Trial Sequential Analysis. / Anticoagulantes Orais Diretos versus Antagonistas da Vitamina K para Trombo Ventricular Esquerdo: Uma Metanálise com Análise Sequencial de Ensaios.

BACKGROUND: Vitamin K antagonists (VKAs) are the recommended first-line treatment for left ventricular thrombus (LVT); however, direct oral anticoagulants (DOACs) have been considered an alternative therapy. OBJECTIVES: To evaluate the efficacy and safety of DOACs compared with VKAs therapy in patients with LVT. METHODS: PubMed, Embase, and Cochrane were systematically searched for randomized clinical trials or cohort studies that compared DOACs versus VKAs for LVT. Risk ratios (RRs) were computed for binary endpoints, with 95% confidence intervals (95% CIs). Statistical significance was defined as p value < 0.05. RESULTS: A total of 4 randomized clinical trials and 29 cohort studies were included, with 4,450 patients assigned to either DOACs or VKAs. There was no significant difference between groups for stroke or systemic embolic (SSE) events (RR 0.84; 95% CI 0.65 to 1.07; p = 0.157), stroke (RR 0.73; 95% CI 0.48 to 1.11; p = 0.140), systemic embolic (SE) events (RR 0.69; 95% CI 0.40 to 1.17; p = 0.166), thrombus resolution (RR 1.05; 95% CI 0.99 to 1.11; p = 0.077), any bleeding (RR 0.78; 95% CI 0.60 to 1.00; p = 0.054), clinically relevant bleeding (RR 0.69; 95% CI 0.46 to 1.03; p = 0.066), minor bleeding (RR 0.73; 95% CI 0.43 to 1.23; p = 0.234), major bleeding (RR 0.87; 95% CI 0.42 to 1.80; p = 0.705), and all-cause mortality (RR 1.05; 95% CI 0.79 to 1.39; p = 0.752). Compared with VKAs, rivaroxaban significantly reduced SSE events (RR 0.35; 95% CI 0.16 to 0.91; p = 0.029) and SE events (RR 0.39; 95% CI 0.16 to 0.95; p = 0.037). CONCLUSIONS: DOACs had a similar rate of thromboembolic and hemorrhagic events, as well as thrombus resolution, compared to VKAs in the treatment of LVTs. Rivaroxaban therapy had a significant reduction in thromboembolic events, compared to VKAs.

Cardiac disease discrimination from 3D-convolutional kinematic patterns on cine-MRI sequences. / Discriminación de enfermedades cardiacas utilizando patrones cinemáticos codificados con convoluciones 3D en secuencias de cine-RM

INTRODUCTION: Cine-MRI (cine-magnetic resonance imaging) sequences are a key diagnostic tool to visualize anatomical information, allowing experts to localize and determine suspicious pathologies. Nonetheless, such analysis remains subjective and prone to diagnosis errors. OBJECTIVE: To develop a binary and multi-class classification considering various cardiac conditions using a spatiotemporal model that highlights kinematic movements to characterize each disease. MATERIALS AND METHODS: This research focuses on a 3D convolutional representation to characterize cardiac kinematic patterns during the cardiac cycle, which may be associated with pathologies. The kinematic maps are obtained from the apparent velocity maps computed from a dense optical flow strategy. Then, a 3D convolutional scheme learns to differentiate pathologies from kinematic maps. RESULTS: The proposed strategy was validated with respect to the capability to discriminate among myocardial infarction, dilated cardiomyopathy, hypertrophic cardiomyopathy, abnormal right ventricle, and normal cardiac sequences. The proposed method achieves an average accuracy of 78.00% and a F1 score of 75.55%. Likewise, the approach achieved 92.31% accuracy for binary classification between pathologies and control cases. CONCLUSION: The proposed method can support the identification of kinematically abnormal patterns associated with a pathological condition. The resultant descriptor, learned from the 3D convolutional net, preserves detailed spatiotemporal correlations and could emerge as possible digital biomarkers of cardiac diseases.

Introducción. Las secuencias del cine-resonancia magnética (cine-MRI, cine magnetic resonance imaging) son una herramienta diagnóstica clave para visualizar la información anatómica que les permite a los expertos localizar y determinar aquellas anomalías que resulten sospechosas. No obstante, este análisis sigue siendo subjetivo y propenso a errores de diagnóstico. Objetivo. Desarrollar una clasificación binaria y multiclase, considerando diferentes condiciones cardiacas, mediante un modelo espaciotemporal que permita resaltar los movimientos cinéticos para caracterizar cada enfermedad. Materiales y métodos. Este estudio se centra en el uso de una representación de convolución 3D para caracterizar los patrones cinéticos durante el ciclo cardiaco que puedan estar asociados con enfermedades. Para ello, se obtienen mapas cinéticos a partir de mapas de velocidad aparente, calculados mediante una estrategia de flujo óptico denso. A continuación, un esquema de convolución 3D "aprende" a diferenciar patologías a partir de mapas cinemáticos. Resultados. La estrategia propuesta se validó según la capacidad de discriminar entre infarto de miocardio, miocardiopatía dilatada, miocardiopatía hipertrófica, ventrículo derecho anormal y un examen normal. El método propuesto alcanza una precisión media del 78,0 % y una puntuación F1 score del 75,55 %. Asimismo, el enfoque alcanzó el 92,31 % de precisión para la clasificación binaria entre enfermedades y casos de control. Conclusiones. El método propuesto es capaz de apoyar la identificación de patrones cinéticos anormales asociados con una condición patológica. El descriptor resultante, aprendido de la red de convolución 3D, conserva correlaciones espaciotemporales detalladas y podría surgir como posible biomarcador digital de enfermedades cardiacas.

Cardiac Autonomic Neuropathy in Graves' Disease: Smoking and Age as Predictive Factors.

OBJECTIVES: Hypermetabolic state in Graves' disease (GD) has a great impact on heart homeostasis, acting directly on the heart muscle and modulating the autonomic nervous system. To characterize cardiac autonomic neuropathy (CAN) as a possible complication in patients with GD. METHODS: We evaluated euthyroid GD patients and a control group of healthy euthyroid people. CAN was assessed using autonomic tests of cardiovascular reflex and heart rate variability: respiratory, Valsalva, orthostatic and orthostatic hypotension tests, high frequency, low frequency, and very low-frequency bands. Transthoracic echocardiography was performed in GD patients. RESULTS: Sixty GD patients and 50 people in control group were assessed. CAN was diagnosed in 20% of GD and 14% in the control group. Among GD, 13.3% presented incipient, and 6.7% established CAN, while in the control group, it was verified incipient in 8% and established in 6% (P = .7479). All GD patients with CAN presented an alteration in the deep breathing test. Age and smoking were evidenced as factors associated with the presence of CAN, while higher TRAb values at diagnosis decreased the chance of CAN. CONCLUSIONS: The prevalence of CAN in euthyroid GD patients was 20%. Changes in the cardiac autonomic nervous system were identified, pointing to the importance of evaluating this complication in these patients. Smoking was a predictive factor for CAN, increasing its relationship with conditions that aggravate GD.

Factors Associated with Neonatal Arterial Hypertension: Case and Control Study.

Background. Neonatal high blood pressure has been diagnosed more frequently in recent years, and its impact extends to adulthood. However, the knowledge gaps on associated factors, diagnosis, and treatment are challenging for medical personnel. The incidence of this condition varies depending on neonatal conditions. Patients in the Newborn Unit are at increased risk of developing high blood pressure. The persistence of this condition beyond the neonatal stage increases the risk of cardiovascular disease and chronic kidney disease in childhood and adulthood. Methodology. A case-control study was carried out. It included hospitalized patients with neonatal hypertension as cases. Three controls were randomly selected for each case and matched by gestational age. The variables were analyzed based on their nature. Multivariate analysis was performed using a multivariate conditional regression model to identify variables associated with the outcome. Finally, the model was adjusted for possible confounders. Results. 37 cases were obtained and matched with 111 controls. In the univariate analysis, heart disease (OR 2.86; 95% CI 1.22-6.71), kidney disease (OR 7.24; 95% CI 1.92-28.28), bronchopulmonary dysplasia (OR 6.62; 95% CI 1.42-50.82) and major surgical procedures (OR 3.71; 95% CI 1.64-8.39) had an association with neonatal arterial hypertension. Only the latter maintained this finding in the multivariate analysis (adjusted OR 2.88; 95% CI 1.14-7.30). A significant association of two or more comorbidities with neonatal arterial hypertension was also found (OR 3.81; 95% CI 1.53-9.49). Conclusions. The study analyzed the factors related to high blood pressure in hospitalized neonates, finding relevant associations in the said population. The importance of meticulous neonatal care and monitoring of risk factors such as birth weight and major surgeries is highlighted.

Cardiac disease discrimination from 3D-convolutional kinematic patterns on cine-MRI sequences / Discriminación de enfermedades cardiacas utilizando patrones cinemáticos codificados con convoluciones 3D en secuencias de cine-RM

Introduction. Cine-MRI (cine-magnetic resonance imaging) sequences are a key diagnostic tool to visualize anatomical information, allowing experts to localize and determine suspicious pathologies. Nonetheless, such analysis remains subjective and prone to diagnosis errors. Objective. To develop a binary and multi-class classification considering various cardiac conditions using a spatiotemporal model that highlights kinematic movements to characterize each disease. Materials and methods. This research focuses on a 3D convolutional representation to characterize cardiac kinematic patterns during the cardiac cycle, which may be associated with pathologies. The kinematic maps are obtained from the apparent velocity maps computed from a dense optical flow strategy. Then, a 3D convolutional scheme learns to differentiate pathologies from kinematic maps. Results. The proposed strategy was validated with respect to the capability to discriminate among myocardial infarction, dilated cardiomyopathy, hypertrophic cardiomyopathy, abnormal right ventricle, and normal cardiac sequences. The proposed method achieves an average accuracy of 78.00% and a F1 score of 75.55%. Likewise, the approach achieved 92.31% accuracy for binary classification between pathologies and control cases. Conclusion. The proposed method can support the identification of kinematically abnormal patterns associated with a pathological condition. The resultant descriptor, learned from the 3D convolutional net, preserves detailed spatiotemporal correlations and could emerge as possible digital biomarkers of cardiac diseases.

Introducción. Las secuencias del cine-resonancia magnética (cine-MRI, cine magnetic resonance imaging) son una herramienta diagnóstica clave para visualizar la información anatómica que les permite a los expertos localizar y determinar aquellas anomalías que resulten sospechosas. No obstante, este análisis sigue siendo subjetivo y propenso a errores de diagnóstico. Objetivo. Desarrollar una clasificación binaria y multiclase, considerando diferentes condiciones cardiacas, mediante un modelo espaciotemporal que permita resaltar los movimientos cinéticos para caracterizar cada enfermedad. Materiales y métodos. Este estudio se centra en el uso de una representación de convolución 3D para caracterizar los patrones cinéticos durante el ciclo cardiaco que puedan estar asociados con enfermedades. Para ello, se obtienen mapas cinéticos a partir de mapas de velocidad aparente, calculados mediante una estrategia de flujo óptico denso. A continuación, un esquema de convolución 3D "aprende" a diferenciar patologías a partir de mapas cinemáticos. Resultados. La estrategia propuesta se validó según la capacidad de discriminar entre infarto de miocardio, miocardiopatía dilatada, miocardiopatía hipertrófica, ventrículo derecho anormal y un examen normal. El método propuesto alcanza una precisión media del 78,0 % y una puntuación F1 score del 75,55 %. Asimismo, el enfoque alcanzó el 92,31 % de precisión para la clasificación binaria entre enfermedades y casos de control. Conclusiones. El método propuesto es capaz de apoyar la identificación de patrones cinéticos anormales asociados con una condición patológica. El descriptor resultante, aprendido de la red de convolución 3D, conserva correlaciones espaciotemporales detalladas y podría surgir como posible biomarcador digital de enfermedades cardiacas.

An integrated view of cisplatin-induced nephrotoxicity, hepatotoxicity, and cardiotoxicity: characteristics, common molecular mechanisms, and current clinical management.

Cisplatin (CP) is a chemotherapy drug widely prescribed to treat various neoplasms. Although fundamental for the therapeutic action of the drug, its cytotoxic mechanisms trigger adverse effects in several tissues, such as the kidney, liver, and heart, which limit its clinical use. In this sense, studies point to an essential role of damage to nuclear and mitochondrial DNA associated with oxidative stress, inflammation, and apoptosis in the pathophysiology of tissue injuries. Due to the limitation of effective preventive and therapeutic measures against CP-induced toxicity, new strategies with potential cytoprotective effects have been studied. Therefore, this article is timely in reviewing the characteristics and main molecular mechanisms common to renal, hepatic, and cardiac toxicity previously described, in addition to addressing the main validated strategies for the current management of these adverse events in clinical practice. We also handle the main promising antioxidant substances recently presented in the literature to encourage the development of new research that consolidates their potential preventive and therapeutic effects against CP-induced cytotoxicity.

Ocorrência rara de amiloidose por transtirretina na segunda década de vida / Rare occurrence of transthyretin amyloidosis in the second decade of life

INTRODUÇÃO: Sendo p.V50M e p.V142I as variantes mais comuns associadas à amiloidose por transtirretina hereditária (ATTRh), pode haver uma errônea correlação de que a doença se manifeste apenas em idosos já que a apresentação clínica em seus portadores geralmente se inicia tardiamente, em meia idade e acima de 60 anos, respectivamente. Entretanto, existem outras variantes que podem determinar quadro clínico mais grave e precoce. Descrevemos uma série de casos com início em idade inferior a 25 anos associados à identificação de variante rara no gene TTR. MÉTODOS: Estudo observacional de série de casos RESULTADOS: Três pacientes (p) masculinos, aparentados, portadores de ATTRh confirmada por teste molecular positivo para a variante patogênica p.F64S, com idade média de apresentação clínica de 19±3 anos. Características basais dos p expressas na tabela 1. Todos os p apresentavam fenótipo misto, sendo portadores de polineuropatia grave, disautonomia (expressa por disfunção erétil, hipotensão e alterações digestivas) e cardiopatia em graus variáveis, mais evidente no p com instalação da doença há mais tempo. Espessura média do septo de 15,6±4 mm e de 13±3 mm, da parede posterior. Um p apresentou derrame pericárdico volumoso recorrente. Nenhum óbito ocorreu durante o seguimento. Todos os p receberam tratamento específico para amiloidose: o caso índice foi submetido a transplante hepático, outro está recebendo um silenciador gênico (eplontersen em protocolo clínico) e, o último, em uso de tafamidis 20mg. DISCUSSÃO E CONCLUSÃO: descrevemos 3 p aparentados, que apresentaram os primeiros sintomas de ATTRh aos 20 anos de idade com fenótipo misto (polineuropatia e cardiopatia), determinada pela variante p.F64S. Esta variante é muito rara e encontramos 7 casos descritos na Literatura, todos muito jovens que apresentaram fenótipo predominante de polineuropatia, mas a maioria com cardiopatia associada. A variante p.V50M também pode ocorrer em jovens na forma precoce da doença, porém isto ocorre em torno da terceira década de vida. Conclui-se que a amiloidose não deve ser encarada como uma doença exclusiva da população idosa. A forma hereditária pode ocorrer em p mais jovens e a idade de início do quadro dependerá da variante encontrada. Deve-se, portanto, considerar amiloidose como diagnóstico diferencial das hipertrofias ventriculares em jovens.

Combination of Tele-Cardiology Tools for Cardiovascular Risk Stratification in Primary Care: Data from the PROVAR+ Study. / Combinação de Ferramentas de Telecardiologia para Estratificação de Risco Cardiovascular na Atenção Primária: Dados do Estudo PROVAR.

BACKGROUND: Tele-cardiology tools are valuable strategies to improve risk stratification. OBJECTIVE: We aimed to evaluate the accuracy of tele-electrocardiography (ECG) to predict abnormalities in screening echocardiography (echo) in primary care (PC). METHODS: In 17 months, 6 health providers at 16 PC units were trained on simplified handheld echo protocols. Tele-ECGs were recorded for final diagnosis by a cardiologist. Consented patients with major ECG abnormalities by the Minnesota code, and a 1:5 sample of normal individuals underwent clinical questionnaire and screening echo interpreted remotely. Major heart disease was defined as moderate/severe valve disease, ventricular dysfunction/hypertrophy, pericardial effusion, or wall-motion abnormalities. Association between major ECG and echo abnormalities was assessed by logistic regression as follows: 1) unadjusted model; 2) model 1 adjusted for age/sex; 3) model 2 plus risk factors (hypertension/diabetes); 4) model 3 plus history of cardiovascular disease (Chagas/rheumatic heart disease/ischemic heart disease/stroke/heart failure). P-values < 0.05 were considered significant. RESULTS: A total 1,411 patients underwent echo; 1,149 (81%) had major ECG abnormalities. Median age was 67 (IQR 60 to 74) years, and 51.4% were male. Major ECG abnormalities were associated with a 2.4-fold chance of major heart disease on echo in bivariate analysis (OR = 2.42 [95% CI 1.76 to 3.39]), and remained significant after adjustments in models (p < 0.001) 2 (OR = 2.57 [95% CI 1.84 to 3.65]), model 3 (OR = 2.52 [95% CI 1.80 to3.58]), and model 4 (OR = 2.23 [95%CI 1.59 to 3.19]). Age, male sex, heart failure, and ischemic heart disease were also independent predictors of major heart disease on echo. CONCLUSIONS: Tele-ECG abnormalities increased the likelihood of major heart disease on screening echo, even after adjustments for demographic and clinical variables.

FUNDAMENTO: As ferramentas de telecardiologia são estratégias valiosas para melhorar a estratificação de risco. OBJETIVO: Objetivamos avaliar a acurácia da tele-eletrocardiografia (ECG) para predizer anormalidades no ecocardiograma de rastreamento na atenção primária. MÉTODOS: Em 17 meses, 6 profissionais de saúde em 16 unidades de atenção primária foram treinados em protocolos simplificados de ecocardiografia portátil. Tele-ECGs foram registrados para diagnóstico final por um cardiologista. Pacientes consentidos com anormalidades maiores no ECG pelo código de Minnesota e uma amostra 1:5 de indivíduos normais foram submetidos a um questionário clínico e ecocardiograma de rastreamento interpretado remotamente. A doença cardíaca grave foi definida como doença valvular moderada/grave, disfunção/hipertrofia ventricular, derrame pericárdico ou anormalidade da motilidade. A associação entre alterações maiores do ECG e anormalidades ecocardiográficas foi avaliada por regressão logística da seguinte forma: 1) modelo não ajustado; 2) modelo 1 ajustado por idade/sexo; 3) modelo 2 mais fatores de risco (hipertensão/diabetes); 4) modelo 3 mais história de doença cardiovascular (Chagas/cardiopatia reumática/cardiopatia isquêmica/AVC/insuficiência cardíaca). Foram considerados significativos valores de p < 0,05. RESULTADOS: No total, 1.411 pacientes realizaram ecocardiograma, sendo 1.149 (81%) com anormalidades maiores no ECG. A idade mediana foi de 67 anos (intervalo interquartil de 60 a 74) e 51,4% eram do sexo masculino. As anormalidades maiores no ECG se associaram a uma chance 2,4 vezes maior de doença cardíaca grave no ecocardiograma de rastreamento na análise bivariada (OR = 2,42 [IC 95% 1,76 a 3,39]) e permaneceram significativas (p < 0,001) após ajustes no modelo 2 (OR = 2,57 [IC 95% 1,84 a 3,65]), modelo 3 (OR = 2,52 [IC 95% 1,80 a 3,58]) e modelo 4 (OR = 2,23 [IC 95% 1,59 a 3,19]). Idade, sexo masculino, insuficiência cardíaca e doença cardíaca isquêmica também foram preditores independentes de doença cardíaca grave no ecocardiograma. CONCLUSÕES: As anormalidades do tele-ECG aumentaram a probabilidade de doença cardíaca grave no ecocardiograma de rastreamento, mesmo após ajustes para variáveis demográficas e clínicas.

Advanced cell and gene therapies in cardiology.

We review the evidence for the presence of stem/progenitor cells in the heart and the preclinical and clinical data using diverse cell types for the therapy of cardiac diseases. We highlight the failure of adult stem/progenitor cells to ameliorate heart function in most cardiac diseases, with the possible exception of refractory angina. The use of pluripotent stem cell-derived cardiomyocytes is analysed as a viable alternative therapeutic option but still needs further research at preclinical and clinical stages. We also discuss the use of direct reprogramming of cardiac fibroblasts into cardiomyocytes and the use of extracellular vesicles as therapeutic agents in ischemic and non-ischemic cardiac diseases. Finally, gene therapies and genome editing for the treatment of hereditary cardiac diseases, ablation of genes responsible for atherosclerotic disease, or modulation of gene expression in the heart are discussed.

Odontopediatría en el paciente con enfermedad sistémica / Pediatric dentistry in patients with systematic disease

Esta revisión ofrece un enfoque sistemático para establecer una prestación de atención dental segura, integral, coordinada y orientada a la familia del niño con complejidades médicas. Sugerimos que adoptar un enfoque individualizado basado en la fortaleza para la evaluación de niños con afecciones médicas complejas ofrece la base más segura para la prestación de atención en pacientes con enfermedad cardiaca y asma. El objetivo de esta revisión es brindar una visión razonada de atención en el paciente comprometido sistémicamente, basados en protocolos internacionales, y una serie de pasos y modificaciones que deben ser consideradas al momento del manejo odontológico. Se realizó la búsqueda científica en bases digitales contemplando información en idiomas inglés y español, acerca del manejo del paciente dependiendo de su diagnóstico médico y sus complicaciones. Concluimos que el tratamiento dental de pacientes pediátricos con enfermedades sistémicas se puede llevar a cabo de manera eficiente en presencia de un equipo dental bien equipado y apoyo de los padres. Un dentista pediátrico juega un papel importante en el alivio de la ansiedad del niño, manteniendo una relación positiva y haciendo que los servicios de atención se conviertan en experiencias cómodas y libres de complicaciones para pacientes infantiles con enfermedades sistémicas de base, como cardiopatías y/o asma (AU)

This review provides a systematic approach to establishing safe, comprehensive, coordinated, and family-oriented dental care delivery for the child with medical complexities. We suggest that adopting an individualized, strength-based approach to evaluating children with complex medical conditions provides the surest basis for delivering care to heart disease and asthma patients. This review aims to provide a reasoned care approach for the patient with a systemic compromise based on international protocols and a series of steps and modifications that should be considered during dental management. A scientific search was conducted in digital databases, including information in English and Spanish, on managing patients according to their medical diagnosis and complications. We conclude that dental treatment of pediatric patients with systemic diseases can be carried out efficiently in the presence of a well-equipped dental team and parental support. A pediatric dentist plays a vital role in relieving the child's anxiety, maintaining a positive relationship, and making care services become comfortable and complication-free experiences for pediatric patients with underlying systemic diseases, such as heart disease and/or asthma (AU)