Registro Brasileiro de Cardiologia Intervencionista durante a Pandemia de COVID-19 (RBCI-COVID19) / Brazilian Registry of Interventional Cardiology during the COVID-19 Pandemic (RBCI-COVID19)

Resumo Fundamento No início da pandemia de COVID-19, os pacientes com infarto do miocárdio (IM) demoraram para procurar um hospital por medo de contágio ou dificuldades no acesso aos serviços de saúde. Objetivos Avaliar procedimentos de cardiologia intervencionista realizados durante a pandemia de COVID-19 e implicações na abordagem do IM. Métodos Registro prospectivo de 24 centros de hemodinâmica no Brasil, com pacientes adultos submetidos a procedimentos de cardiologia intervencionista entre 26 de maio e 30 de novembro de 2020. Os desfechos foram complicações cardiovasculares (CV) e não CV, morte e IM. A concomitância de COVID-19 foi confirmada com RT-PCR. Técnicas de machine learning foram usadas com modelos não paramétricos de árvores de classificação. Usou-se análise de correspondência simples com o software R. Adotou-se nível de significância de 5%. Resultados Este estudo incluiu 1.282 pacientes, 435 dos quais (33,9%) apresentaram IM: IM com supra de ST (IMCSST), 239 (54,9%); e IM sem supra de ST(IMSSST), 196 (45.1%). Dos 1.282 pacientes, 29 tiveram complicações CV, 47 tiveram complicações não CV e 31 morreram. O diagnóstico de COVID-19 foi confirmado em 77 pacientes (6%), com 15,58% de mortalidade e 6,49% de complicações não CV. A maioria dos pacientes apresentou significativa doença arterial coronariana (63%). Trombo intracoronariano foi mais frequente na presença de IMCSST (3,4%) e COVID-19 (4%). Tempo porta-mesa superior a 12 horas no IMSSST associou-se a 30,8% de complicações, 25% em pacientes com COVID-19. Conclusões Todos os óbitos foram precedidos por complicações CV ou não CV. A presença de COVID-19 foi associada a óbito e complicações não fatais dos pacientes submetidos a procedimentos de cardiologia intervencionista durante a pandemia.

Abstract Background At the beginning of the COVID-19 pandemic, patients with myocardial infarction (MI) took longer to present to hospitals because of fear of contamination and health care access difficulties. Objectives To assess interventional cardiology procedures performed during the COVID-19 pandemic and its implications for MI approach. Methods Prospective registry of 24 cardiac catheterization laboratories in Brazil, with adult patients undergoing interventional cardiology procedures between May 26 and November 30, 2020. The outcomes were cardiovascular (CV) and non-CV complications, death, and MI. Concomitant COVID-19 was confirmed using RT-PCR. Machine learning techniques were used with nonparametric Classification Trees models, and Simple Correspondence Analysis, with R statistical software package. Significance level adopted of 5%. Results This study included 1282 patients, 435 of whom (33.9%) had MI as follows: ST-segment elevation MI (STEMI), 239 (54.9%); and non-ST-segment elevation MI (NSTEMI), 196 (45.1%). Of the 1282 patients, 29 had CV complications, 47 had non-CV complications, and 31 died. The diagnosis of COVID-19 was confirmed in 77 patients (6%), with 15.58% mortality and non-CV complications in 6.49%. Most patients had significant coronary artery disease (63%), and an intracoronary thrombus was more often found in the presence of STEMI (3.4%) and COVID-19 (4%). A door-to-table time longer than 12 hours in NSTEMI was associated with 30.8% of complications, 25% in COVID-19 patients. Conclusions All deaths were preceded by CV or non-CV complications. The presence of COVID-19 was associated with death and non-fatal complications of patients undergoing interventional cardiology procedures during the pandemic.

Degenerative Aortic Stenosis in Women: Challenges and Perspectives

Abstract Degenerative aortic stenosis is currently a public health problem. Affecting the elderly population, this pathology has been showing an increasing prevalence as a direct result of the population aging. In this context, women have a greater life expectancy, corresponding to most of the population with degenerative aortic stenosis. Specific characteristics of this pathology in females are present in the diagnosis, pathophysiology, anatomical aspects, imaging and in therapeutic approach. Women present a more severe disease with less valve calcification than men, more concentric ventricular remodeling, higher transvalvular gradients, and less myocardial fibrosis. Less evident symptoms mean that these patients are referred later for surgical or percutaneous therapeutic treatment. The greater comorbidity presented by females and possibly due to the smaller body surface, bring specific aspects that affect the surgery results, leading to higher mortality rates and, more often, the prosthesis-patient mismatch. Percutaneous valve implantation is a good alternative, with better results in females, when compared to surgery, both in the treatment of native valves and in the treatment of a previously implanted bioprosthesis' dysfunction. The challenges encountered for the treatment of aortic stenosis in women and their possible solutions are described in this article, focusing on the observed difference of aortic stenosis in females and their possible solutions.

Mulheres Médicas: Burnout durante a Pandemia de COVID-19 no Brasil / Women Physicians: Burnout during the COVID-19 Pandemic in Brazil

Resumo Fundamento A COVID-19 adicionou um fardo enorme sobre os médicos ao redor do mundo, especialmente as mulheres médicas, que são afetadas pelo aumento da carga de trabalho e pela perda da qualidade de vida. Objetivo Avaliar os efeitos da pandemia de COVID-19 na qualidade de vida, burnout e espiritualidade de médicas brasileiras que atendem pacientes com COVID-19 direta ou indiretamente. Método Estudo prospectivo, observacional realizado de 28 de julho a 27 de setembro de 2020, no Brasil, com mulheres médicas de 47 especialidades, a mais frequente sendo a cardiologia (22,8%), sem restrição de idade. Elas responderam voluntariamente um questionário online com questões sobre características demográficas e socioeconômicas, qualidade de vida (WHOQOL-brief) e espiritualidade (WHOQOL-SRPB) e enunciados do Oldenburg Burnout Inventory. A análise estatística utilizou o software R, regressão beta, árvores de classificação e matriz de correlação policórica, com nível de significância de 5%. Resultados Das 769 respondentes, 61,6% relataram sinais de burnout. Cerca de 64% relataram perda salarial de até 50% durante a pandemia. Algumas relataram falta de energia para as tarefas diárias, sentimentos negativos frequentes, insatisfação com a capacidade para o trabalho, e que cuidar de outras pessoas não agregava sentido às suas vidas. Os sentimentos negativos correlacionaram-se negativamente com a satisfação com a vida sexual, a satisfação com as relações pessoais e a energia para as tarefas diárias. A incapacidade de permanecer otimista em tempos de incerteza correlacionou-se positivamente com a sensação de insegurança no dia a dia e com o não reconhecimento de que cuidar de outras pessoas trouxesse sentido à vida. Conclusão O presente estudo mostrou uma alta frequência de burnout entre as médicas brasileiras que responderam ao questionário durante a pandemia de COVID-19. Apesar disso, apresentavam uma qualidade de vida relativamente boa e acreditavam que a espiritualidade trazia-lhes conforto e segurança nos momentos difíceis.

Abstract Background COVID-19 has placed a tremendous burden on physicians worldwide, especially women physicians, affected by increased workload and loss of quality of life. Objective To assess the effects of the COVID-19 pandemic on the quality of life, burnout and spirituality of Brazilian women physicians directly or indirectly providing care to COVID-19 patients. Methods Prospective, observational study performed from July 28 to September 27, 2020, in Brazil, with women physicians from 47 specialities, the most frequent being cardiology (22.8%), with no age restriction. They voluntarily answered an online survey with questions on demographic and socioeconomic characteristics, quality of life (WHOQOL-brief), spirituality (WHOQOL-SRPB), and statements from the Oldenburg Burnout Inventory. Statistical analysis used the R software, beta regression, classification trees, and polychoric correlation matrix, with a 5% of significance level. Results Of the 769 respondents, 61.6% reported signs of burnout. About 64% reported wage loss of up to 50% during the pandemic. Some reported lack of energy for daily tasks, frequent negative feelings, dissatisfaction with capability for work, and caring for others not adding meaning to their lives. Negative feelings correlated negatively with satisfaction with sexual life and personal relations, and energy for daily tasks. The inability to remain optimistic in times of uncertainty correlated positively with feeling unsafe daily and not acknowledging that caring for others brings meaning to life. Conclusion This study showed a high frequency of burnout among Brazilian women physicians who answered the survey during the COVID-19 pandemic. Nevertheless, they presented with a relatively good quality of life and believed that spirituality comforted and reassured them in hard times.

Relationship between circulating VCAM-1, ICAM-1, E-selectin and MMP9 and the extent of coronary lesions

OBJECTIVES: Inflammatory molecules play a role in the development of atherosclerosis, which is the primary origin of cardiovascular disorders. However, to the best of our knowledge, no study has attempted to investigate the relationship between these circulating molecules and the prediction of cardiovascular risk. The present study aimed to investigate the relationships of vascular cell adhesion molecule-1, intercellular adhesion molecule-1, E-selectin and matrix metalloproteinase 9 serum concentrations with the extent of coronary lesions. METHODS: Seventy-four individuals who were undergoing coronary angiography for the first time for diagnostic purposes were enrolled in this study. The extent of the coronary lesion was assessed using the Friesinger Index, and subjects were classified into four groups: no lesions, minor lesions, intermediate lesions and major lesions. Serum biochemical parameters and serum concentrations of vascular cell adhesion molecule-1, intercellular adhesion molecule-1, E-selectin and matrix metalloproteinase 9 were analyzed. RESULTS: The vascular cell adhesion molecule-1 concentration was higher than 876 ng/mL in individuals with intermediate and major lesions (p<0.001 and p=0.020, respectively). Moreover, logistic regression analysis showed that these patients had an increased risk of having an intermediate lesion (p=0.007). Interestingly, all individuals with major lesions had vascular cell adhesion molecule-1 concentrations higher than 876 ng/mL. No association was found between the concentrations of the other proteins and the Friesinger Index. CONCLUSIONS: Serum vascular cell adhesion molecule-1 may be associated with the extent of coronary lesions. Moreover, it may represent an alternative to improve the cardiovascular risk classification in patients without acute coronary syndrome.

Comparação do perfil epidemiológico, clínico e dos resultados das intervenções coronárias percutâneas entre os gêneros masculino e feminino, na população brasileira: dados do registro CENIC / Comparison of the epidemiologic and clinical profiles and results of percutaneous coronary interventions in men and women in Brazil: the CENIC registry data

Fundamentos: No cenário dos estudos controlados e randomizados, em mulheres, a doença arterial coronária (DAC) apresenta maiores desafios no que se refere ao diagnóstico e ao tratamento. Essas noções são mais controversas no âmbito do chamado "mundo real", especialmente no que tange ao tratamento por intervenção coronária percutânea (ICP). Objetivo: Comparar os resultados de procedimentos de ICP, na fase hospitalar, em brasileiras e brasileiros. Método: Análise retrospectivamente idealizada a partir dos dados inseridos no registro da Central Nacional de Intervenções Cardiovasculares (CENIC), em sua presente forma de captura eletrônica, conforme ficha padronizada, desde o início de 1999 até o final de 2007: características demográficas e da história clínica, inclusive fatores de risco no contexto da DAC; detalhes técnicos dos procedimentos, de seu sucesso e complicações; tratamento farmacológico adjunto. Resultados: No período, 197.139 intervenções coronárias foram registradas, sendo 131.797 (66,85%) em homens e 65.342 (33,15%) em mulheres. A média de idade foi significativamente superior nas mulheres (64,0 ± 11,6 anos vs. 60,4 ± 11,7 anos; p < 0,0001), que apresentaram maior prevalência de diabetes melito (39,4% vs. 28,5%; p < 0,0001). Nos homens, houve maior prevalência de hipertensão arterial (25,6% vs. 28,9%; p < 0,0001), tabagismo (19,1% vs. 34,0%; p < 0,0001), antecedentes de infarto do miocárdio...

Background: There are major challenges in diagnosing and treating women with coronary artery disease (CAD), particularly in randomized and controlled studies. These notions are more controversial in the real world, especially with respect to percutaneous coronary intervention (PCI). Objective: To compare results from in-hospital PCI procedures in male and female Brazilian patients. Method: A retrospective analysis was done, based on data electronically uploaded into the CENIC (Central Nacional de Intervenções Cardiovasculares) Registry. A standardized form to gather data from patients treated between the beginning of 1999 to the end of 2007 was used and included clinical, angiographic and procedural results, including clinical success and complications. Results: In this period, 197,139 coronary interventions were reported; 131,797 (66.85%) in men and 65,342 (33.15%) in women. Women were older (64.0 ± 11.6 yrs vs. 60.4 ± 11.7 yrs; p < 0.0001), and had a higher prevalence of diabetes mellitus (39.4% vs. 28.5%; p < 0.0001). In contrast, men showed a higher prevalence of hypertension (25.6% vs. 28.9%; p < 0.0001), smoking (19.1% vs. 34.0%; p < 0.0001),...

Prevalência de estenose da artéria subclávia em pacientes candidatos a cirurgia de revascularização do miocárdio: registro multicêntrico / Prevalence of stenosis of the left subclavia artery in CABG candidates: a multicenter registry

Introdução: Aproximadamente 90 por cento dos pacientes submetidos a cirurgia de revascularização do miocárdio (CRM) recebem enxerto de artéria torácica interna esquerda. A ocorrência de estenose da artéria subclávia esquerda pode resultar em falência do enxerto por limitação de fluxo coronário. A prevalência de estenose da artéia subclávia esquerda em pacientes com aterosclerose coronária grave, considerados candidatos a CRM, não é conhecida. Objetivo: Determinar a prevalência e a eficácia da avaliação clínica para diagnóstico a estenose da artéria subclávia esquerda em candidatos a CRM. Método: Em um registro multicêntrico, realizou-se angiografia seletiva da artéria subclávia esquerda em pacientes com indicação de CRM na ocasião da cinecoronariografia. Estenoses maiores ou iguais a 50 por cento antes da origem da artéria torácica interna foram considerdas significativas. Resultados: Dos 205 pacientes estudados, 16 (7,8 por cento) apresentavam estenose significativa da artéria subclávia esquerda. A medida da pressão arterial não-invasiva diferencial entre...

Background: Approximately 90% of the patients submitted to coronary artery bypass graft surgery (CABG) receive a left internal thoracic artery (LITA) graft. Stenosis of the left subclavian artery can result in graft failure due to restricted coronary flow. The prevalence of stenosis of the left subclavian artery in patients with severe coronary atherosclerosis, deemed candidates to CABG, is not known. Objective: To assess the prevalence of stenosis of left subclavian artery in CABG candidates, as well as the diagnostic effectiveness of clinical evaluation. Methods: In a multicenter registry, selective angiography of the left subclavian artery was carried out in patients considered candidates to CABG during coronary cineangiography. Stenoses ≥ 50% proximal to the origin of the LITA were considered significant. Results: A total of 205 patients were included. Significant stenosis of the left subclavian artery was observed in 16 (7.8%) patients. Noninvasive differential arterial blood pressure measurement ≥ 10 mmHg between both arms showed low sensitivity (37.5%) and low positive predictive value (13.3%) for stenosis identification. No clinical predictors of significant stenosis were identified by univariate analysis. Conclusion: Stenosis of the left subclavian artery is not uncommon in CABG candidates. Noninvasive blood pressure gradient between both arms has low diagnostic accuracy. Therefore, in patients candidates to CABG, selective angiography of the left subclavian artery should be considered, because of the risk of reduced flow and coronary-subclavian steal syndrome in patients with non-diagnosed stenosis of the subclavian artery who receive a LITA graft.

Fatores desencadeantes da instabilização da placa aterosclerótica / Precipitating factors for the unstabilization of the atherosclerotic plaque

A doença aterosclerótica e suas complicações trombóticas ainda permanecem como as principais causas de morbidade e mortalidade no Brasil. Embora a aterosclerose (definida como espessamento da parede arterial, com acúmulo de lipídios, macrófagos, linfócitos T, células musculares lisas, matriz extracelular, cálcio e material necrótico) seja mais prevalente, por si só raramente é fatal. O processo final comum para a transformação de uma lesão não-oclusiva, freqüentemente lesão aterosclerótica clinicamente silenciosa, em uma condição potencialmente fatal é a rotura da placa. A mortalidade associada à doença aterosclerótica relaciona-se com as síndromes coronarianas agudas, incluindo infarto agudo do miocárdio, angina instável e morte súbita cardíaca. Substanciais evidências clínicas, experimentais e "post mortem" demonstram o papel central que a trombose aguda sobreposta à rotura da placa tem como desencadeante das síndromes coronarianas agudas. Assim, o manejo terapêutico visa à redução dessas complicações trombóticas na placa aterosclerótica (como antiagregantes plaquetários, anticoagulantes e terapias trombolíticas), para diminuição da morbidade e da mortalidade. Nesta revisão, foram focalizadas as teorias atuais sobre a aterogênese e como elas interferem em nosso entendimento das síndromes coronarianas agudas.