Linking head and heart health: the association between psychiatric outcomes for patients with major depressive disorder and myocardial ischemia - a systematic review.

INTRODUCTION: The development of depression after myocardial infarction is associated with a 2- to 2.5-fold increased risk of all-cause mortality, cardiovascular mortality, and cardiovascular events. The objective of this study was to investigate, through a broad search of the literature, whether major depression is associated with worse psychiatric outcomes in middle-aged patients with myocardial ischemia. METHODS: An extensive search for studies on the association between major depression and myocardial ischemia was conducted in the PubMed, Embase, PsycINFO, and Web of Science databases. Randomized clinical trials of middle-aged patients with myocardial ischemia and concomitant depressive symptoms were included. RESULTS: The 14 articles included in this systematic review did not confirm an association between myocardial ischemia and depression with worse psychiatric outcomes in middle-aged patients. However, worse cardiovascular outcomes have been observed in patients with depression after myocardial infarction. CONCLUSIONS: The findings of this study suggest that major depression increases cardiovascular risk in patients after acute myocardial infarction, possibly because of a more pronounced increase in inflammatory markers. REGISTRATION: This systematic review was registered in the International Prospective Registry of Systematic Reviews (PROSPERO) under the number CRD: 511650.

Barriers to adherence to secondary prevention therapy in patients with ischemic heart disease: a cross-sectional study of a Mexican reference center.

Objective: This article aims to assess the adherence level to second-line therapy for cardiovascular prevention in a tertiary hospital in Mexico City and identify key barriers to adequate pharmacological adherence. Methods: A single-center prospective cross-sectional study was conducted between August 2018 and February 2020. Sociodemographic data were collected, and the Morisky medication adherence scale was performed. Directed interviews during medical consultations were also conducted to determine reasons for non-adherence. Results: Showed that out of 991 patients included with a median age of 65 (58.72) years, 70.3% exhibited inadequate adherence, with forgetfulness being the most common reason (55.4%). Patients receiving combined therapy with coronary revascularization showed higher adherence compared to those on optimal medical therapy alone. Low educational level (OR 1.68, IC 95% 1.23-2.23, p = 0.0001) and the use of optimal medical therapy alone (OR 1.2, I 95% 1.11-2.007 p = 0.007) were identified as predictors of poor adherence. Conclusion: Among patients with ischemic heart disease and pharmacological therapy for secondary prevention, inadequate adherence is observed in 70% of cases. Factors associated with poor pharmacological adherence were low educational level and prescription of medical therapy without revascularization.

Objetivo: Determinar el nivel de adherencia a la terapia secundaria de prevención cardiovascular en un hospital terciario de la Ciudad de México e identificar las barreras que contribuyen a la inadecuada adherencia farmacológica. Métodos: Se realizó un estudio transversal entre agosto de 2018 y febrero de 2020. Se obtuvieron los datos sociodemográficos, la escala de adherencia a la medicación de Morisky, y se realizó una entrevista sobre las razones de la no adherencia. Resultados: 991 pacientes fueron incluidos con una mediana de edad de 65 (58,72) años. La adherencia inadecuada fue de 70.3%, siendo el olvido la causa más frecuente (55.4%). Aquellos pacientes en terapia farmacológica combinada con revascularización coronaria fueron más adherentes que aquellos en terapia médica óptima. El bajo nivel educativo (OR 1.68, IC95%1.23-2.3, p = 0.001) y el uso de tratamiento médico óptimo solo (OR 1.52, IC95%1.11-2.07, p = 0.007) fueron predictores de mala adherencia. Conclusión: En pacientes con cardiopatia isquemica y terapia farmacológica para prevención secundaria se observa adherencia inadecuada en 70%. Los factores asociados a mala adherencia farmacológica fueron el bajo nivel educativo y la prescripción de tratamiento médico sin revascularización.

Bayesian Modeling and Estimation of Spatial Risk for Hospitalization and Mortality from Ischemic Heart Disease in Paraná, Brazil.

Objective: Despite significant advancements in understanding risk factors and treatment strategies, ischemic heart disease (IHD) remains the leading cause of mortality worldwide, particularly within specific regions in Brazil, where the disease is a burden. Therefore, the aim of this study was to estimate the risk of hospitalization and mortality from IHD in the state of Paraná (Brazil), using spatial analysis to identify areas with higher risk based on socioeconomic, demographic and health variables. Methods: This is an ecological study based on secondary and retrospective IHD hospitalization and mortality data obtained from the Brazilian Hospitalization and Mortality Information Systems during the 2010-2021 period. Data were analyzed for 399 municipalities and 22 health regions in the state of Paraná. To assess the spatial patterns of the disease and identify relative risk (RR) areas, we constructed a risk model by Bayesian inference using the R-INLA and SpatialEpi packages in R software. Results: A total of 333,229 hospitalizations and 73,221 deaths occurred in the analyzed period, and elevated RR of hospitalization (RR = 27.412, CI 21.801; 34.466) and mortality (RR = 15.673, CI 2.148; 114.319) from IHD occurred in small-sized municipalities. In addition, medium-sized municipalities also presented elevated RR of hospitalization (RR = 6.533, CI 1.748; 2.006) and mortality (RR = 6.092, CI 1.451; 2.163) from IHD. Hospitalization and mortality rates were higher in white men aged 40-59 years. A negative association was found between Municipal Performance Index (IPDM) and IHD hospitalization and mortality. Conclusion: Areas with increased risk of hospitalization and mortality from IHD were found in small and medium-sized municipalities in the state of Paraná, Brazil. These results suggest a deficit in health care attention for IHD cases in these areas, potentially due to a low distribution of health care resources.

Comparative Efficacy of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in the Treatment of Ischemic Heart Disease: A Systematic Review and Meta-Analysis of Recent Randomized Controlled Trials.

Background: Ischemic heart disease (IHD) is a major global health issue and a leading cause of death. This study compares the effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in the management of IHD, focusing on their impact on revascularization, myocardial infarction (MI), and post-procedural stroke. This study aimed to evaluate and compare the effectiveness of PCI and CABG in treating IHD based on an exhaustive literature review of the past 5 years, emphasizing recent advancements and outcomes in IHD management. Methods: A comprehensive literature review analyzed 32 randomized controlled trials (RCTs) retrieved from databases such as PubMed, Cochrane Library, and Google Scholar. The study specifically assessed the incidences of revascularization, stroke, and MI in patients treated with either PCI or CABG. The comparison between CABG and PCI exclusively focused on lesions with a SYNTAX score exceeding 32. Results: Our findings highlight CABG's significant efficacy over PCI in reducing revascularization and MI. The aggregated Mantel-Haenszel (M-H) value for revascularization was 1.85 (95% confidence interval (CI): 1.65 - 2.07), signifying CABG's advantage. Additionally, CABG demonstrated superior performance in diminishing MI occurrences (M-H = 2.71, 95% CI: 1.13 - 6.53). In contrast, PCI was more effective in reducing stroke (M-H = 0.80, 95% CI: 0.60 - 1.10). Conclusion: The study confirms CABG's superiority in reducing revascularization and MI in IHD patients, highlighting PCI's effectiveness in reducing stroke risk. These findings underscore the importance of personalized treatment strategies in IHD management and emphasize the need for ongoing research and evidence-based guidelines to aid in treatment selection for IHD patients.

Simplified Models to Assess the Mechanical Performance Parameters of Stents.

Ischemic heart disease remains a leading cause of mortality worldwide, which has promoted extensive therapeutic efforts. Stenting has emerged as the primary intervention, particularly among individuals aged 70 years and older. The geometric specifications of stents must align with various mechanical performance criteria outlined by regulatory agencies such as the Food and Drug Administration (FDA). Finite element method (FEM) analysis and computational fluid dynamics (CFD) serve as essential tools to assess the mechanical performance parameters of stents. However, the growing complexity of the numerical models presents significant challenges. Herein, we propose a method to determine the mechanical performance parameters of stents using a simplified FEM model comprising solid and shell elements. In addition, a baseline model of a stent is developed and validated with experimental data, considering parameters such as foreshortening, radial recoil, radial recoil index, and radial stiffness of stents. The results of the simplified FEM model agree well with the baseline model, decreasing up to 80% in computational time. This method can be employed to design stents with specific mechanical performance parameters that satisfy the requirements of each patient.

Modeling the potential impact of a sugar-sweetened beverage tax on ischemic heart disease and stroke in Brazil.

BACKGROUND: A high intake of sugar-sweetened beverages (SSBs) is associated with the risk of several chronic diseases, including ischemic heart disease (IHD) and stroke. This study aimed to model the impact of a 20% tax on all SSBs for IHD and stroke among Brazilian adults. METHODS: This was an ex-ante risk comparative study. The model applied a 20% tax on SSBs and projected the incidence, prevalence and mortality of IHD and stroke over a 20-year period (2019-39). Using data on consumption, previously published cross- and own-price elasticities of SSBs, and relative risk, we estimated changes in IHD and stroke burden. RESULTS: Our model predicts that a 20% SSB tax may reduce new cases of IHD by ~13%, especially among women, and avert ~8% of the deaths attributable to IHD over 20 years. These results represent a decrease of 19 543 new cases and 8466 and 7274 fewer deaths in the period for men and women, respectively. Estimates of reduction in incidence, prevalence and deaths from stroke were not significant over 20 years. CONCLUSIONS: Even under conservative assumptions, our study found that a small reduction in SSB consumption led to a substantial decrease in IHD incidence and mortality in Brazil.

Gender Differences in Trends in Incidence and Mortality of Acute Myocardial Infarction in the Small Island Developing State of Barbados.

Objective To determine trends, identify predictors of acute myocardial infarction (AMI) incidence and mortality, and explore performance metrics for AMI care in Barbados. Methods Data on all cases diagnosed with AMI were collected by the Barbados National Registry for Non-Communicable Diseases (BNR) from the island's only tertiary hospital, the Queen Elizabeth Hospital, and the National Vital Registration Department. Participants who survived hospital admission were then followed up at 28 days and one year post event via telephone survey and retrieval of death certificates. Age-standardized incidence and mortality rates were calculated. Determinants of mortality at 28 days were examined in multivariable logistic regression models. Median and interquartile ranges (IQR) were calculated for performance metrics (e.g., time from pain onset to reperfusion). Results In a 10-year period between 2010 and 2019, 4,065 cases of myocardial infarction were recorded. The median age of the sample was 73 years (IQR: 61,83), and approximately half (47%) were female. Over a 10-year period, standardized incidence increased in women on average yearly by three per 100,000 (95% CI: 1 to 6; p=0.02), while in men, the average increase per year was six per 100,000 (95% CI: 4 to 8; p<0.001). There was no increase in 28-day mortality in women; mortality in men increased each year by 2.5 per 100,000 (95% CI: 0.4 to 4.5; p=0.02). The time from arrival at the hospital to the ECG was 44 minutes IQR (20,113). Conclusion AMI incidence and mortality are increasing in Barbados, and men have a higher velocity of mortality rate increase than women, which contradicts global data.

Ischemic heart disease-related mortality in Brazil, 2006 to 2020. A study of multiple causes of death.

CONTEXT: Both the aging of the population and the increase in noncommunicable diseases may influence the progression and outcomes culminating in death, changing the evolution of ischemic heart diseases (IHDs) and their associated causes. Using the multiple causes of death method could help understand the magnitude of these relationships and enable better targeting of investments in health. OBJECTIVES: To evaluate the mortality from IHD in Brazil between 2006 and 2020 using the method of multiple causes and identify differences in the distribution pattern of IHD mortality by sex and geographic region. METHODS: Based on information extracted from death certificates (DCs) obtained from the database of the Department of Informatics of the Unified Health System (DATASUS), we used the multiple causes method to analyze the causes of death associated with IHD when IHD was defined as the underlying cause of death (UC) and the causes of death listed as the UC when IHD was recorded in any other lines of the DC, from 2006 to 2020, in Brazil. Subsequently, the proportion of these causes of death and differences between sexes and geographic regions were evaluated, with statistical relevance analyzed using the chi-square test, and the dependence between factors illustrated using stacked bar charts and small-world network graphs. RESULTS: When IHD was listed as the UC of death, the most frequent associated causes of death were, in descending order of frequency, acute myocardial infarction (AMI), arterial hypertension (AH), chronic ischemic heart disease (CHID), heart failure (HF), and diabetes mellitus (DM). When IHD was mentioned in any line of the DC, the most frequent UCs of death were AMI followed by DM, CIHD, chronic obstructive pulmonary disease (COPD), stroke, dyslipidemia, and, in the year 2020, COVID-19. The most frequent cause of death in women were DM as the UC and associated cause of death, AH as the UC, and CIHD and Alzheimer's disease as associated causes of death, while the most frequent causes of death in men were substance dependence as the UC and associated cause of death, and cancer as an associated cause of death. The most frequent causes of death were DM and stroke in the North and Northeast, dyslipidemia and obesity in the Midwest, Alzheimer's disease in the South and Southeast, and atherosclerotic heart disease (AHD) and COPD in the South. CONCLUSIONS: Several diseases - including AMI, AH, CIHD, HF, and DM - were the most frequent associated causes of death when IHD was recorded as the UC. In contrast, AMI, DM, CIHD, COPD, and stroke were the most frequent UCs when IHD was listed as an associated cause of death. The degree of these associations varied between sexes and geographic regions.

Estudio fisiológico invasivo para evaluar lesiones coronarias

Introducción: La revascularización mediante intervención coronaria percutánea con colocación de stent, o cirugía de derivación coronaria, alivia la isquemia miocárdica. Sin embargo, las pruebas de estrés no invasivas y la angiografía coronaria no siempre proporcionan la información adecuada sobre la importancia funcional de las estenosis en las arterias coronarias. Objetivo: Describir las recomendaciones actuales de la literatura médica con respecto a la fisiología coronaria en la cardiopatía isquémica. Desarrollo: El índice de reserva fraccional de flujo se considera el estándar de oro para detectar la isquemia miocárdica. Su naturaleza invasiva se equilibra con la resolución espacial inigualable y su relación lineal con el flujo sanguíneo máximo. Los resultados clínicos de pacientes cuya estrategia de revascularización se basa en mediciones de reserva fraccional de flujo son decisivos en varios subconjuntos de diferentes lesiones. En la última década se ha propuesto la evaluación de la gravedad de la estenosis coronaria mediante índices no hiperémicos. Sin embargo, la precisión de estos índices para distinguir correctamente la isquemia miocárdica es solo del 80 %. Conclusiones: Actualmente, la hiperemia máxima se recomienda para una óptima toma de decisiones sobre la revascularización.

Introduction: Revascularization by percutaneous coronary intervention with stenting, or coronary bypass surgery, alleviates myocardial ischemia. However, noninvasive stress testing and angiography do not always provide adequate information on the functional significance of coronary artery stenoses. Objective: To describe the recommendations of the medical literature regarding coronary physiology in ischemic heart disease. Development: The fractional flow reserve index is considered the gold standard for detecting myocardial ischemia. Its invasive nature is balanced by unmatched spatial resolution and its linear relationship to peak blood flow. The clinical outcomes of patients whose revascularization strategy is based on fractional flow reserve measurements are decisive in several subsets of other lesions. In the last decade, assessment of coronary stenosis severity by non-hyperemic indices has been proposed; however, the accuracy of these indices to correctly distinguish myocardial ischemia does not exceed 80%. Conclusions: Currently, maximal hyperemia is recommended for optimal revascularization decision making.

Conglomerados espaciales de mortalidad por cáncer, cardiopatía isquémica y enfermedad cerebrovascular isquémica en la provincia de Santiago de Cuba / Space conglomerates of mortality due to cancer, ischemic heart disease and ischemic cerebrovascular disease in Santiago de Cuba province i: en

Introducción: Uno de los aspectos que más interés suscita en lo referente a la distribución geográfica de la mortalidad por cáncer es la formación de conglomerados espaciales. Objetivo: Identificar el patrón espacial de la mortalidad por cáncer, cardiopatía isquémica y enfermedad cerebrovascular isquémica mediante la detección y descripción de conglomerados espaciales en la provincia de Santiago de Cuba. Métodos: Se realizó un estudio ecológico exploratorio espacial de los fallecimientos por cáncer, cardiopatía isquémica y enfermedad cerebrovascular isquémica durante el período comprendido desde el 1 de enero hasta el 31 de diciembre de 2019 en la provincia de Santiago de Cuba, para lo cual se procedió a la detección de conglomerados espaciales de elevada y baja mortalidad por las causas antes citadas. Se empleó el método de escaneo espacial estadístico con el programa Satscan y las variables independientes fueron divididas en demográficas y clínicas. Resultados: De los 36 conglomerados espaciales de mortalidad detectados, 23 correspondieron al cáncer (65,8 %), 7 a cardiopatía isquémica (18,4 %) y 6 a enfermedad cerebrovascular isquémica (15,8 %); asimismo, 44,7 % del total eran de elevado riesgo y 55,3 % de bajo riesgo. Conclusiones: El patrón de la distribución espacial de mortalidad por cáncer de próstata, pulmón, mama, colon, esófago, cardiopatía isquémica y enfermedad cerebrovascular isquémica se caracterizó por la formación de conglomerados espaciales de elevada y baja mortalidad.

Introduction: One of the aspects that more interest raises regarding the geographical distribution of mortality due to cancer is the formation of space conglomerates. Objective: To identify the space pattern of mortality due to cancer, ischemic heart disease and ischemic cerebrovascular disease by means of the detection and description of space conglomerates in Santiago de Cuba province. Methods: A space exploratory ecological study of deaths due to cancer, ischemic heart disease and ischemic cerebrovascular disease was carried out during January 1st to December 31, 2019 in Santiago de Cuba province, for which space conglomerates of high and low mortality due to the abovementioned causes were detected. The statistical space escanning method was used with the Satscan program and the independent variables were divided in demographic and clinical. Results: Of the 36 space conglomerates of mortality detected, twenty three corresponded to cancer (65.8%), seven to ischemic heart disease (18.4%) and six to ischemic cerebrovascular disease (15.8%); also, 44.7% of the total was of high risk and 55.3% of low risk. Conclusions: The space distribution pattern of mortality due to prostate, lung, breast, colon, esophagus cancer, ischemic heart disease and ischemic cerebrovascular disease was characterized by the formation of high and low mortality space conglomerates.

Ruta de atención y manejo de la dislipidemia en el paciente con síndrome coronario agudo: brechas y recomendaciones / The care pathway management of dyslipidemia in patients with acute coronary syndrome: gaps and recommendations

Resumen Objetivo: el síndrome coronario agudo es una importante causa de morbimortalidad en Colombia, con una alta carga en calidad de vida, muertes, impacto social y costos para el sistema. El control subóptimo de las dislipidemias tiene múltiples causas, entre ellas el uso inadecuado de las estatinas, la inercia terapéutica, la baja difusión y la adopción de las guías y protocolos de manejo, adicional a las barreras de acceso a la atención y a los medicamentos, y la falta de trazabilidad en la atención a partir del evento isquémico agudo. El proyecto "Ruta de atención y manejo de los lípidos en el paciente con síndrome coronario agudo" busca identificar las brechas en la atención clínica y el manejo de la dislipidemia en los pacientes con síndrome coronario agudo en Colombia, y plantear soluciones para cerrarlas. Materiales y método: se realizaron 178 encuestas a profesionales médicos en instituciones de todo el país, para conocer las pautas de manejo de los pacientes con dislipidemia en el paciente con síndrome coronario agudo. Un panel de 17 expertos analizó los resultados y definió las brechas entre la práctica clínica, la evidencia disponible y el manejo recomendado, y planteó recomendaciones para cerrarlas. Resultados y Conclusiones: este artículo muestra las principales brechas detectadas en el manejo de la dislipidemia en pacientes con síndrome coronario agudo en Colombia, y emite recomendaciones de manejo de la dislipidemia, coherentes con las necesidades y características del Sistema de Salud colombiano.

Abstract Objective: acute coronary syndrome (ACS) is an important cause of morbidity and mortality in Colombia, imposing a heavy burden in terms of quality of life, deaths, social impact, and costs to the system. Suboptimal control of dyslipidemia, associated with inadequate statin use, therapeutic inertia, and low rate of dissemination and adoption of the management protocols and guidelines are clinical and healthcare-related factors that contribute to this situation. This is compounded by barriers that hinder access to care and medications, and the lack of care traceability after the acute ischemic event. The "Care Pathway and lipid management in patients with Acute Coronary Syndrome" project seeks to identify gaps in clinical care and the management of dyslipidemia in patients with acute coronary syndrome in Colombia and propose solutions to bridge those gaps. Materials and method: to gain insights into the management of dyslipidemia in patients with ACS, 178 surveys were sent to medical professionals working in different institutions throughout the country. A panel of 17 experts analyzed the results and identified gaps in terms of clinical practice, available evidence, recommended management, and proposed recommendations to bridge those gaps. Results and conclusions: this paper describes the main gaps related to the management of dyslipidemia in patients with ACS in Colombia and offers recommendations by the needs and characteristics of the Colombian Health System.

Cardiovascular Prognosis of Subclinical Chronic Obstructive Pulmonary Disease in Patients with Suspected or Confirmed Coronary Artery Disease.

Background: Chronic obstructive pulmonary disease (COPD) worsens prognosis in patients with coronary artery disease (CAD). However, the cardiovascular prognosis in patients with stable or mildly symptomatic COPD remains unclear. Here, we sought to determine the long-term cardiovascular events in patients with subclinical or early-stage COPD with concomitant CAD. Methods: This was a longitudinal analytical study involving 117 patients with suspected or established CAD who underwent assessment of pulmonary function by spirometry and who were followed up for six years (March 2015-January 2021). The patients were divided into two groups, one comprising COPD (n=44) and the other non-COPD (n=73) patients. Cox regression was used to evaluate the association between COPD and cardiovascular events, with adjustment for the established CAD risk factors, and the effect size was measured by the Cohen test. Results: COPD patients were older (p=0.028), had a greater frequency of diabetes (p=0.026), were more likely to be smokers (p<0.001), and had higher modified Medical Research Council scores (p<0.001). There was no difference between the groups regarding gender, body mass index, hypertension, dyslipidemia, family history of CAD, and type of angina. CAD frequency and the proportion of patients with severe and multivessel CAD were significantly higher among COPD than among non-COPD patients (all p<0.001). At six-year follow-up, patients with COPD were more likely to have experienced adverse cardiovascular events than those without COPD (p<0.001; effect size, 0.720). After adjusting for established CAD risk factors, COPD occurrence remained an independent predictor for long-term adverse cardiovascular events (OR: 5.13; 95% CI: 2.29-11.50; p<0.0001). Conclusion: COPD was associated with increased severity of coronary lesions and a greater number of adverse cardiovascular events in patients with suspected or confirmed CAD. COPD remained a predictor of long-term cardiovascular events in stable patients with subclinical or early-stage of COPD, independently of the established CAD risk factors.

Comorbidities and clinical symptoms can modify myocardial function: a cross-sectional study with PET/CT / Comorbilidades y síntomas clínicos que pueden modificar la función miocárdica: estudio transversal con PET/TC

Abstract Objective: Associating comorbidities and cardiac symptoms that alter myocardial mechanical function could help clinicians to correctly identify at-risk population. Methods: We conducted a functional open population cross-sectional study of patients referred to a positron emission tomography/computed tomography unit in Mexico City for evaluation of myocardial function, perfusion, and coronary circulation. Ischemia was defined as a sum difference score ≥ 2. Association between comorbidities and cardiac symptoms was tested using logistic regression models and trend analysis. We performed an interaction analysis to evaluate the addition of any accompanying symptoms to comorbid conditions on impairment of myocardial function. Results: One thousand two hundred and seventy-three patients were enrolled, 66.1% male, with a mean age of 62.4 (± 12.7) years, 360 (28.7%) with ischemia, 925 (72.7%) with at least one comorbidity, and 676 (53.1%) had at least one associated cardiac symptom. Patients without ischemia, type 2 diabetes, arterial hypertension, and adverse cardiac symptoms were associated with adverse mechanical, perfusion, and coronary flow parameters. We observed a trend of a cumulative number of comorbidities and cardiac symptoms with increased ischemia and decreased coronary flow. Only in decreased left ventricular ejection fraction, we demonstrated an interaction effect between increased comorbidities and adverse symptoms. Conclusion: The high burden of comorbidities and symptoms in our population alters myocardial function regardless of the level of ischemia.

Resumen Objetivo: La asociación de comorbilidades y síntomas cardíacos que alteran la función miocárdica podría ayudar a los médicos a identificar correctamente a poblaciones de riesgo. Métodos: Se realizó un estudio transversal en población abierta de pacientes referidos a una unidad de PET/CT en la Ciudad de México para evaluación de la función miocárdica, perfusión y circulación coronaria. La isquemia se definió como una suma de diferencia de puntuación (SDS) ≥ 2. La asociación entre las comorbilidades y los síntomas cardíacos se fundamentó mediante modelos de regresión logística y análisis de tendencias. Realizamos un análisis de interacción para evaluar la adición de cualquier síntoma acompañante a condiciones comórbidas en el deterioro de la función miocárdica. Resultados: Se incluyeron 1.273 pacientes, 66,1% del sexo masculino, con una edad media de 62,4 (± 12.7) años, 360 (28,7%) con isquemia, 925 (72,7%) con al menos una comorbilidad y 676 (53,1%) con al menos una menos un síntoma cardíaco asociado. En pacientes sin isquemia, la diabetes mellitus tipo 2, la hipertensión arterial y los síntomas cardíacos adversos se asociaron con parámetros mecánicos, de perfusión y de flujo coronario adversos. Se observó una tendencia con el número acumulado de comorbilidades y síntomas cardíacos con aumento de la isquemia y disminución del flujo coronario. Solo en la disminución de la FEVI se demostró un efecto de interacción entre el aumento de las comorbilidades y los síntomas adversos. Conclusión: La alta carga de comorbilidades y síntomas en nuestra población altera la función miocárdica independientemente del nivel de isquemia.

Dosimetric Evaluation of Cardiac Structures on Left Breast Cancer Radiotherapy: Impact of Movement, Dose Calculation Algorithm and Treatment Technique.

Background: Breast cancer is the most frequently diagnosed and leading cause of cancer-related deaths among females. The treatment of breast cancer with radiotherapy, albeit effective, has been shown to be toxic to the heart, resulting in an elevated risk of cardiovascular disease and associated fatalities. Methods: In this study, we evaluated the impact of respiratory movement, treatment plans and dose calculation algorithm on the dose delivered to the heart and its substructures during left breast radiotherapy over a cohort of 10 patients. We did this through three image sets, four different treatment plans and the employment of three algorithms on the same treatment plan. The dose parameters were then employed to estimate the impact on the 9-year excess cumulative risk for acute cardiac events by applying the model proposed by Darby. Results: The left ventricle was the structure most irradiated. Due to the lack of four-dimensional computed tomography (4DCT), we used a set of images called phase-average CT that correspond to the average of the images from the respiratory cycle (exhale, exhale 50%, inhale, inhale 50%). When considering these images, nearly 10% of the heart received more than 5 Gy and doses were on average 27% higher when compared to free breathing images. Deep inspiration breath-hold plans reduced cardiac dose for nine out of 10 patients and reduced mean heart dose in about 50% when compared to reference plans. We also found that the implementation of deep inspiration breath-hold would reduce the relative lifetime risk of ischemic heart disease to 10%, in comparison to 21% from the reference plan. Conclusion: Our findings illustrate the importance of a more accurate determination of the dose and its consideration in cardiologists' consultation, a factor often overlooked during clinical examination. They also motivate the evaluation of the dose to the heart substructures to derive new heart dose constraints, and a more mindful and individualized clinical practice depending on the treatment employed.

Sex Differences in Prognosis of Heart Failure Due to Ischemic and Nonischemic Cardiomyopathy.

BACKGROUND: Limited research has explored sex-specific differences in death predictors of HF patients with ischemic (iCMP) and nonischemic (niCMP) cardiomyopathy. This study assessed sex differences in niCMP and iCMP prognosis. METHODS: We studied 7487 patients with HF between February 2017 and September 2020. Clinical features and echocardiographic findings were collected. We used Kaplan-Meier, Cox proportional hazard models, and chi-square scores of Cox regression to determine death predictors in women and men. RESULTS: The mean age was 64.3 ± 14.2 years, with 4417 (59%) males. Women with iCMP and niCMP exhibited a significantly higher mean age, higher mean left ventricular ejection fraction, and smaller left ventricular diastolic diameter than men. Over 2.26 years of follow-up, 325 (14.7%) women and 420 (15.7%) men, and 211 women (24.5%) and 519 men (29.8%) with niCMP (p = NS) and iCMP (p = 0.004), respectively, died. The cumulative incidence of death was higher in men with iCMP (log-rank p < 0.0001) but similar with niCMP. Cox regression showed chronic kidney disease, diabetes, stroke, atrial fibrillation, age, and myocardial infarction as the main predictors of death for iCMP in women and men. CONCLUSIONS: Women exhibited a better prognosis than men with iCMP, but similar for niCMP. Nevertheless, sex was not an independent predictor of death for both CMP.

2023 UPDATE: Luso-Brazilian evidence-based guideline for the management of antidiabetic therapy in type 2 diabetes.

BACKGROUND: The management of antidiabetic therapy in people with type 2 diabetes (T2D) has evolved beyond glycemic control. In this context, Brazil and Portugal defined a joint panel of four leading diabetes societies to update the guideline published in 2020. METHODS: The panelists searched MEDLINE (via PubMed) for the best evidence from clinical studies on treating T2D and its cardiorenal complications. The panel searched for evidence on antidiabetic therapy in people with T2D without cardiorenal disease and in patients with T2D and atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or diabetic kidney disease (DKD). The degree of recommendation and the level of evidence were determined using predefined criteria. RESULTS AND CONCLUSIONS: All people with T2D need to have their cardiovascular (CV) risk status stratified and HbA1c, BMI, and eGFR assessed before defining therapy. An HbA1c target of less than 7% is adequate for most adults, and a more flexible target (up to 8%) should be considered in frail older people. Non-pharmacological approaches are recommended during all phases of treatment. In treatment naïve T2D individuals without cardiorenal complications, metformin is the agent of choice when HbA1c is 7.5% or below. When HbA1c is above 7.5% to 9%, starting with dual therapy is recommended, and triple therapy may be considered. When HbA1c is above 9%, starting with dual therapyt is recommended, and triple therapy should be considered. Antidiabetic drugs with proven CV benefit (AD1) are recommended to reduce CV events if the patient is at high or very high CV risk, and antidiabetic agents with proven efficacy in weight reduction should be considered when obesity is present. If HbA1c remains above target, intensification is recommended with triple, quadruple therapy, or even insulin-based therapy. In people with T2D and established ASCVD, AD1 agents (SGLT2 inhibitors or GLP-1 RA with proven CV benefit) are initially recommended to reduce CV outcomes, and metformin or a second AD1 may be necessary to improve glycemic control if HbA1c is above the target. In T2D with HF, SGLT2 inhibitors are recommended to reduce HF hospitalizations and mortality and to improve HbA1c. In patients with DKD, SGLT2 inhibitors in combination with metformin are recommended when eGFR is above 30 mL/min/1.73 m2. SGLT2 inhibitors can be continued until end-stage kidney disease.

Cardiac Imaging in Women with Ischemic Heart Disease.

Cardiac diseases are the main cause of death for both sexes worldwide. Treatment varies widely according to the sex of a patient, as there are differences in physiopathology, epidemiology, clinical presentation and management. However, women have been largely excluded from research studies in this field. At present, differences are starting to be recognized and more attention is being paid to the identification of female-specific (or emergent) atherosclerotic risk factors. Diagnostic testing also merits attention because cardiac imaging offers important information to help diagnosis and guide cardiac disease management. In this sense, multimodal imaging should be used with the most cost-effective approach, integrating this information into the clinical sphere according to the pretest probability of the disease. In this review, we address sex-specific features of ischemic heart disease that should be considered in the clinical assessment of women, as well as the value of different imaging techniques (including technical and clinical aspects) for management of women with ischemic heart disease, and identify future areas of action concerning ischemic heart disease in women.

Risk Factors Control After an Acute Coronary Syndrome and Association with Major Adverse Cardiovascular Events: A Single Center Experience in Latin-America.

INTRODUCTION: An important challenge in the secondary prevention of cardiovascular diseases is the optimization of risk factors (RFs) after hospital discharge. These have been shown to be insufficiently controlled in clinical practice. AIM: To evaluate whether secondary prevention goals were met at our institution at 12 months after an acute coronary syndrome (ACS) index event, as well as analyzing if achieving these goals was associated with a lower incidence of major adverse cardiovascular events (MACE). METHODS: Retrospective cohort of patients with a former diagnosis of ACS over a period of 4 years. To evaluate the proportion of patients who met RF control goals at 12 months after the index event, we used two sets of preestablished goals: stringent and lenient. During follow-up we evaluated the occurrence of MACE, defined by the following: ACS, coronary revascularization, stroke, hospitalization because of acute heart failure and cardiovascular death. RESULTS: We included 468 patients during the study period. The mean age of the patients was 60 ± 10.76 years, 20.5% were women, and mean follow-up was 41.8 ± 22.0 months. The proportion of patients that met all secondary prevention stringent and lenient goals accounted for 5.5% and 17.2%, respectively, and 8% did not achieve any target. Overall, 9.6% presented the composite of MACE during follow-up. The number of RFs in control at 12 months was associated with a lower rate of MACE, both with stringent and lenient goals. CONCLUSION: Achieving established goals for modifiable RFs can lower the incidence of MACE during long-term follow-up.

Comorbidities and cardiac symptoms can modify myocardial function regardless of ischemia: a cross-sectional study with PET/CT.

Objective: Associating comorbidities and cardiac symptoms that alter myocardial mechanical function could help clinicians to correctly identify at-risk population. Methods: We conducted a functional open population cross-sectional study of patients referred to a positron emission computed tomography/computed tomography unit in Mexico City for evaluation of myocardial function, perfusion, and coronary circulation. Ischemia was defined as a sum difference score (SDS) > 2. Association between comorbidities and cardiac symptoms was tested using logistic regression models and trend analysis. We performed an interaction analysis to evaluate the addition of any accompanying symptoms to comorbid conditions on impairment of myocardial function. Results: One thousand two hundred and seventy-three patients were enrolled, 66.1% male, with a mean age of 62.4 (± 12.7) years, 360 (28.7%) with ischemia, 925 (72.7%) with at least one comorbidity, and 676 (53.1%) had at least one associated cardiac symptom. Patients without ischemia, type 2 diabetes, arterial hypertension, and adverse cardiac symptoms were associated with adverse function, perfusion, and coronary flow parameters. We observed a trend of a cumulative number of comorbidities and cardiac symptoms with increased ischemia and decreased coronary flow. Only in decreased LVEF, we demonstrated an interaction effect between increased comorbidities and adverse symptoms. Conclusions: The high burden of comorbidities and symptoms in our population alter myocardial function regardless of the level of ischemia.

Impact of the Mexican education system and age on basic knowledge about ischemic heart disease in the pre-COVID-19 era.

BACKGROUND AND OBJECTIVE: To assess general population's knowledge about ischemic heart disease (IHD) and its relationship to years of schooling in Mexico. METHOD: Analysis of surveys designed to measure knowledge about IHD applied in Mexico City. RESULTS: 530 surveys were analyzed. 51.7% were women. The median age was 43 years (IQR: 15-92) and the median of schooling was 18 years (IQR: 15-18). 64.5% of respondents scored less than 50% of correct answers. A slight increase in the knowledge level and years of study (p < 0.001) and age (p = 0.101) was observed, but with low correlation indexes (r = 0.215 and r = 0.071, respectively). CONCLUSIONS: Knowledge about IHD in general population is deficient and doesn't increase adequately neither with age nor academic studies. It is necessary to review our health education strategies.

ANTECEDENTES Y OBJETIVO: Evaluar los conocimientos sobre cardiopatía isquémica (CI) de la población general y relacionarlos con los años de escolaridad y la edad. MÉTODO: Análisis de encuestas diseñadas para medir conocimientos sobre CI aplicadas en Ciudad de México. RESULTADOS: Se analizaron 530 encuestas. El 51.7% fueron mujeres. La mediana de edad fue 43 años (RIC: 15 a 92) y la de años de estudio fue de 18 años (RIC: 15-18). El 64.5% de los encuestados obtuvo menos del 50% de aciertos. Se documentó un ligero incremento en el nivel de conocimiento con los años de estudio (p < 0.001) y con la edad (p = 0.101), pero con bajos índices de correlación (r = 0.215 y r = 0.071, respectivamente). CONCLUSIONES: Los conocimientos sobre CI en la población general son deficientes y no se incrementan adecuadamente con la edad ni con los años de estudios académicos. Es necesario revisar nuestras estrategias de educación en salud.