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Introduction: Although there is evidence that a significant proportion of veteran athletes have coronary atherosclerotic disease (CAD), its prevalence in recreational athletes with low to intermediate cardiovascular (CV) risk is not established. This study aimed to characterize the coronary atherosclerotic burden in veteran male recreational athletes with low to intermediate CV risk. Methods: Asymptomatic male athletes aged ≥40 years with low to intermediate risk, who exercised >4 hours/week for >5 years, underwent cardiac computed tomography (CT) for coronary artery calcium (CAC) scoring and CT angiography. High coronary atherosclerotic burden was defined as at least one of the following: CAC score >100; CAC score ≥75th percentile; obstructive CAD; disease involving the left main, three vessels or two vessels including the proximal left anterior descending artery; segment involvement score >5; or CT Leaman score ≥5. Athletes were categorized by tertiles of exercise volume, calculated by metabolic equivalent of task (MET) scores. Results: A total of 105 athletes were included, all with SCORE 100, 13 (12.4%) had CAC score ≥75th percentile and six (5.7%) had obstructive lesions. The extent and severity of coronary plaques did not differ according to exercise volume. Conclusions: The prevalence of subclinical CAD detected by cardiac CT in veteran male recreational athletes with low to intermediate CV risk was high. Up to a quarter of our cohort had a high coronary atherosclerotic burden. Resumo: Introdução: Apesar de estar descrita uma proporção significativa de atletas veteranos com doença arterial coronária aterosclerótica (DAC), a sua prevalência em atletas de nível recreativo com risco cardiovascular (CV) baixo-intermédio não está esclarecida. O objetivo deste estudo foi caracterizar a carga aterosclerótica coronária em atletas veteranos do género masculino de nível recreativo com risco CV baixo-intermédio. Métodos: Atletas assintomáticos do género masculino com ≥40 anos com risco baixo-intermédio, praticantes de >4horas/semana de exercício durante >5 anos, realizaram tomografia computorizada cardíaca com determinação do score de cálcio (ScCa) e angiografia coronária (Angio-TC). Definiu-se elevada carga aterosclerótica coronária a presença de pelo menos uma das seguintes características: ScCa >100; ScCa≥p75 (percentil); DAC obstrutiva; doença envolvendo tronco comum, 3-vasos ou 2-vasos incluindo a artéria descendente anterior proximal; segment involvement score >5; CT-adapted Leaman score ≥5. Os atletas foram categorizados em tercis de volume de exercício, calculado por Metabolic Equivalent Task (MET) scores. Resultados: Foram incluídos 105 atletas, todos com score 100, 13 (12,4%) ≥p75 e 6 (5,7%) lesões obstrutivas. A extensão e a gravidade das placas coronárias não diferiram de acordo com o volume de exercício. Conclusões: A prevalência de DAC subclínica detetada por Angio-TC cardíaca em atletas veteranos do género masculino de nível recreativo com risco CV baixo-intermédio foi elevada. Um quarto da nossa amostra apresentou uma elevada carga aterosclerótica coronária.

Funding Acknowledgements Type of funding sources: None. Background Anomalous origin of the right coronary artery (right ACAOS) with interarterial course (IAC) has been associated with increased risk of sudden cardiac death (SCD). Widespread use of coronary computed tomographic angiography (CCTA) has led to increasing recognition of this condition, even among healthy individuals. This study sought to examine the prevalence, anatomical characteristics and outcomes of right ACAOS with IAC in patients undergoing CCTA for all-indications. Methods We conducted a retrospective analysis of consecutive patients referred for CCTA at one tertiary hospital between January 2012 and December 2020. Right ACAOS patients with IAC were analyzed for cardiac symptoms (anginal chest pain, syncope, aborted SCD) and long-term outcomes were evaluated for myocardial infarction, ischemic test results, revascularization procedures and all-cause or cardiovascular (CV) mortality. CCTAs were reviewed for proposed high-risk features (ie., take-off angle, length and severity of proximal narrowing, intramural course, interarterial length) and concomitant coronary artery disease (CAD). Association between high-risk features was analyzed. Long-term outcomes were evaluated. Results Among 10,928 patients referred for CCTA during the study period, we identified 28 patients (0.3% prevalence) with right ACAOS and IAC. Mean age was 55 ± 17 years, 64% were male and 11 (39.3%) presented cardiac symptoms. During a median follow-up of 44.1 ± 31.8 months, there were no CV deaths and only 1 patient (3.65%) underwent surgical revascularization. Baseline characteristics and CCTA findings are presented in figure 1. Conclusion Right ACAOS and IAC is an uncommon finding, with an observed prevalence of 0.3%. CCTA provides excellent anatomical characterization of anomalous vessels, including suggested high-risk features. In a population of asymptomatic patients who survived this condition well into adulthood, the risk of events was very low and medical follow up might be a reasonable option.

Anomalous origin of the right coronary artery from the opposite sinus (right-ACAOS) with interarterial course (IAC) has been associated with increased risk of sudden cardiac death (SCD). Widespread use of coronary computed tomography angiography (CCTA) has led to increased recognition of this condition, even among healthy individuals. Our study sought to examine the prevalence, anatomical characteristics, and outcomes of right-ACAOS with IAC in patients undergoing CCTA for suspected coronary artery disease (CAD). We conducted a retrospective analysis of consecutive patients referred for CCTA at one tertiary hospital from January 2012 to December 2020. Patients exhibiting right-ACAOS with IAC were analyzed for cardiac symptoms and mid-term occurrence of first MACE (cardiac death, SCD, non-fatal myocardial infarction (MI) or revascularization of the anomalous vessel). CCTAs were reviewed for anatomical high-risk features and concomitant CAD. Among 10,928 patients referred for CCTA, 28 patients with right-ACAOS with IAC were identified. Mean age was 55 ± 17 years, 64% were male and 11 (39.3%) presented stable cardiac symptoms. Most patients had at least one high risk anatomical feature. During follow-up, there were no cardiac deaths or aborted SCD episodes and only 1 patient underwent surgical revascularization of the anomalous vessel. Right-ACAOS with IAC is an uncommon finding (prevalence of 0.26%). In a contemporary population of predominantly asymptomatic patients who survived this condition well into adulthood, most patients were managed conservatively with a low event rate. Additional studies are needed to support medical follow-up as the preferred option in this setting.

On March 2020, WHO has declared the coronavirus disease (COVID-19), caused by the virus severe acute respiratory syndrome coronavirus 2 outbreak, a pandemic. Young people can be affected by the disease, and some of them require hospital admission and intensive care. The clinical manifestations of COVID-19 include cardiac involvement and complications, among which are myocarditis (including fulminant cases), arrhythmias and rapid-onset heart failure.1 Since the first cases reported in Wuhan, China, increased levels of serum myocardial biomarkers were found in the sickest patients and associated with worst outcomes. In a series of 41 cases, 12% patients had elevated levels of troponin, indicating myocardial injury.2 Another study showed acute arrhythmias in 17% and acute myocardial injury in 7% of patients with COVID-19.3 In a meta-analysis including six studies with a total of 1527 patients with COVID-19, 8.0% suffered acute cardiac injury with an incidence about 13-fold higher in critically ill patients admitted in intensive care units.4 Increased levels of natriuretic peptides has also been reported in these patients and associated with worst prognostic.1 In some …

© 2018 John Wiley & Sons Ltd, Aims: To evaluate the impact of one-year high intensity interval training (HIIT) combined with resistance training (RT) vs continuous moderate intensity training (MCT) combined with RT on glycaemic control, body composition and cardiorespiratory fitness (CRF) in patients with type 2 diabetes. Materials and Methods: A randomized controlled trial included 96 participants with type 2 diabetes for a one-year supervised exercise intervention with three groups: Control, HIIT with RT and MCT with RT). The control group received standard counseling regarding general PA guidelines, with no structured exercise sessions. The main outcome variable was HbA1c (%). Secondary outcomes were other glycaemic variables, body composition, anthropometry measurements, CRF and enjoyment of exercise. Generalized estimating equations (GEE) were used to model outcomes. Results: Among the 96 participants enrolled in the intervention, 80 were randomized, with a mean (SD) age of 58.5 years (7.7) and a mean HbA1c of 7.2% (1.6). After adjusting the model for sex and total moderate-to-vigorous physical activity (MVPA), we found that both the MCT with RT (β, 0.003; P, 0.921) and the HIIT with RT (β, 0.025; P, 0.385) groups had no effect on HbA1c. A favourable effect was observed in the MCT with RT group, with a reduction in whole body fat index (β, −0.062; P, 0.022), android fat index (β, −0.010; P, 0.010) and gynoid fat index (β, −0.013; P, 0.014). Additionally, CRF increased during the intervention, but only in the MCT with RT group (β, 0.185; P, 0.019). Conclusions: The results from this study suggest that there was no effect of either MCT with RT or HIIT with RT on glycaemic control in individuals with type 2 diabetes. However, the combination of MCT and RT improved body composition and CRF following a one-year intervention., J. M., P. B. J. and R. R. are supported by fellowships from the Portuguese Foundation for Science and Technology (J. M. grant: SFRH/ BD/85742/2012; P. B. J. grant: SFRH/ BPD/115977/2016; R. R. grant: SFRH/BPD/110426/2015).

Introduction: Assessment of the electrocardiogram (ECG) in athletes remains controversial, with lack of standardization and difficulty in applying specific criteria in its interpretation. The purpose of this study was to assess variability in the interpretation of the ECG in athletes. Methods: Twenty ECGs of competitive athletes were assessed by cardiologists and cardiology residents, 11 of them normal or with isolated physiological changes and nine pathological. Each ECG was classified as normal/physiological or pathological, with or without the use of specific interpretation criteria. Results: The study presents responses from 58 physicians, 42 (72.4%) of them cardiologists. Sixteen (27.6%) physicians reported that they regularly assessed athletes and 32 (55.2%) did not use specific ECG interpretation criteria, of which the Seattle criteria were the most commonly used (n=13). Each physician interpreted 15±2 ECGs correctly, corresponding to 74% of the total number of ECGs (variation: 45%-100%). Interpretation of pathological ECGs was correct in 68% (variation: 22%-100%) and of normal/physiological in 79% (variation: 55%-100%). There was no significant difference in interpretation between cardiologists and residents (74±10% vs. 75±10%; p=0.724) or between those who regularly assessed athletes and those who did not (77±12% vs. 73±9%; p=0.286), but there was a trend for a higher rate of correct interpretation using specific criteria (77±10% vs. 72±10%; p=0.092). The reproducibility of the study was excellent (intraclass correlation coefficient=0.972; p

Background: Anterior T-wave inversion (ATWI) on electrocardiography (ECG) in young white adults raises the possibility of cardiomyopathy, specifically arrhythmogenic right ventricular cardi...

Introduction White-coat hypertension (WCH) is a prevalent entity, which has been associated with an increased cardiovascular risk. Aim Assess whether WCH is associated with a higher coronary atherosclerotic burden, evaluated by coronary computed tomography angiography (CCTA) and coronary artery calcium (CAC) scoring. Methods A total of 1362 patients who performed CCTA and simultaneous CAC for the assessment of coronary artery disease (CAD) were prospectively enrolled in a single-center registry and divided into three groups: (A) patients with normal blood pressure (BP) (n=386); (B) patients with WCH (n=174; without a history of hypertension or antihypertensive medication, but with systolic BP ≥140 and/or diastolic BP ≥90 mmHg before examination acquisition); and (C) patients with hypertension (n=802). The following coronary atherosclerotic markers were evaluated: CAC above the 50th percentile (CAC>p50), prevalence of CAD (any plaque), and obstructive CAD (plaque with>50% stenosis). Results Patients with WCH had a higher coronary atherosclerotic burden compared with patients with normal BP for all markers (30.5 vs. 19.4%, P=0.004 for CAC>p50; 50.6 vs. 36.8%, P=0.002 for CAD, any plaque; and 13.8 vs. 8.3%, P=0.045 for obstructive CAD). On multivariate analysis, WCH was an independent predictor of a CAC>p50 [odds ratio (OR) 1.563, 95% confidence interval 1.018-2.400, P=0.041], but not of the presence of CAD (any plaque) (OR 1.335, P=0.169) or obstructive CAD (OR 1.376, P=0.301). Conclusion In this registry of patients, WCH was an independent predictor of a CAC above the p50. It was also associated with higher other markers of coronary atherosclerotic burden, such as the presence of CAD on CCTA, compared with patients with normal BP.

Current guidelines recommend the use of the Modified Diamond-Forrester (MDF) method to assess the pre-test likelihood of obstructive coronary artery disease (CAD). We aimed to compare the performance of the MDF method with two contemporary algorithms derived from multicenter trials that additionally incorporate cardiovascular risk factors: the calculator-based 'CAD Consortium 2' method, and the integer-based CONFIRM score.We assessed 1069 consecutive patients without known CAD undergoing coronary CT angiography (CCTA) for stable chest pain. Obstructive CAD was defined as the presence of coronary stenosis ≥50% on 64-slice dual-source CT. The three methods were assessed for calibration, discrimination, net reclassification, and changes in proposed downstream testing based upon calculated pre-test likelihoods.The observed prevalence of obstructive CAD was 13.8% (n=147). Overestimations of the likelihood of obstructive CAD were 140.1%, 9.8%, and 18.8%, respectively, for the MDF, CAD Consortium 2 and CONFIRM methods. The CAD Consortium 2 showed greater discriminative power than the MDF method, with a C-statistic of 0.73 vs. 0.70 (p0.001), while the CONFIRM score did not (C-statistic 0.71, p=0.492). Reclassification of pre-test likelihood using the 'CAD Consortium 2' or CONFIRM scores resulted in a net reclassification improvement of 0.19 and 0.18, respectively, which would change the diagnostic strategy in approximately half of the patients.Newer risk factor-encompassing models allow for a more precise estimation of pre-test probabilities of obstructive CAD than the guideline-recommended MDF method. Adoption of these scores may improve disease prediction and change the diagnostic pathway in a significant proportion of patients.

Introduction: Athletes can exhibit abnormal electrocardiogram (ECG) phenotypes that require further evaluation prior to competition. These are apparently more prevalent in high-intensity endurance sports. The purpose of this study was to assess the association between ECG findings in athletes and intensity of sport and level of competition. Methods: A cohort of 3423 competitive athletes had their ECGs assessed according to the Seattle criteria (SC). The presence of abnormal ECGs was correlated with: (1) intensity of sport (low/moderate vs. at least one high static or dynamic component); (2) competitive level (regional vs. national/international); (3) training volume (≤20 vs. >20 hours/week); (4) type of sport (high dynamic vs. high static component). The same endpoints were studied according to the ‘Refined Criteria’ (RC). Results: Abnormal ECGs according to the SC were present in 225 (6.6%) athletes, more frequently in those involved in high-intensity sports (8.0% vs. 5.4%; p=0.002), particularly in dynamic sports, and competing at national/international level (7.1% vs. 4.9%; p=0.028). Training volume was not significantly associated with abnormal ECGs. By multivariate analysis, high-intensity sport (OR 1.55, 1.18-2.03; p=0.002) and national/international level (OR 1.50, 95% CI 1.04-2.14; p=0.027) were independent predictors of abnormal ECGs, and these variables, when combined, doubled the prevalence of this finding. According to the RC, abnormal ECGs decreased to 103 (3.0%), but were also more frequent in high-intensity sports (4.2% vs. 2.0%; p20 horas/semana); 4) tipo de desporto (elevados componentes dinâmico versus estático). Os mesmos endpoints foram estudados pelos Refined Criteria (RC). Resultados: De acordo com os SC, 225 (6,6%) atletas tinham alterações patológicas, mais frequentes nos envolvidos em desportos de elevada intensidade (8,0 versus 5,4%; p=0,002), sobretudo dinâmica, e em nível nacional/internacional (7,1 versus 4,9%; p=0,028). O volume de treino não esteve significativamente associado a estas alterações. Em análise multivariada, desporto de elevada intensidade (OR 1,55, IC 95% 1,18-2,03; p=0,002) e o nível nacional/internacional (OR 1,50, IC 95% 1,04-2,14; p=0,027) foram preditores independentes de ECG anormais, variáveis que combinadas duplicaram a prevalência. Com os RC o número de ECG patológicos decresceu para 103 (3,0%), também mais frequentes nos desportos de elevada intensidade (4,2 versus 2,0%; p

© The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated., Background: Exercise, when performed on a regular basis, is a well-accepted strategy to improve vascular function in patients with type 2 diabetes. However, the exercise intensity that yields maximal adaptations on structural and functional indices in patients with type 2 diabetes remains uncertain. Our objective was to analyze the impact of a 1-year randomized controlled trial of combined high-intensity interval training (HIIT) with resistance training (RT) vs. a combined moderate continuous training (MCT) with RT on structural and functional arterial indices in patients with type 2 diabetes. Methods: Patients with type 2 diabetes (n=80) were randomized into an exercise intervention with three groups: control, combined HIIT with RT and combined MCT with RT. The 1-year intervention had 3 weekly exercise sessions. High-resolution ultrasonography of the common carotid artery and central and peripheral applanation tonometry were used to assess the changes in structural and functional arterial indices. Generalized estimating equations were used to model the corresponding outcomes. Results: After adjusting the models for sex, baseline moderate-to-vigorous physical activity, and mean arterial pressure changes, while using the intention-to-treat analysis, a signifcant interaction was observed on the carotid intimamedia thickness (cIMT) for both the MCT (β=−4.25, p, The authors declare that the research was conducted in the absence of any commercial or fnancial relationships that could be construed as a potential competing interest. JM and RTR are supported by a scholarship from the Portuguese Foundation for Science and Technology (JM grant: SFRH/ BD/85742/2012, RTR grant: SFRH/BPD/110426/2015). This work is also fnanced by a national grant through the FCT—Fundação para a Ciência e Tecnologia within the unit I&D 472 (UID/DTP/00447/2019).

Background: Cardiac remodeling depends on the intensity, duration, and training method. Objective: To evaluate if the training performed in a Portuguese military special operations troop increases cardiac remodeling in a sample of young individuals who previously practiced competitive sports. Methods: A prospective study involving 76 military candidates for military special operations, 45 of whom previously practiced at competitive level (> 10 hours per week). Of these military athletes, only 17 successfully completed the course. The evaluation was performed at 6 months intervals and included a complete clinical history, physical examination, vital signs, anthropometric data and echocardiographic evaluation. Statistical significance was considered when p < 0.05, with a 95% confidence interval. Results: At the end of the course, there was a decrease in the percentage of fat mass (19.1 ± 3.3% vs. 13.1 ± 3.5%; p < 0.01), an increase in the percentage of lean mass (41.3 ± 2.1% vs. 44.4 ± 1.8%; p < 0.01), and decreased systolic and diastolic blood pressure and heart rate. Regarding cardiac remodeling, there was an increase in left ventricular diastolic diameter (49.7 ± 3.2 mm vs. 52.8 ± 3.4 mm; p < 0.01), an increase trend in left atrial volume (27.3 ± 4.5 mL/ m2 vs. 28.2 ± 4.1 mL/m2; p = 0.07) and increased left ventricular mass (93.1 ± 7.7 g/m2 vs. 100.2 ± 11.4 g/m2; p < 0.01). Functional variables also changed, with an increase in S' (15 (13-16) cm/s vs. 17 (16-18) cm/s; p < 0,01) and a decrease in left ventricular ejection fraction (60 ± 6% vs. 54 ± 6%; p < 0.01). Conclusion: Intense military physical training resulted in additional cardiac remodeling in athletes of competitive level, both structural and functional. (Int J Cardiovasc Sci. 2018; [online].ahead print, PP.0-0) Resumo Fundamento: A remodelagem cardíaca depende da intensidade, da duraçao e do método de treinamento. Objetivo: Avaliar se o treinamento realizado em uma tropa especial portuguesa incrementa a remodelagem cardíaca em uma amostra de jovens que previamente praticavam esporte de competiçao. Métodos: Estudo prospectivo que incluiu 76 militares candidatos a tropas especiais, 45 dos quais praticavam previamente exercício físico de nível competitivo (> 10 horas por semana). Destes militares atletas, apenas 17 concluíram com sucesso o curso. A avaliaçao foi realizada com 6 meses de intervalo e incluiu história clínica completa, exame físico, sinais vitais, dados antropométricos e avaliaçao ecocardiográfica. Considerou-se significância estatística quando p < 0,05, com intervalo de confiança de 95%. Resultados: No final do curso, verificaram-se diminuição da porcentagem de massa gorda (19,1 ± 3,3% vs. 13,1 ± 3,5%; p < 0,01), aumento da porcentagem de massa muscular (41,3 ± 2,1% vs. 44,4 ± 1,8%; p < 0,01), e diminuição da pressão arterial sistólica, diastólica e frequência cardíaca. Em relação à remodelagem cardíaca, verificaram-se aumento do diâmetro diastólico do ventrículo esquerdo (49,7 ± 3,2 mm vs. 52,8 ± 3,4 mm; p < 0,01), aumento tendencial do volume do átrio esquerdo (27,3 ± 4,5 mL/m2 vs. 28,2 ± 4,1 mL/m2; p = 0,07) e aumento da massa do ventrículo esquerdo (93,1 ± 7,7 g/m2 vs. 100,2 ± 11,4 g/m2; p < 0,01). As variáveis funcionais também sofreram alterações, com aumento do S' (15 (13-16) cm/s vs. 17 (16-18) cm/s; p < 0,01) e diminuição da fração de ejeção do ventrículo esquerdo (60 ± 6% vs. 54 ± 6%; p < 0,01). Conclusão: O treinamento físico militar intenso provocou remodelagem cardíaca adicional em atletas de nível competitivo, tanto estrutural como funcional. (Int J Cardiovasc Sci. 2018; [online].ahead print, PP.0-0)

Objective: To evaluate the performance of traditional cardiovascular (CV) risk factors in identifying a higher than expected coronary atherosclerotic burden. Methods: We assessed 2069 patients undergoing coronary CT angiography, with assessment of calcium score (CS), for suspected coronary artery disease. A higher than expected atherosclerotic burden was defined as CS >75th percentile (CS >P75) according to age and gender-adjusted monograms. The ability of traditional CV risk factors to predict a CS >P75 was assessed in a customized logistic regression model (“Clinical Score”) and by the calculation of SCORE (Systemic Coronary Risk Evaluation). The population attributable risk (PAR) of risk factors for CS >P75 was calculated. Results: The median CS was 3.0 (IQR 0.0–98.0); 362 patients had CS >P75. The median SCORE was 3.0 (IQR 1.0–4.0). With the exception of hypertension, all traditional CV risk factors were independent predictors of CS >P75: diabetes, dyslipidemia, smoking and family history (OR 1.3–2.2, p≤0.026). The areas under the ROC curves for CS >P75 were 0.64 for the Clinical Score (95% CI 0.61–0.67, pP75 were in the two lower quartiles of the Clinical Score. Altogether, the traditional risk factors explain 56% of the prevalence of CS >P75 (adjusted PAR 0.56). Conclusion: Despite the association of CV risk factors with a higher than expected atherosclerotic burden, they appear to explain only half of its prevalence. Even when integrated in scores, the predictive power of these risk factors was modest, exposing the limitations of risk stratification based solely on demographic and clinical risk factors. Resumo: Objetivo: O objetivo deste trabalho foi avaliar o desempenho dos fatores de risco cardiovascular (CV) clássicos na identificação de carga aterosclerótica superior ao esperado. Métodos: Avaliámos 2069 doentes (dts) que realizaram AngioTC cardíaca e ScCa para exclusão de doença coronária. Definiu-se carga aterosclerótica superior ao esperado um ScCa acima do percentil 75 (ScCa>p75) de acordo com nomogramas ajustados para o sexo e idade. A capacidade dos fatores de risco clássicos preverem ScCa>p75 avaliou-se num modelo de regressão logística customizado (score clínico) e pelo SCORE. Avaliou-se o Population Attributable Risk (PAR) dos fatores de risco para ScCa>p75. Resultados: A mediana de ScCa foi 3,0 [IIQ 0,0-98,0]; 362 dts com ScCa>p75. A mediana do HeartScore foi 3,0 [IIQ 1,0-4,0]. Exceto a hipertensão arterial, todos os fatores de risco foram preditores independentes de CaSc>p75: diabetes mellitus, dislipidemia, tabagismo e história familiar (OR 1,3-2,2, p≤0,026). As áreas abaixo da curva ROC para SaCa>p75 foram 0,64 para score clínico (IC95% 0,61-0,67; pp75 encontravam-se nos dois quartis de score clínico mais baixos. No seu conjunto, os fatores de risco clássicos explicam 56% da prevalência de ScCa>p75 (PAR ajustado 0,56). Conclusão: Apesar de os fatores de risco CV se associarem a uma carga aterosclerótica superior ao esperado, justificam pouco mais de metade da sua prevalência. O poder preditor destes fatores de risco é modesto, mesmo integrados em scores, revelando as limitações da estratificação de risco baseada apenas em dados demográficos e fatores de risco clínicos. Keywords: Atherosclerotic burden, Risk factor, Attributable risk, Calcium score, CT angiography, Palavras-chave: Carga Aterosclerótica, Fator de risco, Score de cálcio, AngioTC

Introduction: Exercise-induced cardiac remodeling is frequent in athletes. This adaptation is structurally manifested by an increase in cardiac dimensions and mass. Soldiers are also subject to intense physical exercise, although with different characteristics. Objective: To compare exercise-induced cardiac remodeling in competitive athletes and in soldiers on a special forces training course. Methods: We studied 17 soldiers (all male and Caucasian, mean age 21±3 years) who completed a special forces course and 17 basketball players (47.3% male, 64.7% Caucasian, mean age 21±3 years). Assessment included a transthoracic echocardiogram and analysis of myocardial mechanics. This assessment was performed at the beginning and end of the military course and the sports season, respectively. Results: Cardiac remodeling was observed in both groups. The soldiers presented a predominantly eccentric pattern, with increased left ventricular (LV) size (49.7±3.2 vs. 52.8±3.4 mm; p

Introduction and aims Randomized trials and registries have shown that drug-eluting stents (DES) have an overall better performance than bare-metal stents in patients treated in the setting of both ST-segment and non-ST-segment elevation acute coronary syndromes, mainly by reducing restenosis. Whether or not the use of newer second-generation devices (vs. first-generation DES) differs in these high-risk patients remains to be determined. Methods and results In a single-centre prospective registry, 3266 patients underwent a percutaneous coronary intervention with at least one DES from January 2003 to December 2009. Of these, 1423 (43.6%) were treated in the setting of an acute coronary syndrome, using either first-generation-only DES [paclitaxel or sirolimus; n=923 (64.9%)] or second-generation-only [zotarolimus or everolimus; n=500 (35.1%)]. The occurrence of death from any cause, nonfatal myocardial infarction or target vessel failure (composite primary endpoint) was compared between these two groups; repeat revascularization of the index stented lesion and definite stent thrombosis [according to the academic research consortium (ARC) definition] were assessed as isolated secondary outcomes. At a median follow-up of 598 days (interquartile range 453-1206), the incidence of death was 10.7% (152), 136 patients (9.6%) had a new myocardial infarction and target vessel failure events occurred in 147 patients (10.3%). Disparity in the follow-up duration was accounted for by considering only the 1-year major adverse cardiac event rate (n=161; 11.3%). After adjustment for baseline characteristics using a Cox proportional hazard model, we could not find a significant difference in the incidence of the composite primary endpoint at 1-year between first-generation (10.8%) and second-generation DES (12.2%) [hazard ratio (HR): 1.1; 95% confidence interval (CI): 0.82-1.57, P=0.463], nor in the occurrence of repeat target lesion revascularization (3.6 vs. 4.4%; HR 1.35; 95% CI 0.77-2.34; P=0.293). In a per patient analysis, at 1 year, ARC-definite ST was documented in 1.0% of patients treated with second-generation DES versus 2.8% in those treated with first-generation DES (corrected HR 0.36; 95% CI 0.14-0.94; P=0.037), owing mostly to a higher difference in late ST. Conclusion Our results suggest that both first-generation and second-generation DES seem to be similarly effective in patients undergoing a percutaneous coronary intervention in the setting of acute coronary syndromes. However, newer second-generation devices may offer potential advantages because of a significantly lower incidence of ARC-definite ST.

Introduction: Increased activation of the sympathetic nervous system plays a central role in the pathophysiology of hypertension (HTN). Catheter-based renal denervation (RDN) was recently developed for the treatment of resistant HTN. Aim: To assess the safety and efficacy of RDN for blood pressure (BP) reduction at six months in patients with resistant HTN. Methods: In this prospective registry of patients with essential resistant HTN who underwent RDN between July 2011 and May 2013, the efficacy of RDN was defined as ≥10 mmHg reduction in office systolic blood pressure (SBP) six months after the intervention. Results: In a resistant HTN outpatient clinic, 177 consecutive patients were evaluated, of whom 34 underwent RDN (age 62.7±7.6 years; 50.0% male). There were no vascular complications, either at the access site or in the renal arteries. Of the 22 patients with complete six-month follow-up, the response rate was 81.8% (n=18). The mean office SBP reduction was 22 mmHg (174±23 vs. 152±22 mmHg; p

The absence of coronary calcification is associated with an excellent prognosis. However, a calcium score of zero does not exclude the presence of coronary artery disease (CAD) or the possibility of future cardiovascular events. Our aim was to study the prevalence and predictors of coronary artery disease in patients with a calcium score of zero. Prospective registry consisted of 3,012 consecutive patients that underwent cardiac CT (dual source CT). Stable patients referred for evaluation of possible CAD that had a calcium score of zero (n = 864) were selected for this analysis. The variables that were statistically significant were included in a multivariable logistic regression model. From 864 patients with a calcium score of zero, 107 (12.4%) had coronary plaques on the contrast CT (10.8%, n = 93 with nonobstructive CAD and 1.6%, n = 14 with obstructive CAD). By logistic regression analysis, the independent predictors of CAD in this population were age >55 years [odds ratio (OR) 1.63 (1.05-2.52)], hypertension [OR 1.64 (1.05-2.56)] and dyslipidemia [OR 1.54 (1.00-2.36)]. In the presence of these 3 variables, the probability of having coronary plaques was 21%. The absence of coronary artery calcification does not exclude the presence of coronary artery disease, but the prevalence of obstructive disease is very low. In this population, the independent predictors of CAD in the setting of a calcium score of zero were hypertension, dyslipidemia, and age above 55 years. In the presence of these 3 predictors, the probability of having CAD was almost 2 times higher than in the general population.

The relation between body mass index (BMI) and coronary artery disease (CAD) extension remains controversial. The aim of this study was to evaluate the correlation between BMI and CAD extension documented by coronary computed tomography angiography (CCTA).Prospective registry including 1706 consecutive stable patients that performed CCTA (dual source scanner) for the evaluation of CAD. The population was stratified by BMI: normal 530 (31.1%), overweight 802 (47.0%) and obesity 374 (21.9%). BMI was significantly higher in patients with CAD (27.7 ± 4.3 vs 26.8 ± 4.3 kg/m(2), p 0.001); these patients were also older, more often male and had higher prevalence of diabetes, hypertension and dyslipidemia. By multivariate analysis (logistic regression) BMI remains an independent predictor of CAD (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01-1.06; p = 0.012). Regarding the severity of CAD, BMI was not significantly different among patients with and without obstructive CAD (27.7 ± 4.3 vs 27.2 ± 4.3 kg/m(2), p = 0.120). In 319 patients (4516 segments; 4077 evaluable), a detailed atherosclerotic burden was evaluated and compared among BMI classes, defined according to the presence of plaque and the degree of stenosis. Obstructive CAD was identified in 16.9% of the patients and 45.1% had non-obstructive CAD. The discriminative threshold for high burden, established by the segment involvement score (SIS), was5 segments with plaque (15.4% patients). The prevalence of SIS5 among the BMI classes was: 18.7%, 13.7% and 13.6% for normal, overweight and obesity respectively (p values for the specific classes versus all other patients: 0.241, 0.450 and 0.663).In this population of stable patients undergoing CCTA for suspected CAD, BMI was an independent predictor of its presence, but was not correlated with the coronary disease severity.

To describe a coronary computed tomography angiography (CCTA)-adapted Leaman score (CT-LeSc) as a tool to quantify total coronary atherosclerotic burden with information regarding localization, type of plaque and degree of stenosis and to identify clinical predictors of a high coronary atherosclerotic burden as assessed by the CT-LeSc. Single center prospective registry including a total of 772 consecutive patients undergoing CCTA (Dual-source CT) from April 2011 to March 2012. For the purpose of this study, 581 stable patients referred for suspected coronary artery disease (CAD) without previous myocardial infarction or revascularization procedures were included. Pre-test CAD probability was determined using both the Diamond-Forrester extended CAD consortium method (DF-CAD consortium model) and the Morise score. Cardiovascular risk was assessed with the HeartScore. The cut-off for the 3rd tercile (CT-LeSc ≥8.3) was used to define a population with a high coronary atherosclerotic burden. The median CT-LeSc in this population (n = 581, 8,136 coronary segments evaluated; mean age 57.6 ± 11.1; 55.8 % males; 14.6 % with diabetes) was 2.2 (IQR 0-6.8). In patients with CAD (n = 341), the median CT-LeSc was 5.8 (IQR 3.2-9.6). Among patients with nonobstructive CAD, most were classified in the lowest terciles (T1, 43.0 %; T2, 36.1 %), but 20.9 % were in the highest tercile (T3). The majority of the patients with obstructive CAD were classified in T3 (78.2 %), but 21.8 % had a CT-LeSc in lower terciles (T1 or T2). The independent predictors of a high CT-LeSc were: Male sex (OR 1.73; 95 % CI 1.04-2.90) diabetes (OR 2.91; 95 % CI 1.61-5.23), hypertension (OR 2.54; 95 % CI 1.40-4.63), Morise score ≥ 16 (OR 1.97; 95 % CI 1.06-3.67) and HeartScore ≥ 5 (OR 2.42; 95 % CI 1.41-4.14). We described a cardiac CT adapted Leaman score as a tool to quantify total (obstructive and nonobstructive) coronary atherosclerotic burden, reflecting the comprehensive information about localization, degree of stenosis and type of plaque provided by CCTA. Male sex, hypertension, diabetes, a HeartScore ≥5 % and a Morise score ≥ 16 were associated with a high coronary atherosclerotic burden, as assessed by the CT-LeSc. About one fifth of the patients with nonobstructive CAD had a CT-LeSc in the highest tercile, and this could potentially lead to a reclassification of the risk profile of this subset of patients identified by CCTA, once the prognostic value of the CT-LeSc is validated.

AIMS Nonobstructive coronary atherosclerotic lesions can lead to ST-elevation myocardial infarction (STEMI). Thrombus aspiration during a primary percutaneous coronary intervention provides a setting to evaluate the degree of stenosis of culprit lesions leading to STEMI. The aim of this study was to assess the degree of culprit lesion residual stenosis after thrombus aspiration and to compare the demographic, clinical, and angiographic characteristics between patients with obstructive versus nonobstructive residual stenosis. METHODS AND RESULTS From a single-center registry of 483 consecutive patients with STEMI undergoing a primary percutaneous coronary intervention, 172 patients underwent thrombus aspiration and were eligible for our study. We defined two groups according to the residual stenosis after thrombus aspiration: group A (n=119, 69%) with residual stenosis greater than or equal to 50%, and group B (n=53, 31%) with residual stenosis less than 50%.In terms of the baseline angiographic characteristics, patients with residual stenosis less than 50% had significantly lower prevalence of multivessel disease (15.1 vs. 46.2%, P

(1) To study the prevalence and severity of coronary artery disease (CAD) in diabetic patients. (2) To provide a detailed characterization of the coronary atherosclerotic burden, including the localization, degree of stenosis and plaque composition by coronary computed tomography angiography (CCTA). Single center prospective registry including a total of 581 consecutive stable patients (April 2011-March 2012) undergoing CCTA (Dual-source CT) for the evaluation of suspected CAD without previous myocardial infarction or revascularization procedures. Different coronary plaque burden indexes and plaque type and distribution patterns were compared between patients with (n = 85) and without diabetes (n = 496). The prevalence of CAD (any plaque; 74.1 vs. 56%; p = 0.002) and obstructive CAD (≥50% stenosis; 31.8 vs. 10.3%; p < 0.001) were significantly higher in diabetic patients. The remaining coronary atherosclerotic burden indexes evaluated (plaque in LM-3v-2v with prox. LAD; SIS; SSS; CT-LeSc) were also significantly higher in diabetic patients. In the per segment analysis, diabetics had a higher percentage of segments with plaque in every vessel (2.6/13.1/7.5/10.5% for diabetics vs. 1.4/7.1/3.3/4.4% for nondiabetics for LM, LAD, LCx, RCA respectively; p < 0.001 for all) and of both calcified (19.3 vs. 9.2%, p < 0.001) and noncalcified or mixed types (14.4 vs. 7.0%; p < 0.001); the ratio of proximal-to-distal relative plaque distribution (calculated as LM/proximal vs. mid/distal/branches) was lower for diabetics (0.75 vs. 1.04; p = 0.009). Diabetes was an independent predictor of CAD and was also associated with more advanced CAD, evaluated by indexes of coronary atherosclerotic burden. Diabetics had a significantly higher prevalence of plaques in every anatomical subset and for the different plaque composition. In this report, the relative geographic distribution of the plaques within each subgroup, favored a more mid-to-distal localization in the diabetic patients.

Hypertension is an important cardiovascular risk factor and although there have been many improvements in pharmacological treatment, a significant percentage of patients are still considered resistant. The authors describe two cases of radiofrequency renal sympathetic denervation that illustrate the feasibility of this new technique for the treatment of resistant hypertension. The procedure consists of the application of radiofrequency energy inside the renal arteries to ablate afferent and efferent sympathetic renal activity, which has been implicated in the pathophysiology of hypertension. Resumo: A hipertensão arterial é um importante fator de risco cardiovascular e apesar dos inúmeros avanços na terapêutica farmacológica, existe ainda uma percentagem importante de doentes que são resistentes. Os autores descrevem 2 casos clínicos de ablação da atividade simpática renal por radiofrequência, que ilustram a exequibilidade de uma nova técnica para o tratamento da hipertensão arterial resistente. O procedimento consiste na aplicação de energia de radiofrequência nas artérias renais, para ablação da atividade simpática renal aferente e eferente, implicada na fisiopatologia da hipertensão arterial. Keywords: Resistant hypertension, Renal denervation, Renal arteries, Palavras-chave: Hipertensão arterial resistente, Ablação por radiofrequência, Artérias renais

Aims Redefinition of myocardial infarction (MI) based on specific cardiac troponins (cTn) was universally accepted in 2007. The new definition has been widely discussed for including a large spectrum of quantitative myocardial necrosis and their clinical implications remain under debate. Our aim was to assess the impact of the universal definition of MI on mortality at 10 years. Methods and results We studied 676 consecutive patients (Pts) admitted to our intensive cardiac care unit for acute coronary syndrome (ACS) between January 1999 and December 2000. We calculated the relative risk of the total death at 10 years adjusted with the Cox proportional hazards model, between the presence and absence of MI following different definitions: (1), typical symptoms and persistent ST-segment elevation or left bundle branch block (ST-segment elevation definition); (2), typical symptoms and CK-MB activity rise and/or fall >ULN (old definition); and (3), typical symptoms and cTn I rise and/or fall >99th percentile (universal definition). The total mortality at 10 years was 23.8%. The proportion of Pts with AMI was 33.6% for ST-segment elevation definition, 55.8% for old definition, and 70.1% for universal definition. The adjusted hazard ratio of death at 10 years between the presence and absence of AMI was 0.71 (95% confidence interval (CI): 0.46–1.08; P = 0.11) for ST-segment elevation definition, 0.84 (95% CI: 0.55–1.27; P = 0.40) for old definition, and 1.58 (95% CI: 1.07–2.40; P = 0.03) for universal definition. Patients submitted to myocardial revascularization during the initial hospital stay (72%) presented a significantly lower mortality at 10 years, compared with patients not revascularized (adjusted hazard ratio: 0.63, 95% CI: 0.44–0.91; P = 0.014). Conclusions In a population with the entire spectrum of ACSs, the universal definition of MI increased this diagnosis by one-quarter and was an independent predictor of mortality at 10 years. Furthermore, myocardial revascularization was associated with a significantly lower mortality at 10 years.

Anomalous origin of coronary arteries represents a clinical challenge because of the anatomical variability and possible functional consequences, the pathophysiological mechanisms involved, and the lack of large published series that would provide evidence to guide the clinical and therapeutic approach. The authors describe the case of a 55-year-old male patient with a long history of atypical chest pain who was considered to have a low to intermediate likelihood of coronary artery disease. Therefore, and also bearing in mind his physical limitations (congenital left leg atrophy), he was referred for cardiac CT to rule out coronary artery disease. The exam showed a left coronary artery arising from the right coronary cusp and with an interarterial course, between the aorta and pulmonary trunk. Although this is a potentially malignant anatomical variant with surgical indication, a conservative approach was chosen, considering the late diagnosis and particular risk-benefit profile. Resumo: A origem anómala das artérias coronárias constitui um importante desafio clínico pela variabilidade anatómica, possíveis repercussões funcionais, mecanismos fisiopatológicos implicados e também pela ausência de grandes séries na literatura que forneçam sólida evidência científica para a sua orientação clínica e terapêutica.Os autores descrevem o caso de um doente de 55 anos, com antecedentes de hipertensão, dislipidemia e atrofia congénita da perna esquerda, que se apresentou com quadro de dor retroesternal atípica com um ano de evolução. Tendo em conta os fatores de risco cardiovasculares e exames complementares de diagnóstico previamente realizados, considerou-se ser um doente com probabilidade baixa a intermédia de doença coronária. Assim, e pela sua limitação funcional, realizou angioTC cardíaca que revelou uma origem anómala da coronária esquerda na cúspide coronária direita e com trajeto entre a aorta e a artéria pulmonar. Embora esta seja uma variante anatómica com potencial evolução maligna, optou-se por uma atitude conservadora após ponderação do risco-benefício no contexto clínico deste doente. Keywords: Anomalous origin of coronary arteries, Cardiac CT, Sudden death, Palavras-chave: Origem anómala das coronárias, AngioTC cardíaca, Morte súbita

Introduction: Pulmonary embolism (PE) is an entity with high mortality and morbidity, in which risk stratification for adverse events is essential. N-terminal brain natriuretic peptide (NT-proBNP), a right ventricular dysfunction marker, may be useful in assessing the short-term prognosis of patients with PE. Aims: To characterize a sample of patients hospitalized with PE according to NT-proBNP level at hospital admission and to assess the impact of this biomarker on short-term evolution. Methods: We performed a retrospective analysis of consecutive patients admitted with PE over a period of 3.5 years. Based on the median NT-proBNP at hospital admission, patients were divided into two groups (Group 1: NT-proBNP < median and Group 2: NT-proBNP ≥ median). The two groups were compared in terms of demographic characteristics, personal history, clinical presentation, laboratory, electrocardiographic and echocardiographic data, drug therapy, in-hospital course (catecholamine support, invasive ventilation and in-hospital death and the combined endpoint of these events) and 30-day all-cause mortality. A receiver operating characteristic (ROC) curve was constructed to determine the discriminatory power and cut-off value of NT-proBNP for 30-day all-cause mortality. Results: Ninety-one patients, mean age 69±16.4 years (51.6% aged ≥75 years), 53.8% male, were analyzed. Of the total sample, 41.8% had no etiological or predisposing factors for PE and most (84.6%) were stratified as intermediate-risk PE. Median NT-proBNP was 2440 pg/ml. Patients in Group 2 were significantly older (74.8±13.2 vs. 62.8±17.2 years, p=0.003) and more had a history of heart failure (35.5% vs. 3.3%, p=0.002) and chronic kidney disease (32.3% vs. 6.7%, p=0.012). They had more tachypnea on initial clinical evaluation (74.2% vs. 44.8, p=0.02), less chest pain (16.1% vs. 46.7%, p=0.01) and higher creatininemia (1.7±0.9 vs. 1.1±0.5 mg/dl, p=0.004). Group 2 also more frequently had right chamber dilatation (85.7% vs. 56.7%, p=0.015) and lower left ventricular ejection fraction (56.4±17.6% vs. 66.2±13.5%, p=0.036) on echocardiography. There were no significant differences in drug therapy between the two groups. Regarding the studied endpoints, Group 2 patients needed more catecholamine support (25.8% vs. 6.7%, p=0.044), had higher in-hospital mortality (16.1% vs. 0.0%, p=0.022) and more frequently had the combined endpoint (32.3% vs. 10.0%, p=0.034). All-cause mortality at 30 days was seen only in Group 2 patients (24.1% vs. 0.0%, p=0.034). By ROC curve analysis, NT-proBNP had excellent discriminatory power for this event, with an area under the curve of 0.848. The best NT-proBNP cut-off value was 4740 pg/ml. Conclusion: Elevated NT-proBNP levels identified PE patients with worse short-term prognosis, and showed excellent power to predict 30-day all-cause mortality. The results of this study may have important clinical implications. The inclusion of NT-proBNP measurement in the initial evaluation of patients with PE can add valuable prognostic information. Resumo: Introdução: O tromboembolismo pulmonar (TEP) é uma entidade responsável por elevada morbi-mortalidade, na qual a estratificação de risco assume um papel fulcral. A porção N-terminal do péptido natriurético tipo B (NT-proBNP), marcador de disfunção ventricular direita, poderá ser um biomarcador útil na avaliação prognóstica a curto-prazo dos doentes com TEP. Objectivos: Caracterizar uma amostra de doentes internados com TEP agudo de acordo com o valor sérico de NT-proBNP à data da admissão hospitalar e avaliar o impacto deste biomarcador na evolução a curto-prazo. Metodologia: Análise retrospectiva de doentes admitidos consecutivamente por TEP, durante 3,5 anos. De acordo com o valor da mediana do NT-proBNP doseado à data da admissão hospitalar, subdividimos os doentes em dois grupos (Grupo 1: NT-proBNP < mediana e Grupo 2: NT-proBNP ≥ mediana). Comparámos os dois grupos quanto às características demográficas, antecedentes pessoais, apresentação clínica, parâmetros analíticos, electrocardiográficos, ecocardiográficos, terapêutica instituída, evolução intrahospitalar (suporte catecolaminérgico, ventilação invasiva, morte intra-hospitalar e o endpoint conjunto destes eventos), bem como a mortalidade por todas as causas aos 30 dias. Construímos uma curva ROC (Receiver Operating Characteristic Curve) para determinar o poder e limiar discriminatório (valor de corte) do NT-proBNP para a ocorrência de morte por todas as causas aos 30 dias após o evento agudo. Resultados: Foram analisados 91 doentes, m=69±16,4 anos (51,6%≥75 anos), 53,8% do género masculino. Da totalidade da amostra, 41,8% não apresentava factores etiológicos/predisponentes para TEP e a maioria, 84,6% dos doentes, estratificava-se em TEP de risco intermédio. A mediana de NT-proBNP sérico foi 2440 pg/ml. Os doentes do Grupo 2 eram significativamente mais velhos (74,8±13,2 versus 62,8±17,2 anos, p=0,003) e tinham mais frequentemente história de insuficiência cardíaca (35,5% versus 3,3%, p=0,002) e de doença renal crónica (32,3% versus 6,7%, p=0,012); na avaliação clínica inicial apresentaram mais polipneia (74,2% versus 44,8, p=0,02), menos frequentemente dor torácica (16,1% versus 46,7%, p=0,01) e valores mais elevados de creatininemia (1,7±0,9 vs 1,1±0,5 mg/dl, p=0,004). Quanto aos dados ecocardiográficos o Grupo 2 apresentou mais frequentemente dilatação das cavidades direitas (85,7% versus 56,7%, p=0,015) e menor fracção de ejecção ventricular esquerda (56,4±17,6% vs 66,2±13,5%, p=0,036). Os doentes do Grupo 2 necessitaram mais frequentemente suporte catecolaminérgico (25,8% versus 6,7%, p=0,044) e tiveram maior taxa de mortalidade intrahospitalar (16,1% versus 0,0%, p=0,022) e do endpoint conjunto (32,3% vs 10,0%, p=0,034). O evento morte por todas as causas aos 30 dias ocorreu apenas no Grupo 2 (24,1% versus 0,0%, p=0,034). Na análise por curva ROC, o NT-proBNP teve um poder discriminatório excelente para a ocorrência deste evento, com área sob a curva=0,848; o valor de corte do NT-proBNP foi 4740 pg/ml. Conclusão: Níveis elevados de NT-proBNP identificaram os doentes com TEP e pior evolução a curto-prazo, apresentando uma excelente acuidade para a predição da morte de qualquer causa aos 30 dias. Os resultados deste estudo poderão ter implicações clínicas importantes, porque a incorporação do doseamento do NT-proBNP na avaliação inicial dos doentes com TEP, poderá fornecer informação prognóstica importante. Keywords: Pulmonary embolism, Risk stratification, NT-proBNP, Prognosis and mortality, Palavras-chave: Tromboembolismo pulmonar, Estratificação de risco, NT-proBNP, Prognóstico e mortalidade

ObjectivePreparticipation evaluation of veteran athletes should focus on accurate cardiovascular (CV) risk stratification and subclinical detection of coronary artery disease (CAD), which is the main cause of sudden cardiac death in this population. We aimed to investigate the effectiveness of current preparticipation methodology used to identify veteran athletes with high coronary atherosclerotic burden.MethodsA total of 105 asymptomatic male athletes aged ≥40 years old, with low to moderate CV risk (Systematic Coronary Risk Estimation ResultsThe majority of the athletes (n=88) engaged in endurance sports, with a median volume of exercise of 66 (44; 103) metabolic equivalent task score/hour/week. Exercise testing was abnormal in 13 (12.4%) athletes, 6 (5.7%) with electrocardiographic criteria for myocardial ischaemia and 7 (6.7%) with exercise-induced ventricular arrhythmias. A high coronary atherosclerotic burden was present in 27 (25.7%) athletes, of whom 11 (40.7%) had CV risk factors and 6 had abnormal exercise tests, including 3 who were positive for myocardial ischaemia.ConclusionsConventional methodology used in preparticipation evaluation of veteran athletes, based on clinical CV risk factors and exercise testing, was poor at identifying significant subclinical CAD. The inclusion of more objective markers, particularly data derived from cardiac CT, is promising for more accurate CV risk stratification of these athletes.

BACKGROUND: Catheter-based sympathetic renal denervation (RDN) is a recent therapeutic option for patients with resistant hypertension. However, the impact of RDN in left ventricular (LV) mass and function is not completely established. Our aim was to evaluate the effects of RDN on LV structure and function (systolic and diastolic) in patients with resistant hypertension (HTN). METHODS AND RESULTS: From a single centre prospective registry including 65 consecutive patients with resistant HTN submitted to RDN between July-2011 and April-2015, 31 patients with baseline and 1-year follow-up echocardiogram were included in this analysis. Mean age was 65 ± 7 years, 48% were males, 71% had type 2 diabetes. Most had hypertension lasting for more than 10 years (90%), and were being treated with a median number of 6 anti-hypertensive drugs, including 74% on spironolactone. At 1-year, there was a significant decrease both on office SBP (176 ± 24 to 149 ± 13 mmHg, p

Resumo: Mulher com miocardiopatia hipertrófica, que sofre enfarte do miocárdio aos 28 anos, sem doença coronária angiográfica. Dois anos mais tarde inicia manifestações de insuficiência cardíaca e instala-se disfunção sistólica ventricular esquerda com elevação persistente da troponina I cardíaca. A partir daí houve deterioração progressiva da função ventricular. Abstract: We present the case of a woman diagnosed with hypertrophic cardiomyopathy who suffered a myocardial infarction when she was 28 years old, without coronary artery disease on coronary angiography. Two years later, she presented signs of heart failure and left ventricular systolic dysfunction with persistent troponin I elevation, followed by progressive worsening of ventricular dysfunction. Palavras-chave: Miocardiopatia hipertrófica, Troponina, Insuficiência cardíaca, Keywords: Hypertrophic cardiomyopathy, Troponin, Heart failure

We present the case of a woman diagnosed with hypertrophic cardiomyopathy who suffered a myocardial infarction when she was 28 years old, without coronary artery disease on coronary angiography. Two years later, she presented signs of heart failure and left ventricular systolic dysfunction with persistent troponin I elevation, followed by progressive worsening of ventricular dysfunction. Resumo: Mulher com miocardiopatia hipertrófica, que sofre enfarte do miocárdio aos 28 anos, sem doença coronária angiográfica. Dois anos mais tarde inicia manifestações de insuficiência cardíaca e instala-se disfunção sistólica ventricular esquerda com elevação persistente da troponina I cardíaca. A partir daí houve deterioração progressiva da função ventricular. Keywords: Hypertrophic cardiomyopathy, Troponin, Heart failure, Palavras-chave: Miocardiopatia hipertrófica, Troponina, Insuficiência cardíaca

Introduction: Risk stratification of Brugada syndrome (BrS) remains controversial and recommendations for an implantable cardioverter-defibrillator (ICD) are not well established. The objective of this study was to assess the long-term prognosis of BrS patients with an ICD. Methods and Results: Of 55 consecutive patients with BrS assessed between April 2002 and October 2012, 36 (mean age 41.7±13.8 years; 81.8% male) underwent ICD implantation. Nineteen (52.8%) were asymptomatic, 11 (30.6%) had previous history of syncope (arrhythmic cause suspected in eight) and six (16.7%) had aborted sudden cardiac death (SCD). Spontaneous type 1 electrocardiographic (ECG) pattern was present in 25 (69.4%) patients and electrophysiological study (EPS), performed in 26 (72.2%), was positive in 22 (84.6%). During a mean follow-up of 74±40 months (>5 years in 72% of cases), seven (19.4%) patients had appropriate shocks (annual event rate 2.8%). These patients most frequently had aborted SCD (54.1% vs. 6.9%; p=0.008) and nonsustained ventricular tachycardia (57.1% vs. 10.3%; p=0.016) during follow-up. Spontaneous type 1 ECG pattern, syncope and positive EPS were not significantly associated with appropriate shocks. Multivariate analysis revealed that aborted SCD was an independent predictor of appropriate shocks (HR 8.07, 95% CI 1.58–41.2; p=0.012). ROC curve analysis demonstrated that aborted SCD had moderate discriminatory power to predict appropriate shocks (AUC 0.751), with sensitivity of 57% and specificity of 93%. In terms of ICD-related complications, eight (22.2%) patients had inappropriate shocks during the follow-up period, mainly due to sinus tachycardia (five patients); one patient had lead infection and another had a lead fracture. Conclusion: In this population of BrS patients with ICD, the long-term rate of appropriate shocks was 2.8%/year. Aborted SCD was associated with a higher risk of appropriate shocks, whereas syncope and spontaneous type I ECG pattern did not predict this event. Resumo: Introdução: A estratificação de risco na síndrome de Brugada (SB) permanece controversa e as recomendações para cardiodesfibrilhador (CDI) não estão bem definidas. O objetivo deste estudo foi avaliar o prognóstico a longo prazo de doentes com SB e CDI implantado. Métodos e resultados: De 55 doentes consecutivos com SB avaliados entre abril/2002-outubro/2012, 36 (idade média 41,7±13,8 anos; 81,8% homens) implantaram CDI. Dezanove (52,8%) eram assintomáticos, 11 (30,6%) tinham história de síncope (oito com suspeita de causa arrítmica) e seis (16,7%) foram reanimados de morte súbita (MS). O eletrocardiograma (ECG) com padrão tipo 1 espontâneo estava presente em 25 (69,4%) doentes e foi realizado estudo eletrofisiológico (EEF) em 26 (72,2%), sendo positivo em 22 (84,6%). Durante o período de seguimento médio de 74±40 meses (>5 anos em 72% dos casos), sete (19,4%) doentes tiveram choques apropriados (incidência anual 2,8%). Estes doentes tinham mais frequentemente história de MS abortada (54,1 versus 6,9%; p=0,008) e taquicardia não mantida (57,1 versus 10,3%; p=0,016) durante o seguimento. Padrão ECG tipo 1 espontâneo, síncope e EEF positivo não se associaram significativamente à ocorrência de choques apropriados. Em análise multivariada a MS abortada manteve-se preditor independente de choques apropriados (HR 8,07 IC95% 1,58-41,2; p=0,012). Em análise de curvas ROC a MS abortada apresentou um poder discriminatório moderado para predizer choques apropriados (AUC 0,751) – sensibilidade 57% e especificidade 93%. Relativamente às complicações relacionadas com o CDI, oito (22,2%) doentes tiveram choques inapropriados durante o período de seguimento, sobretudo por taquicardia sinusal (cinco doentes), um infeção de elétrodo e outro fratura de elétrodo. Conclusão: Na população estudada de doentes com SB e CDI implantado a incidência de choques apropriados foi 2,8%/ano. A MS abortada associou-se a um maior risco de choques apropriados, enquanto a síncope e o padrão de ECG tipo 1 espontâneo não foram preditores deste evento. Keywords: Brugada syndrome, Implantable cardioverter-defibrillator, Prognosis, Syncope, Sudden cardiac death, Appropriate shocks, Palavras-chave: Síndrome de Brugada, Cardiodesfibrilhador, Prognóstico, Síncope, Morte súbita, Choques apropriados

Correspondencia: Helder Dores • Rua Jose Cardoso Pires, N5, 7A, Lumiar, 1750-356, Lisboa E-mail: heldores@hotmail.com Artigo recebido em 22/05/12, revisado em 04/08/12, aceito em 29/10/12. Palavras-chave Oclusao Coronaria/diagnostico, Cardiomiopatia de Takotsubo/diagnostico, Angiografia Coronaria, Cateterismo Cardiaco, Meios de Contraste. Introducao As situacoes de instabilidade hemodinâmica durante a realizacao de coronariografia sao mais comuns em doentes com doenca coronaria grave, sobretudo na presenca de sindromes coronarias agudas. Raramente podem ocorrer em contexto eletivo, mesmo na ausencia de doenca coronaria, devido a embolizacao gasosa inadvertida e ao aumento da vasorreatividade coronaria1,2. O vasospasmo coronario tem sido implicado como um dos possiveis mecanismos fisiopatologicos envolvidos na miocardiopatia de Tako-tsubo (MCT), embora estejam descritos poucos casos na literatura que comprovem esta associacao3. Apresentamos o caso de um paciente com instabilidade hemodinâmica transitoria durante a realizacao de coronariografia eletiva, com evidencia de vasospasmo multivaso e achados sugestivos de MCT.

Introduction and Aims: Percutaneous coronary intervention (PCI) is increasingly used as a treatment option for unprotected left main coronary artery (ULMCA) lesions. We aimed to evaluate the long-term outcome of patients undergoing ULMCA PCI. Methods and Results: We retrospectively analyzed 95 consecutive patients (median EuroSCORE I 2.9 [IQR 1.4;6.1]) who underwent ULMCA PCI between 1999 and 2006, included in a single-center prospective registry. The primary outcome was major adverse cardiovascular events (MACE) defined as all-cause death, myocardial infarction (MI) and target lesion revascularization (TLR) at five years. Forty patients (42.1%) were treated in the setting of acute coronary syndrome and 81 patients (85%) had at least one additional significant lesion (SYNTAX score 24.2±11.8). Single ULMCA PCI was performed in 33% (81.1% with drug-eluting stents) and complete functional revascularization was achieved in 79% of the patients. During the observation period, 20 patients died (21.1%), 6 (6.3%) had MI and 11 (11.6%) had TLR (total combined MACE 28.4%). Independent predictors of MACE were previous MI (HR 2.9 95% CI 1.23–6.92; p=0.015), hypertension (HR 5.7 95% CI 1.86–17.47; p=0.002) and the EuroSCORE I (HR 1.1 95% CI 1.03–1.12; p=0.001). Drug-eluting stent implantation was associated with a significantly lower MACE rate, even after propensity score adjustment (AUC=0.84; HR [corrected] 0.1; 95% CI 0.04–0.26; p

FUNDAMENTO: O trastuzumabe (TZB) é um anticorpo monoclonal humanizado recombinante usado no tratamento do câncer de mama HER2-positivo, com reconhecida cardiotoxicidade associada. Os métodos para sua detecção subclínica precoce não estão bem estabelecidos. OBJETIVO: Avaliar a cardiotoxicidade induzida por TZB em pacientes (pts) portadoras de câncer de mama acompanhadas por um período de 3 meses de tratamento. MÉTODOS: Estudo prospectivo de pts consecutivas em tratamento com TZB para câncer de mama HER2-positivo avançado, admitidas entre maio e setembro de 2010. Foram comparados dados clínicos, laboratoriais e ecocardiográficos antes da introdução de TZB e 3 meses após o início do tratamento com a droga. Foram estudadas a deterioração da função sistólica do ventrículo esquerdo (segundo critérios do Comitê de Avaliação e Revisão Cardíaca) e a função diastólica (classificação da Sociedade Americana de Ecocardiografia). RESULTADOS: Estavam disponíveis dados de 51 pacientes, cuja idade média era de 55,4±14,0 anos. Nenhuma paciente apresentou insuficiência cardíaca sintomática no terceiro mês. Não houve diferenças na fração de ejeção do ventrículo esquerdo (FEVE) aos 3 meses (69,3 ± 7,4 contra 67,1 ± 6,5%, p > 0,05), tendo sido observada redução em 57,9% pts (em apenas uma a FEVE foi < 55%). Houve aumento significativo da relação E/e' (3,9 ± 0,8 contra 8,0 ± 1,9, p < 0,001) devido a uma redução da velocidade e' (0,19 ± 0,02 contra 0,10 ± 0,03, p < 0,001). Os demais parâmetros diastólicos permaneceram inalterados. Tanto o volume atrial esquerdo quanto o ventricular esquerdo permaneceram inalterados. Não houve aumento dos níveis de peptídeo natriurético tipo pró-B N-terminal. Durante o período de seguimento, duas pacientes morreram e duas foram internadas, todas por causas não cardiovasculares. CONCLUSÃO: Durante os três primeiros meses de tratamento com TZB, nenhuma das pacientes apresentou insuficiência cardíaca franca ou deterioração significativa da FEVE. Detectou-se redução significativa da relação e/e', porém sem alterações importantes dos parâmetros de carga e da FEVE. BACKGROUND: Trastuzumab (TZB) is a recombinant humanized monoclonal antibody, used for the treatment of HER2-positive breast cancer, with recognized associated-cardiotoxicity. The methods for its early sub-clinical detection are not well defined. OBJECTIVE: To evaluate TZB-induced cardiotoxicity in patients (pts) with breast cancer followed for a 3-month period of treatment. METHODS: Prospective study of consecutive pts treated with TZB for advanced HER2-positive breast cancer enrolled between May-September/2010. A comparison of clinical, laboratory and echocardiographic data, prior to and at the 3rd month after starting TZB was performed. Left ventricular systolic function deterioration (Cardiac Review and Evaluation Committee criteria) and diastolic function (American Society of Echocardiography classification) were studied. RESULTS: Data were available for 51 women, mean age = 55.4 ± 14.0y. At the 3rd month, no patient had symptomatic heart failure. Left ventricular ejection fraction (LVEF) did not differ at 3 months (69.3 ± 7.4 vs. 67.1 ± 6.5%, p > 0.05), decreasing in 57.9% pts (only one to LVEF < 55%). There was a significant increase in the E/e' ratio (3.9 ± 0.8 vs. 8.0 ± 1.9, p < 0,001) due to an e' velocity reduction (0.19 ± 0.02 vs. 0.10 ± 0.03, p < 0.001). Other diastolic parameters remained unchanged. Both the left atrial and the left ventricular volumes remained unchanged. N-terminal pro-B type natriuretic peptide levels did not increase. During the follow up period two pts died and two were admitted to the hospital, all for non-cardiovascular causes. CONCLUSIONS: During the first 3 months of TZB treatment none of the pts presented overt heart failure or significant LVEF deterioration. A significant reduction in the E/e' ratio was detected, but neither the loading parameters nor LVEF changed significantly .

Cardiac computed tomography (CT) documents the presence of coronary artery disease, regardless of the degree of stenosis. The prognostic value of non-obstructive coronary artery disease documented by cardiac CT has recently been validated. However, there are still no clear guidelines on the management of such patients, particularly concerning initiation of more aggressive pharmacological measures for primary prevention. The approach to these patients remains controversial, especially in cases in which there is a discrepancy between cardiovascular risk and the atherosclerotic burden as documented by cardiac CT.The authors describe the case of a patient with a discrepancy between the extent of documented coronary atherosclerosis and that estimated according to pretest probability and cardiovascular risk scores. As this individual had more severe coronary atherosclerosis than expected (calcium score above the 90th percentile and non-obstructive coronary artery disease on cardiac CT) but was a competitive athlete and otherwise asymptomatic and without risk factors or cardiovascular history, with a very low estimated cardiovascular risk, it was difficult to decide on the risks and benefits of pharmacological primary prevention. Resumo: A tomografia computorizada cardíaca (angioTC cardíaca) permite documentar a presença de doença coronária, independentemente do seu grau de estenose. Recentemente, foi validado o valor prognóstico da doença coronária não obstrutiva documentada por angioTC cardíaca. No entanto, não existem ainda recomendações claras acerca da abordagem destes doentes, nomeadamente sobre o início de medidas farmacológicas mais agressivas em prevenção primária. A abordagem destes doentes permanece controversa, sobretudo nos casos em que existe uma discrepância entre o risco cardiovascular e a carga aterosclerótica objetivada na angioTC.Os autores descrevem o caso de um doente com discrepância entre a extensão da aterosclerose coronária objetivada e a sua estimativa de acordo com os scores de probabilidade pré-teste e de eventos cardiovasculares. Tratando-se de um indivíduo com documentação de aterosclerose coronária acima do esperado - score de cálcio superior ao percentil 90 e doença coronária não obstrutiva na angioTC cardíaca, mas por outro lado, assintomático e sem fatores de risco nem antecedentes cardiovasculares, com uma estimativa de risco cardiovascular muito baixa e atleta de competição, torna-se difícil decidir acerca do risco/benefício de medidas farmacológicas de prevenção primária. Keywords: Cardiac computed tomography, Non-obstructive coronary artery disease, Physical exercise, Palavras-chave: Tomografia computorizada cardíaca, Doença coronária não obstrutiva, Exercício físico

Purpose: To assess and compare the prognostic value of coronary CT angiography (CCTA) and exercise ECG (ExECG) in patients with suspected stable angina pectoris. Methods: Patients with suspected coronary artery disease (CAD) who had undergone both ECG exercise stress testing (ExECG) and CCTA (within 180 days) were identified retrospectively in a single center registry. The presence of 50% or greater coronary stenosis was assessed with CCTA. ExECG results were classified as normal, ischemic, or nondiagnostic. Patients were followed-up for major adverse cardiac events (MACE), defined as cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, and revascularization >90 days after index CCTA. Univariable and multivariable Cox regression analysis was used to determine the prognostic values, and discriminative power was assessed with continuous net reclassification improvement (cNRI). Results: Follow-up was completed for 467 patients (88%), with a median duration of 2.6 years (IQR 2.0-3.8). A total of 23 patients experienced MACE, including 3 deaths and 2 non-fatal myocardial infarctions. In the univariable model, modified CAD Consortium 2 score (HR 1.05, 95% CI 1.02-1.08), non-obstructive CAD (HR 5.63, 95% CI 1.25-25.43) and obstructive CAD (HR 15.43 CI 3.38-70.45) were predictors of MACE. In the multivariable model, only CCTA findings remained independently predictive of MACE. Addition of CCTA results to the clinical and ExECG model yielded a cNRI of 70% (222 reclassified upward, 245 downward). ![Figure][1] Conclusions: CCTA findings are strongly predictive of MACE. Its prognostic power seems superior and incremental to clinical and exercise ECG data. [1]: pending:yes

Introduction: Brugada Syndrome (BS) is associated with increased risk of Sudden Cardiac Death (SCD). Risk stratification of BS patients remains controversial and recommendations for implantable cardioverter-defibrillator (ICD) implantation is not well established. Our aim was to evaluate long-term prognosis of BS patients with ICD implanted and to identify the predictors of appropriate shocks. Methods and results: Fifty-five consecutive patients (age 41.7±13.8 years; 81.8% male) with BS, of whom 36 (65.5%) implanted an ICD, were included. Twenty-five (69.4%) patients had spontaneous Type 1 Electrocardiogram (ECG) pattern, 17 (47.2%) were symptomatic [syncope 11 (30.6%) and aborted SCD 6 (16.7%)] and 14 (38, 9%) had family history of SCD. During the mean follow-up of 74±40 months (>5 years in 72% patients), 7 (19.4%) patients experienced appropriate shocks. These patients had most frequently aborted SCD (54.1% vs. 6.9%, p=0.008) and non-sustained ventricular tachycardia episodes (57.1% vs. 10.3%, p=0.016) during the follow-up. Spontaneous Type 1 ECG pattern and syncope were not significantly associated with the occurrence of these events. By multivariate analysis (Cox regression), aborted SCD was an independent predictor of appropriate shocks (HR 8.07 95% CI 1.58 to 41.2, p=0.012). Receiver operating characteristic analysis showed a moderate discriminatory power of aborted SCD to predict appropriate shocks - area under curve 0.751, sensitivity 57% and specificity 93% (Table 1). View this table: Table 1. Predictive value of different characteristics for appropriate shocks Conclusions: In this population of patients with Brugada syndrome and ICD implanted, the rate of appropriate shocks at long-term was low. Aborted sudden cardiac death was associated with higher risk, while syncope and spontaneous Type I ECG pattern were not predictors of appropriate shocks.

Purpose: To evaluate the performance of classic risk factors, alone or associated in scores, in identifying a higher than expected coronary atherosclerotic burden. Methods: We assessed 2069 consecutive patients (56% men, mean age 58±11 years) undergoing coronary CT angiography (CCTA) with Calcium Score (CaSc) for suspected coronary artery disease. A higher than expected atherosclerotic burden was defined as a CaSc >75th percentile (CaSc>p75) according to age and sex-adjusted nomograms. The ability of traditional risk factors to predict a CaSc>p75 was assessed in a customized logistic regression model (clinical score) and by the calculation of the HeartScore. The Population Attributable Risk (PAR) of the various risk factors for CaSc>p75 was also calculated. Results: The median CaSc was 3.0 [IQR 0.0-98.0], with 362 patients (17.5%) having CaSc>p75. The median HeartScore was 3.0 [IQR 1.0-4.0]. With the exception of hypertension, all classic risk factors were independent predictors of CaSc>p75: diabetes mellitus, dyslipidemia, smoking and family history (all OR 1.3-2.2, p≤ 0.026). The areas under the ROC curves to predict CaSc>p75 were 0.64 for the clinical score (95% CI 0.61-0.67, p p75 were in the two lower quartiles of the clinical score (Figure). Altogether, the various classical risk factors seem to explain only 56% of the prevalence of CaSc>p75 (adjusted PAR 0.56). Conclusion: Despite the statistical association of CV risk factors with a higher than expected atherosclerotic burden, they seem to justify only half of its prevalence. Even when integrated in scores, the predictive power of these risk factors is relatively modest, exposing the limitations of a risk stratification based solely on demographic and clinical risk factors.

Gerbode defect is a rare type of left ventricle to right atrium shunt. It is usually congenital in origin, but acquired cases are also described, mainly following infective endocarditis, valve replacement, trauma or acute myocardial infarction. We report a case of a 50-year-old man who suffered an extensive and complex infective endocarditis involving a bicuspid aortic valve, the mitral-aortic intervalvular fibrosa and the anterior leaflet of the mitral valve. After dual valve replacement and annular reconstruction, a shunt between the left ventricle and the right atrium - Gerbode defect, and a severe leak of the mitral prosthesis were detected. Reintervention was performed with successful shunt closure with an autologous pericardial patch and paravalvular leak correction. No major complications occurred denying the immediate post-surgery period and the follow-up at the first year was uneventful.