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Background Impaired left ventricular ejection fraction (LVEF) and chronic kidney disease (CKD) have been associated with poorer outcomes in acute coronary syndrome (ACS). Increasing evidence on global left ventricular longitudinal strain (GLS) suggests superiority over left ventricular ejection fraction (LVEF) in risk stratification. Methods This study was based on a retrospective analysis of consecutive patients admitted to a Coronary Care Unit between 2009 and 2016. Baseline characteristics and echocardiographic parameters, including LVEF, were assessed. For each patient, a two-dimensional speckle tracking of the left ventricle was assessed and average GLS was calculated using 2, 3 and 4-chamber views. Blood creatinine was measured during hospital stay and used to estimate glomerular filtration rate (GFR) with Modification of Diet in Renal Disease (MDRD) equation. A cox regression analysis was performed to determine mortality prediction value of average GLS, LVEF and GFR in this population. Receiver operating characteristic (ROC) curve analysis was conducted and area under the curve (AUC) was estimated. Results A total of 85 patients (66.7±12.7 years old; 78.8% males) were enrolled. LVEF mean was 49.4±9.8% and average GLS was −16.0±4.0%. GFR median was 80.0±48.9 ml/min/1.73m2. In cox regression analysis, worse average GLS was associated with greater mortality (HR 0.721; 95% CI 0.599–0.867; P=0.001). GFR was inversely related to death (HR 0.967; 95% CI 0.944–0.991, P=0.008). In cox regression analysis using average GLS and GFR as covariates, both proved to be independent predictors of mortality (for average GLS, HR 0.748; 95% CI 0.610–0.918, P=0.005; for GFR, HR 0.974; 95% CI 0.949–0.999; P=0.044). The AUC of average GLS to predict mortality was 0.78 (P Conclusions GLS and CKD proved to be independent predictors of mortality in ACS patients. GLS showed superiority when compared to LVEF in risk stratification and in the future it might replace LVEF. The model combining GLS and GFR emphasized the increased risk of CKD patients and how they should be seen as high-risk patients. ROC curve analysis Funding Acknowledgement Type of funding source: None

Background Myocardial perfusion imaging (MPI) plays a significant role in diagnostic and therapeutic decision making in coronary artery disease (CAD). An isolated apical defect in the 17th segment in SPECT/CT scans is a common finding, sometimes attributed to the apical thinning phenomenon. However, the clinical significance of apical thinning or other isolated apical defects is unknown. Purpose The purpose of this study is to assess the prognostic impact of an isolated apical perfusion defect (17th segment) in patients (P) with suspicion of significant CAD. Methods A cohort of 612 consecutive P that underwent a MPI test with a SPECT/CT scanner, between January 2017 and December 2017, in a single nuclear medicine centre, was included in this retrospective study. The inclusion criteria for this study were either a normal perfusion exam (group 1 – G1) or only an isolated apical defect in the 17th segment, either reversible suggesting ischemia (group 2 – G2) or fixed suggesting necrosis (group 3 – G3). Images with and without attenuation correction were analysed. Mean follow-up was 29±4 months. The chi square test was used for categorical variables, and analysis of variance for continuous variables. Binary logistic regression was used to control for confounding. Results A total of 612 P were included (57% male sex, mean age of 69±10) and divided in G1 (n=494, 80.7%), G2 (n=62, 10%) and G3 (n=56, 9.2%). P in G3 had higher body mass index (31±7, p=0.028) and higher prevalence of dyslipidemia (84%, p=0.001), while P in G1 had lower ejection fraction at rest (54±15, p=0.001). There was no association between the presence of isolated apical defect and all- cause mortality (G1 = 7.3% vs G2 = 6.5% vs G3 = 5.4%, p=0.851). There was a statistically significant difference between groups in the referral for coronary angiography in the bivariate analysis (G1 = 7.9% vs G2 = 35.5% vs G3 = 10.7%, p=0.001), but this association did not remain when accounted for potential confounders (angina, ejection fraction, previous CAD and diabetes) – OR=3.94, 95% CI: [0.968–16.093], p=0.056. In those P that underwent coronary angiography, there was no statistically significant difference between the 3 groups in revascularization of significant CAD (G1 = 38.5% vs G2 = 36.4% vs G3 = 50%, p=0.830). During the follow-up time, 11 P of group 1 suffered an acute coronary syndrome (ACS), but there were no events in group 2 or 3. Conclusion Isolated apical myocardial defect on a SPECT/CT exam has no association with all-cause mortality in this patients. There is no significant difference in referral for coronary angiography or need for coronary revascularization between P with normal exams and P with isolated apical defects. Funding Acknowledgement Type of funding source: None

Background Statins are highly effective in preventing major acute cardiovascular events in the setting of atherosclerotic arterial disease. On the other hand, given their antithrombotic and anti-inflammatory properties, statins may also attenuate patients' odds of developing venous thromboembolism (VTE). However, clinical studies have yielded variable estimates of this effect. Purpose To perform a meta-analysis designed to evaluate the extent to which statin use influences the rate of subsequent VTE events. Methods We systematically searched MEDLINE, Embase, Web of Science, Cochrane Library and Google Scholar for both randomized controlled trials (RCTs) and observational studies addressing the association between statins and VTE risk, published up until December 1, 2019. Manually reviewed references and key investigators interaction via e-mail correspondence were also data sources. RCTs comparing the effects of statin therapy with those of a placebo or no treatment were included, while interventional studies appraising different lipid-lowering pharmacological strategies were not. Observational studies encompassed both cohort and case-control designs. The primary endpoints were general VTE, deep vein thrombosis or pulmonary embolism. Patients with cancer, heart failure and chronic kidney disease (CKD) were further investigated separately. Study-specific relative risks (RRs) were pooled using generic inverse variance outcome meta-analytic technique with a random-effects model. Results 23 RCTs comprising 118.464 participants, 12 cohort studies encompassing 2.881.184 patients and 9 case-control studies including 354.367 patients were regarded as eligible for quantitative evaluation. Specifically, 5 observational studies comprising 9.656 cancer patients, 3 studies encompassing 9.693 heart failure patients and 4 studies including 4.353 CKD patients were gathered. In RCTs, statin therapy was proven slightly superior to placebo or no treatment in lowering VTE incidence (RR 0.85, 95% CI 0.73–0.99, p=0.04, i2=14%). Observational studies were found to corroborate this effect, with statin treatment resulting in VTE risk reduction overall (RR 0.72, 95% CI 0.64–0.81, p Conclusion Currently available evidence suggests that statins significantly reduce patients' odds of developing VTE. Given their favorable safety profile and low cost, statin treatment should now be considered in high-risk individuals, particularly in those with cancer. Funding Acknowledgement Type of funding source: None

Background Among all subsets of coronary artery lesions, bifurcations stand out due to high incidence, demanding percutaneous interventions (PCIs) and poor outcomes. Amid the different PCI strategies, the provisional (PS) approach is generally recommended over 2-stent (TS) techniques, but this paradigm has been challenged. Purpose To compare PS with TS for PCI of coronary bifurcation lesions, concerning procedural aspects and both immediate and long-term patient outcomes. Methods Retrospective study encompassing patients consecutively referred to a tertiary interventional cardiology unit for coronary angiography, who were found to have at least 1 native bifurcation lesion. According to operator experience and angiographic features, patients were managed with PS or/(and) TS. Procedural aspects regarding radiological variables, angiographic success and immediate complications were reviewed, as were in-hospital outcomes. Besides, clinical follow-up, by clinic appointment or telephone calling, was performed targeting stent failure, target vessel revascularization (TVR), acute coronary syndromes (ACS), heart failure and mortality. Results From January 2010 to June 2017, 404 patients with 433 bifurcation lesions were included. Median age was 70 (62–77) years and 25.3% were female. Median follow-up was 2 (1–3) years. Chronic angina was the dominant PCI context (61.3%) with 9.7% presenting with ST-segment elevation myocardial infarction (MI). Medina class 1,1,1 was documented in 54.1% and 64.9% of lesions were hailed as true bifurcations. 303 patients underwent PS, whereas 67 were managed with TS, with TAP (43.3%) and mini-crush (34.3%) as the leading techniques. True bifurcations were more frequently approached with TS (p Conclusion PS outperforms TS during follow-up, particularly due to lower stent failure odds. Thus, this study further supports the concept of PS as the standard approach for coronary bifurcation lesions. Funding Acknowledgement Type of funding source: None

Background Historically, women (W) with acute coronary syndrome (ACS) have worse outcomes compared with men (M). This fact may occur due to gender-specific differences in the presentation and management of patients (P), which were mainly observed in studies dealing with ST-segment elevation infarction (STEMI). There seems to be a gap of knowledge in gender-specific differences in non- ST elevation myocardial infarction (NSTEMI) and unstable angina (UA). Purpose Assess gender-specific differences in presentation, treatment and outcomes in NSTEMI and UA patients. Methods A retrospective cohort study from consecutive ACS patients enrolled in a multicentre national registry from October 2010 to December 2018 was conducted, identifying 11394 P admitted with NSTEMI or UA. Demographic, clinical and treatment variables were compared between male gender and female gender P. A Cox multivariate regression was performed to evaluate predictor factors of stablished endpoints: mortality at 1-year (1y) and cardiovascular (CV) hospitalization at 1-year. Results A total 11394 P were included, 8145 M (71.5%) and 3249 W (28.5%), mean age of 68±13. W, comparing with M, had higher age (72±12 vs 66±13, p=0.001), higher prevalence of hypertension (85% vs 72%, p=0.001) and diabetes (41% vs 34%, p=0.001) and longer time from symptoms to hospital admission (360 minutes vs 297 minutes, p=0.001). Chest pain was less frequent as first symptom in W (85.6% vs 91.3%, p=0.001). In medical treatment, W had higher chance of not having administration of a loading dose of P2Y12 inhibitor (22.1% vs 18.1, p=0.001) and of being medicated with clopidogrel (85.7% vs 82.1%, p=0.002). At discharge, W were less frequently medicated with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (82.6% vs 84.4, p=0.028). Coronary angiography was less frequently performed in W (77.3% vs 85.7%, p=0.001). Coronary artery disease was less frequently found in the female gender (12.4% vs 4.8%, p=0.001). In-hospital mortality was higher in W (2.9% vs 2.1%), but in the multivariate analysis the female gender was not an independent predictor of in-hospital mortality (OR 1.05 [0.67- 1.65], p=0.823). 1-year mortality was higher in W (9.2% vs 7.3%) and 1-year CV hospitalization was higher in M (16.8% vs 14.4%). After adjusting for covariates in Cox regression analysis, difference was still significant for mortality (HR= 1.274 [1.038 - 1.564], p=0.02) and hospitalization (HR = 0.852 [0.726- 0.998], p=0.047). Conclusion In this NSTEMI and UA cohort, there are important gender-specific differences in comorbidities, diagnosis, management and outcomes. Gender was an independent predictor of 1-year mortality and 1-year CV hospitalization, but not an independent predictor for in-hospital mortality. Funding Acknowledgement Type of funding source: None

Background Currently available pharmacological options for rhythm control in atrial fibrillation (AF) are overshadowed by suboptimal efficacy and both frequent and potentially severe adverse events. Recent studies have added evidence to the hypothesis that ranolazine might exert antiarrhythmic effects, particularly in atrial tachyarrhythmias. Purpose To perform a systematic review with meta-analysis in order to ascertain the potential role of ranolazine in the management of AF. Methods We systematically searched MEDLINE, Embase and Scopus for randomized controlled trials (RCTs) and cohort studies addressing the association between ranolazine and AF outcomes, published up until December 1, 2019. The primary endpoint was incidence of AF, which was evaluated under a ranolazine versus placebo design. In this regard, patients in the setting of postcardiac surgery were further investigated separately. Secondary endpoints included AF cardioversion outcomes, which were addressed through comparison between ranolazine plus amiodarone and amiodarone alone for proportional efficacy and temporal requirements (time-to-cardioversion). The latter analysis was also undertaken in a dose-sensitive fashion (≤1000mg vs. 1500mg of ranolazine). Tertiary endpoints covered AF burden and episodes, in paroxysmal AF patients, and safety outcomes, namely death, QTc interval prolongation and hypotension. Study-specific odds ratios (ORs) were pooled using meta-analytic techniques with a random-effects model. Results A total of 10 RCTs comprising 8.109 participants and 3 cohort studies encompassing 37.112 patients were regarded as eligible for evaluation. Ranolazine was found to attenuate patients' odds of developing AF (OR 0.53, 95% CI: 0.41–0.69, p Conclusion Current evidence suggests that ranolazine provides an effective and safe option for a chemical rhythm control strategy in AF management, a field in which medical breakthroughs are desperately needed. Funding Acknowledgement Type of funding source: None

Background As the population ages, doctors are being challenged by the decision to offer intervention treatment in increasingly older and fragile patients. The comorbidity burden and performance status should be considered when making the decision. Purpose To assess the impact of optimal medical therapy (OMT) versus percutaneous coronary intervention (PCI) in non-ST elevation acute coronary syndrome (ACS) patients older than 80 years. Methods 182 patients older than 80 years old admitted to a single coronary care unit with a diagnosis of non-ST elevation ACS, who survived hospital stay were included. Clinical, laboratorial and echocardiographic data were evaluated. Two groups were created: Group A (OMT group) N=83; Group B (PCI group) N=99. The primary endpoint was long-term all-cause mortality. Kaplan-Meyer curves and Cox regression were conducted to evaluate the impact of OMT versus PCI on the primary endpoint. The mean time of follow-up was 37±29 months. Results Groups were homogenous regarding gender, cardiovascular risk factors, heart failure diagnosis, left ventricular (LV) systolic function and peak troponin I. OMT group patients were older (85.1±3.7 vs 82.7±3.2 years old, P Conclusion Increased survival in older patients receiving PCI after a non-ST elevation ACS may be ascribed to the selection of patients with less comorbidities. This reinforces the idea it may be applied in well-fit patients regardless of age. In our elderly population, lower Hb level, peak troponin and impaired LV systolic function appear to be the main contributors to decreased survival, irrespective of intervention.

Introduction In a normal heart, the passive leg lifting maneuver (LLM) will result in an increase in myocardial contractility, according to the mechanistic concept of the Frank-Starling law. With the progression of myocardial disease this ability is impaired and the myocardial functional reserve (mFR) is reduced (Figure1 – Panel A). The variation of left ventricular global longitudinal strain (as an index of contractile function) with LLM may thus represent a marker of left ventricular mFR. Purpose To assess the variation of left ventricular global longitudinal strain (LV GLS) with LLM as a marker of mFR in a healthy population and in patients with myocardial disease (hypertrophic myocardiopathy - HCM and systolic dysfunction patients – SystDysf. Methods and results We evaluated the variation of LV GLS by 2-dimensional Speckle Tracking Echocardiography (2D-STE), in response to passive LLM, in a population of 103 individuals (54 healthy individuals, 28 HCM patients and 21 left ventricular SystDysf patients). Clinical, demographic and echocardiographic parameters (including LV longitudinal mechanics obtained with 2D-STE before and after LLM) were described. The population had a mean age of 46±18 years and 55% were women. Increased venous return to the heart during LLM was confirmed by an increase in the maximal diameter of the inferior vena cava (15,1±3,6 vs 20,6±3,8 mm, p There was a significant variation of LV GLS in healthy individuals submitted to LLM (−20,58±3,0 vs −21,5±2,6%, p=0,02, Δ 0,6%, 95% CI 0,1–1,1%). Regarding the HCM and SystDysf groups, no significant change in LV GLS was observed with LLM (−13,2±2,8 vs −12,3±2,9%, p=0,12, Δ +0,6%, 95% CI −1,4 to 0,18% and −10,2±2,5 vs 10,2±2,7%, p=0,79, Δ 0,08%, 95% CI −0,7 to 0,5%, respectively). Figure 1 (Panel B) Conclusion To our knowledge, this is the first report describing the use of LV GLS and LLM to assess mFR in this clinical setting. The absolute increase of LV GLS in the healthy population suggests that this may be a reliable method and a sensitive marker to assess the mFR. Conversely, patients with HCM and with SystDysf show poor or no response to the LLM, suggesting, as expected, a low myocardial functional reserve. Given the non-invasiveness and cost-effectiveness nature of this technique, we suggest that this maneuver could pose a feasible way to assess mFR. Further studies are needed to validate this technique and to assess the role of mFR by 2D-STE as a prognostic marker.

Background Prediabetic patients are at increased risk of composite cardiovascular (CV) events and all-cause mortality. The impact of prediabetes diagnosis in the context of an acute coronary syndrome (ACS) remains to be determined. Purpose To assess the differences on long-term mortality between well controlled diabetic and prediabetic patients admitted with non-ST elevation ACS. Methods 352 non-ST elevation ACS patients admitted to a single coronary care unit between 2009 and 2016 were included. Clinical, laboratorial and echocardiographic data were evaluated. Two groups were created based on the diabetic status and HBA1c level: Group A (prediabetic patients, HBA1c between 5.7–6.4%) N=229; Group B (diabetic patients, HBA1c ≤7%) N=123. The primary endpoint was long-term all-cause mortality. Kaplan-Meyer survival curves and Cox regression were done. The mean time of follow up was 48±30 months. Results The groups were similar regarding demographics, CV risk factors, ACS type, heart failure diagnosis, peak troponin I, left ventricular (LV) systolic function, multivessel disease and treatment option (PCI, CABG or OMT). On the contrary, well controlled diabetic patients had a higher prevalence of chronic kidney disease (CKD) (27.9% vs 39.0%, P Conclusion In the context of an ACS, prediabetics should be regarded as a high-risk group. This study raises the provocative question that prediabetics and diabetics patients should be approached in similar ways in terms of risk stratification and therapeutic options after an ACS. In these patients, age, peak troponin and impaired LV function appear to be the main contributors to decreased survival.

As equipes multiprofissionais foram adotadas na Estratégia de Saúde da Família (ESF), justamente para que este modelo de atenção permita a articulação entre saberes na prática da assistência à saúde. OBJETIVO: Investigar a percepção dos médicos, enfermeiras e odontólogos sobre o funcionamento de equipes multiprofissionais na Saúde da Família do município de Coari (AM). MÉTODOS: Pesquisa qualitativa, com roteiro semiestruturado, aplicado em entrevistas individuais a todos os profissionais da atenção primária do município, comparadas a entrevistas com fisioterapeutas e psicólogos de serviço secundário, analisadas à luz da hermenêutica dialética. RESULTADOS: Com exceção do discurso dos psicólogos, a percepção dos médicos e demais profissionais de Saúde da Família demonstra a fragilidade na construção do projeto de intervenção conjunta, necessário principalmente à ESF, apresentando a perspectiva de que o trabalho multiprofissional se dá apenas em teoria e não na lógica que rege o processo de trabalho. The Family Health Strategy (FHS) in Brazil has employed multidisciplinary teams, precisely for this health care model to allow linking knowledge in the provision of care. OBJECTIVE: This study's objective was to investigate the perceptions of physicians, nurses, and dentists concerning the functioning of multidisciplinary family health teams in the municipality (county) of Coari, Amazonas State, Brazil. METHODS: This was a qualitative study with a semi-structured questionnaire applied through individual interviews with all the primary care professionals in the municipality, compared to interviews with physical therapists and psychologists from secondary care services, analyzed through dialectic hermeneutics. RESULTS: Except for the psychologists' discourse, the perceptions by physicians and other family health professionals revealed weaknesses in the development of a joint intervention project, particularly necessary for the FHS, thereby revealing that multidisciplinary teamwork only occurs in theory and not according to the underlying logic of the work process in family health care.