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Ischaemic heart disease (IHD) is a major cause of morbidity and mortality worldwide. While there have been major advances in this field, these patients are still a higher risk subgroup. As such, strategies to mitigate risk and tailor secondary prevention measures are of the utmost relevance. Cardiac rehabilitation (CR), encompassing several domains including exercise training, cardiovascular risk factor optimization, nutritional and psychological assessments, as well as other ancillary interventions has shown to be one of the pillars in the contemporary management of patients with IHD. Indeed, CR is associated with several benefits in this population, ranging from functional capacity to improvements in outcomes. Whilst this, there are still several issues concerning the optimal application of CR which are still not fully ascertained, such as lack of referral and completion, as well as questions related to programme design (particularly among patients with multiple comorbidities). In this review, we aim at presenting a pragmatic overview on the current role of CR in the management of individuals with IHD, while also discussing some of the caveats in the current data, as well as future concepts which could help improve the uptake and personalization of this pivotal time-tested intervention.

Introduction and objectives: As short-term mortality continues to decrease after myocardial infarction (MI), secondary prevention strategies attain increasing relevance. This study aimed at assessing the control of cardiovascular (CV) risk factors, including dyslipidemia, hypertension and diabetes, in a contemporary cohort of MI survivors who completed an exercise-based cardiac rehabilitation (EBCR) program. Methods: Observational, retrospective cohort study including patients admitted to a tertiary center with acute MI between November 2012 and April 2017, who completed a phase II EBCR program after discharge. Achievement of low-density lipoprotein (LD) cholesterol, blood pressure and HbA1c guideline recommended targets was assessed. Lipid profile parameters were assessed and compared at three time points (hospitalization, beginning and end of the program). Results: A total of 379 patients were included. Mean age was 58.8±10.6 years; 81% were male. Considering the European Society of Cardiology's guidelines on contemporary data collection, 61%, 87% and 71% achieved the recommended LDL cholesterol, blood pressure and HbA1c targets, respectively, at the end of the program. Combining all three risk factors, 42% achieved the recommended targets. High-sensitivity C-reactive protein decreased between the beginning and the end of the program [0.14 (0.08-0.29) mg/L to 0.12 (0.06-0.26) mg/L; p

Background Metabolic syndrome (MetS) is a cluster of cardiovascular risk factors, including abdominal obesity, dyslipidaemia, arterial hypertension and abnormal glucose homeostasis, which occur together more frequently than by chance. Diastolic dysfunction (DD) is one of the most frequent manifestations of subclinical cardiac involvement of MetS, ultimately leading to heart failure with preserved ejection fraction. Metformin's new potential therapeutic actions include prevention of cardiac remodeling and fibrosis. Purpose We aimed to evaluate if metformin improves diastolic function (DF) in non-diabetic patients with MetS. Methods A prospective, randomized, open-label, blinded-endpoint trial was conducted over 24 months. Fifty-four non-diabetic adults with MetS and DD (defined as mean e' Results Forty-nine patients (mean age=51.8±6.4; 55% males) were included in the mITT analysis. Metformin use, on top of lifestyle counseling, led to an increase in mean e' velocity during follow-up (figure 2), with results at 24 months of +0.67±1.90cm/s (vs. −0.33±1.50cm/s in the control group, p=0.056), which reached statistical significance in PP analysis (+0.80±1.99cm/s vs. −0.37±1.52cm/s, p=0.039). In a random intercept linear mixed model adjusting for age, gender, treatment with drugs targeting the renin-angiotensin-aldosterone axis, presence of heart failure and baseline degree of DD, both mITT and PP analysis showed a statistically significant improvement of DF with metformin over time (β-coefficient=0.28, standard error (SE)=0.13, p=0.034, and β-coefficient=0.35, SE=0.14, p=0.011, respectively). This effect was independent of the observed reduction in insulin resistance. There were no differences regarding peak VO2 nor SF-36 score. Conclusions Treatment with metformin of non-diabetic MetS patients with DD, on top of lifestyle counseling, was associated with improved diastolic function. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Merck Study algorithmPrimary endpoint results

Introduction Severe aortic stenosis (AS) and mitral regurgitation (MR) often coexist. Transcatheter aortic valve implantation (TAVI) is becoming widely used for the treatment of patients (pts) with symptomatic severe AS. However, conflicting data reside concerning the impact of MR on outcomes after TAVI. Also, very few data exist regarding the benefits of a cardiac rehabilitation program (CRP) following TAVI in pts with MR. Purpose To evaluate the effect of a CRP in functional parameters after TAVI, particularly in pts with MR grade ≥ II. Methods Retrospective study which included all pts submitted to TAVI between 2014 and 2020 that completed a CRP following the procedure. Cardiopulmonary exercise tests (CPET) were performed after TAVI at baseline (pre-CRP) and post-CRP. We evaluated pre- and post-CRP peak oxygen consumption (pVO2), pVO2 at the anaerobic threshold (AT), respiratory exchange ratio (RER), VE/VCO2 and CPET duration. The exercise protocol included low/medium intensity exercises and consisted of sessions 3 times per week carried over 3 months. MR grading severity was assessed with transthoracic echocardiography performed after TAVI and was divided into 2 groups (grade < II vs grade ≥ II). Results Fifty-two pts were included, 59,6% were male, mean age of 78,6±8,6 years-old. Mean Society of Thoracic Surgery (STS) risk score was 4,9. Mean pre-TAVI aortic valve area was 0,68 cm2, with a mean gradient of 45,5 mmHg and a mean ejection fraction (EF) of 51%. The majority of pts implanted a self-expandable prosthesis (55,8%). Twenty-seven (51,9%) pts had MR grade ≥ II. Baseline characteristics were similar between pts with MR grade < II vs MR grade ≥ II, with the exception of the prevalence of coronary artery disease which was higher in MR grade ≥ II (p=0,036). Patients with MR grade < II had higher maximum and median aortic gradients before TAVI (p Conclusions Patients with MR grade < II after TAVI who underwent a CRP significantly improved pVO2 and CPET duration. Although pts with MR grade ≥ II did not improved pVO2 after a CRP, an improvement in CPET duration may translate into a clinical benefit in these pts. These results highlight the importance of further research and personalization among this potentially higher risk subset of pts. Funding Acknowledgement Type of funding sources: None.

Exercise is a pivotal physiological activity, associated with benefits. Whilst the importance of physical activity is consensual along different steps of the cardiovascular (CV) continuum, there has been interest in assessing the CV adaptations to vigorous exercise. Indeed, exercise can be associated with increases in cardiac biomarkers, though the scope of this observation remains elusive. Interleukin 1 receptor related protein, Suppression of tumorigenicity 2 (ST2) is a biomarker related to the pathophysiology of fibrosis, having shown promise in the study of heart failure. Knowledge of ST2 kinetics could improve understanding of the mechanistic pathways related to CV adaptations to exercise. To assess the current state-of-the-art concerning ST2 levels after exercise in healthy individuals. A systematic review was carried out on three databases (Pubmed, ISI Web of Science and Scopus), up to October 2020, using the queries “ST2” or “ST-2” + “exercise” or “running”. A total of six studies were included in the review, encompassing 349 subjects (73% male gender) in which ST2 was assessed. Most studies reported increases in ST2 levels after exercise. Three studies, encompassing a total of 219 individuals, described a cut-off level of 35 ng/dL for ST2. In these, 92.7% of subjects had ST2 levels above this cut-off after exercise (running in all studies). Most studies report increased levels of ST2 after exercise, with an important number of individuals exceeding the 35 ng/dL threshold. Given the small number of individuals represented and the lack of imaging data and long-term follow-up, further prospective larger studies should target this.

Throughout the centuries, across cultures and distinctive religions, the patient-physician relationship remains the most fundamental element in the practice of medicine. The indissociable link between patient and the doctor is based on trust and honest communication. Over the years, several

Background: Exercise-based cardiac rehabilitation (EBCR) plays a pivotal role in the management of acute myocardial infarction (AMI). Studies have shown that older individuals have a worse prognosis after an AMI, attesting to the importance of risk reduction strategies. We aimed at assessing the impact of age (patients dichotomized as ≥65 years old or Design: Observational, retrospective cohort study. Participants: All patients admitted due to an AMI who completed a phase II EBCR program after discharge, between November 2012 and April 2017. Intervention: EBCR program. Measurements: Functional parameters were assessed by a symptom-limited cardiopulmonary exercise test. Results: A total of 379 patients were included (30% aged ≥65 years). After the EBCR program, peak oxygen uptake (pVO2) and exercise duration increased significantly. Patients aged ≥65 years presented with more comorbidities and a lower functional capacity. Those aged ≥65 years presented significantly smaller improvements in pVO2 (0.79 ± 2.61 vs. 1.60 ± 3.11 mL/kg/min, p = 0.016) and exercise duration [75 (59–120) vs. 120 s (60–180), p = 0.002]. This was maintained after adjusting for several potential confounders. Conclusion: Older patients have a worse functional capacity than their younger counterparts. Still, a contemporary EBCR program was associated with significant functional improvements among those aged ≥65 years. The smaller improvements even after adjustments for potential confounders suggest that physiological differences may contribute to this finding. These results highlight the relevance of EBCR among this higher-risk subgroup.

Introduction and Objectives: Cardiac magnetic resonance (CMR)-based tissue tracking (TT) enables quantification of myocardial deformation and may be used as an objective measure of myocardial involvement in myocarditis. The aims of this study were to characterize myocardial deformation alterations in myocarditis and to determine their relationship with the extent of late gadolinium enhancement (LGE), regional wall motion abnormalities (WMA) and left ventricular ejection fraction (LVEF). Methods: A single-center, retrospective study was conducted by identifying patients with clinically suspected myocarditis who underwent CMR between 2012 and 2016. The myocardial deformation parameters were derived by TT and correlated with LVEF, LGE and WMA, through Spearman's coefficient. Results: A cohort of 78 patients with myocarditis (aged 42.7±17.2 years) were included. CMR characteristics including morphologic parameters (LVEF 52.1±12.8%), extent of WMA (29.3±41.0%) and of LGE (30.5±21.8%) were assessed. Significant correlations were found between all deformation parameters (strain, strain rate, velocity and displacement) and both LVEF and extent of WMA. LGE was significantly correlated with systolic radial strain (r: -0.32, p=0.004), strain rate (r: -0.27, p=0.017) and displacement (r: -0.32, p=0.004) as well as systolic circumferential strain (r: 0.28, p=0.013). Conclusion: Deformation parameters are an objective method for quantification of myocardial function in myocarditis. They correlate with LVEF, extent of WMA and degree of myocardial damage. Further studies are needed to assess their incremental beneficial value for the diagnosis and risk stratification of myocarditis. Resumo: Introdução e objetivos: A avaliação de tissue tracking (TT) por ressonância magnética cardíaca (RMC) permite quantificar a deformação miocárdica e pode ser usada como uma medida objetiva em doentes com miocardite. O objetivo deste estudo foi caraterizar as alterações de deformação miocárdica na miocardite e determinar a sua relação com a quantidade de realce tardio (RT), alterações da contractilidade segmentar (ACS) e fração de ejeção ventricular esquerda (FEVE). Métodos: Conduzimos um estudo unicêntrico, retrospectivo, que incluiu doentes com suspeita de miocardite, submetidos a RMC de 2012 a 2016. Os parâmetros de deformação miocárdica derivados por TT foram correlacionados com a FEVE, o RT e as ACS, através do coeficiente de Spearman. Resultados: Foram avaliadas as RMC de 78 doentes com miocardite (42,7±17,2 anos), incluindo parâmetros morfológicos (FEVE: 52,1±12,8%), quantidade de ACS (29,3±41,0%) e extensão de RT (30,5±21,8%). Encontrámos correlações significativas de todos os parâmetros de deformação (strain, strain rate, velocidade e deslocamento) com a FEVE e com a quantidade de ACS. O RT correlacionou-se de forma significativa apenas com o strain (r: -0,32, p=0,004), strain rate (r: -0,27, p=0,017) e deslocamento radial sistólico (r: -0.32, p=0.004), assim como com o strain circunferencial sistólico (r: 0,28, p=0,013). Conclusão: Os parâmetros de deformação representam uma medida objetiva para quantificar a função nos doentes com miocardite. Relacionam-se com a FEVE, quantidade de ACS e extensão de lesão miocárdica. São necessários estudos adicionais que avaliem o benefício destes parâmetros no diagnóstico e estratificação do risco nos doentes com miocardite. Keywords: Cardiac magnetic resonance, Tissue tracking, Myocarditis, Palavras-chave: Ressonância magnética cardíaca, Tissue tracking, Miocardite

Heart failure (HF) is associated with significant morbidity and mortality. Despite major advances in the treatment of HF, there are still important unmet needs among this patient population. Cardiac rehabilitation has a central role in cardiovascular prevention and for overall disease management, and can have an important impact among HF patients. The authors present a brief overview on the current role of cardiac rehabilitation among HF patients in a contemporary setting and discuss some areas of future research in the context of this intervention.

Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Merck Background Metabolic syndrome (MetS) affects one out of 3 adults in the western world and is associated with preclinical diastolic dysfunction that impairs functional capacity and quality of life (QoL). Purpose This randomized trial was designed to evaluate if the addition of metformin to the standard treatment of non-diabetic patients with MetS improves diastolic dysfunction. Methods Prospective, randomized, open-label, blinded-endpoint trial. Fifty-four non-diabetic adults with MetS and diastolic dysfunction were randomized to lifestyle counseling or lifestyle counseling plus metformin (target dose 1000 mg bid). The primary endpoint was the change in mean e’ velocity (assessed at baseline, 6, 12 and 24 months). Secondary endpoints were improvements in insulin resistance, functional capacity and QoL. Linear mixed effects modelling was used for longitudinal data analysis using modified intention-to-treat (mITT) and per-protocol (PP) approaches. Results Forty-nine patients were included in the mITT analysis (mean age = 51.8 ± 6.4; 55% males). Metformin treatment was associated with a significant decrease in HOMA-IR. There was a significantly different mean change in e’ velocity during the study period between trial arms, both in the mITT (at 24 months, change of +0.67 ± 1.90cm/s in metformin arm vs. -0.33 ± 1.50cm/s in control arm) and PP populations (+0.80 ± 1.99cm/s in metformin arm vs. -0.37 ± 1.52cm/s in control arm), using a random intercept linear mixed model. There were no significant differences in peak oxygen uptake and SF-36 scores between trial arms. Conclusion Treatment with metformin of non-diabetic MetS patients with diastolic dysfunction, on top of lifestyle counseling, is associated with improved diastolic function. Abstract Figure.

Inflammation plays an important role in several stages of the cardiovascular continuum. In recent decades a plethora of studies have provided new data highlighting the role of inflammation in atherogenesis and atherothrombosis in two-way interactions with various cardiovascular risk factors and further influencing these dynamic processes. The concept of targeting residual inflammatory risk among individuals with ischemic heart disease (IHD) is therefore gaining increasing attention. Recently, several landmark randomized controlled trials have assessed different pharmacological approaches that may mitigate this residual risk. The results of some of these studies, such as CANTOS with canakinumab and COLCOT and LoDoCo2 with colchicine, are promising and have provided data to support this concept. Moreover, though several aspects remain to be clarified, these trials have shown the potential of modulating inflammation as a new target to reduce the risk of cardiovascular events in secondary prevention patients. In the present review, we aim to present a pragmatic overview of the complex interplay between inflammation and IHD, and to critically appraise the current evidence on this issue while presenting future perspectives on this topic of pivotal contemporary interest. Resumo: A inflamação apresenta um papel de destaque ao longo do continuum cardiovascular. Ao longo das últimas décadas diferentes estudos reforçaram o papel da inflamação na aterogénese e na aterotrombose, interagindo com diversos fatores de risco cardiovascular de forma bidirecional, sendo capaz de influenciar estes processos dinâmicos. Neste contexto, o conceito de abordar o risco residual inflamatório em indivíduos com doença cardíaca isquémica (DCI) tem ganhado destaque. Recentemente, diversos ensaios clínicos aleatorizados avaliaram diferentes estratégias farmacológicas no sentido de mitigar este risco residual. Os resultados de alguns destes estudos, como o CANTOS com o canakinumab ou o COLCOT e LoDoCo2 com a colquicina, foram promissores e forneceram dados que corroboram este conceito. Adicionalmente, e apesar da necessidade de clarificação adicional de diversos pontos, estes estudos reforçaram o potencial da modulação inflamatória como um novo alvo na redução do risco de eventos cardiovasculares em prevenção secundária. O presente artigo tem por objetivo apresentar uma revisão pragmática referente à interação complexa entre a inflamação e a DCI e avaliar de forma crítica a evidência atual referente a este tópico, apresentando também uma perspetiva futura no âmbito desta temática de ampla relevância contemporânea.

Introduction: Cardiac rehabilitation (CR) programs have a central role in cardiovascular medicine, encompassing a comprehensive framework able to holistically address various facets of cardiovascular disease. However, several obstacles to their optimal application have been reported. Over the years, the Portuguese Society of Cardiology has periodically conducted a national survey on the state of CR in Portugal. Objectives: This study reports the results of the 2019 survey on CR. Methods: In December 2019 a voluntary questionnaire was sent to centers offering CR programs, consisting of several items concerning this intervention. Results: In 2019, 25 centers provided structured CR programs. A total of 2182 patients underwent phase II programs, representing an increase of 13% from the previous survey. Of these, 67.2% were referred due to ischemic heart disease, and 14.5% due to heart failure. Acute coronary syndromes (ACS) comprised 49.3% of referrals, leading to an estimated 9.3% CR coverage. A total of 606 patients participated in phase III programs (a decrease of 37%). Drop-out rates ranged from 0-68%; 91% of centers presented drop-out rates

Resumen Introduccion y objetivos La hipertension causa cambios subclinicos en la estructura y la funcion del ventriculo izquierdo, es decir, disfuncion diastolica. La disfuncion diastolica es un predictor de insuficiencia cardiaca, pues participa en la asociacion entre hipertension e insuficiencia cardiaca con fraccion de eyeccion conservada. El objetivo es evaluar en una gran cohorte poblacional de adultos asintomaticos si los pacientes con prehipertension tienen cambios precoces en la funcion diastolica. Metodos Se evaluo de manera transversal una cohorte poblacional consistente en 925 adultos de 45 anos o mas sin enfermedad cardiovascular conocida. Todos los participantes se sometieron a un examen clinico y ecocardiografico detallado. Se clasifico a los participantes, segun las guias europeas para la clasificacion de la presion arterial (PA) en la consulta, como optima, prehipertension (normal y normal-alta) e hipertension. La funcion diastolica se evaluo mediante ecocardiografia usando las velocidades de e’ y la razon E/e’. La disfuncion diastolica se definio utilizando las recomendaciones conjuntas de ASE/EACVI de 2016 y un algoritmo de orientacion clinica de 2017. Resultados En esta cohorte (61,5 ± 10,5 anos; el 37% varones), tenia prehipertension el 30,4% e hipertension el 51,0%. Se utilizo la PA optima como referencia, y se observo una disminucion progresiva de la velocidad e’ en los individuos prehipertensos e hipertensos (12,2 ± 3,5 frente a 11,3 ± 3,1 frente a 9,6 ± 2,9 cm/s respectivamente; p de tendencia Conclusiones En esta cohorte poblacional, los adultos con prehipertension mostraron una relajacion cardiaca alterada antes del inicio de la hipertension.

Resumo: Introdução: A oxigenação por membrana extracorporal (ECMO) permite o suporte mecânico em doentes com falência cardiovascular e/ou pulmonar. Neste estudo pretendemos descrever as indicações, características clínicas, complicações e mortalidade associadas ao uso de ECMO num hospital terciário. Métodos: Foi realizado um estudo de coorte retrospetivo e observacional de todos os doentes que implantaram ECMO, em duas unidades de cuidados intensivos (polivalente e cardíaca), desde o primeiro doente canulado em abril/2011 até outubro/2016. Resultados: Quarenta e oito doentes colocaram ECMO: 29 ECMO venoarterial (ECMO‐VA) e 19 ECMO venovenoso (ECMO‐VV). No ECMO‐VA, o enfarte agudo do miocárdio foi a principal indicação para a sua implantação. A complicação mais frequente foi a isquemia do membro inferior e a disfunção de órgão associada mais comum foi a renal. No ECMO‐VV, a síndrome de dificuldade respiratória aguda secundária a infeção viral foi o motivo dominante para a utilização do dispositivo. A hemorragia pelo local de acesso e a disfunção hematológica foram, respetivamente, a complicação e a disfunção de órgão mais prevalentes. Foram descanulados com sucesso quase 70% dos doentes, em ambos os grupos. Os doentes em ECMO‐VA tiveram sobrevivência hospitalar de 37,9% e os em ECMO‐VV 63,2%. O número de agentes inotrópicos foi preditor de mortalidade no ECMO‐VA. Conclusão: Os doentes que colocaram ECMO após falência respiratória tiveram sobrevivência superior aos que colocaram após falência cardíaca. No ECMO‐VA, a necessidade de mais fármacos inotrópicos foi preditor de mortalidade. Este é o primeiro registo publicado com a experiência global com ECMO num hospital terciário, em Portugal. Abstract: Introduction: Extracorporeal membrane oxygenation (ECMO) provides mechanical pulmonary and circulatory support for patients with shock refractory to conventional medical therapy. In this study we aim to describe the indications, clinical characteristics, complications and mortality associated with use of ECMO in a single tertiary hospital. Methods: We conducted a retrospective observational cohort study of all patients supported with ECMO in two different intensive care units (general and cardiac), from the first patient cannulated in April 2011 up to October 2016. Results: Overall, 48 patients underwent ECMO: 29 venoarterial ECMO (VA‐ECMO) and 19 venovenous ECMO (VV‐ECMO). In VA‐ECMO, acute myocardial infarction was the main reason for placement. The most frequent complication was lower limb ischemia and the most common organ dysfunction was acute renal failure. In VV‐ECMO, acute respiratory distress syndrome after viral infection was the leading reason for device placement. Access site bleeding and hematologic dysfunction were the most prevalent complication and organ dysfunction, respectively. Almost 70% of ECMO episodes were successfully weaned in each group. Survival to discharge was 37.9% for VA‐ECMO and 63.2% for VV‐ECMO. In VA‐ECMO, the number of inotropic agents was a predictor of mortality. Conclusion: Patients with respiratory indications for ECMO experienced better survival than cardiac patients. The need for more inotropic drugs was a predictor of mortality in VA‐ECMO. This is the first published record of the overall experience with ECMO in a Portuguese tertiary hospital. Palavras‐chave: Oxigenação por membrana extracorporal, Choque cardiogénico, Falência respiratória, Complicações, Resultados, Keywords: Extracorporeal membrane oxygenation, Cardiogenic shock, Respiratory failure, Complications, Outcome

Exercise-based cardiac rehabilitation (EBCR) is paramount after an acute myocardial infarction (AMI). Older individuals have been reported as having a worse prognosis after an AMI, and some series have reported differences in the functional response to EBCR. The peak circulatory power (CP), a non-invasive parameter, has been described as a surrogate for the cardiac power, showing promising results as a comprehensive measure of the cardiovascular response. Whilst this, data concerning the impact of EBCR on CP, particularly among elderly individuals, remains elusive. To address this issue, an observational, retrospective study including all patients admitted due to an AMI who completed a phase II EBCR programme between 11/2012 and 4/2017, was conducted, with CP being analysed by a symptom-limited cardiopulmonary exercise test. A total of 379 patients, 30% aged ≥65 years-old, were included. CP significantly improved after the EBCR programme (in all patients, as well as in both subgroups). Older patients presented lower CP than their younger counterparts at the beginning and the end of the programme, while presenting smaller improvements (122 ± 540 vs 293 ± 638 mmHg mL/kg/min, p = 0.013). This was maintained after adjusting for several potential confounding factors. A contemporary ECBR programme was associated with significant improvements in CP among AMI patients. Though those aged ≥65 years-old presented smaller improvements in CP than younger individuals, these still presented significant increases in this parameter. These results highlight the importance of EBCR in this challenging higher risk group of patients.

Background: Anthracyclines are chemotherapeutic agents frequently used in breast cancer (BC) treatment. Although improving disease-free and overall survival, the use of anthracyclines is associated with a cumulative risk of cardiac toxicity. Preventive strategies to optimize and balance cardiac health are needed, being exercise proposed as a potential non-pharmacological approach for counteracting of anthracycline-related cardiotoxicity (ARC). Despite most of the data analysing the role of exercise against cardiac toxicity and dysfunction caused by anthracyclines derived from animal studies, human studies claim for more accurate and valuable clinical biomarkers. Moreover, clinical trials in real-world setting and large samples are of pivotal importance. Methods: This protocol describes a two-arm prospective randomized controlled trial that will explore the cardioprotective effect of a structured exercise program against ARC in women with BC. Eighty-six adult women with early BC and with a therapeutic decision to receive anthracycline-containing chemotherapy (ACT) will be randomly assigned (1:1) to an intervention group or to a control group. Patients allocated to the intervention group will perform a 3-weekly supervised exercise program combining resistance and aerobic training with progressive intensity (light-to-vigorous), during the overall ACT. The control group will receive standard BC care. Primary outcomes related to cardiac (dys)function will be circulating N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, resting left ventricular (LV) longitudinal strain, and resting LV ejection fraction. Secondary outcomes will include the assessment of resting blood pressure, resting heart rate (HR), resting HR variability (HRV) and recovery HR. Exploratory outcomes include physical function outcomes, self-reported physical activity level, health related to quality of life and fatigue. Data will be obtained at baseline (t0), after the end of anthracycline-treatment (t1), and three months after t2 (t2). Additionally, NT-proBNP levels will be measured between 1-24 hours prior to each anthracycline-treatment cycle. Discussion: The implementation of the present study design, using novel clinical biomarkers and “between” outcomes’ associations, will help to understand the effectiveness of structured exercise interventions at mitigating ARC, further contributing to the improvement of supportive cancer care. Trial registration: ISRCTN, ISRCTN32617901. Registered on 24 October 2018. Last updated on 11 January 2019, https://doi.org/10.1186/ISRCTN32617901. Keywords: Breast cancer, cardiotoxicity, cardiac healthcare, supervised exercise, supportive cancer care.

Exercise stress testing can have a central role in the assessment of cardiovascular disease. Contemporary data, however, has highlighted the added value of imaging modalities over the exercise electrocardiogram in the investigation of coronary artery disease. Given the physiological changes associated with exercise and the possibility to address other parameters such as rhythm changes and the chronotropic response, exercise stress testing with continuous electrocardiographic monitoring can still have an important place in contemporary clinical practice. We report the case of a complete atrioventricular block associated with exercise and discuss the current role of exercise stress testing with continuous electrocardiographic monitoring in this entity.

Anthracyclines are chemotherapeutic agents frequently used in breast cancer (BC) treatment. Although it improves disease-free and overall survival, the use of anthracyclines is associated with a cumulative risk of cardiac toxicity. Preventive strategies to optimize cardiac health are needed and exercise is proposed as a potential non-pharmacological approach for counteracting anthracycline-related cardiotoxicity (ARC). Most of the data on the effects of exercise to reduce ACT are from animal studies, with only a few studies in a limited number of patients indicating beneficial effects. To better understand the effectiveness of exercise in the mitigation of ARC, clinical, real-world trials claim require a larger sample size and more accurate and valuable clinical biomarkers. In this study, we intend to include a large sample and investigate cardiac function through serial measures of biomarkers and imaging techniques., Banco Santander (BID/ICI-FCSH/SANTANDER UNIVERSIDADES-UBI/2017)

Background: Pericardial effusion (PE) can develop in several pathological scenarios, and is often initially evaluated by means of echocardiography. Computed tomography (CT) has been used as an aid in the management of patients presenting with PE, in selected cases. The role of CT-guided pericardiocentesis in contemporary practice, however, remains not fully ascertained. We aimed at presenting a systematic review concerning the state-of-the-art of this technique. Methods: A systematic review of published data on the use of CT for guiding pericardiocentesis was carried out (search performed on PubMed, ISI Web of Knowledge and Scopus databases). Results: From title and abstract analysis, 14 articles were included that met the prespecified criteria. After full-text analysis, six articles were excluded. The eight articles under analysis included a total of 635 procedures performed in 571 patients. CT guidance was mostly used in a postoperative setting (364 procedures). Most procedures were done mainly for therapeutic purposes (528 procedures). Success rates ranged from 94% to 100%. Complications ranged from 0% to 7.8%. Conclusion: CT-guided pericardiocentesis is a useful technique in the approach to PE, in several clinical scenarios. Its use can be especially relevant in the postoperative period, as well as in individuals with suboptimal image quality (as assessed by echocardiography, for the moment the first choice in the approach to most cases of PE).

The course of epicardial coronary arteries into a muscular tunnel under a bridge of myocardium is known as myocardial bridging (MB). This could be a benign anomaly, nevertheless, it could have a great impact on the quality of life in the setting of severe anginal symptoms. The clinical presentation and diagnosis could be challenging in those patients. The treatment options start from simple medical therapy to surgical intervention in refractory cases, the role of percutaneous coronary intervention (PCI) is limited in MB. We are describing a case of severe MB presenting as Wellens pattern with underlying left ventricular hypertrophy (LVH).

The prevalence of auto-antibodies associated to pulmonary arterial hypertension in scleroderma patients was reviewed, based on reports cited in two major scientific databases. Data were collected on the following types of antibodies: antinuclear, anti-double-stranded DNA, anticentromere, anti-CENP-A, anti-CENP-B, anti-bicaudal D2, anti-nucleolar, anti-Scl-70 (anti-topoisomerase I), anti-topoisomerase II α, anti-RNP, anti-U1RNP, anti-U3RNP, anti-RNA polymerase III, anti-Th/To, anti-histone, antiphospholipid, anti-PmScl, anti-Sm, anti SSA (anti-Ro),anti SSB (La), anti-Ro52 (TRIM 21), anti-Ku, anti-B23, anti-RuvBL1, anti-RuvBL2, anti-fibrin bound tissue plasminogen activator, anti-endothelial cell, anti-phosphatidylserine-prothrombin complex, anti-endothelin-1 type A receptor, anti-angiotensin II type 1 receptor, anti‑carbonic anhydrase II, anti-fibroblast, anti-cyclic citrullinated peptide, anti-4-sulfated N-Acetyl-lactosamine, class I and II anti-human leukocyte antigen. Auto-antibodies were shown by different authors to be associated to this condition, with different prevalence values for each type of auto-antibody. Antinuclear antibodies, anti-centromere antibodies, antiphospholipid antibodies, anti-U3 RNP antibodies and anti-Th/To antibodies would appear to show a particularly important prevalence in scleroderma patients with pulmonary hypertension, appearing in about 8/10 (antinuclear), 1/ 2 (anti-centromere, anti-phospholipid), and 1/4 (anti-U3RNP, anti-Th/To) of patients. The available evidence points in the direction of a strong association between auto-immune mechanisms and pulmonary hypertension in the setting of scleroderma.

Throughout the centuries, the heart and the cardiovascular system have been the focus of intense reflection from scientific, emotional, and philosophical points of view. The role of the heart as “the seat of the soul, thought, and psychic functions” was deeply influenced by Aristotelian notions

Physical exercise is one of the pillars of a healthy lifestyle, being associated with a reduction in cardiovascular events and total mortality. More recently, the importance of physical exercise has extended to the disease, being now considered an important therapeutic tool in several cardiovascular diseases, including the patient after myocardial infarction or with heart failure. Both in healthy individuals and in patients with heart failure or myocardial infarction, exercise can reduce cardiovascular events, improve quality of life, and increase functional capacity. These benefits can occur by changes in the heart, vessels, muscles, and lungs. The long-term effects of exercise on cardiac function can be protean. They depend on the clinical context, on the characteristics of the individual, and on the type, intensity, and duration of the exercise-training program. This chapter will provide an update on the available evidence regarding the effects of exercise training on both systolic and diastolic function in different clinical scenarios, from the healthy individual to the patient after myocardial infarction or with heart failure.

Introduction and objectives: Hypertension causes subclinical changes in left ventricular structure and function, namely diastolic dysfunction. Diastolic dysfunction is a predictor of heart failure, being involved in the association between hypertension and heart failure with preserved ejection fraction. We aimed to determine whether patients with prehypertension have early changes in diastolic function in a large community-based cohort of asymptomatic adults. Methods: A cross-sectional evaluation was performed of a community-based cohort consisting of 925 adults, aged 45 years or older, without known cardiovascular disease. All participants underwent detailed clinical and echocardiographic examination. The participants were categorized according to the European guidelines for the classification of office blood pressure (BP) levels as optimal, prehypertensive (normal and high-normal categories), and hypertensive. Diastolic function was evaluated by echocardiography using e’ velocities and E/e’ ratio. Diastolic dysfunction was defined using the 2016 ASE/EACVI Joint Recommendations and a 2017 clinically-oriented algorithm. Results: In this cohort (61.5 ± 10.5 years; 37% men), prehypertension was present in 30.4% and hypertension in 51.0%. Using optimal BP as the reference, there was a progressive decrease of e’ velocity in prehypertensive and hypertensive individuals (12.2 ± 3.5 vs 11.3 ± 3.1 vs 9.6 ± 2.9 cm/s, respectively; P for trend < .001). After multivariable adjustment, both BP categories were independent predictors of a lower e’ velocity (β = -0.56, P = .035 for prehypertension and β = –1.08, P < .001 for hypertension). Conclusions: In this large community-based cohort, adults with prehypertension already showed impaired cardiac relaxation before the onset of hypertension.

Introduction: Extracorporeal membrane oxygenation (ECMO) provides mechanical pulmonary and circulatory support for patients with shock refractory to conventional medical therapy. In this study we aim to describe the indications, clinical characteristics, complications and mortality associated with use of ECMO in a single tertiary hospital. Methods: We conducted a retrospective observational cohort study of all patients supported with ECMO in two different intensive care units (general and cardiac), from the first patient cannulated in April 2011 up to October 2016. Results: Overall, 48 patients underwent ECMO: 29 venoarterial ECMO (VA-ECMO) and 19 venovenous ECMO (VV-ECMO). In VA-ECMO, acute myocardial infarction was the main reason for placement. The most frequent complication was lower limb ischemia and the most common organ dysfunction was acute renal failure. In VV-ECMO, acute respiratory distress syndrome after viral infection was the leading reason for device placement. Access site bleeding and hematologic dysfunction were the most prevalent complication and organ dysfunction, respectively. Almost 70% of ECMO episodes were successfully weaned in each group. Survival to discharge was 37.9% for VA-ECMO and 63.2% for VV-ECMO. In VA-ECMO, the number of inotropic agents was a predictor of mortality. Conclusion: Patients with respiratory indications for ECMO experienced better survival than cardiac patients. The need for more inotropic drugs was a predictor of mortality in VA-ECMO. This is the first published record of the overall experience with ECMO in a Portuguese tertiary hospital. Resumo: Introdução: A oxigenação por membrana extracorporal (ECMO) permite o suporte mecânico em doentes com falência cardiovascular e/ou pulmonar. Neste estudo pretendemos descrever as indicações, características clínicas, complicações e mortalidade associadas ao uso de ECMO num hospital terciário. Métodos: Foi realizado um estudo de coorte retrospetivo e observacional de todos os doentes que implantaram ECMO, em duas unidades de cuidados intensivos (polivalente e cardíaca), desde o primeiro doente canulado em abril/2011 até outubro/2016. Resultados: Quarenta e oito doentes colocaram ECMO: 29 ECMO venoarterial (ECMO-VA) e 19 ECMO venovenoso (ECMO-VV). No ECMO-VA, o enfarte agudo do miocárdio foi a principal indicação para a sua implantação. A complicação mais frequente foi a isquemia do membro inferior e a disfunção de órgão associada mais comum foi a renal. No ECMO-VV, a síndrome de dificuldade respiratória aguda secundária a infeção viral foi o motivo dominante para a utilização do dispositivo. A hemorragia pelo local de acesso e a disfunção hematológica foram, respetivamente, a complicação e a disfunção de órgão mais prevalentes. Foram descanulados com sucesso quase 70% dos doentes, em ambos os grupos. Os doentes em ECMO-VA tiveram sobrevivência hospitalar de 37,9% e os em ECMO-VV 63,2%. O número de agentes inotrópicos foi preditor de mortalidade no ECMO-VA. Conclusão: Os doentes que colocaram ECMO após falência respiratória tiveram sobrevivência superior aos que colocaram após falência cardíaca. No ECMO-VA, a necessidade de mais fármacos inotrópicos foi preditor de mortalidade. Este é o primeiro registo publicado com a experiência global com ECMO num hospital terciário, em Portugal. Keywords: Extracorporeal membrane oxygenation, Cardiogenic shock, Respiratory failure, Complications, Outcome, Palavras-chave: Oxigenação por membrana extracorporal, Choque cardiogénico, Falência respiratória, Complicações, Resultados

Takotsubo cardiomyopathy (TC) is characterized by the sudden onset of reversible left ventricular dysfunction, with a presentation similar to that of an acute coronary syndrome. Although cardiogenic shock is a rare occurrence in TC, if it does occur it may require the use of a left ventricular assist device.We report the use of extracorporeal life support (ECLS) in a patient with TC and refractory cardiogenic shock. With ECLS it was possible to reduce inotropic support, and a normal left ventricular ejection fraction was documented by echocardiography on day 2.This is, to our knowledge, the first reported case of TC with refractory cardiogenic shock treated with ECLS in Portugal. Resumo: A miocardiopatia de Takotsubo (MT) é caracterizada por uma disfunção ventricular esquerda súbita, tendo uma apresentação semelhante à de uma síndrome coronária aguda. Apesar do choque cardiogénico ser uma ocorrência rara na MT, caso ocorra, pode levar ao uso de dispositivos de assistência ventricular esquerda.Reportamos o caso de uma doente com MT e choque cardiogénico onde foi utilizado suporte de vida extracorporal (SVEC). Com o SVEC foi possível reduzir o suporte aminérgico e documentada em ecocardiografia uma fração de ejeção normal ao 2.° dia.No conhecimento dos autores este é o primeiro caso, em Portugal, de choque cardiogénico por MT em que é usado o SVEC como ponte para a melhoria. Keywords: Takotsubo cardiomyopathy, Cardiogenic shock, Extracorporeal life support, Palavras-chave: Miocardiopatia de Takotsubo, Choque cardiogénico, Suporte de vida extracorporal