Ischaemic heart disease is the leading cause of death worldwide, with an increasing trend from 6.1 million deaths in 1990 to 9.5 million in 2016, markedly driven by rates observed in ...low/middle-income countries (LMIC). Improvements in myocardial infarction (MI) care are crucial for reducing premature mortality. We aimed to evaluate the main challenges for adequate MI care in LMIC, and possible strategies to overcome these existing barriers.Reperfusion is the cornerstone of MI treatment, but worldwide around 30% of patients are not reperfused, with even lower rates in LMIC. The main challenges are related to delays associated with patient education, late diagnosis and inadequate referral strategies, health infrastructure and insufficient funding. The implementation of regional MI systems of care in LMIC, systematising timely reperfusion strategies, access to intensive care, risk stratification and use of adjunctive medications have shown some successful strategies. Telemedicine support for remote ECG, diagnosis and organisation of referrals has proven to be useful, improving access to reperfusion even in prehospital settings. Organisation of transport and referral hubs based on anticipated delays and development of MI excellence centres have also resulted in better equality of care. Also, education of healthcare staff and task shifting may potentially widen access to optimal therapy.In conclusion, efforts have been made for the implementation of MI systems of care in LMIC, aiming to address particularities of the health systems. However, the increasing impact of MI in these countries urges the development of further strategies to improve reperfusion and reduce system delays.
Resumo Fundamento O Programa Boas Práticas em Cardiologia é uma iniciativa da Sociedade Brasileira de Cardiologia (SBC) destinada à melhoria do cuidado cardiovascular nos hospitais públicos ...brasileiros. Objetivos Descrever características dos pacientes internados com Síndrome Coronariana Aguda (SCA) e Insuficiência Cardíaca (IC) e avaliar os indicadores de desempenho alcançados nos braços (SCA e IC) em um hospital público terciário, com uma meta pré-estabelecida de 85% de aderência às recomendações da SBC. Métodos Estudo do tipo transversal descritivo realizado por meio da coleta de dados de pacientes que estiveram internados entre maio de 2016 e setembro de 2019. Resultados Foram incluídos 1036 pacientes, 273 pacientes no braço IC e 763 no braço SCA. A média de idade foi de 59,8 ± 12,0 anos na SCA e 57,0 ± 14,1 anos na IC, com predomínio do sexo masculino em ambos os grupos. Mais da metade dos pacientes não tinham ensino fundamental completo e mais de 90% declararam renda mensal inferior a cinco salários-mínimos. Na SCA, predominou o diagnóstico de SCA com supradesnivelamento do segmento ST (66,3%) e 2,9% dos pacientes foram a óbito. Na IC, a etiologia mais comum foi a Doença de Chagas (25,8%) e 17,9% dos pacientes foram a óbito. Na avaliação dos indicadores de desempenho, nove dos 12 indicadores tiveram taxas de aderência acima de 85%. Conclusão Programas de qualidade são essenciais à melhoria do cuidado e os indicadores de desempenho do hospital apontam para uma boa adesão às diretrizes assistenciais da SBC, particularmente no braço da SCA.
ObjectiveA substantial proportion of patients with rheumatic heart disease (RHD) have tricuspid regurgitation (TR). This study aimed to identify the impact of functional TR on clinical outcomes and ...predictors of progression in a large population of patients with RHD.MethodsA total of 645 patients with RHD were enrolled, mean age of 47±12 years, 85% female. Functional TR was graded as absent, mild, moderate or severe. TR progression was defined either as worsening of TR degree from baseline to the last follow-up echocardiogram or severe TR at baseline that required surgery or died. Incidence of TR progression was estimated accounting for competing risks.ResultsFunctional TR was absent in 3.4%, mild in 83.7%, moderate in 8.5% and severe in 4.3%. Moderate and severe functional TR was associated with adverse outcome (HR 1.91 (95% CI 1.15 to 3.2) for moderate, and 2.30 (95% CI 1.28 to 4.13) for severe TR, after adjustment for other prognostic variables. Event-free survival rate at 3-year follow-up was 91%, 72% and 62% in patients with no or mild, moderate and severe TR, respectively. During mean follow-up of 4.1 years, TR progression occurred in 83 patients (13%) with an overall incidence of 3.7 events (95% CI 2.9 to 4.5) per 100 patient-years. In the Cox model, age (HR 1.71, 95% CI 1.34 to 2.17), New York Heart Association functional class III/IV (HR 2.57, 95% CI 1.54 to 4.30), right atrial area (HR 1.52, 95% CI 1.10 to 2.10) and right ventricular (RV) dysfunction (HR 2.02, 95% CI 1.07 to 3.84) were predictors of TR progression. By considering competing risk, the effect of RV dysfunction on TR progression risk was attenuated.ConclusionsIn patients with RHD, functional TR was frequent and associated with adverse outcomes. TR may progress over time, mainly related to right-sided cardiac chambers remodelling.
Sickle cell disease (SCD) is a hemoglobinopathy that is common worldwide. It usually presents with cardiac involvement, although data on systolic function are somewhat controversial. The aim of this ...study was to investigate the value of speckle-tracking strain, a deformation index, in detecting ventricular dysfunction in SCD.
Ninety adult patients with SCD were compared with 20 healthy controls. Doppler echocardiography with Doppler tissue imaging was performed in all, and the left and right ventricles were analyzed by the use of two-dimensional speckle-tracking strain.
The mean age of the patients with SCD was 26 years, and 43% were men. Left ventricular (LV) dimensions and mass were higher in patients with SCD, whereas LV ejection fraction did not differ from the controls. E and A waves, as well as E/e' ratio, were also higher in patients with SCD. Two-dimensional speckle-tracking strain of both ventricles in the patients with SCD was not different from that of controls. The factors independently associated with LV longitudinal strain were age (P = .009), oximetry (P = .001), lactate dehydrogenase (P = .014), LV ejection fraction (P < .001), and right ventricular systolic annular velocity (P = .010).
Ventricular enlargement with normal ventricular function was a frequent finding in SCD. Two-dimensional speckle-tracking strain of both ventricles was similar in patients and controls, suggesting normal myocardial contractility in patients with SCD. LV global longitudinal strain was associated with age, intensity of hemolysis, and ventricular function.
Resumo Fundamentos: Os mecanismos subjacentes pelos quais a doença cardíaca reumática (DCR) levam à disfunção valvar grave não são totalmente compreendidos. Objetivo: O presente estudo avaliou as ...alterações histopatológicas nas valvas mitrais (VM) buscando uma associação entre o padrão de disfunção valvar predominante e os achados histopatológicos. Métodos: Em 40 pacientes submetidos à troca da VM devido a DCR e em 20 controles submetidos a transplante cardíaco, foram analisados os aspectos histológicos da VM excisada. Dados clínicos e ecocardiográficos também foram coletados. As análises histológicas foram realizadas usando coloração com hematoxilina-eosina. Determinou-se inflamação, fibrose, neoangiogênese, calcificação e metaplasia adiposa. Valores de p<0,05 foram considerados estatisticamente significativos. Resultados: A idade média dos pacientes com DCR foi de 53±13 anos, sendo 36 (90%) do sexo feminino, enquanto a idade média dos controles foi de 50±12 anos, semelhante aos casos, sendo a maioria do sexo masculino (70%). O endocárdio valvar reumático apresentou espessura maior que os controles (1,3±0,5 mm versus 0,90±0,4 mm, p=0,003, respectivamente), e infiltrado inflamatório mais intenso no endocárdio (78% versus 36%; p=0,004), com predominância de células mononucleares. Ocorreu fibrose moderada a acentuada mais frequentemente em válvulas reumáticas do que em válvulas controle (100% vs. 29%; p<0,001). Ocorreu calcificação em 35% das valvas reumáticas, principalmente entre as valvas estenóticas, associada à área valvar mitral (p=0,003). Conclusões: Apesar do intenso grau de fibrose, o processo inflamatório permanece ativo na valva mitral reumática, mesmo em doença tardia com disfunção valvar. A calcificação predominou em valvas estenóticas e em pacientes com disfunção ventricular direita.
Sepsis is a serious syndrome, characterized by the excessive release of inflammatory mediators and thermoregulatory changes, being fever the most common sign. However, despite the importance of ...Angiotensin (Ang)-(1−7) in controlling the inflammation, the role of the peptide in the febrile response and mortality in animals submitted to experimental model of sepsis is still not clear. In this way, we evaluate the effect of continuous infusion of Ang-(1−7) in inflammatory response, thermoregulation and in mortality of Wistar male rats submitted to colonic ligation puncture (CLP). Before CLP surgery, the infusion pumps (Ang-(1−7), 1.5 mg/mL or saline) were inserted into the abdominal cavity and maintained for 24 h. CLP rats showed a febrile response starting from 3 h after and persisted until the 24th hour of experiment. Continuous treatment with Ang-(1−7) attenuated the febrile response and reestablished the euthermia 11 h after CLP, until the end of experiment, which coincided with an increased heat loss index (HLI). This effect was associated with a decrease in production of pro-inflammatory mediators in liver, white adipose tissue (WAT) and hypothalamus. Moreover, an increase in norepinephrine (NE) content in interscapular brown adipose tissue (iBAT) was observed in CLP animals, which was attenuated with treatment with Ang-(1−7), and decreased mortality in CLP animals treated with Ang-(1−7). Taken together, the present study demonstrates that continuous infusion treatment with Ang-(1−7) can promote a global anti-inflammatory effect, reestablishing the tail skin heat loss as a key thermo-effector function, resulting in an increased survival of animals submitted to experimental sepsis.
•Treatment with Ang-(1−7) improves the survival of rats with polymicrobial sepsis.•Ang-(1−7) promotes neuroinflammation by peripheral inflammatory attenuation.•The thermoregulatory effect of Ang-(1−7) is independent of central PGE2 production.•Ang-(1−7) controls fever via iBAT and tail vasculature modulating in septic animals.•Ang-(1−7) promotes direct action on the cutaneous vasculature of the tail.
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