Prevalência da anticoagulação oral em doentes com fibrilhação auricular em Portugal: revisão sistemática e meta‐análise de estudos observacionais

Introduction and ObjectivesOral anticoagulation (OAC) is an effective treatment in the prevention of thromboembolic events in patients with atrial fibrillation (AF). The aim of this review was to estimate the prevalence of OAC therapy in patients with AF in Portugal.MethodsMEDLINE, the Index of Portuguese Medical Journals and SIBUL (the Bibliographic Catalog of the Integrated Library System of the University of Lisbon) were searched for Portuguese observational studies reporting the proportion of anticoagulated patients with AF. The pooled estimated prevalence of anticoagulated patients and respective 95% confidence interval (CI) were determined by means of a meta‐analysis.ResultsSeven studies were included for analysis, of which four were conducted in a hospital environment and three in the general community. These studies enrolled a total of 891 patients with AF. The pooled estimated prevalence of anticoagulated patients was 40% (95% CI: 32–48%).ConclusionsThe prevalence of OAC in Portuguese AF patients is low. There is a need to promote change in OAC prescribing habits for AF patients in Portugal, in accordance with international guidelines.     

Impacto da frequência posológica na adesão terapêutica em doenças cardiovasculares crónicas: revisão sistemática e meta‐análise

Introduction and ObjectiveNon‐adherence to drug treatment is a major health problem. In Europe, it has been estimated that 9% of cardiovascular events can be attributed to non‐adherence. The complexity of dosing regimens is one of the factors identified as contributing to non‐adherence. In this systematic review we aimed to assess the impact of dosing frequency on adherence to drug treatment in patients with chronic cardiovascular disease.MethodsMEDLINE and the Cochrane Library (November 2013) were searched for randomized controlled trials (RCTs) comparing different dosing regimens (once‐daily administration vs. two or more daily administrations) and assessing adherence to therapy in patients with chronic cardiovascular disease. Only trials with at least five months of follow‐up were included. The results of the studies were pooled through a random effects meta‐analysis. Relative risk (RR) and 95% confidence interval (CI) were derived. Statistical heterogeneity was calculated using the I² test.ResultsFour RCTs (a total of 2557 patients) were included. Dosing regimens with once‐daily administration were associated with a significant 56% reduction in risk of non‐adherence to drug therapy (RR: 0.44; 95% CI: 0.35‐0.54, I²=25%).ConclusionsFew clinical trials have assessed the long‐term impact of dosing frequency on medication adherence in chronic cardiovascular disease. The best available evidence suggests that taking medication once daily decreases the risk of non‐adherence to treatment by approximately 50%. The impact on clinical outcomes remains to be established.     

Quantificação do fluxo sanguíneo miocárdico por tomografia por emissão de positrões – Atualização

Cardiovascular disease is the leading cause of death worldwide and ischemic heart disease is the most frequent etiology, with high economic costs for both treatment and diagnosis. Over the past two decades, the assessment of patients with this disease has undergone various changes, with cardiac positron emission tomography (PET) emerging as a powerful and versatile imaging exam for diagnosis and risk stratification of these patients. This review aimed to assess the utility of this exam, particularly through quantification of myocardial blood flow and myocardial flow reserve in the diagnosis and risk stratification of coronary artery disease. Compared to other imaging methods, measurement of these parameters by cardiac PET provides a better characterization of coronary artery disease, with particular value in microvascular and balanced multivessel disease.     

Exercício físico na diabetes: missão impossível ou uma questão de motivação?

Pulling from self-determination theory (SDT) and motivational interviewing (MI), this article sought to present contemporary frameworks for understanding and promoting human motivation as useful tools for health professionals aiming to facilitate adoption and adherence to physical activity, presenting empirical evidence for its use. Practical strategies that may be used by a health professional to create an autonomy-supportive, well-structured, and interpersonally involved exercise counseling environment, more likely to support selfdetermined motivation, also are presented.Combining the strong theoretical underpinnings of SDT and the strong clinical base of MI should allow for much progress in developing the kind of motivation required to initiate and maintain exercise behaviors over the long term. These relatively simple and straightforward principles can be incorporated into existing approaches currently used by professionals who desire to improve their effectiveness, enhancing positive outcomes in terms of exercise adoption, adherence, and well-being;     

Uma causa reversível de disfunção ventricular esquerda: caso clínico e breve revisão

The authors describe a case of a patient admitted to the emergency department with diabetic ketoacidosis. Although there were no symptoms attributable to the cardiovascular system, lab tests revealed elevated troponin I and natriuretic peptides, coupled with repolarization abnormalities on the ECG. The transthoracic echocardiogram (TTE) showed a non‐dilated left ventricle with severe left ventricular systolic dysfunction due to diffuse hypokinesia, and a concomitant diagnosis of profile L heart failure was proposed. Etiologic investigation was negative, and when a new TTE was performed seven days after the first, left ventricular function was normal. Although rarely considered, metabolic and electrolyte disorders, especially diabetic ketoacidosis, can be a cause of left ventricular systolic dysfunction, and should be considered in the differential diagnosis. This is another way diabetes can have an impact on the cardiovascular system.     

Qual o verdadeiro impacto da intervenção coronária percutânea on‐site? Análise de score de propensão de doentes admitidos por síndrome coronária aguda

IntroductionIn an era in which coronary heart disease is one of the leading causes of death worldwide, several studies report the persistence of obstacles to accessing revascularization, and percutaneous coronary intervention in particular, which may be associated with worse outcomes.ObjectivesTo compare cardiovascular outcomes in patients admitted to hospitals with and without on‐site percutaneous coronary intervention (PCI) capabilities.Material and MethodsA retrospective study based on the National Registry of Acute Coronary Syndromes (ACS) ‐ with data collection from 2010 to 2018. Division of the patients into two groups: with and without ST‐elevation. Two subgroups were subsequently created according to the presence/absence of on‐site PCI. A propensity score was performed to standardize the results. Patients without information about hospital admission (with/without PCI) were excluded.Results6008 patients were included after exclusion criteria and propensity score were applied. We found that patients admitted for ACS with ST‐elevation (STE‐ACS) had more episodes of sustained ventricular tachycardia (OR 2.14; CI (1.26‐3.61); p=0.004) in hospitals without on‐site PCI. Regarding ACS without ST elevation (NSTE‐ACS), there were more cases of congestive heart failure (OR 0.79; CI (0.65‐0.98)) in hospitals with on‐site PCI.ConclusionThe incidence of a greater number of major adverse events in hospitalizations without on‐site PCI, particularly in the case of STE‐ACS, is a consequence of the delay before revascularization. National and local strategies must be established to reduce the negative impact of the absence of on‐site PCI and the resulting time before revascularization.     

Recomendações para a realização de testes genéticos em cardiologia – revisão das principais diretrizes internacionais

In recent years, the importance of genetic causes of cardiovascular diseases has been increasingly recognized, as the result of significant advances in molecular diagnosis techniques. This growing knowledge has enabled the identification of new phenotypes and the subclassification of clinical syndromes, impacting the therapeutic approach and genetic counseling offered to affected families.This paper describes the state of the art of genetic testing in the main cardiovascular diseases, aiming to provide a useful tool to help cardiologists and other health professionals involved in the care of individuals with hereditary heart diseases and their families.     

Ablação de arritmias da câmara de saída do ventrículo direito e esquerdo com sistema de navegação magnética por controlo remoto

ObjectiveThe aim of this study was to assess the efficacy and potential complications of a remote-controlled magnetic navigation system (Niobe II, Stereotaxis) for mapping and ablation of right or left ventricular outflow tract ventricular tachycardia or premature ventricular contractions.MethodsWe studied 32 consecutive patients, mean age 43±11 years, 24 female. Mapping of the arrhythmia was performed using the CARTO RMT mapping system, remotely guided by the Niobe II. Radiofrequency ablation was performed at the site of earliest ventricular activation with pacemapping of at least 11/12 leads.Acute success was defined as suppression and non-inducibility of the arrhythmia after stimulation with isoprenaline. After a minimum 3-month follow-up, we assessed clinical success (absence of symptoms and suppression of the arrhythmia on Holter recording), defined as less than 50 premature ventricular contractions/24 hours.ResultsThe origin of the arrhythmia was in the right ventricular outflow tract in 28 patients (88%), in the left in three, and in the epicardium in one. Acute success was achieved in 26 patients (81%). Two patients underwent a second successful procedure, in one of which an epicardial approach was necessary. The overall clinical success rate, after two repeat procedures, was 88%. No complications occurred.There were two recurrences during a mean follow-up of 307±204 days.ConclusionThe Niobe II remote control system for mapping and ablation of ventricular outflow tract arrhythmias is effective and safe, and provides precise mapping and a high success rate, with no complications.     

Documento de Consenso sobre Estratificação de Risco Cardiovascular e estudo da doença coronária em Portugal: a posição dos Grupos de Estudo de Cardiologia Nuclear,Ressonância Magnética e Tomografia Computorizada Cardíaca,de Ecocardiografia e de Fisiopatologia do Esforço e Reabilitação Cardíaca

Despite constant medical evolution, the reimbursement policy of Portuguese National Health Service (NHS) for the study and risk stratification of coronary heart disease has remained unchanged for several decades. Lack of adjustment to contemporary clinical practice has long been evident. However, the recent publication of the European Guidelines for diagnosis and treatment of chronic coronary syndromes further highlighted this gap and the urgent need for a change. Prompted by these Guidelines, the Working Group on Nuclear Cardiology, Cardiac Magnetic Resonance and Cardiac CT, the Working Group on Echocardiography and the Working Group on Stress Pathophysiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology, began a process of joint reflection on the current limitations and how these recommendations could be applied in Portugal. To this end, the authors suggest that the new imaging methods (stress echocardiogram, cardiac computed tomography and cardiac magnetic resonance), should be added to exercise treadmill stress test and myocardial perfusion scintigraphy in the available exam portfolio within the Portuguese NHS. This change would allow full adoption of European guidelines and a better use of tests, according to clinical context, availability and local specificities. The adoption of clinical guidance standards, based on these assumptions, would translate into a qualitative improvement in the management of these patients and would promote an effective use of the available resources, with potential health and financial gains.     

Segurança e eficácia da angioplastia pulmonar por balão em Portugal num centro de referência em hipertensão pulmonar

IntroductionBalloon pulmonary angioplasty (BPA) is an alternative therapy in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) or residual/recurrent pulmonary hypertension (PH) after surgery. The aim of this study was to assess the short‐term efficacy and safety of a BPA program.MethodsThis prospective single‐center study included all BPA sessions performed in CTEPH patients between 2017 and 2019. Clinical assessment including WHO functional class, plasma biomarkers, 6‐min walk test (6MWT) and right heart catheterization was performed at baseline and six months after the last BPA session.ResultsA total of 57 BPA sessions were performed in 11 CTEPH patients (64% with inoperable disease, 82% under pulmonary vasodilator therapy). Nine patients completed both the BPA program and a minimum six‐month follow‐up period. There were significant improvements in WHO functional class (p=0.004) and 6MWT (mean increase of 42 m; p=0.050) and a trend for significant hemodynamic improvement: 25% decrease in mean pulmonary artery pressure (mPAP) (p=0.082) and 42% decrease in pulmonary vascular resistance (PVR) (p=0.056). In the group of patients with severely impaired hemodynamics (three patients with mPAP >40 mmHg), the reduction was significant: 51% in mPAP (p=0.013) and 67% in PVR (p=0.050). Prostacyclin analogs and long‐term oxygen therapy were withdrawn in all patients. Minor complications were recorded in 25% of patients. There were no major complications or deaths.ConclusionsA BPA strategy on top of pulmonary vasodilator therapy further improves symptoms, exercise capacity and hemodynamics with an acceptable risk‐benefit ratio in patients with inoperable CTEPH or residual/recurrent PH after surgery.     

Caracterização do perfil lipídico nos utentes dos cuidados de saúde primários em Portugal

AimTo characterize the distribution of total cholesterol (TC), LDL cholesterol (LDL-C), HDL cholesterol (HDL-C) and triglycerides in primary health care users.MethodsWe performed a cross-sectional study in a primary care setting, involving 719 general practitioners based on stratified distribution proportional to the population density of each region of Portugal.The first two adult patients scheduled for an appointment on a given day were invited to participate. A questionnaire was applied to assess sociodemographic, clinical and laboratory data including lipid profile.ResultsThe study included 16 856 individuals (mean age 58.1±15.1 years; 61.6% women). Data on TC, LDL-C, HDL-C and triglycerides were available for 95.9% (n=16 159), 59.1% (n=9956), 95.4% (n=16 074) and 97.9% (n=16 494) of the population, respectively. Hypercholesterolemia (TC ≥200 mg/dl) was detected in 47%, and 38.4% had high levels of LDL-C (≥130 mg/dl). Hypertriglyceridemia (≥200 mg/dl) and low HDL-C (<40 mg/dl) were less prevalent, affecting roughly 13% of the population. Dyslipidemia was more common in middle-aged men and in post-menopausal women. Of the population aged over 40, 54.1% met eligibility criteria for lipid-lowering therapy and 44.7% were medicated with statins, but only 16.0% of these had TC ≤175 mg/dl.ConclusionsDyslipidemia is highly prevalent in primary health care users in Portugal. It is particularly common in middle-aged men and post-menopausal women, who should be considered target groups for preventive public health measures.     

Os benefícios da reabilitação cardíaca na doença coronária: uma questão de género?

Introduction and ObjectivesCoronary heart disease is the leading cause of death in women worldwide and several studies have shown that they are under‐represented in cardiac rehabilitation therapy. The objectives of this study were to assess the prevalence of women in a cardiac rehabilitation program and to assess their response to this intervention.MethodsThis is a retrospective study of 858 patients who attended an exercise‐based cardiac rehabilitation program after an acute coronary syndrome or elective percutaneous coronary intervention, between January 2008 and December 2012. The patients were analyzed by gender, and the impact of the intervention on cardiovascular risk factors and NT‐proBNP was studied. In a subgroup of 386 patients the impact on functional capacity, resting heart rate, chronotropic index and heart rate recovery was also analyzed.ResultsOnly 24% of the 858 patients who attended the program were women. Women showed statistically significant improvements in all cardiovascular risk factors, NT‐proBNP, functional capacity and heart rate recovery (p<0.05) after the program. There were also improvements in resting heart rate and chronotropic index, but these were not statistically significant (p=0.08 and p=0.40, respectively) and when the improvements in these two parameters were compared between genders, there was no statistically significant difference (p=0.33 and p=0.17, respectively).ConclusionsOnly 24% of the patients attending the program were women. We found that they benefited from cardiac rehabilitation therapy, with significant improvements in cardiovascular risk factors and in most of the prognostic markers studied.