Publications by authors named "Lino Gonçalves"

222 Publications

Cardiac microcalcification burden: Global assessment in high cardiovascular risk subjects with Na[F]F PET-CT.

J Nucl Cardiol 2021 Apr 6. Epub 2021 Apr 6.

Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal.

Background: Fluorine-18 sodium fluoride (Na[F]F) atherosclerotic plaque uptake in positron emission tomography with computed tomography (PET-CT) identifies active microcalcification. We aim to evaluate global cardiac microcalcification activity with Na[F]F, as a measure of unstable microcalcification burden, in high cardiovascular (CV) risk patients.

Methods And Results: Thirty-four high CV risk individuals without previous CV events were scanned with Na[F]F PET-CT. Cardiac Na[F]F uptake was assessed through the global molecular calcium score (GMCS), which was calculated by summing the product of the mean standardized uptake value times the area of the cardiac regions of interest times the slice thickness for all cardiac transaxial slices, divided by the total number of slices. Mean age is 63.5 ± 7.8 years and 62% male. Median GMCS is 320.9 (240.8-402.8). Individuals with more than five CV risk factors (50%) have increased GMCS [356.7 (321.0-409.6) vs. 261.1 (225.6-342.1), P = 0.01], which is positively correlated with predicted fatal CV risk by SCORE (r = 0.32, P = 0.04). There is a positive correlation between GMCS and weight (r = 0.61), body mass index (r = 0.66), abdominal perimeter (r = 0.74), thoracic fat volume (r = 0.47), and epicardial adipose tissue (r = 0.41), all with P ≤ 0.01. There is no correlation between GMCS and coronary calcium score nor coronary artery wall Na[F]F uptake.

Conclusions: In a high CV risk group, the global cardiac microcalcification burden is related to CV risk factors, metabolic syndrome variables and cardiac fat. Cardiac GMCS is a promising risk stratification tool, combining a straightforward and objective methodology with a comprehensive analysis of both coronary and valvular microcalcification.
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http://dx.doi.org/10.1007/s12350-021-02600-2DOI Listing
April 2021

Aortic strain in bicuspid aortic valve: an analysis.

Int J Cardiovasc Imaging 2021 Apr 5. Epub 2021 Apr 5.

Faculty of Medicine, Universidade de Coimbra, Coimbra, Portugal.

Bicuspid aortic valve (BAV) is monitored by transthoracic echocardiography and computed tomography (CT) angiography. However, it does not have any early marker of disease progression. This study evaluated speckle-tracking echocardiography (STE) aortic and left ventricular (LV) strain prognostic values, their discriminative power, and their correlation with the degree of valvular regurgitation. We conducted a retrospective analysis of a prospectively enrolled cohort of 45 diagnosed with BAV and 20 gender and age matched controls. We performed 2D-STE aortic and LV strain analysis of the selected population. The cohort was followed-up during a median period of 19.9 months (IQR 12.9-25.2), and outcomes (hospital admission for heart failure (HF), aortic valve replacement (AVR), and death) were determined. The mean patient age was 46.6 ± 15.5 years and 80 % were male. LV indexed volumes and aortic diameter were higher in BAV patients. LV global longitudinal strain (GLS) was impaired (p < 0.001) and aortic GLS was significantly augmented (p = 0.027) in BAV patients. Aortic global circumferential strain (GCS) did not vary between groups. Aortic diameter was the best parameter related to BAV (AUC 0.92) and aortic GLS was best correlated with significant AR (AUC 0.76). AVR was the only outcome observed and its only predictor was indexed LV end-diastolic volume. BAV had impaired LV-GLS values. Aortic GLS was abnormally augmented in BAV patients, which might reflect higher aortic diameters that distorted strain calculations. STE aortic strain is related to AR but does not appear to be a reliable predictor of surgery in BAV patients, at 19 months.
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http://dx.doi.org/10.1007/s10554-021-02215-1DOI Listing
April 2021

Investigating the Usefulness of European Society of Cardiology Guidelines for Hospitalization in Acute Pericarditis at a Single Tertiary Center.

Cureus 2021 Feb 7;13(2):e13189. Epub 2021 Feb 7.

Cardiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT.

Background The European Society of Cardiology (ESC) guidelines for the diagnosis and management of pericardial diseases identify predictive factors of poor prognosis and advise either in favor or against hospitalization accordingly. We aim to evaluate the adequacy of hospitalization criteria in a cohort of patients presenting to the emergency department (ED) with acute pericarditis. Methods Retrospective analysis of patients admitted to ED with acute pericarditis, from 2009 to 2019. During ED stay, all patients were evaluated by a cardiologist who decided if the patient was to be discharged or hospitalized. Hospitalized and discharged patients were compared regarding the primary outcome, defined by a composite of: the need for pericardiocentesis and/or cardiac surgery, pericarditis recurrence, and all-cause death. The clinical decision was then counterpoised with ESC guidelines. Results A total of 192 patients were included in the analysis (median age 44.5 years old, 83.3% male) of which 87 (45.5%) were hospitalized. A total of 25% registered the primary outcome, mainly due to acute pericarditis recurrence, occurring in 21.9%. Predictors of recurrence were: glucocorticoid therapy (Odds Ratio [OR]=11.93, 95% Confidence Inirtval [CI] 3.13-45.5, p<0.001), fever at admission (OR=2.67, 95% CI 1.29-5.49, p=0.008), immunosuppression (OR=4.03, 95% CI 1.280-12.659, p=0.017) and increased cardiothoracic index (OR 3.85, CI 95% 1.67-8.86, p=0.002). Regarding hospitalisation/discharge decision, the ESC guidelines were respected in 73.4% of the cases. However, no significant difference in the primary outcome was noted whether the ESC guidelines were respected or not (27.5% vs. 24.3%, p=0.707). Conclusions Discrepancy between current guidelines and the clinical decision did not translate into a different outcome.
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http://dx.doi.org/10.7759/cureus.13189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7942027PMC
February 2021

Iatrogenic atrial septal defect after percutaneous left atrial appendage closure: a single-center study.

Int J Cardiovasc Imaging 2021 Mar 14. Epub 2021 Mar 14.

Cardiology Department, Centro Hospitalar e universitário de Coimbra - Hospital Geral, Quinta dos Vales - São Martinho do Bispo, 3043-853, Coimbra, Portugal.

There is conflicting evidence regarding the significance of iatrogenic atrial septal defects (iASDs) after transseptal puncture during percutaneous cardiac interventions. To study the clinical outcome of iASD after percutaneous left atrial appendage occlusion (LAAo). Single-center, retrospective study of 70 consecutive patients who underwent percutaneous LAAo between May 2010 and August 2017, and subsequent transesophageal echocardiography (TEE) at 1 month. The sample population was divided into two groups: A (with iASD, 22 (37%) patients) and B (no iASD, 44 (63%) patients). Procedures were guided either by TEE (36 patients (54%)) or intracardiac echocardiography (ICE) from the left atrium (30 patients (46%)). The primary end point was presence of iASD at 1 month, and secondary end points included mortality, hospital admission due to heart failure (HF), and right atrium (RA) size during follow-up. 70 patients were included in this study and the prevalence of iASD at 1 month was 37%. The use of ICE was associated with iASD (adjusted odds ratio, 3.79; 95% CI 1.27-11.34). The presence of iASD was not associated with adverse events (mortality, 15.4% vs 20.5%; P = 0.60; HF hospitalizations, 7.7% vs 13.6%, P = 0.45; and RA area, 24.8 ± 7.0 cm vs 22.2 ± 6.8 cm, P = 0.192). At 1-month follow-up after LAAo, iASD was present in one third of patients, but was not associated with clinical outcomes. The use of ICE was associated with a higher risk of short-term iASD.
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http://dx.doi.org/10.1007/s10554-021-02212-4DOI Listing
March 2021

Admission hyperglycemia and all-cause mortality in diabetic and non-diabetic patients with acute myocardial infarction: a tertiary center analysis.

Intern Emerg Med 2021 Mar 13. Epub 2021 Mar 13.

Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta, R. Professor Mota Pinto, 3004-561, Coimbra, Portugal.

Admission hyperglycemia (AH) is associated with worse prognosis in patients with acute myocardial infarction (AMI). Controversy remains whether the impact of AH differs among patients previously diagnosed with diabetes mellitus (DM). We retrospectively evaluated consecutive patients admitted in a coronary care unit with AMI, from 2006 to 2014. Patients were divided into 4 groups: patients without known DM with admission glycemia (AG) ≤ 143 mg/dL (group 1), patients without known DM with AG > 143 mg/dL (group 2), known DM with AG ≤ 213 mg/dL (group 3), and known DM with AG > 213 mg/dL (group 4). Primary outcome was defined as all-cause mortality during follow-up. A total of 2768 patients were included: 1425 in group 1, 426 in group 2, 593 in group 3, and 325 in group 4. After a median follow-up of 5.6 years, 1047 (37.8%) patients reached primary outcome. After multivariate analysis, group 4 was associated with the worst prognosis (HR 3.103, p < 0.001) followed by group 3 (HR 1.639, p = 0.002) and group 2 (HR 1.557, p = 0.039), when compared to group 1. When groups were stratified by type of AMI, patients in group 2 had a worse prognosis than patients in group 3 in the case of non-ST-segment elevation AMI. AH is associated with higher all-cause mortality in patients with AMI, irrespective of previous diabetic status.
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http://dx.doi.org/10.1007/s11739-021-02693-0DOI Listing
March 2021

The efficacy and safety of direct oral anticoagulants plus aspirin in symptomatic lower extremity peripheral arterial disease: a systematic review and meta-analysis of randomized controlled trials.

J Thromb Thrombolysis 2021 Mar 11. Epub 2021 Mar 11.

Serviço de Cardiologia, Hospital Geral, Centro Hospitalar e Universitário de Coimbra, Quinta dos Vales, S. Martinho do Bispo, 3041-801, Coimbra, Portugal.

Patients with lower extremity peripheral artery disease (PAD) are at increased risk of major adverse limb events (MALE). The efficacy and safety of direct oral anticoagulants (DOACs) in this context is evolving. To assess the efficacy and safety of DOAC combined with aspirin compared to the use of antiplatelet agents in patients with symptomatic lower extremity (LE) PAD. We systematically searched PubMed, Embase and Cochrane databases, in September 2020, for randomized controlled trials (RCTs) that were designed to investigate the effect of DOACs in the treatment of PAD. A random-effects meta-analysis was performed targeting ischemic and bleeding events. Three randomized clinical trials were included, providing a total of 9533 patients, and 744 pooled MALE events (316 in DOAC plus aspirin and 428 in control). Only data on rivaroxaban and edoxaban were available. The use of DOAC plus aspirin in PAD patients significantly decreased the rate of MALE (pooled OR 0.70 [0.61-0.83], P < 0.001; I = 0%). In terms of safety, there was a significantly higher rate of major bleeding events (pooled OR 1.46 [1.16-1.84], P = 0.001; I = 52%). In rivaroxaban-RCTs, the addition of low-dose rivaroxaban to aspirin was still associated with a lower MALE compared to aspirin alone (pooled OR 0.68 [0.53-0.88], P = 0.003; I = 28%), but also conferred higher major bleeding rate (pooled OR 1.48 [1.18-1.86], P < 0.001; I = 0%). In conclusion, our pooled data suggests that for patients with symptomatic LE-PAD, the use of DOAC combined with aspirin reduced the risk of major ischemic limb events at the expense of an increased risk of major bleeding.
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http://dx.doi.org/10.1007/s11239-021-02417-3DOI Listing
March 2021

Man with hypotension and chest pain.

J Am Coll Emerg Physicians Open 2021 Feb 17;2(1):e12365. Epub 2021 Feb 17.

Cardiology Department Centro Hospitalar e Universitário de Coimbra Coimbra Portugal.

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http://dx.doi.org/10.1002/emp2.12365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7890037PMC
February 2021

Impact of catheter ablation for atrial fibrillation in patients with heart failure and left ventricular systolic dysfunction.

Rev Port Cardiol 2021 Feb 24. Epub 2021 Feb 24.

Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal.

Introduction And Aims: Catheter ablation has been shown to improve left ventricular (LV) ejection fraction (LVEF) in patients with atrial fibrillation (AF) and heart failure (HF). Our aim was to assess the impact of AF ablation on the outcome of patients with HF and LV systolic dysfunction.

Methods: We performed a retrospective observational cohort study of all patients with HF and LVEF <50% and with no apparent cause for systolic dysfunction other than AF who underwent catheter ablation in a tertiary referral center between July 2016 and November 2018. The primary endpoint was a ≥5% improvement in LVEF. Secondary endpoints included improvement in New York Heart Association (NYHA) class and reduction in LV end-diastolic diameter (LVEDD) and left atrial diameter (LAD).

Results: Of 153 patients who underwent AF ablation in this period, 22 (77% male, median age 61 [IQR 54-64] years) fulfilled the inclusion criteria. Median follow-up was 11.1 months (IQR 6.1-19.0). After ablation, median LVEF increased from 40% (IQR 33-41) to 58% (IQR 55-62) (p<0.01), mean NYHA class improved from 2.35±0.49 to 1.3±0.47 (p<0.001), and median LAD and LVEDD decreased from 48.0 (IQR 43.5-51.5) mm to 44 (IQR 40-49) mm (p<0.01) and from 61.0 (IQR 54.0-64.8) mm to 55.0 (52.2-58.0) mm (p<0.01), respectively.

Conclusion: In patients with HF and LV systolic dysfunction, AF ablation is associated not only with improved functional status but also with favorable structural remodeling, including improvement in LVEF and decreases in LAD and LVEDD.
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http://dx.doi.org/10.1016/j.repc.2020.08.014DOI Listing
February 2021

Successful retrieval of a broken PentaRay catheter spine in a patient with mechanic mitral valve prosthesis.

J Interv Card Electrophysiol 2021 Feb 27. Epub 2021 Feb 27.

Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

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http://dx.doi.org/10.1007/s10840-021-00965-5DOI Listing
February 2021

Usefulness of universal beta-blocker therapy in patients after ST-elevation myocardial infarction.

Medicine (Baltimore) 2021 Jan;100(3):e23987

Department of Cardiology, Centro Hospitalar e Universitário de Coimbra.

Abstract: The use of beta-blockers (BB) in the context of ST-segment elevation myocardial infarction (STEMI) was a universal practice in the pre-reperfusion era. Since then, evidence of their use for secondary prevention after STEMI is scarce. Our aim is to determine treatment results associated with BB therapy after a STEMI at 1-year follow-up in a contemporary nationwide cohort.A prospective analysis involving 49 national centers, including patients admitted with STEMI, enrolled between October 2010 and September 2019 was conducted. The primary outcome was defined as the composite of all-cause mortality or hospital re-admission for a cardiovascular (CV) cause in the first year after STEMI. The patients were distributed into 2 groups, depending on whether they received therapy with BB at hospital discharge or not (BB and NB group, respectively).A total of 3145 patients were included in the analysis, of which 2526 (80.3%) in the BB group. A total of 12.2% of patients reached the primary outcome. Regarding the univariate Cox regression analysis, the BB group presented lower mortality or re-admission for CV cause at 1-year follow-up [hazard ratio (HR) 0.69, confidence interval (CI) 95% 0.55-0.87, P = .001]. However, after adjustment for significant covariates, this association was lost (HR 0.73, CI 95% 0.51-1.04, P = .081). In patients with preserved (HR 0.73, CI 95% 0.51-1.04, P = .081) and mid-range (HR 1.01, CI 95% 0.64-1.61, P = .959) left ventricular ejection fraction (LVEF), the primary outcome was similar between the 2 groups, while in patients with reduced LVEF, the BB group presented a better prognosis, with fewer patients reaching the primary outcome (HR 0.431, CI 95% 0.262-0.703, P = .001).BB universal therapy after STEMI has not proved useful, but it seems to be beneficial in patients with reduced LVEF.
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http://dx.doi.org/10.1097/MD.0000000000023987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837933PMC
January 2021

A Rare Complication of Implantable Cardiac Defibrillator Placement.

J Cardiovasc Echogr 2020 Jul-Sep;30(3):167-170. Epub 2020 Nov 9.

Department of Cardiology, Coimbra Hospital and University Center, Portugal.

Implantable cardiac defibrillators (ICDs) are a popular and effective option in heart failure with left ventricular systolic dysfunction patients. Although frequently underdiagnosed, inadvertent malposition can lead to endocardial damage and thrombotic events. As ICD implants tend to increase in the following years, the recognition of their complications is critical. The authors present a case of a 64-year-old female with advanced heart failure and ICD malposition. This accidental discovery was denounced by the presence of a right bundle branch block (RBBB) pattern and later confirmed by echocardiography which showed the lead tip in contact with the midsegment of the left ventricular anterolateral wall. As the patient's hospitalization was complicated with refractory ascites and cardiogenic shock, she underwent cardiac transplantation, with no recurrence of heart failure symptoms. An electrocardiogram showing a RBBB pattern during VVI pacing should arise the suspicion of inadvertent incorrect placement of a pacing/ICD lead. The many facets of echocardiography should be used for the diagnosis of this complication, as they were paramount in this case, as highlighted.
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http://dx.doi.org/10.4103/jcecho.jcecho_8_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799063PMC
November 2020

Left atrial functional assessment and mortality in patients with severe aortic stenosis with sinus rhythm.

Cardiovasc Ultrasound 2021 Jan 2;19(1). Epub 2021 Jan 2.

Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Praceta, R. Prof. Mota Pinto, 3004-561, Coimbra, Portugal.

Background: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence keeps growing. While other risk factors in severe AS are well documented, little is known about the prognostic value of left atrial (LA) function in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up.

Methods: We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up.

Results: A total of 408 patients were included in the analysis, with a median follow-up time of 45 months (interquartile range 54 months). 57.9% of patients underwent AVR and 44.9% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.845, 95%CI 0.81-0.88, P < 0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF < 37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (HR 13.91, 95%CI 6.20-31.19, P < 0.001 and HR 3.40, 95%CI 1.57-7.37, P = 0.002, respectively). After adjustment for AVR, excess risk of LAEF < 37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (HR 11.71, 95%CI 5.20-26.40, P < 0.001 and HR 3.59, 95%CI 1.65-7.78, P = 0.001, respectively).

Conclusions: In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.
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http://dx.doi.org/10.1186/s12947-020-00231-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7778823PMC
January 2021

Late challenges after full plastic jacket in spontaneous coronary dissection.

Rev Port Cardiol 2021 Feb 25;40(2):143-144. Epub 2020 Dec 25.

Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal.

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http://dx.doi.org/10.1016/j.repc.2019.08.011DOI Listing
February 2021

Pattern Matching Filter and multielectrode mapping catheter - A new approach for complex premature ventricular contraction ablation.

Rev Port Cardiol 2020 Dec 8. Epub 2020 Dec 8.

Pacing & Electrophysiology Unit, Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal.

Purpose: Our goal was to assess usefulness of Pattern Matching Filter (PMF) software combined with the PentaRay catheter for complex premature ventricular contraction (PVC) ablation.

Methods: A prospective observational study of consecutive patients referred for complex PVC ablation at our tertiary center from January to September 2018. Patients underwent ablation using a pre-specified mapping strategy with the PMF and the PentaRay catheter (PVCs with ≥97% correlation with the template morphology were collected). Procedural endpoints and acute and 12-months success rates were assessed and compared to a retrospective cohort of patients who also underwent a complex PVC ablation with standard activation mapping performed with a Thermocool SmartTouch catheter.

Results: During the nine-month enrollment period, seven patients fulfilled our inclusion criteria, while there were four patients in the control group. Patients treated with the PMF and PentaRay had a fivefold number of points acquired (507±213 vs. 90±62) and a halved procedure time (67±42 vs.130±54 min), required a shorter radiofrequency ablation time (294±112 vs.706±613 sec) and had a higher overall success rate (100% vs.75%) when compared to the standard approach. No major complications occurred in either group.

Conclusions: In this first study assessing the combined use of the PentaRay catheter and the PMF for complex PVCs ablation, we demonstrate how this approach can improve the level of detail, accuracy and reliability of the activation map, while reducing the number of radiofrequency applications and procedural time. Further studies are warranted to confirm whether this approach can lead to improved outcomes.
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http://dx.doi.org/10.1016/j.repc.2020.08.009DOI Listing
December 2020

Micro-RNA Analysis in Pulmonary Arterial Hypertension: Current Knowledge and Challenges.

JACC Basic Transl Sci 2020 Nov 23;5(11):1149-1162. Epub 2020 Nov 23.

University of Coimbra, Coimbra Institute for Clinical and Biomedical Research, Faculty of Medicine, Coimbra, Portugal.

Pulmonary arterial hypertension (PAH) is a rare, chronic disease of the pulmonary vasculature that is associated with poor outcomes. Its pathogenesis is multifactorial and includes micro-RNA (miRNA) deregulation. The understanding of the role of miRNAs in PAH is expanding quickly, and it is increasingly difficult to identify which miRNAs have the highest translational potential. This review summarizes the current knowledge of miRNA expression in PAH, discusses the challenges in miRNA analysis and interpretation, and highlights 4 promising miRNAs in this field (miR-29, miR-124, miR-140, and miR-204).
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http://dx.doi.org/10.1016/j.jacbts.2020.07.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691282PMC
November 2020

Glycoprotein IIb/IIIa inhibitors for cardiogenic shock complicating acute myocardial infarction: a systematic review, meta-analysis, and meta-regression.

J Intensive Care 2020 Nov 11;8(1):85. Epub 2020 Nov 11.

Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Quinta dos Vales, 3041-801, Coimbra, Portugal.

Background: Cardiogenic shock complicates 5-10% of myocardial infarction (MI) cases. Data about the benefit of glycoprotein IIb/IIIa inhibitors (GPI) in these patients is sparse and conflicting.

Methods: We performed a systematic review, meta-analysis, and meta-regression of studies assessing the impact of GPI use in the setting of MI complicated cardiogenic shock on mortality, angiographic success, and bleeding events. We systematically searched for studies comparing GPI use as adjunctive treatment versus standard care in this setting. Random-effects meta-analysis and meta-regression were performed.

Results: Seven studies with a total of 1216 patients (GPI group, 720 patients; standard care group, 496 patients) were included. GPI were associated with a 45% relative reduction in the odds of death at 30 days (pooled OR 0.55; 95% CI 0.35-0.85; I = 57%; P = 0.007) and a 49% reduction in the odds of death at 1 year (pooled OR 0.51; 95% CI 0.32-0.82; I = 58%; P = 0.005). Reduction in short-term mortality seemed to be more important before 2000, as this benefit disappears if only the more recent studies are analyzed. GPI were associated with a 2-fold increase in the probability of achieving TIMI 3 flow (pooled OR, 2.05; 95% CI 1.37-3.05; I = 37%, P = 0.0004). Major bleeding events were not increased with GPI therapy (pooled OR, 1.0; 95% CI 0.55-1.83; I = 1%, P = 0.99). Meta-regression identified that patients not receiving an intra-aortic balloon pump seemed to benefit the most from GPI use (Z = - 1.57, P = 0.005).

Conclusion: GPI therapy as an adjunct to standard treatment in cardiogenic shock was associated with better outcomes, including both short- and long-term survival, without increasing the risk of bleeding.
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http://dx.doi.org/10.1186/s40560-020-00502-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656750PMC
November 2020

Left Ventricular Thrombus Therapy With Direct Oral Anticoagulants Versus Vitamin K Antagonists: A Systematic Review and Meta-Analysis.

J Cardiovasc Pharmacol Ther 2021 May 1;26(3):233-243. Epub 2020 Dec 1.

Serviço de Cardiologia, 58411Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

Background: Current guidelines recommend vitamin K antagonists (VKAs) for left ventricular thrombus (LVT) resolution. Direct oral anticoagulants (DOACs) are increasingly evaluated as alternatives to the standard of care in anticoagulation.

Methods: We performed a systematic review and meta-analysis to assess the use of DOACs vs VKAs for LVT treatment. The occurrence of LVT resolution, systemic embolism (SE) or stroke, and bleeding events were compared during follow-up using random-effects analysis.

Results: The 5 included studies were all observational (a total of 828 patients). Of these, 284 patients (34%) were treated with DOACs, and 544 (66%) treated with VKAs. Thrombus resolution was similar for both methods (pooled odds ratio [OR], 0.91; 95% CI, 0.47-1.75; = 63%; = .78). The incidence of SE or stroke was also similar (pooled OR, 1.59; 95% CI, 0.85-2.97; = 0%; = .14). Clinically relevant bleeding incidence was similar for both groups (pooled OR, 0.66; 95% CI, 0.31-1.40; = 0%; = .28), although all bleeding events were less frequent in the DOAC group (pooled OR, 0.49; 95% CI, 0.26-0.90; = 0%; = .02).

Conclusion: Our systematic review and meta-analysis suggests DOACs were as effective as VKAs for LVT resolution, with a similar risk of systemic embolism/stroke and clinically relevant bleeding. These results, obtained from observational studies, are not definitive and hence randomized controlled trials are needed. Nevertheless, our analysis identifies key experimental features required in future studies.
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http://dx.doi.org/10.1177/1074248420977567DOI Listing
May 2021

Determinants and prognostic implication of periprocedural myocardial injury after successful recanalization of coronary chronic total occlusion.

Cardiovasc Interv Ther 2020 Nov 1. Epub 2020 Nov 1.

Department of Cardiology, Coimbra University Hospital Centre, Coimbra, Portugal.

Periprocedural myocardial injury (PMI) has been generally associated with major adverse cardiac events (MACE), however, limited studies addressed its clinical implications following chronic total occlusion (CTO) percutaneous coronary intervention (PCI). To evaluate the determinants and prognostic implication of PMI following CTO-PCI. Retrospective single-centre study of 125 consecutive patients undergoing CTO-PCI was attempted between December 2013 and December 2017. Angiographic success was achieved in 115 patients (92.0%) and cTn-I values were obtained 12-24 h following PCI. PMI was defined as an elevation of cTn-I above 5 times the 99th-percentile upper reference limit. Baseline demographic, clinical, angiographic and procedural characteristics were compared. Multivariate analysis was performed to determine the predictors of PMI and the correlates of PMI and 1-year MACE, a composite of all-cause death, non-fatal myocardial infarction, and target lesion revascularization. Overall, mean age was 67 ± 17 years; 25 patients (21.7%) were female; and PMI occurred in 41 patients (35.7%). Multivessel coronary artery disease (MVD) (odds ratio [OR], 3.41; 95% confidence interval [CI], 1.09-10.67; p = 0.04) and procedural complications (a composite of iatrogenic coronary artery dissection/haematoma or perforation) (OR, 19.08; 95% CI, 3.77-96.65; p < 0.01) predicted PMI. Significant collateralization (Rentrop 3) (hazard ratio, [HR], 0.19; 95% CI, 0.06-0.64; p < 0.01) and procedural complications (HR, 8.86; 95% CI, 2.66-29.46; p < 0.01) were independently associated with 1-year MACE, while PMI was not (p = 0.26). In this contemporary cohort, PMI following successful CTO-PCI was a common finding and was predicted by MVD and procedural complications. PMI was not independently associated with 1-year MACE.
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http://dx.doi.org/10.1007/s12928-020-00727-6DOI Listing
November 2020

Myocardial infarction affects Cx43 content of extracellular vesicles secreted by cardiomyocytes.

Life Sci Alliance 2020 12 23;3(12). Epub 2020 Oct 23.

University of Coimbra, Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, Coimbra, Portugal

Ischemic heart disease has been associated with an impairment on intercellular communication mediated by both gap junctions and extracellular vesicles. We have previously shown that connexin 43 (Cx43), the main ventricular gap junction protein, assembles into channels at the extracellular vesicle surface, mediating the release of vesicle content into target cells. Here, using a comprehensive strategy that included cell-based approaches, animal models and human patients, we demonstrate that myocardial ischemia impairs the secretion of Cx43 into circulating, intracardiac and cardiomyocyte-derived vesicles. In addition, we show that ubiquitin signals Cx43 release in basal conditions but appears to be dispensable during ischemia, suggesting an interplay between ischemia-induced Cx43 degradation and secretion. Overall, this study constitutes a step forward for the characterization of the signals and molecular players underlying vesicle protein sorting, with strong implications on long-range intercellular communication, paving the way towards the development of innovative diagnostic and therapeutic strategies for cardiovascular disorders.
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http://dx.doi.org/10.26508/lsa.202000821DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652393PMC
December 2020

ESC Core Curriculum for the Cardiologist.

Eur Heart J 2020 10;41(38):3605-3692

Cardiology, University Heart Center Zürich, Rämistrasse 100, Zürich, CH-8091, Switzerland.

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http://dx.doi.org/10.1093/eurheartj/ehaa641DOI Listing
October 2020

External Automated Defibrillator-Assisted Diagnosis of Patient After Bringing Him Back to Life.

JAMA Intern Med 2020 10;180(10):1378-1379

Department of Cardiology, Coimbra University Hospital, Coimbra, Portugal.

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http://dx.doi.org/10.1001/jamainternmed.2020.2549DOI Listing
October 2020

Fusion imaging in interventional cardiology.

Rev Port Cardiol 2020 08 28;39(8):463-473. Epub 2020 Jul 28.

Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal; Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

The number and complexity of percutaneous interventions for the treatment of structural heart disease has increased in clinical practice in parallel with the development of new imaging technologies, in order to render these interventions safer and more accurate. Complementary imaging modalities are commonly used, but they require additional mental reconstruction and effort by the interventional team. The concept of fusion imaging, where two different modalities are fused in real time and on a single monitor, aims to solve these limitations. This is an important tool to guide percutaneous interventions, enabling a good visualization of catheters, guidewires and devices employed, with enhanced spatial resolution and anatomical definition. It also allows the marking of anatomical reference points of interest for the procedure. Some studies show decreased procedural time and total radiation dose with fusion imaging; however, there is a need to obtain data with more robust scientific methodology to assess the impact of this technology in clinical practice. The aim of this review is to describe the concept and basic principles of fusion imaging, its main clinical applications and some considerations about the promising future of this imaging technology.
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http://dx.doi.org/10.1016/j.repc.2020.03.014DOI Listing
August 2020

Looking in the mirror: An unusual optical coherence tomography image.

Rev Port Cardiol 2020 Jul 14;39(7):409-410. Epub 2020 Jul 14.

Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal.

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http://dx.doi.org/10.1016/j.repc.2019.09.015DOI Listing
July 2020

Activated double-negative T cells (CD3CD4CD8HLA-DR) define response to renal denervation for resistant hypertension.

Clin Immunol 2020 Sep 30;218:108521. Epub 2020 Jun 30.

Faculty of Medicine (FMUC), University of Coimbra, Coimbra, Portugal; Department of Cardiology, Coimbra's Hospital and University Centre (CHUC), Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal.

Purpose: To explore the cellular immune response of patients with resistant hypertension treated with renal denervation (RDN).

Methods And Results: Twenty-three patients were included and blood samples were obtained in six timings, pre and post procedure. Response was evaluated at six-months and one year and was observed in 69.6% and 82.6% of patients, respectively. Absolute values of HLA-DR+ double negative (DN) T cells were significantly lower in the group of 'responders' at one year, and interaction between the timings were found in three T cell subsets (T CD4, T CD8 and naïve T CD8 cells), with the 'responders' tending to present with lower absolute values and little inter-timing variation.

Conclusions: 'Responders' significantly present with lower absolute values of activated DN T cells and have lower and more stable values of total T CD8+, CD4+, and naïve T CD8+ cells. These cell types may be able to predict response to RDN.
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http://dx.doi.org/10.1016/j.clim.2020.108521DOI Listing
September 2020

A 10- and 15-year performance analysis of ESC/EAS and ACC/AHA cardiovascular risk scores in a Southern European cohort.

BMC Cardiovasc Disord 2020 06 19;20(1):301. Epub 2020 Jun 19.

Cardiology Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

Background: A key strategy for the primary prevention of cardiovascular disease (CVD) is the use of risk prediction algorithms. We aimed to investigate the predictive ability of SCORE (Systematic COronary Risk Estimation) and PCE (Pooled Cohort Equations) systems for atherosclerotic CVD (ASCVD) risk in Portugal, a low CVD risk country, at the 10-year landmark and at a longer, 15-year follow-up.

Methods: The SCORE and PCE 10-year risk estimates were calculated for 455 and 448 patients, respectively. Discrimination was assessed by Harrell's C-statistic. Calibration was analyzed by standardized incidence ratios (SIR).

Results: During the 10-year follow-up, 7 fatal ASCVD events (the SCORE outcome) and 32 any ASCVD events (the PCE outcome) occurred. The SCORE system showed good discrimination (C-statistic 0.83), while the PCE showed poor discrimination (C-statistic 0.62). Calibration was similar for both systems, according to SIR: SCORE, 0.3 (95% CI 0.1-0.7); PCE, 0.5 (95% CI 0.4-0.7). Globally, both 10-year fatal ASCVD risk and any ASCVD risk were overestimated in the overall population and men. However, the risk was underestimated by both systems in women. Despite an overestimation of 15-year fatal ASCVD by SCORE, the 15-year any ASCVD observed incidence was 1.8 times the 10-year incidence among men and 1.4 times among women. This acceleration of CVD risk was more relevant in the lowest classes of ASCVD risk.

Conclusion: In this prospective, contemporary, Portuguese cohort, the SCORE had better discriminatory power and similar calibration compared to PCE. However, both risk scores underestimated 10-year ASCVD risk in women.
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http://dx.doi.org/10.1186/s12872-020-01574-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7304198PMC
June 2020

Novel anticoagulants in an older and frail population with atrial fibrillation: the effect of inappropriate dosing on clinical outcomes.

Eur Geriatr Med 2020 10 16;11(5):813-820. Epub 2020 Jun 16.

Department of Cardiology, Coimbra University Hospital, Coimbra, Portugal.

Purpose: An individualized approach should be taken regarding the use of novel oral anticoagulants (NOAC) in frail and older patients with atrial fibrillation (AF). We hypothesized that there would be a high proportion of underdosed patients among an older and frail population, where bleeding risk is higher.

Methods: We retrospectively analyzed patients admitted to an Internal Medicine ward with a previous diagnosis of AF and discharged with a NOAC (n = 327). We compared survival and incidence of dosing-related events (stroke, systemic embolism, and major bleeding) at 1-year between inappropriately underdosed patients (dose reduction without a formal indication) and the rest of the population.

Results: A total of 167 patients (51%) received a reduced dose despite lacking formal criteria for dose reduction. Before adjustment, underdosed patients, in comparison with non-underdosed patients, had a higher mortality at 1 year (HR = 1.6, 95% CI 1.2-2.1, p = 0.003) and a higher combined stroke, systemic embolism, and major bleeding event rate at 1-year (HR = 3.2, 95% CI 1.3-8.0, p = 0.015). After adjustment, combined stroke, systemic embolism, and major bleeding event rate was higher in underdosed patients (HR 3.7, 95% CI 1.1-12.3, p = 0.030), but survival was not different in the adjusted model (HR 1.4, 95% CI 0.9-2.1, p = 0.110).

Conclusions: Underdosed patients have a significant survival disadvantage and this may be due to clinician prescription bias, since this difference does not remain after adjusting for confounders. Combined stroke, systemic embolism, and major bleeding event rate was higher in underdosed patients.
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http://dx.doi.org/10.1007/s41999-020-00343-wDOI Listing
October 2020