Publications by authors named "Maria Júlia Maciel"

99 Publications

Temporal trends of lipid control in very high cardiovascular risk patients.

Rev Port Cardiol 2021 Jun 7. Epub 2021 Jun 7.

Cardiology Department, Centro Hospitalar Universitário de São João, Porto, Portugal.

Introduction: Since 2011, the European guidelines have included a specific low-density lipoprotein cholesterol (LDL-C) target, <70 mg/dl, for very high cardiovascular risk (CVR) patients. However, registries have shown unsatisfactory results in obtaining this level of adequate lipid control.

Objectives: To assess temporal trends in the use of lipid-lowering therapy (LLT) and attainment of adequate control in very high CVR patients since 2011.

Methods: We performed a retrospective observational study including very high CVR patients admitted in two periods: the first two years since the 2011 guidelines (2011/2012) and five years later (2016/2017). Lipid values, LLT, clinical variables and adequate lipid control rates were analyzed.

Results: A total of 1314 patients were reviewed (2011/2012: 638; 2016/2017: 676). Overall, 443 patients (33.7%) were not under LLT and only a slight improvement in drug prescription was observed from 2011/2012 to 2016/2017. In LLT users, the proportion of high-intensity LLT increased significantly in the later years (6.4% vs. 24.0%; p<0.001), but this was not associated with adequate lipid control. Overall, mean LDL-C was 95.4±37.2 mg/dl and adequate control was achieved in 320 patients (24.4%), without significant differences between 2011/2012 and 2016/2017 (p=0.282). Independent predictors of adequate control were male gender, older age, diabetes, chronic kidney disease, prior acute coronary syndrome, prior stroke and LLT, while stable coronary artery disease was associated with higher risk of failure.

Conclusion: Even after the introduction of specific LDL-C targets, these are still not reached in most patients. Over a five-year period, LLT prescription only improved slightly, while adequate lipid control rates remained unchanged.
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http://dx.doi.org/10.1016/j.repc.2020.10.018DOI Listing
June 2021

Comparison of levosimendan, NO, and inhaled iloprost for pulmonary hypertension reversibility assessment in heart transplant candidates.

ESC Heart Fail 2021 Apr 23;8(2):908-917. Epub 2021 Feb 23.

Department of Surgery and Physiology, Cardiovascular R&D Centre, Faculty of Medicine, University of Porto, Porto, Portugal.

Aims: Assessing reversibility of pulmonary vascular changes through vasoreactivity testing (VRT) optimizes end-stage heart failure patient selection for heart transplant. All efforts should be made to unload the left ventricle and reduce pulmonary vascular resistance to effectively exclude irreversible pulmonary hypertension.

Methods And Results: We reviewed our centre's cardiac transplant registry database (2009-2017) for VRT and compared haemodynamic responses with 40 ppm inhaled NO (n = 14), 14-17 μg inhaled iloprost (n = 7), and 24 h 0.1 μg/kg/min intravenous levosimendan (n = 14). Response to levosimendan was assessed by repeat right heart catheterization within 72 h. Baseline clinical and haemodynamic features were similar between groups. VRT was well tolerated in all patients. All drugs effectively reduced pulmonary artery pressures and transpulmonary gradient while increasing cardiac index, although levosimendan had a greater impact on cardiac index increase (P = 0.036). Levosimendan was the only drug that reduced pulmonary artery wedge pressure (P = 0.004) and central venous pressures (P < 0.001) and increased both left and right ventricular stroke work indexes (P = 0.020 and P = 0.042, respectively) and cardiac power index (P < 0.001) compared with NO and iloprost. Right ventricular end-diastolic pressures and central venous pressure were only decreased by levosimendan. The rate of positive responses (≥10 mmHg decrease or final mean pulmonary artery pressure ≤40 mmHg with increased/unaltered cardiac index) was lower with inhaled iloprost (14%) than with either levosimendan or NO (71% and 64%, respectively; P < 0.05).

Conclusions: Levosimendan may be a safe and effective alternative for pulmonary hypertension reversibility assessment or a valuable pre-test medical optimization tool in end-stage heart failure patient assessment for heart transplantation offering extended haemodynamic benefits. Whether it increases the rate of positive responses or allows a better selection of candidates to heart transplantation remains to be established.
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http://dx.doi.org/10.1002/ehf2.13168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006659PMC
April 2021

Embolization of a left atrial appendage closure device.

Rev Port Cardiol (Engl Ed) 2021 Mar 20;40(3):247-248. Epub 2021 Jan 20.

Serviço de Cardiologia, Centro Hospitalar Universitário de São João, E.P.E., Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Porto, Portugal.

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http://dx.doi.org/10.1016/j.repc.2019.12.010DOI Listing
March 2021

Cardiac rehabilitation in older patients: Indication or limitation?

Rev Port Cardiol (Engl Ed) 2021 Jan 9;40(1):13-20. Epub 2021 Jan 9.

Department of Physical Medicine and Rehabilitation, Centro Hospitalar de São João, Porto, Portugal.

Objective: To assess the clinical impact of a cardiac rehabilitation program in an older population.

Methods: This is a retrospective analysis of 731 coronary patients who attended phase 2 of a cardiac rehabilitation program between January 2009 and December 2016. We compared the response to the program of older (≥65 years) and younger (<65 years) patients, analyzing changes in metabolic profile (including body mass index, waist circumference and lipid profile), exercise capacity, cardiac autonomic regulation parameters (such as chronotropic index and resting heart rate), and health-related quality of life scores.

Results: Older patients represented 15.9% of our cohort. They showed significant reductions in waist circumference (male patients: 98.0±7.9 cm vs. 95.9±7.9 cm, p<0.001; female patients: 90.5±11.4 cm vs. 87.2±11.7 cm, p<0.001), LDL cholesterol (102.5 [86.3-128.0] mg/dl vs. 65.0 [55.0-86.0] mg/dl, p<0.001) and triglycerides (115.0 [87.8-148.5] mg/dl vs. 97.0 [81.8-130.0] mg/dl, p<0.001). Post-training data also showed a noticeable improvement in older patients' exercise capacity (7.6±1.8 METs vs. 9.3±1.8 METs, p<0.001), along with a higher chronotropic index and lower resting heart rate. Additionally, health-related quality of life indices improved in older subjects. However, our overall analysis found no significant differences between the groups in changes of the studied parameters.

Conclusion: Older coronary patients benefit from cardiac rehabilitation interventions, similarly to their younger counterparts. Greater involvement of elderly patients in cardiac rehabilitation is needed to fully realize the therapeutic and secondary preventive potential of such programs.
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http://dx.doi.org/10.1016/j.repc.2020.04.009DOI Listing
January 2021

Left ventricular pacing with a temporary pacemaker: Case report.

Rev Port Cardiol (Engl Ed) 2021 Feb 26;40(2):141.e1-141.e4. Epub 2020 Dec 26.

Department of Cardiology, Centro Hospitalar São João, EPE, Porto, Portugal.

We report a case of temporary pacemaker lead malposition in the left ventricle crossing the interventricular septum (IVS). The majority of described cases occur due to a patent foramen ovale and are frequently incidental findings. A course across the IVS is rarely found and this complication with temporary leads is not even reported in the literature. This very rare location entails a risk of dangerous complications associated with left-to-right flow after lead removal. Echocardiography was an essential tool to diagnose the lead's course inside the heart and enabled secure removal of the lead with cardiac surgery backup.
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http://dx.doi.org/10.1016/j.repc.2020.12.006DOI Listing
February 2021

A Case of Acute Myocardial Infarction and Pericarditis Unmasking Metastatic Involvement of the Heart.

Arq Bras Cardiol 2020 04;115(1 suppl 1):22-24

Centro Hospitalar Universitário de São João, Porto - Portugal.

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http://dx.doi.org/10.36660/abc.20190534DOI Listing
April 2020

Caseous calcification of the mitral annulus in a cardiac arrest survivor.

Rev Port Cardiol (Engl Ed) 2020 May 10;39(5):295-297. Epub 2020 Jun 10.

Serviço de Cardiologia, Centro Hospitalar Universitário de São João, E.P.E., Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Porto, Portugal.

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http://dx.doi.org/10.1016/j.repc.2019.09.012DOI Listing
May 2020

Echocardiographic appearance of a rare condition - tracheobronchomegaly.

Rev Port Cardiol (Engl Ed) 2020 Apr 20;39(4):229-230. Epub 2020 May 20.

Cardiology Department, Centro Hospitalar Universitário de São João, Porto, Portugal.

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http://dx.doi.org/10.1016/j.repc.2019.03.010DOI Listing
April 2020

Patient and system delays in the treatment of acute coronary syndrome.

Rev Port Cardiol (Engl Ed) 2020 Mar 6;39(3):123-131. Epub 2020 May 6.

EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal; Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.

Introduction: Early reperfusion for patients with ST-segment elevation myocardial infarction (STEMI) is indicated by the European Society of Cardiology, while a timely invasive strategy is recommended for patients with high-risk and intermediate-risk non-ST-elevation acute coronary syndromes (NSTE-ACS). This study aims to assess patient and system delays according to diagnosis and risk profile, and to identify predictors of prolonged delay.

Methods: We assembled a cohort of patients (n=939) consecutively admitted to the cardiology department of two hospitals, one in the metropolitan area of Porto and one in the north-east region of Portugal, between August 2013 and December 2014.

Results: The proportion of patients with time from symptom onset to first medical contact (FMC) ≥120 min was highest among high-risk NSTE-ACS (57.7%), followed by intermediate-risk NSTE-ACS (52.1%) and STEMI (43.3%). Regardless of diagnosis and risk stratification, use of own transportation and inability to interpret cardiac symptoms correctly were associated with prolonged delays. Regarding system delays, we found that 78.0% of patients with STEMI and 65.8% of patients with high-risk NSTE-ACS were treated in a timeframe exceeding the recommended limits. Admission to a non-percutaneous coronary intervention-capable hospital, admission on weekends and complications at admission were associated with prolonged delays to treatment.

Conclusions: Due to both patient and system delays, a large proportion of STEMI and high-risk NSTE-ACS patients still fail to have access to timely reperfusion.
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http://dx.doi.org/10.1016/j.repc.2019.07.007DOI Listing
March 2020

Infective endocarditis: When an image surprises the echocardiographer.

Rev Port Cardiol (Engl Ed) 2019 Nov 6;38(11):831-832. Epub 2020 Feb 6.

Cardiology Department, Centro Hospitalar São João, Porto, Portugal; Faculty of Medicine, Porto University, Porto, Portugal.

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http://dx.doi.org/10.1016/j.repc.2019.01.009DOI Listing
November 2019

Role of Left Ventricle Function in Cardiac Rehabilitation Outcomes in Stage B Heart Failure Patients.

J Cardiopulm Rehabil Prev 2020 01;40(1):E5-E9

Departments of Cardiology (Drs Braga, Nascimento, Nunes, Araújo, Pinto, Rodrigues, Araújo, and Maciel) and Physical Medicine and Rehabilitation (Drs Parada-Pereira and Rocha), Centro Hospitalar São João, Porto, Portugal.

Purpose: To study the role of left ventricle systolic function in cardiac rehabilitation program (CRP) response in stage B heart failure patients.

Methods: A retrospective analysis was completed of 691 patients with previous myocardial infarction that underwent a CRP, classified in 3 groups: preserved ejection fraction (pEF), mid-range ejection fraction (mrEF), and reduced ejection fraction (rEF). We compared the response to CRP analyzing the relative changes of estimated cardiorespiratory fitness (CRFe), resting heart rate (HR), and chronotropic index (CI).

Results: After exercise training (median [interquartile range]) mrEF (23.9% [9.7, 40.8]) and rEF (23.9% [9.7, 41.2]) groups had a better CRFe response to CRP than pEF groups (17.6% [0.0, 35.9]), P = .009. CI increased similarly in all groups. We found a small effect of CRP on resting HR.

Conclusion: Exercise-based CRP yields notable benefits to mrEF and rEF groups and the magnitude of its benefits is, at least, similar to that found in pEF patients.
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http://dx.doi.org/10.1097/HCR.0000000000000461DOI Listing
January 2020

Benefits of Cardiac Rehabilitation in Coronary Artery Disease: DOES WEIGHT MATTER?

J Cardiopulm Rehabil Prev 2019 11;39(6):386-390

Departments of Cardiology (Drs Braga, Nascimento, Pinto, Araújo, Nunes, Rodrigues, Araújo, and Maciel) and Physical Medicine and Rehabilitation (Drs Parada-Pereira and Rocha), Centro Hospitalar São João, Porto, Portugal.

Purpose: To evaluate the response of patients with obesity to a cardiac rehabilitation program (CRP), compared with patients without obesity.

Methods: We performed a retrospective analysis of 731 patients who completed phase II of a CRP after an acute coronary syndrome. The response to the CRP was assessed using the relative changes in exercise capacity (EC), resting heart rate (HR), and chronotropic index (CI).

Results: Only 23% of patients had obesity. Patients with obesity showed lower EC and CI at baseline and at the end of phase II of the CRP. Despite that, we reported a higher relative improvement for EC in patients with obesity (median [interquartile range], 23.9% [5.2, 40.8] vs 17.6% [8.1, 35.9], P = .043) and similar improvements in CI (10.9% [-1.4 to 34.2] vs 7.1% [-7.1 to 28.2], P = .100), compared with patients without obesity. There were no significant changes in resting HR.

Conclusion: Regardless of their lower exercise performance at baseline, patients with obesity had a remarkably positive response to the CRP compared with patients without obesity.
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http://dx.doi.org/10.1097/HCR.0000000000000442DOI Listing
November 2019

Impact of a brief psychological intervention on lifestyle, risk factors and disease knowledge during phase I of cardiac rehabilitation after acute coronary syndrome.

Rev Port Cardiol (Engl Ed) 2019 May 17;38(5):361-368. Epub 2019 Jun 17.

Faculdade de Medicina, Universidade do Porto, Portugal.

Introduction: This study examined the efficacy of a brief inpatient psychoeducational intervention on knowledge about acute coronary syndromes (ACS), control of risk factors, and adaptive health habits and lifestyle. The intervention was intended to facilitate rehabilitation after ACS and its short- and medium-term impact was assessed.

Methods: One hundred and twenty-one patients with ACS, admitted to a central cardiology unit in Portugal, were randomized to an experimental group (EG, n=65) or a control group (CG, n=56). We used the Portuguese versions of the Knowledge Questionnaire and the Health Habits Questionnaire. Patients were assessed at hospital admission, hospital discharge and one- and two-month follow-up.

Results: The intervention had a significant impact, increasing knowledge about ACS (F=500.834; p=0.000) in the EG, which was maintained at two-month follow-up, and changing health habits at two-month follow-up (F=218.129; p=0.000). The CG demonstrated decreased knowledge (F=3.368; p=0.069) during the same period.

Conclusions: A brief inpatient psychoeducational intervention has a positive effect on knowledge about ACS, risk factor control and promotion of positive health habits, and is effective in improving cardiac rehabilitation.
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http://dx.doi.org/10.1016/j.repc.2018.09.009DOI Listing
May 2019

TAVI in TAVI: new paradigm.

Acta Cardiol 2020 Apr 29;75(2):172-174. Epub 2019 Mar 29.

Centro Hospitalar de São João, Serviço de Cardiologia, Porto, Portugal.

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http://dx.doi.org/10.1080/00015385.2019.1569311DOI Listing
April 2020

Cardiac papillary fibroelastoma: Report of a surgical series.

Rev Port Cardiol (Engl Ed) 2018 Dec 7;37(12):981-986. Epub 2018 Dec 7.

Cardiothoracic Surgery Department, Centro Hospitalar de São João, Porto, Portugal.

Introduction: Papillary fibroelastoma (PFE) is a rare primary benign tumor of cardiac origin that predominantly affects the cardiac valves. Although most patients are asymptomatic, serious complications may result given their propensity for embolization. Advances in imaging technology have enabled earlier detection and more accurate characterization of these tumors. We report a case series, describing clinical presentation, treatment and outcome.

Methods: Institutional records of a tertiary center between 1997 and 2015 were reviewed for all patients diagnosed with PFE treated surgically and confirmed histologically. Demographic and clinical characteristics, echocardiography findings and treatment modalities were analyzed and recurrence at follow-up was studied.

Results: A total of 26 patients (69% male), aged 54±18 years, had a PFE. Clinically, PFE presented with neurologic deficits in eight cases and was asymptomatic in 65.4%. The mitral valve surface was the predominant tumor location (53.8%), followed by the aortic valve (34.6%). Tumor size ranged between 3 mm and 22 mm, 26.9% had a pedicle and 42.4% were mobile. All patients were treated successfully by complete resection, isolated in 88.5% and with valve repair in three cases. No other cardiac procedure was performed concomitantly and there were no major postoperative complications. Median follow-up was 61±49 months and no tumor recurrence or embolic events were documented.

Conclusions: Fibroelastomas are generally small, single and detected by chance during routine imaging exams. Complete surgical resection of the tumor has an excellent prognosis and appears to be a good strategy.
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http://dx.doi.org/10.1016/j.repc.2018.02.011DOI Listing
December 2018

Is it important to assess the ascending aorta after tetralogy of Fallot repair?

Rev Port Cardiol (Engl Ed) 2018 Sep 25;37(9):773-779. Epub 2018 Aug 25.

Centro Hospitalar São João, Department of Cardiology, Porto, Portugal; University of Porto, Faculty of Medicine, Porto, Portugal.

Introduction And Objectives: Aortic dilatation can develop late after tetralogy of Fallot repair. Its extension beyond the aortic root is not clearly understood. We aimed to assess the prevalence and predictors of ascending aorta dilatation to set up an imaging protocol.

Methods: In this prospective study including adult patients after tetralogy of Fallot repair followed at a referral center, we assessed the aorta by cardiovascular magnetic resonance and defined ascending aorta dilatation as an observed-to-expected ratio >1.5.

Results: We included 78 adults (mean age 31±10 years; 56% female), with a mean follow-up of 23±7 years since tetralogy of Fallot repair. The prevalence of ascending aorta dilatation was 11.5%. The ascending aorta was larger than the sinuses of Valsalva in 12.8% of cases. Patients with ascending aorta dilatation were older, predominantly male, with later repair and larger left ventricular mass and volumes. By multivariate analysis left ventricular mass index (LVMI) was the only factor independently associated with ascending aorta dilatation (odds ratio 1.10, 95% confidence interval 1.01-1.20, p=0.03). A cut-off value of ≥57.9 g/m for LVMI had 89% sensitivity and 71% specificity for ascending aorta dilatation.

Conclusions: Ascending aorta assessment as part of a routine cardiovascular magnetic resonance study after tetralogy of Fallot repair is recommended to screen for future aortic complications, particularly in males and older patients, and those with later repair and larger left ventricles. LVMI assessment has potential as a screening tool for ascending aorta dilatation with future clinical implications.
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http://dx.doi.org/10.1016/j.repc.2017.11.014DOI Listing
September 2018

Aortic dilatation after tetralogy of Fallot repair: A ghost from the past or a problem in the future?

Rev Port Cardiol (Engl Ed) 2018 Jul 29;37(7):549-557. Epub 2018 Jun 29.

Department of Cardiology, Centro Hospitalar São João, Faculty of Medicine, University of Porto, Porto, Portugal.

Introduction And Aims: Intrinsic aortopathy can lead to dilatation late after tetralogy of Fallot (TOF) repair. Its extent and prevalence are not known. We aimed to assess aortic dimensions and elasticity and to find predictors of aortic dilatation.

Methods: A total of 126 adults were prospectively included after TOF repair and compared to 63 gender- and age-matched controls. Transthoracic echocardiography was used to assess aortic diameters at the level of the sinuses of Valsalva and ascending aorta and aortic dilatation was defined as z-score >+2. M-mode parameters of the ascending aorta were used to calculate strain, distensibility and stiffness index.

Results: TOF patients (mean age 30±9 years; 52% male) had a complete repair at a median age of five (2-49) years; mean follow-up time since repair was 23±7 years. The prevalence of aortic dilatation at the sinuses of Valsalva and ascending aorta was 29% and 24%, respectively. Compared to controls, TOF patients had a higher ascending aorta z-score, lower strain (6.4% [0.0-61.5] vs. 15.2% [0.0-45.0], p<0.01) and higher stiffness index (7.3 [0.8-23.6] vs. 3.1 [0.9-14.1], p<0.01). On multivariate analysis male gender was strongly associated with sinuses of Valsalva dilatation (odds ratio 6.3, 95% confidence interval 1.5-26.3, p=0.01).

Conclusions: The prevalence of aortic dilatation late after TOF repair is significant, with a larger and stiffer ascending aorta. Male gender appears to influence aortic root dilatation. This aortopathy requires careful follow-up in order to prevent future complications.
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http://dx.doi.org/10.1016/j.repc.2017.10.014DOI Listing
July 2018

Quality of Care and 30-day Mortality of Women and Men With Acute Myocardial Infarction.

Rev Esp Cardiol (Engl Ed) 2019 Jul 3;72(7):543-552. Epub 2018 Jul 3.

EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal; Centro de Epidemiologia Hospitalar, Centro Hospitalar São João, EPE, Porto, Portugal; Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.

Introduction And Objectives: Despite increased awareness of sex disparities in care and outcomes of acute myocardial infarction (AMI), there appears to have been no consistent attenuation of these differences over the last decade. We investigated differences by sex in management and 30-day mortality using the European Society of Cardiology Acute Cardiovascular Care Association quality indicators (QIs) for AMI.

Methods: Proportions and standard errors of the 20 Acute Cardiovascular Care Association QIs were calculated for 771 patients with AMI who were admitted to the cardiology departments of 2 tertiary hospitals in Portugal between August 2013 and December 2014. The association between the composite QI and 30-day mortality was derived from logistic regression.

Results: Significantly fewer eligible women than men received timely reperfusion, were discharged on dual antiplatelet therapy and high-intensity statins, and were referred to cardiac rehabilitation. Women were less likely to receive recommended interventions (59.6% vs 65.2%; P <.001) and also had higher mean GRACE 2.0 risk score-adjusted 30-day mortality (3.0% vs 1.7%; P <.001). An inverse association between the composite QI and crude 30-day mortality was observed for both sexes (OR, 0.08; 95%CI, 0.01-0.64 for the highest performance tertile vs the lowest).

Conclusions: Performance in AMI management is worse for women than men and is associated with higher 30-day mortality, which is also worse for women. Evidence-based QIs have the potential to improve health care delivery and patient prognosis in the overall AMI population and may also bridge the disparity gap between women and men.
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http://dx.doi.org/10.1016/j.rec.2018.05.012DOI Listing
July 2019

Ascending aorta in tetralogy of Fallot: Beyond echocardiographic dimensions.

Echocardiography 2018 09 13;35(9):1362-1369. Epub 2018 Jun 13.

Department of Cardiology, Centro Hospitalar São João, Porto, Portugal.

Background: Late after tetralogy of Fallot (TOF) repair some patients exhibit aortic dilatation and stiffness. Noninvasive assessment of aortic stiffness could contribute to understand this aortopathy and may be important in risk stratification for major aortic event.

Methods: We included prospectively 82 adults after TOF repair and 41 age- and sex-matched normal controls. Aortic diameters were measured by two-dimensional transthoracic echocardiography and the aortic z-score was estimated. Aortic deformation was assessed by M-mode strain and global peak circumferential ascending aortic strain (CAAS), derived from two-dimensional speckle tracking echocardiography (2D-STE). Corrected CAAS was calculated as CAAS/pulse pressure. Ascending aorta (AAo) distensibility and stiffness index were calculated.

Results: TOF patients (age 29.7 ± 8.4 years; follow-up since TOF repair 23.0 ± 6.8 years) had smaller body surface area but a larger aorta compared to controls. TOF patients had lower AAo distensibility (2.2 [0.0-21.0] vs 5.6 [0.0-12.5] cm dyne 10 , P < .01), higher aortic stiffness index (9.5 [2.7-98.4] vs 7.1 [2.3-20.4], P = .02) and lower CAAS (6.0 ± 3.9 vs 8.1 ± 4.4%, P = .01) compared to controls. CAAS showed a better correlation with AAo z-score (r = -.25, P = .03) compared to M-mode strain. Systemic arterial compliance, arterial stiffness and corrected CAAS (β = -0.23, P = .02) were independently associated with AAo diameter.

Conclusions: TOF patients have a larger and stiffer AAo compared to controls. CAAS derived from 2D-STE allows a routine noninvasive method for assessing AAo stiffness, with advantages over M-mode strain, and may be used as predictor of major aortic or cardiovascular events.
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http://dx.doi.org/10.1111/echo.14046DOI Listing
September 2018

Left atrial volume index is critical for the diagnosis of heart failure with preserved ejection fraction.

J Cardiovasc Med (Hagerstown) 2018 Jun;19(6):304-309

Faculdade Medicina Universidade Porto.

Background: Heart failure with preserved ejection fraction (HFpEF) is now well recognized but the identification of patients with HFpEF can be challenging. We aimed to evaluate the performance of tissue Doppler imaging indexes and left atrial size in HFpEF diagnosis.

Methods And Results: We designed a case-control study in which cases are patients with acute heart failure and controls are age-matched and sex-matched patients with multiple cardiovascular risk factors admitted to hospital because of stroke. An echocardiogram was performed with tissue Doppler imaging evaluation. Receiver operating curves (ROC) were obtained to identify the best cut-off of BNP, global longitudinal strain (GLS), E/E' and left atrial volume index (LAVI) for the identification of patients with HFpEF whenever compared with those without heart failure.We analyze data from 195 age-matched and sex-matched patients: 65 patients with heart failure with reduced ejection fraction, 65 patients with HFpEF and 65 stroke patients. The best cut-offs for identification of HFpEF patients when compared with the nonheart failure control group of patients with stroke were 15 for GLS, 15 for E/E' ratio and 34 ml/m for LAVI. The area under the curve (AUC) for GLS was 0.81 (CI 0.72-0.90); for the ratio E/E', the AUC was 0.79 (CI 0.70-0.88) and for LAVI, it was 0.90 (CI 0.84-0.96).

Conclusion: We observed that ecochardiographic indices of diastolic and systolic function do identify patients with HFpEF. Our results point towards LAVI, E/E' ratio and GLS as relevant indices to identify patients with HFpEF, especially LAVI.
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http://dx.doi.org/10.2459/JCM.0000000000000651DOI Listing
June 2018

Sex differences in presenting symptoms of acute coronary syndrome: the EPIHeart cohort study.

BMJ Open 2018 02 23;8(2):e018798. Epub 2018 Feb 23.

EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.

Objectives: Prompt diagnosis of acute coronary syndrome (ACS) remains a challenge, with presenting symptoms affecting the diagnosis algorithm and, consequently, management and outcomes. This study aimed to identify sex differences in presenting symptoms of ACS.

Design: Data were collected within a prospective cohort study (EPIHeart).

Setting: Patients with confirmed diagnosis of type 1 (primary spontaneous) ACS who were consecutively admitted to the Cardiology Department of two tertiary hospitals in Portugal between August 2013 and December 2014.

Participants: Presenting symptoms of 873 patients (227 women) were obtained through a face-to-face interview.

Outcome Measures: Typical pain was defined according to the definition of cardiology societies. Clusters of symptoms other than pain were identified by latent class analysis. Logistic regression was used to quantify differences in presentation of ACS symptoms by sex.

Results: Chest pain was reported by 82% of patients, with no differences in frequency or location between sexes. Women were more likely to feel pain with an intensity higher than 8/10 and this association was stronger for patients aged under 65 years (interaction P=0.028). Referred pain was also more likely in women, particularly pain referred to typical and atypical locations simultaneously. The multiple symptoms cluster, which was characterised by a high probability of presenting with all symptoms, was almost fourfold more prevalent in women (3.92, 95% CI 2.21 to 6.98). Presentation with this cluster was associated with a higher 30-day mortality rate adjusted for the GRACE V.2.0 risk score (4.9% vs 0.9% for the two other clusters, P<0.001).

Conclusions: While there are no significant differences in the frequency or location of pain between sexes, women are more likely to feel pain of higher intensity and to present with referred pain and symptoms other than pain. Knowledge of these ACS presentation profiles is important for health policy decisions and clinical practice.
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http://dx.doi.org/10.1136/bmjopen-2017-018798DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855399PMC
February 2018

Missed Opportunities in Symptomatic Patients before a First Acute Coronary Syndrome: The EPIHeart Cohort Study.

Cardiology 2018;139(2):71-82. Epub 2017 Dec 23.

EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.

Objectives: The aim of this study was to assess the proportion of patients with a first episode of acute coronary syndrome (ACS) reporting preceding chest pain, having previously sought medical care and undergone the performance of exams, and to identify the determinants of seeking medical advice and undergoing electrocardiogram (ECG).

Methods: Within a cohort study, 690 patients with a first episode of ACS were evaluated. A questionnaire was applied to assess chest pain within the preceding 6 months of the event and health system resources utilization. Determinants were identified by logistic regression.

Results: Preceding chest pain was reported by 61% of patients, 43% of these sought medical help, of whom less than half underwent ECG, and in 39% pain was attributed to a problem of the heart. Patients with hypertension were more likely to seek medical care (adjusted odds ratio, OR, 2.13, 95% CI 1.29-3.51), and former smokers (OR 0.52, 95% CI 0.28-0.99) and patients of a higher social class (OR 0.16, 95% CI 0.05-0.48) were less likely to seek medical care. The performance of ECG was associated with male sex (OR 2.56, 95% CI 1.11-5.87), health subsystem coverage (OR 3.88, 95% CI 1.11-13.53), and living in the northeastern region (OR 9.07, 95% CI 4.07-20.24), whereas cognitive impairment (OR 0.37, 95% CI 0.15-0.92) and being employed (OR 0.36, 95% CI 0.14-0.97) were inversely associated.

Conclusions: These results suggest there are opportunities to improve the diagnosis of myocardial ischemia before acute coronary events.
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http://dx.doi.org/10.1159/000484713DOI Listing
October 2018

The role of biomarkers in dilated cardiomyopathy: Assessment of clinical severity and reverse remodeling.

Rev Port Cardiol 2017 Oct 6;36(10):709-716. Epub 2017 Oct 6.

Cardiology Department, Centro Hospitalar São João, Porto, Portugal; Porto Medical School, Porto, Portugal.

Introduction: Biomarkers in dilated cardiomyopathy (DCM) reflect various pathobiological processes, including neurohormonal activation, oxidative stress, matrix remodeling, myocyte injury and myocyte stretch. We assessed the role of biomarkers in clinical and echocardiographic parameters and in left ventricular (LV) reverse remodeling (LVRR).

Methods: In this prospective study of 50 DCM patients (28 men, aged 59±10 years) with LV ejection fraction (LVEF) <40%, LVRR was defined as an increase of >10 U in LVEF after optimal medical therapy.

Results: Baseline LVEF was 25.4±9.8% and LV end-diastolic diameter (LVEDD)/body surface area (BSA) was 34.2±4.5 mm/m. LVRR occurred in 34% of patients within 17.6±15.6 months. No correlation was found between B-type natriuretic peptide (BNP), 25-hydroxyvitamin D (25(OH)D), CA-125, high-sensitivity C-reactive protein (hs-CRP), lipoprotein(a) [Lp(a)], noradrenaline, adrenaline, renin or aldosterone and LVRR. Patients in NYHA class III or IV, with pulmonary congestion or ankle edema, had higher CA-125, cystatin C, BNP and hs-CRP levels (p<0.05). CA-125 was correlated with BNP (r=0.61), hs-CRP (r=0.56) and uric acid (r=0.52) (all p=0.01). BNP correlated directly with LVEDD (r=0.49), LV volumes (r=0.51), pulmonary artery systolic pressure (PASP) (r=0.43) and E/e' (r=0.31), and was inversely correlated with LVEF (r=-0.50) and e' velocity (r=-0.32) (p<0.05). CA-125 was positively correlated with left atrial volume/BSA (r=0.46), E/A ratio (r=0.60) and PASP (r=0.49) (p<0.05).

Conclusions: No correlation was found between biomarkers and LVRR, but CA-125, BNP and hs-CRP were predictors of clinical severity and congestion. BNP correlated with parameters of systolic and diastolic dysfunction, while CA-125 correlated with measures of diastolic dysfunction.
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http://dx.doi.org/10.1016/j.repc.2017.02.015DOI Listing
October 2017

Brief psychological intervention in phase I of cardiac rehabilitation after acute coronary syndrome.

Rev Port Cardiol 2017 Sep 4;36(9):641-649. Epub 2017 Sep 4.

Faculdade de Medicina, Universidade do Porto, Portugal.

Introduction: Acute coronary syndrome (ACS) is an important cause of mortality and significant personal and financial costs. Cardiac rehabilitation (CR) programs have shown positive effects in reducing cardiovascular mortality and improving functional capacity. However, adherence is low and appears to be influenced by psychosocial factors, such as patients' cognitions and emotional state. The objective was to evaluate the efficacy of a brief in-hospital psychological intervention to promote cognitive and emotional adaptation after ACS.

Methods: One hundred and twenty-one patients with ACS, admitted to a coronary care unit in a central hospital, were randomized to an experimental group (EG, n=65) and a control group (CG, n=56). Portuguese versions of the HADS and BIPQ were used to measure emotional well-being and illness cognitions. Two 1 h 15 min sessions were conducted 2-3 days after hospital admission, and a 20-minute follow-up session took place one month after discharge. Patients were assessed at four different time points: pre-test, post-test, and at 1- and 2-month follow-up.

Results: The intervention had significant effects on anxiety, depression and illness cognitions. Anxiety and depression were significantly reduced and illness cognitions improved significantly in the EG compared to the control group. For the EG, these changes were maintained or enhanced at 1- and 2-month follow-up, whereas for the CG there was a deterioration in psychosocial adjustment.

Conclusions: These results indicate that a brief psychological intervention program delivered during hospitalization for ACS and combined with standard medical care can have positive effects in terms of psychosocial outcomes that have proven impact on cardiac rehabilitation and prognosis.
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http://dx.doi.org/10.1016/j.repc.2017.01.005DOI Listing
September 2017

PR interval and survival in diabetic patients with acute myocardial infarction.

Indian Heart J 2017 Jul - Aug;69(4):523-525. Epub 2017 Jun 2.

Faculdade de Medicina da Universidade do Porto, Portugal; Department of Cardiology, Hospital Sao Joao, Porto, Portugal.

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http://dx.doi.org/10.1016/j.ihj.2017.06.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5560883PMC
September 2018

Antidiabetic therapy at admission and survival in diabetic patients with acute myocardial infarction.

Porto Biomed J 2017 Jul-Aug;2(4):111-114. Epub 2017 Mar 9.

Faculdade de Medicina da Universidade do Porto, Porto, Portugal.

Highlights: Anti-diabetic drugs used at admission in myocardial infarction patients were studied.195 admissions corresponding to different patients were under analysis.No difference in survival was seen in patients using or not using DPP-4 inhibitors.

Introduction: is frequently associated to cardiovascular disease. We aimed at studying the relations between anti-diabetic drugs in use at admission by diabetic patients with acute myocardial infarction and survival after a period of at least 36 and up to 52 months after admission.

Methods: Retrospective study based on electronic records. Data from a total number of 195 admissions corresponding to different patients were under analysis.

Results: Kaplan-Meier analysis, as well as Cox analysis, failed to show a difference in survival associated to the use of DPP-4 inhibitors ( = 35 patients). A non-significant trend toward increased survival was seen with metformin ( = 92 patients), and in the opposite direction with both insulin ( = 51 patients) and sulfonylureas ( = 51 patients).

Conclusions: The use of DPP-4 inhibitors at admission, in patients with admitted for acute myocardial infarction, was not associated to a different survival after no less than 36 months and up to 52 months after admission.
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http://dx.doi.org/10.1016/j.pbj.2017.02.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6806965PMC
March 2017

A rare primary cardiac benign tumour: diagnosis by non-invasive cardiac imaging.

Acta Cardiol 2017 Jun 21;72(3):345-346. Epub 2017 Mar 21.

a Serviço de Cardiologia, Centro Hospitalar de São João , Porto , Portugal.

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http://dx.doi.org/10.1080/00015385.2017.1305198DOI Listing
June 2017

Plasma alkaline phosphatase and survival in diabetic patients with acute myocardial infarction.

Ann Transl Med 2016 Jun;4(11):210

1 Faculdade de Medicina da Universidade do Porto, Porto, Portugal ; 2 Department of Cardiology, Hospital Sao Joao, Porto, Portugal.

Background: Alkaline phosphatase (ALP) removes phosphate groups from many types of molecules. The aim of the present research was to study the relation between plasma ALP and survival in diabetic patients with myocardial infarction.

Methods: Retrospective study: from 954 admissions (15 months period) in a coronary care unit, we selected 200 admissions corresponding to 195 patients with myocardial infarction and diabetes mellitus. Survival after no less than 48 months, and up to 61 months, after the myocardial infarction episode, was under study, in association with ALP levels.

Results: A relatively weak but significant correlation was seen between the peak plasma cardiac troponin I and ALP levels (r: 0.21, significance level: 0.003). Using the median value for ALP as cut-off (74 IU/L), plasma creatinine was significantly higher in patients with higher values for ALP. Patients with elevated ALP had decreased survival in Kaplan-Meier analysis (significance level in log-rank test: 0.032). This finding was noted for male patients (significance level in log-rank test: 0.035), but not for female patients (significance level in log-rank test: 0.497).

Conclusions: Elevated ALP acts as a prognostic indicator of decreased survival in diabetic patients with acute myocardial infarction, possibly in association to decreased renal function. This finding is limited to male patients, pointing to a possible different role for phosphatase activity in cardiovascular disease in male and female diabetic patients.
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http://dx.doi.org/10.21037/atm.2016.06.01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4916366PMC
June 2016