André Rodrigues Durães

High-intensity interval training versus moderate-intensity continuous training on exercise capacity and quality of life in patients with coronary artery disease: A systematic review and meta-analysis:

Background Exercise is an effective strategy for reducing total and cardiovascular mortality in patients with coronary artery disease. However, it is not clear which modality is best. We performed a meta-analysis to investigate the effects of high-intensity interval versus moderate-intensity continuous training of coronary artery disease patients. Methods We searched MEDLINE, PEDro, LILACS, SciELO and the Cochrane Library (from the earliest date available to November 2016) for controlled trials that evaluated the effects of high-intensity interval versus moderate-intensity continuous training for coronary artery disease patients. Weighted mean differences and 95% confidence intervals were calculated, and heterogeneity was assessed using the I2 test. Results Twelve studies met the study criteria, including 609 patients. High-intensity interval training resulted in improvement in peak oxygen uptake weighted mean difference (1.3 ml/kg/min, 95% confidence interval: 0.6–1.9, n = 594) compared with moderate-intensity continuous training. No significant difference in physical, emotional, and social domain of quality of life was found for participants for participants in the high-intensity interval training group compared with the moderate-intensity continuous training group. Sub-analysis of three studies with isocaloric exercise training showed no significant difference in peak oxygen uptake weighted mean difference (0.4 ml/kg/min, 95% confidence interval: –0.1–0.9, n = 137) for participants in the high-intensity interval training group compared with moderate-intensity continuous training group. Conclusions High-intensity interval training may improve peak oxygen uptake and should be considered as a component of care of coronary artery disease patients. However, this superiority disappeared when isocaloric protocol is compared.

High intensity interval training versus moderate intensity continuous training on exercise capacity and quality of life in patients with heart failure with reduced ejection fraction: A systematic review and meta-analysis

OBJECTIVE The aim of this study was to investigate the effects of high intensity interval training (HIIT) versus moderate intensity continuous training (MICT) in heart failure patients with reduced ejection fraction (HFrEF). BACKGROUND Despite the well-known positive effects of exercise in heart failure patients, the best mode of exercise is still under discussion. METHODS We searched Pubmed/MEDLINE, Cochrane Central Register of Controlled Trials, PEDro data base, and SciELO (from the earliest date available to October 2017) for randomized controlled trials that evaluated the effects of HIIT versus MICT in HFrEF patients. Weighted mean differences (WMD) with 95% confidence interval (CI) were calculated, and heterogeneity was assessed using the I2 test. RESULTS 13 studies met the study criteria, including 411 patients. Compared to MICT, HIIT resulted in improvement in Peak VO2 WMD (1.35 mL·kg-1·min-1 95% CI: 0.03 to 2.64 N = 411). HIIT resulted in no difference in VE/VCO2 slope WMD (-1.21 95% CI: -3.0 to 0.58 N = 135), and quality of life measured by Minnesota Living with Heart Failure questionnaire WMD (1.19 95% CI: -5.81 to 8.19 N = 79). Sub-group analyses comparing studies with and without isocaloric exercise training protocol also showed a nonsignificant difference in peak VO2 for participants in the HIIT group compared with MICT group. CONCLUSIONS HIIT improves peak VO2 and should be considered as a component of care of HFrEF patients. However, its superiority versus MICT disappears when isocaloric protocols are compared. An important caveat is uncertainty and variation of actual training intensities compared to program targets.

Evaluation of variables responsible for hospital mortality in patients with rheumatic heart disease undergoing double valve replacement

Objective To describe the hospital mortality and associated clinical and echocardiographic variables in patients with rheumatic disease who underwent double valve replacement surgery. Methods This is a cross sectional descriptive study of mortality, performed in a referral hospital in Salvador, Bahia. Records from patients with rheumatic disease who underwent double valve replacement surgery during the years 2007-2011 were analyzed. Results The studied sample comprises 104 patients and 60 (57.7%) were male. The mean age was 38.04±14.45. Sixty five bioprostheses and 38 mechanical prostheses were used in these patients at the time of surgery. There were statistically significant differences between the two groups, when we analyzed the following variables: the mean age (36.30±13.03 vs. 45.35±17.8 years-old, P=0.011), mean hemoglobin (11.10±2.19 vs. 9.22±2.26 g/dL, P=0.002), mean hematocrit (34.22±5.86 vs. 28.44±6.62%, P<0.001). New York Heart Association functional class III and IV (NYHA) (P=0.022) was statistically associated with mortality. Conclusion We concluded that the mean hemoglobin/hematocrit level and the NYHA functional class was the major variables associated to the mortality among these patients. Based on these data one may concern about the patient best moment for surgery and the patient hemoglobin level.

Impact of aspirin use in the incidence of thromboembolic events after bioprosthesis replacement in patients with rheumatic disease

INTRODUCTION There is still much debate regarding the kind of antithrombotic therapy in the immediate postoperative period of bioprosthesis replacement (first three months). Thus, the authors consider relevant to determine the contemporary incidence of thromboembolic events in rheumatic patients early after implantation of aortic and mitral bioprosthesis replacement (first 90 days in the post-operative period) and perform a comparison between isolated Aspirin uses versus no-antiplatelet therapy, in this same context. METHODS Between the period of January 2010 to July 2012, all consecutive rheumatic patients, with basal sinus rhythm, who performed mitral and aortic valve replacement with bioprosthesis (pericardial bovine), were included in this prospective cohort study, 184 patients in total. The primary endpoint evaluated were the rate of embolic events. RESULTS In the first 30 days, there were three cerebral ischemic events among patients treated in Aspirin group (5.2%) compared with two events in patients without Aspirin therapy (1.7%), HR = 3.18; 95% CI 0.5 to 19.6; P=0.33. Between 31 and 90 days postoperatively, no patient had a primary outcome. The embolism-free survival, bleeding events and the overall survival were not statistically significant between the aspirin and no-antiplatelet groups. CONCLUSION In conclusion, in this prospective cohort of rheumatic patients, we found a low and very rare incidence rate of embolic events during the first 90 days postoperative period in mitral and isolated aortic position, respectively. The use of aspirin did not significantly reduce the rate of thromboembolism.

Usefulness and Safety of Rivaroxaban in Patients Following Isolated Mitral Valve Replacement With a Mechanical Prosthesis

Rivaroxaban has previously been tested in experimental and animal models with encouraging results. We prospectively selected seven patients between May 2017 and January 2018 who underwent isolated mitral valve replacement with a mechanical prosthesis and had unstable INR control at least 3 months after surgery. An intervention of rivaroxaban 15mg was then administered twice daily for a period of 90days. No patient presented intracardiac thrombus, reversible ischemic neurological deficit, ischemic or hemorrhagic stroke, and hospitalization or death during 3 months of follow-up. Two patients eradicated the presence of spontaneous echo contrast. Mean and peak pressure gradients, peak velocity, effective orifice area, and PHT were similar before and after the intervention. In conclusion, the use of rivaroxaban for 90days in seven patients after replacement of mitral valve with the mechanical prosthesis did not present thromboembolic or bleeding events (NCT02894307).

Antithrombotic strategy in the three first months following bioprosthetic heart valve implantation

Heart valve prosthesis unquestionably improve quality of life and survival of patients with severe valvular heart disease, but the need for antithrombotic therapy to prevent thromboembolic complications is a major challenge to clinicians and their patients. Of the articles analyzed, most were retrospective series of cases or historical cohorts obtained from the database. The few published randomized trials showed no statistical power to assess the primary outcome of death or thromboembolic event. In this article, we decided to perform a systematic literature review, in an attempt to answer the following question: what is the best antithrombotic strategy in the first three months after bioprosthetic heart valve implantation (mitral and aortic)? After two reviewers applying the extraction criteria, we found 1968 references, selecting 31 references (excluding papers truncated, which combined bioprosthesis with mechanical prosthesis, or without follow-up). Based on this literature review, there was a low level of evidence for any antithrombotic therapeutic strategy evaluated. It´s therefore interesting to use aspirin 75 to 100 mg / day as antithrombotic strategy after bioprosthesis replacement in the aortic position, regardless of etiology, for patients without other risk factors such as atrial fibrillation or previous thromboembolic event. In the mitral position, the risk of embolism, although low, is more relevant than in the aortic position, according to published series and retrospective cohorts comprised mostly of elderly non-rheumatic patients. The current evidence is limited to have a consistent and safe level of evidence regarding the best therapeutic strategy. Based on these studies, 75 to 100 mg/day of aspirin is interesting as antithrombotic strategy after implantation of aortic bioprosthesis, regardless of etiology, for patients with no other risk factors such as atrial fibrillation or previous thromboembolic event. As for mitral bioprosthesis, the risk of embolism, although low, is more relevant than in the aortic position, according to published series and retrospective cohorts - usually elderly non rheumatic patients.

SGLT2 inhibition and heart failure—current concepts

Type 2 diabetes mellitus (T2DM) is a major risk factor for several cardiovascular (CV) conditions, including heart failure (HF). However, until recently, no therapy to treat patients with diabetes could also reduce CV risks related to HF. The EMPA-REG OUTCOME trial with empagliflozin was the first to demonstrate significant cardioprotective benefits in this population. Its impressive 35% reduction in hospitalizations for HF drew the attention of the scientific community to the possibility that pharmacologic sodium-glucose cotransporter 2 (SGLT2) inhibition could be part of the armamentarium for treating patients with HF, with and without diabetes. The recently published CANVAS Program (with canagliflozin) and real-life data from the CVD-Real Study (using dapagliflozin, empagliflozin, and canagliflozin) further strengthened this hypothesis, suggesting that the observed benefit is not restricted to a particular drug, but is rather a class effect. This review explores the effects of pharmacologic SGLT2 inhibitors’ use in cardiac function and discusses the potential role of this class of medication as a treatment for HF.

Efficacy and safety of pharmacological interventions in metabolic syndrome: protocol for systematic review and network meta-analysis

Introduction: The prevalence of metabolic syndrome (MetS) and MetS-related stroke is set to increase dramatically in coming decades. MetS is a complex disease that includes endothelial dysfunction, insulin resistance, diabetes, hypertension, ectopic obesity, and dyslipidaemia and an increased risk of cardiovascular events.This study aims to fill this gap of research by conducting a Bayesian network meta-analysis to compare major drugs to treat MetS. Methods and analysis: We will search the PubMed, EMBASE, Cochrane Library, Web of Science, Embase, google scholar, clinical trials registry (ClinicalTrials. gov) for unpublished or undergoing research listed in registry platforms. Randomized controlled trials (RCTs) on the drug therapy of MetS with outcome measures including diagnostic criteria of MetS will be included. The quality of included RTCs will be evaluated according to the Cochrane Collaboration’s risk of bias tool. Traditional pairwise meta-analysis and Bayesian network meta-analysis will be conducted to compare the efficacies of antidiabetic drugs. Sensitivity analysis on the sample size of RCTs, meta-regression analysis on the follow-up periods, dosages and baselines of outcome measure, contradiction analysis between pairwise and network meta-analyses, and publication bias analysis, will be performed. Randomized controlled trials (RCTs) on the drug therapy of MetS with outcome measures criteria of MetS diagnostic will be included. The quality of included RTCs will be evaluated according to the Cochrane Collaboration’s risk of bias tool. Traditional pairwise meta-analysis and Bayesian network meta-analysis will be conducted to compare the efficacies of drugs. Sensitivity analysis on the sample size of RCTs, meta-regression analysis on the follow-up periods, dosages and baselines of outcome measure, contradiction analysis between pairwise and network meta-analyses, and publication bias analysis, will be performed. Ethics and dissemination Ethics approval was not required for this study because it was based on published studies. The results and findings of this study will be submitted and published in a scientific peer-reviewed journal. Trial registration number: PROSPERO (CRD42018083468). *Correspondence to: Leonardo Roever, MHS, Federal University of Uberlândia, Department of Clinical Research, Brazil, Email: leonardoroever@hotmail.com

Warfarin Therapy: New Challenges of an Old Drug

The anticoagulant drug warfarin is a vitamin K antagonist (VKA), coumarin derivative, formed by the racemic mixture of two optically active isomers known by Rectus (R) and Sinister (S) enantiomers in equal proportion, being the S-warfarin five times more potent. Although warfarin is still considered the mainstay of oral anticoagulant treatment, it is a difficult drug to manage due to its narrow therapeutic index. An inappropriate management of patients can lead to subtherapeutic or supratherapeutic levels, increasing the risk of thromboembolic episodes or hemorrhagic episodes, respectively. Common indications for the use of warfarin include stroke prevention in atrial fibrillation, preventing thrombus formation in patients with heart valves and treatment of venous thromboembolism. Unlike situations as nonvalvular atrial fibrillation (and thromboembolic risk factors such as hypertension, diabetes or ventricular dysfunction), venous thrombosis and pulmonary embolism where there is evidence for the use of the new oral anticoagulants (dabigatran, apixaban, rivaroxaban, etc), warfarin and similar remain only option for patients with cardiac valve prosthesis requiring anticoagulation.

Subclinical Atherosclerosis in Non-dialysis Chronic Renal Patients

Background: Nowadays cardiovascular diseases are the main cause of morbid-mortality. Atherosclerosis is one of the most important in this class of diseases. Aim: Identifying subclinical atherosclerosis in a population of non-dialytic patients with chronic kidney disease. Methods: From November 2012 to December 2013, we selected 40 patients with stage 3 or 4 of CKD (Chronic kidney disease) who did not need hemodialysis. CACS (coronary artery calcium score) and MTCA (miointimal tichness carotid artery) were calculated and their mean and standard deviation, median and quartiles. To verify the association between the variables we used the Fisher exact test and the Spearman correlation (p<0.05). Results: The distribution of the CACS was not as expected and the median increased with age groups. The CACS was null in : 50% of the sample in all patients below 45 years of age, 50% of those between 45-49 years of age and 50-54 years of age, 53.8% in those 55-59 years of age and 25% of those 60-65 years of age, however p value=0.102. The median MTCA was 0.9 mm with interquartile range of 0.7-1.2 mm. In percentil75 for age and sex were : 80% of 45 year olds, 25% of 45-49 year olds, 66.7% of 50-54 year olds, 69.2% of 55-59 year olds and 50% of 60-65 year olds, though p value was 0.602. We found a moderate positive correlation between age and CACS (r=0.458 p=0.03) and between age and MTCA weak (r=0.346 p=0.029) when performed correlation of age with the values of CACS and MTCA. The correlation between MTCA and CACS was strong(r=0.807) p<0.001. Conclusion: Non-invasive tests in CKD non-dialytic patients can identify subclinical atherosclerosis through the CACS and MTCA. This may change the clinical management, evolution and prognosis.