Bruno Ramos Nascimento

Global, Regional, and National Burden of Rheumatic Heart Disease, 1990-2015.

BACKGROUND Rheumatic heart disease remains an important preventable cause of cardiovascular death and disability, particularly in low‐income and middle‐income countries. We estimated global, regional, and national trends in the prevalence of and mortality due to rheumatic heart disease as part of the 2015 Global Burden of Disease study. METHODS We systematically reviewed data on fatal and nonfatal rheumatic heart disease for the period from 1990 through 2015. Two Global Burden of Disease analytic tools, the Cause of Death Ensemble model and DisMod‐MR 2.1, were used to produce estimates of mortality and prevalence, including estimates of uncertainty. RESULTS We estimated that there were 319,400 (95% uncertainty interval, 297,300 to 337,300) deaths due to rheumatic heart disease in 2015. Global age‐standardized mortality due to rheumatic heart disease decreased by 47.8% (95% uncertainty interval, 44.7 to 50.9) from 1990 to 2015, but large differences were observed across regions. In 2015, the highest age‐standardized mortality due to and prevalence of rheumatic heart disease were observed in Oceania, South Asia, and central sub‐Saharan Africa. We estimated that in 2015 there were 33.4 million (95% uncertainty interval, 29.7 million to 43.1 million) cases of rheumatic heart disease and 10.5 million (95% uncertainty interval, 9.6 million to 11.5 million) disability‐adjusted life‐years due to rheumatic heart disease globally. CONCLUSIONS We estimated the global disease prevalence of and mortality due to rheumatic heart disease over a 25‐year period. The health‐related burden of rheumatic heart disease has declined worldwide, but high rates of disease persist in some of the poorest regions in the world. (Funded by the Bill and Melinda Gates Foundation and the Medtronic Foundation.)

Diagnostic accuracy of intravascular ultrasound-derived minimal lumen area compared with fractional flow reserve--meta-analysis: pooled accuracy of IVUS luminal area versus FFR.

Although intravascular ultrasound minimal luminal area (IVUS‐MLA) is one of many anatomic determinants of lesion severity, it has been proposed as an alternative to fractional flow reserve (FFR) to assess severity of coronary artery disease.

The prognostic significance of electrocardiographic changes in Chagas disease

INTRODUCTION The meaning of electrocardiographic changes appearing during the clinical follow-up of Chagas disease (ChD) is unknown. In this study, a patient cohort with ChD was followed to describe the electrocardiographic changes that may make it possible to identify patients whose left ventricular function has deteriorated. METHODS The study sample consisted of a prospective cohort followed since 1998 to 1999, involving 220 patients aged 15 to 55 years, 30 controls, and 190 with ChD, without other comorbidities. The group was reexamined between 2004 and 2006, and new electrocardiograms were obtained for 153 patients, 25 (83%) of 30 in the control group and 128 (72%) of 177 in the ChD group. Electrocardiographic variables associated with a significant decrease in ejection fraction (5% or more) were identified. RESULTS A significant decrease in ejection fraction was observed in 21 patients in the ChD group (18.7%) but in none of the non-ChD group (P = .024). Only the presence of a new electrocardiographic abnormality and an increase in QRS duration correlated with a decrease in an ejection fraction of 5% or more. QRS duration was correlated with both an increase in left ventricle diastolic diameter and a deterioration in the ejection fraction (r(s) = 0.225, P = .017, and r(s) = -0.300, P < .001). A QRS increase of 5 milliseconds had 77.8% sensitivity and 62.2% specificity for identifying patients with significant decrease in ejection fraction. CONCLUSION The increase in the duration of the QRS complex and the appearance of new electrocardiographic alterations may help in identifying patients with a significant decrease (of 5% or more) in left ventricle ejection fraction.

Meta-Analysis of Deferral Versus Performance of Coronary Intervention Based on Coronary Pressure–Derived Fractional Flow Reserve

Fractional flow reserve (FFR) has been proposed as the gold standard to assess functional severity of coronary artery stenosis and to stratify which lesions should be subjected to intervention (percutaneous coronary intervention [PCI]). A systematic review was performed in MEDLINE and EMBASE including studies indexed until November 2013 that used FFR for deferral or performance of PCI. Outcomes of interest were death, acute myocardial infarction (AMI), and new revascularization (RV). Nineteen studies were included, totaling 3,097 patients (3,796 lesions). Mean follow-up was 21.2 months. In indirect comparisons, FFR-PCI and FFR-defer groups had similar death (2.2% vs 2.0%, respectively, p = 0.86) and AMI rates (1.9% vs 1.9%, respectively, p = 1.00). RV rates were higher in the FFR-PCI group (14.0% vs 4.4%, p = 0.002). Direct comparisons (2-arm trials) also showed no differences in death (odds ratio [OR] 1.86 [95% CI 0.81 to 4.27], I(2) = 11.5, p = 0.14) and AMI rates (OR 0.75 [95% CI 0.21 to 2.69], I(2) = 47.1, p = 0.66); RV rates were again higher in the FFR-PCI (OR 3.10 [95% CI 1.25 to 7.70], I(2) = 72.2, p = 0.015). Meta-regression suggests influence of male gender on RV rates (β = 0.058, p = 0.026). In conclusion, deferral of PCI based on FFR is a safe strategy. Considerable heterogeneity was observed, however.

Improvement of the functional capacity is associated with BDNF and autonomic modulation in Chagas disease

35%) [2] must be considered. The power of these findings are limited by thesmall numberof patientswithmoderate airways reversibility (n=4). However,we take some reassurance from the goodproportionof patients diagnosed with asthma recruited to the study. Despite the limitation, we believe our study provides important hypothesis-generating data that contributes to a paucity of relevant literature in this area. A larger long-term study is required to provide definitive data regarding the effect of nebivolol on CHF patients withmoderate reversibility airways disease.

Global health and cardiovascular disease

The modern definition of Global Health has expanded its scope beyond neglected diseases and low-income and underdeveloped countries. The current initiatives focus on improvement of health, reduction of disparities and protection against global threats, seeking for interaction with health practices, policies and systems. There has been a growing interest on Global Health research, given the epidemiological transition currently underway in low and mid-income countries and the increasing epidemiological importance of cardiovascular and other non-communicable diseases, to the detriment of infectious diseases and nutritional deficiencies. Various aspects—formerly neglected—of these diseases, such as epidemiology, prevention, diagnosis and therapy, have been addressed in Global Health publications, leading to a better understanding of the importance of health as a public good, beyond borders. Scientific evidence supports broader initiatives in which governments, foundations and the civil society must share responsibilities and funding to achieve health equity, the main goal of Global Health.

Use of optical coherence tomography for accurate characterization of atherosclerosis

Optical coherence tomography (OCT) is a novel imaging technology based on low-coherence interferometry that uses scattering of near-infrared light as a signal source to provide vascular cross-sectional imaging with definition far superior to any other available modality. With spatial resolution of up to 10 microm, OCT provides 20-fold higher resolution than intravascular ultrasound (IVUS), currently the most used modality for intra-coronary imaging. OCT has the capacity to provide invaluable insight into the various phases of atherosclerotic disease and vascular response to therapeutics. Studies have shown the ability of OCT to detect arterial structures and assist in the determination of different histological constituents. Its capacity to distinguish different grades of atherosclerotic changes and the various types of plaques, as compared to histology, has recently been demonstrated with acceptable intra-observer and inter-observer correlations for these findings. OCT provides unrivaled real-time in vivo endovascular resolution, which has been exploited to assess the vascular structures and response to device deployment. While depth remains a limitation for OCT plaque characterization beyond 2-mm, near-histological resolution can be achieved within the first millimeter of the vessel wall allowing unique assessment of fibrous cap characteristics and thickness. In addition, assessment of neointimal coverage, para-strut tissue patterns and stent apposition can now be scrutinized for individual struts on the micron scale, the so-called strut-level analysis. OCT has propelled intravascular imaging into micron-level in vivo vascular analysis and is expected to soon become a valuable and indispensable tool for the cardiologists on both clinical and research applications.A Tomografia de Coerencia Otica (TCO) e uma nova tecnologia de imagem baseada em interferometria de baixa coerencia que utiliza a dispersao de luz quase-infravermelha como uma fonte de sinal para fornecer imagens transversais vasculares com definicao muito superior a de qualquer outra modalidade disponivel. Com uma resolucao espacial de ate 10μm, a TCO fornece uma resolucao 20 vezes maior do que o ultrassom intravascular (USIV), a modalidade atualmente mais utilizada para obter imagens intra-coronarias. A TCO tem uma capacidade de fornecer um entendimento das varias fases da doenca aterosclerotica e a resposta vascular ao tratamento. Estudos tem mostrado a capacidade da TCO em detectar estruturas arteriais e ajudar na determinacao de diferentes constituintes histologicos. Sua capacidade de distinguir diferentes graus de alteracoes ateroscleroticas e os varios tipos de placas, quando comparada a histologia, tem sido recentemente demonstrada com correlacoes inter e intra-observador aceitaveis para esses achados. A TCO fornece uma resolucao endovascular excepcional em tempo real in vivo, que tem sido explorada para avaliar as estruturas vasculares e a resposta ao uso do equipamento. Embora a profundidade permaneca uma limitacao para a caracterizacao de placa alem de 2 mm atraves da TCO, uma resolucao proxima a histologica pode ser obtida dentro do primeiro milimetro da parede do vaso, permitindo uma avaliacao extraordinaria das caracteristicas e espessura da capa fibrosa. Alem disso, a avaliacao da cobertura de neointima, padroes de tecido para-haste e aposicao de stent podem agora ser escrutinizados para hastes individuais na escala de microns, a assim chamada analise em nivel de haste. A TCO levou a imagem intravascular ao nivel de micron na analise vascular in vivo e espera-se que breve se torne uma ferramenta valiosa e indispensavel para cardiologistas em aplicacoes clinicas e de pesquisa.

Can we measure the ankle-brachial index using only a stethoscope? A pilot study

BACKGROUND Ankle-brachial index (ABI) is an excellent method for the diagnosis of peripheral arterial disease (PAD) when it is performed with Doppler. However, this device is not always available for primary care physicians. The ABI measured with stethoscope is an easy alternative approach, but have not been proved to be useful. OBJECTIVE To assess the accuracy of the ABI measured using a stethoscope comparatively to that of the current eligible method for the diagnosis of PAD, the Doppler ABI, and describe the characteristics of this new approach. METHODS We conducted a diagnostic study of ABI measured with a stethoscope and a Doppler probe and compared the results. Eighty-eight patients were accessed by both methods. RESULTS Mean stethoscope ABI, 1.01 +/- 0.15, and mean Doppler ABI, 1.03 +/- 0.20, (P = 0.047) displayed a good correlation. Measurements of stethoscope ABI diagnostic accuracy in recognizing a Doppler ABI are described. The comparison of this data with the current gold standard method results gave a sensitivity of 71.4% [95% confidence interval (CI), 41.9-91.6] and specificity of 91.0% (95% CI, 81.5-96.6), with predictive positive value of 62.5% (95% CI, 38.6-81.5) and negative predictive value of 93.8% (95% CI, 85.2-97.6). The study accuracy was 87.7%. The area under the ROC curve was 0.895 (95% CI, 0.804-0.986, P < 0.0001). CONCLUSIONS According to our study, the stethoscope ABI is a useful method to detect PAD and it may be suitable for its screening in the primary care setting.

Carotid intimal-medial thickening and endothelial function in coronary artery disease

OBJECTIVE To investigate the correlation between the endothelial function and the carotid intimal-medial thickening (IMT) in a population of patients with coronary artery disease, as well as that between the endothelial function and carotid IMT with the severity of the coronary lesions. METHODS Forty-three patients aged 60.5+/-9.2 years, (67.4% males) with coronary artery disease at the coronariography were studied. Endothelial function was assessed using the brachial artery reactivity test (BART), which measured the percentage of flow-mediated dilatation (%FMD). The carotid IMT was evaluated through vascular ultrasound. RESULTS The mean %FDM was 4.7 +/- 3.6 and the mean carotid IMT was 1.08 +/- 0.23 mm. The carotid MIT and %FMD measurements showed a statistically significant correlation, with Spearmans coefficient of 0.315, p= 0.042, demonstrating that lower %FMD values corresponded to an increased carotid IMT (r = -0.315, p = 0.042). There was no correlation between %FMD or IMT and the severity of coronary lesions. CONCLUSIONS The presence of a correlation between carotid IMT and %FMD demonstrates a concomitance of anatomical and functional vascular alterations in coronary artery disease, regardless of the severity of the atherosclerotic lesions.

Echocardiographic prevalence of rheumatic heart disease in Brazilian schoolchildren: Data from the PROVAR study

BACKGROUND Accurate estimates of Rheumatic Heart Disease (RHD) burden are needed to justify improved integration of RHD prevention and screening into the public health systems, but data from Latin America are still sparse. OBJECTIVE To determine the prevalence of RHD among socioeconomically disadvantaged youth (5-18years) in Brazil and examine risk factors for the disease. METHODS The PROVAR program utilizes non-expert screeners, telemedicine, and handheld and standard portable echocardiography to conduct echocardiographic screening in socioeconomically disadvantaged schools in Minas Gerais, Brazil. Cardiologists in the US and Brazil provide expert interpretation according to the 2012 World Heart Federation Guidelines. Here we report prevalence data from the first 14months of screening, and examine risk factors for RHD. RESULTS 5996 students were screened across 21 schools. Median age was 11.9 [9.0/15.0] years, 59% females. RHD prevalence was 42/1000 (n=251): 37/1000 borderline (n=221) and 5/1000 definite (n=30). Pathologic mitral regurgitation was observed in 203 (80.9%), pathologic aortic regurgitation in 38 (15.1%), and mixed mitral/aortic valve disease in 10 (4.0%) children. Older children had higher prevalence (50/1000 vs. 28/1000, p<0.001), but no difference was observed between northern (lower resourced) and central areas (34/1000 vs. 44/1000, p=0.31). Females had higher prevalence (48/1000 vs. 35/1000, p=0.016). Age (OR=1.15, 95% CI:1.10-1.21, p<0.001) was the only variable independently associated with RHD findings. CONCLUSIONS RHD continues to be an important and under recognized condition among socioeconomically disadvantaged Brazilian schoolchildren. Our data adds to the compelling case for renewed investment in RHD prevention and early detection in Latin America.