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Resumen Objetivo: recopilar información de factores de riesgo de la enfermedad arterial coronaria en población adulta evidenciados mediante estudios de aleatorización mendeliana. Métodos: de acuerdo con las recomendaciones de la escala para la Evaluación de Artículos de Revisión Narrativa (SANRA), se realizó una revisión desde el usuario de la Universidad Militar Nueva Granada en las bases de datos de PubMed, EMBASE y BIREME. Resultados: se obtuvieron 757 artículos, luego se aplicaron los criterios de inclusión y exclusión, y se eligieron 29 artículos en los que se investiga la asociación de la enfermedad arterial coronaria con la apolipoproteína B, colesterol LDL, triglicéridos, colesterol total, apolipoproteina C3, proteína de transferencia de ésteres de colesterol, HDL, omega 6, lipoproteína (a), obesidad, hemoglobina A1C, diabetes mellitus tipo 2, glucosa en ayunas, inicio del hábito de fumar, presión arterial, hormona paratiroidea sérica, niveles de fosfato sérico, enfermedad del hígado graso no alcohólico, síndrome de ovario poliquístico, globulina fijadora de hormonas sexuales, testosterona, filoquinona circulante, proteína gla de la matriz inactiva, antioxidantes circulantes derivados de la dieta, glicina, homocisteína, ácido úrico, marcadores inflamatorios, hemoglobina, hematocrito y recuento de glóbulos rojos. Conclusión: esta revisión sugiere nuevos estudios con información genética colombiana para respaldar los factores de riesgo aquí presentados, teniendo en cuenta que en ninguno de los estudios evaluados se utilizó información genética latinoamericana, lo cual puede limitar la extrapolación de los resultados.

Summary: Objective: To compile information on risk factors for coronary artery disease in the adult population evidenced by Mendelian randomization studies.. Methods: A search was carried out from the user of the Nueva Granada Military University in the databases of PubMed, EMBASE and BIREME and a narrative review of the literature was carried out in accordance with the recommendations of the scale for the Evaluation of Narrative Review Articles (SANRA). Results: 757 articles were obtained, after the application of inclusion and exclusion criteria, 29 articles were chosen that investigated the association of apolipoprotein B, LDL cholesterol, triglycerides, total cholesterol, apolipoprotein C3, cholesterol ester transfer protein, HDL, omega 6, lipoprotein (a), obesity, hemoglobin A1C, type 2 diabetes mellitus, fasting glucose, smoking initiation, blood pressure, serum parathyroid hormone, serum phosphate levels, non-alcoholic fatty liver disease, polycystic ovary syndrome , sex hormone-binding globulin, testosterone, circulating phylloquinone, inactive matrix protein gla, circulating dietary-derived antioxidants, glycine, homocysteine, uric acid, inflammatory markers, hemoglobin, hematocrit, and red blood cell count, with coronary artery disease. Conclusion: This review suggests new studies with Colombian genetic information to support the risk factors presented here, considering that none of the studies evaluated used Latin American genetic information, which may limit the extrapolation of the results.

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INTRODUCTION: Risk prediction models, such as The Society of Thoracic Surgeons (STS) risk score and the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), are recommended for assessing operative mortality in coronary artery bypass grafting (CABG). However, their performance is questionable in Brazil. OBJECTIVE: To assess the performance of the STS score and EuroSCORE II in isolated CABG at a Brazilian reference center. METHODS: Observationaland prospective study including 438 patients undergoing isolated CABG from May 2022-May 2023 at the Instituto Dante Pazzanese de Cardiologia. Observed mortality was compared with predicted mortality (STS score and EuroSCORE II) by discrimination (area under the curve [AUC]) and calibration (observed/expected ratio [O/E]) in the total sample and subgroups of stable coronary artery disease (CAD) and acute coronary syndrome (ACS). RESULTS: Observed mortality was 4.3% (n=19) and estimated at 1.21% and 2.74% by STS and EuroSCORE II, respectively. STS (AUC=0.646; 95% confidence interva [CI] 0.760-0.532) and EuroSCORE II (AUC=0.697; 95% CI 0.802-0.593) presented poor discrimination. Calibration was absent for the North American mode (P<0.05) and reasonable for the European model (O/E=1.59, P=0.056). In the subgroups, EuroSCORE II had AUC of 0.616 (95% CI 0.752-0.480) and 0.826 (95% CI 0.991-0.661), while STS had AUC of 0.467 (95% CI 0.622-0.312) and 0.855 (95% CI 1.0-0.706) in ACS and CAD patients, respectively, demonstrating good score performance in stable patients. CONCLUSION: The predictive models did not perform optimally in the total sample, but the EuroSCORE was superior, especially in elective stable patients, where accuracy was satisfactory.

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The use of invasive physiology methods in patients with renal dysfunction is not well elucidated. Our objective was to evaluate the in-hospital and long-term results of using intracoronary physiology to guide revascularization in patients with chronic kidney disease. In this retrospective study, we evaluated 151 patients from January 2018 to January 2022, divided into 2 groups: CKD (81 patients [114 lesions]) and non-CKD (70 patients [117 lesions]). The mean age was higher (p < 0.001), body mass index was lower (p = 0.007), contrast volume used was lower (p = 0.02) and the number of ischemic lesions/patients was higher (p = 0.005) in the CKD group. The primary outcomes (rate of major adverse cardiac events during follow-up, defined as death, infarction, and need for new revascularization) in the CKD and non-CKD groups were 22.07% and 14.92%, respectively (p = 0.363). There was a significant difference in the target lesion revascularization (TLR) rate (11.68%, CKD group vs. 1.49%, non-CKD group, p = 0.02), this initial statistical difference was not significant after adjusting for variables in the logistic regression model. There was no difference between the rates of death from all causes (6.49%, CKD group vs. 1.49%, non-CKD group, p = 0.15), reinfarction (3.89%, CKD group vs. 1.49%, non-CKD group, p = 0.394), and need for new revascularization (11.68%, CKD group vs. 5.97%, non-CKD group, p = 0.297). As there was no difference in the endpoints between groups with long-term follow-up, this study demonstrated the safety of using intracoronary physiology to guide revascularization in patients with CKD.

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Tuberculosis is an increasing disease that affects about one-third of the global population. In line with the rise of tuberculosis, cardiovascular disease has shown a similar trend, with ischemic coronary heart disease becoming the leading cause of death worldwide. Based on the literature, a relationship can be drawn between tuberculosis and ischemic coronary heart disease through their shared multiple risk factors and a possible pathophysiological substrate linking them. The presentation of these two conditions reported so far is varied: it has been found as the onset of acute coronary syndrome in patients with active tuberculosis, the progressive development of coronary atherosclerosis in patients with latent tuberculosis, among others. Given this possible link and the progressive increase in their incidence rates, we can assert that we are facing an unnoticed syndemic, with their concurrent management posing a challenge due to significant pharmacological interactions. The purpose of this review is to clarify this possible link, propose an approach for diagnosis, and provide a treatment algorithm for the entire spectrum of coronary disease coexisting with tuberculosis according to the current available literature.

La tuberculosis es una enfermedad que viene en aumento y que afecta cerca de un tercio de la población mundial. En consonancia con el aumento de la tuberculosis, la enfermedad cardiovascular ha tenido un comportamiento similar, de este grupo, la cardiopatía coronaria isquémica se ha convertido en la principal causa de muerte en todo el mundo. Se podría extraer, en base a la literatura, una relación entre la tuberculosis y la cardiopatía coronaria isquémica a través de que comparten múltiples factores de riesgo en común y desde un posible sustrato fisiopatológico que las vincula. La forma conjunta de presentación de estas dos entidades reportada hasta el momento es variada: se ha encontrado como debut de un síndrome coronario agudo en pacientes con tuberculosis activa, el desarrollo progresivo de aterosclerosis coronaria en pacientes con tuberculosis latente, entre otras. Dado este posible vínculo y el aumento progresivo de sus tasas de incidencia podemos afirmar que estamos ante una sindemia inadvertida, siendo su manejo conjunto un desafío por las grandes interacciones farmacológicas. El propósito de esta revisión es esclarecer este posible vínculo, plantear un enfoque para el diagnóstico, así como suministrar un algoritmo de tratamiento de todo el espectro de la enfermedad coronaria que coexiste con la tuberculosis de acuerdo con la literatura actual disponible.

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Resumen Objetivo: Caracterizar la población de pacientes hospitalizados por falla cardiaca aguda con fracción de eyección (FEVI) menor al 50% en el Hospital Departamental de Villavicencio. Materiales y método: Estudio descriptivo de cohorte retrospectiva, de pacientes hospitalizados por falla cardiaca aguda con FEVI menor al 50%, entre el 1.o de enero de 2020 y el 31 de diciembre de 2021. Resultados: Se incluyeron 206 participantes con mediana de edad 70 años, de los cuales el 71.8% fueron hombres. Las comorbilidades más frecuentes fueron hipertensión (76.2%), enfermedad coronaria (47.1%) y diabetes (32%); las principales etiologías de la falla cardiaca fueron isquémica (62.1%) e hipertensiva (27.2%), con un 6.8% de etiología chagásica; las causas de descompensación más frecuentes fueron el síndrome coronario agudo (39.3%) y la mala adherencia al tratamiento (25.7%). La mediana de estancia hospitalaria fue 7.5 días y la mortalidad hospitalaria de 14.6%, con el síndrome coronario agudo como principal causa de muerte (56.7%). Se encontró alto requerimiento de manejo en unidad de cuidado intensivo (UCI) (20.4%), siendo mayor en pacientes con FEVI levemente reducida, comparada con FEVI reducida (35.7 vs. 18%; RR0 = 1.98; p = 0.03), con una mortalidad similar entre ambos grupos (17.9 vs. 14; RR = 1.32; p = 0.54). Conclusiones: Se encontró una alta prevalencia de cardiopatía isquémica, con elevado requerimiento de manejo en UCI y alta mortalidad hospitalaria.

Abstract Introduction: To characterize the population of patients hospitalized for acute heart failure with an ejection fraction of less than 50% in the Departmental Hospital of Villavicencio. Materials and method: This is a descriptive retrospective cohort study of patients hospitalized for acute heart failure with an ejection fraction (LVEF) of less than 50% between January 1, 2020, and December 31, 2021. Results: A total of 206 participants were included, with a median age of 70 years, of the participants, 71.8% were men, the most frequent comorbidities were hypertension (76.2%), coronary disease (47.1%), and diabetes (32%). The main etiologies of heart failure were ischemic (62.1%) and hypertensive (27.2%), with 6.8% attributed to Chagas disease. The most common causes of decompensation were acute coronary syndrome (39.3%) and poor adherence to treatment (25.7%). The median hospital stay was 7.5 days, and the hospital mortality rate was 14.6%, acute coronary syndrome was the leading cause of death (56.7%). A high requirement for intensive care unit (ICU) management was observed (20.4%), which was higher in patients with slightly reduced LVEF compared to those with reduced LVEF (35.7% vs. 18%, RR = 1.98, p = 0.03), however, the mortality rate was similar between both groups (17.9% vs. 14%, RR = 1.32, p = 0.54). Conclusions: It was found a high prevalence of ischemic heart disease, along with a high requirement for ICU management and high in-hospital mortality.

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Resumen Objetivo: describir las características de los pacientes con infarto agudo de miocardio sin lesiones coronarias obstructivas (MINOCA), así como sus desenlaces cardiovasculares a dieciocho meses. Materiales y método: estudio de cohortes, ambispectivo, de los pacientes que fueron llevados a angiografía coronaria por diagnóstico de infarto agudo de miocardio (IAM), entre los años 2015 y 2019. Se seleccionó el grupo de MINOCA y obtuvieron datos de desenlaces como reconsultas y eventos cardiovasculares mayores a dieciocho meses. Resultados: de los 433 pacientes incluidos, 141 (33%) cumplían definición de MINOCA; el dolor torácico y los equivalentes anginosos fueron las manifestaciones clínicas más prevalentes (62 y 62.4% respectivamente). La mayoría se presentaron con IAM sin elevación del ST (92.1%), con FEVI ≥ 50% (42.6%). En el seguimiento a dieciocho meses, se obtuvieron datos de 102 pacientes, de los que el 22% reconsultó y 18% presentó reinfarto. La mortalidad durante el seguimiento fue del 12% por causa cardiovascular y del 36% por todas las causas. Conclusiones: se encontró una mayor proporción de MINOCA respecto a lo descrito en la literatura y con predominio de manifestaciones clínicas atípicas. Es llamativo, igualmente, el alto porcentaje importante de preinfartos y muerte de origen cardiovascular durante el seguimiento de esta cohorte.

Abstract Objective: to describe the characteristics of patients with acute myocardial infarction without obstructive coronary lesions (MINOCA), as well as their cardiovascular outcomes at 18 months. Materials and methods: ambispective cohort study that included patients who underwent coronary angiography after being diagnosed with acute myocardial infarction (AMI) between 2015 and 2019. The MINOCA group was selected, and outcomes such as readmissions and major cardiovascular events were obtained at 18 months. Results: data form 433 patients who met the inclusion criteria were obtained, of which 141 (33%) met the criteria for MINOCA. The most prevalent clinical manifestations were chest pain and anginal equivalents (62% and 62.4% respectively), The majority presented with non-ST elevation myocardial infarction (92.1%), with left ventricular ejection fraction (LVEF) ≥ 50% (42.6%). During the 18-month follow-up, data were obtained from 102 patients, of whom 22% had readmissions; 18% experienced reinfarction, mortality during the follow-up was 12% due to cardiovascular causes, and 36% due to all causes Conclusions: a higher proportion of MINOCA was found compared to what is described in the literature, with a predominance of atypical clinical manifestations. Equally striking is the significant percentage of pre-infarctions and cardiovascular deaths during the follow-up of this cohort.

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BACKGROUND: Advances in health have highlighted the need to implement technologies as a fundamental part of the diagnosis, treatment, and recovery of patients at risk of or with health alterations. For this purpose, digital platforms have demonstrated their applicability in the identification of care needs. Nursing is a fundamental component in the care of patients with cardiovascular disorders and plays a crucial role in diagnosing human responses to these health conditions. Consequently, the validation of nursing diagnoses through ongoing research processes has become a necessity that can significantly impact both patients and health care professionals. OBJECTIVE: We aimed to describe the process of developing a mobile app to validate the nursing diagnosis "intolerance to physical activity" in patients with acute myocardial infarction. METHODS: We describe the development and pilot-testing of a mobile system to support data collection for validating the nursing diagnosis of activity intolerance. This was a descriptive study conducted with 11 adults (aged ≥18 years) who attended a health institution for highly complex needs with a suspected diagnosis of coronary syndrome between August and September 2019 in Floridablanca, Colombia. An app for the clinical validation of activity intolerance (North American Nursing Diagnosis Association [NANDA] code 00092) in patients with acute coronary syndrome was developed in two steps: (1) operationalization of the nursing diagnosis and (2) the app development process, which included an evaluation of the initial requirements, development and digitization of the forms, and a pilot test. The agreement level between the 2 evaluating nurses was evaluated with the κ index. RESULTS: We developed a form that included sociodemographic data, hospital admission data, medical history, current pharmacological treatment, and thrombolysis in myocardial infarction risk score (TIMI-RS) and GRACE (Global Registry of Acute Coronary Events) scores. To identify the defining characteristics, we included official guidelines, physiological measurements, and scales such as the Piper fatigue scale and Borg scale. Participants in the pilot test (n=11) had an average age of 63.2 (SD 4.0) years and were 82% (9/11) men; 18% (2/11) had incomplete primary schooling. The agreement between the evaluators was approximately 80% for most of the defining characteristics. The most prevalent characteristics were exercise discomfort (10/11, 91%), weakness (7/11, 64%), dyspnea (3/11, 27%), abnormal heart rate in response to exercise (2/10, 20%), electrocardiogram abnormalities (1/10, 9%), and abnormal blood pressure in response to activity (1/10, 10%). CONCLUSIONS: We developed a mobile app for validating the diagnosis of "activity intolerance." Its use will guarantee not only optimal data collection, minimizing errors to perform validation, but will also allow the identification of individual care needs.

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Objective: This study aimed to evaluate the rate of major adverse cardiac events (MACEs; the sum of death, myocardial infarction, and revascularization rates) according to interventional strategies guided by invasive physiological methods in both sexes in a Brazilian population during long-term follow-up for an average of 2 years. Methods: This retrospective single-center study included 151 consecutive patients (232 lesions) between January 2018 and January 2022. The participants were divided into two groups: the female group (FG), comprising 59 patients with 88 lesions, and the male group (MG), comprising 92 patients with 144 lesions. Results: The FG had a greater mean age (FG: 67.96 ± 13.12 vs. MG: 62.36 ± 12.01 years, p = 0.009) and lower mean creatinine clearance (FG: 79.35 ± 38.63 vs. MG: 92.02 ± 38.62 mL/min, p = 0.02) than did the MG. The percentage of lesions in the left main coronary artery was higher in the FG than in the MG (12.5% vs. 2.78%, p = 0.006). The mean follow-up time was longer in the MG than in the FG (795.61 ± 350 vs. 619.19 ± 318 days, respectively; p = 0.001). MACE occurred in 11.86% and 13.04% of patients in the FG and MG, respectively (p = 0.850). Secondary outcomes, such as death, reinfarction, and the need for new revascularization, showed no significant between-sex differences. Conclusions: Our study demonstrated the safety of invasive physiological methods to determine coronary revascularization in both male and female patients in a Brazilian population, as evidenced by the low rates of adverse cardiac events and death after a long-term follow-up.

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As doenças cardiovasculares, com destaque para a síndrome coronariana aguda (SCA), representam a principal causa de mortalidade mundial. Essa síndrome é a manifestação clínica mais comum da doença arterial coronariana (DAC). O intervalo de tempo entre o início dos sintomas e a reperfusão do miocárdio é crucial para a sobrevivência dos pacientes. Contudo, a falta de conhecimento e a demora para reconhecer os sintomas isquêmicos são os principais fatores que influenciam no atraso do atendimento pré-hospitalar. Programas educativos e instrumentos de avaliação são importantes estratégias para educar a população e reduzir eventos recorrentes da SCA. Nossa revisão de literatura demonstrou que, no Brasil, não dispomos de um instrumento validado para avaliar o conhecimento dos indivíduos sobre esta síndrome. O Acute Coronary Syndrome (ACS) Response Index avalia a resposta do indivíduo à SCA, por meio de seu conhecimento, atitudes e crenças. Dessa forma, o objetivo deste estudo metodológico foi adaptar culturalmente e verificar as propriedades de medida da versão adaptada para o Brasil do ACS Response Index, em pacientes com 18 anos ou mais, de ambos os sexos e diagnosticados com DAC. O processo de adaptação cultural transcorreu de acordo com as seguintes etapas: tradução inicial; obtenção do consenso das versões em português; comitê de especialistas; retrotradução; obtenção do consenso das versões em inglês; avaliação pelo autor da versão original; análise semântica; e pré-teste. As seguintes propriedades de medida foram avaliadas: consistência interna, validade de face e de conteúdo, validade de construto entre grupos conhecidos, validade de constructo convergente, validade estrutural e presença de efeitos teto e chão. O nível de significância adotado foi de 0,05. Participaram do estudo 244 indivíduos com DAC. As pontuações médias para as subescalas de conhecimento, atitudes e crenças foram, respectivamente: 12,75 (DP=2,6), 13,48 (DP=3,39) e 22,40 (DP=3,16). A consistência interna da subescala de conhecimento foi avaliada pelo KR-20, cujo valor foi de 0,399. Os resultados dos alfas de Cronbach para as subescalas de atitudes e de crenças foram 0,735 e 0,577, respectivamente. A estrutura original do instrumento foi testada mediante análise fatorial confirmatória, para a qual obteve-se índices de ajuste satisfatórios para as subescalas de conhecimento (SRMR=0,065; RMSEA=0,058; CFI=0,792; TLI=0,761), atitudes (SRMR=0,027; RMSEA=0,053; CFI=0,988; TLI=0,970) e crenças (SRMR=0,047; RMSEA=0,048; CFI=0,971; TLI=0,952). As hipóteses prévias sobre a validade de constructo por grupos conhecidos foram testadas para comparar os valores das três subescalas segundo a faixa etária, presença de orientação prévia sobre sua doença cardíaca e nível escolaridade. Apenas as seguintes hipóteses foram confirmadas: na subescala de conhecimento, os indivíduos com até 59 anos apresentaram melhores níveis de conhecimento quando comparados aos indivíduos com 60 anos ou mais (p=0,003); na subescala de crenças, maiores valores foram obtidos no grupo que relatou orientação prévia sobre sua doença (p=0,008) e naqueles com maior escolaridade (p=0,022). A avaliação da validade de constructo convergente mostrou correlação fraca e positiva entre as subescalas de conhecimento e crenças (r=0,217; p<0,05), e de conhecimento e atitudes (r=0,128; p<0,05). Não encontramos correlação entre os valores das demais subescalas. Constatamos a presença do efeito teto em todos os itens das subescalas de atitudes e de crenças. Os resultados mostraram que o ACS Response Index-BR manteve as equivalências, validade de face e de conteúdo, validade de constructo entre grupos conhecidos nas subescalas de conhecimentos e crenças, ajuste adequado ao modelo estrutural original e confiabilidade satisfatória para a subescala de atitudes. Entretanto, dadas as particularidades da amostra, sugerimos a realização de estudos adicionais com a versão adaptada em diferentes instituições de saúde, assim como, em amostras com características sociodemográficas distintas.

Cardiovascular diseases, especially Acute Coronary Syndrome (ACS), represent the main cause of mortality worldwide. This syndrome is the most common clinical presentation of coronary artery disease (CAD). The time interval between the onset of symptoms and myocardial reperfusion is crucial for patient survival. However, lack of knowledge and delay in recognizing ischemic symptoms are the main factors that influence delays in pre-hospital care. Educational programs and assessment tools are important strategies to educate the population and reduce recurrent ACS events. Our literature review demonstrated that, in Brazil, we do not have a validated instrument to assess individuals' knowledge about this syndrome. The ACS Response Index assesses an individual's response to ACS, through their knowledge, attitudes and beliefs. Therefore, the objective of this methodological study was to culturally adapt and verify the measurement properties of the version adapted for Brazil of the ACS Response Index, in patients aged 18 or over, of both genders and diagnosed with CAD. The cultural adaptation process occurred according to the following stages: initial translation; obtaining consensus on the Portuguese versions; expert committee; back translation; obtaining consensus on English versions; evaluation by the author of the original version; semantic analysis; and pre-test. The following measurement properties were evaluated: internal consistency, face and content validity, construct validity by known groups, convergent construct validity, structural validity and ceiling and floor effects presence. The significance level adopted was 0.05. This study included 244 individuals with CAD. The mean scores for the knowledge, attitudes and beliefs subscales were, respectively: 12.75 (SD=2.6), 13.48 (SD=3.39) and 22.40 (SD=3.16). The internal consistency of the knowledge subscale was assessed using the KR-20, the value of which was 0.399. Cronbach's alpha results for the attitudes and beliefs subscales were 0.735 and 0.577, respectively. The original instrument's structure was tested using confirmatory factor analysis, for which satisfactory fit indices were obtained for the knowledge (SRMR=0.065; RMSEA=0.058; CFI=0.792; TLI=0.761), attitudes (SRMR=0.027; RMSEA =0.053; CFI=0.988; TLI=0.970) and beliefs subscales (SRMR=0.047; RMSEA=0.048; CFI=0.971; TLI=0.952). Previous hypotheses about construct validity by known groups were tested to compare the values of the three subscales according to age range, presence of previous guidance about heart disease and education level. Only the following hypotheses were confirmed: in the knowledge subscale, individuals aged 59 years or younger presented better levels of knowledge when compared to individuals aged 60 years or older (p=0.003); in the beliefs subscale, higher values were obtained in the group that reported previous guidance about their disease (p=0.008) and in those with higher education level (p=0.022). The evaluation of the convergent construct validity showed a weak and positive correlation between the knowledge and beliefs subscales (r=0.217; p<0.05), and knowledge and attitudes subscales (r=0,128; p<0,05). We did not find any correlation between the values of the other subscales. We found the presence of the ceiling effect in all items of the attitudes and beliefs subscales. The results showed that the ACS Response Index-BR maintained equivalences, face and content validity, construct validity by known groups in the knowledge and beliefs subscales, adequate fit to the original structural model, and satisfactory reliability for the attitudes subscale. However, given the particularities of the sample, we recommend conducting additional studies with the adapted version in different healthcare institutions, as well as in samples with different sociodemographic characteristics.

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Objectives: To investigate the effect of exercise intensity on functional capacity in individuals with coronary artery disease, assess adherence to the heart rate training zone (HRTZ), and relationship between trained intensity and functional capacity. Methods: Retrospective study led with medical records of 54 outpatients with coronary artery disease in a public hospital. The prescribed intensity started at 50 ­60% of heart rate reserve, increasing monthly to 70 ­80% by the third month. Spearman's test was used to assess the correlation between improvement in distance in the incremental shuttle walk test (ISWT), exercise intensity, and rating of perceived exertion (Borg­RPE). Adherence was classified as 'below' when HRTZ was not achieved in any phase of the program, 'intermediate' when HR was within the HRTZ for one or two months, and 'above' when HR was at or higher than HRTZ two months. Improvement was tested with t-test and one-way ANOVA. Results: 51.9% of participants had an increase in ISWT of ≥70 m (p < 0.0001). In at least one month, 50.9% trained below HRTZ. Trained intensity did not go below 8.6% of the prescribed minimal threshold of HRTZ. Changes in ISWT were not significantly correlated with exercise intensity (p = 0.87) or Borg­RPE (p = 0.16). Conclusion: While a significant increase in functional capacity was found, considerable heterogeneity in changes were observed. This may, in part, be related to adherence to HRTZ with progressive exercise intensity and to the variability in exercise volume incardiovascular rehabilitation programs.

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Background: Complex calcified coronary lesions are a frequent finding during percutaneous coronary intervention, representing for decades a challenge and limitation in patients with indication of revascularization, due to suboptimal angiographic results, high incidence of perioperative complications and long-term adverse events despite the multiple strategies employed, such as the use of cutting balloon, high-pressure balloons or rotational or orbital atherectomy, interventions with limitations that have hindered its routine use, recently a new plaque modification technique known as coronary intravascular lithotripsy has burst into the treatment of this complex entity, which consists in the use of a specially modified balloon for the emission of pulsatile mechanical energy (sonic pressure waves) that allows modifying the calcified plate. Clinical case: By presenting a series of clinical cases and reviewing the literature, our initial experience is presented, key elements are summarized and discussed in the understanding of this new intervention technique necessary for decision making. Conclusion: Coronary intravascular lithotripsy is projected as a promising technique for the modification and preparation of superficial and deep calcified coronary lesions, through microfractures that allow the apposition and effective expansion of the stent, strategy that according to different trials (Disrupt CAD series, SOLSTICE assay) and records presents a high efficiency and good safety profile, data consistent with our initial experience.

Introducción: las lesiones coronarias calcificadas complejas son un hallazgo frecuente durante el intervencionismo coronario percutáneo, han representado durante décadas un desafío y limitante en pacientes con indicación de revascularización, debido a resultados angiográficos subóptimos, alta incidencia de complicaciones perioperatorias y eventos adversos a largo plazo a pesar de las múltiples estrategias empleadas, como el uso de balones de corte, balones de alta presión o la aterectomía rotacional u orbital, intervenciones con limitantes que han dificultado su uso rutinario. Recientemente, una nueva técnica de modificación de placa conocida como litotricia intravascular coronaria ha irrumpido en el tratamiento de esta compleja entidad, la cual consiste en la utilización de un balón especialmente modificado para la emisión de energía mecánica pulsátil (ondas de presión sónicas) que permite modificar la placa calcificada. Caso clínico: mediante la presentación de una serie de casos clínico y revisión de literatura se presenta nuestra experiencia inicial, se resume y discuten elementos claves en el entendimiento de esta nueva técnica de intervencionismo necesarios para la toma de decisiones. Conclusión: la litotricia intravascular coronaria se proyecta como una técnica prometedora para la modificación y preparación de lesiones coronarias calcificadas superficiales y profundas, mediante microfracturas que permiten la aposición y expansión efectiva del stent; estrategia que de acuerdo con diferentes ensayos (serie Disrupt CAD, ensayo SOLSTICE) y registros presenta una eficacia alta y buen perfil de seguridad, datos concordantes con nuestra experiencia inicial.

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RESUMEN Introducción: Los protocolos de diagnóstico acelerado de dolor torácico, con el avance de la troponina de alta sensibilidad, permiten identificar a los pacientes que ingresan al servicio de urgencias con dolor torácico de bajo riesgo para un evento cardiovascular adverso mayor, que podrían ser dados de alta de forma temprana y segura, con ahorro de tiempo y recursos. Objetivo: Evaluar ensayos clínicos que utilicen protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad. Material y métodos: se realizó una búsqueda de ensayos clínicos aleatorizados que evaluaran protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad en los servicios de urgencias, en las bases de datos MEDLINE/Ovid, Cochrane y EMBASE utilizando los criterios de evaluación del manual Cochrane y la estrategia PRISMA Resultados: Tras una tamización de 3509 estudios se incluyeron 5 ensayos clínicos que incluyeron 1513 pacientes; se identificaron 409 (27%) altas tempranas, el 91% para el protocolo 0/3 h ESC, 72% para el 0/1 h, 48% para el EDACS, 40% para el HEART, 19 y 32% para ADAPT y 8 y 18% para el cuidado usual. El valor predictivo negativo fue alto, en un rango de 99,1 al 100% La duración media de la estancia hospitalaria fue más baja para los protocolos 0/1 h y 0/3 h ESC, con 4,6 y 5,6 horas respectivamente. Conclusiones: Los protocolos de diagnóstico acelerado en dolor torácico que implementan el uso de troponina de alta sensibilidad permiten lograr alta proporción de altas tempranas con baja tasa de eventos cardiovasculares mayores, con disminución del tiempo de estancia y recursos consumidos.

ABSTRACT Background: Accelerated diagnostic protocols for chest pain, with the advancement of high-sensitivity troponin, make it possible to identify patients admitted to the emergency department with chest pain and low risk for a major adverse cardiovascular event, who could be discharged immediately, early and safely, saving time and resources. Objective: The aim of this study was to assess clinical trials using accelerated diagnostic protocols based on high-sensitivity troponin. Methods: A search of randomized clinical trials evaluating accelerated diagnostic protocols based on high-sensitivity troponin in emergency services was carried out in MEDLINE/Ovid, Cochrane and EMBASE database, using the assessment criteria of the Cochrane manual and the PRISMA strategy. Results: After screening 3509 studies, 5 clinical trials, including 1513 patients, were analyzed. Early discharges were identified in 409 (27%) of patients, in 91% of cases for ESC 0/3-h protocols, 72% for 0/1-h, 48% for EDACS, 40% for HEART, 19% and 32% for ADAPT and 8% and 18% for standard care protocols. The negative predictive value was high, in the 99.1-100% range. Mean length of hospital stay was lower for the 0/1-h and ESC 0/3-h protocols, with 4.6 and 5.6 hours, respectively. Conclusions: Accelerated diagnostic protocols in chest pain using high-sensitivity troponin allow a higher proportion of early discharges with a low rate of major cardiovascular events, with reduction in length of hospital stay and resources used.

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La aterectomía rotacional es un procedimiento específico utilizado para el manejo de lesiones coronarias complejas, especialmente cuando existe calcificación de las arterias coronarias (CAC). Esta técnica fue muy utilizada hasta la última década del siglo pasado; actualmente, aunque es poco usada, juega un papel importante en pacientes que podrían ser candidatos a revascularización quirúrgica pero que, por diferentes patologías ―como la enfermedad ateromatosa difusa, en la que se requieren estents largos, reestenosis in-stent, lesiones ostiales calcificadas y oclusiones totales crónicas―, se rechaza la opción quirúrgica. La aterectomía rotacional es un método que utiliza una fresa recubierta de diamante para reducir el volumen de las placas ateroescleróticas y la calcificación de los vasos. Este dispositivo dispersa la placa en microfragmentos, con lo que se consigue un aumento del diámetro luminal. Estos fragmentos, que tienen un diámetro mínimo, pasan predominantemente a la circulación capilar y luego son absorbidos por el sistema reticuloendotelial. Dentro de las complicaciones de esta técnica destacan la disección arterial, el atrapamiento del dispositivo, la bradicardia y la microperforación de arterias coronarias. Esta última puede ser corregida con el uso de trombina, de grasa subcutánea o de perlas. Este artículo reporta el caso de una paciente anciana con enfermedad coronaria multivaso asociada a calcificación extensa de todas las arterias coronarias, por una historia de radioterapia recibida en años anteriores por cáncer de mama y que, al no ser candidata a terapia quirúrgica por cirugía cardiovascular, requirió manejo con aterectomía rotacional que se vio complicada por microperforación de una arteria coronaria, pero que posteriormente evolucionó de manera satisfactoria.

Rotational atherectomy is a specific procedure for managing complex coronary artery lesions, especially when there is coronary artery calcification (CAC). This technique was widely used until the last decade of the 20th century; however, although it is rarely used, it currently plays an important role in patients who could be candidates for surgical revascularization but reject surgeries due to different pathologies-such as diffuse atheromatous disease requiring long stents, in-stent restenosis, calcified ostial lesions and chronic total occlusions. Rotational atherectomy is a method that uses a diamond-coated burr to reduce the volume of atherosclerotic plaques and calcification of vessels. This device breaks up plaque into microfragments, leading to an increase in lumen diameter. These fragments, which have a tiny diameter, pass predominantly into the capillary circulation and are then absorbed by the reticuloendothelial system. Among the complications of this technique are arterial dissection, device entrapment, bradycardia and microperforation of coronary arteries. The latter can be corrected with the use of thrombin, subcutaneous fat or beads. This article reports the case of an elderly female patient with multivessel coronary artery disease associated with extensive calcification of all the coronary arteries secondary to radiotherapy received in previous years for breast cancer. The patient, not being a candidate for cardiovascular surgery, required a rotational atherectomy that resulted in a microperforation of a coronary artery but with good subsequent progress.

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Objective: To evaluate the degree of incomplete revascularization in patients with multiarterial coronary artery disease who underwent percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) using the Syntax revascularization index (SRI) and its relationship to major cardiovascular events during follow-up. Materials and Methods: Observational, retrospective study with 4-year follow-up of patients with multiarterial coronary artery disease who underwent surgical or percutaneous coronary revascularization, in whom the baseline Syntax score (SSb) and the residual Syntax score (SSr) were calculated. The Syntax Revascularization Index (SRI) was determined with the following formula: SRI = (1- [SSr/SSb]) x 100, and major cardiovascular events at 4-year follow-up were compared. Results: Two hundred patients (100 in each group) were evaluated. Mean SSr in group 1 was 83.2%, and in group 2, 79.0% (p=0.88). Mean complete revascularization was 41% in the first group and 35% in the second. A cutoff point of ≤90% of IRS had the best accuracy for predicting major cardiovascular events (area under the curve of 0.60; 95% CI: 0.49-0.71, p<0.05). In multivariate analysis IRS was an independent predictor of major cardiovascular events (HR 2.6; 95%CI: 1.32-3.22, p= 0.043). Conclusions: The Syntax Revascularization Index may be useful for measuring the degree of revascularization in patients with multiarterial coronary artery disease treated percutaneously or surgically. An SRI ³90% may be an acceptable target for revascularization.

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Hypoplastic coronary artery disease (HCAD) is a rare coronary artery anomaly that may be the cause of sudden death. It can involve a single or all coronary arteries. This anomaly may cause circulatory insufficiency leading to myocardial infarction. HCAD has no symptoms or may exhibit cardiovascular signs like syncope, dyspnea, chest discomfort, or dizziness. It is often diagnosed at autopsy, and early diagnosis is made with a coronary angiogram. We report HCAD as the cause of the sudden death of a 25-year-old female with a history of loss of consciousness following exertion. On autopsy, all the coronary arteries' lumen was narrowed with thin vessel walls. Histopathological examination shows an underdeveloped and missing muscular layer of the left anterior descending and circumflex coronary arteries' vascular wall. Many cases of HCAD diagnosed by radiographic imaging in living patients have been reported in the literature, but a structural anomaly of coronaries leading to HCAD has not been reported. We report a case of HCAD describing the histopathological examination findings of the vascular wall of coronary vessels illustrating the structural difference.

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Background: Postoperative radiation therapy (RT) is the standard treatment for almost all patients diagnosed with breast cancer. Even with modern RT techniques, parts of the heart may still receive higher doses than those recommended by clinically validated dose limit restrictions, especially when the left breast is irradiated. Deep inspiration breath hold (DIBH) may reduce irradiated cardiac volume compared to free breathing (FB) treatment. This study aimed to evaluate the dosimetric impact on the heart and left anterior descending coronary artery (LAD) in FB and DIBH RT planning in patients with left breast cancer. Materials and methods: A retrospective cohort study of women diagnosed with left-sided breast cancer submitted to breast surgery followed by postoperative RT from 2015 to 2019. All patients were planned with FB and DIBH and hypofractionated dose prescription (40.05 Gy in 15 fractions). Results: 68 patients were included in the study. For the coverage of the planned target volume evaluation [planning target volume (PTV) eval] there was no significant difference between the DIBH versus FB planning. For the heart and LAD parameters, all constraints evaluated favored DIBH planning, with statistical significance. Regarding the heart, median V16.8 Gy was 2.56% in FB vs. 0% in DIBH (p < 0.001); median V8.8 Gy was 3.47% in FB vs. 0% in DIBH (p < 0.001) and the median of mean heart dose was 1.97 Gy in FB vs. 0.92 Gy in DIBH (p < 0.001). For the LAD constraints D2% < 42 Gy, the median dose was 34.87 Gy in FB versus 5.8 Gy in DIBH (p < 0.001); V16.8 Gy < 10%, the median was 15.87% in FB versus 0% in DIBH (p < 0.001) and the median of mean LAD dose was 8.13Gy in FB versus 2.92Gy in DIBH (p < 0.001). Conclusions: The DIBH technique has consistently demonstrated a significant dose reduction in the heart and LAD in all evaluated constraints, while keeping the same dose coverage in the PTV eval.

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Median sternotomy is the Gold Standard access for surgical revascularization of the myocardium, but it is not free of complications, especially in patients with multiple comorbidities. Minimally invasive access offers the advantage of avoiding sternotomy, achieving a more accelerated postoperative recovery, with less hospital stay time and a higher level of satisfaction with quality of life. We present the case of a 49-year-old male patient, diabetic, hypertensive, smoker, with multiarterial coronary artery disease, very symptomatic, who underwent surgical revascularization by left mini-thoracotomy.

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Abstract Background: Home-based virtual reality technology may become an alternative to cardiac rehabilitation. Objectives: To evaluate the effects of a specific, home-based exercise program, performed either through a virtual reality (Kinect) or a conventional format (booklet) in the maintenance stage of cardiac rehabilitation for six months on functional muscle strength of the lower limbs, physical activity and exercise tolerance. Methodology: This is a randomized clinical trial (ClinicalTrials.gov — NCT02753829) with individuals with coronary artery disease from a hospital in Porto, Portugal, randomly allocated to an experimental group "1" (EG1; n = 11), submitted to a virtual reality exercise program (Kinect); an experimental group "2" (EG2; n = 11), submitted to an exercise program described in a booklet (conventional format); or a control group (CG) (n=11), submitted to routine care. Parameters of functional muscle strength of the lower limbs (sit-to-stand test), physical activity (accelerometer) and exercise tolerance (stress test) were assessed and compared between the groups. Descriptive and inferential statistics were applied, with 95% with a significance level of 0.05. Results: Significant improvements in functional muscle strength of the lower limbs were observed in EG1 compared to EG2, at three months (19.5 ± 7.7 versus 11.9 ± 4.7, p = 0.042), and at six months (23.0 ± 7.7 versus 14.6 ± 4.6, p = 0.027) of intervention. Conclusions: The program did not demonstrate superior results, in relation to the control group and among the different formats, in physical activity and effort tolerance. In relation to the functional muscle strength of the lower limbs, the virtual reality format showed significantly better results when compared to the conventional format only.