MARCIO SOMMER BITTENCOURT
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- Anomalous Coronary Arteries: When to Follow-up, Risk Stratify, and Plan Intervention(2021) ADAM, Eduardo Leal; GENEROSO, Giuliano; BITTENCOURT, Marcio SommerPurpose of Review Coronary artery anomalies are a diverse group of entities, ranging from benign variations of normal anatomy to life-threatening conditions. There is, however, no universal consensus in their classification, risk stratification, and management. The aim of this review is to develop a straightforward clinical approach for the assessment and care of patients with anomalous coronary arteries. Recent Findings Autopsy series and population screening studies have recently provided useful clinical data on the prevalence and outcomes of coronary anomalies. Also, findings on coronary computed tomography angiography, magnetic resonance imaging, and invasive angiography, enriched with fractional flow reserve and intravascular ultrasound, have allowed identification of several high-risk features associated with specific coronary anomalies. Management of patients with anomalous coronary arteries requires an individualized approach based on clinical, physiological, and anatomic features. High-quality studies are paramount for further development of this fascinating field.
- Impact of CPAP on arterial stiffness in patients with obstructive sleep apnea: a meta-analysis of randomized trials(2021) CHALEGRE, Sintya T.; LINS-FILHO, Ozeas L.; LUSTOSA, Thais C.; FRANCA, Marcus V.; COUTO, Tarcya L. G.; DRAGER, Luciano F.; LORENZI-FILHO, Geraldo; BITTENCOURT, Marcio S.; PEDROSA, Rodrigo P.Purpose This study aimed to perform a systematic review and meta-analysis of randomized trials investigating the effect of continuous positive airway pressure (CPAP) on non-invasive markers of arterial stiffness in patients with OSA. Methods The purpose of the study was to evaluate the effect of CPAP on markers of arterial stiffness (pulse wave velocity (PWV) and augmentation index (Aix)) in patients with OSA. The study adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We systematically reviewed MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, and LILACS databases for randomized trials (RT) evaluating the changes in markers of arterial stiffness (pulse wave velocity (PWV) and augmentation index (Aix) comparing CPAP vs. controls in patients with OSA. Reviewer Manager version 5.3 (R Foundation for Statistical Computing, Vienna, Austria) was used to perform meta-analysis. Risk of bias analysis was performed using the Cochrane tool. Results Of the 464 studies initially retrieved, 9 relevant studies with 685 participants were included in the analysis. The studies presented moderate risk of bias. CPAP did not significantly reduce Aix (mean difference, - 1.96 (95% confidence interval (CI) - 5.25 to 1.33), p = 0.24), whereas it significantly changed PWV (mean difference, - 0.44 (95% confidence interval (CI) - 0.76 to - 0.12), p = 0.00). Conclusion CPAP treatment was effective in improving arterial stiffness by reducing PWV in patients with OSA. Additional randomized trials, however, should be performed to confirm these findings.
- Early-onset prosthetic valve endocarditis definition revisited: Prospective study and literature review(2018) SICILIANO, Rinaldo Focaccia; RANDI, Bruno Azevedo; GUALANDRO, Danielle Menosi; SAMPAIO, Roney Orismar; BITTENCOURT, Marcio Sommer; PELAES, Christian Emmanuel da Silva; MANSUR, Alfredo Jose; POMERANTZEFF, Pablo Maria Alberto; TARASOUTCHI, Flavio; STRABELLI, Tania Mara VarejaoObjective: To determine the annual incidence of prosthetic valve endocarditis (PVE) and to evaluate its current classification based on the epidemiological distribution of agents identified and their sensitivity profiles. Methods: Consecutive cases of PVE occurring within the first year of valve surgery during the period 1997-2014 were included in this prospective cohort study. Incidence, demographic, clinical, microbiological, and in-hospital mortality data of these PVE patients were recorded. Results: One hundred and seventy-two cases of PVE were included, and the global annual incidence of PVE was 1.7%. Most PVE cases occurred within 120 days after surgery (76.7%). After this period, there was a reduction in resistant microorganisms (64.4% vs. 32.3%, respectively; p = 0.007) and an increase in the incidence of Streptococcus spp (1.9% vs. 23.5%; p = 0.007). A literature review revealed 646 cases of PVE with an identified etiology, of which 264 (41%) were caused by coagulase-negative staphylococci and 43 (7%) by Streptococcus spp. This is in agreement with the current study findings. Conclusions: Most PVE cases occurred within 120 days after valve surgery, and the same etiological agents were identified in this period. The current cut-off level of 365 days for the classification of early-onset PVE should be revisited. (C) 2017 The Authors.
- Renin-angiotensin System Antagonists and Beta-blockers in Prevention of Anthracycline Cardiotoxicity: a Systematic Review and Meta-analysis(2023) AVILA, Monica Samuel; SIQUEIRA, Suellen Rodrigues Rangel; WALDECK, Lucas; AYUB-FERREIRA, Silvia Moreira; TAKX, Richard; BITTENCOURT, Marcio Sommer; BOCCHI, Edimar AlcidesBackground: The evidence supporting the use of renin-angiotensin-aldosterone system (RAAS) inhibitors and beta-blockers for the prevention of anthracycline-induced cardiomyopathy is controversial. Objective: We performed a meta-analysis to assess the effectiveness of these drugs in preventing cardiotoxicity. Methods: The meta-analysis included prospective, randomized studies in adults receiving anthracycline chemotherapy and compared the use of RAAS inhibitors or beta-blockers versus placebo with a follow-up of 6 to 18 months. The primary outcome was change in left ventricular ejection fraction (LVEF) during chemotherapy. Secondary outcomes were the incidence of heart failure, all-cause mortality, and changes in end-diastolic measurement. Heterogeneity was assessed by stratification and meta-regression. A significance level of p < 0.05 was adopted. Results: The search resulted in 17 studies, totaling 1,530 patients. The variation (delta) in LVEF was evaluated in 14 studies. Neurohormonal therapy was associated with a lower delta in pre- versus post-therapy LVEF (weighted mean difference 4.42 [95% confidence interval2.3 to 6.6]) and higher final LVEF (p < 0.001). Treatment resulted in a lower incidence of heart failure (risk ratio 0.45 [95% confidence interval0.3 to 0.7]). There was no effect on mortality (p = 0.3). For analysis of LVEF, substantial heterogeneity was documented, which was not explained by the variables explored in the study. Conclusion: The use of RAAS inhibitors and beta-blockers to prevent anthracycline-induced cardiotoxicity was associated with less pronounced reduction in LVEF, higher final LVEF, and lower incidence of heart failure. No changes in mortalitywere observed. (CRD PROSPERO 42019133615)
- Presence of Late Gadolinium Enhancement by Cardiac Magnetic Resonance Among Patients With Suspected Cardiac Sarcoidosis Is Associated With Adverse Cardiovascular Prognosis: A Systematic Review and Meta-Analysis(2016) HULTEN, Edward; AGARWAL, Vikram; CAHILL, Michael; COLE, Geoff; VITA, Tomas; PARRISH, Scott; BITTENCOURT, Marcio Sommer; MURTHY, Venkatesh L.; KWONG, Raymond; CARLI, Marcelo F. Di; BLANKSTEIN, RonBackground Individuals with cardiac sarcoidosis have an increased risk of ventricular arrhythmia and death. Several small cohort studies have evaluated the ability of late gadolinium enhancement (LGE) by cardiac magnetic resonance imaging (MRI) to predict adverse cardiovascular events. However, studies have yielded inconsistent results, and some analyses were underpowered. Therefore, we sought to systematically review and perform meta-analysis of the prognostic value of cardiac MRI for patients with known or suspected cardiac sarcoidosis. Methods and Results We systematically searched for cohort studies of patients with known sarcoidosis with suspected cardiac involvement who underwent cardiac MRI with LGE with at least 12 months of either prospective or retrospective follow-up data regarding post-MRI adverse cardiovascular outcomes. We identified 7 studies of 694 subjects (mean age 53; 42% men).One hundred and ninety-nine patients (29%) were LGE positive. All-cause mortality occurred in 19 LGE-positive versus 17 LGE-negative subjects (annualized incidence, 3.1% versus 0.6%). The pooled relative risk was 3.38 (95% confidence interval, 1.07-10.7; P=0.04). Cardiovascular mortality occurred in 10 LGE-positive versus 2 LGE-negative subjects (annualized incidence, 1.9% versus 0.3%; relative risk 10.7 [95% confidence interval, 1.34-86.3]; P=0.03). Ventricular arrhythmia occurred in 41 LGE-positive versus 0 LGE-negative subjects (annualized incidence, 5.9% versus 0%; relative risk 19.5 [95% confidence interval, 2.68-143]; P=0.003). A combined end point of death or ventricular arrhythmia occurred in 64 LGE-positive versus 18 LGE-negative subjects (annualized incidence, 8.8% versus 0.6%; relative risk 6.20 [95% confidence interval, 2.47-15.6]; P<0.001). There was no significant heterogeneity for any outcomes. Conclusions LGE is associated with future cardiovascular death and ventricular arrhythmia among patients referred to MRI for known or suspected cardiac sarcoidosis.
- Anatomical References to Evaluate Thoracic Aorta Calcium by Computed Tomography(2019) PEDROSA, Jesiana Ferreira; BARRETO, Sandhi Maria; BITTENCOURT, Marcio Sommer; RIBEIRO, Antonio Luiz PinhoPurpose of Review Thoracic aortic calcium (TAC) has received some interest in recent studies as an important subclinical marker of atherosclerosis. Besides that, using computed tomography (CT) scans performed with cardiac or chest protocols, ECG-gated, or non-gated, TAC can be easily evaluated with no addition in radiation dose. This review discusses the particularities of the aortic wall calcium formation, as well as the differences between the aortic segments and summarizes the current status of TAC evaluation, mainly concerning the anatomical references used in the studies. Recent Findings The studies have evaluated TAC considering different anatomical references. It was identified two different study groups. In the first one, researchers have analyzed the aorta as the sum of calcium in the ascending aorta (ATAC), aortic arch (AAC), and descending thoracic aorta (DTAC). The second group has used cardiac CT scans to assess TAC; therefore, they did not include AAC; however, the aortic root calcium (ARC) was added in the analysis. So, caution is advisable when interpreting and comparing studies that used different TAC anatomical references. The broad methodological variability, in addition to the variations in the population characteristics of the studies on TAC, may be in part contributing to the differences between results of different studies. Currently TAC does not have a role in clinical decisions, so it is necessary to create a standard protocol for the aortic calcium research as well as exists for the coronary artery calcium evaluation.
- Polypills in Cardiovascular Disease Prevention: Mass-Strategy Approach, Precision Medicine, or an Essential Intertwine Between Them?(2021) GENEROSO, Giuliano; BITTENCOURT, Marcio SommerPurpose of ReviewThis review considers the framework of high-risk vs. population approaches as proposed in the Rose's axiom within the context of cardiovascular diseases, including its benefits and limitations. We also contextualize the use of precision medicine in primary prevention therapy and contrast that with population approach.Recent FindingsAlthough the high-risk strategy aims at individualized care, the complexity of pharmacologic regimens and other limitations reduces its real-life impact. On the other hand, broad population strategies include treatment of a substantial number of low-risk individuals who are unlikely to benefit from treatment. The use of additional strategies to identify those low-risk individuals, instead of targeting at identifying the high-risk population, is and alternative strategy to be considered. Evidence of the potential use of coronary artery calcium score and polypills for this strategy is discussed.SummaryA more targeted population approach to primary prevention in cardiovascular diseases with the use of polypills and coronary artery calcium score might be considered in a structured mass-strategy approach to risk reduction.
- New 2018 ACC/AHA Guidelines on Cholesterol Management: Key Changes and Implications(2019) BITTENCOURT, Marcio; GENEROSO, Giuliano
- Subclinical coronary atherosclerosis and cardiovascular risk stratification in heterozygous familial hypercholesterolemia patients undergoing statin treatment(2019) MINAME, Marcio H.; BITTENCOURT, Marcio S.; NASIR, Khurram; SANTOS, Raul D.Purpose of review To discuss the heterogeneity of atherosclerotic cardiovascular disease (ASCVD) risk in heterozygous familial hypercholesterolemia and evidence and limitations of clinical risk scores and subclinical coronary atherosclerosis (SCA) imaging to evaluate risk. Recent findings Risk evaluation in contemporary familial hypercholesterolemia cohorts needs to consider the cause of the familial hypercholesterolemia phenotype, for example the presence of autosomal molecular defects that impart a greater ASCVD risk than in polygenic hypercholesterolemia, prospective follow-up and the impact of statin treatment. As atherosclerosis is multifactorial, clinical scores like the Montreal familial hypercholesterolemia score and SAFEHEART risk equation have been proposed to stratify ASCVD in statintreated, molecularly defined familial hypercholesterolemia individuals. However, these scores need further validation. SCA distribution in familial hypercholesterolemia individuals undergoing conventional lipidlowering treatment is heterogeneous, with 45-50% of individuals not presenting any coronary artery calcification (CAC). One study suggests that the absence of CAC associates with no ASCVD events in asymptomatic familial hypercholesterolemia individuals undergoing statin therapy despite elevated residual LDL-cholesterol levels. In contrast, the presence of CAC was independently associated with ASCVD events. Summary ASCVD risk is heterogeneous in statin-treated familial hypercholesterolemia individuals. Further studies are necessary to determine how risk stratification, especially with SCA detection, impacts on prescription of proprotein convertase subtilisin kexin type 9 inhibitors within a cost-constrained environment.
- Triglycerides and triglyceride-rich lipoproteins in the development and progression of atherosclerosis(2019) GENEROSO, Giuliano; JANOVSKY, Carolina C. P. S.; BITTENCOURT, Marcio S.Purpose of review In this review, we intend to show the heterogenicity of the triglyceride group, including the triglyceride-rich lipoproteins and its subparticles, apolipoproteins, and its role in atherogenesis through epidemiological and genetic studies, observing the association of these various components and subclasses with subclinical atherosclerosis and cardiovascular events. Also, we reevaluated the moment of blood collection for the triglyceride measurement and its repercussion in atherosclerosis. Finally, we present the current scenario and new insights about the pharmacologic treatment of hypertriglyceridemia. Recent findings Recent studies have been observed, a correlation between cardiovascular disease and triglyceride components (as apolipoproteins A-V, C-I, C-III) as well as proteins involved in the metabolism pathway, such as the angiopoietin-like proteins. Also, the triglyceride-rich lipoproteins, also known as remnants, were recently associated with atherogenesis. Another important topic addressed is about nonfasting triglyceride level, which has been postulated as a better predictor of cardiovascular events than fasting collection. Summary Regarding hypertriglyceridemia treatment, the drug therapy was updated, as the omega-3 polyunsaturated fatty acids were tested in primary prevention as eicosapentaenoic acid and docosahexaenoic acid combination resulted in no benefit, whereas the administration of icosapent ethyl in secondary prevention and high-risk patients showed a robust decrease of the cardiovascular outcomes.