MARCIO SOMMER BITTENCOURT
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- Coronary Calcium Score vs. Computed Tomography Angiography as Tools to Stratify Cardiovascular Risk(2018) BITTENCOURT, Marcio S.This review evaluates the evidence for and against the use of coronary artery calcium (CAC) score and coronary computed tomography angiography (CTA) on the cardiovascular risk stratification for primary prevention in asymptomatic individuals. Recent evidence suggests that the presence and extent of CAC are robust predictors of events across various populations and variable baseline risk. On the other hand, the absence of CAC is associated with a good prognosis event in older individuals or in those with multiple risk factor or high clinical risk. While coronary CTA is also useful for risk stratification, its results did not provide incremental discrimination of individuals once the CAC is accounted for. Thus, current evidence does not support its use in asymptomatic individuals. CAC is a powerful tool for additional cardiovascular risk stratification in individuals where the need for pharmacological therapy for risk reduction in primary prevention is uncertain, such as in individuals with intermediate risk. Since coronary CTA does not further improve risk stratification in this population, it is not currently recommended in asymptomatic individuals.
- Prognostic Value of Nonobstructive and Obstructive Coronary Artery Disease Detected by Coronary Computed Tomography Angiography to Identify Cardiovascular Events(2014) BITTENCOURT, Marcio Sommer; HULTEN, Edward; GHOSHHAJRA, Brian; O'LEARY, Daniel; CHRISTMAN, Mitalee P.; MONTANA, Philip; TRUONG, Quynh A.; STEIGNER, Michael; MURTHY, Venkatesh L.; RYBICKI, Frank J.; NASIR, Khurram; GOWDAK, Luis Henrique W.; HAINER, Jon; BRADY, Thomas J.; CARLI, Marcelo F. Di; HOFFMANN, Udo; ABBARA, Suhny; BLANKSTEIN, RonBackground- The contribution of plaque extent to predict cardiovascular events among patients with nonobstructive and obstructive coronary artery disease (CAD) is not well defined. Our objective was to evaluate the prognostic value of plaque extent detected by coronary computed tomography angiography. Methods and Results- All consecutive patients without prior CAD referred for coronary computed tomography angiography to evaluate for CAD were included. Examination findings were classified as normal, nonobstructive (< 50% stenosis), or obstructive (>= 50%). Based on the number of segments with disease, extent of CAD was classified as nonextensive (<= 4 segments) or extensive (> 4 segments). The cohort included 3242 patients followed for the primary outcome of cardiovascular death or myocardial infarction for a median of 3.6 (2.1-5.0) years. In a multivariable analysis, the presence of extensive nonobstructive CAD (hazard ratio, 3.1; 95% confidence interval, 1.5-6.4), nonextensive obstructive (hazard ratio, 3.0; 95% confidence interval, 1.3-6.9), and extensive obstructive CAD (hazard ratio, 3.9; 95% confidence interval, 2.2-7.2) were associated with an increased rate of events, whereas nonextensive, nonobstructive CAD was not. The addition of plaque extent to a model that included clinical probability as well as the presence and severity of CAD improved risk prediction. Conclusions- Among patients with nonobstructive CAD, those with extensive plaque experienced a higher rate of cardiovascular death or myocardial infarction, comparable with those who have nonextensive disease. Even among patients with obstructive CAD, greater extent of nonobstructive plaque was associated with higher event rate. Our findings suggest that regardless of whether obstructive or nonobstructive disease is present, the extent of plaque detected by coronary computed tomography angiography enhances risk assessment.
- Association Between Smoking and Serum GlycA and High-Sensitivity C-Reactive Protein Levels: The Multi-Ethnic Study of Atherosclerosis (MESA) and Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)(2017) KIANOUSH, Sina; BITTENCOURT, Marcio S.; LOTUFO, Paulo A.; BENSENOR, Isabela M.; JONES, Steven R.; DEFILIPPIS, Andrew P.; TOTH, Peter P.; OTVOS, James D.; TIBUAKUU, Martin; HALL, Michael E.; HARADA, Paulo H. N.; BLAHA, Michael J.Background-Inflammation is suggested to be a central feature of atherosclerosis, particularly among smokers. We studied whether inflammatory biomarkers GlycA and high-sensitivity C-reactive protein are associated with cigarette smoking. Methods and Results-A total of 11 509 participants, 6774 from the MESA (Multi-Ethnic Study of Atherosclerosis) and 4735 from ELSA-Brasil (The Brazilian Longitudinal Study of Adult Health) were included. We evaluated the cross-sectional association between multiple measures of smoking behavior and the inflammatory biomarkers, GlycA and high-sensitivity C-reactive protein, using regression models adjusted for demographic, anthropometric, and clinical characteristics. Participants were 57.7 +/- 11.1 years old and 46.4% were men. Never, former, and current smokers comprised 51.7%, 34.0%, and 14.3% of the population, respectively. Multivariable-adjusted mean absolute difference in GlycA levels (mu mol/L) with 95% confidence interval (CI) were higher for former (4.1, 95% CI, 1.7-6.6 mu mol/L) and current smokers (19.9, 95% CI, 16.6-23.2 mu mol/L), compared with never smokers. Each 5-unit increase in pack-years of smoking was associated with higher GlycA levels among former (0.7, 95% CI, 0.3-1.1 mu mol/L) and current smokers (1.6, 95% CI, 0.8-2.4 mu mol/L). Among former smokers, each 5-year increase in time since quitting smoking was associated with lower GlycA levels (-1.6, 95% CI, -2.4 to -0.8 lmol/L) and each 10-unit increase in number of cigarettes/day was associated with higher GlycA among current smokers (2.8, 95% CI, 0.5-5.2 mu mol/L). There were similar significant associations between all measures of smoking behavior, and both log-transformed GlycA and high-sensitivity C-reactive protein. Conclusions-Acute and chronic exposure to tobacco smoking is associated with inflammation, as quantified by both GlycA and high-sensitivity C-reactive protein. These biomarkers may have utility for the study and regulation of novel and traditional tobacco products.
- Race and Resting-State Heart Rate Variability in Brazilian Civil Servants and the Mediating Effects of Discrimination: An ELSA-Brasil Cohort Study(2016) KEMP, Andrew H.; KOENIG, Julian; THAYER, Julian F.; BITTENCOURT, Marcio S.; PEREIRA, Alexandre C.; SANTOS, Itamar S.; DANTAS, Eduardo M.; MILL, Jose G.; CHOR, Dora; RIBEIRO, Antonio L. P.; BENSENOR, Isabela M.; LOTUFO, Paulo A.Objectives African Americans are characterized by higher heart rate variability (HRV), a finding ostensibly associated with beneficial health outcomes. However, these findings are at odds with other evidence that blacks have worse cardiovascular outcomes. Here, we examine associations in a large cohort from the ELSA-Brasil study and determined whether these effects are mediated by discrimination. Methods Three groups were compared on the basis of self-declared race: black (n = 2,020), brown (n = 3,502), and white (n = 6,467). Perceived discrimination was measured using a modified version of the Everyday Discrimination Scale. Resting-state HRV was extracted from 10-minute resting-state electrocardiograms. Racial differences in HRV were determined by regression analyses weighted by propensity scores, which controlled for potentially confounding variables including age, sex, education, and other health-related information. Nonlinear mediation analysis quantified the average total effect, comprising direct (race-HRV) and indirect (race-discrimination-HRV) pathways. Results Black participants displayed higher HRV relative to brown (Cohen's d = 0.20) and white participants (Cohen's d = 0.31). Brown relative to white participants also displayed a small but significantly higher HRV (Cohen's d = 0.14). Discrimination indirectly contributed to the effects of race on HRV. Conclusions This large cohort from the Brazilian population shows that HRV is greatest in black, followed by brown, relative to white participants. The presence of higher HRV in these groups may reflect a sustained compensatory psychophysiological response to the adverse effects of discrimination. Additional research is needed to determine the health consequences of these differences in HRV across racial and ethnic groups.
- Recurrent pulmonary edema caused by chronic left main coronary artery occlusion(2012) BITTENCOURT, M. S.; OLIVEIRA, A. L. V. De; GOWDAK, L. H. W.; CESAR, L. A. M.
- 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.
- Atherosclerosis in HIV patients: A different disease or more of the same?(2015) BITTENCOURT, Marcio Sommer; PEIXOTO, Driele
- Heart Disease and Stroke Statistics-2019 Update A Report From the American Heart Association(2019) BENJAMIN, Emelia J.; MUNTNER, Paul; ALONSO, Alvaro; BITTENCOURT, Marcio S.; CALLAWAY, Clifton W.; CARSON, April P.; CHAMBERLAIN, Alanna M.; CHANG, Alexander R.; CHENG, Susan; DAS, Sandeep R.; DELLING, Francesca N.; DJOUSSE, Luc; ELKIND, Mitchell S. V.; FERGUSON, Jane F.; FORNAGE, Myriam; JORDAN, Lori Chaffin; KHAN, Sadiya S.; KISSELA, Brett M.; KNUTSON, Kristen L.; KWAN, Tak W.; LACKLAND, Daniel T.; LEWIS, Tene T.; LICHTMAN, Judith H.; LONGENECKER, Chris T.; LOOP, Matthew Shane; LUTSEY, Pamela L.; MARTIN, Seth S.; MATSUSHITA, Kunihiro; MORAN, Andrew E.; MUSSOLINO, Michael E.; O'FLAHERTY, Martin; PANDEY, Ambarish; PERAK, Amanda M.; ROSAMOND, Wayne D.; ROTH, Gregory A.; SAMPSON, Uchechukwu K. A.; SATOU, Gary M.; SCHROEDER, Emily B.; SHAH, Svati H.; SPARTANO, Nicole L.; STOKES, Andrew; TIRSCHWELL, David L.; TSAO, Connie W.; TURAKHIA, Mintu P.; VANWAGNER, Lisa B.; WILKINS, John T.; WONG, Sally S.; VIRANI, Salim S.Each year, the American Heart Association (AHA), in conjunction with the National Institutes of Health and other government agencies, brings together in a single document the most up-to-date statistics related to heart disease, stroke, and the cardiovascular risk factors in the AHA's My Life Check - Life's Simple 7 (Figure1), which include core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure [BP], and glucose control) that contribute to cardiovascular health. The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions. Cardiovascular disease (CVD) produces immense health and economic burdens in the United States and globally. The Statistical Update also presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease [CHD], heart failure [HF], valvular disease, venous disease, and peripheral arterial disease) and the associated outcomes (including quality of care, procedures, and economic costs). Since 2007, the annual versions of the Statistical Update have been cited > 20 000 times in the literature. Each annual version of the Statistical Update undergoes revisions to include the newest nationally representative data, add additional relevant published scientific findings, remove older information, add new sections or chapters, and increase the number of ways to access and use the assembled information. This year-long process, which begins as soon as the previous Statistical Update is published, is performed by the AHA Statistics Committee faculty volunteers and staff and government agency partners. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, a new chapter on sleep, an enhanced focus on social determinants of health, a substantively expanded focus on the global burden of CVD, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the AHA's 2020 Impact Goals. Below are a few highlights from this year's Statistical Update.
- Clinical Outcomes After Evaluation of Stable Chest Pain by Coronary Computed Tomographic Angiography Versus Usual Care: A Meta-Analysis(2016) BITTENCOURT, Marcio Sommer; HULTEN, Edward A.; MURTHY, Venkatesh L.; CHEEZUM, Michael; ROCHITTE, Carlos E.; CARLI, Marcelo F. Di; BLANKSTEIN, RonBackground Limited data exist on how noninvasive testing options compare for evaluating patients with suspected stable coronary artery disease. In this study, we have performed a meta-analysis of randomized controlled trials comparing the use of coronary computed tomographic angiography (CTA) with usual care. Methods and Results We systematically searched databases for randomized clinical trials comparing coronary CTA with usual care for the evaluation of stable chest pain with follow-up for cardiovascular outcomes. The primary outcomes were myocardial infarction and all-cause mortality. We identified 4 randomized clinical trials, including a total of 7403 patients undergoing coronary CTA and 7414 patients undergoing usual care with various functional testing approaches. When compared with usual care, the use of coronary CTA was associated with a significant reduction in the annual rate of myocardial infarction (rate ratio, 0.69; 95% confidence interval, 0.49-0.98; P=0.038), but no difference was found in all-cause mortality. There was a trend toward more invasive coronary angiographies among patients undergoing coronary CTA (odds ratio, 1.33; 95% confidence interval, 0.95-1.84; P=0.09) and higher use of coronary revascularizations (odds ratio, 1.77; 95% confidence interval, 1.14-2.75). Significant heterogeneity for invasive coronary angiography and revascularization was noted, which was attributable to the Scottish Computed Tomography of the HEART (SCOT-HEART) study. We found no difference in the rate of admission for cardiac chest pain (rate ratio, 1.21; 95% confidence interval, 0.95-1.54). Conclusions In comparison to usual care, an initial investigation of suspected stable coronary artery disease using coronary CTA resulted in a significant reduction in myocardial infarction, an increased incidence of coronary revascularization, and no effect in all-cause mortality. Future studies should further define whether the potential reduction in myocardial infarction identified justifies the increased resource utilization associated with coronary CTA.
- The contribution of the systolic and diastolic components for the diagnosis of arterial hypertension under the 2017 ACC/AHA Guideline and metabolic heterogeneity among individuals with Stage 1 hypertension(2020) CESENA, Fernando H. Y.; NARY, Fernando C.; SANTOS, Raul D.; BITTENCOURT, Marcio S.Little is known about the impact of the 2017 ACC/AHA hypertension guideline on the distribution pattern of hypertension modalities (isolated systolic hypertension [ISH], isolated diastolic hypertension [IDH], and systolic-diastolic hypertension [SDH]). This cross-sectional study had the following objectives: to compare the prevalence of hypertension, ISH, IDH, and SDH, according to the definitions of the JNC 7 or the 2017 guideline; to determine the relative contribution of the systolic and the diastolic components for the diagnosis of hypertension; and to compare the metabolic profile of ISH, IDH, or SDH among new hypertensive individuals by the 2017 guideline. The authors retrospectively evaluated 33 594 patients (42 +/- 10 years, 67% male) who underwent a routine health evaluation. Hypertensive patients not using antihypertensive medication were classified into ISH, IDH, or SDH using guideline-defined thresholds. The prevalence of hypertension increased from 21.1% by the JNC 7 definition to 54.7% using the 2017 criteria (2.6-fold increase). More profound increases were seen in the prevalence of IDH (8.7-fold) and SDH (3.3-fold), whereas the prevalence of ISH reduced from 1.1% (JNC 7) to 0.5% (2017 definition). Among patients with Stage 1 hypertension by the 2017 document, 85% had IDH and fewer metabolic abnormalities compared to those with SDH or ISH. The authors concluded that the 2017 guideline inflates the role of the diastolic component and diminishes the contribution of the systolic component for the diagnosis of hypertension. Individuals with Stage 1 hypertension by the 2017 guideline are metabolically heterogeneous and may have different long-term prognoses.