Gabriel Tensol Rodrigues Pereira

Background: Rheumatic heart disease (RHD) remains a significant public health concern in middle- to low-income countries. Despite advancements in healthcare access and public health measures in Brazil, future projections of RHD burden are essential to guide policy-making. Thus, we projected the national and regional burden of RHD in Brazil through 2050. Methods: Annual prevalence counts and disability-adjusted life years (DALYs) for RHD from 2000 to 2021 were extracted from the 2021 Global Burden of Disease (GBD) dataset for 10-year age brackets (5–74 years). Age-standardized prevalence (asPR) and DALYs rates (asDALYs) per 100,000 were calculated nationally and regionally. Bayesian age-period-cohort models were used to project trends through 2050, with results reported as medians (25th, 75th percentiles) and estimated annual percentage changes (EAPCs). Results: From 2000 to 2021, Brazil’s population grew by 27%. Nationally, the asPR declined slightly from 1,503 to 1,495 per 100,000 [EAPC: –0.04% (95% CI: –0.05, –0.03)], with reductions observed in most regions. However, increases were noted in the North [EAPC: 0.14% (95% CI: 0.13, 0.15)] and Northeast [EAPC: 0.02% (95% CI: 0.01, 0.03)]. Males experienced greater reductions [EAPC: –0.16% (95% CI: –0.19, –0.13)] compared to females, who showed a slight increase [EAPC: 0.05% (95% CI: 0.03, 0.07)]. Projections indicate that asPR will decline nationally to 1,418 per 100,000 by 2050 [EAPC: –0.20% (95% CI: –0.20, –0.19)], with the South and Central West regions reducing the most. The asDALY rates declined from 142 to 104 per 100,000 [EAPC: –1.58% (95% CI: –1.69, –1.46)] during 2000–2021, with all regions showing decreases, particularly the Southeast [EAPC: –1.83% (95% CI: –1.98, –1.69)]. Nationally, projections suggest further reductions to 75 per 100,000 by 2050 [EAPC: –1.17% (95% CI: –1.22, –1.11)]. Conclusion: The burden of RHD in Brazil has decreased nationally and regionally over recent decades. Projections suggest that these trends will continue.

BACKGROUND: Persistent mineralocorticoid receptor activation is a pathologic response in type 2 diabetes and chronic kidney disease. Whereas mineralocorticoid receptor antagonists are beneficial in reducing cardiovascular complications, direct mechanistic pathways for these effects in humans are lacking. METHODS: The MAGMA trial (Mineralocorticoid Receptor Antagonism Clinical Evaluation in Atherosclerosis) was a randomized, double-blind, placebo-controlled trial in patients with high-risk type 2 diabetes with chronic kidney disease (not receiving dialysis) on maximum tolerated renin-angiotensin system blockade. The primary end point was change in thoracic aortic wall volume, expressed as absolute or percent value (ΔTWV or ΔPWV), using 3T magnetic resonance imaging at 12 months. Secondary end points were changes in left ventricle (LV) mass; LV fibrosis, measured as a change in myocardial native T1; and 24-hour ambulatory and central aortic blood pressures. Tertiary end points included plasma proteomic changes in 7596 plasma proteins using an aptamer-based assay. RESULTS: A total of 79 patients were randomized to placebo (n=42) or 25 mg of spironolactone daily (n=37). After a modified intent-to-treat, including available baseline data of study end points, patients who completed the trial protocol were included in the final analyses. At the 12-month follow-up, the average change in PWV was 7.1±10.7% in the placebo group and 0.87±10.0% in the spironolactone group ( P =0.028), and ΔTWV was 1.2±1.7 cm ³ in the placebo group and 0.037±1.9 cm ³ in the spironolactone group ( P =0.022). Change in LV mass was 3.1±8.4 g in the placebo group and −5.8±8.4 g in the spironolactone group ( P =0.001). Changes in LV T1 values were significantly different between the placebo and spironolactone groups (26.0±41.9 ms in the placebo group versus a decrease of −10.1±36.3 ms in the spironolactone group; P =6.33×10 ⁻⁴ ). Mediation analysis revealed that the spironolactone effect on thoracic aortic wall volume and myocardial mass remained significant after adjustment for ambulatory and central blood pressures. Proteomic analysis revealed a dominant effect of spironolactone on pathways involving oxidative stress, inflammation, and leukocyte activation. CONCLUSIONS: Among patients with diabetes with moderate to severe chronic kidney disease at elevated cardiovascular risk, treatment with spironolactone prevented progression of aortic wall volume and resulted in regression of LV mass and favorable alterations in native T1, suggesting amelioration of left-ventricular fibrosis. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02169089.

This study aimed to investigate whether plaque characteristics derived from intravascular optical coherence tomography (IVOCT) could predict a long-term cardiovascular (CV) death. This study was a single-center, retrospective study on 104 patients who had undergone IVOCT-guided percutaneous coronary intervention. Plaque characterization was performed using Optical Coherence TOmography PlaqUe and Stent (OCTOPUS) software developed by our group. A total of 31 plaque features, including lesion length, lumen, calcium, fibrous cap (FC), and vulnerable plaque features (e.g., microchannel), were computed from the baseline IVOCT images. The discriminatory power for predicting CV death was determined using univariate/multivariate logistic regressions. Of 104 patients, CV death was identified in 24 patients (23.1%). Univariate logistic regression revealed that lesion length, calcium angle, calcium thickness, FC angle, FC area, and FC surface area were significantly associated with CV death (p < 0.05). In the multivariate logistic analysis, only the FC surface area (OR 2.38, CI 0.98–5.83, p < 0.05) was identified as a significant determinant for CV death, highlighting the importance of the 3D lesion analysis. The AUC of FC surface area for predicting CV death was 0.851 (95% CI 0.800–0.927, p < 0.05). Patients with CV death had distinct plaque characteristics (i.e., large FC surface area) in IVOCT. Studies such as this one might someday lead to recommendations for pharmaceutical and interventional approaches.

Despite ongoing progress in stent technology and deployment techniques, in-stent restenosis (ISR) still remains a major issue following percutaneous coronary intervention (PCI) and accounts for 10.6% of all interventions in the United States. With the continuous rise in ISR risk factors such as obesity and diabetes, along with an increase in the treatment of complex lesions with high-risk percutaneous coronary intervention (CHIP), a substantial growth in ISR burden is expected. This review aims to provide insight into the mechanisms, classification, and management of ISR, with a focus on exploring innovative approaches to tackle this complication comprehensively, along with a special section addressing the approach to complex calcified lesions.

Background With its near histological resolution and its optical contrast, intravascular optical coherence tomography (IVOCT) is the only imaging modality that allows a unique assessment of microscopic plaque characteristics. This study aimed to investigate whether plaque characteristics derived from IVOCT could predict a long-term major adverse cardiovascular event (MACE). Methods This study was a single-center, retrospective study on 104 patients who had undergone IVOCT-guided percutaneous coronary intervention. Plaque characterization was performed using OCTOPUS software developed by our group. A total of 31 plaque features, including lesion length, lumen, calcium, fibrous cap (FC), and vulnerable plaque features (e.g., microchannel and cholesterol crystal), were computed from the baseline IVOCT images (obtained before stenting). For IVOCT plaque features, the discriminatory power for predicting MACE was determined using univariate/multivariate logistic regression as assessed by area under the receiver operating characteristic curve (AUC). Results Of 104 patients, MACE was identified in 24 patients (23.1%). Univariate logistic regression revealed that lesion length, maximum calcium angle, maximum calcium thickness, maximum FC angle, maximum FC area, and FC surface area were significantly associated with MACE (pConclusions Patients with MACE had distinct plaque characteristics in IVOCT. In particular, large FC surface areas were a risk factor. Interestingly, cap thickness, a commonly highlighted feature for lesion vulnerability, was less predictive than cap area. Studies such as this one might someday lead to recommendations for pharmaceutical and interventional approaches.

BACKGROUND: Use of intracoronary imaging is associated with improved outcomes in patients undergoing percutaneous coronary intervention (PCI). Yet, the impact of intracoronary imaging on real-time physician decision-making during PCI is not fully known. METHODS: The LightLab Initiative is a multicenter, prospective, observational study designed to characterize the use of a standardized optical coherence tomography (OCT) workflow during PCI. Participating physicians performed pre-PCI and post-PCI OCT in accordance with this workflow and operator assessments of lesion characteristics and treatment plan were recorded for each lesion based on angiography alone and following OCT. Physicians were categorized as having low (n=15), intermediate (n=13), or high (n=14) OCT use in the year preceding participation. RESULTS: Among 925 patients with 1328 lesions undergoing PCI, the prescribed OCT workflow was followed in 773 (84%) of patients with 836 lesions. Operator lesion assessment and decision-making during PCI changed with OCT use in 86% (721/836) of lesions. Pre-PCI OCT use changed operator decision-making in 80% of lesions, including lesion assessment (45%), vessel preparation strategy (27%), stent diameter (37%), and stent length (36%). Post-PCI OCT changed stent optimization decision-making in 31% of lesions. These findings were consistent across strata of physician prior OCT experience. CONCLUSIONS: A standardized OCT workflow impacted PCI decision-making in 86% of lesions, with a predominant effect on pre-PCI lesion assessment and planning of treatment strategy. This finding was consistent regardless of operator experience level and provides insight into mechanisms by which intravascular imaging might improve PCI outcomes.

Microvessels in vascular plaque are associated with plaque progression and are found in plaque rupture and intra-plaque hemorrhage. To analyze this characteristic of vulnerability, we developed an automated deep learning method for detecting microvessels in intravascular optical coherence tomography (IVOCT) images. A total of 8403 IVOCT image frames from 85 lesions and 37 normal segments were analyzed. Manual annotation was performed using a dedicated software (OCTOPUS) previously developed by our group. Data augmentation in the polar (r,θ) domain was applied to raw IVOCT images to ensure that microvessels appear at all possible angles. Pre-processing methods included guidewire/shadow detection, lumen segmentation, pixel shifting, and noise reduction. DeepLab v3+ was used to segment microvessel candidates. A bounding box on each candidate was classified as either microvessel or non-microvessel using a shallow convolutional neural network. For better classification, we used data augmentation (i.e., angle rotation) on bounding boxes with a microvessel during network training. Data augmentation and pre-processing steps improved microvessel segmentation performance significantly, yielding a method with Dice of 0.71 ± 0.10 and pixel-wise sensitivity/specificity of 87.7 ± 6.6%/99.8 ± 0.1%. The network for classifying microvessels from candidates performed exceptionally well, with sensitivity of 99.5 ± 0.3%, specificity of 98.8 ± 1.0%, and accuracy of 99.1 ± 0.5%. The classification step eliminated the majority of residual false positives and the Dice coefficient increased from 0.71 to 0.73. In addition, our method produced 698 image frames with microvessels present, compared with 730 from manual analysis, representing a 4.4% difference. When compared with the manual method, the automated method improved microvessel continuity, implying improved segmentation performance. The method will be useful for research purposes as well as potential future treatment planning.