Vanda Devesa Neto

This study analyses the research output expected for the final curricular evaluation of Portuguese medical residency programs, with particular focus on cardiology. All publicly available specialty-specific evaluation grids were reviewed in December 2024. Cardiology required 46 research items to attain maximum scoring, including research papers and congress abstracts stratified by journal quartile. This was the highest requirement among all specialties, compared to a median of 11 across all specialties. Uniquely, cardiology was the only specialty to quantitatively specify participation in research projects, clinical trials, and registries. In contrast, it scored below average in the most recent national residency satisfaction survey. However, no significant correlation was observed between the number of required research items and overall satisfaction. These findings suggest a potential misalignment between curricular evaluation criteria and the actual conditions of residency training. Reviewing these requirements may help create a more balanced and sustainable training environment.

BACKGROUND Cardiac resynchronization therapy (CRT) has been a major therapeutic advancement for patients with heart failure and electrical dyssynchrony. While CRT improves symptoms, reduces hospitalizations, and enhances survival, the role of implantable cardioverter-defibrillators (ICDs) alongside CRT in patients with non-ischemic cardiomyopathy (NICM) remains controversial. To evaluate and compare the outcomes of CRT with ICD (CRT-D) versus CRT with pacemaker-only (CRT-P) in individuals diagnosed with NICM, with a specific focus on the elderly. METHODS A comprehensive search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials was conducted in January 2024. Studies comparing CRT-D and CRT-P in patients with NICM were included, with subgroup analyses focusing on patients aged 75 years and older. RESULTS Twelve studies, including two randomized clinical trials, with a total of 62,145 patients and 16,754 pooled death events (9,171 in CRT-D and 7,583 in CRT-P), were analyzed. CRT-D was associated with a significantly lower risk of all-cause mortality compared to CRT-P (pooled OR = 0.72; 95% CI: 0.61–0.85; P < 0.01), with significant heterogeneity (I² = 83%). RCT subgroup analysis, was not statistically significant (pooled OR = 0.82; 95% CI: 0.64-1.06; P = 0.41; I² = 0%). In patients older than 75 years, no significant difference in mortality risk was observed (pooled OR 0.96; 95% CI: 0.81–1.15; I²=39%). CONCLUSION Our meta-analysis suggests that the addition of ICD therapy to CRT in patients with NICM significantly reduces all-cause mortality. However, this benefit does not extend to cardiovascular mortality, likely due to the primary role of ICDs in preventing sudden cardiac death rather than other causes such as progressive heart failure. The survival advantage of CRT-D is most pronounced in younger patients, with those over 75 years of age deriving less benefit. This highlights the importance of careful patient selection, considering age and comorbidities, when deciding on ICD implantation in NICM patients.

Kontext: Stratifikace rizika u syndromu Brugadov?ch (Brugada syndrome, BrS) p?edstavuje i nad?le zna?n? probl?m. C?lem t?to studie bylo zm??it vstupn? intervaly na klidov?m elektrokardiogramu (EKG) kohorty portugalsk?ch pacient? a jejich p??bu...

Background: Cardiac resynchronization therapy (CRT) stands as a notable medical breakthrough for individuals with heart failure and electrical desynchrony. This intervention aims to alleviate symptoms, diminish hospitalization rates, and enhance overall survival, both in conjunction with and without implantable cardioverter-defibrillator (ICD) therapy. Despite these advancements, the role of defibrillator therapy in addition with CRT for patients with non-ischemic cardiomyopathy (NICM) remains a topic of debate. Objective: To assess and compare the outcomes of individuals diagnosed with NICM who have underwent CRT with implantable cardioverter-defibrillator (CRT-D) against those who received CRT with a pacemaker only (CRT-P). Methods: We conducted a systematic search of PubMed, Embase and Cochrane database during August 2023 for studies comparing CRT-P and CRT-D in patients with nonischemic cardiomyopathy. Results: Thirteen studies, including two randomized clinical trials, were incorporated, with a total of 61,326 patients providing 16,446 pooled death events (9,108 in CRT-D and 7,338 in CRT-P). The meta-analysis revealed that CRT-D was associated with a significantly lower risk of all-cause mortality compared to CRT-P (pooled HR 0.74; 95% CI: 0.62-0.88; I2=84%). Subgroup analysis focusing on propensity score-matched studies yielded consistent findings (pooled HR 0.82; 95% CI: 0.77-0.87; I² = 0%, P<0.001). However, subgroup analysis for patients older than 75 years suggested no statistically significant difference in mortality risk within this specific age group (pooled HR 0.96; 95% CI: 0.811-1.15; I² = 39%, P<0.001). Regarding the secondary endpoint of cardiovascular mortality, no significant risk reduction with CRT-D was observed (pooled HR 0.70; 95% CI: 0.49-1.01; I² = 92%), albeit with high heterogeneity. Conclusion: Our study suggests that the addition of defibrillator therapy significantly reduces all-cause mortality in CRT-eligible patients with NICM, although results were not observed for patients older than 75 years.All-cause MortalityPatients older 75 years old

Vanda Devesa Neto, Joana Correia, Júlio Gil Pereira, Miguel Correia, Nuno Craveiro; Deep in the heart – a rare cause of ST-elevation, European Heart Journal - C

A CXR was performed (figure 1).

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Funding Acknowledgements: Type of funding sources: None. Introduction: ST-elevation myocardial infarction (STEMI) encompasses a heterogeneous group of patients with distinct prognoses. In worse clinical scenarios with the development of cardiogenic shock (CS), mortality may ascend to 40%. Observatoire Régional Breton sur l'Infarctus risk score (ORBIs) was developed to predict the development of in-hospital CS in patients with STEMI treated with primary percutaneous coronary intervention (PCI). Aim: To validate ORBI score as a predictor of in-hospital mortality (IHM) and long-term outcomes in STEMI. Methods: Retrospective analysis of 296 patients admitted for STEMI and treated with PCI. Patients presenting with CS at admission were excluded. ORBIs evaluates the presence of 11 variables: age >70 years, prior stroke/transient ischemic attack, cardiac arrest upon entry, anterior STEMI, first medical contact-to-PCI delay >90 min, Killip class, heart rate >90/min, a combination of systolic blood pressure <125 mmHg and pulse pressure 10 mmol/L, culprit lesion of the left main coronary artery, and post-PCI thrombolysis in myocardial infarction flow grade <3. The score derived from these variables allowed the classification of patients into four risk categories: low (0-7 points), low-to-intermediate (8-10 points), intermediate-to-high (11-12 points), and high (≥13 points). The Mann-Whitney U test was used for median comparison between groups. Kaplan-Meier survival plots were used to evaluate the predictive power of ORBIs on INM and on 12-month cardiovascular events (12MH). Results: Mean age was 63,9±13 years; 75% were men. 11% had a history of coronary artery disease, and 8% had been submitted to PCI previously. Mean LVEF was 54±12%. 69% had radial artery access. Left anterior descending artery disease was present in 68% of patients. Mean time since beginning of symptoms and hospital admission was 369±492 minutes. Mean duration of hospitalization was 5,68±3,5 days. ORBIs was calculated, and the population was divided into 2 groups: 45% were included in low and low to intermediate risk group (LR) (n=134), and 55% in intermediate to high- and high-risk group (HR). IHM was 3,7%. HR ORBIs was significantly associated with in-hospital mortality (6,2% vs 0,7%; p<0,01; OR 8,8 IC 95% 1,1;69,7). HR ORBIs was also significantly associated with long-term events (mortality and hospitalizations) (15% vs 6%; p<0,01). In univariate analysis, HR group showed significantly different LV ejection fraction (53,6±14,3 vs 61,0±13,1; p<0,01), troponin I at admission (33,3±94,12 vs 15,2±41,9; p<0,01), BNP (424,9±533,4 vs 194,1±170,1; p<0,01), duration of hospitalization (6,1±3,1 vs 5,2±3,9; p<0,01) and age (68,2±12,7 vs 58,9±11,5; p<0,01). Conclusion: Higher ORBIs is associated with increased mortality in patients with STEMI. ORBIs may be a simple predictive model for short and long-term mortality and cardiovascular events in STEMI patients.

Funding Acknowledgements: Type of funding sources: None. Introduction: Prognostic value of programmed electrical stimulation (PES) in Brugada Syndrome (BrS) remains controversial. Substantial controversy exists regarding usefulness of PES in identifying BrS patients at risk of sudden cardiac death (SCD). Implantation of an implantable cardioverter-defibrillator is the only reliable form of SCD prevention in this specific population Purpose: To determine if induction of sustained ventricular arrhythmia (VA) in PES is a predictor of cardiac events (CE), defined as the composite of SCD, appropriate ICD therapy for VA or unexplained syncope. Methods: A retrospective analysis of 34 patients with spontaneous or pharmacologically induced type 1 Brugada pattern, submitted to electrophysiology study with PES between 2015 and 2019 in a Portuguese Center, was performed. Patients were followed for 24 months. Hospital records and monitoring data from cardiac devices were consulted. The Mann-Whitney U test was used for median comparison between groups. Binary logistic regression through the stepwise method was performed to evaluate categorical features. Results: 35% (n=12) and 27% (n=9) had spontaneous type 1 and type 2 Brugada pattern in basal electrocardiography, respectively. 23% (n=8) had VA induced by PES. The mean age was 51,2±12,3 years. 71% (n=24) were male. 15% (n=5) had history of cardiac syncope, and 27% (n=9) had a family history of SCD. 9% (n=3) were carriers of a SNC5A mutation. Mean AH time and HV time were, respectively, 105±31,9, and 49±8,5ms. During the 24 months of follow-up, 9% (n=3) suffered a CE (2 unexplained syncope and 1 SCD). None of the patients who suffered CE had VA inducible at PES study. There was no statistical significance in the occurrence of cardiac events when comparing both groups (VA induced in PES vs. no induced arrhythmia) (p=0,49, OR 0,89, IC 95% 0,70;1,02). Through binary logistics, adjusted for potential confounders (gender, history of syncope, history of family SCD and identification of a genetic variant), patients with spontaneous type 1 Brugada pattern in basal electrocardiography were 2,2 times more likely to have a CE (IC 95% 0,12;40,2). Conclusion: In this population, VA induced by PES was not a predictor of CE during the follow-up period, which highlights the difficulty of risk stratification in patients with BrS. New risk-stratification tools are urgently needed to select those patients at higher-risk of SCD, which are candidates for prophylactic ICD implantation.