Hospital do Coração

High platelet reactivity (HPR) in patients with coronary artery disease receiving P2Y12 inhibitors increases ischemic risk. Chronic kidney disease (CKD) is an established contributor to HPR during clopidogrel therapy. The objective of the study was to assess whether CKD influences platelet reactivity (PR) in patients treated with clopidogrel or ticagrelor. This double-blind, double-dummy study enrolled 106 stable patients more than one year after an acute coronary syndrome, with or without CKD. Participants were matched by age and sex and randomized to clopidogrel or ticagrelor. PR was measured using the VerifyNow™ P2Y12 assay, and HPR was defined as P2Y12 reaction units (PRU) ≥ 208. Median glomerular filtration rates were 80 mL/min/1.73 m2 in non-CKD patients and 41 mL/min/1.73 m2 in CKD patients (p < 0.01). Ticagrelor produced similarly low PR in both groups (36 vs. 35 PRU; p = 0.61). Clopidogrel resulted in a numerically higher PR in CKD patients (209 vs. 180 PRU; p = 0.07). The magnitude of PR reduction with ticagrelor relative to clopidogrel was greater in CKD patients (p-interaction = 0.09). HPR was markedly more common with clopidogrel, particularly in CKD (difference 37%; adjusted OR 4.42; p = 0.01). In conclusion, CKD significantly impairs clopidogrel responsiveness but does not affect ticagrelor, resulting in a greater relative advantage of ticagrelor in patients with CKD.

ABSTRACT Indigenous lands in the Brazilian Amazon are critical to ecosystem conservation and cultural preservation but face increasing wildfire risks exacerbated by climate change and environmental degradation. This study explores how participatory mapping supports local resilience against wildfire risks, drawing on experiences from three villages in the Capoto/Jarina Indigenous land in Brazil. In each village, participatory maps were produced, and participants identified important locations for fire management, marking areas based on fire use, wildfire risks or the presence of fire‐vulnerable resources. The results provide local insight into vegetation changes affecting wildfire and demonstrate how the interaction between vegetation and traditional fire use, including some small fires that are not detected by satellite, shapes wildfire risk. Results revealed the role of invasive plant species, such as Brachiaria spp., in shaping local wildfire risks. Participatory mapping helped pinpoint critical resources and vegetation types that are fire‐sensitive and essential to local livelihoods. Finally, participatory mapping provided a spatially explicit representation of fire use, some of which were specific to environmental benefits, and wildfire risk management strategies across communities. The findings demonstrate that participatory mapping can help strengthen the resilience of local communities to wildfire risks by eliciting local fire use and wildfire management preferences while facilitating the creation of new local fire knowledge. The maps can be integrated into a broader wildfire risk assessment process, bringing together different knowledge systems to enrich stakeholders' understanding of shifting wildfire risks and planning for targeted interventions. As Brazil embraces the benefits of Indigenous and traditional fire use, participatory mapping can serve as a valuable tool for strengthening community‐driven resilience strategies such as local fire brigade initiatives. Its accessibility and adaptability make it particularly effective for engaging diverse stakeholders, enabling greater participation and supporting the continuous adaptation of fire management practices in response to evolving environmental conditions.

BackgroundTelemedicine is increasingly used in musculoskeletal care, but the accuracy of remote physical examination for rotator cuff syndrome, compared with magnetic resonance imaging (MRI), remains unclear. This study evaluated the diagnostic performance of telemedicine-based shoulder maneuvers against MRI, with secondary analyses including in-person examination.MethodsA cross-sectional diagnostic accuracy study was conducted. Patients underwent standardized teleconsultations with Jobe, infraspinatus, and Bear Hug tests, each analyzed for pain and weakness. All patients also underwent the same in-person maneuvers. MRI of the affected shoulder, reviewed by blinded musculoskeletal radiologists, served as the reference standard. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and balanced accuracy were calculated. Secondary analyses included comparisons between telemedicine and in-person performance, and agreement between modalities.ResultsThirty-two patients (mean age, 59.6 years) were included. Against MRI, telemedicine tests were highly sensitive: Jobe pain sensitivity was 96.2%, infraspinatus weakness sensitivity was 76.9%, and Bear Hug weakness sensitivity was 57.1%. In-person tests showed similar sensitivity for most maneuvers, with a tendency to classify fewer tendons as weak in MRI-negative shoulders. Paired analyses demonstrated minor differences for pain outcomes, but significant differences for weakness, with telemedicine being more sensitive and in-person examinations being more conservative in classifying weakness. Agreement between modalities was excellent for pain (κ up to 1.00) and moderate for weakness (κ, 0.11-0.47).ConclusionTelemedicine-based shoulder examination demonstrated high sensitivity compared with MRI, similar to in-person examination. Because all patients had MRI-confirmed pathology, and few true negative tendons were available, the ability of either modality to rule out rotator cuff tears based solely on clinical testing was limited. These findings support the use of telemedicine as a sensitive triage tool, while MRI remains necessary for definitive diagnosis and treatment planning.

Brugada syndrome (BrS) significantly contributes to sudden cardiac death in otherwise healthy individuals, primarily due to life-threatening ventricular fibrillation (VF). Traditional treatment prevents SCD but does not eliminate the risk of recurrent VF episodes. Recent developments in catheter ablation techniques targeting the arrhythmogenic substrate in the right ventricular epicardium have emerged as promising alternatives; however, there is a lack of randomized controlled trials (RCTs). To address this, we conducted a reconstructed individual patient data (IPD) meta-analysis to synthesize RCT evidence and estimate the time to benefit (TTB) of epicardial ablation in malignant BrS. We systematically searched major databases for RCTs comparing epicardial ablation versus ICD only in patients with malignant forms of BrS. IPD were reconstructed from Kaplan-Meier curves. Hazard ratios (HRs) and 95% confidence intervals (CI) were estimated using Cox regression, and Weibull models were applied to calculate TTB. Two RCTs (Nademandee et al; and Pappone et al.) including 90 patients (mean age 43.5 years) were included. Epicardial ablation therapy reduced the risk of VF recurrence (HR 0.17; 95% CI: 0.07-0.43; p < 0.001). The TTB to prevent one VF per 100 patients was 0.2 months (97.5% CI: 0.1-8.1 months). In patients with malignant forms of BrS, epicardial ablation was linked to a reduction in VF. These findings indicate that, for selected patients, adjunctive ablation procedures may provide a more favorable benefit profile than relying solely on ICDs.

Sacral chordoma is a rare bone tumor frequently treated with pre-surgical radiation; however, treatment response is difficult to determine based on imaging features of conventional MRI. We hypothesized that MRI texture analysis may be capable of demonstrating the effects of radiation therapy. We retrospectively examined pre- and post-radiation therapy MRI of patients with sacral chordomas. Firstly, the regions of interest delimiting the largest cross-sectional area of the tumors on coronal T1-weighted images were compared between pre- and post-radiation therapy MRI. Texture analysis features were extracted, analyzed, and classified. Secondly, all the coronal T1-weighted images were compared using large language models (LLM) to extract texture features. A total of 22 patients received pre-surgical radiation therapy (RT) and obtained pre- and post-radiation therapy MRI. A linear discriminant analysis model of the top 10 texture analysis features classified correctly 79.5% of chordomas pre- vs. post-treatment. The top 4 textural features had 81.8% sensitivity and 77.2% specificity in differentiating pre- vs. post-radiation chordomas, with a receiver operator area under the curve (AUC) of 84.5% (P = 0.003). Three texture features were related to pixel relationships and one to variations in pixel gray level (wavelet). The second approach using all the coronal-T1 images analyzing gray-level co-occurrence matrix (GLCM) features revealed a significant increase in correlation after RT (mean pre, 0.92; mean post, 0.95; P = 0.016). Texture analysis is a quantitative tool capable of differentiating pre- and post-radiotherapy chordomas and may provide biomarkers of treatment response.

Ortner's syndrome, or cardiovocal syndrome, is an uncommon cause of hoarseness resulting from left recurrent laryngeal nerve palsy due to cardiovascular pathology. We present the case of a 78-year-old male with systemic hypertension, chronic kidney disease, and a history of multiple complex aortic repairs, including Stanford type A dissection repair, thoracoabdominal aortic aneurysm reconstruction, and infrarenal endovascular repair. He developed progressive hoarseness and dysphagia over four months. Videolaryngoscopy revealed left vocal fold paresis, and computed tomography angiography demonstrated a 53-mm aortic arch aneurysm with type IA endoleak adjacent to the recurrent laryngeal nerve. The patient underwent zone 0 thoracic endovascular aortic repair with parallel stenting of the brachiocephalic trunk and left carotid artery, and left subclavian artery occlusion. Hoarseness improved significantly by postoperative day one. This case highlights the importance of considering Ortner's syndrome in patients with unexplained hoarseness and aortic disease, as prompt endovascular intervention can achieve rapid symptomatic relief, even before aneurysm sac regression occurs. To our knowledge, Ortner's syndrome occurring after three extensive aortic repairs, including open thoracoabdominal reconstruction and staged endovascular procedures, has not been previously reported. • Ortner's syndrome is a rare but clinically relevant complication of aortic arch aneurysms. • The importance of multidisciplinary collaboration for timely diagnosis and management is essential. • Rapid symptomatic improvement after advanced endovascular treatment in a high-risk/reoperative case is feasible.