que se leu este artigo
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Um registo unicêntrico" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1276 "Ancho" => 1600 "Tamanyo" => 56909 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Peak transaortic gradient assessed invasively pre- and post-transcatheter aortic valve implantation.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Rita G. Francisco, Miguel Nobre Menezes, Pedro Carrilho Ferreira, Cláudia Jorge, Doroteia Silva, Eduardo Infante de Oliveira, Fausto J. 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"apellidos" => "Pinto" ] 7 => array:2 [ "nombre" => "Pedro" "apellidos" => "Canas da Silva" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117301324?idApp=UINPBA00004E" "url" => "/08702551/0000003600000004/v1_201704060057/S0870255117301324/v1_201704060057/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S0870255117301269" "issn" => "08702551" "doi" => "10.1016/j.repc.2016.09.014" "estado" => "S300" "fechaPublicacion" => "2017-04-01" "aid" => "963" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2017;36:239-46" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3044 "formatos" => array:3 [ "EPUB" => 215 "HTML" => 2315 "PDF" => 514 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "The importance of the neutrophil-to-lymphocyte ratio in patients with hypertrophic cardiomyopathy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "239" "paginaFinal" => "246" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "A importância da relação neutrófilos/linfócitos em doentes com miocardiopatia hipertrófica" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2439 "Ancho" => 3314 "Tamanyo" => 337758 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Neutrophil-to-lymphocyte ratio and (a) fragmented QRS, (b) ejection fraction, (c) ventricular tachycardia, (d) predicted five-year risk of sudden cardiac death, (e) corrected QT, and (f) presyncope in patients with hypertrophic cardiomyopathy. fQRS: fragmented QRS; 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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "247" "paginaFinal" => "249" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Dulce Brito" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Dulce" "apellidos" => "Brito" "email" => array:1 [ 0 => "dulcebrito59@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital de Santa Maria, CHLN, Centro Cardiovascular da Universidade de Lisboa (CCUL), Centro Académico Médico de Lisboa (CAML), Universidade de Lisboa, Lisboa, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Previsão de risco de morte súbita na miocardiopatia hipertrófica: poderão marcadores simples adicionais constituir uma ajuda?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypertrophic cardiomyopathy (HCM) is a common genetic cardiovascular disorder, of which sudden cardiac death (SCD) is the most feared potential manifestation. Risk stratification for SCD has always been one of the greatest challenges in the management of the disease.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Malignant ventricular arrhythmias are possibly the most common cause of SCD in HCM, although there are other potential causes, and in fact the pathophysiologic mechanisms leading to syncope and SCD in HCM are not completely understood. Myocyte disarray, cardiac hypertrophy, small-vessel coronary artery disease, and increased interstitial fibrosis are consistently found in the disease,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> and unquestionably play a role in the risk of SCD, although possibly to different and varying degrees in individual patients, depending also on the underlying genetic sarcomere alteration and tempered by additional genetic and external factors. The disease substrate contributes to functional endothelial and myocardial impairment, malignant arrhythmias, myocardial remodeling, and autonomic dysfunction, all of which can trigger sudden death under the appropriate circumstances. Translated into the clinical scenario, non-sustained ventricular tachycardia episodes, unexplained non-vasovagal syncope (particularly in young patients), abnormal blood pressure response to exercise, left ventricular outflow obstruction, degree of hypertrophy, and progression to chamber dilatation, are some of the known identifiable potential risk factors for the occurrence of SCD. Several of these clinical signs are included in the prognostic index currently recommended for application to HCM patients,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> a risk prediction model that estimates individual five-year risk of SCD. Age at diagnosis and a family history of sudden death are other risk factors incorporated in the model. The strategy currently used, although validated,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> is not without its critics.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> In fact, in such a complex disease, there will never be a perfect strategy to accurately predict the risk of SCD.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Besides clinical and imaging-derived risk factors, an ideal biomarker for risk stratification in HCM would be one that could easily, accurately and cost-effectively help identify HCM patients at higher risk for cardiovascular events (including SCD), and would be better than or at least additive to already identified biomarkers for determining prognosis and in decision-making processes.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Several biomarkers – considered here in a strict sense as biochemical molecules – have been studied in HCM, including some involved in inflammatory, hypertrophic and fibrosis signaling pathways.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">5,6</span></a> However, only natriuretic peptides (NPs) – wall stress markers – have been reproducibly associated with symptoms of heart failure, severity of hypertrophy, cardiac remodeling and imaging signs of left ventricular dysfunction.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">5–7</span></a> High levels of NPs are also associated with the presence of fibrosis in cardiac magnetic resonance imaging of patients with symptomatic ventricular arrhythmias. However, although the utility of late gadolinium enhancement for detecting myocardial fibrosis is well established, current data do not support its use in prediction of SCD risk.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2,8</span></a> Regarding prognosis, plasma NP levels are independent predictors of morbidity and mortality, particularly with regard to heart failure-related events, but not to SCD.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">9–11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Inflammation plays a central role in the pathogenesis of many clinical conditions. Interleukin-6 (IL-6) and tumor necrosis factor (TNF-α) are the inflammatory biomarkers most studied in HCM patients. IL-6, a pro-inflammatory cytokine that regulates leukocyte activity, is secreted by all the nucleated cells of the heart and also by skeletal muscle. Its levels are elevated in HCM patients, although no correlation with left ventricular hypertrophy or function has been found.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">5,12,13</span></a> TNF-α (cachexin), a cytokine involved in systemic inflammation whose levels are generally found to be increased in HCM,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> is produced not only by activated macrophages but also by many other cell types. Its primary role is in the regulation of immune cells. It has diverse actions on various organ systems, generally together with interleukin-1 and IL-6. Both biomarkers (TNF-α and IL-6) may promote the development of cardiac hypertrophy and fibrosis, through the activation of matrix metalloproteinases and their tissue inhibitors, and may have a role in the pathogenesis of HCM, although by as yet unidentified mechanisms.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">5,12,13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In the study by Ozyilmaz et al. published in this issue of the <span class="elsevierStyleItalic">Journal</span>,<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> the authors studied another marker of inflammation, the neutrophil-to-lymphocyte ratio (NLR), in a population of 97 patients with HCM followed for three years, and analyzed the association of NLR with prognosis. They found higher NLR in patients than in controls, and higher NLR values were identified in patients with fragmented QRS, ventricular tachycardia, pre-syncope, longer QTc interval (>440 ms), and >6% predicted five-year risk of SCD. Correlation was found only between QTC duration and NLR.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The authors linked higher NLR values to high-risk patients (with a worse prognosis regarding ventricular arrhythmic events), indicating a possible need for closer monitoring for ventricular arrhythmias in patients with high NLR.</p><p id="par0040" class="elsevierStylePara elsevierViewall">NLR can be altered in diverse clinical conditions and may predict cardiovascular mortality,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a> and has emerged as a strong marker of an adverse prognosis, including in acute coronary syndromes<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">15–18</span></a> and in acute decompensated heart failure.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a> In fact NLR may be a predictor of mortality in all conditions,<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> since it is potentially affected in a large number of diverse situations, including hypertension, diabetes mellitus, heart disease, thyroid, renal and hepatic dysfunction, cancer, local or systemic infection, inflammatory disease, and medication with various drugs.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> It should be noted that some (but not all) of these conditions were excluded from the study by Ozyilmaz et al.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> It may not always be possible to exclude all potential confounders, because a ‘pure’ middle-aged HCM population probably does not exist. However, the effects of the aforementioned potential confounders on NLR levels should be taken into account when assessing the application of a new biomarker of SCD risk in HCM that may impact on the decision whether to implant an implantable cardioverter-defibrillator.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The role of chronic inflammation and reparative fibrosis predisposing to ventricular (and possibly atrial) arrhythmias and remodeling in HCM is yet to be demonstrated. It is not known whether inflammation and cardiac repair (fibrosis) in the disease is actually responsible for both increased NLR values and QRS prolongation, which would explain the association found by Ozyilmaz et al.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> Furthermore, genetic characterization is an important marker of HCM, and it would be interesting to assess in future studies whether different genetic populations with HCM – associated with mutations in the same or different sarcomere genes – behave similarly or differently regarding NLR values.</p><p id="par0050" class="elsevierStylePara elsevierViewall">It is possible that as a marker of prognosis – or index of frailty? – in many situations, NLR, although non-specific, may be also useful in HCM, and the work by Ozyilmaz et al. encourages us to keep an open mind regarding new possibilities of risk stratification in HCM.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypertrophic cardiomyopathy: the interrelation of disarray, fibrosis, and small vessel disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.M. 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Ano/Mês | Html | Total | |
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2024 Novembro | 9 | 4 | 13 |
2024 Outubro | 45 | 40 | 85 |
2024 Setembro | 44 | 23 | 67 |
2024 Agosto | 57 | 39 | 96 |
2024 Julho | 33 | 30 | 63 |
2024 Junho | 31 | 20 | 51 |
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2024 Abril | 43 | 23 | 66 |
2024 Maro | 46 | 24 | 70 |
2024 Fevereiro | 41 | 37 | 78 |
2024 Janeiro | 27 | 38 | 65 |
2023 Dezembro | 32 | 24 | 56 |
2023 Novembro | 29 | 17 | 46 |
2023 Outubro | 21 | 16 | 37 |
2023 Setembro | 20 | 17 | 37 |
2023 Agosto | 23 | 19 | 42 |
2023 Julho | 26 | 9 | 35 |
2023 Junho | 24 | 10 | 34 |
2023 Maio | 34 | 21 | 55 |
2023 Abril | 18 | 4 | 22 |
2023 Maro | 24 | 24 | 48 |
2023 Fevereiro | 27 | 25 | 52 |
2023 Janeiro | 25 | 10 | 35 |
2022 Dezembro | 30 | 22 | 52 |
2022 Novembro | 48 | 23 | 71 |
2022 Outubro | 49 | 22 | 71 |
2022 Setembro | 26 | 32 | 58 |
2022 Agosto | 29 | 32 | 61 |
2022 Julho | 33 | 37 | 70 |
2022 Junho | 20 | 25 | 45 |
2022 Maio | 21 | 33 | 54 |
2022 Abril | 37 | 38 | 75 |
2022 Maro | 25 | 27 | 52 |
2022 Fevereiro | 20 | 31 | 51 |
2022 Janeiro | 34 | 26 | 60 |
2021 Dezembro | 21 | 27 | 48 |
2021 Novembro | 33 | 38 | 71 |
2021 Outubro | 45 | 47 | 92 |
2021 Setembro | 21 | 28 | 49 |
2021 Agosto | 38 | 41 | 79 |
2021 Julho | 28 | 23 | 51 |
2021 Junho | 30 | 27 | 57 |
2021 Maio | 49 | 30 | 79 |
2021 Abril | 67 | 36 | 103 |
2021 Maro | 67 | 22 | 89 |
2021 Fevereiro | 62 | 29 | 91 |
2021 Janeiro | 55 | 16 | 71 |
2020 Dezembro | 46 | 19 | 65 |
2020 Novembro | 49 | 22 | 71 |
2020 Outubro | 53 | 16 | 69 |
2020 Setembro | 67 | 19 | 86 |
2020 Agosto | 44 | 14 | 58 |
2020 Julho | 60 | 15 | 75 |
2020 Junho | 43 | 18 | 61 |
2020 Maio | 40 | 4 | 44 |
2020 Abril | 51 | 15 | 66 |
2020 Maro | 42 | 16 | 58 |
2020 Fevereiro | 111 | 22 | 133 |
2020 Janeiro | 53 | 8 | 61 |
2019 Dezembro | 28 | 6 | 34 |
2019 Novembro | 35 | 8 | 43 |
2019 Outubro | 34 | 5 | 39 |
2019 Setembro | 17 | 7 | 24 |
2019 Agosto | 41 | 11 | 52 |
2019 Julho | 47 | 11 | 58 |
2019 Junho | 30 | 9 | 39 |
2019 Maio | 35 | 15 | 50 |
2019 Abril | 32 | 19 | 51 |
2019 Maro | 71 | 7 | 78 |
2019 Fevereiro | 73 | 10 | 83 |
2019 Janeiro | 123 | 7 | 130 |
2018 Dezembro | 102 | 13 | 115 |
2018 Novembro | 85 | 6 | 91 |
2018 Outubro | 174 | 27 | 201 |
2018 Setembro | 44 | 16 | 60 |
2018 Agosto | 29 | 10 | 39 |
2018 Julho | 19 | 4 | 23 |
2018 Junho | 35 | 6 | 41 |
2018 Maio | 28 | 8 | 36 |
2018 Abril | 65 | 14 | 79 |
2018 Maro | 72 | 9 | 81 |
2018 Fevereiro | 23 | 14 | 37 |
2018 Janeiro | 42 | 6 | 48 |
2017 Dezembro | 52 | 18 | 70 |
2017 Novembro | 53 | 11 | 64 |
2017 Outubro | 16 | 13 | 29 |
2017 Setembro | 28 | 10 | 38 |
2017 Agosto | 29 | 11 | 40 |
2017 Julho | 26 | 9 | 35 |
2017 Junho | 48 | 13 | 61 |
2017 Maio | 83 | 43 | 126 |
2017 Abril | 156 | 53 | 209 |
2017 Maro | 9 | 14 | 23 |