ABC | Volume 112, Nº2, February 2019

Review Article Fontes-Carvalho et al The Year in Cardiology 2018: ABC Cardiol and RPC at a glance Arq Bras Cardiol. 2019; 112(2):193-200 identified five predictors of increased patient-delay: 1) age > 75 years; 2) symptom onset between 0:00 and 8:00 a.m.; 3) attending a primary care unit before first medical contact; 4) not calling the national medical emergency number; and 5) self‑transport to the emergency department. Therefore, this article provides important information to plan more effective patient-directed campaigns that can decrease patient-delay time and improve STEMI management and prognosis. 10 The latest 2018 myocardial revascularization guidelines have focused on the importance of hemodynamic assessment of intermediate-grade coronary artery lesions, which can be done either by FFR or iFR. 11 iFR is a new technique to access the severity of coronary stenosis, which has the advantage of not requiring the administration of a vasodilator, such as adenosine. Two recently published randomized trials have shown comparable clinical results between these two techniques in patients with intermediate-grade stenosis. 12,13 However, some studies have shown that there can be some inconsistencies between the two measurements. 14 In a provocative article published in Rev Port Cardiol, Menezes et al. 15 report their experience directly comparing FFR and iFR information in 150 patients. They have demonstrated that, in general, FFR and iFR are concordant, but in a significant proportion of cases (13%) the results differed between the two techniques. Therefore, this article is another important contributor for the ongoing discussion about the underlying mechanisms responsible for this discordance and their clinical implications. 16-18 An issue that remains open in coronary artery disease care is higher mortality after coronary artery bypass surgery (CABG) in patients with stent. Farsky et al. 17 evaluated inflammatory markers (LIGHT, IL-6, ICAM, VCAM, CD40, NFKB, TNF α , IFN γ ) in peripheral blood cells and in coronary artery tissue obtained during CABG in patients with stent (n = 41) compared to controls (n = 26). They observed that patients with stent showed higher TNF α (p = 0.03) and lower CD40 gene expression (p = 0.01) in peripheral blood cells than controls without stent. In coronary artery samples, the TNF α protein staining was higher in patients with stent, not only in the intima-media layer (5.16 ± 5.05 vs 1.90 ± 2.27; p = 0.02), but also in the adipose tissue (6.69 ± 3.87 vs 2.27 ± 4.00; p < 0.001), which had a higher interleukin-6 protein (p = 0.04). They concluded that higher systemic levels of inflammatory markers in patients with stents may contribute to a worse clinical outcome, contributing to our better understanding of pathophysiological changes that occur in patients with coronary stents who underwent coronary artery bypass grafting. Another challenge in coronary artery management is cardiac complications and deaths in the post-operation period of non-cardiac surgeries, mainly due to acute myocardial infarction (AMI). Antiplatelet agents are the cornerstone for primary and secondary prevention of cardiovascular events. Borges et al. 18 conducted a cross-sectional study to assess factors associated with inadequate management of antiplatelet agents in the perioperative period of non-cardiac surgeries. The sample consisted of adult patients undergoing non-cardiac surgeries and who would use acetylsalicylic acid (aspirin) or clopidogrel (n = 161). The management failed to comply with the recommendations in the guidelines in 80.75% of the sample. After multivariate analysis it was observed that patients with a higher level of education (OR = 0.24; CI95% 0.07‑0.78), and those with a previous episode of AMI (OR = 0.18; CI95% 0.04-0.95) had a higher probability of using a therapy complying with the guidelines. These findings emphasized the importance of a Heart Team to develop a patient-directed educational tool to improve adherence to the treatment of coronary artery disease to patients. In medical science, it is important to keep questioning established dogmas. For decades, the use of beta-blockers has been considered a cornerstone of medical therapy after ACS, having a class I or a class IIa indication for patients after STEMI and non-STEMI, respectively. 19,20 However, in the era of reperfusion therapy, several studies have questioned this indication, especially in patients without left ventricular dysfunction. 21,22 In the November issue of Rev Port Cardiol, Timoteo et al. 23 published a new article about this topic which “adds more fuel to the fire” to the ongoing discussion. Using a single center registry, they have used propensity score analysis to evaluate the one-year outcome of patients treated with beta-blockers in a sample of 1520 post-ACS patients. They observed that beta‑blocker use was an independent predictor of total mortality, including in patients with normal or mildly reduced ejection fraction. This analysis had some limitations. Although they have used propensity score matching, some caution is advised in the interpretation of these results because of residual confounding. Moreover, compliance with treatment and, more importantly, the reasons for not prescribing a beta‑blocker could not be assessed in this study. Therefore, this study is important because it reinforces the urgent need to design a pragmatic clinical trial to reassess the effectiveness and safety of beta-blockers in the modern era of reperfusion therapy. Also, in medical science, it is important to keep questioning the treatment effectiveness delivered to our patients. De Souza e Silva et al. 24 studied the survival rate of ischemic heart disease adult patients treated with percutaneous coronary intervention (PCI), in the state of Rio de Janeiro (RJ), from 1999 to 2014, paid by the Brazilian public healthcare system (SUS). They showed data of 19,263 patients (61 ± 11 years old, 63.6% men), and survival rates of men vs. women in 30 days, one year and 15 years were: 97.3% (97.0-97.6%) vs. 97.1% (96.6-97.4%), 93.6% (93.2-94.1%) vs. 93.4% (92.8-94.0%), and 55.7% (54.0-57.4%) vs. 58.1% (55.8‑60.3%), respectively. They also observed that the oldest age group was associated with lower survival rates in all periods; PCI with stent placement had higher survival rates than those without stent placement during a two‑year follow‑up, and women had a higher survival rate than men within 15 years after PCI. These findings performed in a real‑world population may help physicians to make decisions regarding the indication of PCI, considering the benefits and risks observed with this procedure. Arrhythmias Atrial fibrillation (AF) is the most common sustained arrhythmia, and a significant risk factor for stroke, heart failure and mortality. 25,26 The SAFIRA study, 27 recently published in the RPC journal, aimed to determine the prevalence and epidemiology of AF in a large sample of 7500 elderly 195